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Building Focus
By Susan Birk
Monday June 8, 2009

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The majority of children drift away occasionally during a boring class, and many find it impossible not to squirm during a long movie. Still, most children, most of the time, can pay attention, sit still, tune out distractions, organize tasks, and control their behavior in an age-appropriate way, without a huge conscious effort. This isn’t so easy for the estimated 8 million children in the United States with attention deficit hyperactivity disorder, a neurobiological condition marked by inattention, hyperactivity, and impulsivity.

This isn’t so easy for the estimated 8 million children in the United States with attention deficit hyperactivity disorder, a neurobiological condition marked by inattention, hyperactivity, and impulsivity.

Although the causes of ADHD are not fully known, one line of current thinking suggests that the disorder stems from an impairment of the frontal lobes of the cerebrum, the area of the brain involved in motor function, impulse control, planning, problem solving, and other key tasks.

Because ADHD affects about one in 20 children, PTs and PTAs who work with young patients are likely to encounter at least a few children and teens with ADHD
during the course of their careers.

Focus on Facts

Children with ADHD are significantly more accident prone than the general population, which means they may be more likely to sustain injuries that require physical therapy. Studies have shown that 16% of children with ADHD versus 5% of children in the general population have had at least four serious accidental injuries, including fractures, and that 40% of teens with ADHD compared to 6% of teens in the general population have had two or more driving accidents.

The inattentiveness, impulsivity, and hyperactivity that are the behavioral hallmarks of ADHD can seep into PT sessions, making it harder to accomplish the goals of treatment. These extra challenges can be managed by understanding something about what makes children with ADHD tick and by translating that insight into practice. According to experts, the key to working effectively with children who have ADHD is to provide the clarity, structure, and consistency that they have trouble providing for themselves, and to combine it with liberal doses of novelty and plenty of positive reinforcement for desired behavior.

Manage Behavior

Russell A. Barkley, PhD, author of “Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment,” and a research professor at the State University of New York Upstate Medical University, Syracuse, recommends that PTs use many of the same behavioral management strategies that have been found to work well for teachers.

“Have clear rules for the session, post them in a visible location, and review them just before starting,” says Barkley, who is also the editor of The ADHD Report, a newsletter for clinicians and parents. Among his other recommendations:
* Use incentives, or rewards, for following the rules during the session. Clearly explain those rewards and how they can be earned, and review them with the child at the beginning of each session.
* Give the child specific feedback on his or her performance at the end of each session.
* Send a note card home for parents reporting the child’s behavior during the session. The card can be linked to home privileges that the child values, such as video game or computer time.

“Since many of these youth have organizational problems, clear, single-step commands, and assuring that the child actually hears and understands the commands, are essential,” notes Timothy Wilens, MD, a child psychiatrist at Massachusetts General Hospital, Boston, who conducts research on pharmacotherapy for ADHD.

“I recommend using many of the techniques that PTs are so well-versed in, applied aggressively,” Wilens says. “These youth need novel stimuli, active engagement and re-engagement, frequent changes of venue, positive reinforcement, and, of course, fun while doing activities.”

Michelle Maniaci, PT, RYT, CIIM, a physical therapist and yoga instructor who runs Nurturing Moves Inc. in Miami, can attest to the need for engagement, re-engagement, and fun when working with children who have ADHD.

“The therapist must motivate the child or the child won’t pay attention,” she says. The key to that motivation is devoting some additional time and energy to listening, communicating with the child on his or her level, finding out what kinds of activities he or she enjoys, and incorporating them into the session if possible. It also means drawing on one’s “inner clown” as needed, and being prepared to change activities as necessary to keep the child interested.

Active Movement

According to many experts, regular exercise may help children and teens with ADHD focus and function more effectively.

John Ratey, MD, associate clinical professor of psychiatry at Harvard Medical School and co-author of “Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood to Adulthood,” believes that the increases in dopamine, norepinephrine, and serotonin that occur with exercise can enhance the ability to focus and lower the brain’s need for stimulation for the person with ADHD.

“Anecdotally, parents clearly support that regular exercise not only improves a [child with] ADHD’s ability to sit still, but to concentrate as well,” Wilens agrees. “Limited literature that is emerging seems to suggest a very similar phenomenon. That is, children with ADHD who exercise show improved outcome in their attention spans, concentration, and their academic performance.”

According to Wilens, one form of regular exercise that parents routinely endorse is martial arts. “Not only is the physicality of martial arts important, but the mental effort that is required seems to complement a child with ADHD’s attention limitations,” he says.

Calm Environments

Maniaci believes in the benefits of creating a soothing environment at the beginning of each session. “The easiest thing the PT can do is to change the environment so that the environment drives the child to be calmer,” she says. She lowers the lights, filters out distracting noises, and employs aromatherapy — lavender, specifically — to “engage the relaxation response.”

Maniaci describes her approach as holistic. “I’m not just working with the child in isolation; the whole environment is causing the child to have the mind-body experience,” she explains. “If there’s a background noise, no matter how good a motivator I am, that child is going to want to look at whatever is more exciting.”

She says that instruction in diaphragmatic breathing is a critical part of her holistic strategy because the technique helps to keep her patients focused and “in the moment” during sessions. The technique works “with any patient of any diagnosis,” she says, but it becomes particularly useful with children who have ADHD. “If I work with the child on diaphragmatic breathing, I’m going to have a calmer, organized, posturally effective body,” she says, as well as a child who is more receptive to therapy.

Resources
* Attention Deficit Hyperactivity Disorder, National Institute of Mental Health: www.nimh.nih.gov/health/publications/adhd/summary.shtml
* CHADD (Children and Adults with Attention Deficit/Hyperactivity Disorder): www.chadd.org
* Barkley R. ADHD and accident proneness. The ADHD Report. 2002;10(2):2-5.
* Haffner J, Roos J, Goldstein N, et al. The effectiveness of body-oriented methods of therapy in the treatment of attention-deficit hyperactivity disorder (ADHD): results of a controlled pilot study. Kinder Jugendpsychiatr Psychother. 2006;34(1):37-47.

Susan Birk is a medical writer for the Gannett Healthcare Group. To comment, e-mail pteditor@gannetthg.com.

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