Use of occupational therapy: cognitive frame of reference in children with attention deficit hyperactivity disorder

Paediatric occupational therapy is a specialised branch of occupational therapy providing services which include:

· Improving, developing or restoring functions impaired or lost through neurological insult, illness, injury or deprivation.

· Improving ability to perform tasks for independent functioning when functions are impaired or lost.

· Preventing through early intervention, initial or further impairment or loss of function (the Individuals with Disabilities Education Act [IDEA] of 2004, 34 CFR 300.24 [b][5]).

· Habilitate a child to the highest level of functioning in the areas of motor, social, cognitive, sensory processing, play, pre and academic skills.

A common condition seen by paediatric occupational therapists is attention deficit hyperactivity disorder (ADHD). This has received significant attention in the past few years. It has however also been misdiagnosed frequently in view of its features presenting in early years. The text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)[American Psychiatric Association 2000] has been the single best of diagnostic criteria for assessment as it clearly mentions that inattention, hyperactivity and impulsivity have to significantly impair daily functioning.

ADHD, in addition to the above mentioned concerns, mainly features issues from the occupational therapy view point as sensory processing issues, cognitive functioning and executive functioning issues along with difficulties in psychosocial interaction. There is also difficulty in peer group interaction skills as also play skills get affected. The most neglected area becomes difficulty in functioning in basic activities of daily living such as self-care and social participation within the community (psychosocial frame of reference [psychosocial FOR] for children).

A frame of reference (FOR) is a set of interrelated internally consistent concepts, definitions, postulates that provide a systematic description of and prescription for a practitioner’s interaction within a particular aspect of a profession’s domain.[Mosey 1981] In the field of occupational therapy a cognitive frame of reference (cognitive FOR) has been used on the theoretical constructs of Piaget’s stages of development mainly with the adult population. It is now finding its way in use with children with ADHD in view of the impairment in executive functioning noted with these children. Occupational therapists used a cognitive behavioural and sensory integrative frame of reference to manage the difficulties in these children.

The cognitive FOR presented difficulties in children as young as five to six years of age, hence the behaviour management gained momentum primarily. However, when Barkeley[1997] revised his model towards the argument that ADHD is essentially impairment in the development of executive functioning, mainly the ability to inhibit; the perspective of management of this condition changed.

Many researchers have studied the cognitive impairments in children with this condition. On the basis of neuropsychological evaluation, tests of executive functioning were used to assess the functioning of these children. It is observed that ADHD is no longer only a triad of three main features but an entity encompassing difficulty with executive functioning[Castellanos 1999] and self-regulation.[McCloskey]

Executive functioning can be thought of as a diverse group of highly specific cognitive processes collected together to direct cognition, emotion, motor activity including functions associated with the ability to engage in purposeful, organised, strategic, self-regulated and goal directed behaviour.[McCloskey]

Thus today the occupational therapy perspective has widened its horizons on the management of ADHD with aiming to improve the level of self-regulation and the executive functioning abilities. Hence the cognitive FOR as was delineated for adults on the work of Piaget, Luria and Allen has translated in paediatric practice for improving the cognitive skills (process skills) of children with ADHD.

Occupational therapy management uses the uniform terminology (UF-OT) which is a standardised format used globally for occupational therapy evaluation for assessing the concerns faced by a child and the areas of concern are divided into three: performance areas, components, contexts. From the cognitive FOR perspective, these impact a child with ADHD tremendously. The performance areas include the self-care, community, social mobility and health management skills. The components include sensory, gross motor and fine motor, perceptual and the contexts include physical, social and cultural.

These impact a child’s performance at home, in the school, on the playground, in social gatherings, on vacations, in public places. They also depend on multiple intrinsic and extrinsic factors related to the child. The intrinsic include level of arousal, sleep, temperament and personality, energy and drive functions and so on. The extrinsic ones include the impact of the environment on the child.

A detailed evaluation of these and in addition the sensory processing abilities, perceptual and cognitive perceptual skills, social skills, language skills (by a speech therapist), play skills are done. This is to be done on standardised assessment tools to improve efficacy of evaluation. The performance contexts help to co-relate the information obtained from the parents and from the school to analyse the impact of difficulties faced by the child.

The cognitive FOR works hand in hand with the psychosocial FOR as the condition impacts not only the child but also the family. After evaluation a detailed report formulation occurs identifying the strengths and weaknesses of the child. The condition has undergone transformations from use of much safer allopathic medications to use of homeopathic medication and also cognitive behavioural management in recent years. A mainstay of management has been use of occupational therapy to reduce the impact of difficulties faced by the child on his function.

The Alert program based on the self-regulation principle in children who are older has enabled many of them to be able to modulate their levels of sensory processing which are often affected.[Williams and Shellenberger 1996] In younger children sensory diets have been useful as parents are able to carry out the same at home. Many a times, occupational therapist combines use of a specialised sensory diet for home and a sensory integrative program in the clinic to facilitate an adaptive response. These enhance cognitive processing abilities to facilitate appropriate thoughts and idea formation. The executive functions are translated in all areas of development of a child.

The executive functions can be combined together with self-regulation as described on a model given by McCloskey. These assess a set of 20 and more components which are enlisted and can be compared on the cognitive integration and the cognitive components given in the UF-OT. Some of the 20 factors include perceive, initiate, modulate effort, gauge, inhibit, hold, sustain and many more. The cognitive integration factors include level or arousal, orientation, recognition, initiation and termination of activity, command following, imitation skills etc.

Thus these can be combined using sets (self-regulation and cognitive component) to improve cognitive and executive functioning of children and an Alert program can serve as a parallel to these to manage the sensory processing concerns.

A chief component of use of cognitive FOR is that the following considerations are essential:

a) The level of cognitive functioning of each child differs as does the attention span. Hence the therapist needs to adapt the amount of input according to the level of performance of the child.

b) The therapist needs to work on the cognitive level of performance and not on the behaviour alone.

c) There is a need for more practice for them to maintain the changes achieved.

d) There is also the need to generalise these skills to different situations and the therapist needs to guide them to achieve them to do so.

e) The parents also need to provide an appropriate atmosphere along with the school teachers to enable the children to function independently.

Occupational therapists also need to implement use of the cognitive FOR in other areas related to independent functioning of a child with ADHD such as everyday self-care skills, play skills, academic skills such as reading, handwriting skills, visual perceptual skills, reasoning and analytical skills as also social participation to enable them to be at par to their peers in all domains of development.

The occupational therapy cognitive FOR serves to improve the level of functioning of a child, restores his sense of self-image and esteem which is reduced due to the constant criticism which the child faces and treats him not as someone who has no awareness of his difficulties but as someone who wants a solution to the issues faced and in a socially acceptable manner.

Suggested reading

Brown TE (2006) Executive functions and attention deficit hyperactivity disorder: implications of two conflicting views. International Journal of Disability, Development and Education 53:35-46

Dunbar SB (2007) Occupational therapy models for intervention with children and families. Thorofare, NJ: SLACK Incorporated

The Colorado Department of Education. Occupational therapy [Internet]. 2008 [cited 2012 Aug 31]. Available from: http://www.cde.state.co.us/cdesped/RS-OT.asp

US Law. 34 C.F.R. § 300.24 Related Services. [cited 2012 Aug 31]. Available from: http://law.justia.com/cfr/title34/34-2.1.1.1.1.1.33.24.html

References

American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: American Psychiatric Association

Barkley RA (1997) ADHD and the nature of self-control. New York: Guilford Press

Castellanos FX (1999) Psychobiology of ADHD. In: Quay HC, Hogan AE, editors. Handbook of disruptive behavior disorders. New York: Kluwer Academic/Plenum Publishers; p. 179-98

McCloskey G. The role of executive functions in childhood learning and behavior [Internet]. [cited 2012 Aug 31]. Available from: http://www.lanlfoundation.org/Docs/George%20McCloskey.pdf

Mosey AC (1981) Occupational therapy: configuration of a profession. New York: Raven Press

Williams MS, Shellenberger S (1996) How does your engine run?: A leaders’guide to the Alert program for self-regulation. Albuquerque, NM: Therapy Works