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An occupational therapy delineation model of practice is presented, which

guides a multidimensional understanding of the psychopathology of attention

deficit hyperactivity disorder (ADHD) and its management. Previous research
has established that occupational therapists lack detailed training or theory in
this field. he delineation model of practice is based on a literature review,
clinical e!perience and a consensus study carried out with occupational
therapists to determine their priorities for the evaluation of, and intervention
with, children with ADHD.
Part " of this article presents the model and e!amines its implications for
evaluation and intervention at the levels of child, task and environment. A family#
centred assessment and treatment package, based on the delineation model, is
described. Part $ of this article will report the results of a multicentre study,
which was designed to evaluate the effectiveness of this package.
%ccupational herapy for &hildren
with Attention Deficit Hyperactivity
Disorder (ADHD), Part "' a Delineation
(odel of Practice
Sidney Chu
and Frances Reynolds
In the United Kingdom (UK), occupational therapy for
children with attention deficit hyperactivity disorder (ADHD)
is a small field of practice (Chu !!"a), even though #$ of
school%aged children in the population are affected &y the
condition (American 'sychiatric Association (A'A) *++,)-
.ccupational therapists have much to offer children with
ADHD in facilitating engagement in meaningful tas/s and
successful participation in different occupations, &ut lac/
holistic models of evaluation and intervention-
In part * of a two%part article, an occupational therapy
delineation model of practice is presented, in order to
provide guidelines for understanding the specific
psychopathology and management of this disorder from a
multidimensional perspective- 0he model is &ased on an
1aling 'rimary Care 0rust-
2runel University, U3&ridge, 4iddlese3-
Corresponding author: Dr 5idney Chu, 'aediatric .ccupational 0herapy 5ervice
4anager, 1aling 'rimary Care 0rust, 6indmill 7odge (1aling Hospital 5ite),
U3&ridge 8oad, 5outhall, 4iddlese3 U2* "1U- 1mail9 sidney-chu:nhs-net
Submitted: # 4ay !!;- Accepted: *" <uly !!=- Key
words: 4odel of practice, attention deficit hyperactivity
disorder, outcome study-
Reference: Chu 5, 8eynolds > (!!=) .ccupational therapy for children
with attention deficit hyperactivity disorder (ADHD), part *9 a delineation
model of practice- British ournal of !ccupational "herapy# $%&'(# "=%"?"-
e3tensive literature review, the first author@s clinical
e3perience and the data gathered from occupational
therapists a&out their priorities for assessment and
treatment (Chu !!#)- 4any strategies are suggested
for assessing, understanding and addressing the
needs of children with ADHD- 0he application of this
model is discussed &y descri&ing specific occupational
therapy evaluation and intervention procedures that are
suita&le for a family%centred assessment and treatment
pac/age- 5ome validation for this model is achieved
through a multicentre evaluation, which will &e reported
in part of this article-
*ackground information
ADHD is a specific neuropsychiatric disorder (A'A
*++,)- Children diagnosed with ADHD Aappear
impulsive, overactive andBor inattentive to an e3tent
that is unwarranted for their developmental age and is
a significant hindrance to their social and educational
success@ (2ritish 'sychological 5ociety *++;, p?)-
0here have &een few pu&lished studies descri&ing the
role of occupational therapy for children with ADHD
(Chu !!"&), apart from those addressing a sensory
integrative approach (.etter *+?;a, *+?;&, Cerma/
*+??a, *+??&) or a specific treatment method
('eterson *++", 6oodrum *++", 5haffer et al !!*)-
+,$ *ritish -ournal of %ccupational herapy 5eptem&er !!= =!(+)
In 1urope and Corth America, clinical guidelines have
&een pu&lished on ADHD and hyper/inetic disorder for
medical, psychological and other health care practitioners
(2ritish 'sychological 5ociety *++;, American Academy of
Child and Adolescent 'sychiatry *++=a, *++=&, 0aylor et al
*++?, .vermeyer and 0aylor *+++, Cational Institutes of
Health !!!, American Academy of 'ediatrics !!!, !!*,
0aylor et al !!,)- Although these guidelines are primarily
medically and psychologically &ased, certain assessment
and treatment components are useful for occupational
therapy practiceD for e3ample, &ehavioural assessment
procedures, psychoeducational programmes for parents and
the &ehavioural management of the child- In order to
integrate the use of these components with specific
occupational therapy evaluation and intervention procedures
for children with ADHD, occupational therapists need to
synthesise relevant information and frame them within an
occupational therapy model of practice- 0he development of
a model of practice for children with ADHD will guide
therapists in the process of evaluation and intervention, and
esta&lish the specific role of occupational therapy within a
multidisciplinary team-
.hat is a delineation model
of practice/
A delineation model identifies evaluation and intervention
principles for specific groups of clients and can &e
conceptualised within a &roader professional model that
emphasises the concept of occupation for health
(Kortman *++,)- It &uilds on and integrates
interdisciplinary /nowledge and is applica&le in a
particular field of practice (Kielhofner *++)- It presents
and organises a num&er of theoretical concepts used &y
therapists in their wor/ (>eaver and Cree/ *++")- A good
delineation model gives clear guidelines a&out what to
assess and how to assess it, and states the goals of
treatment with clear intervention strategies- 0hus, a
delineation model has the dual tas/ of e3plaining a group
of phenomena and guiding practice related to those
phenomena for a specific client group (Dunn !!!)-
heoretical concepts of an
occupational therapy
delineation model of practice
for children with ADHD
0heoretical concepts relating to order, disorder and
therapeutic intervention are the primary theoretical core
of occupational therapy- 0hey provide logic, coherence
and rationale for the clinical applications of the model
(Kielhofner *++)- 0he occupational therapy delineation
model of practice for children with ADHD is &ased on the
theoretical concepts relating to the child, the environment,
the tas/, the interaction among these /ey factors and the
child@s participation in different occupations-
>ig- * illustrates the interaction of these factors within
the proposed model- It helps the understanding of a
child@s pro&lems at different levels of dysfunctionD the
Fig) 1) An occupational therapy delineation model of practice for children with attention deficit hyperacti*ity disorder &A+,+()
*ritish -ournal of %ccupational herapy 5eptem&er !!= =!(+) +,+
effect of different environmental factorsD the demands
of the tas/ selectedD and the child@s level of
participation in different occupations, which are
purposeful and meaningful within different situations
and with different levels of family support-
he child with ADHD
0he model presented in >ig- * highlights the interaction
&etween the child and his or her environment and tas/s at
different levels of functions (that is, neurological,
psychological and &ehavioural) &y synthesising different
research evidence (as reviewed &y Chu !!"&)-
0heories a&out the neurological &asis of ADHD have
identified the roles of the frontal%&asal ganglia and dopamine
pathways, with impaired functioning resulting in pro&lems of
attention control and &ehavioural inhi&ition (7ou *++;,
Castellanos *++=)- 0he &rain functions as a whole9 higher
cortical processes reEuire the sensory processing function
that occurs at lower su&cortical levels, and lower su&cortical
levels depend on cortical functions for interpreting sensory
information (2undy et al !!)- Foeller (!!*) &roadened the
proposed neurological &asis of ADHD to include prefrontal%
su&cortical circuits- 0he frontal lo&e, &asal ganglia and
thalamus may form a system or loop, which activates and
inactivates ascendingBarousal and descendingBinhi&iting
pathways (Cummings *++")- 0his conceptualisation lin/s the
three levels of functionsBdysfunctions as interrelated
components in e3plaining the aetiological factors of ADHD-
0his model suggests that we need assessment tools to
evaluate the primary &ehavioural features pertaining to
ADHD and also tools to identify the different neurological
and psychological correlates for the presenting &ehavioural
patterns- In terms of management, the model emphasises
that a child with ADHD needs neurological, psychological
and &ehavioural intervention strategies to support
performance and promote participation in different
he environment
1nvironments are the conte3ts in which children engage in
different tas/s or occupations, and include the physical and
social settings (Case%5mith !!*)- Different environments
have inherent features that can ena&le or disa&le a child@s
performance- Children with ADHD typically have different
symptoms at different times and in different situations- >or
e3ample, some children with ADHD may e3hi&it considera&ly
&etter self%control, appropriate &ehaviour and improved
performance with a teacher who maintains a relatively calm
atmosphere, with structured tas/s, well%defined e3pectations
and positive reinforcement for appropriate &ehaviour
(Du'aul and 5toner !!")-
5chools that offer relatively effective programmes
for children with ADHD are also strong on organisational
and environmental factors, which include positive attitudes
towards and understanding of ADHD, support at authority
level, and provision of coordinated intervention through
teams of professional wor/ers (2urcham et al
*++")- 0herefore, it is important to assess different
environmental factors that may contri&ute to the
presentation of different &ehavioural patterns in
children with ADHD- 0he assessment provides a
&asis for effective intervention &y addressing those
environmental factors that induce or e3aggerate the
&ehavioural patterns of a child with ADHD-
he task demands
0as/s are defined as AseEuences of actions in which
persons engage to satisfy either e3ternal societal
reEuirements or internal motives@ (Kielhofner *++#, p*!*)-
.ccupational therapists classify these tas/s into self%
care, schoolBwor/, play and leisure, and social
participation (6atson and 7lorens *++=)- 0as/s are
related to occupations, at particular ages and in specific
environments (Case%5mith !!*)- 6hen considering the
dimension of tas/ demands, varia&les such as the goal,
novelty, appropriateness, the level of challenge and the
importance of the tas/, and also the motivation of the
child, are salient- 0he goal of a tas/ is the central /ey
factor- It is critical to identify what the child wants or
needs to do when planning interventions- All this supports
the need to assess the child@s neurological and
psychological functions, &ehavioural regulation,
perceptual%motor functions and other environmental
factors that may contri&ute to the child@s presenting
pro&lems in different tas/s- It also provides the &asis for
different management strategies-
0amily support
It is important to consider the impact of family support
and parental involvement on the child@s &ehaviours
(Humphry !!)- 8ecent research has demonstrated that
the more parents hold informed &eliefs a&out ADHD, the
less li/ely they are to use ineffective discipline (<ohnston
and >reeman !!)- 0his highlights the importance of
appropriate education or information sharing with parents
so that they can interact with and support the child in an
appropriate manner, achieving &etter long%term outcomes
(Harrison and 5ofronoff !!, HinoGosa et al !!)-
&hild#environment#task balance
0he child%environment%tas/ &alance determines the
success of occupational performance and participation in
different occupations- .ccupational performance is a
process of interacting with the environment according to
the child@s goals or intentions- It refers to the match
&etween the s/ills and a&ilities of the childD the demands
of the tas/D and the characteristics of the physical, social
and cultural environments (7aw et al *++;)- >or e3ample,
if a child with ADHD is as/ed to engage in a tas/ that
over%challenges his or her attention control, this will
contri&ute to an unsuccessful occupational outcome-
Alternatively, if the environment is highly distracting, it
will &e difficult for the child to sustain sufficient attention
control to complete the tas/, even though the tas/ itself
is at an appropriate level for the child-
+,1 *ritish -ournal of %ccupational herapy 5eptem&er !!= =!(+)
0amily#centred care approach
.ccupational therapists recognise that the ultimate
outcome of a child@s development is highly influenced
&y the caregiving environment (HinoGosa et al !!)-
0hey strive for a colla&orative relationship with parents
and appreciate that the child with ADHD is part of an
interactive family system- .ccupational therapists
wor/ing with children with special needs are part of the
formal social support system and are in a position to
encourage the family@s efforts to networ/ among friends,
family mem&ers and parent groups-
A family%centred approach is demonstrated when the
therapist ena&les parents to &ecome eEual team mem&ers
(2rown et al *++=)- A family%centred service recognises that
each family is uniEueD that the family is the constant in the
child@s lifeD and that parents are the e3perts on the child@s
a&ilities and needs- 0he strengths and needs of all family
mem&ers are considered- 0herapists wor/ colla&oratively
with parents to ma/e informed decisions a&out the services
and supports availa&le, and to empower and ena&le them in
the whole intervention process- 6hen applying these
principles to the management of children with ADHD, all the
evaluation and intervention procedures adopted should &e
framed within a family%centred care approach, as advocated
&y 8osen&aum et al (*++?) and Humphry and Case%5mith
2ecause of the comple3ity of the condition, a
multidimensional evaluation approach and a multifaceted
intervention framewor/ are adopted in the clinical application
of the model- Different evaluation and intervention
procedures from different treatment approaches (for
e3ample, &ehavioural, sensory integrative and
psychoeducational approaches) are integrated into this
delineation model for children with ADHD- 0he following
sections descri&e the range of evaluation and intervention
procedures and their application, &ased on the principles of
the family%centred care approach advocated in the model-
(ultidimensional evaluation of
children with ADHD
1ach child with ADHD has a uniEue constellation of
pro&lems and multiple domains of functioning may &e
affected (6halen and Hen/er *++;)- 0herefore, it is
important to adopt a multidimensional evaluation
approach (Chu !!"c) in order to determine whether or
not ADHD is present and how it affects the child@s
development and performance in different areas of
occupation- .ver half of children with ADHD are
influenced &y one or more of the associated comor&idities
that cause additional psychiatric, neurological and
learning pro&lems (0annoc/ *++?, 2rown !!!)- 0here
are also many different conditions that mimic the clinical
features of ADHD (Hill and Cameron *+++)- 0herefore, it
is important to ma/e a differential diagnosis and to
identify comor&idity when evaluating children with ADHD-
>ig- illustrates the application of some of these
evaluation procedures within the model and suggests a
num&er of relevant standardised scales- Although each of
Fig) 2) Application of the model in the multidimensional e*aluation of children with attention deficit hyperacti*ity disorder &A+,+()
*ritish -ournal of %ccupational herapy 5eptem&er !!= =!(+) +,2
these evaluation procedures is limited in some manner,
when they are used in a multidimensional evaluation
pac/age a system of chec/s and &alances develops
such that the draw&ac/s of any single measure are
&alanced &y data o&tained through other means
(2ar/ley *++?, Anastopoulos and 5helton !!*)-
Assessing the child at the neurological level
8ecent research indicates that poor sensory modulation
function could &e a &asis for the presenting &ehavioural
pattern in children with ADHD (Cerma/ *+??a, 4angeot
et al !!*)- 5ensory modulation is the capacity to
regulate and organise the degree, intensity and nature of
responses to sensory input in a graded and adaptive
manner, so that an optimal range of performance and
adaptation to challenges from the environment can &e
maintained (7ane et al !!!)- Dysfunction in sensory
modulation has a strong impact on a child@s &ehaviour in
the areas of arousal, attention, affect and action
(6illiamson and AnHalone !!*, 5chaaf and AnHalone
!!*)- Children with ADHD tend to present a pattern of
sensory see/ing &ehaviour that interferes with their
regulation of &ehaviour and also with participation in
different occupations (Dunn and 2ennett !!)-
0he 5ensory 'rofile (Dunn *+++) is a Gudgement%
&ased caregiver Euestionnaire- It measures children@s
&ehaviours hypothesised to &e lin/ed to sensory
processing a&ilities and profiles the effect of sensory
processing on functional performance in the daily life of
children #%*! years of age- A separate wor/sheet is
developed for assessing children with ADHD- 0herapists
should also ma/e o&servations of sensory%&ased
&ehaviour within clinical and classroom settings to
complement the data generated from the 5ensory 'rofile-
Assessing the child at the psychological level
0he psychological &asis of ADHD is usually addressed &y
clinical psychologists unless the occupational therapist
has appropriate postgraduate training in the
administration and interpretation of different
psychological tests, such as the Conners@ Continuous
'erformance 0est I II (Conners !!*) or the 2ehaviour
8ating Inventory of 13ecutive >unction (Jioia et al !!!)-
0herapists may need to o&tain information from
psychologists if they have assessed the child-
Assessing the child at the behavioural level
It is important to chec/ whether the ranges of inattentive,
hyperactive and impulsive &ehaviours presented &y the
child were present &efore the age of = years, occur in
two or more settings and also cause impairment in
social, academic or occupational functioning (A'A
*++,)- 0he ADHD 8ating 5cale I IF (Du'aul et al *++?)
is useful for screening, assessment and the evaluation
of treatment outcome- 2oth Home and 5chool Fersions
are completed independently &y a child@s parent and
teacher, and are reported to provide relia&le and valid
data regarding the freEuency of ADHD symptoms-
2esides using the ADHD rating scale, semi%
structured interviews with parents, teacher and child are
an important component of the evaluation- 0he
interviews provide the phenomenological data that
rating scales cannot capture (2ar/ley and 1dwards
*++?)- 0herapists can develop an interview form &ased
on the wor/ of different authors in the field (6odrich
*++,, 2ar/ley and 1dwards *++?, 2ar/ley and 4urphy
*++?, Dowdy et al *++?, Du'aul and 5toner !!")-
It is important to note that interview and rating scale data
are su&Gect to a num&er of limitations, including the inherent
&iases of those answering the interview Euestions and
completing the Euestionnaires (2ar/ley and 1dwards *++?)-
0hus, ideally, these data should &e supplemented with
o&servational assessment of the child@s &ehaviour and
psychosocial functions in the natural environment, such as
the child@s emotional control, peer%group relationships, social
s/ills and interaction with parents-
Assessing the environment
0he therapist should also gather information related to
the home environment through the interview or
the information from other team mem&ers (for e3ample,
information on family dynamic and support from the
family therapist)- 5chool is another environment in which
children with ADHD e3perience many challenges-
A useful evaluation tool designed specifically for
children with ADHD is the 5trengths and 7imitations
Inventory9 5chool Fersion (57I) (Dowdy et al *++?)-
0he 57I is a multidimensional rating scale designed to
document the strengths and limitations that may &e
manifested in an academic setting- It consists of items
that address memory, reasoning, e3ecutive function,
socialBemotional status, communication, reading,
writing and mathematics- 0he teacher or anyone who
has o&served the child over time can complete it-
Another important means of assessment is classroom
o&servation- 0he therapist can o&serve the child across a
variety of settings (for e3ample, classroom, playground and
dining hall) and in interaction with different individuals- In
many cases, direct o&servations will provide the most
fruitful data when conducted during independent seatwor/
situations and transitions &etween lessons (Dowdy et al
*++?)- It is also helpful to o&serve the &ehaviour of the
teacher and the other children in the class- >or instance,
teacher &ehaviours (for e3ample, prompts, reprimands,
feed&ac/ and shouting) could &e possi&le antecedent
andBor conseEuent events for the child@s &ehaviour (Du'aul
and 5toner !!")- In addition to classroom o&servation,
therapists can also interview teachers to gather more
information and analyse the sensory components of the
physical environment for possi&le effects on the child@s
Assessing task performance
0he assessment of perceptual%motor and functional s/ills
provides information on the underlying functions and
dysfunctions of the child, and their impact on the child@s
+,3 *ritish -ournal of %ccupational herapy 5eptem&er !!= =!(+)
a&ility to carry out different tas/s and engage in different
occupations- Information generated in this area of evaluation
helps to ma/e a differential diagnosis and identify
comor&idity, such as developmental coordination disorder
(DCD)- Detailed information on the child@s functional
difficulties forms the &asis for different intervention
strategies- 0herapists can administer a &attery of
standardised perceptual%motor tests within routine paediatric
occupational therapy practiceD for e3ample, the 4otor >ree
Fisual 'erception 0est I 0hird 1dition (Colarusso and
Hammill !!")D the 2eery%2u/tenica Developmental 0est of
Fisual%4otor Integration I #th 1dition (2eery and 2eery
!!,)D the 4ovement Assessment 2attery for Children I nd
1dition (Henderson and 5ugden !!=)D and the DCD
Kuestionnaire (6ilson et al !!!)-
>or assessing functional s/ills, therapists can use
different standardised tools, such as the 'erceived
1fficacy and Joal 5etting 5ystem (4issiuna et al !!,),
the 5chool >unction Assessment (Coster et al *++?) and
the 5chool Fersion of the Assessment of 4otor and
'rocess 5/ills (>isher and 2ryHe *++?)- However, some
therapists may use non%standardised Euestionnaires or
chec/lists &ecause most of these standardised tools
either are too e3pensive, ta/e a long time to administer,
are not readily availa&le in certain wor/ settings or are
not standardised for the UK population-
Assessing family dynamic and support
0he therapist can gather information on the family
dynamic and support through an interview with the
parents and the o&servation of the interaction &etween
the child and parents- 0he therapist should also
incorporate information from other professionals (for
e3ample, child psychiatrist, clinical psychologist and
family therapist) for the overall interpretation and
management of the child@s presenting pro&lems-
4sing the assessment data
0he overriding goals of the multidimensional evaluation
are to derive accurate data regarding the freEuency and
severity of ADHD &ehaviours across settings and with
different individuals, as well as the possi&le causes of
the child@s difficulties in performing and participating in
different occupations- After gathering all the data, the
therapist analyses and interprets the results, which
provides relevant information for the selection of different
treatment components within the multifaceted
intervention programme descri&ed &elow-
(ultifaceted intervention of
children with ADHD
In order to remediate the various facets of the disorder,
a framewor/ of multifaceted intervention (Chu !!"c) is
adopted in this model- >ig- " illustrates the application of
some of these intervention strategies within the delineation
model for children with ADHD- 0he positive outcomes in
empowering and ena&ling parents and teachers through the
family%centred care approach are an important contri&ution
to the ultimate success of the intervention-
Fig) -) Application of the model in the multifaceted inter*ention for children with attention deficit hyperacti*ity disorder &A+,+()
*ritish -ournal of %ccupational herapy 5eptem&er !!= =!(+) +,,
reatment through education and
training for parents and teacher
After the completion of the multidimensional evaluation, a
feed&ac/ session should &e conducted with &oth parents
and teachers so that they &oth hear the same information- It
is important to set common goals and o&Gectives with
parents, teachers and the child- >rom the family%centred
care perspective, sharing information a&out the child@s
condition with the main caregivers is an important aspect of
wor/- 0he research studies reviewed suggested that &etter
treatment outcomes can &e achieved &y improving parents@
and teachers@ understanding of the condition (2urcham et al
*++", Cor/um et al *+++, HoHa et al !!!, <ohnston and
>reeman !!) and &ehavioural management strategies
(Co/er and 0hyer *++!, Hinshaw and 4elnic/ *++, 2ar/ley
*++?)- 0he sharing of information can &e achieved &y using
information pac/s, seminars and direct consultation with
parents and teacher-
reatment through environmental
Different environmental factors may contri&ute to the
presentation of different &ehavioural patterns in children
with ADHD and suita&le modification will help to facilitate
the child@s participation in different occupations- Clinical
e3perience indicates that for children with ADHD, a
calming environment with less stimulation is desira&le to
maintain their attention control and promote self%
regulation, such as a classroom with a clear layout and a
neutral colour scheme- 0he adaptation of the sensory
and physical environments is considered to &e an
important area of intervention in paediatric occupational
therapy practice (4c1wen *++!)- 0he therapist needs to
help parents and teacher to appreciate the e3tent to
which naturally occurring activities and interactions
within the environment provide the sensory input
reEuired to regulate, or disrupt regulation of, arousal
level, attention control and activity level (6illiamson and
AnHalone !!*)-
It is important to note that reasona&ly consistent,
predicta&le and structured daily routines help children to
self%regulate- 0he therapist should introduce the use of a
visual timeta&le within the home and classroom
environments- A visual timeta&le is a visual presentation
of a daily schedule on a large piece of paper (Dowdy et al
*++?)- It provides a predictive schedule and helps the
child to /now what is a&out to happen- 2eing a&le to
anticipate events ena&les the child to move from a
reactive mode to a purposeful, self%initiated mode of
&ehaviour, which, in turn, helps the child to cope more
successfully with changes in the environment-
0he therapist should also chec/ other
environmental factors in relation to the child@s
associated pro&lems, such as the appropriate
dimensions of chair and ta&le to address poor postural
control, the selection of seating position to address
potential ocular%motor deficits and the provision of a
special device to aid efficient handwriting performance-
reatment of the child at the
neurological level
As discussed, recent research studies have provided
evidence of the association &etween dysfunction in
sensory modulation and ADHD (4angeot et al !!*,
Dunn and 2ennett !!)- 5ensory techniEues may &e
effective in addressing many of the pro&lem &ehaviours
characteristic of children with ADHD, including inattention,
disorganisation and hyperactivity (2hatara et al *+=?,
Kantner and 0acco *+?!, 2hatara et al *+?*)- 0he
ultimate goal of sensory integrative intervention is to
facilitate a child@s development, self%actualisation and
occupational performance (2undy et al !!)-
In order to address the child@s sensory needs, the
therapist needs to consider how the child@s sensory diet
varies throughout the day (6illiams and 5hellen&erger
*++,)- 0he concept of Asensory diet@ is &ased on the
idea that each individual reEuires a certain amount of
sensory stimulation to &e in his or her most alert,
adapta&le and s/ilful state (6il&arger *++#)- 0his is
much li/e a person@s nutritional reEuirement- >or
e3ample, for a child with sensory see/ing &ehaviour,
the teacher can assign the child to distri&ute learning
materials within the classroom so that the child can get
the necessary movement stimulation-
>or therapists who have completed postgraduate training
in certain specific sensory%&ased techniEues, the Alert
'rogramme for 5elf%8egulation (6illiams and 5hellen&erger
*++, *++,), the 4.819 Integrating the 4outh with 5ensory
and 'ostural >unction (.etter et al *++#) and the
0herapeutic 7istening 'rogramme (>ric/ and Hac/er !!!)
can provide effective techniEues in regulating the child@s
&ehaviour- 0here are also different sensory modulation
techniEues, which could &e scheduled into the child@s
sensory diet programme- 0hese include giving the child deep
pressure touch (Krauss *+?=)D using late3%free ru&&er tu&ing
as a Achewy@ (5cheerer *++)D using a weighted vest
(Fanden2erg !!*)D and allowing the child to sit on a therapy
&all chair while doing his or her schoolwor/ (5chilling et al
!!")- 0he therapist should integrate the use of a visual
timeta&le with a sensory diet programme-
reatment of the child at the
psychological level
'sychologically%&ased treatment is usually the role
of a clinical psychologist within the multidisciplinary
team- 5ome children with ADHD will &enefit from
specific training in attention and impulse control,
and also the treatment of e3ecutive dysfunctions
(2ar/ley *++=, Dawson and Juare !!,)-
reatment of the child at the behavioural
Different systematic reviews confirm that &ehavioural
management is an effective treatment for children with
ADHD (>iore et al *++", 'elham and Jnagy *+++)- 2ar/ley
(*++#) identified *! guiding principles for raising a child with
ADHD- 0hese *! principles highlight the specific
+,5 *ritish -ournal of %ccupational herapy 5eptem&er !!= =!(+)
needs of children with ADHDD for e3ample, they need
immediate, freEuent and powerful conseEuences to esta&lish
and maintain desira&le &ehaviour- 0hese guide parents to
pause &efore reacting to the present misconduct of the child,
use the delay to reflect on the principles and choose a response
to the child that is consistent with these principles-
ADHD places children at serious educational ris/
(2ar/ley *++?)- 0herapists can apply the principles of
&ehavioural management and sensory modulation in
developing a programme of classroom management and
environmental adaptation- As noted a&ove, the visual
timeta&le with sensory diet activities can &e integrated
into the schedule- 0he teacher can also set up &asic
rules of classroom &ehaviour for all children- .ther
suggestions include changes in the lesson schedule, the
classroom layout and the seating position of the child-
0he guide to classroom interventions accompanying the
57I provides e3amples of appropriate interventions for
specific &ehaviours identified in the 57I (Dowdy et al
*++?)- 5ome children may also &enefit from a structured
social s/ill training programme integrated into the real%life
environment (Juevremont *++", 5heridan et al *++;)-
reatment through appropriate task
selection and remediation of
developmental and functional problems
In terms of tas/ demands and selection, Lentall (*++")
advocated an increase in active participation, the use of
a ver&al as opposed to a written response, a focus on
the novelty of tas/s and self%pacing, and also a
reduction in the amount of Aseat wor/@ in order to
ma3imise the tas/ performance of children with ADHD-
As identified &y 6hitmont and Clar/ (*++;), 2ar/ley
(*++?) and 'ie/ et al (*+++), children with ADHD present
a range of perceptual, language, motor and functional
pro&lems- 0hese pro&lems have a strong impact on the
child@s performance in different tas/s and affect the
child@s successful participation in different occupations-
0he presence of these pro&lems could &e part of the
ADHD features or related to comor&id conditions, such
as DCD- 0he therapist should identify the pro&lems and
provide intervention accordingly-
he development of
assessment and treatment
packages based on the model
0he model suggests a num&er of different evaluation and
intervention procedures, a smaller array of which may &e
selected to formulate a specific assessment and treatment
pac/age, managea&le within limited resources- 0he
pac/age should &e afforda&le, in terms of time and
resourcesD fle3i&le, so as to meet an individual family@s and
child@s needsD servicea&le, with clinical procedures applied
in some very concrete waysD and practical, so that therapists
do not need to go through e3tensive training-
0he first author has developed a &asic pac/age &y
ta/ing into consideration the cost, time, resources and
training involved- 0he pac/age reEuires the use of
assessment tools that are ine3pensive or readily availa&le
in most paediatric occupational therapy departments- 0he
&asic rationale is that the assessment tools selected can
provide sufficient information to identify the child@s
underlying dysfunctions and to plan an intervention
programme that is child and family centred-
0he pac/age consists of a clinical pathway of *
wee/ly contacts, with a com&ination of clinic
appointments and school visits- 0he duration of the
pathway is afforda&le &ecause it is consistent with
most of the pac/ages of care for different care
groups (for e3ample, children with DCD) provided
&y paediatric occupational therapy services
throughout the countries in the UK (see >ig- ,)-
0he processes of evaluation and intervention
are &ased on the principles of the family%centred
care approach- In the multidimensional evaluation
process, it is recommended that the therapist uses
the following assessment procedures9
*- For the neurological basis of A+,+, the 5ensory
'rofile (Dunn *+++) and clinical o&servation
- For the beha*ioural patterns of A+,+ and the child.s
psychosocial s/ills, semi%structured interview,
o&servational assessment and the ADHD 8ating 5cale I
IF, Home and 5chool Fersions (Du'aul et al *++?)
"- For the en*ironmental factors, semi%structured interview,
classroom o&servation and the 5trengths and 7imitations
Inventory9 5chool Fersion (Dowdy et al *++?)
,- For the child.s tas/ performance# perceptual0motor
and functional s/ills, the DCD Kuestionnaire for
parents (6ilson et al !!!) and other perceptual%motor
#- 1nformation from other professionals (for e3ample,
child psychiatrist, psychologist and family therapist) is
incorporated into the whole evaluation process-
In the multifaceted intervention programme, the
following components are advocated9
*- 2ducation of parents and teachers about A+,+
through a feed&ac/ session and also the provision of
information pac/s (<ones et al *+++, CHADD !!!)-
5haring information a&out the results of the
evaluation helps to promote the understanding of the
child@s underlying dysfunctions and their effect on
the child@s &ehaviour- 0he educational process is
reinforced through su&seEuent contacts to train
parents and teachers-
- "reatment at the neurological le*el &y using different
sensory modulation concepts and techniEues selected
from the Alert 'rogramme (6illiams and 5hellen&erger
*++, *++,) and the 4.81 (.etter et al *++#), and also
the sensory diet programme (6il&arger *++#)-
"- Adaptation of home 3classroom en*ironment and routine
&y considering the sensory characteristics of the
environment (Cac/ley !!*), using the predictive visual
timeta&le, and integrating different sensory modulation
techniEues into the home and classroom routine-
*ritish -ournal of %ccupational herapy 5eptem&er !!= =!(+) +,6
Fig) 4) Clinical pathway of the assessment and treatment pac/age) &onclusion
4'.C (King et al *++#, *++?)D ADHD 8ating 5cale (Du'aul et al *++?)-
,- "reatment at the beha*ioural le*el &y integrating
appropriate educational management strategies
(Dowdy et al *++?), &ehavioural management
strategies (2ar/ley *++#, *++?) and sensory
modulation techniEues to regulate the child@s
&ehaviour, in order to promote his or her
engagement in different tas/s at home and school-
#- 2nhancement of tas/ performance &y remediating
any developmental and functional difficulties
identified through child%appropriate treatment
strategies or approaches, such as perceptual%
motor s/ills, handwriting s/ills and self%care s/ills-
6ithin the UK, occupational
therapy for children with
ADHD is a small field of practice
even though considera&le
num&ers of children are affected-
In part * of this two%part article,
the authors have com&ined
theoretical information &ased on
data gathered from previous
research studies, a literature
review and clinical e3perience,
and organised it into an
occupational therapy
delineation model of practice
for children with ADHD-
0he model emphasises the
interaction &etween the child, the
tas/ to &e carried out &y the
child, and the environment in
which the child carries out
the tas/- In order to achieve
successful participation in
different occupations, a
goodness%of%fit amongst all
three factors needs to &e
achieved- 0he model also
highlights a new understanding
of ADHD as comple3,
multifaceted clusters of
impairments in the neurological,
psychological and &ehavioural
domains- Jiven the multiple
dysfunctions involved, a
multidimensional evaluation
and multifaceted intervention is
proposed- A selective family%
centred assessment and
treatment pac/age &ased on the
model, yet feasi&le within limited
resources, is descri&ed-
0his model of practice remains
to &e validated- Any assessment
and treatment pac/age developed
needs to &e field%tested in
clinical practice and evaluated- 'art of this article will
report the results of a multicentre research study, which
evaluated the effectiveness of a family%centred assessment
and treatment pac/age &ased on the model outlined a&ove
as well as assessing its accepta&ility to parents-
0he first author would li/e to than/ the College of .ccupational
0herapists in awarding the 2yers 4emorial >und and also the
Hospital 5aving Association in awarding the 'hD 5cholarship
Award !!* for his doctoral study at the 5chool of Health
5ciences and 5ocial Care, 2runel University-
+57 *ritish -ournal of %ccupational herapy 5eptem&er !!= =!(+)
American Academy of Child and Adolescent 'sychiatry (*++=a) 5ummary of
the practice parameters for the assessment and treatment of children,
adolescents and adults with ADHD- ournal of the American Academy of
Child and Adolescent 5sychiatry# -6&'(# *"**%*=-
American Academy of Child and Adolescent 'sychiatry (*++=&) 'ractice
parameters for the assessment and treatment of children,
adolescents and adults with ADHD- ournal of the American Academy
of Child and Adolescent 5sychiatry# -6&1%(# 5upplement, ?#5%**5-
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and evaluation of the child with attention%deficitBhyperactivity disorder
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American Academy of 'ediatrics (!!*) Clinical 'ractice
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American ournal of !ccupational "herapy# -2# "**%*;-
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Cerma/ 5 (*+??&) 0he relationship &etween attention deficit
and sensory integration disorders I 'art II- A!"A Sensory
1ntegration Special 1nterest Section =ewsletter# 11&-(# "%,-
CHADD (!!!) "he C,A++ information and resource guide to A+3,+)
7andover, 4D9 Children and Adolescents with
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Chu 5 (!!"&) Attention deficit hyperactivity disorder (ADHD), part one9
a review of literature- 1nternational ournal of "herapy and
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Chu 5 (!!"c) Attention deficit hyperactivity disorder (ADHD),
part two9 evaluation and intervention- 1nternational ournal
of "herapy and Rehabilitation# 1%&6(# #,%;-
Chu 5 (!!#) +e*eloping a model of occupational therapy practice
for children with attention deficit hyperacti*ity disorder &A+,+()
Unpu&lished 'hD thesis- U3&ridge, 4idd39 5chool of
Health 5ciences and 5ocial Care, 2runel University-
Co/er KH, 0hyer 2A (*++!) 5chool and family &ased treatment of children
with attention deficit hyperactivity disorder- Families in Society# $1# =;%?-
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third edition &;:5"0-() Covato, CA9 Academic 0herapy 'u&lications-
Conners CK (!!*) "he Conners Continuous 5erformance
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on enrolment and adherence to a *%month treatment trial-
Canadian ournal of 5sychiatry# 44# *!,"%,?-
Coster 6, Deeney 0, Haltiwanger <, Haley 5 (*++?) School Function
Assessment &SFA() 5an Antonio, 0N9 'sychological Corporation-
Cummings <C (*++") >rontal%su&cortical circuits and human &ehaviour-
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Dunn 6 (!!!) Best practice occupational therapy: in community
ser*ice with children and families) 0horofare, C<9 5lac/-
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in children with attention deficit hyperactivity disorder-
!ccupational "herapy ournal of Research# 22&1(# ,%*#-
Du'aul J<, 'ower 0<, Anastopoulos AD, 8eid 8 (*++?)
A+,+ Rating Scale 9 1:) Cew Mor/9 Juilford 'ress-
Du'aul J<, 5toner J (!!") A+,+ in the schools: assessment and
inter*ention strategies) nd ed- Cew Mor/, CM9 Juilford 'ress-
>eaver 5, Cree/ < (*++") 4odels for practice in
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British ournal of !ccupational "herapy# 76&2(# #+%;-
>iore 0A, 2ec/er 1A, Cero 8C (*++") Research
synthesis on education inter*entions for students with
A++) Corth Carolina9 8esearch 0riangle Institute-
>isher AJ, 2ryHe K (*++?) School A;5S: School :ersion of the Assessment of ;otor
and 5rocess S/ills) nd research ed- >ort Collins, C.9 0hree 5tar 'ress-
>ric/ 5, Hac/er C (!!!) >istening with the whole body) Hugo, 4C9 'D' 'ress-
*ritish -ournal of %ccupational herapy 5eptem&er !!= =!(+) +5"
Jioia JA, IsEuith 'K, Juy 5C, Kenworthy 7 (!!!)
Beha*iour Rating 1n*entory of 2<ecuti*e Function &BR12F()
.dessa, >79 'sychological Assessment 8esources-
Juevremont DC (*++") 5ocial s/ills training9 a via&le treatment for ADHD-
A+,+ Report# 1&1(# ;%=-
Harrison C, 5ofronoff K (!!) ADHD and parental psychological
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Henderson 51, 5ugden DA (!!=) ;o*ement Assessment Battery
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Hill ', Cameron 4 (*+++) 8ecognising hyperactivity9 a guide for the
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HinoGosa <, 5proat C0, 4an/hetwit 5, Anderson < (!!) 5hifts in
parent%therapist partnerships9 twelve years of change-
American ournal of !ccupational "herapy# 76&7(# ##;%;"-
Hinshaw 5', 4elnic/ 5 (*++) 5elf%management therapies and
attention deficit hyperactivity disorder9 reinforced self%evaluation
and anger control interventions- Beha*iour ;odification# 16# #"%="-
HoHa 2, .wens <5, 'elham 61, 5wanson <4, Conners CK, Hinshaw
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of child treatment response in attention deficit hyperactivity disorder-
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Humphry 8 (!!) Moung children@s occupations9 e3plicating
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Humphry 8, Case%5mith < (!!*) 6or/ing with families- In9 < Case%5mith, ed-
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<ones C2<, 5earight H8, Ur&an 4A (*+++) 5arent articles about
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King 5, 8osen&aum ', King J (*++?) "he ;easure of 5rocesses of Care
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Australian !ccupational "herapy ournal# 41&-(# **#%-
Krauss K1 (*+?=) 0he effects of deep pressure touch on an3iety-
American ournal of !ccupational "herapy# 41&6(# ";;%="-
7ane 5<, 4iller 7<, Hanft 21 (!!!) 0oward a consensus in
terminology in sensory integration theory and practice- II9
5ensory integration patterns of function and dysfunction-
Sensory 1ntegration Special 1nterest Section ?uarterly# 2-# *%"-
7aw 4, Cooper 2, 5trong 5, 5teward D, 8ig&y 8, 7etts 7 (*++;) 0he person%
environment%occupation model9 a transactive approach to occupational
performance- Canadian ournal of !ccupational "herapy# 6-&1(# +%"-
7ou HC (*++;) 1tiology and pathogenesis of ADHD9 significance of
prematurity and perinatal hypo3ic%haemodynamic encephalopathy-
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4angeot 5D, 4iller 7<, 4cIntosh DC, 4cJrath%Clar/e <, Hagerman
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with attention%deficitBhyperactivity disorder- +e*elopmental ;edicine
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4c1wen 4 (*++!) 0he human%environment interface in occupational
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Cational Institutes of Health (!!!) Consensus 5tatement9 Diagnosis
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of the American Academy of Child and Adolescent 5sychiatry# -'&2(#
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Sensory 1ntegration Special 1nterest Section =ewsletter# '# ;%=-
.etter ' (*+?;&) A sensory integrative approach to the
treatment of attention deficit disorder- A!"A Sensory
1ntegration Special 1nterest Section =ewsletter# '# *%-
.etter ', 8ichter 1, >ric/ 5 (*++#) ;!R2: 1ntegrating the mouth with
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'eterson CK (*++") ADHD9 evaluation and treatment- A!"A +e*elopmental
+isabilities Special 1nterest Section =ewsletter# 16&1(# %,-
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in &oys with ADHD- +e*elopmental ;edicine and Child =eurology# 41#
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and young children- In9 55 8oley, 1I 2lanche, 8C 5chaaf, eds-
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54, Dee CC, 4organ <C, 4cCormic/ 41, 6al/er D (*++;)
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in cognitive, neuro&iological, and genetic research- ournal of
Child 5sychology and 5sychiatry# -'&1(# ;#%++-
+5$ *ritish -ournal of %ccupational herapy 5eptem&er !!= =!(+)
0aylor 1, Dopfner 4, 5ergeant <, Asherson ', 2anaschews/i 0,
2uitelaar <, Coghill D, Danc/aerts 4, 8othen&erger A, 5onuga%
2ar/e 1, 5teinhausen H%C, Luddas A (!!,) 1uropean clinical
guidelines for hyper/inetic disorder I frist upgrade- 2uropean
ournal of Child and Adolescent 5sychiatry# &Suppl) 1(# 1-# *B=%*B"!-
0aylor 1, 5ergeant <, Doepfner 4, Junning 2, .vermeyer 5, 4o&ius H<,
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2uropean ournal of Child and Adolescent 5sychiatry# $# *?,%!!-
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6il&arger ' (*++#) 0he sensory diet9 activity programs
&ased on sensory processing theory- A!"A Sensory
1ntegration Special 1nterest Section =ewsletter# 18&2(# *%,-
6illiams 45, 5hellen&erger 5 (*++) An introduction to
B,ow does your engine runC.: the Alert 5rogram for Self0
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6illiams 45, 5hellen&erger 5 (*++,) ,ow does your engine runC
A leader.s guide to the Alert 5rogram for Self0Regulation)
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6odrich D7 (*++,) A+,+ 9 what e*ery parent wants to /now)
2altimore9 'aul H 2roo/es 'u&lishing-
6oodrum 5C (*++") A treatment approach for ADHD using
the 4odel of Human .ccupation- A!"A +e*elopmental
+isabilities Special 1nterest Section =ewsletter# 16&1(# *%-
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