Int J Physiother.

Vol 2(4), 652-657, August (2015) ISSN: 2348 - 8336

1
Rahul Shaik
2
Kamala Kumari.P
3
Syed Ahmed Basha

ABSTRACT
Background: The principle features of Attention deficit hyperactivity disorder (ADHD) are
hyperactivity, inattention and impulsivity. There is little evidence that confirms that Attention deficit
hyperactivity disorder (ADHD) is arising purely from child rearing methods or social factors.76 % of
children with ADHD has a family history, and the similar cases can be seen in the family. The
symptoms of more than 50 % of ADHD children will continue in adulthood which requires treatment.
Most of the causes appear for ADHD are categorizing the condition in a group of neurobiological and
genetic disorders. This does not mean to say that the influence of environmental factors on the severity
of disorder, impairment and suffering the child may experience is nil, but those factors do not give rise
to the condition by themselves. The chances of getting associated problems like Oppositional Defiant
Disorder (ODD) in children with ADHD is one-third to one-half and ODD is more common in boys with
ADHD. These children are often non compliant, stubborn, defiant, have outbursts of temper, or become
belligerent.
Case description: This is a case report of a child who diagnosed as attention deficit hyper active
disordered and Oppositional Defiant Disordered (ODD) child, with finger contractures of right hand,
which treated with medications, behavioral therapy, physiotherapy, relaxation techniques and music
therapy as the means of rehabilitation.
Outcome measures: The evaluation measures used are Nine-hole peg test, behavioral rating scale and
a seven items temperament evaluation scale.
Discussion: A holistic rehabilitation therapy increased attention, listening to suggestions, short stories
and sleeping in time. Oppositional behaviors were also reduced both at home and school. Her
relationships with parent, teachers and school mates were improved. Listening skills, attention, daily
activities such as wake up, brushing, bathing, going to school in time were also improved. The single
case study design limits generalization but this work supports THE role of multi disciplinary approach
in testing ADHD children.
Key words: Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disordered
(ODD), rehabilitation, Behavioral therapy, Physiotherapy, Music therapy, Yoga and Relaxation
techniques.

Received 18th May 2015, revised 27th June 2015, accepted 15th July 2015

DOI: 10.15621/ijphy/2015/v2i4/67746

www.ijphy.org
CORRESPONDING AUTHOR
1
2
SIMS college of physiotherapy, Guntur, Rahul Shaik
India.
3
Psychiyatrist, Green Hospital, Centre for Assistant professor,
Neuropsychiatric and Diabetic Care SIMS college of physiotherapy,
Gunturuvari Thota, Kothapet, Guntur. Guntur, India.

Int J Physiother 2015; 2(4) Page | 652

INTRODUCTION at least one will have ADHD. So, several
Each case of attention deficit hyperactive disorder researchers focused on ADHD and thousands of
(ADHD) can be unique1, with behaviors varying scientific papers have been published on ADHD
from child to child. Even though several similar and they had provided information on its nature,
subtypes are noticed, understanding of typical course, causes, impairments and treatments but it
developmental neuropsychiatric disorders in is still challenging problem to them. There is no
ADHD is based on two principals. First one is complete remedy for ADHD. A child with ADHD
children with high precision and the second one is faces a difficult but not insurmountable task ahead.
with nested behavior2. For these reasons, it is In order to achieve his or her full potential and he
critical for early childhood educators and therapy or she should receive highly sophisticated
providers to diagnose and treat them. Stimulant interdisciplinary approach to treatment, including
medication and non-stimulant medication are drug therapy, behavior modification, cognitive-
there to treat Attention deficit hyperactivity developmental techniques, classroom
disorder (ADHD) and most children treated with intervention, and more 9.
Attention deficit hyperactivity disorder (ADHD) ADHD children should receive help from
medication have some side effects. Some of the psychological counselors, therapists and the public
side effects will disappear but some of them will be education system, need guidance and
dangerous. Even though some studies proved the understanding from parents. This case study offers
superiority of stimulant medications over information on ADHD and its management,
behavioral therapy and routine community care, including information on medications and
the evidences are not sufficient to ignore the behavioral interventions, as well as helpful
influence of such therapies. resources on educational options. Because ADHD
The cost of illness in case of attention deficit often continues into adulthood and this case study
hyperactive disorder is also high when compared contains a section on the diagnosis and treatment
to other diseases3 due to multiple domain of ADHD to a child aged about 5 years. She was
involvement. For example, the educational domain diagnosed as ADHD along with ODD.
is affected due to learning disabilities, juvenile Case Report:
justice domain is affected with conduct problems, A 5 years girl child was seen in physiotherapy
health care and family domains will be affected due outpatient department due to her residual finger
to asthma and other health conditions4, 5. Three deformity which was not corrected completely
folds of children with ADHD also showed an after surgery. During physiotherapy sessions the
incidence of Convergence Insufficiency which is child was noticed hyper active behaviors,
main limiting factor for concentrated reading and oppositional to parents and therapists, pinching
learning at school age6. The focus of researchers parents and therapist no contextually and
shifted from activity component problems, provocatively. According to her mother baby was
attention problems to poor impulse control or lack born with contractures of right index, middle and
of inhibition which in turn leading to cognitive and little fingers at metacarpo phalengial and proximal
social difficulties. Children with attention deficit inter phalengial joints. All milestones were
hyperactive disorder (ADHD) and oppositional attained at appropriate age. Between two and half
defiant disorder (ODD) have hyper activity, years to three years of age her Mother noted
stubborn nature; uncontrolled tempers and they hyperactivity and oppositional behavior in baby. At
argue with adults and refuse to obey. the age of three and half years the child joined the
With these difficulties the children with ADHD will Lowe Kinder Garden. At that time teachers were
face serious problems of inter personal relationship reported the baby is impulsive and hyperactive and
and this will also affects their families, friends, and she is not paying attention and she may have
spoils the performance at school. This multisystem isolation behavior. She is not attentively sit in a
failure highlights the need for interdisciplinary place and always moving in class room. Gradually
approach in the research and management of she was accustomed to school environment. At the
ADHD 7, 8. Attention Deficit Hyperactivity Disorder age of four years she went for surgical releases of
(ADHD) is sometimes apparent in preschool finger contractures. Parents and grandparents
children and children in early school years. These stated that they have neglected the child’s behavior
children fail to control their behavior and/or pay and they were thinking that this may be due to
attention. It is estimated that between 3 to 5 petting. So that she became more stubborn. From
percent of children have attention deficit physiotherapy the baby was referred to psychiatry
hyperactivity disorder (ADHD). This means that consultation. In a national institute she was
in a classroom of 25 to 30 children, it is likely that diagnosed as a case of Attention Deficit
Int J Physiother 2015; 2(4) Page | 653
Hyperactivity Disorder (ADHD) with Oppositional course of treatment. Initially parents are instructed
defiant disorder (ODD). The baby is also having to record at a timely interval of one week for three
hyperactivity Presents with symptoms like months then twice in a month and then every
distractibility, stubbornness, and temper outburst month. The changes in initial recordings and
in the context of demands not being met, since the recordings at the end of 10th month after treatment
age of two years. The interviewers also diagnosed were analyzed.
Behavioral inhibition in baby’s father. After one Examination:
month the parents visited physiotherapy Finger dexterity was assessed by using Nine-hole
department once again with a prescription for peg test12. Before the treatment sessions stared the
three month treatment with Methylphenidate with time taken to complete the task was 107 seconds.
a dose of 5 mg for 3 months. In national institute After 10 months of treatment the time taken to
the child was given behavioral therapy for one complete Nine-hole peg tests was recorded as 24
month along with medications. seconds.
Multi disciplinary treatment: Behavioral assessment was done by using a
After careful examination and evaluation a variety behavioral rating scale13, to have an accurate view
of problems were noticed in this child. She is of the child’s problem. The child has problem in
having a severity of 96 on behavioral rating scale activities like playing alone, during meals time, in
out of 140 and 53 score on a 70 point personality public places with huge gatherings like shopping
evaluation scale. Finger dexterity was measured malls and churches, in doing toileting activities,
with Nine-hole peg test. The time taken to and during bedtime. The child had a mild problem
complete the task at initial assessment was 107 in all the aspects before the treatment. But the
seconds. During the test child was noticed child showed a significant improvement in all the
attention deficits. With this the plan of action was aspects after treatment of ten months. The child
shifted to a multidisciplinary approach which specially improved in socializing, her personal
aimed to behavioral, emotional, physical and social body care activities and feeding activities.
problems. A treatment plan was designed with the
help of school teachers, yoga teacher, psychiatrist The temperament or personality evaluation was
and physiotherapist. The child was given done by using a seven item scale where each item
physiotherapy for finger contractures by means of has a maximum of 10 points. The scale consists of
wax and mobilizations, peg board activities, the questions like, does the child scream or yell
stretching for long flexor of forearm and fingers, instead of speaking softly, does the child grab
daily training of writing, and finger dexterity. And things from others probably by beating them etc. a
these exercises were withdrawn after 20 days due total score of 25 or more indicates that the child is
to fever and sever illness of the child. The illness is a problematic and the scores below 25 denote that
due side effects of medication and parents stopped the child has normal coping strategies. Before the
medications after one month with a telephonic treatment, the child had a score of 53 and after the
confirmation from the psychiatrist in national treatment the score is 30 with a noticeable change
institution. Physiotherapy sessions were restarted in the emotional behavior, willingness to share her
after resolving of side effects. Physiotherapy was belongings with peers, improvements in
given for 4 days in a week for 10 months. concentration/ attention span. Hence behavioral
Yoga10, deep breathing exercises and music therapy, though very time consuming and
therapy11 sessions were given 3 days in a week for frustrating proved to be a better help than other
10 months. In these classes she uses to practice therapies with no side effects.
pranayama and meditation. Relaxation exercises Now she is able to play for 30-minute continually
were also clubbed with these techniques. Teachers without any attention deviation. According to
in the school were requested to monitor her patient parents this therapy increased attention,
behavior closely and record any observable listening to suggestions, short stories as well as
changes are noticed. Mother was trained daily activities such as wake up, brushing, bathing,
behavioral therapy at psychiatric institute and going to school in time, and sleeping in time with
continued make the child to practice the behavioral calmness, also decreased oppositional behavior
therapy at home. Grandparents were asked not to both at home and at school.
pamper the child during therapy sessions. The
DISCUSSION
reports of timely reviews conducted by parents
were showing improvements in attention span and Researchers are not able to confirm the causes of
personality of the child. We asked the parents to ADHD, like many other illnesses the genes play a
record the behavioral changes observed during the large role. In addition to genetics, ADHD may

Int J Physiother 2015; 2(4) Page | 654

results from a combination of factors and listening short stories and spiritual themes
researchers are looking at possible environmental including instructions, she is enjoying in the events
factors, and are studying how brain injuries, of social occasions and shopping etc.
nutrition, and the social environment might Parents are child’s best advocate, to be a good
contribute to ADHD. Therefore, evaluation of advocate for child, they should learn as much as
children suspected of having ADHD needs to be a they can, about ADHD and how it affects the child
multistep and multidisciplinary process. Any at home, in school, in social situations. If a child
diagnosis should be based on a complete medical has shown symptoms of ADHD from an early age
examination and history, information gathered by and has been evaluated, diagnosed, and treated
interviews with a number of persons who know the with either medication or behavior modification or
child and observations made in different a combination of both, when a child enters the
naturalistic settings at different times and scores school system, let his or her teachers know. In a
on parent and teacher rating scales. A clinical new world away from home teachers will be better
criterion for the diagnosis of adult ADHD (the Utah prepared to help the child. If, after a child enters
Criteria) which combined both past history of school and is experiencing difficulties that lead
ADHD and current evidence of ADHD behaviors14. parents to suspect that he or she has ADHD, parent
Atomoxetine (Strattera) was tested in controlled can either seek the services of an outside
studies in both children and adults which found to professional or parent can ask the local school
be effective15. Preschool age children are administration to conduct an evaluation. Some
infrequently diagnosed with ADHD. The parents prefer to go to a professional of their own
medication alone cannot cure the children with choice. But it is the school’s obligation to evaluate
ADHD16. a child that the suspect has ADHD or some other
In this case parents noticed adverse effects like disability that is affecting not only their academic
pyrexia and lethargy at 4th week of medication. work but their interactions with classmates and
Parents discontinued medicines after telephone teachers.22, 23
consultation with psychiatrist. Medication therapy So the scope of education system should also
for children with ADHD involves the intake of a change. Teachers should be given training in
substance which alters brain chemistry and hereby identifying special children and coping strategies
changes the outward behavior of the affected child. with these children. Once the child has been
Usually the most commonly administered diagnosed with ADHD and qualifies for special
medications are stimulants. Stimulant medications education services, the school must assess the
come in different forms, such as a pill, capsule, child’s strengths and weaknesses and design an
liquid, or skin patch. Some medications also come Individualized Educational Program24 (IEP).Parent
in short-acting, long-acting, or extended release should be able periodically to review and approve
varieties in which the active ingredient is the same, their child’s Individualized Educational Program
but it is released differently in the body. Several (IEP). In this case scenario the school teacher has
studies were estimated that between 30% and 70% given proper training of behavioral modulation
of children with ADHD will continue to exhibit therapy and evaluation techniques. According to
symptoms in the adult years17. Family members of school faculty after rehabilitation the child
children being treated with ADHD medication improved in her school performance and she
should read the medication guides and talk to their became more alert in classes and concentration is
child’s doctor if they have any questions or also improved.
concerns18.
This case report is having some limitations like
Behavioral parent training studies includes parent
irregular therapy sessions; discontinuation of
Training, child-focused Treatment, school-based
medications, the behavioral therapy was not given
interventions19, 20, 21. Living with ADHD child is
by experts. Long duration of the study is also a
challenging because there is no cure for ADHD, but
limitation of this study where the influences of
to achieve good results in this child mother was
external factors of development are not
asked to manage the symptoms of ADHD with
concentrated. Even though the medications
appropriate moral support, educational support
stopped, the child recovered in a long term this can
and advice, walking with child, telling short stories
give strength to multidisciplinary therapy
and spiritual themes and conducting yoga classes
approach of treating children with ADHD.
daily in the morning. In this case study mother
However there is less evidence to confirm the
observed the following improvements like the
results shown in this case report, one should not
child herself is going to sleep in time at night, going
ignore the role medication in treating ADHD.
to school in time regularly, she is attentively
There exist a lot of studies which confirms the
Int J Physiother 2015; 2(4) Page | 655
importance of medications25, 26. In this case the 7. Barkley, R. A., Anastopoulos, A. D.,
discontinuation of medications due to side effects Guevremont, D. C., & Fletcher, KE. (1991).
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Citation
Rahul Shaik, Kamala Kumari.P, & Syed Ahmed Basha. (2015). MULTI DISCIPLINARY APPROACH IN
TREATING A GIRL CHILD DIAGNOSED WITH ATTENTION DEFICIT HYPER ACTIVE DISORDER
AND OPPOSITIONAL DEFIANT DISORDER. A CASE REPORT. International Journal of Physiotherapy,
2(4), 652-657.

Appendix – 1

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