Context is Everything- Effective Support for Students with ADHD

Context is Everything!

We have all had these students, they are awesome one to one.

Funny, bright, engaging kids. Absolute pleasure to have in your therapy room. Then you talk to the teacher , or the parent , and you are hit with a long list of problem behaviors that leave you wondering, maybe even with a hint of judgement……

“What is going in that class or in that home?”

Unlike most conditions seen in school based practice , the severity of ADHD symptoms is incredibly context dependent. Generalization of skills across settings is often impaired due to time blindness and working memory deficits.

This post explains why most children and teens with ADHD show significant fluctuations in behavior across different settings in the school environment.

Contextual Dependence of ADHD

Occupational therapists define context as both the environmental and personal factors specific to each student that influence engagement and participation in occupations.

Environmental factors are aspects of the physical, social, and attitudinal surroundings in the school or home setting.

Personal factors are the particular background of a person’s life and living and consist of the unique features of the person that are not part of a health condition or health state ( age, stage , gender and cultural characteristics).

As you can imagine, the context contains an infinite number of possible barriers or bridges to functioning.

Children and teens with ADHD show significant fluctuations in the severity of their symptoms across diverse environments, situations, settings and activities because of the goodness of fit between the student and the context.

Read that again.

In general, symptoms of ADHD may often be worse in school contexts that:

• Are boring or uninteresting (too easy or too hard)
• Place substantial restrictions on movement
• Require waiting or involve significantly delayed consequences
• Require working independently of others (while amongst others)
• Lack supervision and clear structure
• Involve larger groups of children
• Have lengthy verbal instruction before starting

The Point of Performance

When we work with children or teens with ADHD, we MUST intervene at the point of performance.

It is there (and only there) that assessment and intervention must occur if it is to address the problem in that situation.

Point of performance interventions improve the goodness of fit between the student and the context and will improve occupational performance of students with ADHD in the educational environment.

Evidenced Based Point of Performance OT Interventions

Teacher and Parent Collaboration

Providing both teachers and parents up to date information on ADHD and the impact on school based occupational performance for the specific student (personal factors and environmental factors considered) .

Environmental Modifications

Adjusting environmental barriers (universally) including lighting, sounds, limiting distractions, use of adaptive seating , standing desks, calm down areas and organizational supports etc.

Executive Function Supports

Scaffolding support strategies within the natural environment for students to use to compensate for poor executive function skills . (signs, lists, agendas, reminders).

Task Modification

Modifying the steps or cues of a task to promote independence while keeping with the learning objectives ( differentiation, chunking strategies, paper choices, blocking supports, ect.).

Key Takeaway

The most important support for students with ADHD is to determine and intervene at the level of contextual factors that are barriers to performance.

When school based OT’s collaborate with the caregivers (teachers and parents) and intervene at the point of performance we systematically cultivate the skills and resources required for ongoing classroom management and self management of ADHD in the school environment.

Download The Occupational Therapy Contextual Supports Checklist below to help.

The Occupational Therapy Contextual Supports Checklist is aligned with the fourth edition of the Occupational Therapy Practice Framework: Domain and Process. The OTPF–4, is an official document of the American Occupational Therapy Association (AOTA). The OTPF–4 presents a summary of interrelated constructs that describe occupational therapy practice.to help structure and document the collaborative process.