ADHD is not “Sensory”… it is ADHD

School based occupational therapists (SBOT) have an incredible knowledge base surrounding sensory processing dysfunction* (SPD) and its impact on classroom performance. Problems with sensory processing, regulation and modulation are highly coexistent with ADHD, an estimated 40% in the typical population and 60% in clinical samples of the children with one disorder also have symptoms of the other (Ahn et al, 2004).

Approaching ADHD in schools with the “sensory integration” lens is highly problematic , has lead to some bad press and is limiting to the full scope of interventions SBOT’s can provide in the school setting.

While I am not disputing the significant impact difficulties with sensory processing will have on the school based function of a child with ADHD , sensory integrative therapy is not considered effective practice model for ADHD. Lucy Jane Miller, Ph.D., director of the Sensory Processing Treatment and Research (STAR) Center at the Children’s Hospital in Denver explains, “When ADHD and SPD do coexist, it’s important to distinguish one from the other because their treatments are different”.

ADHD is a chronic neurodevelopmental condition. Conclusive medical evidence has clearly defined that ADHD impacts the function of the prefrontal cortex of the brain. ADHD is associated with abnormally low levels of the neurotransmitters impacting the top-down regulation of information processing between the prefrontal cortex and distant broadly dispersed brain regions including the basal ganglia and the brainstem neuromodulatory systems.

The difficulty many children with ADHD have with processing and modulating sensory stimuli is due to this “top down” difference in the neurological connections of the brain. While most of the connections are reciprocal in nature, pure “bottom up” sensory integrative interventions have not been supported by evidence to improve the child’s function in school.

The use of evidenced based “top down” strategies are required to treat ADHD and include medication to balance out the neurotransmitters and behavioral management to address developmental delay in executive functioning skills.

Sensory integration therapy relies heavily on a “bottom-up” approach to facilitate improved neurological responses through active participation in specifically structured , systematically graded sensory environment that then generalizes over time to improved processing and modulation.

Our role, purpose and overarching goal as school based occupational therapists is to support the access to, participation in and progress within the educational curriculum for children with ADHD. It is important for all school based OT’s to clearly delineate between ADHD and/or SPD when providing interventions to facilitate classroom performance.

A 2019 article published by FIU ( see the article here) claims to describe the ” first study to evaluate the effect of occupational therapy (OT) techniques, on classroom behavior and academic productivity in elementary-aged children with Attention Deficit Hyperactivity Disorder (ADHD)”.

How exciting?

NOPE . The study “The Effect of Weighted Vests and Stability Balls With and Without Psychostimulant Medication on Classroom Outcomes for Children With ADHD.” claims to reveal that “low doses of medication in addition to behavioral classroom management techniques, such as rewards for positive behavior, led to improvements in classroom behavior and academic productivity for children with ADHD while the OT interventions did not. ” Macphee, F. L., et al. (2019).

OUCH Fortunately, the study was extremely limited in they only looked at the use of two non-evidenced based sensory “OT techniques”, specifically stability balls and weighted vests and then compared it to stimulant medications/behavioral interventions. It is absolutely mind-blowing that the authors equated two non-evidenced based interventions that anyone can pick up on Amazon as “the effect of occupational therapy on classroom behavior and academic productivity”.

Fiona Macphee, the lead author of the study was quoted saying “Schools should allocate funds toward implementing behavioral approaches rather than giving children devices such as weighted vests or stability balls,”. Well, Fiona I totally agree with that. As does the leading researchers in ADHD, the American Academy of Pediatrics and the AOTA. The problem, Fiona, is that handing out stability balls and weighted vests is not in any way encompassing of school based occupational therapy.

Regardless of the limitations of this now highly debated “study”, it clearly illustrates the level of damage that already exists to our professional credibility surrounding this “sensory OT” stigma and represents one of the bricks in the wall that block us from effectively helping children with ADHD in the school setting.

School based OT’s are not “sensory therapists” as much as we are not “handwriting teachers”. When we use these “sensory OT techniques” without a clear and complete intervention plan that encompasses the full scope of physical, behavioral and emotional performance challenges with evidenced based interventions we are supporting this stigma.

School based occupational therapy is not the ” either or” to classroom behavioral management . School based occupational therapists have the training, knowledge and scope to provide the classroom behavioral management techniques described as effective in this study and by the AAP. We have extensive knowledge and training in environmental/ task modification and cognitive processes to scaffold executive functions and develop caregiver/ teacher capacity with education and parent training.

School based occupational therapists are uniquely equipped to help delinate between the complex overlaying symptoms of ADHD and sensory processing dysfunction and design an individualized plan of care that aligns with current best practice for ADHD with individualized sensory informed supports to the educational environments.

Although ADHD and SPD can look similar in the way they impact functional performance they have different causes, impacts different areas of the brain by different mechanisms, and require different evidence-based treatments. 

In fact, school based OT’s are the only profession in the school building that has within our scope the different tools needed to support both the student with ADHD and the estimated 40-60% of kids with ADHD with coexisting sensory processing dysfunction.

Evidenced Based Occupational Therapy Interventions and Best Practice Cheat Sheet for School Based Support of ADHD

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*Sensory Processing Dysfunction(SPD) is used in this article rather than Sensory Processing Disorder because it is currently not a medically accepted diagnosis. In 2012, the American Academy of Pediatrics released a statement titled ‘Sensory Integration Therapies for Children With Developmental and Behavioral Disorders” cautioning pediatricians to not use “Sensory Processing Disorder” as a diagnosis and cautioning parents upon the effectiveness of the therapy, stating it needs more evidence. AOTA’s response was in polite agreement (click here to see full AOTA response) with the AAP statement. The Interdisciplinary Council on Developmental and Learning Disorders Task Force included sensory processing disorder in its Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, but it has not yet been recognized as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) or International Classification of Diseases, Tenth Edition (ICD-10) medical manuals. “

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