School-Based OT Scope of Practice for Students with ADHD Evidenced Based Interventions

Limiting your Scope? 

How often have you heard a teacher say, “The student is having difficulty with his OT skills”? Way too many. 

School-based occupational therapists frequently operate in a scope limited by misconceptions in the school building about what we do. Most teachers and administrators think our professional domain is limited to: 

• handwriting
• fine motor skills
• sensory 

Honestly, I can’t blame them; I spend much of my day supporting students with their handwriting, fine motor, and sensory processing skills. But, for years, I ran from building to building, session to session, never having the time or availability to fully educate my colleagues on the broad scope of my professional domain.

The purpose and overarching goal of school-based occupational therapy is to support the student’s occupational performance within the school setting to enable them to access, participate and progress in their education. Nowhere does our practice limit this to handwriting, motor skills, or sensory processing. 

The Role of Occupational Therapy for ADHD in the School Setting

Q: “I am sometimes confused as to what is considered to be an OT’s role when treating students with ADHD, as it pertains to the school setting.” 

Our role when treating students with ADHD in the school setting is the same as it is for all students. School-based occupational therapists “support the students’ occupational performance within the school setting to enable them to access, participate and progress in the education .”The “WHY” the child is having functional performance difficulties does not determine “IF” the student needs OT support. Instead, it specifies “HOW” the OT needs to support them. 

Occupational therapists are qualified to provide a multitude of interventions to support the occupational performance of children with ADHD. Our background knowledge, training, and expertise perfectly match the actual needs of the ADHD student far more than any other profession in the school setting. 

School-based OTs are uniquely suited to address the functional limitations and participation restrictions associated with ADHD. We have the skills and positioning within the system to provide targeted interventions before secondary and life-long effects develop (Chandler, 2007; Schultz, 2003). 

Many school-based occupational therapists still operate in a scope limited by misconceptions in the school building. Many OTs report inadequate training on ADHD and executive dysfunction to intervene with confidence and fidelity. 

When it comes to ADHD, there is no single cookie-cutter approach to intervention. School-based practitioners must remain relevant and updated on ADHD’s dynamic impact on occupational performance, comorbid conditions, and medication side effects. ADHD is a highly prevalent multifaceted neurodevelopmental disorder of contextually based performance. In essence, ADHD is a disorder of occupational performance. 

A wealth of information is available, but not a single resource will give you actionable strategies that will definitely work for your student. Instead, most highly acclaimed resources list a virtual buffet of possible accommodations and strategies. 

In this post, I will be unpacking our role with links to the most current evidence-based interventions available to inform your decision making for best practice.

The Second Edition of Best Practices for Occupational Therapy in Schools describes occupational therapy’s role and reviews current evidenced informed best practices that school occupational therapy practitioners can implement to support school performance and participation among students with ADHD. In addition, Clark et al. recommend that school-based OTs facilitate performance and participation by educating the family and teacher in classroom interventions to enhance participation in occupations.

Furthermore, they suggest school-based OTs 

• Use a person-occupation or activity-environment model to observe interactions between components. 
• Educate and Collaborate with family as a Team Member
• Provide Professional Development to determine strategies to enhance general education performance 
• Provide Tier 1 interventions to facilitate performance and participation 
• Provide education about sensory modulation techniques
• Provide adaptation of the home and environment and routines
• Provide integrated educational management strategies
• Provide behavioral management strategies
• Provide remediation of any developmental or functional challenges that interfere 

Where’s the framework? Where are the actionable strategies? I find that most if not all information available continues to be choice heavy and overwhelming, lacking any proper framework. Decision fatigue is real. 

The Do’s and Don’ts to Effective Interventions for ADHD

After 20 years and the past three specializing in ADHD, I have found the following solutions to be ineffective in the reality of the elementary school building. 

• Host Professional Development Presentations on ADHD  While it is imperative that every general education teacher fully understands the nature of ADHD and its impact on instruction, teachers do not want more irrelevant PD. While ADHD is undoubtedly a relevant topic, the complexity of the ADHD presentation within the context decreases the useability of general knowledge.  
• Providing teachers with lengthy accommodation/strategy checklists to enhance general education performance– They “have tried them all” after reading only the first 5. 
• Providing Monthly Consultation meetings – While the OT may be a wealth of information, using the expert model undermines the teacher’s professional competency, and advice is generally not well received. We are not the experts in the teachers’ classroom. 

• Using only Sensory Lens – It is not sensory; it is ADHD. While many students with ADHD also have sensory processing difficulties, the interventions differ. Read more here 

Effectively Facilitating Classroom Occupational Performance for Students with ADHD

To increase participation in occupational performance, therapists must use an individualized approach that centers around the student’s ability to function in the specific context at the point of performance. Luckily, this is precisely what OTs are trained to do. That is what occupational therapy is. 

Below I outline the four critical components to supporting occupational performance for students with ADHD in the school setting. Interventions used within the components will vary depending on the student’s specific needs. 

Key 1. Collaborate 

Educate/ Support Teachers through Structured Collaboration

Current best practice recommends that school-based occupational therapy practitioners consistently collaborate with families and caregivers( teachers) and provide services in the natural context of the desired occupation.

Structured collaboration is effective in: 

1. Provide a clear understanding of ADHD and common comorbidities as it relates to the specific student
2. Remove common misconceptions, and guide teachers’ understanding of the effects of ADHD on the students’ occupational participation and performance. 
3. Guide teachers to reframe ADHD as a disorder of executive functions and self-regulation, 
4. Provide modeling and implementation guidance of educational and sensory informed behavioral management techniques specific to the unique student 

By developing a structured collaborative relationship with teachers, we remove the expert model, build caregiver capacity through guided questioning and promote empathy and generalization. In addition, accurate knowledge of ADHD will help to reduce the perpetuation of common myths and stigmas about ADHD, which may create a more positive learning environment for these students (Bell, Long, Garvin, & Bussing, 2011). 

 “Teachers do well when they can.” 

Key 2. Accommodate:

Accommodate/ Modify the CONTEXT

Occupational therapists define context as environmental and personal factors specific to each student that influence engagement and participation in occupations. Context is everything when it comes to ADHD, and no one understands context like school-based occupational therapists. Because occupational performance does not exist in a vacuum, context must always be considered”. OTPF4 

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

When the OT examines the entire context of the desired occupational performance, we can identify and modify barriers and supports to performance within the physical, social and attitudinal environment. In addition, we can establish external environmental conditions tailored for the student’s individual needs based on the severity and symptoms of their ADHD and any other co-occurring disorders.

The Occupational Therapy Contextual Supports Checklist aligns with the fourth edition of the Occupational Therapy Practice Framework: Domain and Process. Download the Occupational Therapy Contextual Supports Checklist to structure your observation and support strategies. 

Key 3. Scaffold

Scaffold Executive Functioning  

ADHD is more than just a problem with inattentiveness, hyperactivity, and impulsivity. It is a disorder of the brain’s executive function system, a system essential for effective functioning in the school domain. Research has substantiated the negative impact of executive functioning deficits on occupational performance among people with attention deficit hyperactivity disorder; Biederman et al., 2006; Chiang & Gau, 2014. 

Many of the “behavioral” problems we see in the classroom in students with ADHD are due to delayed development in executive function and self-regulation. Leading researcher Dr. Russell Barkley estimates that children with ADHD will demonstrate a developmental delay in executive functions, approximately 30% behind their neurotypical peers. 

Occupational therapists can support students with ADHD by identifying executive functioning delays and providing developmentally appropriate scaffolds in the classroom to systematically help the students attain a new skill that may be just outside their developmental zone.

Occupational therapists can systematically scaffold executive functions at the point of performance in the classroom by: 

• Explicitly teaching the EF skill and exposing students to options for increasing efficiency.
• Demonstrate and prompt self-monitoring toward the goal
• Ask guiding questions and provide prompting to assist with flexible thinking. 
• Model key EF skills while engaging with the student in the task.

Key 4. Empower 

Empower the Student

Children with ADHD receive 20,000 more negative messages by the time they are 12 than children without the disorder. These kids need empowerment like none other. ADHD is not a disorder of ability; it is a disorder of performance. These children do not need to be told to ‘focus” or told to “try harder.” Students need to have a deep understanding of their strengths and support required due to ADHD. Co-creating a “how to” playbook with the student at an early age can reduce the damaging effects of daily “not living up to your potential” messages. Therapeutic use of self is always the most essential and powerful tool in your toolbox. Providing psycho-education about ADHD to the student and family will enhance understanding, promote self-advocacy and reduce the risk of secondary complications to the ADHD diagnosis. 

 ADHD is a disorder of occupational performance. 

The dynamic occupational performance deficits caused by ADHD and its possible comorbidities, age/stage presentation, and contextual dependence leave teachers and school admin with no singular effective intervention for “ADHD.” 

Students with ADHD need continuous, highly individualized support tailored to different stages of development to enable participation in the school setting and remove barriers caused by the dynamic ADHD presentation. In addition, we must address the student within the realm of their current context and consider the presence and prevention of comorbidities that may introduce additional challenges. 

The role of the school-based occupational therapist is essential in facilitating functional performance for students with ADHD in the school setting. Best practice and the most effective intervention plan for school-based occupational therapy practitioners is ongoing collaborative problem solving with caregiver (teacher and parent), accommodations and modification to the learning context, strategic scaffolding of executive functioning skills, and point of performance interventions in the natural environment to empower the student.  

Subscribe to follow along with us as we develop tools to guide practice.  

OT4ADHDs mission is to: 

• Empower therapists with current evidenced informed classroom strategies and tools for executive functioning deficits associated with ADHD. 
• Build a community of therapists empowered with evidenced-based research and interventions that support school-based performance
• Reframe ADHD and remove the negative intent bias rampant in the school system.
• Provide evidenced informed systems to build strong, sustainable collaborative relationships with the classroom teacher to support our kids at the point of performance.

Resources

Occupational Therapy Interventions for Children and Youth Ages 5 to 21 Years Stephanie Beisbier; Susan Cahill DOI: 10.5014/ajot.2021.754001

Toffel, A., Rhein, J., Khetani, M. A., Pizur-Barnekow, K., James, L. W., & Schefkind, S. (2017). Partnering with families is best practice and essential in promoting school readiness and healthy development. OT Practice, 22(18), 9–13.

Occupational Therapy Association. (2015). Importance of interprofessional education in occupational therapy curricula. American Journal of Occupational Therapy, 69(Suppl. 3), 691341 020. https://doi.org/10.5014/ajot.2015.696S02

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

American Occupational Therapy Association. (2013). Cognition, cognitive rehabilitation, and occupational performance. American Journal of Occupational Therapy, 67(6 Suppl.), S9–S31.http://doi.org/10.5014/ajot.2013.67S9

CAST, Inc. (2021). The UDL guidelines. https://udlguidelines.cast.org/?utm_source=castsite&lutm_medium=web&utm_campaign=none&utm_content=aboutud

Hahn-Markowitz, J., Berger, I., Manor, I., & Maeir, A. (2017). Impact of the Cognitive–Functional (Cog–Fun) intervention on executive functions and participation among children with attention deficit hyperactivity disorder: A randomized controlled trial. American Journal of Occupational Therapy, 71, 7105220010. https://doi.org/10.5014/ajot.2017.022053

Dunn, W. (2017). Coaching: An evidence-based practice that supports participation and efficacy [online course]. Retrieved from https://www.occupationaltherapy.com/ot-ceus/course/coaching-evidence-based-practice-that-3134Schilling, D. L., Washington, K., Billingsley, F. F., & Deitz, J.

(2003). Classroom seating for children with attention deficit hyperactivity disorder: Therapy balls versus chairs. American Journal of Occupational Therapy, 57, 534–541. doi: 10.5014/ajot.57.5.534