Students with ADHD often experience challenging behaviors that can significantly impact their learning and occupational performance in the classroom.

Unfortunately, without a clear understanding of ADHD, these behaviors can be misunderstood as willful misconduct. Caregivers may judge these students as “disruptive, troublemakers, lazy, unmotivated, procrastinators, explosive, students that don’t care,” and so forth. This misunderstanding can be a formidable barrier to the student’s health, academic achievement, and future prognosis.

I have to be honest. When I read the term “behavior intervention”, I think ABA. I picture compliance based operant conditioning^.and I cringe. Thankfully, operant conditioning is not supported by evidence to improve classroom functioning of students with ADHD.  

“Behavioral interventions” include numerous evidence-based psychosocial interventions that can help address the root cause of these behavioral problems. These interventions target both performance deficits and skills deficits in order to truly address the educational needs of students with ADHD and ultimately decrease their “problematic” behaviors. 

This post will guide the reader’s understanding of the root cause of behavioral problems associated with ADHD and provide understanding of the evidence-based interventions that can help students with ADHD improve their classroom behavior.

Understanding Problem Behaviors in Students with ADHD 

Behavior is a triggering word today. Our society has too long ignored the varied possible explanations of ones behavior, favoring a compliance above all else model, especially in the school system.

Behavior is defined as an “observable response to a stimulus”.  Therefore when we are discussing behavior, we are always referring to a response or reaction to a stimulus from our internal or external environment. One can not separate a behavior from its stimulus or its context. 

ADHD is not a behavioral disorder. ADHD is a neurodevelopmental disorder that impacts our neurochemistry altering the levels of availability of neurotransmitters in the brain. Insufficient neurotransmitter activity in the prefrontal cortex of the brain causes a delayed development of executive function and self regulation skills. 

The observable “behaviors” of an individual with ADHD are caused by neurodevelopmental differences .

The severity of ADHD symptoms is highly impacted by the context , which may be self evident, since behavior is a response to a stimulus. Whats in the context? You, me, this chair and everything else that is not the child.

Children with ADHD lag behind in terms of performance and skill acquisition compared to their peers, and these deficits can manifest as certain behaviors that differ from typically developing peers. For this reason, discipline and behavior modification techniques – such as rewards and consequences – will not effectively address the root cause of challenging behaviors. Punishing, shaming, or bribing a child is not the answer. 

Therapists, teachers, and caregivers must understand that ADHD symptoms can only be accurately understood by looking at their neurochemical and developmental origins and their contextual triggers. When the underlying causes are addressed, more sustainable, positive results can be achieved.

“Behavioral Interventions” are Not What You Think 

The American Academy of Pediatrics (AAP) Clinical Practice Guideline encourages three evidence-based interventions to manage behavioral outcomes of children with ADHD: medication, behavioral therapy, and school supports. 

• Medication aims to normalize the neurochemical cause of symptoms, but is only active during treatment.
• Behavioral therapy, as the AAP describes, is “aimed to change the child’s physical and social environments to help him improve his attention and activity”.
• School supports such as accommodations and educational/ behavioral interventions support positive behavioral outcomes. 

Notice that the AAP’s target is not to change the child. They know that ADHD is a chronic neurodevelopmental disorder and that we can not change the neurological wiring of our students. The target is to manage behaviors in context . And when you read closely, the target of the “behavior therapy” is actually the caregiver. Adult caregivers are in charge of the environment.

Behavioral therapy as defined by the AAP , refers to Parent or Caregiver Training and involves training adults to influence the environment to improve the behavior of a child or adolescent in that setting.

School-based occupational therapists take a holistic approach to remove barriers to performance, collaborating with caregivers and capitalizing on the student’s strengths to inspire improved performance and participation. This approach is precisely what the AAP describes when they reference behavioral therapy.

Evidenced Based Classroom “Behavioral” Interventions to Manage ADHD

The school setting is the most impaired life domain for a child with ADHD. Vast research has been conducted to investigate how to improve their behavioral outcomes in this context, and a multimodal approach is essential. Attentive teachers, highly effective accommodations, and research-supported interventions must be implemented to be successful.

Proactive Strategies

The purpose of using what literature often refers to as a ” Antecedent Based Strategy” is to influence the behavior of the person by changing the situation or stimuli that would evoke a certain response. Antecedent based strategies are proactive , preventative strategies that can be used to respectfully consider the students ability in context and set them up for success. Examples of EB proactive strategies strategies include caregiver education, structured teaching, clear expectations, and environmental supports.

Caregiver Education

The most important and effective intervention that can be provided by a school based occupational therapist is caregiver education. Research clearly states that without an understanding of ADHD , classroom behavioral interventions will not be effective. As Ross Greene aptly said, “Your explanation guides your intervention.”

“Your explanation guides your intervention”

Ross Greene 

Students with ADHD require educated and understanding teachers that can provide a safe engaging learning environment with the strong student-to-teacher connections.

• Teachers must develop a clear understanding of the child’s specific skill strengths and weaknesses as it relates to ADHD , executive function skills, self regulation, trauma history and co-morbidities.
• Teachers need to identify and differentiate between behaviors that are within the child’s control and not due to disability.
• Teacher must develop expectations that are developmentally appropriate for the specific child. (apply 30 % rule to the students age)
• Students with ADHD must feel safe and believe they can trust the teacher. 

Structured Explicit instruction

Structured Environment: Children with ADHD function best in a structured learning environment. They often do poorly in unstructured and unpredictable environments.

Therapists can provide EBI’s to structure the environment for improved classroom behavior.

• Provide a Visual Schedule- provide the student with a visual schedule or checklist of the instructions for the task or day.
• Externalized Rules and Directions (visual) – students can not hold multiple things in mind while working ,provide rules and expectations in an area that is at eye level and noticeable to the student.
• Distractions Minimized – reduced distractions, temptations and visual, auditory clutter
• Externalized Support for Performance in Routines: The difference between compliance and completion is difficult to determine in the classroom environment. Provide support to performance in specific procedures and classroom routines.

Explicit Instruction: Explicit instruction is systematic, direct, engaging, and success oriented. Instructions are clear and leave no room for implicit interpreation. Expert AnnArcher, identifies 16 elements of explicit instruction. (Archer & Hughes, 2011) 

Positive Reinforcement Strategies for ADHD

Students with ADHD require POSITIVE classroom management. Therapists working with children who have ADHD need to focus on positive classroom management strategies. Children with ADHD often come into contact with teacher feedback that can feel negative and create strained relationships.

Although these children have the capacity to understand what is expected, their actual performance can lag significantly due to the unique nature of their condition. Negative consequences don’t help children understand what they should or should not be doing, nor do they provide them with the tools and skills to achieve their potential. Plus, over time, these types of consequences can increase the frequency and intensity of inappropriate behavior as a result of feeling that they are unable to succeed. 💔

Positive Attending “Praise”

Students with ADHD require an increased frequency of praise. Experts agree upwards of a 4:1 ratio positive to corrective feedback.

Praise must be: 

• Preventative:  Educators are encouraged to look for a behavior to praise before, and not after, a child gets off task.
• Specific: Praise is most impactful when it’s specific to a student’s behaviors: focus on what they did right, and name the exact actions that were desirable. For example, instead of saying, “Good job for not disturbing the class,” applaud them for completing the reading lesson on time and in a quiet manner.
• Immediate: Give praise immediately. The sooner that approval is given regarding appropriate behavior, the more likely the student will repeat it.
• Varied: Vary the statements given as praise. The comments used by teachers to praise appropriate behavior should vary; when students hear the same praise statement repeated over and over, it may lose its value.
• Consistent: Appropriate behavior should receive consistent praise. Consistency among teachers promotes a positive learning experience and helps set achievable goals.
• Sincere: Students will notice when teachers give insincere praise, and this insincerity will make praise less effective.

Nonverbal “Behavioral Prompts”

These prompts help remind students about expectations for their learning and behavior in the classroom at the point of performance. Teachers can expect that a student with ADHD will need an increased frequency of refocusing and redirection to maintain attentive. This is not because they lack the desire to stay on task. It’s important to use respectful and pre-determined, nonverbal techniques for re-directing their attention. An alternative to shouting “FOCUS!”, these techniques can ensure an effective learning atmosphere.

• Visual Cues. Establish simple, nonintrusive visual cues to remind the child to remain on task.
• Proximity control. To regain attention move closer to the child. Your physical proximity to the child will help the child to focus and pay attention to the lesson.
• Hand gestures. Use hand signals to communicate privately with a child with ADHD.

Homework Interventions 

There are multiple evidenced based interventions that are designed to address the highly prevalent problem with homework completion, that are covered in detail in a separate post.

Proactive strategies include:

• Reasonable Amount: Teacher assignment of a reasonable amount of homework given the child’s age, developmental ability, and attention skills .
• Homework Plan: Establishing a place for homework that is relatively free from distraction and delineating a time for homework that is responsive to times of the day during which children are most attentive and parents are able to monitor homework
• Goal setting and chunking -the parent and child review together the assignments and break up the work into manageable units that can be completed before taking a brief break, mutually identify reasonable goals for number of problems to be completed, number of correct responses, and amount of time.

Summary

While most school based OT’s are not to go to professional in the school setting for “behavior problems”, the behavioral outcomes of ADHD are most often related to the underlying skill and performance deficits in relation to the learning context.

School based occupational therapists sustainably support the classroom behavioral performance of their students with ADHD in multiple ways:

• Teacher Collaboration: Provide ongoing collaborative problem solving with caregiver (teacher and parent ) to promote a clear understanding of the child’s specific skill strengths and weaknesses as it relates to behavior including executive function skills, self regulation, trauma history and comorbidities. “Your explanation will always guide your intervention”.
• Accommodations and Environmental Modifications: Provide accommodations and modification to the learning context that reduce barriers to performance and facilitate better behavior.
• Scaffolding Better Behavior : Provide strategic scaffolding of executive functioning skills to support completion of classroom routines that are often confused with non compliance.
• Empowerment: Provide point of performance interventions in the natural environment to empower the teacher and student relationship. model positive reinforcement and differentiate material for explicit instruction.

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 classroom setting. Improved “behavior” is just a welcomed side effect. 😉

While article does not cover all the possible ways to support behavior in the classroom, some were purposely excluded. There are EBI’s that are frequently cited as effective in research that are in my opinion grossly misused to an extent that they are counterproductive and damaging to the child’s esteem. The misuse of Daily Report Cards and various rewards programs will be discussed at length in a future post.

Key Takeaways:

1. ADHD is a neurodevelopmental disorder that affects the availability of neurotransmitters in the brain and can manifest as certain behaviors that differ from typically developing peers.
2. The role of the school-based occupational therapist is essential in facilitating functional performance for students with ADHD in the classroom setting.
3. Behavior modification techniques such as rewards and consequences will not effectively address the root cause of challenging behaviors, so teachers must understand ADHD and its contextual triggers to provide effective interventions.

Tools for Practice

References 

Ahmann, Elizabeth, et al. “Interventions for ADHD in children and teens: a focus on ADHD coaching.” Pediatric Nursing, vol. 43, no. 3, May-June 2017, pp. 121+. Gale Academic OneFile, link.gale.com/apps/doc/A502001266/AONE?u=nysl_oweb&sid=googleScholar&xid=7d81aef1. Accessed 18 Feb. 2023.

Pfiffner LJ, Haack LM. Behavior management for school-aged children with ADHD. Child Adolesc Psychiatr Clin N Am. 2014 Oct;23(4):731-46. doi: 10.1016/j.chc.2014.05.014. Epub 2014 Aug 10. PMID: 25220083; PMCID: PMC4167345.

Staff AI, van der Oord S, Oosterlaan J, Hornstra R, Hoekstra PJ, van den Hoofdakker BJ, Luman M. Effectiveness of Specific Techniques in Behavioral Teacher Training for Childhood ADHD Behaviors: Secondary Analyses of a Randomized Controlled Microtrial. Res Child Adolesc Psychopathol. 2022 Jul;50(7):867-880. doi: 10.1007/s10802-021-00892-z. Epub 2022 Jan 11. PMID: 35015187; PMCID: PMC9246781.

Ward RJ, Bristow SJ, Kovshoff H, Cortese S, Kreppner J. The Effects of ADHD Teacher Training Programs on Teachers and Pupils: A Systematic Review and Meta-Analysis. J Atten Disord. 2022 Jan;26(2):225-244. doi: 10.1177/1087054720972801. Epub 2020 Dec 17. PMID: 33331193; PMCID: PMC8679179.

Eiraldi RB, Mautone JA, Power TJ. Strategies for implementing evidence-based psychosocial interventions for children with attention-deficit/hyperactivity disorder. Child Adolesc Psychiatr Clin N Am. 2012 Jan;21(1):145-59, x. doi: 10.1016/j.chc.2011.08.012. PMID: 22137818; PMCID: PMC3233687.