School Based OT for Students with ADHD: A Response to Research

Clarifying the Role of Occupational Therapy

In a recent article published in the Journal of School Psychology, Dr. G.A. Fabiano and colleagues presented a thorough critique of the current systems in place to support students with ADHD in schools. These respected researchers identified several systemic issues, including under-preparation of general education teachers, inconsistent implementation of 504 Plans and IEPs and over reliance on disciplinary consequences.

As a school-based occupational therapist, I was encouraged to see their call for more timely, integrated, school-based supports that center around student participation, especially when framed within a Multi-Tiered System of Supports (MTSS).

However, I was also deeply concerned by the article’s characterization of occupational therapy as an “ineffective related service” because it is “not designed to reduce the core symptoms of ADHD.”

School-based occupational therapy is not, and has never been, designed to reduce the core symptoms of any diagnosis, whether ADHD, cerebral palsy, or autism.

Our role is schools is not symptom reduction. Our role is to reduce impairment.

That does not negate our essential role in addressing the functional impairments that stem from those symptoms. And that distinction matters.

An Important Distinction

School based occupational therapy practitioners focus on improving students’ access to education by supporting their functional performance across school-based occupations. Our job is to help students meaningfully participate in what they need and/or want to do, to access, and progress in their education.

We don’t aim to eliminate symptoms. We aim to remove barriers to participation.

So while we do not “treat” impulsivity, we do develop strategies and systems to ensure that impulsivity doesn’t interfere with a student’s ability to function and participate successfully in the classroom. That’s not semantics, it’s a fundamental and appropriate distinction. That’s our purpose. And unfortunately, the misunderstanding of that purpose is not just a harmless oversight.

Systemic Misunderstandings

School-based occupational therapy is still too often minimized or misunderstood as a related service that’s role is to improve fine motor, handwriting  and sensory processing skills. 

Improving ADHD Support In Schools

Dr. Fabiano and his colleagues propose a path forward for ADHD support in schools (Fabiano et al, 2024), one that may sound strikingly familiar to occupational therapists.

Their key recommendations include:

• Shift the focus from symptoms to function.
  • Interventions should ask, “Is this child experiencing classroom impairment and how can we reduce it?” (Fabiano et al, 2024)
• Create dynamic, individualized, strength-based support plans that consider context.
  • Plans should be client-centered and consider the entire context in which behavior occurs.
  • Identify specific areas of difficulty and address them in a systematic way.
• Support the educators.
  • Provide general education teachers with the tools and training they need to sustain interventions.
• Target the areas that matter most to teachers and families.
  • These include peer and adult relationships, academic progress, and full participation in the classroom.
• Act early and responsively.
  • Don’t wait for a diagnosis, offer support based on functional classroom observations, as one would with an academic difficulty.

These are not radical ideas. Nearly every recommendation aligns with what school-based OT is already designed to do, though it’s rarely recognized as such. Especially challenging in the content of ADHD, which is equally as misunderstood.

The Core Challenge of ADHD Intervention

One of my favorite quotes from Dr. Russell Barkley, captures the core challenge of ADHD intervention in a way that still resonates today.

“Disorders like ADHD pose great consternation for the mental health and educational arenas of service because they create disorders mainly of performance rather than knowledge or skills. Mental health and education professionals are more experts at conveying knowledge—how to change; far fewer are experts in ways to engineer environments to facilitate performance, where and when to change.” (Barkley, R.A. , 2010)

We are not focused on what a child knows. We’re focused on what gets in the way of using that knowledge in real time. We call this functional cognition.

We build systems, shape environments, and design strategies to support performance in school, and this is exactly what this peer reviewed research is describing.

This OT Month, Let’s Make It Clear

In honor of OT Month, I encourage every school-based occupational therapist to begin making one small shift starting now in your everyday practice to help explain our role in terms that educational stakeholders can truly understand. (Sorry, but I struggle to understand AOTA’s explanation myself.)

Let’s normalize using the words participation and occupation in our everyday practice. Whether it’s during evaluations, in progress reports, or even in those quick hallway consults.

We can:

• Add an introduction to any evaluations/screening forms explaining the purpose of OT and defining occupation.

• Stop describing skills and start describing participation and performance . School based OT is NOT working on fine motor skills. We are working on pencil control so the student can participate in written expression.

• Describe the student’s current level of performance in the school-based occupations assessed, not JUST the underlying performance skills. Ie: Moderate support is needed for written communication tasks due to challenges with letter formation and visual-motor integration.

This small but mighty switch, in time, may help everyone understand what it is we actually do.

My sincere gratitude to Breda Lyons, OT, for recommending this article, and to Dr. Gregory Fabiano for his ongoing work and advocacy. His article not only reveals how deeply the misunderstanding of our profession runs, but also underscores the immense value of our work with this population. I’m grateful for his thoughtful and timely response to my letter and look forward to future collaboration to help create a better path forward for our most misunderstood students.

References

Fabiano GA, Lupas K, Merrill BM, Schatz NK, Piscitello J, Robertson EL, Pelham WE Jr. Reconceptualizing the approach to supporting students with attention-deficit/hyperactivity disorder in school settings. J Sch Psychol. 2024 Jun;104:101309. doi: 10.1016/j.jsp.2024.101309. Epub 2024 Apr 22. PMID: 38871418; PMCID: PMC11331420

Barkley, R.A. (2010). The Important Role of Executive Functioning and Self-Regulation in ADHD©.

OT4ADHD’s mission is to empower school-based professionals with the knowledge, tools, and resources they need to improve the participation and performance of students with ADHD across all school-related occupations.
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