School-Based OT Intervention Framework for ADHD
The Role of Occupational Therapy for ADHD in the School Setting
Our role when treating students with ADHD in the school setting is the same as it is for all students, to support the student’s occupational performance within the school setting to enable them to access, participate and progress in their education.
- 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.
Facilitating Classroom Performance with E.A.S.E.
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 of 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. EASE stands for Educate, Accommodate, Scaffold, and Empower.
Key 1.Educate
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:
- Provide a clear understanding of ADHD and common comorbidities as it relates to the specific student
- Remove common misconceptions, and guide teachers’ understanding of the effects of ADHD on the students’ occupational participation and performance.
- Guide teachers to reframe ADHD as a disorder of executive functions and self-regulation,
- 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.
Evidenced Informed Tools for Practice
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Join OT4ADHD’s mission 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.