ADHD In Action: Empowering Occupational Therapy Practitioners In Elementary Schools

Editor's note: This text-based course is a transcript of the webinar, ADHD In Action: Empowering Occupational Therapy Practitioners In Elementary Schools, presented by Elisabeth Bahr, OTD, MS, OT/L.

Learning Outcomes

• After this course, participants will be able to:
  • identify the unique challenges faced by children with ADHD in school settings and their impact on academic performance, school function, and social interactions.
  • recognize evidence-based strategies for supporting children with ADHD in schools.
  • list creative intervention ideas tailored to enhance engagement, organization, and self-regulation skills for children with ADHD.

Introduction

Thank you for the introduction. Our session today is about ADHD, which is a topic that can often be puzzling. As OT practitioners, hopefully, you're going to pick up some effective ways to deal with this. This is part one of a two-part series, and we'll have another session that focuses on adolescents and teens dealing with ADHD.

The goal for today is to arm you with tools that will help you confidently assist kids on your caseload who've been diagnosed with ADHD. We'll go over the basics of ADHD and how OT can make a difference. We won't be diving into evaluations, fancy techniques, or assessment tools in this session.

First, we'll chat about the unique challenges of an ADHD diagnosis and how it messes with school life. Then, we'll move on to proven strategies and cool OT tricks that are all about what works best for the clients. We're are also going to get practical, exploring ways to boost academic performance, supercharge social skills, handle symptoms like a pro, and in the end, make school life better overall.

My aim today is for you to walk out of here feeling confident and equipped with what you need to provide direct and indirect support for students with ADHD.

Now, beyond the intro, I've got real-world experience working in schools, especially in the New York City Department of Education. I still keep busy as a contract evaluator and supervisor for other pediatric evaluators. I've also worked in sensory clinics, early intervention, and even telehealth, working with kids of all ages across the pediatric spectrum.

ADHD Definition

• ADHD: One of the most prevalent disorders affecting children
• Symptoms:
  • Inattention: Difficulty focusing
  • Hyperactivity: Excessive, unfitting movement
  • Impulsivity: Hasty, unthoughtful actions
• Chronic and debilitating disorder impacting multiple life aspects:
  • Academic and professional achievements
  • Interpersonal relationships
  • Daily functioning (Harpin, 2005)
• Untreated ADHD can result in:
  • Poor self-esteem
  • Poor social function in children (Harpin et al., 2016)

Let's delve into the definition of ADHD. To start, let's introduce a narrative. Picture a remarkable cohort of individuals who share a unique bond due to their experience with ADHD. Consider Simone Biles defying gravity, Justin Timberlake infusing the air with captivating melodies, and Michael Phelps effortlessly gliding through water like a human dolphin. Add to that Adam Levine, whose soulful voice resonates deeply, and Jamie Oliver, an artist in the realm of culinary delights. These individuals have excelled not solely due to their ADHD, but rather by acquiring strategies, routines, and rituals from professionals like you who provide essential support within educational settings.

ADHD, a globally prevalent disorder, presents profound challenges. It disrupts one's capacity to concentrate, manifests as hyperactivity, and gives rise to impulsive behaviors. Its significance cannot be underestimated. This condition has the potential to cast a shadow over academic and vocational accomplishments, exerting influence over various facets of life. It can intricately entangle interpersonal relationships and complicate day-to-day functioning. Left untreated, ADHD can corrode self-esteem and foster a sense of being out of sync with a fast-paced world. 

As OTPs, it's crucial for us to begin to grasp the depth of this disorder. It demands our understanding, attention, and empathy.

Understanding the Neurobiology of ADHD

• Biological origin of ADHD: Uncertain
• Nature of ADHD: Neurologically-based developmental disorder
• Brain Development: Delay in frontal cortex by an average of 2-4 years, delayed peak cortical thickness (30, 31) - delayed executive functioning skills
• Role of Dopamine: Variations in dopamine diffusion and availability
• Brain Network Interaction: Synchronization issues between the default mode network and task networks

Let's now delve into the neurobiology and neuroscience underpinning ADHD. As we explore the biological origins, it's essential to recognize that the forthcoming descriptions offer a simplified overview of the intricate neurochemical and brain network processes at play. The actual mechanisms and interactions are significantly more complex, constituting an active area of research that unfolds with each passing day.

At its core, ADHD is a neurologically rooted developmental disorder. To conceptualize our attention, envision a highlighter. As you read through a section of a book, the highlighted portion stands out, guiding your visual focus to that specific area. This act is not solely about centering your attention on that block of text; it also encompasses the skill of disregarding stimuli and information unrelated to the task. Research on ADHD brains has indicated a two to four-year delay in the frontal cortex, which substantially affects executive functioning skills.

The frontal cortex oversees attention coordination and suppression. Drawing from the highlighter analogy, ADHD significantly disrupts this process. As many are aware, the prefrontal cortex might not fully develop until a person reaches their mid-twenties. This developmental timeline needs to be considered when examining individuals with ADHD. Further elaboration on executive functioning skills will be provided in the second part of this series.

Turning our attention to the neurotransmitter that often garners great interest—dopamine—it's indeed a noteworthy topic, especially within social media discussions. This pivotal neurotransmitter plays a crucial role in various brain functions, encompassing motivation, reward, and attention. Within individuals with ADHD, variations in dopamine diffusion and availability contribute to a heightened impact on focus and motivation. A particularly apt metaphor from Dr. Huberman's Huberman Lab Podcast likens dopamine to an orchestra conductor coordinating various brain components. 

The interplay between the default mode network and the task network, which has garnered recent research attention, proves captivating. The default mode network encompasses brain regions activated during periods of rest or internal mental processes—instances of daydreaming and introspection. In contrast, the task network engages brain regions involved in goal-oriented activities like problem-solving and decision-making, which are significantly influential in educational contexts. For individuals with ADHD, the synchronization between these two networks can be disrupted, ultimately affecting cognitive performance. 

In the typical brain, the default mode network and task network inhibit one another, ensuring attention and focus maintenance. However, in ADHD, these networks are modulated by dopamine, occasionally leading to inadvertent activation. As psychologist Ari Tuckman aptly phrases it, ADHD fundamentally concerns self-regulation challenges. Our focus as occupational therapy practitioners (OTPs) revolves around comprehending how these neurological disparities characteristic of ADHD manifest in real-world functioning, particularly within educational environments.

Contrary to prevalent misconceptions or simplified portrayals found on platforms like TikTok, ADHD transcends being a mere attention or dopamine deficiency—it's a multi-dimensional condition. Our scrutiny must extend to how these diverse facets collectively shape an individual's functionality.

ADHD Subtypes

1. ADHD-Hyperactive Type
2. ADHD-Inattentive type - most common (4)
3. ADHD-Combined type - most likely referred for clinical services (4)

There exist three distinct subtypes of ADHD: Hyperactive Type, Inattentive Type, and Combined Type. The Hyperactive Type can be viewed as the archetypal representation of ADHD. Its origins trace back to 1902 when a British pediatrician named George Frederic Still coined the term, characterizing it as an anomaly in normal control among children. He astutely observed that certain affected children struggled to regulate their behavior in the same manner as their typical peers, despite possessing significant intelligence.

The Inattentive Type constitutes the most prevalent subtype, while the Combined Type emerges as the most common subtype leading individuals to seek services. Each of these subtypes manifests with distinct attributes. It's important to note that ADHD primarily affects attention rather than intelligence or IQ. Its impact is rooted in the intricate wiring of neural circuits and the corresponding neurotransmitter activity.

Despite the hurdles posed by ADHD, effective strategies and treatments are available to ameliorate symptoms and enhance focus within educational settings. We will delve into these strategies shortly.

Neurodiversity and ADHD

• Concept of Neurodiversity
  • Definition: “Neurodiversity describes the idea that people experience and interact with the world around them in many different ways; there is no one ‘right’ way of thinking, learning, and behaving, and differences are not viewed as deficits.”- Harvard Health (5)
• Strength-Based Practice in ADHD
  • Emphasis on Creativity: ADHD students show less constraint in task examples and demonstrate higher conceptual expansion in experimental tasks, contributing to original and innovative thinking. (6)
  • Highlight on Divergent Thinking: ADHD may be beneficial in contexts requiring creative and innovative thinking, potentially advantageous in cutting-edge fields (Scientific American, 2023) (7, 8)

Before delving into the diagnostic criteria, let's take a moment to discuss neurodiversity in the context of ADHD. This is an area of personal passion for me.

The concept of neurodiversity underscores the natural and indispensable range of neurological differences among humans. It reframes disparities in thought processes, learning styles, and behaviors as variations rather than deficits. Neurodiversity encompasses conditions like ADHD, dyslexia, and autism, placing them within a broader framework.

Within the realm of ADHD, adopting a strength-based approach goes beyond focusing solely on its challenges. Instead, it presents an opportunity to spotlight unique abilities. While it's important to refrain from labeling ADHD as a "gift" or "superpower," a strength-based practice aids students in identifying their innate talents and equips them with strategies to effectively utilize these abilities in their daily lives.

Additionally, I'd like to emphasize the interplay between creativity and divergent thinking. Divergent thinking involves generating multiple novel solutions or creative ideas. ADHD individuals may possess an advantage in this domain, approaching problems with heightened originality and adaptability. These might be the students in your class who produce thought-provoking essays that meld concepts in unique ways. Their aptitude is evident in their ability to expand upon ideas conceptually and excel in experimental tasks. Essentially, their expansive thought processes contribute to remarkably innovative thinking. This capacity holds particular promise in certain career contexts, as we'll explore in our upcoming lecture.

In cutting-edge fields like design or technology, this unique cognitive approach can be a genuine asset, amplifying distinct perspectives. Individuals with ADHD often excel in divergent thinking, fostering an environment conducive to creativity and innovation.

Diagnosis

Healthcare professionals typically rely on the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) for diagnostic guidance. This manual aids in identifying the characteristics and criteria that define ADHD and its various subtypes.

Inattentive type

• “Inattentive refers to challenges with staying on task, focusing, and organization. For a diagnosis of this type of ADHD, six (or five for individuals who are 17 years old or older) of the following symptoms occur frequently:
  • Doesn’t pay close attention to details or makes careless mistakes in school or job tasks
  • Has problems staying focused on tasks or activities, such as during lectures, conversations, or long reading
  • Does not seem to listen when spoken to (e.g., seems to be elsewhere)
  • Does not follow through on instructions and doesn’t complete schoolwork, chores, or job duties (may start tasks but quickly loses focus)
  • Has problems organizing tasks and work (for instance, does not manage time well; has messy, disorganized work; misses deadlines)
  • Avoids or dislikes tasks that require sustained mental effort, such as preparing reports and completing forms
  • Often loses things needed for tasks or daily life, such as school papers, books, keys, wallets, cell phones, and eyeglasses
  • Is easily distracted
  • Forgets daily tasks, such as doing chores and running errands; Older teens and adults may forget to return phone calls, pay bills, and keep appointments.”

(9, Source: psychiatry.org )

In diagnosing Inattentive Type, a set of criteria must be met. For children up to the age of 16 years, there should be the presence of six or more symptoms of inattention. Adolescents aged 17 years and older should exhibit five or more such symptoms. These symptoms of inattention should persist for a minimum of six months and should be incongruent with the individual's developmental level. Moreover, these symptoms must manifest in multiple settings, encompassing areas like home, school, work, interactions with friends, and engagement in other activities.

The critical factor here is that these symptoms substantially interfere with daily functioning. Their impact should be evident in various aspects of life. It's essential to exclude the possibility of these symptoms arising due to another disorder. Furthermore, it's important to note that these symptoms should not solely align with the course of schizophrenia or any other disorder.

This classification pertains to individuals who grapple with challenges related to focus, task management, and organizational skills. Key symptoms indicative of this subtype may involve missing details, struggling to maintain focus, appearing inattentive or daydreaming, exhibiting difficulty in following through with tasks, and experiencing rapid loss of focus while engaged in activities. These individuals might also encounter problems such as losing items, becoming easily distracted, or being forgetful.

In a sense, some describe this subtype as featuring "intrinsic hyperactivity," where internal distractions significantly hinder functional abilities and the individual's role, particularly in academic or occupational settings.

Hyperactive/Impulsive Type

• Hyperactivity refers to excessive movement such as fidgeting, excessive energy, not sitting still, and being talkative. Impulsivity refers to decisions or actions taken without thinking through the consequences. For a diagnosis of this type of ADHD, six (or five for individuals who are 17 years old or older) of the following symptoms occur frequently:
  • Fidgets with or taps hands or feet, or squirms in seat
  • Not able to stay seated (in classroom, workplace)
  • Runs about or climbs where it is inappropriate
  • Unable to play or do leisure activities quietly
  • Always “on the go,” as if driven by a motor
  • Talks too much
  • Blurts out an answer before a question has been finished (for instance may finish people’s sentences, can’t wait to speak in conversations)
  • Has difficulty waiting for his or her turn, such as while waiting in line
  • Interrupts or intrudes on others (for instance, cuts into conversations, games or activities, or starts using other people’s things without permission); Older teens and adults may take over what others are doing.”

(9, Source: psychiatry.org )

Similarly to the Inattentive Type, for diagnosis in the Hyperactive/Impulsive Type, six or more symptoms must be present in children up to the age of 16, while adolescents aged 17 or older should exhibit five or more symptoms. This symptomatology should persist for at least six months. The distinguishing feature of this type lies in its characteristic attributes of excessive movement, high energy levels, restlessness, and impulsive behavior.

Typical symptoms that frequently manifest in this type encompass behaviors like squirming, an inability to remain seated, engaging in running or playing loudly, constant restlessness, responding abruptly without consideration, and interrupting ongoing activities or conversations. This category is sometimes referred to as "extrinsically hyperactive," as it involves conspicuous behaviors associated with heightened activity levels. The external manifestation of symptoms, such as excessive movement and impulsivity, tends to be more apparent and recognizable to teachers, parents, caregivers, and occupational therapy practitioners (OTPs). It's often the stereotypical image that comes to mind when people think of ADHD.

Combined Type

The Combined Type combines elements of both Hyperactive ADHD and Inattentive ADHD.

Prevalence

• "Healthy People 2030" aims to increase the proportion of children and adolescents with ADHD who receive appropriate treatment (Objective EMC‑04). (10)
• A 2012 meta-analytic study found no significant differences in ADHD prevalence between countries or regions after controlling for diagnostic algorithm differences. (11)
• This study supports the diagnostic validity of ADHD and refutes the idea that it's a cultural construct specific to any one region or country. (11)

"Healthy People 2030" is an initiative focused on enhancing ADHD management. This initiative underscores the significance of recognizing and effectively managing ADHD for the well-being of individuals, particularly children, across the globe. The primary objective is to ensure that children and adolescents with ADHD receive appropriate treatment, a subject we will delve into shortly.

Another notable study worth highlighting is a meta-analytic study that affirms ADHD's status as a global condition. The study demonstrates that ADHD affects individuals worldwide, with consistent prevalence rates across different countries. This finding challenges the notion that ADHD is merely a cultural construct; instead, it solidifies its position as a substantiated diagnosis supported by robust evidence.

On a more anecdotal note, as an OT evaluator, I've observed an increasing number of students being referred for OT evaluations due to ADHD diagnoses. However, it's important to recognize that a diagnosis itself doesn't always indicate functional difficulties warranting school-based therapy. The rise in diagnoses can be attributed to multiple factors, including heightened awareness of ADHD symptoms, improved societal acceptance, and revisions in the diagnostic criteria outlined in the DSM. These changes expand the criteria, making it more accessible for individuals who require a diagnosis to obtain one.

Nevertheless, it's crucial to acknowledge that certain groups, particularly girls and children of color, might be less likely to receive an accurate diagnosis. This disparity will be discussed in more detail shortly.

Current Treatments

• Multidisciplinary team/Multimodal treatment
• Medication
• Parent training
• Skills training
• Mental health treatment
• Behavioral therapy (see parent training)
• Classroom interventions 

(12)

Medication is frequently the first line of treatment prescribed by physicians to manage ADHD symptoms. These medications effectively address hyperactivity, impulsivity, and inattention. Nonetheless, parents might harbor concerns about potential side effects or how medication efficacy evolves as their children grow older. Robust sources of evidence support the effectiveness of medication in managing ADHD symptoms. A highly recommended resource in this regard is the Huberman Lab podcast, which provides an in-depth exploration of the most commonly prescribed medications for ADHD, their impact, and the underlying evidence.

Parent training stands as another prominent treatment strategy. This approach empowers parents with strategies to help their children manage ADHD symptoms within the home environment. It focuses on enhancing communication, establishing structured routines, and fostering a harmonious atmosphere at home.

Skills programs constitute another avenue. These tailored programs aim to cultivate skills that prove challenging for individuals with ADHD, particularly executive functioning skills. This encompasses areas like time management, organization, and problem-solving. Such programs bolster confidence and independence in day-to-day life.

Mental health treatment is crucial, especially when addressing co-occurring mental health issues like anxiety or depression. Therapy and counseling offer holistic support to address a spectrum of mental health concerns beyond the scope of ADHD symptoms.

Behavioral therapy, particularly cognitive behavioral therapy, can be facilitated by professionals like school psychologists or guidance counselors. This form of therapy reinforces positive coping mechanisms and equips individuals to navigate social and personal situations effectively.

Classroom interventions involve a collaborative effort between teachers and, ideally, OTPs to establish an ADHD-friendly learning environment. Implementing strategies such as visual supports, personalized accommodations, and sensory interventions can greatly facilitate the learning process. Drawing from personal experience as a school-based therapist, I've found that neuropsychological reports within Individualized Education Programs (IEPs) offer invaluable insights into the specific skills impacted by ADHD, aiding in targeted assessments.

In summary, the treatment landscape for ADHD encompasses a comprehensive array of approaches, ranging from medication to skills development programs and therapeutic interventions that holistically address the challenges faced by individuals with ADHD.

Co-occurring Conditions in ADHD

• Approximately 2/3 of children with ADHD have coexisting conditions
  • Common Co-occurring Conditions:
    • Autism Spectrum Disorder (ASD): 1 out of 4 children with ADHD
    • Anxiety: 1 out of 5 children with ADHD
    • Depression: 1 out of 10 children with ADHD
    • Bipolar Disorder: 1 out of 5 children with ADHD
    • Speech Challenges: 1 out of 10 children with ADHD
    • Tourette Syndrome: 1 out of 10 children with ADHD; 2/3 of children with Tourette Syndrome have ADHD
  • Behavior Disorders:
    • Conduct Disorder: 1 out of 4 children with ADHD
    • Oppositional Defiant Disorder (ODD): 1 out of 2 children with ADHD
  • Learning Disorders:
    • Dysgraphia, Dyscalculia, Dyslexia: 1 out of 2 children with ADHD
  • Increased Risk of Injuries and Oral Health:
    • Children with ADHD have an increased risk of injuries and may require extra attention to oral health care.

(13, 14)

Approximately two-thirds of children diagnosed with ADHD also experience concurrent conditions. These coexisting conditions encompass a wide spectrum, including autism, mood disorders such as anxiety, depression, and bipolar disorder, speech challenges, Tourette syndrome, behavioral disorders like conduct disorders and oppositional defiant disorders, and learning disorders like dyslexia and dysgraphia. Due to this intricate interplay, the American Academy of Pediatrics mandates that children with ADHD undergo screening for these coexisting conditions.

Of particular significance are findings related to Oppositional Defiant Disorder (ODD) and Tourette syndrome. It's striking to note that one out of every two children with ADHD is diagnosed with ODD. Similarly, with Tourette syndrome, an eye-catching statistic emerges: two-thirds of children with Tourette syndrome are also diagnosed with ADHD. Additionally, children with ADHD face an elevated risk of injuries, underscoring the necessity for safety precautions and measures. Their oral health also requires heightened attention and care.

As we progress, it's important to acknowledge that we will delve into the topic of sensory processing in ADHD, although it isn't included in this current discussion.

Culture, Race, and Gender

• Cultural Factors:
  • ADHD affects individuals across diverse cultural backgrounds
  • Cultural beliefs and practices influence perceptions and management of ADHD
  • Cultural competency is important for accurate diagnosis and support
• Race and Ethnicity:
  • ADHD prevalence rates vary across racial and ethnic groups
  • Disparities in diagnosis and access to care exist
  • Equitable care requires addressing racial and ethnic disparities
• Gender Differences:
  • Boys are commonly diagnosed; girls may be underdiagnosed
  • Girls may present with different symptoms, such as inattentiveness
  • Individualized assessment and experience working with girls with ADHD is crucial
• Intersectionality:
  • Considering the intersection of culture, disability, race, and gender enhances understanding and support
  • Recognition of diverse experiences and needs = more culturally competent care

(15, 16)

Understanding the cultural context surrounding ADHD is paramount in providing comprehensive support. It involves acknowledging disparities, comprehending gender variations, and recognizing the interplay of culture, race, and gender in shaping an individual's experience with ADHD.

Particularly with regard to girls who have ADHD, they might present with more intrinsic symptoms, aligning with the Inattentive Type. This can lead to misdiagnoses or underdiagnoses, reflecting a broader issue in how ADHD is perceived and identified. The Centers for Disease Control and Prevention (CDC) highlights that the estimated number of children aged 3 to 17 diagnosed with ADHD is around 6 million, accounting for 9.8% of the population based on data from the 2016 to 2019 national survey of parents. Notably, boys are more likely to receive an ADHD diagnosis than girls, with rates of 13% for boys and 6% for girls.

When examining these cultural dimensions and intersectional factors that influence access to care, it becomes evident that a nuanced understanding is imperative. Ensuring accurate diagnoses and effective support hinges on recognizing the diverse ways ADHD manifests within various cultural and gender contexts.

Impact on School Function

• ADHD significantly affects academic performance, behavior, organization, social interactions, and engagement in school activities.
  • Impact may vary based on ADHD subtype (inattentive, hyperactive/impulsive, combined)
  • Stigma:
    • Stigma surrounding ADHD creates challenges for students in school
    • Misconceptions and lack of awareness contribute to stigma
    • Promoting understanding reduces barriers and fosters inclusivity

ADHD can significantly affect a student's performance in school. This impact is further compounded by the intersecting factors of culture, race, gender, ADHD subtype, and severity. Neurodivergent students may encounter stigma from teachers, peers, and even parents. Teachers' perceptions and assumptions about children with ADHD can influence their expectations and interactions. Therefore, a pivotal goal for OTPs working with students with ADHD is to foster an understanding of the true nature of ADHD and counteract misconceptions.

Stigmatization can be particularly harmful, leading to labels like "daydreamer" or "lazy." It's essential to underscore that ADHD does not diminish intelligence. Nevertheless, I've personally observed how disclosing an ADHD diagnosis can alter perceptions. In psychological terms, this phenomenon is referred to as the fundamental attribution error. For instance, if a person with ADHD forgets to follow up on an email, there's an automatic assumption that it's due to their ADHD, without considering other life roles such as education, career, or caregiving responsibilities.

Furthermore, individuals, especially those with undiagnosed ADHD, may perceive their ADHD-related behaviors as fixed personality traits. This can lead to self-blame and shame. For instance, one might internalize procrastination tendencies as part of their identity. However, it's crucial to acknowledge that every person with ADHD, or any neurodivergent condition for that matter, possesses a unique constellation of strengths, weaknesses, roles, and meaningful activities that shape their occupational identity.

In your role as an OTP, you play a pivotal part in dispelling myths, promoting understanding, and assisting students with ADHD in developing strategies to overcome challenges and leverage their inherent strengths.

School Performance and Subtypes

• Study Objective: Investigated the association between ADHD symptoms and subtypes with school performance
• Data Source: 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome (NS-DATA)
• Findings:
  • Children with ADHD-C and ADHD-I had higher odds of reduced overall school performance.
  • Inattentive symptoms were significantly related to reduced performance in reading, writing, and handwriting.
  • Six out of nine symptoms are significantly associated with reduced performance in mathematics.
• ADHD-I Subtype: More likely to receive a school-based Individualized Education Program or 504 Plan.
• Implications: ADHD-I symptoms may broadly impact school performance, emphasizing the need for targeted interventions and support systems. (27)

The study revealed that children with ADHD, specifically the Combined and Inattentive subtypes, were more likely to exhibit reduced overall school performance compared to those without ADHD. Notably, Inattentive symptoms were strongly associated with diminished performance in areas like reading, writing, and handwriting. In addition, six out of nine symptoms showed significant links to reduced performance in mathematics.

The findings further indicated that students with the Inattentive subtype were more inclined to receive school-based Individualized Education Programs (IEPs) or 504 plans. On the other hand, the Hyperactive subtype tends to exhibit more external symptoms, making them particularly noticeable within the school and social environments.

This underscores the necessity of screening for Inattentive symptoms, especially among demographics such as young girls, children with other disabilities or co-occurring conditions, and children of color. Understanding these dynamics can aid in tailoring interventions and support strategies that address the unique challenges associated with each subtype and individual circumstances.

OT Role in Elementary Schools

• At least 1 out of 5 elementary school students with ADHD lack a 504 plan or Individualized Education Program (IEP).
• The majority (69.3%) of students with ADHD currently receive school services. (17)
• Teachers may have inadequate knowledge about ADHD and insufficient training in managing students with ADHD. (18)
• School-based occupational therapy programs can provide teacher training on diagnosis, behavior support, environmental modification, and available resources to support students with ADHD and their parents.
• In one (2020) survey, children with ADHD comprised 26-75% of therapists' caseloads.
• Over 90% of OTPs used interventions to address impairments, activity, and participation related to ADHD. (24)
• Most common intervention = sensory, individual session (24)

Occupational therapy practitioners (OTPs) have a pivotal role to play in supporting students with ADHD within elementary schools. Research has illuminated the vital contribution OTPs make in this regard.

In terms of 504 plans and Individualized Education Programs (IEPs), it's noteworthy that approximately one out of five students with ADHD lack such plans. This highlights the need for accessible resources and also underscores the importance of focusing on school function before diagnosis. Not all students with ADHD necessarily require an IEP or 504 plan. Interestingly, about 69.3% of students with ADHD receive some form of school services to bolster their academic and social achievements.

Teacher training emerges as an area where OTPs can significantly impact school environments. Many educators lack comprehensive knowledge about ADHD, presenting an opportunity for OTPs to step in and provide crucial training. This training enhances classroom strategies, creating a supportive learning atmosphere.

Additionally, OTPs can bridge knowledge gaps for teachers and facilitate a conducive learning environment. A survey indicates that children with ADHD make up a substantial portion (around one-quarter to one-third) of OTP caseloads. Many OTPs employ direct individual services to address challenges and foster participation. Interestingly, the prevalent model used for intervention revolves around a sensory integration framework.

Given the anticipation surrounding sensory integration, we will shortly discuss strategies for intervention that encompass this crucial aspect.

Promoting School Occupational Engagement for Students with ADHD

• Occupations
  • Education: Classroom tasks (reading, writing, taking notes, homework, completing projects)
  • Recess, lunch and cafeteria, socialization
• Healthy Behaviors Support A Student’s Role: 
  • Healthy, regular meals
  • Sleep schedule
  • Managing screen time
  • Regular physical activity

(26)

In the realm of education, it's crucial to recognize that students' primary occupation is learning. However, we must also consider other occupations that significantly impact their roles, such as managing health behaviors, sleep, social interactions, play, activities of daily living (ADLs), and instrumental activities of daily living (IADLs). These aspects significantly influence school performance. Children with ADHD often grapple with suboptimal sleep patterns, ranging from staying up too late to having difficulties falling asleep. Maladaptive eating patterns also surface, exemplified by instances like forgetting to eat while hyper-focused. This phenomenon might seem incredulous to some, but it's a genuine challenge experienced by many.

Challenges in interacting with same-age peers are also noteworthy. Emphasizing sleep and eating habits is essential, considering their link to interoception – the awareness of internal bodily sensations. These foundational components can impact various school-related activities like classroom engagement, recess, cafeteria interactions, after-school programs, and completing homework.

Setting a strong foundation involves promoting healthy behaviors such as consistent balanced eating, maintaining regular sleep schedules, managing screen time, and engaging in regular physical activity. While these practices are carried out at home, they profoundly contribute to a student's academic achievements and overall well-being.

To facilitate these aspects, I've included a comprehensive resource with over 50 pages of worksheets in the resource section. These worksheets can be immensely useful in addressing foundational occupations and roles. For instance, you might consider creating habit trackers or morning routine schedules that students can use both at home and in collaboration with their families. These interventions foster healthy routines that significantly impact academic success and holistic development.

Strategies for Intervention: Person-Level

• Behavioral Management Techniques:
  • Implementing behavior management strategies tailored to the individual needs of students with ADHD
  • Promoting positive behaviors, self-monitoring, and self-regulation
• Strength-Based Practice:
  • Recognizing and building upon the strengths and capabilities of students with ADHD
  • Fostering self-esteem, motivation, and resilience
• Sensory Strategies:
  • Incorporating sensory-based interventions to address sensory processing difficulties, weighted vests
• Self-Regulation Tools:
  • Teaching and implementing self-regulation strategies, such as deep breathing exercises, mindfulness techniques, and visual supports
  • Enhancing emotional regulation, attention, and impulse control
• Motor Skills:
  • Addressing motor skill difficulties through targeted interventions
  • Improving fine and gross motor skills, coordination, and balance

(19-25)

We'll start by exploring person-level strategies and then transition to strategies focused on task adaptation and environmental considerations – a particularly effective approach given the developmental variations in the frontal cortex.

First, let's touch upon behavioral management techniques. These could encompass cognitive-behavioral strategies and self-monitoring techniques. Utilizing tools like worksheets can be effective, especially for fostering self-awareness through self-monitoring. Strength-based practice is also crucial. Recognizing and nurturing a student's strengths, interests, and unique abilities can counteract the shame often associated with ADHD diagnoses. This approach fosters a positive role identification and encourages active participation in educational pursuits.

Empowering students with self-regulation tools like mindfulness, yoga, and deep breathing techniques is vital. These tools enhance emotional regulation, attention, and impulse control – essential skills for navigating academic and social settings. Moreover, addressing motor skills is integral. Focusing on fine motor skills and potentially expanding to coordination and balance can provide students with a well-rounded skill set that supports their engagement and participation.

As we move forward, we'll delve deeper into strategies that adapt tasks and environments, tailoring interventions to accommodate the unique needs and challenges posed by ADHD.

Strategies for Intervention: Environmental Strategies

• Built Environment:
  • Optimize the physical space for students with ADHD - consider lighting, visual distractions, noise
  • Create a well-structured and organized environment - color coding, desk, and folder organization
  • Utilize visual cues, minimize distractions, and consider classroom layout
  • Clocks!!!
• Social Environment:
  • Collaborate with teachers - reduce stigma, educate on strengths of student
  • Implement sensory strategies - movement breaks, adaptive seating, classroom roles (handing out and collecting papers, line leader, etc.)
• Collaboration with Parents:
  • Use Cog-Fun strategies to enhance executive functioning skills
  • Focus on planning, organization, and time management (25)
  • Parent-Child psychoeducation

Let's explore the role of optimizing both the built and social environment and how Occupational Therapy Practitioners (OTPs) can collaborate with teachers and parents to enhance focus, organization, and executive functioning skills for students with ADHD.

A highly effective strategy revolves around using digital clocks, especially in classrooms and therapy rooms. Students with ADHD often experience time blindness and temporal discounting. Having accessible digital clocks can provide a much-needed external reference point, helping them manage their time better. Socially, it's valuable to identify roles within the classroom that align with the unique abilities of students with ADHD. For instance, a child with hyperactivity might excel as the designated classroom courier or assist in maintaining tidiness between subjects and activities.

Another approach is "Cog-Fun," an evidence-based strategy that has a positive impact on parents. Given the genetic link often observed in families with ADHD, this strategy can be helpful for parents and caregivers too.

Sensory Processing and ADHD

• ADHD and Sensory Processing:
  • SPD frequently co-occurs with ADHD, impacting daily life and social interactions.
  • Individuals with ADHD may exhibit sensory-seeking or sensory-avoidant behaviors.
  • Occupational therapy interventions can improve sensory regulation and participation. (28)
• ADHD and Sensory Processing Problems:
  • ADHD subtypes do not show distinct sensory processing problems.
  • Co-morbidities like oppositional defiant disorder and anxiety predict more severe sensory processing problems. (29)

While sensory processing issues often coincide with ADHD, it's vital to recognize that these are separate conditions. Each individual with ADHD possesses distinct sensory preferences and needs. However, when considering a school environment, tailoring sensory interventions becomes paramount to enhance school function. This involves adapting sensory strategies to align with classroom requirements and academic tasks. In doing so, OTPs can significantly contribute to boosting engagement and performance among students with ADHD.

It's important to note that research doesn't support a direct correlation between ADHD subtypes and specific sensory processing types. For instance, not all children with the Hyperactive ADHD subtype exhibit sensory-seeking behaviors. This observation underscores the complexity of the relationship between sensory processing and ADHD. While an in-depth evaluation of sensory challenges goes beyond the scope of our discussion, it's crucial that if you suspect sensory issues, students undergo some form of sensory checklist, screening, or assessment. Identifying comorbidities – the co-occurring conditions – is of paramount importance, as they can be linked to more pronounced sensory challenges.

While OTPs aren't responsible for diagnosing conditions, they do play a pivotal role in the team by identifying symptoms, understanding their impact on students' participation, and compiling evidence to advocate for accurate diagnoses. This collaborative effort helps ensure that students receive the appropriate support and interventions tailored to their specific needs.

Strategies

Here are some strategies in this chart.

I have this broken into three levels. We have the student level, the environmental level, and the task level.

• Student Interventions
  • Understanding learning style (e.g., VARK)
  • Understanding strengths (e.g., VIA strengths inventory)
  • Socializing and problem-solving through role-playing and games
  • Collaborative problem-solving activities
• Environment Interventions
  • Encouraging parent-teacher communication and collaboration for consistency in strategies and expectations - parents should have access to curriculum
  • Push-in student support: desk, backpack, folder, binder organization, using a planner
• Task Interventions
  • Task initiation strategies (5, 4, 3, 2, 1, go)
  • Implement study strategies that work (e.g., Pomodoro technique)
  • Visual schedules and routines
  • Color-coded organization systems

Let's continue exploring specific intervention strategies for working with students with ADHD. I'll walk you through some more techniques and approaches that can be employed to support these students effectively.

• Body Doubling: This strategy involves partnering with someone who provides a calming presence and helps maintain focus on a task. It can be two students working together, a parent and child working on separate tasks in the same space, or even a group of individuals with a shared interest collaborating online.
• Weighted Vests or Lap Pads: While there's evidence that weighted vests can be effective for some students with ADHD, it's important to consider individual sensory preferences and needs. It might not apply to everyone, but for those it does benefit, it can have a positive impact.
• Motor Coordination Skills Practice: This can include activities that enhance fine and gross motor skills. Tailoring these activities to the student's interests can make them engaging and effective.
• Sensory Diets and Schedules: These are based on assessment results and should be personalized to the individual. Working with other professionals, such as occupational therapists, can help create effective sensory strategies.
• Mindfulness Activities: Short mindfulness exercises, yoga, and deep breathing can enhance self-awareness and attention. Keep these activities brief and focused, especially for students with ADHD.
• Regular Breaks: Implementing regular breaks during therapy sessions can help maintain attention and engagement. You can gradually extend the duration of focused work between breaks to help build attention span.
• Classroom Interventions: Collaborate with teachers to optimize the classroom environment. Consider strategies such as establishing calming zones, reducing distractions, flexible seating options, and offering psychoeducation on ADHD for parents and teachers.
• Task-Level Strategies: These are interventions that can be implemented during specific tasks or assignments. Consider using rubrics, providing assistive technology like voice-to-text or audiobooks, emphasizing handwriting legibility, and incorporating planners and schedules to help manage time and tasks effectively.
• Student-Based Interventions: Encourage students to complete learning preference inventories like VARK (Visual, Auditory, Reading/Writing, Kinesthetic). This information can guide instructional strategies and enhance engagement. Use strengths inventories like VIA Strengths to leverage individual strengths for motivation.
• Socializing and Problem Solving: Engage students in role-playing and games to foster problem-solving skills through play. Collaborative problem-solving activities can enhance critical thinking and communication.
• Parent-Teacher Communication: Encourage open communication between parents and teachers to ensure consistency in strategies and expectations. Parents should have access to curriculum information and important dates to support their children effectively.
• Task Interventions: Implement techniques such as the 5, 4, 3, 2, 1, go method to initiate tasks, use the Pomodoro technique for focused work and breaks, and provide visual schedules and routines to offer structure and predictability.

These strategies encompass a wide range of approaches that can be tailored to individual students' needs and preferences. Collaborating with teachers, parents, and other professionals is essential to ensure that these interventions are effective in enhancing students' engagement, focus, and overall academic success.

Most Important

• ADHD = mismatch between intention and action

It's crucial to remember that ADHD presents a unique challenge where students may comprehend what needs to be done but struggle to take action. This gap between intention and action can lead to frustration and guilt if strategies are provided without addressing the underlying issues. Imagine this challenge as a bridge connecting two lands. In the context of ADHD, students often stand on one side of the bridge, aware of their goal but finding it difficult to step forward due to issues like task initiation, procrastination, or time management. Merely offering advice without addressing these underlying occupational issues is like providing directions from afar without guiding them across the bridge.

As Occupational Therapists, our role is to actively assist students in navigating this bridge. We bridge the gap between intention and action by providing personalized strategies, practice, and support through client-centered care. Collaboratively working with students, we empower them to move from knowing what they should do to actually taking action. We serve as guides to help them overcome challenges and provide the necessary tools for success.

I want to express my deep appreciation to all of you for your engagement and dedication in supporting students with ADHD in the elementary school setting. Your commitment to their success and well-being is truly commendable. Furthermore, remember that each child with ADHD possesses unique strengths and talents that, with nurturing and support, can contribute to their personal growth and achievements in life. Let's continue advocating for understanding, inclusivity, and evidence-based interventions in our classrooms and communities, ensuring that these students receive the support they need to thrive.

Questions and Answers

Do you have any recommendations for books on parent training?
I recommend looking into literature on Cog-Fun and exploring references such as #25, which is an effective strategy for young children. Additionally, you might find the book "NeuroTribes" useful, as it delves into the concept of neurodiversity in more depth.

My biggest challenge is teacher carryover, as they want pullout services only. How can I address this?
Teacher carryover can indeed be challenging. To overcome this, consider creating handouts that emphasize the benefits of in-class OT services for both the student and the teacher. Highlight the strategies you can offer to make their lives easier and collaborate on classroom strategies to support the student's needs.

Is there a specific strategy you've used to get teachers on board with implementing strategies?
Collaborating with teachers is crucial. To get them on board, offer ways to make their job easier. Provide handouts, statistics, and resources that demonstrate the positive impact of OT strategies in the classroom. Showing your willingness to collaborate and support their efforts can encourage teacher engagement.

Most parents are hesitant to try medication for their child with ADHD. Any advice on this?
Educating parents is key. Provide articles, handouts, and resources that discuss the benefits of ADHD medication and its positive outcomes. Highlight the research-based evidence and encourage parents to explore the information available to make an informed decision.

What is the earliest age you've seen students with ADHD?
ADHD diagnoses are now being made at younger ages. While it can be difficult to identify attentional differences in infants and toddlers, preschool and kindergarten-aged children are commonly diagnosed with ADHD. However, the diagnostic process has evolved with the changes in diagnostic criteria.

If parents don't want their child evaluated due to fear of a lasting diagnosis, how can I address this?
Addressing concerns about diagnosis involves providing education and reassurance. Emphasize the potential benefits of early intervention and support, which can help children thrive. Discuss how identifying and addressing challenges early can lead to better outcomes in the long run.

Why do you recommend digital clocks over analog clocks for students with ADHD?
Digital clocks can be easier for students with ADHD due to their challenges with working memory. Digital clocks provide an immediate and clear visual representation of time, minimizing the cognitive load. Analog clocks require interpreting the position of the clock hands, which can be challenging for some students.

I've noticed a significant increase in ADHD diagnoses, particularly in girls in second grade. Could COVID and increased screen time be factors?
The increase in ADHD diagnoses may indeed be influenced by various factors, including changes in lifestyle due to COVID-19. Increased screen time and virtual learning may contribute to attentional difficulties, while disruptions to daily routines could impact the development of executive functioning skills. It's essential to consider these elements when assessing and addressing ADHD in children.

How can I make parents more open to medication for their child's ADHD?
Educating parents about the potential benefits of medication is essential. Share research-based information, resources, and success stories that highlight how medication can positively impact children's lives. Encourage parents to consult with healthcare professionals and consider the comprehensive approach that combines medication with other strategies.

Summary

Feel free to reach out to my email address provided if you have more questions. Thank you all for your engagement and dedication in supporting students with ADHD! Your commitment to their success is truly commendable. Remember, each child with ADHD has unique strengths that, when nurtured, contribute to their personal growth and achievements. Let's keep advocating for understanding, inclusivity, and evidence-based interventions in our classrooms and communities.

References

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