The ADHD - What Now Blog

Reducing stress, growing skills, and building responsive relationships so that your family with neurodiverse kids can thrive.

How Occupational Therapists Work with Kids with ADHD

Jun 03, 2022

Have you wondered if this program or solution you've been given is really going to help your kiddo struggling with learning or attention?

You've been trying and he/she doesn't seem to be making the progress you both hoped for.  

And of course, it seems logical that if they are struggling with

  • reading, try more phonics
  • paying attention, maybe a fidget will help
  • impulsive, emotional outbursts, try working with the psychotherapist.

It is hard to figure out what will really help and what is worth spending time, money, and energy on.

Heather Hodgins-Chan is an occupational therapist. She recently shared how it breaks her heart when parents come to her after spending hundreds of dollars on psychotherapy for a year or more, only to find their kiddo isn't making much progress.  

Heather then shared how often the kiddo is struggling in regulating their nervous system, so they are unable to communicate effectively about their emotions.

It is like asking the kiddo to climb a ladder to reach a goal, but they are literally missing the first 3 steps of that ladder.

In this conversation with Heather, she shares the building blocks to learning so you can make sure those first ladder steps are there.  

Heather then also gives examples of programs that can be used at home or school to help address learning, attention, and regulation.  

Knowing the order, you can avoid wasting time, effort, or money on top of the ladder solutions if your kiddo really needs the first few steps of the ladder filled in first.

In this interview, we discussed:

  • The building blocks of learning development - summarized in one graphic.
  • Where to start so you're not trying to climb a ladder that is missing the first 3 steps.
  • Programs that can be done in a few minutes a day to help build those first few ladder steps.



On The Ball

Brain Gym

Quick Shifts

Pyramid of Potential



Veronica: Have you been looking for ways to help your child who has learning attention or trauma issues and you just want to know what can I potentially do at home? Are there programs that I can do to help them out? Well, I'm delighted to have today, our guest, Heather, from On The Ball Pediatric Physio-Occupational Therapy. Did I say that right, Heather?

Heather: You did.

Veronica: Awesome. My name is Veronica with ADHD -What Now? And we're just going through what are the different ways that we can help our kiddos and what is available? What are the options that are out there? And I'm delighted that Heather is going to share with us today a little bit and she, you know, I just wanted to start, we were just talking and I wanted to start with, she says a lot of people come in and say, "OTs can help?" So can you share a little bit, what is your experience there, Heather?

Heather: Yes. So a lot of people don't realize that occupational therapy can help children who have a diagnosis of ADHD. And that often comes as a surprise to therapists because this is what we do. And we help children function in all different parts of their life. And so we help them become more independent with their daily living activities, school activities, social skills. And so this is what we do is we help children function.

And obviously, you know, a lot of children with ADHD have difficulty functioning due to difficulties paying attention or sitting still, or there's so many different factors. And so that's what we're here to do, is to help them become more independent.

Veronica: Actually, before we get into learning, can you talk a little bit about OT? Like what was your training? What's the scope of which you look, and I think you sent me something, a nice visual for this that we can share. So I'm going to share my screen and then you can walk us through it for a minute. That work? 

Heather: So as an occupational therapist, we actually have a background, a science background typically, and we learn all about neurophysiology and anatomy and the muscles and the brain. And we sort of combine science with the arts as well.

And so we use a lot of functional activities to help people either rehabilitate their bodies so that they can become independent. Or we, in terms of pediatrics, we often help children learn. And we sort of are the detectives behind why a child would be having difficulties with learning.

So this visual here is the Canadian Occupational Performance Model, which has been around for several years, but it helps to explain what OT is all about. And so the individual is at the center of our assessment and treatment. And we look at the areas of self care, productivity, and leisure activities. For adults that would be, you know, self care, work, and leisure, but for children, their work is actually to go to school and learn and play.

And so we're really focused on that as well. And we have to take into account the environment in which the child is having difficulties and the social, cultural, and physical barriers that might be in the environment. And so recognizing that the child is at the center and addressing those areas. So we look at the physical, the cognitive and the affective, or the social-emotional aspects to learning. So we do a lot.

Veronica: Absolutely. That's pretty comprehensive. I'm trying to think of a time when my kid didn't make sense to me. Right? So for example, my son was going out into the backyard and digging holes, right? So instead of being able to be listening or learning or attending to what I'm saying, he's like obsessed with digging holes. And it was the occupational therapist who explained to me why that was and what was going on behind that type of behavior. And once she started addressing the need that was driving him to be able to do that, then it opened up the possibility for him to be able to do so much more.

Heather: Yes. So there's always a reason for the behavior. And so in that sort of situation an occupational therapist would look at why he's doing it.

We may like give them the parents a sensory profile assessment or a checklist to kind of find out if they have any sensory processing issues. And what that means is how children take in and process the sensory information and how they make sense of that information in order to move and interact and learn.

And so in that situation, the OT probably addressed the sensory components as to why your child might doing that. Perhaps, maybe he was a tactile seeker of that information, and it helped him to understand or helped him to regulate his body by experiencing the touch of the sand, or perhaps the heavy work that was involved in that activity. So using the shovel to dig and that sort of activity gives feedback to the muscles and the joints, and it actually has a calming effect.

And so we often provide sensory diet activities in order to help children regulate. And so in the area of pediatrics and learning, that is a huge thing about what we look at. We look at all the areas of sensory processing to see if perhaps the child is seeking that behavior because they need that information in order to make sense of their world or whether or not they're avoiding certain sorts of activities; that can tell us a lot about how children function and what they need to work on or what they need to learn about themselves.

Veronica: When you're talking about learning. Is that all that you're thinking of? Or are there some additional factors? I know you sent me another graphic. Would that be something that would apply when we're asking what do you look at as an occupational therapist looking at learning and their attention?

Heather: Yes, absolutely. So we kind of approach the child and the family, and we really try and take an investigative approach to learning. One of the visuals that I love coming back to over and over again, is a visual from Maryann Trot and her colleague who put this together several years ago. And I did have communication with her to share this visual.

So learning is at the top of this pyramid. Learning is a higher-level task. It involves us to have good executive functioning skills. It involves like being able to sit and attend and take in information. And so as an occupational therapist, what we do is we look at this pyramid and we try and pull out those little skills that children may need to work on in order to have success, to build that ladder up so that children are successful with learning.

So I always tell parents that it's kind of like building a brick wall. We need to have a really strong foundation of those very basic skills. And it all starts with the central nervous system. So when children are born prematurely or they might've had an early life traumatic experience, those sorts of early life issues, even though they may not seem to parents as being a big deal or a huge deal in terms of the nervous system development of that child.

So a child that perhaps was in the NICU for awhile, and didn't move around a lot. Sometimes those children are very sensitive to noises and they startle easily, you know, some may get used to it and there may not be any sort of issue. So as an OT, we always go back to the neonatal period to see if the mother was stressed and how that can affect the child. And also look at the early life experiences that that child has gone through.

So for example, we look at the sensory systems and you'll see seven there, in this model. Now, since this diagram went out, there's actually been identified another area of sensory processing, and that is called interoception. So interoception is knowing inside what our body needs. Are we hungry? Do we need to use the washroom? So we really look at all of these sensory systems and how they are developed in a child.

One of the big systems that I really like to talk about is the proprioceptive sense. So proprioception is our ability to know where we are in space. It's our ability to know how much pressure to put on a toy, or how hard to push a door shut. It's our ability to know where we are in space when we're sitting up, you know, am I leaning to one side? So it's our self-awareness.

And so a lot of children with ADHD don't know where they are in space. And so you may see those children going up to someone and being right in their face. And they don't mean to be right in their face. It's just that they don't have that appropriate susceptible bareness. And so a lot of children with that difficulty or that if the proprioceptive system is underdeveloped, they may appear kind of clumsy. They may have difficulties with coordination. They may have trouble keeping up in gym class, or they may be falling out of their chair or slumped over at their desk.

And those are things that you see in a lot of children who have ADHD. And so those sorts of things can affect learning, right? If I am working so hard to keep myself upright in my chair, and I'm using that energy to focus on keeping myself upright. I may not be paying attention to the teacher. And so it's very important to look at these underlying issues so that we can see what we need to work on to build up that awareness.

So the vestibular sense is another one that comes to mind for children with ADHD and children who are vestibular seeking. They often will move around constantly and the vestibular system and the proprioceptive systems, they speak to one another. And so if a child is in constant motion, you know, they may be seeking that vestibular input, but they also might have difficulties with that body awareness as well.

And so they're always moving because I need to feel my body. I need to move all over. I don't know where I'm supposed to be. And so when you combine these things with core muscle strength and auditory sensitivity, that some children may have, you know, they need to move, they don't have the strength to keep their muscles upright while they're sitting.

And then in addition, they may be overwhelmed by noises that are in the classroom, those sorts of things affect learning. And so what we really do is we focus on activities and games and exercises that help children develop maturity with these sensory systems. I hope that that makes sense. Sometimes it's hard to break these things down.

Veronica: It absolutely does make sense. And as you're talking, I'm thinking, you know, when I'm looking at what programs would help, like if that's my end goal, what can I do? What programs can I access perhaps at home or in collaboration with an OT in order to help my kid out with their learning their attention or trauma, then I really need to be able to begin to understand what's behind those behaviors what's going on. And so it's just sounding like an occupational therapist is a great place to go to begin to get that understanding, right?

Heather: Yes. So for example, you know, a child that might seek that proprioceptive input, activities like swimming and martial arts are wonderful activities or programs to get your children into because they are quite individual in nature. You can have a group class, but it doesn't involve say, a higher level of body awareness skills like say perhaps hockey or soccer would. And so, you know, individual sports like tennis, and like I mentioned, those martial arts or swimming, those sorts of activities are a little bit easier for children who have ADHD. They also work on giving the child that input that they need.

So the proprioceptive martial arts programs, you know, or kickboxing, where they have to like, you know, hit at a target with their mitts, that sort of input is giving input back to the body. And it is very calming for a lot of children. So I often do recommend martial arts for these children and swimming, because it does give that feedback to the body. And it also helps to work on the core muscles and breathing.

So just getting back to core muscles, you'll see postural security on the sensory motor development. And we see a lot of children at our clinic who appear to be quite sporty. However, when you look closely at their muscles, they're not using their core muscles to stabilize themselves. And so they may have strong legs, but when it comes to their core, they often, you know, slouch over in their desk and they're weak. And so physiotherapy and occupational therapy can both help work on the postural system, which is important for learning. And again, getting back to, you know, focusing and sitting up right, you know, if we're weak, you know, we get tired. And so it's hard for children to focus.

The awareness of the two sides of the body as well. So we are finding that a lot of children with learning challenges or ADHD have not had a lot of time in the crawling position or crawling phase. They often are early walkers. And so crawling is an essential developmental activity in order to build up the awareness that they need to cross the both sides of the body.

And also for their core strengthening, because they're upright, they're working against gravity to keep their little cores engaged while they're crawling. So children that don't crawl for a very long time, often have difficulties with the proprioceptive sense, knowing where they are in space and it affects their ability to attend in school.

So when we see children, we'll do an assessment and we'll look at a lot of movement patterns. And so, you know, we'll get the child to actually crawl for us, even though they might be seven years old. And so surprisingly, a lot of these children, they're not able to crawl and the parents are often shocked. Like, wow, I didn't know they couldn't crawl. They just walked early. And I just thought they were really, really fast to develop. But some of these early experiences can really affect learning later on.

Veronica: Is this really - when we're looking at this pyramid -is it correct to presume that you need to go through the things at the bottom in order to develop and be able to successfully do the things at the top?

Heather: Yes, it is. So by working on those very primitive skills, like the sensory systems, getting very good awareness of those systems, we will have improved awareness of both sides of the body. We'll have improved motor planning. That's our ability to see something and to plan out a movement. And all of these things need to happen in order for children to have the ability to learn.

You may see children that, you know, skip some of these phases and they're learning that they're still missing pieces to the puzzle. So for example, I'm just looking at the pyramid here. We have a lot of children that they may fidget in their chairs, and they may be bothered by the tags on their clothing. A lot of these children, they can't sit still.

And so one of the first things that comes to mind is ADHD. And then whenever the OT will do a reflex assessment, we'll find that there are retained primitive reflexes that are still there and should have probably disappeared whenever they were very young. So we use a lot of exercise programs and games and activities in order to help with the integration of those reflexes. So a lot of these are the building blocks -all of these stages are the building blocks to learning.

Veronica: Awesome. So let's get into a little bit, like, what are some of the programs that you use then within your practice and are there any that we can do at home too? But I find this pyramid so helpful because what it means to me is I can't go looking just at the behavior, perhaps I need to understand kind of what are some of these foundational things, because if I want to get some of the biggest bang for my buck, so to speak, to help my kiddo in school, I really have to know, is there something like underlying here, like a root cause thing.

Like, do you think there are, I'm thinking of this phrase, like a band-aid solution versus like a root cause solution, do you think there are some programs out there that are not -or perhaps, could you give us some examples of like band-aid things that we do as opposed to like root cause types of things that we might do?

Heather: Sure. So what comes to mind is perhaps, you know, a child who is in grade one, and who's struggling with printing skills, for example. You know, often one of the first things that comes to mind for a lot of educators would be to provide that child with some sort of Chromebook in order to be able to type.

And so, you know, when I see that it's all fine and dandy that you're going to have this tool, but what are the reasons why this child can't print? And so when you go back into the developmental history and you look at this pyramid in a functional sort of way, you know, the child may at the bottom, the child may have tactile difficulties. They may not like the feeling of having a pencil in their hands. They may have proprioceptive difficulties. They may not know how hard to press on the pencil. So they may have like a death grip on that pencil. They may have, going up the pyramid, they may have motor planning issues. And so we can really help to work on activities and games that will help work on those skills specifically.

And so in that kind of example, you know, they might've just received a Chromebook when really they could have gone to a therapist and figured out what is the key area here? What is going on? There are a lot of children that can't cross midline. And so when they go to read or write, you know, they have difficulty, you know, using their ocular motor skills from going from left to right.

And so there's so much more behind the learning. And so I think it's, it's safe to say that, you know, sometimes there are little solutions that are there, but we're not really addressing the underlying cause.

Veronica: So one more thought or other programs then that can help. So in your practice, what types of programs might you use in your practice as an OT to address some of these root causes? And then can you comment on, are we able to use any of them at home if perhaps access to these programs are challenging for us?

Heather: Yes, absolutely. So we do a lot of games and activities that, you know, tap into those specific skills. And so OTs look at activity analysis and that they take a game and they will analyze what sort of skills that you need to do to work on this. And so we have these activities in our OT brains and we pull them out to work on skills.

But what comes to mind are a few of the programs that you can look up: Brain Gym is one of them, Brain Gym is a program that's used a lot in schools and it helps children to learn how to cross midline, you know, helps them to relax their bodies.

Another one that I had just recently became aware of was Calm Connect, and Calm Connect is a really fun program that you make a subscription toon a yearly basis. And it uses rhythm and movement in order to help organize the nervous system. So it can help children relax or focus. In some instances, some children have a very low level of arousal and so they need to wake themselves up. So I think a lot of the time when we think about ADHD, many parents think that they need to bring their child down.

Whereas sometimes you might find a child who has inattentive ADD has very low arousal, sort of leaning over the desk and not engaged. And so some of these programs really help to wake up the nervous system. So we need to figure out what each child needs and then figure out, do we need to wake them up or do we need to help them slow down their brains?

Veronica: So do some of these programs, like Calm Connect, does that address both directions or only one?

Heather: It really depends on how the child processes that information. So, you know, it can wake children up or it can help slow them down. There are different parts of the Calm Connect. There's a calm, and there's a focus section. There are a few different sections I'm still learning about, but it taps into the idea that OTs have known for forever.

And that is that rhythm helps to organize the brain. Music is such a powerful tool in order to help children focus, and we use it a lot in our therapy. I'll actually use a traditional metronome to help children focus. And so we're combining movement and rhythm to help them with concentration. Then after a while, we're able to add in more skills.

And I had a little boy this morning who, you know, we were using rhythm and movement and I was trying to get him to like work on multitasking at the same time. And he was doing his multiplication tables while we were moving and using the rhythm.

And so once we get children used to, you know, putting this all together, it just helps to organize them better. And then afterwards, we'll notice that they're calmer or they're just more, they're able to pay attention better in school. So it's all about the individual child. Some children, you know, what might rev one up might calm down the other one, really depends on their sensory needs.

Veronica: Interesting. So then you've mentioned some that are used in schools and then you can also get access at home.

Heather: Yes. So the Calm Connect is something that parents can order online. It's also something that the therapist can order and use within their therapy sessions. Another program that comes to mind is Therapeutic Listening and the Quick Shifts program that we use.

So Quick Shifts, it's usually recommended by a therapist, but it's a way to shift a child from one high level of arousal into a lower level or the opposite. And so some of these well, the music is used to stimulate different parts of the brain. And what happens is that it helps with focus and attention, or it helps bring children down from, in the middle of a meltdown, for example. And so I've utilized that program quite a bit.

Another really great, very accessible program would be YouTube. So go onto YouTube and have a look at some of the programs like Pyramid of Potential, where they tap into reflex integration exercises.

You know, typically it'd be better to have these reflexes assessed by a therapist, but if you're just wanting to try to get your child to, you know, practice crossing midline and see what that did, you know, I have a lot of children where we use multiple programs and games and therapy, but those are a few that come to mind and another really fun one is Catch a Brainwave. And it's a fun little program that you can find on YouTube.

I believe there's a book in our public library as well. And so that again, uses music and movement movement really helps to organize the sensory system. And so that's why early movement is very important. You know, we need to see that crawling in order for those sensory systems to develop. And often you'll hear of, you know, low arousal types of babies that were just so content to sit there and they were happy, but sometimes, you know, when they haven't gone through that movement, they don't have maturity of those sensory motor systems.

And so as a therapist, we'll actually go back in time and I will get children to practice crawling on the floor, like a lizard, so that they're like, you know, working on that cross body coordination and that movement, and I'll get them to crawl. I'll get them to go through tunnels, even though they're maybe eight years old.

So something that, you know, a lot of people are not aware of is that these early life experiences can really impact the nervous system, which is important for learning. 

Veronica: I know at one point in time I had somebody tell me, oh, just sign your child up for soccer and he'll be fine. Now I have a lot of thoughts about that. But I guess part of the reason why I'm bringing that up is can you just spend a quick moment commenting on why there's a big difference between soccer or like just what are the differences between just signing up for soccer and what you're talking about? Because my impression is that things like that, they're wonderful and they're great, but they're not necessarily targeting those fundamental skills. So, go ahead.

Heather: So soccer is a very complex sport. You know, we need to have like a really good sense of body awareness on the field, you know, to know how to meet the ball. We need to have good Praxis, which is, you know, our ability to plan and organize and movement in a productive way, timing and sequencing of running and hitting the ball is like really important.

But if we have some of those underlying skills that we talked about in the pyramid that are perhaps maybe not fully developed, those activities are very challenging in soccer. And so soccer is a great activity, but it may be overwhelming for a lot of these kids because you know, they're not used to, they might be overwhelmed being so close to whenever the children come to wrestle with the ball or to fight for the ball, right. It sometimes can be very loud. Sometimes the whistle is very overwhelming for kids. Sometimes it's overwhelming for parents hearing that whistle.

And so you have children who have these sensory processing difficulties that haven't really been sorted out and they may, you know, they may be frustrated. They may have a tantrum after, and you may wonder, well, why did they have a tantrum after soccer? It seemed like a fun activity. But I think when speaking with an occupational therapist, we can sort of problem solve together and figure out, okay, what was going on at that time? What sort of sensory input may have been overwhelming for the child? You know, does the child know how hard to kick the ball? Because you often see these children that really give it a strong boot and they over fire their movements because they don't have that sense of proprioception, or know how much force to put on the ball.

So there's so much at play here. It's a complicated sport for someone who has these challenges. It doesn't mean that the sport isn't valuable for that child, it's just that it may be overwhelming, and then they might get frustrated with it and then give up. And so it's always important to, you know, address these underlying skills and make sure that your child's not going to fail at everything. Right. We don't want them to fail and then have poor self-esteem and then get depressed. So that's why soccer can be very challenging for a lot of kids.

Veronica: Thank you so much because I think this is really important as I'm the parent and, and maybe even educator, as I'm looking to figure out where do I get the most, like, return on investment, right? Like ROI, where do I get the most return on investment for our time and the things that we're going to choose to do. Right.

So having an understanding of that pyramid and kind of where to start, can help me to decide where to start to invest time and energy and resources, right? And understanding too, that occupational therapists can really help to identify those base parts of that pyramid. And then perhaps guide what programs we would choose to bring in either working with you or be able to bring into our home.

Now, some of the ones that you've mentioned are they like almost universally good? Or do you really still need to understand more about the kiddo before maybe selecting one or selecting what to do inside of that program?

Heather: You know, every child is special. Every child is different. We all have different skills and abilities and we have strengths. And it's just, it's important to kind of tap into why these things are happening. You know, and often a lot of professionals out there don't even know what we do, but I really find that it's effective in working with psychologists and working with the teachers, because it kind of, we all can work together by kind of figuring out what's going on with the child and then, you know, moving forward.

So just as an example, I work with a lot of psychotherapists who have had children who've been through developmental trauma, some children who have been adopted or who have been, you know, abused at a very young age. And so a lot of those psychotherapists will tell their families, "you know what, before we get into talking, you know, I really think you should go see an occupational therapist so we can figure out how your body responds to stress and what is going on in your body".

So we can work on the body in OT. And then what it does is it helps the child feel more in control. And so then they're able to go and express their feelings with a psychologist or a psychotherapist.

And so a lot of people are not aware that that is something that we do. There are some occupational therapists that are trained as psychotherapists as well, but really we are kind of the sensory detectives about what's going on. We look at movement, we look at the brain and we really work on the body. So the child can feel organized and learn and go ahead and speak with different professionals.

So in order to be present in our cognitive brain or to be organized and process what someone is saying in psychology sessions, we need to actually, you know, be calm and we can bring that information in and use it effectively. But if a child is in a constant state of hyper arousal in fight or flight, their frontal cortex is not really engaged.

You know, they're higher level cognitive skills are not online. So that's, I guess something that I think is very important for people to understand and it's okay, right. It takes a whole team to help these children. And, you know, we just have to figure out different pieces of the puzzle.

Veronica: Absolutely. I love that summary and putting together that picture of essentially like where to start and where to get kind of get everybody involved so that we can really help these kiddos out at the source of what they need.

Heather: Absolutely. It's not just one profession helping. It takes many different people sometimes to help figure things out.

Veronica: Thank you, Heather, for being here today and we look forward to continuing to keep in touch.

Heather: Sounds great. Thanks, Veronica. Bye.


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