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ADHD Awareness Month: Can ADHD mask sensory processing challenges?

On the NIMH website you will read that “ADHD or Attention Deficit Hyperactivity Disorder is one of the most common childhood disorders and can continue through adolescence and adulthood. Symptoms include difficulty staying focused and paying attention, difficulty controlling behavior, and hyperactivity (over-activity).”

Because September is ADHD awareness month, I wanted to highlight how sometimes sensory processing challenges may also co-exist with ADHD.

Joe, a bright second grader, who had been diagnosed with ADHD in kindergarten, was still having challenges, despite daily medication for ADHD (Focalin: to increase attention and decrease restlessness). Joe had an IEP with special school programs to address the ADHD.

The psychologist had recommended that Joe receive services to help him learn “executive function” strategies for better management. Joe was seen by the counselor in groups including “Care Bears” to help with calming down, anger management and problem solving. He was also in “Silver Spurs” to learn how to address feelings. Additional recommendations to assist with organization in class included having a buddy clue him and using color coding for folders.

Joe was also seeing the school-based occupational therapist (OT) to address the challenges resulting from his ADHD. The long term goal she developed for him was to “Develop appropriate work habits to be able to attend to and complete activities without disrupting the classroom environments”.
Her objectives included:
1. Respect personal space of himself & others by decreasing unwanted contact with peers while completing school related tasks.
2. Transition through the school environments without disrupting his peers physically or verbally (classroom to recess, classroom to lunch, etc).

Because Joe was still having difficulties in school on a daily basis, despite programs in place to address the ADHD, the following question was asked:
Is ADHD solely responsible for the behavior challenges, or are sensory issues also contributing?

In her book Sensational Kids: Hope and help for children with sensory processing disorder (SPD) Dr. Lucy Jane Miller reported that among a group of children with preexisting diagnoses of ADHD and/or sensory processing disorder (SPD), 60% had symptoms of both SPD and ADHD, whereas 20% had a sensory processing disorder only, and the remaining 20% solely had ADHD. Therefore when a student is diagnosed with ADHD, it is also important to assess for sensory processing challenges.

A gold standard for evaluating sensory processing challenges is the Sensory Processing Measure (SPM).
One of its unique features is that rating forms were developed not only for the parents and main classroom teachers to complete, but also PE, art, music, cafeteria, bus and playground staff.

In addition to those above, the speech therapist, the school psychologist, the school nurse as well as the school OT also participated in the SPM test results team meeting and reported their observations too.
SPM test scores across all environments fell in the “Some Problems” range indicating mild to moderate difficulties in sensory challenges. Specifically, scores related to body awareness (Joe’s ability to sense his position in space of his limbs, fingers and other body parts) were not within normal limits. Specific Items related to perception (inability to judge and control the forcefulness, direction or speed of his motion) and sensory seeking (seeking intense input into the muscles and joints) helped put light on some of Joe’s behavior challenges  noted in school. These included running and bumping into other students as well as  needing to push, pull and stretch, even when considered inappropriate.

Below are some of the intervention strategies used to address Joe’s sensory processing challenges:
1. In his main classroom, his teacher began using stretching and movement breaks on a daily basis.

2. On the playground, Joe was encouraged to use the playground equipment and climb the climbing wall.

3. In PE, tug of war was introduced.

4. During transitions from class to music, Joe’s teacher allowed the entire class to move forward when in line, by playing “train” where each student held on to the student in front. This provided additional muscle input for increased body awareness and helped keep students evenly spaced from each other when walking in line, for better spatial organization.

5. In the resource room and at home, Joe was encouraged to count the number of steps while doing the  wheelbarrow walk . He enjoyed the challenge of doing more steps each time.

At home, Joe played push-pull games to encourage development of shoulder stability and to provide receive additional muscle input.

His parents were encouraged to provide touch pressure with the ball, to calm before bed.

And when done using the heavy sofa cushions, returning them on the sofa for additional muscle work.

The person responsible in the cafeteria also participated. During the initial team meeting, she explained that she was concerned with Joe’s daily behavior during lunch. She expressed frustration because he was showing “inappropriate behavior every day” and “today he was sucking applesauce through a straw”.

The use of the SPM Cafeteria Form (W-466C%285%29_CAF_v1.pdf) helped the entire team understand that although Joe was receiving services in the classroom and OT, there was also the need to address Joe’s behavior challenges in the cafeteria. The cafeteria worker’s job was to maintain organization in the cafeteria and to ensure that student’s ate their lunch. Once the cafeteria worker understood Joe’s sensory challenges and his need for “oral motor input” , together with the team she proposed the following strategies:

1. Allow Joe to use a straw and have an agreement that if he makes a mess, he will clean it up
2. Joe’s parents will provide a cup with a lid and straw, so it is not apparent that it is applesauce.
3. Provide Joe with a thick yogurt drink and drink that with a straw
4. Give Joe chewing gum as a transition tool on the way to lunch.
5. Make a sports bottle available throughout the day
6.Provide Joe with a ChewEase Invisible Pencil Topper
which easily slides over the tip of a standard pencil>
7. Add fire retardant “cozy shades
over fluorescent fixtures. These have been found to have an overall calming result in cafeterias.
8. Record daily on the SPM Quick Tips Record Form (SPMQuickTipsRecordForm.pdf) each time one of the strategies is used. At retest, participate in analyzing if changes in Joe’s behavior are noted, as a result of the sensory strategies used throughout his day.

After the meeting, team collaboration continued with a better understanding of how sensory challenges could be addressed with sensory-based strategies. The music teacher was so intrigued that she invited the OT to join her to co-teach and integrate sensory strategies into the music curriculum.

Intensity is key when using sensory-based strategies! Joe was provided with opportunities to engage in appropriate “heavy work” muscle activities throughout the day across all school environments, as well as at home and in the community.

Joe went to the resource room every morning to participate in some “heavy work” muscle activities. At recess, staff encouraged climbing and tether ball play with peers under the recess assistant’s direction. When in transitions, Joe was encouraged to carry a heavy object and or a hand fidget

Retest two months later using the SPM indicated good progress overall. The team agreed both at home and at school that Joe had been doing well, and that they had seen a decrease in challenging behaviors during unstructured times. Three months later when the team regrouped, they noted that there had been no incidences.

When evaluating for ADHD, it is important to also evaluate sensory processing challenges. As we saw with Joe, although he still was diagnosed with ADHD, identifying and addressing the sensory processing challenges resulted in great improvement in his behavior, through the use of sensory –based strategies across environments.

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