Journal of Occupational Therapy, Schools, & Early

Intervention

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/wjot20

The Role of Occupational Therapy with Children

with Attention Deficit Hyperactivity Disorder
(ADHD): A Canadian National Survey

Lina Ianni , Barbara Mazer , Aliki Thomas & Laurie Snider

To cite this article: Lina Ianni , Barbara Mazer , Aliki Thomas & Laurie Snider (2020): The Role
of Occupational Therapy with Children with Attention Deficit Hyperactivity Disorder (ADHD): A
Canadian National Survey, Journal of Occupational Therapy, Schools, & Early Intervention, DOI:
10.1080/19411243.2020.1822259

To link to this article: https://doi.org/10.1080/19411243.2020.1822259

Published online: 20 Sep 2020.

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JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION
https://doi.org/10.1080/19411243.2020.1822259

The Role of Occupational Therapy with Children with Attention

Deficit Hyperactivity Disorder (ADHD): A Canadian National
Survey
Lina Ianni, Barbara Mazer, Aliki Thomas , and Laurie Snider
School of Physical and Occupational Therapy, McGill University, Montréal, QC, Canada

ABSTRACT ARTICLE HISTORY

Children with Attention Deficit Hyperactivity Disorder (ADHD), Received 20 March 2020
a neurobehavioral disorder prevalent in childhood, demonstrate Accepted 8 September 2020
a persistent pattern of inattention and hyperactive and/or impulsive KEYWORDS
behavior that is more severe than their typically developing peers. Attention deficit
Much of this challenging behavior is observed in the classroom. hyperactivity disorder
However, current literature on ADHD for school-aged children largely (ADHD); occupational
examines issues of clinical diagnosis and pharmacological manage­ therapy; pediatrics; youth
ment. Consequently, the associated challenges in functional limita­
tions and participation restrictions that these children demonstrate
have not been well examined. Fortunately, as members of the school-
based team, occupational therapists are uniquely suited to address
this important perspective. Therefore, the purpose of this study was
to 1) identify the scope of occupational therapy (OT) practices in
assessment, intervention and service delivery with children/youth
with ADHD across Canada, 2) indicate potential research and practice
gaps, and 3) discuss future implications with respect to OT interven­
tion for children with ADHD. A bilingual national survey was created
based on a comprehensive literature review and consultation with
experts in pediatrics and knowledge translation. The survey link was
sent to pediatric occupational therapists across Canada through mail­
ing lists obtained from national and provincial organizations. A total of
172 surveys were completed (response rate = 10%). The majority of
respondents reported that children with ADHD comprised 26–75% of
their caseloads. More than 90% of respondents reported using OT
interventions to address skills related to impairments (sensory proces­
sing), activity (fine motor function), and participation (school function­
ing) in their treatment of children with attentional disorders. OTs
frequently reported using sensory-based principles to address the
behavioral symptoms of children with ADHD. The most common
form of service delivery was individualized sessions, followed by con­
sultation. Potential gaps and implications at the research, practice and
organizational levels are discussed to further support the role of OT
with school-aged children with ADHD.

Introduction
Attention deficit/hyperactivity disorder (ADHD) is characterized by a persistent pattern of
inattention and/or hyperactive and impulsive behavior that is more frequent and severe than

CONTACT Lina Ianni lina.ianni@mail.mcgill.ca School of Physical and Occupational Therapy, McGill University,
Montréal, QC, H3G 1Y5, Canada
© 2020 Taylor & Francis
2 L. IANNI ET AL.

that of their typically developing peers (Efron, Sciberras, & Hassell, 2008). It is the most
common neurobehavioral disorder of childhood with the prevalence estimated at 3% to 8% of
school-age children (Jitendra, Dupaul, Someki, & Tresco, 2008; Power, Tresco, & Cassano,
2009). ADHD affects academic achievement, well-being, and social interactions
(Subcommittee on Attention-Deficit/Hyperactivity Disorder & Management, 2011).
Moreover, the behaviors associated with ADHD compromise successful execution of tasks
in daily activities, such as classwork and play, placing the children at high risk for antisocial
behavior, social exclusion and school expulsion (Efron et al., 2008; Loe & Feldman, 2007;
Polderman, Boomsma, Bartels, Verhulst, & Huizink, 2010). Comorbid disorders include
behavioral disorders (e.g. oppositional defiant disorder), mood disorders, anxiety disorders,
developmental coordination disorder and learning disabilities (Dineen & Fitzgerald, 2010;
Kadesjö & Gillberg, 2001; Spencer, Biederman, & Mick, 2007). In schools, teachers often refer
children exhibiting attentional difficulties for additional school support, documenting con­
cerns about their problematic classroom behaviors involving control and discipline, difficul­
ties with social skills, poor academic performance and problems complying with instructions
(Kos, Richdale, & Hay, 2006; Ogg et al., 2013; Sciutto, Terjesen, & Frank, 2000).
The current literature has largely focused on referrals for psychological services, typically
for cognitive assessment or consultation regarding academic or behavioral difficulties
(Bramlett, Murphy, Johnson, Wallingsford, & Hall, 2002; Landau & Burcham, 1995).
Behavioral symptoms of ADHD are typically treated with stimulant medication. There is
an upward trend in the prescription of ADHD medications in Canada (Brault & Lacourse,
2012). However, little evidence of improvement in behavior has been found in the medium
and long-term, suggesting that complementary methods to manage symptoms beyond
pharmacological intervention are needed (Brault & Lacourse, 2012; Currie, Stabile, &
Jones, 2014). Within the educational and medical literature, authors have advocated for
a more collaborative practice across disciplines to provide a cohesive and holistic way to
“maximize the impact of different disciplinary expertise” (Press, Sumsion, & Wong, 2010,
p. 53) in order to manage the impact of ADHD symptoms on children’s functional abilities
in daily life (Boshoff & Stewart, 2013; Press et al., 2010). Thus, a comprehensive and
standardized assessment of the child’s functional skills is necessary to derive a clear indica­
tion for intervention (Bölte et al., 2013).
Recently, an international consensus meeting of multidisciplinary experts on the assess­
ment of functioning in ADHD used the World Health Organization’s International
Classification of Functioning, Disability and Health (ICF), a common framework to under­
stand and describe functioning and disability, to develop core sets of ICF categories, or ‘ICF
Core Sets’, as they relate to ADHD (Bölte et al., 2018). The use of the ICF framework
emphasizes the intersection between individuals’ abilities and the impact of the specific
context on individual functioning in identifying real-life challenges (Castro & Pinto, 2013).
These core sets comprehensively highlight a range of categories related to function, from
activities of daily living, social relationships, academic achievement, occupational function­
ing, and self-care (Arnold, Hodgkins, Kahle, Madhoo, & Kewley, 2015; Fredriksen, Halmoy,
Faraone, & Haavik, 2013; Hoza, 2007; Michielsen et al., 2015), underscoring the recognition
of functional problems in daily life as the reason for the initial referral to services, as well as
the focus of interventions (Bölte et al., 2018).
The development of ICF Core Sets for ADHD marks a milestone toward an interna­
tionally standardized functional assessment of ADHD across the lifespan, and across
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 3

educational, administrative, clinical and research settings. However, little is known about
the nature of actual multidisciplinary referrals for assistance to support children’s function­
ing in the specific domains of self-care, leisure and activities of daily living.
As members of the multidisciplinary school-based team, occupational therapists have an
expertise in functional assessment and intervention in daily living activities, participation
and occupational performance in the real life context (Cramm, Aiken, & Stewart, 2012;
Darzins, Fone, & Darzins, 2006). The occupational therapy model of practice emphasizes
theoretical concepts relating to the child, the environment, the relevant occupational tasks
and the interaction among these factors (Chu, 2003). For example, an occupational therapy
assessment of a child with ADHD can demonstrate the impact of the child’s inattention and
impulsivity on daily classroom participation and learning capacity (Chapparo & Lane,
2012). Occupational therapists assess multiple factors associated with difficulties with
classroom behavior seen in children with ADHD, including sensory modulation dysfunc­
tion, problems with executive functions, and poor social skills (Chu, 2003), which can
contribute to the diagnosis of an attention disorder, as well as facilitate the planning for
long-term intervention.
The literature pertaining to occupational therapy for children with ADHD focuses on
body structure and functions, as per ICF terminology, including sensory, motor and
cognitive skills, which, if impaired, can interfere with children’s performance in daily
occupations. For instance, sensory processing and sensory modulation are often described
as areas of difficulty among children with ADHD which interfere with participation in
everyday life (Cheney, 2008; Davies & Tucker, 2010; Lane, Reynolds, & Dumenci, 2012;
Lane, Reynolds, & Thacker, 2010; Yochman, Alon-Beery, Sribman, & Parush, 2013). Several
studies examined the effects of sensory-based environmental modifications, such as the use
of tools and their effects on behavior, attention and concentration (Fedewa & Erwin, 2011;
Lin, Lee, Chang, & Hong, 2014; Olson & Moulton, 2004a, 2004b; Pfeiffer, Henry, Miller, &
Witherell, 2008; Schilling, Washington, Billingsley, & Deitz, 2003; VandenBerg, 2001). The
underlying premise of these studies is that targeting the tactile and proprioceptive sensory
systems can help children regulate their responses to sensory input (Olson & Moulton,
2004b). Evidence for the use of sensory-based interventions suggests that there is trend
toward positive outcomes in sensorimotor skills and behavioral regulation, however there is
variability in the consistency of research findings due to methodological and replicability
concerns; and empirical support remains limited (Leong, Carter, & Stephenson, 2015; May-
Benson & Koomar, 2010).
Occupational therapists may also intervene with difficulties with motor skills, as children
with ADHD may present with co-morbidities in this domain (Kirby, Salmon, & Edwards,
2007), such that a large subset (41.2%) of children with a diagnosis of developmental
coordination disorder (DCD) meet the criteria for an ADHD diagnosis (Cardoso,
Magalhães, & Rezende, 2014; Kirby, Sugden, & Purcell, 2014). Children with DCD and
comorbid ADHD are referred to occupational therapy for screening or assessment to
determine the impact of poor motor control on everyday life, such as running, using
scissors, buttoning, and writing (Brossard-Racine, Majnemer, Shevell, Snider, & Belanger,
2011; Hamilton, 2002; Lavasani & Stagnitti, 2011; Lee, Chen, & Tsai, 2013). Writing
difficulties are often addressed by occupational therapists (Case-Smith, 2002; Ratzon,
Efraim, & Bart, 2007). Findings from several observational studies indicate that children
with ADHD present with poor writing performance characterized by illegibility and
4 L. IANNI ET AL.

inappropriate speed, as a result of either poor attention, poor visual motor skills, hyper­
activity and/or poor underlying fine motor skills (Brossard-Racine, Majnemer, Shevell, &
Snider, 2008; Brossard-Racine, Majnemer, Shevell, Snider, & Bélanger, 2011; Doyle, Wallen,
& Whitmont, 1995; Rosenblum, Epsztein, & Josman, 2008).
A recent systematic review of occupational therapy interventions for children with
ADHD (Nielsen, Kelsch, & Miller, 2017) highlighted the effectiveness of a cognitive-based
intervention with children with ADHD, the Cog-Fun, which demonstrated significant
improvement in executive functioning skills in children with ADHD (Hahn-Markowitz,
Manor, & Maeir, 2011; Maeir et al., 2014) and parental self-efficacy (Hahn-Markowitz,
Berger, Manor, & Maeir, 2018). In addition, preliminary research on the use of the
Cognitive Orientation to Occupational Performance (CO-OP), a cognitive-based goal-
setting approach originally designed for children with DCD, has demonstrated effectiveness
in improving motor performance in children with ADHD (Gharebaghy, Rassafiani, &
Cameron, 2015).
A few observational and intervention studies addressed the major life areas pertinent to
occupational therapy practice (i.e. productivity, play and leisure). Children with ADHD
showed lower preference for participating in leisure, physical, social, and formal activities
than their typically developing peers (Engel-Yeger & Ziv-On, 2011; Shimoni, Engel-Yeger,
& Tirosh, 2010). Play-based interventions were found to have positive and long-term
effectiveness in developing the social play skills of children with ADHD (Cornell, Lin, &
Anderson, 2018; Wilkes, Cordier, Bundy, Docking, & Munro, 2011; Wilkes-Gillan, Bundy,
Cordier, & Lincoln, 2014a, 2014b).
Homework is often a challenging daily activity for children with ADHD as they
may exhibit difficulty focusing, attending, or completing the homework task. As
parents are typically involved in the homework process, these challenges can affect
parent-child interactions and the establishment of a sustainable routine (Segal &
Hinojosa, 2006).
In terms of service delivery, although occupational therapists directly intervene with
children with ADHD, the literature shows they also work closely with families of children
with ADHD to address parenting skills, teach adaptive strategies, reconstruct daily occupa­
tions, help build positive routines and improve parent interactions with their children
(Cronin, 2004; Segal, 2000).
While occupational therapists may contribute to the management of skills and behaviors
associated with ADHD, the nature and extent of their involvement with respect to assess­
ment and intervention is not well documented in the literature, particularly with respect to
Canadian practices. Thus, the purpose of this study was to determine the extent of current
practice of occupational therapists working with children with ADHD, regarding assess­
ment, intervention, and service delivery within Canada.

Methods
Study Design
The study consisted of a cross-sectional survey of occupational therapists working in
Canada who fulfilled the inclusion/exclusion criteria outlined below.
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 5

Participants
To be eligible to participate in the study, occupational therapists had: 1) to be working with
children and/or youth between the ages of 3 and 17 years diagnosed with ADHD or un-
diagnosed attention difficulties; and 2) to have at least one year of clinical work experience
as an occupational therapist.
A mailing list of members of the Canadian Association of Occupational Therapists
(CAOT) who agreed to be contacted for research purposes was obtained and a web-link
to access the survey was e-mailed to eligible occupational therapists across Canada. A total
of 420 members of CAOT were on the final list and met the inclusion criteria. Provincial
professional organizations were contacted but did not provide mailing lists, with the
exception of the Quebec regulatory organization (Ordre des ergothérapeutes du Québec;
OEQ) which had a protocol to follow when contacting its members for research. The OEQ
list consisted of 1296 members who met the criteria and who agreed to be contacted for
research. This subset was also sent the link to the survey. The survey was available in French
and English.

Measures
Data were collected using an on-line survey. The domains and specific items were based on
the results of a scoping review (Ianni, 2017) which described the skills and areas commonly
addressed in occupational therapy practice (e.g. sensory, motor, cognitive skills) and
frequently reported outcome/assessment measures. Additionally, an informative-based
discussion was held via a meeting with the research team to guide and organize the domains
of the questionnaire.
Co-investigators with previous experience in survey design (BM, AT) reviewed and
provided feedback on the first draft of the survey. Although no changes were made to the
domains, suggestions on wording and definitions were made, categories were added to
multiple response questions, item reduction was used to remove questions that were
redundant or not relevant to the research objectives, and the Likert scale was modified
for particular questions (e.g. scale wording modified to “Never” to “Always,” or “Strongly
Disagree” to “Strongly Agree”). Two other rehabilitation clinicians then reviewed the
revised draft for clarity and format.
The survey was translated from English to French by a professional translator whose
mother tongue was French. A backward translation of the survey from French to English
was carried out by a bilingual research assistant with experience working in rehabilitation
research. The two versions of the survey were compared to check for discrepancies in
wording, clarity of items and format.
To pretest the questionnaire and to determine clarity of wording, a group of five
rehabilitation specialists completed the survey. Rehabilitation specialists included:
a physical therapist working in private practice with experience in pediatrics and
four occupational therapists with various areas of expertise (e.g. adults, children with
orthopedic conditions, children with hearing impairments, research). Three therapists
completed the English version, and two completed the French version of the survey.
Following the pretest, one definition was added, and one question was reworded (see
Figure 1).
6 L. IANNI ET AL.

The final version of the survey consisted of 35 questions organized into five sections. The
first section, demographic and employment information, consisted of 16 items, including
multiple choice, short answer and multiple selection (e.g. ‘check box’) formats. The second
section included two multiple choice and two multiple selection questions addressing
occupational therapy involvement with children with attention disorders. Section 3
included five multiple selection items on assessment practices. Section 4, intervention
practices, consisted of three multiple choice and two multiple selection items. The fifth
section focused on professional development and clinical decision-making and included
multiple choice and 5-point Likert scale statements. An open-ended question intended to
elicit information about what occupational therapists would like to learn with respect to
working with students with attention disorders (i.e. knowledge, theory, assessments and/or
interventions) was added. The final survey was disseminated using an online survey plat­
form (FluidSurveys).

Data Analysis
Respondents accessed the survey by clicking on the link they received via e-mail. For the
quantitative information, descriptive statistics were used to summarize and tabulate the
data, in terms of frequencies, means, ranges and medians. The IBM-SPSS statistical software
was used to carry out these operations. For the one open-ended question in the survey,
recurrent or repeated statements or comments were summarized according to their fre­
quencies; only direct excepts were extracted.

Results
Of 1716 e-mails sent, 20 e-mails were returned as ‘undeliverable.’ A total of 1696 received the
survey link and 202 completed the survey for a response rate of 12%. Of these, 172 (10.1%)
completed it fully. The response rate is an estimate as some professional colleges sent the
survey link informally (e.g. through blog posts, e-mails sent to member, contact made via
social medial platforms such as Facebook) and not all members had access to the link.

Figure 1. Outline of survey development.

 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 7

Demographic Characteristics of Participants

The majority of respondents were women (n = 164; 95.3%). Almost 38% were in the 30-to
-39-year age range, with a mean of 13.7 years (median: 13.0; range: 1–37) of experience
working as an occupational therapist and an average of 10.9 years (median: 9.0; range: 1–36)
working as a pediatric therapist. Two thirds held a bachelor’s degree (n = 112; 65%)
followed by an entry-level Master’s degree (33.1%) (Table 1). A large subset of the respon­
dents was from the province of Quebec (n = 76; 44.2%), followed by Ontario (n = 24; 14%)
(Table 1). This discrepancy was accounted for by the fact that the Quebec provincial
occupational therapy regulatory body had an established protocol to contact members for
participation in research.
Approximately 70% of occupational therapists reported working full time (>35 hours per
week). Over 50% (n = 92) of respondents reported working in a school or pre-school setting,
followed by private practice (n = 58; 33.7%) and rehabilitation centers (n = 40; 23.3%)
(Table 2). When asked about work roles, 89% (n = 153) of occupational therapists identified
“clinician” as their primary work role. The second most commonly reported work role was
“consultant” (n = 67; 39%) (Table 2).

Services
Twenty-six percent (n = 45) of participants reported that more than half of their caseload
consisted of children or youth with attention disorders (Table 3). Respondents indicated

Table 1. Demographic characteristics.

Age N %
20 to 29 33 19.2
30 to 39 65 37.8
40 to 49 51 29.7
50 to 59 20 11.6
60 to 69 3 1.7
Gender N %
Female 164 95.3
Male 8 4.7
Province N %
Alberta 19 11.0
British Colombia 17 9.9
Manitoba 11 6.4
New Brunswick 2 1.2
Nova Scotia 7 4.1
Ontario 24 14.0
Prince Edward Island 2 1.2
Quebec 76 44.2
Saskatchewan 11 6.4
Northwest Territories 3 1.7
Qualification degree for OT practice N %
Diploma 2 1.2
Bachelor’s 112 65.1
Entry-level Master’s 57 33.1
Other 1 0.6
8 L. IANNI ET AL.

Table 2. Employment characteristics.

Employment status N %
Part-time (<10 hours per week) 1 0.6
Part-time (11 to 20 hours per week) 16 9.3
Part-time (21 to 30 hours per week) 35 20.3
Full-time (>31 hours per week) 120 69.8
Work settings * N %
General hospital 9 5.2
Children’s hospital 7 4.1
Rehabilitation center 40 23.3
Community 29 16.9
Primary healthcare 8 4.7
Home-based care 21 12.2
Daycare, pre-school or school-based 92 53.5
Private practice 58 33.7
Research center 1 0.6
Other 12 7.0
Work roles * N %
Clinician 153 89.0
Manager 12 7.0
Consultant 67 39.0
Case manager 6 3.5
Researcher 4 2.3
Other 2 1.2
*Participants could select more than one answer.

Table 3. Provision of services.

Proportion of caseload consisting
of children with AD N %
Less than 10% 15 8.7
11–25% 40 23.3
26–50% 56 32.6
51–75% 45 26.2
76–100% 16 9.3
Referral sources* N %
Parents 88 51.2
Referral from IDT** 74 43.0
Professionals 109 63.4
Physicians 73 42.4
Teachers 109 63.4
OT services for children with AD* N %
Assessment services 158 91.9
School-based consultation 148 86.0
Treatment 123 71.5
Home-based intervention 87 50.6
Other services 1 0.6
* Participants could select more than one response.
**IDT = Interdisciplinary team meeting.

that other professionals or teachers typically refer children with attention disorders for
occupational therapy services. A majority of occupational therapists (n = 158; 91.9%)
indicated they provide assessment/evaluation services. The second most common service
approach was school-based consultation, followed by treatment services.
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 9

Assessment Practices
The most commonly used theoretical model was Sensory Integration (n = 115; 77.2%),
followed by occupation-based models such as the Canadian Model of Occupational
Performance – Engagement (CMOP-E) (n = 91; 61.1%) and the Person-Environment-
Occupation (PEO) Model (n = 62; 41.6%). The Cognitive Orientation to Occupational
Performance (CO-OP) model was also frequently cited (n = 76; 51%). Other commonly
used frames of reference were the Neurodevelopmental Treatment (NDT) approach
(n = 65; 43.6%) and Motor Learning (n = 61; 40.9%).
The most common reason for assessment was to develop an intervention plan (n = 143;
83.1%), followed by consultative purposes (n = 109; 63.4%), diagnosis purposes (n = 67;
39.0%), and to rule out comorbidities (n = 42; 24.4%). The skills most commonly assessed
were sensory/perceptual skills, fine motor skills, and school functioning. The least common
areas of focus addressed by occupational therapists were social skills, communication skills
and cognitive skills (Table 4).
Participants were asked to select the range of measures they typically used for assessment
of children with attention disorders. Typically reported were standardized measures that
addressed sensory processing skills (n = 165; 95.5%), visual motor and visual perceptual
skills (n = 158; 91.9%), and motor skill assessments (n = 146; 84.6%). Almost all respondents
indicated they used informal evaluation or screening tools (n = 169; 98.3%). These include
unstructured interviews, ‘in-house’ questionnaires, or observations of the child. The least
commonly used assessment tools were those addressing behavioral constructs (n = 33;
19.2%) and cognitive skills (n = 5; 2.9%). The most common types of outcome measures or
standardized tools were developmental and motor skills assessments, assessments of sen­
sory processing skills, visual motor and visual perceptual assessments, assessments of
occupational performance, and writing or printing assessments. The most frequently
reported assessment tools are listed in Table 5.

Intervention Practices
Occupational therapists reported intervening in the areas of fine motor skills (n = 129;
75.4%), sensory processing skills (n = 138; 80.7%), and school functioning (n = 143; 83.6%).
“School functioning” refers to the student’s ability to participate in school-related activities

Table 4. Skills assessed in occupational therapy.

Skill area* N %
Sensory/perceptual skills 163 94.8
Fine motor skills 162 94.2
School functioning 158 91.9
ADLs 136 79.1
Physical environment 131 76.2
Gross motor skills 119 69.2
Emotional regulation 110 64.0
Play & leisure 108 62.8
Visual/ocular motor skills 87 50.6
Social environment 73 42.4
Communication and social skills 65 37.8
Cognitive Skills 49 28.5
Other 6 3.5
*Participants could select more than one response.
10 L. IANNI ET AL.

Table 5. Commonly used assessment tools by occupational therapists for children with ADHD.
Type of assessment Names of assessments* N %
Developmental and motor assessments BOT 96 55.8
M-ABC 84 48.8
PDMS 59 34.3
MFUN 26 15.1
MAP 26 15.1
Talbot 22 12.8
Sensory processing assessments Sensory Profile 154 89.5
SPM 80 46.5
Visual motor and visual perceptual assessments VMI 151 87.8
TVPS 63 36.6
MVPT 36 20.9
Occupational performance assessments COPM 52 30.2
PACS 23 13.4
Writing/printing assessments Print Tool (HWT) 41 23.8
McMaster 35 20.3
ETCH 30 17.4
*Participants could select more than one respons
BOT = Bruininks-Oseretsky Test of Motor Proficiency; M-ABC = Movement Assessment Battery for Children;
PDMS = Peabody Developmental Motor Scales; MFUN = Miller Function and Participation Scales; MAP = Miller
Assessment for Preschoolers; Talbot = Batterie d’Évaluation Talbot; SPM = Sensory Processing Measure; VMI = Beery-
Buktenica Developmental Test of Visual Motor Integration; TVPS = Test of Visual Perceptual Skills; MVPT = Motor-
Free Visual Perception Test; COPM = Canadian Occupational Performance Measure; PACS = Pediatric Activity Card
Sort; Print Tool = Handwriting Without TearsTM Print Tool; McMaster = McMaster Handwriting Assessment Protocol;
ETCH = Evaluation Tool of Children’s Handwritin

and tasks such as printing, writing, reading, copying from the board, organizing his/her
materials, and following the classroom routine. Occupational therapists also reported
intervening with children with attention disorders through physical environmental mod­
ifications and via consultation services (Table 6). In terms of the frequency of occupational
therapy sessions, a large proportion of respondents indicated they provide sessions 2–3
times/per month (n = 43; 25.3%) or saw clients once a week (n = 50; 29.4%). Approximately
one quarter (n = 42; 24.7%) of therapists indicated providing occupational therapy services
at a less frequent rate of 2–3 sessions per year or less. Almost half (n = 75; 45.5%) indicated
the duration of occupational therapy intervention typically lasts five months or more and
14.5% (n = 24) of occupational therapists specified they provide a one-time consultation
only.

Table 6. Purpose of occupational therapy interventions.

Intervention* N %
School function 143 83.6
Sensory processing 138 80.7
Consultation 137 80.1
Physical environmental accommodations 136 79.5
Fine motor skills 129 75.4
Emotional regulation 109 63.7
ADLs 98 57.3
Social environmental accommodations 79 46.2
Gross motor skills 73 42.7
Leisure/play skills 68 39.8
Vision/ocular motor skills 58 33.9
Communication/social skills 44 25.7
Cognitive skills 28 16.4
Other 10 5.8
*Participants could select more than one response.
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 11

A large proportion of respondents (n = 147; 87%) reported that they provide direct
and individual services to children/youth with attention disorders. The second most
common type of service delivery was consultation (n = 107; 63.3%), followed by
intervening within the classroom setting (n = 68; 40.2%). Offering services in
a group format (2 children or more) was also indicated (n = 63; 37.3%).
Respondents reported that they worked mainly in pre-school/school settings and
private settings, largely providing assessment services, and identifying their occupa­
tional roles as “clinicians” and “consultants.”

Professional Development Related to Knowledge about ADHD

More than half of the respondents (n = 99; 57.6%) had not attended any professional
development activities over the past year, 29.1% (n = 50) indicated they had not attended
a course or workshop in the last 5 years, 26.7% (n = 46) reported they had attended one
course/workshop related to attention disorders, and 29.7% (n = 51) reported that they had
attended 2–3 courses on the topic in the past five years.

Clinical Decision-making regarding Children with ADHD

Participants were asked about clinical decision-making in relation to working with children
with attention difficulties. Almost two thirds reported that they make clinical decisions
based on knowledge gained from their professional experiences (n = 111; 64.5%) and more
than half (n = 101; 58.7%) often used knowledge from professional development courses.
Clients’ wishes were considered one of the most important factors in clinical decision-
making according to two-thirds of the participants (n = 114; 66.7%). Participants sometimes
used search engines to acquire knowledge (n = 78; 45.6%), while 42.4% (n = 72) sometimes
consulted with their coworkers, and 47.1% (n = 81) sometimes used scientific resources to
make clinical decisions. Overall, 65.3% (n = 111) agreed that there was an expectation to
practice in an evidence-based manner.

Respondents’ Reports
Using one open-ended question, respondents were asked about what information they
would like to have with respect to occupational therapy for children with ADHD. Of the
28.5% (49 out of 172) unique responses received, 32.7% (n = 16) mentioned they would like
to learn more about assessments, including behavioral and cognitive assessments, and
65.3% (n = 32) reported they would like to learn about interventions, treatment activities
and programs to use with children with ADHD. Almost a third of respondents (n = 14;
28.6%) indicated they would like to know more about evidence-based practices, research,
knowledge or theory related to working with this population.
Several participants reported wanting to learn about alternative interventions to best
support students with ADHD, according to the following excerpts: “want to know more
regarding the efficacy of our interventions”, “best way to help them with concentration”,
“learn the best approach for the population”, “what really works for this clientele”, “effective
early intervention strategies with lasting effects”, and “evidence behind intervention
approaches”. A few comments (n = 4) were made with respect to the consultant role as
12 L. IANNI ET AL.

respondents indicated they would like to learn about “techniques for parents, teachers and
school assistants to use”, “evidence to be a better consultant”, and “ways to clearly explain to
parents if it is sensory or behavioral”.

Discussion
The purpose of this study was to survey the current practice patterns of Canadian occupa­
tional therapists providing services to children with ADHD. Overall, the results indicated
that occupational therapists typically based their assessments and interventions for these
children on a sensory integrative approach with a focus on sensory processing and motor
skills. These findings were consistent with the results of a recent systematic review of the
effectiveness of occupational therapy interventions for children with ADHD, which found
that occupational therapists addressed motor and sensory components of occupational
performance (Nielsen et al., 2017).

Occupational Therapy Assessment and Intervention with Children with ADHD

While ADHD is defined according to its symptoms, research suggests that it must be
“viewed from a wider perspective, taking into account personal, social, and environmental
factors, and functioning” (Bölte et al., 2018, p. 1262). This perspective is conceptually
aligned with the practice of occupational therapy with its emphasis on occupation, daily
living, participation, and performance in real life contexts (Bölte et al., 2018; Cramm et al.,
2012; Darzins et al., 2006; Haglund & Henriksson, 2003; World Health Organization
[WHO], 2007). Using the framework and terminology of the ICF (WHO, 2007) to frame
the survey results, findings suggest that occupational therapists typically assess motor skills
and sensory-based behaviors (body functions and impairments), as well as activities of daily
living, school functioning, and play (activities and participation).
Though occupation-centered models (e.g. Canadian Model of Occupational
Performance – Engagement [CMOP-E], Person-Environment-Occupation [PEO]) and
sensory integration approaches were commonly reported frameworks for clinical practice,
the assessments reported in this study largely addressed the domains of body functions (e.g.
Sensory Profile, (Dunn, 1999) and activity (e.g. motor skills: Bruininks Oseretsky Test of
Motor Proficiency (Bruininks & Bruininks, 2005), Movement Assessment Battery for
Children (Henderson, Sugden, & Barnett, 2007), Peabody Developmental Motor Scales
(Folio & Fewell, 2000)). These assessments are psychometrically sound and represent best
practice for assessment of these domains (Brown & Lalor, 2009; Deitz, Kartin, & Kopp,
2007). Nonetheless, utilization of standardized assessments to measure activity and parti­
cipation (e.g. School Function Assessment (Coster, Deeney, Haltiwanger, & Haley, 1998)),
was reported less frequently. This finding is consistent with previous reports that occupa­
tional therapists tend to use assessments focused on body functions (Mohammed-Alotaibi,
Reed, & Nadar, 2009; Piernik-Yoder & Beck, 2012). Similar to the study results by Brown,
Rodger, Brown, and Roever (2007), there was a lack of consistency between the frames of
reference and the type of assessments used. Finally, almost all respondents (98.3%) reported
using informal, non-standardized testing tools to gather information on their clients’
environment and occupational performance difficulties.
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 13

Sensory processing was regarded as an important area of intervention as children with

attention disorders may demonstrate difficulty in dealing with the challenges associated
with poor modulation of sensory responses (Cermak & Mitchell, 2006; Miller, Nielsen, &
Schoen, 2012; Parush, Sohmer, Steinberg, & Kaitz, 1997). These results are consistent with
the evidence in the literature, emphasizing that children with ADHD may exhibit inade­
quate sensory processing that may hinder their participation in self-care, leisure and school
activities (e.g. the ability to persist on completion of relevant tasks) (Dunn & Bennett, 2002;
Paris & Murray-Slutsky, 2016).
As ADHD is highly comorbid with developmental coordination disorder (Kadesjö &
Gillberg, 2001; Pitcher, Piek, & Hay, 2003), children with ADHD often present with
impaired motor skills (e.g. manual dexterity, poor quality of handwriting) (Flapper,
Houwen, & Schoemaker, 2006). Survey results supported occupational therapy intervention
in this area through intervention on fine motor skills to improve performance in school-
based tasks (i.e. writing, coloring, self-care activities). These findings are in line with
Canadian ADHD Resource Alliance practice guidelines with respect to potential comorbid
difficulties with balance, dyslexia and poor handwriting (Canadian ADHD Resource
Alliance [CADDRA], 2018).
While not all reported interventions were sensory or motor-based, addressing cognitive
skill deficits was the least reported area of occupational therapy assessment (28%) and
intervention (16%). In regard to cognitive functioning, executive function deficits of
children with ADHD may hinder their performance of complex daily functions (Hahn-
Markowitz et al., 2011).
Based on our results, occupational therapists were found to use cognitive-based inter­
ventions, specifically the CO-OP, to improve motor or sensory-based skills and activities
(e.g. handwriting, activities of daily living, self-regulation). Most occupational therapists
focused on these outcomes (i.e. greater than 94% of respondents) rather than on cognitive
skills or behaviors (i.e. less than 30% of respondents) associated with ADHD, such as
attention, organizational skills, and executive functioning skills (DuPaul & Stoner, 2004)
to improve occupational performance in daily tasks. Notably, one-third of the respondents
expressed they would like to learn about cognitive-based and/or behavioral assessments or
interventions. This finding may suggest occupational therapists are unintentionally una­
ware of the effect of impaired cognitive skills, such as executive functioning difficulties, on
occupational performances, as they may attribute the issues to sensory or motor difficulties
(Cramm, Krupa, Missiuna, Lysaght, & Parker, 2013a).
Overall, the survey results demonstrate the wide range of domains in which occupational
therapists intervene with school-aged children with ADHD. According to their chosen
occupation-centered practice models or approaches, occupational therapists reported
focusing on the symptoms of ADHD (e.g. underlying motor and sensory processing skills)
and their impact on the child’s activities and participation.

Service Delivery of Occupational Therapy for Youth with ADHD

The survey results highlight that a majority of occupational therapists provide assessment
and consultation services. These were more frequent than the direct provision of treatment,
possibly due to the expanding role of occupational therapists employed as consultants in
school-based or community-based teams (Clough, 2019; Missiuna et al., 2012). In these
14 L. IANNI ET AL.

roles, therapists may conduct an assessment and devise a recommended treatment plan to
be implemented by parents and/or teachers, rather than carried out directly by the therapist.
In Canada, methods for providing occupational therapy in schools vary from province to
province (Villeneuve, 2009). Since many children with ADHD are in mainstream class­
rooms, caseloads may be large and therefore an efficient model of service delivery is
required. Consultative models, where the occupational therapist engages in the classroom
routine, and supports the efforts of the teacher in problem-solving strategies within the
classroom (Hanft & Shepherd, 2016) are more common.
There is evidence to suggest the effectiveness of using a consultative model as a service
delivery model (Polatajko & Cantin, 2010). Models such as the Partnering for Change (P4C)
and Occupational Performance Coaching are examples of successful indirect service deliv­
ery models in which educators and caregivers are the first-line recipients of services
(Graham, Rodger, & Ziviani, 2010; Missiuna et al., 2012). There is little evidence from the
literature regarding the implementation of these models, specifically with children with
ADHD.

Occupational Therapists’ Clinical Decision-making

Occupational therapists reported they ‘occasionally’ consulted the scientific evidence and
agreed there is an expectation to work using an evidence-based approach. However,
decision-making seemed to be equally dependent on professional experience, consultation
with coworkers, and using generic search engines to look for information. Furthermore,
many indicated that they base their clinical decisions on their clients’ wishes along with
their professional experience. This finding is congruent with research showing that occupa­
tional therapists’ clinical reasoning and ways of intervening are influenced by their level of
expertise, their personal context, and their clients’ needs (Carrier, Levasseur, Bédard, &
Desrosiers, 2010; Thomas & Law, 2013, 2014).
In addition, occupational therapists may be unaware of the extent of evidence available
on children with ADHD and where to find it, which may explain, in part, why occupational
therapists may not refer to the research literature. These results highlight the repeated
finding that occupational therapists may refer to non-experimental research to determine
optimal processes of care and determinants of outcomes, such as expert opinion (someone
who is very knowledgeable on the topic), or base decisions on individual experience
(Palisano, 2007).

Implications for Practice and Future Research

Our results show that occupational therapists in Canada are indeed providing services to
children with ADHD and that these children make up a large proportion of their caseload.
Occupational therapy practice tends to emphasize body structure and functions, such as
improving sensory processing or self-regulation skills and motor skills necessary to parti­
cipate in daily activities. Although the impact of cognitive skill deficits, such as executive
functioning difficulties, on function and occupation is recognized, future research is needed
to identify occupational therapists’ knowledge of executive functioning issues across the
lifespan and how to effectively intervene in this area of performance (Cramm, Krupa,
Missiuna, Lysaght, & Parker, 2013b).
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 15

Regarding service delivery, given the high prevalence of ADHD among children and the
significant academic and behavioral sequelae, research on school-wide, consultative models,
or universally designed pedagogy as potentially effective and salient service delivery
approaches is needed.
Finally, although evidence-based practice as a decision-making process was not investi­
gated in depth in this study, approximately thirty percent of occupational therapists
indicated a need to learn about evidence-based practices and knowledge specific to working
with children with ADHD. These preliminary results, as well as those found in previous
studies, suggest that finding scientific evidence may be a possible barrier and occupational
therapists may also experience challenges in appraising research (Lyons, Brown, Tseng,
Casey, & McDonald, 2011; Upton, Stephens, Williams, & Scurlock-Evans, 2014). Overall,
there is a need to understand the processes related to the practitioner and the context
involved in the enactment of evidence-based practices in occupational therapy (Halle et al.,
2018; Thomas & Law, 2013). These findings further highlight the need for educational or
knowledge translation activities and a broad professional development approach in either
pre-service coursework or post-professional training to develop occupational therapy
practice skills in the school context (Laverdure, 2014).

Limitations
The survey was disseminated via an online platform and the response rate was relatively
low, though similar to other studies of this nature. Furthermore, there were differences in
the distribution of the survey across provinces. The Province of Québec followed a separate
protocol to contact members who had previously agreed to participate in research, which
was a more effective strategy. Also, the survey was emailed only to CAOT members who
agreed to be contacted for research purposes. Thus, the survey would not have reached
therapists who are not members of CAOT or who did not provide permission to be
contacted.
In Canada, health service delivery varies from province to province. Our results were
heavily weighted by the Province of Quebec where local, community-based pediatric
occupational therapy services are minimal (Cotellesso, Mazer, & Majnemer, 2009) and
there is no obligation for school boards to provide occupational therapy services (Jasmin
et al., 2019). Further, Quebec occupational therapists tend to follow an individualized,
traditional or medical model of service delivery (Jasmin et al., 2019). This is in contrast to
other provinces (e.g. Ontario), which have utilized collaborative or consultative-based
models of service delivery (e.g. P4C model) (OSOT, 2015).
Most of the survey questions were close-ended. Although not a goal of the study,
including more open-ended questions would have led to greater elaboration on the per­
spectives of occupational therapists working with this population. Respondents could have
provided more detailed information on the types of interventions they implement with
children with attention disorders, which could have added richness to the data.

Conclusion
This study found that occupational therapists in Canada are intervening with children with
ADHD to support their functioning, particularly in school settings. In line with Canadian
16 L. IANNI ET AL.

practice guidelines in support of multimodal treatment of ADHD, occupational therapists

are highly involved with respect to carrying out assessments of motor, perceptual and
sensory skills which impact children’s day-to-day functioning (CADDRA, 2018).
Although the literature on occupational therapy treatment for this population is limited,
this research adds to the body of evidence regarding occupational therapists’ involvement
with this population in not only addressing the primary symptoms of ADHD, but also their
effects on participation and inclusion from a biopsychosocial standpoint.
Overall, important practice and research needs have also been identified. There appears
to be wide-ranging differences in service delivery models for children with ADHD across
Canadian provinces. Rigorous research into the investigation of effective service delivery
models is needed, along with translation activities to implement these findings into inte­
grated health and education policies and practices.
It is our hope that these results can shed light on the important role of occupational
therapists as part of an interdisciplinary team to improve the overall health, well-being and
life participation of children with ADHD.

Disclosure Statement
No potential conflict of interest was reported by the authors. Data are not shared.

Funding
This study was supported by the Edith Strauss Knowledge Translation Rehabilitation Research Grant.

ORCID
Aliki Thomas http://orcid.org/0000-0001-9807-6609

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