Attention Magazine October 2024

Having worked as an occupational therapist in schools for many years, I have seen the inside of way too many backpacks. Backpack management is an essential skill for all students and requires a level of executive function often delayed in students with ADHD.

This delay can be as much as one-third the chronological age of the student. So, that nine-year-old in grade three may have the executive function of a six-year-old. One would expect that a third grader would be able to manage getting their homework to and from home and school on their own—but not a first grader. The homework may be done, but if it is not handed over to the teacher, they get no credit for it.

So, what is the answer?

ADHD often runs in families, and creating scaffolding may be challenging for some parents who also forget where they left something. Careful listening to all parties is needed to find out what works best for everyone.

Scaffolding is the term we use when we provide external support to a student to help them function at an age-appropriate level. Occupational therapists do this by explaining the issues to the parents, the teachers, and the student. We remove the “they should be doing this on their own” approach and replace it by giving the parents and teachers “permission” to treat this student as if he/she were a first grader—not for everything but for this one challenging task.

For example, parents load the backpack or check the contents, and the teachers remind the student to check their backpack for homework. Likewise, the teacher will check that the student has the required books in the backpack to complete the homework before the student heads out the classroom door. This way the teacher can grade the homework for its academic content and not for the student’s executive functioning. As the student matures, the scaffolding is removed, piece by piece. They may eventually just need verbal prompts and not the physical “search and find.”

Sensorimotor awareness
Another aspect often associated with ADHD is a weak sensorimotor awareness. Few adults would leave home without their purse or briefcase. Their bodies would tell them that something is missing, and they would go and find the missing item before leaving home. Many of our students with ADHD do not have this sensory reminder and need help.

At home, for example, a student may leave their backpack by the door at night so that they must trip over it in the morning when leaving for school. At school I have seen many backpacks abandoned in hallways; usually these were “dropped off” before recess and “lost” by a student who is not able to go back in their mind to work out where they were when they last had their backpack—another executive function skill. Aware students and teachers become adept at recognizing abandoned backpacks and reuniting them with their owners—another example of scaffolding.

By acknowledging the need for scaffolding, the shame and blame are taken away from the student and they are able to let their strengths shine through. As we know, ADHD often runs in families, and creating scaffolding may be challenging for some parents who also forget where they left something. Careful listening to all parties is needed to find out what works best for everyone.

Scaffolding reviews
The high schoolers’ backpacks were often the worst. I would routinely go through a student’s backpack when they came for their OT session. It became a joke: What would I find today? The homework from last week? The sandwich from last week? How many dirty socks?

Executive function delays can be seriously handicapping and need constant scaffolding review.

One student, for example, had missed several math assignments. We worked together to locate those assignments and wrote out a schedule as to when he would complete them. We marked each page with a sticky note, and we even put some blank paper inside the book so he wouldn’t have to go and find some. We clipped the schedule to the front of the book. I placed it inside his backpack. I even emailed a copy to his mother.

Two days later, when I saw him for his regular backpack check, there it was pristine, completely untouched. Exasperated, I pulled it out and muttered under my breath, “You can lead a horse to water, but you can’t make it drink!” I stopped myself and apologized, as I thought he would not understand, but he said he did, adding, “The problem is, I am not a horse!” As I started to explain the allegory, he asserted: “I am a camel!” What a profound insight! He was exactly right. He was not a horse who needed regular water—he was a camel, who could go for days without water. He was, and is, a completely different type of animal! I have never forgotten that.

Executive function delays can be seriously handicapping and need constant scaffolding review. In this case the mother had been so preoccupied by the social-emotional dramas of her daughter that the seemingly milder issues of her son had not warranted her attention. More listening and discussion were needed to come up with a better plan.

From scaffolding to accommodations
Do the executive function delays catch up with the chronological age? In some cases, yes—but executive functioning does not fully mature until the late twenties for the neurotypical brain. It is not unusual to see a bright eighteen-year-old who has ADHD heading off to college with the executive functions of a twelve-year-old. One would never send a twelve-year-old to college on their own, without their mom to manage the laundry, never mind the homework.

Many freshmen crash and burn in that first year, not because of their academics but because of their executive function delays. So, how do we scaffold for them? A gap year (or two) is often a good idea to give the prefrontal lobes time to develop, without the stresses of independent college life. Another approach is to start college near home, at a community college where the parents can continue to support the executive functions while the student focuses on the social and academic challenges of life beyond high school.

Once they become adults are we home and free? No! We no longer refer to managing these issues as scaffolding, but as “accommodations.” We all use these tricks we employ to remember to take our keys or our phone with us. (The little “find my phone” button is the most-used button on my Apple watch!) I have often observed that some of the most successful adults I know with ADHD either have an assistant or a partner who is ultra-organized, who basically has the executive function for both. In life, the secret to success is finding the “right fit’ in both job and partner. This allows for the ADHD individual to shine through their strengths and to minimize and manage their weaknesses.

Zara Harris is a pediatric occupational therapist with many years of experience working with children, teens, and adults with ADHD and coexisting conditions. She has worked in private practice and in schools around the world. She has presented internationally on ADHD, DCD, handwriting, and using technology to compensate for weaknesses. Harris served on the planning committee for the Annual International Conference on ADHD for many years. She is the deputy chair of the editorial advisory board for CHADD’s Attention magazine.