Does Deep Pressure Therapy for ADHD Always Work?

Occupational therapists have been using deep pressure therapy for ADHD for years and reporting positive results. However, we report all the information on pressure therapy, not just positive results. As with any type of therapy, there will be times when weighted blankets and weighted vests won’t have a desired impact on the targeted symptom.

These “failed” studies per se are equally as helpful in literature because they give us more insight into how an intervention works and what the limits of that intervention are. Thus, we find it essential to write about an instance where weighted vests –a form of deep pressure stimulation –were ineffective in attenuating symptoms of ADHD. 

How Can We Use Weighted Vest Information in Weighted Blanket Research?

Before diving into the study, it’s important to understand the connection between weighted vest for ADHD and a weighted blanket for ADHD. Unlike weighted blankets, there are a lot more studies dedicated to weighted vests, and we can use this information to draw connections between the two interventions. Why are ADHD weighted jackets so popular in academic settings? Why do they seem to be the go-to intervention for occupational therapists? The simple answer: Because they’re easy. Of course, there are many tried and true methods of shifting behaviors in children with concentration problems; some of them are reported by Riccio & French (2004):

• Keep the child close to the teacher/board and away from windows to limit possible distractions. 
• Place the child in an enclosed desk. (You know the ones you see in college libraries with walls built up on three sides.) 
• Use behavioral Modification strategies such as positive reinforcement with rewards when the child does what is expected and negative consequences when they go against what is expected. 
• An additional method that I teach clients is to set a timer for X amount of time, which will be the designated focus time. Once that time is up the person can take a 5-minute break, then back to refocusing for that X amount of time. Over time one will build up their focus tolerance. 

These methods can be challenging to implement in a classroom setting where there are 30 + children who may all need different teaching tactics. Also, each child presents with different levels of lack of focus and thus the tactics aforementioned may not cut through more severe symptoms of ADHD. If keeping a child (or let’s be honest, an adult) on task was as simple as putting them in an enclosed desk, you’d see classrooms filled with desks that have built-in blinders.

The unfortunate, or fortunate (depending on how you look at it) fact is, all humans are different, and we require different techniques to overcome challenges. If something works, great! But, that doesn’t mean we should stop striving for more methods to help with the inability to focus.

So, in short, the main reason for continued research on weighted vests with children (and adults) who suffer from problematic behaviors — or symptoms — that challenge them academically is to determine (a) who would most benefit from said weighted vests, (b) understand the limits of the effectiveness, so that we can more provide more efficient treatment recommendations.   

With this information found on weighted vest, we can then begin to apply the same information to weighted blankets, which are much more accessible and popular to the general public. 

Does Wearing a Weighted Vest for ADHD Improve Concentration?

This is the question that led to Collins & Dworkin (2011). Their justifications for conducting yet another study on ADHD and weighted vests in children were based on the flaws found in previous weighted vest studies including small sample sizes, lack of honesty in reporting, and no control group. So, again, it’s essential to build on research to gain more understanding and better use the intervention being studied. These researchers attempted to go above and beyond and determine once and for all if weighted vests help with a lack of concentration.

Participants

Although they made attempts to gain a larger sample size –and originally had 25 participants — various problems arose, and ultimately they were only able to use data from 10 participants who met the following criteria related to paying attention:

• Difficulty staying in the seat, compared to their peers
• Difficulty keeping eyes on teacher/ board, compared to their peers
• Has to be reminded more frequently to stay on task, compared to their peers
• Asks more irrelevant/off-task questions, compared to their peers.

Though these criteria do follow typical ADHD symptoms, the authors did not give more specific information to define these conditions; we do not know the average frequency of distraction-related behaviors for the participants’ peers. Despite common expectations, children are going to be more easily distracted, thus why this baseline information from the participants’ peers would have been helpful for the dissection of this article. 

Participants did not have an individualized educational plan (IEP) meaning they were in a general classroom and were not given individualized attention from the teacher frequently; they were all in the second grade; their ages ranged from 7.41 – 10.25 years of age. They came from various socioeconomic classes and were comprised of a variety of genders/ races (to increase generalizability).

***Note that there was no confirmation of an ADHD diagnosis for all of the participants, but rather their eligibility to participate was based on a single teacher-report. An accurate ADHD diagnosis comes from both parent-report, multiple teacher-reports, and sometimes a self-report from the child if they are able.***

Procedure

The researchers entered into classrooms and talked to the class about the experiment before its start; they told the students about the vests and were told that it would be used to see if they did their work better. To me, this seems like a major flaw because the participants knew about the study, and this could have influenced behavior.

The participants were randomly assigned to either the control group or the experimental group. The groups were not even due to participant elimination/ drop out from the original sample of 25; thus, there were seven participants in the experimental group and three in the control group. Both wore the exact same denim vest (which was the exact same vest design utilized in our other ADHD weighted vest post).

The experimental group wore the vest with weights, and the control group wore the vest, but the weights were replaced with styrofoam inserts that had the same shape as the weights used in the experimental group.

The participants were videotaped nine times, for ten minutes, over several weeks. The first three videotaped sessions acted as a baseline (where no vest was used); the next three videotaped sessions were experimental (where the vests were in place for the control and experimental group); the final three sessions were post-treatment (with no vest, to determine if any differences occur in behavior when the vest is removed).

The participants were videotaped while completing seatwork which included:

• Coloring/ cutting & pasting activities
• Worksheet completion
• Workbook completion

After all the data were collected, teachers were asked to complete a survey which assessed their trustworthiness of participant identifiers (inattentiveness) and provided some insight on their perceptions of the weighted vest effects.

Six occupational therapists were utilized as data coders. Data coding entailed watching the videos and at every 15-second mark determining if the participant was on task, off task, or unknown.

Unlike the other weighted vest ADHD study, these coders always considered a dropped writing utensil as off-task behavior. The present study’s analysis differed in that the analyzers did not make subjective judgments on the action, but instead focused on what was considered as on-task behavior. On-task behavior was defined as:

• All materials to complete the task are in front of the student
• Eyes remain on either the teacher, the board, or the task at hand
• Asking appropriate, on-task, questions to another individual (teacher or peer)
• Working on the task

Deep Pressure Therapy for ADHD Results

Teacher Perceptions

On-Task Behavior Data

Percentages of On-Task Behavior

There were no significant changes found between the percentage of on-task behavior between the two groups. 

Experimental Group Individual Percentage of On-Task Behavior

Control Group Individual Percentages of On-Task Behavior

Our Insights

Veronica’s Notes:

Despite wanting to make their study more generalizable, I do not believe these results are generalizable. I typically include in all of my articles that results are not generalizable anyways due to the vast idiosyncrasies that each person holds, so it goes without saying that this article is no different. Their inclusion criteria for participants do not warrant an ADHD diagnosis; thus, these results are not applicable to ADHD. However, inattention ranges on a spectrum and is a chronic problem in both children and adults, so the inability to generalize these findings to ADHD specifically is okay.

The individual data graphs demonstrate that there were a couple of participants who may have experienced benefits from the weighted vest; however, this could be coincidental. Multiple factors could explain why there was no significant change, including:

• The participants having knowledge about the study, and thus behaving differently.
• The weight not being enough (the manuscript did not report how much weight was used).
• The task that was required of the student was too easy and possibly mundane.
• Because the participant was aware they were different in the sense of wearing the vest when their classmates were not, and knowing what the vest was for, they may have been distracted and felt pressure to perform.
• Different definitions for what on-task and off-task behaviors are between studies.

What is interesting to note, however, is that although this study showed little to no overall benefit of weighted vests on children with inattentiveness, there still have been studies which demonstrate the opposite. For a better picture of results associated with a weighted blanket and students, I would opt for a more longitudinal study, where they are observed over the course of an entire school year.

Of course, this type of research would have its flaws in that there would be nothing similar to compare the results against due to the changing nature as children advance onto the next grade level. But, by conducting a study utilizing this methodology, we would gain more long-term data and gain an understanding if there is a required length or if there is a point in time where children get used to the weight and thus the mechanism loses its effectiveness. 

There is also the factor of what children do when they are not at school. Some children may work on a farm and thus have developed muscle mass which would defeat the purpose of weight, as their bodies are used to dealing with heavy weights frequently. Though the 10% of the body-weight rule is the standard for deep pressure stimulation tools, I do not believe this is an accurate standard, as muscle-mass, fat levels, and activity levels may create conditions for which the child would need more or less weight for effectiveness to ensue.

Ryan’s notes:

Although this study did not find a significant improvement in second-grade children who exhibit difficulty with on-task activities, the study was well controlled for. The control groups received a non-weighted vest made of the exact same material and were also structurally similar. Proper controls such as these are lacking in much of the research that concerns both weighted vest and blankets. 

However, there is a significant flaw in the study design that was addressed above. The class was told that “the student or students who were chosen would be wearing a vest to see whether it helped them work better.” Basically, unblinding the subject and asking them to perform better, or even worse, giving them an opportunity to be defiant.

A better experimental design would be for the entire class to wear the vests, and not tell the students why (or give them a reason that did not relate to behavior or performance). Then determine which students demonstrated improvement with on-task difficulties, presumably the ones identified by the teacher. Isolating one student in front of their peers will undoubtedly result in confounding behaviors.  

 Another reason why the experiment may have failed to produce significant results is that the vests themselves may be distracting. This could explain the reported trend that most students exhibited worse on-task behavior difficulties when wearing a vest. Perhaps the vest is not as comfortable as a blanket and annoys the student. I personally would not like to sit here and write this blog while wearing a vest. Weighted or not. A soft, comfortable blanket, on the other hand…

Reference

Collins, A., & Dworkin, R. (2011). Pilot study of the effectiveness of weighted vests. American Journal of Occupational Therapy, 65(6), 688-694. doi:10.5014/ajot.2011.000596

Riccio, C., & French, C. (2004). The status of empirical support for treatment of attention deficits. Clinical Neuropsychologist, 18, 528 – 558. doi:10.1080/138540490516662