German schools are increasingly asking unruly and hyperactive children to wear heavy sand-filled vests in an effort to calm them and keep them on their seats, despite the misgivings of some parents and psychiatrists.
The controversial sand vests weigh between 1.2 and six kilograms (2.7-13Ib) and are being used by 200 schools across Germany.
Advocates of the vests say they have witnessed a remarkable change in behaviour in many of the children who have worn them, claiming the heavy vests help to curb children’s restlessness.
A growing number of children are being diagnosed with attention deficit hyperactivity disorder (ADHD) each year in Germany, as elsewhere. Schools that use the vests argue they are an uncomplicated way of tackling the phenomenon head on, and a gentler and less complicated form of therapy than drugs such as Ritalin.
“Children love to wear the vests and no one is forced into wearing one against their will,” claimed Gerhild de Wall, head of the inclusion unit at the Grumbrechtstrasse school in the Harburg district of Hamburg, which has been one of the sand vest pioneers.
But critics say the vests are reminiscent of straitjackets used to constrain violent patients in psychiatric hospitals, and are in danger of stigmatising their wearers.
One parent who vented her anger over the use of the vests on Facebook, wrote: “It would be best if we avoided such torture methods. How can you say to a child, ‘You’re sick, and as a punishment you have to wear this sand-filled jacket which is not only physical agony but will make you look like an idiot in front of the rest of the class.’ I think some people have lost the plot”.
But another parent, Barbara Truller-Voigt, whose nine-year-old son Frederick has worn a 2kg sand vest at his Hamburg school for the past three years as a kind of therapy for his ADHD, said she was convinced it had a positive influence on him.
“He voluntarily puts it on,” she said, “and has the feeling that it helps him. He can concentrate better and is more able to take an active part in lessons because he’s not spending the whole time trying to keep his arms and legs under control.”
Frederick confirmed as much to the Hamburger Abendblatt: “The vest helps to calm me down,” he said. “And when I have it on my handwriting isn’t as scrawly.”
De Wall first came across the vests when she taught in the United States, where they are sometimes used for children with autism and are variously referred to as compression vests or squeeze jackets. She said that, far from constraining a child, they can help them to feel centred.
“Kids who fidget a lot or have a sensory disorder, often have problems being able to sort out one stimulus from another,” she said. “The vests help them to have a better sense of themselves, and that in turn helps them to concentrate.”
She said the vests should never be worn for more than 30 minutes at a time, but claims their weight is not a problem for most children because it is spread evenly over the upper body.
She also said there was great competition in her school to wear the vest. “The pupils jump at the opportunity to wear them, so we make sure to also let the kids wear them who don’t actually need them, which helps to ensure there’s no stigma attached to having one.”
One teacher, who declined to be named, said the experience of using the vests in her class led her to compare the use of the vests to “laying a hand on a child’s shoulder … or giving them a hug, which the children often need, but which we’re obviously not allowed to do”.
But many psychiatrists are sceptical about the vests’ use, particularly without knowing the long-term effect of them.
Michael Schulte-Markwort, director at the Child and Youth Psychiatry University Clinic in the north-western Hamburg district of Eppendorf, told German newspaper Die Tageszeitung the vests were “ethically questionable” and could easily be interpreted as a single remedy to fit all attention deficiency disorders.
Schulte-Markwort also criticised the fact that in schools too much emphasis was placed on ensuring a child changed their behaviour to fit the class, rather than focusing on the child’s individual problems. “We should be doing that far more,” he added.
Yvonne Gebauer, schools minister for the western state of North Rhine Westphalia, has said she could not support the use of the vests in her region. “This is an unusual method, whose application I can only view with a great deal of criticism,” she said in an interview with the Westdeutsche Allgemeine Zeitung. “Neither are there any verified findings or studies about their effectiveness.”
The main manufacturer of sand vests in Germany, Beluga Healthcare in Lower Saxony, said the company had made vests for “thousands of happy customers” and had been doing so for the past 18 years.
But the controversy unleashed following reports of the vests’ use in German schools has forced the company to put out a statement on its website. In it, Roland Turley owner of Beluga, which also produces diving vests for the German Navy, states: “We don’t want the vests to be viewed as a magic solution to be deployed in every case of concentration disorder. Not every restless child needs a sand vest. Children need to wear them voluntarily and it’s necessary to have an informed diagnosis from an occupational therapist or a paediatrician.”
He admitted that no study has been carried out on the long-term effectiveness of the vests. “We’ve tried to find an institute that might do it, but so far there’s been no interest,” he added.
Analysis: why the debate about sand vests is important
The revelation that schools in Germany are deploying sand vests intended to help children with ADHD raises important questions about how mental illness and special educational needs are approached in schools.
According to experts, there is still a lack of awareness of the condition in classrooms, resulting in many children becoming disillusioned with education.
“They’re often labelled the naughty kid and excluded,” said Louise Theodosiou, a consultant psychiatrist based in Manchester. “If you’ve already got that label it’s easy to see how you’re more vulnerable.”
Theodosiou said proactive support could make a significant difference to the school experience of children with ADHD, their self-esteem, and ultimately success.
However, any intervention – particularly one aimed at a group who already face extra challenges – needs to be carefully assessed before being rolled out, she said. There is some tentative evidence that weighted clothing could be useful. A 2014 study of 110 children wearing this clothing suggested they paid more attention in class. But questions remain about whether these improvements would be sustained in the long term and whether the garments would have other downsides.
“What we don’t want is something where children are wearing something visibly stigmatising,” said Theodosiou. “We need to know, how does the child feel about it, are they being teased about it?”
“I would want more studies on potential impact on breathing, pressure on the spine. There would be too many variables to understand before we recommended this.”
More broadly, the the evidence that sensory aids, such as fidget toys, are helpful for children with ADHD is fairly scant, although some parents anecdotally report that they are helpful.
“It’s an idea that has caught people’s imaginations, particularly among occupational therapists, but I’ve not seen good evidence for this,” says Philip Asherson, a professor of molecular psychiatry at King’s College London. “There’s a risk that you impose something on a child that they don’t like.”
Asherson said a crucial element of helping children with ADHD thrive is to find things they do well and are passionate about.
“It’s interesting to think about the people with ADHD who do quite well,” he said. “The ones who do well often found something that they were good at as children – it might be sport, drama or arts. They’re often in these areas that aren’t valued as much in [the classroom] but they’ve had parents who recognise that they’re really good at certain things and support them in developing that.”
What is it? And what are the symptoms?
People with attention deficit hyperactivity disorder (ADHD) have a pattern of behavioural symptoms, including hyperactivity, impulsiveness and having difficulty concentrating. The traits are often noticeable at an early age, but can become more of a problem when a child starts school. The condition tends to run in families – parents and siblings of a child with ADHD are four to five times more likely to have ADHD themselves – and genetics plays a significant role.
MRI scans have showed up some subtle differences in the brain structure and activity, but how these translate into changes in behaviour aren’t well understood at this stage.
How is it diagnosed?
There’s no quick, simple test to diagnose ADHD and a challenge is that many of the relevant behaviours – fidgeting, being easily distracted and blurting out inappropriate comments – are a normal part of childhood. Such behaviours can also be triggered by external factors such as disruptions in home life or anxiety about school, so the person making the diagnosis (normally a psychiatrist or education specialist) first needs to rule out this possibility.
Children with ADHD lie at one extreme of a spectrum and tend to show these traits much more consistently, and to an extent that causes problems in learning and socialising. While a child without ADHD might find it hard to stay focused in a lesson, a child with the condition will also struggle to stay on topic when having a conversation about something they have a real enthusiasm for, such as their favourite football team or film.
An assessment will involve discussions with parents, a one-to-one conversation with the child and sometimes a standardised computer-based assessment, called the Qb test is used, which gives an objective score of symptoms.
How many people have it?
This depends a bit how people are counted. One of the biggest studies, a meta-analysis done in 2007, estimated the prevalence at between 6-7% in children and teenagers across the world. However, some studies, which have been based on parents or teachers reports have found higher figures – for instance, a recent study based on parent reports in the US put the figure at 9.5%. However, in some populations the rates are far higher – for instance, 20-30% of prisoners meet the ADHD diagnostic criteria.
It also depends what age group is being considered. About a third of children with mild ADHD will outgrow their symptoms or learn to manage them so they no longer have a significant impact.
What can be done to treat it?
Nice guidelines recommend that for children with mild symptoms, the first-line treatment should be family work, helping parents with boundary-setting and ensuring that strategies are put in place at school – for instance, assigned a teaching assistant to help with focused work sessions. Behaviour therapies can also help children learn strategies to help manage their symptoms.
Medication is only viewed as appropriate in moderate to severe cases of ADHD and for children of seven years or older. Ritalin is not widely used in the UK – a significant downside is that children need to take a second dose of medicine at lunchtime. Giving children a slow-release form of the active ingredient in Ritalin, called methylphenidate, can be helpful.
Why is medication so controversial?
Giving medication that has an influence on the brain while it is still developing is a concern for many parents. The drugs have been shown to be safe in the short-term, but the long-term effects on the human brain are not yet well understood. For some children, doctors and parents may decide that the benefits of being able to concentrate better and socialise more easily might outweigh potential risks.
There are also physical side-effects: methylphenidate can increase blood pressure and pulse rate and reduce appetite, meaning all these variables need to be closely monitored if a child is put on this kind of medication.
Which famous people have it?
People with ADHD may find it harder to concentrate, but with the right support it does not need to limit a child’s or adult’s expectations of what they can achieve – particularly if they find something that they are passionate about early in life. A number of high profile athletes, including the US swimmer Michael Phelps and British gymnast Louis Smith, have described how the structure of a training programme was helpful for them. The US gymnast Simone Biles also spoke out about her ADHD after it was revealed she took medication to help control symptoms. In a documentary last year, the comedian Rory Bremner described ADHD as like having a “brain like a pinball machine”.