ATTENTION ( DEFICIT/HYPERACTIVITY ) DISORDER: HOW CAN EDUCATORS HELP CHILDREN AND PARENTS? “BUT HE...

ATTE

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“BUT HE CAN FOCUS ON VIDEO GAMES FOR HOURS!”

NORRINE L.

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HAVE YOU EVER. . .

Thought a child was lazy because they seemed to never start an assignment?Gotten mad at the child who kept getting out of their seat?

Become so frustrated with the child in the back of the room banging his pencil on his desk over and over and over again?

Reminded a child to bring home their book at least five times and then they still forget it?

Been in the middle of a lesson when a child blurts out some random information irrelevant to the lesson?

Had a child listen to you talk and then not know

WHAT YOU JUST SAID?

IF YOU ANSWERED YES. . .

You are not alone.

Today, in every classroom across the country there are several students who are diagnosed with ADHD.

It is vital for teachers to understand ADHD to minimize feelings of being frustrated, upset, or defeated and increase the likelihood of student success.

WHAT WE ALL NEED TO UNDERSTAND

“If they could, they would.”

Ross Greene

The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated,

Chronically Inflexible Children

WHAT WE’LL COVER TODAY

What are the statistics and myths of ADHD?

What is ADHD?

How is it diagnosed and what is the teachers role?

What causes ADHD?

What are Executive Functions?

What deficits do children with ADHD have?

What can a teacher do to help children with these deficits?

What medication should teachers know about?

Where can help be found about ADHD?

STATISTICSThe Diagnostic and Statistical Manual of Mental Disorders Fourth

Edition suggests that ADHD affects 3 to 5% of school aged children.

This adds up to 1.46 to 2.46 million children in schools today

ADHD is the most commonly diagnosed childhood psychiatric disorder

4 to 13% of the United States Population is affected by ADHD Boys are 4 to 9 times more likely to be diagnosed than girls 1/4 to 1/3 of ADHD students also have learning disabilities Symptoms in a child may change as that child grows older but

that does not mean that the child will grow out of their ADHD diagnosis

ADHD children are at higher risk for unintentional injuries, delinquency, and anti-social behavior

ADHD MYTHS BUSTED

As published on ADDitude Magazine’s website, these are the most common ADHD myths:

#7: People with ADHD are stupid and lazy.#6: ADHD children on medication will abuse drugs as teenagers.#5: ADHD is the result of bad parenting.#4: ADHD affects only boys.#3: Children with ADHD often outgrow the condition.#2: Children given ADHD accommodations are given an unfair advantage.#1: ADHD is not a real medical disorder.

From: www.additudemag.com

WHAT

IS A

DHD?

WHAT

IS A

DHD?

annoying

WELL, THIS IS USUALLY WHAT YOU’LL HEAR…

Inattention Hyperactivity Impulsivity

Fails to give close attention to details Difficulty sustaining attention in tasks Does not seem to listen when spoken to directly Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace Often has difficulty organizing tasks and activities Often loses things necessary for tasks or activities Is often easily distracted Often forgetful in daily activities

Often fidgets with hands or feet or squirms in seat Often leaves seat in classroom or in other situations in which remaining seated is expected Often runs about or climbs excessively Often has difficulty playing or engaging in leisure activities Often is “on the go” or as if “driven by a motor”

Talks excessively Often blurts out answers before questions are completed Has difficulty awaiting turn Interrupts or intrudes on others

DIAGNOSTIC CRITERIA

A: Six or more of the previously noted symptoms persisting for 6 months or longer qualifies for a diagnosis of ADHD in either the inattentive category or hyperactivity-impulsive category. If both inattentive and hyperactive-impulsive symptoms are present then a combined type diagnosis is given. Please see chart on previous screen.

B: One of the symptoms needs to have been present before the age of 7.

C: Some impairment from the symptoms is present in two or more settings, such as school or home.

D: There must be clear and significant evidence of a social, academic, or occupational impairment.

E: The symptoms are not better accounted for by another mental disorder.

Note: Taken from American Psychiatric Association DSM-IV (1994, p. 83-85)

WHAT DO CURRENT EXPERTS THINK ADHD IS?

A Deficit in Self-Regulation

REASONS ADHD STUDENTS MISBEHAVE

1. Frustration because they have a different perception of the situation.

2. Lack of structure.3. They act the role of being “bad.”4. They don’t know how to ask to get what they need so they act

out.5. The classroom is full of distractions.6. The child feels misunderstood.7. Hunger.8. They feel overwhelmed with tasks assigned.9. They feel criticized.10. They are stuck in the “victim cycle.”

Note: From Appelbaum Training Institute’s How to Handle the Hard-to-Handle Student Resource Handbook, (2005).

WHAT EDUCATORS NEED TO REMEMBER:

According to Schuck & Crinella (2005), “the most worrisome deficits of children with ADHD are not the product of low IQ, but rather of instability of control processes that govern everyday applications to the environment” (p. 275).

The ADHD student is not dumb, lazy, or out of control. They are children who need our help to gain the proper strategies to be successful.

YOU can be the one to make a lifelong difference.

REMEMBER…

“If they could, they would.”

Ross Greene

The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated,

Chronically Inflexible Children

WHAT CAN AN EDUCATOR DO IF SOME SYMPTOMS APPEAR TO BE PRESENT?1. Maintain behavior logs citing observations of behaviors and

situations. Remember to include inventions used and their efficiency.

2. Inform parents of behavioral concerns and discuss behaviors at home.

3. Request child study or equivalent meeting with parents, special education teachers, school psychologist, etc. to discuss classroom behaviors. This can lead to diagnosis from a doctor and then an IEP for the student.

4. If needed, rating scales may be given to teachers and parents.

Diagnosis and identification of ADHD needs to come from a complete evaluation, preferably from a doctor, psychologist, or psychiatrist.

The most helpful thing teachers can do is to observe the child and find interventions that work to make that child successful and support the parents.

Note: From Vaughn, Bos, & Schumm (2006).

WHAT CAUSES ADHD?Average heritability of .80 - .85 Environmental factors are not the cause, but may contribute to the expression,

severity, course, and comorbid conditions

Dysfunction in prefrontal lobes Involved in inhibition, executive functions

Genes involved in dopamine regulation Dopamine transporter (DAT1) gene implicated 7 repeat of dopamine receptor gene (DRD4) implicated Gene x environment interactions

Possible differences in size of brain structures

Prefrontal cortex, Corpus callosum, caudate nucleus

Abnormal brain activation during attention & inhibition tasks

WHAT WE KNOW ABOUT THE NEUROBIOLOGY OF ADHD

Compared to someone without ADHD, children with ADHD have:

• Differences in brain chemicals (neurotransmitters)

• Differences in the size of parts of the brain– Caudate nucleus; striatum; globus pallidus; corpus callosum

• Less activity in parts of the brain– Right prefrontal region

• Most of these differences are located in the prefrontal cortex

– The “conductor” of the brain

ADHD AND NEUROTRANSMITTERS

Neurotransmitter differences, particularly in levels of:DopamineNorepinephrineEpinephrineSerotonin

Dopamine has been associated with approach and pleasure-seeking behaviors

Norepinephrine plays a role in emotional/behavioral regulation

EXECUTIVE F

UNCTIONIN

G

WAIT

, THE

KID I’

M THIN

KING O

F DOES

N’T S

EEM LI

KE AN E

XECUTI

VE

WHAT ARE EXECUTIVE FUNCTIONS?An executive function is “a

neuropsychological concept referring to the cognitive processes required to plan and direct activities, including task initiation and follow through, working memory, sustained attention, performance monitoring, inhibition of impulses, and goal-directed persistence.” (Dawson & Guare, 2004, p. vii)

Response Inhibition

Working Memory

Emotional Control

Sustained Attention

Task Initiation

Planning/Prioritization

Organization

Time Management

Goal-directed Persistence

Flexibility

Metacognition

TAXONOMY OF EXECUTIVE SKILLS

WHY ARE EXECUTIVE FUNCTIONS IMPORTANT?These skills allow us to “organize our

behavior over time and override immediate demands in favor of longer-term goals” (Dawson & Guare, 2004, p. 1).

They also allow for the management of emotions and effective thought monitoring.

EXECUTIVE SKILLS AND LEARNING:HOW DOES A LACK OF EXECUTIVE FUNCTIONING CREATE A PROBLEM IN THE CLASSROOM?

DEFICIT: RESPONSE INHIBITION

This is “the capacity to think before you act” (Dawson & Guare, p. 47).

Children with this deficit tend to be impulsive. They will say things without thinking about what it is that they are saying.

DEFICIT: WORKING MEMORY

This is “the ability to hold information in mind while performing complex tasks” (Dawson & Guare, p. 49).

Students with this deficit tend to forget easily. They may forget their homework or books at school on a regular basis.

DEFICIT: SELF-REGULATION OF AFFECT

This is “the ability to manage emotions in order to achieve goals, accomplish tasks, or control and direct behavior” (Dawson & Guare, p. 50).

These students tend to become upset quickly with situations, unable to control their emotions. These students tend to have outbursts that disrupt daily functioning.

DEFICIT: SUSTAINED ATTENTION

This is “the capacity to maintain attention to a situation or task in spite of distractibility, fatigue, or boredom” (Dawson & Guare, p. 52).

Students with this deficit tend to have a hard time getting started and staying productive with a task or project. These students will get up often when a task is given. They talk to other students when they shouldn’t.

DEFICIT: TASK INITIATION

This is “the ability to begin a task without undue procrastination, in a timely fashion” (Dawson & Guare, p. 54).

These students tend to put off doing work that they need to complete. They lack the processes to start the task.

DEFICIT: PLANNING

This is “the ability to create a roadmap to reach a goal or to complete a task. It also involves being able to make decisions about what’s important to focus on and what’s not important” (Dawson & Guare, p. 55).

These students tend to wait till the last minute to complete tasks and then not know what to do when they go to complete them.

DEFICIT: ORGANIZATION

This is “the ability to arrange or place things according to a system” (Dawson & Guare, p. 58).

These students tend to have messy desks or cubbies. They lose papers often and frequently shove papers instead of placing them in appropriate spots.

DEFICIT: TIME MANAGEMENT

This is “the capacity to estimate, allocate, and execute within time constraints” (Dawson & Guare, p. 60).

These children get work done at the last minute and frequently ask for assignment extensions. They underestimate how long work will take. Sometimes we refer to children with ADHD as time-blind.

DEFICITS: GOAL-DIRECTED PERSISTENCE

This is “the capacity to have a goal, follow through to the completion of the goal, and not be put off by or distracted by competing interests” (Dawson & Guare, p. 62).

These students are able to create goals for themselves but are not able to achieve them. They are not able to understand the necessary steps to reach a goal and often become distracted with outside stimuli negatively impacting their task completion.

DEFICIT: FLEXIBILITY

This is “the ability to revise plans in the face of obstacles, setbacks, new information, or mistakes” (Dawson & Guare, p. 63).

These students have difficulty in transitions and new situations. These students struggle longer than others at the beginning of each year. They also are thrown off by changes in daily schedules. These students have limited problem solving strategies.

DEFICIT: METACOGNITION

This is “the ability to stand back and take a bird’s-eye view of oneself in a situation. It is an ability to observe how you problem solve. It also includes self-monitoring and self-evaluative skills” (Dawson & Guare, p. 65).

These students make careless mistakes frequently. They also will complete one step then stop, instead of finishing the series of steps. For example, these students may add instead of subtract over and over again while failing to review their work and realizing their mistake. Also, these students will do one step of long division and then stop, not reflecting on the whole process needed to complete the task.

BUT WHAT DO I DO?

PROVIDE HELP FOR DEFICITS AT THE MOMENT IT IS NEEDED, NOT NEGATIVE FEEDBACK WHEN IT IS ALREADY TOO LATE.

UNFORTUNATELY, THE SIMPLE REALITY IS THAT PUNISHMENT DOES NOT USUALLY TEACH THE NEEDED BEHAVIORS.

THIS IS BECAUSE MANY CHILDREN WITH ADHD HAVE DIFFICULTY “DOING WHAT THEY KNOW,” NOT “KNOWING WHAT TO DO.”

THEY ALREADY “KNOW,” FOR EXAMPLE, THAT THEY SHOULD COME TO CLASS PREPARED.

ONCE WE UNDERSTAND THAT PUNISHMENT HAS NOT BEEN WORKING, WE ARE READY TO PROVIDE RELIEF FOR THEIR DISABILITIES BY GUIDING THEM AT THE MOMENT GUIDANCE IS NEEDED—RATHER THAN CONTINUED DISBELIEF THAT THEY DID IT WRONG AGAIN.

TEACH THIS PROCESS

1. STOP

2. THINK

3. PLAN

4. DO

RESPONSE INHIBITION

Reduce situations where the child can get into troubleUse Proximity Control: Increase supervision of the childDemonstrate impulse control by modeling appropriate behavior

To teach the skill: Explain the skill and behaviors Model behaviors Discussion situations to use the skill Reinforce the skill Ignore inappropriate behavior

Note: From Dawson & Guare, (2004).

WORKING MEMORY

Enforce use of assignment books consistently

Utilize checklists and to-do lists

Use cue devices such as verbal reminders, alarm clocks, and Post-Its

To teach the skill: Explain the skill Give options to the child for cues and checklists to use Create a monitoring system for the child to monitor their own

skill usage


SELF-REGULATION OF AFFECTPrepare child for problem situationsGive child scripts for problem situations and practice regularlyStructure environment to avoid situations that can lead to

problemsGive breaks to child during tasks as neededTeach child I-statementsUse social stories that teach emotional control

To teach this skill: Explain the skill Provide coping strategies Practice with the child Reinforce child when strategies are used Discuss real life situations of using the strategy


SUSTAINED ATTENTION

Write start and stop times on assignments

Use incentive systems

Break down tasks into steps

Make tasks interesting for students

Give child something fun to do when task is completed

Provide attention and praise when student is remaining on task

To teach the skill: Discuss attention time with the student Teach them to break down tasks on their own Help them make work plans for completing tasks Reinforce them when they use the plan


TASK INITIATION

Use verbal cues to get child startedCreate a visual cue to prompt child to get started, such as a note

on their deskWalk through the first part of the task to help child get startedHave child tell you when they will begin the task and cue them

when the time arrives

To teach the skill: Teach the child to create a written plan for starting the task

including time and type of task Teach child to break down the task if needed Teach child to use cue such as alarm clock to start task Reinforce child when no additional cues are needed Fade supervision


PLANNING

Plan a schedule for the child

Use rubrics

Break long assignments into smaller pieces with deadlines for each piece

Create planning sheets with due dates

Use assignment planners

To teach the skill: Walk through the planning process with the child Have child model the planning process Tell student to create roadmaps for tasks Ask questions such as “What do you have to do first?”


ORGANIZATION

Maintain an organized classroom

Create schemes for organizing backpacks and folders

Color-code folders, notebooks, and papers for classes

To teach the skill: Teach child to separate papers and categorize them Have them create their own organization plan

Get the plan in writing Have them implement the plan


TIME MANAGEMENT

Give child a schedule to followPrompt student with each step of a taskImpose time limits for assignmentsProvide frequent reminders for remaining time to complete taskUse cueing devices such as alarm clocks

To teach the skill: Help child understand what the task involves Have child think of distractions that may be present when

completing task Create an estimated time for completion; compare estimated

time to actual time Find strategies to decrease distractions


GOAL-DIRECTED PERSISTENCE

Give students goals and have them keep track of their progress

Goals need to have motivational interest to the student

Include students in establishing goals

Create reasonable goals

To teach the skill: Follow a coaching process:

Hold a goal setting session where a goal is set, obstacles are discussed and a plan is written

Hold daily coaching sessions where goal is re-discussed and progress is assessed by asking questions


FLEXIBILITY

Give advance warning for new schedules or activitiesAllow student to practice new schedules or activitiesProvide rubrics to followRead social stories to teach coping strategies in problem

situationsOffer positive reinforcement and step by step assistance with

difficult problems

To teach the skill: Teach students what inflexibility is and how to recognize it Teach and model coping strategies with plans and cues Create strategies to fall back on Teach relaxation strategies


METACOGNITION

Ask child to explain how they solved the problem or if they can think of another way to solve the problem.

Create buddy systems for students to check work.

Give assignments where students can evaluate their work ethic and give a grade.

Use rubrics.

To teach the skill: Define the skill and what is needed to use the skill

appropriately Practice the skill Create error-monitoring checklists Teach children to ask themselves self-monitoring questions

while tasks are being completed


TEACH THIS PROCESS

1. STOP

2. THINK

3. PLAN

4. DO

CLASSROOM SETUP TO ACCOMMODATE ADHDSeat ADHD student away from distractions, preferably front

and center (www.addinschools.com).Seat student near a good role model

(www.addinschools.com).Increase distance between desks to decrease distractions

(www.addinschools.com).Create a cool-down area (National Education Association,

2005).Play quiet music (Appelbaum Training Institute’s How to

Handle the Hard-to-Handle Student Resource Handbook, (2005).

Create a stage for announcements in the classroom (Appelbaum Training Institute’s How to Handle the Hard-to-Handle Student Resource Handbook, (2005).

OTHER SOLUTIONS TO HELPING THE CHILD WITH EXECUTIVE FUNCTIONING CHALLENGESMake lessons very clearUse lots of visualsPair students together to complete assignmentsProvide hand signalsPlay beat the clockUse behavioral contractsUse sticker chartsProvide study carrels or private officesAllow students to move aroundAllow more time for testsPut luggage tags on book bag to remind students of what to bring homePut sponges or mouse pads on desks for students who like to tapHave special highlighters for students to useUse picture mats or file folders cut into thirds to chunk assignmentsProvide headphones for students to useUse manipulatives such as Koosh balls or hand exercisers for students

Note: From Appelbaum Training Institute’s How to Handle the Hard-to-Handle Student Resource Handbook, (2005).

SUCCESSIVE BEHAVIORAL INTERVENTIONS ARE:

Intensive ConsistentImmediate Reinforcing

TEACH THIS PROCESS

1. STOP

2. THINK

3. PLAN

4. DO

MEDICAT

IONS

ADHD: STIMULANT TREATMENT

Pharmacological treatment usually involves

Methylphenidate productsDextro-amphetamine/amphetamine products

CNS stimulants highly effective Reduce core symptoms of inattention, hyperactivity, and impulsivity in 75% to 90% of children with ADHD


Research has shown that stimulants:

Are highly effective in reducing ADHD symptoms in the short term

Decrease disruption in the classroomIncrease academic productivity and on-task behavior

Improve teacher ratings of behavior


Common side effects Insomnia, decreased appetites, dysphoric mood

Irritability, reduced motor activityHeadaches, G-I complaintsTicsDecreased frequency of social interactions

LIMITATIONS OF STIMULANT TREATMENT

Individual differences in response Not all children respond (approximately 80%)

Limited impact on domains of functional impairment

Primary reason for treatment seeking

Does not normalize behaviorFamily problems beyond the scope of

medicationNo long-term effects establishedLong-term use rare Limited parent/teacher satisfactionSome families are not willing to try medication

One thing to remember…

“Pills don’t teach skills”

American Medical Association (AMA)

“encourages the use of individualized therapeutic approaches…which may include pharmacotherapy, psycho-education, behavioral therapy, school-based and other environmental interventions, and psychotherapy, as indicated by clinical circumstances and family preferences.” (p.1106)”

American Academy of Pediatrics (AAP)

“the clinician should recommend medication (strength of evidence: good) and/or behavior therapy (strength of evidence: fair), as appropriate, to improve target outcomes in children with ADHD (strength of recommendation: strong)” (p. 1037)

American Academy of Child & Adolescent Psychiatry (AACAP)

Treatment “may consist of pharmacological and/or behavior therapy” but that “pharmacological intervention for ADHD is more effective than a behavioral treatment alone” and that “behavioral intervention alone might be recommended as an initial treatment if the patient’s ADHD symptoms are mild with minimal impairment…or parents reject medication” (p.902)…”if a child has a robust response and shows normative functioning…then psychopharmacological treatment alone is satisfactory” (p. 912)…

If the child does not show a robust response to all FDA-approved medications, the clinician should “consider behavior therapy and/or the use of medications not approved by the FDA for treatment of ADHD” (p.907)

WHAT WORKS BEST?

MEDICATION + BEHAVIORAL SUPPORTS

SUMMARY

1. ADHD is a highly prevalent, brain-based disorder which is associated with lifelong impairment in functioning

2. Environmental factors can contribute to the expression, severity, course, and comorbid conditions

3. Long-term developmental outcomes for individuals with ADHD can include serious substance abuse, chronic criminality, depression and suicide

4. Stimulant medications and behavior therapy are currently the only established evidence-based treatments for ADHD

5. Combined behavioral-pharmacological treatment has the greatest impact on functional outcomes, is preferred by parents and teachers, and is most likely to result in normalization of behavior

CONCLUSION

“ADHD is not a problem with knowing what to do; it is a problem of doing what you know.”

-Barkley, 2006

ATTENTION ( DEFICIT/HYPERACTIVITY ) DISORDER: HOW CAN EDUCATORS HELP CHILDREN AND PARENTS? “BUT HE...

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