TEACHING STRATEGIES FOR STUDENTS WITH ADHD: FINDINGS FROM THE FIELD

N ancy J. H amilton University o f Arkansas at Little Rock

Randall L. A stramovich Idaho State University

Children with ADHD often experience academic challenges and in­terpersonal difficulties which may impact their educational success. Using a case study approach, the authors explored the experiences of a child with attention deficit hyperactivity disorder (ADHD) in a fifth grade school setting. Findings indicated that the student had an elevat­ed intelligence, but was working below her potential, and that despite taking psychostimulant medication for several years, the student’s academic success was still being compromised by ADHD symptoms. Therefore, in addition to psychostimulant medication, teachers may help children with ADHD, and themselves, by utilizing strategies focused on conflict resolution, improved communication, increased organizational skills, as well as individualized homework and instruc­tional assistance.

Keywords: ADHD, teaching strategies, case study, conflict resolution, tutoring

Attention Deficit Hyperactivity Disorder (ADHD) is a commonly diagnosed child­hood behavioral disorder affecting millions of children in the U.S. every year (National Institute of Mental Health [NIMH], 2012), with prevalence rates between 5% and 11% of the population. (American Psychiatric Association [APA], 2013; CDC, 2014). The primary signs of ADHD include a per­sistent pattern of inattention or hyperactivity lasting in duration for six months or longer with an onset before 12 years of age. These behaviors are inappropriate for the child’s age level and symptoms typically interfere with functioning in multiple environments. Two primary types of the disorder include inattentive and hyperactive/impulsive, with

a combined type when both inattention and hyperactivity occur together. Inattentive ADHD is evidenced by executive function­ing deficits such as being off task, lacking sustained focus, and being disorganized. Hy­peractive ADHD is evidenced by excessive talkativeness and fidgeting, with an inability to control impulses that may result in harm. Children with ADHD often experience peer rejection, neglect, or teasing and family in­teractions may contain high levels of discord and negative interactions (APA, 2013).

Historically, much research on ADHD has focused on the academic impact of behavioral symptoms such as reading (Benezra & Douglas, 1988; Bremer & Stem, 1976; Doublas & Benezra, 1990;

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Dykman & Ackerman, 1992; Felton, Wood, Brown, Campbell, & Harter, 1987; Levy & Hobbes, 1989; McGee, Williams, Moffitt, & Anderson, 1989; Narhi & Ahonen, 1995; Pennington, Grassier, & Welsh, 1993) and mathematics (Ackerman, Anhalt, & Dyk­man, 1986; Zentall & Smith, 1993). Other research has examined singular traits such as executive function deficits in the school setting (Bear & Rys, 1994; Bijur, Golding, Haslum, & Kurzon, 1988; Brown & Wynne, 1982), task performance in the school setting (Berk, 1986), driving (Barkley, Guevremont, Anastopoulos, DuPaul, & Shelton, 1993), and awareness of time (Barkley, Koplowicz, & Anderson, 1996; Zakay, 1992.). However, researching academic aspects of the school experience does not provide a comprehen­sive understanding of the systemic effects of ADHD in the school environment. Such narrowly focused studies, while relevant, have not informed teaching practices that would benefit this particular student popula­tion. Many general education teachers report utilizing behavioral interventions in their classrooms (Fabiano & Pelham, 2003), but mainstream teachers are not trained at the preservice level in how to teach to special needs students, and thus are less likely to utilize behavioral interventions than spe­cial education teachers (Fomess & Kavale, 2001; Zentall & Stormont-Spurgin, 1995.) Arcia, Frank, Sanchez-LaCay, and Fernan­dez (2000) found that most teachers do not understand the characteristics of ADHD and are not familiar with classroom management techniques for students with these disabili­ties. Identifying strategies for increasing the academic success of students with ADHD is therefore crucial to their long term academic and life success.

Method

The goal of the current study was to ex­plore the school experience of a student with ADHD in order to help identify strategies teachers may implement when working with this population. We utilized a case study design in order to examine an individual student in the natural school environment, specifically exploring factors affecting school success. Case study research emphasizes the use of multiple data sources including direct observation, interviews, and relevant artifacts to gain an in depth understanding of the par­ticular case (Creswell, 2007).

Participant Selection

A fifth grade female student, whom we will call Gail, was enrolled at a religiously-af­filiated elementary school in a large, urban Southwestern city. She was purposefully cho­sen for this case study because she had been diagnosed with ADHD, inattentive type, and her academic performance was below what would have been expected, given that psy­chological testing indicated she had an above average intelligence. Upon initial diagnosis in second grade, Gail was prescribed two psychostimulants, Ritalin and Focalin, to help control her symptoms. Both medications are stimulants and, in individuals with ADFTD, they serve to increase short-term memory and learning performance (Barkley, 2014). When used together they are found to be 80-90% effective (Greenhill et al, 2002.) At the time of the study, Gail was prescribed to take 40mg of Ritalin and 5mg of Focalin each morning, with another 5mg dose of Focalin in the af­ternoon. However, Gail’s mother indicated the afternoon dose was often not adminis­tered because of the hectic pace of the school schedule. Psychological testing found that Gail’s medication, when taken as prescribed, helped control her symptoms of inattention and impulsivity.

Teaching Strategies For Students With Adhd: Findings From The Field / 453

Data Collection and Procedures

An Institutional Review Board approved this study, and informed consent was obtained from both the participant and her parent. This study was conducted during a four week period in February and March in Gail’s fifth grade year. Data collection involved exten­sive semi-structured interviews with Gail (30 minute pre and post study), her mother (30 minute pre and post study), her primary class­room teacher (30 minute pre, middle, and post study), her social studies teacher (one 10 minute during study), her physical education teacher (one 10 minute during), and her fourth grade teacher (one 30 minute during study). Artifacts collected included psychological test reports (Connors’ Ratings Scales for Parents and Teachers, Wechsler Intelligence Scale for Children, Test of Variables of Attention), grade report cards from second through fifth grades, and over 35 hours of observation in the academic setting (classroom, lunchroom, physical education class, social studies class, music class, recess time, and art class) con­ducted by the primary researcher.

Data Analysis

Observational, multiple interview, and ar­tifact data was collected in this single-subject case study. Observation data was documented through field notes and all interviews were transcribed verbatim by the primary research­er. All observation and interview data was then systematically analyzed and coded using qualitative strategies highlighted by Creswell (2007) and Huberman and Miles (1994). The data grouped itself into four primary themes of behavioral concerns, academic abilities (e.g., the outcome of classwork, homework, art projects), organization of time and/or materi­als, and interpersonal relations. All data points were triangulated with each other and member checked with the classroom teacher to ensure accuracy of interpretation and findings.

Results

The first observation of Gail was on a Monday morning and she was only aware of what the rest of the class had been told - that a researcher was present to observe the class. The primary researcher anticipated getting a more accurate understanding of Gail’s behav­ior if she was not aware of being specifically observed. Concerns that this observation ap­proach could lead to feelings of betrayal when Gail was later was informed of the research­er’s true purpose was considered. However, one day of anonymous observation was un­dertaken at the urging of her mother who ex­pressed concerned that Gail might change her behavior if she knew she was being observed. Later that evening, when the researcher’s pur­pose was revealed, Gail expressed excitement at having been the participant of the observa­tion. After the initial day of observation, Gail was then aware of the focus of the primary researcher in subsequent school observations.

Theme 1: Behavioral Concerns

Gail’s behavior during the day, and for most days of observation, could be described as typical of her classroom peers. During the majority of observations she remained at her desk at appropriate times, spoke at ap­propriate times, and was no more disruptive to other students in the class than any other student. She volunteered to answer questions more than some students and less than oth­ers. In other words, except for her inattention during lesson times, she did not exhibit the typical characteristics of a student with un­controlled ADHD, such as being disruptive during lessons or excessive physical motions like fidgeting. Gail’s behavior patterns re­mained consistent during the four weeks of observation.

Gail’s behavior was only markedly dif­ferent on one day, mostly due to the fact that she had a cold and had not taken her ADHD

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medication that morning. The following ex­cerpt from the field notes on that day docu­ments her behavior when she was off her prescribed psychostimulants:

“ 1:30 pm Science. The class is taking a Science test today. As the papers are handed out the students that have done extra credit projects are turning them in. Gail hands one in, but takes quite a long time to do it. She misses part of the instructions regarding the test since she is taking an inordinate amount of time to put her poster board with the other projects along the wall closest to her desk. While the students are working on the test, Gail does the same. Breaks in her focus occur when she takes a longer time than necessary to choose a different pen, watches the girl beside her put her hair in a ponytail holder, and goes to the restroom.

The process for going to the restroom is that the student who wants to go signs out on the clipboard by the door and takes one of three keys hanging beside the clipboard. The student signs in on the clipboard when he/she returns from the restroom.

When Gail goes to the restroom this time she spends two minutes (timed) rearranging the keys on the hooks that hold them. Then she goes to the restroom- is gone four minutes- and then comes back and signs back in.She spends another minute signing back in by reading the time on the clock, and taking a circuitous route back to her desk. She then goes back to taking her test. For the 15 minutes remaining of this Science period, she goes off task again 3 minutes later and starts writing on her hand. I no­tice something already drawn on the back of one hand and I wonder what

it is and when it got there. She marks one answer on her test and then goes across the room to wash the stuff off her hands at the sink. This lasts for two minutes then she comes back and sits down. She then begins looking around at the other students milling around the class, because most of the other class members are finished with their tests and are working on homework for tomorrow or reading books. Then she begins to draw on her knee, below her skirt. She takes a moment to look back at her test and mark an answer. She is marking her knee again when Mrs. King, the classroom teacher, asks who in the classroom is still working on their test. Approximately five students raise their hands- Gail and two of her tablemates being three of the five. Gail goes back to working on her test and marking on her leg. Mrs. King walks the room and stands behind her. Gail takes this nonverbal cue and begins to work on her test again and the teacher moves away. This focus lasts for three minutes and then is broken by the girls whispering quietly behind her so she turns to watch them switching glasses and trying on other students’ glasses in the group. At 2:15 pm Mrs. King asks who is still working and there are three now, Gail and two other girls. They are instructed to continue working on their tests and the rest of the class to get out their religion books. When one of the girls at Gail’s table is getting out her books, she and Gail have a whispered conversation. Once the lesson starts, Mrs. King tells those still working to go to the library to finish their tests. Gail leaves with the other two to go to the library. Then she comes back and gets one of her papers that she has left on her desk. She leaves again quickly,

Teaching Strategies For Students With Adhd: Findings From The Field / 455

practically running out of the room.This is the fastest I’ve seen her moveduring my observation periods (this isthe fourth such observation).

This classroom observation documented Gail’s behavior when her executive function­ing skill of self-regulation and her hyperac­tivity were not being managed by her med­ication. Her behavior was therefore typical of untreated ADHD (e.g., out of her seat at inappropriate times, speaking at inappropri­ate times, and impulsive behaviors such as drawing on her hands and knees). She was still off task at times when taking her medica­tion as prescribed, but much less frequently, approximately 25% of the time. The reduc­tion of ADHD behavioral symptoms when Gail was medication compliant matches the findings from prior research documenting the effectiveness of psychostimulants in symp­tom management (Barkley, 2014; Barkley, DuPaul, & Connor, 1999).

Theme 2: Academic Abilities

During an observation of a science lesson, it was discovered that Gail had scored a 45% on a recent science test and that her science grade at the end of the first trimester had been 74% (considered a “C” at her school). In an initial interview with Gail, she shared, “The hardest thing in school today was science. I wasn’t sure what steps to do in our experi­ment and I’m not sure when the extra credit is due, either.” Even though she felt unsure of what steps to take in that day’s assignment, her trimester grade suggests that she under­stands enough information to maintain an average grade. Clearly, Gail’s grade would drop if she continued to get test and home­work scores similar to the 45%. Also, during the initial interview, Gail made the comment, “I don’t get good grades because I don’t study outside class.” Certainly Gail’s academic per­formance would be severely impacted if her

symptoms of ADHD were not managed on most days.

Gail’s science test failure was an illus­tration of the academic impact of not taking her medication. Yet, even on days when she was medication compliant, many of her as­signments were not completed satisfactorily or were not turned in on time. Gail’s report cards during her fifth grade year, as well as from previous years, suggested she needed additional help beyond psychostimulant med­ication; specifically, with completing home­work assignments. Interviews with Gail’s teacher, Gail’s mother, and Gail herself, as well as classroom observations support this conclusion. During an interview, Gail made the comment, “I have too many things to do after school so I don’t always get my home­work done.” This shows an awareness of her needing additional organizational skills.

Theme 3: Organization of Time and/or Materials

Gail was aware she needed help with or­ganization in order to get assignments com­pleted and submitted on time. She asked the school psychologist to come in during lunch recess one day to help her organize her desk. The school psychologist did and Gail seemed pleased to get help with this project and to spend time with the school psychologist, with whom she appeared comfortable. During the desk organization the psychologist made the comment that, “getting it organized is one thing; keeping it organized is another.” Gail gave a verbal agreement of the psychologist’s comment, but neither explored strategies for achieving this goal.

Interestingly, although Gail expressed being involved in too many outside activities to get her homework completed, the only formal extracurricular activity she had was a music lesson one afternoon each week. The other four weekday afternoons she remained at school for an extended-care program where

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she was to work on her homework, or if she had no homework, she had free time. Gail therefore had ample time to complete assign­ments and it became clear that she needed additional support, beyond only psychostim­ulant medications, to help her stay focused on her academic success. Specifically, she might have benefitted from individualized assis­tance to keep her focused on assignments and get them completed. Although Gail’s mother was an elementary teacher, their relationship had high levels of tension commonly found between parents and children with ADHD. Therefore, having help outside of the family may have alleviated some of the tension be­tween Gail and her mother.

Overall, it appeared Gail understood most of the content in her courses as evidenced by her grades. Her grade point average (GPA) at the end of 4th grade was an 80%. After two tri­mesters in fifth grade year her GPA was 75%. Given that psychological testing indicated her intelligence was almost two standard deviations above the mean, it was clear her GPA was not reflective of her true abilities to succeed academically. It would seem un­likely she would be able to have a solid “C” GPA if she did not understand the academic content. Although she had managed to obtain passing grades so far in her schooling, her decreasing GPA in fifth grade suggested that as her coursework became more challenging in middle school and beyond, her intelligence alone may not be enough to ameliorate the organizational challenges she experienced as a symptom of ADHD.

Theme 4: Interpersonal Considerations

At school, Gail was not openly rejected or teased by peers; however, she was frequently ignored and, thus, excluded from many social interactions. She had one friend with whom she socialized almost exclusively. Her inter­actions with her teachers seemed to be largely non-conlfontational, and she appeared to be

well-liked by her homeroom teacher, with whom she spent most of the academic day.

Although the school environment ap­peared to be largely non-confrontational, her family interactions were frustrating for both Gail and her mother, particularly regarding schoolwork. Both mentioned in interviews the struggle regarding getting schoolwork done at home and having it completed in a neat and comprehensive manner. Gail’s mother provid­ed her thoughts on the conflict saying:

[Gail] procrastinates when doing her homework or doesn’t get it done. She’s always saying, “Later, mom, later. I ’ll do it later.” And then it doesn’t get done without a fight. And sometimes she lies to me and tells me it’s done be­cause she doesn’t want to do it, or she doesn’t want me to look at her home­work because she knows I’ll make her re-do it if it’s wrong. And honestly, I don’t want to fight all the time over homework, either. It’s kind of a battle at our house sometimes. It’s easier to give in.”

Discussion

There are several key findings from this case study. Generally, Gail performed well within the complex web of interactions need­ed to excel in an academic setting. Drawing on her elevated intelligence, the support of psychostimulant medication, and the use of organizational strategies, Gail had managed to maintain an average level of academic per­formance despite her diagnosis of ADHD. In- terpersonally, Gail was liked by her teachers and the one close friend she had in her class. She was not openly rejected or teased by her classmates as has been found in some studies (Dirks, Treat, & Weersing, 2007), but was, rather, invisible to them.

A second finding of this study concerns executive functioning. Gail’s intelligence was

Teaching Strategies For Students With Adhd: Findings From The Field / 457

above average, however, problems with time management, inattention to detail, self-regu­latory issues, and lack of strategic planning prohibited her from achieving her full po­tential. Although in the fifth grade Gail was successful in compensating for these deficits with her elevated intelligence, the long-term sustainability of this strategy is doubtful. As academic content gains more complexity, especially once she enters middle school, she may no longer be able to rely on her intelli­gence as a coping strategy.

A third finding of this study is the inter­personal tension and conflict that homework brought to the relationship between Gail and her mother. The participant’s parent acknowl­edges the conflict and admits that sometimes it is easier to give in than to fight it. This find­ing of family discord is consistent with pre­vious research (Barkley, 2014; Cunningham & Barkley, 1979; Gerdes, Hoza, & Pelham, 2003; Mash & Johnston, 1982).

Strategies for Academic SuccessCase study research does not generally pro­

vide sufficient validity or reliability to make generalizations across populations. However, based on the findings from this study, we have four recommendations that may have applicability for other children with ADHD experiencing similar challenges. First of all, conflict resolution training may be helpful for children with ADHD, their teachers, and family members (Barkley, 2014. ) The symp­toms of ADHD frequently lead to contentious interactions with authority figures including teachers and parents, as well as other family members and peers. Conflict resolution train­ing for students with ADHD and their teach­ers may facilitate better communication and reduce potential tensions in the classroom. Although Gail generally had non-confronta- tional relationships with her teachers, many students with ADHD experience interperson­al conflict and therefore such training may

significantly improve teacher-student rela­tionships. Beyond conflict issues specifically, increasing the interpersonal communication abilities of students with ADHD may prevent miscommunications that may negatively affect relationships with peers, parents, and family members. Teachers may specifically collaborate with school counselors to help identify and implement conflict resolution interventions and improved communication strategies for students with ADHD (Hamilton & Astramovich, 2014).

Secondly, modifying the classroom envi­ronment has been shown to be effective for students with ADHD (Dupaul, Eckert & Vilar- do, 2012). Specifically, teachers could allow time in the classroom for individualized study time with a tutor, such as an older student or classroom volunteer. An in-class tutor could work with the student one-on-one, assisting the student to get organized and focused, so he or she can complete assignments. Teachers could also help parents identify appropriate after-school tutors to help ensure homework assignments are regularly completed. Ulti­mately, the use of one-on-one tutors may re­duce stress related to assignment completion for the student with ADHD, his or her parents, and teachers.

Thirdly, organizational training can em­power children with ADHD to become re­sponsible for their academic success (DuPaul & Stoner, 2014; Pfiffner, 2011) by being able to keep track of and submit homework and other in-class assignments. Key to this type of training is consistency of the use of orga­nizational skills because when a student with ADHD loses attention, he or she misses part of each interaction. Therefore, it takes much longer for any new skill to become a relied upon strategy. While such repetition may be irritating to the teacher, it is crucial to the stu­dent. Organization techniques may include a two pocket folder wherein the left side is ded­icated to work to be completed each day and

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the right to work that is completed by the end of each day/night, a homework journal that is signed by the teacher and student before it leaves school each day and parent after he/she sees the work has been completed and is in the proper side of the folder, and/or various pockets/holders to keep supplies contained within the student’s desk/locker/book bag.

Lastly, stimulant use has been shown to be both safe and effective for treating symptoms of ADHD by decreasing inattention to school tasks, increasing school productivity, and im­proving performance on academic tests (Bar­kley, 2014). Thus, identifying strategies to ensure medication compliance can minimize preventable, negative impacts on student’s academic performance. Teachers may be able to assist with this by having school hour dos­age time(s) written into the student’s journal, the teacher setting an alarm on their phone to remind the student it’s time for his/her dos­age, and/or having an hour-glass or egg timer started at a time right after recess (or whatever set activity is close to dosage time) may all be viable options for the teacher to assist in this strategy.

Limitations and Future Research

This study utilized a single subject, qual­itative case study design (N = 1). Therefore, the unique experiences documented may not be generalized to other children with ADHD. However, Gail’s symptoms and experiences were consistent with the literature on ADHD effects on academic success, so it may be pos­sible for other researchers and practitioners to identify with Gail’s characteristics, chal­lenges, and strengths. Given the particularly stressful nature of the conflict between chil­dren with ADHD, their parents, other family members, friends, and teachers, it seems that further research specific to conflict resolution training for children with ADHD is warranted. In addition, further studies about the psycho­social ramifications of ADHD in the school

environment may help identify strategies to help children with ADHD develop stronger interpersonal skills.

Conclusion

The challenges for students with ADHD are numerous and occur in multiple contexts in the home and school settings. This case study highlighted the need for students with ADHD to receive additional support beyond psychostimulant medication to help manage symptoms of inattention while at school. In the classroom, teachers may help foster the development of conflict resolution and orga­nizational skills in students with ADHD. In addition, teachers can help coordinate indi­vidualized tutoring during the day, and help parents locate tutors for after school hours to keep students with ADHD focused on com­pleting academic assignments. Ultimately, by providing such interventions, children with ADHD can develop confidence in their abil­ities and achieve their highest academic and interpersonal potentials.

Teaching Strategies For Students With Adhd: Findings From The Field /459

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