Attention Deficit Hyperactivity Disorder

(ADHD)

Implications for TeachersUlidia Resource Centre

October 2002Roz Lacey & Gayle Nixon (Educational Psychologists)

Aims

o To increase understanding of Attention Deficit Hyperactivity Disorder (ADHD) and its implications

o To provide practical strategies for the management of ADHD in the classroom

Programme

o What is ADHD?o Causes, prevalence and co-morbidityo Coffeeo Assessment & diagnosiso Treatmento Medicationo Luncho Strategies for school

Please fill in the firstsection of your

evaluation forms.

Remember these arecompletely confidential.

Thanks!

Activity - ADHD in class

o Describe the types of behaviour that would lead you to believe a child had ADHD.

o What difficulties do these behaviours pose in school for:o The teacher?o The child?o His / her classmates?

o What strategies are typically employed by your school to deal with these behaviours?

o Are these effective?

ActivityHow much do you know about

ADHD?

Current Diagnostic Criteriao Diagnostic & Statistical Manual of

Mental Disorders – 4th Edition, American Psychiatric Association, 1994 (DSM-IV)o Entirely behavioural in natureo 2 clusters of symptoms (Inattention &

Hyperactivity / Impulsivity)o Each cluster consists of 9 behavioural

descriptionso Behaviours must also:

o Be developmentally inappropriate;o Be present for at least 6 months;o Be present before age 7;o Cause impairment in at least 2 settings;o Result in clinically significant impairment in social

or academic functioning.

Current Diagnostic Criteria - DSM-IV

o DSM-IV outlines 3 subtypes of ADHD:o ADHD(I) Predominantly Inattentive

Typeo ADHD(HI) Predominantly Hyperactive-

Impulsive Typeo ADHD(C) Combined Type

ADHD(I) - Inattentive Type

Inattention

Distractibility

ADHD(I) - Inattentive Type

o Look out for the child who…o Is often off-tasko Doesn’t finish their worko Makes careless mistakeso Appears lazy / disinterestedo Daydreams / Appears not to listeno Misses instructions / asks for things to be

repeatedo Can’t seem to focuso Is unable to maintain effort over timeo Is forgetful / disorganised

ADHD(HI) - Hyperactive Impulsive Type

Impulsivity

Problemswith

activity level

ADHD (HI) – Hyperactive Impulsive Type

o Look out for the child who…o Talks excessivelyo Shouts / blurts outo Interrupts / intrudeso Can’t wait her turno Doesn’t wait to hear instructionso Is restless / fidgety / out of seato Is always “on the go”

ADHD(C) - Combined Type

Problemswith activity

level

Inattention Distractibility

Impulsivity

Coffee?

Biological Level

Cognitive Level

Behavioural Level

Environmental

What causes ADHD?

o Research suggests that ADHD is genetico Symptoms are a result of

neurotransmitter dysfunctiono Recent research suggests dopamine is

not being recycled properlyo MRI scans show differences in brain

activity between ADHD children and controls

How many children have ADHD?

o 3% - i.e. one in every class of 30o 1% ADHD (I)o 2% ADHD (HI)

o Boys more frequently diagnosed than girlso Ratio of ~4:1o Girls more likely to be diagnosed with

ADHD(I)o Frequency of ADHD diagnoses tend to

increase dramatically from the pre-school to the primary school years.

What aboutyour

school?

Is ADHD a unitary condition?

o Difficulties of differential diagnosiso Co-morbidities

o Emotional disordero Antisocial behaviour disordero Tic disordero Pervasive developmental disordero Learning difficultyo Motor planning problemo Self-esteem problem

o Gt. Ormond St. Studyo DAMP

Assessment and diagnosisRecognition of indicators

(home or school)

Referral to G.P. or E.P.

Referral to Paediatrician / Child Psychiatry

Assessment across contexts(DSM-IV)

Diagnosis or not

In yourexperience…?

Biological Level

Cognitive Level

Behavioural Level

Environmental

Medicationo Psychostimulants - most common

o Ritalin (methylphenidate)o Dexedrine (dextroamphetamine)

o Considered to be very safeo Immediate, observable effects (1/2 hr)o Wears off in 3-4 hours (not addictive)o Monitoring should be by consultanto Personality should not seem dulledo Some side effects possibleo NOT SUFFICIENT BY ITSELF!!!

The MTA Studyo Biggest study ever completed on

ADHD treatmento 4 groups

o 1) Medication managemento 2) Behaviour treatmento 3) Combined treatmento 4) Community care

The MTA Study (Cont.)o Findings –

o Medication alone better than behaviour alone on core symptoms

o Combination not substantially better than medication

o Carefully managed medication had fewer side effects (no additional medication needed)

o Combined treatment group needed lower doses of medication

Help for parents

o Increased understanding and insighto Support groupso Good quality liaison with schoolo Programmes such as ‘1,2,3 magic’

by Thomas Wheelano Excellent Booklet “All about ADHD”,

Tel: 020 7535 7400

ActivityHow much have you learned?

Lunch

Practical Strategies for Schools

o Aim: To maximise the potential for all children in the classroom by reducing the time the teacher has to spend responding to the child’s behaviour.

o Aim: To reduce teacher stress!!!

Favouriteso Headphones / screeno Traffic lightso Behaviour programmeso Visual timetable / chunkingo Attention trainingo Brain gymo Stress toyo ICTo Circle timeo Coffee jar challenge

Knowledge of ADHD & Strategies Chosen

o Knowledge level influences choice of behaviour management strategyo Higher knowledge = whole class strategies

chosen

o Different strategies affect behaviour in different ways…o Individual strategies = increased attention

and concentrationo Whole-class strategies = reduced

hyperactivity

Strategies for Particular Diffficulties: Sustaining effort

o Reduce task length (differentiation)o Break long assignments into chunks &

reward completion promptlyo Follow difficult task with preferred tasko Short breaks between taskso Use timero Quality rather than quantityo Alternative methods of recording

Strategies for Particular Diffficulties: Easily distracted

o Seat at front away from distractionso Use earphoneso Utilise study carrels / flexible seatingo Use physical proximityo Ensure eye contact when giving

instructionso Cue pupil to stay on tasko Attention training

Strategies for Particular Diffficulties: Talking out of turn

o Ignore inappropriate comments & questions

o Traffic light systemo Positive reinforcement for listening

Strategies for Particular Diffficulties: Poor Recall

o Multi-sensory approacho Seeing, saying, writing, doingo Role-playing activitieso Computer assisted instructiono Memory techniques Mnemonics

VisualisationSub-vocalisationVerbal mediation

Strategies for Particular Diffficulties: Untidy/Disorganised

o Assist pupil with personal organisationo Arrange for peer supporto Reward tidinesso Be willing to repeat expectationso Keep worksheet format simpleo Keep materials needed to hando Develop a clear system for keeping track

of completed and uncompleted work

Strategies for Particular Diffficulties: Transition Time

o Use individual / group work schedules (in picture or written format)

o Define requirements carefullyo Aim for consistency across

tasks/classeso Always give a 5 minute warning

before ending an activity

Strategies for Particular Diffficulties: Peer Problems

o Arrange joint activities in class with likely friends

o Use co-operative learning activities

o Reward appropriate social behaviour (involve parents and lunchtime supervisors)

o Assign pupil responsibility in the presence of his/her peer group

o Utilise Circle Time /P.S.E /Drama to teach concepts of communication, participation and co-operation

Strategies for Particular Diffficulties: Fidgets /

Squirms

o Break tasks into small stepso Allow alternative seatingo Allow alternative movement where

possibleo Stress toyo Consider ‘Brain Gym’

Whole-class strategies: Behaviour Management

o Provide frequent, immediate and consistent feedback about acceptable and unacceptable behaviour

o Praise specific behaviouro Be sure to criticise the behaviour,

not the child

Whole-class strategies: Rules & Routines

o Keep classroom rules clear and simpleo Display them [positively]o Ensure that pupils know what happens if

these rules are kept or brokeno Strive for consistency of expectation,

action, reward and punishmento Establish a daily classroom routine and

schedule

Whole-class strategies: Giving Instructions

o Get quiet attention firsto Be clear and conciseo Give instructions in the order you

want them to be carried outo Follow up oral instructions with

written reminderso Keep checking that pupils know

what to do

Whole-class strategies: Marking work

o Use self-correcting materialso Pair pupils to check worko Encourage pupils to check over

their worko If possible, correct work in

presence of pupilo Write useful, specific comments

Whole-class strategies: Lesson Structure &

Presentationo Review previous lessons on the topico Set learning and behavioural expectations

at outseto Actively involve pupils in presentationo Keep lessons short & interestingo Include a variety of activitieso Vary the paceo Use multi-sensory approach or ITo Allow adequate time for lesson review /

recap

Behaviour Programmes

o Why?o Help the child to focus on specific

targetso Shift the emphasis from bad to good

behaviouro Should positively impact on behaviour

in class, self-esteem & peer relations

Behaviour Programmes

o How?o 3 simple targets

o 1 achieves alreadyo 2 sometimes manageso 3 more difficult but not impossible

o Keep it visual (e.g. chart / diary)o Involve parentso Only comment on positive behaviouro Build in rewardso Reward effort, not just achievemento Don’t shift the goal posts too soon!

Behaviour Programmes using response cost

o Children with ADHD have difficulty visualizing the potential reward

o Give rewards at the start of time period with potential to lose

o Build in an early warning systemo Keep it tangible & visualo Reward approximate behaviour

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Peter

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Response Cost System

Encouragement

o You’re on 2!o Keep it up!

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‘You can earn out of it’

Child has Control

Reduces TeacherStress

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Aim

o 60% intact by the end of the dayo Focus on the Positive [how they

managed to stay on task]o IGNORE empty boxeso Reward at the end of each day

[hierarchical]

Choosing Time

o 3 periods intact = Do a favourite activity

o Less that 3 periods intact = Do a less favourite activity

o Mostly blanks or reds! = Boring activity.

Important!

o Allow success for the first few days to show the child they are capable of achieving.

o Problems achieving 60%??o Shorten the time period.

Problems?

o Cumbersomeo 11 o’clock and I haven’t

remembered?

Changing the way children think

I’m useless

Changing the way children think

o 94-96% of language heard is negativeo External locus of controlo Defence mechanisms are often

damaging, eg. class clowno So…

o Reframe everythingo Explain difficulties in an ego-enhancing wayo Teach child problem solving skills (eg. Pilot)o Involve them in finding solution

Useful web-sites

o www.attention.como www.helpforadd.como www.adders.orgo www.cdipage.como www.add.org (this one sings!)

IEPs for ADHD

o Agreed with parentso Understood and followed by all staffo Very specific targetso Include strategies that will be

employed to help child meet targetso Reviewed regularly

Let’s be realistic!!

What happens if these children are not helped?

o Typically complete fewer years of educationo More likely to be unemployed as adultso 33% go on to suffer clinical anxiety &

depressiono Many adolescents exhibit pervasive conduct

problems and become known to the criminal justice system

o They are more likely to be involved in substance abuse and have relationship problemsWith the appropriate help, the likelihood of all

of the above is reduced.

Aims Revisited

o To increase understanding of ADHD and its implications

o To provide practical strategies for the management of ADHD in the classroom

ADHDo ADHD is a genuine

medical diagnosis.o Life can be tough for

young people with ADHD.

o School staff are in a powerful position to make changes which will positively impact upon their lives.

o The strategies that are recommended for pupils with ADHD are also the best possible strategies for all pupils.

Thank you for listening.

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