Transcript Attention Deficit Hyperactivity Disorder: Teacher Basics to Help in

“BUT HE CAN FOCUS ON VIDEO GAMES FOR
HOURS!”
Mother
Educator
Psychologist
Advocate
Coach
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?
STATISTICS
The 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 antisocial 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
annoying
WELL, THIS IS USUALLY WHAT YOU’LL HEAR…
Inattention
 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
Hyperactivity
Impulsivity
 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.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Frustration because they have a different perception of the situation.
Lack of structure.
They act the role of being “bad.”
They don’t know how to ask to get what they need so they act out.
The classroom is full of distractions.
The child feels misunderstood.
Hunger.
They feel overwhelmed with tasks assigned.
They feel criticized.
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.
2.
3.
4.
Maintain behavior logs citing observations of behaviors and
situations. Remember to include inventions used and their efficiency.
Inform parents of behavioral concerns and discuss behaviors at
home.
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.
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:
 Dopamine
 Norepinephrine
 Epinephrine
 Serotonin
 Dopamine has been associated
with approach and pleasure-seeking behaviors
 Norepinephrine plays a role in emotional/behavioral regulation
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)
TAXONOMY OF EXECUTIVE SKILLS
Response Inhibition
Working Memory
Emotional Control
Sustained Attention
Task Initiation
Planning/Prioritization
Organization
Time Management
Goal-directed
Persistence
Flexibility
Metacognition
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 selfmonitoring 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 trouble
Use Proximity Control: Increase supervision of the child
Demonstrate 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
Note: From Dawson & Guare, (2004).
SELF-REGULATION OF AFFECT
Prepare child for problem situations
Give child scripts for problem situations and practice regularly
Structure environment to avoid situations that can lead to problems
Give breaks to child during tasks as needed
Teach child I-statements
Use 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
Note: From Dawson & Guare, (2004).
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
Note: From Dawson & Guare, (2004).
TASK INITIATION
Use verbal cues to get child started
Create a visual cue to prompt child to get started, such as a note on their desk
Walk through the first part of the task to help child get started
Have 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
Note: From Dawson & Guare, (2004).
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?”
Note: From Dawson & Guare, (2004).
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
Note: From Dawson & Guare, (2004).
TIME MANAGEMENT
Give child a schedule to follow
Prompt student with each step of a task
Impose time limits for assignments
Provide frequent reminders for remaining time to complete task
Use 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
Note: From Dawson & Guare, (2004).
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
Note: From Dawson & Guare, (2004).
FLEXIBILITY
Give advance warning for new schedules or activities
Allow student to practice new schedules or activities
Provide rubrics to follow
Read social stories to teach coping strategies in problem situations
Offer 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
Note: From Dawson & Guare, (2004).
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
Note: From Dawson & Guare, (2004).
TEACH THIS PROCESS
1. STOP
2. THINK
3. PLAN
4. DO
CLASSROOM SETUP TO
ACCOMMODATE ADHD
Seat 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 CHALLENGES
Make lessons very clear
Use lots of visuals
Pair students together to complete assignments
Provide hand signals
Play beat the clock
Use behavioral contracts
Use sticker charts
Provide study carrels or private offices
Allow students to move around
Allow more time for tests
Put luggage tags on book bag to remind students of what to bring home
Put sponges or mouse pads on desks for students who like to tap
Have special highlighters for students to use
Use picture mats or file folders cut into thirds to chunk assignments
Provide headphones for students to use
Use 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
Consistent
Immediate
Reinforcing
TEACH THIS PROCESS
1. STOP
2. THINK
3. PLAN
4. DO
ADHD: STIMULANT TREATMENT
Pharmacological treatment usually involves
 Methylphenidate products
 Dextro-amphetamine/amphetamine products
CNS stimulants highly effective
 Reduce core symptoms of inattention, hyperactivity,
and impulsivity in 75% to 90% of children with ADHD
ADHD: STIMULANT TREATMENT
Research has shown that stimulants:
Are highly effective in reducing ADHD symptoms
in the short term
Decrease disruption in the classroom
Increase academic productivity and on-task
behavior
Improve teacher ratings of behavior
ADHD: STIMULANT TREATMENT
Common side effects
 Insomnia, decreased appetites, dysphoric mood
 Irritability, reduced motor activity
 Headaches, G-I complaints
 Tics
 Decreased 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 behavior
Family problems beyond the scope of medication
No long-term effects established
Long-term use rare
Limited parent/teacher satisfaction
Some 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, psychoeducation, 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