Attention (Deficit/Hyperactivity) Disorder: How can educators help children and parents?

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Attention (Deficit/Hyperactivity) DisorderHow
can educators help children and parents?

• But he can focus on video games for HOURs!

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Norrine L. Russell, Ph.D.Developmental
psychologist

• Russell Coaching Consulting
• www.norrinerussell.com

• Mother
• Educator
• Psychologist
• Advocate
• Coach

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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?
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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.

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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

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What well 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?

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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
  anti-social behavior

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ADHD Myths Busted

• As published on ADDitude Magazines 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
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What is ADHD?
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What is ADHD?
annoying
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Well, this is usually what youll hear
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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
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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)
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What do current experts think adhd is?

• A Deficit in
• Self-Regulation

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

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Remember

• If they could, they would.
• Ross Greene
• The Explosive Child A New Approach for
  Understanding and Parenting Easily Frustrated,
  Chronically Inflexible Children

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What Can An Educator Do If Some Symptoms Appear
To Be Present?

• 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).
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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

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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

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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/behaviora
  l regulation

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Executive functioning

• Wait, the kid Im thinking of doesnt seem like
  an executive

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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)

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Taxonomy of Executive skills

• Response Inhibition
• Working Memory
• Emotional Control
• Sustained Attention
• Task Initiation
• Planning/Prioritization

• Organization
• Time Management
• Goal-directed Persistence
• Flexibility
• Metacognition

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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.

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Executive skills and learningHow does a lack of
executive functioning create a problem in the
classroom?
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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.

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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.

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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.

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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 shouldnt.

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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.

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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 whats
  important to focus on and whats 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.

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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.

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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.

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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.

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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.

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Deficit Metacognition

• This is the ability to stand back and take a
  birds-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.

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But what do i DO?
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  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.
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  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.
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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 neededrather than continued
disbelief that they did it wrong again.
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Teach this process1. stop2. think3.
plan4. do
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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).
44
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).
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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).
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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).
47
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).
48
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).
49
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).
50
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).
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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).
52
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).
53
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).
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Teach this process1. stop2. think3.
plan4. do
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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 Institutes
  How to Handle the Hard-to-Handle Student Resource
  Handbook, (2005).
• Create a stage for announcements in the classroom
  (Appelbaum Training Institutes How to Handle the
  Hard-to-Handle Student Resource Handbook, (2005).

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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 Institutes How to
Handle the Hard-to-Handle Student Resource
Handbook, (2005).
57
Successive behavioral interventions are

• Intensive
• Consistent
• Immediate
• Reinforcing

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Teach this process1. stop2. think3.
plan4. do
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Medications
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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

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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

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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

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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

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• One thing to remember
• Pills dont teach skills

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• American Medical Association (AMA)
• encourages the use of individualized therapeutic
  approacheswhich 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)

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• 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)

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• 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 patients ADHD symptoms
  are mild with minimal impairmentor parents
  reject medication (p.902)if a child has a
  robust response and shows normative
  functioningthen 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)

68
What works best?Medication behavioral
supports
69
summary

• ADHD is a highly prevalent, brain-based disorder
  which is associated with lifelong impairment in
  functioning
• Environmental factors can contribute to the
  expression, severity, course, and comorbid
  conditions
• Long-term developmental outcomes for individuals
  with ADHD can include serious substance abuse,
  chronic criminality, depression and suicide
• Stimulant medications and behavior therapy are
  currently the only established evidence-based
  treatments for ADHD
• 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

70
Conclusion

• ADHD is not a problem with knowing what to do
  it is a problem of doing what you know.
• -Barkley, 2006