Attention Deficit Hyperactivity Disorder (ADHD)

1. Attention Deficit Hyperactivity Disorder (ADHD) Prepared by: CiciliaEviGradDiplSc., M.Psi

2. Challenges • The symptoms interfere daily life activities • At risk for failing at school, being suspended, abusing substances, dropping out of school, having a very high rate of conflicts with their families over doing chores and HW (Salend & Rohena, 2003) • Parents often express frustration and stress (Barkley, 2005) • Negatively influence their relationships with others  rejected and disliked  lonely and friendless

3. Challenges (2) • For most individuals  symptoms continue throughout their lives (Barkley 2005, 2006)  affect adult life in many ways  35 lost days of work in a year, totaling more than $19 billion in wasted human capital nationally • Can have very successful lives  but require accurate identification and effective services (CHADD, 2007)

4. Definition • DSM-IV-TR  breaks down ADHD into 3 subcategories: Predominantly Inattentive, Predominantly Hyperactive-Impulsive, and Combines  “is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development” (APA, 2000, p. 85)  excessive and cause significant impairment in social, academic or occupational functioning (p. 93)

5. Definition (2) • Before age 7, for at least 6 months, in more than 1 setting • Students must experience heightened alertness to environmental stimuli (extraneous classroom events  pencil tapping), which results in limited alertness to their educational environment (teacher’s instructions, lessons)”

6. Coexisting Disabilities • In most cases, ADHD coexists with another disability  comorbidity • With LD • With Emotional or Behavioral Disorders

7. With LD • 1/3 of ADHD students • Score higher on intelligence than other students, incld those with LD and significant reading problems (Kaplan et al., 2000)  but score lower on standardized achievement tests than their classmates without disabilities (Barkley, 2006) • Each requires an individualized educational program to meet their specific need

8. With Emotional or Behavioral Disorders • Approximately 58% of students receiving special education services under the emotional or behavioral disorders category also had ADHD (Schnoes et al., 2007) • Boys  more into aggressive and antisocial behavior  resulting in higher referral rates for this category • Girls  same level of impulsiveness but lower level of hyperactivity, aggression, defiance and conduct problems  not classified into EBD (Barkley, 2006)

9. Characteristics • They rely more on others (external factors) to explain their accomplishments, and therefore they are less persistent, expend less effort, prefer easier work, and take less enjoyment in learning • Behavioral • Academic • Social

10. Behavioral Characteristics • The root of many academic problems experienced by ADHD students is at least one of these 3: • Inattention • Hyperactivity • Impulsivity • Explain why students seem to daydream, miss the little (but important) details about assignments, and submit incomplete HW (Salend, Elhoweris & van Garderen, 2003)

11. Inattention • Commonly noticed by parents, teachers, researchers • They get distracted and don’t focus for the seemingly short time span required to complete their work  miss the details of the problems • Carelessness, distractibility, and forgetfulness  associated with inattention

12. Hyperactivity • Implying an excessive level of activity (Montague & Dietz, 2006)  but the definition is hard to agree, due to subjectivity of level of a specific activity • Diminish with age? • Adolescents and adults  may still have trouble with distractions due to daydreaming or ongoing flows of thoughts and ideas in their mind when concentration is needed for college course or business meeting  internal restlessness (Weyandt et al., 2003)

13. Impulsivity • “an inability to control one’s response to the environment “ (Montague & Dietz, 2006)  they tend to blurt out a quick response before thinking the question through • They tend to redirect the topic of class discussion, talk out of turn, or “butt into conversations” (APA, 2003; Fowler, 2002, 2004)  gain fewer positive response from their classmates and decrease social acceptance (Merrell & Boelter, 2001)

14. Academic Performance • Spend less time engaging in academic tasks than their classmates without ADHD (Duhaney, 2003)  trouble studying for long periods of time • Disorganized and forgetful, messy handwriting, sloppy and careless work, incomplete assignments, their work is not logical and not organized • They need structure to support their learning and social performance (Salend et al., 2003)

15. Contd. • Teachers should make assignments interesting, individualized when possible, and relevant to their backgrounds and interests  content enhancements and the use of learning strategies are also of great benefit

16. Social Behavior • ADHD characteristics  decrease positive social interactions and increase antisocial behaviors (Merrell & Boelter, 2001) • They see themselves as having more internalizing behaviors and are more introspective about their problems (Volpe et al., 1999)  judge themselves as social failures, engage in more solitary activities, contributing to a cycle of increasing alienation and withdrawal; sharpen pencil more often than their classmates, looking out for something on the bookshelf during quiet time or play with objects during lessons (Duhaney, 2003)

17. Contd. • Teachers can help: • Providing explicit instructions on how to interact with others and behave in a more socially appropriate manner • Using functional behavioral assessment data  to reduce or eliminate inappropriate behaviors • Teaching self-management strategies  including rewards for conforming to classroom rules • Positive characteristics of ADHD  intense creativity, intuitiveness, emotional awareness, exuberance (Honos-Webb, 2005)  think outside the box, nonstandard problem solving

20. Prevalence • The exact numbers are unavailable • General consensus  3%-7% of schoolchildren have ADHD (Barkley, 2006) • Boys are generally identified at significantly higher rates  girls are under-identified, possibly due to a lack of awareness of how their behavioral needs differ from those of boys • Culture may be an important factor to consider  understand and selecting the best intervention

21. Causes • The exact cause is unknown  arises from many different sources: brain injury (trauma or infection), genetic contributions, and risk factors, such as prenatal use of alcohol and tobacco ; biological predisposition  inherent differences in the way the brains of individuals with ADHD function  ADHD has a neurological basis • Executive functions  cognitive abilities that enable us to plan, self-regulate, inhibit appropriate behaviors and engage in goal-directed activities

22. Contd. • Biology + environment = ADHD • Genetics may contribute  same family members • A parent with ADHD may be less likely to follow consistent routine and provide clear and concise expectations or directions  intensified their child’s ADHD characteristics • P. 208

23. Overcoming Challenges • Behavioral techniques, direct and systematic instructions that is evaluated on a frequent basis and a highly motivating instructional materials  but, before that … medication • Over 2 millions ADHD students consume Ritalin, Concerta, Adderall, or Dexadrine  to control their behavior (Austin, 2003)  increase the arousal level of CNS, enhancing blood flow to the frontal lobes or increasing electrical activity in the brain and improving functions (working memory, attention, planning and self regulations)

24. Contd. • Stimulants  increase levels of certain neurotransmitters that enhance brain functioning (Ward & Guyer, 2002); help them to focus their attention on assigned tasks, and medication is effective for most (Forness & Kavale, 2001) • Controversy  rapid increase of prescriptions, side effects (reduction in appetite, problems sleeping, jitteriness, dizziness)  need to monitor their health and performance carefully

25. Contd. • Educators need to work with family to: • Medications not uniformly effective • Take several adjustments  classroom obs • Negative side effects  classroom obs • Medications  not directly improve academic functioning  more effective with behavioral therapy

26. Assessment • Early Intervention • Less common than during school years  parents might see the symptoms, but need professional help to determined whether those are typical or excessive for the child’s age (NIMH, 2006) • Become noticeable when compared to their peers • Pediatricians, child psychologist/psychiatrist • Behavioral training for parents and social skills training for the child

27. Assessment (2) • Prereferral • Purpose  to avoid unnecessary referrals to special education by implementing research- validated practices in the general education classroom • Focus on preventing problem behaviors  physical and instructional structure of the classroom must be considered • Well-planned behavior management system, rules, procedures, and consistently delivered consequences  maintenance of regular classroom routine!

28. Assessment (3) • Identification • Include multidimensional evaluations (Barkley & Edwards, 2007; Weyandt, 2007)  include: • Diagnostic interview • Medical examinations • Behavior rating scale • Standardized tests • Observations • Include medical profession  to gather the data needed to understand each individual’s problems and types of support/system needed  academic performance, behavioral patterns, social interactions and medical history

29. Assessment (4) • Evaluation: Testing Accommodations • Extending time  typically 8-12 minutes longer to answer test items  surprisingly, giving longer period does not significantly improve their scores  but they feel more motivated, less frustrated, and thought they performed better (Elliott & Marquart, 2004) • Testing in alternate setting  where distractions may be limited

30. Early Intervention • Preschoolers with ADHD  have poorer social skills, more demanding and noisy during peer interactions, display higher level of verbal and physical aggression, and require more frequent medical attention than non-ADHD peers (DuPaul & Stoner, 2003) • Parent behavior training  positive results  reduction in parent-child conflicts • Classroom-based behavioral interventions  positive reinforcement, response cost, daily rewards, and additional strategies

31. Contd. • Community-based interventions  combined with medical treatment, parent training, and classroom-based behavioral interventions  reduce negative characteristics of ADHD and improve social skills and interactions, particularly in classroom settings • Results usually short-term and don’t produce associated improvements in academic performance (DuPaul & Stoner, 2003)  need further research

32. Access to General Classroom • Cumulative effects of unmet instructional and behavioral needs  resulted in poor academic achievements  because they miss blocks of information and experience interruptions in the learning process  access to general classroom is inconsistent • Selecting effective accommodations and interventions  based on individual student’s problems  the sooner the better

33. Instructional Accommodations • Reducing distracting stimuli  avoid high-traffic areas, pencil sharpener, hallway door, trash bin; placing them near teacher and peer model to influence positive behaviors • Physical accommodations  pointers or bookmarks to help students track words visually during reading exercises, timers as reminders of time left, visual cues (turn off the light to indicate that the noise level is too high)

34. Contd. • Accommodations  bring benefit for all students! But mostly for ADHD students • Instructions that are engaging, exciting and culturally relevant to the students, pace of presentation varies; teachers monitor the understanding of key concepts and adjust the lesson accordingly, directions are clear, concise and thorough • Feedback if students with ADHD able to delay gratifications

35. Data-Based Practices • If students engage in acting-out behaviors  teachers need to check of the work is too difficult for them • Lack of motivation and persistence to make the extra effort to learn when it is difficult for them • Carefully planned educational procedures  let them choose academic assignments from a group of alternatives, shortening the task, giving clear and precise instructions, reward for achievement

36. Self-Management Strategies • Self-monitoring  learn to evaluate her own behavior by determining whether it is on task or off task • Self-instruction or self-talk  use self-induced statements to guide their actions • Goal-setting  helpful to determine the level of expected performance for a task • Self-reinforcement  powerful self-regulation strategy that allows students to earn rewards for accomplishments

37. Technology • Personal organizers  provide structures necessary to reduce the number of incomplete homework assignments or skipped meetings with a tutor • Software programs • Web pages  provide interesting text and stimulating pictures combined with movie or audio clips  help them engage in prolonged period of time and shift attention frequently

38. Transition • Combination of medical interventions and counseling  including individual, family/marriage and/or vocational counseling • Components needed in effective programs (p. 219) • Information sharing (p. 220) • Teachers can assist family (p. 221)