week 5
Students With Attention-Deficit/ Hyperactivity Disorder
5
Creatas/Thinkstock
Pre-Test:
1. Students with ADHD must exhibit inattentive and hyperactive symptoms. T/F
2. ADHD and ADD are the same disorder. T/F
3. Boys exhibit inattentive characteristics of ADHD more than girls. T/F
4. A student’s home or school environment may contribute to ADHD. T/F
5. Students with ADHD are typically diagnosed by a teacher at their school. T/F
6. Most students are diagnosed with ADHD in elementary school. T/F
7. Peer tutoring is a beneficial strategy for students with ADHD. T/F
Answers can be found at the end of the chapter.
Learning Objectives
After reading this chapter, you should be able to:
1. Describe the differences between the ADHD definitions provided by IDEA 2004 and the DSM-IV.
2. Explain why ADD is no longer the favored term for ADHD.
3. Describe the characteristics of students with ADHD.
4. Identify factors associated with causes of ADHD.
5. Explain how medical professionals use checklists and observations to diagnose ADHD.
6. Explain why preschool and elementary school may be the first environments where ADHD may be identified.
7. Describe how classroom organization and classroom management may help students with ADHD.
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CHAPTER 5Section 5.1 What Is Attention-Deficit/Hyperactivity Disorder?
Introduction
Have you ever met someone who was fidgety and couldn’t sit still for more than a few min-utes at a time? How about someone who had difficulty paying attention to a conversation or a movie? You yourself have probably experienced the feeling that you need to get up and stretch your legs or that you can’t remember anything you read in the last chapter, but for some people this occurs so often that it interferes with school and work. These people may have Attention-Deficit/Hyperactivity Disorder (ADHD).
5.1 What Is Attention-Deficit/Hyperactivity Disorder?
T his chapter discusses a disability that is not a separate category under IDEA 2004: ADHD. It is one of the more prevalent disabilities in schools today (Stolzer, 2007). This section pres-ents the formal definition of ADHD and discusses the difference between the terms ADHD and ADD. It highlights how IDEA 2004 defines ADHD and how prevalent it is in students.
Defining ADHD Students with Attention-Deficit/Hyperactivity Disorder (ADHD) typically exhibit some combina- tion of inattention, hyperactivity, and impulsivity. A student displaying inattention might have trouble focusing on a task for an extended period of time, be easily distracted, or struggle with paying attention to details. Hyperactivity might be seen in class as a tendency to fidget and have difficulty staying seated for reasonable amounts of time. A student who exhibits impulsivity may speak at inappropriate times or have difficulty waiting for his or her turn.
Displaying inattention, hyperactivity, or impulsivity does not necessarily indicate that a student has ADHD. In fact, most students occasionally show one or even all of these behaviors. Any stu- dent may daydream or jump out of their seat and run to the window to see something outside. Any student may grab a marker from another student or talk fast and appear jittery. However, when these difficulties are severe and persistent enough to interfere with regular activities, the student who exhibits them may be diagnosed with ADHD.
ADHD and IDEA 2004 ADHD falls under the IDEA 2004 category of Other Health Impairment (OHI). For a student to qualify for special education services under IDEA 2004 in the OHI category, the student must exhibit an academic deficit related to ADHD and exhibit characteristics of ADHD.
ADHD is one of the more commonly identified disabilities that falls under OHI. Other disabilities that may fall under the OHI umbrella include diabetes, epilepsy, and Tourette syndrome (although some schools categorize Tourette syndrome under EBD). Students with ADHD spend most, if not all, of their time in general education classrooms. Thus, a typical general education teacher will likely teach many of these students in his or her classroom (Ambalavanan & Holten, 2005).
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CHAPTER 5Section 5.1 What Is Attention-Deficit/Hyperactivity Disorder?
. Aurelie and Morgan David de Lossy/cultura/Corbis
As discussed in Chapter 4, an FBA helps members of the IEP team determine the antecedents, settings, specific events, and consequences of a student’s inappropriate behavior. BIPs integrate student strengths and motivations in an individualized plan to increase the likelihood of sustained success.
Students with ADHD may have either an IEP under IDEA 2004 or be covered by the Americans with Disabilities Act and have a 504 plan. Each school forms its own criteria and uses them to decide whether a student with ADHD receives services under IDEA 2004 or Section 504. Teach- ers use these plans as a guideline to determine appropriate accom- modations or modifications. Most students with ADHD, however, do not have many accommodations or modifications listed in their IEP. Instead, accommodations or modifications are most often in the form of a Functional Behavior Assessment (FBA) and Behavior Intervention Plan (BIP).
DSM-IV and ADHD Medical professionals often use the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) to diagnose; it provides another definition of ADHD (American Psychiatric Associa- tion, 2000). The DSM-IV outlines the three subtypes: ADHD predominantly inattentive type, ADHD predominantly hyperactive-impulsive type, and ADHD combined type (Larsson, Dilshad, Lichtenstein, & Barker, 2011). Students with the predominantly inattentive type struggle with inattention without major difficulties with hyperactivity and impulsivity. Students with the predominantly hyperactive-impulsive type struggle with hyperactivity and impulsivity without major difficulties with inattention. Students identified with ADHD combined type exhibit both inattentive and hyperactive-impulsive characteristics. See Table 5.1 for some examples of each type of characteristic as described by the DSM-IV.
Table 5.1: Inattentive, Hyperactive, and Impulsive Symptoms of ADHD
Inattentive Hyperactivity Impulsivity
Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
Often fidgets with hands or feet or squirms in seat
Often blurts out answers before questions have been completed
Often has difficulty sustaining attention in tasks or play activities
Often leaves seat in classroom or in other situations in which remaining seated is expected
Often has difficulty awaiting turn
Often does not seem to listen when spoken to directly
Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
Often interrupts or intrudes on others (e.g., butts into conversations or games)
(continued)
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CHAPTER 5Section 5.1 What Is Attention-Deficit/Hyperactivity Disorder?
Inattentive Hyperactivity Impulsivity
Often does not follow through on instructions and fails to finish school work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
Often has difficulty playing or engaging in leisure activities quietly
Often has difficulty organizing tasks and activities
Is often “on the go” or often acts as if “driven by a motor”
Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
Often talks excessively
Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities
Source: Adapted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, (Copyright 2000). American Psychiatric Association.
Table 5.1: Inattentive, Hyperactive, and Impulsive Symptoms of ADHD (continued)
Prevalence of ADHD ADHD affects approximately 3–10% of school-age students (Ambalavanan & Holten, 2005). Because the criteria for diagnosing and delivering services to students with ADHD vary considerably by state, there is a wide variability in the percentage of stu- dents diagnosed with ADHD in school classrooms from state to state (anywhere from 3–15%).
Boys are more often identified with ADHD—in fact, up to three times as often—than are girls (Bruchmüller, Margraf, & Schneider, 2012; Barkley, 2006). How- ever, boys generally exhibit more hyperactive charac- teristics of ADHD, while girls exhibit more inattentive characteristics (Abikoff et al., 2002). This difference may be one reason why males are diagnosed more often: Hyperactivity is usually more apparent and distracting to adults, whereas inattention is not as obvious or bothersome.
Interestingly, African-American students tend to be diagnosed less with ADHD than Caucasian stu- dents (Mandell, David, Bevans, & Guevara, 2008).
iStockphoto/Thinkstock
The hyperactive and impulsive characteristics that boys with ADHD exhibit can lead to more cases of juvenile delinquency among this group than among boys without ADHD (Sibley et al., 2011).
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CHAPTER 5Section 5.2 How Has the ADHD Field Evolved?
However, African-American students tend to be over-diagnosed with EBD, which probably indi- cates that schools tend to categorize students (with the same behavioral characteristics) differ- ently based on racial category. Researchers have also discovered that the younger students (by age) in a classroom may be identified more often than older students in the same classroom (Zoëga, Valdimarsdóttir, & Hernández-Diaz, 2012). Perhaps younger students take longer to learn behavior patterns in a typical classroom.
5.2 How Has the ADHD Field Evolved?
Behaviors that educators and medical professionals now associate with ADHD have been highlighted in medical literature for at least the last 200 years. While “bad parenting” was sometimes blamed, some early physicians did believe that the difficulties their patients had in performing certain tasks stemmed from brain anomalies.
An early description of ADHD may be found in a children’s poem, “The Story of Fidgety Philip”, published in 1845, by German psychiatrist and author Heinrich Hoffman. The boy in the poem can- not sit still at the dinner table, and fidgets despite his parents’ requests to stop. At the beginning of the 20th century, an English doctor, George Frederic Still, described young boys with behavioral difficulties that he believed were due to differences in their biological makeup—specifically, in the brain. Still’s work, along with that of others, such as the physician William James, was vital in explaining that the behavior of some children was not a moral failing on the part of parents.
In 1934, Eugene Kahn and Louis Cohen published a study in the New England Journal of Medicine that described patients with impaired attention, impulse control, and self-regulation. Soon after, in 1937, Charles Bradley produced evidence that linked a stimulant drug to the reduction of symp- toms for children with behavior difficulties. As more and more researchers worked with these children and tried to find medications to assist with their daily functioning, the term minimal brain dysfunction began to be used to describe their condition. Another term, hyperkinetic syndrome, emerged in the 1950s to describe brain function that is overactive or overwhelmed.
As previous chapters have explained, the 1960s and 1970s were a time of tremendous growth in understanding disabilities, including ADHD. In 1968, the DSM-II recognized ADHD as an actual disorder, hyperkinetic reaction of childhood. The terms Attention Deficit Disorder and, later, ADHD were coined in the 1980s (Brown, 2006).
Attention Deficit Disorder (ADD) is an outdated term. When people use the term ADD, they are usually referring to ADHD predominantly inattentive type. Some adults prefer the term ADD, since they do not experience hyperactivity as much as children and adolescents do, but this chapter will refer to the disorder as ADHD.
In the last few decades, much of the research on ADHD has focused on learning more about the chemicals in the brain that receive and transmit signals (neurotransmitters), understanding the role of medication in helping to control ADHD, determining how to better assess students with behavioral difficulties, and learning how to best teach students with ADHD. These topics will all be covered in the remainder of this chapter.
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CHAPTER 5Section 5.3 What Are the Characteristics of Students With ADHD?
5.3 What Are the Characteristics of Students With ADHD?
The inattention, hyperactivity, and impulsivity of people with ADHD can emerge in a variety of ways. Table 5.2 lists the common characteristics of ADHD identified by the Centers for Disease Control and Prevention (CDC). Table 5.2: Common Characteristics of ADHD
Inattentive characteristics Hyperactive characteristics Impulsive characteristics
Has difficulty paying attention Is in constant motion Frequently loses necessary items
Makes careless mistakes Is unable to stay seated Is unable to play quietly
Daydreams Squirms or fidgets Acts and speaks without thinking
Doesn’t seem to listen Has difficulty following through Has difficulty taking turns
Is easily distracted Talks out of turn or too much Interrupts others
Is forgetful
Has difficulty organizing information
Source: Centers for Disease Control and Prevention (CDC). Retrieved from http://www.cdc.gov/ncbddd/adhd/facts.html.
Of course, not all children (or adults) who exhibit these qualities have ADHD. In fact, for a diag- nosis, students must exhibit inattentive or hyperactive-impulsive characteristics more frequently than is observed in other students of the same age.
How do educators differentiate ADHD? There are three governing principles outlined by the DSM-IV that all must be in place for a student to receive a diagnosis of ADHD:
1. A student must exhibit characteristics (i.e., inattentive and/or hyperactive-impulsive) for a sustained period of time (six months or more) and in multiple settings (e.g., at home and in school).
2. The behaviors must be disruptive to the classroom or home environment. 3. Some of the inattentive, hyperactive, or impulsive behaviors must have been manifested
before the student was 7 years of age.
When students exhibit the behaviors that are characteristic of ADHD, it is important to rule out extenuating factors. For example, a student who has recently experienced a sudden death in the family or who is coming to terms with his parents’ divorce might act in atypical ways. It is also important to rule out other medical reasons (such as seizures or depression) that may cause stu- dents to appear to have ADHD.
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CHAPTER 5Section 5.3 What Are the Characteristics of Students With ADHD?
Many students with ADHD are also diagnosed with other disabilities, such as SLD (see Figure 5.1). In fact, the rate for comorbidity (i.e., the likelihood that a student has two or more disabilities rather than just one) with ADHD is as high as 50–60% (Jensen et al., 2001). ADHD can occur along- side behavioral disorders, such as Oppositional Defiant Disorder (ODD), conduct disorder, bipolar disorder, anxiety disorder, depression, or Tourette syndrome (Takeda, Ambrosini, deBerardinis, & Elia, 2012). Some students with ADHD may also have Autism Spectrum Disorder (Grzadzinski et al., 2011), or be considered gifted (Foley-Nicpon, Rickels, Assouline, & Richards, 2012).
Figure 5.1: Comparison of Students With ADHD and SLD
The number of students with ADHD, with SLD, and with both is compared with the total number of school-age students. Note that the number of boys diagnosed with ADHD, SLD, or both is higher than the number of girls diagnosed with either disability.
Source: CDC/NCHS, National Health Interview Surveys, 2004–2006.
P e rc
e n
t
ADHD without SLD
SLD without ADHD
NOTES: ADHD is attention-deficit/hyperactivity disorder. “Both” is ADHD and SLD. “All ADHD” includes ADHD with and without SLD. “All SLD” includes SLD with and without ADHD.
Both All ADHD All SLD 0
2
4
6
8
14
12
10
GirlsBoys
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CHAPTER 5Section 5.4 What Are the Causes of ADHD?
From My Perspective: Researching ADHD I’m Mike, and I’ve spent the past 10 years working with and studying children with ADHD, and I wouldn’t trade it for the world. These kids have specific challenges, but most of them are great kids that really want to do well and make you proud of them. Here are a few of the things I’ve learned over the years.
1. ADHD isn’t a “new” disorder, an American fad, or a motiva- tion problem (Volpe et al., 2006). The earliest description comes from Hippocrates (490 B.C.), who described patients with an “overbalance of fire over water” that were impulsive and had problems sustaining attention.
2. Rates of ADHD are highly similar around the world (3% to 5% of children have ADHD). We know that it is to some degree caused by neurological factors. Kids with ADHD won’t neces- sarily “grow out of it.” We now know that about 66% of kids with ADHD continue to have it as adults, and almost all of them continue to have difficulties in important areas of life functioning.
3. Medication is the best treatment we have, but it’s not a cure. Stimulant medication results in huge improvements in behavior for about 90% of children with ADHD. It also appears to be a protective factor against later substance abuse. On the other hand, medication only works on days students take it, and it does not improve school grades, standardized test scores, or peer relationships.
4. Hyperactivity may be functional. We all move around more to help us stay alert and focus. Next time you’re in a long meeting, watch as everyone starts to shift in their chairs and move around after a while. So unless their behavior is interrupting the class, let kids fidget, sit weird in their chairs, or do their work standing up. Reinforce the work, not the motor activity.
5. Break down instructions into parts, write them down, use charts, and don’t give multi-step direc- tions. One of the biggest problems for many children with ADHD is working memory, which is the ability to hold things in your brain while thinking about those things, or while doing some other task. So if you tell a child with ADHD to “go upstairs, put on your pajamas, brush your teeth, and pick out a book to read before bed,” don’t be surprised to find him upstairs in his pajamas play- ing with his favorite toy. This usually isn’t oppositional behavior—it’s a working memory prob- lem, and the child probably does not remember that you wanted him to do something other than put on his PJs. He heard you just fine, but the other steps were lost from memory along the way (Martinussen & Major, 2011).
Corbis/SuperStock
5.4 What Are the Causes of ADHD?
Researchers have not identified a primary cause of ADHD. They believe that it is probably related to a combination of biology, genetics, and the student’s environment (Larsson et al., 2011; Thapar, Cooper, Eyre, & Langley, 2013). As technology improves over the next few decades, researchers will be better equipped to understand how these causes work and combine to affect students with ADHD.
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CHAPTER 5Section 5.4 What Are the Causes of ADHD?
Blend Images/SuperStock
With recent advances in technology, such as a functional Magnetic Resonance Imaging (fMRI), researchers can learn more about the brain and its role in inattentive or hyperactive and impulsive behaviors. Already, fMRI scans indicate that when students with ADHD are presented with new information, different areas of their brains respond compared to students without ADHD.
The Role of Biology Many researchers hypothesize that students with ADHD are either missing specific neurotransmit- ters or that the actions of these neurotransmitters are faulty. When neurotransmitters are not work- ing as normal, the information processing system of a student’s brain has difficulty handling new infor- mation. In other words, the “hardware” in the brain has trouble organizing new information, so the brain becomes overloaded and shuts down.
Indeed, brain scans of students presented with a dif- ficult or distracting task show marked differences between students with and without ADHD. Students with ADHD often show a decrease in brain activ- ity compared with students without ADHD. Before the difficult or distracting task, all students demon- strated similar patterns in brain activity.
It is well-established that the brain is involved in the intake and processing of information; what may be less obvious is that the rest of the body is also involved. Many students with ADHD experi- ence sensory overload (i.e., too many noises or too much visual activity in the classroom). They may focus on the music playing in the background or the busy collage on the wall instead of focusing on the task at hand.
Genes also appear to play a role in the likelihood of a student developing ADHD (Thapar et al., 2013). While no single gene has been identified as responsible, approximately one-third of students with ADHD have a sibling with ADHD, and approximately half of students with ADHD have a parent with ADHD (Freitag, Rohde, Lempp, & Romanos, 2010; Polderman et al., 2007). The role of genetics in ADHD is further complicated by the fact that about half of students diagnosed with ADHD in school will outgrow their ADHD characteristics by adulthood (Garnier-Dykstra, Pinchezsky, Caldeira, Vincent, & Arria, 2010; Martel, von Eye, & Nigg, 2012).
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CHAPTER 5Section 5.5 How Are Students Diagnosed With ADHD?
The Role of the Environment Quite a few environmental factors have been linked to ADHD (Thapar et al., 2013). Several causal factors may occur during gestation. For example, mothers who smoke or engage in substance abuse may have babies with an elevated risk of ADHD (Graham et al., 2013). Babies born premature or at a low birth weight may also have a higher risk of ADHD. After birth, malnutrition or other dietary factors—such as too much sugar or fatty acids—could possibly be risk factors for ADHD. In addition, researchers hypothesize that some students with ADHD may have had exposure to pesticides or lead (Thapar et al., 2013).
Some researchers believe that family dynamics may contribute to students developing ADHD. For example, if parents and students experience hos- tility or anger toward one another on a constant basis, or if students are abandoned or feel unsafe in their environment, this may put them at a higher risk for ADHD.
Blend Images/SuperStock
If a student’s home environment is hostile or volatile, the student may have an increased chance of ADHD. How parents treat their children (or how parents treat one another) can have a negative effect on a student.
5.5 How Are Students Diagnosed With ADHD?
Like some other disabilities, ADHD is diagnosed by medical professionals or clinicians using DSM-IV criteria or using parent and teacher rating scales along with observations of the student (Rushton, Fant, & Clark, 2004). No test exists for diagnosing ADHD. The profession- als may gather checklists, rating scales, and observations from teachers and other school staff members to aid in the diagnosis.
Teachers and school staff can talk with parents about the possibility of their child needing to undergo an evaluation for ADHD, but the official diagnosis must come from a medical professional or clinician (i.e., medical doctor, psychiatrist, or psychologist). Often, parents discuss their con- cerns with a pediatrician or family physician, who then refers the family to a clinic for professional screening for, and diagnosis of, ADHD.
Checklists Medical professionals use a checklist of characteristics, along with information in the form of anecdotal evidence and behavioral observations from parents, caregivers, teachers, or other school professionals, to thoroughly evaluate a student. This evaluation usually takes weeks or months to complete because data about the student’s behaviors have to be gathered over time and from a variety of sources. If the screening is conducted properly, it is not possible for a student to walk into a clinic or doctor’s office for the first time and receive an ADHD diagnosis.
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CHAPTER 5Section 5.5 How Are Students Diagnosed With ADHD?
As you learned, ADHD is divided into three categories: ADHD predominantly inattentive type, ADHD predominantly hyperactive-impulsive type, or ADHD combined type. Refer to Table 5.2 for a checklist of characteristics divided into inattentive, hyperactive, and impulsivity categories.
Rating Scales and Behavioral Observations Rating scales, such as the widely-used Conners test or the Barkley Scale, provide one of the more common ways to gather information from teachers, parents, or even individual students when they exhibit characteristics of ADHD.
There are three versions of the Conners test: one for parents or guardians, one for teachers, and one for students who are old enough to rate themselves (i.e., middle- or high-school students). Parents, teachers, or students fill out the form and rate the student’s behavior by answering multiple-choice questions. The Barkley Rating Scale also involves parents and teachers filling out different versions of a questionnaire about the frequency of difficult behaviors of the student. The information from these tests and scales, if gathered properly, can aid doctors or clinicians in a diagnosis of ADHD. They should never depend on just one rating scale or source, however, to determine whether a student has ADHD; a proper diagnosis should have documentation from multiple sources.
Behavioral observation is also useful in information gathering for a diagnosis of ADHD. Teach- ers, parents, or other trained professionals may observe students in different settings (e.g., in the classroom and at after-school workshops). In a behavioral observation, the observer notes whether and how often certain behaviors occur. This information can be used to aid medical professionals in their diagnosis.
When Are Students Diagnosed? ADHD is often diagnosed near the end of the early childhood period, during preschool or kindergarten. Around age 5, many students begin to exhibit characteristics common to ADHD as they start school and learn the new rou- tines associated with the struc- tured setting of the classroom. Starting school involves learning how to follow directions and how to act in group settings, and if students are not used to school expectations, they may display some of the inattentive, hyperac- tive, or impulsive characteristics of ADHD (Anderson, Watt, Noble, & Shanley, 2012).
.Wolfgang Flamisch/Corbis
Diagnosing ADHD before school age can be difficult; it may be hard to determine whether the student’s inattention or hyperactivity and impulsivity is due to ADHD or to being young and inexperienced in social cues and norms. However, ADHD students can be identified earlier than the age of 5 if they exhibit very severe symptoms of ADHD.
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CHAPTER 5Section 5.5 How Are Students Diagnosed With ADHD?
Special Education: Your Profession The Medication Debate Medical professionals who diagnose a child with ADHD may decide, in consultation with the family, to prescribe medication to help alleviate some of the student’s difficulties with inattention, hyperactivity, or impulsivity (Huang & Tsai, 2011; Mahon, Woodruff, Horn, Marjerrison, & Cole, 2012). The role of the teacher in this decision is usually minimal, though the teacher may be asked to describe how often the student’s lack of attention or hyperactivity has occurred in the classroom. This anecdotal evidence may help the doctor and family determine how much and what type of medication to administer.
The most common medications prescribed for ADHD are stim- ulants, such as Ritalin or Adderall, or non-stimulants, such as Atomoxetine. Stimulants help increase brain chemicals that send messages to nerves. The increase usually improves attention and focus. Non-stimulants help increase attention and focus, but by a different route. Stimulants often work very quickly, whereas non-stimulants take weeks or months to be fully effective.
Because stimulant drugs can have addictive properties, and even the non-stimulants can lead to side effects, including weight loss, muscle tics, dizziness, and sleeping issues, among others, the treatment of ADHD with medication has become controversial (Stolzer, 2005). Some doctors and families feel that the benefits of these drugs outweigh the risks, while others choose not to medicate and pursue other treatment options, such as dietary modifications.
Once parents have decided that their child should take medica- tion, teachers and other school professionals need to support that decision, no matter what their opinions may be (Snider, Busch, & Arrowood, 2003). Teachers need to take care not to use the student’s medication (or lack of it) as an explanation as to why a student can or cannot do something. For example, a teacher may be tempted to speculate that “Devin may not be able to take that test today because his mom forgot to give him his meds.” This statement could cause Devin to not perform well because he feels his teacher’s expectations are low.
However, this does not mean they have ADHD. If a student comes from a home where lots of physical activity is encouraged, it may take the student a while to learn how to not run around the classroom all the time or jump out of her seat when an adult enters the room. Once students become familiar with the classroom rules and expectations, their classroom attention and behav- ior should improve. Those students who do not show improvement may have ADHD.
Most students with ADHD are diagnosed around second or third grade, or between the ages of 8 and 10. At that time, they are expected to work more independently and are held more account- able for their schoolwork. When these expectations are placed upon those students whose brains find it difficult to process new information readily, they may begin exhibiting characteristics of ADHD. Students may have displayed ADHD characteristics for a few years, but they were not as noticeable during their participation in the larger-group activities of preschool or kindergarten as they are in a more “academic” setting.
. Hero Images/Fancy/Corbis
While many adults debate the use of medication for students with ADHD, the students themselves generally think favorably about taking medication to control their behavior (Singh et al., 2010). Students report that they see decreases in problematic behavior, and they feel they have better relationships with their classmates.
(continued)
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CHAPTER 5Section 5.6 How Does ADHD Differ Across Grade Levels?
Special Education: Your Profession The Medication Debate (continued) In addition, the statement shows that Devin’s teacher is penalizing him for not taking his medication. (The situation may be more complicated than Devin’s mom “forgetting” to give him his medication.) That said, teachers should take care to work with the school and parents to establish the importance of a student taking medication as prescribed.
The research on dietary changes in ADHD is not conclusive, but dietary modification is often high on the list of options for parents who choose treatment routes other than medication (Millichap & Yee, 2012). Diets that eliminate gluten, sugar, or dairy products are popular because they seem to alleviate some students’ symptoms. Because high amounts of sugar have sometimes been shown to lead to difficulties in students’ concentration, some students may benefit from reduced sugar intake.
While the teacher is not likely to be involved in the decisions made about the diet of an ADHD student, schools should support the dietary requests of parents and students to the greatest extent possible. Doing so may mean not having cupcakes at a classroom birthday party or eliminating candy from the vending machine, but such changes may be beneficial for all students.
5.6 How Does ADHD Differ Across Grade Levels?
Teaching strategies for students with ADHD show some similarities across grade levels, as well as some differences. For example, all students may benefit from classroom manage-ment and organization techniques, but these techniques may have to be amended based on the student’s grade level.
Early Childhood ADHD is often diagnosed near the end of the early childhood period, during preschool or kindergarten, when students are first asked to participate in and finish tasks, fol- low directions and rules, sit qui- etly, and control their movements. Students who have a harder than average time sitting still or tran- sitioning from one activity to another may be showing symp- toms of ADHD. For instance, teach- ers may ask students to move from an art center to the carpet area for story time, and students with ADHD may act out or refuse to follow directions because they find it difficult to leave one task to do another. Many of the teaching strategies highlighted later in this chapter are appropriate for very young students with ADHD.
iStockphoto/Thinkstock
For many students, preschool is the first time that they experience a situation where they have to follow directions and fit in with a group. Preschool teachers may observe students who have difficulty with the behavioral expectations in the classroom. Some of these students may have ADHD, although they may not be diagnosed until elementary school.
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CHAPTER 5Section 5.6 How Does ADHD Differ Across Grade Levels?
Elementary School Most students diagnosed with ADHD will be identified in the elementary grades. Students in this age group may experience difficulties related to spending hours in a classroom during the school day. Students may struggle with inattention to classroom material and hyperactive or impulsive behavior in groups.
When teaching elementary school students with ADHD, it is helpful to present lessons in smaller groups. This allows the classroom teacher to better differentiate instruction and monitor on-task behavior. To differentiate, teachers tailor assignments or materials to the individual student to ensure that the student is getting the most out of the lesson. Peer tutoring, delivering lessons in an explicit manner and at a brisk pace, and using a variety of instructional tools for conceptual understanding are all methods that are known to be helpful in teaching elementary-aged ADHD students (Harlacher, Roberts, & Merrell, 2006). When teaching in an explicit manner, teachers pro- vide direct and focused instruction on a topic area. The teacher helps the student by guiding the student through material and providing many opportunities for feedback and discussion.
Keep in mind that many students with ADHD are hypersensitive to sights and sounds. Think hard about whether to show a presentation with many graphics or a movie with lots of music and noise. Allowing students to have some choice of topics to study (or how to study certain topics) can also be helpful, and tends to help motivate a broad range of students. Activities that are “hands-on” are also more compelling for these students. These kinds of activities include conducting a science experi- ment with bacteria samples in petri dishes and learning fraction concepts through dividing pizzas.
Teachers need to remember that in-class and homework assignments may take students with ADHD much longer to complete accurately than the typical student. The practice of sending home unfinished classroom activities or work to be completed as homework is not usually effective for students with ADHD. If these students demonstrated difficulty completing an assignment in the classroom with teacher monitoring and feedback, they will probably also struggle with completing this assignment at home. This will only add to their frustration—and that of their parents.
Secondary School The transition from middle to high school can be difficult for any student, and particularly so for someone with ADHD. First and foremost, expectations from teachers at the secondary level are different than those at the elementary level. Students are expected to be much more responsible for themselves and their learning. They must show up to the correct classroom at the right time, keep track of their academic materials and assignments, and take notes on class material in a way that will help them score well on assessments. Second, secondary students are experiencing numerous physical and emotional changes that can lead to changes in the manifestation of their ADHD. For example, students may become less hyperactive but more impulsive.
Many of the teaching approaches highlighted in Chapter 2 are helpful for secondary school stu- dents with ADHD—for example, using explicit instruction, involving students in peer tutoring, and using differentiation. It also may also be helpful to collaborate with the students themselves to find solutions to their educational problems. High school students frequently complain that they are not treated or respected like adults are, so teachers may want to involve them in decisions about what, how, or when they study for a certain topic.
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CHAPTER 5Section 5.7 How Do I Teach Students With ADHD?
A teacher with high expectations for students, who does not treat them like elementary students but instead provides opportunities for them to take on new responsibilities and exercise auton- omy, will contribute to their self-confidence, which in turn can improve behavior. Teachers should assume students can handle certain tasks until they prove otherwise.
Transition Secondary students with ADHD will also have transition plans to ensure that high school courses and support services align to postsecondary goals. In addition to specifying the effective instructional practices listed in this chapter, transition planning can help students, family members, and educa- tors prepare for ongoing success. These plans can help set up support that continues after gradua- tion from high school. Transition plans should include appropriate service providers, including social services and mental health counselors. Strategic planning increases the likelihood that students with ADHD will complete high school and successfully transition to college or career opportunities.
Individuals with ADHD can absolutely be successful in colleges and careers with the appropriate resources and support. Gaining insight about ADHD, managing behaviors, and utilizing sources of support can all help students achieve (Meaux, Green, & Broussard, 2009). Meaux et al. (2009) outline the following recommendations for postsecondary students with ADHD:
• Gain insight about ADHD • Learn from experience • Seek information • Acknowledge difficulties • Open up for support
• Manage life and behavior • Be accountable • Learn from consequences • Set alarms and reminders • Take prescribed medication • Engage in self-talk • Stay busy and schedule activities
• Utilize sources of support • Parents • Friends • Teachers/Tutors • Academic support and disability services
5.7 How Do I Teach Students With ADHD?
Effective teachers at all grade levels make their classroom environments and practices more conducive to students who struggle with inattention, hyperactivity, or impulsivity.
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CHAPTER 5Section 5.7 How Do I Teach Students With ADHD?
Special Education: Your Profession Evidence-Based Practices for Teaching Students with ADHD Research has identified evidence-based practices for use with students with ADHD, including the following (Carbone, 2001; Simonsen, Fairbanks, Briesch, & Myers, 2008; Kapalka, 2008):
• High classroom structure • Physical classroom arrangement that minimizes
distraction • Active teacher supervision • Response cards • Direct/explicit instruction • Peer tutoring • Specific praise • Group contingencies for behavior • Behavioral contracts • Token economies
Teachers have quite a few choices in terms of evidence-based practices, and many that work for stu- dents with EBD also work for students with ADHD (Cook, 2005). Teachers can use one or more of these practices and decide which ones to use based on the student’s IEP or from their knowledge of the student’s and class’s needs.
Teachers—especially newer teachers—may find it difficult to teach students with ADHD (Glass, 2011; Greene, Beszterczey, Katzenstein, Park, & Goring, 2002). Luckily, learning how to use evidence-based prac- tices with students with ADHD gives these teachers a good starting point (Jones & Chronis-Tuscano, 2008).
As mentioned, many of the teaching techniques (such as explicit instruction and peer tutoring) that are effective for students with SLD and emotional and/or behavioral difficulties have also been proven to be effective for students with ADHD. In addition, the use of strategies related to classroom organization and delivery of instruction can provide an optimal learning environment for all the students in the general education classroom.
iStockphoto/Thinkstock
Teachers should keep in mind that the biggest challenge that students with ADHD face in the class- room is their tendency to be easily overwhelmed or frustrated, either by their environment or by the tasks they are being asked to perform. The characteristics of students with ADHD may lead to classroom behaviors like the following:
• Making careless mistakes on assignments • Daydreaming during lectures • Keeping materials and desks unorganized • Only paying attention during “fun” activities • Not following directions and rules • Turning in assignments unfinished • Causing disruptions in class
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CHAPTER 5Section 5.7 How Do I Teach Students With ADHD?
Classroom Organization Appropriate organization of the classroom is crucial in reducing the stress an ADHD student feels in the typical, busy classroom (Carbone, 2001). The teacher should make sure that all aspects of instruction are well organized, from the way the classroom functions to the arrangement of fur- niture and the materials within it. Good classroom organization also extends to helping students bring order to their assignments and providing schedules to follow.
An organized classroom will help students focus on classroom tasks (e.g., taking notes from a lecture, participating in group instruction, completing a book report), minimizing distractions that could lead students astray. An organized classroom also enables the teacher to focus on quality academic instruction without having to spend time on redirecting student attention or correcting off-task behavior.
Functional Organization: Routines, Procedures, and Classroom Rules Effective functional organization of a classroom involves the establishment of routines and pro- cedures. These provide structure to the classroom and the school day. They help students under- stand expectations for behavior. A routine might be as basic as one that involves students walking into the classroom at the beginning of the school day and turning in their homework:
1. Walk into the classroom quietly. 2. Walk to your locker. 3. Take your homework assignments out of your backpack. 4. Place your homework assignments in the green bucket. 5. Place your backpack into your locker. 6. Walk to your assigned desk. 7. Sit at your desk and begin your morning work.
This routine provides a framework for students in terms of classroom behavior. Teachers could have a procedure for getting materials from the art center for a painting project, breaking into partners to proofread a narrative, or returning library books to the school library.
Teachers should provide explicit instruction and modeling for routines and procedures (Jacobson & Reid, 2010), and students should have opportunities to practice them while the teacher provides feedback. They are important ways to guide students throughout the day. With established rou- tines and procedures, students know how things in the classroom operate and thus are less likely to be distracted from the main focus of the academic task by the logistical details of getting it done.
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CHAPTER 5Section 5.7 How Do I Teach Students With ADHD?
Functional classroom organization also includes the creation of classroom rules that apply to all students. These rules should be positive and brief, with clearly stated consequences for not fol- lowing them. Ideally, there is a set of rules for the entire school, as this consistency helps ADHD students understand the expectations in every classroom, not just their homeroom. Rules for elementary and secondary students may differ slightly, but the underlying concepts are the same (Figure 5.2). Rules are stated positively, are applicable across various school situations, and help students understand school expectations.
Figure 5.2: Classroom Rules
Rules for a second-grade classroom (left) and for a tenth-grade classroom (right) reflect similar expectations for student behavior. Both sets of rules are positive and age-appropriate.
Classroom Rules Our Class Rules
We will treat others and ourselves with respect.
We will come prepared for class.
We will listen attentively and follow directions.
We will not interrupt while others are talking.
We will actively participate in class.
1.
2.
3.
4.
5.
Please raise your hand.
Be quiet and respectful.
Keep hands and feet to yourself.
Use your indoor voice.
Follow directions.
Keep your classroom clean.
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CHAPTER 5Section 5.7 How Do I Teach Students With ADHD?
Cusp/SuperStock
Organization of Space Appropriate organization of the classroom space is also important for students with ADHD (Carbone, 2001). Cluttered walls or bulletin boards, for example, can easily be distracting. Classrooms should have meaningful posters and wall hangings, but teachers should keep them to a minimum. Meaning- ful posters and hangings include things that are important to cur- rent classroom instruction or that outline classroom rules and expectations. Content that has not yet been introduced in class, on the other hand, is likely to pull students away from lessons in progress.
Both elementary and secondary teachers should also pay atten- tion to the placement of student desks and work areas. All students should be able to see the teacher at all times without having to turn around in their seats. If there are tables in the classroom, teachers will have to arrange them in such a way that all students can focus on the teacher without strain.
Carbone (2001) suggests placing desks in rows because rows help students avoid the distractions of being seated at a table. If students can focus on the teacher (and the teacher can focus on each stu- dent), there is less opportunity for distraction and off-task behavior (see Figure 5.3 to consider seating options). Many secondary class- room teachers do place student desks in rows, and elementary teachers may also find it helpful.
Spencer Grant/age fotostock/SuperStock
Two first-grade classrooms use a variety of meaningful resources to help students learn language arts, mathematics, and the content areas. However, one does a better job than the other at organizing the information in a less distracting way. Which classroom do you think students with ADHD might find overwhelming and distracting? What would you do to change this as a classroom teacher?
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CHAPTER 5Section 5.7 How Do I Teach Students With ADHD?
Figure 5.3: Elementary Classroom Seating Options for a Student with ADHD
In this floor plan for an elementary classroom, the red circle indicates the seat for a student with ADHD. What do you think about this choice of seat? What would you do to change this as a classroom teacher?
Regardless of whether student desks or tables are in rows, groups, or some other arrangement, teachers should always assign all students, not just those with ADHD, to work spaces. A student with ADHD will benefit from having an organized work area. Teachers can suggest the use of different colored folders for each class period for secondary students. They can encourage elementary stu- dents to place plastic boxes or tubs in their desk to hold small items like pens, pencils, and erasers.
To help elementary students who fidget with writing utensils or scissors, the teacher should store these items in an accessible area that is not within the student’s immediate reach. Teachers should also keep the student’s workspace as clean and free of distraction as possible, avoiding extrane- ous and overly decorated items (as shown in Figure 5.4).
Student table
Student table
Student table
Student table
Student table
Student table
Student table
Student table
Teacher’s desk
L ib
ra ry
Learning rug
DoorWhiteboard
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CHAPTER 5Section 5.7 How Do I Teach Students With ADHD?
Figure 5.4: Overly Colorful Nameplate
This nameplate is less than ideal for a student with ADHD. It begs for student distraction, with its U.S. map, colorful patterns, and busy charts. A student may spend time tracing the states when all she really needs to see is how to write the letter J. Would this distract you if it were on your desk?
0 1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
10mm 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 210 220 230 240 250 260 270 280 290 300 310 320 330 340 350 360 370 380 390 400 410 420 430 440 450
Name
HUNDRED THOUSANDTHS
1/100,000
TEN THOUSANDTHS
1/10,000
THOUSANDTHS 1/1,000
HUNDREDTHS 1/100
TENTHS 1/10
MILLIONTHS 1/1,000,000
HUNDRED THOUSANDS
100,000
TEN THOUSANDS
10,000
THOUSANDS 1,000
HUNDREDS 100
TENS 10
ONES 1
MILLIONS 1,000,000
Circle Triangle Square Rectangle Diamond Pentagon Hexagon Octagon Star
Red Orange
Green Blue Purple
Yellow
Organization of Assignments Many strategies to help students organize their assignments may help students with ADHD in writing, reading, or mathematics. For example, students may have difficulty solving multi-digit computation problems in mathematics (e.g., 5,462 x 23) because they cannot keep their work organized on the page. Students may have trouble keeping the numbers in columns or writing their numbers small enough for their workspace. Teachers can show them how to use graph paper to keep the place value of numbers intact and organized (see Figure 5.5). Turning lined notebooks sideways helps with organization, as well, because the (now) vertical lines of the note- book paper can help students organize their columns by place value (i.e., ones, tens, hundreds, thousands, etc.).
Figure 5.5: Computation Examples
By using graph paper, students can keep each number in the right place. This strategy enables students to organize their work and make fewer mistakes.
Teachers can encourage students to use plain bookmarks as they read to help them focus on the text line by line. For writing assignments where handwriting is not the focus of the lesson, students with ADHD may find it easier and less frustrating to type their assignment.
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CHAPTER 5Section 5.7 How Do I Teach Students With ADHD?
In assigning work, teachers should consider whether it is reasonable to ask students to complete 10, 20, or 50 problems. Often, students with ADHD can demonstrate mastery of a skill by complet- ing just 10 problems of 30 on a worksheet. Students with ADHD may need longer assignments to be broken into smaller, manageable pieces. This may also be true for other students, as well. For example, when middle school students in an American government class are asked to write an essay on interest groups that influence politics, a teacher could break the assignment into the following parts:
1. Investigate different types of interest groups. List the types of interest groups. Provide three examples of each group.
2. Investigate different ways in which these interest groups can influence political policy. Use a graphic organizer to explain five ways political policy is influenced by these interest groups.
3. Choose three specific interest groups for your research report. Make sure they have enough in common that you can develop a thesis statement about the methods they use to influence American political policy.
4. Develop an outline or graphic organizer that includes a thesis statement for the introduc- tion, supporting details about how the groups influence policy in each body paragraph, and a concluding paragraph.
5. Write a five-paragraph essay as the first draft of your report.
Further details and examples can be provided in class discussions about the assignment, as needed. The student turns in each part of the assignment before proceeding to the following step. The teacher provides timely feedback and guidance to the student to ensure success on each part of the assignment. By breaking an assignment into parts, the individual tasks may not appear as daunt- ing as an assignment that states, “Write a five-paragraph essay on how interest groups influence American politics.” Students also feel a sense of accomplishment with the completion of each step.
The Importance of a Schedule Like other students with disabilities, students with ADHD may function better in the classroom when they are aware of the daily schedule. A visual or written schedule placed in a prominent place in the classroom, in the student’s daily planner, or on the student’s desk can be tremen- dously helpful (Figure 5.6). If the student works with a specialist at certain times during the school day, these appointments should be listed on the student’s schedule.
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CHAPTER 5Section 5.7 How Do I Teach Students With ADHD?
Some elementary grade teachers use pictures of clock faces with the hands pointing to the appro- priate times for each different activity during the school day. This strategy is especially helpful for students who have difficulty reading the analog classroom clock.
Figure 5.6: Sample Schedules
A schedule for a first-grade classroom hangs in the classroom (left), and a smaller copy could be taped to a student’s desk. A schedule for an eighth-grade student (right) will be unique to the student, so it is taped into the student’s daily planner.
ClassClass Schedule Period
Homeroom
English
Math
Science
Lunch
Art
French 1
Music
Social Studies
Reading
Writing
Math
Lunch
Recess
Science
Gym
Music
1
2
3
4
5
6
7
8:00
8:45
9:30
10:15
11:15
12:15
1:00
1:45
2:30
Delivery of Instruction As discussed in Chapter 2, instruction for students with disabilities should be explicit. In other words, the instruction should be clear and concise, with many opportunities to check for student progress and understanding (Gremillion & Martel, 2012). This is important for students with ADHD because students may have fewer opportunities for inattention or hyperactivity/impulsivity if they are actively engaged in the academic lesson. Effective instructional delivery techniques include prioritizing subjects, making sure students participate in the lesson, modeling, providing adequate breaks, and encouraging self-monitoring (Jacobson & Reid, 2010).
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CHAPTER 5Section 5.7 How Do I Teach Students With ADHD?
Prioritizing Subjects Teachers of students with ADHD should prioritize the subjects according to the best times to teach them. For example, reading instruction is usually best in the morning, when students are fresh and ready to learn, rather than, say, the last 45 minutes of the school day after students have just returned from a physical education activity. The end of the day might be better suited for review activities or checking homework because these activities require less concentration and focus than learning new academic content.
Students at the middle or secondary school level who switch classrooms multiple times per day usually have their longest attention span at the beginning of any given period. Teachers, then, should use the beginning of a period to deliver new and important content. Tasks for which full attention is less crucial, or that offer a social element that can refocus attention—such as review- ing homework or completing a group assignment—are better left until the end of the class period, when student attention begins to wane. Teachers should be mindful that students with ADHD may need to switch between tasks at frequent intervals.
Ensuring Participation and Modeling Teachers should provide frequent opportunities for students to actively participate in a lesson to engage them and monitor understanding and involvement. This participation may be in the form of signaling a thumbs up, raising a hand to answer a question, completing a problem on a white board, discussing an idea with a partner, or echo reading. Echo reading involves a teacher or stu- dent reading a sentence or passage and then another person (or the class) repeating the same sentence or passage. The more opportunities students have to interact with and respond to the teacher, the less likely they are to lose focus.
Teachers should also model a concept or skill and practice it multiple times with the student before asking the student to complete an assignment independently. When modeling, the teacher works through a problem or shows students how to complete a task. This helps alleviate student frustra- tion and decrease behaviors that are reactions to frustration. For example, if the teacher asks the students to use a graphic organizer to write a persuasive essay, the teacher can model how to fill in the graphic organizer—with the students—before asking students to fill in their own graphic organizer with a partner or on their own.
Providing Breaks and Releases Even with organized and effective delivery of instruction, students with ADHD may need brief breaks from the classroom to release their hyperactive or inattentive tendencies (i.e., have some “down time”). Some students may need a quick stretch break at the completion of each academic task. This stretch break may be established as a classroom routine so that it is not distracting to other students, or teachers may find that all students benefit from taking these breaks.
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CHAPTER 5Section 5.7 How Do I Teach Students With ADHD?
© Sean Justice/Corbis
Some students in a classroom may sit in chairs, while a few students sit on balance balls.
Students with ADHD may find it helpful to draw or doodle as an outlet for their energy. If this drawing is not distracting to the rest of the class, teachers should allow it to occur. Some students may find it helpful to have a squeeze ball to squeeze and release multiple times during tasks. This technique can help eliminate hyperactive behavior and help the student focus.
Teachers and students should become aware of trig- gers that lead to hyperactive or impulsive behavior and develop signals and routines to use when the student needs a break from the current activity or assignment. For example, if a student is feeling antsy and needs to get out of his seat and stretch, he can raise his hand. The teacher can then nod to signal that the student can move to the back of the class- room to stand for a few minutes. While this might be distracting to some teachers, developing a routine for stretching or standing is better than having a stu- dent jump out of his seat and disrupt the entire class.
Many students with ADHD, in fact, may find it diffi- cult to sit for long periods of time. Some elementary schools allow students to sit on exercise balls, which require the student to focus on balance rather than squirm around (Harlacher, Roberts, & Merrell, 2006). This practice is less frequently used at the secondary level, when students switch class- rooms throughout the day.
Encouraging Self-Monitoring As discussed in Chapter 2, encouraging students with disabilities to self-monitor their behavior is an important step in fostering autonomy and ownership of their learning and success (Johnson, Reid, & Mason, 2011). Having students use checklists is one way teachers can help students moni- tor their own progress in completing tasks or following classroom rules. In addition, a student may stay more focused on an academic or behavioral task if she has a written checklist or set of direc- tions that accompanies verbal directions. Students with ADHD may have difficulty focusing on a long set of verbal prompts, and a visual or written reminder will help them.
Checklists for academic tasks can help students with ADHD break down assignments into manage- able parts (Figure 5.7). Checklists for behavior (Figure 5.8) can also be helpful. At the secondary level, students may use more complex checklists.
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CHAPTER 5Section 5.7 How Do I Teach Students With ADHD?
Students with ADHD may also benefit from learning problem-solving strategies as discussed in Chapter 4 (Jacobson & Reid, 2010). The strategy D.I.R.T. (Define the problem, Identify choices, Reflect on choices, Try it out) helps students with EBD and students with ADHD (Cook, 2005). Problem-solving strategies can help students monitor their own behavior and improve student attention to academic tasks (Iseman & Naglieri, 2011).
Figure 5.7: Sample Checklist in a Writing Classroom
A checklist can help keep students focused in a sixth-grade writing classroom. The student answers questions that lead to the completion of a written assignment with an introduction, body, and conclusion. The color coding in the checklist corresponds to the original instruction provided by the classroom teacher on writing different types of paragraphs and serves as a reminder to the student.
Writing Checklist
√ √
Name:
1. Finish Introduction
Answer the questions in the introduction packet
Review your introduction and add additional information as needed
3. Organization
Are my paragraphs in the correct order?
Introduction Green Paragraph Red Paragraph Conclusion
Are all of my sentences complete?
2. Conclusion
Does my conclusion restate my thesis?
Does my conclusion answer one or more of the reflective questions?
Does my introduction have a hook?
Does my introduction have the background information?
Does my introduction have a thesis statement?
√ √ √
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CHAPTER 5Section 5.7 How Do I Teach Students With ADHD?
Figure 5.8: Behavior Checklist
A student-generated checklist reminds the student to listen and raise his hand. The student has indicated that he can earn stickers for sitting at his desk, reading independently, raising his hand to use the bathroom, participating in whole-class instruction, and cleaning up after snack time. At the bottom the student has shown the reward he will earn for four stickers—computer time.
Stickers =
Behavior Reward Completed Behavior
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CHAPTER 5
From My Perspective: Parenting a Child With ADHD Hi, my name is Mira, and I’m the mother of a child with ADHD. “Anna seems to be struggling with reading; her last assess- ment showed that she still doesn’t know all of her letters.” These are the only words that I remember hearing at my daughter’s final Kindergarten parent-teacher conference.
As a mom and an educator I was shocked, confused, and worried. I wanted to respond, “But I’ve been reading to her since before she was born! When I work with her at home she recites her letters! She LOVES books and has since she could sit up. Are you sure you are talking about MY child?” Instead, I sat in silence and listened to her teacher’s advice.
After this initial meeting, I quickly set up afterschool tutoring for Anna. By second grade, Anna had made some improvements, but she was still falling behind—now in both reading and math. Her teach- ers began to describe her as being “on” at times and “lost” at other points. The inconsistency in her skills and abilities was “baffling,” they said. I began to ask more questions, based on my own observations of Anna. She was always full of random questions, and I noticed that she often fidgeted with her pencil or her fingers when doing homework. I mentioned ADHD to her teachers, but they assured me that she had no problem sitting still or waiting for a turn to speak. They described her as a well-behaved, polite, friendly, and caring young lady who had lots of friends. However, after further observation, her second grade teacher agreed that her struggles might have to do with her ability to stay attentive.
I contacted her pediatrician, filled out an ADHD checklist, and requested that her teachers do the same. Her pediatrician interviewed and observed Anna and determined that she qualified for the diagnosis of ADHD. After some discussion, we decided to see if Anna would respond to medication. She started taking medication in the middle of third grade and continued to receive extra help both in and out of school. Her teachers described an improvement in her ability to retain and organize information, but I often felt guilty for putting Anna on medication. She sometimes seemed more reserved than normal and many people warned me about potential side effects.
Anna was prescribed a low dose: one pill in the morning and then one more after lunch at school. When she got home in the afternoons, she would sometimes complain of a headache, which is a pos- sible side effect of the medicine. After consulting with her doctor again, we decided to take her off the pill on a trial basis. A few days after this change, Anna came home from school and when it was time to do homework, she began to melt down in the middle of a math problem, crying out: “Mom, I can’t do this without the medicine! When I don’t take it I feel like everything in my head is spinning around like crazy—and I can’t keep track of it all, I can’t remember what I’m supposed to do or where to start!” I was shocked and impressed by her description. It made sense—swirling thoughts. How can anyone focus if information and ideas are constantly spinning in her head? I felt sad for my little girl. At the same time, my guilt about giving her medication dissipated, since it was clearly helping Anna. If she was able to verbalize this and if her doctor felt the medication was safe, then why should I worry about what other parents thought?
Section 5.7 How Do I Teach Students With ADHD?
Another way to help students monitor their behavior is through the use of a timer that beeps at set, intermittent points. When the timer beeps, students check their behavior and ask themselves questions targeted to their own goals, such as “Am I in my seat?” or “Am I paying attention?” The questions differ based on the student and the situation.
Eyecandy Images/Thinkstock
(continued)
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CHAPTER 5
Case Study: Determining Appropriate Instruction Based on Classroom Behavior
Destiny is an eighth-grade student in your general education math class. You teach Destiny for sixth period, which is in the afternoon, after lunch. Destiny consistently exhibits signs of hyperactivity-impulsivity in your class, and has been officially diagnosed with ADHD. Her family recently worked with the school to develop a 504 plan for her.
Destiny’s behavior often disrupts classroom instruction and distracts other students. She shouts out answers without waiting to be called on, often interrupts you during instruction, and frequently gets out of her seat without permission. Your classroom management system of issuing warnings and contingen- cies for off-task behavior doesn’t seem to be working for Destiny, and she often receives all her warnings and minor consequences within the first 20 minutes of class. She has received several referrals, and the amount of time she spends outside of class (i.e., in the principal’s office or in detention) due to behavior is alarming. You and several other teachers have decided that additional intervention is necessary to help Destiny succeed in school.
Questions to Consider:
1. What behavior(s) would you prioritize as the most important to correct? Why? 2. What would you set as the desired target behavior? What would the desired frequency or accuracy
of the behavior be? 3. Who would you involve in this process? How would you decide who will be responsible for
what? 4. How would you involve Destiny in the process? Destiny’s family? 5. Would you officially initiate an FBA for this situation? Why or why not? 6. How would you monitor and reinforce progress? 7. What classroom adjustments and accommodations could you include in Destiny’s intervention?
From My Perspective: Parenting a Child With ADHD (continued) Currently, Anna is in fifth grade and doing well! She continues to work on organizational skills and ben- efits greatly from a predictable schedule. But her thoughts are no longer spinning; she is more produc- tive in her schoolwork and at home. Her confidence is growing and now the positive comments stand out in my mind at every parent-teacher conference.
Section 5.7 How Do I Teach Students With ADHD?
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CHAPTER 5Post-Test
Wrap-Up
• Attention-Deficit/Hyperactivity Disorder (ADHD) is not a separate category under IDEA; it often falls under the category of Other Health Impairment (OHI). It is a prevalent dis- ability in schools today, with boys being diagnosed more often than girls. Students with ADHD typically exhibit some combination of inattention, hyperactivity, and impulsivity.
• Medical professionals use inattentive and hyperactive/impulsive criteria set forth by the DSM-IV to diagnose ADHD. The DSM-IV outlines three subtypes: ADHD predomi- nantly inattentive type; ADHD predominantly hyperactive-impulsive type; ADHD com- bined types. Three governing principles must be in place for a student to be diagnosed with ADHD: (1) a student must exhibit characteristics for a sustained period in multiple settings; (2) the behavior must be disruptive to the classroom or home environment; (3) some of the behaviors must have been manifested before the age of 7.
• ADHD has a high cormorbidity rate with several other disabilities, including SLD, ODD, conduct disorder, bipolar disorder, anxiety disorder, depression, and Tourette syndrome. Many students with ADHD take stimulant or non-stimulant medication to help control symptoms.
• Research thus far indicates that causes of ADHD include some combination of biology (genetics) and environment.
• Diagnosis of students with ADHD most often occurs in elementary school, although stu- dents may be diagnosed earlier or later in life. Medical professionals may use checklists, rating scales, anecdotal evidence, and behavioral observations to diagnose a student with ADHD.
• Teachers can use a variety of different strategies to teach students with ADHD, depend- ing upon the student’s grade level. Classroom organization, functional organization (rou- tines, procedures, and classroom rules), careful organization of space and assignments, and regular provision of breaks and releases can all be helpful.
• Students with ADHD benefit from learning self-monitoring strategies, such as checklist usage.
Post-Test
1. How is ADHD categorized under IDEA 2004? a. Attention-Deficit/Hyperactivity Disorder b. Attention Deficit Disorder c. Other Health Impairment d. Emotional Disturbance
2. When was ADHD first recognized by the DSM? a. DSM-I b. DSM-II c. DSM-III d. DSM-IV
3. More students are identified with which type of ADHD? a. Predominantly hyperactive-impulsive type b. Predominantly inattentive type c. ADD d. Predominantly combined type
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CHAPTER 5Post-Test
4. How does stimulant medication help a student with ADHD? a. Aids with controlling arms and legs b. Aids with attention and focus c. Aids with wakefulness d. Aids with staying seated
5. How is a diagnosis of ADHD made? a. Teacher referral to school psychologist b. IEP team c. Parent or guardian d. Formal evaluation by medical professional
6. Who makes decisions about ADHD medication? a. Parent or guardian and medical professional b. Parent or guardian and classroom teacher c. School nurse d. Medical professional
7. How many inattentive or hyperactive/impulsive behaviors must a student exhibit for a diagnosis of ADHD? a. 1 or more b. 4 or more c. 6 or more d. All
8. When are students typically identified with ADHD? a. Preschool b. Elementary School c. Middle school d. High school
9. How are academic checklists effective for students with ADHD? a. They show the number of on-task behaviors. b. They aid in completion of tasks. c. They help students finish work faster. d. They require less interaction from teacher.
10. Which of the following would not be an example of a classroom procedure for turning in homework? a. Students place homework in a bin titled “HOMEWORK.” b. Students hand teacher homework as they enter the classroom. c. Teacher asks students to pass homework to front of room. d. Students leave homework in their locker.
Answers: 1 (c); 2 (b); 3 (a); 4 (b); 5 (d); 6 (a); 7 (c); 8 (b); 9 (b); 10 (d)
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CHAPTER 5Additional Resources
Discussion Questions
1. Why do you think ADHD is not recognized as a separate disability category under IDEA 2004?
2. How does brain research help us understand more about ADHD? 3. Why are most students with ADHD educated in the general education classroom? 4. Which special education teaching techniques may be most beneficial for students with
ADHD?
Answers and Rejoinders to Pre-Test
1. False. Students with ADHD may exhibit inattentive or hyperactive symptoms, or a com- bination of the two.
2. True. ADD is the out-of-date term for ADHD. 3. False. Girls typically exhibit inattentive characteristics of ADHD more often than boys. 4. True. Students in chaotic or hostile environments (at home or at school) may be at
greater risk for developing ADHD. 5. False. Students with ADHD are diagnosed by medical professionals. 6. True. ADHD is most often identified in the elementary grades, when students are 8–10
years old. 7. True. Peer tutoring has been highlighted as an evidence-based practice for students
with ADHD.
Additional Resources
• The site for Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) contains information about the causes and symptoms of ADHD, along with information on the treatment of ADHD. www.chadd.org
• This is another site of ADHD resources provided by CHADD. www.help4adhd.org
• This site from the Attention Deficit Disorder Association (ADDA) contains information for adults living with ADHD, but some of the information is helpful to understanding the symptoms of ADHD and how to live with ADHD at all ages. www.add.org
• This site is particularly helpful for classroom teachers. It contains information about classroom organization and teaching strategies. www.addinschool.com
• A question-and-answer site related to ADHD for teachers, parents, and students. www.addvance.com
• This site provides resources for students with ADHD; it is particularly helpful for older students and adults with ADHD. www.edgefoundation.org
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CHAPTER 5Key Terms
Acronyms Used in Chapter 5
Acronym Description
ADD Attention Deficit Disorder
ADHD Attention-Deficit/Hyperactivity Disorder
BIP Behavior Intervention Plan
CDC Centers for Disease Control and Prevention
CHADD Children and Adults with Attention-Deficit/ Hyperactivity Disorder
DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
EBD Emotional and Behavioral Disorder
FBA Functional Behavior Assessment
fMRI Functional Magnetic Resonance Imaging
IDEA 2004 Individuals with Disabilities Education Act
IEP Individualized Education Program
ODD Oppositional Defiant Disorder
OHI Other Health Impairment
SLD Specific Learning Disability
Key Terms
ADHD combined type Student exhibits six or more inattentive characteristics and six or more hyperactive-impulsive characteristics.
ADHD predominantly hyperactive-impulsive type Student exhibits six or more hyperactive-impulsive characteristics and fewer than six inattentive characteristics.
ADHD predominantly inattentive type Stu- dent exhibits six or more inattentive character- istics and fewer than six hyperactive-impulsive characteristics.
Attention-Deficit/Hyperactivity Disorder (ADHD) A disorder related to inattention, hyperactivity, impulsivity, or a combination of these conditions.
hyperactivity Difficulty staying still or control- ling movements for a reasonable amount of time.
impulsivity Difficulty controlling actions or talking.
inattention Difficulty paying attention or focus- ing on a task for an extended amount of time.
Other Health Impairment (OHI) A catch-all category for disabilities, disorders, and condi- tions that do not fall under other categories.
non-stimulants Medication that improves focus without increasing brain chemicals.
stimulants Medication that increases brain chemicals that send messages to nerves in order to improve focus.
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CHAPTER 5References
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