Attention Deficit Hyperactivity Disorder (ADHD)

1. Attention Deficit Hyperactivity Disorder (ADHD) Implications for Teachers Ulidia Resource Centre October 2002 Roz Lacey & Gayle Nixon (Educational Psychologists)

2. Aims • To increase understanding of Attention Deficit Hyperactivity Disorder (ADHD) and its implications • To provide practical strategies for the management of ADHD in the classroom

3. Programme • What is ADHD? • Causes, prevalence and co-morbidity • Coffee • Assessment & diagnosis • Treatment • Medication • Lunch • Strategies for school

4. Please fill in the first section of your evaluation forms. Remember these are completely confidential. Thanks!

5. Activity - ADHD in class • Describe the types of behaviour that would lead you to believe a child had ADHD. • What difficulties do these behaviours pose in school for: • The teacher? • The child? • His / her classmates? • What strategies are typically employed by your school to deal with these behaviours? • Are these effective?

7. Activity How much do you know about ADHD?

8. Current Diagnostic Criteria • Diagnostic & Statistical Manual of Mental Disorders – 4th Edition, American Psychiatric Association, 1994 (DSM-IV) • Entirely behavioural in nature • 2 clusters of symptoms (Inattention & Hyperactivity / Impulsivity) • Each cluster consists of 9 behavioural descriptions • Behaviours must also: • Be developmentally inappropriate; • Be present for at least 6 months; • Be present before age 7; • Cause impairment in at least 2 settings; • Result in clinically significant impairment in social or academic functioning.

9. Current Diagnostic Criteria - DSM-IV • DSM-IV outlines 3 subtypes of ADHD: • ADHD(I) Predominantly Inattentive Type • ADHD(HI) Predominantly Hyperactive-Impulsive Type • ADHD(C) Combined Type

10. ADHD(I) - Inattentive Type Inattention Distractibility

11. ADHD(I) - Inattentive Type • Look out for the child who… • Is often off-task • Doesn’t finish their work • Makes careless mistakes • Appears lazy / disinterested • Daydreams / Appears not to listen • Misses instructions / asks for things to be repeated • Can’t seem to focus • Is unable to maintain effort over time • Is forgetful / disorganised

12. ADHD(HI) - Hyperactive Impulsive Type Impulsivity Problems with activity level

13. ADHD (HI) – Hyperactive Impulsive Type • Look out for the child who… • Talks excessively • Shouts / blurts out • Interrupts / intrudes • Can’t wait her turn • Doesn’t wait to hear instructions • Is restless / fidgety / out of seat • Is always “on the go”

14. ADHD(C) - Combined Type Inattention Distractibility Problems with activity level Impulsivity

15. Coffee?

16. E n v i r o n m e n t a l Biological Level Cognitive Level Behavioural Level

17. What causes ADHD? • Research suggests that ADHD is genetic • Symptoms are a result of neurotransmitter dysfunction • Recent research suggests dopamine is not being recycled properly • MRI scans show differences in brain activity between ADHD children and controls

18. How many children have ADHD? • 3% - i.e. one in every class of 30 • 1% ADHD (I) • 2% ADHD (HI) • Boys more frequently diagnosed than girls • Ratio of ~4:1 • Girls more likely to be diagnosed with ADHD(I) • Frequency of ADHD diagnoses tend to increase dramatically from the pre-school to the primary school years.

19. What about your school?

20. Is ADHD a unitary condition? • Difficulties of differential diagnosis • Co-morbidities • Emotional disorder • Antisocial behaviour disorder • Tic disorder • Pervasive developmental disorder • Learning difficulty • Motor planning problem • Self-esteem problem • Gt. Ormond St. Study • DAMP

21. Assessment and diagnosis Recognition of indicators (home or school) Referral to G.P. or E.P. Referral to Paediatrician / Child Psychiatry Assessment across contexts (DSM-IV) Diagnosis or not

22. In your experience…?

23. E n v i r o n m e n t a l Biological Level Cognitive Level Behavioural Level

24. Medication • Psychostimulants - most common • Ritalin (methylphenidate) • Dexedrine (dextroamphetamine) • Considered to be very safe • Immediate, observable effects (1/2 hr) • Wears off in 3-4 hours (not addictive) • Monitoring should be by consultant • Personality should not seem dulled • Some side effects possible • NOT SUFFICIENT BY ITSELF!!!

25. The MTA Study • Biggest study ever completed on ADHD treatment • 4 groups • 1) Medication management • 2) Behaviour treatment • 3) Combined treatment • 4) Community care

26. The MTA Study (Cont.) • Findings – • Medication alone better than behaviour alone on core symptoms • Combination not substantially better than medication • Carefully managed medication had fewer side effects (no additional medication needed) • Combined treatment group needed lower doses of medication

27. Help for parents • Increased understanding and insight • Support groups • Good quality liaison with school • Programmes such as ‘1,2,3 magic’ by Thomas Wheelan • Excellent Booklet “All about ADHD”, Tel: 020 7535 7400

28. Activity How much have you learned?

29. Lunch

30. Practical Strategies for Schools • Aim: To maximise the potential for all children in the classroom by reducing the time the teacher has to spend responding to the child’s behaviour. • Aim: To reduce teacher stress!!!

31. Favourites • Headphones / screen • Traffic lights • Behaviour programmes • Visual timetable / chunking • Attention training • Brain gym • Stress toy • ICT • Circle time • Coffee jar challenge

32. Knowledge of ADHD & Strategies Chosen • Knowledge level influences choice of behaviour management strategy • Higher knowledge = whole class strategies chosen • Different strategies affect behaviour in different ways… • Individual strategies = increased attention and concentration • Whole-class strategies = reduced hyperactivity

33. Strategies for Particular Diffficulties: Sustaining effort • Reduce task length (differentiation) • Break long assignments into chunks & reward completion promptly • Follow difficult task with preferred task • Short breaks between tasks • Use timer • Quality rather than quantity • Alternative methods of recording

34. Strategies for Particular Diffficulties: Easily distracted • Seat at front away from distractions • Use earphones • Utilise study carrels / flexible seating • Use physical proximity • Ensure eye contact when giving instructions • Cue pupil to stay on task • Attention training

35. Strategies for Particular Diffficulties: Talking out of turn • Ignore inappropriate comments & questions • Traffic light system • Positive reinforcement for listening

36. Strategies for Particular Diffficulties: Poor Recall • Multi-sensory approach • Seeing, saying, writing, doing • Role-playing activities • Computer assisted instruction • Memory techniques Mnemonics Visualisation Sub-vocalisation Verbal mediation

37. Strategies for Particular Diffficulties: Untidy/Disorganised • Assist pupil with personal organisation • Arrange for peer support • Reward tidiness • Be willing to repeat expectations • Keep worksheet format simple • Keep materials needed to hand • Develop a clear system for keeping track of completed and uncompleted work

38. Strategies for Particular Diffficulties: Transition Time • Use individual / group work schedules (in picture or written format) • Define requirements carefully • Aim for consistency across tasks/classes • Always give a 5 minute warning before ending an activity

39. Arrange joint activities in class with likely friends Use co-operative learning activities Reward appropriate social behaviour (involve parents and lunchtime supervisors) Assign pupil responsibility in the presence of his/her peer group Utilise Circle Time /P.S.E /Drama to teach concepts of communication, participation and co-operation Strategies for Particular Diffficulties: Peer Problems

40. Strategies for Particular Diffficulties: Fidgets / Squirms • Break tasks into small steps • Allow alternative seating • Allow alternative movement where possible • Stress toy • Consider ‘Brain Gym’

41. Whole-class strategies: Behaviour Management • Provide frequent, immediate and consistent feedback about acceptable and unacceptable behaviour • Praise specific behaviour • Be sure to criticise the behaviour, not the child

42. Whole-class strategies: Rules & Routines • Keep classroom rules clear and simple • Display them [positively] • Ensure that pupils know what happens if these rules are kept or broken • Strive for consistency of expectation, action, reward and punishment • Establish a daily classroom routine and schedule

43. Whole-class strategies: Giving Instructions • Get quiet attention first • Be clear and concise • Give instructions in the order you want them to be carried out • Follow up oral instructions with written reminders • Keep checking that pupils know what to do

44. Whole-class strategies: Marking work • Use self-correcting materials • Pair pupils to check work • Encourage pupils to check over their work • If possible, correct work in presence of pupil • Write useful, specific comments

45. Whole-class strategies: Lesson Structure & Presentation • Review previous lessons on the topic • Set learning and behavioural expectations at outset • Actively involve pupils in presentation • Keep lessons short & interesting • Include a variety of activities • Vary the pace • Use multi-sensory approach or IT • Allow adequate time for lesson review / recap

46. Behaviour Programmes • Why? • Help the child to focus on specific targets • Shift the emphasis from bad to good behaviour • Should positively impact on behaviour in class, self-esteem & peer relations

47. Behaviour Programmes • How? • 3 simple targets • 1 achieves already • 2 sometimes manages • 3 more difficult but not impossible • Keep it visual (e.g. chart / diary) • Involve parents • Only comment on positive behaviour • Build in rewards • Reward effort, not just achievement • Don’t shift the goal posts too soon!

48. Behaviour Programmes using response cost • Children with ADHD have difficulty visualizing the potential reward • Give rewards at the start of time period with potential to lose • Build in an early warning system • Keep it tangible & visual • Reward approximate behaviour

49. 9.45-10.30 Group 2 Response Cost System 10.30-11.15 11.15-12 12-12.45 9-9.45 John Peter Group 1

50. Encouragement • You’re on 2! • Keep it up!