ATTENTION DEFICIT HYPERACTIVE DISORDER (ADHD)

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ATTENTION DEFICIT HYPERACTIVE DISORDER(ADHD)

• PRESENTER
• Harry E. McCormick, Ed.D.
• School Psychologist
• Metropolitan Nashville Public Schools

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OVERVIEW

• FACTS AND MYTHS
• Pre-Test
• CHARACTERISTICS
• DIAGNOSTIC FEATURES
• DIAGNOSTIC ISSUES
• TREATMENT
• MEDICAL
• PSYCHOSOCIAL
• EDUCATIONAL

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Many Names for AD/HD
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Many Names for AD/HD (contd)
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PRIMARY CHARACTERISTICS

• Inattention
• Hyperactivity
• Impulsivity

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Inattention

• Fails to pay close attention to details
• Difficulty sustaining attention
• Does not seem to listen
• Does not follow through on instructions
• Difficulty with organization
• Avoids tasks that require sustained mental effort

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Inattention (contd)

• Often loses things
• Often easily distracted
• Forgetful in daily activities

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Hyperactivity

• Fidgets
• Out of seat
• Runs or climbs excessively
• Difficulty playing quietly
• Is often on the go
• Talks excessively

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Impulsivity

• Often blurts out answers before questions have
  been completed
• Often has difficulty waiting turn
• Often interrupts or intrudes on others

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SECONDARY CHARACTERISTICS

• Academic
• Social
• Emotional

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Academic Difficulties

• Poor study habits
• Difficulty beginning and completing assignments
• Disorganized
• Poor handwriting
• Inconsistent/poor recall
• Difficulty generalizing
• Auditory processing problems
• Poor visual perception
• May have additional learning problems

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• ADHD is not a specific developmental disorder
  or learning disability as these disorders are
  currently defined, but there may be some overlap,
  or comorbidity, of these two types of disorders.
  Approximately 20 to 25 of ADHD children will
  have significant delays in the development of
  math, reading, or spelling, and 10 to 30 may
  have problems with language.

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Social Difficulties

• Does not take responsibility for actions
• Needs to be the center of attention
• Difficulty relating to peers
• Disturbs others who are trying to work and listen
• Bullies or bosses other children
• Teases peer excessively
• Difficulty following rules of games
• Aggressive, spiteful and vindictive
• Rejected by peers

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Emotional Difficulties

• Low self-esteem
• Irritable, low frustration tolerance
• Loses temper, gets mad easily
• Defiant attitude
• Argumentative
• Emotionally immature
• Frequent, unpredictable mood swings

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• Major life events may cause added stress
  resulting in some of the same types of behaviors
  that are characteristic of children who have ADHD.

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Where are Students with AD/HD Educated

• General education
• Teacher initiated accommodations in general
  classroom, curriculum, and instruction
• Support Team Intervention Plan
• Identification of a disability under Section 504
  development of a 504 Service Plan for
  accommodations in general curriculum and
  modifications in instruction
• Identification of need for special education and
  related services - - IDEIA

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Chances Are You Will Be Teaching a Student
Diagnosed with AD/HD

• Occurs in 3 to 7 of school-age children
• All socioeconomic, cultural, and racial
  backgrounds
• All intellectual levels
• More prevalent in males
• 41 male to female ratio in the general
  population
• 91 male to female ratio in the clinical
  population

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• AD/HD can span throughout the individuals life.
  50 to 80 of AD/HD children continue to have
  some degree of their symptoms in adulthood.
• AD/HD is a chronic or life-long condition. As
  one grows older the symptoms may become less
  severe, especially in the case of hyperactivity,
  but some manifestations of the condition may be
  expected to be present throughout adulthood.

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• Hereditary link has been suggested
• One can not tell by looking at a childs overt
  behavior.

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Symptoms May ChangeAD/HD Is Not Outgrown

• Preschool
• Excessive activity
• Increased talking
• Resistance to routines and rules
• Aggressive in play
• Demanding personality
• Accident prone

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Symptoms May ChangeAD/HD Is Not Outgrown (contd)

• Elementary School
• Fidgety
• Excessive talking
• Erratic performance
• Bossy
• Constant demand for attention

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Symptoms May ChangeAD/HD Is Not Outgrown (contd)

• Adolescence
• Restlessness
• Talking out of turn
• Problems at school
• Problems with peers
• Difficulty establishing independence from parents
• Poor judgment

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CRITERIA FOR SYMPTOMS

• Age-Inappropriate behaviors
• First appeared before age 7
• Persist for 6 months (or more)
• Present in at least 2 settings
• Significant clinical impairment

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DSM-IV Subtypes of AD/HD

• Inattentive Type
• Hyperactive-Impulsive Type
• Combined Type

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Executive Functioning

• Executive functions are a collection of
  inter-related processes that are responsible for
  goal-directed, problem solving behavior which
  involves the prefrontal lobe.

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Types of Executive Functioning

• Inhibit (the ability to inhibit, resist or not
  act on impulse)
• Shift (the ability to move freely from one
  activity to another)
• Initiate (beginning a task, generating ideas or
  problem-solving)
• Working Memory (the capacity to hold information
  in mind for the purpose of completing a task)

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Types of Executive Functioning (contd)

• Plan/Organize (the ability to manage current and
  future demands)
• Organization of Materials (orderliness of work)
• Monitor (assess work-checking habits)

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• Teachers, parents, psychologists,
• and physicians are key to
• diagnosis and successful
• outcomes

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AD/HD Procedures andBest Practicesfor

• Metro-Nashville Public Schools

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Student is Currently on Medication

• Teacher completes Medication Effectiveness
  Documentation (MED) form
• Concerns - Follow new Support Team process
• No concerns - Place MED form in cumulative
  record. The process ends.

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Student with Academic/Behavioral Concerns

• Follow the New Support Team process
• Forms and procedures have changed
• Training will occur in the very near future
• Try interventions for at least one month
• Reconvene Support Team to review progress or lack
  of progress and make other recommendations

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Student with Academic/Behavioral Concerns
(contd)

• The severity of the case will determine the need
  to move more quickly through the Support
  Team/504/IDEIA Process. If the student has
  severe enough behavioral issues, then the Support
  Team can begin the AD/HD evaluation process.

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AD/HD Evaluation Process

• Assessment Specialist (psychologist) must be in
  attendance at Support Team
• Obtain parental consent for evaluation
• Global Behavior Rating Scale (Home/School)
• Specific Behavior Rating Scale for AD/HD
  (Home/School)

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AD/HD Evaluation Process (contd)

• Teacher Checklist
• Classroom Observations in Multiple Settings
• Social/Developmental/Medical History
• Vision/Hearing Screenings (within one year)
• Psychologist writes report of the AD/HD screening
  results.

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Review Support Team

• Review results of AD/HD Evaluation and determine
  if an educational diagnosis of AD/HD can be
  made.
• If Yes - determine if 504 eligible (follow the
  504 procedures)
• If not 504 - Write Support Team Intervention
  Plan

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After Leonard took his case to the Support Team,
he was given a 504 Service Plan which allowed him
to play his armpit in the school band.
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Review S-Team (contd)

• If No - Review/Rewrite Support Team Intervention
  Plan to address other pertinent concerns.
• Both plans should be reviewed (at least yearly).
• A medical diagnosis is not required for
  eligibility under Section 504.

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IDEIA - Other Health Impairment

• A student with AD/HD can qualify for special
  education as Other Health Impairment (OHI) if
• The student must have a current (within one year)
  medical statement from a licensed health service
  provider which includes the diagnosis,
  prognosis, information regarding medications (if
  applicable), special health care procedures,
  special diet, and/or activity restrictions.

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IDEA - Other Health Impairment (contd)

• A comprehensive developmental or educational
  assessment which indicates the effects of the
  health impairment on the students educational
  performance, and documents deficit skills
  resulting from the health impairment in
  pre-academics or academic functioning, adaptive
  behavior, social/emotional development, motor,
  communication, and cognitive. If an AD/HD
  evaluation has not been conducted to address the
  above mentioned areas, then one should take place
  using the previously outlined procedures.

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IDEA - Other Health Impairment (contd)

• If the student is found to be eligible under
  IDEIA, then the IEP Team completes the
  Eligibility Report, OHI Documentation Form,
  OHI/ADHD Documentation Form, and writes the IEP.
• If the student is not found to be eligible under
  IDEIA, then follow 504 or Support Team
  procedures.

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RE-EVALUATION FOR OHI

• Special Education Teachers Responsibilities
• List all students due for re-evaluation
• Give a copy to appropriate assessment specialist
• Complete or collect observations, checklist
  parent information, current vision and hearing,
  and current academic information
• Schedule IEP Re-evaluation Team Meeting

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RE-EVALUATION FOR OHI (contd)

• Psychologists Responsibilities
• Complete the Re-evaluation Summary Report
• Collect any additional information that the IEP
  Team deems necessary (e.g. comprehensive
  assessment, current medical)
• Complete Eligibility Report, OHI Evaluation
  Review, and OHI Documentation Form

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A Multi-Modal Treatment for AD/HD Is Optimal

• Medical
• Psychosocial
• Educational

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Medical Management

• Psychostimulants
• Antidepressants

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• 50 years of research has shown that stimulants
  are therapeutic and do not cause drug addiction
  when used appropriately
• Proper treatment of ADHD with stimulants can lead
  to a lower risk of the student abusing alcohol
  and other drugs

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Stimulant Medication
Stimulant Medication

• Clinical benefits of stimulant medication
• Reduces core symptoms of the disorder
• Inattention
• Impulsivity/Hyperactivity
• Improves associated features
• Academic performance
• Interactions with parents and teachers
• Improves social behavior with peers
• Improves aggressive behavior

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Stimulant Medication Sustained Release

• Concerta
• Ritalin SR
• Ritalin LA
• Metadate ERl
• Methylin ER
• Metadate CD
• Adderall XR
• Dexedrine Spansule

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Stimulant Medication Immediate Release
Stimulant Medication Immediate Release

• Ritalin
• Methylin
• Focalin
• Adderall
• Dexedrine
• Dextrostat

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Antidepressants

• Norpramin
• Tofranil
• Elavil
• Pamelor
• Prozac
• Zoloft

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Other Medications
Other Medications

• Clonidine
• Risperdal
• Wellbutrin

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Dietary Treatments for ADHD

• Caffeine
• Herbs
• Limiting intake of food additives and red color
  dye
• Removal of sugar
• Are not clinically proven to be effective

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Psychosocial Interventions

• Self-Monitoring Training
• Self-Control Training
• Social Skills Training
• Teacher Training for Classroom Management
• Group and Individual Counseling
• Parent Counseling

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Behavioral Therapy
Psychosocial Interventions (contd)

• Broad set of specific interventions
• Change physical and social environment to change
  behavior
• Be consistent
• Use positive reinforcement
• Teach problem-solving skills
• Ongoing consistent communication with parents
• Notes, Phone Calls, E-Mail

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Classroom Management Strategies
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Classroom Management Strategies

• Behavioral Strategies
• Structural
• Physical
• Management Strategies
• Organizational skills
• Time management
• Teaching Strategies
• Cultural Competence

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Classroom Management StrategiesStructure

• A structured, positive classroom that is
  welcoming, inclusive, and well managed
• Establish a clear routine
• Post the rules and review frequently
• Review your expectations with established
  visual/auditory prompts
• Prepare for and provide structure and supervision
  during transition times, changes of routine, and
  unstructured situations

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Classroom Management StrategiesBehavioral
Strategies

• Implement a classroom behavior-management plan
• Use praise significantly more than reprimands
• Role play appropriate behavior
• Give praise, a small privilege, or token to
  students who are engaged in appropriate behaviors
• Increase the immediacy and frequency of positive
  feedback and reinforcements
• Communicate with parents frequently

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Functional Behavioral Assessment(FBA)

• Useful for those students with ADHD whose
  behaviors are affecting school performance
• Assesses why a student behaves as he/she does,
  given the nature of the student and what is
  happening in the environment

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Functional Behavioral Assessment(FBA)

• Teachers input
• Context of behavior
• Contributing factors (triggers)
• Function of behavior
• Teacher response/student reaction
• Previous interventions
• Is behavior continuing? Why?
• Potential rewards for change

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Positive Behavior Intervention Plan(BIP)

• BIP is based on results of the FBA
• Development of the BIP
• Prevention
• Teaching new skills
• Prevent reinforcement of problem behavior
• Increase reinforcement of desired and replacement
  behaviors
• Positive reinforcement
• Negative reinforcement

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Classroom Management StrategiesCreative Positive
Reinforcers

• Work on board
• Choice of seat
• Messenger carrier
• Pass to library
• Pet or plant caretaker
• Decorating room
• Listen to music
• Reduced homework
• Puzzles

• Monitor lines/computer
• Special pens, paper
• Pop bubble wrap
• Jokes
• Puzzles
• Cartoons/drawing
• Talking periods
• Arts and crafts
• Board games

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Classroom Management StrategiesPhysical
Environment

• Create a U-shaped seating arrangement
• Seat student near you Source of instruction to
  cue and prompt
• Seat student near well-focused students good
  role models
• Seat student away from high-traffic areas,
  windows, doors, and other distractions
• Provide students with quiet, distraction free
  area for study and test-taking

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Classroom Management StrategiesOrganization

• Require the use of a 3-ring binder/notebook
  (starting in 3rd grade)
• Require the use of subject dividers and a pencil
  pouch
• Require the use of a monthly assignment calendar
  (use consistently with regular teacher
  monitoring)
• Handouts 3-hole punched

• Teach how to organize papers and desk
• Have periodic desk and notebook checks
• Provide time and assistance for cleaning desk and
  notebook
• Encourage organization first thing in the morning
• Color code materials

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Classroom Management StrategiesTime Management

• Teach how to tell time
• Teach how to read calendars
• Establish a daily routine
• Direct all assignments to be recorded in calendar
• Call close attention to due dates
• Assist with prioritization of activities
• Utilize to do lists

• Break down longer assignments into smaller,
  manageable increments
• Check in on long-term projects (book reports etc)
• Provide advanced notice about upcoming projects
• Assign study buddies
• Use frequent praise and rewards
• Visual timer

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Classroom Management StrategiesTeaching
Strategies

• Instructional activities versus didactic lectures
• Encourage cooperative learning
• Ensure high interest and novelty are an integral
  part of the lesson
• High-impact visual aids
• Display and support mnemonic strategies to aid
  memory
• Call on students by random method

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Classroom Management StrategiesTeaching
Strategies

• Adaptations for students with ADHD
• Adjust for hyperactivity by providing
  opportunities for the student to move
• Clarify and simplify instructions
• Provide guidance with time management
• Allow extra time
• Utilize reading aids
• Alter testing
• Address homework strategies

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Classroom Management StrategiesCultural
Competence

• Developing a classroom that is culturally
  competent suggestions for teachers
• Take note of your own personal and cultural
  biases
• Engage and establish rapport with students and
  their families whenever possible
• Provide interventions for home
• Learn to listen effectively across cultures
• Parents of children with ADHD can teach school
  personnel about ADHD and effective techiques they
  use at home

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Classroom Management StrategiesSummary

• Direct, focused instruction
• Consistency
• Structure
• Brevity, variety, choices
• Effective classroom management and positive
  discipline
• Bringing out student strengths
• Respect for differences and feelings
• Communicate, communicate, communicate!

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Summary

• ADHD has many faces
• The role of the teacher is to recognize and
  report behaviors that look like ADHD
• Cultural competence is key to successful
  communication
• Teachers play an integral role in the ADHD
  Process
• Effective classroom strategies are the key to
  overall success of the student

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• Please take a moment to share one
  take-away that you could begin implementing as
  a result of this presentation.

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References

• Barkley, R. A. (1990). Attention-deficit
  hyperactivity disorder A handbook for diagnosis
  and treatment. New York Guilford Press.
• Barkley, R. A. (1991). Attention-deficit
  hyperactivity disorder A clinical workbook. New
  York Guilford Press.
• DuPaul, G. J., Stoner, G. (1994). ADHD in the
  schools Assessment and intervention strategies.
  New York Guilford Press.
•  www.interventioncentral.org

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• Questions and Answers