Teacher ADHD Referral Theory Modification May Reduce Referrals for Student ADHD Diagnosis. Melissa Malen. University of Minnesota

Transcription

1 Teacher ADHD Referral Theory Modification May Reduce Referrals for Student ADHD Diagnosis Melissa Malen University of Minnesota

2 Paper Abstract An integrative literature review of ADHD is presented in this paper where teacher professional development is considered as a factor that may contribute to the reduction of referrals for student ADHD diagnosis, thereby ultimately reducing ADHD misdiagnosis. The literature review focused on developing an understanding of the influence that behavioral indicators of ADHD such as inattentiveness, hyperactivity, and impulsiveness have on ADHD referral and possible subsequent misdiagnosis of ADHD due to the fact that ADHD behaviors may also be indicative of students that are gifted and/or learning disabled as well as students that may have a variety of different mental health disorders. Teacher referral for ADHD diagnosis is of concern because the route to student ADHD diagnosis usually begins with teacher identification of ADHD behaviors. Teachers then make referrals to a school psychologist or via parents to a physician or mental health practitioner for ADHD diagnosis. In many cases, after an interview, use of an assessment tool that gathers teacher and parent perspectives on student behavior such as the Conners continuous performance test, and review of the student file, students are often diagnosed with ADHD and treated with stimulant medication. The theory that teachers and practitioners use to make decisions in practice involves identifying students that demonstrate high levels of inattention, hyperactivity and/or impulsivity and then referring the students for ADHD diagnosis. However, the literature indicates that many diverse learning and physiological factors influence the expression of ADHD behaviors. Teachers are not consistently trained in pre-service or in-service to evaluate alternative influences that precipitate ADHD behaviors, thus they do not often consider alternative influences prior to making an ADHD referral. Lack of teacher professional development regarding factors that influence the demonstration of ADHD behaviors contributes to an

3 increasing concern about the prevalence of ADHD misdiagnosis. In fact, according to Johnson- Gros (2007), misconstruing behaviors as causative explanations [does not warrant] a reflexive diagnosis of ADHD. Strong theoretical implications of teacher referrals for ADHD diagnosis exist and can be conceptualized and put into practice whereby teachers would be trained to: 1) identify student behavior as inattentive, hyperactive, and/or impulsive and present at a higher frequency than typical for his/her developmental age, 2) evaluate the factors discussed in this paper that influence the expression of ADHD behavior and team with parents to make educational plans that will decrease the frequency of the ADHD behaviors, and 3) make an ADHD referral as a final step if the ADHD behaviors persist at a higher than typical frequency. Increased teacher professional development regarding the range of factors that influence ADHD behavior may reduce teacher referrals for ADHD diagnosis, thus ultimately reducing the frequency of ADHD misdiagnosis.

4 Background The most common referral for mental health evaluation of American children is Attention Deficit/Hyperactivity Disorder (ADHD). ADHD is a condition that affects approximately 3-7% of school-aged children (U.S. FDA, 2007). ADHD is characterized by the demonstration of the majority of symptoms in either category of inattention, hyperactivity, and impulsivity. A wide variation in prevalence rates of ADHD and increasing numbers of students taking stimulant medications have triggered a debate regarding the possibility of misdiagnosis (Edwards, 2007). Misdiagnosis of ADHD has serious ramifications for students because students are often treated with stimulant medication. Increasing concern is mounting about the health risks that exist for students taking this medication. In fact, the concern is serious enough to have prompted the FDA to require a warning that serious cardiovascular adverse events and drug-related psychiatric events may occur as side-effects of taking this medication (FDA, 2007). Thus, the goal of preventing misdiagnosis of ADHD is becoming a paramount health issue for students that demonstrate ADHD behaviors. There is an abundance of literature that has not made its way from theory to practice with regard to ADHD referral and diagnosis. There are two reasons for developing an integrative literature review on this topic: 1. A variety of learning factors exist that precipitate the demonstration of inattentive, hyperactive and/or impulsive behaviors. 2. A variety of physiological and mental health factors exist that underlie behaviors that are typical of ADHD.

5 A range of factors influence the expression of ADHD behaviors in students, therefore an integrative literature review might function as a general guide that organizes and synthesizes a broad range of research that discusses inattention, hyperactivity and impulsivity and the various factors that influence these behaviors. Ultimately, this information can be used as a roadmap that teachers and parents can use to learn about alternative influences on ADHD behavior which can be considered prior to selecting the path of referral for ADHDdiagnosis. Methods This paper critiques the theory that underlies teacher referral for ADHD diagnosis. The conceptual model that frames the view of this theory is that teachers initiate ADHD assessment process by identifying inattention, hyperactive and/or impulsive behaviors demonstrated by a student on a more frequently basis than others. Once the behaviors are identified, a referral for ADHD diagnosis is often made. The literature review was conducted by searching the following keywords on EBSCO Host, a research data base: ADHD & misdiagnosis, ADHD & referral, ADHD & Gifted, ADHD & Learning Disabilities, ADHD & Dyslexia, ADHD and LD and teacher, ADHD and LD and referral, ADHD and brain, ADHD and late brain maturation, ADHD & physiology, ADHD and iron, ADHD and Environment. The criteria for selecting or discarding literature were: 1. Research on factors that influence the expression of inattention, hyperactivity, and/or impulsiveness.

6 2. Research that identifies factors to consider as alternatives to referral for ADHD diagnosis. Articles selected were published in refereed journals. Due to the limits of the length of this paper, the review is not exhaustive within each topic. Articles were categorized by topic areas as follows: Gifted and Talented and ADHD, Dyslexia and ADHD, Physiology and ADHD, and Environment and ADHD. Literature Reviewed Gifted & Talented and ADHD Recently, the issue of misdiagnosis of ADHD for children that are gifted and talented (GT) is increasingly discussed; however, studies about the coexistence of ADHD with GT are few. Typical GT behaviors that mimic ADHD behaviors are: Inattentiveness, inconsistent completion of tasks, disorganized, high activity level, impulsive, and excessive talking (Piechowski, 1991; Renzulli, et al., 1976; Silverman, 1998). The following articles were selected in support of the main argument in this paper which is that alternatives to ADHD diagnosis should be considered prior to teachers making a referral for ADHD diagnosis. A study by Harnett, Nelson and Rinn (2004) looks at the possibilities of misdiagnosis of ADHD rather than giftedness. This study spotlights school counselors and their potential to diagnose students as ADHD if they are not trained to consider giftedness and ADHD. Graduates in a school counseling program were study participants and were asked to diagnose a young boy described in a vignette who had the characteristics of both giftedness and ADHD. One group was asked to offer an explanation for his behavior and the other group was asked if the behavior could be attributed to ADHD or due to his being gifted? The results indicate that the mere

7 suggestion of giftedness as a reason for demonstrating typical ADHD behaviors swayed nearly half the subjects to consider giftedness. There is a possibility that counselor training programs may not adequately clarify the behavioral differences and similarities that exist for ADHD students and gifted students, thus lack of counselor training may lead to a referral for ADHD. Future studies that include samples of in-service teachers would generate information regarding the impact that professional development on this topic would have on teacher ADHD referral theory. Mika (2006) wrote an article in response to the previously discussed article by Hartnett, Nelson and Rinn (2004). Mika disputes the idea that gifted children are misdiagnosed with ADHD and claims there is no reliable evidence to support that ADHD for GT misdiagnosis is a trend. Mika makes a great effort to discredit the notion that misdiagnosis of ADHD for GT exists because she claims there is no evidence to support this trend and further claims there is no evidence to support the definition that giftedness includes over excitable behaviors. One concern is that the lack of research regarding misdiagnosis of ADHD for GT does not mean that this trend is absent. The actual status of ADHD misdiagnosis for GT is unknown rather than non-existent. A second concern is that Mika is viewing misdiagnosis from the psychology practitioner s perspective and is likely presenting her argument to professionals in her field. The argument in this paper is directed toward the theory behind teacher referral for ADHD assessment. In this case, advocating that teachers become aware of GT student behaviors, especially in the area of over excitability and inattention will change the pace at which teachers

8 make an ADHD referral and will encourage teachers to address the GT component that influences student behavior. Goerss, et al. (2006) analyze Hartnett, et al. s (2004) study that indicates that diagnostic confusion between ADHD and giftedness exists. They also analyze the response that Mika made to this article. The authors disagree with Mika s logic which underlies her position that there is no empirical evidence of misdiagnosis of gifted children as having ADHD. They claim that such misdiagnosis does occur and that possible concurrent risks also exist. The Hartnett, et al.(2004) study was well planned and provided a valid case for factoring giftedness into the differential diagnosis equation when the initial complaint is based on the observation of a student demonstrating inattentive, hyperactive or impulsive behaviors. The authors also note that many cases of misdiagnosis are not identified. Baum and Olenchak (2002) present a case study and explore the phenomena of children that receive multiple diagnoses after initially receiving an ADHD diagnosis. The authors indicate the problems that occur when teams do not consider behavioral characteristics [such as ADHD behaviors] from a multidisciplinary perspective. (Baum & Olenchak, p. 77). The child profiled in the case study is gifted and diagnosed with ADHD and subsequently was diagnosed with oppositional defiant disorder (ODD), generalized anxiety disorder (GAD), and learning disabled (LD). The case study method used in this article is appropriate and provides a powerful example of the negative effects that impact individuals misdiagnosed as ADHD rather than GT. A study like this may go a long way to bridge the gap between theory and practice because

9 examples such as meetings and the staff evaluation process for ADHD students are illustrated clearly in case study descriptive writing. The case study could be used as a wake-up call to teachers to encourage their empathy and buy-in when invited to alter their ADHD referral theory to include an assessment of alternative influences that contribute to ADHD behavior. Dyslexia & ADHD Reading disorders (RD) such as dyslexia and ADHD are two of the most common sources for referral and diagnosis in children. Diagnosis of ADHD and learning disability occur between 10-50% with the most frequent being ADHD and reading disability (Riccio & Jemison, 1998). There is an abundance of research on the topics of reading disorders, ADHD and the comorbidity of the two diagnoses, however, there is virtually no research on the topic of teacher referral or professional development regarding the topic of the ADHD and RD student. The issue the current paper seeks to define is how knowledge of the frequent co-morbidity of ADHD and RD can be interpreted to have an impact on the ADHD referral theory that teachers utilize in an educational setting. The most frequent psychiatric diagnosis of children with language impairment (LI) is ADHD. A study by Cohen et al. (2000) sought to clarify the differences between children that were diagnosed with co-morbid ADHD and LI with children that were diagnosed with a psychiatric diagnosis other than ADHD and LI. The results indicated that children with LI were at the most disadvantage regardless of the psychiatric diagnosis. Another interesting finding was that working memory measures which are used to tap the core cognitive deficit of ADHD, were more closely associated with LI than with ADHD. The authors concluded that caution must be

10 exercised when attributing behaviors to ADHD that may more accurately reflect typical behaviors of LI of which dyslexia is common. Although this article does not have the purpose of investigating the issue of misdiagnosis of ADHD for dyslexia or other learning impairments, the results demonstrate an overlap between inattentive ADHD behaviors and behaviors observed in children with LI. Because the indicator used to diagnose ADHD (working memory) is more closely associated with LI, enough evidence exists that educators should at least evaluate students for LI before referring them for ADHD diagnosis. If this shift in teacher referral for ADHD diagnosis theory occurs, students may be identified as LI or dyslexic and educational planning may occur as an initial step that may reduce the frequency of ADHD behaviors. In turn, fewer students may end up in the ADHD overdiagnosis pool. ADHD and Reading Disorders (RD) are frequently diagnosed in the same student. Bental and Tirosh (2007) investigated the profile of attention/control functions and reading domain functions and the nature of their relationship in a sample of boys with ADHD+RD. Based on the range of results data, the authors conclude that children with both ADHD and RD shared the same impairments in attention that pure ADHD group demonstrated. Children included in the ADHD groups had their diagnoses qualified by neurodevelopmental pediatricians that ensured all DSM-IV criteria were met and none of the children were medicated during the study. Stringent criteria were used to select participants in this study in an effort to clearly distinguish the participant groups. There is a high incidence of co-morbidity of ADHD with oral language deficits and interpreting links between reading domain abilities and attention/control actually may not be possible.

11 A relevant conclusion drawn in this study is that reading performance was shown to be linked in ADHD groups to rapid naming and to EF rather than to phonological processing which is linked to RD. Assessment of rapid naming and working memory when evaluating for RD may indicate a diagnosis of ADHD and RD. Although the authors conclude that ADHD should be added to the assessment criteria when diagnosing for RD, I disagree because it still has not been consistently demonstrated how rapid naming and working memory can truly be used as separate indicators for ADHD and RD. The implication in education for this finding is that once ADHD behaviors are identified, evaluation for RD should occur to determine if the student has mostly phonological processing issues which can be addressed in education. If the student demonstrates deficits in working memory, EF and rapid naming, then an ADHD referral would be the next step. Physiology & ADHD Physiology and ADHD is a topic of many research studies due to the interest in finding a biological or biochemical root cause of ADHD-like behaviors. The literature reviewed in this article regarding physiology was selected by virtue of offering evidence of a confounding or alternate factor that may result in the expression of ADHD-like behavior. A brain imaging study conducted by researchers at the National Institute of Mental Health (2008) investigates ADHD and late brain maturation. This study utilized a new image analysis technique that allowed researchers to analyze 40,000 points of measurement that evaluated the thickening and thinning of thousands of cortex sites in children and teens from both the ADHD and non-adhd groups. The results demonstrate a significant number of ADHD participant brains reach peak thickness at an average age 10.5 compared to a similar non-

12 ADHD group that reached the same brain maturation at average age 7.5. The greatest delay in ADHD participants occurred in the frontal and temporal areas that integrate sensory information with executive functions. The frontal areas support the ability to express self-control, attention, working memory and control movement. The findings support the theory that ADHD results from delay in cortex maturation. (NIMH, 2007). Students with ADHD demonstrate difficulty with the ability to express attention, selfcontrol, and working memory as it relates to executive functioning processes. One conclusion drawn from this study is that, due to a 3 year delay in brain maturation when compared to peers, ADHD students may outgrow their symptoms as the brain continues to thicken. The implications for teachers and professionals in practice in an educational setting is that the theory for ADHD referral should be adapted to allow the student time to outgrow the ADHD-like behaviors, especially if the student does not have a confounding educational challenge such as a reading disability (Tymms & Merrell, 2006). Richardson (2006) reports that omega-3 fatty acids are dietary essentials that are critical to brain development and function. The article focuses on the role of omega-3 in ADHD and findings that dietary supplementation with fish oils (both EPA and DHA) alleviates ADHDsymptoms in some children. Although omega-3 is not supported by current evidence as a primary treatment for ADHD, the author recommends further research on omega-3 as a potential ADHD treatment. The impact that this article has for teachers and professionals in education is that it offers one more possible confounding or alternative factor that may influence the expression of ADHDlike behaviors in children. A modification to the ADHD-referral theory could be to discuss with

13 parents the findings in this article and ask them to consider the child s diet to determine if the child may be lacking omega-3. Konofal et al. (2004) published an article and theorized that because treatment with dopamine stimulant medication reduces the frequency of ADHD-like behavior there might be physiological reason connected to dopamine that results in the expression of ADHD-like behavior. Iron is necessary for dopamine synthesis, thus the authors investigated the role of low levels of stored iron by analyzing levels of ferritin, the protein complex to which iron binds, in children with and without ADHD. Children with ADHD had significantly lower ferritin levels than the control group. Furthermore, the children with the most severe iron deficiency were the most inattentive, impulsive and hyperactive. This article offers another alternative factor that contributes to the expression of ADHDlike behaviors. Teachers could advise parents to discuss this information with their pediatrician and evaluate the student for stored iron deficiency. Environment & ADHD Harder (2004) examines whether or not spending more time playing amid greenery improves behavior in children with ADHD. Researchers developed a questionnaire that gathered information from parents about how children with ADHD respond to dozens of extracurricular activities in settings including leafy backyards, indoor playrooms, and artificial outdoor environments such as urban playgrounds. The results indicate that green environments have the effect of improving attention and focus. The information in this article has implications for teachers and students that demonstrate ADHD-like behavior. Once ADHD-like behaviors are identified, the amount of green outside time can be evaluated.

14 CONCLUSIONS Currently there is a debate about ADHD diagnosis because the percentage of students diagnosed is increasing past the generally accepted mark of 3% of the population. Overdiagnosis of ADHD is even more ominous for students because the most common treatment for ADHD is stimulant medication which the FDA warns may be dangerous to the student s health. Teachers initiate the referral for ADHD assessment, thus teachers are in the optimal position to mitigate over-diagnosis by taking a more stringent approach to student evaluation prior to referring a student for ADHD diagnosis. The main argument in this paper is that the teacher referral theory can be modified to include an additional step between identification of ADHDlike behaviors and ADHD referral. That step is to consider a number of non-clinical factors that the literature reports to influence the expression of ADHD-like behavior. The factors reviewed in this paper that should be evaluated by the teacher and parent prior to ADHD referral for diagnosis are: 1. Gifted and talented status based on creativity and IQ testing, 2. Dyslexia or reading disorder assessment, 3. Maturation evaluation to determine if student might outgrow symptoms by age 10, 4. Medical evaluation to determine if student has low ferritin levels or low stored iron levels, 5. Nutrition assessment and pediatrician advice regarding omega-3 therapy, 6. Evaluation of and/or addition of time student spends in green space. The current culture in education is ripe for taking steps to modify the theory used in practice by teachers when deciding what to do for students that demonstrate typical ADHD behaviors. A rising tide of complaints about ADHD misdiagnosis and concern about

15 unnecessary treatment of children with stimulant medication is occurring, however limited information has been provided to teachers about the many confounding influences on ADHD behavior. I argue that the literature review in this paper identifies several alternative influences that mimic ADHD behavior, and that the teacher ADHD referral for assessment theory should be modified to include steps that rule out alternative influences before teachers make the referral for ADHD assessment. Ultimately teacher professional development on the topics of ADHD, ADHD and GT students, ADHD and dyslexia, ADHD and physiology and ADHD and green space should be offered to pre-service and in-service teachers.

16 REFERENCES (579 words) American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4 th Edition, Text Revision) (DSM-IV-TR). Washington, DC: APA. Baum, S. & Olenchak, R. (2002). The alphabet children: GT, ADHD, and more. Exceptionality, 10, (2), pp Bental, B. & Tirosh, E. (2007). The relationship between attention, executive functions and reading domain abilities in attention deficit hyperactivity disorder and reading disorder; a comparative study. Journal of Child Psychology and Psychiatry, 48, (5), pp Bloom B., & Cohen, R.A. (2007). Summary health statistics for U.S. children: National health interview survey, National Center for Health Statistics. Vital Health Statistics, 10, (234), p. 5. Cohen, N.J., et al. (2000). The interface between ADHD and language impairment: An examination of language, achievement and cognitive processing. Journal of Child Psychology and Psychiatry, 41 (3), pp Edwards, M. et al.(2007). Estimates of the validity and utility of the Conners continuous performance test in the assessment of inattentive and/or hyperactive-impulsive behaviors in children. Journal of Abnormal Child Psychology, 35, (3), pp Food and Drug Administration (2007). FDA directs ADHD drug manufacturers to notify patients about cardiovascular adverse events and psychiatric adverse events. Retrieved May 12, 2008, from Goerss, J. et al. (2006). Comments on Mika s critique of Hartnett, Nelson, and Rinn s article, Gifted or ADHD? The possibilities of misdiagnosis. Roeper Review, 28, (4), pp Hartnett, D., Nelson, J., & Rinn, A. (2004). Gifted or ADHD? The possibilities of misdiagnosis. Roeper Review, 28, (2), Johnson-Gros, K., (2007). ADHD: The great misdiagnosis. Journal of Child Neurology, 22, (2), pp Konofal, E., et al. (2004). Iron deficiency in children with attention-deficit hyperactivity disorder. Archives of Pediatric and Adolescent Medicine, 158, (12), pp Mika, E. (2006). Research commentary point-counterpoint: Diagnosis of giftedness and ADHD. Roeper Review, 28, (4), pp

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