Attention Deficit/Hyperactivity Disorder 1

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1 ADHD Goes To School Mark Bertin, M.D. Developmental Pediatrics 6/23/ ADHD Goes To School - Outline Part One Definition of ADHD Evaluating for Possible ADHD in School School Management 101 Part Two Educational interventions for ADHD Academic Planning 6/23/ ADHD definition A persistent pattern of inattention and/or hyperactivity/impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development. - DSM-IV 6/23/ Attention Deficit/Hyperactivity Disorder 1

2 Definition Inattention Lack of attention to detail Can t sustain attention Poor organization Easily distracted Avoids tasks that require concentration Loses things required for tasks Activity/Impulsivity Fidgets or squirms Leaves seat often Runs and climbs excessively Talks excessively Difficulty maintaining play Interrupts others Can t wait for his/her turn 6/23/ Definition Symptoms started before age twelve years Symptoms in two or more settings Symptoms not better explained by another condition Clear evidence of significant impairment such as in social, academic or occupational functioning 6/23/ Definition This traditional definition is limited (and limiting) ADHD is not an attention disorder Understanding the full range of impairments related to ADHD allows for logical and effective educational intervention 6/23/ Attention Deficit/Hyperactivity Disorder 2

3 ADHD Goes To School - Outline Part One Definition of ADHD What Mimics ADHD (differential diagnosis) & what Tags Along (comorbidity) School Management 101 Part Two Educational interventions for ADHD Academic Planning 6/23/ Differential Diagnosis 1. Developmental disorders 2. Psychiatric disorders 3. Medical conditions 6/23/ Comorbidity by the Numbers Multimodal Treatment of ADHD (MTA) study: Oppositional/defiant disorder: 40% Conduct disorder: 14% Anxiety disorders: 34% Depressive disorders: 4% Learning disabilities: % 6/23/ Attention Deficit/Hyperactivity Disorder 3

4 Co-morbid conditions 1. Developmental disorders 2. Psychiatric disorders 3. Medical conditions Many of the disorders that can mimic ADHD also can occur with ADHD. 6/23/ ADHD Goes To School - Outline Part One Definition of ADHD What Mimics ADHD (differential diagnosis) & what Tags Along (comorbidity) School Management 101 Part Two Educational interventions for ADHD Academic Planning Prognosis and follow-up 6/23/ Etiology (What Causes ADHD?) Genetic Studies 30-40% of people with ADHD report a family member with ADHD, compared to 8% in controls Biological Factors Neurological Findings 6/23/ Attention Deficit/Hyperactivity Disorder 4

5 Diagnosis Medical and psychological tests are not yet specific enough to help in diagnosis Based on subjective - but research basedbehavioral criteria Determined through history taking, direct observation, and ADHD specific rating scales Information obtained from multiple sources 6/23/ Executive Function Executive function - brain s ability to monitor itself and organize information Executive function skills originate in areas of the frontal lobes These deficits almost certainly the underlying cause of ADHD (although not exclusive to ADHD) 6/23/ Executive Function A child takes a toy from you on the playground. The teacher is writing your homework on the board, and your best friend is telling you about his new video game. Your parents need to leave for your flight. They ask you to run upstairs, get your sneakers and a book to read in the car, brush your teeth, and use the bathroom. Your teacher assigns a report due in three weeks on the history of the United States space program. You ve almost gotten to the next level of your new video game, and your parents yell into the room that it s time for dinner. Attention Deficit/Hyperactivity Disorder 5

6 Executive Function School Management Task Management 2. Attention Management 3. Action Management 4. Information Management (Working Memory) 5. Emotional Management 6. Effort management 6/23/ Executive Function Working memory affects the ability to: Remember and follow instructions Memorize facts and perform mental computations Remember parts of an assignment or math problem while working on another Organize thoughts for writing Learning from mistakes 6/23/ Objectivity and education. Executive function explains symptoms not part of the ADHD diagnosis such as: Acts moody / irritable / short tempered Behaves stubbornly / seems self directed Poor short term memory Poor time management Executive function impacts reading, writing and math 6/23/ Attention Deficit/Hyperactivity Disorder 6

7 Executive Function Educating parents, teachers, families, communities separating skill deficits from character flaws ADHD is not a disorder primarily regarding attention or hyperactivity. Executive function deficits are their own learning disability and should be directly addressed and during planning. 6/23/ ADHD Goes To School - Outline Part One Definition of ADHD Evaluating for Possible ADHD in School School Management 101 Part Two Educational interventions for ADHD Academic Planning 6/23/ Treatment Supporting Families Multimodal treatment is most successful Understanding executive function from the perspective of a child & family Neurobiological condition effecting self-regulation and planning Family education Collaboration between parents, teachers and providers 6/23/ Attention Deficit/Hyperactivity Disorder 7

8 ADHD and Families Parents of children with ADHD: Increased anxiety and depression (Anastopoulus, 1995) Increased struggle with decision making (Brinkman, 2009) Increased risk of marital strife (Harvey, 2000) 6/23/ Treatment Multimodal Treatment of ADHD (MTA study) Randomized groups: Medication, behavior, behavior and medicine, and community treatment Goal to titrate medication to normal Studied children age 6 12 only 6/23/ Treatment Medical Interventions Teachers are vital reporters providing information about benefits and side effects during the day. Teachers see kids more than parents at peek dosing Role is to directly inform observations Benefits 18 symptom ADHD checklist Side effects Recommendation for other EF supports 6/23/ Attention Deficit/Hyperactivity Disorder 8

9 Treatment - Medication First line medications are the stimulants Used for more than fifty years Successful in up to ninety percent of correctly diagnosed children when well managed Goal of NO side effects 6/23/ Treatment - Alternative Alternative medicine has not been shown to be effective alone for ADHD Exercise Nutrition Direct training 6/23/ Academic Planning Overview 1. Address executive function 2. Behavior management 3. Homework and testing modifications 4. Curriculum choices 5. Classroom management 6/23/ Attention Deficit/Hyperactivity Disorder 9

10 Address executive function Support organization through routine Write down assignments and rules Organizational strategies Sequence tasks into smaller parts Help with note taking, homework lists, handing in assignments, duplicate books 6/23/ Address executive function Behavioral Management Structured, reward based behavioral plans Communication with parents Use a home report card (Imber 1979, Witt 1983) Maintain overall program and planning over time Reevaluate progress often 6/23/ Address executive function Behavioral Management Keep directions simple Write lists down Repeat instructions (and ask for repetition) 6/23/ Attention Deficit/Hyperactivity Disorder 10

11 Address executive function ADHD affects communication Monitor for language delays Obtain their attention before starting Keep it short Keep it simple Repeat when needed, and ask for repetition Write it down 6/23/ Address executive function Homework Supports Structured, nightly homework schedule Adjust expectations Monitor homework volume 6/23/ Address executive function Testing modification Consider extended test time Testing away from distractions Repeated directions Oral testing Separate test taking skills from content knowledge 6/23/ Attention Deficit/Hyperactivity Disorder 11

12 Curriculum Choices At risk population Early implementation of evidence based methods Emphasis on fluency Rote learning v problem solving 6/23/ Classroom planning Seating in front of organized classrooms that minimize distraction Seat away from distractions Monitor windows, doors, wall hangings Rate of disruptions 3x higher in desk clusters (Jones, 2003) 6/23/ Classroom planning Clear expectations and routines Prompt for transitions Offer choices Allow scheduled breaks 6/23/ Attention Deficit/Hyperactivity Disorder 12

13 Classroom planning Exercise / recess Breaks for physical activity Choose consequences that avoid worsening symptoms Avoid punishment for skill deficits 6/23/ ADHD Goes To School - Outline Part One Definition of ADHD Evaluating for Possible ADHD in School School Management 101 Part Two Educational interventions for ADHD Academic Planning 6/23/ Academic Planning Identify ADHD and executive function symptoms Identify comorbid conditions Short term plan safety net Long term plan build skills 6/23/ Attention Deficit/Hyperactivity Disorder 13

14 Academic Planning Low threshold for testing At least 50% with learning disability Near 50% with writing disability Developmental delays Mental health concerns Be proactive, no need to watch and wait 6/23/ Academic Planning Student Involvement Developmental delay in planning, judgment, and self-monitoring Observe for: Understanding of ADHD and executive functioning Developmental age Ability to plan and to maintain a plan Offer appropriate options (instead of expecting a selfcreated plan) 6/23/ Academic Planning Establish accommodations Calibrate expectations on developmental age, not biological age Proactive behavioral supports Organizational planning and direct instruction Mandatory supports at any age (executive function affects planning and prioritization) 6/23/ Attention Deficit/Hyperactivity Disorder 14

15 If it seems like a lot everything we ve reviewed supports all children. 6/23/ Summary ADHD is a chronic medical problem of attention management, self regulation, organization and planning Parents and teachers collaborate in both diagnosis and treatment Comprehensive care typically involves a balance of family, behavioral and educational and medical interventions 6/23/ Useful References The Family ADHD Solution CHADD Educator s Manual on Attention Deficit/Hyperactivity Disorder Phelan, Thomas 1,2,3 Magic 6/23/ Attention Deficit/Hyperactivity Disorder 15

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