ADHD. An educator s guide

Transcription

1 ADHD An educator s guide

2 2 The most powerful resource is gaining a good understanding about the DISORDER

3 INTRODUCTION Attention Deficit Hyperactivity Disorder (ADHD) affects approximately 4-10% of North American children. It is a chronic, neurobiological disorder that can make it difficult for children to pay attention, sit still, concentrate, and control their behaviour. As a teacher, you may encounter children with ADHD. This resource will give you information on what ADHD is, how it is diagnosed and treated, and what you can do to help optimize your student s educational experience. WHAT IS ADHD? Attention deficit/hyperactivity disorder (ADHD) is a chronic medical condition. When a child has ADHD, you may notice one or more of the following: motor hyperactivity, impulse control problems, inattentiveness, and educational concerns. The following chart summarizes some of the behaviours that may suggest inattentiveness, hyperactivity or impulsivity. Of course, most children may exhibit some of the behaviours listed from time to time. To be diagnosed with ADHD, a child or youth must meet specific criteria (see the section, How is ADHD diagnosed?). ADHD is typically divided into three sub-types: Predominantly hyperactive-impulsive Predominantly inattentive Combined hyperactive-impulsive and inattentive A child with hyperactivity and impulsivity may be noticed by teachers because he or she frequently disrupts the classroom, is easily distracted or is constantly fidgeting. Sometimes ADHD can be missed because the child s behaviour is confused with emotional or disciplinary problems. A child whose primary symptom is inattentiveness may sit quietly and appear to work. But he or she may have trouble paying attention and underachieve academically. Girls with ADHD may present somewhat differently in the classroom than boys. Girls with primarily the inattentive form of the disease may appear as daydreamers, unwilling to take risks, easily discouraged and overwhelmed, shy, under active, self-blaming, anxious or depressed. 3

4 Symptoms of inattention Symptoms of hyperactivity Symptoms of impulsivity Being easily distracted, missing details, forgetting things, frequently switching from one activity to another Having difficulty focusing on one thing Becoming bored with a task after only a few minutes unless doing something enjoyable Having difficulty focusing attention on organizing and completing a task or learning something new (e.g., having trouble completing or turning in homework assignments or losing things needed to complete tasks or activities) Not seeming to listen when spoken to Daydreaming, becoming easily confused and moving slowly Having difficulty processing information as quickly and accurately as other children the same age Struggling to follow instructions Losing things Fidgeting and squirming when seated Talking nonstop Dashing around, touching or playing with anything and everything in sight (always on the go) Having trouble sitting still during lunch, school or story time Being constantly in motion Having difficulty doing quiet tasks or activities Being very impatient Blurting out inappropriate comments, showing emotions without restraint or acting without regard for consequences Having difficulty waiting for things they want or waiting their turns in games Frequently interrupting conversations or others activities 4

5 Those with hyperactivity or impulsivity or a combination of both traits may express their hyperactivity by being over-talkative, fidgety, bossy and risk taking but unable to keep up with their work load. Other traits that may be noticed include immaturity or an inability to read other people s body language or vocal cues. They may be children who have difficulty fitting in or who lack friends. HOW COMMON IS ADHD? Estimates of the prevalence of ADHD vary. One review of studies in different countries found the prevalence ranged between 3% and 9%. Another review reported rates between 4% and 10% among North American children. ADHD occurs in many countries, and estimates of its prevalence can vary according to the diagnostic criteria used, the age of the children and the country in which the study was conducted. Behaviours consistent with ADHD are more common among males than females. WHAT CAUSES ADHD? No single cause has been identified for ADHD. A number of factors may be involved, such as genetics, exposure to risk factors before or after birth (prenatal and perinatal), and neurological deficits. HOW IS ADHD DIAGNOSED? In Canada, pediatricians and family physicians are on the front line in screening for, assessing, and initiating treatment for ADHD in children or referring to a specialist. For adult diagnosis, psychiatrists and family doctors assess and manage adults with ADHD. However, since ADHD is a very common childhood neurobehavioural disorder, adequate levels of service delivery for ADHD are only going to be feasible when it becomes a disorder that primary care providers are trained to deal with, and when they can access specialist care when needed. In complicated cases of ADHD, where there are comorbid conditions, differential diagnosis and management with multiple interventions and multiple medications, assessment and treatment of ADHD may be more difficult. These cases should be diagnosed by a specialist. However, once the patient is assessed and treatment initiated, it is reasonable for follow-up to be conducted by family doctors and primary care pediatricians. There is no one test that can diagnose ADHD. It is normal for children to be inattentive, hyperactive or impulsive from time to time. But for children with ADHD, these behaviours are more severe and occur more frequently. As a rule, to be diagnosed with ADHD a child must have symptoms for 6 months or longer and these behaviours should be more severe than other children the same age. 5

6 ADHD can occur on its own or can co-occur with other psychological, emotional or learning disorders. Diagnosing ADHD is a process that can take some time. The Canadian ADHD Practice Guidelines suggest that even for children with uncomplicated ADHD, many visits may be needed to: screen for behaviours that suggest ADHD evaluate other possible causes for the behaviour gather relevant information from parents and teachers using standardized forms ask for and receive results of psychoeducational testing or assessment collect a medical history conduct a physical exam form a diagnosis develop treatment recommendations, which may include referrals to specialists, therapists or other services discuss the diagnosis and treatment plan with the child and parent(s) or guardian(s) establish a schedule of follow-up visits To help in the diagnosis of ADHD, forms have been created for physicians, parents and teachers. These forms can be accessed from the Canadian Attention Deficit Hyperactivity Disorder Resource Alliance website ( It is important to document behaviour and have regular contact with parents when a pattern of ADHD symptoms is present in your classroom. This documentation is important in the diagnostic process. In addition to the routine process of having children diagnosed through the General Practitioner (GP), then by referral, parents can access and pay individually for an assessment and diagnosis. LEARNING DIFFICULTIES WITH ADHD Other psychosocial and learning difficulties may co-occur with ADHD. Some include: Central Auditory Processing Disorder (CAPD) children with CAPD often do not recognize subtle differences between sounds in words. The cause of CAPD is not clear. It may co-occur with conditions such as dyslexia, ADHD, autism, autism spectrum disorder, language disability, pervasive development disorder, or developmental delay. Children with CAPD typically have normal hearing and intelligence but may be observed to have trouble paying attention to, and remembering, information presented orally or carrying out multistep 6

7 directions. They are sometimes referred to as having poor listening skills, and may exhibit behavioural problems, language difficulties, difficulty with reading, comprehension, spelling and vocabulary, and low academic performance. Graphomotor Disorder handwriting is a complex perceptual-motor skill that is dependent upon the student s maturation and integration of cognitive, perception and motor skills. Problems in any of these areas can make it difficult for the child to write clearly at a reasonable pace. Problems with executive functioning not every child with ADHD has problems with executive functioning. But ADHD is associated with weaknesses in executive function. Executive functioning refers to a person s ability to inhibit actions and regulate emotions, resist distractions and control attention, and adapt flexibly to changing situations. It is important to document behaviour when ADHD symptoms are present Slow processing speed some children with ADHD may not process information as quickly as other children. In the classroom they may not catch all the instructions for completing a task, be slow at copying down information, or slow to retrieve the information they need. Working memory weakness working memory weakness has been linked with ADHD. This is the mental workspace where information is used and stored. This problem can contribute to inattention and problems with verbal and non-verbal working memory tasks. Screening for academic problems and learning disabilities and the creation of an individual education plan (IEP) may be helpful for students with ADHD. 7

8 WHY IS IT IMPORTANT TO TREAT ADHD? Children and adolescents with ADHD are at greater risk for: learning problems dropping out of high school poor self-esteem increased parent-child conflict and stress more mental health issues as they grow up problems with social skills and peer relationships increased number and severity of driving accidents substance abuse becoming a juvenile offender With ADHD: 23% Without ADHD: 10% Never graduate high school With ADHD: 38% Without ADHD: 4% Be involved in a pregnancy With ADHD: 55% Without ADHD: 27% Abuse drugs or alcohol Without ADHD: 11% With ADHD: 49% Be at-fault in a car accident With ADHD: 55% Without ADHD: 23% Get fired Above data drawn from 4 studies of varying design and size. 8

9 HOW IS ADHD TREATED? ADHD cannot be cured but there are options for treating it. The CADDRA Guidelines suggest a five-tiered management plan consisting of: 1. adequate education of patients and their families; 2. behavioural and/or occupational interventions; 3. psychological treatment; 4. educational accommodations, and 5. medical management, as a way to facilitate other interventions. Combining psychosocial interventions and medication can be beneficial. In the following sections, we ll talk about three specific approaches to ADHD: 1. Behavioural interventions 2. Educational accommodations 3. Medication BEHAVIOURAL INTERVENTIONS The first step in helping a child with ADHD is education of the child, parents, caregivers and teachers. It is helpful if everyone understands what ADHD is and how it can be treated. Behavioural therapy may be helpful. Therapists may be able to help the child learn how to monitor his or her behaviour and better control it. In some cases, therapists may help teach social skills, such as how to read facial expressions, wait your turn, share, ask for help, or respond to teasing. EDUCATIONAL ACCOMMODATIONS Teachers play a very important role in helping children with ADHD. The goal is not simply to reduce disruptive behaviours, but to help students develop ways of coping with their ADHD (adaptive learning skills). You may be able to help by making adaptations in the classroom (e.g., the seating arrangement) or your instructional style (e.g., how you explain or set up assignments). Some common strategies for students with ADHD involve modifying the classroom environment, the teaching or instructional style, and/or how children are assessed. Here are some helpful ideas and tips. Instructional Style Create an environment in the classroom that is positive, encouraging and supportive. Try to provide student with more encouragement and positive feedback than negative feedback. For example, try to state rules in a positive manner (e.g., Please walk compared to Don t run ). 9

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11 Provide positive feedback when a student does something appropriate (e.g., Thank you for walking to the door quietly ). Give one direction at a time and make directions clear, short and specific. Chunk and repeat important parts of long explanations and instructions. Always check for understanding (can the student repeat the instruction?) and give frequent feedback on how the child is doing. Seating Try to ensure the child sits in an area where disturbances can be kept to a minimum. You may want to avoid placing the student in a high-traffic area (e.g., close to the door or where students come for materials or supplies) or at a group table. In some cases, it can be helpful if the child is seated close to the teacher, so he or she can ask for help when needed. Cueing Provide visual supports for instruction, such as a checklist of to do items or posters. Set up one or more cues or warning signals that you can use when the student s behaviour is disrupting others. Try to make it something unobtrusive such as a shoulder squeeze, hand signal or a sticky note on the student s desk. If you need to discuss the student s behaviour, do so in private. To help students who have difficulty with transitions (from activity to activity or class to class), give advance warning (e.g., cue five to ten minutes before changes), set up visual schedules, and establish transition routines that are consistently followed. Create predictable schedules for classroom tasks or actions. Review those routines frequently and have checklists or visual cues illustrating key steps and what is expected. Predictable schedules and routines can help students with ADHD handle transitions, turn in homework, ask for help and get supplies or materials. Adaptations Technical aids such as a calculator, computer or tape recorder can be helpful. Students who find it difficult to write may benefit by using appropriate computer software or scribes. The student with ADHD may need extra time for testing or alternative test formats, such as an oral test. You may want to teach test-taking skills and strategies. Other accommodations may include the use of a scribe or testing in a quiet room free of distractions. 11

12 If the student is hyperactive, give frequent opportunities to get up and move around. If fidgeting is a problem, give the student a squeeze ball or play dough to manipulate while you teach the lesson. Students can be provided with checklists listing the items they need for specific activities. Management of objects, such as assignments, can be facilitated by providing the student with structure and routines. For example, teachers can teach routines for handing in work (e.g., a consistent place and time to hand in assignments), writing down assignments, or organizing desks or workspaces. Students may also benefit from coding schemes, such as colour coding of materials and notebooks. Management strategies have also been developed that may be helpful for students with ADHD. Consequence-oriented behaviour management strategies include such things as a: token management system, in which the student is provided with tokens or some other secondary reinforcer when he or she demonstrates a specific target behaviour behavioural contract, in which the student and teacher identify a target behaviour, set daily or weekly goals and an activity reward when the goal is met (e.g., free time on the computer) 12

13 self-monitoring system, in which the student counts how often they do behaviours that are appropriate (e.g., on-task behaviour ) or inappropriate (e.g., off-task behaviour ) Another important part of helping a student with ADHD is maintaining regular communication with the parents. Parents can help teachers understand the student s interests and educational history, while teachers can provide parents with information on the student s classroom behaviour and what steps are being taken to help the student succeed. There are a number of ways in which teachers and parents can communicate with each other: phone calls newsletters log books notes informal visits parent/teacher conference report cards daily report cards to monitor progress towards goals It is important that you report any changes in behaviour to parents. Changes in behaviour may be attributed to a number of causes including a change in medication. Management strategies have been developed that help students MEDICATIONS Several types of prescription medications are used in the treatment of ADHD symptoms for children aged six and older, adolescents and adults. These medications fall into two broad categories: 1. Stimulant medication 2. Non-stimulant medication Both types of stimulant medications (methylphenidates and amphetamines) come in short-, intermediate-, and long-acting formulations. 13

14 Short-acting medications are typically taken 2 to 3 times a day. Usually the first pill is taken in the morning, another at lunchtime, and the third after school. Intermediate-acting medications are typically taken once or twice a day. Long-acting medications are typically taken once a day, usually in the morning and last the whole day. If you are teaching a child with ADHD who has been prescribed medication, it is helpful to know the type of drug the child has been prescribed and the dosing schedule. It is also important to know if a child has changed medications so you can monitor and report any type of changes in behaviour. Category Class Type and Brand Names # of doses a day Stimulants Methylphenidates Long-acting: CONCERTA and 1 BIPHENTIN Intermediate-acting: RITALIN SR * (sustained release) Short-acting: RITALIN 2-3 (immediate release) Amphetamines Long-acting: ADDERALL XR, VYVANSE 1 Intermediate-acting: DEXEDRINE 1 spansules (sustained release) Short-acting: DEXEDRINE (immediate release) 2-3 Non-stimulant medication Selective Norepinephrine Reuptake Inhibitor Long-acting: STRATTERA 1-2 *Dosing should be based on the consideration that RITALIN SR has a duration of approximately 8 hours WHAT SHOULD I DO IF ONE OF MY STUDENTS IS PRESCRIBED ADHD MEDICATION? There are a number of things you can do to help if you have a student or students who have been prescribed ADHD medication. 1. The decision as to whether to use medications as part of ADHD management is made on a case-by-case basis by the family, the student and their physician. You may be asked to complete daily or weekly ratings of the child s behaviour and academic performance, as well as any side effects. These ratings can help 14

15 the child s physician decide whether medication may be helpful, evaluate the effect of different medications, or adjust the dose. 2. Help to ensure the child receives the appropriate medication at the appropriate time. If the child needs a dose during the day, someone at the school will need to take responsibility for storing the medication and giving it to him or her. ADHD medication should be delivered to the school by the parent or guardian and one person at the school should maintain primary control and responsibility for it. Some safety tips include: All medications should be kept in their original containers with the label stating the student s name and the name, strength, frequency and dose of the medication, and name and telephone number of the prescribing physician. A medication record should be created which shows the name of the student, grade, homeroom, date the medication was received, name and amount received (number of pills), signatures of the deliverer and receiver, and emergency contact numbers. Medications should be stored in a secure and locked location. Medications should be administered by the designated, responsible person in a location where there is adequate space and lighting and few distractions, clutter or noise. Each child or youth should be observed during administration to ensure the medication has been taken correctly. Medication should never be shared or misused (do not allow students to give away, sell or be bullied for their medication). Prior to preparing or administering medication, practice good infection control (e.g., wash your hands). All doses should be recorded on a standardized medication record for each child. Try to establish standard times for the administration of medications (i.e., the same time every day). 3. Like all medications, those for ADHD may have some side effects for children and adolescents, which vary from one medication to another. Severe side effects from ADHD medications are rare. It is important to be aware of, and understand, any side effects experienced or witnessed, and these should be discussed with 15

16 the child s parent(s) or guardian(s). You may want to speak with them about the specific medication the student is taking and what side effects you should report. Common side effects are trouble getting to sleep, loss of appetite or weight loss, stomach ache, dizziness, tiredness, constipation, headache and jitteriness. Additional side effects can include irritability, agitation, hostility, anxiety and sometimes suicidal thinking. POTENTIAL FOR ABUSE Abuse of stimulant drugs may lead to dependence. Because of the potential for misuse, it is important to ensure stimulant medications kept on school property are safely stored and that they are taken solely by the child to whom the medications are prescribed. Stimulant medications should be given cautiously to patients who have a history or an ongoing problem with drug dependence and/or alcoholism. Studies have also shown that ADHD in and of itself appears to be a risk factor in the development of Substance Use Disorder (SUD), i.e., a disorder in which people use/abuse illicit drugs and/or alcohol. The risk of developing an SUD is higher in those people that have other coexisting mood and conduct disorders. Factors that appear to influence the risk in youth with ADHD include self-medication, family history, and environmental mediators. Kids do well, if they can Ross Greene 16

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18 ONLINE RESOURCES FOR MORE INFORMATION Centre for ADD/ADHD Advocacy Canada Teach ADHD Portal British Columbia Ministry of Education. Special Education Teaching Students with Attention Deficit/Hyperactivity Disorder: A Resource Guide for Teachers CH.A.D.D. Canada Learning Disabilities Association of Canada National Resource Center on AD/HD (US) Attention Deficit Disorder Association (US) Learning Disability Online (US) ADD in School: School Classroom Interventions (US) 18

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