Rethinking ADHD: Abilities in the classroom C&ognitive at home - Very low oral comprehension. Saaled Inclusion Congress- 2011 Very low spelling and no written products. - Struggles with sequencing of information. Behaviour - Difficulty staying in seat and on task. - Refuses to complete written work. - Leaves the room and does not return. - Struggles with friendships due to wanting to engage in activities appropriate to younger student - Highly distracted by activities outside the room. Rosemary Tannock, PhD - Engages in avoidance behaviour when asked Canada Research Chair & Professorto in complete challenging work. www.teachadhd.ca Special Education; Professor of Psychiatry, University of Toronto; Senior Scientist, The Hospital for Sick Children , Toronto, CANADA Myth #1 ADHD is a new disorder – a problem of modern society Dr Alexander Crichton: “On attention & its diseases” “When born with a person it becomes evident at a very early period of life, and has a very bad effect, in as much as it renders him..” “…and what is very fortunate, it is generally diminished with age..” 1798 “…incapable of attending with constancy to any one object of education.” (p.271) Early dual conceptualizations of ADHD “Fidgety Phil” “ “Johnny-Head-In-The-Air” Dr. Heinrich Hoffman 1845 Dr. George Still 1902 “Morbid defect of moral control” ADHD in the 1950’s-1960’s ‘the brain-damaged child” Speech, Language Social interaction Cognitive function Emotion Mood Motor function Behavior Myth #2 -ADHD is not FACT •World-wide prevalence of ADHD: real – it is just a ~ 5% in children & adolescents (1-2 students per class) North American ~2- 4% in adults problem •More common in males than females (3: 1) •Not specific to socioeconomic status A medical/mental health category: Childhood-onset Disruptive behavior disorder: Inattention, impulsiveness,hyperactivity But in DSM-V, it is likely to be classified among the Neurodevelopmental Disorders • • • • • • Intellectual Disability Autistic Spectrum Disorder Communication Disorders Developmental Motor Co-ordination Disorder ADHD Learning Disorders ADHD 1994-2011 ADHD poor attention excessive activity impulsivity CD extreme antisocial behaviour: bullying, lying, stealing, cruelty Differs from: Persistent negativistic behavior: argumentative, defiant, provocative , hostile ODD Myth #3 FACT -ADHD is not real AD/HD is a neurobiological, -a label given to kids who are naughty - kids who are not disciplined by their parents - a label used by teachers for kids who are naughty, lazy, unmotivated genetically-based condition characterized by differences in brain functioning that affect behaviour, thoughts and emotions. The differences in brain function cause inattention, hyperactivity and/or impulsivity, along with a number of related difficulties, that are inappropriate for an individual’s age and impairing. ADHD: evidence of delayed brain growth in frontal cortex, which controls attention view of the brain from the side Front Greater than 2 years’ delay 0 to 2 years delay Sample: ADHD=223; Controls = 223 Educational Implications 2-3 year discordance between age & ability to control attention, behavior & emotion Will require support from teachers/parents for much longer than their peers Most likely caused by abnormalities in the brain’s chemical messengers (neurotransmitters) ◦ the ADHD brain is inefficient or sluggish in the areas that control impulses, screen sensory input and focus attention. AD/HD tends to run in families – is heritable ◦ heritability is about 76% -heritability of height is 90%, schizophrenia is 80% ◦ Parents and siblings of children with AD/HD often have similar symptoms. Other possible causes: ◦ Fetal exposure to alcohol, cigarettes/nicotine & environmental toxins (lead); prematurity What causes ADHD? Observable symptoms of Hyperactivity/Impulsivity & Inattention Used in diagnosis, with evidence of impairment Altered brain structure & function Inefficient brain function Genetic factors Difficult to manage behavior ◦ Inattention/Disorganization, Impulsivity, Hyperactivity Social emotional difficulties ◦ Misperceive social cues, over-reactive, problems managing emotions/anger Executive Function difficulties ◦ Higher-order brain functions (next slide) Poor functioning at school ◦ Problems learning & poor academic outcome What are the key characteristics of ADHD? “Cool” & “Hot” Executive functions: typology executive function problems in ADHD Response inhibition Working memory Set shifting Sensitivity to reinforcement Ability to delay gratification regulating alertness focusing & sustaining effort & attention processing information at consistent & appropriate speeds planning, organizing and prioritizing tasks remembering details & accessing short-term memory distinguishing essential from nonessential detail delaying gratification inhibiting behaviours managing frustration & other emotions evaluating information,self-monitoring own performance & regulating actions Executive function problems in ADHD Percent of sample with deficit Preschoolers with ADHD typically have several developmental problems 50 45 40 35 30 25 20 15 10 5 0 Overall Developmental Ability Visuo-motor Integration Oral Language Sensory Profile ADHD Controls Academic & social impact of ADHD in the preschool years: summary •Problems maintaining attention •Easily distracted •Constantly on the go (unable to sit still during circle time) •Excessive running, climbing •Does not follow instructions Will enter school at significant disadvantage •Pre-academic skill deficits •Cognitive deficits •Higher frequency of negative social behavior Parents report higher stress levels, less adaptive coping, less likely to seek support from relatives & neighbours Achievement gap between ADHD and their peers increases over time Scheffler et al (2009) Pediatrics 123(5): 1273-79 Academic Achievement Scores 160 140 Reading scores 120 Mathematics scores 100 Full sample ADHD 80 Full sample2 60 ADHD2 40 Full sample: n=8370 ADHD: n=594 (9%) 20 0 K-Fall K-Spring Gr-1 Gr-3 Gr-5 17 Pay attention to Inattention! 387 children followed from Kindergarten - Grade 5 Inattention in kindergarten as reported by teachers Poor reading in Gr. 5 even after controlling for IQ, hyperactivity, emotional problems, & reading ability in Kindergarten/Grade 1 Early attention problems impede high school achievement Assessed & followed an ethnically & socioeconomically diverse sample of 823 children aged 5-6 yrs until 17yrs of age (84% of original sample) Detroit Teacher-reported inattention (age 5-6) (Breslau J., et al, Pediatrics, 2009) • Unique predictor at age 17yrs • WJ-R Broad Reading • WJ-R Broad Math Teacher reported internalizing • Even after controlling for these & externalizing problems, IQ, school-entry variables Family SES ADHD impairs functioning from morning to night! Before school: Problems waking up Getting ready for school Bedtime: Problems settling down & falling asleep During school: Cannot focus, distracted Disorganized Poor performance Problems with peers After school: Problems with homework Problems with friends, siblings Rethinking ADHD Understanding & helping children with ADHD “When you plant lettuce, if it does not grow well, you don’t blame the lettuce. You look into the reasons it is not doing well. It may need fertilizer, or more water, or less sun. You never blame the lettuce. Yet if we have problems with our friends or family, we blame the other person. But if we know how to take care of them, they will grow well, like lettuce.” Reflection Thich Nhat Hanh 1991; Vietnamese Monk, Activist and Writer. b.1926) Why do students with ADHD have difficulty learning and achieving at school? Behavioral symptoms of ADHD: inattention, Hyperactivity/impulsivity Social-emotional problems Academic enablers Executive Function Problems A c a d e m ic Academic & social underachievement School/home context Academic Competence: Academic skills + Learning Enablers Academic Competence Organization & Study Skills Motivation ADHD associated with impairments in most aspects Interpersonal Skills Academic Skills •Reading •Mathematics Written Expression •Critical Thinking Active Engagement Build Home-School Partnership & Teamwork Who are the team players? • parents, • teachers, teacher-assistants • psychologist, speech-language pathologist •, physicians • & of course the student! Basic principles for home-school communication Communicate frequently & regularly Phone call, Email, Spontaneous notes, Notebook, HomeSchool Daily/WeeklyReport Cards, Face-to-face Increase parents’ comfort at meetings Provide notice of time and room in advance along with brief list of topics/questions, ask for parent questions; provide written summary of decisions Highlight student’s strengths (concrete examples) Communicate about student’s needs (concrete examples) Work with parents to help create structure & routines & to generate solutions Communicate respect www.education.gov.ab.ca/k_12/specialneeds/resources.asp Daily Report An Circle the number that best describes how the student demonstrated the behavior today excellent Wonderful Satisfactory Needs resource improvement for 1 Brings all needed supplies & 3 2 books to class educators Name:________________ Date:__________ Follows directions 3 2 1 Starts work with minimal prompting 3 2 1 Interacts positively with peers 3 2 1 Responds positively to teacher requests 3 2 1 Students signature______________________ Teacher signature_______________________ Parent signature________________________ In-class performance today: ___Wonderful ___Satisfactory ___Needs improvement 2. Create supportive classroom environment Organize physical environment to reduce distractions (near teacher, between well-focused students, away from distractions) Organize materials so they are easy to identify & store (color coding) Establish routine for writing down & turning in homework Take ‘Triple-P’ proactive approach to behavior Predict, Precue, Praise Post (& remind) 3-5 basic ‘positive’ classroom rules Pace – move around room, prompt& praise student Provide Instructions in written format On board & on worksheet Copied in assignment book by student and checked by teacher (on school/class website) Post schedules on board & in student’s binder Post classroom rules 30 Use Effective Instructions & Commands ATTRACT the student’s attention Maintain eye contact SPEAK clearly, paced Use short sentences (‘chunked’) Use visual cues & wait for compliance PAUSE between sentences MONITOR the student If child has ‘blank look’ stop & repeat instruction TO REPEAT INSTRUCTION Restate slowly and simply Do not expand Break tasks into smaller/shorter chunks Homework Break into smaller units / shorter time period Use Help get started count-down timer check understanding set timer, then leave! Take brief, timed, structured breaks Help plan out longer-term assignments Mark the due date List all regular/planned activities List all the required steps for the project Work out time needed for each step Backwards-planning Insert all steps into the planner November Activities Mon 22nd 5-6pm Hockey practice Tues 23rd Wed 24th Step-1 Step-2 Thurs 25th Steps-3 & 4 Fri 26th Sleep-over at Jake’s Sat 27th 8-9 am Hockey Sun 28th Step-5, rough draft Review draft Final version Mon 29th 5-6pm Hockey practice Tues 30th History project due Getting organized Set goals & prioritise Everything in its own place Desks, Bags, Closets, Binders Time Management Choose & use a Day Planner Basic teaching techniques Daily review Chunk lesson. teacher modeling, followed by guided practice & immediate feedback until mastery learning occurs. Independent practice Begin with objectives. Proceed in small steps. Highlight key points. Procedural learning of relevant past learning & homework continue until responses are accurate, quick,automatic. Weekly reviews routine and systematically build on previously learned materials. Six explicit steps to teach strategies 1. Develop background knowledge 2. Discuss it 3. Model it 4. Memorize it 5. Support it 6. Establish independent practice Use familiar, easier-level materials when teaching a new strategy Behavioral Accommodations Use positive Reinforcement •Positive verbal or written feedback •Reward systems and incentives •Give tasks that can be successfully completed •Private signals to refocus student •Role play situations •Weekly individual time •Conference opportunity Be consistent With rewards & consequences With academic expectations Sleep hygiene Limit screen time Establish bed-time routine Non-Screen activity 30 minutes before bedtime Bedtime story/ritual Lights-off time No screens in bedroom! Rethinking ADHD: Summary Intervention for students with ADHD needs to focus on promoting their learning & academic success Intervention to improve academic progress must focus on instruction Instructional accomodations for students with ADHD will benefit all students, including those with other types of learning and mental health problems ADHD needs a co-ordinated, sustainable, multi-system approach • System : home, school, Systemlevel Student & parents Schoolwide education, medical, judicial •Transition plans (sectorto-sector, school-to-school, grade-to-grade, class-toclass) • Instructional pathways (credit-recovery, creditrescue, co-op etc) • Ongoing capacitybuilding (parent programs, professional development) Classroombased Useful Resources on ADHD www.ed.gov/about/offices/list/osers/osep/products.html www.education.gov.ab.ca/k_12/specialneeds/resource.asp http://research.aboutkidshealth.ca/teachadhd . TIME FOR ME TO STOP! ANY QUESTIONS?