Rethinking ADHD in the classroom and at home

Report
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?

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