ADHD in the ClassroomCan anyone survive?

Quote for the Day

I was trying to daydream, butmy mind kept wandering.

Steven Wright

Planning Outline for Presentation

By the end of today’s session, this may be how you will feel:

Information Overload

• Google for ADHD = 15,700,000 sites

• Amazon books listed on ADHD = 689 books

• Local opinions = 1 (mine)

ADHD: Living Without Brakes(book title by M. Kutscher)

I couldn’t repair your brakes, so I made your horn louder.

Steven Wright

Which child has ADHD?

Let’s get down to the issues.

How would you describe the ADD/ADHD child in your classroom?

The better we can describe the behaviors, the better we can plan interventions.

Attention

• How would you describe inattention?• Is being inattentive the same as being

distractible?

Note: Inattention increases with difficulty of task.

Attention

• As the child matures into adulthood, symptoms of inattention evolve into forgetfulness, losing things, and avoiding menial tasks.

Impulsivity

• How would you describe impulsivity?• What about excitability?• What about emotional regulation?

Impulsivity

• Common characteristics within ADHD include:– Low frustration tolerance– Quickness to anger– Impatience– Being easily excitable

These characteristics tend to persist into adulthood, even more so than hyperactivity.

•Impulsivity

Inattention

• As the child matures into adulthood, impulsivity evolves into poor driving performance and self-medication.

Hyperactivity

• What does hyperactivity look like?• Is being fidgety the same as being hyper?• What about sensory overload?• What about exciteability?

Hyperactivity

• Compared to inattention and impulsivity, hyperactivity may be the least important symptom.

• Also, hyperactivity tends to decrease as the child ages.

Official Diagnosis• Often fails to give close attention to details or makes careless mistakes in

schoolwork, work, or other activities.• Often has difficulty sustaining attention in tasks or play activities.• Often does not appear to listen when spoken to directly.• Often does not follow through on instructions and fails to finish

schoolwork, chores, or duties in the workplace (not due to oppositional behavior of failure to understand instructions).

• Often has difficulty organizing tasks and activities.• Often avoids, dislikes, or is reluctant to engage in tasks requiring sustained

mental effort (such as schoolwork or homework).• Often loses things necessary for tasks or activities (for example,, toys,

school assignments, pencils, books, or tools).• Is often easily distracted by extraneous stimuli.• Often forgetful in daily activities.

Official Diagnosis• Often fidgets with hands or feet or squirms in seat.• Often leaves seat in classroom or in other situations in which remaining

seated is expected.• Often runs about or climbs excessively in situations in which it is

inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness).

• Often has difficulty playing or engaging in leisure activities quietly.• Is often “on the go” or often acts as if “driven by a motor.”• Often talks excessively.• Often blurts out answers before questions have been completed.• Often has difficulty awaiting turn.• Often interrupts or intrudes on others (for example, butts into

conversations or games).

Diagnosis

• DSM-IV differentiates between three different types of the disorder.

1. ADHD – predominately hyperactive/impulsive type (without inattention symptoms being significant).

2. ADHD – predominately inattentive type (without the hyperactive/impulsive symptoms being significant).

3. ADHD – combined type (the most common).

Diagnosis

• There is a problem for researchers and clinicians with the present diagnostic criteria for ADHD.

• What if inattention is something entirely separate from impulsivity and hyperactivity?

Why conduct a workshop on ADHD?

• ADHD has long lasting and serious consequences for the child.

• ADHD is the most common global disability experienced in the classroom.

• There are still too many myths about ADHD.• ADHD in the classroom can be so frustrating.

Long lasting, serious consequences:

• The national percentile score in reading achievement in early adolescence for children with ADHD is almost 30 points lower than for non-ADHD age- and gender-matched controls.

Long lasting, serious consequences:

• Youths with ADHD have higher rates of absentee days, especially after the 6th grade.

• Students with ADHD are three times as likely to be retained in a grade by age 12.

• The school drop-out rate is twice as high for boys with ADHD.

Long lasting, serious consequences:

• ADHD adolescent drivers have four times as many auto accidents and three times the number of speeding tickets as non ADHD adolescent drivers.

• In adults, driving under the influence of ADHD produces similar driving errors as when under the influence of alcohol.

Long lasting, serious consequences:

• ADHD is associated with higher teen pregnancy rates

• ADHD is associated with earlier experimentation with drugs and alcohol.

• Girls with ADHD have a higher risk of pathological eating behavior and a desire for thinness.

• ADHD increases the risk for certain psychiatric disorders.

Long lasting, serious consequences:

• Boys with ADHD are three times more likely to be arrested or incarcerated as adults (but there is more to this story).

• In adults, ADHD produces diverse and serious impairments in functioning in education, occupation, social relationships, sexual activities, dating and marriage, parenting, financial management, and overall mental health.

Frequency

ADHD is the most common global disability experienced in the classroom.

• Nearly 7% of elementary–age children in the United States have been diagnosed with ADHD.

• The number of boys diagnosed with ADHD outnumbers the girls almost 4 to 1.

Myths about ADHD

• Myth: Children grow out of it when the reach puberty or adulthood.

• Fact: Only about a third lose their symptoms by adulthood. Inattention and emotional factors persist. Some symptoms change in nature.

Myths about ADHD

• Myth: ADHD is not a real condition. It was created by the drug companies to sell medications.

• Fact: ADHD is a well documented neurological disorder. (to be discussed further)

Myths about ADHD

• Myth: ADHD is over diagnosed.

• Fact: While some children may be misdiagnosed, many children with ADHD are never identified, especially girls.

Myths about ADHD

• Myth: We never had ADHD when I was growing up!

• Fact: Actually the symptoms were described in a medical document back in 1798. It has gone by many names since then.

Myths about ADHD

• Myth: ADHD is caused by too much TV and too much junk food, especially sugar.

• Fact: ADHD may be aggravated by these factors, but the causes are primarily genetic and trauma to the developing system.

Myths about ADHD

• Myth: Children who take medication for ADHD will become addicted and will start using other drugs.

• Fact: Medications used to treat ADHD do not increase the risk of future drug and alcohol abuse in early adulthood.

Myths about ADHD

• Myth: All he needs is a good whooping.

• Fact: Good discipline is essential, but spankings are usually short lived and not nearly as effective as structure and positive guidance.

A Question to Ponder

Who has the hardest time in the classroom?

A. The ADHD child B. The teacher

What is our attitude toward the ADHD child?

Just because you are in a wheelchairdoesn’t mean you can’t walk down thesteps like everyone else!

• We struggle to understand:

– What is really due to ADHD, and what is just being lazy, or not caring, or defiance, or …….?

– What do we have a right to expect/demand?

What is ADHD?

It is a neurological disorder characterized by inattention, hyperactivity and impulsivity.

(see DSM-IV diagnostic criteria, Rief list 1-3)

• Note the three types:– Predominantly hyperactive/impulsive type– Predominantly inattentive type– Combined type

The Brain and ADHD

• The brains of children with ADHD were 3% to 4% smaller than the brains of children without ADHD.

• A recent study found a 3 year delay in brain maturation measured by cortical thickness.

• (No wonder they can act so immature!)• These delays in maturation were most

noticeable in brain regions related to executive control of attention, behavioral inhibition, working memory, evaluation of reward contingencies, coordination of higher order plans, and motor control.

The Brain and ADHD

What is ADHD?

AHDH is now perceived by many as characterized by deficits in executive functioning, or the management of brain functions.

(see Rief list 1-2)

Here is where the disabilities show up.

The Major Concerns

• Deficits in executive functions• Inattention• Deficits in inhibition• Deficits in working memory• Deficits in processing speed

• http://www.aboutkidshealth.ca/ADHD/The-High-Risk-Triad-Inattention-Poor-Working-Memory-and-Academic-Underachievement.aspx?articleID=6894&categoryID=AD-nh1-04d

Working MemoryPhonological Task

Working MemoryVisuospatial Task

Working MemoryVisuospatial Task

Working MemoryResults for Phonological Task

Working MemoryResults for Visuospatial Task

Associated Characteristics

• Impatience• Demandingness• Low frustration tolerance• Poor listening skills• Avoidance of chores and academics• Poor task completion

Associated Characteristics

Positive Illusory Bias

Classroom Issues

• Excessive movement about the room or at seat• Excessive talking• Failure to attend or keep up• Failure to start , complete, or turn in assignments• Conflict with peers• Restricted academic performance• Argumentative

Writing Issues

• Difficulty copying from board• Slow copying from book or paper• Poor legibility of handwriting• Resistance to writing at all– Fails to start– Rushes through, writing anything– Quits after brief start

Reading Issues

• Lose place (poor tracking)• Lose train of thought• Forget what just read, have to reread

repeatedly (impedes comprehension)• Silent reading difficult (may subvocalize)• Lack of fluency• Learning deficits in reading (phonological,

processing, language)

Math Issues

• Remembering math facts• Following multiple steps• Recalling rules, procedures, directions, sequences• Poor attention to sign changes or operational

changes• Poor self-correction• Poor alignment of numbers on page• Slow processing or writing speed• Difficulty with word problems

Discipline Issues

• Needing constant redirection• Impulsiveness• Desire for attention• Feeling picked on• Anger• Few discipline options

What to do?! – What to do?!

Be PatientBe StructuredBe Interesting

End of Part 1

The Co-conspirators

(1/2 to 2/3 have comorbid behavior disorders)

• ODD (Oppositional-Defiant Disorder)• CD (Conduct Disorder)• BPD (Bipolar Disorder)• ASD (Asperger’s Disorder)• TD (Tourette’s Disorder)• OCD (Obsessive-Compulsive Disorder)• Epilepsy

Oppositional Defiant Disorder

• Essential Feature: a recurrent pattern of negativistic, defiant, disobedient, or hostile behavior toward authority figures.

• Characterized by: – Losing temper– Actively refusing to comply– Deliberately annoying others– Being touchy or easily annoyed– Being angry and resentful– Being spiteful or vindictive

Conduct Disorder

• Essential Feature: repetitive and persistent pattern of behavior in which the basic rights of others or major societal norms or rules are violated.

• Characterized by:– Aggression to people and animals– Destruction of property– Deceitfulness or theft– Serious violation of rules

Bipolar Disorder

• Essential feature: severe mood dysregulation

• They may cycle through moods or present a chronic irritability

Asperger’s Syndrome

• Essential Features: severe and sustained impairment in social interaction and the development of restrictive, repetitive patterns of behaviors, interests, and activities.

Difficult Combinations

• ADHD, Tourette’s, OCD

• ADHD, Asperger’s, OCD

• ADHD, ODD, and or CD

• ADHD and Epilepsy

ADHD or CD?

• Within the ADHD adults with multiple repeat offenses and arrests, three behavior rating items in their childhood were predictive:

• “often gets into fights with other children”• “lies to get out of trouble”• “takes things from other children”

More Co-conspirators

• Learning Disorders• Sensory Integration Disorders• Auditory Process Disorder (CAP-D)• Motor Deficits• Sleep Disorders• Bedwetting

Parents as Co-conspirators?

ADHD children with ADHD parents:

• Higher rates of ODD• Higher rates of mood or anxiety disorders

Issues to Confront

• Organization• Time estimation• Volume estimation• Transitions• Motivation• Social interactions• Emotional adaptability/control

What not to do.

1. Tie him up and put duck tape over his mouth.2. Embarrass him.3. Constantly call out his name.4. Be overly critical.5. Repeatedly tell him to stop rather than telling

him what to do.6. Run yelling and screaming out of the room.

What to do?! – What to do?!

Help the ADHD student organize. Develop a system and stick with it. (Use color coding and other organizational strategies.)

Question: Is it wrong to provide paper and pencils for the student?

What to do?! – What to do?!

Use Visual Prompts

• About rules (color wheel, posters, lists)• About procedures/steps (printed instructions, reminders)• About content (key words, ideas)• About time (clocks, time remaining)

What to do?! What to do?!

• Use the three “P’s”

• Prepare • Pre-teach• Practice

What to do?! – What to do?!

Help Student Plan

• What is my task?• What materials do I need?• How will I start?• What will I do next?• How long will this take?• When should I ask for help?

What to do?! – What to do?!

Monitor & Supervise

• Redirect• Remind• Review• Reward

How do we motivate?

• Positive regard (forge a positive relationship)• Encouragement• Expectations• Guidance• Reward Systems

Social Interactions & Adaptability

• Help students learn how to shift from a change-oriented or problem solving strategy when a situation is controllable to a coping-oriented or emotion regulation strategy when a situation is less controllable.

Other Suggestions

• Utilize deep breathing techniques.• Exercise• Try a mirror• Nature (get outside)• Use peers

How can we help children with ADHD?

1. Acknowledge and accept the reality of the disorder

2. Structure, structure, structure3. Support, guide, assist4. Use visual supports5. Care and embrace with compassion

REMEMBER

Patience, Patience,

Patience

Medications for ADHD

• Originally – Dexedrine, Ritalin• Then – Adderall, Cylert• Then time released – Metadate, Concerta, Adderall

XR• Something different – Strattera (norepinephrine

reuptake inhibitor)

• Most recent – Vyvanse, Guanfacine (Intuniv, Tenex)• Patch - Daytrana

Additional Medications

• Welbutrin (antidepressant)• Clonadine (blood pressure medication)• SRI’s (anti-depressants)• Risperdal, Seraquel, Abilify (anti-psychotics)

Complications with Medications

• Rebounding• Disturbed sleep• Weight loss and delayed growth• Irritability, anger, psychotic thoughts• Heart rate increase• Anhedonia

Causes

• Genetics• Environmental Risks– Prenatal alcohol/drug exposure– Oxygen deprivation– Brain trauma– Febrile seizures– Lead exposure– Maternal illness during pregnancy

• Genetics load the gun, environment pulls the trigger.

• What about sugar?• What about food dyes and preservatives?• What about exposure to TV and video games?• What about abuse?

Don’t forget!

Patience, Patience,

Patience