Attention Deficit or Hyperactivity Disorder in Children
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If his symptoms include at least six elements of each of these, his diagnosis would be Attention Deficit/Hyperactivity Disorder, Combined Type. Most children diagnosed with ADHD have the Combined Type (APA, 2013). While Inattentive Type is most associated with academic deficits, and Hyperactive/Impulsive Type is most associated with social problems and accidental injury, Combined Type may be the most impairing overall, including the challenges of both. It’s important to note, too, that his diagnosis is not fixed – he may exhibit the signs of Combined Type, for example, and then later develop the Inattentive Type, or vice versa.
His ADHD diagnosis is also based on the pattern of observed behaviors which have lasted for the previous six months, and which don’t occur just in the context of another disorder, such as Persistent Developmental Delay, or Schizophrenia or a Mood Disorder, for example. The evaluation is always made relative to what is considered appropriate for his developmental level for the listed criteria. Any of these diagnoses are associated with significant challenges affecting his life in the context of family, friends and schooling (APA, 2013). Another very important aspect of his diagnosis is that the observed behaviors must cause some degree of impairment in more than one setting, typically home and school, with evidence of clinically significant impairment in at least one setting, such as school. For that reason, a physician making the diagnosis of ADHD uses at least one of the validated assessment scales (questionnaires) which are formatted to gather information from parents and teachers about how he exhibits the diagnostic behaviors of ADHD.
The most commonly used of these are Conners Comprehensive Behavior Rating Scale (for children 6-18), the Child Behavior Checklist – Attention Problem Scale (versions for children ages 2-18), and the Vanderbilt Assessment Scale (for children 6- 12, from the National Institute for Children’s Health Quality, or NICHQ) (Chang et al., 2016; Wolraich et al., 2003). All are validated for use with children in the USA in order to make a reliable diagnosis of ADHD. In general, each of these assessment scales includes a list of the diagnostic behaviors of ADHD based on the DSM-5, with a version for parents and another for teachers; the respondent indicates the frequency of each behavior over the prior six months in the home (parents) or school (teachers) setting. Though the pediatrician or psychologist usually also talks with the child about his experiences, especially if he/she is over 6 years of age, the diagnosis is largely based on the responses on the validated scales and diagnostic criteria from the DSM-5. The diagnosis with subtype is made on the basis of the scores for the respective traits of those subtypes (Visser et al., 2015).
There is no laboratory test, no biological marker or physical sign of his ADHD, and no known cause. He could have experienced injury, exposure to environmental toxins such as lead, premature birth or prenatal trauma to the brain such as ischemia that contributes to his disorder, but research has not found conclusive evidence of a causal agent. Current scientific evidence suggests a strong genetic link based on evidence from twin studies and identified genetic linkages, with growing evidence that epigenetic mechanisms may be in effect. He has a better-than-even chance that at least one of his parents also has ADHD (Singh et al., 2015).
The validity of these subtype groupings has been often challenged, and new evidence is emerging from brain imaging studies that show not only distinct connectivity patterns among subtypes, which may point to distinctly different diagnoses in the future – but a very wide heterogeneity among the population of children with ADHD that underscores the need to individually consider each child’s expression of this disorder when planning instruction (Fair et al., 2013). If he is a she, these symptoms and experiences may look quite different, and that may underlie the difference in diagnosis rate by sex. Girls are more likely to have internalized rather than easily-observed external signs of ADHD, and are far less often referred for diagnosis by teachers. She will be more likely to be diagnosed with the Inattentive Subtype of ADHD, and in addition to exhibiting a degree of inattention significantly higher than her peers, she is also likely to experience anxiety and depression. She probably has better coping strategies than her male peers, and may be able to mask the typical signs of inattention and make satisfactory academic progress, though this should not preclude an ADHD diagnosis, as, left untreated, symptom severity will likely increase (Quinn and Madhoo, 2014).
He, or she, is also statistically likely to have other conditions which affect learning. These “co-morbidities”, as referred to clinically, are known to co-exist with ADHD: Approximately 50% of children with ADHD also have Oppositional Defiance Disorder or Conduct Disorder Mood Disorders, such as depression – estimates range from 10-30% Anxiety Disorders – approximately 25% Learning Disorders – over 50%; dyslexia, dysgraphia, dyscalculia are commonly experienced by children with ADHD Bipolar Disorder – as many as 50% of children diagnosed with Bipolar Disorder also meet the criteria for ADHD. This is a percentage of the population with Bipolar Disorder, not of the population with ADHD. Medication for ADHD may exacerbate the symptoms of Bipolar Disorder. Communication Disorders – Dysfluencies such as stuttering, Specific Language Impairment, Auditory Processing Disorder. Estimates of ADHD among children who have language impairment are around 37% (Mueller and Tomblin, 2012). Tourette Syndrome – as with Bipolar Disorder, about 50% of children with Tourette’s also exhibit ADHD. Autism Spectrum Disorder – 14% (CDC, 2018).
Special Education Services As briefly touched on above, the most profound effects of ADHD are probably seen in school; children with ADHD are at a disadvantage compared with typically-developing peers due to their impaired academic functioning (Singh et al., 2015). ADHD impairs the executive functioning skills and capacity for self-regulation needed in most modern classroom learning environments. In any given classroom of 30 or so students in the United States of America, then, there are probably 1-3 students with diagnosed or diagnosable ADHD, based on a rough calculation from the overall rate, and teachers will encounter many students with this disorder throughout their careers. Instructional strategies for students who have ADHD in addition to one of the impairments listed above need to take into account the particular attentional and social challenges faced by children with ADHD in a school environment. While a diagnosis of ADHD alone may not be enough to trigger special education services under the provisions of the Individuals with Disabilities in Education Act (IDEA), if the multidisciplinary evaluation team determines that the child’s educational performance is impaired by diminished ability to pay attention to learning tasks or over-alertness to irrelevant stimuli, or other behaviors attributable to ADHD, services will be provided under the Other Health Impairment category of IDEA.
Students usually receive services in their general education classroom, most often regarded as the Least Restrictive Environment for children with ADHD. The IEP may list accommodations such as preferential seating, frequency of teacher check-ins, modifications to tasks, i.e., breaking tasks into smaller sections, shortening assignments, requiring only enough work completion to demonstrate understanding. A Special Education teacher and/or School Psychologist might work with a student with ADHD on a regular basis, offering instruction in learning skills, organizational skills, self-management or social skills/awareness. Example goals and parameters for measuring progress for the student could be reducing number of required repetitions of instructions, reducing classroom disruptions, achieving academic mastery in a specific subject, completion of assignments, increasing time in seat, or improving relationships with peers, to name a few. Some students with ADHD will qualify for services because they have other co-existing disabilities, such as a Learning Disability or Specific Language Impairment. If the student is not judged to be eligible for services under IDEA, he/she may receive legal protection under Section 504 of the Rehabilitation
Act of 1973. In this law, a disability is a condition which limits a major life activity, which includes learning. A “504 Plan” includes accommodations to be made for the student in the classroom, such as preferential seating, extended time for assignments, reduced assignments or specified testing environments. Teaching Strategies It’s important that a teacher identifies the particular needs of each child – with respect to a child with ADHD, this will include identifying when inattentive or impulsive behaviors are most disruptive to the child’s learning and also, if possible, how and why those behaviors are triggered. This is essential if the teacher is to select and implement the most effective teaching practices, matched to the child’s needs, and will be important information as the teacher works with the evaluation team to develop IEP or 504 plan to support the student (Henderson, 2008). Some typical school-based strategies work very differently with students with ADHD than with non-ADHD students. For example, reward systems have limited value when working with children with ADHD.
Research has established that these children have difficulty envisioning future consequences, and neurobiological studies suggest that the brain’s reward circuit connectivity is in fact different in these children from their peers (Wilson et al., 2011). Token economy systems or other long-term reward systems to reinforce behaviors, therefore, are likely to be much less effective with students with ADHD, though they are sometimes recommended as a behavior management strategy. Keeping rewards short-term, specific and relevant to the desired behavior (praise, access to a pleasurable activity) has greater extrinsic effects on motivation. Other understandings of learning motivation may have to be re-calibrated a bit to work effectively with students with ADHD. For example, teachers who value learning theorists such as Albert Bandura – who posited that it is not reward and punishment, but social learning and a desire for self-efficacy that shape behavior and affect learning behaviors and success – may not achieve typical positive results with these strategies without extra effort to model and teach basic skills to increase independence and self-efficacy. This is because ADHD interferes with the child’s ability to observe and emulate role models on their own, and also these children have likely received negative inputs about their apparent ability to control their behavior, leading to a deficit in self-efficacy.
A comprehensive but non-exhaustive list of effective strategies teachers may employ to good effect with students with ADHD is in Table 1. These strategies address different aspects of the learning process and the learning environment. Table 1. Teacher strategies to help students with ADHD access learning and achieve academic success Academic Instruction Strategies Modifications Eliminate/reduce timed tests Frequent physical breaks Simplify instructions Smaller chunks of work, breaking tasks or assignments into parts Aids Use highlights to help focus on key points in text Offer frequent check-ins and reminders to focus Offer advance warnings of change of activity Provide advance organizer Assistive technology Provide, or develop with student, organizational assignment notebooks, planners, color-coded folders Allow more time to complete tasks Provide oral and written follow-up directions Reduce or don’t use timed tests Teaching learning skills Teach to read problems twice Note-taking skills Keeping a checklist of frequent mistakes for self-reference Covering/folding worksheets to create smaller sequential tasks Teach how to underline important facts in math problems Best practices especially supportive of ADHD student Use cooperative learning strategies (e.g., Think/Pair/Share) Review prior relevant lessons Teach metacognition Focus on the purpose of learning Set clear expectations for learning and social behavior, for what materials are needed, and what resources are available Provide a high degree of structure and consistency to classroom and lessons Use formative assessment frequently Behavioral Intervention Strategies Removal of nuisance items Use of quiet manipulatives (fidget items) Activity reinforcement (desirable activity follows undesirable activity) Visual cues to correct specific behavior Proximity control – be closer to teachers or strong-model peers Develop self-management systems with child Offer frequent praise for appropriate behavior Timers, vibrating device to re-focus attention periodically Classroom Accommodation Strategies Preferential seating, near teacher, peer models, away from distractions Lower classroom noise level Assistive technologies offer promising ways to help students with ADHD engage more successfully with their learning.
Computer-assisted learning programs offer immediate feedback and opportunities to respond to learning prompts, individualized problem difficulty, and opportunities to practice and shorter/self-paced lesson formats. Research reports indicate that use of reading and math programs with a game format and unlimited time to respond result in significant improvement in behaviors such as fidgeting, talking to neighbors, and impulsivity, though more so for math than for reading. Children with ADHD using a computer-assisted math program in another study completed twice as many problems with the program than with pencil and paper. Reviews of these studies, however, highlight critical flaws in experimental methodologies. As yet there is not adequate empirical evidence that computer-aided instruction can make a lasting positive difference in education of children with ADHD.
Behavioral modification and biofeedback technologies have been used with students with ADHD to improve classroom behaviors which support learning. Though results with biofeedback systems have been inconclusive, behavioral modification programs have been associated with significant reductions in off-task behaviors among children with ADHD, saving strain on teachers’ time for this training (Xu et al., 2002). While this may confer some social benefits, the programs studied generally have not been oriented toward social or emotional aspects of the child’s life. Until more credible evidence is available, computer-assistive technologies should be regarded as a support to classroom experience and a means to provide variety to students with ADHD, but not an everyday go-to for teaching these students. Other assistive technologies may be useful to children who exhibit inattentional symptoms in particular tasks or settings. Audiobooks may be helpful to students who find the sustained effort of reading challenging, either as a stand-alone or read-along, even if the student does not have dyslexia associated with his ADHD.
The use of silent vibrational devices or timers has helped students re-focus attention on learning tasks. There is anecdotal information that computer programs or features of programs which offer writing assistance, from simple spellchecking to predictive word tools, may be helpful to the student with ADHD, who is typically a reluctant writer. Prognosis for ADHD-impaired learners New technologies available to neuropsychologists are showing great potential to increase our understanding of the brain’s processes in ADHD. The classification of sub-types identified in DSM-5 may not hold with new evidence showing distinct regional brain network functioning between people in subtype groupings (Fair et al., 2010; Saad et al. 2017). By increasing the precision with which this disorder can be diagnosed, we may be able to increase the precision with which medical, behavioral and educational interventions can be offered to children at earlier ages, when the lifelong potential for correction is greatest. Until then, consistently and continually supporting the learning of children with ADHD with the best practices we have designed for inattentive and hyperactive learners is critical to the academic success of all students.