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October 1, 2015
Vol. 73
No. 2

Special Topic / ADHD: From Stereotype to Science

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In almost every classroom, at least one or two students are identified as having attention deficit hyperactivity disorder (ADHD). Sometimes the parents mention at the start of the term that their child has been diagnosed with ADHD; sometimes word comes from a 504 plan or a teacher who previously had that student in class. Usually the ADHD label is taken as a warning that the student is likely to be difficult to teach and manage, that he or she will be more restless and disruptive than most other students in the class.
However, this image of the student with ADHD as Dennis the Menace is an outdated stereotype. Some students with ADHD are restless and disruptive, but many others with this disorder are quieter, more distracted and passive, and not very productive or consistent in their work.
Ever since it was first described in the medical literature in 1902, the disorder, now referred to as ADHD, has been considered essentially a behavioral problem. For a long time, it was seen as just a problem of hyperactive little boys who couldn't sit still, wouldn't stop talking, and frustrated their parents and teachers with chronic misbehavior. The term attention deficit wasn't added to the name until 1980. Since then, there have been substantial changes in our scientific understanding of ADHD that are important for educators to know.

An Update on the Basic Facts

These facts are now well-established in the scientific research.

Figure 1. Executive Functions Impaired in ADHD

The Central Mystery of ADHD

There's one fact about ADHD that's most puzzling: The symptoms are situationally variable. That is, people who struggle with chronic ADHD problems may have none of those problems when they engage in a particular activity or task.
Although they struggle to focus on their schoolwork, students with ADHD may demonstrate a remarkable ability to focus and work effectively when they're playing a sport, creating art or music, doing mechanical tasks, or playing a favorite video game. Although they may not be able to keep directions for assignments in mind or retain basic facts learned in social studies or math, they may have an incredible ability to recall the statistics about their favorite baseball team or the lyrics of popular songs.
When asked why they can focus so well when it comes to these few activities, students with ADHD often reply that it depends on whether the task is interesting—that if it's not, they just can't stay tuned. Although this may be true for everyone—that we focus better on things that interest us—there's an important difference here. Most of us can make ourselves focus on something we recognize as important, even though it's pretty boring. For those with ADHD, doing so is much more difficult.
A patient once remarked to me that having ADHD "is like having erectile dysfunction of the mind. If the task you're trying to do is something that really interests you, you can perform. But if the task you are trying to do is not intrinsically interesting, you can't make it happen." Although ADHD often appears to be a problem with willpower, it's not. It's a problem with the dynamics of the chemistry of the brain.
When people are faced with a task that really interests them—because it appears to offer pleasure to them at that moment or seems to ward off some imminent unpleasantness they want to avoid—that perception, conscious or unconscious, instantly changes the chemistry of the brain. This motivation process is not under our voluntary control.

ADHD and Reading

The motivation problem is often apparent in reading. Students with ADHD often report that they may understand a text as they read it—they can decode all the words and understand what's being said. Yet just a few minutes later, they don't have the foggiest idea what they just read. To extract the meaning of the text and retain it, they often have to reread it several times. One student with ADHD reported,
When I'm reading something that's not really interesting to me, it's like I'm licking the words and not chewing them. I know what all the words mean as I'm reading them, but they just don't stick inside my head. I don't really digest them. That's why I have to write notes while I'm reading or use a highlighter or else just read the same page over several different times.

ADHD and Memory

Many students with ADHD have adequate or even exceptionally good long-term storage memory. They may be able to recite extended song lyrics or explain in detail the storyline of a movie they saw years ago. Yet they may have great difficulty keeping in mind the directions the teacher just gave for an assignment. During class discussions, students with ADHD may raise their hands to answer a question the teacher has posed and then forget what they intended to say if the teacher calls on someone else first.
Their problem isn't with long-term storage memory; the memory problem in ADHD is more with short-term working memory, the ability to keep one bit of information in mind while thinking about or doing something else.
Students with ADHD will sometimes study for a test the night before the test is given. A parent may quiz them until they have all the material clearly in mind. They walk into class the next day expecting to get a really good grade, only to find that a big chunk of what they knew so well the night before has suddenly evaporated. They can't recall the information when they need it for the test, but a few hours or days later, something jogs their memory and the information is back again.
It's not that the students hadn't learned it; they simply weren't able to retrieve the information from memory when they needed it. Working memory is the search engine of the brain. Those with ADHD often suffer from chronic difficulties with their working memory even though their longer-term storage memory works very well.

ADHD and Writing

Of all the primary academic tasks, typically the most difficult one for students with ADHD is written expression. In the earliest grades, the student with ADHD may be exceptionally slow in doing any written work. In the time it takes most other students to put the heading on their paper and copy the first three sentences from the board, the student with ADHD may still be working on getting his or her name and date in the heading. When writing tasks get more lengthy and complex in the higher grades, students with ADHD often report that they have many good ideas for what to write, but it takes them forever to put their thoughts into organized sentences and paragraphs.
Written expression makes more demands on the executive functions that are often impaired in ADHD than do reading and writing. The words and numbers found in texts and math problems provide a structure and an organization to assist the reader, whereas written expression requires students to organize, prioritize, sequence, and elaborate their thoughts in a structure they need to create. Slow processing speed is often characteristic of students with ADHD.

What Can Educators Do?

Assessment and diagnosis of ADHD usually require a licensed physician, psychologist, or other medical specialist who has been trained to recognize the disorder and design appropriate treatment. But classroom teachers and school administrators have an important role to play.
Educators who are aware of our new understandings about ADHD are better equipped to identify students who may be struggling with this disorder. When a student demonstrates impairments that may be related to ADHD, the teacher can describe the student's difficulties in detail and encourage the family to present this information to their pediatrician or other specialist. Such early identification can prevent students with ADHD from becoming demoralized by repeated experiences of frustration and failure and can ensure that they receive the assessment and support they need to succeed.
References

Biederman, J., Petty, C. R., Evans, M., Small, J., & Faraone, S. V. (2010). How persistent is ADHD? A controlled 10 year follow-up study of boys with ADHD. Psychiatry Research 177, 299–304.

Biederman, J., Petty, C. R., Monuteaux, M. C., Fried, R., Byrne, D., Mirto, T., Spencer, T., et al. (2010). Adult psychiatric outcomes of girls with attention-deficit hyperactivity disorder: 11-year follow-up in a longitudinal case-control study. American Journal of Psychiatry. 167(4), 409–417.

Faraone, S., Perlis, R. H., Doyle, A. E., Smoller, J. W., Goralnick, J. J., Homgren, M. A. & Sklar, P. (2005). Molecular genetics of attention deficit/hyperactivity disorder. Biological Psychiatry, 57(11), 1313–1323.

Shaw, P., Eckstrand, K., Sharp, W., Blumenthal, J., Lerch, J. P., Greenstein, D., Clasen, L., et al. (2007). Attention-deficit/hyperactivity disorder is characterized by a delay in cortical maturation. Proceedings of the National Academy of Sciences, 104(49), 19649–19654.

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