Students increasingly walk through the classroom door wearing invisible labels and prescriptions. A list of psychiatric and learning disorders that was intended to clarify the difficulties different students experience has instead bewildered teachers and administrators. Educators must make sense of their students' new diagnostic criteria and glean from this information the most effective ways to assist their pupils. Given the enormous increase in the diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) among school-age children, neuropsychiatric problems characterized by inattention and hyperactivity are pressing classroom issues.
Students diagnosed with ADHD often arrive in the classroom with medication and teaching recommendations that are based on completed psychological testing. In spite of these recommendations, teachers frequently have little or no contact with their students' clinicians. Tight budgets, large classrooms, and often multiple students with the same diagnosis who require different teaching strategies substantially challenge the educator's primary objective: to teach and inspire every student dynamically and efficiently. Reaching that goal starts with an understanding of ADHD and how teachers can help students who have been diagnosed with the disorder.
Describing and Diagnosing ADHD
ADHD is a neuropsychiatric disorder that begins before 7 years of age (American Psychiatric Association, 1994). Problems in the three core domains of inattention, hyperactivity, and impulsivity characterize the disorder.
Clinicians define inattention as age-inappropriate poor attention span and hyperactivity as age-inappropriate increased activity in multiple settings. For example, an inattentive child may pay poor attention to details or appear as though his or her mind is elsewhere. Often, the child has difficulty sustaining a single activity. One mother describes her son's bedtime difficulties: He starts to brush his teeth, follows the cat into the playroom while his mouth is full of toothpaste, notices the blocks and sits down to play, and in two minutes turns on the computer at the other end of the room.
Hyperactive children may fidget excessively and have difficulties playing quietly. Children with ADHD display, sometimes paradoxically, a level of inflexibility that leads them to experience intense frustration when asked to break from one activity and move on to something new. The child will appear to have well-honed attentional skills, but his or her rigidity will increasingly lead to tantrums and agitation.
Impulsivity refers to the tendency to act rashly and without judgment or consideration. A child might frequently interrupt others, take other children's toys, or appear consistently impatient and frustrated.
As these descriptions suggest, the symptoms of ADHD exist along a spectrum. Most children will occasionally display many of the aspects ascribed to ADHD, and this recognition may account for much of the controversy surrounding the disorder. To standardize the diagnosis, the Diagnostic and Statistical Manual-IV (DSM-IV) lists formal criteria (American Psychiatric Association, 1994) (see fig. 1). ADHD can be characterized as three types: predominantly inattentive, predominantly hyperactive-impulsive, or a combination of the two types. To some extent, these differentiations account for the increasingly recognized population of children—often girls—who display what appear to be difficulties primarily with attention but who respond to conventional treatments.
Diagnosing ADHD in Children
Diagnosing ADHD in Children
A. The child exhibits symptoms listed in either 1 or 2 below:
Inattention. At least six of the following symptoms have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level.
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 seem to listen to what is being said to him/her;
often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not because of oppositional behavior or failure to understand instructions);
often has difficulties organizing tasks and activities;
often avoids or strongly dislikes tasks (such as schoolwork or homework) that require sustained mental effort;
often loses things necessary for tasks or activities (school assignments, pencils, books, tools, or toys);
often is easily distracted by extraneous stimuli;
often is forgetful in daily activities.
Hyperactivity-Impulsivity. At least four of the following symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level.
Hyperactivity:Impulsivity:
often fidgets with hands or feet or squirms in seat;
leaves seat in classroom or in other situations when remaining seated is expected;
often runs about or climbs excessively in situations when it is inappropriate;
often has difficulty playing or engaging in leisure activities quietly.
often blurts out answers to questions before the questions have been completed;
often has difficulty waiting in lines or awaiting turn in games or group situations.
B. The child's symptoms occur no later than age 7.
C. The symptoms are present in two or more situations (at school, work, and home).
D. The disturbance causes the child to experience clinically significant distress or impairment in social, academic, or occupational functioning.
E. The child's behavior does not occur exclusively during the course of Pervasive Developmental Disorder (PDD), schizophrenia, or other psychotic disorder, and is not better accounted for by mood, anxiety, or a dissociative or personality disorder.
Diagnosis by Type
314.00 ADHD, Predominantly Inattentive Type: if criterion A(1) is met but not criterion A(2) for the past six months.
314.01 ADHD, Predominantly Hyperactive-Impulsive Type: if criterion A(2) is met but not criterion A(1) for the past six months.
314.01 ADHD, Combined Type: if both criteria A(1) and (2) are met for past six months.
314.9 is ADHD NOS, for other disorders with prominent symptoms of attention-deficit or hyperactivity-impulsivity that do not meet criteria above.
From Diagnostic and Statistical Manual for Mental Disorders, 4th ed. Copyright © 1994 by American Psychiatric Association. Reprinted with permission.
Finally, one of the most difficult and important aspects of understanding ADHD is to consider the child's developmental expectations. Obviously, we don't expect the same judgment or attention span from a 6-year-old and a teenager. In addition, symptoms must persist over time and exist in more than one setting. The brief adolescent tantrum or the distraction of an 8-year-old before vacation does not constitute sufficient data for a diagnosis of ADHD.
In fact, the heterogeneity and developmental aspects of ADHD make the diagnosis of the disorder potentially quite complicated (Cantwell, 1996). Ideally, the clinician should take a very careful history from as many sources as possible and note such important factors as the persistence of the symptoms and the extent to which these symptoms cause problems. Because emotionally troubled children often appear inattentive or agitated, the clinician should ask about difficulties in the child's life that might account for a change in the child's behavior. We must also remember, however, that many children experience difficult life changes but do not display symptoms of agitation or inattention.
Although research addresses the efficacy of specific laboratory tests, the descriptive criteria of ADHD remain the most effective means of making an accurate diagnosis. Clinicians must take the time to speak with parents and teachers, noting that children with ADHD will often appear normal in a brief office visit or in a one-on-one situation. As evidence mounts of a strong genetic component to the disorder, clinicians should ascertain whether siblings, parents, or close relatives suffer similar symptoms. Because many parents were not diagnosed as children, simply asking whether they were diagnosed with something similar to ADHD is usually not sufficient (Biederman et al., 1992). The clinician must probe parents for their memories of their childhood behavior.
Do inattention and hyperactivity always equal ADHD? In addition to the heterogeneity of ADHD, we must note that other psychiatric processes may account for many of the disorder's symptoms. Children with intense anxiety or depression are particularly likely to have problems that appear similar to ADHD, and evidence also exists that suggests that symptoms of depression—as the child's self esteem suffers in the face of continuing social and developmental failures—can complicate ADHD (Zametkin & Monique, 1999). Clinicians should also screen for problems with substance abuse, Tourette's syndrome, and psychosocial stressors. Clinicians, parents, or teachers may mistakenly attribute symptoms of these conditions to ADHD, and the symptoms may complicate the course of a child who happens also to suffer from ADHD.
In general, younger children with ADHD are happy. The preteen diagnosed with ADHD who is not generally in good spirits should be carefully scrutinized for other or additional psychological problems. Conversely, as children with untreated ADHD age, they may develop significant self-image problems. These difficulties come about as the young people continually endure academic and social failures; simply treating their ADHD will often not meet all of their social, developmental, and learning needs.
Although we don't clearly understand the causes of ADHD, current research suggests evidence of potentially causative brain abnormalities. Many of these studies implicate problems with frontal lobe function (Rubia et al., 1999). In general, the frontal lobe region of the cerebral cortex allows for the planning and execution of complex and complicated tasks. We often refer to the activity of this portion of the brain as executive function, and we think that children with ADHD have deficits in executive functioning.
Evidence for these deficits has been generated both by neuropsychological testing and by neuroimaging studies, as well as by the observation that individuals with frontal lobe injuries display behavior similar to that of people with ADHD. As stated earlier, strong evidence for a genetic component of the disorder also exists (Biederman et al., 1992). Further, mounting evidence suggests that psychological and environmental stress can lead to the development of the syndrome (Weiss, 1996). Although we know of no clear cause for the disorder, most theorists would argue that both environmental and biological factors play substantial roles in the development of ADHD.
Treating ADHD
Treatments for ADHD include behavioral and medical therapies. Stimulants such as methylphenidate (Ritalin) and dextroamphetamine (Dexedrine) continue to be first-line medical treatments, with more than 40 years of experience confirming the relative safety and effectiveness of these medications. Although the number of stimulants on the market proliferates, response to a specific stimulant remains idiosyncratic; some children will do better on one stimulant than the other, and it is difficult to predict which medication will work best. In addition to the stimulants, tricyclic antidepressants such as desipramine can be very effective, though their use is somewhat limited in younger children. Medications such as clonidine (Catapress) and guanfacine (Tenex), both high blood pressure medications, appear to treat the impulsive symptoms of the syndrome, but are not effective for inattention.
In general, if medical therapies work and the child receives the appropriate dose and stimulant, the child's behavior should improve relatively quickly. If a child does not improve or improves only minimally, both the proposed treatment regimen (dose and/or medication) and often the diagnosis itself should be re-evaluated. Nevertheless, we need to understand the limitations of medical therapies. Although such symptoms as overactivity, attention span, impulsivity, aggression, social interaction, and academic performance will often improve, such specific skills as reading and such antisocial behavior as cheating or stealing may not show marked progress without additional interventions (Zametkin & Monique, 1999). Children still must master the fundamental developmental task of learning to focus on activities or subjects that are not of immediate interest. No medication can take the place of the mastery of skills and attainment of maturity necessary for academic and social success.
Behavioral treatments of ADHD include daily report cards, positive reinforcement, social skills groups, and individual therapy (Barkley, 1990). As the child matures, these treatments may also address the child's self-image. Although psychodynamic therapies (play or talk therapies) may not be directly effective, we have found that the relationship between a child and an effective therapist often ameliorates many of the problem behaviors associated with ADHD.
Finally, when deciding on treatment, the parents and the child must take part in the decision-making process. Some families prefer behavioral remedies; others may request medications. Attention to such details as the meaning of each treatment modality, as well as the hopes and concerns of both the parents and the child, will have enormous benefits. Adolescents may not wish to take medications, for instance, but may be willing to implement equally effective study and behavioral strategies. Conversely, both time and financial constraints may limit the efficacy of psychotherapy. Clinicians must educate families about ADHD and its treatment and help the families make informed decisions. Clinicians should leave time at the end of an appointment for questions—if families cannot ask questions, their understanding of and compliance with treatment is severely threatened.
The issue of alcohol and drug abuse and ADHD deserves special mention. Because stimulants are addictive substances, we often worry that prescribing these medications will predispose children to addictive problems. Although caution is always necessary when using stimulants, recent research suggests that, in fact, the number of children developing substance abuse problems is substantially higher in those with ADHD who do not receive adequate treatment (Biederman, Wilens, Mick, Spencer, & Faraone, 1999). Nevertheless, in adolescents with pre-existing problems with substances, clinicians often prefer treatment with medications other than stimulants.
ADHD in the Classroom
Just as diagnosing and treating children with ADHD is complex, working with the inattentive and hyperactive child challenges all teachers. The problems that children with ADHD experience may lead to chaotic classrooms, missed and incomplete assignments, and miserable teachers and students alike. Educators have found, however, a number of useful classroom techniques.
First, teachers must view the child as a whole person. The child is not a person with ADHD, or an "ADHDer," but a complete and unique individual. Although seemingly obvious, teachers must resist the tendency to label a child with unfair expectations. Most important, teachers can remind students that they are capable of learning and of enjoying the learning process. Many students diagnosed with ADHD will arrive in the classroom severely demoralized, having gleaned from their parents and peers that they are unable to excel academically. On the other hand, telling students that they can learn as easily as students without attentional deficits might reintroduce a pattern of failure and disappointment.
Educators, therefore, should be proactive when they suspect a psychiatric reason for a student's difficulties. Studies have demonstrated that teachers are valuable sources of clinical information. At the same time, teachers should be aware of their own biases. Many of the studies, for instance, suggest that teachers frequently suspect ADHD in boys more often than in girls (Dulcan, 1997).
To assist the student with ADHD, educators need to exercise caution, creativity, and vigilance. Teachers must employ all of their professional skills to structure classrooms and make assignments clear. Educators should let students with ADHD know that they will work creatively with the students to explore learning and organization strategies. An honest relationship between teacher and student is essential.
To be most effective, teachers should discuss the strategies with the student outside of class so that the student understands the teacher's expectations and the kinds of support the teacher will offer. Specific strategies might include nonverbal reprimands for out-of-control behavior. A simple and silent hand on the student's shoulder inconspicuously tells the student that his or her behavior is inappropriate. Similarly, relying on such cues as lost eye contact between a student and teacher might help a teacher recognize wavering attention. If a child is persistently unable to focus, move his or her seat to a less distracting part of the room. Some other strategies include the following:
Require meticulously organized assignment books. For every class, the student with ADHD must have each day's homework recorded. When the teacher doesn't assign homework, the student writes "no homework" in the appropriate place. If the student fails to keep the log current, he or she must get the teacher's signature in the assignment book at the end of class. The teacher should also both write the assignment on the board and repeat the assignment aloud. This time-honored teaching technique of appealing to multiple senses works well for children with ADHD.
Teach students with ADHD to break down assignments into smaller, less overwhelming components. When reading textbooks, for example, we have found a variation of Robinson's SQ3R method to be effective (Robinson, 1961). The student surveys each section of the text by first reading the boldfaced print, looking at the visuals, and reading the captions under the visual displays. The student then generates a general statement about what he or she will be reading, allowing him or her to focus on the content of the reading material. After each section, the student stops to recap the main idea of the completed segment. This strategy helps the student become actively engaged with and focused on the text.
Use flash cards. After students give themselves a pretest to determine what they have already mastered, they make flash cards of all of the material that they don't know. They then can separate the cards into three piles: mastered material that they know without hesitation, material that they've guessed correctly but without confidence, and material that they don't know. In this way, the students gain a sense of control over the learning situation and learn to transfer these strategies to other academic and non-academic learning settings. The corresponding sense of accomplishment for both teacher and students can be enormously rewarding.
Experienced teachers will note that many of these strategies have been around for years—long before we reached our present understanding of ADHD. We know now that ADHD leaves the student with deficits in executive functioning and that the time-honored classroom techniques create for the student a kind of external frontal lobe. Good teachers have simply hit upon these techniques in their quests to engage and teach their students.
Teachers need not be overwhelmed by the growing complexity of psychiatric and psychological diagnoses that follow their beleaguered students. As always, good educators remain central to a child's development. Teachers should never hesitate to contact a child's clinician. If a student appears different or suffers a behavioral change, a physician or psychologist will use this valuable information to determine a diagnosis and treatment. Although clinicians and teachers have just begun to work together, educational and clinical collaborations need to evolve and prosper. The teacher, the clinician, and most important, the student, will benefit enormously.
