Chapter 5

Chapter 5: Learners with Attention Deficit

Hyperactivity Disorder

Jason Cumming

TECP 50

Dr. Dunn

31 July 2013

History of ADHD1798: Sir Alexander Crichton defines attention and inattention in “On Attention and its Diseases.”• Distinguishes abnormal inattention as

“oppositional poles of pathologically increased or decreased “sensibility of the nerves”

1865: Dr. Heinrich Hoffmann composes “The Story of Fidgety Philip” in his book, Struwwelpeter. It is the first work of literature that alluded to observation of behaviors similar to today’s definition of ADHD

1899: Psychiatrist Thomas Smith Clouston writes on the “state of excitability and mental explosivness in children”

1902: Dr. George Frederic Still presents the concept of psychical conditions with “abnormal defect of moral control” in children during the “Goulstonian Lectures” at the Royal College of Physicians of London, calling for his colleagues to scientifically investigate the condition.

1932: Dr. Franz Kramer and Dr. Hans Pullnow provide their first reference to the disorder, “Über eine hyperkinetische Erkrankung im Kindesalter“ (Hyperkinetic Disorder in Children).

1934: Eugene Kahn and Louis Cohen publish Organic Driveness in the New England Journal of Medicine from observations of hyperkinesis in children who had encephalitis that affected parts of the brain, and left resulting characteristics that are now the basis for diagnosis of ADHD.

1940s: Heinz Werner and Alfred Strauss conduct study on children with Minimal Brain Damage, leading to the diagnosis of the Strauss Syndrome.

1957: William Chuickshank conducts a study using children with Cerebral Palsy to discover that children without Mental Retardation can still display distractability and hyperactivity characteristics.

1957: Dr. Leon Eisenberg summarizes prominent Clinical Features in the Psychiatric Journal with his article, Psychiatric Implications in Brain Damaged Children.

1957: Laufer and Denoff define as “Hyperkinetic Impulse Disorder in Children’s Behavior Problems” in Psychosomatic Journal

1958: APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM-II) establishes first diagnostic criteria for professionals/practioners.

1970: Canadian Virginia Douglas writes “Specific Disabilities of Hyperactive Children”, naming the condition we currently know as “Attention Deficit Disorder, with or without hyperactivity”.

1980: APA’s DSM-III first uses “Attention Deficit Disorder, with or without hyperactivity” in the APA’s DSM.

2000: DSM-IV-TR provides the Contemporary Concept of ADHD and establishes the diagnostic criteria currently in use.

Identification of ADHD: Ruling out all other options Medical Examination

Is there a medical reason (tumors, thyroid condition, seizures) for inattentiveness/hyperactivity?

Clinical Interviews Interview is conducted with parents and child

(separately) Provides information on physical and

psychological characteristics, family dynamics and home life, and social skills

Ratings Scales Completed by teachers, parents, and children Based upon 18 criteria set forth by DSM-IV Connors Ratings Scales-Revised; ADHD Rating

Scale-IV

Identification of ADHD: Ruling out all other options (con’t)

Behavioral Observations Continous Performance Test

Stimuli flashing on the screen; Measures reaction to stimuli and attentive ability.

Tracks correct and incorrect responses, omissions, and responses to wrong stimulus

Classroom Observations May have student brought into specially

designed classroom to observe tasks completed and the manner/time tasks are completed.

Diagnostic CriteriaEither one of the following:

• Inattention• At least 6 of 9 criteria set forth by DSM-IV must

have persisted for at least 6 months.

• Hyperactivity-Impulsivity• At least 6 criteria of the 6 Hyperactivity and 3

Impulsivity (combined) must have persisted for 6 months

• All Behaviors must exist to a degree that hinders the ability to function and learn consistently at the developmental level expected of age and normal capability.

Other Criteria for Diagnosis of ADHD

Any symptoms that caused impairment prior to age 7

Any symptoms cause impairment in two or more settings (home, work, school, social settings)

Clear evidence of significant impairment on ability to function in settings such as social, academic, or occupation.

The symptoms do not occur during the presence of or are accounted for in other mental disorders

Diagnosis of ADHD: Coding the Condition Attention-Deficit/Hyperactivity Disorder, Combined

Type Both conditions for Diagnosis are met

Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type “Inattention” conditions are met, but

“Hyperactivity-Impulsivity” conditions are not met

Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive “Hyperactivity-Impulsivity” conditions are met,

but “Inattention” conditions are not

“In Partial Remission” when some symptoms are no longer met

What Causes ADHD? Neurological Dysfunction -Consistent Abnormalities found

in areas of the brain.

Prefrontal and Frontal Lobes – Controls the functions to regulate behavior.

Basal Ganglia – Controls coordination and motor behavior. Caudate and globus pallidus; present in the

brain behind the frontal lobes.

Cerebellum – Assists in control of motor skills, contains half of all neuron’s in the brain.

Corpus Callosum – Connects the brain’s hemispheres for cognitive functions.

What causes ADHD? (con’t) Heredity

Parents of ADHD children have a greater chance of also having ADHD

Siblings of children with ADHD have 32% chance of having ADHD

Children of Adults with ADHD have 57% chance of having ADHD

Twins: Identical Twins more likely to share disorder than fraternal twins

Toxins and Medical Factors Consumption and/or use of drugs and/or tobacco

place the unborn child at an increased risk of ADHD.

Characteristics of ADHD Lack of Behavorial Inhibition

Inability to control responses in social, academic, and/or occupational settings Waiting in line or in turn Response elicits interruptions of class,

situations, or settings Hold normal level of attention on task when

subordinate distractions arise. Evidence points to abnormalities in the caudate

of the basal ganglia.

Characteristics of ADHD (con’t)

Lack of Executive Functions

Inability/difficulty manipulating working memory Forgetfulness, time management, thought

processes

Inability/difficulty following rules, guidelines, and/or instructions

Inability/difficulty managing emotions and reactions to stimuli (positive or negative). Overreactions, over-dramatizations

Characteristics of ADHD (con’t)

Time Awareness / Management Diminished problem-solving ability

Inability to navigate or overcome obstacles in goals

Diminished ingenuity Tendency to give up when tasks become more

difficult Diminished flexibility

Greater tendency to react on impulse because of inability to control emotions

Inability to assemble thoughts in an organized and coherent manner, taking longer or unable to complete goals.

Lack of

Characteristics of ADHD (con’t)

Lack of Persistent Goal-Directed Behavior

Problematic manipulation of executive functions lead to inability or difficulty navigating, participating, and/or completing goal-directed activities

High variability in progression and production rates during work strategies.

Inconsistent accuracy, performance, or quality of work

Lack of ability for Adaptive Behavior

Characteristics of ADHD (con’t) Problems Socializing with Peers

Negative Social Status

Long-lasting reaction to peer rejection

Stemming from the inability to control emotions

Educational Consideration

Effective Educational Programming

Classroom Structure / Direction

Reduce irrelevant stimulus in the classroom Bright colored posters, shining objects near

or opposite windows Clear, defined routines Concrete directions, expectations, and

guidelines Loose timelines to reduce the distraction of

tight deadlines. Displayed schedule and timetables for easy

reference by students

Educational Considerations (con’t)

Classroom Structure / Direction

Introduction of Lessons

Provide an organizer and help them to use itWorking towards establishment of

independence with self-monitoring

Review lessons

Set Expectations and Needed Materials/Resources

Simple directions, choices, scheduling

Educational Considerations (con’t) Classroom Structure / Direction

Conducting Lessons

Consistent structure and routine Encourage participation with cues for tasks,

calling upon, etc. (Teach like a Champion is a great book for strategies on this subject)

Keeping tasks in smaller units to allow for evaluation and self-monitoring

Eliminate Timed Tests Students won’t be preoccupied with time

elapsed or time remaining; reduce stressors/pressure

Educational Consideration (con’t) Functional Behavior Assessment (FBA)

Know the antecedents to undesired behavior Confirm the consequences for undesirable

behavior Develop strategies for maximizing occurrence of

positive/desired behaviors

Contingency-based self-management

Student tracks own behavior, receive rewards and consequences based upon behavior

Use together for maximum awareness and performance independence

Educational Considerations (con’t)

U.S. Department of Education doesn’t recognize ADHD as a special education category.

Actual statistics relating to diagnosed students, actual students, and students receiving services is a giant disparity in number from the students who should be receiving services.

While some students respond well with inclusion (mainstreaming), others respond better in self-contained environments with other ADHD students

Medicating ADHDHistory Benzadrine (1932)

Originally thought disorder was to be a result of encephalitis

Charles Bradley’s “The Behavior of Children Receiving Benzadrine” documents the increased performance of students taking Benzedrine sulfate; also discusses dosage, side effects, unfavorable responses, and duration effects. (1937)

Methylphenidate Trademarked as “Ritaline” in 1954

Helps to control the neurotransmitters, dopamine and norepinephrine

Most common medication prescribed; psychostimulant

Effectiveness of Medicating ADHDPsychiatry Journals have been documenting the success of medicating disorder patients since 1937:

Charles Bradley, “The Behaviour of Children Receiving Benzedrine” (1937)

Matthew Molitch and John Sullivan, “The Effect of Benzedrine Sulfate on Children Taking the New Stanford Achievement Test” (1937)

Maurice Laufer and Eric Denhoff: “Hyperkinetic Impulse Disorder in Children’s Behavior Problems” (1956)

C. Keith Connors and Leon Eisenberg; “The Effects of Methylphenidate on Symptomatology and Learning in Disturbed Children (1963)

Cautions Regarding Medicating ADHD Premature Medication Determination

Don’t prescribe at the first sign; go through full diagnosis procedures, ratings, criteria, and tests.

Medicating doesn’t increase accuracy on achievement tests. Behavior may improve, rate of task completion may increase, but there has been very little increase in the results of standardized achievement tests

There should be a level of responsibility for taking the medications and reinforcement of taking self-responsibility of the student’s actions and initiative.

Communicating dosage between school, parents, physicians, and student, as well as the effects.

Assessing Progress of the ADHD Student Progress Monitoring

Students with ADHD commonly are diagnosed with learning disabilities or intellectual disabilities. Monitoring of all aspects of the student’s

experiences during the school day needs to be paramount to insure strategies are working.

Curriculum-based measurement (CBM) Minimal time and task-focused measurement

caters to the ADHD student in a positive way. Monitoring Behavior

Rating scales Direct observation

Can work with FBAs for Reward Consequence

Transitioning to Adulthood Studies completed as late as 2008 have shown that

about 50% of those diagnosed as children retain ADHD symptoms into adulthood.

Prevalence Rate of 4 -5% of adult ADHD diagnosis (similar to that of youth)

ADHD Coaching is very important for success in employment, relationships, and personal triumphs.

QUESTIONS?

Thank you!