ADHD - EDUCATIONAL ISSUES (Text for Conference Presentation)
MJC April 2005
One principal and ongoing task on the part of the educational psychologist is to ensure that ADHD is seen as a real condition. Perhaps it may sometimes be used as a means of excusing simply non-compliant behaviour, but for the child appropriately diagnosed and his family, ADHD is a real and significant problem with a range of symptoms impacting not only on behaviour but also on learning and social-emotional performance.
This was brought home to me by a recent question from a secondary school teacher who asked whether ADD or ADHD could apply to a boy whose performance and attention were erratic ….. he could work well and concentrate for a time, then his efforts would tail off …. and this provided the opportunity to talk about the reality of the condition and about the different ways in which it can present and about the circumstances when the difficulties would be most evident.
Some critics might ague that ADHD is a kind of social construct that excuses or medicalises difficult behaviour in order to reassure anxious parents but recent evidence (Taylor-Institute of Psychiatry) indicates the neurological or biological basis for ADHD.
For example, brain imaging studies indicate differences in size of parts of the brain, such as a smaller right hand part of the prefrontal lobes or reduced volume of the cerebellum in children with ADHD. The parts of the brain that are under-active are those which are involved in supplying restraint and impulse control. Under-reactivity in evoked responses has been described, along with features such as reduced rate of cerebral blood flow or glucose metabolism in some brain areas including the cortex.
Children with ADHD can be differentiated from other children in terms of the level of activation in certain brain areas when given a task involving vigilance; and a common view has it that ADHD involves some anomaly in brain chemistry and the transmission of neural messages
Further, genetic factors are significant in that siblings of children with diagnosed ADHD are 3 to 5 times more likely to have the condition compared to non-related control children.
There is also evidence that children with ADHD are at greater risk than others of later emotional problems such as depression.
So…. the initial point is about recognising the significance of the condition and not underestimating the impact, even if the condition is not immediately evident to onlookers …. In the same way, children with autism have been described as experiencing the invisible condition because they appear quite ordinary in their appearance.
One needs, in other words, to be ready on occasions to counter a view that the pupil who displays behaviour difficulty has some choice about what he or she is doing, unlike the pupil with some more obvious difficulty such as some sensory weakness.
One practical implication, perhaps particularly in the secondary school, is to maintain staff awareness of the nature of ADHD.
A survey a few years back of opinions or concerns from school staff in Surrey highlighted issues of…
These issues need to be revisited from time to time in local schools.
Participants invited to picture their example of a pupil with this condition. How is the pupil identified? What are the characteristics that mark the condition?
(Do they all pick boys? Do they highlight acting-out behaviour? What about girls? What about attention per se?)
Working definition :
“Hyperactivity (ADHD) refers to a child’s frequent failure to comply in an age appropriate fashion with situational demands for restrained activity, sustained attention, resistance to distracting influences, and inhibition of impulsive responses”
3 elements - inattention hyperactivity impulsivity - not all children display major problems in all three areas.
Another implication is for determining what is reasonable to expect of a child of a given age.
There may also be differences in basic style and temperament (and I suppose I am expressing concern about the current emphasis upon targets to apply to any child irrespective of individual needs and circumstances and the use of quite narrow criteria by which to judge the pupils’ performance and the school’s performance).
For example what is typical for boys compared to girls …. active rather than reflective; preference for some short sharp task; some difficulty in taking on some activity or learning assignment for its own intrinsic sake.
Perhaps ADHD, rather like autistic characeteristics, could be seen as an exaggeration of commonly occurring behaviours.
Might there be some confusion between ADHD and a simple lack of readiness for formal schooling? Again, it is chronological age which is the criterion to determine when to enter school, with the admission date earlier than it used to be, irrespective of the child’s emotional age or social age, and irrespective of the consistent evidence from other European countries of the success and smoother learning process among children who enter formal schooling at a later age.
Incidentally, one might ask why or how policies get implemented. Is it a matter of tried and tested methods? Or is it less organised? Is there a gap in terms of local or wider research to determine the effectiveness of some innovation …. as was discussed in a previous presentation at this conference in respect of gaining clear evidence from controlled studies about the influence of diet, notably fatty acid supplements, or the relative merits of OT-based intervention and medication-oriented intervention for what appear to be ADHD symptoms.
My overall point is about examining each child’s particular needs and circumstances and determining what is reasonable to expect or demand of him, with assessment emphasising a kind of value added or ipsative approach in determining his or her rate of progress and current level against what went before.
(Thank goodness that elderly EPs are not expected to be good at everything!)
Meanwhile, it has proven difficult to decide how good are any of us at paying attention (especially during the second session after lunch on a training day).
One rule of thumb has it that attention or concentration span for a set task (not a self selected activity) is around 1 minute for each developmental year up to a maximum of 15 minutes.
This is admittedly a crude estimate given the effect of variables like the nature of the task, the time of day, mood, grouping, immediate past experience, etc.
However, it could be helpful to keep this in mind especially given one possible hypothesis that certain behaviours observed in some children with ADHD may be designed to increase stimulation, and they would benefit from a fairly rapid shift of elements of a lesson.
(In the same way, in-service training sessions usually involve frequent pauses while participants have to get into groups and play with flip-charts; or there is a constant threat that someone will be chosen to feed back which tends to keep the mind on the topic in hand! However, I will not do this to you but will break off now and again to give you a rest via an anecdote either tenuously or not at all linked to ADHD … for example ………xxxxx).
Meanwhile, while there are always exceptions to prove the rule, it would appear that girls are more prone to some negative reaction, reflected in inhibited attention, when there is apparent pressure surrounding them. A genuine concern on the part of parents (particularly mothers) or teachers that they do well and reach a given level could be interpreted as critical or negative. So, the adults have to tread narrow line between what might be observed as insufficient interest or concern and too much.
Girls, too, appear more concerned about what their peers are doing and saying and may worry if others appear to have done more revision for impending examinations.
Boys, however, appear to be more laid back or even too laid back, but may still be influenced by peers in terms of not wanting to stand out from the crowd in respect of in-class disadvantages, and needing to maintain their street credibility and”cool”.
This becomes relevant to the topic of ADHD (or any other source of disadvantage in the school setting) since there will be a greater proneness to seek alternative ways of gaining self esteem and peer acceptance and regard if there are problems in gaining esteem through legitimate routes.
This applies particularly in the secondary school since, by the middle of secondary schooling, it is the other young people who provide as significant a reference group as parents or teachers. There may be some anxiety about showing problems associated with the effects of ADHD with implications for task avoidance and holding back in lessons so that a vicious circle is set up.
Further, peer relations may be damaged by some of the effects of the ADHD with possible threat to being part of a group, and increased efforts to gain peer approval
by attention-demanding behaviour especially if it is believed that there is not much to be lost in terms of school progress.
So … another implication along with ensuring staff awareness of ADHD, is raising peer awareness of the nature and effects of ADHD, especially among the older pupils.
One might do this by spending part of a tutor group session in discussing individual needs and styles.
The pattern has been set within the field of Asperger Syndrome or autistic spectrum disorder where, for example, the tutor and an EP, might ask the group (in the absence of the pupil in question) for their existing awareness of the condition, followed by a brief presentation of what the condition actually entails and highlighting the kind of misconceptions that may have arisen.
Subsequently, one might seek comments from the group about how they might help in enabling the pupil to be more fully a part of the group and to take advantage of the lessons, coupled with further suggestions provided by the tutor and EP such as peer tutoring, ignoring where appropriate, understanding if the pupils is allowed btrief times-out from the class, etc..
This could equally apply to ADHD as to ASD, with sensitivity ensured by including such discussion as part of a wider look at individual differences and styles (including learning styles) with a number of pupils, including the targeted pupil, describing what they find easy and difficult.
Returning to the theme of types of ADHD ….. one now recognises the varied presentations :
Hyperactive and (quasi-)aggressive
Hypoactive ….. all with at least a degree of inattention and poor concentration, but grouped into”primarily inattentive”or”primarily hyperactive/impulsive”types.
What matters is that the children who show the hyperactive behaviour, and the acting out or apparently aggressive style, will be identified readily and be referred for fuller assessment.
However, if the condition is not of the excitatory type but of the inhibitory type (ie not disruptive but tending towards daydreaming, drifting off tasks, not completing work), it is possible that identification would be less easy.
There is the old dichotomy of disturbed and disturbing whereby the individual who has an impact upon others, teacher and peers, will be identified quickly, and, one hopes, given access to support. Where it is the individual who experiences some problems but does not have any impact on others, one becomes dependent upon the staff to recognise attentional problems which can exist and have negative consequences in the absence of the overt impulsiveness or hyperactivity.
Who has the condition? Who experiences the consequences of the condition?
Are many more boys than girls diagnosed because they frequently show the H part of ADHD while girls are less frequently diagnosed because they may have attentional problems –ADD – but not the hyperactivity element?
The effect is that when girls are referred, their problems tend to be towards the severe end of the scale; but there may be cases where the girls do not readily stand out but do have significant attentional problems, and girls seem more prone to scholastic disadvantages than boys, and also to be more likely to drift apart from other normally progressing girls. Further, a study has revealed a higher prevalence of anxiety and depression among older females with ADD than is typical among the population as a whole.
The implication is for early identification as far as possible in order to avoid the problems becoming more serious
This becomes all the more important in the light of experience indicating that observable symptoms of hyperactivity and impulsiveness tend to moderate over time … but the inattention is much more persistent and the young person or even adult may remain at a disadvantage which may be compounded by these social and emotional issues.
What is also relevant is the outcome of a study in 1997 which examined the inter-relationship of school performance and self esteem … which comes first and which influences which?
It was found that, in the early years, achievement is predominant over self esteem and self concept.
In the middle years, the relationship is reciprocal with each influencing the other.
However, in the secondary school years, it is elf concept which predominates over achievement and motivation.
So, early identification is underlined, along with the reassurance afforded to the pupil and the family that the difficulties are recognised and that no blame is going to be attributed to anyone.
My experience has been that, in many cases, and contrary to what may be said about labels, it can be very helpful and a source of relief to the pupils themselves and their parents to have a diagnosis … not as an excuse but as means of understanding the difficulties and identifying their source and providing the first step towards dealing with the symptoms.
This has applied to dyslexia, where a sample of students with unarguable difficulties of this kind described their relief at having them assessed and identified so that there was an end to negative comments – particularly from parents - about failing to make the necessary efforts, access to support, and a shift in expectations (about how to record work, for example)
It has also strongly applied to ASD and Asperger Syndrome where parents have expressed similar relief at having some means of making sense of otherwise complex behavioural signs and symptoms, and of enabling other family members and friends to understand the child’s presenting style.
It would seem likely that similar effects would follow the identification of ADHD, particularly when the symptoms are at least of a moderate level and interfering with scholastic and social functioning as manifested by a failure to organise work or to complete tasks and to be increasingly set apart from peer groups.
The importance of seeking advice early is underlined by the evidence for competing diagnoses, and there is a clear need to know exactly what the symptoms represent via a multi-disciplinary assessment so that management strategies can be determined.
One recent and competing diagnosis is that of ”Convergence Insufficiency” a visual problem where the child cannot readily focus both eyes upon close stimuli, with implications for concentrating on a task involving reading or examining pictures.
(one might compare this concept with the John Stein hypothesis of magnocellular deficiencies – visual pathways – as an underlying cause of reading disability.
Another competing diagnosis is obsessive/compulsive disorder, with an example cited of a girl who could not face a task until she had completed some ritual (counting the number of ceiling tiles) with implications for appearing not to be on task and to show limited attention to the task in hand.
Further, there are many tried strategies for managing and ameliorating the signs and symptoms of ADD or ADHD. These include …….
These examples could apply to pupils across the age range, and differences with regard to working with secondary school pupils would involve attempts to maximise consistency of expectation among staff, increasing his or her involvement in the planning and monitoring of performance, and ensuring regular access to a kind of counselling session designed to maintain self esteem and where anxieties can be expressed and reassurance given that the difficulties are recognised.
One element of the latter might be to carry out some reframing to counter any growing negativism in self image by highlighting positive elements of the pupil’s particular style. This is not to condone disruptive behaviours but to deliver the message that there can be positive use made of the characteristics and personality style. It is intended to maintain positive self esteem as well as avoiding a cycle of negative responses to the pupil and of behaviours indicative of frustration from the pupil which would reduce the probability of positive relationships with the teachers.
“Response cost” refers to the combined effects of reactions in the form of reprimands or whatever to poor behaviour or disruptive incidents and of positive comments or tangible reinforcement in response to god efforts. It is the contrast which appears effective, when the negative reactions alone (ie punishment) have less impact.
The implication is the usefulness of matching or exceeding the number of negative comments with positive comments or actions.
As a first step, one might undertake a functional assessment of the undesirable behaviours – when, what, where, under which circumstances, and for what apparent goal (such as attracting peer attention?). The important thing is to share with the individual the precise behaviours which are causing concern and details of the circumstances. A plan follows by which to target the undesirable behaviour and encourage the positive by a series of rewards, ideally involving a token system, much positive feedback whenever legitimate, but sharp reprimands or even brief time out if the behaviour is disruptive.
One realises how classroom events trigger inattentiveness because of the attraction of some unfamiliar situation … so, new routines and tasks would be introduced gradually, and the layout of the class examined to determine with whom the targeted pupil would best sit, where to sit (away from distractors and windows, and not on the route of much pupil traffic around the class). There would be warnings given about the time left to complete a task, perhaps with an element of competition to get the task finished before a timer sounds, plus notice about an impending shift in the activity.
Impulsivity could be limited by encouraging the use of self talk and by a visual reminder about his or her particular targets.
Discharge of energy might be aided by ensuring that it is the targeted pupil who helps out by taking messages, handing out material etc, especially if this gives the chance to offer positive feedback. Sometimes the whole group would be rewarded for generally positive efforts, including that of the targeted pupil. Where the teacher stands in the classroom can be significant.
In other words, there may be nothing new or different in kind about the actions, but what matters is the consistency of expectations and routines and making very explicit the behaviour-consequence link.
Similarly, encouraging the pupil to get into a routine of self questioning … what exactly have I got to do / What is the first step? Whom can I ask for help (teacher, LSA, buddy)? How long have I got to finish it? … is something which would be useful for any pupil.
Returning to the concept of reframing … an analogy is with the ASD pupil who causes concern by his circumscribed or even obsessive interests until it is realised that the individual concerned may, as an adult, be highly valued for the extent of knowledge and expertise in a given field.
The problem for ASD pupils and ADHD pupils is that the school experience is all about working in groups towards prescribed ends …. although it is worth reinforcing the point about access to ICT given that working on the computer avoids the issue of delay aversion (a component of the ADHD condition), the pace is dictated by the pupil, there is no direct competition with other pupils, it focuses attention, and any difficulties are more acceptable and certainly not public.
Reframing might include replacing a description of short attention span with occasional bursts of interest by referring to the ability to respond well when motivated, or interpreting a tendency to call out as indicative of wanting to contribute. An over-riding principle here is the recognition of the efforts even if the outcome is not complete or is of lower standard than is typical of the group. These sessions can provide the opportunity for further target setting and planning, with a view increasingly to having the pupil take on responsibility for his or her own performance.
What matters is that one never underestimates the impact of self esteem, either for the better or the worse, in determining engagement with, and valuing of, school goals and routines. There is a practical implication here, too, in that a study in 1995 showed that the anxious pupils tend to show less positive response to the use of medication and to be more at risk of side effects.
Meanwhile, one might ponder over the value of brain gym type exercises, especially in the top end of the primary school, which may well have positive value in their own right in terms of preparing pupils for lessons and generally increasing alertness, but also in providing a legitimate excuse for occasional brief periods away from listening and thinking and concentrating into physical activity.
However, one also needs to keep in mind the likelihood of associated or comorbid weaknesses or difficulties. It is reportedly quite unusual for a pupil to have ”pure” symptoms of one single area of difficulty, but is more likely to have an idiosyncratic mix of symptoms reflective of different areas of weakness.
Problems commonly comorbid (or confused) with ADHD include :
The following indicators listed for ADHD could equally apply to Dyslexia :
Does not pay close attention to detail
Many minor errors
Problems in self-checking for mistakes
Organisational confusion – never has the right materials
Problems with the recording of work
Weak comprehension or listening skill
Therefore, any individual education programme would indeed have to be based upon an assessment of the targeted pupil’s particular areas of strengths and weaknesses … a clinical approach rather than a categorical approach
How one might seek to compensate for the ADHD characteristics does not change in kind with age, but may change in the emphasis or according to the particular profile of the pupil.
As already indicated, early efforts may be more concerned with overtly observable symptoms such as the impulsive calling out, or out-of-seat behaviour; but, with time, the concern may be focused more upon the pupil’s continuing problem with attention and concentration span plus compensation for the threats to self-esteem and self confidence.
This latter point is worth repetition given a 2004 study which indicated that pupils only engage in negative self-evaluations, or comparisons with how other pupils appear to be progressing, during the middle and later stages of primary school when teaching and assessment criteria are geared towards matching the pupils against some external criterion, and there is no credit available for the pupils (or for their schools) for the amount of effort exerted to achieve what they have.
The emphasis upon test and examination results may have led to improved overall performance in terms of the year by year increase in the proportion of a year group achieving a given level, but there are costs in terms of stress impacting not only upon some staff but also upon some pupils.
This 2004 study indicated that the outcome of the negative self evaluation could be a kind of depression or learned helplessness, with the low self esteem and the perceived low achievement maintaining each other.
With further regard to the course of symptoms as pupils move from the primary to the secondary school, one notes the consistent view that ADHD is a long term problem but as presenting in different ways over time.
Particular clusters of symptoms may wax and wane in their severity but the core symptoms – inattention, restlessness, and impulsiveness (reflected in carelessness, poor organisation, and limited follow-through of tasks) – tend to be observable at all ages.
However, intrusive and disruptive behaviours, and an inability to wait one’s turn are seen mainly in the younger children. Adolescents with ADHD are more marked by signs of restlessness, failure to complete independent work, or engagement in”risky”behaviour with enhanced risk of educational failure accidents, and fragile social relationships.
Inattention is long term, even if hyperactivity and impulsivity tend to decrease with age. The emphasis becomes less upon overt behaviours and more upon cognitive performance, BUT as individuals move through adolescence and into young adulthood, there are increasing assumptions about independence in organisation, multi-tasking, working memory, and error correcting.
One further complication is a reported tendency (in a study 0f 2002) that some boys or young men with ADHD exhibit a positive bias or inflation in their self perceptions either through inaccuracy in their reading of situations or as a kind of compensation, and it was interesting that where there was inflation, it was in the area of the greatest impairment … social, or behavioural, or scholastic.
There are implications for great sensitivity in offering advice and support and for care in using high levels of praise if this would only serve to reinforce inaccurate self perceptions.
One approach to by-pass this kind of dilemma is to help the individuals concerned to recognise precisely what constitutes a successful performance of some challenge or task, and the setting of manageable targets thus gently to reduce the overestimation of competence.
According to a 2001 study, the adults concerned may present a positive front and provide themselves with strict routines by which to compensate for continuing weaknesses, but there can still be problems in getting established in a job and in maintaining self-esteem.
There is also evidence that independent working can continue to be a source of strain, as can relationships with supervisors; and the adults with ADHD have an enhanced probability of appearing in the statistics of driving offences or accidents.
It is further noted in recent studies that around 50% of the cases of ADHD diagnosed when the individuals were children will continue to show signs and symptoms as adults. However, the gender ratio is closer (around 2 males to 1 female) at adulthood than in childhood (at least 4 to 1).
Hyperactivity is rare, and around half of adult cases function adequately and are not likely to be differentiated from non-affected peers. However, the remainder continue to have attention and concentration problems which may not be recognised and which can have an impact upon social interactions.
The implication is not only for early assessment but also for ongoing monitoring and a review as the individual moves from paediatric services and becomes eligible for adult services.
Further, when it comes to a move from one school to another, or from school to college, there would usefully be an enhanced system of induction to ensure smoothness of transition. It is important that the continuing needs are recognised so that there can be carried on the pattern of consistency and of providing the pupil or student with a clear set of expectations and minimising situations where he or she is unsure what to do.
Structure – Routine – Predictability are the keynotes (for any pupil, but especially the one with special educational needs including ADHD)
© Mike Connor 2005.
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