Special Education

Teaching Students with Attention-Deficit/Hyperactivity Disorder

What is AD/HD?

Attention-Deficit Hyperactivity Disorder (AD/HD) is a neurological disorder requiring a clinical diagnosis based on criteria outlined in The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV). Students with AD/HD demonstrate significant impairment related to inattention and/or hyperactivity and impulsivity compared to average children of the same age. The prevalence of AD/HD is estimated to be 3 - 5 % of the school-aged population. Clinicians typically report that boys are referred for AD/HD assessment nine times more often than girls, while studies using a general population base indicate that the ratio of boys to girls with the disorder is closer to 3:1.

The following information should be collected by a multi-disciplinary team to assist in making an AD/HD diagnosis:

life history and background of family members, including medical and psychiatric history,
developmental history of the student, including birth history, developmental milestones, records of classroom-based and individual assessments that may be included in the student's permanent record folder at school and medical history,
current physical examination to rule out other health concerns,
information about a student's learning abilities and academic skills,
ratings of the student's behaviour using standardized behaviour rating scales to be completed by parents and teachers, and
descriptions of the student's behaviour in various settings over time provided by parents and teachers (objective observational data provided by the school could be very useful in this regard).

In addition, psycho-educational testing is helpful to determine the student's learning strengths and needs and to determine if learning disabilities are impacting on the student's school achievement.

Matthew, a grade four student, has a hard time getting started on his journal every morning. He loses his pencil and can't find his notebook, usually due to the mess in his desk. As a result, he often wanders around the classroom to borrow things, and in the process, forgets what he was supposed to do in the first place. He rarely completes written assignments. His mother has recently mentioned to the teacher that getting Matthew out of bed and ready for school in the morning is getting harder and harder everyday. He complains that "none of the other kids like him".

Diagnostic Criteria

The following symptoms are listed in the DSM-IV and are used by qualified health professionals to diagnose AD/HD. Some of these symptoms must be displayed in a number of settings, persist over at least six months and must have been observed prior to age seven in order for the diagnosis to be made. The following information is not intended for diagnostic purposes; a referral for diagnosis should be made to a physician or registered psychologist with training in AD/HD and other childhood disorders . The following symptoms are paraphrased from the DSM-IV.

Inattention Symptoms

Often:

fails to give close attention to details or makes careless mistakes in schoolwork, or other related activities, i.e., work often appears messy or seems performed carelessly and without considered thought.
has difficulty sustaining attention in tasks or play activities.
does not seem to listen when spoken to directly.
does not follow through on instructions and fails to finish schoolwork, chores, or duties. (This is due to inattention and not due to a failure to understand instructions.)
has difficulty organizing tasks and activities.
avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort, e.g., homework or paperwork.
loses things necessary for tasks or activities, e.g. toys, school assignments, pencils, books, or tools.
is easily distracted by extraneous stimuli that are usually easily ignored by others, e.g. a car honking, a background conversation.
forgetful in daily activities, e.g., missing appointments, forgetting to bring lunch.

June sits staring out the window. Ms Smith asks the class to get out math books. June reaches in her desk and pulls out a teen magazine, flipping to the picture of the latest teen movie star. Later she wonders why everyone else knows how to do the math questions. She looks over at the way Samantha is doing her work and wonders how she'll ever know what to do.

Hyperactivity Symptoms

Often:

fidgets with hands or feet or squirms in seat.
leaves seat in classroom or in other situations in which remaining seated is expected.
runs about or climbs excessively in situations in which it is inappropriate. (In adolescents or adults this may be limited to subjective feelings of restlessness.)
has difficulty playing or engaging in leisure activities quietly.
is "on the go" or acts as if "driven by a motor."
talks excessively.

Cameron, a grade nine student, is the life of the class. He always has an interesting story to tell, rarely related to the subject being studied. He gets along so well with his peers that no matter where the teacher places him in the classroom, he spends more time socializing than working on the assigned tasks. Teachers, as a last resort, often ask him to sit in the hall so that others can do their work. Cameron is fascinated with computers and cars and will spend endless hours designing programs, working on his car or reading car or computer magazines. He often misses class on test days, especially when an essay test is expected. He's barely passing Language Arts and Social Studies, even though a psychological assessment done when he was in Grade 3 indicates that he has high average ability.

Impulsivity Symptoms

Often:

blurts out answers before questions have been completed.
has difficulty awaiting turn.
interrupts or intrudes on others, e.g., butts into conversations or games.

When caught fighting on the playground for the third time this week, Suzie, a grade seven student, explained that it "wasn't her fault". Karen had made a face at her and the other kids were always calling her names. "You're always picking on me!", she exclaimed to the principal when called into the office. "Nobody ever listens to my side of the story!"

Antonio, a grade 10 student, is thinking of quitting school. He was in a car accident last week. He expected the car ahead of him to turn left on the amber light and intended to follow before the light turned red. That stupid woman, didn't she know how to drive in the city? Anyway, he missed a few days of classes because of the accident (how else was he going to get his car fixed?) and now was very close to failing most of his courses. What was the use anyway? He'd never get good enough marks to get into the mechanics course he was planning on, anyway. It would be so great to sleep in everyday without his mother yelling that he'd be late for school....

The DSM IV outlines three types of AD/HD:

AD/HD Combined Type
Six or more of the symptoms of inattention and six or more of the symptoms of hyperactivity-impulsivity have persisted for at least six months in a child's behaviour. Most children and adolescents with AD/HD have the combined type.
AD/HD Predominantly Inattentive Type
Six or more of the symptoms of inattention, but fewer than six of the symptoms of hyperactivity-impulsivity have persisted over at least six months in a child's behaviour.
AD/HD Predominantly Hyperactive - Impulsive Type
Six or more of the symptoms of hyperactivity-impulsivity, but fewer than six of the symptoms of inattention have persisted for at least six months in a child's behaviour.

Can other disorders accompany AD/HD ?

Students with AD/HD often have other problems as well. Twenty to twenty-five percent of these students also have learning disabilities. The incidence of oppositional defiant disorder and conduct disorder is higher in students with AD/HD than in the general population. Some students with AD/HD have accompanying emotional disorders such as depression or anxiety. A small percentage of students with AD/HD also have Tourette's Syndrome. In addition, students with AD/HD often have difficulty with motor skills and coordination.

Teachers should keep in mind that many students with AD/HD do not have an additional disorder.

Are there other conditions that produce similar symptoms?

The symptoms associated with AD/HD can result from a number of conditions, some physical, some environmental, and some genetic. While it is possible for students with AD/HD to be affected by a number of other conditions, some children displaying these symptoms are doing so for reasons other than AD/HD.

Some circumstances that can result in students displaying patterns of behaviour similar to AD/HD are:

other specific medical, neurological and psychiatric disorders (e.g. hyperthyroid, diabetes, Fetal Alcohol Syndrome or Fetal Alcohol Effects, bipolar disorder),
insufficient sleep on a regular, ongoing basis,
severe personal or family disruption including death of a family member, divorce, or recent family blending,
anxiety,
undiagnosed learning disabilities,
undiagnosed hearing or visual impairments,
significantly above average cognitive ability (gifted),
significantly below average cognitive ability (intellectual disabilities), or
ongoing exposure to damaging environmental influences including abuse or neglect.

Teachers should keep in mind that the presence of symptoms associated with AD/HD is not sufficient for diagnosis. Assessment must consider all possible causative factors and the consistency of these symptoms over time and in a variety of settings. A broad range of possibilities should be explored to ensure that all students are appropriately assisted to achieve their potential.

AD/HD in the Classroom

Students with AD/HD display a persistent pattern of inattention and/or hyperactivity/impulsivity. These students often experience impairment of their ability to address social, academic and vocational expectations. In the classroom, teachers often see students with AD/HD struggling with their school work.

Students with AD/HD may demonstrate the following characteristics in the classroom:

difficulty getting started;
difficulty regulating attention to task or to people;
difficulty organizing or following through on instructions, school work, chores and/or classroom duties;
easily distracted and forgetful;
constantly on the go and into everything, or, for adolescents, a constant feeling of restlessness or lethargy;
often very verbal and impulsive;
often require more supervision than age peers, particularly in unstructured settings;
often display highly erratic production in terms of quality and quantity of work completed from day to day and at different times in the same day; and
difficulty dealing with change, such as moving from one activity to the next.

Myths about AD/HD

Myth #1: All students with AD/HD display aggressive, acting out behaviours that eventually lead to trouble with the law.

Fact: Many children and youth with AD/HD are not aggressive, violent, or in trouble with the law. Some, particularly those who are predominantly inattentive, tend to be withdrawn and reclusive. While students with AD/HD are at greater risk of behavioural problems, appropriate early intervention can reduce the risk.

Myth #2: Medication is the only intervention that works with these students.

Fact: A number of strategies including training for teachers and parents in management strategies are proven to be effective components of treatment for students with AD/HD. Many experts in the field believe that medication may be necessary to maximize the effectiveness of other strategies. In any case, medication alone should never be the sole intervention.

Myth #3: Medication used to treat AD/HD is addictive and will cause drug abuse.

Fact: Stimulant medication taken as directed has not shown to be addictive by scientific studies. Students who respond well to medication and are academically and socially successful may be less at risk for drug misuse and other emotional problems.

Myth #4: The AD/HD diagnosis is being overused.

Fact: Researchers estimate that 3 - 5% of the school aged population have AD/HD. Current medical statistics indicate that the number of children diagnosed in Canada is well within this figure.

Myth #5: Only boys can be diagnosed with AD/HD.

Fact: Although boys are more likely to have AD/HD than girls, it is not a gender-specific disorder. Clinicians typically report that boys are referred for AD/HD assessment nine times more often than girls. Studies using a broader population base generally indicate that the ratio of boys to girls with the disorder is closer to 3:1.

Myth #6: AD/HD is the result of poor parenting or poor teaching. (It's not a "real" disorder)

Fact: Current scientific research points to biological, rather than environmental causes for AD/HD. For example, in people with AD/HD, the brain areas that control attention have been observed to use less glucose, indicating that they are less active. Genetic connections have also been established by research: children who have a parent or other family member with AD/HD are more likely to have the disorder.

Myth #7: Kids outgrow AD/HD after puberty.

Fact: Although about half of the people diagnosed with AD/HD as children will experience decreased hyperactivity after adolescence, many will continue to have difficulty with impulsively, inattention and distractibility throughout their adult years. Students with AD/HD may need support throughout their education and strategies to assist them as adults in the workplace.

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