Supporting Students with ADHD in the Classroom & Beyond Amanda Urena, MS, National Board Certified Counselor, Board Certified Coach Derek Larsen, MS, National Board Certified Counselor, Behavior Analyst Susan Kelly, M. Ed, Senior Disability Specialist, Office for Students with Disabilities, UC San Diego

Overview ADHD Introduction & Statistics Symptoms & Diagnosis Tools & Strategies Inside the Classroom Tools & Strategies Outside the Classroom Community Resources UCSD Campus Resources

ADHD Diagnosis & Academic Tools & Strategies Amanda Urena, MS, National Board Certified Counselor, Board Certified Coach Derek Larsen, MS, National Board Certified Counselor, Behavior Analyst

ADHD Defined Attention Deficit/Hyper Activity Disorder is a neurodevelopmental disorder that can develop in both children and adults, according to The American Psychiatric Association's Diagnostic and Statistical Manual, 5th edition or “DSM V” (American Psychiatric Association, 2013) In the 20th century, ADHD was largely believed to be a condition affecting prominently children. Diagnostic criteria from the DSM II from 1968, reported ADHD “usually diminishes by adolescence’’ (American Psychiatric Association, cited by Barkley, 2006) Revisions to the latest DSM V in 2013 have included diagnostic criteria for teens and adults to be more thoroughly diagnosed with ADHD (American Psychiatric Association, 2013) Average annual increase of 5% per year;

ADHD Statists in the United States: Children National Survey of Children's Health from The Center for Disease Control & Prevention and The Health Resources & Services, collected every four years from parent reports found: 5.1 million children or 1 in 11 children 4-17 years old have a diagnosis of ADHD in 2011 ADHD Diagnosis by Sex: 1 in 5 high school boys 1 in 11 high school girls ADHD Diagnosis by Race-Ethnicity: Higher percentages of White and African-American children have ADHD than in Hispanic- Latino children (Visser, Danielson, Bitsko, Holbrook, Kogan, Ghandour, . . . Blumberg, 2014). Average annual increase of 5% per year;

ADHD Statists in the United States: Children National Survey of Children's Health from The Center for Disease Control & Prevention and The Health Resources & Services, collected every four years from parent reports found: Percentages of US Children 4-17 years-old to have ever received a diagnosis of ADHD by a heath care provider, according to parent reports: 11% in 2011 9.5 % in 2007 7.8 % in 2007 (Visser et al, 2014) Average annual increase of 5% per year;

ADHD Statists in the United States: Children A 2004 study found 25% of children with ADHD, have the diagnosis persists into adulthood (Faraone SV, Spencer TJ, Montano CB, 2004) National Comorbidity Survey Replication found: 4.4% of adults have a diagnosis of ADHD, according to self-reports, in 2006 Sex of Respondents Diagnosed with ADHD 61.6% male 38.4% female Race-Ethnicity Respondents Diagnosed with ADHD 81.8% Non-Hispanic White 7.5% Hispanic 6.2 Black 4.5 Other (Kessler, Adler, Barkley, Biederman, Conners, Demler, … Zaslavsky, 2006) Average annual increase of 5% per year;

ADHD Diagnosis Doctors and mental health professionals such as licensed therapists, social workers, and psychologists use The American Psychiatric Association's Diagnostic and Statistical Manual, Fifth edition (DSM V) to diagnose mental heath issues The current DSM-V was released in May 2013 The DSM-V included several updates to the previously established criteria for ADHD from the DSM-IV More accurately encompasses teens and adults with ADHD (previous emphasis on children) Symptoms can appear in children by age 12 (was previously age 7) Includes a co-morbid disorder with Autism Spectrum Diagnosis (American Psychiatric Association, 2013)

DSM V Diagnostic Criteria ADHD A. “A persistent pattern of inattention and/or hyperactivity- impulsivity that interferes with functioning or development, as characterized by:” Inattention and/or Hyperactivity Children under 17 “Six (or more) symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities.” Note: “The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility or failure to understand tasks or instructions.” (American Psychiatric Association, 2013)  Age 17 & older (Adults) Five symptoms are required. (American Psychiatric Association, 2013)

DSM V Diagnostic Criteria ADHD B. “Several inattentive or hyperactive - impulsive symptoms were present prior to age 12 years.” C. “Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school or work; with friends or relatives; in other activities).” D. “There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic or occupational functioning.” E. “The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).” (American Psychiatric Association, 2013)

DSM V Diagnostic Criteria ADHD-Inattention A. “Often fails to give close attention to details or makes careless mistakes in schoolwork, at work or during other activities (e.g., overlooks or misses details, work is inaccurate).” B. “Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations or lengthy reading).” C. “Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).” D. “Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).” E. “Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).” (American Psychiatric Association, 2013)

DSM V Diagnostic Criteria ADHD-Inattention F. “Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms; reviewing lengthy papers).” G. “Often loses things necessary for tasks or activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).” H. “Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).” I. “Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).” (American Psychiatric Association, 2013)

DSM V Diagnostic Criteria ADHD- Hyperactive-Impulsive A. “Often fidgets with or taps hands or feet or squirms in seat.” B. “Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).” C. “Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.) D. “Often unable to play or engage in leisure activities quietly.” E. “Is often “on the go”, acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).” (American Psychiatric Association, 2013)

DSM V Diagnostic Criteria ADHD-Hyperactive-Impulsive F. “Often talks excessively.” G. “Often blurts out an answer before a question has been completed (e.g. , completes people’s sentences; cannot wait for turn in conversation).” H. “Often has difficulty waiting his or her turn (e.g., while waiting in line).” I. “Often interrupts or intrudes on others (e.g. butts into conversations, games or activities; may start using other people’s things without asking or receiving permission: for adolescents and adults, may intrude into or take over what others are doing).” (American Psychiatric Association, 2013)

ADHD Diagnosis Specify whether: 1. “Combined presentation”: If both criterion for inattention and criterion for hyperactivity - impulsivity are met for the past 6 months. 2. “Predominantly inattentive presentation”: If criterion for inattention is met, but criterion for hyperactivity- impulsivity is not met for the past 6 months. 3. “Predominantly hyperactive/impulsive presentation”: If criterion for hyperactivity -impulsivity is met, but criterion for inattention is not met for the past 6 months). Further Specifies: In partial remissions Severity: Mild, Moderate or Severe (American Psychiatric Association, 2013)

Co-Morbid/Co-occurring Conditions with ADHD Several studies found over 50% of people diagnosed with AHDH also have a secondary diagnosis. (Biederman, Newcorn, Sprich, 1991; Jensen, Martin, Cantwell, 1997) Common co-occurring diagnoses include: Anxiety Major depression Conduct Disorder (children) Tourette Syndrome Substance Abuse Disorder Learning Disorders (Biederman et al, 1991; Biederman, Faraone, Spencer, Wilens, Norman, Lapey, . . . Doyle, 1993) 20%-25% of ADHD children meet criteria for a learning disorder (Pliszka SR, 1998)

Executive Functions Executive functions can be impaired in Individuals with ADHD, as described in the DSM-V symptoms of ADHD Dr.Thomas Brown, Yale Clinic for Attention and Related Disorders, Yale University defines executive functions as: “..a wide range of central cognitive functions that play a critical role for all individuals as they manage multiple tasks of daily life (1). “ Brown’s model includes six categories of impairments in cognitive function 1) Activation-organizing, prioritizing, beginning tasks, estimating time 2) Focus- maintaining focus, shifting topics 3) Effort- maintaining effort for long-term tasks, processing speed issues 4) Emotion*- regulating emotion *(not a symptom in DSM) 5) Memory- recalling information 6) Action- regulating activities (impulsivity) (Brown, 2009)

Tools & Strategies: Inside the Classroom Improving attention to detail: Follow directions using a ruler, piece of paper or post-it to thus be able to read instructions line by line Ask clarifying questions Using highlighters, underlining, making notations, or re-writing directions for increased understanding Review work prior to turning in Be mindful of how long tasks take you (to avoid rushing through)

Tools & Strategies: Inside the Classroom Improving attention to detail: Break down directions sequentially and/or multi-step Ex: Complete the following essay: “Do small dogs stimulate or hinder the economic growth of San Diego? Include 5-7 examples to support your assertion. Be sure to include statistics from chapter 7 of All Dogs Go to San Diego.” Ex: Complete the following essay (with directions rewritten): 1) “Do small dogs stimulate or hinder the economic growth of San Diego?” 2) “Include 5-7 examples to support your assertion.” 3) “Be sure to include statistics from chapter 7 of All Dogs Go to San Diego.”

Tools & Strategies: Inside the Classroom Improving attention span: Proximity control: sit at a location in the room where you will be able to focus best, that reduces distractions to external stimuli Put away cellphone Use of music (words or no words) Draw in margins Utilize breaks Request to take tests in separate location

Tools & Strategies: Inside the Classroom Improving task completion Extended time accommodation (ex: 25% more time given, 50% more time given) A 2011 study found extended time improved the reading scores of adolescents with ADHD Testing under standard time conditions: 53% of adolescents finished the reading comprehension test 42.8% were able to score within 1 SD of their IQ verbal comprehension index (VCI). Testing under extended time: 77.9% of adolescents were able to score within 1 SD of their VCI (Brown, Reichel, & Quinlan, 2011)

Tools & Strategies: Inside the Classroom Improving task completion Create a step-by-step “to do” list or check list before engaging in activity Check off/cross out steps as completed Highlight those steps that need to still be completed Directions written as a checklist: Ex: ____ Read the “Abra Cadabra” poem ____ Find all metaphors within the poem and be ready to discuss ____ Complete a one page reaction to the poem ____ Underline the hyperboles

Tools & Strategies: Inside the Classroom Improving memory Keep an assignment book (paper or electronic) for homework, projects, studying for tests Write down any verbal directions Keep written notes with you Text or email self reminders

Tools & Strategies: Inside the Classroom Improving comprehension-Note taking Experiment with different styles of note taking Know what style of note taking works best for you! Use colored pens to separate out ideas and/or chunk information Draw pictures or symbols, or other codes Ex: Using ??? for information that needs further review, or professor clarification Ex: Using for information that highlights information that is on the test Use post-its Have highlighters ready Use a computer to type notes

Tools & Strategies: Inside the Classroom Maintaining in a physical location for long periods Find a way of moving a part of your body discreetly Ex: Shake leg or tap knee Use of a stress ball, or other tactile aid Stand if needed and/or give self certain space to pace about Take a break when needed Wear a watch

Tools & Strategies: Inside the Classroom Improving understanding of appropriate timing While someone is talking, try to listen for the end of his/her sentence/point before chiming in If you have already contributed to a conversation, count a few seconds before chiming in again to give others a chance to contribute Write down short notes of the comment you want to say (so you both wait and don’t forget) Apologize for interrupting and allow person to finish thought first Raise hand or knock before speaking (when appropriate)

Tools & Strategies: Outside the Classroom Improving task completion & time management: Projects Put all projects, tests and syllabi on a calendar at the start of the semester Color coordinate materials per subject and with text/ink color on calendar Include major personal commitments (ex: birthdays, ect) Break down projects into multi-step components Assign deadline dates Add dates to the calendar

Tools & Strategies: Outside the Classroom Improving task completion & improving focus/restlessness-Homework Setting up study area(s) Academics: Pens, pencils, highlighters, hole punch, hard surface, etc Distractibility: Put away cellphone & other distractions Clear off debris Noise cancelling headphones/earplugs

Tools & Strategies: Outside the Classroom Improving task completion & Improving focus/restlessness-Homework Setting up a study area(s) (continued) Focus: Use of a stress ball, or other tactile aid Use of music or white noise (ex: fan) Drink Inspiration: Inspirational signs or quotes Positive thinking

Tools & Strategies: Outside the Classroom Improving task completion-Homework Study area outside of home: Find a places to study that minimizes distractions Options outside of home (ex: library, café, food court) Have multiple options

Tools & Strategies: Outside the Classroom Improving task completion & Improving focus/restlessness-Homework Take breaks Set a timer (for working periods and break) Pick a break activity that will minimize further distractions Use of a timer to self-pace: Audible alarm or vibrating alarm Visual cues (ex: “Where is my focus?” “Am I on task?”) 2014 study of adolescents who used a vibrating self-monitoring device found: Bell work increased Independent work production increased (Morrison, C., McDougall, D., Black, R. & King-Sears, M., 2014)

Tools & Strategies: Outside the Classroom Improving task completion Understand self to know how long a task will actually take you Time yourself when completing tasks Believe you can finish the task Reward yourself for completion of difficult tasks 

Tools & Strategies: Outside the Classroom Improving task completion & memory Use of a small notebook to record daily “to-do” list for next day Use of post-it/sign for urgent task(s) clipped to bag, backpack or keys Use of checklist for multi-step tasks Make the start of the task easier (ex: If need to ask a librarian a question the next day, write down the li brary’s phone number on piece of paper) Begin the task

Tools & Strategies: Outside the Classroom Improving organization Color coordinate notebooks, binders and folders Use of a separate homework folder Schedule a weekly or monthly cleanout of materials from binder Put cleaning date on calendar Use of a hole punch Have a “home” for school materials when not in use

US Laws 1973 US Rehabilitation Act -Section 504 Prohibits discrimination based on disability in federal institutions or organizations who receive federal funds Reasonable accommodations must be provided to support individuals with documented disabilities (Your Rights under Section 504 of the Rehabilitation Act, 2006) 1990 Americans With Disabilities Act “The ADA prohibits discrimination on the basis of disability in employment, State and local government, public accommodations, commercial facilities, transportation, and telecommunications. It also applies to the United States Congress.” (A Guide to Disability Rights Laws, 2007)

Treatment Options Counseling A licensed mental health counselor or licensed social worker Support clients with emotional, social aspects of ADHD Behavior therapy Coaching A certified ADHD/Life Coach Support clients with academic, career, organizational aspects of ADHD Medication A licensed psychiatrist or general family practitioner Prescription

Community Resources Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) http://www.chadd.org A national nonprofit organization “Improves the lives of people affected by ADHD through education, advocacy, and support.” (Mission Statement. Retrieved from http://www.chadd.org/About- CHADD/Mission-and-History.aspx) Local Chapter-San Diego http://www.chadd.net/template.cfm?affid=403&p=about National Alliance on Mental Health http://www.nami.org “Advocates for access to services, treatment, supports and research and is steadfast in its commitment to raise awareness and build a community for hope for all of those in need.” (About Nami. Retrieved from http://www.nami.org/template.cfm?section=About_NAMI) Local Chapter-San Diego http://www.namisandiego.org/

UCSD Resources Counseling & Psychological Services (CAPS) ADHD Support Group A 4 week group, covering topics related to ADHD. Participants share experiences, strengths and strategies for success with ADHD. http://caps.ucsd.edu/ Office for Students with Disabilities (OSD) http://disabilities.ucsd.edu

Office for Students with Disabilities Susan Kelly, M. Ed. Senior Disability Specialist

What does the OSD do? Meet with students to engage in the interactive process Review medical documentation Determine reasonable accommodations Collaborate with faculty and staff

Conditions OSD Accommodates Permanent Conditions Mobility Sensory (hearing/vision) Chronic Health (MS, CP) Mental Health (anxiety, depression) Learning Disabilities/ADHD Temporary Conditions Surgery or sudden, serious injury or illness Fractures to upper and/or lower limbs Concussions

Process to Obtain Accommodations Complete Intake and consent forms (on-line) Make an appointment Submit documentation Meet with an OSD Disability Specialist

Who determines accommodations and how is this done? Documentation review committee Based on current functional limitations Accommodations provided in 4 areas: Classrooms and labs Exams and quizzes Campus living Program modification

Communicating Accommodations Authorization for Accommodation (AFA) letter is issued by the OSD to the student Students must share AFA letter with faculty, TA, and OSD Academic Liaison and request accommodations OSD informs students they should schedule an appointment to meet with faculty in their offices. This protects the student’s confidentiality while providing an opportunity for the student and faculty to discuss how accommodations will be arranged and course expectations.

Important Reminders Confidentiality Syllabus statement Appropriate questions to ask Setting precedents Accommodations for teaching assistants Contact the OSD if you have questions

University Center 202 (behind Center Hall) Where is the OSD? University Center 202 (behind Center Hall) Contact Information 858.534.4382 osd@ucsd.edu http://disabilities.ucsd.edu

Works Cited About Nami. Retrieved from http://www.nami.org/template.cfm?section=About_NAMI American Psychiatric Association. (1968). Diagnostic and statistical manual of mental disorders (2nd ed.) Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) Washington, DC: Author. Barkley, R. A. (2006). Attention-deficit Hyperactivity Disorder. A Handbook for Diagnosis and Treatment (p. 50). New York: Guilford Biederman, J., Newcorn, J., Sprich, S. (1991). Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety and other disorders. American Journal of Psychiatry, 148 (5), 564-577.

Works Cited Biederman, J., Faraone, S.V., Spencer, T., Wilens, T., Norman, D., Lapey, K.A., . . . Doyle, A. (1993). Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder. American Journal of Psychiatry, 150 (12), 1792-1798. Brown, T.E. (2009). ADD/ADHD and impaired executive function in clinical practice. Current Attention Disorder Reports 2009, 1, 37–41. Brown, T, Reichel, P.R, Quinlan, D.M. (2011). Extended time improves reading comprehension test scores for adolescents with ADHD. Open Journal of Psychiatry, 1, 79-87. CHADD Mission Statement. Retrieved from http://www.chadd.org/About-CHADD/Mission-and-History.aspx

Works Cited Faraone, S.V., Spencer, T.J., Montano, C.B. (2004). Attention-deficit/hyperactivity disorder in adults: a survey of current practice in psychiatry and primary care. Archives of Internal Medicine, 164 (11), 1221–1226. Guide to Disability Rights Laws. (2007). Retrieved from http://www.ada.gov/cguide/htm Jensen, P.S., Martin, D., Cantwell, D. (1997). Comorbidity in adhd: implications for research, practice, and dsm-v. Journal of the American Academy of Child and Adolescent Psychiatry, 36 (8), 1065–1079. Kessler, R.C., Adler, L., Barkley, R., Biederman, J., Conners, C.K., Demler, O., Zaslavsky, A.M. (2006). The prevalence and correlates of adult adhd in the united states: results from the national comorbidity survey replication. The American Journal of Psychiatry, 163(4), 716–723.

Works Cited Morrison, C., McDougall, D., Black, R., King-Sears, M. (2014). Impact of tactile-cued self- monitoring on independent biology work for secondary students with attention deficit hyperactivity disorder. Journal of College Teaching & Learning. 11 (4), 181- 196. Pliszka, S.R. (1998). Comorbidity of attention-deficit/hyperactivity disorder with psychiatric disorder: an overview. Journal of Clinical Psychiatry, 59 (7), 50-58. Visser, S.N., Danielson M.L., Bitsko R.H., Holbrook, J.R., Kogan, M.D., Ghandour, R.M., . . . Blumberg, S.J. (2014). Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 53 (1), 34-46. Your Rights under Section 504 of the Rehabilitation Act. (Rev. 2006). Retrieved from http://www.hhs.gov/ocr/civilrights/resources/factsheets/504.pdf