1. C ognitive Abilities - Very low oral comprehension. - Very low spelling and no written products. - Struggles with sequencing of information. Behaviour - Difficulty staying in seat and on task. - Refuses to complete written work. - Leaves the room and does not return. - Struggles with friendships due to wanting to engage in activities appropriate to younger student - Highly distracted by activities outside the room. - Engages in avoidance behaviour when asked to complete challenging work. Rethinking ADHD: in the classroom & at home Saaled Inclusion Congress 2011 Rosemary Tannock, PhD Canada Research Chair & Professor in Special Education; Professor of Psychiatry, University of Toronto; Senior Scientist, The Hospital for Sick Children, Toronto, CANADA www.teachadhd.ca

2. Myth #1 ADHD is a new disorder – a problem of modern society 1798 Dr Alexander Crichton: “On attention & its diseases” “…incapable of attending with constancy to any one object of education.” (p.271) “When born with a person it becomes evident at a very early period of life, and has a very bad effect, in as much as it renders him..” “…and what is very fortunate, it is generally diminished with age..”

3. Early dual conceptualizations of ADHD “Fidgety Phil” Dr. Heinrich Hoffman 1845 Dr. Heinrich Hoffman 1845 “ Dr. George Still 1902 “Morbid defect “Morbid defect of moral control” Poorly regulated behavior (noncompliance) Poorly regulated attention (learning problems) “ Johnny-Head-In-The-Air”

4. ADHD in the 1950’s-1960’s ‘the brain-damaged child” Speech, Language Social interaction Motor function Emotion Mood Behavior Cognitive function

5. Myth #2 ADHD is not real – it is just a North American problem - ADHD is not real – it is just a North American problem FACT World-wide prevalence of ADHD: (1-2 students per class) ~ 5% in children & adolescents (1-2 students per class) ~2- 4% in adults More common in males than females (3: 1) Not specific to socioeconomic status

6. ADHD 1994-2011 ADHD 1994-2011 A medical/mental health category: Childhood-onset Disruptive behavior disorder: Inattention, impulsiveness,hyperactivity But in DSM-V, it is likely to be classified among the Neurodevelopmental Disorders Intellectual Disability Autistic Spectrum Disorder Communication Disorders Developmental Motor Co-ordination Disorder ADHD Learning Disorders

7. Persistent negativistic behavior: argumentative, defiant, provocative, hostile poor attention excessive activity impulsivity extreme antisocial behaviour: bullying, lying, stealing, cruelty bullying, lying, stealing, cruelty ADHD ODD CD Differs from:

8. Myth #3 ADHD is not real -ADHD is not real -a label given to kids who are naughty - kids who are not disciplined by their parents - a label used by teachers for kids who are naughty, lazy, unmotivated FACT AD/HD is a neurobiological, genetically-based condition characterized by differences in brain functioning that affect behaviour, thoughts and emotions. The differences in brain function cause inattention, hyperactivity and/or impulsivity, along with a number of related difficulties, that are inappropriate for an individual’s age and impairing.

9. ADHD: evidence of delayed brain growth in frontal cortex, which controls attention Greater than 2 years’ delay 0 to 2 years delay Sample: ADHD=223; Controls = 223 Educational Implications  2-3 year discordance between age & ability to control attention, behavior & emotion  Will require support from teachers/parents for much longer than their peers view of the brain from the side Front

10. What causes ADHD? Most likely caused by abnormalities in the brain’s chemical messengers (neurotransmitters) ◦the ADHD brain is inefficient or sluggish in the areas that control impulses, screen sensory input and focus attention. AD/HD tends to run in families – is heritable ◦heritability is about 76% -heritability of height is 90%, schizophrenia is 80% ◦Parents and siblings of children with AD/HD often have similar symptoms. Other possible causes : ◦Fetal exposure to alcohol, cigarettes/nicotine & environmental toxins (lead); prematurity

11. Observable symptoms of Hyperactivity/Impulsivity & Inattention Used in diagnosis, with evidence of impairment Genetic factors Altered brain structure & function Inefficient brain function

12. What are the key characteristics of ADHD? Difficult to manage behavior ◦Inattention/Disorganization, Impulsivity, Hyperactivity Social emotional difficulties ◦Misperceive social cues, over-reactive, problems managing emotions/anger Executive Function difficulties ◦Higher-order brain functions (next slide) Poor functioning at school ◦Problems learning & poor academic outcome

13. Executive functions: typology Response inhibition Working memory Set shifting “Cool” & “Hot” executive function problems in ADHD Sensitivity to reinforcement Ability to delay gratification

14. Executive function problems in ADHD regulating alertness focusing & sustaining effort & attention processing information at consistent & appropriate speeds planning, organizing and prioritizing tasks remembering details & accessing short-term memory distinguishing essential from nonessential detail delaying gratification inhibiting behaviours managing frustration & other emotions evaluating information,self-monitoring own performance & regulating actions

15. Preschoolers with ADHD typically have several developmental problems Percent of sample with deficit

16. Academic & social impact of ADHD in the preschool years: summary Will enter school at significant disadvantage Will enter school at significant disadvantage Pre-academic skill deficitsPre-academic skill deficits Cognitive deficitsCognitive deficits Higher frequency of negative social behaviorHigher frequency of negative social behavior Problems maintaining attentionProblems maintaining attention Easily distractedEasily distracted Constantly on the go (unable to sit still during circle time)Constantly on the go (unable to sit still during circle time) Excessive running, climbingExcessive running, climbing Does not follow instructionsDoes not follow instructions Parents report higher stress levels, less adaptive coping, less likely to seek support from relatives & neighbours

17. 17 Achievement gap between ADHD and their peers increases over time Scheffler et al (2009) Pediatrics 123(5): 1273-79 Full sample: n=8370 ADHD: n=594 (9%) Reading scores Academic Achievement Scores

18. Pay attention to Inattention! Inattention in kindergarten as reported by teachers Poor reading in Gr. 5 387 children followed from Kindergarten - Grade 5 even after controlling for IQ, hyperactivity, emotional problems, & reading ability in Kindergarten/Grade 1

19. Early attention problems impede high school achievement Assessed & followed an ethnically & socioeconomically diverse sample of 823 children aged 5-6 yrs until 17yrs of age (84% of original sample) (Breslau J., et al, Pediatrics, 2009) Detroit

20. ADHD impairs functioning from morning to night! Before school: Problems waking up Getting ready for school During school: Cannot focus, distracted Disorganized Poor performance Problems with peers After school: Problems with homework Problems with friends, siblings Bedtime: Problems settling down & falling asleep

21. Rethinking ADHD Understanding & helping children with ADHD

22. Reflection Thich Nhat Hanh 1991; Reflection Thich Nhat Hanh 1991; Vietnamese Monk, Activist and Writer. b.1926) “When you plant lettuce, if it does not grow well, you don’t blame the lettuce. You look into the reasons it is not doing well. It may need fertilizer, or more water, or less sun. You never blame the lettuce. Yet if we have problems with our friends or family, we blame the other person. But if we know how to take care of them, they will grow well, like lettuce.”

23. Why do students with ADHD have difficulty learning and achieving at school? Behavioral symptoms of ADHD: inattention, Hyperactivity/impulsivity Executive Function Problems Academic & social underachievement Social-emotional problems A c a d e m ic Academic enablers School/home context

24. Academic Competence Organization & Study Skills Interpersonal Skills AcademicSkills ReadingReading Mathematics Written ExpressionMathematics Written Expression Critical ThinkingCritical Thinking ActiveEngagement Motivation Academic Competence: Academic skills + Learning Enablers ADHD associated with impairments in most aspects

26. Build Home-School Partnership & Teamwork Who are the team players? parents, teachers, teacher-assistants psychologist, speech-language pathologist, physicians & of course the student!

27. Basic principles for home-school communication  Communicate frequently & regularly  Phone call, Email, Spontaneous notes, Notebook, Home- School Daily/WeeklyReport Cards, Face-to-face  Increase parents’ comfort at meetings  P rovide notice of time and room in advance along with brief list of topics/questions, ask for parent questions; provide written summary of decisions  Highlight student’s strengths (concrete examples)  Communicate about student’s needs (concrete examples)  Work with parents to help create structure & routines & to generate solutions  Communicate respect

28. www.education.gov.ab.ca/k_12/specialneeds/resources.asp Daily Report Name:________________ Date:__________ Circle the number that best describes how the student demonstrated the behavior today WonderfulSatisfactoryNeeds improvement Brings all needed supplies & books to class 321 Follows directions 321 Starts work with minimal prompting 321 Interacts positively with peers 321 Responds positively to teacher requests 321 Students signature______________________ Teacher signature_______________________ Parent signature________________________ In-class performance today: ___Wonderful ___Satisfactory ___Needs improvement An excellent resource for educators

29. 2. Create supportive classroom environment  Organize physical environment to reduce distractions (near teacher, between well-focused students, away from distractions)  Organize materials so they are easy to identify & store (color coding)  Establish routine for writing down & turning in homework  Take ‘Triple-P’ proactive approach to behavior  Predict, Precue, Praise  Post (& remind) 3-5 basic ‘positive’ classroom rules  Pace – move around room, prompt& praise student

30. Provide Instructions in written format  On board & on worksheet  Copied in assignment book by student and checked by teacher  (on school/class website)  Post schedules on board & in student’s binder  Post classroom rules 30

31. Use Effective Instructions & Commands  ATTRACT the student’s attention Maintain eye contact  SPEAK clearly, paced Use short sentences (‘chunked’) Use visual cues & wait for compliance  PAUSE between sentences  MONITOR the student If child has ‘blank look’ stop & repeat instruction  TO REPEAT INSTRUCTION Restate slowly and simply Do not expand

32. Break tasks into smaller/shorter chunks  Homework  Break into smaller units / shorter time period  Use count-down timer  Help get started  check understanding  set timer, then leave!  Take brief, timed, structured breaks

33. Help plan out longer-term assignments  Mark the due date  List all regular/planned activities  List all the required steps for the project  Work out time needed for each step  Backwards-planning  Insert all steps into the planner NovemberActivities Mon 22 nd 5-6pm Hockey practice Tues 23 rd Wed 24 th Thurs 25 th Fri 26 th Sleep-over at Jake’s Sat 27 th 8-9 am Hockey Sun 28 th Mon 29 th 5-6pm Hockey practice Tues 30 th History project due Review draft Final version Step-5, rough draft Steps-3 & 4 Step-2 Step-1

34. Getting organized Set goals & prioritise Everything in its own place Desks, Bags, Closets, Binders Time Management Choose & use a Day Planner

35. Basic teaching techniques  Daily review  of relevant past learning & homework  Chunk lesson.  Begin with objectives. Proceed in small steps. Highlight key points.  Procedural learning  teacher modeling, followed by guided practice & immediate feedback until mastery learning occurs.  Independent practice  continue until responses are accurate, quick,automatic.  Weekly reviews  routine and systematically build on previously learned materials.

36. Six explicit steps to teach strategies 1. Develop background knowledge 2. Discuss it 3. Model it 4. Memorize it 5. Support it 6. Establish independent practice Use familiar, easier-level materials when teaching a new strategy

37. Behavioral Accommodations Use positive Reinforcement Positive verbal or written feedback Reward systems and incentives Give tasks that can be successfully completed Private signals to refocus student Role play situations Weekly individual time Conference opportunity Be consistent With rewards & consequences With academic expectations

38. Sleep hygiene  Limit screen time  Establish bed-time routine  Non-Screen activity 30 minutes before bedtime  Bedtime story/ritual  Lights-off time  No screens in bedroom!

39. Rethinking ADHD: Summary  Intervention for students with ADHD needs to focus on promoting their learning & academic success  Intervention to improve academic progress must focus on instruction  Instructional accomodations for students with ADHD will benefit all students, including those with other types of learning and mental health problems

40. ADHD needs a co-ordinated, sustainable, multi-system approach System : home, school, education, medical, judicial Transition plans (sector- to-sector, school-to-school, grade-to-grade, class-to- class) Instructional pathways (credit-recovery, credit- rescue, co-op etc) Ongoing capacity- building (parent programs, professional development) Student&parents

41. Useful Resources on ADHD www.education.gov.ab.ca/k_12/specialneeds/resource.asp. www.ed.gov/about/offices/list/osers/osep/products.html http://research.aboutkidshealth.ca/teachadhd

42. TIME FOR ME TO STOP! ANY QUESTIONS?