1. Understanding, teaching, & supporting students with ADHD Rosemary Tannock, Ph.D, Senior Scientist, Associate Professor of Psychiatry, The Hospital for Sick Children & University of Toronto; Investigator with the Canadian Language & Literacy Research Network

2. ADHD Low self esteem Academiclimitations Relationships Smoking and substance abuse Injuries Motor vehicle accidents Legaldifficulties Occupational/vocational Childhood Adulthood Adolescence Potential Areas of Impairment

3. ADHD: Challenges for Educational Systems Education costs 3 to 6 times greater (Forness et al., NIH Concens, 2000)Education costs 3 to 6 times greater (Forness et al., NIH Concens, 2000) –Prevalence (1 or 2 children in every class) –Association with learning & social problems Meaning for educational programming is unclearMeaning for educational programming is unclear –What type of exceptionality/special needs? –What are the Standards for level of service & instruction? –What are the required teacher qualifications?

4. Educational Systems: Principles of Practice Inclusion as basic principle:Inclusion as basic principle: Program StandardsProgram Standards –Exceptionalities/Special Needs –Screening & Assessment –Interventions –Level of Service –Instruction –Qualifications for teachers & other Staff

5. Typically, one’s pedagogical approach to students with special needs reflects one’s own conceptualization of that particular special need

6. Prevailing view: ADHD as a behavior problem Biological & Environmental Factors Factors BrainAbnormalities InattentionHyperactivityImpulsivity Associated Problems (academic, social)

7. Emerging neuroscience/educational perspective Genetic&Environmental Factors Factors BrainAbnormalities Working Memory & other cognitive processes Inattention, Hyperactivity, impulsivity Learning, Academic achievement Treatment targets targets

8. Traditional approaches to helping children with ADHD Medical/Pharmacological (~ 85%) Medical/Pharmacological (~ 85%) Behavioral (~12%) Behavioral (~12%) Educational (?) Educational (?) Alternative approaches (?) Alternative approaches (?)

9. Limitations of traditional approaches to helping children with ADHD PharmacologicalPharmacological –(Philosophical/political) –Temporary effects on behavior & academic productivity –No robust evidence of impact on learning Behavioral approachesBehavioral approaches –Disproportionate emphasis on consequences rather than antecedent scaffolding (support) & control procedures –Limited generalizability beyond the training context

10. Stimulant medication improves: *** Core features of ADHD *** Academic productivity Classroom behaviour Lab measures (inhibitory control, attention) But…...

11. Treatment related improvements in core behavioral features of ADHD & daily academic work have not translated into robust gains in long-term academic achievement (e.g., MTA Study, 1999) WHY NOT? WHY NOT? Unsatisfactory, needs improvement Unsatisfactory Grade 1 Grade 3 The Problem

12. “Beneficial effects of stimulant medication are not infinite” Effects on behavior & academic productivity are immediate but temporary & cannot compensate for “missed instruction and learning”Effects on behavior & academic productivity are immediate but temporary & cannot compensate for “missed instruction and learning” Lack of synchronization between drug schedule and academic scheduleLack of synchronization between drug schedule and academic schedule Stimulants enhance some but not all aspects of cognitive function & so may not target critical cognitive impairmentsStimulants enhance some but not all aspects of cognitive function & so may not target critical cognitive impairments

13. of medical & academic treatment is essential “Reading to Read” instruction for ADHD boys at two intervals post-medication (Kastner et al., 2000)

14. Stimulant have limited effects on reading No effect on phonological processingNo effect on phonological processing (e.g., Balthazor et al., 1991; Richardson et al 1988) Small effects on verbal retrieval mechanisms involved in word recognitionSmall effects on verbal retrieval mechanisms involved in word recognition (e.g., Ballinger, 1984; Evans et al., 1986; Peeke et al., 1984; Richardson et al., 1988; MTA Study 1999) Effects on comprehension are unknownEffects on comprehension are unknown ( e.g, Brock & Knapp, 1996)

15. Stimulants have selective effects on Working Memory Stimulants improve but do not normalize impairments in visuo-spatial span & visuo-spatial working memory, in childhood & adult ADHDStimulants improve but do not normalize impairments in visuo-spatial span & visuo-spatial working memory, in childhood & adult ADHD (Bedard et al., in press; Mehta et al., 2000a, 2000b; Barnett et al., 2002) Stimulants may improve verbal working memory but not verbal span in children, but may be mediated by stimulant effects on spatial working memory (CHI/PASAT;Tannock et al., 1995; Schweitzer et al., 2000)Stimulants may improve verbal working memory but not verbal span in children, but may be mediated by stimulant effects on spatial working memory (CHI/PASAT;Tannock et al., 1995; Schweitzer et al., 2000)

16. Advances in psychopharmacological treatment of ADHD Newer, longer-acting medications for ADHD will facilitate synchronization of pharmacological treatment with educational intervention –Several FDA-approved long-acting stimulants & a non-stimulant drug available in USA –Many of which are or will soon be available in Canada BUT…. May still have temporary & selective beneficial effects on cognitive function

17. Contingency Management intensive behavioral programs includes both negative consequences and positive reinforcement may be difficult to implement across range of situations in school does not take into account underlying reasons for behavior (ie., cognitive deficits)

18. Cognitive-Behavior Therapy characterized by –verbal mediation instruction –cognitive modeling –problem-solving strategies inconsistent results regarding effectiveness - however usually implemented as a ‘package’ in treatment sessions removed from normal environment (i.e., regular classroom)

19. Behavioral techniques (e.g., parent training, cognitive behavioral therapy) improve... Oppositional behavior Some ADHD behavioral symptoms but transfer-of-learning beyond the training context is limited…. (e.g., Abikoff, 1991; Kendall & Panichelli-Mindel, 1995; Pelham et al., 1998; MTA Co-operative Group 1999) WHY?

20. One Problem Non-integrated approaches Family Doctor Psychologist Teacher Specialists

21. NIMH Multimodal Treatment Study –Largest, longest, randomized controlled clinical trial of treatment in ADHD (N ~ 600; ADHD-CT; 14 mos duration) –Four parallel treatment arms 1.Managed Medication 2.Managed Meds + Psychosocial 3.Psychosocial 4.Community Services (included meds) Most effective for ADHD? 1, 2 > 3, 4

22. What else can we do to boost academic and social success, & facilitate learning? (Beyond the MTA)

23. Problems with salience Problems ignoring irrelevant information Lack strategies

24. Working Memory Demands in the Classroom SpellingSpelling MathMath Reading ComprehensionReading Comprehension Following oral directionsFollowing oral directions Problem-solvingProblem-solving Maintain word in mind while printing it Keep steps in sequence while performing and monitoring accuracy Keep steps in sequence while performing and monitoring accuracy Decode words while integrating meaning Maintain correct sequence, update, and check Decode words while integrating meaning Maintain correct sequence, update, and check Pick out key elements, choose strategy & monitor effectiveness Pick out key elements, choose strategy & monitor effectiveness

25. Promising Educational Strategies for ADHD to reduce demands on working memory & enhance learning Teacher-focused interventions –Modifying how teachers think about, adapt & present critical content to help students identify, organize, comprehend & recall it Student-focused interventions –Teach the student skills & strategies needed to learn the critical content (acquire information from print, organize & memorize, problem-solve, & written expression) and succeed in test-taking

26. Social/Emotional - e.g. self-esteem Behavior - fidgety -inattentive Cognitive Strengths and Weaknesses - working memory - language - reading ability Adaptions Modifications Acommodate Strategies Scaffolds

27. approach may be more effective than behavioral contingencies approach may be more effective than behavioral contingencies IN-SITU (“at point of performance”)IN-SITU (“at point of performance”) FREQUENT, LONG-TERMFREQUENT, LONG-TERM CONTEXTUALIZED COACHINGCONTEXTUALIZED COACHING –MODELLING –SCAFFOLDING –STRATEGIES Minimizes need for behavioral contingency management & applicable to ALL childrenMinimizes need for behavioral contingency management & applicable to ALL children

28. Antecedent-Based Approaches stresses the interaction between child and environment manipulate a variety of potential antecedent variables that may affect performance, such as... –nature of the assignment compared to level of functioning of child, –classroom structure, –advance organizers, –modifications in instructional delivery and support

29. What are Cognitive Learning Strategies? “Set of steps that lead to the accomplishment of a task” (Wanzek et al., 2000) How a person thinks & acts when planning, executing, & evaluating performance of a task & its outcomes (Lenz, Ellis & Scanlon 1996) –Includes thinking & physical actions necessary to perform a skill –Physical act provides evidence that student is using a strategy

30. Cognitive Learning Strategies can be taught to all children? promotes intentional learning (self- regulation) helps children be flexible and adaptable learners promotes independent, active learning facilitates transfer to novel contexts helps children organize approach to task

31. Critical Features of Effective Cognitive Learning Strategies (Ellis & Lenz, 2000-(ldonline.org; Minskoff & Allsop, 2003) Accurate & efficient procedures for learning tasks Accessible to students by being –Memorable (labels, visual cues) Simply worded; Uses familiar words Begins with action words –Accessible through Strategy Cue Sheets Contains only essential steps –Number of steps should not exceed student’s ability to remember & perform –Distinguish between primary & secondary steps

32. Systematic Explicit Instruction to teach Cognitive Learning Strategy Task Analysis/ Preskills: Basic Knowledge of Instructional Language, Listening steps, Temporal Concepts 1. Introduce strategy 3. Repeated guided practice 4. Independent practice with little/no support Bedrock 2. Model strategy 5. Generalization to other subject/setting

33. Types of cognitive learning strategies ( Minskoff & Allsop, 2003) Mnemonics Visualization Verbalization Graphic Organizers Structured Steps Multi-sensory learning

34. Strategies to help organization Time management 3C –Create a calendar –Create a weekly planner –Create daily lists Materials management CLASH –Check your calendar –List the items you need for next day –Always gather the materials on your list –Set your bag by the door –Have a list in your locker of materials you need

35. WARF Strategies to improve reading speed Widen your eye span –Read more than one word at a time –Read groups of words (the/a + noun) Avoid skip backs –Keep reading to try to get meaning from context Read silently Flex your reading rate –Read important information slowly –Read familiar information faster –If looking for specific information, read quickly as searching

36. Examples of Decoding Strategies from Word Identification & Strategy Training (Lovett etal., 1994, 2000) Rhyming Vowel Alert Peeling-Off I Spy

37. Word Identification Strategy Training Program Metacognitive strategies (Lovett et al., 2000) S.A.M.E. (select, apply, monitor, evaluate) Use a gameplan –Choose, Use, Check, Score

38. Using Graphic Organizers as a Scaffold for Comprehension Strategies (Ellis, 1998) They show organization of concepts and relationships between concepts Reduce the cognitive demands of learner to organize material, so learner can focus on understanding it Allows higher level critical thinking activities to occur (relate,compare/contrast) Can be used to help students: summarize find supporting details sequence events

39. Is about Cave types and features Key Topic Caves Essential Details Features of Caves Cave Types Main idea Essential Details Limestone: most common Sandstone: wind or water erode sandstone Lava caves Moon-milk (calcium) is name of gel on floors, walls Cave interiors have 3 zones: entrance, Twilight, and dark zone Limestone caves: have stalactites And stalagmites Sea caves Example of Graphic Organizer

40. Story Writing Strategy (Harris, Schmidt, & Graham, 2000) SPACE Setting Place Action Conclusion Emotions

41. P.O.W.E.R (Englert et al., 1991) to help organize ideas when writing an essay P- plan your paper (brainstorm for ideas) O – organize ideas (graphic web) W – write your draft E – edit your work R – revise work

42. Cognitive learning strategies for foundation math skills Whole number computation Word problems DRAW for basic math FAST DRAW for basic math

43. DRAW for basic math from Teaching Students with learning Problems, Mercer&Mercer, 2001 Discover the sign –Scan the problem –Circle and say name of operation sign –Say what the sign means Read the problem –Read the whole problem –Say the problems aloud as you read it Answer or draw & check –Answer problem if you know how to solve it –Or draw picture to solve it –Check your answer Write the answer Example: subtraction 6 l l l l l l - 3 3

44. FASTDRAW for basic math (Mercer & Mercer 1991) John and Mary went to the corner store to buy some candy. John bought 3 packs of gum and Mary bought 4 chocolates. How many candies to they have altogether? Find what you are solving for Underline the question Box key words (altogether= addition or multiplication) Ask what is the important information Find & circle the number phrases Set up the equation 3 gum __ 4 chocolates = Tie down the sign 3 gum + 4 chocolates =

45. Examples of General Metacognitive Strategies I.D.E.A.S. –I state the problem. –Develop some plans –Explore the plans –Ask myself if the plan is working –See if I am successful. Think Aloud (Camp & Bash, 1985) –What is the problem? –What are some plans? –How is my plan working? –How did I do?

46. Four Components of SCORE Tangrams, Geometry, Attribute blocks, Pentominoes, Mazes Social Skills/ Prob.Solve (e.g.) Cooperation Friends Tone of Voice, Explicit application to cognitive/ social problems Organizational/ Study strategies/ Active listening/ Scientific Method: Questioning, observing Emotions/ Anger Mgmt IDEAS lessons Instructional language/ Following directions Problem-Solving strategies Promoting Self- Esteem/ Self -Assessment Think Aloud (verbal mediation) Temporal skills 4. Being a Detective 3. Getting Along Together 2. IDEAS (Thinking aloud) 1. Academic

47. Lesson Delivery fast-paced, focused, energetic little down time - increase student response frequency (e.g, choral responses, cooperative activities) Simplify, chunk & repeat, instructions –establish eye contact, then give instructions, repeat, have child repeat. vary presentation style (active/passive) use visual prompts/aids (e.g., diagrams, pictures, color coding)

48. Content Adaptations greater student response frequency choral response, peer tutoring use visual prompts pictures as reminders, adjust quantity of work match to ability, reduce handwriting/copying increase amount of review/repetition may need more practice to learn new skill

49. Example: Teaching Math reduce amount of workreduce amount of work provide lined paper (spatial deficits)provide lined paper (spatial deficits) use manipulativesuse manipulatives adapt delivery to include visual cues, color coding, mnemonicsadapt delivery to include visual cues, color coding, mnemonics provide extended practice in problem- solving strategiesprovide extended practice in problem- solving strategies

50. Tips for Managing Behaviour Rules: –post rules visually –review before transitions –be consistent, use predetermined consequences anticipate! frequent feedback (eye contact can redirect), use signals use direct requests “When…then…”

51. Managing Behavior Be supportive, highlight shining moments, encourage child to self-evaluate strengths help the child become self-aware and self- observant (e.g., how do you feel about…? you must be proud that …”) teach a new, positive behaviour to replace negative deliver feedback swiftly and systematically

52. Major points ADHD is a biologically-rooted neurocognitive disability ADHD is more usefully conceptualized as a type of learning disability (rather than just a behavior disorder) Oral language, academic, & cognitive function should be routinely assessed in ADHD Intervention for ADHD will be multimodal & include: –Psychoeducation –Psychopharmacology –Antecedent-focused approaches with metacognitive instruction & environmental modifications –Direct & intense academic instruction

53. The future….Targeted, integrated, and synchronized treatments Pharmacological longer-acting medication target neurotransmitter /neural network systems Psychological/Educational target underlying cognitive processes synchronize with pharmacological treatment, in terms of timing and target problems

54. WWW Resources www.ldonline.org/ld_indepth/add_adhd (Useful articles include: Key components of a comprehensive assessment of ADHD; Talking to your children about their ADD; ADD and Gifted students:What do we really know?; Attention deficit disorder in college) www.ld.org/index.html Includes “tips for Teachers” section for ideas on forming parent-teacher partnerships www.ldresources.com (an extensive on-line compensium of books, videotapes, conferences; Education section has articles on homework, transition plans etc) www.ascd.org/readingroom/edlead/ (Nov 2001 issue of Educational Leadership on understanding learning differences includes the on-line article :Reconceptualizing ADHD by Tannock & Martinussen http://coe.jmu.edu/learningtoolbox viusal cues for each step in a strategyhttp://coe.jmu.edu/learningtoolbox