Attention Deficit Hyperactivity Disorder (ADHD) is common in childhood. Its prevalence in the UK is about 3-9%, using the DSM-IV criteria, and 1-2% using the ICD-10 criteria (NICE, 2008). Thus, ADHD is very likely to be present in each classroom (Cooper & O’Regan, 2001). Its main characteristics can lead children with ADHD to many difficulties in schools (DuPaul & Stoner, 2003).
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Hence, like the dyslexia friendly approach in schools, it is necessary to develop an ADHD friendly approach where the needs of children with ADHD will be met. Besides, an approach which is developed to meet the particular needs of these children will benefit all children (Cooper & O’Regan, 2001). The main purpose of this assignment is to examine the changes or adjustments in policy and practice which are required, in order to develop an ADHD friendly school.
In the first section, I will try to clarify what ADHD is. I will present its characteristics, diagnostic criteria and types. I will examine the controversies in the aetiology of ADHD where genetic, environmental and neurological factors will be presented. Finally, I will outline the characteristics of ADHD which may affect children’s learning. This can be helpful for a better understanding of the teaching strategies presented later.
In the second section, I will examine the strategies which an ADHD friendly school should develop. In particular, as an ADHD friendly approach is a whole school approach, I will divide the good practice into four parts, the schools, the classrooms, the teaching strategies and the family and community.
Firstly, I will examine the policy which is needed for achieving an ADHD friendly school. Then I will focus on the teacher factor commenting on the importance of and need for teachers’ training in ADHD. Secondly, I will refer to the changes which are needed in the classroom, focusing on classroom environment and classroom management, as well as on the assessment of the medication effects. Then I will examine and evaluate the teaching strategies which are necessary for meeting the needs of children with ADHD, focusing on the need for structure and organization, on peer tutoring, multisensory methods and ICT (Information and Communication Technology), as well as on strategies for improving social skills. Finally, I will draw the attention on the relationships between schools, family and community and I will refer to the need of training the parents.
Understanding ADHD
What is ADHD?
ADHD is a medical diagnosis (Holowenko, 1999) which refers to children and adults with significant behavioural and cognitive difficulties (Cooper & Bilton, 2002). The main characteristics of ADHD are impulsivity, hyperactivity and inattention (APA, 2000).
DSM-IV-TR (APA, 2000) (App.1) and ICD-10 (WHO, 1992) (App.2) are the most common criteria which are used for the diagnosis of ADHD. According to DSM-IV-TR criteria there are three main subtypes of ADHD:
Predominantly Inattentive Type (ADHD-I)
Predominantly Hyperactivity-Impulsive Type (ADHD-HI)
ADHD Combined Type (ADHD-C)
ICD-10 refers to the symptoms of ADHD as ‘Hyperkinetic disorders’, not recognising the ADHD-I type, as its editors believe that it constitutes a separate disorder. The display of hyperactive behaviours is the main criterion for the diagnosis of ‘Hyperkinetic disorder’.
Causes of ADHD
There is no single cause in explaining ADHD. The aetiology of ADHD includes genetic, environmental and neurological factors (Brock et al., 2009).
There is strong evidence for the aetiological role of genetic factors in ADHD. Family studies show that ADHD ”runs in families’, with a two- to fourfold increased risk among first-degree relatives’ (Nigg, 2006:194). Sprich et al. (2000, cited in Barkley, 2006:227) found that non-adopted relatives of children experiencing ADHD are more likely to have ADHD in comparison with their adopted relatives. Furthermore, Faraone et al. (2005) mention that in 20 twin studies heritability of ADHD averages approximately 76%, while Barkley’s (2006) review of twin studies showed that the average heritability of ADHD is at least 80-90%. Although these studies indicate that ADHD is highly hereditable, genome and candidate gene research has not identified a single gene of large effect in ADHD, but ‘several DNA variants of small effect’ (NCCMH, 2009:28; Brock et al., 2009).
Neurological factors could also be possible causes of ADHD. According to Brock et al. (2009:19), imaging studies have shown that there are differences in brain development – in the size of the brain and specific areas of it – between children with and without ADHD. Moreover, dysfunctions in the ‘frontal – stratial – cerebellar circuits’ result in the behavioural differences of ADHD (ibid).
Furthermore, environmental factors have also been linked to ADHD. Maternal stress, abuse to smoke (Rodrique & Bohlin, 2005), alcohol and other drugs (Brookes et al., 2006; Ornoy et al., 2001), premature delivery, low birthweight (Botting et al., 1997; Levin, 2006), exposure to toxins, brain injury (Toren et al., 1996), dietary factors (lack of omega 3, colourings, ‘E’ numbers) (Millichap, 2010) are some of them. Additionally, psychosocial factors, such as family stressors and ‘discordant family relationships’ may not cause ADHD, but they affect its expression (Brock et al., 2009; NCCMH, 2008:29).
How does ADHD affect learning?
Children with ADHD experience behavioural, emotional, social and academic difficulties in schools (DuPaul & Weyandt, 2006). The main characteristics of ADHD – which are inattention, impulsivity and/or hyperactivity – affect children in a variety of ways. Except for the primary difficulties (see App.1-2) children with ADHD can have some secondary difficulties (DuPaul & Stoner, 2003; Holowenko, 1999):
academic underachievement and/or learning difficulties
behavioural difficulties
poor peer relationships
low self-esteem (ibid).
Therefore, ADHD could be easily deemed to be a problem. However, the extent to which it could be considered to be a problem depends on the environment in which the individual lives or on his/her ‘compensatory skills’ (Cooper & O’Regan, 2001:27). Thus, educationally, if the teacher supports the student with ADHD by adapting the learning environment to his strengths and weaknesses and by helping him to develop strategies to survive in it, ADHD could not be perceived as a problem anymore but as a difference (ibid).
2. Good practice for an ADHD friendly school
The term ‘ADHD friendly schools’ is related to the terms ‘Dyslexia friendly schools’ (DFS), and ‘inclusive schools’ with the difference that its focus is on children with ADHD. As DFS (Pavey, 2007), ADHD friendly schools should not only be friendly to learners with ADHD, but also mirror maximum effort to understand, supply and help them. Moreover, its focus should not be children’s deficits, but the changes which must be made for supporting these students. Considering the fact that the following points can be beneficial for them in an inclusive environment, an ADHD friendly school should:
Ensure teachers’ awareness of each child’s potential and use of strategies which meet all the targets (NCCMH, 2009).
Use assessment strategies to identify children’s difficulties and ensure scrutiny by the best use of all children’s data (DuPaul & Stoner, 2003, Cooper & O’Regan, 2001).
Monitor children’s development and apply interventions with empirical support when required (DuPaul & Power, 2008).
Perceive ADHD as a difference and not as a disorder/problem and care about the value of emotional intelligence.
Aim not just to cover the curriculum, but to adapt it to children’s needs (Cooper & O’Regan, 2001) by giving more importance to strengths than weaknesses (Wodrich, 2000).
Evaluate progress (Cooper & O’Regan, 2001).
Schools
Policy
The Code of Practice for Special Educational Needs (SEN) promotes inclusion indicating that the needs of the children with SEN have to be met in mainstream classes (DfES, 2001). It doesn’t refer to ADHD as a specific category of SEN, but it refers to children ‘who demonstrate features of emotional and behavioural difficulties, who are withdrawn or isolated, distruptive and disturbing, hyperactive and lack concentration’ (para 7.60). Therefore, all schools have to understand the needs of children with ADHD and accommodate their learning process in a way which accords with their needs. An effective whole school policy which celebrates individual differences and affords effective learning and emotional and behavioural support benefits all children (Cooper & Bilton, 2002).
The development of an ADHD friendly school is a whole school approach and so, a well-documented and clearly defined policy which support and reflect practices is necessary. SEN policy, behaviour policy, homework policy, differentiation, teaching, learning, timetabling, environmental factors, monitoring, assessment and inclusion are the main policies which must be reviewed by a school (Couper & Bilton, 2002). Moreover, attention should be given in bullying policy as research shows that children experiencing ADHD are at ‘increased risk’ for being bullies or targets (Unnever & Cornel, 2003:144). It should also involve all these people who contribute to students’ development, such as parents and wider community (Thacker et al., 2002).
Teacher training
The key to meeting the needs of all children lies in the teacher’s knowledge of each child’s skills and abilities and the teacher’s ability to match this knowledge to finding ways of providing appropriate access to the curriculum for every child. (DfES, 2001:para 5.37)
Teachers’ knowledge about ADHD seems to be crucial for the development of children with ADHD. In particular, as teachers are in daily contact with these students, they are the first to identify characteristics of ADHD and they can provide valuable information for the diagnosis (Weyandt et al., 2009; Sherman et al., 2008; Sac & Kautz, 2003). Moreover, they have a crucial role in the implementation of the specialised educational interventions for the students and, as a result, in their academic achievement and behavioural outcomes (Pfiffner et al., 2006). Pfiffner et al. (2006) stress the importance of teachers’ understanding of these students’ needs for the establishment of a positive relationship between them which can contribute to positive academic and social outcomes. These outcomes can also be influenced by teachers’ views over ADHD and its treatment (Sherman et al., 2008). Arcia et al. (2000) also indicate that the nature of these students’ needs demands skillful teachers willing to devote enough time for them. Furthermore, according to a research in the UK, most of parents discuss their concerns about their children with teachers asking for advice (Sayal et al., 2006). It is obvious, therefore, that teachers should be informed about ADHD and trained.
However, many studies have shown that teachers receive little training about ADHD (Jones & Chronis-Tuscano, 2008), they lack information and have misperceptions about this disorder (Weyandt et al., 2009; Sciuto et al., 2000; Arcia et al., 2000). In the US, teachers were found to be informed about ADHD symptoms and diagnosis but not on its nature and treatment (ibid). They also appear to lack knowledge on implementing behavioural management (Arcia et al., 2000). In the UK, teachers’ knowledge and experience about ADHD are variable (NCCMH, 2009).
As lack of teachers’ understanding about ADHD constitutes a great obstacle in meeting the needs of children experiencing ADHD, their training is necessary. Training may improve outcomes (NCCMH, 2009). In Arcia et al. (2000) study, teachers who received training, reported that their confidence increased and they were more able to implement behavioural management and to adjust the lessons. Weyandt et al. (2009) highlight that a better teachers’ understanding of ADHD will help them to have more realistic expectations from their students and as a result, they can avoid their frustration and negative effects on their students’ self-esteem.
Training should be enhanced both at pre-service and in-service stages (NCCMH, 2009). According to NCCMH (2009), teachers need to be informed about possible behavioural difficulties that children with ADHD experience and the reasons of this behaviour and also to have some training in ways of managing these behaviours and using behaviour plans. They also need to be able to adapt lessons for pupils with ADHD and to cope with the stress caused by these children in the classroom (ibid). Pfiffner et al. (2006) and NCCMH (2009) mention that training needs time to be effective. Abey et al. (2004, cited in NCCMH, 2009:218) suggest that 30 hours of in-service training are necessary for ‘sustained changes’. Furthermore, collaboration between teachers and other professionals (school psychologist) will make their training more effective (Pfiffner et al., 2006:550).
Classroom
Classroom environment
Classroom environment plays an important role in the development of all children and especially those with ADHD. The classroom should be structured, controlled and well-organised (Pfiffner et al., 2006; Farrell, 2006; Holowenko, 1999). Daily schedule, classroom rules and feedback charts should be posted for achieving a better function of the classroom with the minimum repetitions of the rules. Cooper and O’Regan (2001) underline that clear and predictable structure benefits all children.
DuPaul and Stoner (2003) mention that classroom arrangements should be planned in a way that the participation in activities can be ensured and opportunities for learning are not restricted. The classroom should be quiet so that no one could distract the children (Holowenko, 1999). Pfiffner et al. (2006) recommend enclosed classrooms for minimising noise and visual distractions. Furthermore, teachers should seat the child with ADHD near them so that they can monitor their behaviour, avoid possible disruptive behaviours and also help the child to attend and follow instructions through better eye contact with him/her (Pfiffner et al., 2006; Wodrich, 2000; Cooper & Bilton, 2002; Holowenko, 1999). In addition, the provision of a quiet place which students can use at certain times is very helpful for those experiencing ADHD, as their attention problems increase their need for quietness (Cooper & Binton, 2002; Holowenko, 1999).
Furthermore, teachers should prepare a supportive learning environment where children will feel secure, valued, understood and unstressed (Holowenko, 1999). This could be achieved by extending the opportunities for success, making them feel accepted, supporting them with positive recognition, using positive language and building their self-esteem (Cooper & Bilton, 2002). Teachers should gain children’s attention and interest by presenting the lesson in an enthusiastic way, allowing children’s participation and giving to them frequent, specific and immediate feedback (Pfiffner et al., 2006; Holowenko, 1999).
Classroom management
Instructions, rules and expectations should be clear and teachers should secure the attention of the children before giving them and ensure that they understood them (DuPaul & Stoner, 2003; Wodrich, 2000). In managing children’s behaviour, emphasis should be given on positive reinforcement (Holowenko, 1999; Pfiffner et al., 2006). Appropriate behaviours should be praised and encouraged by ‘small and immediate rewards’ (Cooper & Bilton, 2002:63) which seem to be more effective if teachers change them regularly and give them a funny and interesting aspect in order to keep children motivated (Pfiffner et al., 2006). Stickers or points for a preferred activity are some good tokens which teachers can use (ibid).
Nevertheless, research shows that child management is more effective when positive approaches are combined with mild use of negative consequences when it is necessary (Pfiffner & O’Leary, 1987; Pfiffner et al., 1985). Reprimands, response cost and time-out from positive reinforcement are some effective strategies (DuPaul & Weyandt, 2006; Pfiffner et al., 2006; DuPaul & Stoner, 2003). Reprimands and response cost strategies can improve on-task behaviour, academic productivity and acceptable classroom behaviour when they are clear, brief and direct and delivered in a calm and firm manner (Pfiffner et al., 2006; Wodrich, 2000; DuPaul et al., 1992). Response cost pertains to the withdrawal of a reinforcer in case of unacceptable behaviour (Pfiffner et al., 2006). DuPaul and Power (2000) highlight that students should receive more positive reinforcement than negative one, otherwise they may be discouraged and led to minimal behaviour changes. Finally, time-out from positive reinforcement should be the ‘last resort’, monitored very thoroughly (DuPaul & Stoner, 2003:157), as it could reinforce children in some circumstances (e.g., child wants to avoid work or to stay alone) (DuPaul & Power, 2000) and it should be brief as long time-outs may be nonproductive (DuPaul & Power, 2000).
Furthermore, self-management strategies (self-monitoring, self-evaluation, self-reinforcement) can be combined with the above strategies and be effective in improving behavioural and academic performance of children with ADHD (Pfiffner et al., 2006). These strategies increase their self-control as they are taught to monitor, evaluate and reinforce their own behaviour (DuPaul & Weyandt, 2006, DuPaul & Stoner, 2003).
Assessment of the medication effects
In the UK less than 1% of school-aged children are receiving medical treatment for hyperactivity (NICE, 2000), while in the US this percentage is 2-2.5% (Cooper, 2001). So, teachers should be educated about the medicines and their effects, in order to be able to observe the pupil, monitor the positive and negative effects of medication, and collect information about the effectiveness of the treatment (Cooper & Bilton, 2002; Selikowitz, 2004). In addition, teachers can use the time the child is on medication as a ‘window of opportunity’ for teaching them strategies to cope and organise themselves (Bentham & Hutchins, 2006:84; Cooper, 2001:393; Hill, 1998:383).
Effective Teaching strategies
Structure and organisation
Children with ADHD benefit when classroom lesson and activities are structured and predictable (Pfiffner et al., 2006; Brock et al., 2009). Teachers should provide daily schedules, lessons outlines and also help pupils to structure their time (Brock et al., 2009; Weyandt, 2007). Moreover, teachers should break tasks into subunits, set achievable goals and deliver lessons in a variety of learning styles in order to increase attention, decrease frustration and achieve the greatest progress (Raggi & Chronis, 2006). Zentall and Leib (1985) examined the effectiveness of structured tasks with children with and without hyperactivity and found that activity levels reduced in all them.
Peer tutoring
Students with ADHD could also benefit from Peer Tutoring, which refers to paired working on an academic task between two students, one of whom provides assistance and feedback to the second one. According to Raggi and Chronis (2006), its advantage is that it provides one-to-one personalised instructions, straight feedback and active involvement of children. It can also improve peer relations (Pfiffner et al., 2006). DuPaul et al. (1998) examined the effectiveness of ‘ClassWide Peer Tutoring’ (Greenwood et al., 1988 cited in DuPaul et al., 1998:580) and found that it is an effective strategy for students with and without ADHD as it increases their attention, accuracy and academic achievement. This strategy can have better success when teachers provide guidance and structure (Wodrich, 2000) and also pay attention in pairing children experiencing ADHD with appropriate-behaved children (Pfiffner et al., 2006).
Multisensory methods
According to Agnew et al. (1996, cited in O’Regan, 2002:20) ‘we remember 20% of what we read, 30% of what we hear, 40% of what we see, 50% of what we say, 60% of what we do and 90% of what we see, hear, say and do’. Mackay (2006) highlights that including all the senses in the process of learning, thus providing information in a variety of ways, makes learning more permanent. This is underlied by the ‘multiple intelligence theory’, according to which, each type of intelligence learn in a different way (Gardner, 1993). Hence, teachers should vary their lessons by providing verbal and written instructions, visual aids, colorful flashcards, games, video-clips, demonstrations and other activities (Wilkinson & Lagendijk, 2007; Weyandt, 2007). Moreover, computer programmes can also be very helpful for applying multisensory methods (ibid).
Use of ICT (Information and Communication Technology)
The use of ICT can be a very useful tool for teachers and can benefit all children, with and without ADHD (Westwood, 2007). It seems to increase children’s motivation, attention and productivity and also give them enthusiasm and increase their confidence (Wilkinson & Lagendijk, 2007; Westwood, 2007; Raggi & Chronis, 2006; DuPaul & Stoner, 2003).
The merits of ICT could be encapsulated in the following points:
Clear demonstration and modelling of instructions (Westwood, 2007; Weyandt, 2007; Pfiffner et al., 2006; DuPaul & Stoner, 2003)
Active participation
Provides straight feedback
Highlights essential material
Simplifies tasks
Provides a multisensory environment (ibid)
Has unending patience (Westwood, 2007)
Provides learning through game formats (DuPaul & Stoner, 2003)
Provides a safe environment (Wilkinson & Lagendijk, 2007)
Wilkinson and Lagendijk (2007), DuPaul and Stoner (2003) and Wodrich (2000) highlight that although the use of ICT has many advantages which are suitable for teaching pupils with ADHD, few studies have examined its effectiveness for them. According to DuPaul and Eckert (1998:68-69), two studies (Kleiman et al., 1981; Ford et al., 1993) indicate that computer-assisted instruction (CAI) software provide some development in work productivity and attention behaviours. Furthermore, Ota and Dupaul (2002) and Mautone et al. (2005) examined the effectiveness of CAI for increasing math achievement of three children experiencing ADHD. They found that children’s attention increased, off-task behaviours decreased and also their performance had some development (ibid).
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Improving social skills
In the framework of an ADHD friendly school, the characteristic difficulties of these children in peer relationships (DuPaul & Stoner, 2003) should also be addressed. Social skills training (SST), however, seems to have little effect on them (Pfiffner et al., 2006; Quinn et al., 1999). This can be explained by the fact that they do not always lack social skills (Pfiffner et al., 2006), but they have deficit in ‘social performance’, namely they cannot apply the rules for social interaction, although they know them (DuPaul & Stoner, 2003:229). According to McQuade & Haze (2008), this argument is based on particular cognitive deficits of these children, which have a negative effect on their ability to interact socially. This difficulty in social interaction is further reinforced by their poor emotional understanding (Kats-Gold & Priel, 2009).
Consequently, SST should develop further to become compatible with their needs (Quinn et al., 1999). Mrug et al. (2001) suggest its combination with other strategies which address their specific cognitive deficits and, in particular, by reinforcing the appropriate behaviours and discouraging the negative ones. It is crucial to focus not only on the behaviour improvement of children with ADHD, but also on their peers’ behaviour towards them in order to improve children’s acceptance. Moreover, children experiencing ADHD should have plenty of opportunities for practising the skills they have acquired in order to maintain and generalise them (ibid). These strategies should also not ignore the aspect of these children’s emotional functioning (Kats-Gold & Priel, 2009).
Family and Community
Collaboration and communication
An ADHD friendly school should interact with the families and the community agencies which help children with ADHD. In particular, not only the assessment of ADHD but also the evaluation of ADHD interventions are complicated processes which demand the cooperation of multiple factors in different settings, such as teachers, parents, physicians and psychologists (DuPaul & Stoner, 2003). Therefore, clear communication and collaboration between them is a ‘cornerstone’ for the effective support of children with ADHD (DuPaul & Stoner, 2003:241; Montaque & Castro, 2005:413).
Furthermore, teachers should help parents to understand ADHD and the strategies which the school apply to support their children. They should also be in regular contact with them in order to discuss about child’s progress, the interventions which take place (Selikowitz, 2004; Wilkinson & Lagendijk, 2007) and to adjust goals (DuPaul, 2007). ‘Daily report cards’ can play a very useful and constructive role in their communication as they provide daily quantitative feedback and information about child’s performance and an ‘ongoing forum’ for their communication (DuPaul & Stoner, 2003:158). This strategy can be used in the framework of a home-based ‘token economy system’ (ibid).
Parent Training (PT)
As mentioned above (1.2), parental factors are associated with the behavioural characteristics of ADHD. Therefore, PT appears to be an important supplementary strategy for the achievement of the aims of an ADHD friendly school. NCCMH (2009) underlines that parents should be informed by schools about local PT programmes. Moreover, DuPaul & Stoner (2003) mention that schools can also provide these programmes, especially when the community does not provide them. PT aims at improving the relationships between parents and children (Anastopoulos et al., 2006; NCCMH, 2009), helping parents to interact less stressfully and more effectively with them bringing about positive changes in their behaviour (ibid). According to NICE and SCIE (2006) these programmes should:
Be structured
Focus on social learning theory
Teach strategies for improving relationships
Contain 8-12 sessions (1.5-2 hours per week)
Empower parents in discovering their ‘own parenting objectives’
Include role-play through sessions and homework between them
Be delivered by well-trained facilitators
‘Adhere to the programme developer’s manual’
Research has shown that PT programmes are very effective as they produce:
Reductions in
inattention and overactivity (Anastopoulos et al., 1993),
child non-compliance and conduct problems (Pisterman et al., 1989),
child aggression (Anastopoulos et al., 1993)
parent stress (Anastopoulos et al., 1993; Weinberg, 1999)
Improvements in
parenting skills (Pisterman et al., 1989, 1992)
parental knowledge and understanding of ADHD (Weinberg, 1999)
parent-child relations (Anastopoulos et al., 2006)
parent self-esteem (Anastopoulos et al., 1993; Pisterman et al., 1992)
Conclusions
In this assignment I have attempted to examine and evaluate the policy and practice of a school which is friendly for children with ADHD. These children experience behavioural, emotional, social and academic difficulties in schools (DuPaul & Weyandt, 2006). From an ADHD friendly perspective, these difficulties can be just differences if effective strategies are followed.
An ADHD friendly approach is a whole school approach. Schools should follow clear whole school policies which celebrate individual differences and afford the maximum learning, emotional and behavioural support. Moreover, teachers’ training is crucial in order to increase their knowledge about each child’s potential and to implement the right strategies. Classroom environment should be structured, controlled and well-organised and its management should put emphasis on positive reinforcement with some mild negative consequences when and if it is necessary.
Providing highly-structured and well-organised lessons and activities, which involve the use of ICT, multisensory methods and peer tutoring appear to have a positive impact on the attention and learning of children with ADHD. Similarly, improving these children’s social skills through strategies which are compatible with their needs seems to be fundamental for an ADHD friendly school. Furthermore, collaboration and communication between schools, families and community should be a ‘cornerstone’ for the success of this approach. Besides, what should be taken into consideration is that ‘the implementation of the right strategies in the context of the right relationships’ is essential for the development of students with ADHD (DuPaul & Power, 2008:519).
What is very important about this approach is that, although the strategies it should use, have been developed to meet the specific needs of students with ADHD, they also seem to be beneficial for all students (Cooper & Bilton, 2001). However, although all these strategies have been researched separately, they have never been researched in the framework of an ADHD friendly school, which should be a whole-school approach, as it has happened in the case of dyslexia-friendly schools.
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