ADHD in Classroom Strategies: Literature Review

To what extent can teachers make provisions for pupils with ADHD (Attention-Deficit Hyperactivity?Disorder) in the mainstream classroom?

CONTENTS (JUMP TO)

Section 1: Referenced Extracts

Section 2a Part One: Analysis and Critical Evaluation of the Issue

Section 2b Part Two: Examination of the Practical Implications for Primary School Teachers

Section 3: Copies of Extracts

Section 4: Bibliography Sources and Further Reading

Section 1: Referenced Extracts

(1) Quarmby, K. (Tuesday 6 December, 2004) Rebels without a Cause: Children with Behaviour Problem are Increasingly Diagnosed with ADHD, in, Education Guardian, pp.1-3

(2) The Disorder named AD/HD: What we know (2004) National Resource Centre for AD/HD: Children and Adults with Attention-Deficit Hyperactivity?Disorder (CHADD; http://www.help4adhd.org/en/about/what/WWK1.pdf , p.2

(3) Rafolovich, A. (2005), Exploring Clinician Uncertainty in the Diagnosis and Treatment of Attention-Deficit Hyperactivity-Disorder, in, Journal of Sociology of Health and Illness, Volume 27, Number 3 London: Blackwell, pp.306?310

(4) Northen, S. (Friday 26 November, 2004), Feed your Head, in, The Times Educational Supplement, p.3

(5) Spencer, T. et al (1995), A Double-Blind Cross?Over Comparison of Methylphenidate and Placebo in Adults with Childhood Onset Attention-Deficit Hyperactivity-Disorder, in, Archives of General Psychiatry, Volume 52, pp.434-443

(6) Education Guardian Opinion (Tuesday 10 October, 2006), p.4

(7) Handy, C. and Aitken, R. (1986) Understanding Schools as Organisations London: Penguin, p.13

(8) Chowdhury, U. (2004) Tics and Tourette’s Syndrome: a Handbook for Parents and Professionals London and New York: Jessica Kingsley, p.115

(9) Raphael Reed, L. (1995) Reconceptualisng Equal Opportunities, in, Griffiths, M. and Troyna, B. (Eds.), Antiracism, Culture and Social Justice in Education Stoke?on?Trent: Trentham, p.88

(10) Guiding Principles for the Diagnosis and Treatment of Attention?Deficit Hyperactivity?Disorder (2006), Presented by the Attention Deficit Disorder Association (ADDA); http://www.add.org/pdf/GuidingPrinciples021206Rev[1].pdf , p.2

(11) Jones, A. (August 2004) Clinical Psychology Publishes Critique of ADHD Diagnosis and Use of Medication on Children, in, Psychminded Website; http://www.psychminded.co.uk/news/news2004/august2004/Clinicalpsycholgy

(12) Swanson, J.M. and Castellanos, F.X. (2002) Biological Bases of ADHD – Neuroanatomy, Genetics and Pathophysiology, in, Jensen, P.D. and Cooper, J.R. (Eds.), Attention Deficit Hyperactivity Disorder: State of the Science Kingston: New Jersey, pp.71-72

(13) ADHD: Strategies for Primary School Teachers; http://premium.netdoktor.com/uk/adhd/living/school/article.jsp?articleIdent=uk.adhd.living.school.uk_adhd_xmlarticle_004691

(14) ADHD in the Classroom – What Helps; http://www.adhd.com/educators/educator_communication_difficulties.jsp

(15) Selikowitz, M. (2004) ADHD: the Facts Oxford: Oxford University Press, p.154

(16) Stein, D.B. (1999) Ritalin is not the Answer: a Drug-Free, Practical Programme for Children Diagnosed with ADD or ADHD New York: Jossey Bass Wiley, Preface

Section 2a Part One: Analysis and Critical Evaluation of the Issue

The issue of ADHD is one of the most pressing contemporary concerns within the broader educational sphere of making adequate provisions for children with learning difficulties. With the help of scientists and the media, ADHD has been transformed from a relatively unknown illness of the brain to a well known national problem for thousands of schoolchildren. The increase in awareness has been accompanied by a steep rise in the number of children being diagnosed with the disease. “The National Institute for Clinical Excellence (NICE) estimates that as many as 500000 children in the UK may have ADHD and, of these, as many as 100000 may be seriously affected.”(1) Unbelievably, this figure amounts to approximately one in twenty of all British schoolchildren. With figures constantly on the rise and awareness increasing in tandem, it is clear that ADHD is, at the beginning of the twenty first century, a highly important concern for any mainstream primary school teacher.

In comparison to other behavioural problems experienced by young people, the illness is relatively new (at least in terms of its recognition from psychiatrists and general practitioners) and, as such, often causes confusion and misunderstanding when the issue is raised in the classroom. Tourette’s syndrome, for example, has a ten year advantage over ADHD in terms of public awareness and forthright medical opinion. Moreover, the illness is also notoriously difficult to accurately quantify with rather ambiguous symptoms like ‘inattentiveness’ and ‘a lack of concentration’ used as precursors to a diagnosis of attention?deficit hyperactivity?disorder. ADHD is consequently considered to be a highly controversial illness that has the medical community split over whether it is a disability in the traditional sense or whether it is a neurological malfunctioning on the part of the child or individual in question. This is not an easy problem to solve not least because of the scarcity of medical facts.

Indeed, the medical facts that are known are somewhat ambiguous and rely heavily on subjectivity rather than objectivity, which would bequeath an improved perspective for scientists and teachers alike. It has, however, been concluded that the illness begins no later than the age of seven and patients who are first diagnosed as ADHD sufferers in adulthood must have displayed the core symptoms from the age of seven to receive treatment for attention?deficit hyperactivity?disorder – this places the issue directly within the realm of the primary (as opposed to the secondary) school teacher as the first tell-tale signs must be evident before the age of seven (year three).

It is therefore prudent to detail these core symptoms of the disease so that the primary school teacher may be in a position to offer better advice to parents and doctors as to the condition to one of their pupils. For this, analysis must turn towards the USA, which is the leading country in terms of diagnosing, treating and including children with the illness in national classrooms. Thus, according to the American National Resource Centre for AD/HD, symptoms can be split into two separate categories (2). The first category comes under the heading of ‘inattention’. The chief features of this are:

Making careless mistakes in homework, in class and in other related activities. Failing to pay close attention.
Difficulty maintaining attention during work or play.
Appearing as if not listening when clearly being spoken to.
Failing to follow simple instructions in class.
Have difficulties with organisation.
Avoiding work with a sustained amount of mental excursion, such as homework or tests.
Loses things.
Easily distracted.
Forgetful in daily activities.

The second category used for ascertaining the most visible symptoms of ADHD comes under the heading of ‘hyperactivity-impulsive behaviour’. The core features of this particular behavioural manifestation are:

Constant ‘fidgeting’ in class with hands or feet. ‘Squirming’ in chairs.
Running or climbing at inappropriate times.
Has difficulty remaining seated.
Difficulties in maintaining silence during quiet play times.
Failing to wait for turn in class.
Interrupting teachers and fellow pupils at inappropriate times.
Act as if they are on a ‘motor’.

It is immediately evident from just a brief overview of the symptoms that ADHD is open to a wide variety of claims of inaccuracy with regards to diagnosis as well as excessive interference on the part of parents, teachers and the state, which has made the cause of children with learning difficulties a chief domestic policy since the end of the twentieth century. Sceptics naturally point to the many years before ADHD became a well known disorder (during the 1980s’) as evidence that the illness has been blown out of proportion (help groups, on the other hand, say this is merely evidence of the way in which the illness has been avoided by education professionals for so long.)

Furthermore, according to an empirical study compiled by Adam Rafolovich (3), even doctors retain strong reservations about diagnosing a child with ADHD on the grounds of the fertile ground for misconception that exists with concerns to the symptoms highlighted above. For instance, there can be little doubt that there is a very fine line between defining a child as ‘clinically inattentive’ and simply viewing that same child as lazy and disinterested in the subject matter at hand. Likewise, the same problem persists with any variety of the core symptoms of ADHD, which are often too close to everyday behavioural disorders that should be expected in children as young as seven or eight. Once again, it is not difficult to understand the sceptic’s point of view, especially when considering that the modern variation of schooling is a lot more pupil friendly than was the case forty or fifty years ago.

Psychiatric experts and doctors are likewise divided over the best means of treatment available to children who have been satisfactorily diagnosed with ADHD. In the 1990’s, medication was seen as by far the most viable route to inclusion in the classroom with the ‘wonder drugs’ Ritalin and Concerta witnessing an explosion in sales at this time. Prescriptions for these two drugs have leapt from 6000 in 1994 to around 345000 by 2003. This marked increase is testimony to the way in which ADHD has become a serious problem for all mainstream teachers, particularly those who work in primary schools. In addition, there have been grave concerns voiced by doctors, parents and teachers regarding the moral aspect of prescribing a child as young as five or six a powerful, sophisticated neurological drug that alters the way the brain perceives key data. Young people’s brains do not fully develop until well into adolescence and often beyond; thus, the risks in having children become dependent on medication at such a young age should be obvious to all concerned. Moreover, as Stephanie Northen (4) points out, the fact that ADHD is seen as a biochemical imbalance in the brain requiring a pharmaceutical treatment while, at the same time, dyslexia is seen as a solely educational problem that has no connection with the brain, severely tests the rationale behind the way that the illness is currently being classified and treated. In many cases the difference between the two is only the opinion of a teacher, doctor or mental health observer.

On the whole, however, medication has proved to be a success in young children with ADHD at least in terms of lessening the tendency for public outbursts and school time tantrums. Research conducted by the MTA Co?Operative Group at the end of the twentieth century discovered that approximately 70 to 80% of school children with ADHD reacted positively to psycho stimulant medications. Significant academic improvement has likewise been noted with an increase in attentiveness in the classroom, compliance on group related tasks and a greater accuracy evident in homework, coupled with a decrease in activity levels, impulsivity, negative social behaviours in groups and verbal hostility (5). The implications of medication and the effects that this can have on a child who displays the key symptoms of inattention, impulsivity and hyperactivity will be discussed in greater detail in Part Two of the discussion, but, at this point, the important point to note is the relatively high level of success of prescription drugs in the effort to minimise the negative

The other major option with regards to effective treatment is the option of psychotherapy involving a mental health expert and groups of child sufferers of ADHD. Utilising a form of cognitive behaviour therapy, qualified experts are able – over time – to challenge the way in which children react to certain environments and situations – those situations that had previously led to evidence of what are considered to be the core symptoms. ADHD ‘coaches’ also help the child to prioritise, organise and develop interactive skills that will lessen the chances of that child experiencing a sense of social exclusion. There are also a number of problems with this kind of therapy not least the obstacle concerning the considerable costs incurred via employing a mental health professional in the current NHS climate. Theory and practice therefore still stand some way apart when it comes to the ideal means of treating children with ADHD faced with the reality of NHS staff shortages and a scarcity of private sector mental health experts who concentrate solely on children with learning difficulties.

There is also the significant problem of stigmatisation when a child is diagnosed and then treated for ADHD or, indeed, any other mental health problem. To understand the severity of the issue, one need only look at the way that the adult labour force in the UK discriminates against employees who have a mental health issue in order to understand the way in which playgrounds can become a source of intensive bullying, especially below the age of eight according to the Guardian Education Opinion in October 2006 (6). When one considers the fact that schools are, according to Charles Handy and Robert Aitken (7), not at all dissimilar to adult commercial organisations, it becomes even more clear that bullying and peer pressure are significant issues when it comes to schooling children with learning difficulties and behavioural problems, which ADHD obviously entails. As Uttom Chowdhury declares, the more a child stands out as different from his or her classmates “because of associated behaviours such as impulsivity, poor handwriting and academic difficulties” (8) the greater the likelihood of bullying and social exclusion. Primary school teachers would have a pivotal role to play in the cessation of bullying on the grounds of a mental illness, in addition to maintaining an effective social balance within the classroom. Furthermore, a pupil who suffers from ADHD is bound to display signs of low self esteem, regardless of bullying in the playground or peer pressure within the classroom. Low self esteem – combined with the unpredictable side effects of the medication as well as mitigating factors that may be occurring at home, means that the task of a mainstream primary school teacher is made all the more time consuming.

It can be seen that attention?deficit hyperactivity?disorder is not only a highly topical issue that is bound to increase in significance in the coming decades, but that it is also a highly problematic area of debate for public education and child welfare due to the ambiguity that resides at the heart of the diagnosis of the condition. While there are a number of tell?tale signs that a child may be suffering from ADHD there are also any number of alternative reasons as to why a student appears to be veering away from the carefully constructed consensus of a primary school classroom. Ultimately, some children would just prefer not to be in school at all. With this in mind, it is prudent to turn attention towards the implications for teachers who wish to advance the governmental policy of social inclusion in the classroom by understanding how ADHD can be married with an award for Quality Teacher Status.

Section 2b Part Two: Examination of the Practical Implications for Primary School Teachers

Section 3.2.4 of the Standards for the Award of Qualified Teacher Status declares that teacher should, “identify and support more able pupils, those who are working below age-related expectations, those who are failing to achieve their potential in learning, and those who experience behavioural, emotional and social difficulties.” Clearly, therefore, with regards to pupils with ADHD, the most pressing concern for primary school teachers is the need to maintain a healthy social balance within the classroom without ostracising the child with the learning difficulty. Inclusiveness must consequently be the teacher’s main priority if they are to fulfil the most basic precept of the QTS. “All children need someone to mediate their learning, but sometimes this feels especially true for children with special educational needs.” (9)

This is a tried and tested educational tightrope that cannot be replicated in a college classroom, in an academic book or in an education?specific journal. Rather, this challenge can only be met through experience. This is, of course, not to state that there are not certain features and attributes that the teacher can learn so as to be in a more advantageous position to deal with potential sufferers of ADHD. The most obvious place to begin would be the acquisition of help from a more experienced teacher – one who hopefully has coped with the demands of teaching children with learning difficulties beforehand, even if the difficulty in question is not ADHD. This would equip the recently qualified primary school teacher with the ability to deal more efficiently with children in the classroom who have already been diagnosed with the illness as well as those pupils that have yet to be diagnosed but who are nonetheless showing a variety of signs of ADHD. This is an important point because, according to the ‘guiding principles for the diagnosis and treatment of attention-deficit hyperactivity?disorder’, ADHD should be “suspected but never presumed.” (10)

Section 2.4.1 of the Standards for the Award of Qualified Teacher Status states that: “they [the qualified teacher] understand how pupils’ learning can be affected by their physical, intellectual, linguistic, social, cultural and emotional development.” With regards to pupils with ADHD, this would involve the ability to liaise with the child’s parents. This has two obvious benefits. The first is to better understand the child’s home life, which experts agree is a vital factor in the formation of the disease, especially if said home life is noticeably chaotic, abusive or violent. “More regard should be given to a child’s social circumstances, experience and history in understanding their behaviour.”(11) Secondly, research has indicated that there are certain generic attributes of ADHD that run through families, which makes the issue of maintaining an effective, coherent working dialogue with the parents of ADHD sufferers all the more imperative (12). Although the illness is inherently complex, involving a cross?over of many genes, there is a strong likelihood that one of the parents will also show signs of ADHD, making empathy with the child easier in the process.

The Standards for the Award of Qualified Teacher Status also require the primary school teacher to be able to effectively plan lessons for all pupils in the class. Moreover, as of January 2002, a revised SEN code of practice dictated that “all teachers are SEN teachers.”(13) Clearly, children with learning difficulties pose unique problems for the planning of lessons, none more so than those pupils with ADHD, which is an inherently disruptive and anti?social illness. Communication between the teacher and the student (not to mention communication between the student and his classmates) is therefore a major problem. Fortunately, there are a number of study aids that are available for teachers to consult. For instance, the official ADHD website in the US offers invaluable advice on how best to manage children with the illness in a classroom setting (14). The following constitutes a small extract of what the organisation considers to be useful information for educators. It should be interpreted as an Individual Education Plan (IEP):

Refrain from ‘popping’ a question which requires a speedy answer.
Give the student extra time to answer questions. For example, use up time by writing on the blackboard.
Speak slowly and provide information in small units. This is especially helpful in the classroom.
Reinforce verbal instructions and lessons with written materials, or by writing on the blackboard.
Work closely with the student to determine and accommodate his or her individual needs.

There are likewise a number of books that have been published in recent years that are a source of encouragement for primary school teachers. Mark Selikowitz, for example, gives advice on the structural planning of the classroom for students with ADHD: “the child with ADHD should be seated at the front of the class near to the teacher’s desk. The old idea of putting the ‘naughty’ child at the back of the class…is totally inappropriate if the child has ADHD.” (15)

Teachers must also be constantly aware of the dangers inherent in educating children who are prescribed powerful doses of medicine. In his critique of the culture of prescription drugs prevalent in the USA and the UK, David Stein warns of the side?effects of Ritalin, which include insomnia, tearfulness, rebound irritability, personality change, nervousness, anorexia, nausea, dizziness, headaches, heart palpitations, and cardiac arrhythmia. (16)

Finally, in accordance with Section 3.3.1.4, tutoring a child with ADHD allows the qualified teacher to test their ability to effectively manage instances of bullying and harassment. Where a child with ADHD is concerned, bullying is especially relevant due to the potentially volatile outbursts of the child in question as well as taking into account the reaction of those classmates who do not understand ADHD. As is the case when constructing an IEP, the primary school teacher must be able to use common sense in order to properly tailor classroom and playground management for the specific needs of the child in question. No two ADHD sufferers are likely to display the same characteristics of the disease.

Section 3: Copies of Extracts

(1)

26 November 2004 – Times Educational Supplement – Feed Your Head

By Stephanie Northen

You are what you eat, according to an Oxford University scientist who is spreading the message that diet is the key to behaviour, mood and learning. Monty Python had a phrase for it: “And now for something completely different.” “That’s what it’s like for me addressing an education conference,” says Alex Richardson. The Oxford University scientist gets plenty of practice at public speaking. Recently she has given the keynote speech at the York festival of food and drink, talked about fish at London’s Royal Institution, and briefed Scottish MPs on autism. And what is she telling them? That what you eat affects how you learn, how you feel and how you behave. For Dr Richardson, who has spent the past decade studying the issue, the links between a healthy diet and a healthy brain are obvious. Yet many people still need persuading. “People ignore the brain,” she says. “But isn’t it obvious that, without the right nutrients, your brain, as well as your body, is not going to function properly?” Initially concentrating on the role of fish oils in treating dyslexia (see below), her work has broadened to cover the influence of diet on learning, mood and behaviour. In 2003, she co-founded the Food and Behaviour Research Group to spread the word and share the work. Over those years she has learned to control a deep-seated impatience with the kind of muddled thinking that once assured her dyslexia didn’t exist. Judging by her list of speaking engagements, she is winning the argument. It has not been easy. Money is often in short supply, as is open-mindedness. “My work bridges health and education and has huge implications for both. But when it comes to education, many people feel threatened by anything biological. They try to dismiss it as irrelevant.” Dr Richardson, the daughter of two teachers, is familiar with the workings of the education world. As a student, she reached what many would consider the top of the pile, graduating in politics, philosophy and economics at Oxford. Yet her success unsettled her. “I found it easy to play the exam game, yet I never got any satisfaction from it because I wasn’t engaged with the subjects.” She remembers an end-of-year exam. “It was on French political history. I had done nothing, but a kind soul brought me his essays at 9am, for the exam starting at 9.30am. I read, read, read and absorbed, went into the exam, let it all out, and I did fine. But it was so unsatisfying, and so unfair.” This sense of unfairness has been a powerful influence on Dr Richardson, now a senior research fellow at Mansfield college. It affected her career choice, or lack of one. “I graduated during the first Thatcher government, the time of yuppies and everyone for themselves. Most people who did PPE at Oxford disappeared to the City to make lots of money. Their golden hellos made me think, ‘Goodness! A salary like that for someone I’ve seen in the pub for the past three years’. Is that really the value society puts on first-class degrees? But I could never see myself in that kind of environment.” Instead, she slipped into the kind of teaching work that abounds in Oxford. She got a job at a tutorial college, otherwise known as a crammer. “If both your parents are teachers, the one thing you decide you are not going to be is a teacher. It was ironic that I found myself drifting that way, but I thoroughly enjoyed it.” Soon she added a PGCE to her degree, eventually ending up at a tutorial college in Stoke-on-Trent. There she met Michael. The boy was clearly affected by dyslexia, but Dr Richardson had been told by her teacher trainers that such conditions did not exist; they were merely middle-class excuses for failure. Dr Richardson taught Michael A-level economics, and one day asked him to come up with a plan for an essay on international trade, a kind of mind map showing how the issues related. The result, she says, was breathtaking. “If a finals student at Oxford had produced this it would have been impressive. Everything was there and how it related to everything else. It was stunning; he’d covered his entire sheet of A4. I was awestruck.” Michael got a D, while another student with little understanding of economics, but a talent for words, was awarded an A. “I thought this was outrageous; in terms of understanding, reasoning and ability to grapple with issues, the result should have been the other way round.” For Dr Richardson, the dyslexic boy’s struggles exemplified what was wrong with the education system. “I’ve always been rewarded for being able to play the exam game and here I was coming across people who made me feel humble. They’d been dismissed as lazy, careless and stupid. But they were battling, trying to find some way to show their ability to get a passport to anything other than the lowest grade of job or future. “This motivated me to do what I would never have thought possible, to go back to college and do a PhD. I recognised that anyone who understood dyslexia would understand the whole of the human mind and brain. It isn’t just to do with reading and spelling, it permeates the whole of somebody’s thinking and perceiving and learning style.” In 1987, she got a job in the dyslexia research clinic at Oxford’s physiology laboratory. Her work focused on the links between physiology and psychology, studying the biological underpinnings of personality traits. Then in 1995 she read a research paper in a medical magazine. A few dyslexic adults, treated with essential fatty acids found in fish oils, had been cured of their night blindness. It was a turning point. While acknowledging the many factors that influence a child’s development, she says it is just daft to deny the role of nutrition. She points out that huge numbers of youngsters have attention deficit hyperactivity disorder and dyslexia. “ADHD is seen as a biochemical imbalance requiring a pharmaceutical approach, so the answer is to treat it with drugs. Yet dyslexia is regarded as an educational problem to do with reading and spelling, and nothing to do with the brain.” Her exasperation is palpable. She feels as strongly about junk food, the “nutritional nightmares”, being peddled to children. “Headteachers say they would like to get rid of the vending machine, but the children know they can forget breakfast and buy a fizzy drink and a chocolate bar at school. Teachers know how this can affect behaviour.” Dr Richardson is aware that vending machines pay teachers’ salaries. “But if diet plays the role it appears to in shaping behaviour, learning and mood, it is a false economy. You can’t let them eat junk and expect it not to backfire and cause more expense.” She is a forceful campaigner, driven by a sense of how unfair life can be. A better diet seems little to ask for children, especially those with special needs. “There is nothing to compare with realising, from the moment you arrive at school, that you struggle with things other children find easy. How are you going to preserve your self esteem? What are you going to do to try to cope with this frank injustice?” Dr Richardson is working hard to help. She says it’s payback time for the ease with which she sailed through the education system.

(4)

Rebels without a cause Children with behaviour problems are increasingly diagnosed with ADHD. But their parents often struggle to get them the education they need. By Katharine Quarmby Tuesday December 6, 2005 The Guardian James Steele, aged 10, from Bermondsey, south London, has seven doses of Ritalin a day to control his behaviour. On one of his first days at Southwark Park primary school, he stripped off naked and was chased round the school by two teachers. His mother, Julie Clapp, had to give up work to cope with him. “It’s been a nightmare,” she says.

“He would crawl over desks, start climbing on equipment in the classroom,” says Angie Sharma, acting headteacher. “Then at one point he opened the window and stood on the ledge. The whole school was in a panic. We seriously thought we might have to exclude James. It was extremely difficult for the teacher to teach to the national curriculum when James was running out of class, refusing to co-operate.”

Before he joined the school, he had already been kicked out of nursery. The school begged Southwark council for help and, at the age of seven, James was diagnosed with attention deficit hyperactivity disorder (ADHD) and given a statement of special educational need. A team of experts assessed James, including the school’s special educational needs co-ordinator, an