Teaching Children with ADHD (page 2)
Inattention, hyperactivity and impulsivity are the core symptoms of Attention Deficit Hyperactivity Disorder (ADHD). A child's academic success is often dependent on his or her ability to attend to tasks and teacher and classroom expectations with minimal distraction. Such skill enables a student to acquire necessary information, complete assignments and participate in classroom activities and discussions (Forness & Kavale, 2001). When a child exhibits behaviors associated with ADHD, consequences may include difficulties with academics and with forming relationships with his or her peers if appropriate instructional methodologies and interventions are not implemented.
There are an estimated 1.46 to 2.46 million children with ADHD in the United States; together these children constitute 3-5 percent of the student population (Stevens, 1997; American Psychiatric Association, 1994). More boys than girls are diagnosed with ADHD; most research suggests that the condition is diagnosed four to nine times more often in boys than in girls (Bender, 1997; Hallowell, 1994; Rief, 1997). Although for years it was assumed to be a childhood disorder that became visible as early as age 3 and then disappeared with the advent of adolescence, the condition is not limited to children. It is now known that while the symptoms of the disorders may change as a child ages, many children with ADHD do not grow out of it (Mannuzza, Klein, Bessler, Malloy, & LaPadula, 1998).
The behaviors associated with ADHD change as children grow older. For example, a preschool child may show gross motor overactivity-always running or climbing and frequently shifting from one activity to another. Older children may be restless and fidget in their seats or play with their chairs and desks. They frequently fail to finish their schoolwork, or they work carelessly. Adolescents with ADHD tend to be more withdrawn and less communicative. They are often impulsive, reacting spontaneously without regard to previous plans or necessary tasks and homework.
According to the fourth edition of the Diagnostic Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association (APA) (1994), ADHD can be defined by behaviors exhibited. Individuals with ADHD exhibit combinations of the following behaviors:
- Fidgeting with hands or feet or squirming in their seat (adolescents with ADHD may appear restless);
- Difficulty remaining seated when required to do so;
- Difficulty sustaining attention and waiting for a turn in tasks, games, or group situations;
- Blurting out answers to questions before the questions have been completed;
- Difficulty following through on instructions and in organizing tasks;
- Shifting from one unfinished activity to another;
- Failing to give close attention to details and avoiding careless mistakes;
- Losing things necessary for tasks or activities;
- Difficulty in listening to others without being distracted or interrupting;
- Wide ranges in mood swings; and
- Great difficulty in delaying gratification.
Children with ADHD show different combinations of these behaviors and typically exhibit behavior that is classified into two main categories: poor sustained attention and hyperactivity-impulsiveness. Three subtypes of the disorder have been described in the DSM-IV: predominantly inattentive, predominantly hyperactive-impulsive, and combined types (American Psychiatric Association [APA] as cited in Barkley, 1997). For instance, children with ADHD, without hyperactivity and impulsivity, do not show excessive activity or fidgeting but instead may daydream, act lethargic or restless, and frequently do not finish their academic work. Not all of these behaviors appear in all situations. A child with ADHD may be able to focus when he or she is receiving frequent reinforcement or is under very strict control. The ability to focus is also common in new settings or while interacting one-on-one. While other children may occasionally show some signs of these behaviors, in children with ADHD the symptoms are more frequent and more severe than in other children of the same age.
Although many children have only ADHD, others have additional academic or behavioral diagnoses. For instance, it has been documented that approximately a quarter to one-third of all children with ADHD also have learning disabilities (Forness & Kavale, 2001; Robelia, 1997; Schiller, 1996), with studies finding populations where the comorbidity ranges from 7 to 92 percent (DuPaul & Stoner, 1994; Osman, 2000). Likewise, children with ADHD have coexisting psychiatric disorders at a much higher rate. Across studies, the rate of conduct or oppositional defiant disorders varied from 43 to 93 percent and anxiety or mood disorders from 13 to 51 percent (Burt, Krueger, McGue, & Iacono, 2001; Forness, Kavale, & San Miguel, 1998; Jensen, Martin, & Cantwell, 1997; Jensen, Shertvette, Zenakis, & Ritchters, 1993). National data on children who receive special education confirm this co-morbidity with other identified disabilities. Among parents of children age 6-13 years who have an emotional disturbance, 65 percent report their children also have ADHD. Parents of 28 percent of children with learning disabilities report their children also have ADHD (Wagner & Blackorby, 2002).
When selecting and implementing successful instructional strategies and practices, it is imperative to understand the characteristics of the child, including those pertaining to disabilities or diagnoses. This knowledge will be useful in the evaluation and implementation of successful practices, which are often the same practices that benefit students without ADHD.
Teachers who are successful in educating children with ADHD use a three-pronged strategy. They begin by identifying the unique needs of the child. For example, the teacher determines how, when, and why the child is inattentive, impulsive, and hyperactive. The teacher then selects different educational practices associated with academic instruction, behavioral interventions, and classroom accommodations that are appropriate to meet that child's needs. Finally, the teacher combines these practices into an individualized educational program (IEP) or other individualized plan and integrates this program with educational activities provided to other children in the class. The three-pronged strategy, in summary, is as follows:
- Evaluate the child's individual needs and strengths. Assess the unique educational needs and strengths of a child with ADHD in the class. Working with a multidisciplinary team and the child's parents, consider both academic and behavioral needs, using formal diagnostic assessments and informal classroom observations. Assessments, such as learning style inventories, can be used to determine children's strengths and enable instruction to build on their existing abilities. The settings and contexts in which challenging behaviors occur should be considered in the evaluation.
- Select appropriate instructional practices. Determine which instructional practices will meet the academic and behavioral needs identified for the child. Select practices that fit the content, are age appropriate, and gain the attention of the child.
- For children receiving special education services, integrate appropriate practices within an IEP. In consultation with other educators and parents, an IEP should be created to reflect annual goals and the special education-related services, along with supplementary aids and services necessary for attaining those goals. Plan how to integrate the educational activities provided to other children in your class with those selected for the child with ADHD.
Because no two children with ADHD are alike, it is important to keep in mind that no single educational program, practice, or setting will be best for all children.
Successful programs for children with ADHD integrate the following three components:
- Academic Instruction;
- Behavioral Interventions; and
- Classroom Accommodations.
The remainder of this document describes how to integrate a program using these three components and provides suggestions for practices that can help children with ADHD in a classroom setting. It should be emphasized that many of the techniques suggested have the additional benefit of enhancing the learning of other children in the classroom who do not have ADHD. In addition, while they have been used most widely with children at the elementary level, the following practices are useful for older students as well.
The first major component of the most effective instruction for children with ADHD is effective academic instruction. Teachers can help prepare their students with ADHD to achieve by applying the principles of effective teaching when they introduce, conduct, and conclude each lesson. The discussion and techniques that follow pertain to the instructional process in general (across subject areas); strategies for specific subject areas appear in the subsequent subsection "Individualizing Instructional Practices."
Students with ADHD learn best with a carefully structured academic lesson-one where the teacher explains what he or she wants children to learn in the current lesson and places these skills and knowledge in the context of previous lessons. Effective teachers preview their expectations about what students will learn and how they should behave during the lesson. A number of teaching-related practices have been found especially useful in facilitating this process:
- Provide an advance organizer. Prepare students for the day's lesson by quickly summarizing the order of various activities planned. Explain, for example, that a review of the previous lesson will be followed by new information and that both group and independent work will be expected.
- Review previous lessons. Review information about previous lessons on this topic. For example, remind children that yesterday's lesson focused on learning how to regroup in subtraction. Review several problems before describing the current lesson.
- Set learning expectations. State what students are expected to learn during the lesson. For example, explain to students that a language arts lesson will involve reading a story about Paul Bunyan and identifying new vocabulary words in the story.
- Set behavioral expectations. Describe how students are expected to behave during the lesson. For example, tell children that they may talk quietly to their neighbors as they do their seatwork or they may raise their hands to get your attention.
- State needed materials. Identify all materials that the children will need during the lesson, rather than leaving them to figure out on their own the materials required. For example, specify that children need their journals and pencils for journal writing or their crayons, scissors, and colored paper for an art project.
- Explain additional resources. Tell students how to obtain help in mastering the lesson. For example, refer children to a particular page in the textbook for guidance on completing a worksheet.
- Simplify instructions, choices, and scheduling. The simpler the expectations communicated to an ADHD student, the more likely it is that he or she will comprehend and complete them in a timely and productive manner.
In order to conduct the most productive lessons for children with ADHD, effective teachers periodically question children's understanding of the material, probe for correct answers before calling on other students, and identify which students need additional assistance. Teachers should keep in mind that transitions from one lesson or class to another are particularly difficult for students with ADHD. When they are prepared for transitions, these children are more likely to respond and to stay on task. The following set of strategies may assist teachers in conducting effective lessons:
- Be predictable. Structure and consistency are very important for children with ADHD; many do not deal well with change. Minimal rules and minimal choices are best for these children. They need to understand clearly what is expected of them, as well as the consequences for not adhering to expectations.
- Support the student's participation in the classroom. Provide students with ADHD with private, discreet cues to stay on task and advance warning that they will be called upon shortly. Avoid bringing attention to differences between ADHD students and their classmates. At all times, avoid the use of sarcasm and criticism.
- Use audiovisual materials. Use a variety of audiovisual materials to present academic lessons. For example, use an overhead projector to demonstrate how to solve an addition problem requiring regrouping. The students can work on the problem at their desks while you manipulate counters on the projector screen.
- Check student performance. Question individual students to assess their mastery of the lesson. For example, you can ask students doing seatwork (i.e., lessons completed by students at their desks in the classroom) to demonstrate how they arrived at the answer to a problem, or you can ask individual students to state, in their own words, how the main character felt at the end of the story.
- Ask probing questions. Probe for the correct answer after allowing a child sufficient time to work out the answer to a question. Count at least 15 seconds before giving the answer or calling on another student. Ask followup questions that give children an opportunity to demonstrate what they know.
- Perform ongoing student evaluation. Identify students who need additional assistance. Watch for signs of lack of comprehension, such as daydreaming or visual or verbal indications of frustration. Provide these children with extra explanations, or ask another student to serve as a peer tutor for the lesson.
- Help students correct their own mistakes. Describe how students can identify and correct their own mistakes. For example, remind students that they should check their calculations in math problems and reiterate how they can check their calculations; remind students of particularly difficult spelling rules and how students can watch out for easy-to-make errors.
- Help students focus. Remind students to keep working and to focus on their assigned task. For example, you can provide follow-up directions or assign learning partners. These practices can be directed at individual children or at the entire class.
- Follow-up directions. Effective teachers of children with ADHD also guide them with follow-up directions:
- Oral directions. After giving directions to the class as a whole, provide additional oral directions for a child with ADHD. For example, ask the child if he or she under-stood the directions and repeat the directions together.
- Written directions. Provide follow-up directions in writing. For example, write the page number for an assignment on the chalkboard and remind the child to look at the chalkboard if he or she forgets the assignment.
- Lower noise level. Monitor the noise level in the classroom, and provide corrective feedback, as needed. If the noise level exceeds the level appropriate for the type of lesson, remind all students-or individual students-about the behavioral rules stated at the beginning of the lesson.
- Divide work into smaller units. Break down assignments into smaller, less complex tasks. For example, allow students to complete five math problems before presenting them with the remaining five problems.
- Highlight key points. Highlight key words in the instructions on worksheets to help the child with ADHD focus on the directions. Prepare the worksheet before the lesson begins, or underline key words as you and the child read the directions together. When reading, show children how to identify and highlight a key sentence, or have them write it on a separate piece of paper, before asking for a summary of the entire book. In math, show children how to underline the important facts and operations; in "Mary has two apples, and John has three," underline "two," "and," and "three."
- Eliminate or reduce frequency of timed tests. Tests that are timed may not allow children with ADHD to demonstrate what they truly know due to their potential preoccupation with elapsed time. Allow students with ADHD more time to complete quizzes and tests in order to eliminate "test anxiety," and provide them with other opportunities, methods, or test formats to demonstrate their knowledge.
- Use cooperative learning strategies. Have students work together in small groups to maximize their own and each other's learning. Use strategies such as Think-Pair-Share where teachers ask students to think about a topic, pair with a partner to discuss it, and share ideas with the group. (Slavin, 2002).
- Use assistive technology. All students, and those with ADHD in particular, can benefit from the use of technology (such as computers and projector screens), which makes instruction more visual and allows students to participate actively.
Reprinted with the permission of the U.S. Department of Education.