Definitions, Prevalence, and Characteristics
Robert has an attention-deficit/hyperactivity disorder and both his family and teacher could benefit from suggestions as to how to best work with him. Robert’s disruptive behaviors and his inability to sustain attention could put Robert at risk for failing in school (Maag & Reid, 1994). Attention-deficit/hyperactivity disorder (ADHD) refers to a “persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development” (American Psychiatric Association, 2000, p. 85). Observations made in the classroom will identify these students as those who often say “Huh, what?” immediately following directions; often appear to be daydreaming; act before they think; blurt out answers; interrupt; and constantly fidget, wiggle, and move around. compares the sharp contrast between commonly noted behaviors on elementary school report cards with students with ADHD.
From 1.35 to 2.25 million children—3% to 5% or more of all school-age children—may have attention-deficit/hyperactivity disorder [American Psychiatric Association (APA), 2000;.Barkley, 1998; Council for Exceptional Children (CEC), 1992]. Most students with ADHD are served full time in general education classrooms, with only about half of them qualifying for special education services under IDEA (CEC, 1992).
The Diagnostic and Statistical Manual-IV–Text Revision (DSM-IV-TR) of the American Psychiatric Association (APA, 2000) describes criteria for classification as ADHD. The symptomatic behaviors must be maladaptive and must be present for a minimum of six months to warrant a classification as either inattentive ADHD or hyperactivity-impulsivity ADHD. Some symptoms should have been present before 7 years of age. Furthermore, a child must display a minimum number of identifying characteristics before ADHD is diagnosed. For example, students must meet six of nine characteristics under Inattention, or six of nine characteristics under Hyperactivity/Impulsivity. There also must be evidence of impairment in social, occupational, or academic functioning, and some impairment from the symptoms must be present in at least two settings.
Any inattentiveness, impulsivity, and hyperactivity must be observed across settings (APA, 2000). Or, as in the case of Robert, the teacher and parents must observe similar behavior patterns at school and at home. Although some symptoms change over time, ADHD is now considered potentially a lifelong disorder (APA, 2000). Males outnumber females about 3 to 1 in the disorder (Barkley, 1998; Bender, 1997).
Students with ADHD are thought to be more likely to have a learning disability than other children. In a sample of students with ADHD, Barkley (1990) identified 21% with disabilities in reading, 26% in spelling, and 28% in math (see also Barkley, 1998).
Causes of ADHD
Precise causes of ADHD are unknown; however, it is thought that many factors contribute to it (Riccio, Hynd, & Cohen, 1997). These factors include genetic, nongenetic, psychosocial, and neurobiological bases. Genetic evidence is based on research with families who have ADHD. Some researchers estimate that as many as 32% of children with ADHD have parents or siblings with ADHD (Biederman et al., 1992), and concordance of ADHD has been seen to be much higher in identical (monozygotic) twins than in fraternal (dizygotic) twins, suggesting a genetic component (Barkley, 1998). Nongenetic factors include prenatal and perinatal factors, allergies, and thyroid disorders (Riccio, Hynd, & Cohen, 1997). Although both food additives (Feingold, 1975) and sugar (Smith, 1975) have been proposed as causes of ADHD, research has not substantiated these as plausible causes of ADHD (Barkley, 2000; Wolraich, Milich, Stumbo, & Schultz, 1985). Other research has investigated the psychosocial and neurological correlates associated with ADHD, with evidence growing in support of neurological indicators (Riccio, Hynd, & Cohen, 1997). To date, however, as with many disorders, no definitive single etiological factor has been uncovered. At present, it seems that ADHD appears to be more influenced by neurological and genetic factors than by social or environmental factors (Barkley, 1998).
Issues in Identification and Assessment of ADHD
Many experts recommend a two-step approach to the assessment of ADHD. The first step is to determine whether ADHD exists, and the second step is to determine whether the student’s educational progress is adversely affected by it (CEC, 1992). During the first step, information is collected on observations of the individual’s behavior throughout the day, medical history, family information, school information, social-emotional functioning, and cognitive-academic functioning (CEC, 1992; Schwanz & Kamphaus, 1997). Rating scales of the individual’s behavior are usually completed by the child’s parents and teachers as part of this evaluation process.
To qualify for special education services in the “other health impairment” category of IDEA, it must be documented that the ADHD has an adverse effect on educational performance. To qualify for special services under Section 504 of the Vocational Rehabilitation Act, it must be documented that the ADHD substantially limits learning. If either of these requirements is met, an intervention plan is designed and implemented as either part of the IEP in compliance with IDEA or the accommodation plan for compliance with Section 504. In the event that students with ADHD do not meet criteria for either IDEA or Section 504, no special accommodations are designed as part of any legally mandated system. However, these students with ADHD also frequently benefit from some of the general classroom adaptations described in this article and listed below.
General Classroom Adaptations for Students with ADHD
Many adaptations described for students with higher-incidence disabilities are appropriate for students with ADHD. The following In the Classroom feature provides some suggestions for accommodations that can add to classroom success (see also Barkley, 2000; Bender, 1997; Markel & Greenbaum, 1996).
Behavioral Interventions
Behavioral interventions are strategies that use the principles of consistent behavior management. Students’ behaviors are first analyzed with respect to antecedent and consequent events (that is, what happened before and after the undesirable behavior occurred). Strategies are then implemented systematically based on that analysis (Duhaney, 2003). For example, a teacher observed that every time a worksheet was distributed in class, Max got out of his seat to sharpen his pencils and get a drink of water, bothering several classmates in the process. After this, the teacher would reprimand Max, which would make Max feel sullen and resentful. After analyzing this behavior, it seemed likely that Max was reacting to the difficulty or interest level of the task, and his own predisposition toward physical activity. The teacher decided to have Max sharpen his pencils and get a drink of water before class every day. In addition, the teacher would praise Max for remaining in his seat and leaving classmates alone after the worksheets were passed out. The teacher also monitored the content of the academic activities, to make sure they were of the appropriate difficulty level and held some interest for Max. She provided alternative opportunities for Max to leave his seat under teacher supervision, so he could engage in some physical movement when needed. Such strategies can be effective when they are designed to meet the specific needs of problem behaviors.
Cognitive-Behavioral Interventions
Cognitive-behavioral interventions use the same principles of behavior management just described, but in addition, add a self-instruction and self-monitoring component to the intervention. For example, Max could be taught to keep daily records of (1) how often he remembered to sharpen his pencils and get a drink of water before class, and (2) whether he was able to stay in his seat once the worksheet was handed out. Specific rewards might even be paired with how well he monitored his own behavior. Other commonly used cognitive-behavioral interventions involve the use of self-monitoring for on-task and task completion. Strategies such as these have been particularly successful with students with ADHD.
Medications
As many as 2 million students with ADHD take psychostimulant medications, such as Ritalin (methylphenidate) or Cylert (dextroamphetamine), to help control their attention and hyperactivity (Austin, 2003). The number of children taking medications for ADHD has risen significantly in recent years. If students are taking medications, teachers must keep thorough records of behavior to help monitor the effects of medications. Reviews of research on the effects of stimulant medication generally indicate positive benefits, in that attention to task increases and hyperactivity decreases (Austin, 2003; Hallahan & Cottone, 1997). However, the practice of administering medications has remained controversial. Some educators and physicians argue that the side effects of medications can be harmful and that no students should be given medications to control their classroom behavior. Barkley (1998) suggested that some organizations have overstated the dangers of medications in an attempt to influence public opinion. When medication is prescribed, however, concomitant behavior therapy, such as the cognitive and behavioral interventions described previously, is generally also recommended (Austin, 2003).
Classroom Scenario
Robert Black
Robert Black had so much energy that he drove everyone around him crazy including his parents; his teacher, Ms. Moore; and his classmates. When he arrived at school everything around him appeared to get caught in a whirlwind of activity: Papers flew to the floor, books were dropped, toys were broken, classmates were annoyed, and teachers threw their hands up in dismay. Robert was a nice 8-year-old boy, but he could not focus on one thing at a time. He seemed mesmerized by everything, moving from activity to activity with limitless energy. When someone spoke, he would interrupt and start talking about something that popped into his head. If he saw something that interested him, he would immediately take it in his hands. His feet, hands, and eyes seemed to be moving constantly. He seemed unable to sit still. Ms. Moore was frustrated and unsure of how to handle Robert in the class, so she called Mr. and Mrs. Black and asked them to come in for a conference. What became immediately evident at the parent conference was that Mr. and Mrs. Black were experiencing similar problems and frustrations at home with Robert—and had been since he was 2 years old.
Questions for Reflection
- Why do you think Mr. And Mrs. Black were experiencing similar challenges with Robert at home?
- What types of strategies might be helpful for Robert and his parents to use at home?
- What behavioral and instructional supports are available for working with Robert in school?
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