Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder, most often referred to as ADD and ADHD, are terms commonly used in daily conversations, media reports and magazine articles. In schools, teachers frequently forecast increased activity levels and lack of attention on the part of students due to “spring fever” or the onset of winter holidays. Parents lament taking extended car trips because Tommy or Susie is just “too hyper.” Committee members avoid being paired with Mr. X or Ms. Y because they “talk impulsively” all the time.
ADD and ADHD are terms associated with specific individual behaviors. In reality, the terms are not well understood. Reid, Maag and Vasa state that ADHD is 50 times more likely to be differentially diagnosed nosed in the U.S. than it is in Britain and France. How can such a discrepancy exist? Reid et al. cite the difference in orientation to the assumed etiology of ADHD due to the United States having assumed a medical-disease model while Britain and France have deemed ADHD to be a function of the constructed world. In other words, the United States places the cause of ADHD within the individual while the other two countries place the cause of ADHD outside the individual but within the environment in which the individual must function.
Neither orientation has a substantive database. Dowdy, Patton, Smith and Polloway indicate that most professionals agree that ADHD is a neurological condition. However, they point out that neurological evidence for explaining ADHD is not yet available. Fiore, Becker: and Nero in their review of ‘current research based knowledge of nonpharmacological interventions relevant to educating students with ADD concluded that the literature is exploratory, not prescriptive.
The existence of ADD/ADHD is validated by the American Psychiatric Association, which provides the following definition:
Primary characteristics of ADD are inattention, hyperactivity and impulsivity. For diagnosis of ADHD, not only must students display the symptoms associated with the primary characteristics, but they also must meet the following criteria regarding persistence, time of onset, persuasiveness and severity. That is, first, an individual must have exhibited either symptoms of inattention and/or hyperactivity-impulsivity as listed in DSM-IV for a period of at least six months to a degree that is developmentally inappropriate. Second, an individual must have displayed these symptoms prior to seven years of age.. Third, the symptoms must be present in two or more situations (e.g., school, home, work, etc.). Fourth, the symptoms presented must be serious enough to cause clinically significant distress or impairment in social, academic, or occupational functioning.
The DSM-IV further states that ADHD can be defined in four different ways depending upon the variability of the symptoms. These four types, are attention-deficit/ hyperactivity disorder, combined type.; attention- deficit/hyperactivity disorder, predominantly inattentive type; attention-deficit/ hyperactivity disorder, predominately hyperactive-impulsive type; and attention-deficit/ hyperactivity disorder not otherwise specified. Whatever the final ADHD diagnosis, it is based upon documentation of observed behaviors. Identification of students based on the DSM-IV criteria has resulted in diagnosing from 2 percent to 30 percent of the population as ADHD, even though it is estimated that only 3 percent to 5 percent of the school-age population should fall under the ADHD rubric.
This lack of clarity has resulted in a number of issues that affect the educational community. A substantial portion of the school population is being diagnosed as ADHD. Parents of these diagnosed students are seeking education programs that will meet the educational needs of their children. School personnel are uncomfortable treating students based on a medical diagnosis that may or may not have educational implications.
Serving the ADHD population
Although many of the students with disabilities who qualify for educational services under the Individuals with Disabilities Education Act of 1990 (IDEA) may have a medical diagnosis, that alone does not qualify them for services. Individuals served under IDEA must meet the eligibility criteria for disability as established in the law. The ADHD population is not a designated category under IDEA, but a student with ADHD could qualify for services under IDEA. In 1991, the Department of Education (DOE) issued a memorandum stating that students with “attention deficit disorder” who need special education and/or related services can be served under existing IDEA categories if eligibility requirements are met.
In particular, the DOE memorandum cited the category of “other health impaired” as a category under which an individual with ADHD might qualify. In addition, an individual with ADHD might meet the special education eligibility requirements under the category of learning disabilities (LD) or the category of seriously emotionally disturbed (SED). Although IDEA was amended and reauthorized as Public Law 105-17 in 1997, the belief that individuals could be served under existing IDEA categories prevailed. Once again, ADHD was not recognized as a separate category.
If an individual with ADHD does not qualify for services under IDEA, it may be possible to qualify for services under Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112). This act is not an education act but a civil rights law that prohibits discrimination against persons with disabilities by school districts receiving federal assistance. Section 504 requires that students with disabilities be provided with a free appropriate public education (FAPE). A disability is, defined as any physical or mental impairment that substantially lim its one or more major life activities (including learning). Section 504, covers all students who meet this definition of disability even if they do not qualify under IDEA and even if they do not need to be in a special education program. If a district has reason to believe that a student might qualify under Section 504, the district must evaluate the student. If the student is determined to be disabled under Section 504, the district must develop and implement a plan for the delivery of services.
Section 504 is not an aspect of special education. It is a responsibility of the comprehensive general public education system. As such, a student with ADHD who qualified under Section 504 would have an education plan but it would not be an IEP as required under IDEA.
What must educators know and be able to do to educate such a group of learners as diverse as the ADHD population? How important is the label? How important are research-based strategies? In the case of ADD/ADHD, where there is, at best, emerging research data on teaching/ learning interventions and accommodations, educators are reliant upon current best practice. Current best practice translates into “ ‘what seems to work” even though a research base has yet to be established.
Current best practice could be likened to the situation of the extended car trips with Tommy or Susie. The child’s family wants to take a vacation but it requires extended car trips, How will the family manage? Knowing their child has a label of ADD/ADHD helps everyone agree that the child’s behaviors often differ from those of typical peers and from other members of the family. The label, however, does not tell the family how to pleasantly sustain the car rides. The key is knowing Tommy or Susie’s characteristics and habits. What sedentary activities hold interest and for how long? What is the tolerance for physical inactivity? How do meals and snacking affect activity levels? Is morning, afternoon or evening a better time for riding? Answers to these questions- help the family create a vacation plan. After returning home, a review of the vacation plan, with whatever adjustments were made along the way, defines “best vacation practices” for the child’s family. So too are best practices in education identified.
A school-based model of intervention
Dowdy et al. suggest a school-based model of intervention. The four fundamental intervention areas of their model are environmental management, instructional accommodations, student-regulated strategies and medical management, which are briefly covered in the paragraphs below.
Environmental management is defined as ” … all teacher-directed activities that support the efficient operations of the classroom and lead to the establishment of optimal conditions for learning and order” What is the physical arrangement of the classroom? How is the day scheduled? How are students grouped for learning? What is the general climate of the classroom? What are the classroom rules and procedures? How is discipline handled? Answers to these a questions provide a picture of the environment in which students are expected to function. This picture further provides a standard for assessing the degree of match between the environmental expectations and the behavioral characteristics of the student with ADD/ADHD.
Instructional accommodations have to do with the variability related to what is taught (curriculum), how it is taught (materials and processes), and in what ways evidence of learning is documented (products).
Student-regulated strategies are student-empowering interventions that employ strategies initially taught by the teacher and eventually used by the student to independently manage his or her own learning. Student-regulated strategies can be considered as a kind of “know-thyself-as-a-learner” concept.
Medical management relates to the role the school can play as an observer of the behavior of students diagnosed with ADD/ ADHD who are taking medication. Monitoring the student, and communicating with parents and physicians regarding the effects of the medication defines the school as a collaborator’, in the management of medications. In many, cases, the primary effects of the medication taken by students with ADHD will only be noticeable during school hours. Educators, therefore, become important informants to the family and the physician on how well the medications are working and whether there is any evidence of side effects (CEC 1992).
Strategies and interventions
A number of publications provide various instructional strategies and interventions for use with students with ADD/ADHD. Zentall delineates nine principles or strategies of remediation for students who demonstrate excessive activity, the inability to wait (impulsivity), failure to sustain attention to routine tasks and activities, noncompliance and failure to complete tasks, difficulty at the beginning of tasks, difficulty completing assignments on time, difficulty increasing planning and sequential organization of thought, poor handwriting and low self-esteem.
Montague and Warger summarize modifications of instruction for students with ADHD into three categories: maintaining student involvement in group lessons, maintaining student involvement in seat work and helping students engage in learning tasks. They identify a research base that has been established to show that self-monitoring and peer tutoring are academic enhancement strategies that teachers can use to prevent problems. Social skills instruction is also showing promise as a classroom intervention.
A quick review of the model of intervention suggested by Dowdy et al., the nine principles of remediation and the summary of modifications, leads to the conclusion that ADHD is more about processing and accessing learning than it is about content instruction. It is also important to keep in mind the function of such strategies and interventions. “Classroom Strategies do not cure ADHD, but when applied appropriately, they can improve teaming results for kids”.
Administrative support and in-service needs
Classroom teachers must be knowledgeable about ADHD, its implications for any given child and what strategies address the needs of students with ADHD. A major element, often overlooked, however, is the role of the administrator in serving students with ADHD. In their two-year study of promising school-based practices for serving students with ADHD and their families, Burcham and Carlson found administrators were major contributors. Districts that were seen as effectively serving students with ADHD had: 1) clear districtwide policies for educating these students; 2) shared goals among the district staff (i.e., the use of teacher assistance teams); 3) an action plan to reach established goals related to these students; 4) on-going staff development on issues related to serving students with ADHD; and 5) a commitment to regular and on-going evaluation of the policies and procedures that the district developed and implemented. All five of these conditions are administrative functions.
Reif suggests that administrators need to increase their sensitivity and awareness with regard to why students with ADHD behave in the ways they do. She believes that a knowledgeable administrator can:
- Facilitate teacher in service training related to ADHD;
- Create time within the work schedules for teachers to share ideas, collaborate, and solve problems with specific students with ADHD;
- Support teachers with disruptive students;
- and Communicate more effectively with parents, medical personnel and mental health providers associated with students with ADHD.
From central office staff to the building principal, the administration sets the tone and priorities of educational service, An administrator who values all learners remains vigilant in facilitating support for all students, including those at risk for learning failure and those who need specialized accommodations or procedures.
Most students with ADHD are served in the general education program. Reid, Maag and Vasa advocate realigning the instruction being provided in schools with that needed by students with ADHD. They would have schools focus on curriculum, instruction and school organization. At a minimum, training is needed in the following areas: cooperative learning, study / organizational skills, learning styles, multiple intelligence, teacher expectation and student achievement, gender and ethnic equity and student achievement, computer literacy and higher-ordering questioning techniques, according to Reif.
Diversity is here to stay and students with ADHD are one part of the challenge. It does not make a difference if the student with ADHD carries an IDEA label, Section 504, eligibility or is thought to be at risk for learning failure. The school must deal with the learner as presented. The label does not dictate the educational needs of the learner.