Thomas E. Brown, PhD
According to a recent study by the U.S. Centers for Disease Control and Prevention, about 7.8 percent of children aged 4 to 17 years are currently diagnosed with AttentionDeficit/Hyperactivity Disorder (ADHD).This means that most teachers are likely to have in every class they teach, on average, at least a couple of students with ADHD. Clearly, it is extremely important for each teacher to have at least a basic grasp of what attention disorders are and what they are not.
Over the years, attention disorders have been known by several names. Currently, educators and medical professionals use different terms to describe this condition. Based upon federal law, educators use the terms ADD and ADHD to differentiate between students who are inattentive and those who are primarily hyperactive, respectively. Doctors diagnose students as having ADHD that is either predominately hyperactiveimpulsive, inattentive, or a combination of the two.Throughout this book, the term ADHD will be used. Information specific only to the ADHD inattentive type will be noted.
Understanding this disorder is not so easy.There are many widespread myths, and scientific understanding of ADHD has changed a lot over recent years. It is now clear that attention disorders are a much more complicated set of problems than was previously understood.
There are three types of ADHD:
ADHD is seen about three times more often in boys than in girls; it affects children of all ethnic backgrounds and all socioeconomic levels.
Although some media coverage suggests otherwise, there is now very strong evidence that ADHD is a neurobiological disorder, a problem with the brain and its neurotransmitters. After a review of the research on ADHD, the American Medical Association concluded that “ADHD is one of the bestresearched disorders in medicine, and the overall data on its validity are far more compelling than for many medical conditions.”
Differences in brain functioning have been shown in multiple imaging studies of people with ADHD compared to those without ADHD.Typically those with ADHD show less activation in critical areas of the brain when performing tasks that require concentration, decisionmaking, or selfcontrol. Some imaging studies have also found differences in the volume of specific brain regions in children with ADHD.
Causes of ADHD are linked to chronic problems in the release and reloading of two specific neurotransmitter chemicals, dopamine and norepinephrine, that are crucial for effective communication in the management system of the brain.The brain of someone with ADHD apparently makes these chemicals, as does everyone else, but often it does not release and reload them effectively.This leads to significant inconsistency in the student’s ability to focus and get things done, especially if the task is not a high-interest activity.
Many still think of ADHD as essentially a behavior problem—students who are unwilling or unable to sit still, listen to the teacher, and follow classroom rules. But researchers now have recognized that ADHD is not so much a behavior disorder as it is an inherited problem in the development of executive functions, the management system of the brain.
One way of thinking about executive functions is to picture a symphony orchestra whose members are all very fine musicians. Even when the musicians are excellent, if there is no conductor, who can organize and integrate the efforts of the individual musicians in the same piece at the same time, the music will not be very good.
The problems with ADHD are not with those parts of the brain that would correspond to the individual musicians. The problems originate one level up in the management system that starts, stops, controls, and manages these activities, integrating them moment by moment to allow us to perform the tasks at hand. This management system is what is referred to as executive functions.
It is important to recognize that executive functions are not the same as intelligence. Some students who are extremely bright have significant impairment in executive function. And among those with average or below average intelligence, as measured by IQ tests, are many with adequate or better than average executive function.
The brain’s executive functions are not fully developed at birth.They gradually develop as the prefrontal cortex develops through early childhood and adolescence and into young adulthood. As executive functions develop, parents, teachers and others in the child’s life often expect the student to exercise an increasing measure of selfmanagement, from the simple tasks of dressing and selfcare to the more adult responsibilities of managing a high school courseload or driving a car.
One way of thinking about children with ADHD is that they are delayed in the development of their executive functions, unable to manage themselves at the same level as their peers. Students with ADHD often experience a roughly 30 percent developmental delay.15 For example, an 18yearold may have executive function skills that are comparable to those of a 12- or 13-year-old. Because this delay often has a profound impact on academic performance, parents and teachers must provide more supervision and support that is commensurate with the student’s developmental age rather than the chronological age.
For some children, problems with ADHD are obvious very early in their development. As preschoolers, these children are extremely difficult to manage, primarily because they are unable to follow even the most basic directions and, if frustrated, are excessively quick to run off or lash out at other students. Such children are often unable to fit into preschool and daycare settings without specialized staffing and services.
Other children with ADHD may have much less extreme behavior problems. Their difficulties appear more in their academic work and may not become noticeable until third or fourth grade when more sustained attention and self-management is expected. Although some may speak out impulsively without being called on, socialize excessively, and be more restless than their peers, others may quietly withdraw and daydream their way through class each day. However, the primary difficulties shared by both groups of students can be seen more in chronic problems with disorganization of books and papers, the inability to complete work, or frequent failure to understand instructions quickly grasped by their classmates.
Not surprisingly, academic underachievement is frequently a hallmark of students with ADHD.These students are atrisk and most will experience major problems at some time in their school career. In one study of students progressing through the school system, 29 percent failed a grade, 35 percent dropped out of school, 46 percent were suspended, and 11 percent were expelled. Providing proper supports and accommodations should prevent many of these students from experiencing these failures.
Some students have ADHD impairments that are not very noticeable until they move into middle school or junior high, where they are no longer in one classroom with one teacher for most of the day. The significant increase in demands on executive functions and increased expectations for planning and self-management are two of the primary reasons for the increased academic struggles at this level. When faced daily with multiple teachers and frequent changes of classroom, these students tend to have much more difficulty than classmates in keeping track of homework assignments, due dates, and test schedules. They show up in class lacking necessary books and materials that have been left at home or in their locker. They forget to take home materials needed for homework or may complete homework assignments and then forget to bring their work to class or hand it in.
Many students with ADHD are successful in school because their parents are very good at providing a scaffolding of reminders and supports to help them manage day-to-day activities. Basically parents are providing the executive functions that their child lacks. The students’ impairments may emerge only when their parents are not present to provide this intensified support, for example, when the student has to write essays in class or has long-term assignments with multiple due dates, of which the parents are not aware. When the parental scaffolding is removed or when the student moves away from home to attend college, these adolescents’ level of achievement can suddenly decline or they can experience unprecedented failure.
A common misconception held by most professionals and parents is that students must behave properly before academic learning is possible. Consequently, teachers often address behavior problems first in hopes of enhancing the student’s academic performance. However, research on students with emotional and behavioral disorders is beginning to paint a different story. One study revealed that when academic tutoring was provided, the student’s behavior and grades improved. However, the converse was not true; grades did not improve for students who received behavioral interventions alone. This is consistent with other research that suggest that some students may act out to avoid aversive academic tasks—tasks that do not match the student’s level, either being too easy or too difficult. Tutoring to improve academic performance also had a positive effect on social skills that was comparable to psychosocial interventions, such as counseling or skills training. Clearly, interventions that focus primarily on improving learning are more likely to improve behavior than interventions that target behavior problems directly.
In a recent study, children, adolescents, and adults with ADHD described their chronic problems at school, home, or work. When their reports were compared with those of people who did not have ADHD, their impairments could be categorized into six clusters:
These six clusters of impairment are reported as chronic by many children, adolescents, and adults with ADHD and tend to overlap and interact with one another. For example, sustaining attention requires the use of working memory to keep important information in mind. Likewise, sustaining attention requires activating and sustaining alertness. Executive function impairment is complex and multifaceted, just as the neural networks of the brain are complex and multifaceted.
This emerging view of ADHD as impairments in the development of cognitive self-management skills is very different from the old view that assumed children with ADHD simply outgrew their impairments as they reached puberty. The earlier view was based on observations of hyperactive children, many of whom do become less hyperactive as they approach adolescence. However, this view did not take into consideration the attentional problems that are the primary and most persistent impairments of ADHD, whether the individual is hyperactive in childhood or not. We now know that 70 to 80 percent of children with ADHD continue to have significant impairments from their symptoms well into adulthood.
This newer understanding of ADHD as a developmental impairment of the brain’s executive function has important implications for the assessment of the disorder. When ADHD was seen as just a disruptive behavior disorder in childhood, diagnosis was based simply on observing behavior. This is no longer an adequate approach. Since executive function impairments are largely cognitive and not easily observed, a different approach to assessment is needed. It is not always possible to notice a child with ADHD simply by observing classroom behavior, because many with this disorder do not misbehave and can appear to be attending to instruction even when their minds are continually spacing in and out.
Assessment of ADHD should take into account two important characteristics of ADHD symptoms; symptoms of this disorder are dimensional and they are situation-specific. In other words, virtually all individuals suffer some impairment in these functions sometimes. Anyone looking at the list of symptoms of ADHD is likely to say, “I have trouble with that sometimes; doesn’t everybody?” But occasional occurrence of ADHD symptoms is not enough to warrant diagnosis. Only ADHD symptoms that are persistent and pervasive in at least two domains of activity, for example, school, work or home, are considered sufficient for a diagnosis of ADHD. The extent to which these symptoms impair life functions, for example, socially, academically, or occupationally, must be considered for a diagnosis.
Most people find it difficult to understand the situational variability of ADHD. Students with ADHD can often engage in activities of intense interest for them without any difficulty paying attention or utilizing executive functions, such as playing sports or video games, drawing, and building Lego creations. When asked how they can concentrate so well on one particular activity when they have so much difficulty sustaining attention for virtually everything else, students with ADHD say they can pay attention when they are “doing something that’s really interesting” to them or if they will “get in big trouble right away unless it’s done now.” “If it is not interesting to me, then I usually can’t make myself pay attention, even when I know it’s important and I really want to get it done.” This makes it appear that ADHD is simply a problem of willpower, but clinical evidence suggests otherwise.
Treatment for ADHD should be preceded by a comprehensive evaluation that uses clinical interviews with the child and family in addition to information from the school. It should assess the child’s past and current functioning in home, school and social relationships, health history, and possible coexisting disorders, including substance abuse. If a learning disorder is suspected, a psychoeducational evaluation should also be done. Diagnostic assessment should be done by a physician or psychologist familiar not only with ADHD, but also with the variety of related disorders.
When a child is with one teacher most of each day, that teacher is likely to notice patterns of inattention, failure to understand directions, disorganization, chronic problems in recall of reading assignments, and excessive difficulties with chronic forgetfulness and in sustaining effort for assigned tasks. Every student has occasional problems of this sort, but if a student seems to have chronic difficulties that significantly impair learning, referral for an evaluation by the school’s “child study team” is warranted.
For students in middle school or high school, where each teacher sees a student in large classes for only one period, it is easy to overlook students with ADHD unless they have disruptive behavior problems as well as chronic inattention. Research suggests that girls with ADHD and very bright students with ADHD who are not hyperactive are at special risk of having their inattention problems overlooked or of being seen simply as lacking motivation.
ADHD is not only a multifaceted disorder in and of itself, it is also often complicated by additional psychiatric or learning disorders. In a National Institute of Mental Health (NIMH) study of 579 children, aged 7 to 9 years, who had a diagnosis of ADHD combined type, 70 percent experienced at least one other psychiatric disorder, such as anxiety, depression, or behavior disorder, within the previous year.
As many as half of all children with ADHD also have a specific learning disability in reading, math, or written expression. Speech and language disorders also have been found to occur frequently with ADHD.
Often the overlap between ADHD and learning disorders is difficult to disentangle. For example, many individuals with ADHD report that they have chronic impairment in their ability to recall adequately what they have read, even just moments after the reading. These individuals have a problem with reading, but, in and of itself, this problem may not constitute a specific learning disability in reading.
The core problem in the reading disorder, dyslexia, is severe impairment in phoneme recognition, the ability to recognize the pronunciation of specific letter combinations that make up words. Those with a learning disability in reading have severe difficulty in making the connections between how a word sounds and how it appears on the page. Yet reading disorders also involve impairments in fluency and in working memory, problems often found in ADHD.
Some students with ADHD are dyslexic, but many with ADHD have adequate phoneme recognition while still having chronic difficulty remembering what they have just read, recalling it from one word, sentence or paragraph, and then integrating it into another. This can severely impair their reading fluency and their reading comprehension. These impairments in reading can also be secondary to impairment of working memory, an essential aspect of the executive function deficits in ADHD.
Other psychiatric disorders are also prevalent among children with ADHD. Among children with ADHD, 25 percent have significant anxiety disorders, compared to 5 percent of the general population of children. When compared to others without ADHD, these children are also three to five times more likely to experience oppositional defiant disorder, obsessive compulsive disorder, substance abuse, and sleep disorders. Sleep disorders, which occur in 56 percent of those with ADHD, can also have a significant impact on related school issues. Students can have difficulty falling asleep at night, waking up each morning, or getting restful sleep, causing the student to be late to school, arrive at school in an agitated state of mind, have difficulty staying awake in class, or have an impaired memory.
Returning to the example of the orchestra, if executive function impairment is best described as an orchestra without a conductor, coexisting disorders can be represented as impaired musicians, such as violinists playing with broken strings. An orchestra can have a poor or absent conductor, poor musicians, or both, just as children with ADHD can have the disorder alone, another psychiatric or learning disorder, or both.
Students who suffer from ADHD can be helped in a variety of ways. Often getting an adequate assessment of the student’s strengths and problems is in itself a big help. When a teacher notices a student having chronic difficulties in school that may be due to ADHD, it can be useful to describe those specific difficulties to the student’s parents and ask if this pattern is familiar. If the parents corroborate the persistent pattern of behavior, they should be encouraged to seek an evaluation either through the school or in the community. If ADHD is diagnosed, making them aware of community resources like local CHADD parent support groups can also be very helpful.
Sometimes it is difficult for teachers or parents to determine whether a student’s attentional problems are due to ADHD or to other causes such as a difficult life situation. The student may show many symptoms of ADHD but also be living with a lot of stress related to an unemployed father, parents who argue a lot, a mother’s worsening depression, an older brother’s drug problems, a grandparent’s progressive decline due to cancer, or coping with a new sibling or bullies.
Sometimes a child without ADHD episodically shows significant symptoms of inattention in reaction to such stressors. However, if the child has ADHD and a stressful life situation, evaluation and interventions for ADHD can help equip the student to cope more effectively with the other life stresses.
Although a diagnosis can be made only after a comprehensive evaluation by an experienced physician or psychologist, teachers play an important role in alerting parents to specific problems in the classroom and referring them to appropriate resources.
Sometimes parents are reluctant to seek an evaluation for their child, even when the student is having considerable difficulty.They may insist that the child is simply being lazy or oppositional, or they may blame the teacher or themselves. They may worry that the evaluator will recommend medications for the child, a treatment they fear as risky or dangerous. In such cases, it can be helpful for the teacher to emphasize that getting a good evaluation does not commit the parents to any specific intervention. The first step is to find out if the student has a real problem, and if so, to get a clear picture of the specific difficulties. Once that is done, the parents can consider with the evaluator the available options to help the student and then decide upon the best course of action for their child.
Students with attention deficits often have many wonderful qualities and special talents that can get lost in the rush to address their disorder. Teachers and parents have a responsibility to identify each child’s strengths and build on his or her “islands of competence.” The high energy and zest for living exhibited by students with ADHD, when properly channeled, can bring joy and enthusiasm to a classroom.These students often see the world in different and interesting ways in comparison to other children. Sometimes their unique analytical skills lead to creative solutions that others may not have considered.
The good news about ADHD is that this disorder can, in most cases, be successfully treated. The American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP) have published science-based guidelines for treatment, which are based on careful study of the voluminous research done on ADHD over the past 60 years. The AAP has also published a review of assessment and treatment of ADHD in adolescents.
The NIMH study discussed earlier assessed the effectiveness of four different treatments: carefully managed medication treatment only; intensive behavioral treatment at day camp, school, and home without any medication; combination of medication management and intensive behavioral treatment; and standard community care, with or without medication, by a pediatrician, neurologist, psychologist, or other local professional selected by the parents. Each child with combined-type ADHD was randomly assigned to receive one of the four different treatments for 14 months. The two groups that received the careful medication management experienced a greater reduction in core ADHD symptoms than the group with intensive behavioral treatment and no medication and those who received standard community care.
What surprised many was that the group of children who received medication alone showed improvement in ADHD symptoms comparable to those who received the combination of medication and the intensive behavioral treatment. However, this combination of interventions, known as multimodal treatment, was better in reducing other non-ADHD problems, including oppositional and aggressive tendencies, feelings of anxiety, teacher-rated social problems, parent-child relations, and reading. In general, parents and teachers favored the combined treatments. These results suggest that carefully managed medication treatment is the key ingredient for successful treatment of most children with ADHD. However, since most children with ADHD do not have the disorder alone, comprehensive multimodal treatment should be helpful in treating some of the coexisting conditions.
ADHD medications do not cure symptoms like an antibiotic may cure a strep throat. But for 70 to 90 percent of those treated, these medications significantly alleviate ADHD symptoms throughout the portion of the day when the medication is active. This is comparable to the correction of vision with eyeglasses. These devices do not cure poor eyesight, but they can significantly improve vision during the time they are worn. It is important to note that preschool children can have more variable responses and side effects from stimulant medications, compared to older schoolaged children.
Some stimulant medications for ADHD are effective for only a few hours while other formulations can be effective for 10 to 12 hours. Additionally, some reports suggest that the nonstimulant, atomoxetine, may be effective for up to 24 hours. In years past, students taking medication for ADHD usually needed three doses each day. Now many students with ADHD are treated once-a-day with longer-acting formulations that eliminate the need for a midday dose at school. The most important factor in medication treatment for ADHD is that the medication be carefully monitored and finetuned to the individual’s body sensitivity and schedule. More detailed information about medications for ADHD is available in the “What We Know” information sheets on the National Resource Center on ADHD website, http://www.help4adhd.org.
Although medication is usually the most effective treatment for many children and adolescents with ADHD, behavioral treatments are especially important when families choose not to use medication or medication is not fully effective. Behavioral treatment strategies have been demonstrated effective for many of the behavioral and learning problems often associated with ADHD. Information on adapting these strategies in the school setting and at home in collaboration with parents is available in several books, on the CHADD website, and in the CHADD Educator’s Manual. A recent study with teens found that stimulant medications in combination with behavioral interventions improved a range of academic outcomes, including note taking, homework completion, daily assignments, and quiz scores.
Unique medication issues often surface during adolescence. During the middle and high school years, it is not uncommon for a medication that worked well in elementary school to lose its effectiveness. Teenagers grow and gain weight, and their hormones change. All of these factors can reduce medication effectiveness. In addition, some students build up a tolerance to medications, especially long-acting forms, and may periodically need to increase the dosage or change to a different medication. In some instances, the dosage of medication is simply too low for maximum effectiveness.
The typical classroom is a terrible place for an ADHD child...after all, we are asking children who have profound problems attending, organizing and controlling their actions to spend hours per day attending, organizing, and controlling their actions.
-Michael Gordon, Ph.D., psychologist
If the student is currently taking medication, but symptoms are still evident, most likely the dose is no longer effective. If medication effectiveness declines, grades can drop and the student can become more irritable. Sometimes this change is so gradual that parents and teachers can miss the underlying reasons for this problem. They may assume the worst, the student is lazy and simply doesn’t care about school. If parents are not aware of these potential medication problems, teachers can suggest that they discuss them with their doctor, especially if the student’s academic performance has declined.
Another medication issue that can arise during adolescence is refusal to take medication. Teens may complain that they don’t like the way medicine makes them feel; they may be more focused but feel less outgoing. Teens may be angry that they have to rely on medication to do well in school or they may feel self-conscious or embarrassed about taking medication, especially at school. Occasionally, there is pressure to share medication with peers who want to try it.
Sometimes, medication refusal is mistaken for simple forgetfulness that is so common among teenagers with attention deficits. Unfortunately, that means that medication can unnecessarily become a focal point for major power struggles between students and their parents. A pattern of medication refusal can evolve as a way for the teen to retaliate. If this is the case, teachers can encourage parents to avoid power struggles and talk with their doctor about this challenge.
The teacher is often in the best position to provide feedback to both parents and the physician regarding the impact of medication on the student’s academic performance and progress. Physicians must rely on teacher and parent reports to ensure that a student’s medication is working at peak effectiveness at school. Specifically, if medication is working effectively, teachers should see improvements such as better grades, increased attention in class, completed homework, and compliance with teacher requests. A few rating scales to give teachers a more objective assessment of academic improvement of students on medication are listed in Chapter 2 of the CHADD Educator’s Manual. The teacher can convey this information to parents who in turn can notify the physician when there are problems and adjustments in medication may be needed. Having rating scales completed by all the teachers who interact with a student will help the doctor make better informed decisions about medication.
ADHD is a complex cognitive disorder, affecting all age groups of both genders. ADHD is increasingly recognized as a developmental impairment of executive functions of the brain, a disorder that is chronic and often persists well into adulthood.The disorder is dimensional; most students experience symptoms of ADHD to varying degrees and extent, which can appear as a simple problem of insufficient willpower. ADHD is not easily assessed by observation alone; comprehensive evaluations, including student, teacher, and family interviews, are essential to diagnosis. ADHD is implicated in many psychiatric and learning disorders. About 80 percent of children who have ADHD benefit substantially from careful evaluation and appropriate treatment.