A PRACTICAL GUIDE FOR TEACHERS OF YOUNG PEOPLE WHO HAVE ATTENTION DEFICIT HYPERACTIVITY DISORDER ADHD

Transcription

1 A PRACTICAL GUIDE FOR TEACHERS OF YOUNG PEOPLE WHO HAVE ATTENTION DEFICIT HYPERACTIVITY DISORDER ADHD Veira Bailey, Eric Taylor, KAH Mirza, Samaa- El -Abd And other members of the Maudsley ADHD group Updated 2009 by Hounslow / CAMHS / ADHD Multiagency Group Adapted 2012 by CFACS/ Hillingdon 1 Mirza KAH, Bailey V, Taylor, E, Smith J-Achieving the Best Teacher Booklet

2 CONTENTS 1 AN INTRODUCTION TO ADHD 1.1 What is ADHD? 1.2 How is ADHD diagnosed? 1.3 Children with ADHD 1.4 What is the cause? 1.5 What is involved in the assessment? 2 PARTNERSHIP BETWEEN SCHOOLS AND PARENTS 2.1 Communication with Parents 2.2 At primary school 2.3 At secondary school 3 INFORMATION ON ADHD FOR TEACHERS 3.1 What difficulties do children with ADHD present in the classroom? 3.2 Classroom organisation 3.3 Routines 3.4 Structuring the learning tasks 3.5 Strategies for managing behaviour 3.6 General 3.7 Specific Skills 4 Further reading 2 Mirza KAH, Bailey V, Taylor, E, Smith J-Achieving the Best Teacher Booklet

3 1 AN INTRODUCTION TO ADHD 1.1 What is Attention Deficit Hyperactivity Disorder? Attention Deficit Hyperactivity Disorder (ADHD) is a term used to describe the condition of children who are inattentive, impulsive, and active at levels higher than expected for their mental and chronological age. 1.2 How is ADHD diagnosed? The three core symptoms used to diagnose ADHD are: Attention Problems: Inattention and distractibility, difficulties in sustaining attention and apparently not listening Difficulties in organising and following through with instructions Losing things and forgetfulness Impulsivity: Difficulties in waiting for his/her turn, often blurting out answers before questions are completed and butting into conversations Acting with out thinking Hyperactivity (restless over activity): Running about or climbing excessively, always on the go, fidgeting with hands or feet or unable to sit still. Britain, like most of Europe, uses the International Classification of Disease (ICD). The ICD10 category for the three features above is HYPERKINETIC DISORDER. As well as all three features, the condition will have to have been present from an early age and in more than one setting, such as at home and in school. Hyperkinetic Disorder occurs in about one child in 100, and in boys more often than girls. In North America, using what is called the Diagnostic and Statistical Manual (DSM), only one of the criteria - attention problems or impulsivity / hyperactivity is necessary to fulfil the diagnosis of ATTENTION DEFICIT HYPERACTIVITY DISORDER. This occurs in about 4 7 per cent of school-age children. The North America terminology and the wider diagnostic criteria used for ADHD are now common in this country. It is recognised that a far greater number of children need help than only those with the full set of features indicating hyperkinetic disorder. It is important to stress that an ADHD diagnosis is made on the basis of a recognisable behaviour pattern. The cause of the behaviour may be 3 Mirza KAH, Bailey V, Taylor, E, Smith J-Achieving the Best Teacher Booklet

4 complex. But as this guide will show, children with the condition can be helped through good parenting, good management at school and the controlled use of medication. Children with ADHD are difficult to raise. They may develop educational, behavioural and conduct problems or emotional difficulties and to suffer from low self-esteem. 1.3 Children with ADHD may also be: Charismatic Imaginative Athletic Hard Working Visionary Adaptable Insightful Sensitive Passionate Energetic Optimistic Humorous Resilient Open minded Artistic Fun loving Creative Enthusiastic 1.4 What is the cause? In the past, professionals tended to blame parents for the behaviour of a child with ADHD. Others have said that the condition was due to additives in the food. However, research has not supported the popular view that ADHD is due to eating food additives, preservatives or sugar. Although the symptoms of some children get worse with certain foodstuffs, this is not the main cause of ADHD. It has even been suggested it is due to poor teaching in schools. It is now known that ADHD is associated with a minor difference in the chemical tuning of the brain affecting skills involved with attention and self regulation. It is commonly genetic and many children with ADHD have a parent or close relative with a similar condition. In rare cases ADHD is associated with pregnancy or birth complications. In a few cases it arises as a direct result of disease or trauma to the central nervous system. There appear to be a number of risk factors that cause ADHD when they coincide. Poor parental management is not thought to be a primary cause of ADHD but can make the symptoms worse. 4 Mirza KAH, Bailey V, Taylor, E, Smith J-Achieving the Best Teacher Booklet

5 1.5 What is involved in the assessment? A child is usually referred for an ADHD assessment when other things to make improvements within school and home have been tried first and not successful. Parents and teachers are asked to fill in a checklist of symptoms if ADHD is suspected. As well as this, more standard questionnaires are used to rule out other explanations or co-occurring difficulties. In the checklist, parents and teachers are asked detailed questions about the child s behaviour in a range of situations. The child will also be observed directly and may undergo tests to clarify ability and attainment. School will be asked to provide information on the child s progress in school. The evaluation may take time. This is necessary as a diagnosis in an individual child needs to consider the level of development that the child has reached and rule out other causes, such as deafness or learning disability. It is also important to find out whether the child has additional problems sometimes found with ADHD. These include learning difficulties, dyspraxia (clumsiness), speech and language problems and autism spectrum problems, if these haven t been highlighted already. 2 PARTNERSHIP WITH SCHOOLS Teachers are now well informed about ADHD but it can be confusing when media stories blame parents and criticise the role of medication or suggest that teaching is to blame. It can, therefore, be very helpful to share information with parents about their child in relation to ADHD and how their child is supported in school so that people s ideas and understanding are joined up. If you teach a child who is on medication, it is important to know at what times the medication is taken and there may be times that parents or professionals ask you to monitor the child whilst at school. This may be to check if the medication seems effective, to notice if there are any side effects, to see how long the medication lasts and to advise on whether it is timed well to help the child in school. There may be times when medication is taken at school and this can provide anxiety for young people and their parents. It will be necessary to negotiate the timing of medication so that it is given with the minimum of fuss and is timed to avoid rebound (the effect of the medication reducing). (For methylphenidate this is generally four hours after the previous dose for most children). 5 Mirza KAH, Bailey V, Taylor, E, Smith J-Achieving the Best Teacher Booklet

6 Some children with ADHD may have specific learning difficulties which will be apparent in tests. As part of an ADHD diagnosis, the child is deemed to show inattention, hyperactivity and impulsivity to a level beyond that expected for their general cognitive ability. A general cognitive assessment (such as a WISC-IV) may be completed or information on all round academic ability gained from school in order to measure this difference. If not completed by an Educational Psychologist then a Clinical Psychologist would complete the testing in a specialist clinic. It is important to remember that ADHD can affect children who have learning disabilities as well as those who are gifted. Sometimes more specific testing around attention will be completed as well. Individual recommendations for the child, family and school will be made to support the child which schools should receive a copy of. At school (as at home) children with ADHD thrive on consistency, calm and structure: They do best in a traditional, closed classroom. Open plan learning provides too many distractions. The child should be seated in the part of the room with the fewest distractions. They do well with sensible seating at the front of the class placed between two calm pupils. Clear, warm, positive rules and a planned routine are helpful. Children benefit from having a timetable and knowing what is planned at the beginning of the day. Information should be given in short, simple steps remembering that children with ADHD have difficulty in concentrating and taking in the whole of a lengthy instruction. 2.1 Communication with Schools Talking with the child s parent about how messages between school and home, can best be received, is important to help clear communication and consistency. A home/school book for messages between parents and teacher may be helpful especially if the child struggles with planning, organising and remembering. Some children who struggle with their handwriting might also find this clarity useful. Parent s may ask for feedback about how their child is managing. Providing feedback about the child s behaviour and how much work he or she is producing is useful in planning the amount of medication and its timing as well as assessing how the child is coping in and out of school. Sometimes young people with ADHD try very hard to hide their struggles and let their frustrations out at home. Sometimes, they thrive on the structure of school and struggle with the flexibility that home can allow. Either way, promoting their strengths and skills will be essential in them having healthy self esteem. 6 Mirza KAH, Bailey V, Taylor, E, Smith J-Achieving the Best Teacher Booklet

7 Try to meet regularly with the child s parents. It can be most helpful to work out together a system of merit awards or clear rewards for staying on task. To be effective it needs to measure daily small targets that are achievable. 2.2 At primary school As with any child, but especially one with ADHD it is important to help the child by keeping school work enjoyable and having clear and realistic expectations. Getting in to good habits and routines early on can help in the future. Children with ADHD may need an opportunity to run around and let off steam between times of settled classroom work, more than other children. They may need cards to use to ask for time out or a spot in the class room where they can have wiggle time. It is important that if they leave the classroom for extended periods, that their work is taken with them. 2.3 At secondary school Daily diaries for homework will be essential. For homework: children with ADHD often tend to put off homework, which can be for a number of reasons. It is important to try to encourage the child to avoid putting off homework. Parents might be encouraged to help their child to have a short break when home from school, perhaps for a drink and a snack and then encourage their child to settle down and get it done. Helping young people to develop a routine with clear timetabling can be useful. Supporting parents to think of immediate small rewards such as extra play, television, games as a reward for completing homework is necessary to reinforce this pattern. In exams: Young people with ADHD need particular help with exams. They may need extra support to learn to plan with headings and lists, to manage time and stay focused. If children don t plan, they may ramble on and miss answering the main question. For revision, visual techniques are often useful; use of highlighter pens, plans, diagrams and making lists. If poor writing is a serious problem young people may need extra time allowed or the use of a laptop computer. To minimise distraction, it may be considered that they have their own quiet and smaller space. 7 Mirza KAH, Bailey V, Taylor, E, Smith J-Achieving the Best Teacher Booklet

8 3 Information on ADHD for Teachers 3.1 What difficulties do children with ADHD present in the classroom? Children with ADHD present many difficulties in the classroom: They find it difficult to listen and to take in instructions, are rarely ready to start their work and often fail to complete work set. They have difficulty concentrating, are easily distracted and are disorganised and forgetful. Other behaviours include calling out, interrupting and butting into conversations inappropriately. Hyperactivity may be particularly marked in younger children who may have difficulties in staying in their seat. Some wriggle so much they actually fall out of their seats. Older children may appear more restless and fidgety, often fiddling dangerously with equipment. Children with ADHD are frequently unpopular with other children because of their unpredictable and irritating behaviour. Children with ADHD can be a challenge for the teacher but can be very rewarding if well managed. All pupils learning is enhanced by increased attention to task so that the following strategies could well benefit the class as a whole, not just the child with ADHD. 3.2 Classroom organisation The following TIPS are often found useful: Place pupils with ADHD in the least distracting place not near a window or door 8 Mirza KAH, Bailey V, Taylor, E, Smith J-Achieving the Best Teacher Booklet

9 Seat children near the front and between good role models in a position where good eye contact can be maintained with the teacher Working in pairs rather than groups and having a separate desk will be easier for the child with ADHD to manage. Write the timetable on the board or have it available daily. 3.3 Routines Clearly defined rules which are few in number and frequently rehearsed; help to prompt the child with ADHD. Use consistent routines. Model and teach routines, eg turn taking, distributing materials, sharing the equipment, Give warnings for beginning and ending of lessons. Children with ADHD have difficulty in re-focusing their attention when changing from one activity to another. Prepare them for the transition and give them time to complete. Prepare pupils for changes to the timetable if known in advance, eg a change of teacher. Place particular emphasis on ensuring that all materials/equipment are readily available. Keep classroom interruptions to a minimum. 3.4 Structuring the learning tasks Give clear, concise instructions after establishing eye contact. Ask the pupil to repeat directions back to the teacher. Break tasks down into small steps chunking. Tasks should initially be short and when mastered gradually increased in complexity. Incorporate short breaks for physical activity into lessons which involve lengthy periods in seat. Pair written instructions with oral instructions. Use a multi-sensory approach to learning. Give regular feedback as children with ADHD respond to frequent positive reinforcement. 9 Mirza KAH, Bailey V, Taylor, E, Smith J-Achieving the Best Teacher Booklet

10 Provide alternative ways for pupils to present their work including tape, word processor, using teacher or peer as scribe and through diagrams and pictures. Aid organisation through the use of lists, daily task sheets, charts and report cards. Use highlighter pens to focus attention on key words and instructions. Use cooker timers for work completion, changing time on task etc. 3.5 Strategies for managing behaviour Remember that the behaviour of the child with ADHD is not intended to irritate teachers or peers. They are unable, not unwilling, to work. These pupils need help in managing their behaviour if they are to take advantage of the learning experiences of the classroom. Frequent use of praise and rewards. These should be given immediately. Pupils with ADHD respond better to immediate rather than delayed rewards. Reprimands should be brief and given calmly. They should be very specific and involve a reminder of the required task. Avoid sarcasm, anger and arguments. Minor disruptions are best ignored. Involve the pupil in his/her management plan. He/she will feel empowered and learn to problem-solve. Transition times as well as less structured times such as breaks and meal times should be closely monitored. The child with ADHD will find these difficult. Identify specific problems, situations and behaviour problems (eg blurts out answers before questions have been completed, wanders around the classroom). Teach children to self-monitor. This is effective in reducing unwanted behaviours and is an important skill for children with ADHD to acquire. Praise appropriate behaviour at every opportunity. Use choices and distractions to avoid confrontations. If it seems that a child is avoiding their work, think about why. What might they be communicating through their behaviour and how might you help them? 10 Mirza KAH, Bailey V, Taylor, E, Smith J-Achieving the Best Teacher Booklet

11 Be alert to opportunities for incidental social skills training eg joining in a conversation, making requests, paying and receiving compliments. Use whole class rewards to encourage peer support. 3.6 General Teachers and parents need to work closely together. Use a schoolhome book or daily report card. A daily report card is a list of individual target behaviours that represent a child s most salient areas of impairment. Teachers set daily goals for each child s impairment targets and parents provide rewards at home for attaining goals. Use a homework assignment chart that can be signed daily by parents and supervise writing down of homework assignments. Check that the child has no other associated problems such as clumsiness or dyslexia, for which they may need help. The school s arrangements for medication should ensure that it is given reliably and with the minimum of fuss. It should be timed to avoid peaks and troughs and rebound. For methylphenidate (Ritalin/Equasym) this is generally four hours after the previous dose. Treat each day as a new beginning. Do not dwell on previous failings. Many of these suggestions will already be in the repertoire of class teachers but will need to be prominent in the management of children with ADHD. These strategies may be suitable for inclusion in pupils Individual Education Plans. More specific advice on behavioural management techniques including contingency management and response cost reinforcement programmes should be available from the local Educational Psychology service or Behaviour Support Team or Early Intervention Team. 3.7 More specific skills 3.71 Memory Many young people with ADHD experience memory difficulties. This is likely due to requirement that information must be processed in order to be remembered and this needs the person to pay attention. In order for information to be learned or stored in the long term, it must be processed in Working Memory first. Working Memory is a temporary storage area for the sensations (hearing, seeing, touch etc). If too much information is presented then some of this is written over (like a tape) and without paying attention, the information cannot be effectively processed as it enters the storage area. From here it can be transferred in to Short Term Memory where it is stored from minutes to hours. 11 Mirza KAH, Bailey V, Taylor, E, Smith J-Achieving the Best Teacher Booklet

12 There are some strategies that help information move from Short Term to Long Term storage such as repetition, emotional connection and association. The information also needs to be retrieved effectively by free recall or a cue. Another type of memory is Prospective Memory. This is our intention to remember things in the future. People with ADHD often have difficulties with all these areas: Working Memory- struggles to work out arithmetic questions in the mind Short Term/ Long Term- forgetting instructions or where things are Prospective- not being in the right place at the right time Strategies External (things outside of the person) Diary/ Weekly Planner/ Annual Wall Planner- Visual prompts. Dictaphone/ Phone Voice Recorder/ Notepad- Verbal prompts. Lists- things for school, homework, location of items etc. Watches/ Timers/ Alarms- to help structure the passage of time and provide cues to start or end activities. Instruction Cards- how to use the dishwasher, how to solve a maths questions etc. These need to be looked at regularly to become familiar. Internal (things within the person) Repetition or rehearsal- practicing things regularly, repeating them verbally. Visual Cue- pair a verbal task with a visual cue so that later on the visual cue can trigger the memory. A parent could then show a cue card without having to explain everything again. Mneumonics- learning cues by condensing the information so it feels less overwhelming. Eg. Going to the shop for Bread, Orange and Biscuits = BOB. Problem-Solving- learning the strategy of retracing steps, working out the logical place, remembering back to another time Organisation and Time Management People with ADHD often struggle to plan and structure their time effectively, sometimes losing track of time or being unsure how long a task will take. Memory difficulties make keeping to time even more problematic. 12 Mirza KAH, Bailey V, Taylor, E, Smith J-Achieving the Best Teacher Booklet

13 As you may have experienced, children with ADHD will often try to put off any task that seems boring or mundane and doesn t catch their attention. Often tasks are left to the last minute and rushed. This means they often don t show their true ability. Other traps they fall in to are getting side tracked by ideas that pop into their minds or a different task altogether. Young people with ADHD also have difficulty delaying their gratification and like to do or have things now so putting things off that are more interesting than the task they are expected to do can be a challenge. Strategies Helping them work out the importance of punctuality- eg, what will happen if they are late to school? What will happen if they don t get work done in time? Identifying triggers- notice in class which tasks or situations are the most difficult or have the greatest impact and tackle these first. Time Planners- daily timetables detailing how long to spend on a task and a timer available to start and finish. Set goals- help the child to prioritize the most important or necessary items first. Add completing tasks on time to things that are praised and rewarded. Time Estimation- help the child to work out how much time would be needed for their task and compare this to how much time is taken to create realistic plans. Don t forget to include breaks. A time slot- dedicate an amount of time to a task e.g. 20 minutes and do as much as possible before a break. Cue cards with verbal cue- design a cue card t prompt your child to return to task if they have gone off track. Diary- fill out a diary week to see how the child uses their time and to pick out time wasting traps, appearing to be busy when not, delaying getting started. Make a goal to use any time that is saved each day allowing the child to do fun, stimulating and rewarding activities or an activity they have in class that they enjoy Impulsivity Impulsivity can exist cognitively and behaviourally. Children with ADHD sometimes find that random thoughts pop in to their minds, that they want to say the first thing they think, that they want to act on their urges and the internal brake that helps to stop and think isn t working. 13 Mirza KAH, Bailey V, Taylor, E, Smith J-Achieving the Best Teacher Booklet

14 Sometimes this means that children with ADHD take unnecessary risks by acting without thinking things through. Sometimes these spontaneous decisions pay off. Many people with ADHD have taken risks that others would not and this has paid off in the business world as well as leading to creativity, inventions and sports success. Having a great interest for a short time helps people with ADHD to approach tasks that interest them with great enthusiasm. Typical difficulties associated with impulsivity include: not seeing consequences, difficulty waiting, seeking immediate gratification, taking short cuts, jumping to conclusions and recklessness. Strategies The first step is identifying the impulsive behaviours for example, running out in roads or shouting out and choosing the priorities. Adults may need to predict when these the impulsive actions happen and make a plan to prevent them within a risk assessment. Making a STOP and THINK card to show the child when you think they are about to do something impulsive. Helping the child to develop self talk: I can stay calm, Stop and Think, I can do this, Take it slow. Help the child to think about the consequences of their impulsive actions and to remind themselves of these consequences in the future. Immediate rewards and praise for using the strategies. Help the child to double check. Is this what they want to do? Have they thought of other options? Do they want to check? Safety proofing the classroom can help remove risk for a child who is curious and impulsive. The optimal outcome is for the child to begin to use these strategies themselves Problem Solving As children grow up they have many problems and dilemmas to solve in different areas of their lives, which help to become independent. Younger children may have adults around them who help them to make decisions, who solve their conflicts for them and who facilitate the child s overcoming of the obstacles they face. Young people with ADHD often have find problem solving more difficult than their peers because of their attention, memory and impulsivity. They may respond impulsively rather than thinking through options, forget the strategies they have thought of, or miss 14 Mirza KAH, Bailey V, Taylor, E, Smith J-Achieving the Best Teacher Booklet

15 important information that is needed to help them solve their problem. Some children react in aggressive or oppositional ways and avoid the challenges they face. Strategies Break the problem down with the child so that this becomes habit. 1 Slow down, what s the problem? 2 What are my choices? 3 What would happen with this choice? How might I feel? 4 Now how do I carry out the best choice? 5 How did that choice work? Should I make another choice next time? Children with ADHD can be resilient and tend to be optimistic about trying new options if something hasn t worked. Making time to support children through this after unhelpful choices can help them make better ones in the future Social Skills Training Use every opportunity to teach children how to behave. Rather than peer problems, there can be a brilliant opportunity to foster resilience, understanding and tolerance in children in a class with others with ADHD. Young people with ADHD often struggle with relationships, because it is difficult for them to behave how others do, they lose track of conversations, they can struggle to tolerate their feelings and have difficulty sticking to boundaries and times which means they sometimes let people down. Opportunities to reflect on these experiences, to repair relationships and make plans to help things go smoothly in the future are important skills for children with ADHD to learn and practice in school. Attending structured social skills groups can also be useful. 4 Further reading Attention Deficit/Hyperactivity Disorder - a practical guide for teachers.. Paul Cooper, Catherine Ideus. 13 ADD Hyperactivity Handbook for Schools Harvey C Parker Mirza KAH, Bailey V, Taylor, E, Smith J-Achieving the Best Teacher Booklet

16 Attention Deficit Hyperactivity Disorder - a Multi-Disciplinary Approach. Holowenko, Henryk. Jessica Kingsley, London Video: Hyperactive children in the Classroom, University of Southampton Media Services. 32 These are obtainable from The ADDISS Resource Centre PO Box 340 Edgware, Middlesex HA8 9HL Tel: Fax: Website: info@addiss.co.uk ADDISS often run conferences which would be helpful to teachers. Adapted with Young-Bramham Resources (2012) CBT for ADHD in Adolescents and Adults. 16 Mirza KAH, Bailey V, Taylor, E, Smith J-Achieving the Best Teacher Booklet