|
||||||||||||||||
|
||||||||||||||||
This is an intermediate-level course intended to provide mental health professionals with a variety of evidence-based methods for addressing school adjustment issues. After completing this course, mental health professionals will be able to:
The materials in this course are based primarily on the book, Managing ADHD in School: The Best Evidence-Based Methods for Teachers, by R. A. Barkley (2016), published by PESI, Eau Claire, WI. It is also based on his more recent book, Treating ADHD in Children and Adolescents: What Every Clinician Needs to Know (2020), Guilford Press. Moreover, recent research was reviewed on best practices for managing ADHD in school settings. This course contains the most accurate information available to the author at the time of this update. The scientific literature on ADHD grows daily, and new information may emerge that supersedes these course materials. This course will equip clinicians to be able to advise parents about, and directly equip educators on, the most effective methods for managing the symptoms of ADHD and associated impairments in children and teens with ADHD in school settings.
Education is the most prevalent domain of impaired major life activities associated with ADHD in children and teens, with more than 90% of those affected having significant problems functioning effectively in this setting. School is also the most seriously impaired domain relative to all other domains such as family, peer, and community functioning. Mental health professionals therefore are routinely called upon to advise families and educators on the most appropriate methods for managing ADHD related symptoms, behavioral problems, and academic performance difficulties in school settings.
This section provides a brief review of the symptoms, associated cognitive deficits, demographics, and etiology of Attention Deficit Hyperactivity Disorder (ADHD) as taken from other courses on this website and other sources by Dr. Barkley (on this website for his other books). It is not intended as a substitute for the information in the other courses on this website. Course participants are encouraged to take those other courses for more extensive knowledge about ADHD. The research supporting the information provided below can be found in the other courses by Dr. Barkley as well as in the latest edition of his handbook and clinician’s guide on ADHD.1, 2
ADHD is a neurodevelopmental condition that consists of developmental delays or deficiencies in at least two types of neuropsychological abilities. These two dimensions are inattention and hyperactive-impulsive symptoms.3 The disorder is classified as neuro-developmental because the scientific evidence for the substantial role of neurological and genetic causes in ADHD is now overwhelming and irrefutable (see Causes of ADHD below). ADHD is considered to be neuro-developmental because it is primarily the result of a delay or lag in the development of specific mental abilities. Those deficits are largely due to delays and/or dysfunctioning in the maturation of the brain areas that underlie those abilities. Such brain maldevelopment seems to arise largely from genetics but can also occur as a consequence of damage or other disruptive influences experienced by the child or teen at any time during development, most often during prenatal brain formation.
The symptoms of ADHD are dimensional in that they reflect the extreme end of a continuum of normal or typical human ability in these two areas. Therefore, children and teens with ADHD have a disorder that:
The general nature of the symptoms most often evident in children and teens with ADHD include:
Inattention:
Hyperactivity-Impulsivity:
To warrant a diagnosis of ADHD, these symptoms must occur at least often, to a degree that is excessive for the child’s age. The child or teen has to have a majority of the symptoms (six or more) on either list. Several symptoms must have developed in childhood (before 12 years of age). These symptoms must have persisted for at least the past six months, must occur in two or more settings (home, school, work, community), and must lead to impaired functioning in major life activities, such as social (family, peers, community), academic, or occupational activities. Only a small percentage of children will meet all of these conditions, making those who do, more problematic than 92%-95% of the child or adolescent population in these respects.
Deficient Mental Abilities that Contribute to the Symptoms
I and many other clinical researchers conceptualize these symptoms as arising from deficits in the executive functions – such functions permit self-regulation:4
If you noticed a recurring theme here, it is that ADHD interferes with thoughts, actions, words, motivations, and emotions aimed at organizing behavior across time and preparing for the future instead of just reacting to the moment. To act impulsively, fail to persist, and be distractible is to be nearsighted to the future – to be preoccupied by moments and so be blind to time. The aforementioned cognitive deficits arise from deficits in executive functioning (EF) and so disrupt daily school activities. Therefore, deficient executive functioning in daily life will be evident in problems with:
The vast majority of children and teens meeting research diagnostic criteria for ADHD fall in the bottom 7% of the population in each of these major areas of executive functioning in daily life.5 It is easy to see how such deficits would produce a myriad of difficulties with functioning in educational settings that typically place a premium on these EF abilities.
Children and teens with ADHD may show significant fluctuations in the severity of their symptoms across diverse situations or settings. In general, symptoms of ADHD may often be worse in settings or tasks that:
All of these settings demand EF and self-regulation. Of course, the symptoms of ADHD can improve in settings that involve factors that are the opposite of those above. Specifically, these best-case situations may involve fun activities, highly stimulating or interesting tasks (e.g., video games), lots of movement (e.g., gym, recess, sports), frequent rewards or feedback, highly supervised settings, working in small teams with peers rather than independently, working one-on-one with an adult, highly novel settings, where supervisors speak briefly but back up their rules quickly with consequences, and where there is little or no pressure to wait for things.
As discussed above, ADHD is known as a neurodevelopmental disorder. That is because its chief causes exist in the broad realms of genetics and neurology rather than in the domain of social causes.
Genetics. ADHD is a highly inherited disorder. For instance, if a parent has the diagnosis, their children are six to eight times more likely to have the disorder (35%-54%). If a child has ADHD, their biological brother or sister is three to five times more likely to have the condition (25%-35%). Their biological mother is three to four times more likely to have ADHD, and their biological father is five to six times more likely to have it. If an identical twin has ADHD, the other twin will be ADHD in 75%-90% of cases. All this clearly shows the genetic (heritable) nature of ADHD.
The degree to which individual differences in genes among people contributes to individual differences in their ADHD symptoms is 65%-80%. In other words, up to 80% of the differences among people in their degree of ADHD symptoms is due to differences in their genetic makeup. This is higher than the genetic contribution to temperament and personality traits, depression, anxiety, antisocial behavior, and even intelligence. It is only slightly less than the genetic contribution to variation among people in their height.
Research currently suggests that there may be as many as 25 to 44 genes involved in causing ADHD. Note that these are not different kinds of genes from those seen in typical people. There is no specific disease gene or genes for ADHD such as may be seen in Tay Sachs or other severe neurological disorders. What is involved in ADHD are different versions of the same genes seen in typical people. For instance, children with ADHD may have a longer version of a gene than that seen in a typical child – this is often known as tandem repeats. For instance, typical children may get four or five copies of a certain gene side-by-side, while children with ADHD may have seven or more copies, thus creating a longer version of this gene. Such variations in gene length and repetition are called polymorphisms. The different version of the gene in cases of ADHD leads to different lengths of proteins and other chemicals, and those lead to different structural changes in the brain. And those differences create differences in the brain’s functioning – sometimes different enough to create ADHD.
This explanation does not mean that all 25 or more risk genes need to have atypical versions in order to create the disorder; only a subset could well cause it. The risk for ADHD increases with the number of risk genes that a child possesses. It also means that cases of ADHD will vary in which genes led to their particular case of the disorder. For instance, as a hypothetical example, it may be that just five to eight genes from among this pool are needed to be different so as to cause a case of ADHD to emerge. But which subset of this risk pool of ADHD genes that differs in any individual case may not be the same subset of genes that caused another case of the disorder. This further means that similar-appearing symptomatic cases of the disorder could still have different underlying genetics for their disorder. Those differences could lead to either subtle or even important differences in the nature of their disorder (some are more impulsive, others more inattentive), in the risks for other disorders (such as depression, learning disorders, smoking or other substance abuse), in the consequences from the disorder (driving impairments, criminal behavior), and even responsiveness to different ADHD medications or other treatments.
Understanding the genetics of ADHD also helps us to understand why ADHD may be more likely to be affiliated with some other psychiatric disorders, as they may share the same or similar underlying genes. Some of the risk genes for ADHD, for instance, have been found in reading disorders, autistic spectrum disorders, and bipolar disorder, while other genes are shared with oppositional defiant disorder, conduct disorder, and even nicotine dependence and alcoholism.
Because ADHD is a disorder that falls along a continuum or dimension, and because it is inherited, one can see signs of an ADHD phenotype within a family having the genetic form of the disorder. That is to say that parents and siblings of a child with ADHD may be more likely to manifest some milder forms of the symptoms or traits of the disorder even if they don’t meet all of the requirements for receiving a diagnosis of it. [Note: the same is true in autistic spectrum disorder, which is also strongly genetically influenced.]
While most cases of ADHD are genetic and involve inheritance of the genes contributing to ADHD from parent to child, new cases of ADHD can arise in a family due to genetic mutations in ADHD-risk genes that occur in the parent’s eggs or sperm. These mutations get passed along to the children, creating a new line of ADHD risk in the family even though the parents do not have the risk genes for the disorder in their own blood or other cells (except their gametes).
Neurology. Hundreds of research studies employing a variety of methods for measuring brain structure, functioning, development, and connectedness (networks) now support the conclusion that ADHD is largely a neurologically caused disorder. At least five to six brain regions are reliably linked to the disorder. These brain regions can be seen in Figure 1, below. They are the prefrontal cortex, the anterior cingulate cortex (at the midline of the frontal lobes), the frontal section of the corpus callosum (the splenium), the basal ganglia, and the cerebellum (mostly the central vermis region). Less certain is whether or not the thalamus and amygdala are involved. Interestingly, evidence suggests that the right side of the brain in some or most of these regions may be somewhat more involved in creating ADHD than the left. But both sides of these regions appear to be involved in the disorder. In general, the brains of children and teens with ADHD are about 3%-10% smaller globally in gray matter volume (the material on the outside layer of the brain). But these five specific brain regions appear to be even smaller – about 15%-30% smaller than normal for age.
Figure 1. (A) Diagram of the human brain - regions involved in ADHD are the prefrontal cortex, anterior cingulate cortex, striatum, cerebellum, and corpus callosum (splenium or anterior aspect). (B) The dopamine system of the brain – a neurotransmitter system influenced by certain ADHD medications. (C) The norepinephrine system of the brain – a neurotransmitter system affected by other ADHD medications. From ehp.niehs.nih.gov.
Research demonstrates that these regions are functionally interconnected to form one of the seven major brain networks – the executive system. In my view, that system underlies the human capacity for self-regulation and, as Fuster concluded, for the cross-temporal organization of behavior toward goals (future-oriented action). There are at least four or five subnetworks in the executive network, each of them associated with different parts of the brain, that can help us understand how executive functions help us self-regulate—or, in the case of ADHD, make it difficult to do so:
You may be wondering where hyperactivity fits into the executive function neuroanatomy picture of ADHD. In part it certainly arises from defective functioning of the inhibitory network. But in addition to the subnetworks listed above is the motor activity regulation network. Disturbances in this network are thought to also give rise to the hyperactive symptoms of the disorder.
Developmental research finds the brain to be two to three years delayed on average in its development in these regions, especially the prefrontal lobes, and to be 10%-30% less active than in typical comparison cases. More recently, fine-grained neuro-imaging methods have revealed defective microstructures in the subcortical (white matter) neural networks that connect these brain regions to each other. These methods make the maturational deficiencies in ADHD even more obvious in the interconnectedness (networks) of these structures than was evident in studies of just surface gray matter. While the size of the entire brain may eventually become closer to normal with age, the connectedness and functioning of the neural networks is likely to remain deficient and highly variable into adulthood for many cases, though not for all cases. There is no doubt now that ADHD is of neurologic origin, hence its classification as a neurodevelopmental disorder.
You can now understand why ADHD is both genetic and neurological. The genes involved in causing ADHD are genes that build and operate certain regions and networks in the brain during development. Different versions of genes involved in ADHD compared to typical people result in differences and even deficiencies in these structures, connectedness, and their functioning. ADHD is therefore a neuro-genetic disorder in many cases.
But ADHD can also arise from non-genetic sources, as shown in Figure 2 below. Most of these are conditions or factors that can potentially interfere with brain growth and functioning, especially in the ADHD-related brain regions mentioned above. For example, it is now known that when a mother drinks alcohol beyond a certain amount during her pregnancy, they increase the risk for ADHD in her unborn child two to three times greater than the typical risk (Fetal Alcohol Exposure in Figure 2). This is likely the result of these substances having a toxic effect on brain development. Other pregnancy complications may do much the same, abnormally altering brain development. These include conditions such as the number of maternal infections during pregnancy, delivery complications (Perinatal hazards in Figure 2), degree to which the baby was born substantially premature (Low Birth Weight in Figure 2), degree of severe stress to which the mother was exposed during pregnancy, extent of abuse of other drugs alcohol during pregnancy, and other factors. A smaller percentage of ADHD cases may be due to brain damage suffered after the child is born. This can include diseases, brain trauma, tumors, stroke, or even poisoning, such as with lead or pesticide exposure (Lead and Post-Natal Damage in Figure 2).
Figure 2. Etiologies of ADHD
Most recently, some research shows that these environmental risk factors can interact with the ADHD risk genes discussed above to further heighten a child’s risk for ADHD. This is illustrated in Figure 3. For instance, if a mother passes one of the major ADHD risk genes to her child and she smokes during that pregnancy, the risk for ADHD in her child is magnified two to three times greater than would have been the case from either the risk gene or maternal smoking alone (evidence of a risk gene by environmental interaction). In summary, about 60%-70% of cases of ADHD are likely due to inheritance or genetic factors. Another 20%-25% arise from pregnancy complications that may adversely affect brain development or that interact with ADHD risk genes to do so. The remaining 5%-10% may arise from injuries to the brain sustained after birth.
Notice here that there is no compelling evidence that social factors, such as parenting or educational environment, have been found to cause ADHD. The degree of evidence against such explanations is now so compelling that no reputable scientist working in this field gives them any credence at this time. This does not mean that social factors are unimportant; just that they are not important in explaining the initial causes of ADHD. They are still important in determining how impaired someone with ADHD will be in specific situations. Social factors are also important in influencing what the risk to a child will be for other psychiatric disorders known to be due in part to these social factors (anxiety, depression, oppositional behavior, conduct disorder, etc.). And surely you will recognize that social environmental factors determine how much access to care children get for treating their ADHD, and the quality of that care, including in the school setting.
Figure 3: ADHD as a risk gateway from multiple prenatal and early developmental risk factors and amplifying risk for a wide range of outcomes related to cascading effects of poor self-control throughout life. From Nigg, J. T and Barkley, R. A. (2013); Attention deficit hyperactivity disorder; in E. J. Mash and R. A. Barkley (Eds.), Child Psychopathology (3rd ed.). New York: Guilford Publications. Copyright 2013 by Guilford Publications. Reprinted with permission.
Research has now ruled out the likelihood that dietary substances such as sugar or food preservatives and additives cause ADHD. However, some children may be sensitive to food colorings enough to induce or mildly worsen their ADHD symptoms. But such effects are found in a minority of children and often when they are preschoolers, not when they are teens or adults. Anti-oxidants have not been found to be linked to ADHD and thus taking food supplements that increase them in the body seem unlikely at this time to benefit children with ADHD. Iron deficiencies have been found in some studies in children with ADHD but this finding is not reliable across studies and it is not clear that iron supplements would be helpful for management of the disorder in these cases. ADHD does not arise from watching TV excessively, using computers too frequently, or playing video games. Although the degree of TV viewing in the early preschool years was correlated to a small degree with inattention in some studies, other studies completely failed to replicate that finding. And the direction of causation is also unclear here. We know that children with ADHD like to watch TV more than typical children so ADHD could be leading to more TV viewing. The disorder is certainly associated with increased use of the Internet or video games, social media, and other screen-based technology, but these don’t cause ADHD, rather ADHD predisposes children to excessive electronic media use. For instance, children with short attention spans would rather play a fast-paced exciting video game than read for pleasure; they would rather watch TV than exercise; they would rather use the Internet or social media on their smartphones to socialize with others, even strangers, than interact in person with neighborhood or school-based peers.
As you can see from the above review, ADHD is a neurodevelopmental disorder of attention, inhibition, and executive functioning that largely arises from neurological and genetic origins.
As noted above, children and teens with ADHD have serious deficits in their executive functioning and self-regulation. In dealing with these deficits, there are several basic principles that must be kept in mind in constructing specific interventions for the educational problems of these individuals. Here are the principles that underlie the effective management of ADHD-related EF deficits in the schools.7
If the process of regulating behavior via internally represented forms of information (e.g. working memory or the internalization of self-directed behavior) is impaired or delayed in those with ADHD and EF deficits, then those students will be best assisted by “externalizing” those forms of information. The provision of physical representations of such information will be needed within the school setting at the point of performance. Since covert or private information is weak as a source of stimulus control, making that information overt and public may assist with the strengthening of control of behavior via that information. Make the information physical and place the physically represented information outside of the child just as it was in earlier development. Internal forms of information generated by the executive system, if they have been generated at all, appear to be extraordinarily weak in their ability to control and sustain behavior toward the future in those with EF deficits. That behavior remains largely under the control of the salient aspects of the immediate context. So, make the information external again.
The solution to this problem is not to nag those with ADHD-related EF difficulties to simply try harder or remember what they are supposed to be working on or toward. Instead, the solution is to fill the immediate context with physical cues comparable to the internal counterparts that are proving ineffective. In a sense, clinicians treating those with EF deficits must beat the environment at its own game. Whenever possible, minimize sources of high-appealing distractors that may subvert, distort, or disrupt task-directed mentally represented information and the behavior it is guiding. In their place should be cues, prompts, and other forms of information that are just as salient and appealing, yet are directly associated with or are an inherent part of the task to be accomplished. Such externalized information serves to cue the individual to do what they know.
If the rules that are understood to be operative during educational or occupational activities, for instance, do not seem to be controlling the child‘s behavior, they should be externalized. They can be externalized by posting signs about the school environment and its rules and having the student frequently refer to them. Having the student verbally self-state these rules aloud before and during individual work performances may also be helpful. One can also record these reminders on a digital recorder that the student listens to through an earphone while working.
Figure 4. Time Escapes Children with ADHD
The organization of an individual’s behavior both within and across time is one of the ultimate disabilities rendered by ADHD. EF deficits create problems with time, timing, and timeliness of behavior such that they are to time what nearsightedness is to spatial vision. They create a temporal myopia in which the individual’s behavior is governed even more than normal by events close to or within the temporal now and the immediate context rather than by internal information that pertains to longer term, future events. This helps us to understand why students with EF deficits make the decisions they do, short-sighted as they seem to be to others around them. If one has little regard for future events, then much of one’s behavior will be aimed at maximizing the immediate rewards and escaping from immediate hardships or aversive circumstances, without concern for the delayed consequences of those actions. Those with deficient EF could be assisted by making time itself more externally represented, by reducing or eliminating gaps in time among the components of a behavioral contingency (event, response, outcome). Caregivers and others can also help to bridge such temporal gaps related to future events.
Another solution is to reduce or eliminate the problematic time-related elements of a task when feasible. The elements should be made more contiguous. Rather than telling the child that a project must be done over the next few days, week, or month, assist them with doing a step a day toward that eventual goal so that when the deadline arrives, the work has been done, but done in small daily work periods with immediate feedback and incentives for doing so.
Externalize Motivation
The EF theory of ADHD also hypothesizes that a deficit will exist in the internally generated and represented forms of motivation needed to drive goal-directed behavior. Complaining to these children about their lack of motivation (laziness), drive, will power, or self-discipline will not suffice to correct the problem. Pulling back from assisting them to let the longer-term natural consequences occur, as if this will teach them a lesson that will correct their behavior, is likewise a recipe for disaster. Instead, artificial means of creating external sources of motivation must be arranged at the point of performance in the context in which the work or behavior is desired.
For instance, the provision of artificial rewards, such as tokens, may be needed throughout the performance of a task or other goal-directed behavior when there is little or no immediate consequences associated with that performance. Such artificial reward programs become for the person with ADHD-related EF deficits what prosthetic devices are to the physically disabled, allowing them to perform more effectively in some tasks and settings with which they otherwise would have considerable difficulty. The motivational disability created by EF deficits makes such motivational prostheses essential for most children deficient in EF.
The methods of behavior modification are particularly well suited to achieving these ends. Many techniques exist within this form of treatment that can be applied to children with ADHD related EF deficits. What first needs to be recognized is that (1) internalized, self-generated forms of motivation are weak at initiating and sustaining goal-directed behavior; (2) externalized sources of motivation, often artificial, must be arranged within the context at the point of performance; and (3) these compensatory, prosthetic forms of motivation must be sustained for long periods. If the external motivation is removed, the behavior will not be further sustained and the individual will regress to more erratic goal-directed behavior with less ability to sustain actions toward tasks and goals.
In general, there are two reasons to do behavior management for anyone: for informational training and for motivational sustaining. The former is done for individuals who have not yet acquired a skill. Once the skill is taught through behavioral or other pedagogical methods, those methods can be withdrawn and the behavior sustained presumably by contact with the natural contingencies. But in EF disorders such as ADHD, the issue is not ignorance or lack of knowledge of a skill; the problems are with the skill’s timing and execution at key points of performance and with the self-motivation needed to sustain the performance. Behavioral treatments can provide the motivational or behavior-sustaining assistance needed. Removing the external motivation after improvement in task performance will result in a loss of motivation and a return to the baseline state of limited self-motivation and an inability to sustain actions toward goals.
By equating EF with self-regulation (SR), the EF theory of ADHD (via Gross’ modal model of emotional self-regulation) illustrates at least five vectors through which EF/SR can influence goal-directed activities:
In attempting to assist students in rehabilitating or at least compensating for their EF deficits, these five vectors offer opportunities in which clinicians can strive to improve such deficits. While this can be done by directly working with the student, it is likely to be greatly assisted by advising caregivers to assist the individual with these five pathways of SR. Modifying the “point of performance,” as further discussed below, readily fits into the situation modification vector of SR. Various cognitive behavioral therapies may prove useful at the re-appraisal pathway. The point here is not to map out all possible ways by which these five vectors of SR could be used to boost EF in those with EF deficits, but to make clinicians cognizant that such pathways are available.
Related to this idea of motivational deficits accompanying EF disorders such as ADHD is the literature on self-regulatory strength and the resource pool of effort (will power) associated with activities of SR. As nicely summarized by Bauer and Baumeister (2011),8 research indicates that each implementation of EF (working memory, inhibition, planning, reasoning, problem-solving, etc.) may deplete this limited resource pool temporarily such that protracted use of EF may greatly deplete the available pool of effort. This can result in students being less capable of SR (EF) in immediately succeeding time periods. They are thus more likely to experience problems or fail outright in their efforts at EF/SR and their resistance to immediate gratification. Such temporary depletions may be further exacerbated by stress, alcohol or other drug use, illness, or even low levels of blood glucose. More recently, debate has centered around whether this view of EF/SR is a limited resource pool or not. Until that is resolved, it seems useful for clinicians to view it as such and try not to overtax EF for extended time periods in those with ADHD while also providing frequent opportunities to restore or replenish it.
Research also indicates what factors may serve to more rapidly replenish the resource pool. These include:
Some research further suggests that the actual capacity of the resource pool may be boosted by routine physical exercise and by routine practicing of tasks involving self-regulation daily for two weeks.
Children with ADHD cannot hold information in mind or manipulate mental information as well as other children. That means that mental problem-solving is difficult for them. To assist them, try to think of ways to make the problem, or parts of the problem, physical in various ways so that the child can manipulate the parts of the problem manually to facilitate mentally held information. For instance, if they have mental arithmetic to do, let them have some marbles, a number line, an abacus, or some other way to physically count and manipulate the information to help them solve the math problems. If the child has a written essay to do, encourage them to use 3x5 file cards and to write a different idea on each card as the ideas come to mind. Just have them think and free associate to the assigned topic. As each idea is stated, have them write it down on a separate card. Now the child can take these “idea cards” and reorganize them into a possible essay on that topic. I am sure you can think of other ways to do this for a child or teen with ADHD. Remember, it’s not the method, but the principle that should be emphasized here: make solving problems manual work and not just mental work.
Given the above principles, clinicians should likely reject most approaches to intervention for students with ADHD related EF deficits that do not involve helping them with an active intervention at the point of performance. Once-per-week tutoring is unlikely to succeed in helping to manage the student with deficient EF without efforts to insert accommodations at key points of performance in natural settings to address the impaired domains of educational activities. This is not to say that extensive training or retraining of EF, as with working memory training, may not have some short-term benefits. Such practice has been shown to increase the likelihood of using working memory and of boosting the SR resource pool capacity in normal individuals, at least temporarily (Bauer & Baumeister, 2011), and chiefly on highly similar tasks. What is missing is evidence of far transfer – that is, of improvements in behavior and functioning in natural settings and on dissimilar tasks involving that same EF component.
Based on the principles reviewed in the previous section for addressing EF deficits in children and teens with ADHD, one can develop 10 specific rules that need to be followed in setting up any program to address those deficits. Others rules can be found in my recent book, 12 Principles for Raising a Child or Teen with ADHD (2021, Guilford Press). The 10 most appropriate for educators are:
Consider the recommendations throughout the remainder of this book as you would a food buffet – choose from among these various methods those you find most suitable for the child or teen with ADHD you have in mind to help. I begin with some basic features of the classroom and teaching style that can help improve the school functioning of children and teens with ADHD. In reviewing these, keep in mind an important distinction between proactive and reactive teaching methods. Many suggestions below are examples of proactive teaching and behavior management. They are in contrast to the customary reactive approach many teachers take with ADHD students. Here, a change is made to a classroom situation or the curriculum or a plan is set up in advance of any problem occurrence. It is done in order to reduce the likelihood of such problems happening in upcoming situations. Proactive teaching also increases the probability that appropriate behavior and school performance are likely to occur. After reading, you will likely agree that proactive methods are superior to reactive methods in dealing with students with ADHD as the former actually reduces or even prevents the likelihood that a problem will arise in a situation. The latter only deals with it after it has occurred.
Evidence clearly demonstrates that when students with ADHD work in dyads with their peers in order to learn new material, they are more likely to concentrate and to learn that material more quickly than if they just listen to a classroom lecture. This is known as peer tutoring.15 It essentially involves the following brief steps:
As noted in previous sections, students with ADHD have far less self-motivation than do other students, meaning they will not be able to persist for as long as others in doing work for which there is no immediate reward or consequence. It was shown that to help make up for this intrinsic motivation deficit, teachers need to provide more “external’ or artificial consequences to students with ADHD when work is to be done. Here we present numerous ways to do this:
Figure 5. Attention Training System (Gordon Systems, Syracuse, NY)
Two of the most effective tools for helping to improve the behavior and school performance of children with ADHD are daily behavior report cards, also known as note-home cards, and behavior contracts. Both are additional methods of proactive teaching and behavior management first addressed above in Classroom Management: Basic Considerations.
Any behavior recording system, or report card, must be set up according to certain rules if it is to be maximally effective.
The boxes below contain instructions that can be shared with parents about a daily behavior report card, how to implement it, and the kinds of cards teachers and parents can create for use with a student with ADHD.
Parent-teacher Handout for Using a Daily School Behavior Report Card |
A daily school behavior report card involves having the teacher send home an evaluation of your child’s behavior in school that day, which can be used by you to give or take away rewards available at home. These cards have been shown to be effective in modifying a wide range of problems with children at school. Due to their convenience and cost effectiveness and the fact that they involve both the teacher(s) and parents, they are often one of the first interventions you should try if behavior problems at school are occurring with your child. The teacher reports can consist of either a note or a more formal report card. We recommend the use of a formal behavior report card like those shown at the end of this handout. The card should list the “target” behavior(s) that are to be the focus of the program on the left-hand side of the card. Across the top should be numbered columns that correspond to each class period at school. The teacher gives a number rating reflecting how well the child did for each of these behaviors for each class period. Some examples are provided at the end of this handout. How the Daily Report Card WorksUsing this system, teacher reports are typically sent home on a daily basis. As the child’s behavior improves, the daily reports can be reduced to twice weekly (Wednesdays and Fridays), once weekly, or even monthly, and finally phased out altogether. A variety of daily report cards may be developed and tailored for your child. Some of the behaviors targeted for the program may include both social conduct (shares, plays well with peers, follows rules) and academic performance (completes math or reading assignments). Targeting low academic performance (poor production of work) may be especially effective. Examples of behaviors to target include completing all (or a specified portion of) work, staying in the assigned seat, following teacher directions, and playing cooperatively with others. Negative behaviors (e.g., aggression, destruction, calling out) may also be included as target behaviors to be reduced by the program. In addition to targeting class performance, homework may be included. Children sometimes have difficulty remembering to bring homework assignments home. They may also complete their homework but forget to return the completed work to school the next day. Each of these areas may be targeted in a school behavior report card program. It is recommended that the number of target behaviors you work on be kept to about four or five. Start out by focusing on just a few behaviors you wish to change, to help maximize your child’s success in the program. When these behaviors are going well, you can add a few more problem behaviors as targets for change. We recommend including at least one or two positive behaviors that the child is currently doing well with, so that the child will be able to earn some points during the beginning of the program. Typically, children are monitored throughout the school day. However, to be successful with problem behaviors that occur very frequently, you may want to have the child initially rated for only a portion of the school day, such as for one or two subjects or classes. As the child’s behavior improves, the card can be expanded gradually to include more periods/subjects until the child is being monitored throughout the day. In cases where children attend several different classes taught by different teachers, the program may involve some or all of the teachers, depending on the need for help in each of the classes. When more than one teacher is included in the program, a single report card may include space for all teachers to rate the child. Alternatively, different report cards may be used for each class and organized in a notebook for children to carry between classes. Again, the card shown at the end of this handout can be helpful because it has columns that can be used to rate the child by the same teacher at the end of each subject, or by different teachers. The success of the program depends on a clear, consistent method for translating the teacher’s reports into consequences at home. One advantage of school behavior report cards is that a wide variety of consequences can be used. At a minimum, praise and positive attention should be provided at home whenever a child does well that day at school, as shown on the report card. With many children, however, tangible rewards or token programs are often necessary. For example, a positive note home may translate into television time, a special snack, or a later bedtime. A token system may also be used in which a child earns points for positive behavior ratings and loses points for negative ratings. Both daily rewards (e.g., time with parent, special dessert, television time) and weekly rewards (e.g., movie, dinner at a restaurant, special outing) may be included in the program. Advantages of the Daily Report CardOverall, daily school behavior report cards can be as or even more effective than classroom-based behavior management programs, with effectiveness increased when combined with classroom-based programs. Daily reports seem particularly well suited for children because the children often benefit from the more frequent feedback than is usually provided at school. These programs also give parents more frequent feedback than would normally be provided by the child. As you know, most children, when asked how their school day went, give you a one-word answer, “Fine,” which may not be accurate. These report card programs also can remind parents when to reward a child’s behavior, and forewarn parents when behavior is becoming a problem at school and will require more intensive work. In addition, the type and quality of rewards available in the home are usually far more extensive than those available in the classroom, a factor that may be critical with children who need more powerful rewards. Aside from these benefits, daily school report cards generally require much less time and effort from your child’s teacher than do classroom-based programs. As a result, teachers who have been unable to start a classroom management program may be far more likely to cooperate with a daily report card that comes from home. Despite the impressive success of report card programs, the effectiveness of the program depends on the teacher accurately evaluating the child’s behavior. It also hinges on the fair and consistent use of consequences at home. In some cases, children may attempt to undercut the system by failing to bring home a report. They may forge a teacher’s signature or fail to get a certain teacher’s signature. To discourage these practices, missing notes or signatures should be treated the same way as a “bad” report (i.e., child fails to earn points or is fined by losing privileges or points). The child may even be grounded for the day (no privileges) for not bringing the card home. Some Examples of Daily School Report CardsSeveral types of school behavior report cards that rely on daily school behavior ratings will be discussed here. Two examples are provided at the end of this handout. These are the cards we recommend most parents use if they want to start a school behavior report card quickly. One card is for classroom behavior, the other is for recess behavior. Use whichever card is most appropriate for the problems your child is having at school. Two sets of each card are provided so that you can make photocopies of that page and then cut the page in half to make double the number of cards. Notice that each card contains five areas of potential behavior problems that children may experience. For the class behavior report card, columns are provided for up to seven different teachers to rate the child in these areas of behavior or for one teacher to rate the child many times across the school day. We have found that the more frequent the ratings, the more effective is the feedback for the children and the more informative the program is to you. The teacher initials the bottom of the column after rating the child’s performance during that class period to ensure against forgery. If getting the correct homework assignment home is a problem for some children, the teacher can require the child to copy the homework for that class period on the back of the card before completing the ratings for that period. In this way, the teacher merely checks the back of the card for the child’s accuracy in copying the assignment and then completes the ratings on the front of the card. For particularly negative ratings, we also encourage teachers to provide a brief explanation to you as to what resulted in that negative mark. The teachers rate the children using a 5-point system (1 = excellent, 2 = good, 3 = fair, 4 = poor, and 5 = very poor). The child takes a new card to school each day. These can be kept at school and a new card given out each morning, or you can provide the card as your child leaves for school, whichever is most likely to be done consistently. As soon as the child returns home, you should immediately inspect the card, discuss the positive ratings first with your child, and then proceed to a neutral, businesslike (not angry!) discussion with your child about any negative marks and the reason for them. Your child should then be asked to formulate a plan for how to avoid getting a negative mark tomorrow. You are to remind your child of this plan the next morning before your child departs for school. After the child formulates the plan, you should award your child points for each rating on the card and deduct points for each negative mark. For instance, a young elementary school aged child may receive five chips for a 1, three for a 2, and one chip for a 3, while being fined three chips for a 4 and five chips for a 5 on the card. For older children, the points might be 25, 15, 5, –15, and –25, respectively, for marks 1–5 on the card. The chips or points are then added up, the fines are subtracted, and the child may then spend what is left of these chips on the privileges on the home reward menu. Another daily report card program is provided for dealing with behavior problems and getting along with others during school recess periods or free time periods each day. Again, two cards are provided on the page so that you can make photocopies of the page and cut the pages in half to double the number of cards. The card is to be completed by the teacher on recess duty during each recess or free time period. It is inspected by the class teacher when the child returns to the classroom, and then should be sent home for use, as above, in a home chip/point system. The classroom teacher should also be instructed to use a “think aloud–think ahead” procedure with the child just prior to the child’s going out for recess or free time. In this procedure, the teacher (1) reviews the rules for proper recess behavior with the child and notes that they are written on the card, (2) reminds the child that he/she is being watched by the teacher on recess duty, and (3) directs the child to give the card immediately to the recess monitor so the monitor can evaluate the child’s behavior during recess or free time. As these cards illustrate, virtually any child behavior can be the target for treatment using behavior report cards. If the cards shown here are not suited for your child’s behavior problems at school, then design a new card with the assistance of your therapist, using the blank cards provided at the end of this handout. They do not take long to construct and can be very helpful in improving a child’s school behavior and performance. From Barkley, R. A. Defiant Children: A Clinician’s Manual for Parent Training. Copyright 1997 by The Guilford Publications. |
Daily School Behavior
Report Card |
|||||||
Child’s Name________________________________________________________ Date________ Teachers: Please rate this child’s behavior today in the areas listed below. Use a separate column for each subject or class period. Use the following ratings: 1 = excellent, 2 = good, 3 = fair, 4 = poor, and 5 = very poor. Then initial the box at the bottom of your column. Add any comments about the child’s behavior today on the back of this card. |
|||||||
| Class periods/subjects: | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
| Behaviors to be rated: | |||||||
|
___ |
___ |
___ |
___ |
___ |
___ |
___ |
|
___ |
___ |
___ |
___ |
___ |
___ |
___ |
|
___ |
___ |
___ |
___ |
___ |
___ |
___ |
|
___ |
___ |
___ |
___ |
___ |
___ |
___ |
| Teacher’s initials: | ___ |
___ |
___ |
___ |
___ |
___ |
___ |
| Place comments below or on back of card | |||||||
| From Barkley, R. A. Defiant Children: A Clinician’s Manual for Parent Training. Copyright 1997 by The Guilford Publications. | |||||||
Daily Recess and Free Time Behavior Report Card |
|||||||
Child’s Name________________________________________________________ Date________ Teachers: Please rate this child’s behavior today during recess or other free time periods in the areas listed below. Use a separate column for each recess/free time period. Use the following ratings: 1 = excellent, 2 = good, 3 = fair, 4 = poor, and 5 = very poor. Then initial at the bottom of the column. Add any comments on the back. |
|||||||
| Class periods/subjects: | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
| Behaviors to be rated: | |||||||
|
___ |
___ |
___ |
___ |
___ |
___ |
___ |
|
___ |
___ |
___ |
___ |
___ |
___ |
___ |
|
___ |
___ |
___ |
___ |
___ |
___ |
___ |
|
___ |
___ |
___ |
___ |
___ |
___ |
___ |
|
___ |
___ |
___ |
___ |
___ |
___ |
___ |
| Teacher’s initials: | ___ |
___ |
___ |
___ |
___ |
___ |
___ |
| Place comments below or on back of card | |||||||
| From Barkley, R. A. Defiant Children: A Clinician’s Manual for Parent Training. Copyright 1997 by The Guilford Publications. | |||||||
Daily School Behavior
Report Card |
||||||||
Child’s Name________________________________________________________ Date________ Teachers: Please rate this child’s behavior today in the areas listed below. Use a separate column for each subject or class period. Use the following ratings: 1 = excellent, 2 = good, 3 = fair, 4 = poor, and 5 = very poor. Then initial the box at the bottom of your column. Add any comments about the child’s behavior today on the back of this card. |
||||||||
| Class periods/subjects: | 1 |
2 |
3 |
4 |
5 |
6 |
7 |
|
| Behaviors to be rated: | ||||||||
___ |
___ |
___ |
___ |
___ |
___ |
___ |
||
___ |
___ |
___ |
___ |
___ |
___ |
___ |
||
___ |
___ |
___ |
___ |
___ |
___ |
___ |
||
___ |
___ |
___ |
___ |
___ |
___ |
___ |
||
___ |
___ |
___ |
___ |
___ |
___ |
___ |
||
| Teacher’s initials: | ___ |
___ |
___ |
___ |
___ |
___ |
___ |
|
| Place comments below or on back of card | ||||||||
|
||||||||
Instead of a behavior report card, teachers can set up an in-class behavior contract.18 These contracts should contain the following elements:
Recall from the above discussion of EF deficits that children and teens with ADHD have very poor working memory. That means that they cannot hold as much information in mind or for as long as other students. They are also less likely to call up such information from memory and keep it consciously in mind when they are entering class periods or during a change in a situation from a prior activity to the next or to a new one. Since “internal” or mental information is not very effective at guiding an ADHD student’s behavior, it is helpful to boost working memory by placing key pieces of information in the student’s visual or other sensory fields in that work location. Putting such information in a physical form in the visual field of the student is called “externalizing” the key information and cues. This section briefly reviews some ways that teachers can help “externalize” critical pieces of information about the situation and any time intervals that may be important for that situation, class, or work period. This is another example of a form of proactive teaching and behavior management.
As noted in a previous chapter, children and teens with ADHD cannot manage or guide their behavior based on their sense of time. So teachers should not rely on a child’s subjective sense of time, which is impaired in children with ADHD. As suggested earlier, “externalize” time. Essentially, this means using some external timekeeping device in the child’s workspace to help children with ADHD see how much time they have to do something, and then how much of it has passed and how much is left as they complete their work. To do this, you can use clocks, timers, watches, recorded time signals, etc., anything to show how much time they have to do an assignment. For example, you can use the Time Timer,20 which is a timer device that is an 8 in. x 8 in. clock with a red dial that signals a time period of up to one hour (see Figures 6 and 7). When a child has deskwork to do within a set time period, you can set this clock to that time period. The time available shows up in red on the clock face and as time passes, the amount of red exposed decreases until time us up and a signal sounds to indicate the end of the work period.
Figure 6. Time Timer
Of course, digital timers can also be found on the Internet, such as the My Time Activity Timer.21
Figure 7. My Time Activity Timer
You can also download a variety of online stopwatches and timer apps for a tablet, iPad, or smartphone at: online-stopwatch.com/classroom-timers. These include traditional clock faces, time bombs, cartoon characters running races, virtual hourglasses, etc.
As you learned above, children and teens with ADHD are less aware of their own behavior than are typical students because they do not monitor their ongoing behavior as well or as often as do those other students. Research does not show any definitive means by which teachers can improve the self-awareness or self-monitoring of students with ADHD. But here are some methods that have been used by clinical researchers and others to try to do so.22
Figure 8. MotivAider
Children and teens with ADHD, as noted previously, have trouble not only with working memory (remembering the rules that apply in a given situation) but also with self-monitoring of their own behavior. Both of these problems conspire along with their inattentiveness to pose frequent problems when the student is transitioning from one activity, class period, or classroom to the next one on their daily schedule. As a result, problem behaviors can often occur during or just after such transitions. To help address this situation, it is recommended to use a method called transition planning. This is to be discussed with the child before it is put into use. Essentially, here is what the student is to do BEFORE starting a new activity, class subject, or even entering a new classroom:
A teacher can also augment or replace this procedure with a 3x5 in. file card on which are written the rules the child is to follow routinely when entering this new situation, class subject, or classroom. That way, the child has the “externalized” rules written on the card to take with them to keep in view on their desk throughout the period.
Too often, teachers allow students to go through these transitions unassisted. Then when problems develop, the teachers are forced to react to this situation, usually with discipline. The proactive behavior management outlined above is far superior to reactive management at creating a better day for both ADHD student and teacher.
Before implementing any of the ideas or methods listed below, a teacher should check with the school principal or school district on their policies concerning any guidelines or regulations pertaining to discipline or punishment. That said, here are some methods that can serve as forms of punishment for student misbehavior.
Some of what follows has already been discussed above for children with ADHD. But other methods here have been developed specifically for use with teens with ADHD in school settings.
Figure 9. Smart Pen
Between 40% and 80% of children and teens with ADHD are likely to be taking an ADHD medication as part of their treatment by a physician. It is therefore helpful for educators to know the types of medications their students with ADHD are likely to be taking, how the drugs work, and what the side effects are likely to be. Children taking medication are likely to be more responsive to the behavioral methods used to manage ADHD-related school problems and the combination of those methods with medication often results in far greater improvement than when either form of treatment is used alone.
For more information on medications, see my course ADHD in Children: Diagnosis, Assessment, and Management. There are three basic categories of ADHD medicines that are approved by the Food and Drug Administration for use with children and teens – stimulants, non-stimulants, and anti-hypertensive drugs. All have to be taken daily. They all control the symptoms of ADHD only as long as your student takes the medications. They produce no enduring positive effects on your student’s ADHD if they stop taking them. Ceasing the use of medication often results in a return of the ADHD symptoms back to their pre-treatment levels. Think of these medicines as you would insulin with a diabetic. Insulin does not cure diabetes, but it does manage it so long as it is used, and if used properly, for most people. But if your student stops the medication the underlying problem and its symptoms will return.
The first two types of ADHD medications typically work by increasing the amount of two (or more) chemicals in the brain known as neurotransmitters. Those chemicals are involved in permitting nerve cells to communicate with each other so the brain can function effectively. More specifically, these drugs increase just how much of these chemicals are residing outside of the nerve cells. That can increase the activity of adjacent nerve cells. The two neurotransmitters are dopamine and norepinephrine. By causing nerve cells to express more of these neurochemicals, or by keeping the nerve cells from pulling these chemicals back into the cell once they have been released, they increase the communication that occurs between nerve cells in regions of the brain that are related to directly causing ADHD. In short, increasing these brain chemicals in these regions lets that brain area function better, and sometimes even normally. Also, recent studies show that children who have taken these medications (especially the stimulants) are likely to have brain development that is closer to normal than children with ADHD who have not taken the medication – a phenomenon known as neuroprotection. The third class of medications works by fine tuning small ports on the nerve cells mainly in the frontal cortex. In doing so, they strengthen the balance of nerve signals to noise within the nerve cell allowing the cell to be more likely to function properly.
There are two basic types of stimulants currently marketed in the U.S. – methylphenidate (MPH) and amphetamine (AMP). These stimulants act in the brain to mainly increase the amount of dopamine available for use outside the nerve cells. Yet they can, to a smaller extent, increase the amount of norepinephrine outside the nerve cells as well. AMP does this mainly by increasing the amount of dopamine that is produced and expressed from the nerve cell when it is activated. To a lesser extent, it may also block the transport system by which the dopamine is normally re-absorbed back into that nerve cell after being released. That can result in more dopamine being left outside the cell to continue to function. MPH mainly acts by preventing this re-absorption of dopamine. That is why it is known as a transport or re-uptake blocker.
Both AMP and MPH have the potential to be abused because they increase dopamine in regions of the brain known as reward centers. Stimulating those centers can lead to an increased likelihood of addiction to drugs that do so. But ADHD medications are very unlikely to do this when taken by mouth and swallowed, as prescribed. They certainly can do so when they are sniffed through the nose as a powder or injected into a blood vein in a solution, such as when mixed with water. Because of this potential for drug abuse, the Drug Enforcement Administration in the U.S. has classified these stimulants as Schedule II Controlled Substances along with other potentially addictive drugs. This classification places limits on how much of the drugs can be produced annually, how the drugs are to be prescribed, how they are to be stored in pharmacies, and how they are to be dispensed and otherwise monitored in the U.S.
There are many different methods by which these two drugs are delivered into the body. The major methods are described in the Box below. The methods differ in how long they maintain the blood levels of the drug in the body, and so in the brain. There are hundreds of studies on the safety and effectiveness of these stimulants and delivery systems.
The different delivery systems are the 5 Ps – pills, pumps, pellets, patches, and pro-drug along with the delayed onset-extended release method (Jornay PM), and the liquid extended release and gummy (oral dissolvable) sustained release methods. The various brand names of ADHD medicines you will hear about are either one form or another of MPH or AMP and involve one of these delivery systems:
|
The most common side effects people experience when taking a stimulant (MPH or AMP) are listed below in their descending order of likely occurrence:
These stimulants also increase heart rate and blood pressure slightly, but generally no more so and often less so than if you had just climbed a half-flight of stairs. You may have heard claims that these drugs increase the sensitivity to or risk for abusing other drugs, especially other stimulants. The vast majority of research does not support this claim. People who have taken ADHD medications such as these stimulants for years, including children growing up with ADHD, were found to be no more likely to abuse drugs than were those not being treated. In fact, in a few studies they were found to be less likely to do so, probably because the ADHD medication was controlling their impulsiveness.
You may have also heard that these drugs, especially the stimulants, might increase the likelihood of sudden death, usually from heart block (heart stops beating). In rare cases, strokes have occurred in people taking these drugs. While some people have died while taking a stimulant, these cases always involve other extenuating factors that alone can account for the sudden death. Those reasons include things like a history of structural heart defects along with engaging in vigorous exercise just preceding the death. The available evidence actually shows that people on stimulants have a somewhat lower likelihood of sudden death than the general population (which is one to seven people per 100,000 per year, depending on age). This is probably because physicians routinely screen for heart problems before starting people on stimulants and, if discovered, usually do not use these medications. So those with the greatest likelihood of having heart problems if they took a stimulant are not prescribed them. Even so, physicians have been cautioned not to put people on stimulants if they have a history of sudden death in their family or a history of structural heart abnormalities, major arrhythmias, or other major cardiac problems. It also makes sense not to treat people with clinically or morbidly high blood pressure with a stimulant for the obvious reason that it can make the situation even more risky for them. The risk to otherwise healthy children and teens with ADHD is not significant if there is any increased risk at all.
In 2003, the FDA approved the first non-stimulant drug for the management of child, teen, and adult ADHD, and the first new drug for ADHD in more than 25 years. That drug was Atomoxetine (ATX), under the brand name Strattera®. This was the most studied ADHD drug before receiving FDA approval that has ever been brought to market. Randomized and double-blinded studies were done involving more than 6,000 patients worldwide to thoroughly study the effectiveness, side effects, and safety of this medication. Now, like the stimulants above, millions of people worldwide take this medication for management of their ADHD. Then, in March of 2021, the FDA approved another NERI type medication – viloxazine (QelBree®), which works in a very similar way as atomoxetine.
As noted above, AMP acts in the brain by increasing the amount of dopamine that is produced and expressed from the nerve cell when it is activated. To a lesser extent, it may also block the transport system by which the dopamine is normally re-absorbed back into that nerve cell after being released. MPH mainly acts by preventing this re-absorption of dopamine and so is known as a transport or re-uptake blocker. Atomoxetine (ATX) and viloxazine (VLX), in contrast, work by blocking the re-absorption of norepinephrine once it has been released. Like, MPH, they are re-uptake blockers, but they block the re-uptake of a different neuro-chemical; that is norepinephrine. Some research shows that by doing this, both drugs probably result in an increase in dopamine outside nerve cells in certain parts of the brain, such as the frontal cortex.
These non-stimulants also differ from the stimulants, however, in that they do not affect the brain centers that are likely to be related to drug addiction or abuse. This is why the drugs are called non-stimulants. It is also why they are not classified as a controlled substances in the U.S. Research shows that the drugs have a very low potential for abuse. That means it is not preferred or liked by known drug addicts more than other psychiatric drugs such as anti-depressants, which is to say addicts like them very little. The different means by which they acts in the brain can result in a different profile of potential side effects and adverse reactions, and possibly somewhat different benefits from these drugs than what one sees with the stimulants.
The non-stimulants are nearly as effective for managing ADHD symptoms as is MPH, but not quite as effective as AMP, the most powerful of the prescribed stimulants. The same percentage of patients appears to positively respond to both these classes of drugs (stimulants and non-stimulants), averaging about 75% of people responding to any single drug. However, some studies suggest that while 50% of people respond positively to both types of medications, 25% may respond better to a stimulant than to a non-stimulant while the remaining 25% may respond better to non-stimulants than to one of the stimulants. In other words, some people are unique responders who do better on one type of ADHD drug than on another. We should not be surprised at this given that not all people are biologically identical especially in the organization and functioning of their brains. Some studies suggest that non-stimulants may not produce quite as much improvement in ADHD symptoms as do the stimulants while others show they are at least equivalent to MPH. But for many children, the degree of improvement is sufficient to effectively manage their disorder while not necessarily producing the same types of side effects that one might get with a stimulant. Also, stimulants have the potential to be abused or diverted for such abuse to others who were not prescribed the drug. Non-stimulants do not adversely affect anxiety, may even reduce it significantly, do not worsen tics or nervous habits, and do not typically result in insomnia.
The issue that physicians face in daily practice with ADHD patients is therefore not which drug works better, but which drug is best suited to which individual patient given their unique profile of characteristics. Having many different drugs, just like having many different delivery systems, lets physicians better tailor their treatment to the uniqueness of each patient. Your student can expect, however, that with a non-stimulant, it will take longer to adjust it to the right dosage than is the case with a stimulant. That is because it takes longer for the body to adjust to the side effects of NERI drugs like ATX. And that is why physicians like to leave patients on a particular dosage a week or two longer than they might with a stimulant before adjusting the dosage upward.
The most common side effects for NERI drugs are:
Although non-stimulants can also increase heart rate and blood pressure, they do so less than the stimulants discussed above. There is an exceptionally rare chance of liver complications that occur once in every 2 million people treated with ATX (two cases out of 4.5 million treated to date; and one of these is arguable). This seems to result from a very rare auto-immune reaction to the drug in which the body’s immune system attacks and inflames the outer layers of the liver. So the risk for this side effect is incredibly low. No evidence has yet accumulated on the latest NERI drug, VLX, to say if it creates this same problem but given its chemical similarity, that remains a possibility. So to be safe, people with a history of liver damage or other liver problems may want to avoid using NERI drugs like ATX.
The package inserts for the non-stimulants contain a warning of a possibility of increased suicidal thinking from this drug, but not suicide attempts, and this increase in ideation was seen only in children. This side effect is highly questionable given the lack of rigor with which the information on which it is based was collected in the initial clinical trials for this drug. This problem of increased suicidal thinking was not found for teens and adults with ADHD taking ATX. Also, more recent large-scale research has found that people with ADHD who are off medication have a far higher rate of suicidal thinking and attempts than do those who are taking either ATX or a stimulant medication. These findings suggest that taking these medicines for ADHD may actually reduce the risk for suicidal thinking and attempts.
Two other medicines are sometimes used to treat adult ADHD, but they should be considered “last choice” medicines to be used only if the other ADHD medicines are not proving satisfactory. Both originated as drugs used to treat high blood pressure, called anti-hypertensive drugs. One is clonidine, and works as an alpha-adrenergic enhancer. Some nerve cells in the brain have little portholes on them called alpha-2 receptors. These drugs seem to act to reduce or close off these portholes and that results in stronger or more effective nerve signals in those cells. At low dosages, this drug appears to stimulate inhibitory systems in the brain. The FDA approved an extended-release version of clonidine, clonidine ER (Kapvay®), in 2010 as a treatment for ADHD in children ages 6-17 years. But as noted above, physicians can use it “off-label” outside of this age range, such as for adults with ADHD. It can be used alone or combined with stimulants. The drug is not as effective as the other ADHD medicines discussed above. So it is sometimes used to treat ADHD when it co-exists with other disorders such as conduct or antisocial problems or irritability and anger. It can also treat tic disorders, sleep disturbances, and may reduce anxiety.
Regular clonidine is fast-acting. But the extended-release version approved for ADHD can last much longer. The most common side effect of clonidine is sedation, which tends to subside with continued treatment. It can also result in reduced blood pressure, called hypotension, and sometimes results in complaints of dry mouth, vivid dreams, depression, and confusion. Unlike other ADHD medicines, this one cannot be stopped abruptly. It requires slow tapering over several days to weeks. The drug should not be used if your student is taking beta-blockers or calcium channel blockers. Experts recommend that anyone using these drugs for treating ADHD have their blood pressure monitored when starting or when tapering off clonidine and when dosages are being increased.
Another anti-hypertensive drug used for ADHD management is guanfacine. In 2009, the FDA approved an extended-release version, guanfacine ER (Intuniv®) for the treatment of ADHD in people 6-17 years of age. Again, physicians can use it with adults off-label if they think it essential to do so. The drug can be given alone or in combination with either of the stimulant medicines discussed above, as monotherapy, or as adjunctive treatment with stimulants.
There may be some advantages of guanfacine over clonidine. These include less sedation, a longer duration of action, and less risk of cardiovascular problems.
This drug can result in minor decreases in blood pressure and pulse rate. Other side effects include sedation, irritability, and depression. Again, this medication probably is not as effective as the stimulants or ATX discussed above. Its benefit may be in helping to treat coexisting disorders with ADHD, such as anger and aggression, and in reducing highly impulsive or hyperactive behavior.
You and your student should be aware that there is very little research on using these two anti-hypertensive drugs to treat ADHD in adults. That is why they were FDA approved mainly for children, on which more research was available. Because of the lack of research, these drugs are considered last choice options for managing adult ADHD. The other ADHD medicines above should be tried first.
The management of ADHD in educational settings requires as a prerequisite that mental health professionals be knowledgeable about the nature of the disorder, its symptoms, the deficits in executive functioning associated with it (both cognitive and in daily adaptive functioning), as well as its demographics and etiologies. With this information in mind, especially the nature of the EF deficits inherent in ADHD, professionals can proceed to tailor a suite of intervention methods for a specific child or teen from a wide array of more than 80 methods of behavior management and classroom accommodation. All of these methods are grounded in a set of 10 overarching principles of management which themselves are grounded in the nature of EF and its deficits in ADHD.
Barkley, R. A. (2015) (Ed.) Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th edition). New York: Guilford Publications.
Barkley, R. A. (2022). Treating ADHD in Children and Adolescents: What Clinicians Need to Know. New York: Guilford Publications.
Barkley, R. A., Shelton, T. L., Crosswait, C., Moorehouse, M., Fletcher, K., Barrett, S., et al. (2000). Multi-method psycho-educational intervention for preschool children with disruptive behavior: Preliminary results at post-treatment. Journal of Abnormal Child Psychiatry and Psychology, 41, 319-332
Bowman-Perrott, L., Davis, H., Vannest, K., Williams, L., Greenwood, C., & Parker, R. (2013). Academic benefits of peer tutoring: A meta-analytic review of single-case research. School Psychology Review, 42, 39-55.
Chaimaha, N., Sriphetcharawut, S., Lersilp, S., & Chinchai, S. (2017). Effectiveness of therapeutic programs for students with ADHD with executive function deficits. Journal of Occupational Therapy, Schools, & Early Interventions, 10(4), 436-456.
Childress, A. C. (2021). Novel formulations of ADHD medications: Stimulant selection and management. Focus: The Journal of Learning in Psychiatry, 19(1), 31-38.
Cooper, H., Robinson, J. C., & Patall, E. A. (2006). Does homework improve academic achievement? A synthesis of research, 1987-2003. Review of Educational Research, 76, 1-62.
DuPaul, G.J., Eckert, T.L., & Vilardo, B. (2012). The effects of school-based interventions for attention-deficit hyperactivity disorder: A meta-analysis 1996-2010. School Psychology Review, 41, 387-412.
DuPaul, G. J., Ervin, R. A., Hook, C. L., & McGoey, K. E. (1998). Peer tutoring for children with attention deficit hyperactivity disorder: Effects on classroom behavior and academic performance. Journal of Applied Behavior Analysis, 31, 579–592.
DuPaul, G. J., Evans, S. W., Mautone, J. A. Owens, J. S., & Power, T. J. (2020). Future directions for psychosocial intereventions for children and adolescents with ADHD. Journal of Clinical Child and Adolescent Psychology. https://doi.org/10.1080/15374416.2019.1689825.
DuPaul, G.J., Jitendra, A.K., Volpe, R.J., Tresco, K.E., Lutz, G., Vile Junod, R.E., Cleary, K.S., Flammer, L.M., & Mannella, M.C. (2006). Consultation-based academic interventions for children with ADHD: Effects on reading and mathematics achievement. Journal of Abnormal Child Psychology, 34, 633-646.
DuPaul, G. J., & Stoner, G. (2015). ADHD in the schools: Assessment and Intervention Strategies (3rd ed.). New York: Guilford Publications.
DuPaul, G.J. & Weyandt, L.L. (2006). School-based interventions for children and adolescents with Attention-deficit/Hyperactivity Disorder: Enhancing academic and behavioral outcomes. Education & Treatment of Children, 29, 341-358.
Evans, J. H., Ferre, L., Ford, L. A., & Green, J. L. (1995). Decreasing attention deficit hyperactivity disorder symptoms utilizing an automated classroom reinforcement device. Psychology in the Schools, 32, 210–219.
Evans, S. W., Pelham, W., & Grudberg, M. V. (1994). The efficacy of notetaking to improve behavior and comprehension of adolescents with attention deficit hyperactivity disorder. Exceptionality, 5(1), 1–17.
Fabiano, G.A., Pelham, W.E.Gnagy, E.M., Burrows-MacLean, L., Coles, E., Chacko, A.,Wymbs, B.T., Walker, K.S., Arnold, F., Garefino, A., Keenan, J.K., Onyango, A.N.,Hoffman, M.T., Massetti, G.M., Robb, J.A., (2007), The single and combined effects of multiple intensities of behavior modification and methylphenidate for children with Attention Deficit Hyperactivity Disorder in a classroom setting. School Psychology Review, 36, 195-216.
Fabiano, G.A., Pelham, W.E., Karmazin, K., Kreher, J., Panahon, C.J., & Carlson, C. (2008). A group contingency program to improve the behavior of elementary school students in a cafeteria. Behavior Modification, 32, 121-132.
Fabiano, G. A., Vujnovic, R. K., Pelham, W. E., Waschbusch, D. A., Massetti, G.M., Pariseau, M. E., Naylor, J., Yu, J., Robins, M., Cronefix, T., Greiner, A. R., & Volker, M. (2010). Enhancing the effectiveness of special education programming for children with attention deficit hyperactivity disorder using a daily report card. School Psychology Review, 39, 219-239.
Fuster, J.M. (2015). The Prefrontal Cortex, Fifth Edition. New York: Raven.
Gast, D. C., & Nelson, C. M. (1977). Time-out in the classroom: Implications for special education. Exceptional Children, 43, 461–464.
Gordon, M., Thomason, D., Cooper, S., & Ivers, C. L. (1990). Nonmedical treatment of ADHD/hyperactivity: The attention training system. Journal of School Psychology, 29, 151–159.
Hart Barnett, J. E. (2017). Helping students with ADHD in the age of digital distraction. Physical Disabilities: Education and Related Services, 36, 1-7.
Hoff, K. E., & DuPaul, G. J. (1998). Reducing disruptive behavior in general education classrooms: The use of self-management strategies. School Psychology Review, 27, 290–303.
Hoza, B. & Smith, A. L. (2015). Is aerobic physical activity a viable management strategy for ADHD? The ADHD Report, 23(2), 1-5.
Jurbergs, N., Palcic, J. L., & Kelley, M. L. (2008). School-home notes with and without response cost: increasing attention and academic performance in low-income children with attention-deficit/hyperactivity disorder. School Psychology Quarterly, 22, 358-379.
Jurbergs, N., Palcic, J. L., & Kelley, M. L. (2010). Daily behavior report cards with and without home-based consequences: improving classroom behavior in low income, African American children with ADHD. Child and Family Behavior Therapy, 32, 177-195.
Kelley, M. L. (1990). School–home notes: Promoting children’s classroom success. New York: Guilford Publications.
Mautone, J. A., DuPaul, G. J., & Jitendra, A. K. (2005). The effects of computer-assisted instruction on the mathematics performance and classroom behavior of children with ADHD. Journal of Attention Disorders, 9, 301–312.
McGoey, K. E., & DuPaul, G. J. (2000). Token reinforcement and response cost procedures: Reducing the disruptive behavior of preschool children with ADHD. School Psychology Quarterly, 15, 330–343.
Meyer, K. (2007). Improving homework in adolescents with attention-deficit/hyperactivity disorder: Self vs. parent monitoring of homework behavior and study skills. Child and Family Behavior Therapy, 29, 25-42.
Mikami, A. Y., Owens, J. S., Evans, S. E., Hudec, K. L., Kassab, H., & Smit, S. (2021). Promoting classroom social and academic functioning among children at risk for ADHD: The MOSAIC Program. Journal of Clinical Child & Adolescent Psychology. Epub ahead of print: https://doi.org/10.1080/15374416.2021.1929250
Nelson, J.R., Benner, G.J., & Mooney, P. (2008). Instructional practices for students with behavioral disorders: Strategies for reading, writing, and math. New York: Guilford.
Ota, K. R., & DuPaul, G. J. (2002). Task engagement and mathematics performance in children with attention deficit hyperactivity disorder: Effects of supplemental computer intervention. School Psychology Quarterly, 17(3), 242–257.
Owens, J. S., Evans, S. W., & Coles, E. K. (2018). Consultation for classroom management and targeted interventions: Examining benchmarks for teacher practices that produce desired change in student behavior, Journal of Emotional and Behavioral Disorders, 28(1), 52-64.
Owens, J.S., Holdaway, A.S., Zoromski, A.K., Evans, S.W., Himawan, L.K., Girio-Herrera, E., & Murphy, C.E. (2012). Incremental benefits of a daily report card intervention over time for youth with disruptive behavior. Behavior Therapy, 43, 848-861.
Pagani, L., Tremblay, R., Vitaro, F., Boulerice, B., & McDuff, P. (2001). Effects of grade retention on academic performance and behavioral development. Development and Psychopathology, 13, 297-315.
Pfiffner, L. J. (2011). All about ADHD: The complete practical guide for classroom teachers (2nd Edition). New York: Scholastic.
Pfiffner, L., & DuPaul, G. J. (2015). Treatment of ADHD in school settings. In R. A. Barkley (Ed.) Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th edition). New York: Guilford.
Pontifex, M. B., Saliba, B. J., Raine, L. B., Picchietti, D. L., & Hillman, C. H. (2013). Exercise improves behavioral, neurocognitive, and scholastic performance in children with attention-deficit/hyperactivity disorder. The Journal of Pediatrics, 162, 543-551.
Power, T. J., Karustis, J. L., & Habboushe, D. F. (2001). Homework success for children with ADHD: A family–school intervention program. New York: Guilford Publications.
Reid, R., Trout, A.L., & Schartz, M. (2005). Self-regulation interventions for children with attention deficit/hyperactivity disorder. Exceptional Children, 71, 361-377.
Rosalez, E., Johnson, C. M., Bradley-Johnson, S., & Kanouse, S. (2020). Effects of white noise on off-task behavior and sleep for elementary-age students with ADHD. Child & Family Behavior Therapy, 42(1), 20-36.
Sheridan, S.M., Welch, M., & Ormi, S.F. (1996). Is consultation effective? A review of outcome research. Remedial and Special Education, 17, 341-354.
Slulter, M. N., Groen, Y., Jonge, P. de, & Tucha, O. (2019). Exploring neuropsychological effects of a self-monitoring intervention for ADHD-symptoms in school. Applied Neuropsychology: Child, 9(3), 246-258.
Spencer, V. G. (2006). Peer tutoring and students with emotional or behavioral disorders: A review of the literature. Behavioral Disorders, 31, 204-222.
Ward, R. J., Bristow, S. J., Kovshoff, H. et al. (2020). The effects of ADHD teacher training programs on teachers and pupils: A systematic review and meta-analysis. Journal of Attention Disorders. Epub ahead of print: https://doi.org/10.1177/1087054720972801
National Association of School Psychologists
Child Development Institute, LLC
Ideas for Teaching Children with ADHD – Leah Davies, M.Ed.
Note 1. Dr. Barkley is a retired clinical neuropsychologist. He was most recently a Clinical Professor of Psychiatry at the Virginia Commonwealth University School of Medicine, Richmond, VA. (Go back)
Note 2. In Barkley, R. A. (2015). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). New York: Guilford Publications. And in Barkley, R. A. (2022). Treating ADHD in Children and Adolescents: What Every Clinician Needs to Know. New York: Guilford Publications. (Go back)
Note 3. For the exact symptom wording see the Diagnostic and Statistical Manual for Mental Disorders (5th ed.). Washington, DC: American Psychiatric Association, 2013. (Go back)
Note 4. See Dr. Barkley’s course on executive functioning. See also Barkley, R. A. (2015). Executive functioning and self-regulation as an extended phenotype: Implications of the theory for ADHD and its treatment. In Barkley, R. A. (2015). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed., pp. 405-434). New York: Guilford Publications. (Go back)
Note 5. Barkley, R. A. (2012). Barkley Deficits in Executive Functioning Scale – Children and Adolescents (p. 112). New York: Guilford Publications. (Go back)
Note 6. See Barkley, R. A. (2015). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment. New York: Guilford Publications. (Go back)
Note 7. From Barkley, R. A. (2015). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed., pp. 405-434). New York: Guilford Publications. And Barkley, R. A. (2012). Executive functions: What they are, How they work, and Why they evolved. New York: Guilford Publications. (Go back)
Note 8. Bauer, I. M. & Baumeister, R. F. (2011). Self-regulatory strength. In K. Vohs & R. Baumeister (Eds.), Handbook of Self-Regulation (2nd ed.) (pp. 64-82). New York: Guilford Press. (Go back)
Note 9. Sheridan, S.M., Welch, M., & Ormi, S.F. (1996). Is consultation effective? A review of outcome research. Remedial and Special Education, 17, 341-354. (Go back)
Note 10. Pagani, L., Tremblay, R., Vitaro, F., Boulerice, B., & McDuff, P. (2001). Effects of grade retention on academic performance and behavioral development. Development and Psychopathology, 13, 297-315. (Go back)
Note 11. Cooper, H., Robinson, J. C., & Patall, E. A. (2006). Does homework improve academic achievement? A synthesis of research, 1987-2003. Review of Educational Research, 76, 1-62. (Go back)
Note 12. Hoza, B. & Smith, A. L. (2015). Is aerobic physical activity a viable management strategy for ADHD? The ADHD Report, 23(2), 1-5. (Go back)
Note 13. Mautone, J. A., DuPaul, G. J., & Jitendra, A. K. (2005). The effects of computer-assisted instruction on the mathematics performance and classroom behavior of children with ADHD. Journal of Attention Disorders, 9, 301–312. (Go back)
Note 14. Fabiano, G.A., Pelham, W.E.Gnagy, E.M., Burrows-MacLean, L., Coles, E., Chacko, A.,Wymbs, B.T., Walker, K.S., Arnold, F., Garefino, A., Keenan, J.K., Onyango, A.N.,Hoffman, M.T., Massetti, G.M., Robb, J.A., (2007), The single and combined effects of multiple intensities of behavior modification and methylphenidate for children with Attention Deficit Hyperactivity Disorder in a classroom setting. School Psychology Review, 36, 195-216. (Go back)
Note 15. See DuPaul & Stoner, 2012; Spencer 2006. Bowman-Perrott, L., Davis, H., Vannest, K., Williams, L., Greenwood, C., & Parker, R. (2013). Academic benefits of peer tutoring: A meta-analytic review of single-case research. School Psychology Review, 42, 39-55. (Go back)
Note 16. McGoey, K. E., & DuPaul, G. J. (2000). Token reinforcement and response cost procedures: Reducing the disruptive behavior of preschool children with ADHD. School Psychology Quarterly, 15, 330–343. (Go back)
Note 17. Gordon, M., Thomason, D., Cooper, S., & Ivers, C. L. (1990). Nonmedical treatment of ADHD/hyperactivity: The attention training system. Journal of School Psychology, 29, 151–159. The device can be purchased at Gordon Diagnostic Systems or at the addwarehouse.com. (Go back)
Note 18. See DuPaul, G. J., & Stoner, G. (2014). ADHD in the schools (3rd ed.). New York: Guilford Publications. (Go back)
Note 19. Adapted from R. A. Barkley (2013). Defiant Children: A Clinician’s manual for Assessment and Parent Training (3rd edition). New York: Guilford Publications. (Go back)
Note 20. specialneedsessentials.com. See also: additudemag.com (Go back)
Note 21. additudemag.com/ (Go back)
Note 22. Hoff, K. E., & DuPaul, G. J. (1998). Reducing disruptive behavior in general education classrooms: The use of self-management strategies. School Psychology Review, 27, 290–303. (Go back)
Note 23. Available at addwarehouse.com (Go back)
Note 24. Gast, D. C., & Nelson, C. M. (1977). Time-out in the classroom: Implications for special education. Exceptional Children, 43, 461–464. (Go back)
Note 25. Evans, S. W., Pelham, W., & Grudberg, M. V. (1994). The efficacy of notetaking to improve behavior and comprehension of adolescents with attention deficit hyperactivity disorder. Exceptionality, 5(1), 1–17. (Go back)
Note 26. Meyer, K. (2007). Improving homework in adolescents with attention-deficit/hyperactivity disorder: Self vs. parent monitoring of homework behavior and study skills. Child and Family Behavior Therapy, 29, 25-42. (Go back)
| © Copyright 2004-2024 by SocialWorkCoursesOnline.Com, Inc. All rights reserved. |
ContinuingEdCourses.Net dba SocialWorkCoursesOnline.com, provider #1107, is approved as an ACE provider to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Regulatory boards are the final authority on courses accepted for continuing education credit. ACE provider approval period: 3/9/2005-3/9/2027.
ContinuingEdCourses.Net dba SocialWorkCoursesOnline.com has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6323. Programs that do not qualify for NBCC credit are clearly identified. ContinuingEdCourses.Net is solely responsible for all aspects of the programs.
ContinuingEdCourses.Net dba SocialWorkCoursesOnline.com is recognized by the New York State Education Department's State Board for Social Work (NYSED-SW) as an approved provider of continuing education for licensed social workers #SW-0561.