"Bear in mind that the wonderful things you learn in your schools are the work of many generations, produced by enthusiastic effort and infinite labor in every country of the world. All this is put into your hands as your inheritance in order that you may receive it, honor it, add to it, and one day faithfully hand it to your children. Thus do we mortals achieve immortality in the permanent things which we create in common." - Albert Einstein

Tuesday, November 4, 2014

Does Your Child Have ADHD?

A diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) is not possible in one office visit to a pediatrician. Instead, symptoms of ADHD must be observed in a child regularly for about six months. The following is a recommendation from the American Academy of Pediatrics:
To make a diagnosis of ADHD, the primary care clinician should determine that Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria have been met (including documentation of impairment in more than 1 major setting); information should be obtained primarily from reports from parents or guardians, teachers, and other school and mental health clinicians involved in the child's care. The primary care clinician should also rule out any alternative cause (quality of evidence B/strong recommendation).

A child with ADHD may exhibit the following (from webMD.com):
  • Are in constant motion
  • Squirm and fidget
  • Make careless mistakes
  • Often lose things
  • Do not seem to listen
  • Are easily distracted
  • Do not finish tasks
After the diagnosis, the next important thing to address is what to do next. First, it should be clear that the behavioral symptoms enumerated above can easily get in the way of learning inside a classroom. For this reason, it is necessary for a school and the child's guardians or parents to provide interventions or services that would meet the needs of a student with ADHD. There are two laws for K-12 students in public school that may offer supports and services for a child with ADHD: the Individuals with Disabilities Education Act (IDEA) and Section 504 of the Rehabilitation Act of 1973. Either one provides an individualized education plan (IEP). The National Center for Learning Disabilities describes an IEP via the following:
Each public school child who receives special education and related services must have an Individualized Education Program (IEP). Each IEP must be designed for one student and must be a truly individualized document. The IEP creates an opportunity for teachers, parents, school administrators, related services personnel and students (when appropriate) to work together to improve educational results for children with disabilities. The IEP is the cornerstone of a quality education for each child with a disability.
This may sound great. It means that as long as a child has been diagnosed with ADHD, the school must provide an IEP. There still remains a huge challenge, however. The question of what interventions should be included in the IEP of a child with ADHD needs to be addressed. And the following paper recently published in School Mental Health raises a serious concern:
This is a survey of high school students. While it is comforting to read that half of students with ADHD are receiving services, it is disconcerting to find that only one out of four interventions commonly implemented are evidence-based. If doctors are prescribing medication or treatment where only one of four is backed by clinical trials, it is a clear reason to worry. Apparently, in schools across the United States, this is the case for students with ADHD. The following is the list of interventions reported for students with ADHD:

Table 2 (copied fromSchool Mental HealthDOI 10.1007/s12310-014-9128-6)
Number and type of accommodations and supports reported for students with ADHD
% of those with an IEP/504 plan
(n = 170)
% of those without an IEP/504 plan
(n = 163)
Academic accommodation/support (M = 3.15, SD = 2.45)
 Extended time on tests
87.9
20.9
 Test read to student
22.4
0.02
 Modified tests
18.2
4.3
 Alternative tests or assignments
7.6
7.4
 Modified grading standards
14.7
4.9
 Slower-paced instruction
24.1
9.8
 Additional time to complete assignments
50.0
14.1
 Shorter or different assignments
24.7
6.7
 More frequent feedback
25.9
11.0
 Reader or interpreter
6.5
1.8
 Teacher aide, instructional assistant, or personal aide
15.9
4.9
 Peer tutors
4.7
4.9
 Tutoring by adult
14.7
17.8
Behavioral Support/Learning Strategy (M = 0.68, SD = 0.77)
 Behavior management program
24.1
3.1
 Learning strategies/study skills assistance
37.1
9.8
 Self-advocacy training
6.5
0.1
Learning Aids (M = 0.75, SD = 1.0)
 Physical adaptations (e.g., special desk)
18.8
4.9
 Large print or Braille books or large print computer
0
0
 Books on tape
5.9
1.8
 Use of calculator (when not permitted by others)
25.3
3.1
 Communication aids (e.g., touch talker)
0
0
 Use of computer when not allowed for others
11.2
1.8
 Computer software for students with disabilities
0
0.01
 Computer software adapted for student’s unique needs
11.2
0
 Use of tape recorder when not allowed by others
1.8
0.01
Other
 Student progress monitored by special education staff
50.6
5.5
_______________________________________________________________________________________
In the table above, supports that have been proven in research are listed in bold. Of the twenty six interventions, only five (shorter assignments, frequent feedback, behavior management, learning strategies, and self-advocacy) are backed by research. 88% gets extended time, but there is no indication from research that this actually works. Raggi and Chronis have reviewed the literature on ADHD interventions and have offered the following list of supports or accommodations that have demonstrated benefits in academic outcomes:
  1. classwide peer tutoring and parent tutoring which employ one-to-one instruction, immediate and frequent feedback, and require active responding;
  2. instructional and task modifications, which may include allowing students to choose assignments from among several pertinent alternatives, presenting material orally and requiring oral responses in addition to presenting material visually, adding structure or using explicit instructions, employing computer-assisted instruction, and using color or texture to increase stimulation within tasks; 
  3. classroom functional assessment procedures; 
  4. self-monitoring and reinforcement, particularly for older children and adolescents; 
  5. strategy training, including note-taking, study skills and organizational skills interventions; and 
  6. homework-focused interventions which incorporate goal setting, parent structuring of the homework process, and parent–teacher consultation approaches.
A child with ADHD needs an advocate. And this advocate is usually the parent so it is important that the parent is aware of what works. The above list is not long, certainly a lot shorter than the list of programs schools are now currently implementing.



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