IDENTIFICATION
Definition
Both the terminology and diagnostic criteria identifying the group of children with ADHD have undergone numerous revisions over the years. The Diagnostic and Statistical Manual for Mental Disorders
(DSM-IV), scheduled for publication in 1994, terms the overall diagnostic category as attention deficit hyperactivity disorder (ADHD) with three subtypes: Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type; Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type; and Attention-Deficit/Hyperactivity Disorder, Combined Type. Within this framework, the criteria identified in Appendix A must be met in order to warrant consideration of a clinical diagnosis of ADHD.
Barkley (1990) developed a "consensus"definition of ADHD:
"Attention Deficit Hyperactivity Disorder is a developmental disorder characterized by inappropriate degrees of inattention, overactivity, and impulsivity. These often arise in early childhood; are relatively chronic in nature; and are not readily accounted for on the basis of gross neurological, sensory, language, motor impairment, mental retardation, or severe emotional disturbance. These difficulties are typically associated with deficits in rule-governed behavior and in maintaining a consistent pattern of work performance over time."(p. 47)
Seven Characteristics of ADHD
This definition incorporates seven elements comprising ADHD:
1. Rather than being an acquired disorder, ADHD is considered to be a developmental disorder in which
certain characteristics will be demonstrated at each developmental level.
2. Through the developmental levels, there are inappropriate degrees of (a) inattention, (b) overactivity, and/or (c) impulsivity.
3. Age of onset is prior to seven years.
4. As a developmental disorder, ADHD is relatively chronic in nature.
5. ADHD cannot be due to conditions such as gross neurological, sensory, language, motor impairment, mental retardation, or severe emotional disturbance. It may co-exist with other conditions.
6. Limitations in compliance with rules tend to exist, due to factors such as forgetting rules and/or consequences, self-management of behavior, and issues surrounding sustained attention.
7. Work performance is often inconsistent over time and setting, and may be due to such factors as cognitive fatigue, attention/concentration issues, task stimulation level, time of day, resultant consequences, and task and setting novelty.
Identification Process
Specific standards must be met for identification as ADHD, as reflected in the DSM-IV. Implied in these standards is that substantial differences in behavioral characteristics may be present and educational needs/programming may vary. Identification processes should be conducted on a case-by-case, collaborative basis. The process of ADHD identification is founded on multiple data sources.
In addition, federal and state regulations regarding the provision of special education apply to eligible children with ADHD. That is, any child suspected of having ADHD and requiring specially designed instruction must be evaluated to determine the child's eligibility and need for special education services. Children with ADHD who do not require special education, but who require modifications to the general education program in order to receive meaningful educational benefit, are afforded all the rights and protections of Section 504 of the Rehabilitation Act of 1973.
Student Needs
While specific behaviors vary considerably, the most common school-based indicators of ADHD are
problems with attention span, impulsivity, and hyperactivity. These problems are often associated with
academic performance problems and behavioral/emotional and social interaction problems. Behaviors
may also be categorized in terms of primary symptoms and associated issues (Frick & Lahey, 1991),
as reflected in the chart below.
When the behaviors of impulsivity, inattention, and hyperactivity interfere with the student's performance in the general education classroom, the teacher should try reasonable strategies to assist the student. These strategies should be those the teacher would typically use to address the normal range of needs in the general education classroom, such as change of placement in the room, use of reinforcement systems (self-monitoring slips, student goal setting, etc.) or cooperative learning procedures. The teacher should also contact the parent(s). If possible, one contact should be a conference.
If the interventions do not lead to marked improvement, the teacher should bring the concern to the
Support Team (S-Team) for peer support and collegial problem-solving. Principals are strongly encouraged to develop such teams in each school, and in general, teachers should be strongly discouraged from referring students directly for a medical evaluation without first reviewing the student's problems with the S-Team. The S-Team is a site-based peer support and problem-solving group, which might consist of only general education staff. Membership might include a combination of some or all the following: principal, school psychologist, school nurse, school counselor, and teachers. The S-Team should discuss and define the student's problems and make recommendations to the teacher. The student's progress should be assessed and reported to the S-Team. If at any time the student is suspected of having a disability which substantially limits a major life activity (not receiving meaningful educational benefit) Section 504 procedures must be implemented. If the student is suspected of having a disability and possible need for special education and related services, IDEA procedures must be implemented.
If the student's behavior has improved, interventions should be continued, and the student's progress should be monitored. If the student's behavior has not improved, the need for further evaluation should be determined. In making this determination and in conducting any subsequent evaluation, all legal requirements of IDEA and Section 504 must be observed. These include protection in evaluation procedures, as well as the right to prior written notice and informed consent. (Refer to IDEA, and Section 504 for specific procedural requirements.)
Once a decision has been made that further evaluation is necessary, a case manager/team leader should be named and an evaluation plan developed. The plan should include what evaluation procedures and instruments will be used and who will obtain the information. Parents must be notified in writing and written consent obtained prior to evaluating the student. (See IDEA, and Section 504 for requirements regarding notice and consent.)
The student's multidisciplinary assessment team should evaluate the student and obtain data documenting the student's school performance in the following areas:
If the student is being evaluated because of a suspected IDEA disability condition and possible need for special education and related services, all eligibility criteria required by federal and state law must be addressed.
Behavior checklists should be distributed to all the student's teachers, including physical education, music, art, and library teachers. Checklists may be sent to other staff (playground, cafeteria, bus) as necessary.
Upon completion of the assessment process, all results should be reviewed and summarized, including the school data base, other school evaluation information, and the health care provider's report regarding the student's health circumstances, including a diagnosis of ADHD, if appropriate, and any planning implications. It is important that these recommendations be couched in terms of the student's unique needs, abilities, and limitations, not in the form of orders for specific educational services. The assessment team must determine any adverse effects of the suspected disability on the student's educational performance and make an eligibility decision. This decision, along with appropriate rationale, must be documented in the evaluation summary. Again, all required written notices must be provided and parent consent obtained, if the student is determined eligible under IDEA or Section 504. Written notice must also be provided if the student is determined not eligible.
INTERVENTIONS
If the student is determined eligible for and in need of special education and related services under one of the disability categories authorized under IDEA, a meeting to plan the student's individual education program should be scheduled. If the student is not eligible under IDEA, Section 504 eligibility should be considered. If the student is determined eligible under Section 504, a student accommodation plan must be developed. (See Section 504 for specific procedural requirements.)
Interventions may be conceptualized as a range of strategies designed to occur across and between school, health care provider, and home. Collaboration will enhance the likelihood of meaningful intervention. This collaboration must continue within the school setting, for meeting the needs of students with ADHD is a shared responsibility of general and special education. Many children with ADHD do not require special education and related services, but do require specific adaptations and accommodations to the general education program.
It is also important to remember that each student with ADHD is an individual, with unique characteristics. Effective educational programs are based on individual student's behavioral and academic needs, rather than on presumed characteristics of the group of individuals with ADHD. Realistic expectations should be set for each student, and those interventions and strategies that will allow the student the best chance to succeed should be implemented.
General education teachers also need training and support to assist them in accommodating children with ADHD. Many schools have student assistance teams that can support teachers in developing and implementing appropriate classroom and instructional accommodations and interventions. In addition, special educational instructional and support personnel such as school psychologists can assist teachers in identifying specific educational needs and developing appropriate classroom accommodations and interventions.
The following chart provides examples of ways to accommodate the needs of children with ADHD in the general classroom environment. Not all areas of concern apply to all students with this diagnosis.
Areas of concern and interventions specific to the individual student should be identified and a written individual education plan developed. This plan should be familiar to and implemented by all the student's teachers.
FOLLOW-THROUGH
Once a student is diagnosed as ADHD, interventions in the classroom and other settings should be implemented. The student's success in the educational setting should be monitored on a regular basis to determine if interventions are effective. Procedures for monitoring the interventions should be determined by the student's evaluation team, or if the student is receiving special education services under IDEA, by the student's IEP team.
If medication is prescribed, the school nurse should monitor the administration at school according to required procedures for administration of medication described above. When a medication trial is implemented for the student with ADHD, a behavior rating scale should be completed bimonthly by the classroom teacher. In addition, systematic observations should be conducted on a regular basis, at scheduled times (e.g., during independent seatwork, every Tuesday) by the school psychologist, special education teacher, or other designated school staff.
Follow-up data from behavior rating scales and observations should be forwarded to the child's health care provider on a regular basis. Initially, the health care provider may request information to be collected weekly or bimonthly until the accurate medication dose is established.
COMMONLY ASKED QUESTIONS ABOUT ADHD
1. What is ADHD?
According to Barkley (1990), "ADHD (ADD) is a developmental disorder characterized by developmentally inappropriate degrees of inattention, overactivity, and impulsivity. These often arise in early childhood; are relatively chronic in nature; and are not readily accounted for on the basis of gross neurological, sensory, language, motor impairment, mental retardation, or severe emotional disturbance. These difficulties are typically associated with deficits in rule-governed behavior and in maintaining a consistent pattern of work performance over time."(p. 47). The specific criteria for this disorder are listed in the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV), to be published in 1994.
2. Is ADHD a new disorder or condition?
No. Physicians, psychologists, parents, and educators have been concerned about this condition for over a hundred years, using an ever-changing variety of terms, labels, and definitions. . . but which essentially refer to the same behavioral disorder. Part of the current confusion is due to this use of different terminology in the past, i.e., Minimal Brain Damage, Minimal Cerebral Dysfunction, Minimal Brain Dysfunction, Hyperactivity, Hyperkinesis, ADD, ADHD.
3. Does ADHD really exist?
Yes. Not every child who has academic or behavioral difficulties in school has ADHD, but it is a very real and significant problem for many children. Much of the controversy about the "reality" of ADHD stems from the various and sometimes conflicting approaches to definition, diagnosis, and treatment strategies. Aside from these theoretical and methodological differences, ADHD is a significant disability which can lead to academic and social difficulties if no intervention takes place.
4. What are classroom symptoms of ADHD?
In the past, much of the classroom focus was on the ADHD student's hyperactivity, i.e., excess fidgeting, talking-out, making noises, getting out of seat without permission. However, current research indicates that other symptoms are probably more significant in terms of the long-term potential for school problems, i.e., difficulty in focusing and maintaining attention, impulsivity, poor task completion, low frustration tolerance, poor organizational skills, difficulty in getting along with other children of the same age, decreased motor skills, and emotional difficulty.
5. Are all children with ADHD hyperactive or overactive?
No. Hyperactivity is a frequently present, but not essential, component of ADHD. However, not all children with ADHD are hyperactive, and some may not be overactive in all situations. In fact, some children with ADHD may demonstrate normal or even below-normal activity levels (daydreaming, staring into space, "spacing-out," etc.). Under the final DSM-IV draft criteria, some children may be diagnosed under the predominantly inattentive type.
6. Do all children with ADHD demonstrate the same symptoms?
No. The symptoms are variable for each child. In addition, some symptoms do not occur similarly in all situations, i.e., they may occur more frequently in group situations that demand sustained attention or impulse control (in the classroom, at church, or at a family meal). Conversely, they may disappear in other settings such as on the playground, playing Nintendo, or participating in a one-to-one interaction with an adult, such as a visit to a physician or school psychologist.
7. Do children with ADHD have other problems?
Many students with ADHD have associated problems, such as poor school performance, specific learning disabilities, poor coordination, social skill deficits, aggressive behavior, low self-esteem, increased physical complaints, depression, or avoidance of school activities. These symptoms may or may not be linked to ADHD. Secondary symptoms will vary for each child, and no two children with ADHD are the same.
8. What are the causes of ADHD?
There is no known single cause. Instead, there seem to be a number of possible factors. ADHD is a neurologically-based, developmental condition. That is, a child may be either born with the condition or symptoms may appear early in life. Studies point to genetics and heredity, prenatal factors, birth trauma, or childhood illness. It is currently suspected that ADHD is associated with differences in neurotransmitters in the brain, especially dopamine and norepinephrine, which are essential to sustain attention, control motor activity, and prevent impulsivity. While the child's ADHD may be influenced by environmental factors such as noise or classroom activity, there is no scientific evidence that these factors cause ADHD.
9. How many children have ADHD?
Opinions and research differ on this issue. The commonly accepted view is that approximately 3 to 5 percent of children have ADHD, but some estimates are much higher. This means that, on the average, one child in every classroom in the United States may have ADHD. However, due to differences in definitions and diagnostic strategies, these estimates vary widely. Research also suggests that more boys than girls have ADHD, but the ratios here also differ widely depending on the study.
10. Will these children outgrow ADHD?
Some children appear to develop coping skills and adaptive strategies for their ADHD, often by adolescence. Some children may outgrow the core deficits of the disorder. However, ADHD may be a life-long factor for some individuals. Much of the currently published research is about children and adolescents with ADHD. As more data about the long-range implications of ADHD begin to emerge, it appears that the disorder may persist into adulthood and be associated with continued difficulties such as the ability to hold a job, substance abuse, and learning problems.
11. How is the diagnosis of ADHD made?
The diagnosis of ADHD is made following a comprehensive evaluation of the child using data and information from a variety of sources. An effective evaluation for ADHD is a complex process of differentiating among a variety of factors; ruling out other possible explanations for the child's symptoms (family stressors, physical illness, school anxiety, etc.); and establishing a constellation of symptoms consistent with ADHD based on the definition above. At a minimum, the evaluation should include the following elements:
Medical evaluation, following the American Academy of Child and Adolescent Psychiatry practice parameters (Appendix B); Complete review of school records and family/social history; and Individual psychoeducational assessment as appropriate.
12. Is there a specific test for ADHD?
Currently, there is no specific test for ADHD. The clinician examines information from different sources and looks for the constellation of symptoms. When parents say that their child is "being tested for ADHD,"they are probably referring to this process of integrating data from a variety of sources. There are behavioral checklists, ADHD rating scales, psychological tests for attention span and memory, but there is no definitive scientific test for assessing ADHD at this time.
13. Who is best qualified to diagnose ADHD?
A variety of specialists may be qualified to diagnose ADHD, including child psychiatrists, pediatric neurologists, and pediatricians knowledgeable about ADHD. Other professionals such as teachers, principals, school nurses, and school psychologists may contribute valuable data to the evaluation process. Parents are often the first to suspect their child's attention problems.
14. What is the school's role in the diagnostic process?
It is inappropriate for the school to diagnose ADHD. The school's primary role in the diagnostic and treatment process is to provide a data base for use by the parents and their primary health care provider in making the diagnosis and other important decisions (such as monitoring progress and effectiveness of treatment and interventions, about the child). The school Multi-Disciplinary Team or S-Team will develop and implement recommendations regarding educational placements and services with input from parents and the child's primary health care provider.
15. What are the major intervention categories for ADHD and who provides them?
There are four general intervention categories. Research is very clear that these are typically most effective when they are implemented in combination, rather than singly. These include:
Medical management and medication, provided by psychiatrists, neurologists, pediatricians, and/or nurse clinicians.
Behavior modification and social skills training provided by school psychologists, school nurses, school social workers, school counselors, and/or other school staff.
Parent education and support, provided by school psychologists, school social workers, counselors, and/or parent support groups.
Classroom interventions and accommodations and inservice training, provided by school staff, educational specialists, and/or instructional assistants or tutors.
Obviously, the implementation of a comprehensive, integrated intervention plan for any child with ADHD requires real cooperation, coordination, and communication among all the participants. In addition, building staff need inservice training regarding effective interventions and accommodations for children with ADHD.
16. Is there a cure for ADHD?
There is no cure for ADHD at this time. However, with the right combination of interventions, the frequency, intensity, and duration of the learning and behavioral problems associated with ADHD may be significantly reduced.
17. How are medication decisions made?
The decision as to whether to medicate a child for ADHD, as well as questions of dosage and type of medication, are made by the child's physician and parents. These clinical decisions are generally made on the basis of formal medical evaluation, anecdotal reports, and the use of various ADHD rating scales that may be completed by parents regarding behavior at home and by school staff regarding behavior at school. School staff will usually be asked to continue completing these rating scales even after the initial decision to medicate is made. This allows the physician to determine whether the medication is really effective, if a dosage change is required, and whether to discontinue the medication. It is also a good idea to have more than one person (such as a classroom teacher, counselor, consulting teacher, or a school psychologist) do ratings at school, to minimize the relative subjectivity of these scales.
18. Should school personnel ever recommend or require that a child be placed on or taken off medication?
No. This is a decision for parents and their physician. As with the issue of diagnosis, the school's role should be to provide a data base of observational and objective information to the parents and physician so they can make the best decision. School staff should avoid giving personal advice or opinions regarding medication because of potential liability.
19. What are the commonly prescribed medications for ADHD? How do they work?
The most commonly prescribed medications for ADHD are psycho-stimulants, such as methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and pemoline (Cylert), as well as antidepressants. It is thought that these medications work by stimulating the production of specific chemicals in the brain which are essential for normal focused attention, planning, and organization. The stimulant medications are relatively fast-acting, and any behavioral changes will typically be seen within an hour for most children. A small percentage of children also require combinations of medications such as stimulants and antidepressants.
20. What are some possible side effects that might be seen at school?
Side effects are specific to the medication and will be described on the authorization for administration of medication form signed by the child's primary health care provider. The school nurse can be a valuable source of information on these issues and can help set up a system for monitoring and reporting side effects.
21. What should teachers do if they observe side effects?
Suspected side effects must be reported immediately to the school nurse, parents, and physician. The physician can then determine if a dosage adjustment or change to another medication is necessary.
22. How should medication be administered at school?
Medication should be administered at school according to procedures developed by the school district’s Board of Education. School staff, such as the school nurse, must take responsibility for safely storing medication and monitoring the timely dispensation of prescribed doses. Some children with ADHD who have difficulty remembering daily routines may need to be reminded to take their medication.
23. Do all children with ADHD also have specific learning disabilities or behavior problems in school? Do they all belong in "special" programs?
No. Not all children with ADHD have learning disabilities or behavioral problems. However, there are some "overlaps"between these issues. Studies estimate that 60 to 80 percent of children with ADHD may have additional learning and/or behavioral problems. However, many of these needs can be accommodated successfully in the regular education classroom, and placement in special programs would thereby be unwarranted.
24. Do all children with a clinical diagnosis of ADHD automatically qualify for special education or other remedial programs?
No. A clinical diagnosis of ADHD does not automatically qualify a child for special education or remedial programs. In fact, it is generally recommended that interventions be implemented in the regular classroom before special programs are even considered. The student's multidisciplinary assessment team must determine the adverse educational impact that requires specially designed instruction through an IEP as discussed in the following question. However, a student who has been diagnosed with ADHD is protected under Section 504 of the Rehabilitation Act of 1973. Refer to the Section 504 manual for more specific information.
25. How does a child with ADHD qualify for special education services?
Qualifying for special education is a complex process of assessment and eligibility determination within specific disability categories. This includes a full and individual evaluation in accordance with the requirements of federal and state special education regulations and a determination by a multidisciplinary team that the child is eligible for and in need of specially designed instruction because of a disability. There is no separate category for qualifying a child as ADHD. A child with ADHD who
has a measurable learning disability and meets eligibility criteria may qualify within the learning
disability category; the child with a behavioral disorder who meets eligibility criteria may the serious
behavioral disability category, respectively. In addition to these categories, a child with diagnosis of ADHD may qualify for special education within the category of ADHD if the multidisciplinary assessment team determines an adverse educational impact that requires specially designed instruction. A medical diagnosis of ADHD is not in itself a guarantee of eligibility. The school's multidisciplinary assessment team (or IEP Team), working cooperatively with the parents, has both the responsibility and authority to determine if the ADHD is so serious that child's educational needs cannot be met in regular education with some accommodations. After this determination is made, the multidisciplinary assessment team may identify the child as eligible for special education.
26. Does the school have any special obligation to the child with ADHD who does not qualify for special education services?
Yes. Federal guidelines state that it is the responsibility of regular and special education to coordinate their efforts to provide services and adaptations to children in regular education who do not qualify for special education. The guidelines also make it clear that some children with ADHD who do not qualify for special education may be entitled to other services or procedural safeguards through Section 504.
27. Are children with ADHD included under Section 504 of the Rehabilitation Act of 1973?
What is the school district's obligation under Section 504?
Yes. ADHD is a disability under Section 504. Even if a child with ADHD is found to be ineligible for special education services under IDEA, the requirements of Section 504 of the Rehabilitation Act of 1973 and its implementing regulations are applicable. If the student's ADHD substantially limits learning, the student would be eligible for protection under Section 504. In general, eligibility under Section 504 is a function of the severity of the child's disability condition, and children with ADHD may or may not fit within that definition. A child with a mild form of ADHD would probably not qualify for services through Section 504. The child whose learning is substantially limited by ADHD and who is not receiving meaningful educational benefit would be eligible for protection under Section 504. The district must prepare a written plan outlining the special education, related aids, and services necessary to enable the student to receive educational benefit.
28. What can parents do if they disagree with school decisions or services?
Ideally, parents, clinicians, and school districts will
develop cooperative partnerships to meet the needs of children with ADHD in
both regular and special education. However, when differences occur, parents do
have numerous and specific procedural safeguards available, i.e., they may
request an independent assessment or a hearing to challenge any actions
regarding the identification, evaluation, placement, or services for their
child if they cannot otherwise resolve their differences. Under Section 504 parents may file a grievance with the district
Section 504 coordinator, file a complaint with the Office of Civil Rights,
request a due process hearing, or go to court.
29. What are some effective classroom strategies for children with ADHD?
There are numerous academic and behavioral interventions that have been found to be successful with children with ADHD. Many of these strategies can be easily implemented in regular education classrooms with only minor adaptations. In general, the key to using any of these interventions is to individualize them to meet the specific classroom needs of each child. Finally, it is important to discuss potential classroom strategies with both the child and parents. Some general classroom strategies are included in the Interventions section.
30. Does providing these special accommodations in classwork, behavioral rewards, or homework modifications simply allow the child to avoid responsibility?
No. These children have a real disability. Just as we would provide eyeglasses to a person with a vision deficit or would allow a child in a wheelchair extra time to get to class, we need to provide appropriate behavior programs, curriculum adaptations and reasonable accommodations to children with ADHD if they are to be successful in school. For example, some children with ADHD have a difficult time remembering the details of homework assignments, and sending home a daily homework sheet for parental supervision would be a relatively simple response to this problem.
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