Understanding, Understanding, teaching, & supporting teaching, & supporting students with ADHDstudents with ADHD

Understanding, Understanding, teaching, & supporting teaching, & supporting students with ADHDstudents with ADHD

Rosemary Tannock, Ph.D, Rosemary Tannock, Ph.D, Senior Scientist, Associate Professor of Psychiatry,Senior Scientist, Associate Professor of Psychiatry,

The Hospital for Sick Children & University of Toronto; The Hospital for Sick Children & University of Toronto;

Investigator with the Investigator with the

Canadian Language & Literacy Research NetworkCanadian Language & Literacy Research Network

ADHDADHD

Low selfLow selfesteemesteem

AcademicAcademiclimitationslimitations

RelationshipsRelationships

Smoking andSmoking andsubstance abusesubstance abuse

InjuriesInjuries

Motor vehicle Motor vehicle accidentsaccidents

LegalLegaldifficultiesdifficulties

Occupational/Occupational/vocationalvocational

Childhood

Childhood

Adulth

ood

Adulth

ood

AdolescenceAdolescence

Potential Areas of Impairment

ADHD: Challenges for Educational ADHD: Challenges for Educational SystemsSystems

• Education costs 3 to 6 times greaterEducation costs 3 to 6 times greater (Forness et al., (Forness et al., NIH ConcensNIH Concens, 2000), 2000)

– Prevalence (1 or 2 children in every class)Prevalence (1 or 2 children in every class)– Association with learning & social problemsAssociation with learning & social problems

• Meaning for educational programming is Meaning for educational programming is unclearunclear– What type of exceptionality/special needs?What type of exceptionality/special needs?– What are the Standards for level of service & What are the Standards for level of service &

instruction?instruction?– What are the required teacher qualifications?What are the required teacher qualifications?

Educational Systems:Educational Systems: Principles of PracticePrinciples of Practice

• Inclusion as basic principle:Inclusion as basic principle:

• Program StandardsProgram Standards– Exceptionalities/Special NeedsExceptionalities/Special Needs– Screening & AssessmentScreening & Assessment– InterventionsInterventions– Level of ServiceLevel of Service– InstructionInstruction– Qualifications for teachers & other Staff Qualifications for teachers & other Staff

Typically, one’s pedagogical Typically, one’s pedagogical approach to students with approach to students with

special needs reflects one’s special needs reflects one’s own own conceptualizationconceptualization of of

that particular special needthat particular special need

Prevailing view: Prevailing view: ADHD as a behavior problemADHD as a behavior problem

BiologicalBiological&&

EnvironmentalEnvironmental FactorsFactors

BrainBrainAbnormalitiesAbnormalities

InattentionInattentionHyperactivityHyperactivityImpulsivityImpulsivity

Associated ProblemsAssociated Problems(academic, social)(academic, social)

Emerging neuroscience/educational

perspective

Genetic Genetic &&

EnvironmentalEnvironmental FactorsFactors

BrainBrainAbnormalitiesAbnormalities

Working MemoryWorking Memory& other& other

cognitive processescognitive processes

Inattention, Inattention, Hyperactivity, impulsivityHyperactivity, impulsivity

Learning, Academic achievementLearning, Academic achievement

TreatmentTreatment targets targets

Traditional approaches to Traditional approaches to helping children with ADHDhelping children with ADHD

• Medical/Pharmacological (~ Medical/Pharmacological (~ 85%)85%)

• Behavioral (~12%)Behavioral (~12%)

• Educational (?)Educational (?)

• Alternative approaches (?)Alternative approaches (?)

Limitations of traditional Limitations of traditional approaches to helping children approaches to helping children with ADHDwith ADHD

• PharmacologicalPharmacological– (Philosophical/political)(Philosophical/political)– Temporary effects on behavior & academic Temporary effects on behavior & academic

productivityproductivity– No robust evidence of impact on learningNo robust evidence of impact on learning

• Behavioral approachesBehavioral approaches– Disproportionate emphasis on Disproportionate emphasis on

consequences rather than antecedent consequences rather than antecedent scaffolding (support) & control proceduresscaffolding (support) & control procedures

– Limited generalizability beyond the training Limited generalizability beyond the training contextcontext

Stimulant medication improves:Stimulant medication improves:

*** Core features of ADHD *** Core features of ADHD ******

Academic productivityAcademic productivityClassroom behaviourClassroom behaviourLab measuresLab measures

(inhibitory control, attention)(inhibitory control, attention)

But…...But…...

Treatment related improvements in core Treatment related improvements in core behavioral features of ADHD & dailybehavioral features of ADHD & dailyacademic work have academic work have notnot translated translated into robust gains in long-term academicinto robust gains in long-term academicachievement (e.g., MTA Study, 1999)achievement (e.g., MTA Study, 1999)

WHY NOT?WHY NOT?

Unsatisfactory,Unsatisfactory,

needs improvementneeds improvement

UnsatisfactoryUnsatisfactory

needs improvementneeds improvement

Grade 1Grade 1 Grade 3Grade 3The Problem

““Beneficial effects of stimulantBeneficial effects of stimulant medication are not infinite” medication are not infinite”

• Effects on behavior & academic Effects on behavior & academic productivity are immediate but productivity are immediate but temporary & cannot compensate for temporary & cannot compensate for “missed instruction and learning”“missed instruction and learning”

• Lack of synchronization between drug Lack of synchronization between drug schedule and academic scheduleschedule and academic schedule

• Stimulants enhance some but not all Stimulants enhance some but not all aspects of cognitive function & so may aspects of cognitive function & so may not target critical cognitive impairmentsnot target critical cognitive impairments

of medical & academic treatment is of medical & academic treatment is essentialessential

0

0.5

1

1.5

2

2.5

3

3.5

4

Trials toMastery

Errors

1 hr post3-4 hrs post

““Reading to Read” instruction for ADHD boys at two intervals post-medication (Kastner et al., 2000)Reading to Read” instruction for ADHD boys at two intervals post-medication (Kastner et al., 2000)

Stimulant have limited effects Stimulant have limited effects on readingon reading

• NoNo effect on effect on phonological processingphonological processing (e.g., Balthazor et al., 1991; Richardson et al 1988)

• Small effects on verbal retrieval Small effects on verbal retrieval mechanisms involved in mechanisms involved in word recognitionword recognition (e.g., Ballinger, 1984; Evans et al., 1986; Peeke et al., 1984; Richardson et al., 1988; MTA Study 1999)

• Effects on Effects on comprehensioncomprehension are unknown are unknown (e.g, Brock & Knapp, 1996)

Stimulants have selective effects Stimulants have selective effects on Working Memoryon Working Memory

• Stimulants improve Stimulants improve but do not normalizebut do not normalize impairments in impairments in visuo-spatial span & visuo-spatial span & visuo-spatial working memoryvisuo-spatial working memory, , in childhood & adult ADHD in childhood & adult ADHD (Bedard et al., in press; Mehta et al., 2000a, 2000b; Barnett et al., 2002)

• Stimulants may improve Stimulants may improve verbal working verbal working memorymemory but not verbal span in children, but not verbal span in children, butbut may be mediated by stimulant effects on may be mediated by stimulant effects on spatial working memoryspatial working memory (CHI/PASAT;Tannock et al., (CHI/PASAT;Tannock et al.,

1995; Schweitzer et al., 2000)1995; Schweitzer et al., 2000)

Advances in psychopharmacological

treatment of ADHD

• Newer, longer-acting medications for ADHD will facilitate synchronization of pharmacological treatment with educational intervention– Several FDA-approved long-acting

stimulants & a non-stimulant drug available in USA

– Many of which are or will soon be available in Canada

BUT…. May still have temporary & selective beneficial effects on cognitive function

Contingency Management

• intensive behavioral programs• includes both negative consequences

and positive reinforcement• may be difficult to implement across

range of situations in school• does not take into account underlying

reasons for behavior (ie., cognitive deficits)

Cognitive-Behavior Therapy

• characterized by

– verbal mediation instruction

– cognitive modeling

– problem-solving strategies

• inconsistent results regarding effectiveness - however usually implemented as a ‘package’ in

treatment sessions removed from normal environment (i.e., regular classroom)

Behavioral techniques (e.g., parent training, cognitive behavioral

therapy) improve...

• Oppositional behavior• Some ADHD behavioral symptoms

• but transfer-of-learning beyond the training context is limited…. (e.g., Abikoff, 1991; Kendall & Panichelli-Mindel, 1995; Pelham et al., 1998; MTA Co-operative Group 1999)

WHY?

One ProblemOne ProblemNon-integrated approachesNon-integrated approaches

FamilyFamily

DoctorDoctor

Psychologis

Psychologis

tt

TeacherTeacher

SpecialistSpecialist

ss

NIMH Multimodal Treatment Study

– Largest, longest, randomized controlled clinical trial of treatment in ADHD(N ~ 600; ADHD-CT; 14 mos duration)

– Four parallel treatment arms1. Managed Medication2. Managed Meds + Psychosocial3. Psychosocial4. Community Services (included

meds)

Most effective for ADHD?Most effective for ADHD? 1, 2 > 3, 41, 2 > 3, 4

What else can we do to boost What else can we do to boost academic and social success, academic and social success, & facilitate learning?& facilitate learning?

(Beyond the MTA)(Beyond the MTA)

Problems with Problems with salience salience

Problems Problems ignoring ignoring irrelevant irrelevant informationinformation

Lack Lack strategiesstrategies

Working Memory Demands in the Working Memory Demands in the ClassroomClassroom

• SpellingSpelling

• MathMath

• Reading Reading ComprehensionComprehension

• Following oral Following oral directionsdirections

• Problem-solvingProblem-solving

Maintain word in mind Maintain word in mind while printing itwhile printing it

Keep steps in sequence Keep steps in sequence while performing and while performing and monitoring accuracymonitoring accuracy

Decode words while Decode words while integrating meaningintegrating meaning

Maintain correct Maintain correct sequence, update, and sequence, update, and checkcheck

Pick out key elements, Pick out key elements, choose strategy & choose strategy & monitor effectivenessmonitor effectiveness

Promising Educational Strategies for ADHD to reduce demands on

working memory & enhance learning

• Teacher-focused interventions– Modifying how teachers think about, adapt

& present critical content to help students identify, organize, comprehend & recall it

• Student-focused interventions– Teach the student skills & strategies

needed to learn the critical content (acquire information from print, organize & memorize, problem-solve, & written expression) and succeed in test-taking

Social/EmotionalSocial/Emotional- e.g. self-esteem- e.g. self-esteem

BehaviorBehavior--fidgetyfidgety-inattentive-inattentive

Cognitive Strengths Cognitive Strengths and Weaknessesand Weaknesses- - working memoryworking memory- language- language- reading ability- reading ability

AAdaptionsdaptionsMModificationsodificationsAAcommodatecommodateSStrategiestrategiesSScaffoldscaffolds

approach may be more effective approach may be more effective than behavioral contingenciesthan behavioral contingencies

• IN-SITUIN-SITU (“at point of performance”) (“at point of performance”) • FREQUENT, LONG-TERM FREQUENT, LONG-TERM

• CONTEXTUALIZED COACHINGCONTEXTUALIZED COACHING– MODELLINGMODELLING– SCAFFOLDINGSCAFFOLDING– STRATEGIESSTRATEGIES

• Minimizes need for behavioral Minimizes need for behavioral contingency management & contingency management & applicable to ALL childrenapplicable to ALL children

Antecedent-Based Approaches

• stresses the interaction between child and environment

• manipulate a variety of potential antecedent variables that may affect performance, such as...– nature of the assignment compared to level of

functioning of child, – classroom structure, – advance organizers, – modifications in instructional delivery and

support

What are Cognitive Learning Strategies?

• “Set of steps that lead to the accomplishment of a task” (Wanzek et al., 2000)

• How a person thinks & acts when planning, executing, & evaluating performance of a task & its outcomes

(Lenz, Ellis & Scanlon 1996)

– Includes thinking & physical actions necessary to perform a skill

– Physical act provides evidence that student is using a strategy

Cognitive Learning Strategies can be taught

to all children?

• promotes intentional learning (self-regulation)

• helps children be flexible and adaptable learners

• promotes independent, active learning

• facilitates transfer to novel contexts

• helps children organize approach to task

Critical Features of Effective Cognitive Learning Strategies

(Ellis & Lenz, 2000-(ldonline.org; Minskoff & Allsop, 2003)

• Accurate & efficient procedures for learning tasks

• Accessible to students by being

– Memorable (labels, visual cues)

Simply worded; Uses familiar words

Begins with action words

– Accessible through Strategy Cue Sheets

• Contains only essential steps

– Number of steps should not exceed student’s ability to remember & perform

– Distinguish between primary & secondary steps

Systematic Explicit Instruction to teach Cognitive Learning

Strategy

Task Analysis/Preskills:

Basic Knowledge ofInstructional Language,Listening steps,Temporal Concepts

1. Introduce strategy

3. Repeated guided practice

4. Independent practice with little/no support

Bedrock

2. Model strategy

5. Generalization to other subject/setting

Types of cognitive learning strategies(Minskoff & Allsop, 2003)

• Mnemonics

• Visualization

• Verbalization

• Graphic Organizers

• Structured Steps

• Multi-sensory learning

Strategies to help organization

• Time management

• 3C– Create a calendar– Create a weekly

planner– Create daily lists

• Materials management

• CLASH– Check your calendar– List the items you need

for next day– Always gather the

materials on your list– Set your bag by the

door– Have a list in your

locker of materials you need

WARFStrategies to improve reading speed• Widen your eye span

– Read more than one word at a time– Read groups of words (the/a + noun)

• Avoid skip backs– Keep reading to try to get meaning from

context• Read silently• Flex your reading rate

– Read important information slowly– Read familiar information faster– If looking for specific information, read

quickly as searching

Examples of Decoding Examples of Decoding Strategies from WStrategies from Word ord

IIdentification & dentification & SStrategy trategy TTrainingraining

(Lovett etal., 1994, 2000)(Lovett etal., 1994, 2000) • Rhyming

• Vowel Alert

• Peeling-Off

• I Spy

Word Identification Strategy Training Program Metacognitive strategies

(Lovett et al., 2000)

• S.A.M.E.(select, apply, monitor, evaluate)

• Use a gameplan– Choose, Use, Check, Score

Using Graphic Organizers as a Scaffold for Comprehension

Strategies (Ellis, 1998)

They show organization of concepts and relationships between concepts

Reduce the cognitive demands of learner to organize material, so learner can focus on understanding it

Allows higher level critical thinking activities to occur (relate,compare/contrast)

Can be used to help students:

summarize

find supporting details

sequence events

Is aboutCave types and features

Key Topic

Caves

Essential Details

Features of CavesCave Types

Main idea Main idea

Essential Details

Limestone: most common

Sandstone: wind or water erode sandstone

Lava caves

Moon-milk (calcium) is name of gel on floors, walls

Cave interiors have 3 zones: entrance, Twilight, and dark zone

Limestone caves: have stalactitesAnd stalagmites

Sea caves

Example of Graphic Organizer

Story Writing Strategy (Harris, Schmidt, & Graham, 2000)

SPACE • Setting• Place• Action• Conclusion• Emotions

P.O.W.E.R (Englert et al., 1991)

to help organize ideas when writing an essay

• P- plan your paper (brainstorm for

ideas)• O – organize ideas (graphic web)• W – write your draft• E – edit your work• R – revise work

Cognitive learning strategies for foundation math skills

• Whole number computation

• Word problems

• DRAW for basic math

• FAST DRAW for basic math

DRAW for basic mathfrom Teaching Students with learning Problems,

Mercer&Mercer, 2001

• Discover the sign– Scan the problem– Circle and say name of operation sign– Say what the sign means

• Read the problem– Read the whole problem– Say the problems aloud as you read it

• Answer or draw & check– Answer problem if you know how to solve it– Or draw picture to solve it– Check your answer

• Write the answer

Example: subtraction

6 l l l l l l

- 3

3

FASTDRAW for basic math(Mercer & Mercer 1991)

John and Mary went to the corner store to buy some candy.John bought 3 packs of gum and Mary bought 4 chocolates.How many candies to they have altogether?

•Find what you are solving for•Underline the question•Box key words (altogether= addition or multiplication)

•Ask what is the important information•Find & circle the number phrases

•Set up the equation•3 gum __ 4 chocolates =

•Tie down the sign•3 gum + 4 chocolates =

Examples of General Metacognitive Strategies

• I.D.E.A.S.

– I state the problem.– Develop some plans– Explore the plans– Ask myself if the

plan is working– See if I am

successful.

• Think Aloud (Camp & Bash, 1985)

– What is the problem?

– What are some plans?

– How is my plan working?

– How did I do?

Four Components of SCORE

Tangrams,Geometry, Attribute blocks, Pentominoes,Mazes

Social Skills/Prob.Solve (e.g.)Cooperation FriendsTone of Voice,

Explicit application to cognitive/social problems

Organizational/Study strategies/Active listening/

Scientific Method:Questioning, observing

Emotions/Anger Mgmt

IDEAS lessons

Instructional language/Following directions

Problem-Solving strategies

Promoting Self-Esteem/Self -Assessment

Think Aloud(verbal mediation)

Temporal skills

4. Being a Detective

3. Getting Along Together

2. IDEAS(Thinking aloud)

1. Academic

Lesson Delivery

• fast-paced, focused, energetic• little down time - increase student response

frequency (e.g, choral responses, cooperative activities)

• Simplify, chunk & repeat, instructions– establish eye contact, then give instructions, repeat, have

child repeat.• vary presentation style (active/passive)• use visual prompts/aids (e.g., diagrams,

pictures, color coding)

Content Adaptations

• greater student response frequency • choral response, peer tutoring

• use visual prompts • pictures as reminders,

• adjust quantity of work• match to ability, reduce

handwriting/copying

• increase amount of review/repetition• may need more practice to learn new skill

Example: Example: Teaching Teaching Math Math

• reduce amount of workreduce amount of work

• provide lined paper (spatial deficits)provide lined paper (spatial deficits)

• use manipulativesuse manipulatives

• adapt delivery to include visual cues, adapt delivery to include visual cues,

color coding, mnemonicscolor coding, mnemonics

• provide extended practice in problem-provide extended practice in problem-

solving strategiessolving strategies

Tips for Managing Behaviour

• Rules:– post rules visually– review before transitions– be consistent, use predetermined consequences

• anticipate!• frequent feedback (eye contact can

redirect), use signals• use direct requests “When…then…”

Managing Behavior

• Be supportive, highlight shining moments, encourage child to self-evaluate strengths

• help the child become self-aware and self-observant (e.g., how do you feel about…? you must be proud that …”)

• teach a new, positive behaviour to replace negative

• deliver feedback swiftly and systematically

Major points• ADHD is a biologically-rooted neurocognitive disability

• ADHD is more usefully conceptualized as a type of learning disability (rather than just a behavior disorder)

• Oral language, academic, & cognitive function should be routinely assessed in ADHD

• Intervention for ADHD will be multimodal & include:– Psychoeducation– Psychopharmacology– Antecedent-focused approaches with metacognitive instruction &

environmental modifications– Direct & intense academic instruction

The future….The future….Targeted, integrated, Targeted, integrated, and synchronized treatmentsand synchronized treatments

PharmacologicalPharmacologicallonger-acting medicationlonger-acting medication

target neurotransmittertarget neurotransmitter/neural network systems/neural network systems

Psychological/EducationalPsychological/Educationaltarget underlying cognitive processestarget underlying cognitive processes

synchronize with pharmacological synchronize with pharmacological treatment, in terms of timing and target treatment, in terms of timing and target

problemsproblems

WWW Resources• www.ldonline.org/ld_indepth/add_adhd

(Useful articles include: Key components of a comprehensive assessment of ADHD; Talking to your children about their ADD; ADD and Gifted students:What do we really know?; Attention deficit disorder in college)

• www.ld.org/index.htmlIncludes “tips for Teachers” section for ideas on forming parent-teacher partnerships

• www.ldresources.com(an extensive on-line compensium of books, videotapes, conferences; Education section has articles on homework, transition plans etc)

• www.ascd.org/readingroom/edlead/(Nov 2001 issue of Educational Leadership on understanding learning differences includes the on-line article :Reconceptualizing ADHD by Tannock & Martinussen

• http://coe.jmu.edu/learningtoolboxviusal cues for each step in a strategy