Subject: Work, health and safety

Rose Dixon gives some practical advice on how to support students with ADHD . . . 

WHAT IS ADHD?

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that affects around 9.4% of children under the age of 18. ADHD is one of the most commonly diagnosed conditions in children (Centers for Disease Control and Prevention, 2015). The diagnostic term attention deficit/hyperactivity disorder (ADHD) refers to individuals who display patterns of inattention, impulsivity, and overactive behavior that interfere with daily functioning (American Psychiatric Association [APA], 2013). The Diagnostic and Statistical Manual (DSM) V (APA, 2013) criteria for diagnosing ADHD list three types of ADHD and the accompanying characteristics. 

THREE TYPES

Inattentive ADHD

Formerly referred to as ADD, students with inattentive ADHD display symptoms of inattention, but do not possess symptoms of hyperactivity or impulsivity. This is the type of ADHD most commonly found in girls. As students with this type of ADHD don’t exhibit the typical high energy and impulsive behaviours, they can often be under identified. 

Hyperactive/Impulsive ADHD

This subset of ADHD displays symptoms of impulsivity or hyperactivity but does not display symptoms of inattention. 

Combined

People with combined ADHD display symptoms of inattention, hyperactivity and impulsivity. 

The combined type of ADHD is characterised by symptoms of both inattention and hyperactivity/impulsivity. Students with combined type ADHD exhibit symptoms of inattention such as struggling to concentrate on their work, difficulty following instructions, appearing distracted, forgetfulness, and misplacing items. They also exhibit hyperactive and impulsive symptoms such as being unable to sit still, restlessness, talkativeness, high energy levels, and interrupting others. 

For all three types, these characteristics have to be present before twelve years of age and be manifested in school and out of school settings. They must also have adverse effects on academic performance, occupational success, or social-emotional development (APA, 2013). To add to the complexity of the diagnosis, children with ADHD are also likely to have co- existing emotional, behavioural, developmental, learning, or physical conditions (Wolraich & DuPaul, 2010). 

Students who have ADHD face many challenges in school. The core symptoms make adapting to behavioural expectations and norms at school very difficult, often resulting in academic problems and peer exclusion (de Boer &Pijl, 2016; Mikami, 2010). Students with ADHD commonly have co-occurring problems such as anxiety, depression and learning disabilities. All predict further school impairment (Larson, Russ, Kahn, & Halfon, 2011; Taanila et al., 2014). 

DIAGNOSIS OF ADHD

ADHD is more commonly diagnosed in boys than girls, usually in a ratio of four to one, but research into ADHD in adulthood suggests an almost equal balance between men and women (Barkley & Fischer, 2008). A lower diagnosis rate among females in childhood can result because girls with ADHD are more likely than boys to have the inattentive form of ADHD and are less likely to show obvious problems or challenging behaviours. 

Whilst students with ADHD need to be diagnosed by a medical professional, teachers may notice some of the following behaviours usually related to the three different types. 

Predominantly inattentive type

The student may:

 Submit inappropriate work or inaccurate work

 Have difficulty attending to conversations, activities or tasks

 Be easily distracted

 Have difficulty following directions

 Frequently lose materials and/or have difficulty organising tasks and materials

Predominantly hyperactive/impulsive type

The student may:

 Appear to be in constant motion

 Frequently fidget and move in their seat

 Become restless during quiet activities

 Leave their seat when expected to remain seated

 Interrupt others and classroom activities

 Talk excessively and/or fail to follow classroom procedures

TREATMENT FOR ADHD

While there is no cure for ADHD, and it can persist into adulthood (Barkley & Fischer,2008), evidence- based treatment can help a great deal with symptoms (Moore et al, 2018). 

Treatment typically involves medications, behavioural and/or educational interventions. Given the often poor school outcomes of students, a growing number of studies have trialled school-based interventions for ADHD (van Krayenoord, Waterworth & Brady,2014) including the daily report card (DRC), where the child is set, and awarded for achieving, specific behavioural targets; academic interventions which focus on antecedents of problems; organisational skills training; and social skills training.(Chronis, Jones, & Raggi, 2006; Evans, Owens, Wymbs, & Ray, 2018). 

USEFUL CLASSROOM STRATEGIES TO SUPPORT STUDENTS FROM YEARS 1 – 6 WITH ADHD

Teachers can employ evidence-based strategies in three key areas which have demonstrated positive outcomes. These include classroom management, organisation training and social skills training.  

1 Evidence-based proactive strategies which improve behaviour

The behavioural classroom management approach encourages a student’s positive behaviours in the classroom, through a reward system or a daily report card, and discourages their negative behaviours. This teacher-led approach has been shown to influence student behaviour in a constructive manner, increasing academic engagement. Although tested mostly in primary schools, behavioural classroom management has been shown to work for students of all ages (Evan, Owens & Burford, 2014; Harrison, Burford, Evans & Owens, 2013) 

Develop routines around homework and classroom activities. You will need to teach and reteach these routines and positively reinforce the student when they follow them. 

Give praise and rewards when rules are followed. 

2 Organisational training

Organisational training teaches students time management, planning skills, and ways to keep school materials organized in order to optimize student learning and reduce distractions. This management strategy has been tested with children and adolescents (Kofler et al, 2011). 

These strategies can include: 

• Giving clear, effective directions or commands. Usually only give one command at a time and use a student’s name in the command. 
• Using Visuals – Place charts around with the Rules and Routines on them  
• Allowing breaks – for children with ADHD, paying attention takes extra effort and can be very tiring. 
• Allow time to move and exercise 

• Transition Buddies  
• Teacher cues for transition between activities, such as claps or music 
• Color-coded folders 
• Extra books – a set at home and a set at school 
• Use of calendars 

• Seating arrangements 

• Close to teacher 
• Separate desks 
• Away from distractions (e.g., electric pencil sharpener) 
• Away from windows, the door and other high traffic areas 

• Avoiding bright display areas at the front of the room or in the group teaching area 

• Assignments and Homework 

• Make assignments clear – check with the student to see if they understand what they need to do 
• Provide choices to show mastery (for example, let the student choose among written essay, oral report, online quiz, or hands-on project) 
• Make sure assignments are not long and repetitive. Shorter assignments that provide a little challenge without being too hard may work well 
• Be creative – creativity is a strength for students with ADHD 
• Use organisational tools, such as a homework folder, to limit the number of things the child has to track. 

• Ask another student, if possible, to be a homework partner  

3 Evidence based Social Skills Training

Social skills training allows children and adults to acquire the knowledge, attitudes, and skills they need to recognise and manage their emotions, demonstrate caring and concern for others, establish positive relationships, make responsible decisions and handle challenging situations constructively. Many available programs provide instruction in and opportunities to practise, apply and be recognised for using social skills. This type of learning is fundamental not only to children’s social and emotional development but also to their health, ethical development, citizenship, motivation to achieve and academic learning (Evan, Owens & Bunford, 2014). 

Research shows that large numbers of children with ADHD are contending with significant social, emotional and mental health barriers to their success in school and life (Kofler et al, 2018). In addition, some children with ADHD engage in challenging behaviours that teachers must address in order to provide high quality instruction. Schools can use a variety of strategies to help students improve their emotional well-being and connectedness with others. Providing children with well managed learning environments and instruction in social skills addresses many of these learning barriers. It does so by enhancing school attachment, reducing risky behaviours, promoting positive development, and positively influencing academic achievement. Well-implemented social skills training is associated with the following outcomes:  

Better academic performance

Achievement scores an average of 11 percentile points higher than students who did not receive social skills training

Improved attitudes and behaviours

Greater motivation to learn

Deeper commitment to school

Increased time devoted to schoolwork, and better classroom behaviour.

Happier/ fewer instances of mental health disorders (e.g. depression)

Less likely to be victims of bullying

Stronger relationships with teachers

(Durlak, Weissberg, Dymnicki, Taylor, & Schellinger 2011, Durlak, Domitrovich, Weissberg, & Gullotta, 2014). 

CONCLUSION

The evidence-based strategies that have been discussed in this paper can usually be implemented in the Year 1-6 classroom. They address the core symptoms of ADHD such as the ability to pay attention, conflict with teachers and peers, challenges with executive function, inattention symptoms, poor organisation skills and self-esteem. However, school- based interventions should target the outcomes identified as most important to the students and their families. Other studies have found that positive teacher- child relationships and good home-school relationships (Gwernan-Jones et al, 2015) and advocacy for the student may be the strongest intervention and have the greatest impact on student’s outcomes. 

Even if you find it difficult to implement the adjustments in the three areas outlined above, just maintaining good relationships with the students and their families can be a very strong starting point. 

References

American Psychiatric Association, D., & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (Vol. 5, No. 5). Washington, DC: American psychiatric association. 

Barkley, R. A., Fischer, M. (2008). ADHD in adults: What the science says. New York, NY: Guilford. Centers for Disease Control and Prevention. (2019). Data and statistics about ADHD. 

Chronis, A. M., Jones, H. A., & Raggi, V. L. (2006). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Clinical psychology review, 26(4), 486-502. 

de Boer, A., & Pijl, S. J. (2016). The acceptance and rejection of peers with ADHD and ASD in general secondary education. The Journal of Educational Research, 109(3), 325-332. 

Durlak J. A., Domitrovich C. E., Weissberg R. P., and Gullotta T. P. (Eds.) Handbook of social and emotional learning: Research and practice. New York, NY: Guilford Press, 2014. 

Durlak J. A., Weissberg R. P., Dymnicki A. B., Taylor R. D., and Schellinger K. B. (2011). The impact of enhancing students’ social and emotional learning: A meta-analysis of school-based universal interventions. Child Development, 2011; 82: 405-432. 

Evans S, Owens J, Bunford N. Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology 2014;43(4):527-551 

Evans, S. W., Owens, J. S., Wymbs, B. T., & Ray, A. R. (2018). Evidence-based psychosocial treatments for children and adolescents with attention deficit/hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology, 47(2), 157-198. 

Gwernan-Jones, R., Moore, D. A., Garside, R., Richardson, M., Thompson-Coon, J., Rogers, M., et al. (2015). ADHD, parent perspectives and parent–teacher relationships: Grounds for conflict. British Journal of Special Education, 42(3), 279–300. 

Harrison JR, Bunford N, Evans SW, Owens JS. Educational accommodations for students with behavioral challenges: A systematic review of the literature. Review of Educational Research 2013;83(4):551-97. 

Kofler, M. J., Rapport, M. D., Bolden, J., Sarver, D. E., Raiker, J. S., & Alderson, R. M. (2011). Working memory deficits and social problems in children with ADHD. Journal of abnormal child psychology, 39, 805-817. 

Kofler, M. J., Sarver, D. E., Harmon, S. L., Moltisanti, A., Aduen, P. A., Soto, E. F., & Ferretti, N. (2018). Working memory and organizational skills problems in ADHD. Journal of child psychology and psychiatry, and allied disciplines, 59(1), 57–67. 

Larson, K., Russ, S. A., Kahn, R. S., & Halfon, N. (2011). Patterns of comorbidity, functioning, and service use for US children with ADHD, 2007. Pediatrics, 127(3), 462-470. 

Mikami, A. Y. (2010). The importance of friendship for youth with attention-deficit/hyperactivity disorder. Clinical child and family psychology review, 13, 181-198. 

Moore DA, Russell AE, Matthews J, Ford TJ, Rogers M, Ukoumunne OC, et al. School-based interventions for attention-deficit/hyperactivity disorder: A systematic review with multiple synthesis methods. Review of Education. Published online October 18, 2018. 

Perry, R. C., Ford, T. J., O’Mahen, H., & Russell, A. E. (2021). Prioritising targets for school-based ADHD interventions: a Delphi survey. School Mental Health, 13(2), 235-249. 

Taanila, A., Ebeling, H., Tiihala, M., Kaakinen, M., Moilanen, I., Hurtig, T., & Yliherva, A. (2014). Association between childhood specific learning difficulties and school performance in adolescents with and without ADHD symptoms: a 16-year follow-up. Journal of Attention Disorders, 18(1), 61-72. 

van Kraayenoord, C. E., Waterworth, D., & Brady, T. (2014). Responding to individual differences in inclusive classrooms in Australia. Journal of International Special Needs Education, 17(2), 48-59. 

Very Well mind – Attention Deficit/Hyperactivity Disorder  https://www.verywellmind.com/adhd-overview-4581801 

Wolraich, M. L., & DuPaul, G. J. (2010). ADHD Diagnosis and Management: A Practical Guide for the Clinic and the Classroom. Brookes Publishing Company. PO Box 10624, Baltimore, MD 21285. 

About the author

Dr Roselyn Dixon has been a special education teacher in both mainstream and special education settings in primary and secondary schools. Rose has been in academia and involved with Inclusive Education for more than 25 years. She has published research in the fields of social skills and behavioural interventions for people with a range of disabilities including students with Oppositional Defiance Disorders and Autism. 

She has been actively involved in examining the relationship between digital technologies and pedagogy in special education and inclusive classrooms for students with Autism as well as the implications of the NDIS on people with disabilities in rural and remote communities. Rose is an Honorary Associate Professor at the School of Education, University of Wollongong, where she was previously the Academic Director of Inclusive and Special Education. She continues to support doctoral students in Inclusive and Special education with a focus on Autism.