Download Subtypes of ADHD

A SPECIAL EDUCATION GUIDELINE FOR
ATTENTION DEFICIT DISORDERS —
ISSUES OF DEFINITION &
RECOMMENDED PRACTICES
N
U
M
B
E
R
2
TO:
FROM:
Principals, Special Education Staff, Student Support Team
Members
Kim Gibbons, Stuart Harder, Korky Gurkanlar
RE:
DATE:
ADHD — Issues of Definition & Recommended Practices
June 11, 2008
This is a revision. Please replace previous Guideline with this number
and file this one.
Attention Deficit Hyperactivity Disorder (ADHD) has become a significant family and
educational issue. Defining the functional characteristics of students diagnosed with
ADHD and formulating an appropriate educational response is currently a matter of
concern and interest. The purpose of this guideline is to provide an overview of ADHD,
school related problems, assessment, treatment, and best educational practices.
Overview of ADHD
Prevalence
 Epidemiological (population survey) studies indicate that approximately 3-7% of
children in the United States can be diagnosed with ADHD (Barkley, 1998;
Pastor & Ruben, 2002). In an average classroom of 20 students, this means that
one student in every classroom will have ADHD.
 Boys with the disorder outnumber girls in both clinic–referred (approximately a
6:1 ratio) and community-based (approximately a 3:1 ratio) samples.
 More than 50% of children with ADHD receive psychotropic mediation for this
condition, while approximately 12% and 34% receive special education and
mental health services, respectively (Pastor & Ruben, 2002). Thus relative to
other childhood conditions (e.g., autism, depression, cognitive disabilities),
ADHD is a “high incidence” disorder that is particularly prominent among
males.
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School Related Problems of Children with ADHD
Core Behavior Difficulties
 Children who are diagnosed with ADHD tend to have difficulty with inattention,
impulsivity, and/or over-activity. Problems with inattention, impulsivity, and
over-activity may serve as a “magnet” for other difficulties that are, in some
cases, more severe than the core deficits of ADHD (Stoner & DuPaul, 2003) such
as:
1. Difficulty completing independent seatwork due to problems sustaining
attention to effortful tasks,
2. Inconsistent performance on class work due to lack of attention to task
instructions,
3. Poor test performance, deficient study skills, disorganized notebooks, desks,
and written reports; and a lack of attention to teacher lectures and/or group
discussion,
4. Poor accuracy on class work and homework due to impulsive, careless
response style on these tasks,
5. Leaving seats without permission, playing with inappropriate objects,
repetitive tapping of hands and feet, and fidgeting in their chairs due to overactivity.
 The three most frequent correlates of ADHD are:
1. Academic underachievement,
2. High rates of noncompliance and aggression, and
3. Disturbances in peer relationships.
Subtypes of ADHD
 The current definition of ADHD includes a list of 18 behavioral symptoms
divided into two sets (inattention and hyperactivity-impulsivity) of nine
symptoms each (American Pediatric Association, 2000).
 There are three subtypes of ADHD:
1. Combined Type (ADHD-CT): Children exhibit at least six of the inattention
symptoms and at least six of the nine hyperactive-impulsive symptoms.
2. Predominantly Inattentive (ADHD-IA): Children exhibit at least six
inattention symptoms but less than six hyperactive-impulsive symptoms.
3. Predominantly Hyperactive-Impulsive (ADHD-HI): Children exhibit at least
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six hyperactive-impulsive symptoms but less than six inattention symptoms.
Inattention Symptoms:
a) Often fails to give close attention to details or makes careless mistakes in
schoolwork or other activities;
b) Often has difficulty sustaining attention in tasks or play activities;
c) Often does not seem to listen when spoken to directly;
d) Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace;
e) Often has difficulty organizing tasks and activities;
f) Often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort;
g) Often loses things necessary for tasks and activities;
h) Is often easily distracted by extraneous stimuli;
i) Is often forgetful in daily activities.
Hyperactivity-Impulsivity Items
a) Often fidgets with hands or feet or squirms in seat;
b) Often leaves seat in classroom or in other situations in which remaining
seated is expected;
c) Often runs about or climbs excessively in situation in which it is
inappropriate;
d) Often has difficulty playing or engaging in leisure activities quietly;
e) Is often on the go or often acts as if driven by a motor;
f) Often talks excessively;
g) Often blurts out answers to questions before the questions have been
completed;
h) Often has difficulty awaiting turn;
i) Often interrupts or intrudes on others.
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
Given that the symptomatic profile will vary across individuals, children
classified with ADHD are a heterogeneous group. In fact, there are at least 7,056
possible combinations of 12 out of 18 symptoms that could result in a diagnosis of
ADHD-CT.

To be considered symptoms of ADHD, the behaviors must have been initially
exhibited in early childhood (i.e., prior to age 7) and must be chronically
displayed across two or more settings. The ADHD diagnosis is usually
determined by establishing the developmental deviance and pervasiveness of the
symptoms. At the same time, it is imperative to rule out alternative causes for
inattention, impulsivity, and over-activity. These may include poor academic
instruction and management practices, gross neurological, sensory, motor, or
language impairment, mental retardation, or severe emotional disturbance.
ADHD With Versus Without Aggression

Children with ADHD and aggression (i.e. oppositional defiant disorder or conduct
disorder) exhibit greater frequencies of antisocial behaviors such as lying,
stealing, and fighting than those who are hyperactive but not aggressive (Jensen,
1997).

Children with ADHD and aggression will require more intensive and continuous
professional service delivery to achieve favorable outcomes.
ADHD With Versus Without Internalizing Disorder

Approximately 13-50% of children with ADHD exhibit symptoms of an anxiety or
depressive disorder (Jensen, 1997)

Some studies have found diminished effect of psychostimulant medication for
children with ADHD and internalizing symptoms relative to children with ADHD
without internalizing symptoms. This finding may have implications on
treatment.
Possible Causes of ADHD

There is no one single cause of ADHD. Most of the research examining etiology of
ADHD is correlational. Thus, we need to be cautious about attributing “causal
status” to identified variables. Variables that have received the greatest
attention in the literature are neurobiological factors and hereditary influences.
Environmental influences (e.g., family stress, poor parental discipline) appear to
impact the severity of the disorder, but do not play a causal role (Barkley, 1998).

“The most prudent conclusion regarding the etiology of ADHD is that “multiple
neurobiological factors may predispose children to exhibiting higher rates of
impulsivity and motor activity along with shorten that average attention spans
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compared to other children. The most promising evidence points to a hereditary
influence that may alter brain functioning” (Stone & DuPaul, 2003, p. 15).

It is important to remember that EVERYONE exhibits symptoms of this disorder
on occasion. What sets children with ADHD apart from their peers is that they
may be genetically predisposed to exhibit these behaviors at a significantly
higher rate than others of the same age and gender (Stoner & DuPaul, 2003).
Long-Term Outcomes of Children with ADHD

For many years, it was assumed that children with ADHD would outgrow their
behavior control difficulties when they reached adolescence or adulthood. This
assumption has not been supported through longitudinal studies of the disorder.

As children with ADHD progress into their teenage years, the absolute
frequency and intensity of their symptoms decline (Barkley, 1998). In other
words, they improve with respect to attention, impulsivity, and especially overactivity as compared to their own behavior during preschool and elementary
years. However, they typically remain discrepant from their same-age peers in
these core areas.

Over 60% of adolescents with ADHD exhibit frequent defiance and
noncompliance with authority figures and rules (Barkley, Fisher, et al., 1990).

More than 40% of teens with ADHD display antisocial behaviors such as
fighting, stealing, and vandalism (Barkley, Fisher, et al., 1990).

When compared to their non-ADHD classmates, adolescents with ADHD are at
greater risk for grade retention, school suspensions, dropping out of school, and
substance abuse.

The two most significant childhood variable that predict adolescent and adult
outcomes appear to be:

1.
Early onset (prior to ages of 8-10) of antisocial behaviors, especially lying.
Stealing, and fighting, and
2.
Peer rejection in childhood.
Rather than try to “cure” the disorder, school professionals and parents should
help children “compensate” for their behavioral control problems.
Assessment of ADHD in School Settings

Multiple assessment techniques typically are used across home and school
settings in the comprehensive evaluation of children who may have ADHD.
While school personnel are not qualified to diagnose ADHD, school professionals
must be knowledgeable regarding appropriate evaluation procedures. School
psychologists and teachers are in a unique position to collect information
relative to an ADHD diagnosis and provide this information to parents and
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physicians.
1.
Problems with attention and behavioral control are two of the most common
reasons for referral.
2.
School psychologists have direct access to sources of information and data
(e.g., observations of behavior in natural settings) crucial to the differential
diagnosis of ADHD.
3.
ADHD is prevalent among certain populations (e.g., children with learning
disabilities).
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
When special education eligibility is considered under the category of Other
Health Disability (OHD), schools must verify that a medical diagnosis has been
conducted using DSM-IV criteria. While the diagnosis of ADD/ADHD may be
made by a licensed physician, mental health or medical professional licensed to
diagnose the condition, a written and signed documentation of a medical
diagnosis must be provided by a licensed physician. (See When ADHD is OHD
above [Source: MDE Other Health Disabilities Manual].) Refer to the Other
Health Disabilities (OHD) criteria worksheet located in this guideline.

There is no single test for ADHD. Multiple assessment techniques are used
across home and school settings.
Overview of Assessment Methods
There are five major components of an ADHD evaluation:
1.
Interviews with parents and teachers to determine the presence or absence
of DSM-IV symptoms as well as to identify the current factors serving to
maintain identified problem behaviors.
2.
Review of school records to help pinpoint the onset and course of ADHDrelated difficulties.
3.
Questionnaires or rating scales completed by parents and teachers provide
information to establish the severity of ADHD-related behaviors relative to
a normative sample.
Parent Rating Scales
a) Child Behavior Checklist (CBCL; Achenbach, 1991b)
b) Behavior Assessment System for Children-Second Edition
(BASC-2; Reynolds & Kamphaus, 2004)
c) Connors Parent Rating Scale (CPRS, Conners, 1997)
d) ADHD Rating Scale–IV
e) Home Situations Questionnaire
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Teacher Rating Scales
a) Teacher Report Form (TRF; Achenbach, 1991c)
b) Behavior Assessment System for Children-Second Edition
(BASC-2; Reynolds & Kamphaus, 2004)
c) Connors Teacher Rating Scales (Conners, 1997)
d) ADHD Rating Scale–IV (DuPaul et al,, 1998)
e) School Situations Questionnaire (SSQ-R; DuPaul & Barkley, 1992).
f) Social Skills Rating System (Gresham & Elliott, 1990)
g) Academic Performance Rating Scale (DuPaul, Rapport, & Perriello,
1991)
4.
Observation of student performance in and across natural settings on
several occasions to establish the frequency and duration of various target
behaviors.
a) ADHD Behavior Coding System (Barkley, 1998)
b) Behavior Observation of Students in Schools (BOSS, Shapiro, 1996)
c) School Hybrid Observation Code for Kids (SHOCK)
d) Deno Behavioral Rating System
5. Academic performance data are collected in basic skill areas.
a) General Outcome Measures of Basic Skills
1) Oral Reading Fluency
2) Early Literacy Measures (Letter Sound Fluency, Blending,
Segmenting, Nonsense Word Fluency)
3) Math Applications and Math Facts
4) Written Expression
b) Completion and accuracy rates on assigned work
c)
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Organization and study skills
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Treatment of ADHD

The prescription of psychotropic medication is the most common treatment for
ADHD. Approximately 1.5 million children are treated with psychostimulant
medications in the United States (Safer & Zito, 2000). The average duration for
medication use is between 2 and 7 years, depending on the age of the child.

Numerous studies have consistently demonstrated the short-term enhancement of
behavioral, academic, and social functioning of the majority of children being
treated with stimulant compounds. However, the limitations of pharmacology (i.e.
side effects, lack of evidence for long-term efficacy) have led to the adoption of
multimodal treatment approaches.
Medication Effects, Non–effects, & Side–effects

Pharmaceutical interventions are often prescribed to lessen the frequency and
intensity of disruptive student behavior, and the change in behavior following
medication startup is potentially sudden and striking. The experimental and
clinical literature supports favorable short-term behavioral and self–control
benefits (e.g., on-task improvement and increased ability to inhibit impulsive
responding) to students taking stimulant medications. Long term, sustained
improvements in behavior across settings, however, is variable and somewhat
questionable.

Reviews of stimulant medication effects on academic productivity and accuracy
have found short-term improvements when using sensitive measures (i.e.,
Curriculum Based Measurement). However, it remains to be seen whether shortterm improvements in academic performance lead to greater scholastic success in
the long run. When CBM measures are used, findings typically show a wider
range of individual responsivity to medications. As such, greater use of these
measures is strongly recommended for determining individual dosage levels.

It is likely, because of misdiagnosed ADHD, that neuroleptic medications (e.g.,
Ritalin or Imipramine) are prescribed in cases for which no need have been
established. As all neuroleptic medications produce side–effects of varying
intensity, frequency, and severity, it is the case that a potentially significant
number of students are exposed to unnecessary risk. Moreover, because use of
medication is the preferred treatment by physicians, parents, and teachers,
behavior-environmental interventions are often not attempted or are implemented
without the necessary thoroughness.

The most frequently reported acute side effects to stimulant medications are
appetite reduction (particularly at lunch) and insomnia. Other less-common side
effects include irritability, headaches, stomachaches, and, in rare cases, motor
and/or verbal tics.
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
One other side effect is “behavioral rebound” in the late afternoon. This
behavioral rebound phenomenon is typically described as deterioration in conduct
that occurs in the late afternoon or early evening following daytime
administration of the medication. This effect occurs in about 33% of children
treated with stimulant medication, however, the magnitude of the rebound varies
considerably across days for individual children.

The only long-term side effect of stimulant medication is suppression of height
and weight gain. A rebound in growth following discontinuation of the treatment
seems to occur with little change in eventual adult height or weight.

The decision to begin a trial of medication should not be an automatic response
following a diagnosis of ADHD. The parents and physician, in collaboration with
the school, should consider the following factors prior to recommending a
medication trial:
1.
Severity of the ADHD symptoms and disruptive behavior. The greater the
severity of attention and behavioral problems, the more likely a medication
trial will be necessary as a supplement to other interventions.
2.
Prior use of other treatments. If other interventions (e.g., classroom behavior
management program) have not been implemented, a trial of medication may
be postponed. If limited success has been obtained with other interventions,
then medication should be considered as an adjunctive treatment.
3.
Empirical support for medication. The specific medication to be used should
be determined, in part, based on prior empirical studies of this treatment.
CNS stimulants have a strong track record of success in treating this
disorder. However, in practice, other medications may be used in isolation or
in combination with stimulants, despite minimal research literature to
support the decision.
4.
Parent attitude toward use of medication. Parents who are strongly “antimedication” should be offered the opportunity to research the advantages and
disadvantages of pharmacotherapy. Parents should not be coerced into a
mediation trial given the higher likelihood of low treatment compliance in
such cases.
5.
Adequacy of adult supervision. The parents must be functioning at a level
where they will adequately supervise the administration of the medication
and guard against its abuse. All adults associated with the child’s treatment
program must make an ongoing investment of time necessary to determine
the short and long –term efficacy of the medication regimen.
Child attitude toward medication. It is important that the use of medication is
discussed with the child and that the rationale is explained.
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Measures to Assess Medication Response in the Classroom
1.
Teacher Rating Scales
a) Connors Teacher Rating Scales (Conner’s, 1997)
b) ADHD Rating Scale –IV (DuPaul, Power, Anastopoulos, &Reid, 1998)
c) School Situations Questionnaire-R (DuPaul & Barkley, 1992)
d) Academic Performance Rating Scale (DuPaul et al., 1991)
e) Side Effects Rating Scale (Barkley, 1990)
2.
Parent Rating Scales
a) Connors Parent Rating Scale (Conners, 1997)
b) ADHD Rating Scale –IV (DuPaul, Power, Anastopoulos, &Reid, 1998)
c) Home Situations Questionnaire-R (DuPaul & Barkley, 1992)
d) Side Effects Rating Scale (Barkley, 1990)
3.
Direct Observations of School Performance
a) Classroom Observation Code (Abikoff et al., 1997)
b) ADHD Behavior Coding System (Barkley et al, 1988)
c) Behavior Observation for Students in Schools (Shapiro, 1996)
d) On-Task Behavior Code (Rapport & Denney, 2000)
e) ADHD School Observation Code (Gadow et al., 1996)
4.
Academic Performance Measures
a) Percentage of assigned work completed correctly
b) Curriculum Based Measures
5.
Self-Reporting Scales
a) Conners-Wells Adolescent Self-Report of Symptoms (Conners et al., 2000)
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Steps to School-Based Medication Evaluation
1.
Parent obtains prescription (e.g., Ritalin, 5 mg) from pediatrician.
2.
Staff member not directly involved with evaluation (e.g., school nurse) and
physician determine the order of administration of several doses (i.e., 5, 10,
15, 20 mg), including a nonmedication trial (placebo).
3.
Parent (or school nurse) administers dose according to predetermined
schedule on a daily basis.
4.
Assessment measures collected on a weekly (daily) basis:
a) Teacher ratings
b) Parent ratings
c) Side Effects rating
d) Observation of classroom behavior by an independent observer during
independent seatwork
e) General Outcome Measures of Basic Skills
1.
Assessment measures must be taken to reflect the child’s behavior during the
active phase of the medication (i.e., 2-4 hours post ingestion for short-acting
preparations).
2.
Are there “significant” changes in behavior (especially academic) at any dose?
3.
If so, what is the lowest dose that brings about the greatest change with the
fewest side effects?
4.
Report results to child’s pediatrician.
Ongoing Monitoring of Medication Response
Once a student’s optimal dosage is established, the measures described above
should be collected periodically throughout the school year to evaluate the need
for dosage adjustments or the onset of side effects. It is usually a good idea to
have the parents complete the Side Effects Rating Scale on a monthly basis and
submit this to the physician.
The Educational Issue
In short, it has become acceptable and desirable in our culture to see some
children as disordered rather than as unique learners needing individualized
instructional or medical interventions.
1. ADHD can be a catch–all phrase describing students who have long been
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problematic and challenging to school programming. Terms used in the
past to label or describe student behavior ranged from unflattering and
demeaning to terms more medically–centered. Differences in terminology
can create confusion and misunderstandings between parents and school
personnel and can lead to turf issues between professionals. Teams must
replace vague and imprecise conceptualizations of student behavior with
clear accurate statements. Accuracy allows concise problem identification
leading to meaningful interventions for students, builds trust in the
competence of school personnel by parents and advocates, and promotes a
confidence among school administrators and staff in their ability to
positively affect students' lives.
2. The suitability, adequacy and efficacy of special education's categorical
service–delivery model is under close scrutiny by parents, advocates and
educators. Also, the increasing expense of providing a civil rights–based
educational program is provoking a public backlash that may hasten
changes in the provision of services to students with disabilities. On the
positive side, however, is a growing recognition among educators that all
students can learn if provided the right instruction. The previous Congress
denied ADHD the status of a separate category but the Education
Department provided the equivalent of categorization by allowing ADHD–
diagnosed students to be easily classified as Other Health Disability (OHD),
Emotional/Behavioral Disability (EBD) or Specific Learning Disability
(SLD).
3. There is controversy over the diagnosis of students with these needs.
School districts retain their role as decision makers regarding special
education assessment and eligibility, subject to parental rights. Schools are
being called on to make staff available to diagnose ADHD. However,
ADHD is currently not a special education category but is a medical diagnosis. School staff is not licensed to make medical diagnoses as part of special
education assessments. Minnesota eligibility rules require a medical
condition to be identified by a physician as one part of Other Health
Disability eligibility.
4. Education District schools are currently using a problem-solving model
that emphasizes the appropriateness of the regular classroom for most
students and sees student problems as program and intervention
challenges. The model places responsibility for problem resolution on all
school staff who by assignment or position have a role to play in a
particular student's education. Since large numbers of staff are not
available for pull–out programs, the model uses pre-referral and formal
behavioral consultation as the preferred process for intervention.
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Recommended Practices
1. Students diagnosed as having an attention deficit disorder should be served
and their educational needs met. This should be done through the problem
solving process) rather than through special education assessment and
placement. If problem-solving interventions are ineffective and the
instructional needs of the student exceed what can be provided by the
regular education teacher, then the team may consider a special education
evaluation. Provision of special education services to an ADHD student is
the first option only when parents insist on a special education assessment,
and only after a discussion with the parents concerning other options.
2. Whether in problem-solving intervention development, implementation of
504 plans, or special education service delivery, interventions must be
tailored to the functional characteristics of the student’s behavior and not
the diagnostic category. (Keeping this caution in mind, the appendix
contains a number of potential interventions for students having ADD
diagnoses.)
3. If and when special education assessment and placement occur, the
preferred service–delivery category should match the needs of the student.
Teams should consider the labels of EBD, SLD, and/or OHD. No matter
what eligibility category is considered, eligibility criteria must be met. In a
problem solving non-categorical system, the labeling and categorization of
children is done for child count and other administrative reasons only.
Most parents will be supportive of this concept if staff embrace and
support it. Case managers will be assigned based on the needs of the
student, however, a staff member licensed in the area of student disability
must be on the IEP team.
4. It is important that school staff shows great sensitivity to parents' and
outside professionals' beliefs regarding this matter as great value may be
placed on the explanatory potential of the ADD label. School staff members
must take sufficient time to explain our problem solving model to parents
and show how their child's needs will be met using existing services. We
are, of course, assuming that the student's needs have been accurately
identified.
5. Until the political issues surrounding the needs of ADHD–diagnosed
students are resolved, and to ensure a productive smooth process, school
psychologists in each district are designated by their official job description
as the ADHD contact person. The responsibilities of the contact person
should be:
a) To serve as a contact source for parents, teachers and outside
professionals. Other school staff should allow the school psychologist
to function effectively in this role.
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b) To handle contacts and inquiries from the sources listed above in an
expeditious manner that leaves parents and others satisfied that the
school will meet the needs of their child or client.
c) To encourage the use of the problem-solving model and to facilitate
whichever process is selected for problem resolution.
d) To hand over responsibilities when parents, and internal and external
contacts seem satisfied with the process and when those assuming
responsibility seem comfortable with the process.
6. Other school staff have roles in the problem solving process, particularly
in the case of ADD:
a) The school nurse should interpret medical information, facilitate
medication dispensation, and assist, when necessary, in the evaluation
of medication efficacy and side effects. The nurse's role is consultative
to the ADD contact person or case manger.
b) OHD staff should not be involved in problem resolution. Even in the
case where a student has been given the OHD category, the
requirement to have a member on the IEP team "knowledgeable" about
the disability is met by having the school nurse, school psychologist,
and/or social behavior service provider on the team. OHD services
may be provided to individual students to assist the team with
interventions.
c) Social behavior staff and Teacher Assistance Teams (TATs)/Student
Assistance Teams (SATs) facilitators should retain their roles in
providing services. Students referred to as ADHD are particularly
likely to need the consultation services of social behavior service
providers.
7. School staff should refer students and their families for medical
assessment only after implementing a behavior consultation–based
intervention and a team–based intervention. These referrals are always
just suggestions for parental consideration and not formal school
recommendations. School staff should provide full cooperation in making
the referral and cooperating in assessment and programming with outside
agencies.
8. Diagnosis of a child as ADHD should not alone be the impetus for special
education placement. This process should be used when student behavior
is resistive to treatment after documented interventions and after
medication trials.
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