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ADHD & Education
Rosemary Tannock, PhD
Canada Research Chair & Professor
of Special Education & Psychiatry,
OISE /University of Toronto;
Senior Scientist, Sickkids Hospital, Toronto
Tannock/CADDAC_2008/ADHD_EDUCATION
“Letters” by Rob
The kids behind the label: An inside look
at ADHD for classroom teachers.
Trudy Knowles (2006: Heinemann)
ADD/ADHD
This plethora of letters
They all describe me
Can’t pay attention
Its messing with my education
But do you really care?
Tannock/CADDAC_2008/ADHD_EDUCATION
Q1-Audience Survey
What is your direct (face-toface) experience with ADHD?
1. Little or no experience
2. Have worked with several students with
ADHD
3. Someone I know quite well has ADHD
4. Both 2 & 3
Key questions
• How are we to understand ADHD, from an
educational perspective?
• Does ADHD have a significant impact on
academic attainment?
• How can we optimize academic outcomes for
youngsters with ADHD?
Tannock/CADDAC_2008/ADHD_EDUCATION
Q 2: Knowledge survey.
What percentage of school-age
Canadian children are likely to have
a diagnosis of ADHD?
1. Less than 1%
2. About 3%
3. At least 5%
4. More than 10%
ADHD rarely occurs by itself!
Comorbid mental health
conditions
Comorbid learning
disabilities
Anxiety/mood disorders
(ODD)
25%- Oral language
48% disorders
Severe tics/Tourette’s 11% Reading disorder
disorder
8%30%
15%40%
Oppositional defiant
disorder (Aggression)
Conduct Disorder
(Aggression)
40%60%
14%20%
10%25%
Bipolar Disorder
(Aggression)
Rare Developmental Co- 40% 60%
ordination
Disorder
0.2%
Mathematics
Disorder
Written language
expression
65%?
Carroll et al (2005) J Child Psychol Psychiat 46:524-532; Jensen et al (2001) JAACAP 40:147-158;
Kessler et al (2005) Am J Psychiatry 163:716-723; Reich et al
(2005) Twin Res Hum Genet 8:459-466
Tannock/CADDAC_2008/ADHD_EDUCATION
ADHD:
Challenges for Education
(Mental)
HEALTH
Medical
diagnosis
Medical
treatment
(medication)
(Special)
EDUCATION
Not a special
educational
needs category
ADHD itself
does not
indicate need
for specific
educational
intervention
Tannock/CADDAC_2008/ADHD_EDUCATION
ADHD: Challenges for Education
• “School boards have obligations under the Ontario
Human Rights Code (OHRC) to accommodate
students with ADHD since the OHRC regards ADHD
as a disability; therefore, such students have
protections under the Code”
Kathleen Wynn, Minister of Education, March 2007
• However, ADHD is not formally recognized as a ‘special
educational needs” category.
• In most Provinces, students with ADHD can only be
identified under the category of LD or Behaviour.
• If the student with ADHD does meet criteria for either of
these diagnoses, then she/he will not qualify for a special
educational needs designation in most school boards
Q 2: Audience opinion.
From the perspective of your role,
what do you see as the primary
challenge of ADHD for Education?
1. Lack of knowledge about ADHD
2. Dealing with ‘difficult to manage classroom
behavior’ on a daily basis
3. Potential costs of servicing students with ADHD
4. The risk for high school drop-out
5. Other
Key questions
• How are we to understand ADHD, from an
educational perspective?
• Does ADHD have a significant impact on
academic attainment?
• How can we optimize academic outcomes for
youngsters with ADHD?
Tannock/CADDAC_2008/ADHD_EDUCATION
Q3: Knowledge Survey
What is the effect of ADHD on
academic outcomes?
•
Educational attainment is commensurate with
intellectual potential
•
Affects day-to-day academic performance but
not academic achievement
•
Has a negative effect on academic
achievement, but not on academic performance
•
Associated with decreased educational
attainment, independent of IQ
ADHD impedes Academic Attainment
Educational Outcome
ADHD vs Peer Group
Low achievement at school
Grade repetition1,2,4
2-fold risk
Low academic grades(C’s/D’s)3
2- to 4-fold risk
Achievement scores
8%–10% lower
(reading, mathematics)1-4,
23rd %ile 5
(low average)
Early school leaving4-5
Highest level completed
2 years less
Tertiary level attainment (college)6-7
College GPA
lower GPA
1. Currie J, Stabile M. J Health Econ. 2006;25(6):1094-1118. 2. Biederman J, et al. J Clin Psychiatry. 2008; 69:1217-1222.
3. Todd RD, et al. J Am Acad Child Adolesc Psychiatry. 2002;41(7)820-828. 4. Fletcher & Wolfe, J Health Economics, 2008
27:794-800 5. Mannuzza S, et al. J Abnorm Child Psychol. 2002;30(2):191-198. 6. Frazier et al., J Learn Disabil 40:49-5,2007; 7.
Gropper & Tannock (in press). J Attention Disorders.
Replication of epidemiological findings
Fletcher J, Wolfe B (2008).Child mental health and human capital
accumulation: The case of ADHD revisited.
J Health Economics 27: 794-800
National Longitudinal Study of Adolescent Health
Grades 7-12 (1994-5): 1- and 6-year follow-up
ADHD symptoms (top 10%ile) increases risk:
• Grade repetition
• Special education
• Suspension/expulsion
• Lower GPA
• Drop-out
• Fewer years of education
• Less likely to attend college
Expected versus Observed Educational
Attainment Levels in Adults with ADHD
100%
80%
32.6
51.8
50.4
20%
0%
Graduate degree
29.3
60%
40%
20.3
College
Graduate
Not College
Graduate
15.6
Expected
Observed
Modified from Biederman et al. (2008) J Clin Psychiatry 69:1217-1222 (Fig 1, p.1219)
How ADHD impacts learning
• I’m a very slow reader. In high school &
middle school I really hated to read because
it took me a long time & I would have to read
things over and over again.
• I would find myself at the end of the chapter
& not remember anything I had just read…I
realized would have to go back and read it all
over again.
• It got to the point in middle school where I
was sick of school already & I hated going.”
Knowles (2006): Grant, a 21-yr-old college student
Tannock/CADDAC_2008/ADHD_EDUCATION
How ADHD interferes with
organization
• “I get frustrated that even when I try to get
organized I can’t so I just stop trying to get
organized. It takes too much time to get stuff
into my notebooks. I have to move on to the
next thing. There’s so much stuff going on.
Someone’s tapping the desk. Someone is
whispering. I can’t take the 30 seconds to
get the thing in my notebook because I
might miss something so I just stick it in my
bag.” Knowles (2006): Rob, an 18-yr-old HS student
Tannock/CADDAC_2008/ADHD_EDUCATION
Identification of factors related to
learning & behavioral difficulties in
the early school years
GIANNOPULO ET AL (2008)
BRIT J ED PSYCHOL 78:127-147
• Cross-sectional & longitudinal study of preschoolers in France
• Health Examination: School Developmental Assessment for
Children Aged 5-6 Years
(Standardized battery used by majority of French doctors)
 Teacher ratings of behavior (21 items based on Conners)
 Vision & hearing
 Standardized tests of cognitive function, reading, & language
Tannock/CADDAC_2008/ADHD_EDUCATION
Inattention (not hyperactivity, conduct problems) at age 5-6 yrs
predicts poor reading in Grade 1 (6-7 years)
(Giannopulo et al, Brit J Ed Psychol, 2008)
With
Inattention
Without
Reading scores
Higher score = better reading
Hyperactivity
Conduct Problems
Tannock/CADDAC_2008/ADHD_EDUCATION
Significance of Inattention
in early childhood for reading
387 children followed from Kindergarten - Grade 5
Inattention in kindergarten
as reported by teachers
Poor reading in Gr. 5
even after controlling for IQ,
hyperactivity &
emotional problems, reading
ability in Grade 1
(Rabiner & Coie, 2000; JAACAP 39(7) p.859-867)
Tannock/CADDAC_2008/ADHD_EDUCATION
Inattention predicts slower acquisition
of math skills
• Inattentive behavior, as rated by classroom
teachers, is a robust predictor of Grade 1 and
Grade 3 children’s development of math skills
in 3 key areas:1-2
Fact fluency/arithmetic
Computation
Story/word problems
• Inattention predicts poor response
to math instruction in Grade 1.3
1. Dobbs et al, Appl Dev Psychol, 2006
2. Fuchs et al, J Ed Psychol, 2006
3. Fuchs et al, J Ed Psychol, 2005
Nordic epidemiological study:
Inattention related to academic impairment
(Rodriguez et al., BMC Public Health, 2007)
• Sweden, Denmark, Finland: 13,087 children
• Teachers rated children on inattention &
hyperactivity/impulsivity symptoms reported
children’s scholastic performance on basic skills
Reading Impairment
Inattention
Hyperactivity
Sweden
Denmark
Finland
Odds Ratio
Odds Ratio
Odds Ratio
4.2*
1.9
10.5*
3.8*
7.9*
4.4*
12.5*
4.9*
5.4*
2.6*
6.7*
3.5*
4.0*
1.5
5.9*
2.4*
10.6*
5.7*
Writing Impairment
Inattention
Hyperactivity
Math Impairment
Inattention
Hyperactivity
Tannock/CADDAC_2008/ADHD_EDUCATION
Ongoing Study:
Effects of teacher Professional Development on ADHD on
teachers’ instructional practice & children’s academic & behavioral
outcomes (Tannock et al: funded by Provincial Centre of
Excellence on Children’s & Youth Mental Health)
Inattention & Oral Reading Fluency
• Teachers completed behavior ratings
• Children: 1 minute to do best reading of a short
passage of text at grade level (CBM: Dibels)
 3 passages each; Median score (middle)
• Research on reading fluency
 Highly predictive of reading ability
(decoding and comprehension)
Tannock/CADDAC_2008/ADHD_EDUCATION
Tannock/CADDAC_2008/ADHD_EDUCATION
Tannock/CADDAC_2008/ADHD_EDUCATION
Risk of Poor Fluency
Low Risk
Some Risk
High Risk
Good attention 54%
25%
21%
Poor attention/ 30%
44%
26%
8%
92%
OK decoding
Poor attention 0
AND
Poor decoding
Tannock/CADDAC_2008/ADHD_EDUCATION
Key Point#1:
Pay Attention to Inattention…
• Inattention not as “noticeable” as
disruptive behaviour in the classroom:
it rarely triggers referral for service
 but it is the behavioural risk factor for
academic problems.
• Inattentive symptoms (not hyperactivityimpulsivity symptoms) are related to poor
academic achievement (Dally, 2006; Todd et al.,
2002; Rabiner & Coie, 2000; Merrell& Tymms, 2002)
Q6.Knowledge survey
Research indicates that inattention is
more likely to occur during….
•
Whole class instructional time
(or group work)
•
Individual seat-work
(e.g., silent desk-work, tests)
•
Non-instructional time
(e.g., transitions, planning an excursion)
•
Other
Simple View
ADHD
behaviour
Poor academic
outcomes
Tannock/CADDAC_2008/ADHD_EDUCATION
Alternate Hypothesis
Poor working
memory
(executive function)
Inattentive
behavior
Poor Academic
Attainment
(reading, mathematics)
Tannock/CADDAC_2008/ADHD_EDUCATION
Working Memory partially mediates link between
inattention & academic outcomes
.27**
Executive Function
-.32** (-.24*)
Working Memory &
Inhibitory Control
Symptoms of
Inattention
Reading, spelling
-.36*** (-.26**)
Mathematics
Executive Function
.27**
Working Memory &
Inhibitory Control
Symptoms of
Hyperactivity/impulsivity
-.43*** (-.36**)
Delay
Aversion
Tannock/CADDAC_2008/ADHD_EDUCATION
Being
in the top
of the on
ADHDeducational
symptom distribution (~diagnosis of
Effects
of 10%
ADHD
ADHD) has major detrimental impact on human capital attainment:
attainment greater than effects of physical
Experiencing +1 symptom ADHD produces similar deterioration in
health problems
outcomes
for children with low & high levels of ADHD symptoms
Educational Outcome
ADHD vs peer group
Low Achievement at School:1-3
Grade repetition
Low academic grades (C’s/D’s)
Achievement scores (reading, mathematics)
Placement in special education
2-fold risk
2- to 4- fold risk
8% -10% lower
2- to 4-fold risk
Early School Leaving:2-3
Highest level completed
High school dropout
Tertiary level attainment (college):4
College GPA
1Currie
1-2 years lower
3-fold risk
0.7 lower GPA
& Stabile (2006): J Health Economics; Fletcher & Wolfe 2008 J Health Economics
Levels of Impact of ADHD
Individual
Family members &
other caregivers
Social & peer groups
School systems
(public education in general)
Employers
(job market in general)
Societal systems of care:
Medical & mental health
Justice systems
Conceptual framework:
Human Capital Accumulation
 Socioeconomic theory
(Schultz, 1979; Becker, 1992: Nobel Prize in Economic Sciences)
 Human capital refers to the knowledge, skills, competencies,
health & other attributes embodied in individuals that are
relevant to economic activity
 Investment in human capital is 3 times as important to
economic growth over the long run as investment in physical
capital
 Human capital indicators based on literacy scores have a
positive & significant effect on long run levels of GDP per
capita & labor productivity
International Adult Literacy Survey: Literacy scores, human capital and
growth across fourteen OECD countries:
(Coulombe, Tremblay, Marchand , 2004)
Intergenerational cycle of human capital formation
(Tannock & Sagvolden in preparation; concepts & figure adapted from Mayer-Foulkes, 2004)
Parental investment
in child’s development
Child/adolescent Investment
in Human Capital formation
Adult’s attained
Human Capital
Child Education
academic
engagement
& achievement
Parental
Human Capital
Attainment:
Health
Education
Income
Adult Human Capital
Health
Education
Income
Child Development
Genetic &
Environmental
factors
Child Health &
Behavior
next generation
Intergenerational cycle of lower human capital
formation in family with ADHD
(Tannock & Sagvolden in preparation)
Parental investment
in child’s development
Parental
Human Capital
Attainment:
Lower household
income
Underemployment
Risky health behavior
Decreased
responsiveness to infant
Child/adolescent investment
in Human Capital formation
Adult’s attained
Human Capital
Child Education
academic
disengagement
& underachievement
Child Development
ADHD Genetic factors
Adult Human Capital
Lower education
Lower income
Risky health behavior
Prenatal nicotine/
alcohol exposure
Neurodevelopmental
immaturity
Child Health &
Behavior
Low self-esteem
Problematic behavior
Unintentional injuries
next generation
Key questions
• How are we to understand ADHD, from an
educational perspective?
• Does ADHD have a significant impact on
academic attainment?
• How can we optimize academic outcomes for
youngsters with ADHD?
Tannock/CADDAC_2008/ADHD_EDUCATION
Interventions for ADHD
Teacher-Focused
Child-Focused
(Medication)
Knowledge,
Awareness
Behavioral
(Parent Training)
Instructional
Strategies
Behavioral
(Social skills)
Hybrid
Behavioral
Academic ?
TANNOCK/Vancouver, 2008
Classroom-based Behavioral Intervention
Barkley et al., J Child Psychol Psychiat 41(3) 319-342, 2000
Shelton et al, J Abnorm Child Psychol 28(30) 253-266, 2000
158 Kindergarten children
At registration for US public school system
Highly aggressive, hyperactive, impulsive, inattention
Treatment duration:1 School Year
No
Treatment
PostTreatment
2-year
Posttreatment
Parent
Training
No effects
(Poor attendance)
No Effects: All had
behavior problems at
home/school
academic achievement
Compared to community controls
Treatment
Classroom
Combined
PT/TC
Improved:
• Teacher-rated attention,
aggression, self-control, social
• Obs. externalizing class-behavior
No Effects:
•Academic achievement
•Parent ratings home behavior
•Lab measures M-C interaction,
attention, impulse control
Tannock/CADDAC_2008/ADHD_EDUCATION
Multi-Modal Intervention for ADHD
MTA Cooperative Group 1999
~ 600 children
Combined Type ADHD
Treatment duration:14 months
1. Community 2. Psychosocial
Treatment
Treatment
After
14 months
Treatment
3. Managed
Medication
4. Combined
Psych/Meds
Positive effects on ADHD Symptoms
Managed
Medication
Combined
Psych/Meds
>
Psychosocial
Treatment
Community
Treatment
No substantial effects on academic achievement
Tannock/CADDAC_2008/ADHD_EDUCATION
WHAT WORKS FOR ADHD & FOR WHAT?
Efficacy of methylphenidate, psychosocial treatments and their
combination in school-aged children with ADHD: A meta-analysis
S Van der Oord et al., Clinical Psychology Review 2008 783-800
Conclusions:
“Both methylphenidate & psychosocial treatments are
effective in reducing ADHD symptoms. However,
psychosocial treatment yields smaller effects than other
treatment conditions… For improvement of academic
functioning no treatment was effective.”
Tannock/CADDAC_2008/ADHD_EDUCATION
Systematic Literature Review:
Teacher knowledge of ADHD
Percent Answered Correctly on
Knowledge Test
(M. Lummack,M.Ed, 2008, OISE/UT)
90
80
70
60
T/F
50
Multi. Choice
40
T/F/DK
30
20
10
0
1992
1994
1996
1998
2000
2002
2004
2006
2008
Year of Study
Tannock/CADDAC_2008/ADHD_EDUCATION
Systematic Literature Review:
Teacher knowledge of ADHD
(M. Lummack,M.Ed, 2008, OISE/UT)
Years of Teaching Experience
40
35
30
25
20
15
10
5
0
0
20
40
60
80
100
Percent Answered Correctly on Knowledge Scale
Tannock/CADDAC_2008/ADHD_EDUCATION
Is teacher extended-PD about
ADHD effective?
• Miranda et al (2002)
J Learn Disabil 35(6):546-562
• Rowe, Rowe, Pollard
(2004)
• RCT: Positive
– teacher knowledge
– parent & teacher ratings of
child ADHD symptoms
– child academic performance
• RCT: Positive
– children’s attention
– reading & math scores
• Merrell & Tymms (2006) • RCT: Positive
Eur J Spec Needs Educ 21(3): 321-337
– Teachers’ knowledge & stress
– Children’s attitudes to school
– Children’s reading
Tannock/CADDAC_2008/ADHD_EDUCATION
Is teacher psychoeducation
about ADHD effective?
• Barbaresi & Olsen (1998)• UNCONTROLLED
J Dev Behav Pediatr 19(2):94100
• Miranda et al (2006)
Psicothema 18(3):335-341
• Sayal et al 2006
Soc Psychiatry Psychiatr
Epidemiol 41:806-813
– Positive effects on teacher
knowledge & stress
• CONTROLLED:QuasiExperimental 3 groups
– Positive effects of
psychoeducation on parent
& teachers rating of
children’s ADHD symptoms
• UNCONTROLLED
– Positive Effects: teachers
more accurate in
recognizing children ‘at risk
for ‘and ‘probable’ ADHD
Tannock/CADDAC_2008/ADHD_EDUCATION
Promising educational practices
• Consultation based academic intervention
– RCT: 15 mos of individualized or generic academic
intervention produced gain in standardized scores of
math computation (ES> 1.0) and reading fluency (ES
= 0.58)
DuPaul et al., J Abnorm Child Psychol, 2006
• Teacher Professional Development
– RCT to determine effects of a series of training sessions for
teachers (8 x 3hrs, at a rate of 2 sessions/month) that focused
on behavior modification, cognitive behavioral strategies,
instructional management strategies
– Marked reduction in ADHD symptoms, plus improved academic
test scores
Miranda et al, J Learn Disabil 2002
Tannock/CADDAC_2008/ADHD_EDUCATION
Vygotskyan-based preschool program
improves cognitive control
(Diamond et al, Science, 2007: 318: 1387-1388)
Tools of the Mind
(Bodrova & Leong)
• Study of 140 preschoolers randomly
assigned to “Tools” or “Balanced
Literacy”
– Low-income, urban district
– 18 classrooms (plus 3/program in year 2)
• 40 activities promoting
executive function (EF)
– self-regulatory self-talk; dramatic play;
memory & attention scaffolds
• Children in Tools showed
marked improvements in EF
measures
• EF performance scores
correlated with standardized
academic measures
Rosemary Tannock,
Rhonda Martinussen, Peter Chaban
and Alison McInnes
In collaboration with
Drs Bruce Ferguson & Hetherington of HSC Community
Health Systems Resource Group;
York University’s ABEL Program
Dr Declan Quinn, University of Saskatchewan, & Tall Pines
School, Mississauga, ON
Funding from: NIMH, CIHR, TVOntario, HSC, Shire
Effects of sustained teacher professional
development on inattention/ADHD (prelim data)
 Randomized controlled trial: schools randomized to
Treatment Group or Wait-List Control
 Year 1: (Feb-June 2007)
 2 Treatment Schools; 2 wait-list schools
 16 teachers; 96 of their students
(evenly distributed across Grades 1 to 4)
 Year 2 (Oct – June 2008)
 3 Treatment Schools; 3 wait-list control (1 withdrew)
 24 (20) teachers; 120 (103) of their students
(evenly distributed across Grades 1 to 4)
Tannock/CADDAC_2008/ADHD_EDUCATION
Intervention effects on teacher
knowledge
Tannock/CADDAC_2008/ADHD_EDUCATION
Change scores for teacher-rated
inattention & hyperactivity after PD
NOTE: Negative values indicate that teachers rated
students as MORE attentive post-intervention
Tannock/CADDAC_2008/ADHD_EDUCATION
Effects of Intervention on children’s
observed classroom behavior
Tannock/CADDAC_2008/ADHD_EDUCATION
Preliminary analysis
indicates greater changes in
reading scores for students
of teachers in intervention
group (TOWRE, DIBELS)
Independent observer report
(anthropologist)


Observed 14 teachers at start and end of
academic year; blind to study objectives
Substantial changes observed in 8 of the 14
teachers:



6 of 9 (67%) teachers from intervention group
1-2 of 5 (20-40%) teachers from control group
Most commonly noted changes



Verbal instructions simplified, more explicit, repeated
Inclusive seating plan: no isolated students
Increased praise
Tannock/CADDAC_2008/ADHD_EDUCATION
Educational Goals for Students with severe
inattention/ADHD

Educational attainment commensurate with
intellectual potential

Successful graduation from high-school


Literacy/numeracy
Health literacy/numeracy
Tannock/CADDAC_2008/ADHD_EDUCATION
To promote educational success, the
Educational Sector must target directly:
the cognitive, academic, &
socio-emotional challenges
which burden students with ADHD
Tannock/CADDAC_2008/ADHD_EDUCATION
GAP ANALYSIS
(special)
EDUCATION
(Mental)
HEALTH
Community
Physicians
School Support
Teams
famil commun
y
ity
Tannock/CADDAC_2008/ADHD_EDUCATION
Q 2: Audience opinion.
From the perspective of your role, what do you
NOW see as the primary challenge of ADHD
for Education?
1.
Lack of knowledge about ADHD
2.
Dealing with ‘difficult to manage classroom behavior’
on a daily basis
3.
Potential costs of servicing students with ADHD
4.
The risk for high school drop-out
5.
Other