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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