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Identifying and including students
with ADHD in the mainstream
classroom; from recognition to
diagnosis – with practical
strategies for the classroom
By
Sally Trowse, Specialist ADHD Nurse, Stockport CAMHS
and
Gareth D Morewood, Director of Curriculum Support
10th December 2012
What is going to happen?
• Give you a context where including young
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people with ADHD has recorded some
success
Highlight some of the barriers to inclusion
that need to be challenged
Provide background and understanding from
a specialist CAMHS perspective
Offer some ideas on how to meet the
challenges facing the inclusion of young
people with ADHD in mainstream schools
Does Every Child Matter?
• Being Healthy
• Staying Safe
• Enjoying and Achieving
• Making a Positive Contribution
• Economic Wellbeing
How Many Children Have AD/HD?
• 5% of the general population
• This is a very conservative estimate
• 70-80% of these children will carry the condition
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on into adulthood
At least 1/3 will have significant problems with
attention without being hyperactive or impulsive
Remaining 2/3 will have significant problems
with hyperactivity
In UK only 0.03% are treated
– Males: Females - 4:1 (9:1 – clinics)
So what is ADHD?
Now to be considered as a disorder of age-inappropriate behaviour:
Hyperactivity-Impulsivity (Inhibition – Executive Function)
Impaired verbal and motor inhibition
Impulsive decision making; cannot wait or defer gratification
Greater disregard of future (delayed) consequences
Excessive task-irrelevant movement and verbal behaviour
– fidgeting, squirming, running, climbing, touching …
• Restlessness decreases with age, becoming more internal,
subjective by adulthood
• Emotionally impulsive; poor emotional self-regulation
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30% deficit of executive function
• The ability to organize cognitive
processes. This includes the ability to
plan ahead, prioritize, stop and start
activities, shift from one activity to
another activity, and to monitor one's
own behaviour.
Causes and Origins
All causes fall in the realm of biology
(neurology, genetics)
Maternal smoking/alcohol
Brain hypoxia
Home &
Community
Head trauma
Brain Developments
ADHD
Premature birth… brain
bleeding
Toxic level lead exposure
Family
75% family link
Brain Structure
Environmental risk factors
• Accounts for 15-20% cases
• Prenatal exposure to:
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– Alcohol*
– Cigarettes*
– Benzodiazepines
Obstetric complications
Prematurity and very low birth weight
Brain diseases/injury e.g.
– Closed head injury
– Neurofibromatosis
Severe early deprivation and institutional rearing
Exposure to toxic levels of lead
Smaller, less active, less developed brain regions found on scans
Coexisting
conditions
Anxiety/
Depression
ASC
Specific
Learning
Difficulty
Asperger’s
ADHD
Tourette’s
Speech
Disorder
Conduct
Disorder
Oppositional
Defiant
Disorder
Coexisting conditions
 MTA Trial (USA)
 ADHD Alone – 31%
 Behavioural Disorders -54%
 Oppositional Defiant Disorder (40%)
 Conduct Disorder (14%)
 Tics – 11%
 Anxiety Disorders – 34%
 Depression – 4%
 Swedish Study (School-aged)
 Learning disability (13%)
 Reading/writing disorder (40%)
 Motor co-ordination disorder (47%)
 Asperger’s (7%)
Tourettes syndrome
• What is it?
• What are tics?
• What treatment?
• What can school do?
So what might you expect?
Inattention
Hyperactivity
Impulsivity
Does not attend
Fidgets
Talks excessively
Fails to finish tasks
Leaves seat in class
Blurts out answers
Can’t organise
Runs/climbs
excessively
Cannot wait their turn
Avoids sustained
effort
Loses things, is
‘forgetful’
Easily distracted
Cannot play/work
quietly
Interrupts others
Intrudes on others
Always ‘on the go’
Talks excessively
DSM-IV – Diagnostic and Statistical Manual, 4th Edition (American Psychiatric Association, 1994).
ICD-10 – International Classification of Diseases, 10th Edition (World Health Organisation, 1993).
What else needs to be considered?
Duration
Age of onset
Pervasiveness
Symptom criteria must have been
met for the past 6 months (? 1yr+)
Some symptoms must have been
present before 6 - 7 years of age (in
childhood)
Some impairment due to symptoms
must have been present in 2 or more
settings (e.g. school, work or home)
How is ADHD clinically defined?
Impairment
Discrepancy
Exclusion
symptoms must have led to
significant impairment (social,
academic, or occupational)
symptoms are excessive in
comparison to other children of the
same age and IQ
symptoms must not be solely
attributable to other mental health
difficulties (anxiety, depression,
autism)
What characteristics may we expect?
NEGATIVE
POSITIVE
• Short attention span
• High levels of
environmental awareness
• Responds well when highly
motivated
• Flexible – ready to change
strategy readily
• Tireless when motivated
• Goal orientated
• Imaginative
but with periods of intense focus
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Distractible
Poor planning/impulsive
Disoriented sense of time
Impatient
Day-dreamer
Don’t forget about girls and ADHD....
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More inattentive than impulsive
Less ODD/CD aggression and delinquency
More depression pre-diagnosis
More underperformance and Learning Difficulties in school
…self blame,
…self attribution,
…demoralisation lead to anxiety and depression,
…development of compensatory behaviours and strategies.
Re-think for girls… not a behaviour disorder more a life
management disorder
Patricia Quinn, 2009
Development of the disorder...
PRESCHOOLERS (3-6 years)
– Reduced play intensity
and duration
– Motor restlessness
– Associated problems
and implications
• developmental deficits
• oppositional defiant behaviour
• problems of social adaptation
PRIMARY SCHOOL CHILDREN
(6-12 years)
– Distractability
– Motor restlessness
– Impulsive and disruptive behaviour
– Associated problems and implications
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specific learning disorders
aggressive behaviour
low self-esteem
rejection by peers - not invited to parties
impaired family relationships
ADOLESCENTS (13-17 years)
– Difficulty in planning and organisation
– Persistent inattention
– Reduction of motor restlessness
– Associated problems
• aggressive, antisocial and
delinquent behaviour
• alcohol and drug problems
• emotional problems
• accidents
ADULTS (18 years and older)
• Residual symptoms
• Associated problems
– other mental disorders
– antisocial behaviour/
delinquency
– lack of achievement in academic and
professional career
Risks & controls associated with ADHD in adolescents...
Normal
ADHD
Dismissal From Job
Sexual Transmission
of Disease
Teen Pregnancy
Repetition of year
Normal
ADHD
Attempted Suicide
Intentional Injury
Incarceration
Substance Abuse
0
10 20 30 40 50 60
% of Subjects
©
Eli Lilly 1998, Barkley RA 1998
©Eli
Lilly 1998, Barkley RA 1998
EFFICACY OF INTERVENTIONS
Symptomatic normalisation rates in the MTA study 1999
(N= 570; mainly middle school boys)
Normalisation rate (%)
80
68
70
56
60
50
40
34
25
30
20
10
0
Community
treatment
Behavioural
treatment
MED
MED +
Behavioural
treatment
Swanson et al 2001
Overview
Efficacy of interventions
Psychoeducation
Psychopharmacotherapy
Behaviour modification
Algorithm
QA
Conclusions
So what’s all this about medication?
• Stimulants - Methylphenidate (Ritalin)
– short acting (lasts up to 4 hrs) &
– long acting
(Equasym XL and Medikinet XL last up to 8 hrs)
(Concerta XL lasts up to 12 hrs)
• Dexamphetamine
Controlled drugs
• Nonstimulant - Atomoxetine (must be taken
every day 24hr effect)
non-controlled drug
How does Methylphenidate Work?
Methylphenidate is thought to:
Promote release of dopamine
& noradrenaline into the
synapse and inhibit their
reuptake into the presynaptic
neuron.
Modified Release
Methylphenidate:
1st phase: a sharp, initial rise in
concentration
2nd phase: another rise about 3
hours later, followed by a
gradual decline
e.g. Concerta, Equasym XL,
Methylphenidate
Neurochemical pathophysiology
Methylphenidate
and atomoxetine
block re-uptake of
noradrenaline
Methylphenidate
and
amphetamines
block re-uptake of
dopamine
Methylphenidate
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This has been used to treat ADHD for >50 years
CNS stimulant
Mechanism of action in ADHD is not completely clear
It is believed that it increases intrasynaptic
concentrations of dopamine and noradrenalin in the
frontal cortex and sub cortical brain regions
associated with motivation and reward
(Volkow et al., 2004)
• It blocks the presynaptic membrane dopamine
transporter (DAT) and so inhibits the reuptake of
dopamine and noradrenalin into the presynaptic
neuron
Advances in Family Treatment
(Russell Barkley, 2009)
• Parent Education About ADHD
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– The first critical step in treatment
– Adopt a ‘parents are shepherds’ perspective
Learning the value and limitations of parent training
– Changes defiance and parent-child conflict, not ADHD (helping parents
‘get’ their child.)
– Works best in younger children
• (<11 yrs, 65-75% respond)
– Modestly useful for teens
• (25-30% show reliable change)
Incorporate teen in treatment and use Problem-Solving,
Communication Training
– (30%+ show reliable change)
– Best to combine it with above Parent Training to reduce drop outs
More Treatment Advances...
• Teacher Education About ADHD
• Classroom Behaviour Management
– Design of classrooms
– Very effective but no generalization or maintenance
after withdrawal
• Special Education Services
• Regular Physical Exercise
– a coping or compensatory tool
• Parent/Client Support Groups
Unproven and Miss-truths...
• Elimination Diets – removal of sugar, additives, etc. (weak
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evidence)
Megavitamins, Anti-oxidants, Minerals (no compelling proof or
have been disproved)
Omega 3 Fatty Acids (Fish Oil) – one recent study with mixed
results (effects at home on parent ratings, no effect at school
on teacher ratings)
Sensory Integration Training (disproved)
Chiropractic Skull Manipulation (no proof)
Play Therapy, Psycho-therapy (disproved)
Self-Control (Cognitive) Therapies for Children (disproved)
Social Skills Therapies for Children (in clinic)
– Better for Inattentive (SCT) Type and Anxious Cases
ADHD – in summary...
• ADHD is probably a disorder of self-regulation
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and executive functioning
ADHD persists to adulthood in 65+% of cases
ADHD largely results from neuro-genetic factors
Impairments exist in most domains of major life
activities
Co-morbidity is very common (80%+)
Many advances in treatment occurred in the
past decade, especially in medications
ADHD can be successfully managed leading to
improved life course and outcomes
Re-cap on characteristics...
• Inattention
• Hyperactivity
• Impulsivity
The ADHD Classroom...
• Seating
• Eye contact
• Small chunk tasks
• Limit instructions/repeat back to you
• Visual aids
• Keep away from stimulations
• Routines
• Praise
• Class rules on wall - consistency
• Systems for tracking work
• Immediate rewards
• Avoid singling out…name the
behaviour
Self-help...
On-line identification?
• http://pediatrics.about.com/cs/adhd/l/bl_adhd_quiz.htm
Financial support?
• http://www.governmentallowances.co.uk/?gclid=CJtgrmFtqACFdkB4wodRWGpUA
Useful websites and downloads:
• http://www.chadd.org/
• http://www.adhdtraining.co.uk/downloads.php
Homework [if we have to!!!]...
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Home-school diary
Bring any homework finished or unfinished into school
Home-work clubs
Check that they hand homework in
Use an exchange system i.e. homework/sticker
Discuss any homework issues with parents/carers
Use homework trays – three different trays, colour coded
- Red – did not understand it at all
- Amber – did it, but not fully understood
- Green – understood it completely
Friendships...
• Use circle time/SEAL to promote positive friendships
• Allow the child/young person ‘cooling down’ time
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following play times
Effective use of lunchtime assistants – supervision and
scaffold – designated places/rooms
Organised games at break time/play times
Encourage shared tasks with peers
Model appropriate behaviours
Encourage and support positive friendships
If the child/young person displays problem behaviours,
identify the problem
Inattention...
• Inattentive Behaviour
• What to try?
Impulsivity...
• Impulsive Behaviour
• What to try?
Hyperactivity...
• Hyperactive Behaviour
• What to try?
Final thought on medication...
• See medication in schools policy
• If the child/young person needs to take
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medication in school, discreetly prompt them to
go to the school office [or designated place] at
the appropriate time
Avoid singling out the child/young person or
repeatedly asking them, ‘have you had your
tablet?’
Doctors try and use long acting medication
where possible to avoid students needing to
take medication in school
Triangulation of support...
HOME
STUDENT
SCHOOL
MEDICAL
Final Thoughts…
• ADHD is probably a disorder of self-regulation
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and executive functioning
ADHD persists to adulthood in 65+% of cases
ADHD largely results from neuro-genetic
factors
Impairments exist in most domains of major
life activities
Co-morbidity is very common (80%+)
Many advances in treatment occurred in the
past decade, especially in medications
ADHD can be successfully managed leading to
improved life course and outcomes
Books and Further Information...
www.addiss.co.uk
Teaching the tiger
by Dornbush and Pruitt
Attention Deficit Hyperactivity Disorder
by Russell A. Barkley
How to teach and manage children with ADHD
by Fintan O’Regan
Hot stuff to Help Kids Chill Out: The Anger Management Book
by Jerry Wilde
Stockport Multi-agency ADHD under 18 Pathway
Recognition
(Referrers need to complete checklist)
Primary Care
GP
HV
School Nurse
Parenting team
Education
EP
SENCO (with training)
SBSS/PBSS
Less than 6 yrs Parenting team for
Webster Stratton
Parenting course
oor
Social Care
Community
Learning
Disability Team
Over 6 yrs –
complete ADHD checklist
with school information
(Community CAMHS practitioners
with completed assessment)
AGE of
patient
Over 5yrs
GPs may use
choose and book
for paediatics
Parenting
support workers
Consultation with ADHD nurses
For unclear or complex cases
SENCO / community CAMHS /
GP
Referral
ADHD Nurse Screening
Paediatrics
CAMHS Panel
Complex cases
Assessment by specialist
ADHD service
Paediatrics
CAMHS
(Generic or LD Team)
ASD symptoms go to ASD pathway within CAMHS
Management
ADHD Specialist clinics
(Paeds / CAMHS)
Medication monitoring
School liaison
GP shared care protocol
Education support
SENCO
(diagnosis and strategies)
Parenting Support
ADHD new diagnosis course
Webster Stratton parenting
course
Education sessions for young
people
Community Learning
Disability Team
Multi-agency working
Parent support group
(Space)
Disability database
OT/SALT
interventions
Parent partnership
Individual (social skills etc) and
Family work
(PBSS, SBSS, Learning mentors
PSA, ADHD nurse, Relate, and
CAMHS)
On going care
16 – 18 yrs
Adult ADHD 16+yrs
(Moving to 18 yrs)
CAMHS Transition
team
(New referrals for
assessment)
Paeds up to 18 yrs
Phase 1 adult service 18+ CAMHS only
Phase 2 adult service all 18+
And finally....
Working with young people who have ADHD is
extremely challenging.
Above all – remember to be
adaptable,
innovative,
empathetic,
and ... open minded,
And remember that not one strategy fits all…
Thanks for listening...
Gareth D Morewood
Director of Curriculum Support
www.gdmorewood.com
Sally Trowse
Specialist ADHD Nurse
[email protected]