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April 25, 2014 | 25th Nisan 5774

Attention Deficit Hyperactivity Disorder - No I, 5765



Attention Deficit Hyperactivity Disorder                                                               No I, 5765




Al sh'loshah d'varim haolam omed:
Al haTorah, v'al ha-avodah, v'al g'milut chasadim.


The world depends on three things:
on Torah, on worship and on loving deeds.
- Pirkei Avot 1:2

This year each issue of V’shinantam will be on a different topic in the area of special needs and written by our consultant, Shana Erenberg, Ph.D. Shana received her doctorate from Northwestern University. For 20 years, she served as the founding director of the Keshet Sunday School for students with disabilities in Northbrook, IL and is currently the Chairman of the Department of Education at Hebrew Theological College in Chicago. She also has a private practice and serves as a consultant.

V’shinantam is organized around the three pillars of Torah, Avodah, and G’milut Chasadim. In the Torah section you will find an overview of the topic, in Avodah, applications for your classroom, and in G’milut Chasadim additional resources.





ADHD Overview

“If she would just pay attention, she would do so much better.” “He can’t sit still for a minute!” How many times have you, as a teacher, uttered these words? Most teachers have experienced students who have difficulty focusing and maintaining attention in class. While the causes of inattentiveness and restlessness can be multifaceted, it is important to understand and recognize the symptoms of Attention Deficit Hyperactivity Disorder (ADHD).

Definition

Attention Deficit Hyperactivity Disorder is a neurobiological condition that affects 3-5% of school-age children. ADHD affects both males and females; however, boys tend to be diagnosed with the disorder more readily than girls. ADHD is characterized by difficulties with focusing and sustaining attention, impulsivity, and in some cases, hyperactivity. Until recently, it was thought that children with ADHD outgrew the condition as they became teenagers, as the symptoms of hyperactivity tended to decrease with age. Current research, however, indicates that ADHD is a lifelong condition, with implications for adults with regard to employment, life skills, and social interactions. Proper identification and early intervention are crucial to avoid the serious consequences of ADHD, which include academic failure, depression and anxiety, social problems, conduct disorder, substance abuse, and job failure.

The DSM IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) identifies three subtypes of Attention Deficit Hyperactivity Disorder:

  • Attention deficit that is predominately inattentive, with minimal or no signs of hyperactivity
  • Attention deficit that is predominately hyperactive and impulsive
  • ADHD combined type, in which individuals manifest symptoms of inattentiveness, hyperactivity, and impulsivity.

Characteristics

What do children (and adults) with ADHD look like in the classroom and at home? Students with Attention Deficit Disorder without hyperactivity

  • have difficulty arousing, focusing, sustaining and shifting attention
  • often fail to pay close attention to details, and tend to make careless mistakes in their work
  • may frequently appear to be daydreaming and do not seem to be listening in class
  • tend to avoid tasks that require sustained mental effort, even when the task is well within their ability level
  • often have difficulty with organization and tend to lose materials and assignments
  • are forgetful, easily distracted, and may struggle to follow through on instructions
  • need frequent repetition of directions, hands-on examples as well as visual cues and reminders
  • tend to do better with one-on-one intervention
  • may have periods of long attention spans, particularly for stimulating activities such as video games

Individuals with an Attention Deficit Disorder that is predominately hyperactive and impulsive

  • are always on the go
  • have a high energy level and difficulty remaining seated
  • may be bouncy and tend to fidget with hands or feet or squirm in their chair
  • may be constantly touching things, seemingly unaware of appropriate boundaries or restrictions regarding other’s property
  • may run about or climb excessively
  • have a low tolerance for frustration and a tendency to give up easily
  • manifest a high level of risk taking behaviors and as such may be more accident-prone
  • do not seem to understand the consequences of their actions or cause and effect relationships
  • may talk excessively, interrupt others and blurt out answers before questions have been completed (often inaccurately)
  • may have difficulty waiting or taking turns and can be excitable or explosive, impacting social relationships and making it difficult for children with ADHD to make and maintain meaningful friendships

Individuals with the combined ADHD subtype meet both sets of inattention and hyperactive/impulsive criteria.

Children with ADHD often display developmental and emotional delays that make them appear less mature and responsible than their peers. In addition, adolescents with ADHD present a complex challenges due to the increased academic and social demands they face. Teens with ADHD may be more susceptible to peer pressures, particularly if they are impulsive and have difficulty understanding consequences. They may be more inclined to self-medicate, using drugs or alcohol. ADHD complicates the issues adolescents typically encounter, including identity and independence, sexuality and social concerns, self-esteem and self-confidence, and learning to make appropriate choices.

Diagnosis

Diagnosing ADHD is a multifaceted and multidisciplinary process. Differential diagnosis based on DSM IV criteria is crucial as there are many conditions that produce similar symptomology. There is no single test to diagnose ADHD; a comprehensive evaluation is necessary to establish a diagnosis. The evaluation should include: a physical exam; rating scale assessments of attention and behavior completed by parents and teachers; an analysis of the learning environment; an assessment of cognitive and academic skills, social and emotional functioning, and developmental levels; as well as hearing and vision exams. A careful history should be taken from the parents, teachers, and when appropriate, the child.

In order to be diagnosed with ADHD, individuals must

  • meet six of nine diagnostic criteria as indicated in the DSM IV
  • have more frequent or severe symptoms than other children the same age
  • present symptoms in two or more settings (home, school, work, social settings)
  • have symptoms for at least six months
  • present symptoms by age 7, unless associated with some type of brain injury later in life

Diagnosis must exclude other causes of inattentiveness, such as mood disorders, cognitive impairment or pervasive developmental delay. In adults, the symptoms must affect the ability to function in daily life and persist from childhood.

While differential diagnosis is indicated in determining the presence of ADHD, it is important to note that the disorder can co-occur with other disabilities, such as depression, anxiety, behavior and conduct disorders, tics or Tourette’s syndrome, or learning disabilities. National Institute of Mental Health research indicates that two thirds of all children with ADHD have a least one other coexisting condition.

The causes of ADHD are not well understood. Research indicates that the disorder is neurobiological in nature and not the result of “poor parenting.” Inheritance may play a factor in the disorder. Current studies are investigating neurochemical relationships and imbalances, neuro-structural anomalies and genetic roots of ADHD.

Treatment

It is important to correctly identify and treat ADHD as early as possible to minimize the impact of the disorder on academic achievement, self-esteem, behavioral repercussions and social interactions. Treatment plans for ADHD must be multifaceted and may include a combination of medical, educational, behavioral and psychological interventions. Research has shown that a combination of approaches in a treatment plan is more effective than a given single intervention. Education and counseling for parents and family members of individuals with ADHD is also beneficial. ADHD is a disorder that affects the child in all situations, not just school. As such, it is important for parents to learn strategies that will provide consistency and structure for the child with ADHD.

Psychostimulant medications are most frequently used to treat the symptoms of ADHD. Seventy to eighty percent of individuals with ADHD respond favorably to the medications, showing increased attention and concentration as well as decreased activity levels and impulsivity. The use of medication requires a period of adjustment with regard to dosage and frequency. Medications such as Ritalin are effective immediately, with a reduction in symptoms noted thirty minutes after a does is taken. Other medications, such as Adderall or Concerta, require an additional time for the full effect to be achieved. Straterra, a relatively new, non-stimulant medication, also requires additional time to be fully effective. Parents may find that there is a period of experimentation before the proper medication and dose is determined. For some children, medication will not be effective and may exacerbate symptoms. In these instances, it is important to re-examine the diagnosis of ADHD and determine if other conditions are causing the inattentiveness, distractibility, hyperactivity and/or impulsivity. Other conditions that mimic ADHD include sensory integration deficits, ocular motor problems, anxiety, depression and learning disabilities.

While psychostimulant medications work effectively in the majority of cases, they do have potentially harmful side effects. Insomnia and loss of appetite are the most frequently reported side effects. Individuals may also experience nausea, headaches and dry mouth. Children who take Ritalin or other short acting forms of medications may experience peaks and valleys in their attentiveness and behavior. A particular problem may arise for children on medication who attend after school programs. The effects of the medication may have worn off by that time, and the parents may be reluctant to give a dose later in the day due to subsequent problems with sleeplessness. In these instances, children may do better with a time-released version of the medication.

Many parents, teachers, and physicians are concerned about the over-prescribing of Ritalin and other ADHD medications. The following statistics illustrate the basis for such apprehension:

  • About six million children, roughly one in eight children, take Ritalin, Adderall, Concerta or other ADHD medications.
  • Since 1991, prescriptions for ADHD medications have increase fivefold.
  • In that same time period, Ritalin use for the symptoms of ADHD increased 700 percent.
  • ADHD medications prescriptions for children ages 2 to 4 increased almost 300% between 1991 and 1995.

Effective treatment plans must include an appropriate behavior management component and classroom accommodations. Children, especially teenagers, should be actively involved as respected members of the school planning and treatment teams.





Implications for Your Classroom

Students with ADHD face unique challenges in the supplementary school setting. First, if the student is taking medication, it may not be as effective in the late afternoon when s/he is in class. Some parents do not give their child medication on weekends, making it difficult for the student to focus and concentrate in a Sunday school setting. Another challenge to teachers in the supplementary schools is the length of time the children are in class and the frequency of those classes. Individuals with ADHD need structure, consistency and predictable routines that may be difficult to implement in classes that meet for two hours, once or twice each week. Below find some tips that will help you address these challenges. Remember the ultimate goal is to a positive Jewish identity; protect the child’s self esteem and help him/her feel good and succeed in your class.

Tips for the Teacher

Communicate with parents.

  • Be as specific as possible in this communication, detailing the behaviors observed but remaining positive about the child.
  • Clearly convey to the parents that you are both on the same side.
  • Understand that parents of children with ADHD (as well as parents of children with any special needs) want an environment where their child can be “a regular kid.”
  • Brainstorm with the parents to develop strategies that will help the child perform well in class, and verbally reaffirm your commitment to the child’s success.
  • Keep the lines of communication with parents open; a team approach to dealing with ADHD will be most effective.
  • In addition to parents, consult with other professionals in your school or with the individuals who work with the child in their regular school placement.

Organize and routinize the class and class work.

  • Have clear and consistent rules and expectations. Teach the rules as routines in the class.
  • Give advance notice to the child (and the parents) if there are going to be changes in the schedule. Work with the student to develop a plan for dealing with unexpected changes or activities.
  • Reduce distractions by seating students close to the teacher, using study carrels and reducing clutter.
  • Provide organizational support or books and materials such as checklists and visual schedules.
  • Incorporate metacognitive strategies into instruction. Teach how to approach the task as well as the content.
  • Repeat directions and check for understanding.
  • Identify the skills necessary for successful completion of the task.
  • Provide an overview of the lesson “why” and “what” before beginning.
  • Reduce the number of concepts covered at one time, increase the amount of time given to complete assignments and tests and reduce the amount of work or length of tests.
  • Alternate demanding tasks with simpler activities, quiet and active times and breaks.
  • Break assignments into shorter segments, giving a specific task to perform within a specified time.
  • Simplify language used to communicate concepts.
  • Use concrete materials to introduce abstract concepts.
  • Relate information to student’s experiences.
  • Schedule short, frequent conferences to check for comprehension.
  • Provide consistent review of lessons before introducing new information.
  • Use cooperative learning groups that allow each child to demonstrate his/her multiple intelligences.




Additional Resources

Learning about ADHD will make you a more effective and sympathetic teacher. The greater your understanding of the disorder, the more effective your interventions will be.

Suggested reading

Barkley, R. (1998). Attention Deficit Hyperactivity Disorders: A Handbook for Diagnosis and Treatment. New York: Guilford Press.

Brown, T.E. (2000) Attention-Deficit Disorders and Comorbidities in Children, Adolescents, and Adults. Washington, D.C.: American Psychiatric Press, Inc.

Dendy, C.A.Z. (1995). Teenagers with ADD. Bethesda, MD: Woodbine House.

Goldstein, S. (1999). The facts about AD/HD: An overview of attention-deficit hyperactivity disorder. CHADD 1999 Conference Book, Landover, MD: CHADD.

Parker, H.C. (1988). The Attention Deficit Disorder Workbook for Parents, Teachers and Kids. Plantation, FL: Impact Publications.

Rief, S. (1993). How to Reach and Teach Children with ADD/AD/HD. West Nyack, NY: The Center for Applied Research in Education.

Helpful links

Attention Deficit Disorder Help Center

ADD Resources

CHADD: Children and Adults with Attention Deficit Hyperactivity Disorder

National Institute of Mental Health

Remember, best practices in special education are in actuality best practices in education, helping all learners to succeed.

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