The way forward for ADHD management in school
In the past 15 years, there has been a greatly increased recognition that attention deficit hyperactivity disorder (ADHD) is a valid and important neurodevelopmental condition that causes challenges to those in education, both in terms of the symptoms displayed within the classroom and the specific issues in assessment and management.
ADHD is a complex neurobiological disorder of self-control, characterised by developmentally inappropriate inattention, and/or hyperactivity and/or impulsiveness, which causes significant functional impairment in major life activities.
It is one of the most important and common childhood conditions affecting between three per cent and five per cent of all children. This means that there is typically at least one child with ADHD in every class. The condition frequently persists through school years and into adulthood from preschool years. ADHD often runs in families. It is more commonly recognised in males, although girls are significantly under-recognised and tend to be more inattentive and less hyperactive generally. ADHD is a progressive and often disabling condition which, if untreated, creates a vulnerability to significant educational, social, psychiatric and youth justice difficulties. However, such problems can be minimised with effective management.
Problems at school
There is a wide spectrum of classroom difficulties that can be attributed to ADHD. Some children with ADHD are excessively verbally, physically and sometimes emotionally impulsive. They are unable to give thought to the outcome of their actions, words or emotional volatility. Generally, they are not malicious but their actions and words are not thought through, which means that they may hit or poke other children, they may call out excessively in class or get upset very easily. Some children with ADHD are hyperactive, but this is not necessarily the case. Often, the hyperactivity lessens with time in any case and most children with ADHD are inattentive and have difficulty in staying focussed, particularly on the less interesting things.
They are frequently able to hyperfocus on things they find interesting but have great difficulty in coping with the mundane and boring, being easily distracted, very disorganised and having poor time management with a marked tendency to procrastination. Some children, particularly girls, tend only to have problems with inattention and frequently daydream. They are termed children with attention deficit disorder, as a subgroup of ADHD. Thus, there is a wide range of ways in which children with ADHD can have difficulties within the classroom and there is therefore a need for teachers to be well informed about the various presentations.
Links to other conditions
In addition, many children with ADHD have other coexisting conditions. Rather than, as was previously thought, for conditions such as dyspraxia, dyslexia and/or autistic spectrum problems to be quite distinct and separate, many children with neurodevelopmental difficulties have these conditions coexisting together. For example, about a third of children with ADHD can also have symptoms on the autistic spectrum and about a third can also have specific learning difficulties. It is important that teachers do not automatically assume that a child’s behaviour or concentration problems are secondary to conditions such as dyspraxia or dyslexia, as they may coexist with these conditions. In these cases, effective management of improving concentration and helping with self control can help the child cope much better with the other coexisting conditions.
Once a child with ADHD has struggled for some time in the school setting, in most cases self-esteem and motivation become poorer. The daily struggle of having to focus, behave, be on time and socialise appropriately with the child’s peer group means, particularly if the child has a sensitive personality, that the child will often become demoralised quite early on. Some children with ADHD are also excessively oppositional and the condition of oppositional defiant disorder – where there is excessive arguing, blaming, annoying and defying in the early years of life – can put enormous pressure on parents and teachers alike.
The second report of the National Institute of Clinical Excellence on ADHD, published in 2008, very much validates the importance of ADHD. It emphasises the fact that ADHD is frequently a progressive condition lasting into adulthood and that many of the intransient problems that occur in adolescence with untreated ADHD could have been prevented if the condition had been recognised earlier and screened for earlier. The much higher incidence of antisocial behaviour, substance misuse, poor employment and relationship records, and of motor vehicle accidents can be greatly minimised by effective early intervention.
How can teachers help?
Teachers have a very important role to play in recognising the possibility of ADHD in the first instance, and in supporting that child educationally to minimise the impact of the core ADHD symptoms on the child. Teachers also have a role in making parents and other support staff more aware of the child’s difficulties and in recognising that both core ADHD symptoms and coexisting conditions can cause a child enormous difficulty yet be very responsive to appropriate strategies and accommodations.
Once teachers understand that ADHD is a brain-based neurodevelopmental difficulty and that the child’s weak concentration, hyperactivity or lack of self-control is innate and makes that child more vulnerable to his or her environment, supportive strategies become more obvious and are much more likely to be effective. The recognition that a child might have ADHD is not an excuse, rather an explanation. Frequently, this subtle but significant change of attitude can make all the difference. Rather than a child being persistently punished for the misdemeanours or lack of organisation, which generally makes little if any difference, appropriate accommodations and strategies to minimise the impact of that child’s concentration or self control difficulties can be put in place, making a great deal of difference.
Diagnosis and medication
Diagnosis should be done by specialists in neurodevelopmental difficulties, either consultant paediatricians or child psychiatrists. Psychological input can also be very valuable. It can be difficult for teachers when the possibility of ADHD is raised by them with the parents for the concerns to be rejected. Once referral is made to a specialist clinic, assessment should be made as to whether or not the child has ADHD and the exact extent of the impairment and whether or not coexisting conditions are present. The Learning Assessment and Neurocare Centre has found the addition of the quantitative EEG in diagnostic assessment very useful. This is a measure of the individual’s brain activity and provides information in regards to physiological reasons for the symptoms. It has been shown that, in the majority of children with clinical ADHD, the brain activity patterns are abnormal, further emphasising the fact that ADHD is a brain based educational condition.
When educational strategies prove less than effective and the problems persist both educationally and with self-esteem, the possibility of a trial of medication can be considered. Medication provides a window of opportunity and allows educational and other strategies to be more effective. The use of medication aims to improve the core ADHD symptoms. It is important that these symptoms be as tightly controlled as possible if there is going to be effective management. Almost always, there is a “flow-on” improvement once the core symptoms are controlled, to improving self-esteem, academic progress, and often handwriting and social skills, depending on the degree of other associated symptoms.
Once the core symptoms are stabilised, it is then possible for other strategies to be more effective, such as specific educational support on the special educational needs register, support for other coexisting conditions, social skills support and/or behavioural management. The use of a coach or mentor may be useful.
It is important that side effects that are frequently associated with ADHD medication are put in perspective. As outlined in the NICE report, the medical management of ADHD is safe, and when used carefully and with the dosage fine-tuned appropriately, side effects are minimised. The most common side effects are appetite suppression or difficulty in switching off and getting to sleep at night. Very rarely, some transient subduing of personality can occur, or headaches or abdominal pain occur. Usually these side effects are minimised by careful adjustment of dosage or timing of medication. There is no evidence of long-term side effects in published studies to date and the medications have been used over the past 65 years.
The development of long-acting Methylphenidate preparations, about 13 years ago, has been an enormous advance in the management of these children. Rather than having to line-up in the school office at lunchtime to take a second dose of four-hour acting medication, medications are now available that last for between nine and 12 hours, which are generally gentle, still work within 20 to 30 minutes of the correct medication dosage being given, and enable the child to concentrate much better and have better self-control throughout the school day. When medication is used, its combination with appropriate educational strategies is very important. It is never an either/or situation.
It is essential for the clinician to work closely with the school to provide effective management. Feedback from the school is necessary prior to diagnosis to help ascertain exactly what difficulties are occurring at school, and also once effective management is undertaken so that there can be feedback as to the benefits of varying strategies and/or medication.
Supporting those with ADHD
In summary, effective assessment and management of ADHD/ADD is an essential part of the provision of special educational needs services. It can no longer be ignored and the various myths and misinformation that have made it difficult for teachers to understand the reality of the condition should now be consigned to history. Educational support and understanding are always an initial important strategy; however, should academic, self-esteem and social problems continue despite this, then the possibility of a trial of medication should be considered.
Very bright children, particularly those in a highly structured and supportive environment can struggle without this always being recognised, particularly if they are inattentive. Frequently, their brightness masks their difficulties until they get into senior school or even beyond. Being able to hyperfocus does not mean that the child does not have ADHD. Children with ADHD are unable to focus on average things even if they can hyperfocus on computers and other very interesting subjects because of an adrenaline buzz.
Careful assessment and supportive management can make all the difference to a child’s life.
Dr Neil Rutterford is a Chartered Psychologist and Chartered Scientist. He is a member of the Division of Teachers and Researchers in Psychology of the British Psychological Society and an associate member of the British Neuropsychological Society and International Neuropsychological Society. He is also the Secretary of the Society of Applied Neuroscience.
Dr Geoff Kewley is a Consultant Paediatrician specialising in the management of children with neurodevelopmental, behavioural and learning difficulties, especially ADHD and related issues. He chairs the Royal College of Paediatrics and Child Health special interest group on AD/HD and related neurodevelopmental difficulties. In 1993, he established the Learning Assessment and Neurocare Centre in Horsham, West Sussex.