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  1. 1. Understanding,teaching, & supporting students with ADHD Rosemary Tannock, Ph.D, Senior Scientist, Associate Professor of Psychiatry,The Hospital for Sick Children & University of Toronto; Investigator with the Canadian Language & Literacy Research Network
  2. 2. Potential Areas of Impairment Injuries Occupational/ Academic vocational limitations Legal difficulties ADHD Relationships Motor vehicle Low self accidents esteem Smoking and substance abuse
  3. 3. ADHD: Challenges for Educational Systems• Education costs 3 to 6 times greater (Forness et al., NIH Concens, 2000) – Prevalence (1 or 2 children in every class) – Association with learning & social problems• Meaning for educational programming is unclear – What type of exceptionality/special needs? – What are the Standards for level of service & instruction? – What are the required teacher qualifications?
  4. 4. Educational Systems: Principles of Practice• Inclusion as basic principle:• Program Standards – Exceptionalities/Special Needs – Screening & Assessment – Interventions – Level of Service – Instruction – Qualifications for teachers & other Staff
  5. 5. Typically, one‟s pedagogical approach to students with special needs reflects one‟sown conceptualization of that particular special need
  6. 6. Prevailing view: ADHD as a behavior problem Brain Abnormalities Biological Inattention & HyperactivityEnvironmental Impulsivity Factors Associated Problems (academic, social)
  7. 7. Emerging neuroscience/educational perspective Brain Abnormalities Genetic Working Memory & & otherEnvironmental cognitive processes Factors Treatment Inattention, targets Hyperactivity, impulsivity Learning, Academic achievement
  8. 8. Traditional approaches to helping children with ADHD• Medical/Pharmacological (~ 85%)• Behavioral (~12%)• Educational (?)• Alternative approaches (?)
  9. 9. Limitations of traditional approachesto helping children with ADHD • Pharmacological – (Philosophical/political) – Temporary effects on behavior & academic productivity – No robust evidence of impact on learning • Behavioral approaches – Disproportionate emphasis on consequences rather than antecedent scaffolding (support) & control procedures – Limited generalizability beyond the training context
  10. 10. Stimulant medication improves: *** Core features of ADHD ***Academic productivityClassroom behaviourLab measures (inhibitory control, attention) But…...
  11. 11. The ProblemTreatment related improvements in corebehavioral features of ADHD & dailyacademic work have not translatedinto robust gains in long-term academicachievement (e.g., MTA Study, 1999) WHY NOT?
  12. 12. “Beneficial effects of stimulant medication are not infinite”• Effects on behavior & academic productivity are immediate but temporary & cannot compensate for “missed instruction and learning”• Lack of synchronization between drug schedule and academic schedule• Stimulants enhance some but not all aspects of cognitive function & so may not target critical cognitive impairments
  13. 13. of medical & academic treatment is essential 4 3.5 3 2.5 2 1 hr post 1.5 3-4 hrs post 1 0.5 0 Trials to Errors Mastery“Reading to Read” instruction for ADHD boys at two intervals post-medication (Kastner et al., 2000)
  14. 14. Stimulant have limited effects on reading• No effect on phonological processing (e.g., Balthazor et al., 1991; Richardson et al 1988)• Small effects on verbal retrieval mechanisms involved in word recognition (e.g., Ballinger, 1984; Evans et al., 1986; Peeke et al., 1984; Richardson et al., 1988; MTA Study 1999)• Effects on comprehension are unknown (e.g, Brock & Knapp, 1996)
  15. 15. Stimulants have selective effects on Working Memory • Stimulants improve but do not normalize impairments in visuo-spatial span & visuo-spatial working memory, in childhood & adult ADHD (Bedard et al., in press; Mehta et al., 2000a, 2000b; Barnett et al., 2002) • Stimulants may improve verbal working memory but not verbal span in children, but may be mediated by stimulant effects on spatial working memory (CHI/PASAT;Tannock et al., 1995; Schweitzer et al., 2000)
  16. 16. Advances in psychopharmacological treatment of ADHD• Newer, longer-acting medications for ADHD will facilitate synchronization of pharmacological treatment with educational intervention – Several FDA-approved long-acting stimulants & a non-stimulant drug available in USA – Many of which are or will soon be available in Canada BUT…. May still have temporary & selective beneficial effects on cognitive function
  17. 17. Contingency Management• intensive behavioral programs• includes both negative consequences and positive reinforcement• may be difficult to implement across range of situations in school• does not take into account underlying reasons for behavior (ie., cognitive deficits)
  18. 18. Cognitive-Behavior Therapy• characterized by – verbal mediation instruction – cognitive modeling – problem-solving strategies• inconsistent results regarding effectiveness - however usually implemented as a „package‟ in treatment sessions removed from normal environment (i.e., regular classroom)
  19. 19. Behavioral techniques(e.g., parent training, cognitive behavioral therapy) improve... • Oppositional behavior • Some ADHD behavioral symptoms • but transfer-of-learning beyond the training context is limited…. (e.g., Abikoff, 1991; Kendall & Panichelli-Mindel, 1995; Pelham et al., 1998; MTA Co-operative Group 1999) WHY?
  20. 20. One ProblemNon-integrated approaches
  21. 21. NIMH Multimodal Treatment Study – Largest, longest, randomized controlled clinical trial of treatment in ADHD (N ~ 600; ADHD-CT; 14 mos duration) – Four parallel treatment arms 1. Managed Medication 2. Managed Meds + Psychosocial 3. Psychosocial 4. Community Services (included meds) Most effective for ADHD? 1, 2 > 3, 4
  22. 22. What else can we do toboost academic and socialsuccess, & facilitatelearning?(Beyond the MTA)
  23. 23. Problems withsalienceProblemsignoringirrelevantinformationLackstrategies
  24. 24. Working Memory Demands in the Classroom• Spelling Maintain word in mind while printing it• Math Keep steps in sequence while performing and monitoring accuracy• Reading Decode words while Comprehension integrating meaning• Following oral Maintain correct sequence, directions update, and check Pick out key elements,• Problem-solving choose strategy & monitor effectiveness
  25. 25. Promising Educational Strategies for ADHD to reduce demands onworking memory & enhance learning• Teacher-focused interventions – Modifying how teachers think about, adapt & present critical content to help students identify, organize, comprehend & recall it• Student-focused interventions – Teach the student skills & strategies needed to learn the critical content (acquire information from print, organize & memorize, problem-solve, & written expression) and succeed in test-taking
  26. 26. Social/Emotional - e.g. self-esteemAdaptionsModifications BehaviorAcommodate -fidgety -inattentiveStrategiesScaffolds Cognitive Strengths and Weaknesses - working memory - language - reading ability
  27. 27. approach may be more effectivethan behavioral contingencies • IN-SITU (“at point of performance”) • FREQUENT, LONG-TERM • CONTEXTUALIZED COACHING – MODELLING – SCAFFOLDING – STRATEGIES • Minimizes need for behavioral contingency management & applicable to ALL children
  28. 28. Antecedent-Based Approaches• stresses the interaction between child and environment• manipulate a variety of potential antecedent variables that may affect performance, such as... – nature of the assignment compared to level of functioning of child, – classroom structure, – advance organizers, – modifications in instructional delivery and support
  29. 29. What are Cognitive Learning Strategies?• “Set of steps that lead to the accomplishment of a task” (Wanzek et al., 2000)• How a person thinks & acts when planning, executing, & evaluating performance of a task & its outcomes (Lenz, Ellis & Scanlon 1996) – Includes thinking & physical actions necessary to perform a skill – Physical act provides evidence that student is using a strategy
  30. 30. Cognitive Learning Strategies can be taught to all children?• promotes intentional learning (self- regulation)• helps children be flexible and adaptable learners• promotes independent, active learning• facilitates transfer to novel contexts• helps children organize approach to task
  31. 31. Critical Features of Effective Cognitive Learning Strategies (Ellis & Lenz, 2000-(; Minskoff & Allsop, 2003)• Accurate & efficient procedures for learning tasks• Accessible to students by being – Memorable (labels, visual cues) Simply worded; Uses familiar words Begins with action words – Accessible through Strategy Cue Sheets• Contains only essential steps – Number of steps should not exceed student‟s ability to remember & perform – Distinguish between primary & secondary steps
  32. 32. Systematic Explicit Instruction to teach Cognitive Learning Strategy5. Generalization toother subject/setting4. Independent practicewith little/no support3. Repeated guided practice Task Analysis/ Preskills:2. Modelstrategy Basic Knowledge of Instructional Language,1. Introduce strategy Listening steps, Temporal Concepts Bedrock
  33. 33. Types of cognitive learning strategies (Minskoff & Allsop, 2003)• Mnemonics • Graphic Organizers• Visualization • Structured Steps• Verbalization • Multi-sensory learning
  34. 34. Strategies to help organization• Time management • Materials management• 3C • CLASH – Create a calendar – Check your calendar – Create a weekly – List the items you need planner for next day – Create daily lists – Always gather the materials on your list – Set your bag by the door – Have a list in your locker of materials you need
  35. 35. WARFStrategies to improve reading speed• Widen your eye span – Read more than one word at a time – Read groups of words (the/a + noun)• Avoid skip backs – Keep reading to try to get meaning from context• Read silently• Flex your reading rate – Read important information slowly – Read familiar information faster – If looking for specific information, read quickly as searching
  36. 36. Examples of Decoding Strategies from Word Identification & Strategy Training (Lovett etal., 1994, 2000) • Rhyming • Vowel Alert • Peeling-Off • I Spy
  37. 37. Word Identification Strategy Training Program Metacognitive strategies (Lovett et al., 2000)• S.A.M.E. (select, apply, monitor, evaluate)• Use a gameplan – Choose, Use, Check, Score
  38. 38. Using Graphic Organizers as a Scaffold for Comprehension Strategies (Ellis, 1998) Can be used to help They show organization of students: concepts and relationships between conceptssummarize Reduce the cognitive demands of learner to organize material, so learner canfind supporting details focus on understanding it Allows higher level criticalsequence events thinking activities to occur (relate,compare/contrast)
  39. 39. Example of Graphic Organizer Key Topic Caves Is about Cave types and featuresMain idea Main idea Cave Types Features of Caves Essential Details Essential Details Limestone: most common Moon-milk (calcium) is name of gel on floors, walls Sandstone: wind or water erode sandstone Cave interiors have 3 zones: entrance, Twilight, and dark zone Lava caves Limestone caves: have stalactites And stalagmites Sea caves
  40. 40. Story Writing Strategy (Harris, Schmidt, & Graham, 2000) SPACE • Setting • Place • Action • Conclusion • Emotions
  41. 41. P.O.W.E.R (Englert et al., 1991) to help organize ideas when writing an essay• P- plan your paper (brainstorm for ideas)• O – organize ideas (graphic web)• W – write your draft• E – edit your work• R – revise work
  42. 42. Cognitive learning strategies for foundation math skills• Whole number • DRAW for basic computation math• Word problems • FAST DRAW for basic math
  43. 43. DRAW for basic math from Teaching Students with learning Problems, Mercer&Mercer, 2001• Discover the sign – Scan the problem Example: subtraction – Circle and say name of operation sign 6 l l l l l l – Say what the sign means - 3• Read the problem – Read the whole problem 3 – Say the problems aloud as you read it• Answer or draw & check – Answer problem if you know how to solve it – Or draw picture to solve it – Check your answer• Write the answer
  44. 44. FASTDRAW for basic math (Mercer & Mercer 1991)John and Mary went to the corner store to buy some candy.John bought 3 packs of gum and Mary bought 4 chocolates.How many candies to they have altogether? •Find what you are solving for •Underline the question •Box key words (altogether= addition or multiplication) •Ask what is the important information •Find & circle the number phrases •Set up the equation •3 gum __ 4 chocolates = •Tie down the sign •3 gum + 4 chocolates =
  45. 45. Examples of General Metacognitive Strategies• I.D.E.A.S. • Think Aloud (Camp & Bash, 1985) – I state the problem. – What is the – Develop some plans problem? – Explore the plans – What are some – Ask myself if the plans? plan is working – How is my plan – See if I am working? successful. – How did I do?
  46. 46. Four Components of SCORE1. Academic 2. IDEAS 3. Getting 4. Being a (Thinking Along Together Detective aloud)Temporal Think Aloud Promoting Self- Problem-Solvingskills (verbal mediation) Esteem/ strategies Self -AssessmentInstructional IDEAS Emotions/ Scientificlanguage/ lessons Anger Mgmt Method:Following directions Questioning, observingOrganizational/ Explicit Social Skills/ Tangrams,Study strategies/ application to Prob.Solve (e.g.) Geometry,Active listening/ cognitive/ Cooperation Attribute blocks, social problems Friends Pentominoes, Tone of Voice, Mazes
  47. 47. Lesson Delivery• fast-paced, focused, energetic• little down time - increase student response frequency (e.g, choral responses, cooperative activities)• Simplify, chunk & repeat, instructions – establish eye contact, then give instructions, repeat, have child repeat.• vary presentation style (active/passive)• use visual prompts/aids (e.g., diagrams, pictures, color coding)
  48. 48. Content Adaptations• greater student response frequency • choral response, peer tutoring• use visual prompts • pictures as reminders,• adjust quantity of work • match to ability, reduce handwriting/copying• increase amount of review/repetition • may need more practice to learn new skill
  49. 49. Example: Teaching Math• reduce amount of work• provide lined paper (spatial deficits)• use manipulatives• adapt delivery to include visual cues, color coding, mnemonics• provide extended practice in problem- solving strategies
  50. 50. Tips for Managing Behaviour• Rules: – post rules visually – review before transitions – be consistent, use predetermined consequences• anticipate!• frequent feedback (eye contact can redirect), use signals• use direct requests “When…then…”
  51. 51. Managing Behavior• Be supportive, highlight shining moments, encourage child to self-evaluate strengths• help the child become self-aware and self- observant (e.g., how do you feel about…? you must be proud that …”)• teach a new, positive behaviour to replace negative• deliver feedback swiftly and systematically
  52. 52. Major points• ADHD is a biologically-rooted neurocognitive disability• ADHD is more usefully conceptualized as a type of learning disability (rather than just a behavior disorder)• Oral language, academic, & cognitive function should be routinely assessed in ADHD• Intervention for ADHD will be multimodal & include: – Psychoeducation – Psychopharmacology – Antecedent-focused approaches with metacognitive instruction & environmental modifications – Direct & intense academic instruction
  53. 53. The future….Targeted, integrated, and synchronized treatmentsPharmacologicallonger-acting medicationtarget neurotransmitter /neural network systems Psychological/Educational target underlying cognitive processes synchronize with pharmacological treatment, in terms of timing and target problems
  54. 54. WWW Resources• (Useful articles include: Key components of a comprehensive assessment of ADHD; Talking to your children about their ADD; ADD and Gifted students:What do we really know?; Attention deficit disorder in college)• Includes “tips for Teachers” section for ideas on forming parent-teacher partnerships• (an extensive on-line compensium of books, videotapes, conferences; Education section has articles on homework, transition plans etc)• (Nov 2001 issue of Educational Leadership on understanding learning differences includes the on-line article :Reconceptualizing ADHD by Tannock & Martinussen• viusal cues for each step in a strategy