Currents in Literacy

ADHD: When to Worry and What to Do

By Jerome J. Schultz

Part One: When to Worry: How to tell the difference between emerging disabilities and normal variations in learning style.

Psychologists often get calls from families of young children who are searching desperately for the answer to the question "Is there something wrong with my child?" Not surprisingly, this question comes up more often when family members take their children in for preschool or kindergarten screening. Prior to subjecting their child to the scrutiny of a team of professional early childhood educators, many family members have had a "gut feeling" that something may be odd or different with their child. They may have minimized or denied or ignored the behavior while the child was at home most of the time. They may first become really concerned about the child's behavior only after a teacher or other professional has raised questions about the child's development at preschool or kindergarten screening.

One of the biggest challenges in working with young children who exhibit unusual or extreme behaviors is whether to label the constellation of behaviors as deviant or to regard them as normal variations in early development. For example, when is it appropriate to use the term Attention Deficit Hyperactivity Disorder (ADHD) to describe a young child who is hyperactive, inattentive, or impulsive (the hallmark symptoms of ADHD)?

Let's do a little exercise to see why it's so difficult to make this decision. As you read the following list of behaviors, indicate whether you think you might expect to see these behaviors in most five-year-old children:

• sometimes doesn't pay close attention to details
• makes careless mistakes
• finds it hard to pay attention or sustain attention to play activities
• doesn't seem to listen when spoken to directly.
• doesn't follow through on instruction and fails to finish schoolwork
• often has difficulty organizing tasks and activities
• avoids tasks that require sustained mental effort
• often fidgets or squirms in seat
• often runs about or climbs excessively
• is often "on the go"
• often talks excessively
• blurts out answers to questions
• has difficulty awaiting turn
• often interrupts or intrudes on others

Well, how did you do in the previous exercise? For how many of the behaviors did you indicate that yes, you would expect to see the behavior in most five-year-old children? I'm willing to bet you said you wouldn't be surprised (or find it worrisome) if you observed most or all of these behaviors in a little child.

Now, go back and read the same list, but this time put in the heading Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder. These items were in fact pulled out of a fuller list of similar items under the category of ADHD in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), which is the book that psychiatrists and psychologists use when they have to decide if a person has a particular disorder.

So you can see why this is such a difficult issue. All children exhibit almost all of the symptoms associated with even the most serious forms of emotional disturbance at some time in their lives (e.g., is childhood fantasy a form of delusional thinking? Does it represent a break from reality?).

Certain behaviors that are a part of the typical repertoire of a preschooler might under some circumstances be considered symptoms of a disorder. The key issues involved are chronicity, intensity, and duration. Regardless of the symptoms exhibited, applying the criteria of chronicity, intensity, and duration help us decide how much to worry about a child's behavior and when to seek more extreme or intensive intervention. Chronicity refers to whether the behavior has existed for a long time. In the case of ADHD, for example, the DSM-IV requires that the behavior must have existed for at least six months. In reality, parents of children with this condition report a life-long history of the symptoms. If the behavior exhibited by one child is more intense than it is in most other children of this age, then parents, teachers and other caregivers begin to regard the problem as being serious. If the individual episodes of behavior are of long duration (e.g., temper tantrums of 30-40 minutes), then that factor tends to differentiate typically developing children from those who might have more serious problems -- problems that may merit labeling.

The question you might be asking is this: What good does it do to label a child? Wouldn't it always be better to describe the behavior and then come up with strategies to deal with the behavior? This is a good approach, but there are several good reasons to use labels when the information about the child merits it.

First, there are established sets of strategies or methodologies that have been developed to help certain children who have earned a particular diagnostic label. Specialists working with children born with Fetal Alcohol Syndrome (FAS), or babies born addicted to crack cocaine, for example, have developed interventions that have been demonstrated to be very effective in turning around some of the developmental delays these children experience. To miss a diagnosis of FAS might result in a teacher who simply "tries her/his best," but in the case of FAS, "her/his best," while good, may not result in the gains seen in a more intensive, specialized approach used in early intervention programs that work with these populations of children. The fact is that most children with FAS or drug-related problems do not get this specialized kind of intervention. Even when they get the "best a school has to offer," this may not be intense enough and the child will miss an opportunity to develop skills and talents that might have been stimulated in an appropriate program -- one based on labels.

We can also see the benefit of accurately labeling a child who has a neurologically based learning disability. Without an accurate diagnosis, a teacher might assign the label of "lazy" or "unmotivated" to such a child, and we can easily see which label is most destructive.

It's important to remember, too, that when a child has "earned" a label, the specialized interventions put into place for him or her will do no harm to other children. In fact, the multi-sensory nature of most learning strategies used with students with LD or ADHD will most probably help all the children learn more effectively.

Another justification for proper labeling of a child is that it gives the families information about which support group or professional association they might contact for support. A family of a boy who is mentally retarded is best served by the Association for Retarded Citizens (ARC), and not by the Learning Disabilities Association of America (LDA), or a family with a child with serious emotional problems might find a great deal of relief from the stress of living with their child by affiliating with other families who share the same concerns or issues. The oft heard phrase "all children are special," seems to avoid the fact that some kids are special in different ways.

On the other side of the coin is the argument that premature labeling of a child locks her or him (and the family) into a track from which it is not easy to escape. People who hear that a child has ADHD might react to him/her differently than they would toward the child who does not have this label. That response may or may not be helpful or healthy. Thinking that all children with ADHD require a full-time one-on-one aide, just because one other child needed that level of service, is an example of someone making an inappropriate assumption based on a disability label. Slogans such as "to label is to disable," and "labels are for jelly jars, not children" have come out of the anti-labeling camp, and give us pause to think before we rush to judgment about what a child is or is not.

Another argument against labeling is that children grow out of some behaviors as a function of normal development. The problem comes when a pediatrician or teacher advises a parent that they should "wait; he'll grow out of it." The child might not grow out of it. By waiting, the child may have missed the opportunity for intervention at a time when it is most likely to have an impact: early childhood. An undiagnosed (unlabeled) serious emotional difficulty can lead to problems of self-esteem, affect the way a child is viewed by parents and other children, and can create a negative aura around a child that can travel with the child as he or she moves through the grades.

An issue that all teachers must keep in mind is that certain behaviors are more (or less) easily tolerated in certain cultures and this may give rise to mis-identification (over or under-identification). For example, ADHD is the most frequently diagnosed childhood psychiatric condition in the United States, but is virtually unknown in Asian countries (and hence Asian immigrant families). During a recent conference at which I presented, interpreters were struggling to come up with a Chinese word for hyperactive. Cultural issues can also lead to misdiagnosis; children from some cultures may be assessed as overly compliant or passive if they follow a parent's advice to "behave, because your teacher is always right." A child whose culture has taught him that staring into an adult's eyes is a sign of defiance or disrespect might erroneously be labeled as having "difficulty making eye contact" or displaying signs of "anxious or avoidant personality."

Children who come from homes where English is not the first language may be having so much difficulty understanding teachers or classmates that they do not do what they are supposed to do. Even if a child seems to speak English well enough for simple social conversation, their language ability may not be strong enough to follow and understand and respond to the fast-paced and complex communication in the classroom. The inappropriate labeling of children whose first language is not English is well documented in Whose Judgment Counts? Assessing Bilingual Children, K-3 by Evangeline Harris Stefanakis (1998, Heinemann Publishers, Portsmouth, NH). In this excellent book, which provides evaluators with guidelines for effective and non-biased early assessment, Harris Stefanakis reminds her readers, "Until educators recognize and include political, social, cultural and linguistic factors as part of the assessment process, it remains a potentially discriminatory practice when applied to bilingual children." (p. 9).

It is also important to remember that children with language-based learning disabilities may have so much trouble processing information that they may be confused and act inappropriately, or they may exhibit negative behavior as a way to get away from the "toxic" effects of language-based activities. Teachers who misread such behavior as a lack of motivation or as oppositional are missing the opportunity to provide effective intervention to students who need specialized assistance.

Carrying out unbiased and competent assessments is a challenging task, and one which requires expertise and sensitivity. It is extremely important that teachers and other professionals working with children understand the impact of inappropriately labeling a behavior as deviant or using the terms disorder or disability too quickly or too freely. Teams of professionals must consider many factors when making a formal diagnosis. They must be particularly sensitive when determining whether certain behaviors are outside the range of what is considered "normal," or are actually a function of normal variations in development, or are explained by cultural or linguistic factors.

Part Two: What to Do: Practical Strategies to Improve the Performance of Students with Attentional Difficulties

There is a growing number of children who have been accurately diagnosed with attention-deficit hyperactivity disorder (ADHD). There are not enough special education teachers to individually serve the needs of the large numbers of children who have this condition, and most people agree that the needs of most children with ADHD can be met through what is called "responsible" or "supported" inclusion. As a result most of these children remain in so-called "regular" classrooms for most of their school day, where their education is often the shared responsibility of regular and special education teachers. Since many regular education teachers have had little or no formal preparation for working with students with ADHD, there is a growing need to provide them with specific strategies about how to effectively teach children with attentional difficulties in the context of the regular classroom. Research has shown us that such strategies have a greater likelihood of being implemented if they are practical, "do-able," and will have a positive effect on all children in the classroom. It is in that spirit that the following strategies are offered. I have made an attempt to give teachers strategies that will not only make learning more efficient for these students, but that will also help to create an inclusive environment which is characterized by respectful, purposeful teacher dialogue which I refer to as "the language of inclusion." I hope that these strategies will be helpful to parents and teachers as they work together to create learning environments in which all children have a better chance of learning in the best way they can.

To get a student to focus on you or on some material:

Research tells us that teachers talk more often to students with ADHD, but that the nature of the communication is often negative, punitive, controlling or corrective. This has an insidious negative impact on self-esteem. Find many opportunities to call the child by name, using a positive statement. Here are some examples:

• "Jamillah, here is something that you will find really interesting!"
• "Lindsay, I am using pantomime to send you a message (or tell you about an object, or to demonstrate a verb, or a math concept, etc.). Watch me and see if you can guess what I am communicating." (Teacher may pair Lindsay and another student, so one stimulates, encourages, and reinforces Lindsay's efforts).
• "Nathan, in just a minute I'm going to ask you a question about this object, and I am pretty sure you'll be able to answer it." (Be careful not to say: "Here's a hard one!" This can scare some kids away.)
• "Miss Garcia, this one's for you. Your first name rhymes with the answer." (Or "the answer begins with the first letter in your first name," etc.)

If kids with ADHD are only required to listen, many "tune out" quickly. Kick off lessons with activities that involve more than one sensory modality (listening, looking, touching, smelling, etc.). For example:

"Close your eyes..." (or put your head down, or cover your eyes) (the teacher can observe these responses, and by doing so, verify student connectedness). "I am going to describe some characteristics of an object I am holding. When you think you know what it is, don't call out (here, the teacher is predicting the need for impulse control, without having to identify a specific student)... raise your hand." (The teacher can observe this, too). Then the teacher can call the children by name and say, "You may open your eyes, David," and after several individual children have been recognized, say to the whole class, "If your hand is up, you may open your eyes." This type of activity increases the likelihood that more learners will be actively engaged in the activity. The teacher can then reinforce the process used. "I know some of you wanted to shout out the answer, but you did a really nice job controlling that impulse."

As a prelude to a lesson on adjectives, a teacher tells her students: "You'll find small plastic jars at each of your work tables." (or for each group of 4-5 students). "When I give the signal (here, the teacher is providing external control cues), I want you to open the jar, smell the contents and get one (appropriate) word in your head (or write it down, or share it with a partner, etc.) that describes the scent."

To keep a child's attention focused on an activity or material:

Since many kids with ADHD exhibit what Dr. Mel Levine has called superficiality, or the tendency to skim over the surface of material without really "getting into" it, there's a need to get them to stay with a task long enough to "go deep." Here are some suggestions:

• "Johnny, will you hold this string, while I slide on these small pieces of plastic straw." A teacher can do this as a demonstration, using a target child as an 'assistant,' or she can put the students in small groups, and make sure the target child has a hands-on task to keep him or her connected.
• "Marguerite, will you count the number of times I use the word 'add' in the next five minutes?" (or "Make a mark on the board each time I use a word that's an action word, or say a word that uses a long vowel sound, or when I use a gesture to make a point," etc.)

Kids with ADHD have problems inhibiting, or stopping behaviors that's why they say: "Oh, just one more time! Pleeeaase?" They have trouble putting on the brakes. Teachers can help them by giving them verbal or (depending on the age of the child) physical, or environmental cues that signal things are coming to a halt soon. Some examples.

• "You can do one more after the timer goes off."
• "When you hear this bell you should "freeze," holding your answer card up high so everyone can see."
• "I will count down from 5 to 1. When you hear me say two, what should you be doing?" (teaching self responsibility). "Right, and every group gets a bonus point if you are, in fact, doing that on the count of 2" (Giving credit for exhibiting necessary and proper work habits). "And watch each other. You are expected to help your partner(s) earn the extra points" (teaching self control as well as accountability for others while promoting social connectedness).
• "How many more will you be able to do in the next five minutes?" (asking a student to plan and predict; the teacher can be a reality checker) "I think ten is a bit unreasonable...how about five or six? If you do get them done, you may do another one."

To get a child to shift his or her attention from one activity to another.

Some children with ADHD have a lot of trouble starting on a new task when they have stopped the preceding one. It is important to build bridges between former activities and new ones. It's also important to create learning conditions that encourage the child to engage in the new task. Here are some examples:

• "The last thing we have to do in today's activity is to predict the next step in the process." (or "decide which category to explore tomorrow," or "pick the color you will use when you start to paint the next time.")
• "On this slip of paper, put the name of someone you would like to do part two with. (Encouraging kids to think ahead about learning). Remember, you'll want to pick someone who can add to your knowledge, or someone who has a skill or talent that can improve the product you're working on (focus on work behaviors and the benefits of collaboration). I can't promise you that you will get to, but I'll consider your request when I make the group assignments."
• "I would like you to give yourself a 'performance rating' on a scale of 1-5 for the work you've done this period. (This stresses the importance of self-assessment of the process of learning). Then I would like you to write down one thing you can do to improve your performance tomorrow." (Preparing for transition, by having the student make a commitment to improving performance).

Jerome J. Schultz, Ph.D. has served as a faculty member and administrator at Lesley University since 1977. Formerly a classroom teacher, Schultz is a licensed clinical neuropsychologist who has maintained a private practice in Wellesley Hills, Massachusetts for the past twenty-two years. He specializes in the diagnosis and treatment of children, adolescents, and adults with learning disabilities, ADHD, and other special needs. He is also the founding director of Lesley's Learning Lab, an interactive learning and assessment center for children, adolescents and young adults with learning difficulties or disabilities, ADHD, and related academic and social challenges.