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ADHD and EducationAude Henin, Ph.D.
Co-Director, Child CBT Program
Massachusetts General Hospital
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Disclosures
“My spouse/partner and I have the following relevant financial relationship with a commercial
interest to disclose:
Oxford University Press
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Contributors to Problems in School
ADHD
EF Deficits
Comorbidity
LDs
Psychosocial Stressors
Sleep and Lifestyle
School Environment
Peer Influences
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Educational, Occupational, and Financial Outcomes of Hyperactive Children
0
20
40
60
80
100
Fail Grade HS Susp. HS Grad College Fired Credit Card Ssvings
Hyperactive Control
Barkley et al. JAACAP ,2006, 45; 192-202
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Impact of Inattention on Subsequent Academic Performance
1.30
1.90
2.50
1.70
1.30
1.80
0.00 0.50 1.00 1.50 2.00 2.50 3.00
Gender
Inattention
Distractibility
Odds Ratio
SNAP Scores at Ages 7-9 Years Predict Lower Academic Performance in High School (N=2491)
vs. high acad function vs. medium acad function
Lundervold et al. 2017 PLoS One: 12(11): e0188310
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Technology Use and Sleep in 8th Graders with and without ADHD (N=302)
Bourchtein et al., 2019
• Teens with ADHD had:– Greater total technology use– 2x as much daily video game use (61 vs. 31 mins)
• Across total sample, greater parent- and adolescent-reported technology use associated with:– more sleep-wake problems– less time in bed.
• ADHD status did not moderate the relations between technology use and these sleep parameters.
• Parent-reported technology use associated with teacher reports of daytime sleepiness only for youth with ADHD.
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What to Do?
• In-School Interventions:
– Accomodations
– IEPs
– School-based behavioral plans
• Clinical Interventions Outside of School
– Medication
– Parent Management Training
– Organizational Skills Training
– Cognitive Training?
– Sleep Interventions?
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Educational Supports are Common Among Youth with ADHD
0 10 20 30 40 50 60 70 80
504 Plan
IEP
Behav Mgmt
Ed Support
Any Service
DuPaul et al. J Atten Disord. 2018 Dec 10:1087054718816169.
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Section 504 of the Rehabilitation Act of 1973
• No otherwise qualified individual with a disability in the United States, as defined in section 706(8) of this title, shall, solely by reason of her or his disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance…” [29 U.S.C. §794(a), 34 C.F.R. §104.4(a)].
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What does this mean?
• Who Qualifies: A student usually ages 3-22
• What is a disability? – A mental or physical impairment that substantially
limits one or more major life activities
– Substantially reduces or lessens student’s ability to access the curriculum in the educational setting
– Determined by a group of persons knowledgeable about the child, meaning of the evaluation data, educational options
– No formal testing required
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Additional Considerations
• Accomodations vs Modifications vs Interventions
• Privacy and Confidentiality
• Accomodations versus lower class placement
• Documentation on Report Cards and Transcripts
• Managing Failure to Implement Approved Accomodations
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Colleges/Universities are covered under Section 504 if they receive
federal monies!
Students should reach out to the Disability Services Office early in the
school year.
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Common Accomodations for Students with ADHD: Environmental Strategies
• Offer preferential seating (e.g., near the teacher; away from windows)
• Provide sensory or movement breaks• Allow the student to work standing up or with sensory tools• Provide a structured learning environment • Adapt environment to reduce distractions• Adapt non-academic times (e.g., lunch, recess)• Offer increased supervision during transition, field trips,
etc.• Utilize a study carrel or separate workspace• Schedule more demanding classes earlier in the day• Preferential course registration
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Common Accomodations: Organizational Strategies
• Model and reinforce organizational systems (i.e. color-coding) • Use simple, concise instructions with concrete steps• Write out homework assignments, check student's recording of assignments,
ask student to restate directions• Highlight important information/directions• Provide checklist for student and/or parents to record assignments and
completed tasks • Use a graphic organizer for writing assignments• Tailor homework assignments toward student strengths and interests • Set time expectations for assignments • Provide clues such as clock faces indicating beginning and ending times • Teach study/organizational skills • Break down long-term assignments with intermediate deadlines• Schedule structured tutoring/homework assistance
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Common Accomodations: Behavioral Strategies
• Clearly post rules and expectations for classroom behavior • Use behavioral management techniques consistently within a
classroom and across classes • Utilize positive verbal and/or nonverbal reinforcements with
greater frequency • Establish nonverbal cue with teacher if distracted • Establish a home/school communication system for behavior
monitoring • Put student on daily/weekly progress report• Reinforce self-monitoring and self-recording of behaviors • Determine trigger points and prevent action leading to unwanted
triggers • Provide for socialization opportunities
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Common Accomodations: Material Presentation Strategies
• Audio-record classes or allow students to record classes• Provide teacher notes and Powerpoints• Provide a peer scribe• Use computer-aided instruction and other audiovisual equipment • Select alternative textbooks, provide books on tape• Provide second set of textbooks for home• Prioritize drill and practice activities for relevance • Vary the method of lesson presentation using multi-sensory techniques• Ask student to repeat/paraphrase context to check understanding • Provide peer tutoring• Do not penalize for missed classes or participation difficulties• Be aware of student's preferred learning style and provide matching instruction
materials • Pre-teach and/or re-teach important concepts • Prepare advanced organizers/study guides for new material
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Common Accomodations: Assignments and Testing
• Modify the amount of homework*
• Adjust assignments to fit attention span*
• Use written directions to supplement oral directions
• Reduce paper and pencil tasks
• Allow for assignments to be word processed
• Lower reading level of assignments*
• Break assignments into a series of smaller assignments
• Extended time on tests
• Separate testing location
• Limit amount of material presented on a single page
• Provide a sample or practice test
• Provide for oral testing
• Provide tests in segments so that student hands in one segment before receiving the next part
• Grade for content integrity rather than neatness/presentation
• Modify weight of tests when grading*
*Modification rather than accomodation
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Individuals with Disabilities Act (IDEA 2004)
• Gives states federal funds to help make special education services available for students with disabilities.
• Provides very specific requirements to ensure a free appropriate public education (FAPE) for students with disabilities.
• Each state must issue rules and regulations about implementation of IDEA in their state– Some states may have regs that go beyond IDEA
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A Couple of Things to Know About IDEA
• From birth through age 2, children with disabilities and their families receive early intervention services.
• From ages 3 through 21, children and youth receive special education and related services
• ADHD is covered under IDEA and ADA, under “other health impairment”
• Having ADHD does not automatically qualify a child for special education services under IDEA
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Eligibility
• Does the child have a documented disability?
• Does that disability affect their ability to make effective educational progress?
• Does the child need specialized instruction (ie, special education and related services) to make progress?
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Special Education Evaluation
• Formal evaluation process that includes a variety of assessment tools
• Requires parental consent• Determination must be made unanimously by the
team, including parents, educators, school psychologist, special education personnel, representative of public agency
• Outside providers can be included• Outside testing may be but does not have to
considered
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Developing an IEP
• Parental concerns and vision for their child• Child’s current level of performance• Annual Goals
– Should be specific, individualized, and measurable
• Progress Reporting– How will the child’s progress towards the goals be assessed?– How will the parent be given information about progress?
• Special Ed Services to be Received– Nature of the service (e.g., reading instruction, org skills)– Frequency, duration (e.g., 60 minutes daily)– Location and setting (e.g., resource room at XX elementary; small
group instruction)
• Supplementary Services (accomodations and modifications)
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Out-of-District Placement
• Must be determined by the IEP Team• May be considered if:
– No in-district program exists to meet the child’s specialized education needs
– The child is not making adequate progress in the in-district program
– The child’s needs can only be met in a specialized program
• What is the least restrictive environment needed for the child to make progress?
• What are additional considerations?– Distance and travel– Residential vs. day schools– Social impact
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Some Common Issues
• Parental right to reject all or part of the IEP
• Approved vs. non-approved schools
• Stay-put rights vs. changing needs over time
• Resolving disagreement:– Take the long view
– Collaboration over conflict (if possible)
– Make use of advocates and special education lawyers if needed
– Consider reaching out to DOE or OCR if egregious offenses
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Stimulants Improve School Functioning
1.4
1.1
0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6
Seatwork
Teacher Ratings of Behavior
EFFECT SIZE (D)
Hawk et al. J Child Psychol Psychiatry. 2018 Dec;59(12):1271-81
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Classroom Behavior
Management
• Regular consultation with classroom teacher
• Psychoeducation re. ADHD
• Identification of target behaviors using functional assessment of behavior
• Instructing teachers re use of praise, planned ignoring, effective commands, time-out
• Use of Daily Report Card
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Results of Meta-Analysis for Behavioral Approaches
0
0.2
0.4
0.6
0.8
1
Effe
ct S
ize
Parent Ratings Teacher Ratings
Fabiano et al. 2009, Clin Psych Rev, 29: 129-140
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Academic and Organizational Skills Interventions
• Modifications to tasks and instruction• Reducing task length• Breaking up tasks• Setting intermediate goals• Multimodal instruction• Modifying classroom setting (e.g., preferential seating)
• Strategy Training• Study skills/Organizational Skills• Managing distractibility and inattention• Homework• Self-reinforcement
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Organizational Skills Training for 3rd to 5th Graders (Abikoff et al. 2013 JCCP)
• Aim: To ameliorate organization, time management and planning
• Design:
– 158 3rd-5th grade children with ADHD randomized to:
• Organizational skills training (OST)
• Non-skills, performance-based intervention (PATHKO)
• Wait-list control condition (WL)
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Structure of OST Intervention
• 20 individual sessions held over 10-12 weeks• Parents included for last 10 mins of session• Skills included:
– Recording assignments and due dates– Organizing school papers/using checklists– Tracking time for task completion– Breaking tasks into steps– Use of skills to address “glitches” and maximize use of their
“Mastermind”
• Work with parents/teachers to monitor/reward skill implementation
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Structure of PATHKO Intervention
• 20 sessions held with parents (children come in briefly at the end)
• Focus is on motivating children
• Training parents and teachers to:
– Establish specific individualized goals
– Use “Daily Report Cards”
– Prompt, monitor, praise/reward children for meeting goals
– Use of token Economy System
– Establish homework rules and structures
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Post-Treatment Response on CGI-I
85.3 86.9
0
OST PATHKO WL
% Responders
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Post-Treatment Clinically Meaningful Change
60 60.1
3
OST PATHKO WL
% No Longer Meeting Criteria for Organizational Deficits
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Results (Abikoff et al., 2013 JCCP)
◼ Children treated with OST (compared to WL) improved significantly in their home and school organization, time management, and planning
◼ There were few differences between OST and PATHKO at post-trmt
◼ OST was superior to PATHKO in parent ratings of organizational skills at post-trmt and 2 Yr follow up
◼ Though there was some decline, org skills remained improved over 2 yr FU
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Integrated Psychosocial Treatment for ADHD-Inattentive Subtype
(Pfiffner et al., 2014; JCCP; 82(6): 1115-1127)
• Child Life and Attention Skills (CLAS)• 3 components:• 1) group-based parent training• 2) group-based child training (including organizational
and social components)• 3) teacher consultation including daily report card• Adaptations of well-established interventions,
including positive reinforcement, social assertion, distraction management, parent training, use of common terminology
• Decreased emphasis on reducing impulsivity
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Evaluation of CLAS
• 199 children (ages 7-11 years) from 2 sites randomized to 10-13 weeks of:– CLAS– Parent-training – TAU
• Evaluated at baseline, posttreatment, and 5-7 mo fu• Child Characteristics:
– primary dx of DSM-IV ADHD-I– Mean child age 8.6 years– >50% in 2nd or 3rd grade– 54% caucasian, 17% Latino, 5% African-American, 8% Asian-American,
17% mixed race– 58% Boys– 4.5% taking medication at time of randomization
Pfiffner et al., 2014; JCCP; 82(6): 1115-1127
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Study Results: Effect Sizes Across Conditions
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Inattention-P Org. Skills-P Social skills-P
CLAS-PFT
CLAS-TAU
PFT-TAU
Pfiffner et al., 2014; JCCP; 82(6): 1115-1127
