Teacher's Guide to ADHD

Many children with ADHD show signs of the attention disorder before they reach school age. But it’s in school, when they are having trouble meeting expectations for kids in their grade, that most are referred for diagnosis.

That’s why it’s important that educators be well-informed about the attention deficit hyperactivity disorder — able to recognize children who might be struggling with ADHD, but also aware that the symptoms and behaviors associated with ADHD may also have other possible explanations.

There are three kinds of behavior involved in ADHD: inattention, hyperactivity and impulsivity. Of course all young children occasionally have trouble paying attention to teachers and parents, staying in their seats and waiting their turn. Kids should only be diagnosed with ADHD if their behavior is much more extreme in these areas than other kids their age.

These symptoms of ADHD are divided into two groups — inattentive and hyperactive-impulsive. Some children exhibit mostly inattentive behaviors, and others, predominantly hyperactive-impulsive. But the majority of those with ADHD have a combination of both, which can make it very difficult for them to function well in school.

Here are behaviors signs of ADHD you might observe in school in those two categories.

Inattentive Symptoms of ADHD:

• Makes careless mistakes in schoolwork, overlooks details
• Is easily distracted or sidetracked
• Has difficulty following instructions
• Doesn’t seem to be listening when spoken to directly
• Has trouble organizing tasks and possessions
• Often fails to finish work in school or chores in the classroom
• Often avoids or resists tasks that require sustained mental effort, including doing homework
• Often loses homework assignments, books, jackets, backpacks, sports equipment

Hyperactive or Impulsive Symptoms of ADHD:

• Often fidgets or squirms
• Has trouble staying in his seat
• Runs and climbs where it’s inappropriate
• Has trouble playing quietly
• Is extremely impatient, can’t wait for his turn
• Always seems to be “on the go” or “driven by a motor”
• Talks excessively
• Blurts out answers before a question is completed
• Interrupts or intrudes on others’ conversations, activities, possessions

It’s important to keep in mind that not every high-energy or impulsive child has ADHD. Children are diagnosed with ADHD only if they demonstrate these symptoms so often that they are causing real difficulty in at least two settings — i.e., at school and at home. And the pattern that’s causing them serious impairment must persist for at least six months.

ADD, or attention-deficit disorder, is an older term for the disorder we now call ADHD, or attention-deficit hyperactivity disorder. It was called ADD up until 1987, when the word “hyperactivity” was added. Some people still use the old term, ADD, out of habit, or because it’s a more familiar term than ADHD. Some use it to refer to kids with ADHD who aren’t hyperactive.

Within any given classroom, there is an age range of students that spans almost a year, and a year can make a big difference in a child’s ability to self-regulate. That’s why it’s important when teaching kids with ADHD and when considering a child’s behavior, to compare it to other children the same age — not to the range of kids in their class or grade.

Two studies in the last few years concluded that kids who are youngest in their class are disproportionately diagnosed with ADHD. A Michigan study found that kindergarteners who are the youngest in their grade are 60 percent more likely to be diagnosed with ADHD than the oldest in their grade. And it doesn’t affect just kindergarteners: a North Carolina study found that in fifth and eighth grade, the youngest children were almost twice as likely as the oldest to be prescribed medication for ADHD.

Defiance and emotional outbursts are not themselves symptoms of ADHD, but kids with ADHD are at higher risk for developing these behaviors. Some kids who have ADHD tend to become frustrated and overwhelmed by demands placed on them that they cannot consistently fulfill, because of inherent deficits in paying attention, reining in impulses and controlling their activity level.

Making transitions from one activity to another can be particularly difficult for kids with ADHD in the classroom, especially when they involve stopping some activity they find more stimulating than what comes next. Clinicians call it an inability to “attention switch,” and it can result in children disrupting the class or acting out.

A child who can’t seem to sit still, who blurts out answers in class without raising his hand, who doesn’t finish his homework, who seems to be daydreaming when the teacher gives instructions — these actions are associated with ADHD behavior, but they can also be a result of other factors, from anxiety to trauma to just being younger than most of the kids in the class, and hence a little less mature.

That’s why it’s important for teachers and parents both to be aware of other things that could be influencing a child’s behavior.

• Inattention: A child who is inattentive could be distracted by a worrisome or painful situation at home, or because she’s being bullied on the playground, and recess is coming up. If a child with OCD doesn’t know the answer to the question, it looks like he wasn’t paying attention, but it’s really because he was distracted by obsessions. When a child seems to be looking everywhere but at the pages of the book she is supposed to be reading, another possible cause is that she has a learning disorder.
• Hyperactivity: If a child is fidgeting when she’s supposed to be reading, she could have sensory issues that are making her uncomfortable, or a learning issue that is causing her great frustration. And if she bolts from her chair, it could be because she is ashamed that she doesn’t seem to be able to do what the other kids can do, and intent on covering that fact up.
• Impulsivity: Anxiety is another condition, often hidden, that can cause kids to be unable to follow rules or wait their turn, or to lash out when they are upset.

The stereotype of ADHD is boys disrupting the classroom by jumping up from their seats, getting in other kids’ business or blurting out answers without raising their hands. But girls get ADHD too, and they tend to be diagnosed much later because their symptoms are more subtle.

• More of them have only the inattentive symptoms of ADHD, and they get written off as dreamy or ditzy.
• If they have the hyperactive-impulsive symptoms they are more likely to be seen as pushy, hyper-talkative or overemotional.
• Impulsive girls may have trouble being socially appropriate and struggle to make and keep friends.
• They often work so hard to compensate for their weaknesses that they are able to hide their challenges.
• The growing awareness, as they get older, that they have to work much harder than their peers without ADHD is very damaging to their self-esteem.
• Girls who are chronically hard on themselves about their mistakes may be struggling with thoughts that they’re stupid or broken.

Executive functions are the self-regulating skills that we all use to accomplish tasks,
from getting dressed to doing homework. They include:

• Planning
• Organizing time and materials
• Making decisions
• Shifting from one situation to another
• Controlling emotions
• Learning from past mistakes

Most kids with ADHD have deficits in some executive functions, though not all children with executive function issues have ADHD.

Children with ADHD in the classroom who have trouble complying with rules and completing tasks can benefit from a daily report card system that sets positive behavioral goals and rewards to reinforce the behavior when they meet those goals.

The desired behaviors might be for the child to remain seated, to finish schoolwork, to raise his hand before speaking. The child receives points for successfully meeting goals, and his parents receive a daily behavior report card, enabling them to further to reinforce positive behavior in school with praise and prizes earned.

This system allows teachers to focus on what the child is doing well — rather than what he isn’t doing well. It can bolster his self-esteem and help him feel positive about school.

Many children with ADHD are prescribed stimulant medication to help reduce their symptoms. There are two main classes of stimulant ADHD medications:

• Methylphenidate-based medications: Ritalin, Methylin, Concerta, Metadate, Daytrana Patch, Ritalin LA
• Dextroamphetamine-based medications: Adderall, Vyvanse, Dexedrine, Focalin

There are also many different release formulas for stimulant medications, which make them effective for different periods of time:

• Immediate-release formulas are effective for about four to six hours.
• Extended-release formulas last as long as nine to twelve hours.

Children taking immediate-release formulas are often given medication in the middle of the school day by a school nurse. The goal is to maintain an effective dose during the school day but have the ADHD medication out of the child’s system by bedtime, to facilitate sleep.