How Can a Child with ADHD Be Supported and Included in School Education - Essay Example

Running Heads: CHILD WITH ADHD How Can a Child with ADHD Be Supported And Included In School Education of the of the institution] How Can a Child with ADHD Be Supported And Included In School Education Introduction Perhaps the most striking omission of school-based treatment outcome research for students with ADHD has been the examination of teacher factors that may have a significant bearing upon outcome. As a result, the conceptualization of ADHD and its treatment is incomplete. A perspective incorporating goodness-of-fit/systems theory may be a more adequate model from which to view interactions between students with ADHD and their teachers and a more predictive model from which to hypothesize anticipated treatment outcomes. Two compatibility issues are explored in some detail: teacher-treatment compatibility (i.e., the match between teacher characteristics and commonly recommended behaviour management procedures) and teacher-student compatibility (i.e., the match between teacher characteristics and student characteristics). Potential teacher factors which might be important to consider in such compatibility equations are discussed, along with the implications of these variables for school-based assessment and intervention processes and future research. Literature review A substantial literature on children with attention deficit/hyperactivity disorder (ADHD) has accumulated over the past 2 decades. An impressive portion of this literature has addressed the difficulties students with ADHD experience in school classrooms and the efficacy of interventions to minimize these difficulties. Medication and behaviour management procedures remain the two most commonly employed school-based interventions for children with ADHD (Rapport, 1992, 155-163). Due to well-documented limitations associated with both strategies, some combination of the two is generally accepted as the optimal approach to treatment. Nevertheless, an increasingly common finding in studies which examine the efficacy of such a combined approach to treatment is the considerable variability in treatment response among individual students (Pelham, 1993). As such, a case-by-case assessment of treatment ingredients and potencies is necessary (Abramowitz, 1994; Hoza, 1992). Hence, successful school outcomes for students with ADHD depend upon the degree to which treatment components and potencies match the needs of particular children. This "match" between treatment and student may best be conceptualized as a "compatibility equation" (in this case, student-treatment compatibility) in which characteristics of both child and treatment are taken into consideration in planning treatment and evaluating outcome. Studies examining student response to treatment can be criticized for an almost singular focus on treatment ingredients, as well as a relative neglect of student characteristics that may mediate treatment outcome. Yet perhaps the most striking limitation of school-based treatment outcome research has been the lack of consideration of teacher characteristics that may have a significant bearing on outcome. Two additional compatibility equations --teacher-treatment compatibility (the match between different teachers and different treatment ingredients and potencies) and student-teacher compatibility (the match between a particular teacher and a particular student with ADHD with regard to a variety of factors) -- have been virtually ignored. This article suggests that a more adequate and predictive model from which to conceptualize classroom outcome for students with ADHD will be one in which "teacher factors" are given greater consideration. Goodness-of-Fit and System Theory The terms compatibility and match can be traced most directly to the goodness-of-fit literature (Thomas, 1998). Goodness-of-fit is a concept that has been applied productively to child-care-giver interactions (Bell & Harper, 2003; Thomas & Chess, 2001); several authors have noted that the concept may be relevant to child-teacher interactions involving a variety of special student populations, including those diagnosed with ADHD (Brooks, 1984; Conners & Wells, 2002; Shaywitz & Shaywitz, 2005; Whalen & Henker, 2001 for a comprehensive discussion of the "social ecology" of ADHD). Goodness-of-fit can be defined as the degree to which the capacities, motivations, and style of behaving of an organism (the child) are compatible with properties, expectations, and demands of the environment (the teacher and classroom). Consonance and dissonance are two general terms describing this compatibility between an organism and its environment(s). Consonance refers to a situation in which good compatibility exists and under which optimal development and progress is thought to occur. Dissonance refers to the opposite situation; under such circumstances distorted development and maladaptiveness is thought to occur. Goodness-of-fit and systems theory are useful frameworks for conceptualizing the classroom difficulties of students with ADHD because they compel focus not only upon the manner in which the student with ADHD is compatible or incompatible with the classroom environment, but also on the manner in which the classroom environment is compatible or incompatible with the student with ADHD. As a "situation-specific" disorder (Barkley, 1989; Whalen & Henker, 2001; Zentall, 1997), ADHD characteristics are apt to be more or less problematic depending on certain environmental contexts. If a student's ADHD-related behaviour is exacerbated or improved in certain situations -- such as interactions with certain teachers, classroom environments, or specific tasks -- then a goodness-of-fit/systems approach necessitates examination of those aspects of the environment contributing to positive and negative variations in behaviour. From such a perspective, it is impossible to conceptualize the deficits in attention, self-regulation, and motivation that characterize ADHD separately from the environmental contexts in which they occur. Accordingly, a unidirectional perspective in which the difficulties exhibited by students with ADHD are viewed solely as a function of their ADHD status (i.e., their organismic status) is apt to be less adequate and predictive. In the following section, two important issues are discussed to underscore the notion that failing to consider the impact of situational factors increases the likelihood of linear, unidirectional thinking, thereby reducing the adequacy and predictive utility of our conceptualizations about children with ADHD. The first issue of unidirectionality relates to the assessment and diagnostic process for ADHD, and the second to the (sole) use of medication in reducing the severity of ADHD-related behaviours. Teacher-Treatment Compatibility Classroom-based behaviour modification procedures typically involve a combination of token reinforcement and mild punishment strategies. Fairly detailed descriptions of such methods have been provided by numerous authors (Abramowitz, 1994; DuPaul, 1994; Pfiffner & Barkley, 2000; Pfiffner & O'Leary, 1993). Others have proposed various teaching strategies and classroom modifications to minimize the difficulties exhibited by students with ADHD (Algozzine & Ysseldyke, 1992). Although behaviour management programs enhance the academic performance and behaviour of students with ADHD contingency management procedures; even more than medication, have not been found to normalize children's classroom behaviour. (Abikoff & Klein, 1992)Studies have shown that even when behavioural treatments produce clinical improvements, children with ADHD may still be significantly more deviant than normal classroom controls on a number of crucial dimensions (Abikoff & Gittelman, 1992; 881-892). Consideration of teacher-treatment compatibility should improve our understanding of these treatment outcome issues. Are commonly recommended behaviour management strategies compatible with the expectations, capacities, motivations, and behavioural styles of teachers The treatment acceptability literature suggests a variety of factors related to characteristics of both teachers and treatments relevant to this question including: (a) perceived severity of a child's problem, (b) nature of treatment, (c) time demands involved in implementing a treatment, (d) perceived effectiveness of a treatment, and (e) teacher background variables (see Elliott [2005] for a comprehensive review of these factors). Other possible teacher factors related to successful implementation can be extrapolated from the literature regarding parental implementation of behaviour management strategies. As summarized by McMahon and Wells (1989), family composition (single- versus two-parent households), socioeconomic status, personal and marital distress (including parenting stress), parent personality traits, and parental knowledge, attitudes, and beliefs may be important to the successful implementation of behaviour management programs with children exhibiting problems similar to those seen in ADHD. Several of these characteristics can be reframed for application to teachers and their ability to implement classroom behaviour management programs. For example, classroom composition and structure (presence of an aide, inclusion of other special needs students), personal distress (including the stress of having a given child in the class), teacher personality Waits, and knowledge, attitudes, and beliefs about children with ADHD (the degree to which certain ADHD-related behaviours are interpreted as "intentional") may all be related to effective implementation of behaviour management procedures. There has been little systematic evaluation of these teacher and setting variables. Although clearly nonexhaustive, the above discussion strongly suggests that the notion of treatment potency -- defined earlier as the practice of applying variable intensities of specific treatment components on a case-by-case basis depending on the individual needs of a given child with ADHD -- also must be applied as it relates to the needs and characteristics of the teacher charged with implementation. The characteristics and potency of a behaviour management program deemed consonant for a child may produce a high degree of dissonance in a teacher whose capacities, motivations, style of behaving, and teaching demands have not been taken into account. Such a program would be expected to have low compliance, effectiveness, and maintenance (Reimers, Wacker, & Koeppl [1999] for a model of treatment acceptability incorporating this perspective). Student-Teacher Compatibility The above discussion suggests that teacher factors may play a critical role in determining the acceptability and successful implementation of a school-based behaviour management program. It is unclear, however, whether a teacher's implementation of such a program is the most critical component of overall school outcome for students with ADHD. Other teacher characteristics may bear even greater influence on both student-teacher interactions and the broader behavioural and academic prospects of students with ADHD in classrooms. The notion that school outcome for students with ADHD may be related to student-teacher compatibility has been suggested by several authors (Whalen et al., 2001, 1280-1282), and similar suggestions have been made regarding generically defined emotionally or behaviorally challenging populations (Kauffman & Wong, 1991; 225-237; Landrum, 1992: 135-144). Theorists have posited that the difficulties of students with EBD (emotional or behavioral disorders) are often due in part to incompatibilities between pupils and teachers and mismatches in their behavioral styles, perceptions, or expectations (Wong, Kauffman, & Lloyd, 1991: 108-115). Unfortunately, there has been little systematic study of which teacher characteristics are most influential in facilitating successful interactions with students with ADHD. A final category of teacher characteristics is suggested by the literature on child temperament and parent-child goodness-of-fit. As noted by Seifer (unpublished manuscript), goodness-of-fit consists of objective and subjective constructs. Objectively-defined goodness-of-fit can include expectation-behaviour matching (a process of comparing adult expectations and child characteristics for degree of fit). Subjectively-defined goodness-of-fit can include an individual's cognitive appraisal of the degree of fit (i.e., how is a behaviour interpreted) and affective response to the perceived degree of fit (i.e., how do the appraisals feel). Some of these goodness-of-fit components have been studied in relation to teachers and students, though typically not in direct examination of student-teacher compatibility. For example, with regard to objectively-defined goodness-of-fit, researchers have shown that most classroom teachers have similar expectations and attitudes regarding successful student adjustment. Such adjustment is characterized by a behavioural repertoire that (a) facilitates academic performance (i.e., listening to the teacher, following instructions and directions, working on assigned tasks, complying with teacher requests, etc.) and (b) is marked by the absence of disruptive and/or unusual behaviours that challenge the teachers' authority and disrupt classroom atmosphere or are objectionable to teachers and difficult for them to cope with. Children with ADHD clearly do not fit this description of the model behavioural profile. As such, their style of behaving elevates the risk for heightened tension in their interactions with most teachers. There is, however, little evidence to suggest that the disparity between teachers' behavioural expectations and the behaviour of students with ADHD inevitably leads to negative outcomes. At present, we lack information regarding other related, but more variable, aspects of teacher expectations (flexibility of expectations) that may be more potent contributors to objectively-defined goodness-of-fit. Other research seems germane to subjectively-defined goodness-of-fit. For instance, while there is general consensus among teachers regarding the unacceptability of maladaptive pupil behaviour that threatens classroom control, there is far less agreement among teachers about the degree to which various adaptive behaviours are critical to a student's success in their classrooms (Lloyd, 1991: 115-126). This suggests that teachers have different tolerances for various student behaviours, and that low teacher tolerance (in this case, for ADHD-related behaviours) is likely to result in negative outcomes for both teacher and student (Hersh & Walker, 1983; Walker & Rankin, 1983). As noted earlier, teachers may also interpret and react to ADHD-related behaviours in diverse ways (Whalen, 2000: 1280-1282), and these interpretations and reactions may contribute to the compatibility that exists between a student with ADHD and his or her teacher (Brooks, 1984). These goodness-of-fit issues also await exploration. Implications for School-Based Assessment and Intervention It may be useful at this point to summarize and expand upon many of the points made above as they apply to school-based assessment and intervention processes for students with ADHD. Readers are referred to other sources for reviews of the complex array of factors that must be considered in the assessment of ADHD (DuPaul & Stoner, 1994) and other childhood behaviours. These sources underscore the necessity of assessing the contexts in which behaviours occur; however, they typically do not provide detail about how to assess teacher characteristics that may represent a major aspect of such contexts. The assessment literature can, nevertheless, provide a useful framework for discussing mechanisms by which the assessment process can be expanded to include teacher characteristics and other contextual variables. For further details of the finding please see appendix. References Abikoff, H., & Klein, R. G. (1992). Attention-deficit hyperactivity and conduct disorder: Comorbidity and implications for treatment. Journal of Consulting and Clinical Psychology, 60, 881-892. Abramowitz, A. J. (1994). Classroom interventions for disruptive behaviour disorders. Psychiatric Clinics of North America, 3, 343-360. Algozzine, B., & Ysseldyke, J. E. (1992). Strategies and tactics for effective instruction. Longmont, CO: Sopris West. Barkley, R. A. (1989). Attention deficit hyperactivity disorder. In E. J. Mash & R. A. Barkley (Eds.), Treatment of childhood disorders (pp. 39-72). New York: Guilford. Bell, R. & Harper, H. (2003). Child effects on adults. Hillsdale, NJ: Erlbaum. Brooks, R. B. (1984). Success and failure in middle childhood: An interactionist perspective. In M. Levine & P. Satz (Eds.), Middle childhood: Development and dysfunction (pp. 87-128). Baltimore: University Park Press. Conners, C. K., & Wells, K. C. (2002). Hyperkinetic children: A neuropsychosocial approach. Beverly Hills, CA: Sage. DuPaul, G. J., & Stoner, G. (1994). ADHD in the schools: Assessment and intervention strategies. New York: Guilford. Hoza, B., Pelham, W. E., Sams, S. E., & Carlson, C. (1992). An examination of the "dosage" effects of both behaviour therapy and methylphenidate on the classroom performance of two ADHD children. Behaviour Modification, 16, 164-192. Kauffman, J. M., & Wong, K. L. H. (1991). Effective teachers of students with behavioural disorders: Are generic teaching skills enough Behavioural Disorders, 16, 225-237. Landrum, T. J. (1992). Teachers vs. victims: An interactional analysis of the teacher's role in educating atypical learners. Behavioural Disorders, 17, 135-144. Lloyd, J. W., Kauffman, J. M., Landrum, T. J., & Roe, D. L. (1991). Why do teachers refer pupils for special education An analysis of referral records. Exceptionality, 2, 115-126. Pfiffner, L. J., & Barkley, R. A. (2000). Educational placement and classroom management In R. A. Barkley (Ed.), Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (pp. 498-539). New York: Guilford. Pfiffner, L. J., & O'Leary, S. G. (1993). School-based psychological treatments. In J. L. Matson (Ed.), Handbook of hyperactivity in children (pp. 284-255). Boston: Allyn and Bacon. Rapport, M. D. (1992). Treating children with attention-deficit hyperactivity disorder. Behaviour Modification, 16, 155-163. Reimers, T. M., Wacker, D. P., & Koeppl, G. (1999). Acceptability of behavioural treatments: A review of the literature. School Psychology Review, 16, 212-227. Shaywitz, S. E., & Shaywitz, B. A. (2005). Attention deficit disorder: Current perspectives. In J. E. Kavanagh & T. J. Truss, Jr. (Eds.), Learning disabilities: Proceedings of the National Conference (pp. 369-567). Parkton, MD: York Press. Thomas, A., & Chess, S. (2001). The dynamics of psychological development. New York: Brunner/Mazel. Thomas, A., Chess, S., & Birch, H. G. (1998). Temperament and behaviour disorders in children. New York: University Press. Whalen, C. K., Henker, B., & Dotemoto, S. (2001). Methylphenidate and hyperactivity: Effects on teacher behaviours. Science, 208, 1280-1282. Whalen, C. K., Henker, B., & Dotemoto, S. (2000). Methylphenidate and hyperactivity: Effects on teacher behaviours. Science, 208, 1280-1282. Wong, K. L. H., Kauffman, J. M., & Lloyd, J. W. (1991). Choices for integration: Selecting teachers for mainstreamed students with emotional or behavioural disorders. Intervention in School and Clinic, 27, 108-115. Zentall, S. S. (1997). Stimulus-control factors in search performance of hyperactive children. Journal of Learning Disabilities, 18, 480-485. Appendix The following are suggested guidelines for assessments and interventions for ADHD in school settings, and are adapted from the various references cited above. 1. Assessments must be systems-oriented and must incorporate the possibility of situational influences on behaviour because behaviour may not be consistent across time and settings. Thus, school-based assessments for ADHD should be broad enough to include not only the child but also the multiple adults (parents and teachers) who interact (and have previously interacted) with the child in multiple settings (various contexts within the school and home). Diagnostic conclusions will be more definitive if there is stability in the child's behaviour across time and contexts. In instances of inconsistency across situations -- for example, the child's ADHD-related behaviour is more frequent and intensive in interactions with a particular classroom environment -- the evaluation process must focus on finer compatibility issues that may account for the inconsistency. As discussed above, this expanded assessment process will by definition include examination of teacher characteristics that may be impacting upon a child's behaviour and vice versa. Such a process should increase understanding of the complex, reciprocal factors affecting child and teacher behaviours and facilitate appropriate interventions in the specific contexts where incompatibility exists. Targets for interventions may subsequently encompass specific characteristics of the child, teacher, classroom environment, tasks, and so forth. 2. Assessments must be multimodal, including different informants and methods. These should include naturalistic observation (direct observation of the child in different contexts), rating scales completed by multiple sources, interviews with multiple sources, and review of other relevant information (psychoeducational testing). Although the necessity of naturalistic observation has been questioned, it is difficult to imagine circumstances under which a comprehensive understanding of ADHD-related behaviour can be achieved in the absence of such observation. Inconsistency among sources would once again compel focus on finer issues of incompatibility, as described above, thereby allowing appropriate interventions in the specific situations (and with specific individuals) where incompatibility is evident. 3. A diagnosis should be viewed as merely descriptive, not explanatory. Thus, assessments must focus less on assigning a child to a category and more on obtaining information that is directly relevant to treatment. "Relevance for treatment" refers to the usefulness of information in pinpointing treatment goals, the selection of targets for intervention, the design and implementation of interventions, and the evaluation of intervention outcomes. By itself, concluding that a child has ADHD provides no useful information about the contexts in which the disorder is most problematic. Pinpointing situations in which ADHD-related behaviour is exacerbated (transitions between classes or activities, group discussions, standing in line for lunch, playing softball, interacting with certain teachers) helps identify the compatibility issues that should be targeted for intervention and thereby allow more educated and fine-tuned selection of intervention options. Furthermore, assessment should be viewed as an ongoing, fluid process, especially in school settings where contexts can change dramatically from class to class and year to year. 4. Assessments must be conducted by persons with the training and experience in ADHD to execute them in an educated fashion and take into consideration the complex compatibility issues discussed above. Such persons must have the skills to analyze, organize, integrate, and communicate the vast array of information gathered in the assessment process for the purposes of (a) arriving at a comprehensive understanding of a child's interactions with their environment(s); (b) requiring that additional information be collected when such an understanding has not been achieved; (c) making accurate judgments regarding the developmental deviance of a child's behaviour; (d) determining the most appropriate persons and behaviours to be targeted for change and the interventions most likely to produce these desired changes; and (e) maintaining contact over the long term with the various adults who continue to interact with the child, are charged with implementation of interventions, and/or are targets of intervention to monitor and maintain the ongoing assessment process and facilitate reformulation of "the problem" as necessary. 5. Interventions should be guided not only by consideration of the needs of the student with ADHD, but also by the degree to which recommended strategies are acceptable to the teachers charged with implementation. Selection of intervention strategies should be viewed as a separate assessment process; teachers should be assessed along the various dimensions discussed above prior to design of an intervention program and should be active participants in the design process. Assessment should continue after intervention has been initiated to determine responses of both child and teacher. Finally, intervention should include not only traditional child-targeted strategies (medication, behaviour management programs, accommodations, etc.) but also teacher-targeted strategies (education and training). Read More