Attention Deficit /
Hyperactivity Disorder
Case Study
MT is a 10 years old male, studying in Grade 4 of an English medium school following
the ICSE board curriculum. He lives in an extended family (with grandparents), and
has no siblings. The spoken language at home is Gujarati and English. There was no
presence of prenatal complications; it was a full term normal delivery (aided by
forceps); no post-natal complications reported. He is right handed. He has repeated
Sr. Kg as he was younger for his class in school.
He has been facing difficulties in coping with academics since grade 2. Currently
difficulties are reported with comprehending verbal instructions and speaking in
English, Reading comprehension, spellings, written expression, handwriting and Math.
Case Study
Parent reports of the child’s aversion to any written task. He exhibits very poor
attention skills, especially in the classroom. There is considerable hyperactivity in the
home environment. Parents report of the presence of considerable aggression and
hostility in peer interaction, tantrums at home and lack of self-confidence.
Progress report of the current grade indicated below average performance across all
subjects, with failure in English language and Math. In grade 3, performance was in the
below average range across most subjects. Writing work samples in the classroom
indicates incomplete and untidy productions, spelling errors (bizarre spellings) ,
illegible and immature handwriting, capitalization and punctuation errors. Teachers’
remarks in the notebooks refer to the need to complete written work, participate in
class discussions, stop disturbing others, pay attention to verbal instructions.
Case Study
What is ADHD?
ADHD is primarily a condition of brain dysfunction,
involving difficulties at multiple sites in the brain, giving rise
to educational, behavioral and other difficulties. It especially
involves difficulties in concentration, impulse control,
hyperactivity, rule governed behavior, motivation and time
awareness.
Probable Causes
Environmental Agents:
There is risk for ADHD :
○ In the offspring of the pregnancy where there is a ‘usage of
cigarettes and alcohol during pregnancy’
○ Where there is high level of lead in the bodies of young pre-school
children.
Brain Injury:
○ A small percentage of children who have suffered accidents leading to
brain injury have shown signs of behavior similar to ADHD.
Food Activities and Sugar:
○ Symptoms of ADHD are exacerbated by sugar/ food activities.
○ It was also found that diet restrictions helped about 5% of
children with ADHD.
○ Biochemical factors
Outcome
ADHD
Inattention
Short attention span, disorganized, distractible, forgetful
Impulsivity
Acts before thinking, difficulty in following rules,blurts out answers,
cannot await turn
Hyperactivity
Restless, overactive, fidgeting, always “on the go”
Inattentiveness
The child often….
● fails to give CLOSE attention to details or makes careless mistakes in
schoolwork, work or other activities.
● has difficulty sustaining attention in tasks or play activities.
● does not seem to listen when spoken to directly.
● does not follow through on instructions and fails to finish schoolwork,
chores or work duties.
● has difficulty organizing tasks or activities.
● avoids, dislikes, or is reluctant to engage in tasks that require sustained
mental effort.
● loses things necessary for tasks or activities.
● easily distracted by extraneous stimuli.
● is forgetful in daily activities.
Hyperactivity
The child often….
● fidgets
● is often Out of seat in class Often runs about or climbs excessively
in situations in which it is appropriate.
● has difficulty playing or engaging in leisure activities quietly.
● is often ‘on the go’ or often acts as if ‘ driven by a motor’.
● often talks excessively.
Impulsivity
The child often….
●
blurts out answers before questions have been completed.
●
has difficulty awaiting turn.
●
interrupts or intrudes on others.
●
exhibits physical impulsiveness
●
exhibits verbal impulsiveness
●
exhibits emotional impulsiveness
Presentations in Adolescence &
Adulthood
●
Sense of inner restlessness rather than hyperactivity
●
Poor organizational skills; difficulty working independently
●
Engaging in excessive risk taking, e.g., speeding while driving
●
Difficulty with authority figures
●
Poor self esteem
●
Poor peer relations
●
Emotional labile (unpredictable outbursts)
●
Underachievement in school and workplace
Procedure for Help
Intervention
Primary Intervention
Bi-modal: Pharmacology (medication) & Behaviour therapy
Supportive Intervention
Remedial education therapy, parent counselling, teacher awareness
Benefits of Medication
●
75% have real overall improvement in behavior
●
Increase attention span, decrease hyperactivity and
decrease impulsiveness
●
Able to remain on boring, repetitive activities
●
Grades in school improve
●
Better social relationships
Behavior Modification
4 Steps To Success
Behavior Modification
●
Providing more frequent and immediate feedback (including rewards and
punishment)
●
Setting up more structure in advance of potential problem situations
●
Providing greater supervision and encouragement to children with ADHD in
relatively unrewarding or tedious situations.
●
Modeling behaviour by encouraging good behaviour with healthy praise or
rewards. This works best if the reward or praise immediately follows the
positive behaviour.
●
Negatively reinforcing behaviour by allowing appropriate consequences to
occur naturally.
What Counselors can do...
●
Individual therapy using cognitive-behavioral approaches can be very
helpful in the treatment of Attention Deficit Disorder ADHD.
●
Stop and Think Therapy, teaching the ADHD child how to solve problems,
and teaching him how to decrease his impulsivity is great.
●
Teaching the child how to monitor his own behaviors is important as well.
●
Academic related concerns
○
time management, planning, and organizational tasks. A counselor helps
persons with ADHD develop strategies for managing their academic
responsibilities and monitors progress towards these goals.
●
A counselor can be helpful in treating some of the issues frequently
associated with ADHD, including low self-confidence, anxiety, and
depression.
●
The counselor can also help to identify and build on strengths, cope with
daily problems, and control attention and aggression.
What Parents can do...
●
Explanations should be given to the child, but these must be
tailored to take account of individual capacities.
●
Regular liaison with all professionals involved is essential.
●
Behaviour modification approach known to be most effective.
●
Dietary manipulation and other alternative therapies is as yet
unproven.
Management of ADHD in the classroom
3 elements of change: You can BET on it!!
❖ Modification of Behaviour
❖ Modification of Environment
❖ Modification of Task
Modify Behaviour
• Improve attention to directions
• Use systematic praise and ignoring
• Call time-out for disruptive behaviours. Use desirable
activity periods for time-out
• Immediately draw attention for off-task behaviour
• Token reinforcement (stars, coins, smileys)
• Positive /corrective feedback should immediately follow
the behaviour
Modify Environment
•
•
•
•
•
•
•
Position of child/place in classroom
Least distracting position
Vary class schedule
Identify a ‘study buddy’
Teacher-student relationship
Teacher expectations
Instructional methodology
Modify Task
•
•
•
•
•
One assignment at a time
Vary tasks (keep it interesting, challenging, yet achievable)
Use ‘active’ tasks
Break assignment into smaller parts
Alter or decrease written workload
General Strategies
●
Schedule a consistent routine. Have the same routine every day, from wake-up time
until bedtime. The schedule should include time for homework and time for play
(including outdoor recreation and indoor activities such as computer games). Have the
schedule on the refrigerator or a bulletin board in the kitchen. If a schedule change must
be made, make it as far in advance as possible.
●
Organize items that are needed every day. Have a place for everything and keep
everything in its place. This includes clothing, backpacks, and school supplies.
●
Use homework and notebook organizers. Stress the importance of writing down
assignments and bringing home needed books.
●
Create and enforce rules. Children with ADHD need consistent rules that they can
understand and follow. If rules are followed, give small rewards. Children with ADHD
often receive and expect criticism. Look for good behavior and praise it.
Strategies : Specific Behaviours
'Slowing the Motor'
Helping the Hyperactive/Impulsive Student to Manage Problem Motor or Verbal Behaviors
Activity : Give the student a soft 'stress ball' and encourage the student to
squeeze it whenever he or she feels the need for motor movement. Or if
the setting is appropriate, allow the student to chew gum as a replacement
motor behavior.
'Slowing the Motor'
Activity : Selective ignoring can be an effective teacher response to
minor fidgeting or other motor behaviors.
'Slowing the Motor'
Activity :Take away (or direct the student to put away)
any items that the student does not need for the work assignment
but might be tempted to play with (e.g., extra pens, paper clips).
Bringing into Focus: Helping Students to Attend to
Instruction
Activity : Allow them brief 'attention breaks'. Contract with
students to give them short breaks to engage in a preferred
activity each time that they have finished a certain amount
of work. For example, a student may be allowed to look at a
favorite comic book for 2 minutes each time that he has completed
five problems on a math worksheet and checked his answers.
Attention breaks can refresh the student –and also make the
learning task more reinforcing.
Bringing into Focus: Helping Students to Attend to
Instruction
Activity :This 'advance organizer' provides students
with a mental schedule of the learning activities,
how those activities interrelate, important materials
needed for specific activities, and the amount of time
set aside for each activity.
‘Extinguishing the Blaze’: & Helping Students to Keep Their
Cool
Activity: Select a corner of the room
(or area outside the classroom with adult supervision) where
the target student can take a
brief 'respite break' whenever he
or she feels angry or upset. Be sure to
make cool-down breaks available to all students
in the classroom, to avoid singling
out only those children with anger-control issues.
‘Extinguishing the Blaze’: & Helping Students to Keep Their
Cool
Activity: You can pose ‘who’, ‘what’, ‘where’, ‘when’,
and ‘how’ questions to more fully understand
the problem situation and identify possible solutions.
Some sample questions are "What do you
think made you angry when you were
talking with Billy?" and "Where were you when
you realized that you had misplaced your
science book?" One caution: Avoid asking ‘why"’questions
because they can imply that you are blaming the student.
Myths
●
All children with "ADHD" outgrow it
●
ADHD is not a physiological condition
●
Bad parenting and indiscipline is responsible for the condition
●
Affects males much more than females
●
Can only be treated with medication
●
Medication is not helpful in adolescence/adults
FACTS
● ADHD is a lifelong condition; it is not curable; it is manageable
● ADHD is a neurological condition
● Poor parenting and discipline can only worsen the situation, not
cause it
● Males are identified more than females
● Multi-modal therapy, i.e. Medication and behavioural therapy is
the best treatment option for ADHD.
Conclusions
● Characterized by Inattention, Hyperactivity, and Impulsivity
● The worldwide prevalence is estimated to be 3% to 7%
● Impairments often occur in home, school, and job settings and
persist from childhood through adulthood
● Genetic factors often contribute to the etiology
● Dyslexia is life-long
● In ADHD, hyperactivity diminishes but inattention remains
Case Study
MT is a 10 years old male, studying in grade 4 of an English medium school following
the ICSE board curriculum. He lives in an extended family (with grandparents), and
has no siblings. The spoken language at home is Gujarati and English. There was no
presence of prenatal complications; it was a full term normal delivery (aided by
forceps); no post-natal complications reported. He is right handed. He has repeated
Sr. Kg as he was younger for his class in school.
He has been facing difficulties in coping with academics since the primary school
grades. Currently difficulties are reported with comprehending verbal instructions
and speaking in English, Reading comprehension, spellings, written expression,
handwriting and Math.
Case Study
Parent reports of the child’s aversion to any written task. He exhibits very poor
attention skills, especially in the classroom. There is considerable hyperactivity in the
home environment. Parents report of the presence of considerable aggression and
hostility in peer interaction, tantrums at home and lack of self-confidence. Progress
report of the current grade indicated below average performance across all subjects,
with failure in English language and Math. In grade 3, performance was in the below
average range across most subjects. Writing work samples in the classroom indicates
incomplete and untidy productions, spelling errors (bizarre spellings) , illegible and
immature handwriting, capitalization and punctuation errors. Teachers’ remarks in
the notebooks refer to the need to complete written work, participate in class
discussions, stop disturbing others, pay attention to verbal instructions.
Case Study
A psycho-educational assessment indicates VIQ as being in the above average range
and PIQ & FSIQ to be in the average range. Scores on a standardized achievement
test shows MT to be functioning 1.6-2 years below his grade level in the areas of
reading comprehension, written expression & Math. Curriculum based assessment
indicated oral reading, reading comprehension and written expression functioning
at beginning of grade level 3. Reading errors made were largely mispronunciations;
reading comprehension and written expression tasks reflected poor vocabulary
skills, syntax & spelling errors. Mild-moderate deficits were present in the areas of
auditory processing, visual-motor integration, and memory skills.
Case Study
Information from parents and school indicated great concerns in the areas of
inattention, hyperactivity/impulsivity. Significant concerns were expressed in the
area of executive functioning and peer relations. Results on emotional and behavioral
evaluations indicated significant emotional conflict and behavioral difficulties.
Presence of ADHD was diagnosed. This is accompanied by emotional difficulties,
deficits in spoken English language, and severe learning difficulties, The student was
recommended to consult a pediatric neurologist for the problem of ADHD, begin with
behavioral therapy, occupational therapy and Remedial Education therapy.
Case Study
Behavioural therapy was recommended for a duration of six months. The goals to
be attended to as stated in his counselling plan were management of inattention
and hyperactivity, building up self-esteem, increasing motivation for academic
tasks. Parent involvement was focal to the plan. Outcome of therapy indicated
improved attention span during remedial therapy sessions; but classroom
disturbances continued. Medication was administered by the Neurologist. This is
reviewed after a period of 3 months. Occupational therapy has helped with
attention skills and handwriting skills.
Case Study
Remedial therapy was recommended for duration of a year, at a frequency of 2 hours
a week. Goals in the areas of behaviour modification, social skills, perception-auditory
& visual, spoken language, word reading, reading comprehension, spellings, grammar,
written language were included in the IEP.
Remedial methods involved use of phonetics and sight word reading methods, word
lists for word reading; vocabulary development and story telling for reading
comprehension; various word lists, phonetics and sight word methods for spellings;
visual stimulation, story starters, role-play, etc for written expression.
Goal evaluation for progress reporting indicated that MT is now functioning at middle
or end of grade level 4 across the different areas; he shows a progress of
approximately 6 months-1 year through application of multi-modal therapy.
Reference Links
http://www.nimh.nih.gov/health/publications/attention-deficit-hyperacti
vity-disorder/complete-index.shtml
http://kidshealth.org/parent/medical/learning/adhd.html
http://www.adhdnews.com/adhd-information.htm