Treatment of children with ADHD in school

(Read this article in Norwegian)

ADHD is basically to be understood as a biochemical phenomenon that produces an imbalance and immaturity in the child’s neurological executive system.  This imbalance is related to a disability to adapt ones behaviour in relationship to the environment. The immaturity has to do with the fact that a child with ADHD is immature in specific areas, thereby discriminating it from general mental retardation. For instance, a 12-year-old child with ADHD may have the capacity to withhold his/her impulses that one normally would expect from a child at the age of 7 years. The child’s imbalance and immaturity is more directly “measured” through their impression toward other people: Problems with attention, impulsiveness and hyperactivity. All children have problems in these three areas, the younger they are the more common and “normal” it is. For this reason, one normally does not consider a ADHD-diagnosis until the child is at least 5 years. As the child grows up and parents (or teachers) are puzzled by the fact that some behaviour problems does not “mature away”, the grown up normally consider something to be “wrong” with the child, and the question of ADHD may come to ones mind. The ADHD-diagnosis is set when (1) a criteria-list on attention, impulsiveness and hyperactivity is confirmed to a certain degree, (2) the problems also existed before the age of 5 (3) the problems is observed in more than one area, (4) the problems are significant, and (5) there is no other psychiatric diagnosis that can explain it.

Some consequences of considering ADHD as an imbalance and immaturity problem are:

1. The problems can not be removed in a simple way through “training”. Since it is unwise to “push a river” one has to cooperate with the child’s natural speed of getting more mature.
2. The child needs support through compensation and accommodation.
3. The child is to a relatively small degree “king in his/her own house”. Or: This is not first of all a question of lack of “understanding” (“man-to-man” the child normally is aware of the behaviour problem), but a question of the lack of ability to execute / perform. Here lies a common pitfall: Believing that discussion and explanation is sufficient for changing the child’s behaviour, and, when the child in spite of this does not change his/her behaviour in a positive direction, one draws the conclusion that the problem is caused by the child’s negative attitudes.
4. The expectations from the grown-ups regarding appropriate behaviour must be related to their actual level of maturity, and not their age of level.
5. Many children with ADHD (at least 2/3) improve their behaviour and becomes more accessible with the use of adequate medicine (Ritalin, Dexamin).
6. One must follow the “scratch where it itches” – principle. In other words: Find out where the ADHD-problems are evident in school. For instance: On the question of attention in the classroom ask the following problem: Where is the problem:

In the process of receiving information? From my experience this is an area where many children with ADHD have significant problems. The children often report problems when instructions are long and complicated, or that their attention is “somewhere else” when instructions are given. Logically, the teacher in such cases must adapt to this through making instructions less complicated and ensure that they in fact do have the child’s attention when a instructions are given. Such an attention problem can be both auditory and visual. From my experience auditory attention problems is most common.

1. In the process of decoding/understanding the information?
2. In the process of getting to work (mobilization)? The children with ADHD often have organizing problems than makes it hard for them to get started. They can find it hard to make a system of priority and to organize in sequences. The more alternatives, the more complicated. The consequence of this would be to limit the number of alternatives, and arrange the order for the child (“Now you can do this, and when you are finished, I will tell you what to do next”).
3. In the process of endurance / vigilance? The children may have problems to “stay on the track” because of his/her impulsiveness and hyperactivity. In these cases the teacher’s concern would be to “keep them on the track” through encouragement, helping them keep the goal in focus, and to shield them from whatever may distract them in the classroom. The children may also have problem with “automatically” behaviour: Most children have the ability to use lesser and lesser energy in performing a certain type of behaviour when it is repeated (Illustration: The first time a child try to bicycle he/she needs a lot of attention to succeed. For each time this is repeated, he/she does not become so exhausted, and can “set free” capacity of attention to focus on people around, the traffic, thinking of something else etc.). Children with ADHD often have problems in this area. They easily get exhausted, do not have the necessary capacity to use and “put into context” what they are working with, and have a genuine need for pauses.   

Some other guidelines in the treatment of ADHD in school:

1. Focus on the child’s strong sides.
2. Let him/her often experience that a work is finished. For children with ADHD this is often more important than having the pleasure to be “on the way” – contrary to “normal” children. Therefore, helping the child to finish, is often a good help.
3. Focus on topics that are relevant for the child.
4. Because they may be insecure what they were supposed to do, have mobilization problems, work slower, get more easily exhausted, and/or easily distracted, it is normally wise to reduce the amount of work the child is given.
5. Acknowledge the fact that they are very dependent on being motivated. Injunctions seldom lead to good work and behaviour.
6. As a teacher: Be aware of “the way” information is give to the child (loudness of voice, the way one communicate through the eyes and physically touching the child), not only the content.
7. If the “chemistry” between the child and the teacher does not function, consider the possibility of letting someone else be the child’s “primary contact”. In some cases it can be wise to move the child (or the teacher?) to another class.
8. Give the child the feeling that “I see you, I know what your trouble is, and I help you when you get into trouble”.
9. Give the child the opportunity to be reinforced frequently, from the teacher’s encouragement and/or the child’s experiences of succeeding his/her work.
10. Work primarily where the problems are. If the child’s basic problem is in the classroom, start first to think if it possible to help the child function in the classroom.
11. Don’t underestimate the child’s ability to explain his/her problem and to be involved in the discussion “how can we work together on this problem”. Having a good relationship to the child and showing interest in listening to him/her, is often a crucial factor in helping a child with ADHD in school.
12. Be aware that the child’s capacity fluctuates. They are often tired at the end of the day or at the end of a session.
13. Avoid embarrassing the child.
14. Have a coaching-role to the child.
15. Don’t let the child be a victim for the teacher’s moralistic attitudes (se below), impatience or lack of understanding.
16. Help the child having the necessary overview. What is taking place? Where, when, in which sequence, etc.
17. Prepare the child for the day’s timetable / schedule and for what is lying ahead.
18. Change activity before the child becomes exhausted.
19. Write the homework for the child if he/she has problems to write it down himself/herself.
20. Give the child “5 minutes to clear the desk” after a session.
21. Give the child opportunities to, in an acceptable way, to “take out” his hyperactivity, for instance “Take a run 3 times around the school and return afterwards” or give him/her something to manipulate with during the work.
22. To teach a child with ADHD my sometimes be as easy as “teaching a tiger”. This may be a big challenge for the teacher and cooperation and support from colleges is important.
23. Sometimes be “untraditional”, and consider ”the least of two evils”. For instance: Must the child have homework?
24. Be aware that a child in school with ADHD in the long run will develop “secondary problems”, that, in fact, may be more serious than the original problems. (Example: After some time refusing to cooperate with the grown-ups and to adapt to the school system). Such “secondary problems” must not misled the grown-ups to think than the problem is not ADHD “after all”, but it can be a starting point from where one can “wind up” the situation and then gradually discover that child’s real problems is an ADHD-problem (for instance that the whole learning processing never, or seldom, get adequately started because of the child’s problems with focused attention and assimilation / processing of information from the very start).
25. The other pupils, the atmosphere in the classroom, and what the children as a group is focused on easy influence a child with ADHD. A good management of these aspects will therefore often be crucial in helping a child with ADHD to function in the classroom.
26. This is not meant to be a “cook-book”. A good treatment in school is often a question of the right knowledge and the right attitudes. When this is “in its place”, the teacher in most cases will react adequately and suitably, including when he/she has to react spontaneously. The point of “spontaneously” is particularly important, because “things happens around the child” much more frequently for the children with ADHD, and the teacher often does not have the necessary time to think out in forehand how to react.

Finally: Here are some typical examples of so-called moralistic attitudes:

1. The grown-up makes improper demands regarding the child behaviour by expecting it to have abilities he/she in fact do not have.
2. The grow-up focus on explaining, theorizing and instruction with a ”you must understand” - attitude.
3. Problem behaviour is normally defined as ”intentional” and not ”impulsive”.
4. ”Why” is a more commonly used question than ”what” and “how” when focus is on clearing up problems.
5. When the child does not behave as expected, the grown-up becomes irritated and indignated.

Copyright © 2001 Kjell Totland Psykologtjenester

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