Attention Difficulties, Poor

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Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder) Teaching and managing children and school students LOGO Cataloguing-in-publication data 618.92 ATT Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder). – [Adelaide] : Dept. of Education, Training and Employment, 1999. 28 p. : ill. 1. Attention deficit disorders – Care and treatment. 2. Learning disabilities. 3. Hyperactive children. DDC21: 618.928589 ISBN: 0 7308 5792 1 SCIS order no.: 962336 South Australian government and non-government centres and schools are permitted to copy this document to use in supporting children/students. Health professionals are permitted to copy relevant sections for use in collaboration with centres, schools and families. The centre, school or health professional shall not sell, hire or otherwise derive revenue from copies of the material, nor distribute copies of the material for any other purpose. © 1999 Department of Education, Training and Employment, 1999 Acknowledgments This resource could not have been produced without the generous assistance of a wide range of professionals in health, care and education and many families living with children with attention difficulties, poor impulse control, overactivity or ADHD. Cover illustration by P & D Design Layout and word processing by Julia Rowe ISBN 0 7308 5792 1 Foreword Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students has been written to help careworkers and educators improve the participation and success of children and students in centre and school communities. It is relevant to parents and health professionals. This document is the result of extensive collaboration between Department of Education, Training and Employment personnel; paediatricians; child psychiatrists; general practitioners; psychologists; parent representatives and families. As a result, it reflects and supports both departmental policy and practice, particularly in the areas of behaviour and health care management, and the recommendations of the 1997 National Health and Medical Research Council report Attention deficit hyperactivity disorder. Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students details practical teaching and management strategies and emphasises the importance of a strong partnership between home, centre and school, and health professionals. It is recommended to centre and school communities to enhance teaching, learning and care for all South Australian children and students. Geoff Spring CHIEF EXECUTIVE Experts agree that people working together using a combination of educational, family, behavioural, psychosocial and medical interventions offer the best outcomes for these students. Early intervention is preferable to delay. The diagnosis of ADHD in toddlers and pre/schoolers is complicated by normal developmental changes and environmental factors. Behaviour management and parent guidance is essential, and medication should be used with caution. National Health and Medical Research Council 1997 Attention Deficit Hyperactivity Disorder (ADHD) Contents Chapter Page 1 ADHD within a spectrum of behaviour ....................................................................................................... 7 2 Assessment and diagnosis ............................................................................................................................. 8 3 2.1 Professional assessment and diagnosis 2.2 Specific issues relating to the assessment of young children 2.3 ADHD and other difficulties 2.4 Role of teachers and care workers Teaching and behaviour management strategies............................................................................... 10 3.1 Early childhood 3.2 School 4 Medication ......................................................................................................................................................... 14 5 Roles and responsibilities ............................................................................................................................ 15 6 Sample documentation ................................................................................................................................. 17 Sample letter from a doctor or psychologist to a principal/director Learning behaviour questionnaire General health information Medication plan 7 Resources and support services: South Australia .............................................................................. 23 Parent information pamphlets .................................................................................................................... 24 ADHD within a spectrum of behaviour In the course of their development, some children/students have difficulty concentrating and paying attention. They are easily distracted and don't seem to plan their actions, and so have a disorganised, chaotic personal style. They do not seem to consider the consequences of their actions and will repeatedly break the rules or upset others. They can be fidgety and always on the go. They may crave stimulation and have difficulty understanding social cues. All these behaviours may be quite age appropriate, especially for younger children, as part of a child’s normal behavioural development. Teachers provide activities to help such children develop more productive learning and behavioural patterns. In some children, these behaviours may be persistent, excessive and may seriously interfere with learning. They may pose significant management challenges for parents and teachers. Frustration experienced by the child, peers, teachers and parents can also create complexity. At such times teachers and parents may seek advice and assistance from a range of support services within early childhood and schooling services, child and mental health services, doctors, or psychologists. Sometimes professional assessment will lead to a diagnosis of attention deficit disorder or attention deficit/hyperactivity disorder (ADHD). There is considerable professional debate about whether ADHD refers to specific conditions or to extremes of normal distributions of behaviours. 1 The most recent diagnostic manual1 describes ADHD as a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development. ADHD occurs much more frequently in boys, especially in the hyperactive-impulsive form. Three subtypes of ADHD have been identified: • predominant features of hyperactivity and impulsivity • predominant features of difficulties with attention • a mixture of both of these. For ADHD to be diagnosed: • there must have been some symptoms present before the age of seven, although diagnosis will frequently not be made until the demands of preschooling and schooling reveal difficulties • symptoms must have lasted for over six months • there must be problems present in at least two settings eg at home and at school • these problems must be severe enough to impair the child/student's functioning in social, academic or occupational settings • the symptoms are not better accounted for by another mental/behavioural disorder. 1 American Psychiatric Association. 1994 Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students 7 Assessment and diagnosis 2 2.1 Professional diagnosis assessment and The identification of this disorder is a matter for doctors and psychologists. In making a diagnosis these professionals would normally consider reports from the child/student’s teachers, parents and other people who know him/her well to assess whether the behaviours occur across a variety of settings, or are dependent on changing features of the child/student’s environment. Impact on the child/student’s functioning needs to be carefully assessed. Professionals must also consider a number of possible explanations of the behaviours in order to rule out other explanations and diagnoses, such as: • difficulties with vision or hearing • difficulties understanding or using language • neurological problems, for example head injury, epilepsy, brain tumours, high blood lead levels or allergies • psychological or emotional factors, for example depression, anxiety, mood disorders, trauma or stress • difficulties within the family, for example ongoing conflict within relationships or parental discipline styles • intellectual difficulties or disability • developmental delay • advanced development. Teachers may be asked to complete behaviour questionnaires or rating scales. They may be asked for comment or behavioural observations related to behaviour management strategies and outcomes, and learning strengths and weaknesses. Assistance by all centre and school staff in providing behavioural observations will ensure the best possible decisions are made about the nature of the child/student's needs and any subsequent management plan. 2.2 Specific issues relating to assessment of young children the The diagnosis of ADHD in toddlers and preschoolers is complicated by normal developmental changes and environmental factors. Behaviour management and parent guidance is essential, and medication should be used with caution 2. There is considerable professional debate about whether ADHD refers to a specific disorder or to extremes of the normal range of behaviours. The determination of whether a young child's behaviour is excessive or severe compared to other children is complex. High activity levels, short attention spans and difficulty controlling their impulses are behaviours that often characterise young children and may represent developmentally appropriate behaviours. Surveys of parent opinion of children under four years old demonstrate that over 50% of parents report their children to be 'hyperactive'. The common, current rating scales and questionnaires that are used to assess and diagnose ADHD have been designed for older children (over seven years old). The behaviours described in these measures (eg inability to remain seated for a period of time) are not necessarily appropriate for younger children. These measures are also based on comparisons with older children: age appropriate comparisons are not available for the younger age population. It is not valid to draw conclusions on the basis of comparing the behaviour of a four-year old child with that of an eight year-old child. Some professionals use questionnaires with preschool children to assess hyperactivity and attention problems. These do not give a diagnosis but can be used to advise clinical interventions. Young children display a wider variation of behaviours in different settings, further complicating the reliability and validity of assessment. Any assessment of a young child should include the review of the strategies addressing the learning, skills and behaviour of that child. Whilst diagnosis of ADHD in preschool-aged children could be considered, great care should be given before attaching such a diagnosis to a young child. If that diagnosis is considered, a second expert opinion is often sought as confirmation. There is no medical or other test that absolutely confirms or rules out a diagnosis of this condition. Diagnosis and assessment of ADHD are complex and require analysis by doctors and psychologists who have the information and training on which to make such a judgement. 2 8 National Health and Medical Research Council. 1997. Attention deficit hyperactivity disorder. Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students ADHD and other difficulties 2.3 The co-existence of other difficulties/conditions which may also require diagnosis, treatment and intervention can add to the complexity of managing some children/students with ADHD. Research on ADHD indicates the possible coexistence of conditions and disorders such as: • learning difficulties • language difficulties • poor, short-term memory • underachievement at centre/school • immature motor coordination • low self-esteem, emotional immaturity • mood and anxiety disorders • Tourettes syndrome: 'multiple motor tics/spasms and one or more vocal tics/utterances occurring many times a day' Role of teachers and care workers 2.4 As with any other medical or psychological condition, centre and school-based staff members cannot diagnose ADHD. Nor should they anticipate a diagnosis (for example by telling parents that they suspect ADHD or advising them to go to their doctor for medication). If staff members are concerned about a child/student's behaviour they should share their observations with the child’s parent(s) as soon as possible. They may discuss referral to departmental guidance, behaviour or early childhood services or to a private practitioner for appropriate assessment and advice. It is not the role of teachers to question a doctor’s or psychologist’s diagnosis. They may however, seek, through the parent, further clarification about the student’s management plan and offer to document behavioural observations to advise review of this plan. and for school aged children: • oppositional defiant disorder: negative, provocative, compulsive behaviour (eight years and older) • conduct disorder: deliberate breaking of rules with lack of consideration of others, lack of 'moral conscience' (ten years and older) • obsessive-compulsive disorder: recurrent obsessions or compulsions that are severe enough to be time consuming or cause marked distress or significant impairment (five years and older). Many individual, family, centre/school and other environmental factors can contribute to a child or student acting in a particular way. What constitutes difficult or inexplicable behaviour may be a short term or long term response to changes in the individual’s circumstances. If ongoing concern remains, further assessment, by doctors (including psychiatrists and paediatricians) and psychologists, is recommended. Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students 9 3 3.1 Teaching and behaviour management strategies Early childhood Q What are some good ways to adapt teaching and behaviour management strategies in the centre environment? A There are many successful strategies. Most involve positive behaviour management strategies and good teaching practice. Effective management of children who exhibit attention difficulties, poor impulse control or overactivity begins with a thorough observation of the centre, the program, the teaching style, the child's behaviours and the interactions between these factors. In line with effective approaches, consider: behaviour management Environmental adaptation This includes the physical environment, the program or curriculum, teaching and interaction styles and the overall 'culture' of the setting. Positive programming and teaching This refers to adapting the curriculum to meet the child's needs and may involve the teaching of specific skills. Corrective strategies These are specific behavioural strategies used to increase or decrease specific behaviours. Collaboration with parents This is necessary to ensure generalisation of approach. consistency and Environmental adaptation Adaptations can be made to: • ensure all areas are safe, visible and well monitored • establish both 'active' areas and 'quiet' areas • organise busy traffic areas well away from areas requiring focus and concentration • identify 'hot spots' and re-organise them • identify 'distracters' (noise, visual material) and modify them. Positive programming and teaching Programs can be adapted to: • provide warning before a change in activities and close supervision during transition times • provide limited choices during free activity • use activity cards to follow through until the task is completed • break tasks down into smaller steps • allow extra time to complete tasks • take the child's attention span/activity level into account when organising daily activities (eg mat time) 10 • use smaller groups when possible • utilise the child's strengths and interests when planning activities routines and create a predictable environment be consistent use visual signs to cue teaching and provide reminders for the child teach and practise centre routines, with patient repetition, as needed. • establish • • • The teaching and interaction style supports the student when it: • is positive and enthusiastic • models positive thinking about learning and the process of learning • builds a positive relationship with the child, aiming towards building the child's self confidence and self esteem • shows a genuine interest in the child's strengths • acknowledges small steps of progress or small changes for that individual • encourages effort as well as outcome • frequently provides encouraging feedback. Children can be taught explicitly to: • request help • request a break • say 'stop' • say what they need rather than gesture or wait. Teaching listening skills is fundamental to building success. This can be enhanced when the teacher: • models good listening • consistently establishes eye contact and the child's attention when speaking to him/her • uses language the child understands • asks the child to repeat back instructions • programs listening games • provides specific feedback - ‘great listening!'. Teaching self control is most important. This will be enhanced when teachers: • use the 'stop, think, do' process • teach body awareness • discuss the consequences of actions • introduce the idea of ‘your choice' in relation to behaviour. Teaching coping skills will provide a foundation for effective functioning. This includes explicitly teaching: • anger management • relaxation strategies • assertive behaviour. Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students Teaching social skills may be especially important. Ideas to help include: • teach the language which facilitates positive social interaction • teach specific skills such as using people's names, taking turns, sharing, saying sorry • teach conflict resolution in a way which is developmentally appropriate. Corrective strategies This group of children may need rewards and reinforcement to a much greater degree than others. Ways to achieve this include: • increase the use of verbal reinforcers (eg praise, encouragement, feedback) • increase the use of non-verbal reinforcers (eg smiles, glances, nods) • negotiate cues you will use specifically with the child (eg touching your ear as a cue for the child to listen) • use tokens, star charts, work and behaviour contracts • allow the child to earn activity time • negotiate rewards, making sure they are important to the child and 'earnable' within a short time • renegotiate rewards regularly so their novelty does not wear off. When rewards are delayed offer more frequent feedback. Give reminders of the goal and express confidence that the goal can be achieved. With all these actions it will be necessary for staff to work in a consistent, planned way as much as possible. Opportunities to learn and practise skills in a variety of ways over a period of time will be needed. Time-out or other deterrents are best used in a planned and specific way. Children with attention difficulties, who have difficulty controlling impulses or who are very overactive can be extremely challenging. An important message for staff is manage your own stress level. Look after yourself! Ways to do this include: • monitor your own stress • accept the limits of the situation • define for yourself small goals/targets and think in 'small steps of progress’ • involve other centre staff, or support staff in problem solving or when working through the heat of a particularly stressful incident/day. Early childhood psychologists are able to provide more information about these strategies. Collaboration with parents Parents are generally the first and most significant carers and educators of their children. Effective support for these children requires an on-going partnership between parents and centre staff. Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students 11 3.2 School Q What are some good ways to adapt school teaching and classroom management strategies ? A There are many successful approaches. Most are good teaching practices recommended for use with all students Build positive relationships Children with attention difficulties or poor impulse control, or who are overactive will be supported by teaching and classroom management strategies which build positive relationships. Ways to achieve this include: • get to know the students’ interests • have informal conversations • use the students’ interests within a reward system • have fun. Foster emotional resilience Teachers are in a position to communicate optimism and hope and help put difficulties into perspective. Ways to do this include: • be reassuring • model a positive approach to ‘mistakes’ • use humour • use encouraging language, talking in a positive way about the future • emphasise ‘progress’, identifying measures of progress and involving the student in the process • discuss emotions within the curriculum, identifying alternative, acceptable ways of dealing with anger, frustration, happiness and sadness • allow time to ‘cool off’ when angry. Establish classroom routines These students need a predictable environment. Ways to achieve this include: • • • visually display and review rules refer to an overview for the day/lesson be consistent when managing behaviour. These students are greatly supported by consistent and predictable teacher expectations and behaviour management strategies. It is helpful when the teacher: • stays calm • is non-confrontational while maintaining expectations • gives reminder cues • has curriculum activities ready for difficult times of the day • closely monitors transition times. 12 Develop a plan for the unexpected It is helpful to be prepared for unexpected changes to routine and interruptions. Useful strategies include: • give feedback about the student’s level of excitement and asking for calmer behaviour • use peer support • use a distraction such as an errand or classroom task • have a teacher-buddy classroom. Use rewards and reinforcements This group of students may need reinforcers to a much greater degree than other students. Ways to achieve this include: • increase the use of verbal reinforcers, praise, encouragement and feedback • increase the use of non-verbal reinforcers, such as glances and smiles • negotiate and use cues, for example touching the ear means ‘listen’ • use tokens, star charts, work contracts • provide a system of (individual, small group or whole class) reward, through ‘earned’ time • negotiate rewards, ensuring they are ‘earnable’ in the short-term, and use them for a limited-time before renegotiating new rewards. When rewards are delayed, offer more frequent feedback. Give reminders of the goal and express confidence that the goal can be achieved. Help develop planning skills When tasks require sustained attention planning and organisation, this group needs assistance. The teacher can: • prepare the student for ‘special effort’ sustained attention • break the task into smaller steps • use story plans or project plans • display relevant cognitive question prompts for example What do I have to do? What’s the first step ... then ... last? Am I following my plan? Is my answer sensible, realistic? Am I happy with this work? • use cue cards and other signals to help the student sustain attention/follow their plan • adopt general approaches such as ‘stop-think-do’ • provide a checklist to help the student manage the task (brainstorm with whole class before beginning the activity; the student might need to be trained to use the checklist) • use a buddy/teacher to check the homework diary • use a tape-recorder to tape assignments/homework. Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students Help develop memory Teach group skills and social skills explicitly Difficulties with short-term memory are common in this group. Ways to help minimise the effects of poor shortterm memory include: • recap the last lesson, that is refer to important points and create links to the new lesson • visually display class rules and current themes and tasks • have procedure sheets, for example for consistent formatting of work • ask the student to repeat or summarise instructions • encourage the student to develop their own strategies, such as writing things down or taperecording reminders and instructions. Parents of children with ADHD frequently express concern about their child lacking social skills and being socially rejected. Some ways to enhance social skills are to: • use explicit social skills teaching programs • sit near the student in group activities • prepare the student for group activity by rehearsing a relevant focus, for example ‘listening’ or ‘watching body language’ • give the student a specific task in the group • frequently check for feedback asking the student to evaluate their own performance and progress with social skills • create lots of opportunities for the development of social skills within a structured setting, for example paired learning, groupwork using explicit roles such as facilitator or observer, organising a buddy-forthe-day or person of the week. Manage time-on-task Students will benefit from explicit strategies to increase their time-on-ask. Strategies include: • seat the student between quieter students • get the student to nominate a peer ‘study-buddy’ as a good influence • use egg-timers or clocks • have the student monitor their own performance, for example colour in the smiley face or circle the rating which describes effort and time on task in the previous lesson • negotiate an on-task reminder cue • for students who work quickly and impulsively introduce a visual record of checking work, for example writing ‘ch’ on the bottom of the page to indicate checking has been done. Be aware of the student’s need to move Students who are overactive will benefit from extra opportunities to move around. Ways to accommodate this include: • introduce and legitimise a ‘seat-break’, for example to run an errand, or stand up to work • allow a few minutes to stretch between lessons • supervise transition times closely. Manage your own stress level Look after yourself! You can: • monitor your own stress • manage emotional involvement • accept the limits of the situation • give yourself small goals/targets; think in small steps • involve colleagues. Support available School psychologists are able to provide more information about these strategies and to explore either concerns you may have about the student. Collaboration with parents Parents are generally the first and most significant carers and educators of their children. Effective support for these children requires an on-going partnership between parents and centre staff. Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students 13 4 Medication Doctors may prescribe medication for children diagnosed with ADHD. When correctly prescribed use of such drugs as Methylphenidate (brand name Ritalin) and Dexamphetamine (brand name Dexamphetamine) have been found to be both effective and safe in the short term3. These drugs, in the prescribed dosages, have effects on most people rather than having specific effects only on those diagnosed as having ADHD. This means that response to medication is not a diagnostic test. For preschool age children caution must be exercised in using medication as there is limited research on the effects of medication in this age group. The research does indicate that children of this age do not respond as well to medication as older children. The side effects of medication are more pronounced in young children3. Research into the use of medication with students diagnosed with ADHD/ADD suggests that 70-80% of students show significant improvements in their ability to sustain attention, to concentrate, to control impulsivity and to function socially and academically. There are well documented side effects of stimulant medication. These include appetite loss, irritability, sleep disturbance and mood or tic problems. The doctor is responsible for monitoring any such sideeffects. Drug therapy should be combined with educational, family and behavioural strategies. This requires liaison and effective communication between doctors, educators, parents and others involved, such as psychologists or family therapists. Multiple drug regimes, in which a child is prescribed a combination of more than one drug, are not recommended by most paediatricians and particularly not for preschool aged children. If asked to supervise multiple drug regimes, staff can, through the parent, seek clear confirmation from the treating doctor that this is required during the school day. 3 14 National Health and Medical Research Council. 1997. Attention deficit hyperactivity disorder. The role of centre and school staff in medication management Support offered by school staff to children or students who are prescribed medication is determined by duty of care and occupational health safety and welfare obligations, and the requirement to ensure there is no discrimination in provision of departmental services to students with health care needs. In practice this means that school staff should: • actively seek to obtain up-to-date, relevant health care information This will include a plan for medication details which, for medical reasons, cannot be taken outside school hours. Parents should provide a medication plan, completed by the doctor or pharmacist, before asking teachers to accept responsibility for supervising student medication. • store medication Any medication accepted by the school to be stored for a student must be in the original dispensing container. Schools should ideally accept medication on a daily basis and certainly no more than a week's supply at a time. Parents can ask the pharmacist for a second fully labelled container for medication kept at home. • record medication as supervised by school staff Schools do not generally administer medication. They can supervise a child taking medication and must record this in a daily medication log, detailing the student's name, medication, dose, method of taking medication and the time it was taken. • negotiate ways for students to remember to take their medication Staff cannot guarantee they can remind children to take their medication, but they can help establish reminder systems, particularly for children with ADHD who often have difficulty remembering tasks. Students could wear alarmed wrist watches or medication can be scheduled at the same time as something else, for example the lunch break. • adhere to review dates Long term medication should be regularly reviewed by the doctor: medication plans for ADHD should be reviewed at least every 6 months. Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students Roles and responsibilities Effective management depends on a partnership between the student, parents, teachers and others involved, with each fulfilling clear and agreed actions and responsibilities. The following checklist can be used as a guide and should be adapted to each situation. Role of principals and directors • inform parents as soon as possible of concerns • • • • • • • • • regarding the management of the child/student’s health care, learning and behaviour management needs ensure that procedures are developed and used to resolve issues arrange for, or recommend, the involvement of resource persons, support groups or other people or agencies who may be able to help in formulating support plans manage development of an individual child/student's support plan which sets out agreed roles and responsibilities, monitors and reviews plans, and ensures planning for transition from one setting to another require written advice from professionals treating all children/students diagnosed with ADHD, and ensure this is incorporated onto the child/student’s medical records ensure that management needs including medication arrangements (if medication is prescribed to be taken within school hours) are based on written medical advice and are in accordance with school policy communicate student management and support needs to relevant staff in a confidential manner, and implement support plans in an appropriate manner ensure efficient and confidential processes for storage of and staff access to medical record cards and child/ student support plans ensure that record cards and child/student support plans are updated regularly ensure that staff have access to information and training opportunities in order to fulfil their agreed roles as documented in the child/student’s support plan. Role of teaching and support staff • keep the principal/director informed • encourage and provide opportunities for the • • • child/student to take responsibility for his/her behaviour in a manner that reflects age, stage of development and capability become familiar with the medical record cards and individual support plans of children/students in your care, respecting the confidential nature of the information contained in these records support the management of children/students diagnosed with ADHD as documented on medical record cards and in the individual's support plan inform parents as soon as possible of concerns regarding management of the child/student’s health care, learning and behaviour management needs 5 • work with other professionals, such as school • • • psychologists and behaviour support staff, in consultation with parents, if concerns continue ensure learning strategies include children/students diagnosed with ADHD: this will involve strategies important for all children/students and those requiring explicit planning and perseverance for children/students diagnosed with ADHD help to plan and implement a student's support plan, if one is needed document and report on the child's/students’ behaviour and learning, including reporting observations of individual behaviour and learning, using checklists and other instruments. It does not involve making assessments of the effects of medication, or making or presuming a diagnosis. Role of parents/caregivers/guardians • continue to take primary responsibility for their child's well being and educational program • encourage and provide opportunities for the child to • • • • • • • • take responsibility for her/his behaviour in a manner that reflects her/his age, stage of development, and capability approach the centre/school if in need of information or support, or if difficulties arise be prepared to discuss how concerns can be resolved, or whether other people or resources are needed help write their child's support plan and undertake home-based management strategies which support and generalise the plan involve other professionals such as support services within DETE, doctors and/or psychologists, if concerns remain inform the centre/school if their child has been diagnosed with ADHD complete, with the doctor, the medical record and the medication schedule liaise with the doctor and centre/school to ensure that details of managing medication (if necessary) are negotiated and carried out, and they involve minimal supervision or interruption to the centre/school day deliver any prescribed medication required with the doctor’s written instructions, in a single-dose fully labelled container (or weekly dose if that has been negotiated). Role of students • take increasing responsibility, whenever safe and • possible, and in a manner reflecting their age, stage of development and capability, for their health care, behaviour and learning fulfil responsibilities as agreed through the student support plan process. Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students 15 Role of doctors or specialists in relation to centres and schools • consult with parents/caregivers/guardians on the • • • • 16 most effective way to provide additional information to the centre or school about the child’s individual management needs liaise, if appropriate, with centres or schools to assist in or advise on the implementation of intervention programs If medication is prescribed and must be taken during centre/school hours: provide a medication plan for the school day recognise that centre/school staff cannot force a student to take medication try to make arrangements (eg timing) that will fit in with the centre/school and the child/student's program. provide general information about ADHD and guidelines for helping the child/student if requested support and contribute, if appropriate, to reviews of interventions and programs devised to assist diagnosed/assessed children or students. Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students Sample documentation FORM 1 sample letter from a doctor or psychologist to a principal/director FORM 2 Learning behaviour questionnaire FORM 3 General health information FORM 4 Medication Plan Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students 6 17 FORM 1 Sample letter from a doctor or psychologist seeking cooperation in completing a request for information. This letter implies that some form of behaviour observation sheet is attached. Doctor/psychologist’s name: ........................................................................................................................ Address: ........................................................................................................................................................... Phone:.......................................................................... Fax: ......................................................................... Dear Principal/Director I write regarding one of my patients/clients: Name: ...............................................................................................Date of birth: ........................................................... requesting information concerning his/her behaviour at centre/school. This letter is written in accord with agreed Department of Education, Training and Employment procedures for obtaining advice from a centre/school concerning a child’s behaviour and learning when the information is needed to assist in an assessment/diagnostic process or to be used in a treatment/intervention plan. To assist with this process, please complete the enclosed questionnaires: (a) Name of rating scale or questionnaire (b) Learning/Behaviour Questionnaire for behaviours causing the greatest concern at centre/school. Please ring me on ............................................................................................. if you would like to discuss this request. What are the best times for me to contact you? ................................................................................................................... .............................................................................................................................................................................................. Permission to release information: Parent’s or guardian' s authorisation .................................................................................................... give permission to the staff of ...................................... (name of parent / guardian) ........................................................................................................................ centre/school to release information to: (name of preschool / school) Dr/Mr/Ms/Miss/Mrs -------------------------------------------------------------------------------------------------------------------------------------(name of doctor / psychologist) concerning my child -----------------------------------------------------------------------------------------------------------------------------------(name of child) for the purpose of assisting in the assessment and management of my child. (Signed) 18 _______________________________ _____________________ Name of parent / guardian Date Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students FORM 2 LEARNING BEHAVIOUR questionnaire Child/student's name: ........................................................................................................................................ Date of birth: ....................................................................................................................................................... 1. What are the child/student’s interests and personal strengths? 2. What behaviours are causing the greatest concern in your setting? 3. Do you have concerns in relation to the child/student’s learning? If so, please outline. 4. When were these difficulties first reported? And by whom? 5. Please describe how often, for how long, and at what level of intensity the concerning behaviours have been occurring. Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students 19 FORM 2 6. Please describe how the child/student's difficulties impact on his/her functioning in your setting. 7. Do these behaviours occur in all situations with all staff? If not, please specify any discrepancies. 8. Have any interventions been implemented? If yes, please specify and indicate how they worked. 9. Who has provided support or advice in developing these interventions? 10. Are there any factors that seem to affect/be related to the behaviours or learning difficulties? Please attach any additional comments Thank you for your time and support Dr/Mr/Ms/Miss/Mrs ................................................................................................................................................................ Date ...................................................................................................................................................................................... 20 Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students Centre or School FORM 3 GENERAL HEALTH INFORMATION Confidential To be completed by the treating health professional (general practitioner, psychiatrist, psychologist, nurse) for any children/students who need additional care/supervision related to their mental health and well-being. This information is confidential and will be available only to supervising staff and emergency medical personnel. Child/Student Name ................................................................................. Date of Birth ......................................... Family name First name Medic Alert Number (if relevant) ...................................................................... Review Date .......................................... Description of the condition It is not necessary to provide a full medical history. Centre/school staff need know only information relevant to the care, education and welfare of the child/student while in their care. Management issues for the centre/school Please include only information that centre/school staff will need to care for and teach the child/student, for example: impact on capacity to attend and participate in daily classroom activities limitations on physical activity need for rest/privacy need for additional emotional support behaviour management plan considerations necessary for camps, excursions Please provide details. Additional information/requests attached to this record Medication plan (if supervision of medication is recommended at the centre/school) Yes No Behaviour/learning questionnaire for completion by staff Yes No Observation/behaviour log for completion by staff Yes No General information about this child/student’s condition Yes No Other (please specify) ................................................................................................................................................... Yes No ............................................................................................................................................................................................................................... Authorisation and release Health professional ............................................................................................................... Signature....................................................... Printed name Address........................................................................................................................................................................................................... Phone ....................................................................................................................Date................................................................................. Should you need to contact me, with the child/student and parent’s consent, I can be reached at .............................................................. ............................................................. . Preferred times............................................................................................................................... I have read and understand this information and any attachments indicated above. I approve the release of this information to centre or school staff and emergency medical personnel. I understand it is my responsibility to ensure this information is up-dated each year and more often if necessary. Parent/Guardian or Adult Student .............................................................................................................................................................. Family name First name Signature ........................................................................................ Date ....................................................................................................... Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students 21 Centre or School FORM 4 MEDICATION PLAN Confidential To be completed by the DOCTOR and the PARENT/GUARDIAN. This information is confidential and will be available only to supervising staff and emergency medical personnel. Child/Student name .................................................................................. Date of birth .......................................... Family name Medic Alert number (if relevant) First name ..................................................................... Review date .......................................... To the doctor Please: complete all sections of this form schedule medication outside care/school hours wherever possible. be specific: As needed is not sufficient direction for teaching staff nominate the simplest method. For example: Oral or ‘puffer’ medication is much easier to arrange than a nebuliser. Please note: staff accept only medication which is in the original, fully labelled pharmacy container staff do not monitor the effects of medication as they have no training to do this staff are instructed to seek emergency medical assistance if concerned about a child/student’s behaviour following medication. NAME OF MEDICATION How much is to be taken at the following times (Cross X squares where no medication is needed) Before school/session care Recess/ morning break time Lunch time After school/session care Authorisation and release Medical practitioner .............................................................................................................. Signature....................................................... Printed name Address........................................................................................................................................................................................................... Phone ....................................................................................................................Date................................................................................. I have read and understand this information and any attachments indicated above. I approve the release of this information to centre or school staff and emergency medical personnel. I understand it is my responsibility to ensure this information is up-dated each year and more often if necessary. Parent/Guardian or Adult student .............................................................................................................................................................. Family name First name Signature ...............................................................................................................Date................................................................................. 22 Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students Resources and support services: South Australia 7 The most effective management support for the child or student uses a combination of educational, family, behavioural, psychosocial and medical interventions, including: • modification of curriculum content and delivery with explicit teaching of new skills • behaviour management (behaviour modification, cognitive behaviour therapy) • family support • for some older children, medication. Support services and resources within the South Australian Department of Education, Training and Employment for preschool-aged children: • Early Childhood Support Services (ECSS) This is a multidisciplinary team of psychologists, special educators, speech pathologists and social workers who have specialised skills in working with young children. They may be involved in the identification and assessment process and assist staff in developing and implementing management plans involving a range of strategies best suited to the needs of the child, centre and family. • Training and development These programs, provided by the ECSS team, include both information sessions and skills based courses. • Early Childhood Resource Centre This centre contains a wide range of books, videos, and articles. Support services/resources within the department for school-aged students include: • Guidance officers Guidance officers are registered psychologists and teachers. They may be involved in helping the classroom teacher to clarify issues related to the student’s learning and ways to adapt the curriculum to meet the student’s needs. Assessment of cognitive and social-emotional functioning may also be completed. The guidance officer may have a role in facilitating discussion between the teacher and parent to further explore the student’s educational needs and how these can be met in an integrated way. Such discussions may involve senior staff, school counsellors or others. • Behaviour support teams Behaviour support teams comprise trained, experienced teachers working with students with behavioural difficulties. They can help teachers, students and parents focus on behavioural strategies to manage difficult behaviour. • Speech pathologists Speech pathologists can assess a child’s speech and language needs and provide programming advice. These services can be contacted at departmental district offices, usually through a referral from the school principal, or centre director or teacher. Prereferral discussion is often appropriate. Resource centres and support personnel can provide advice about the many relevant resources/programs in areas such as collaborative learning, development of social skills, anger management, conflict resolution, peer mediation, developing self-esteem, coping with change, relaxation and inner mental training, optimistic thinking. There are also materials about ways to monitor time-on-task, improve memory, cognitive strategies to help self-talk/planning, and develop thinking skills, for example, the Internet/Web Page access Newsgroup or Listserv, or the Departmental web page – www.nexus.edu.au Services outside the department include: • Child and Adolescent Mental Health Services • Child and Youth Health, which also has a 24 hr Parent Helpline • general practitioners, who can refer to specialists such as paediatricians and child psychiatrists • private psychologists • therapists including speech therapists, family therapists, occupational therapists. The parent information, which follows, can reproduced by centres and schools for distribution. Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students be 23 Support at your centre Where can you get support? Difficulties with listening, acting before thinking or being overactive can interfere with your child’s learning and affect interactions with other children. Please discuss with centre staff any concerns you have and ways to help you address these concerns. The following agencies can provide support: Staff can, with your permission, request support from early childhood support services which include psychologists, speech pathologists, social workers and special educators who have specialised skills in working with young children. Good communication with the centre is essential. Please approach the centre if difficulties arise and discuss how they can be resolved. • local community centres (various supports) • Child and (CAMHS) Eastern Western Northern Southern Adolescent Mental Health Services (Paradise) ....... Ph: 8207 8999 (Pt Adelaide) ... Ph: 8341 1222 (Elizabeth) ....... Ph: 8252 0133 (Marion)........... Ph: 8292 7744 (Noarlunga) ..... Ph: 8362 1234 (Flinders) ......... Ph: 8204 5412 Mt Gambier ....................... Ph: 8724 2446 Murray Bridge ................... Ph: 8535 6780 Berri ........................ Ph: 8582 4290 • Child and Youth assessment). Phone: 8303 1500 Health ATTENTION DIFFICULTIES, POOR IMPULSE CONTROL OR OVERACTIVE BEHAVIOURS in (developmental preschool-aged children • Parent Help Line (advice). Phone: 1300 364 100 • Women’s & Children’s Hospital. Phone: 8204 7000. You can also get information from: • Attention Disorders Phone: 8221 5166 Association of SA. • Students and Youth with Attention Deficit Disorder, PO Box 6058 Halifax Street 5000. Phone: 041 227 3310 Parents, children and professionals working together • books and videos at your local library • newsgroups or listserv on the Internet • private psychologists or doctors listed in the yellow pages. 24 Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students What are we talking about? Recommended interventions Professional help If your child has difficulty listening, is easily distracted, acts before thinking or is always on the go, remember: An approach uses the benefits of behaviour management strategies and teaches new skills, rather than medication, is considered to be best practice for preschool-aged children. A doctor or psychologist will consider other factors that could be causing the behaviour such as neurological, developmental, emotional, family or physical (eg earache, headache) issues. He/she will want to take a family history and ask you to describe how your child behaves in a range of settings. • many children show these tendencies to some degree as they’re growing up and learning to control themselves • most children eventually respond to positive teaching and parenting practices that shape behaviour and help the child take increasing responsibility. If your child’s behaviour continues to concern you and doesn’t respond to your management you might like to: • talk with staff about how your child behaves at the centre • talk to a psychologist or your family doctor about your child. Effective communication between parents and all the professionals involved is also crucial. Interventions for use with young children include: • modification of centre programs Centre staff might be asked to comment on how your child behaves at the centre. • behaviour strategies • teaching new skills (eg social skills, listening) • specialised therapies (occupational, speech). Each child, however, is unique and complex, and will need individual assessment and an individual intervention plan. The issue of medication Medication is not generally recommended for preschool-aged children. If your child is prescribed medication, the preschool will need written advice on the proposed management. Other conditions Other conditions can make the management of a child with attentional or behavioural difficulties more complex. These other conditions can include: • learning difficulties • language difficulties or poor short-term memory • immature motor coordination • low self-esteem, emotional immaturity • mood/anxiety disorders • behavioural difficulties. Further assessment and intervention by a paediatrician, psychiatrist or psychologist could be required if your child has other difficulties. 25 Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students Support at your school Where can you get support? Difficulties with attention, impulse control or overactivity can interfere with your child’s learning and affect interactions with other students. Please discuss with school staff any concerns you have and ways to help you address these concerns. The following agencies can provide support: local community centres (various supports) Child and Adolescent Mental Health Services (CAMHS) Eastern (Paradise) ....... Ph: 8207 8999 Western (Pt Adelaide) ... Ph: 8341 1222 Northern (Elizabeth) ....... Ph: 8252 0133 Southern (Marion)........... Ph: 8292 7744 (Noarlunga) ..... Ph: 8362 1234 (Flinders) ......... Ph: 8204 5412 Mt Gambier ....................... Ph: 8724 2446 Murray Bridge ................... Ph: 8535 6780 Berri ........................ Ph: 8582 4290 The school can, with your permission, request support from district support services which include guidance officers (educational psychologists), speech pathologists and behaviour support teams. If your child is diagnosed as having ADHD the school will need written advice on any proposed interventions. If your child needs to take medication during school time please provide the doctor’s written instructions to the school and deliver the medication in a single dose, fully labelled container. Good communication with the school is essential. Please approach the school if difficulties arise and discuss how they can be resolved. Remember, home support is vital. Child and Youth assessment). Phone: 8303 1500 Health (developmental Parent Help Line (advice). Phone: 1300 364 100 Women’s & Children’s Hospital. Phone: 8204 7000. You can also get information from: Attention Disorders Association ph 8221 5166 in of SA, Students and Youth with Attention Deficit Disorder, PO Box 6058 Halifax Street 5000, Ph: 041 227 3310 books and videos at your local library newsgroups or listserv on the Internet private psychologists or doctors listed in the yellow pages. 26 ATTENTION DIFFICULTIES, POOR IMPULSE CONTROL OR OVERACTIVE BEHAVIOURS or ATTENTION DEFICIT/ HYPERACTIVITY DISORDER (ADHD) school-aged children Parents, students and professionals working together Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students What are we talking about? Recommended interventions Professional help If your child can’t concentrate or listen, is easily distracted, disorganised, acts before thinking and is always active, remember: many children show these tendencies to some degree as they’re growing up most children eventually respond to positive teaching and parenting practices that shape behaviour and help the child take increasing responsibility. The best outcomes are when people work together using a combination of educational, family, psychosocial and medical interventions. In assessing the situation, a specialist will consider other factors that could be causing the behaviour. These may be neurological, developmental, emotional, family or physical (eg earache, headache) issues. He/she will want to take a family history and ask you to describe how your child behaves in a range of settings. If your child’s behaviour continues to concern you and doesn’t respond to your management you might like to: talk with the classroom teacher about how your child behaves that way at school talk to a psychologist or your family doctor about your child. Successful interventions are: modification of school programs family counselling behaviour modification cognitive–behaviour therapy other therapies (occupational, speech) medication teaching new skills (social skills, listening). Each child, however, is unique and complex, and will need individual assessment and an individual intervention plan. School staff might be asked to comment on how your child behaves at school. Other conditions Other conditions can make the management of a child with ADHD more complex. Difficulties that can accompany attention difficulties, poor impulse control or overactive behaviours include: learning difficulties language difficulties or poor short-term memory immature motor coordination low self-esteem, emotional immaturity mood/anxiety disorders behavioural difficulties. Further assessment and intervention by a paediatrician, psychiatrist or psychologist at some stage of your child’s schooling could be required if your child has other difficulties. 27 Attention difficulties, poor impulse control, overactivity or ADHD (attention deficit/hyperactivity disorder): teaching and managing children and school students