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November 1, 2001
Vol. 59
No. 3

Reconceptualizing ADHD

New findings suggest that ADHD is a learning disorder rather than a behavioral disorder. Thus, teaching strategies that target cognitive weaknesses may be more effective than behavioral management techniques in promoting academic success for students with ADHD.

In schools in many parts of the world, it is likely that every classroom has at least one or two students who have been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). These students have a hard time concentrating on one thing for more than a few minutes, and the slightest noise may distract them. As a result, their work is often incomplete and full of errors. They may find it difficult to organize and complete a multistep task or learn something new. Often they do not think ahead and forget to write down homework assignments or take needed materials home. They may interrupt the class or talk excessively—yet give minimal responses or not even remember their response when called upon to answer a question. For many, sitting still for an entire lesson is impossible.
With about 2–5 percent of school-aged children worldwide diagnosed with ADHD, educators are confronted daily with the challenges of trying to teach these students along with the rest of the class. A further complication is that students vary in the type of ADHD symptoms that they exhibit: some are slow-moving, quiet, dreamy, and inattentive; a few are loud, impulsive, and con-stantly in motion but can listen on the run; and many show both inattentive and hyperactive or impulsive behavior. In any case, these behaviors vary day to day, minute to minute, and across different learning contexts. Many students with ADHD also have specific learning disabilities and additional mental health problems that may lead to the misconception that the term ADHD encompasses all problematic classroom behavior.
Increasingly, teachers are at the front line, identifying students who have these types of difficulties, assisting with diagnostic assessment or treatment evaluation by filling out questionnaires, and trying to implement the recommended behavioral techniques for increasing desired behavior and decreasing unacceptable behavior. Too often, however, improvements are short-lived, and students and teachers continue to struggle with problematic behavior and poor academic performance.
Why is this so? One explanation is the lag in translating scientific advances from the laboratory to the classroom. Educators may lack knowledge about the current understanding of ADHD, hold misperceptions about ADHD, and continue to use traditional intervention approaches that are inconsistent with current knowledge and have proven ineffective. What do we now know about ADHD that may alter how teachers handle students with ADHD?

New Insights

The direct causes of ADHD are still unknown, but science is yielding important clues. Contrary to popular belief, research indicates that ADHD is not usually caused by food allergies, excess sugar, too much TV, poor parenting, poor home life, or poor schools. Rather, neurobiological factors play a major role.
ADHD is a heritable, brain-based disorder. ADHD tends to run in families, suggesting that genetic factors play a role. For example, students with ADHD are likely to have at least one close relative with ADHD. Even more convincing are the findings that identical twins are much more likely to both have ADHD than are fraternal twins. This research suggests that about 80 percent of the differences in inattention, hyperactivity, and impulsivity between students with and without ADHD can be explained by genetic factors (Kuntsi & Stevenson, 2000). Scientists have even identified some genes that appear to be linked with ADHD. These genes regulate the transport the chemical dopamine, one of the brain's neurotransmitters that convey signals from one neuron to another. Dopamine imbalances appear to be closely related to ADHD symptoms. Nongenetic factors include premature birth, maternal use of alcohol and tobacco during pregnancy, and exposure to high levels of lead in early childhood.
Other researchers are identifying regions of the brain that are involved in ADHD; discovering what happens in those regions when individuals with and without ADHD are asked to process, remember, and respond to different types of information; and finding out how stimulant medication, such as Ritalin, affects the brain's functioning. For example, researchers at the National Institute of Mental Health found that several regions of the brain (for example, the right prefrontal cortex; two of the clusters of nerve cells found deep in the brain, known as the basal ganglia; and regions of the cerebellum) are significantly smaller in both boys and girls with ADHD than in those without it (Giedd, Blumenthal, Molloy, & Castellanos, 2001). These brain regions, which are rich in dopamine, are known to regulate attention, working memory (the ability to retain, associate, and manipulate information "online" over brief time intervals), impulsiveness, and motor control. Recent studies have shown that stimulant medication, widely used to treat ADHD, works by increasing the levels of dopamine in the brain.
Smaller size of specific brain regions does not necessarily mean poorer function, but several studies suggest that not only do individuals with ADHD perform more poorly than those without ADHD when confronted with tasks requiring a high working memory load, but also that different brain regions are activated in individuals with ADHD while performing the task.
An intriguing illustration is a recent study (Schweitzer et al., 2000) in which adults with and without ADHD were asked to listen to a series of numbers. As each number was given, they were to add it to the previous number and say the answer aloud. For example, if the numbers read aloud were 3, 2, 5, 4, the answers would be 5, 7, and 9. The adults with ADHD were more inclined to add the new number spoken to the sum of the two previous ones, rather than adding it to the last number in the series, and often "missed" the next new number.
Also, those with ADHD explained that they performed the task by visualizing images rather than by hearing the spoken numbers—the strategy described by the adults without ADHD. Findings from brain-imaging technology corroborated their performance descriptions. Regions associated with visual processing were activated in the adults with ADHD, whereas regions associated with memory and the processing of auditory information were activated in adults without ADHD.
Why these differences occurred is unclear. One possibility is that the adults with ADHD were using a coping or compensatory strategy (albeit an ineffective one). Children with ADHD also exhibit difficulty with tasks that require them to rapidly and continuously update and use information "online"—a working memory demand evident in many classroom activities, such as listening to a teacher's explanation while taking notes.
Cognitive problems are primary rather than secondary features of ADHD. Current theories propose that the behavioral symptoms of ADHD are not primary features of the disorder but are attributable to underlying deficits in cognitive control processes that guide both behavior and cognitive functioning (Barkley, 1998). Working memory is one type of cognitive control process implicated in ADHD. Recent research indicates that working memory plays a major role in helping the mind focus and screen out distractions. Scientists have shown that even well-functioning, healthy adults become highly distractible when they have to think hard and continually rehearse information, which puts a heavy load on working memory (de Fockert, Rees, Frith, & Lavie, 2001). In other words, "the ability to act upon relevant information and ignore irrelevant distractors depends upon the availability of working memory" (Wickelgren, 2001, p. 1685).
Working memory is required for many complex cognitive activities, including reading comprehension, mental arithmetic, planning, and problem solving. Not surprisingly, therefore, researchers have found that individual differences in children's working memory abilities and inattention are related to academic achievement. One study used measures of working memory to identify, with a high degree of accuracy, those students who performed poorly on a national curriculum assessment in language arts and mathematics (Gathercole & Pickering, 2000). Another found that attention problems in kindergarten predicted reading achievement in 5th grade, even after controlling for prior reading achievement, I.Q., and other behavioral difficulties, such as hyperactivity and anxiety. Even inattentive 1st graders with normal reading scores after kindergarten were at risk for poor reading outcomes in 5th grade (Rabiner & Coie, 2000). These findings suggest that working memory problems may account for some of the behavioral symptoms of ADHD, as well as for some of the academic difficulties. Currently, however, there is no biological or psychological diagnostic test for ADHD; diagnosis is made on the basis of a careful clinical assessment of the behavioral symptoms.
Current treatment approaches have limited impact on the cognitive features of ADHD. The two most common treatment approaches for ADHD are pharmacological (stimulant medication, most commonly Ritalin) and behavioral (behavioral management, parent training). The Multimodal Treatment Study of pharmacological and behavioral intervention for ADHD (MTA Cooperative Group, 1999), conducted by the National Institute of Mental Health, provides strong evidence of the beneficial effects of stimulant medication on the behavioral symptoms of ADHD, other disruptive kinds of behavior, and the amount of work completed. Moreover, the study found that neither behavioral interventions alone nor standard care provided in the community were as helpful as carefully managed medication for improving ADHD symptoms. The behavioral interventions used in the study consisted primarily of the systematic use of contingencies for behavioral management at home and in the classroom (for example, incentives and time-outs).
One problem is that the beneficial effects of stimulant medication are temporary. When the effects wear off—usually after three to four hours—the problems reappear. Also, the beneficial effects of stimulants on classroom behavior and academic productivity do not appear to translate into gains in academic achievement. The study suggests that the combination of pharmacological and behavioral approaches may be helpful in terms of improving noncompliance and social skills (as reported by teachers) and possibly for some aspects of academic achievement (single-word reading, for example); but this latter finding remains unclear. Moreover, there is little credible evidence that either stimulant medication or behavioral approaches have systematic and robust effects on the cognitive features of ADHD.

Implications for the Classroom

The emerging reconceptualization of ADHD as a cognitive disorder requires that educators and others rethink how to best help students with attention and behavior problems achieve academically and socially. Currently, both the pharmacological and behavioral intervention approaches target the overt behavioral symptoms of ADHD. An alternative approach is to try to moderate the behavioral symptoms by using instructional practices based on an understanding of the cognitive weaknesses associated with the disorder. The benefit is that these practices can help all students fit well into both a general and a special education classroom, and they are part of many educators' repertoires.
For the past five years, in a study funded by the Canadian Institutes of Health, we have been implementing intervention programs for students with ADHD and reading difficulties in a laboratory classroom in a regular elementary school. Our daily interactions with students who have ADHD have led to a number of observations about the types of instructional settings and methods that seem to help students manage their behavioral symptoms and achieve academically. Three key questions have guided our thinking when designing and implementing the programs.

Key Questions

Does the student have the preskills needed to acquire the knowledge or concepts that I am teaching? We noticed that many of the students had difficulty understanding the language used for instruction—such words as before, after, or more than—and thus were unable to begin the task. As a result, the students were frequently off task. Alternatively, many had difficulty with temporal concepts and could not organize themselves appropriately because they found it difficult to sequence temporal events or to use clocks to mark time. This difficulty meant that they became increasingly more focused on asking if we were finished yet than on thinking about the lesson at hand. When we posted a list of items to be completed on the board and crossed them off as they were done, however, the students were able to use the list to mark time, and time-on-task behaviors increased.
Does my lesson content and delivery match the needs of the students? Inherent in this question is the belief that teachers are responsible for closing the gap between what students already know and what they need to learn. With some students who have ADHD, the gap may be due to the lack of support they receive in accessing the content, which is related to how lessons are presented. We found that a framework adapted from the research findings of Troy Mariage, Carol Englert, and M. Arthur Garmon (2000) on early literacy instructional practices was especially useful as a way to organize and describe the types of modifications we have made to meet the needs of students with ADHD. The framework outlines four elements that teachers can use to meet the individual needs of students in their classrooms: using specific types of "teacher talk," teaching social skills, changing the level of support, and providing instructional supports.
The first element, teacher talk, includes such strategies as modeling, repeating, elaborating, and defining. For example, students with ADHD frequently have difficulty understanding language and clearly expressing themselves. A teacher can rephrase a student's sentence to help make the student's ideas accessible to the class and to give the student a model to guide future expressions. In addition, students may need to have concepts elaborated on and linked to more concrete, familiar ideas to remember the new concept more easily. For example, to help students recall the names of the Great Lakes, we had them link the name of the lake with a picture of something that they associated with the name—for example, Lake Superior and soup, or Lake Erie and ear. The links helped them recall the names much more easily.
The second element, teaching social skills, helps students learn how to interact socially in order to reduce negative comments and increase cooperative learning. We found that this element was important because many of our students were not using such social skills as taking turns during discussions. With younger children, we used a toy microphone to help them remember who the "speaker" was. Physically passing the microphone helped students to become more aware of what the concept of "taking turns" means.
The third element, changing the level of support, is crucial because we found that each of our students seemed to require different levels of support. We tended to begin new lessons using multiple supports and a teacher-directed lesson in which the teacher acted as "expert" and modeled what was to be learned. Then we used guided practice and slowly allowed the students to take more control over the process.
The fourth element, providing instructional supports, directly addresses the controlled processing or working memory deficits that many students with ADHD exhibit. Instructional supports can be reflected in the level of instruction (group versus individual), number or type of cues used, or type of correction procedures used (a question versus providing the answer). Other supports include visual aids, mnemonics, and graphic organizers. Most of these supports either reduce the working memory load of the student because they help the student maintain the needed information externally (using a list of steps, for example) or because they facilitate organization and "chunking" of information into manageable pieces (using such strategies as mnemonics or graphic organizers).
How can I help my students become self-regulated strategic learners? We found that many of the students we work with do not use efficient strategies and self-monitoring procedures. As a result, we sought to teach them both domain-specific and more general metacognitive strategies to improve their problem-solving, organizational, planning, and social skills. We also had to integrate this strategic knowledge instruction with instruction that focuses on more basic component skills.
First, we analyzed the strategy to determine which preskills needed to be taught—listening skills and temporal concepts, for example. Next, we modeled the strategy frequently and used it in different contexts, if possible. When students already knew more than one strategy, we taught them to compare the new strategy with the known strategy to help them identify the advantages of each. Finally, they practiced the strategy in a variety of situations, with slowly decreasing levels of support until they could use it independently.
  • can be applied across multiple settings,
  • addresses a frequent demand, and
  • targets a common but important problem.
  • correctly and efficiently sequences steps,
  • cues students to use specific strategies,
  • cues students to select, apply, and use appropriate skills or actions, and
  • includes only essential steps.
  • uses a remembering system,
  • is simply worded,
  • begins with action words, and
  • uses familiar words.

The Ultimate Goal

Each day we learn something new about working with students who have significant attention and behavior problems. Our guiding perspective is to try to provide instruction that will help students manage their behavior and achieve both socially and academically.

Barkley, R. A. (1998). Attention-deficit hyperactivity disorder. Scientific American, 279(3), 66–71.

de Fockert, J. W., Rees, G., Frith, C. D., & Lavie, N. (2001). The role of working memory in visual selective attention. Science, 291(5509), 1803–1806.

Deschler, D. D., Ellis, E. S., & Lenz, B. K. (1996). Teaching adolescents with learning disabilities: Strategies and methods (2nd ed.). Denver, CO: Love.

Gathercole, S. E., & Pickering, S. J. (2000). Working memory deficits in children with low achievements in the national curriculum at 7 years of age. British Journal of Educational Psychology, 70(2), 177–194.

Giedd, J. N., Blumenthal, J., Molloy, E., & Castellanos, F. X. (2001, June). Brain imaging of attention deficit/hyperactivity disorder. Annals of the New York Academy of Sciences, 931, 33–49.

Kuntsi, J., & Stevenson, J. (2000). Hyperactivity in children: A focus on genetic research and psychological theories. Clinical Child and Family Psychological Review, 3(1), 1–23.

Mariage, T. V., Englert, C. S., & Garmon, M. A. (2000). The teacher as "more knowledgeable other" in assisting literacy learning with special needs students. Reading and Writing Quarterly, 16(4), 299–336.

MTA Cooperative Group. (1999). A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder: Multimodal treatment study of children with ADHD. Archives of General Psychiatry, 56(12), 1073–1086.

Rabiner, D., & Coie, J. D. (2000). Early attention problems and children's reading achievement: A longitudinal investigation. Journal of the American Academy of Child and Adolescent Psychiatry, 39(7), 859–867.

Schweitzer, J. B., Faber, T. L., Grafton, S. T., Tune, L. E., Hoffman, J. M., & Kilts, C. D. (2000). Alterations in the functional anatomy of working memory in adult attention deficit hyperactivity disorder. American Journal of Psychiatry, 157(2), 278–280.

Wickelgren, I. (2001, March 2). Working memory helps the mind focus. Science, 291(5509), 1684–1685.

Rosemary Tannock has been a contributor to Educational Leadership.

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