Attention Deficit Hyperactivity Disorder presents itself in many different ways for many different people. It is further complicated by the fact that there are three types of ADHD recognized by the DSM-IV and even further evidence that females and males manifest the disorder in different ways. ADHD has been a challenge to school administrators for many years. The symptoms of the disorder not only interfere with the educational process of the affected child but they also can be disruptive and interfere with the education of students who learn with and interact with the affected child. ADHD impacts many aspects of the school day including the learning process, socialization and maturity. Its impact cannot be underscored enough as it has the potential to create self-esteem issues which can lead to inappropriate behavior, serving to further interfere with the learning process. Schools are often the first entities to notice the symptoms of ADHD. When a child gets into the structured setting of a classroom and is expected to maintain focus and perform task that require sustained concentration the symptoms often become more evident than they may have been in the past. Many times the child's parents are unaware of the problem or they are suspicious there may be a problem but are not sure how to address its possibility. In addition, teachers have varying teaching styles and there are varied classroom dynamics in each setting which can further complicate the suspicion of ADHD. This project designed an assessment that can be used by school nurses at all grade school levels. The assessment will be useful in the decision to approach parents to allow an ADHD diagnostic battery in a suspected child. It will also be useful to assess the level of success any one child's treatment is currently providing, which can lead to earlier needed treatment adjustments and stop the cycle of problems that are often seen with ADHD that is uncontrolled.
FLOW OF INFORMATION
Table of Contents
Statement of Problem
There is no denying ADHD exists and it impacts education across the nation. ADHD manifests itself in many different ways however, the outcome is often the same, a problem effectively educating the affected child.
"Attention Deficit Disorder is the most commonly diagnosed psychiatric disorder of childhood (National Institutes of Health [NIH] Consensus Statement, 1998). According to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994), ADHD affects approximately 3% to 5% of school-age children (Busch, 2003). Children with ADHD are unable to stay focused on a task, cannot sit still, act without thinking, and rarely finish projects they begin at home or school. Children who have been diagnosed with ADHD are frequently treated with psychostimulant medications, most commonly methylphenidate (e.g., Ritalin; Frankenberger, Lozar, & Dallas, 1990; Kwasman, Tinsley, & Lepper, 1995; Reeve, 1990; Runnheim, Frankenberger, & Hazelkorn, 1996). According to data provided by the U.S. Drug Enforcement Agency (2002), there was a 900% increase in methylphenidate production from 1990 to 2001. Ninety percent of the methylphenidate was consumed in the United States for the treatment of ADHD. Production of other drugs used to treat ADHD has also increased. From 1993 to 2001, the production of amphetamines (Dexedrine and, later, Adderall) increased by 5,767%. By 2001, amphetamine production accounted for 44% of the stimulants produced in the United States, the vast majority of which are used to treat ADHD (Busch, 2003)."
"The behaviors associated with ADHD may be first observed or most troublesome in a classroom setting. Snider, Frankenberger, and Aspensen (2000) found that teachers were involved in making the initial referral nearly 40% of the time. This suggests that teachers play an important role in the initial screening for ADHD. In light of current concerns about treatment of ADHD with stimulant medication, it is critical that teachers are knowledgeable and objective if they are to play a role in the diagnosis of ADHD (Busch, 2003). "
There have been a small number of studies to examine the true ability of teachers to notice and recognize possible symptoms of ADHD (Busch, 2003).
" They found that teachers with more training and experience had more confidence than inexperienced teachers but that all identified important barriers to effective instruction, including lack of time to administer specialized interventions, lack of training, large class size, and severity of students' problems. Jerome, Gordon, and Hustler (1994) evaluated Canadian and U.S. teachers' knowledge of concepts related to ADHD and found that although teachers had little training regarding ADHD, they did well on knowledge-based questions regarding etiology and educational implications (Busch, 2003). "
According to experts, ADHD is among the most common of all diagnosed childhood disorders. Unfortunately it is often not recognized until the negative impact has already occurred on the child's school experience and learning abilities (Hart, 2002).
'Because of the highly familial nature of the disorder (Epstein et al., 2000), it is quite likely that parents with ADHD will have at least one child who displays clinically significant ADHD symptoms themselves (Hart, 2002). Rutter et al. (1999) report that the first-degree relatives of those with ADHD are 68% more likely to present with ADHD themselves than are controls. Faraone and Biederman (1997) have suggested that up to 25% of children presenting with ADHD will have a parent with ADHD. Even in the absence of a formal diagnosis of ADHD, children of parents with ADHD are more likely to be impulsive, inattentive, and overactive than their peers (Hart, 2002)."
This statistic further complicates the ability for early assessment of an ADHD student as the ADHD parent may fail to recognize important signals of the disorder. In addition it can be difficult to determine whether the parent's ADHD impacted parenting style is at the root of the student's difficulty or if the student has the actual disorder.
In one study more than 80 children from preschool were evaluated for effectiveness of parental ability to recognize the symptoms in their own child.
"These children were selected at the time of their 3-year developmental check from two cohorts (1992-93 and 1995-96, respectively) (Hart, 2002). Children came from families living in the New Forest and Southampton regions of Southern England (N = 7,068). These areas comprise a mix of urban, suburban, and rural settings that include areas of prosperity and significant pockets of relative deprivation (Hart, 2002). The children selected from cohort 1 (n = 30) constituted the PT arm of a randomized controlled trial previously reported in this journal (Sonuga-Barke et al., 2001). The 59 children in cohort 2 participated in a second trial of the same PT package. In both trials, children were randomly assigned to either PT (total n = 89), an alternative treatment (n = 28), or a waiting list group (n = 30). Children from non-PT groups were not included in the current analysis. A three-stage screening procedure previously described by Sonuga-Bar ke et al. (2001) was used in both cohorts (Hart, 2002)."
The results indicated that maternal ADHD served as a strong barrier to an effective use of parental diagnostic screening tools. Because of the high genetic influence of ADHD there is a significant chance that parents will not recognize the disorder in their children because they are dealing with it in their own life. These studies further point to a need for a school nurse assessment tool that will allow early identification of possible ADHD.
Over the years there have been many studies performed to address the issue of ADHD. Studies have looked into the symptoms, the causes, the impact and the outcome of having the disorder, both in and outside of the educational process. Literature tracking the way the disorder affects learning indicate that it can have a negative impact on the process of learning, particularly in the area of reading (Busch, 2003). Literature about ADHD has included studies about understanding the difference between true learning disabilities and what appears to be learning disabilities that are rooted in an underlying problem such as ADHD. These studies further underscore the importance of a development of an assessment tool for the purpose of school nurse screening for ADHD students.
One study found that educators and those who work in administrative positions with students have limited knowledge about how to recognize the symptoms of the disorder.
"A random sample of 200 general educators and 200 special educators from Wisconsin were surveyed. Results revealed that teachers had limited knowledge about ADHD and the use of psychostimulant medication (Busch, 2003). Teachers' opinions about the effect of stimulant medication on school-related behaviors were generally positive, although special education teachers were more positive than general educators (Busch, 2003). The survey confirmed previous research indicating that teachers were the school personnel who most frequently recommended an assessment for ADHD. The results are discussed in terms of their educational significance and implications for teacher preparation and continuing education (Busch, 2003)."
There have been studies about the impact stimulant meds have on academic performance as well.