Attention Deficit Hyperactive Disorder ... a Teacher's Perspective

ADHD, or Attention Deficit Hyperactivity Disorder, is a label given to children and adults who suffer from inattention, impulsivity, hyperactivity and boredom. ADHD is one of the most common mental disorders among children. The National Institute of Mental Health reports that three to five percent of all children — perhaps as many as two million American children — are diagnosed with ADHD, an average of at least one child in every classroom in the United States.

The Itch

Garrulous students occupied my sixth grade classroom after lunch, a few actually seated for class, many clustered with friends in small groups, and some strolling leisurely into the classroom. I stood before my class and raised my hand, feeling a moment of satisfaction as murmurs dwindled slowly. I took a deep breath, preparing for ninety minutes of geometry.

Twenty-eight students sat quietly, their eyes focused on me. Melissa, however, was not in her seat. I felt familiar frustration rise toward the child. She was weaving her way around desks, passing most of the students in her less than direct path toward me. Students began whispering amongst themselves. It would be difficult to regain their attention. Before I could admonish Melissa for interrupting, she handed me an envelope, “Mom said to give you this.”

My heart beat faster as I felt my face flush. Even after fourteen years in the classroom, I felt the momentary panic a note from any parent always caused. I mentally reviewed the last several days. What had I done that upset her mom? Melissa was happy in school, an A student, energetic and bright, but impulsive. She loved math so much she often blurted the answer before the rest of the class had even started the problem.

I sighed as I opened the envelope in front of the class. Bad protocol, but past experience had taught me it was best to respond quickly to parents. The envelope contained a card with a handwritten message inside. The class became a roar of talking, laughing and whispering voices as with a pounding heart I read,

“Please accept this small token of my deep appreciation in regards to the pleasant phone call I received about my daughter, Melissa Smith. It was truly a nice surprise (as well as a shock) to have a teacher call and praise a child about her good grades rather than calling about a discipline problem. I can honestly say that I have never had a teacher call me to tell me what a good job Melissa was doing in class. Ms. Allen, you made my day. Melissa is lucky to have been in your class! Thank you for having such a positive impact on my daughter and much continued success to you!

Sincerely,

Amy Smith.”

Tears wet my eyes. I turned my back to the class and faced the board. I allowed myself the luxury of reading the card again. Melissa would continue to be a challenging child in any teacher’s classroom. But she, and equally as important, her peers would learn.

Several things I did were unorthodox. I “wasted” instructional time calling Melissa’s mother during class, and even worse, I discussed a child’s progress in front of other students. To both, I plead guilty. If an administrator had walked into my classroom while my back was turned, while my students were off task and talking, I most certainly would have faced a reprimand and a letter would have been put in my file.

During the years I spent in the classroom I have watched students like Melissa learn -- and yes, I sometimes met failure with students who didn’t succeed. On those occasions I did not consider myself a failure, although many in my profession would. The needs of some children were beyond those that could be met in my classroom.

The Tasmanian Devil

Three review problems written on the overhead projector welcomed students as they entered the classroom. Students were required to sit quietly and copy and answer the problems. It was a necessary “warm-up” routine designed to engage their sixth-grade minds in “school mode.” In an exclusive front row seat, sat Richard Hunt, also known as the “Tasmanian Devil.” His desktop contained one sneaker, one shoelace and one pencil. Richard was intensely concentrating on inserting the shoelace back into the eyelets of his sneaker. No textbook, paper or any other implement of learning cluttered his otherwise empty desktop.

I handed him a copy of the overhead review questions. “Start your warm-up, Richard,” I whispered. He didn’t acknowledge my presence. I took the sneaker, rather forcefully because he didn’t want to let go. “I’ll lace your shoe; you do your warm-up.” Richard looked unsure. His eyes remained on the sneaker in my hands while the class finished their warm-up, his questions left blank on the paper I’d given him.

I taught the math lesson; then students worked in small groups practicing some problems. After a few minutes, lined paper littered the floor in a large circle around Richard’s team. Each sheet of paper was filled with big black numbers. Richard, his lips puckered in concentration, wrote with one of my blackboard markers. He stopped, sniffed the marker and stared at it, fascinated. “No, that’s wrong, Richard,” his teammate Alex said. Richard angrily threw the paper to the growing pile on the floor enveloping his team and pulled a new sheet of notebook paper from his binder.

“Richard, where is your pencil?” I asked.

“I don’t know. I lost it,” Richard replied, shrugging. I stared at the child, then at his floor and desktop. The pencil was nowhere in sight, but it could be under any one of the twenty or thirty sheets of paper on the floor. I sighed, gave him another pencil and removed the marker before he could become high from snuffing.

“Would you all please help Richard clean up these papers before you answer any more questions?”

“Yes, Ms. Allen,” students chorused.

The “Tasmanian devil” that was Richard Hunt sat in the front. He required preferential seating. Even so, a small hurricane usually ensued from in his general direction before the end of class. It began with a murmur of talking. Then spitballs, staples or any number of projectiles would fly through the air.

I was required to give Richard copies of my overhead notes. He couldn’t copy information from the board. His writing ability was on sixth-grade level, his reading slightly below that. Ability wasn’t the problem. He was just so fascinated by the sound the overhead projector made or the small rainbow of light it reflected onto the ceiling that he couldn’t concentrate long enough to copy information. He drew pictures on his paper, fascinated by their shapes. He could spend an entire ninety-minute class on one detailed drawing. I thought he showed exceptional ability in art, although his art teacher didn’t think so. Richard painted his pencils with correction fluid, and then scraped it off, leaving tiny white shavings covering his desk and the floor. He snuffed the fluid and the shavings.

Richard played with anything on his or his neighbor’s desk. Because he never remembered his own supplies, or he lost them during class, he stole supplies from his neighbor, usually causing a disagreement. I frequently had to change the seating of students sitting next to him due to complaints from students and parents. I gave Richard two textbooks so he could keep one textbook at home and one in his locker. Still the textbook was an enigma that somehow never made it to class.

Richard kept an assignment book where he recorded his homework assignments. I initialed it before her left my class each day. At the group home where Richard lived, he earned privileges based on completion of the homework assignments written in his assignment book. Still, I rarely saw his homework. It was lost in transition.

He had lived in the group home since first grade. That year he was in a car accident that killed both of his parents. When Richard began having behavior problems in his new home and in school, the school psychologist, in cooperation with the school resource teacher, administered a series of tests that revealed he had a condition known as Attention Deficit Hyperactivity Disorder, or ADHD.

Richard is a student with a disability, also known as an exceptional child (EC). The Individuals with Disabilities Education Act (IDEA), a federal law reauthorized in 1997, guarantees children with disabilities a “free appropriate public education” in the least restrictive environment (LRE). Children with disabilities must be educated with children without disabilities, to the maximum extent possible. So, the least restrictive environment is typically the regular classroom.

Children with disabilities may be removed from the regular educational environment only when the disability is so severe that education in regular classes is not possible. It was possible (if not ideal) to educate Richard Hunt in the regular classroom. Toward that end, Richard’s teachers, the school psychologist, and the assistant principal wrote an Individual Education Plan, or IEP, for him. Richard’s IEP gave him modifications to help him in school. These included extended time on tests, testing in a separate room, having tests read orally to him, study guides, preferential seating away from distractions, and copies of the teacher’s notes.

ADHD is one of the most common mental disorders among children Richard’s age. The National Institute of Mental Health (NIMH), states that 3 to 5 percent of all children — perhaps as many as two million American children — have been diagnosed with ADHD. On the average, at least one child in every classroom in the United States is diagnosed with the disorder, boys two or three times more frequently than girls.

Attention Deficit Hyperactive Disorder is perplexing because it is not one particular mental disorder, but rather it is a group of symptoms, or behaviors, that fall under the diagnosis of ADHD. Any one of three groups of behaviors: hyperactivity, impulsivity and inattention, or any combination of the three, lead to the classification ADHD. Richard was inattentive and hyperactive. His attention was focused on insignificant things in his environment, such as his shoelaces and the smell of the marker he was using. He was unaware of the important event in his environment, the math concepts. He moved around constantly, touched his neighbors and anything around him.

The Diagnostic and Statistical Manual of Mental Disorders, or DSM, is a checklist of behaviors used to classify a child with ADHD. According to the DSM, inattention means a child is so distracted by irrelevant sights and sounds that he fails to pay attention to details and makes careless mistakes. He has difficulty following instructions without being redirected. He loses or forgets tools needed for a task, like textbooks, homework, toys, or pencils. According to the DSM, some signs of hyperactivity and impulsivity are fidgeting, squirming, running, difficulty waiting in line or for a turn and restlessness. The student leaves his seat or blurts out answers during a classroom setting (like Melissa). He answers questions before hearing the whole question.

This could be because children with ADHD have a lower level of activity in the part of the brain that inhibits impulses. Scientists at NIMH used positron emission tomography, or a brain scan, to look at brains of people with ADHD and those without. Tests showed that the brains of people with ADHD were less active in the area that inhibits impulses, proving that there is a physical condition behind the behaviors classified as ADHD.

Supporting this, ADHD seems to be genetically inherited. Children with ADHD usually have at least one close relative with the disorder. One-third of all fathers who had ADHD will pass it on to their children. The “dopamine hypothesis” is generally accepted as the cause of ADHD, which postulates that ADHD is due to insufficient availability of the neurotransmitter dopamine in the central nervous system. Dopamine is responsible for alertness, motivation, deliberate movements, appetite control and sleep.

The Surgeon General’s report in 1999 proposed a dopamine-transporter gene on chromosome 5, and a dopamine-receptor gene on chromosome 11 as possible sources of genetic variation. Severe ADHD may be caused by abnormalities in the dopamine-transporter gene (DAT1).

Stimulants increase the availability of dopamine, controlling the symptoms of ADHD. Stimulants given to increase dopamine availability include methylphenidate (Ritalin, Metadate, and Concerta). Ritalin is the most widely known form of methylphenidate, a central nervous system stimulant. In normal adults it effects are more potent that caffeine and less potent than amphetamines. In children with ADHD it has a calming, focusing effect. Other stimulants used to treat ADHD are amphetamine (Adderall), dextroamphetamine (Dexedrine, Dextrostat), and pemoline (Cylert). Some children who do not respond to stimulants are given antidepressants such as bupropion (Wellbutrin).

Side effects of such stimulants are reduced appetite, insomnia and, less frequently, liver damage. On a cautionary note, stimulants do not have Food and Drug Administration (FDA) approval for use in children. A physician treating a young child with ADHD may prescribe a medication that has been approved by the FDA for use in adults or older children. This is called "off-label" prescription. Even though the FDA approves a stimulant for a defined population (adults), after that drug is approved and on the market, any physician may prescribe the drug to any patient, including children. The sponsor, however, is allowed to market the drug only for the approved population. This is why most drugs used to treat mental disorders in children are dispensed with this warning: "Safety and efficacy have not been established in pediatric patients." A physician who prescribes an “off-label” drug for a child does so without the benefit of any research on safety and dosages in children.

While researchers study the genetic roots of ADHD, environmental and nongenetic factors are equally compelling. Hyperactivity and inattention correlate positively in children whose mothers smoked or used alcohol or other drugs during pregnancy. Alcohol and nicotine in cigarettes may damage developing nerve cells in fetuses. Fetal alcohol syndrome (FAS), caused by the mother’s heavy alcohol consumption during pregnancy, is a condition leading to behaviors similar to those of ADHD. FAS can also cause intellectual impairment, low birth weight and physical abnormalities in addition to ADHD-like symptoms.

Cocaine — including crack, the smokable form — when used by a pregnant woman, seems to interfere with the formation of brain receptors in the fetus. In such children incoming signals from the senses (eyes, ears, and skin) are not transmitted to the brain, so the child seems unaware of his surroundings. These children often display ADHD symptoms.

Dr. Jekyll and Mr. Hyde

Taylor Reed transferred into my school district a few weeks into sixth grade. After attending our school about a month, Taylor was put into my first period science class and my third period math class. His math teacher, a veteran teacher of twenty years, threatened to quit if Taylor wasn’t removed from his class. This was Taylor’s second try at sixth grade. The previous year he had scored only the 3rd percentile on his End of Grade math test. He had attended summer school, but had been absent too frequently to be promoted. Because Taylor’s achievement in math, reading and writing were all below his ability level, he was considered learning disabled (LD) in all three areas. Due to his disabilities he was protected by the IDEA, or Individuals with Disabilities Education Act, which allowed him modifications in the regular classroom.

In addition, his pediatrician prescribed Ritalin for him to treat ADHD symptoms. But, he did not take his Ritalin most days; instead, he sold it. About a week after being placed on my team, Taylor was busted for selling marijuana to an eighth grade student at school and was suspended for ten days.

By the time I had a chance to work with Taylor it was three months into the school year. He was a high-achieving student during science. He couldn’t read the science textbook, but would listen when partnered with another student who read to him. He answered all the science questions carefully in neat, beautiful handwriting. He loved science experiments, hands-on activities and science class. I rarely had to redirect him. He was a model student who did well and was rarely absent.

In contrast, however, Taylor attended my third period math class only about three days out of five. The remaining two days he was either suspended and sent home for the rest of the day or on in-school suspension, or ISS. This was mainly because he didn’t like math, and with good reason. He didn’t know even elementary level math concepts.

The first day in my math class he said, “I am not going to do that f*cking work. It is too hard. You need to learn to f*cking teach.” His disrespectful treatment toward me would have cost me the other students’ success, so I had no choice but to send him to the office. The rest of the days followed a disturbingly similar pattern. As soon as he entered the classroom for math, he immediately created a conflict with a fellow classmate or myself. One day he made the mistake of calling Jamal a “crack head.” Jamal punched him, and then Taylor threw a desk at Jamal. I had to call our security guard, the principal or both to remove Taylor from my class on more than one occasion.

Taylor never brought his textbook, paper or pencil to math class in the afternoon, although he brought all three to science in the morning. Taylor was truly a Jekyll and Hyde. He was a dedicated student during science who changed into an unrecognizable monster, Mr. Hyde, during math class in the afternoon. There were two reasons: First, Taylor didn’t like math. Second, he took a 24-hour dose of Ritalin in the morning. But, the timed-release dose didn’t seem to work properly because his impulsivity became more pronounced during the afternoon.

My goal after Taylor joined my team was simply to get through math class each day without physical violence erupting in my classroom or students getting hurt. I had given up on teaching anyone math. But somehow, without any prompting from me, and against the preferential seating modification written into his Individual Education Plan, Taylor started sitting in a desk at the back of the room during math. Eventually he moved to a table at the back of the room and then started sitting under the table on the floor. He said he didn’t like the front of the room. The lights hurt his eyes.

I breathed a sigh of relief. He was quiet. I could teach the others. At first I ignored him there, didn’t ask him to participate and just ignored him, crossing my fingers that I would not have to call the deputy that class.

One day I gave Taylor an old third grade math workbook. I told him I needed the answers filled in to use for my next class and asked if he’d start a few for me so I could see how hard they were. By the end of class he had done five problems. So from then on, before I gave the rest of the class their assignment I got Taylor started on his “own” math problems. At first his goal was to work for five minutes alone. I gradually increased his goal by a few minutes every couple of weeks. By the end of the year Taylor could make it through forty minutes working at the third grade level. He always took a ten or fifteen minute break to walk around the classroom, get water and move around my personal papers on my desk.

Class was ninety minutes long, so even with Taylor’s improvement, he was still on task for less than one half of the class period. After he finished his math problems Taylor played Solitaire on the computer or organized science equipment for the next day. He counted test tubes and labeled my shelves in the science equipment room. He stapled worksheets. He sorted my files. He ran errands. I kept him very busy.

Even so, by school standards, Taylor was not successful in my classroom. At the end of sixth grade he again scored in the 3rd percentile on his end of year math test. He retested at only the 2nd percentile. But, Taylor did not go to summer school. Instead, due to his many discipline referrals and lack of progress that year, the Committee on Special Education placed him in a more restrictive environment for the seventh grade. Taylor would be in the Behaviorally Educably Handicapped class which consisted of twelve students, one teacher and one teacher assistant. He would finally receive the help he so badly needed. But help came too late for Taylor.

Taylor would be fifteen before Christmas his seventh grade year, and sixteen midway into his eighth grade year. He was a prime candidate to drop out at sixteen, without even an eighth grade education. In fact, Taylor missed forty-nine days of school in seventh grade, scoring in the fifth percentile on his math EOG test. His retest was even lower, in the first percentile. Due to his ADHD and learning disability in math, Taylor was promoted to the eighth grade. He was not required to go to summer school. He told his seventh grade teacher that he hated math and had a mental block against it. He felt like he didn’t fit in at school.

Taylor sees a probation officer now and has tested positively for marijuana on a routine drug test. He is scheduled to go to court for selling marijuana. He’s had several problems with the law. If he isn’t sent to juvenile detention he will go to Wilderness Camp, a home for troubled kids.

What turned Dr. Jekyll into Mr. Hyde?

How could this happen? Melissa, Richard and Taylor all suffer from the same disorder, ADHD. All three take medication for their disorder. Melissa is a strong A student, who frustrates her teachers, but her behaviors are controlled. Richard is a “Tasmanian Devil,” who is hard to manage but will learn in the regular classroom — with modifications of course. He will probably not earn A’s or make the honor roll, but he will learn. In contrast, Taylor is truly “Mr. Hyde.” He has not been successful either in the regular education environment or in the more restrictive environment of the behaviorally educably handicapped classroom. He is in trouble with the law and a prime candidate to drop out without even the skills necessary to perform the most menial jobs in society.

What is the difference? The answer is chance. Melissa was fortunate. She had a caring mother who monitored her progress closely and worked with her doctors and the school system from the time she was diagnosed in kindergarten. Richard was also lucky, although some might argue that to lose both parents tragically is not luck. But with that loss, Richard was protected by the child welfare system. When he began having difficulty at school something was done for him immediately. Richard was put on Ritalin and continued to be monitored closely, both by the school system and his caretakers. He will most likely finish high school and may go on to college.

Taylor’s story, unfortunately, is not uncommon. Unlike Melissa and Richard he was likely born with damaged receptors for sensory input so common in “crack babies.” He was shuffled from family member to family member because none of them could manage the behaviors his disability caused. It wasn’t until his second try at sixth grade that he came to live with his grandmother. She forced him to take his medication at home and tried to work with the school, but Taylor’s behaviors were already learned.

Why didn’t his teachers help him? Taylor spent so little time at one school that his teachers didn’t know him. He should have been placed in a more restricted environment soon after kindergarten. But, it takes several months, sometimes a whole school year, to get a student placed in a more restrictive environment. There are no short cuts in a system that attempts to protect children. Even when glaring signs of trouble in school and with the law were evident, Taylor still floundered in the regular educational system until age fifteen. Taylor didn’t have someone to advocate for him.

There are few clinical psychiatrists trained to diagnose and treat mental disorders in children. School counselors, pediatricians, and family physicians step up to the plate out of necessity. These pinch hitters do not have the specialized training of a clinical psychologist or the time necessary to do a follow up evaluation requiring several hours. Children suffering from ADHD symptoms are medicated with no further treatment.

Many educators believe that ADHD is over diagnosed and overmedicated. They feel that ADHD is the result of bad teaching, bad parenting, and willful disobedience by children. On the contrary, ADHD is a real neurological disorder that must be treated as such. According to Harvard Medical School, Attention Deficit Disorder is caused by insufficient availability of the neurotransmitter norepinephrine in the central nervous system. Stimulant medications, such as Ritalin, can increase the levels of norepinephrine and help relieve the symptoms of inattention, boredom and impulsiveness.

ADHD may be caused by underdeveloped connections in the brain related to the number and size of brain cells and the number of connections between them. If the brain lacks the neurons to process incoming information it will process some, but the rest will be lost, like a computer unable to run software due to lack of available memory. Some programs may run, but they must be shut down before running others or the system will overload and the computer will freeze. An ADHD student’s mind becomes overloaded with information, and the student becomes distracted.

Teachers and parents of children with ADHD work miracles every day in the least restrictive environment and in the home. Pediatricians and physicians do the only thing they can do: prescribe medication. Social workers, psychologists and psychiatrists that work with children are underpaid and overworked. The government and child welfare protect our children while scientists continue working to find a “cure” for this perplexing disorder called ADHD.

Note: Although Melissa, Richard and Taylor are representative of typical students, they do not exist.

References

ADHD.com, the online community (2004). http://www.adhd.com/index.html

Buresz, Allen MD. Natural Health and Longevity Resource Center. Attention Deficit Disorder & Hyperactivity Success. Retrieved July 5, 2003 from http://www.all-natural.com/add.html

Least Restrictive Environment Coalition. (1999-2001). Laws on LRE. Retrieved July 5, 2003, from [http://www.lrecoalition.org/02_lawsOnLRE/#3]

National Institute on Drug Abuse. (June 25, 2003). Methylphenidate (Ritalin). Retrieved July 5, 2003, from http://www.nida.nih.gov/Infofax/ritalin.html

National Institute of Mental Health. (September 30, 2004). Attention Deficit Hyperactivity Disorder [http://www.nimh.nih.gov/publicat/adhd.cfm#intro]

The ADHD Information Library. (2003) Retrieved October 5, 2004 from http://www.newideas.net

U.S. Department of Health and Human Services (1999), Mental Health: A Report of the Surgeon General. Rockville, Md. http://www.surgeongeneral.gov/library/mentalhealth/home.html

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