Center for Children with Special Needs Tufts-New England Medical Center Floating Hospital for Children To Whom It May Concern: __________________________ has been evaluated in our office with hope that we may coordinate learning and developmental issues. This student’s clinical history is consistent with a diagnosis of attention deficit hyperactivity disorder (ADHD), _________________ type. The approach to ADHD is multi-modal with behavioral and environmental tactics employed within the school and home setting and consideration of medication use. Partnering between schools, families and a physician’s office is critical for successful treatment of ADHD. If we are using medication with this child, it will be very important to get your feedback on how the child’s behavior and performance are changing in the classroom. You are essential for assuring that a child’s medication use is appropriate and effective. Effective teaching strategies are also critical. Last, behavioral modification based on evidence-based models can be highly effective in terms of changing child behavior. Some teachers have had excellent training in ADHD and its management in the classroom. Others have not. We are providing the attached information to assist in this student’s management plan for the school setting. What types of problems do children with ADHD have in the classroom? Children with ADHD experience difficulties in many or all of the skills needed for academic success including: Starting and finishing tasks and organizing multi-step tasks due to lack of organizational skills Waiting turns and staying seated due to impulsivity and hyperactivity Staying on task due to inattention Making transitions, behavior in lunchroom and on playground due to difficulties with change in expectations and “unstructured” times Following through on multi-step directions due to problems with short term memory retrieval Producing work consistently due to intermittent inability to retrieve information from memory Learning new material (need lots of opportunities to master basic skills) Getting along with peers. What types of classrooms work well for children with ADHD? Research has found that the following characteristics are important in the classroom: Predictability and structure Short work periods Small teacher-pupil ratio More individualized instruction Interesting curriculum Preferential seating away from distractions, doors, windows and other distracting children Use of all senses to teach material (visual, auditory, kinesthetic) Use of positive reinforcers. What types of teachers are helpful for teaching children with ADHD? Research has also found teacher characteristics that are important in the classroom for the child with ADHD. Like other children with disabilities, students with ADHD are helped best when the teacher understands the child’s specific problems and makes necessary modifications in the educational program. Other important characteristics of teachers include: Positive academic expectations Frequent monitoring and checking of work Clarity in giving instructions Consistency, firmness and structured setting Warmth, patience and humor Knowledge of different behavioral interventions Maintenance of eye contact with students and use of gestures to emphasize points Knowledge that children with ADHD have learning problems and are not “problem children” Willingness to work with a special education teacher. Center for Children with Special Needs Tufts-New England Medical Center Floating Hospital for Children What interventions work in the classroom for a child with ADHD? Help the student clear his/her desk between tasks so the child can focus on the necessary items. Directions ideally should be simple and one-step clearly enunciated when attention has been completely attained, since children with ADHD have limited short-term working memory. He/she would likely do best with visual cues and hands-on manipulatives. It may also help to write down steps needed to complete an assignment and check with the child with ADHD to make sure he/she understands the directions. • Gentle re-direction and reiteration of directions/instructions would be quite pertinent. He/ she should be encouraged, not discouraged, to re-ask for directions or explanations. “All eyes to the front, not all of us are listening. I will repeat directions once all eyes are to the front,” may be a gentle way to redirect him/her without putting him/her at risk for low self-esteem. The teacher may be able to develop a silent technique to gently redirect, such as tapping him/her on the shoulder. • Provide extra help to acquire basic skills and anticipate the need for extra practice to master information. • Help a child to learn organizational strategies. These do not come naturally to the child with ADHD. If a learning center or resource center is available, this would be helpful for guidance on a once a week basis for learning strategies, organizational skills and to work on areas of academic difficulty. • Give immediate feedback. Try to find the four positive things to say for every one negative comment. • A planner between home and school may be helpful if he/she tends to forget assignments or not write them down as completely as the teacher would like. The planner can be signed or co-signed by the teacher and parent daily or weekly. This is essential vis-à-vis communication with the parents. • If a directed study program for doing homework during a free period during the day or an after school program/homework club is available, this would be the type of program ideal for him/her in the future. • As long term projects and follow through assignments can be quite difficult for patients with attention deficit hyperactivity disorder, it would be helpful for a teacher to break these down into smaller, less complex units with reinforcers built in as the student finishes each part. Students need help to organize an approach to long-term assignments (such as outlines, rough drafts and final drafts deadlines with a tangible reward system in place). Points should be based not on the completed project, but on the completion of each of the parts. • Given a tendency to be easily distracted, there should be the option of taking tests in a quieter environment such as a resource room, learning center or library with a teacher nearby for clarification if necessary. He/she should be eligible for untimed, relaxed timed settings for all tests including standardized tests such as SATs. What about behavior management in the classroom? Behavior management in the classroom is critical for the success of the child with ADHD, even if they are on medication. Some helpful strategies include: • Using reward systems that encourage students to work toward earning privileges or rewards by gaining points for desired behaviors or losing points for undesirable behavior. These must be given immediately so the child understands why he is being rewarded or punished. Rewards for a child with hyperactivity can allow for motor activity such as cleaning the blackboard, taking attendance lists to the office etc. • Have a pre-specified” calm down” location where a child can regroup. • Taking care to not inadvertently reward bad behavior (go to principal/library/home if behavior is bad). • Establishing a few rules that result in immediate consequences if they are broken. • Use a home-school report card on a daily or weekly basis to maintain consistent rules and management strategies for both home and school. Children with ADHD have difficulty understanding different rules for different places. The more teachers and parents communicate, the more they can help to make a child successful. • • When do I need to worry about a learning disability in a child with ADHD? Since the CDC has reported that approximately 50% of children with ADHD have co-existing learning disabilities, it will be important to rule out any underlying specific learning disabilities. If this child’s academic performance is not at grade level, formal cognitive (intelligence) and achievement testing should be coordinated as soon as possible through the school’s special education department. If performed recently (e.g. within the last two years), please forward us a copy of detailed assessment and any recent individual education plan. Developed for the Learning, Education, and Attention in Pediatrics (LEAP) Clinic by the Center for Children with Special Needs (CCSN) and the Center on Child and Family Outcomes (CCFO) at Tufts-New England Medical Center. © 2007.