MAKING SENSE OF ATTENTION DEFICIT/HYPERACTIVITY DISORDER by Carol R. Lensch Dissertation submitted to the Faculty of the Virginia Polytechnic and State University in partial fulfillment of the requirements for the degree of DOCTOR OF EDUCATION in Teaching and Learning APPROVED: _________________________ _________________________ Jerome A. Niles, Co Chair David J. Parks, Co Chair _________________________ _________________________ Kay F. Longley Carol Whitaker _________________________ Dianne W. Yardley September, 1998 Blacksburg, Virginia Key Words: AD/HD, Hyperactivity, Teachers Copyright 1998. Carol R. Lensch MAKING SENSE OF ATTENTION DEFICIT/HYPERACTIVITY DISORDER by Carol R. Lensch Jerome A. Niles, Ed.D., Co-Chair Teaching and Learning Department David J. Parks, Ph.D., Co-Chair Educational Leadership & Policy Studies Department (ABSTRACT) In recent years there has been a notable increase in the number of students being identified with Attention Deficit/Hyperactivity Disorder (AD/HD) in American schools. Although there is a tremendous amount of research being done in the area of AD/HD, parents, educators and individuals with AD/HD are ill-equipped to deal with the demands of the disorder. Only through extensive research and a better understanding of what AD/HD is can we expect to develop more effective means of dealing with AD/HD on a daily basis at home and in school. The primary purpose of this book is to bridge the gap between research knowledge and the knowledge in use by educators on AD/HD. The book is a review and interpretation of selected studies on the causes, co-occurrence with other disorders, diagnosis, and treatments of AD/HD. It provides the reader with the opportunity to gain an understanding of AD/HD for making mindful, informed decisions on approaches best suited to meet the challenges presented by this disorder. Five misconceptions are identified and refuted by research presented in chapters two through five. The findings of these studies lend support to: (a) a genetic and environmental basis for AD/HD; (b) a comorbid and hetergeneous nature to the disorder; (c) a need for educators to approach AD/HD from an educational perspective; (d) the need to consider a variety of interventions in addition to medication for the treatment of AD/HD; and (e) the unique response to interventions by individuals with AD/HD. In conclusion, educators are seeking information on this disorder because they are faced with an ever-increasing number of students with AD/HD, and they want to effectively meet the needs of this growing population of children. The emphasis in chapter six is on using a collaborative team approach, involving all persons who have an impact on the life of the student with AD/HD. Only through knowledge, understanding, and collaboration can educators be empowered to do the job that so desperately needs to be done. MAKING SENSE OF ATTENTION DEFICIT/HYPERACTIVITY DISORDER iv Contents LIST OF TABLES vii LIST OF FIGURES viii Chapter 1. Introduction 1 Background 1 Purpose and Format of The Book 8 Article Selection and Organization 9 References 13 Chapter 2. Causes 15 Genetic Factors 17 Environmental Factors 25 Maternal Smoking 25 Low-birth-weight 27 Physiological Brain Differences 28 Low-birth-weight and Ultrasound 29 Dopamine 32 Essential Fatty Acid and Zinc Deficiencies 33 Magnetic Resonance Imaging and Physiological Brain Differences 35 Gender Differences 39 Chapter Summary 42 References 47 MAKING SENSE OF ATTENTION DEFICIT/HYPERACTIVITY DISORDER v Contents Chapter 3. Comorbidity (Co-occurrence with Other Disorders) 51 Review of Literature on Comorbidity 54 Conduct Disorder 59 Anxiety Disorder 59 Oppositional Defiant Disorder 59 Mood Disorder 59 Learning Disabilities 60 Mental Retardation 60 Tourette’s Syndrome 60 Longitudinal Study of Comorbidity with AD/HD 61 Bipolar Disorder 66 Allergies and AD/HD 69 A School-based Prevention Program 71 Chapter Summary 73 References 76 Chapter 4. Diagnosis (Diagnostic Techniques) 79 Overview of Current Diagnostic Process 81 Diagnostic Issues 83 Diagnostic Criteria 90 Laboratory Measures 95 Chapter Summary 100 References 102 Chapter 5. Interventions 106 MAKING SENSE OF ATTENTION DEFICIT/HYPERACTIVITY DISORDER vi Contents Educational Interventions 108 Behavioral Modifications 109 Cognitive-behavioral Therapy 120 Academic Interventions 132 School-based Interventions 141 Social Skills Training 146 Medical Interventions 148 Chapter Summary 153 References 160 Chapter 6. Tying It All Together 173 Misconceptions 174 Collaboration 178 Chapter Summary 187 Final Note 187 References 189 Appendixes Appendix A: Definition of AD/HD 192 Appendix B: Evaluation Criteria For Article Selection 195 Appendix C: Reader Feedback 200 Appendix D: Feedback from Pediatric Psychiatrist 204 Appendix E: Definition of Conduct Disorder 205 Appendix F: Definition of Oppositional Defiant Disorder 206 Appendix G: Definition of Oppositional Defiant Disorder 207 Appendix H: Self-management Techniques Resource List 209 Appendix I: Social Skills Resource List 211 MAKING SENSE OF ATTENTION DEFICIT/HYPERACTIVITY DISORDER vii Appendix J: Medications Used in the Treatment of AD/HD 213 Appendix K: Guidelines for Educational Interventions 215 Appendix L:Additional Intervention Strategies Resource List 218 LIST OF TABLES Summary Table of Results for Causes of AD/HD 44 Summary Table of Results for Comorbidity with AD/HD 74 Summary Table of Results for Interventions for AD/HD 156 MAKING SENSE OF ATTENTION DEFICIT/HYPERACTIVITY DISORDER viii LIST OF FIGURES Figure 1: Interaction Among Collaborative Team Members 174 MAKING SENSE OF ATTENTION DEFICIT/HYPERACTIVITY DISORDER 1 1 INTRODUCTION The essential thing at the start is the habit of thinking. - Henry Cabot Lodge - The study of how the human brain works, especially that of children, can be both intriguing and challenging as one attempts to analyze how learning takes place. As a special educator I have had an abundance of opportunities to observe children, particularly those with special needs. Although our educational system categorizes students into groups of special education and general education, all children are special and unique in the ways they learn. An area of particular interest and concern regarding individual learning differences is that of Attention Deficit/Hyperactivity Disorder (AD/HD). Typically, an AD/HD child will exhibit excessive motor activity, impulsivity, and difficulty attending to tasks (APA, 1994). Incidence Over the years I have seen a growing number of students diagnosed as having Attention Deficit/Hyperactivity Disorder, and AD/HD appears to be on the increase. Between the years 1990 and 1995, the diagnosis of AD/HD has more than doubled (Turecki, 1997). This increase in identification leads one to question what MAKING SENSE OF ATTENTION DEFICIT/HYPERACTIVITY DISORDER 2 changes have taken place to bring it about and what can be done to deal with the challenges created by the increase and numbers of children with the disorder. Has the nature of the student or the tolerance of educators changed in recent years? Are there environmental or societal factors to consider? The incidence of AD/HD is estimated to be 3-5% of school-age children to as high as 12% depending on how the disorder is defined (Augustine & Damico, 1995; Patel, 1996). The Diagnostic and Statistical Manual of Mental Disorders , fourth edition (DSM-IV), provides a detailed description of the characteristics that must be identified for a medical diagnosis of AD/HD (APA, 1994) (see Appendix A). These criteria are based on the observation of behavior and are divided into three subtypes: (1) Attention Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type; (2) Attention Deficit/Hyperactivity Disorder, Predominantly Inattentive Type; and (3) Attention Deficit/Hyperactivity Disorder, Combined Type. Previous editions have delineated between Attention-Deficit Disorder (ADD) and Attention Deficit/Hyperactivity Disorder (AD/HD), but in keeping with the language and definition of subtypes used in DSM-IV, AD/HD will be used throughout this book. The D iagnostic and S tatistical M anual of Mental Disorders (DSM) has been revised and is now in its fourth edition. Have the criteria changed significantly? Perhaps the increase in the number of students being diagnosed with AD/HD is in part due to this inconsistency in defining the disorder. Or do we truly have more individuals with AD/HD in modern American society? MAKING SENSE OF ATTENTION DEFICIT/HYPERACTIVITY DISORDER 3 While some may believe that AD/HD is on the rise, other authorities contend that a pseudo AD/HD accounts for 50-60% of the diagnosed cases (Hallowell & Ratey, 1994). By pseudo AD/HD Hallowell means the manifestation of a set of behaviors which mimic AD/HD, but are actually the result of environmental influences such as fast food, fast-paced media and video games, and a pervasive societal attitude towards immediate gratification. It is my belief that more physiologically based diagnostic procedures must be developed and used to identify individuals with AD/HD. Technology is being developed which can accomplish this task through a clinical, scientific approach, including magnetic resonance imaging (MRI)(Castellanos et al., 1996) and positron-emission tomography (PET)(Weiss,1990) by identifying brain differences. Currently, these techniques are used in research settings, but as they are proven and perfected they may become part of a routine diagnostic assessment. AD/HD is also, in part, identified through