ADHD Perspectives

 

Educational and Child Psychology Vol. 14, No. 1, 1997

ADHD: ADH D: PER PERSPE SPECT CTIVE IVES S FROM EDUCATIONAL PSYCHOLOGY

 

Editorial policy for Educational and Child Psychology The Editorial Board seeks to publish original contributions contributions to the field f ield of educational and child psychology. Such contributions may take the form of  accounts of research or the discussion of theoretical and professional issues. The presentation should be of relevance to professional applied psychologists and explicitly promote the application of psychology in education. Thus, submissions are particularly welcome from educational psychologists, both academic and practictioner. We also seek to encourage other applied psychologists to present their work in this journal in order to stimulate a wider understanding of new developments. General Ed Editor: Edit itor oriial Boa Boarrd:

Simon G Giibbs (N (North Yorks C. C.C.) Joe Joe E Ell llio iott tt (U (Un nivers versiity of Sun Sunde derrla land nd))  Joan Figg (London Borough of Southwark) Ingrid Lunt (Institute of Education) Education)  Jonathan Solity (University of Warwick) Warwick) Rob Stoker (London Borough of Hammersmith and Fulham)

Subscriptions The annual subscription (for a volume of four parts) is £28. These rates are applicable to to non-members of the the DECP whether individuals individuals or institutions. institutions. (Individual parts are available and details can be supplied on request from the office of The British Psychological Society.) Subscription enquiries should be made to the Society, and subscriptions made payable to the DECP at the Society’s Society’s offices. offices. © 1997 The British Psychological Society ISBN 1 85433 236 8 ISSN 0267 1611 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording or any information storage retrieval system, without permission in writing from the publisher.

 

ADHD: ADH D: PER PERSPE SPECT CTIVE IVES S FROM EDUCATIONAL PSYCHOLOGY

EDUCATIONAL EDUCA TIONAL AND CHILD D PSYCHOL PSYCHOLOGY OGY VOLUME 14,CHIL NUMBER 1

Guest Editors Rea Reason and Sonia Sharp

 

Contents About the contributors Editorial Rea Reason & Sonia Sharp

6

Attention deficit hyperactivity disorder: over here and over there Robert Reid & John W. Maag

10

Between a rock and a hard place: an Australian perspective on education of children with ADHD Ivan M. Atkinson, Julie A. Robinson & Rosalyn H. Shute

21

Biology, behaviour a Biology, and nd education: ADHD and the bio-psycho-social perspective Paul Cooper

31

‘Helicopter children’ and ‘butterfly brains’: ADHD perceptions, issues and implications Pam Maras & Terry Redmayne with Claire Hall, Deborah Braithwaite & Philip Prior

39

A little understood solution to a vaguely defined problem: p parental arental perceptions of Ritalin Sarah F. Wright

50

Understanding and managing attention deficit hyperactivity disorder: the perspective from educational psychology M.J Connor, C. Epting, R. Freeland, S. Halliwell & R.J. Cameron

60

ADHD: the development of a collaborative model of practice within North Somerset Unitary Authority G. Evans, K. Fuller, D. Heller, C. Morgado, P P.. Salisbury & R. Salis Salisbury bury

70

Getting it all together: a multi-professional approach to the assessment and treatment of ADHD Daphne Keen, Jacquelin Olurin-Lynch & Keith Venables

83

 

About the contributors Ivan Atkinson, Clinical Psychologist and Doctoral Postgraduate at Flinders University, Adelaide, South Australia. Deborah Braithwaite is a member of the steering group for the University of Greenwich EBD Project Sean (R.J.) Cameron is Senior Educational Psychologist with responsibility for Practice Development in the Surrey Educational Psychology Service. Mike J. Connor is an Educational Psychologist in the Farnham, Ash and Goldalming Team, Surrey Educational Psychology Service. Paul Cooper is in the School of Education, University of Cambridge. Carla Epting is an Educational Psychologist in the Woking and Runnymede South Team, Surrey Educational Psychology Service Surrey. Surrey. Gill Evans is Principal Educational Psychologist of North Somerset Educational Psychology Service. Robin Freeland is an Independent Educational Consultant. Ken Fuller is an Educational Psychologist in Devon. Claire Hall is a researcher on the University of Greenwich EBD Project. Sheila Halliwell is an Educational Psychologist in Tandridge, Redhill and Horley Team, Surrey Educational Psychology Service. Doug Heller is Consultant Community Paediatrician in North Somerset. Daphne Keen is Consultant Paediatrician (Community Child Health) with Doncaster Royal Infirmary NHS Trust.  John Maag is Associate Professor in the Department of Special Education at the University of Nebraska, Lincoln. Pam Maras is Senior Lecturer in Psychology at the University of Grenwich. Clare Morgado is an Educational Psychologist in Croydon.  Jacqueline Olurin-Lynch Olurin-Lynch is a Clinical Psychologist with the Doncaster Child and Family Psychiatry Service. Philip Prior is a member of the steering group for the University of Greenwich EBD Project Tutor tor,, Educational Psychology Psychology,, University of Manchester Rea Reason is Associate Course Tu and Senior Educational Psychologist with Oldham. Terry Redmayne is a County Educational Psychologist in Kent. Robert Reid is Assistant Professor in the Department of Special Education at the University of Nebraska, Lincoln.  Julie Robinson Robinson is a Lecturer in Psychology at Flinders University, Adelaide, South Australia. Pam Salisbury is an Educational Psychologist in North Somerset. Ruth Salisbury is a Behaviour Support Teacher in North Somerset. Sonia Sharp is a Senior Educational Psychologist in Lincolnshire. University,, Adelaide, South Australia. Rosalyn Shute is Senior Lecturer in Psychology at Flinders University Keith Venables is an Educational Psychologist with Doncaster Local Education Authority. Sarah Wright is an Educational Psychologist in Hampshire.

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

Editorial Rea Reason and Sonia Sharp Guest Editors

This edition of Educational and Child Psychology can be regarded as a sequel to the BPS Working Party report on Attention Deficit Hyperactivity Disorder (ADHD) published p ublished in September 1996. The report was prepared in order to clarify the topic of ADHD and ensure that children and young people were offered the most appropriate help available. Articles in the present issue develop that theme through further debate about the implications of the notion of  ADHD in educational contexts (Paul Cooper; Pam Maras & Terry Redmayne), descriptions of  parental experiences (Sarah Wright) and examples of multi-disciplinary approaches in Doncaster (Daphne Keen, Jacqueline Ja cqueline Olurin-Lynch & Keith Venables), Venables), in N North orth Somerset (Gill Evans et al.), and in Surrey (Mike Connor et al.). al.). We arethe particularly pleased include Robert Reidepidemic' and John in Maag's contribution, dis-a cusses factors that have to produced an 'ADHD the USA and then which proposes functional analysis of ADHD with a focus on intervention rather than 'diagnosis'. Similarly Ivan Atkinson, Julie Robinson and Rosalyn Shute provide an overview of developments in South Australia and consider the dilemmas faced by teachers operating in demanding but under-resourced under-resour ced environments. From different perspectives all articles emphasize the role of psychologists in questioning and researching the notion of ADHD while acknowledging that practitioners need to respond in a sensitive and sensible way to public concerns. Implications clearly point to multi-professional networks which involve interdisciplinary planning and the sharing of skills. This issue assumes that readers are familiar with the content of the BPS Working Party report. As a reminder, we have reproduced below the summary and the recommendations made by the Working Party.

6

 

Educational and Child Psychology (1997) Vol. 14 (1)

ADHD: a psychological response to an evolving concept Summary of the BPS Working Party report  'I don't care what you call it – my child needs help.' 1. The above plea illustrates the views of many parents. It also captures the feeling of the W Partyofwhose members are committed providing roviding that help. Phrases the text such asorking 'the notion ADHD' or 'a word of caution' to arep not intended to belittle the in plight of those whose difficulties are being considered, but to stress that there are theoretical, empirical and practical questions yet to be addressed. 2. The category of Attention Deficit Hyperactivity Disorder (ADHD) originates in the USA. It refers to children and young persons whose behaviour appears impulsive, overactive and/or inattentive to an extent that is unwarranted for their developmental age and is a significant hindrance to their social and educational success. The term is now in widespread international use. As described in this report, it is a changing changi ng and evolving cconcept. oncept. W Wee can only give a snapshot of the current situation as we see it. 3. The concept of ADHD as a unitary condition is controversial for many reasons. Reference to in the title doesdemonstrates not imply a simple s imple deficit in the affect psy psychological chological of 'attention attention. deficit' A review of research that many man y factors the way mechanism attention is deployed in particular situations. An alternative theory focuses on behavioural inhibition associated with impulsiveness. It would seem, however, that problems regarded as either attentional or inhibitory may be underpinned by an inability to maintain effort over time in order to meet task demands. No single cause or mechanism appears to determine the maintenance of that effort which is influenced by a combination of biological, neurological, psychological and environmental factors. 4. A small minority of children have problems with activity activity,, attention and impulsivity because of acute neurological damage or chronic illness. The majority of those described as having ADHD show no known neurological aetiology and, at present, neuroanatomical, neurochemical and neurophysiological studies provide suggestive rather than conclusive evidence that frontal lobes are implicated in some children. A careful and comprehensive assessment should always include developmental, medical and familial histories. 5. ADHD is usually considered a particular problem of childhood and early adolescence, with a substantial proportion 'growing out' of it. Delayed neurological development may account for this effect or, alternatively, maturity may bring compensatory cognitive strategies. Nevertheless, a condition assumed to have a neurobiological component should manifest itself throughout the lifespan in some form. To date, however, a limited number of prospective longitudinal studies suggest that inattention may persist while hyperactivity and impulsiveness decrease during adolescence. Those making links between ADHD in childhood and later anti-social behaviour, including delinquency, have drawn predominantly on clinical samples of severely hyperactive and aggressive children. 6. With regard to assessment, everyday manifestations of overactivity, impulsivity and inattention do not necessarily imply the existence of the abstract concept ADHD. Furthermore, in a multi-cultural society, measures of ADHD need to demonstrate that they are valid for dif7

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

ferent subgroups of the population and do not unjustifiably discriminate against minority groups. While questionnaires and behavioural rating scales provide expedient means for quantifying adult opinion, assessment for the purposes of clinical c linical or educational practice aims to obtain as comprehensive a picture as possible of the many factors that influence the child in a particular situation. It is the uniqueness of the child that is more important than the diagnostic classification. The assessment is most constructive when it involves the child as an active partner in the process. 7. Intervention strategies recommended under the heading ADHD are also beneficial for other children because effective parenting and teaching takes account of individual differences and tailors interactions and environmental demands accordingly. accordingly. A small number of children may need detailed individual help. Educational suggestions cover active participation, self-pacing, appropriate learning content with variety and interest, and the development of collaborative skills for working together. Research studies on the efficacy of intervention include methods of behavioural management and parent support. The studies have been criticized for their sample selection, the use of laboratory or clinical rather than naturalistic settings and the assumptions made about the educational context. 8. According to research evidence, psychostimulant medication is not a cure but it can facilitate parenting parentin g and teaching in conjunction with psychological, educational and social support. The intention this report about is neither to recommend nor toinvolved reject theinuse of psychostimulants but to provideofinformation the multiplicity of factors tailoring plans to meet individual needs. This may, or may not, include medication and depends on the clinical judgments of the physicians involved. Nevertheless, we heed the warnings of the US Drug Enforcement Administration about the over-use and abuse of a drug listed in Schedule II of the Convention on Psychotropic Substances along with amphetamine and metamphetamin metamphetamine. e. 9. In the USA USA special educational legislation is based on categories of disability disability.. The legislation does not currently consider ADHD a separate category because of its overlap with existing headings such as learning disability, conduct and emotional disturbance and other health impairments. In contrast with the USA, British educational legislation does not in principle require categories of disability in order to provide for children with special educational needs. Practitioners can draw on the functional assessment of variables involved in particular cases as advocated by many authors. Medical intervention, however, requires diagnostic criteria particularly if it includes prescription. 10. Important national reports recommend that the mental health hea lth needs of child children ren and young persons are recognized and met through the co-ordinated efforts of health, education and social services. Such developments are likely to include multidisciplinary networks and joint strategies, particularly in response to the needs identified under the heading ADHD.

8

 

Educational and Child Psychology (1997) Vol. 14 (1)

Recommendations of the BPS Working Party report We recommend that:

The concept of ADHD 1. Psychologists and other relevant professionals familiarize themselves with the concept of  ADHD as set out in DSM IV and, more conservatively, as hyperkinetic disorder in ICD 10. These classifications need to be viewed as evolving, with many theoretical, empirical and practical questions yet to be resolved. 2. Researchers and practitioners use all means available to ensure that this classification is applied appropriately so that only children with significant impairments are identified when alternative explanations have been thoroughly investigated. 3. Professional bodies and practitioners use this report to enable all those involved to evaluate the conceptual and scientific basis of ADHD and to make informed choices about the issues in practice.

 Assessment and intervention 4. Relevant professional bodies develop a joint statement about ADHD and the multi-professional involvement required. 5. There is emphasis on the fostering of adaptive environments and social contexts which cater for a wide range of individual differences including those associated with ADHD. 6. There is active support for current policy developments which seek partnership between health, education and social services. It is only through the co-operation of teachers, parents, the children themselves and other relevant professionals that the needs of those considered to have ADHD can be met.

Research 7. British and European organizations responsible for providing financial support to research give increased priority to the following theoretical and applied areas covered in this report: ◆

◆

The validities of the classification, particularly in relation to ethnicity, gender and age. The developmental origins and psychological bases of ADHD, including indications in the pre-school years.

◆

The development of assessment techniques and the standardization of existing instruments with a British population.

◆

The impact of the notion of ADHD and its treatment on children's understanding of  themselves and their behaviour.

◆

The differential outcomes of non-pharmacological interventions in their own right and in conjunction with pharmacological treatment in the severest cases.

◆

Research initiatives undertaken in naturalistic contexts at home and at school.

9

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

Attention deficit hyperactivity disorder: over here and over there Robert Reid and John W. Maag University of Nebraska-Lincoln

 Abstract In the United States, attention deficit hyperactivity disorder (ADHD) has been the subject of  unprecedented attention. As a result, ADHD has undergone an explosive growth in terms of the number of professional publications appearing in journals, presentations at national conferences, and media exposure devoted devote d to this topic. top ic. However However,, ADHD continues to generate a great deal of controversy regarding its etiology, diagnostic criteria, and approaches to treatment. In addition, there appears to be pronounced disparities between American and European perspectives on ADHD. In this article we describe the American view of ADHD, discuss factors that have ‘ADHD epidemic’, and contrast American andwhich British perspectives. We then argueproduced that, foran non-medical practitioners, functional analysis, focuses on intervention rather than diagnosis, is the most effective approach. George Bernard Shaw once described the United States and Britain as two great peoples separated by a common language. When one examines the disparate perspectives of the two psychiatric communities, which are based on distinctly different traditions and perspectives on psychopathology, this separation becomes readily apparent. Some differences are ideological in nature, a point Kramer (1993) illustrated through his discussion of the diagnostic distinction between manic depression and schizophrenia. At the turn of the century, century, Emil Kraepeli Kraepelin, n, a contemporary of Sigmund Freud, demonstrated that individuals with manic depression have a different course of pathology than that of individuals with schizophrenia. Many American psychiatrists ignored Kraepelin’s distinction and favoured a view that all mental illnesses were similar butConsequently, may differ quantitatively in external manifestations a position Karlqualitatively Menninger advocated. Consequently , American psychiatrists began labelling –all mentally ill patients ‘schizophrenic’. Donald Klein, a formidable critic of the American approach, was an advocate for the British criteria, based on Kraepelin’s distinction. One byproduct of these differences were international data showing that New York had more schizophrenics and fewer manic depressives than did London. Numerous theories were put forth to explain these discrepancies. In 1972 the landmark US/UK study concluded that when uniform diagnostic criteria were employed, the proportion of patients with manic depression and schizophrenia were almost identical. Therefore, the initial differences in the number of manic depressives and schizophrenics between countries was entirely due to differences in physicians’ diagnostic criteria. The story of manic depression and schizophrenia illustrates how the way a phenomenon is conceptualized more accurately accounts for its phenomenology than some internal characteristic of individuals so diagnosed. In the case of manic depression and schizophrenia, the question of which conceptualization was superior still remained. Of course, that question was 10

 

Educational and Child Psychology (1997) Vol. 14 (1)

answered by a drug that has the quality of legend – Lithium – which demonstrated that the British position was correct. Unfortunately, Unfortunately, in the case of attention deficit hyperactivity disorder (ADHD) there is no drug, not even Ritalin, which has provided us with the type of diagnostic distinction as did Lithium for manic depression and schizophrenia. schiz ophrenia. Therefor Therefore, e, we must turn to other factors to account for the disparity between the way the United States and Britain conceptualize ADHD. The differences between two countries areprofessional exemplifiedcommunities by the mythic ‘Atlantic which refers to the lack of the congruence between on either side Effect’ of the Atlantic as to how ADHD should be conceptualized, diagnosed, and treated (e.g. Taylor, 1989). In Britain, children are much less likely to be diagnosed with ADHD and treated with medication. The fact that the US consumes more methylphenidate than the rest of the world combined – with few questions raised as to the propriety of the practice (Diller, 1996) – is stark testimony of major conceptual difference. In part, these differences may be due to differing diagnostic standards and practices between the ICD-10-CM and DSM-IV; although these systems are  becoming increasingly congruent congruent.. However However,, diagnostic agreement between American and British clinicians remains low even when identical criteria are employed (Prendergast et al.,1988). al.,1988). This finding, along with the more general implications of the story of manic depression and schizophrenia, would point to deeply rooted cultural differences – in Britain, ADHD is conceptualized as a psychosocial problem whereas in America ADHD is viewed as a medical problem. conceptualization willphenomenon lead to different theories regarding the etiology,there classification, andEach treatment of ADHD. This should not be entirely unexpected: are numerous instances of cross-cultural differences in perceptions of psychopathology in general and ADHD in particular (e.g. Mann et al., al., 1992; Mueller et al., al., 1995; Reid, 1995). The purpose of this article is to provide an overview of factors that contribute to Americans using a medical-disease model to conceptualize ADHD. To accomplish this goal we will first describe and critique current US dogma on the nature of ADHD. Second, we will examine the social forces which contribute to the growth of the ADHD diagnosis in America. Finally, we will present a functional perspective of ADHD, and argue that, for educators, a functional approach to ADHD is the most efficacious means to effective treatment for children with ADHD.

The reification of ADHD: current dogma and critique Clinicians in the US currently present ADHD as a discrete diagnostic entity which is inherent to the individual and neurobiological or heritable. heritabl e. Through literally thousands of articles, presentations, and exposure in the popular media, ADHD has been reified into a concrete physical disorder; although there is no conclusive (or in our opinion compelling) evidence substantiating this conclusion. Nevertheless, there are literally dozens of hypothesized causes for ADHD, some of which range from the obvious (e.g., perinatal insult) to the absurd (e.g., fluorescent lighting) (Herskovitz & Rosman, 1982). However However,, most hypothesized causes focus on neurobiological aspects such as central nervous system dysfunction and metabolic anomalies in neurotransmitters (e.g., dopamine, norepinepherine, and serotonin) (Goldstein & Goldstein, 1990; Hern et al., al., 1991; Hunt et al., al., 1987; Shekim et al., al., 1987; Zametkin, 1989; Zametkin & Rapoport, 1986). In a widely heralded study, Zametkin and his colleagues investigated the cerebral glucose metabolism levels in a sample of adult ADHD and control sub jects and concluded that a lower rate of cerebral glucose metabolism was a likely factor in attentional problems (Zametkin et al., al., 1990). 11

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

Scientific blinders and ADHD The belief that ADHD is caused by neurobiological deficits has been uncritically accepted since it was first described by Still (1902) almost 100 years ago. However, as Schachar (1986) noted in his trenchant and scathing sca thing critique of ADHD, the notion of ADHD as biological entity is presumptive, often uncritically accepted, and often based on circumstantial, methodologically inexact, or impressionistic evidence. In effect, we have willingly donned blinders which allow only one vision of ADHD based on its existence as a neurobiological entity. This ‘tunnel’ vision hasawarded resultedto inother manyphenomena researchers while exhibiting an dismissing astoundingcogent lack ofand proper scientific scepticism quickly continuing criticism of ADHD (Reid et al., al., 1994). This phenomenon is not unusual – scientists often fit data to their expectations and, in some cases, have been incapable of seeing data that disagreed with their perspective or attending to alternative explanations (Kuhn, 1970). For example, in a review of research on ADHD, Zametkin (1989) noted that the etiology of ADHD is unknown, and research in family studies, drug response, biological markers, and ADHD's association with other neuropsychiatric syndromes individually are insufficient to warrant a generalized neurobiological cause for f or ADHD. However However,, he then noted that these inconclusive lines, when combined, substantiate a neurobiological cause for ADHD.

 Media and the sensationalizing of ADHD The medical-disease orientation of many American researchers clinicians has been fueled, in part, by the amazing advances in technology as typified and through the use of Positron Emission Tomography (PET) and Magnetic Resonance Imagining (MRI). Perhaps a more powerful force than technology has been the way popular media sensationalizes research findings. It is typical for the media to prominently report dramatic announcements regardless of the vigour with which researchers stress a cautionary stance. Horgan (1993) noted that researchers have reported genetic bases for crime, manic depression, schizophrenia, alcoholism, and homosexuality, homosexuality, all of which have been either retracted or demonstrated to be spus purious. Unfortunately, as Horgan noted, much less attention is paid to retractions or cautions regarding the limitations of a study than to the initial announcement. For example, Zametkin et al.’s al.’s (1990) original study, study, including false-colour photographs of ‘normal’ and ‘hyperactive’  brains, was widely widely reported in the popular pr press ess as ‘proo ‘prooff ’ of the existence of ADHD as a neurobiological condition (e.g. Wallis, 1994). However, follow-up studies which failed fa iled to replicate the (Zametkin or which suggest that the differences in little, the original study al., 1993) al., mayresults have been due to et gender differences (Andreason , 1994) attracted if any media et al., al. attention.

Conceptual and methodological flaws We view a great deal of ADHD research as fundamentally flawed due to conceptual and methodological limitations. Conceptually, ADHD is a tautological disorder – children have ADHD because they exhibit a certain number of behaviours and they exhibit the behaviours  because they have ADHD. Thus, ADHD literally defines itself – the symptoms are the syndrome. This tautology would not pose a serious problem if there were objective indicators of  ADHD. However, because a diagnosis is based solely on a clinician’s subjective judgement, it is difficult to differentiate ADHD from other disorders that bear a superficial resemblance to it. For example, Weinberg and Brumback (1992) found that out of 100 children who were consecutively referred to a behaviour neurology program, 80 per cent met the DSM-III-R diagnostic criteria for ADHD. They also found that three other conditions, either alone or in com12

 

Educational and Child Psychology (1997) Vol. 14 (1)

 bination (affective illness, primary disorder of vigilance, and llearning earning disability), d isability), were more accurate diagnoses than ADHD. It is difficult to say that certain behaviours are the result of  ADHD when they are equally diagnostic of other conditions. This problem is exacerbated when considering that the medical-disease approach of the DSM taxonomy is categorical – an individual either has or does not have ADHD. The DSM does not allow clinicians to diagnose individuals as ‘kind of’ having ADHD. However, as Barkley (1994) between andmeans disordered behaviourwhether is arbitrary. Thus, ADHDnoted, cannotthe bedemarcation falsified as there is nonormal objective of determining or not the defining behaviours actually represent a distinct pathological condition. Further, the degree to which clinicians view the symptoms to be sufficiently deviant to warrant a diagnosis is fick fick-le because of the subjective nature of the process. Therefore, it is err erroneous oneous to portray ADHD as the psychological equivalent of a broken arm which can infallibly be distinguished di stinguished through a diagnostic process analogous to examining an x-ray. Research on the etiology of ADHD may also be questioned on methodological grounds. A great deal of this research (e.g. Zametkin et al., al., 1990) employed a correlational or non-experimental design in that an independent variable was not manipulated (Cook & Campbell, 1979). These studies focused on discovering whether certain variables covaried with the presence or absence of ADHD. However, it is axiomatic that correlation does not imply causation; thus, we wouldMoreover, argue that,when at best, these studies can only provide evidence ofofbiologic causality. correlations are found, there seemssuggestive to be a presumption unidirectional causal flow – differences in purported biological markers are invariably presented as the cause rather than the potential result of attention problems. Researchers frequently run dozens of statistical tests without control for chance, thus findings are often inflated, and in many instances, if proper statistical controls were implemented, would be negative. We would also note that correlations can be spurious. Therefore, the hypothesized relation  between ADHD and biolo biologic gic correlates could be due to the influence of o other ther unaccounted for variables. For example, none of the correlative studies could rule out natural human variation as a ‘cause’ of ADHD.

 ADHD as Piltdown man In 1912 Charles British lawyerwhich and amateur archeologist, several cranial fragments and a Dawson, lower jawanear Piltdown he believed to be from‘found’ a prehistoric hominid. These findings were subsequently presented to the Geological Society of London and were largely accepted, despite the fact that the skull actually belonged to a modern human and the  jaw was that of an orangutan. How could such an obvious obvious hoax be perpetrated upon some of  the most renowned scientists of the era? Gould (1980) provided several explanations – all of  them grounded in the myth “that facts are 'hard' and ... that scientific understanding increases by patient collection and sifting of these objective bits of pure information" (p.115). He pointed out that, in reality, reality, science is a human activity often motivated by hope, prejudice, and a nd the possibility of glory. Because of England's desire not to be outdone by France, which had an abundance of Neanderthal and Cro-Magnon remains, and the typical racial views of  Europeans that whites were superior to peoples of Asian and African descent – Peking man who lived in China had a brain two-thirds modern size while Piltdown man had a fully developed brain and, not coincidentally, resided in England – they largely and uncritically accepted Piltdown man as ‘fact’.

13

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

It is worth noting that there have been several nonexistent disorders of childhood. For example, Morens and Katz (1991) concluded that between 1884 and 1900 the ‘fourth disease’ (Dukes disease) which followed rubella (‘third disease’) and preceded erythema infectiosum (‘fifth disease’) never existed. Although it was rarely recognized by the 1930s and dropped from textbooks by the 1960s, all cases could be completely explained as misdiagnosed rubella and scarlet fever. The authors pointed to the failures of scientists of the time to critically examine the data. We We believe the same phenomenon as Piltdown man and the ‘fourth disease’ disease ’ may be occurring with ADHD in the United States. way ADHD isasuncritically as a neurobiological condition suggests that it may The be masquerading a late 20thaccepted century Piltdown man. However, we doubt that the passage of time will unmask ADHD the way it did with the ‘fourth disease’ since there are powerful social and cultural factors in the United States that perpetuate the medical-disease orientation.

The social and cultural faces of ADHD in the United States ADHD has been, and continues to be, conceptualized from a medical-disease perspective at the micro-level which focuses solely on characteristics inherent to the individual (Whalen & Henker, 1980). This micro focus on ADHD as a neurobiological disorder ignores the fact that what defines an individual’s behaviour as disordered is, at least in part, a process that is socially negotiated and socially defined. This assertion is congruent with the definition of the word ‘abnormal’. to Wicks-Nelson and Israel (1991), “ Ab means away, or from, while normal refersAccording to the average or standard. Thus, abnormal simply means something that deviates from the average” (p.2). Of course, this definition requires determining what standards will be used to determine whether deviance exists – a process that is very much affected by social and a nd cultural factors. As W Wakefield akefield (1992) noted, the very concept of dis disorder order exists in a grey area between the given natural world and the constructed social world. Thus, disorders are subjected to social forces, may elicit differing social responses, and may serve socially defined ends (Noblit et al., al., 1991).

 All labels are not created equally One of the most powerful social forces that perpetuates the medical-disease approach to ADHD is the effect of ‘labels’. Labels are discursive – through language we are able to understand communicate how aa context phenomenon constructed and defined (Parkerare et interpretal., 1995). al., In thisand regard, labels provide withiniswhich the actions of individuals ed by society (Noblit et al., al., 1991). They serve to provide meaning to behaviour, and the social message of a label may lead us to ascribe different meanings to the same behaviour if individuals are labelled differently. For example, although they reflect the same behaviour, the labels ‘drunk’ and ‘alcoholic’ may evoke distinctly different responses. ‘Drunk’ may lead one to assume that there is something wrong with the will or moral nature of the individual – he/she is purposely engaging in excessive behaviour. This view results in ‘drunk’ being a label of damnation. Other labels of damnation applied to children include conduct disorder, social maladjustment, and juvenile delinquency. Conversely, ‘alcoholic’ is a label of forgiveness since the individual often is perceived as being unable to control their excessive behaviour. This label implies that society should uphold special norms or make exceptions for the individual so labelled. Labels of forgiveness applied to children include learning disability, minimal brain dysfunction, and ADHD since they all are thought to have some neurobiological bases, thereby exculpating the individual of responsibility for their actions. Therefore, all labels are not created equally. 14

 

Educational and Child Psychology (1997) Vol. 14 (1)

The labelling phenomenon represents a powerful social force in the United States which supports and maintains the perspective of ADHD being a neurobiological condition. ADHD is a potent and desirable label of forgiveness because it attributes troubling behaviour to physiological forces (i.e., neurobiological) outside an individual’s control. It is difficult to blame a child for refusing to follow directions or sit quietly if these behaviours are perceived as having an organic basis. Imagine telling someone with epilepsy to just stop seizuring. This request is ludicrous since the seizure is beyond the control of the individual. By conceptualizing ADHD as a neurobiological condition, it becomes a ‘no label.behaviour. No one – not parent, teacher, nor even child – is responsible or blameworthy forfault’ problem This phenomenon has lead to what some term an ‘ADHD epidemic’ (Zirkel, 1994). Although maintaining ADHD as a label of forgiveness may serve to exculpate individuals of   blame or sanction unacceptable behaviour behaviour,, it has also lead to a backlash in which ADHD is portrayed as a mythical disorder maintained and supported by a cabal of liberal parents, psychologists, educators, and physicians, in collusion with the pharmacology industry (Armstrong, 1995a,b). Other authors view ADHD as another example of America’s propensity toward glorifying victimization (Smelter et al., al., 1996). There is perhaps a grain of truth in these accusations. For example, parent groups, with extremely large memberships, have actively lobbied to have ADHD made a category of disability in the US (Aleman, 1991) and have attempted to influence the Drug Enforcement Agency to allow an increase in the production ofbest, methylphenidate conspiracy theories are far fetched at mean spirited sp irited(Merrow, at worst, 1995). and doHowever, little more than to propagate falsesomewhat dichotomies which serve to further polarize an already highly charged issue (DuPaul, 1995).

Beneficial social functions of the ADHD label The medical-disease conceptualization of ADHD as a neurobiological condition serves three powerful, and sometimes beneficial, social functions (Reid, 1996). First, the ADHD label legitimizes parents’ concerns that children do, in fact, manifest problems and that those problems are recognized, common, and socially palatable. Problem behaviour now can be portrayed as an inability to respond appropriately to an underlying disorder, rather than unwillingness, lack of motivation, or poor parenting. Second, the ADHD label allows parents to ‘externalize the disorder’ thereby separating the ‘good’ child from the ‘bad’ behaviour (White & Epston, 1990). behaviour canThird, then be interpreted as the ‘ADHD out’ as opposed a wilful Problem or thoughtless action. a diagnosis of ADHD may becoming the most powerful routetofor parents to secure services for children. A formal diagnosis can invoke legal protection, and has what Damico and Augustine (1995) termed “reactive power.” The attachment of the medical label may be a sufficient stimulus to cause schools to seriously attend to the refractory behaviours.

Dereifying ADHD: a functional perspective Constructs or causes are useful if, and a nd only if, correct diagnosis informs i nforms treatment – a position that has not been effective in the case of ADHD (e.g. DuPaul & Stoner, 1994). Thus, for practitioners who deliver treatment, the debate on the reality of ADHD serves as little more than a perceptual stumbling block which shifts attention away from what should be the focus of  treatment – the behaviours. We have argued that a more efficacious perspective on ADHD, and one more suited for practitioners, is one based on a functional perspective of ADHD (Maag & Reid, 1994, 1996; Reid & Maag, in press). press). A functional perspective focuses on indi15

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

vidual-specific deficiencies (behavioral, cognitive, self-control) and environmental factors (antecedents, consequences, and outcomes) that interfere with the production of appropriate  behaviour.. From this perspective, a dia  behaviour diagnosis gnosis is irrelevant since it provides no more information than what is readily apparent: a child is displaying inappropriate behaviour and a robust intervention is warranted. In a way, a functional approach is differential diagnosis backwards. Traditionally, a diagnosis is required to provide information on the best treatment. In a functional approach, various individual-specific and environmental variables are first manipulated (i.e., intervention) to acquire assessment information on the most efficacious course of  treatment.

 Functional assessment: a brief overview Functional assessment can be characterized as a series of hypotheses-testing hypotheses- testing sequences (Elliott individual-specifi c and environmental factors et al., al., 1987). Hypotheses are generated based on individual-specific that prevent the performance of appropriate behaviour. Manipulations are then performed to either confirm or refute the hypotheses. In our conceptualization, individual-specific factors involve behavioural, cognitive, and selfcontrol deficiencies (Maag & Reid, 1994, 1996). Behavioral B ehavioral deficiencies refer to the requisite skills required to perform certain behaviours. Determining a behavioural deficiency involves a fairly straightforward subcomponents of the target skill are operationally defined, the childskill-testing is instructed process: to perform the skill, a powerful reinforcer is identified to increase the child’s motivation to perform the skill, and a clinician observes his performance. The child probably has a behavioural deficiency if he/she fails to perform the target skill. If a child possesses the requisite skills but still fails to perform the appropriate behaviour, then cognitive and self-control factors are targeted for remediation. Cognitive deficiencies can either involve distortions (i.e. irrational beliefs) or deficiencies (i.e. erroneous problem solving strategies). Selfcontrol deficiencies involve the inability of children to monitor and evaluate their behaviour. Environmental variables include antecedents, consequences, and outcomes. Antecedents precede behaviour and serve as a prompt, or cue, for the occurrence of certain behaviours. Consequences transpire after a behaviour and serve to either maintain, increase, or decrease the future probability of the behaviour occurring. Outcomes refer to the intent of behaviour. When acts, withresult, behaviours considered be inappropriate, does so to achievea achild result. Theeven desired or outcome, can betoviewed as the intenthe/she of the behaviour. Even inappropriate behaviours are used to achieve outcomes desired by all individuals. For example, a child may become aggressive in order to gain acceptance with his/her peers. The desire to affiliate with others is quite appropriate; although the form (i.e. aggression) is inappropriate. In functional assessment these variables would be manipulated and their effects o on n  behaviour observed (Reid & Maag, in press). For example, if the desired outcome of aggression was affiliation, the child would be taught an appropriate behaviour to affiliate with his/her peers while observing the number of aggressive episodes. If the number of aggressive episodes decrease, the hypothesis that the desired outcome was affiliation would be confirmed. If aggression continued, then another outcome would be hypothesized and tested.

Rationale for a reasons functional There are several whyapproach clinicians should consider conside r adopting a functional approach. One of the major reasons is that, unlike many trends in the field of ADHD, it is not a new and 16

 

Educational and Child Psychology (1997) Vol. 14 (1)

untested approach. Functional assessment techniques have been used for over 10 years to ameliorate problems such as aggression, self-injurious behaviour, disruptions, non-compliance, opposition, off-task, and tantrums (e.g., Carr & Durand, 1985; Childs et al., al., 1994; Cooper et al., al., 1992; Day et al., al., 1988; Iwata et al., al., 1982). Although functional approaches were originally developed for individuals with developmental disabilities (Dunlap et al., al., 1993), there is an emerging body of literature documenting the effectiveness of functional approaches with children with either an ADHD diagnosis or behaviours typical of ADHD (e.g., Childs et al., al., 1994; Cooper et 1995). DePaepethe , 1996; Dunlap 1994; Dunlap , 1991; Kern et al., , 1994; al., 1992; al., et al., al. et al., al., is et al., al. al.impleUmbreit, Moreover, functional approach practical and can be effectively mented in a variety of settings including school classrooms (e.g., Cooper et al., al., 1990; Northrup et al., al., 1991; Sasso et al., al., 1992).

Conclusion In this article we have been critical of the way ADHD is primarily conceptualized in the United States. We readily recognize that our criticisms and proposed alternative approach swim against the stream of dogma. Ironically we see the position of The British Psychological Society,, that ADHD is best viewed as an evolving construct, as the most proper stance for clinSociety cl inicians – one that a cursory examination of the history of ADHD would confirm. We see the medical-disease orientation to ADHD as inappropriate for practitioners as it does nothing positive to guide treatment. In addition, it may have the than negative effect ofplace locating ownership of problem behaviour in an undesirable disorder rather the proper – parents, educators, and clinicians. Whether or not ADHD ‘exists’ as a discrete disorder is simply irrelevant to the demonstrable fact that disruptive and maladaptive behaviour problems are invidious in our society today. Our job is to treat the behaviour, an approach we might note which is effective even with disorders of known biologic etiology such as Down Syndrome. Consequently, the important question is how can we effectively improve the performance of children with chronic refractory behaviour problems – regardless of the label?

References issues. Congressional Aleman, S.R. (1991) Special education for children with attention deficit disorder: current issues. Research Service, Library of Congress. Andreason, P.J., P.J., Zametkin, A.J., Guo, A., Baldwin, P. & Cohen, R.M. (1994) Gender-related differences in regional cerebral glucose metabolism in normal volunteers. Psychiatry Research, 51, 51, 175-183. Armstrong, T. T. (1995a) ADD as a social invention. Education Week , 18 October 1995, 32-33. child. New York: Dutton. Armstrong, T. (1995b) The myth of the ADD child. Barkley,, R.A. (1987) The assessment of attention deficit hyperactivity disorder. Barkley disorder. Behavioral Assessment, 9, 9, 207-233. Carr, E. & Durand, M. (1985) Reducing behavior problems through functional communication training.  Journal of Applied Behavior Analysis, 18, 18, 111-126. Childs, K., Dunlap, G., Clarke, S. & Falk, G. (1994) Using assessment-based curricular interventions to improve the classroom behavior of a student with emotional and behavioral challenges.  Journal of   Applied Behavior Analysis, 27, 27, 7-19. Cooper, L., Wacker, D., Sasso, G., Reimers, T. & Donn, L. (1990) Using parents as therapists to evaluate appropriate behavior. behavior. Journal of Applied Behavior Analysis, 23, 23, 285-296. Cooper, L., Wacker, D., Thursby, D., Plagmann, L., Harding, J., Millard, T. & Derby, M. (1992) Analysis

17

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

of the effects of task preferences, task demands, and adult attention on child behavior in outpatient and classroom settings. Journal settings. Journal of Applied Behavior Analysis, 25, 25, 823-840. Damico, J. & Augustine, L. (1995) Social considerations in the labeling of students as attention deficit 16, 259-274. hyperactivity disordered. Seminars in Speech and Language, 16, Diller, L. (1996, March-April) The run on Ritalin: attention deficit disorder and stimulant treatment 26, 2, 12-18. medication in the 1990’s. Hastings 1990’s. Hastings Center Report, 26, Day,, R., Rea, J., Schussler, Day Schussler, N., Larsen, S. & Johnson, W. W. (1988) A functionally based approach to the treatment of self-injurious behavior. behavior. Behavior Modification, 12, 12, 565-589. DePaepe, P., Shores, R., Beck, S. & Denny, R. (1996) Effects of task difficulty on the disruptive and ontask behavior of students with severe behavior disorders. Behavioral Disorders, 21, 21, 216-225. Dunlap, G., dePerczel, M., Clarke, S., Wilson, D., W Wright, right, S., White, R. & Gomez, A. (1994) Choice making to promote adaptive behavior for students with emotional and behavioral challenges. Journal challenges.  Journal of Applied Behavior Analysis, 27, 27, 505-518. Dunlap, G., Kern, L., dePerczel, M., Clarke, S., Wilson, D., Childs, K., White, R. & Falk, G. (1993) Functional analysis of classroom variables for students with emotional and behavioral disorders. Behavioral Disorders, 18, 18, 275-291. DuPaul, G.J. (1995) False and simplistic dichotomies: a response to Valentine. NASP Communiqué, 24, 24, 3, 17, 19. practice. New York: Guilford Press. DuPaul, G. & Stoner, G. (1994) ADHD (1994) ADHD in the schools: assessment and practice. Elliott, S.N., Gresham, F.M. & Heffer, R.W. (1987) Social-skills interventions: research findings and training techniques. In C.A. Maher & J.E. Zins (Eds) Psychoeducational interventions in the schools (pp.141159). New York: Pergamon. Goldstein, S. & Goldstein, M. (1990) Managing (1990)  Managing attention disorders in children. children. New York: York: John Wiley. Wiley. Herskovitz, J. & Rosman, N.P. (1982) Pediatrics, neurology, and psychiatry – common ground. ground. New York: Macmillan. American, 122-131. Horgan, J. (1993, June) Eugenics revisited. Scientific American, Hunt, R.D., Cohen, D.J., Anderson, G. & Mineraa, R.B. (1987) Noradrenergic mechamiams in ADHD. In disorder: new research research in attention, treatment, treatment, and psychopharmacology L. Bloomingdale (Ed.) Attention (Ed.) Attention deficit disorder: (Vol. 3, pp.129-148). New York: Pergamon. Hynd, G.W., Hern, K.L., Voeller, K.K. & Marshall, R.M. (1991) Neurobiological basis of attention-deficit hyperactivity disorder (ADHD). School Psychology Review, 20, 20, 174-186. Iwata, B., Dorsey, M., Slifer, K., Bauman, K. & Richman, G. (1982) Toward a functional analysis of selfinjury. Analysis and Intervention in Developmental Disabilities, injury. Analysis Disabilities, 22,, 3-20. Kern, L. Childs, K., Dunlap, G., Clarke, S. & Falk, G. (1994) Using assessment-based curricular intervention to improve the classroom behavior of a student with emotional and behavioral challenges.  Journal of Applied Behavior Analysis, 27, 27, 7-19. Kramer, P.D. (1993) Listening to Prozac. Prozac. New York: Viking Press. Kuhn, T.S. (1970) The structure of scientific revolutions (2nd edn). edn). Chicago, IL: University of Chicago Press. Maag, J. & Reid, R. (1996) Treatment of attention deficit-hyperactivity disorder: a multi-modal model for schools. Seminars in Speech and Language, 17, 17, 1, 37-58. Maag, J.W. & Reid, R. (1994) Attention Deficit-Hyperactivity Disorder: a functional approach to assessment and treatment. Behavioral Disorders, 20, 20, 5-23. Mann, E.M., Ikeda, Iked a, Y., Y., Mueller, C.W., C.W., Takahashi, Takahashi, A., Tao, Tao, K.T., Humris, E., Li, B.L. & Chin, D. (1992) Cross-cultural differences in rating hyperactive-disruptive behaviors in children.  American Journal of  Psychiatry, 149, 149, 1539-1542. Merrow, J. (1995, October, 21) Reading, writing, and Ritalin. New York Times, Merrow, Times, p.21 Op-Ed. Morens, D.M. & Katz, A.R. (1991) The “Fourth Disease” of childhood: re-evaluation of a nonexistent

18

 

Educational and Child Psychology (1997) Vol. 14 (1)

disease. American disease.  American Journal of Epidemiology, Epidemiology, 134, 134, 628-640. Noblit, G.W., Paul, J.L. & Schlechty, P. (1991) The social and cultural construction of emotional disturbance. In J.L. Paul & B.C. Epanchin (Eds) Educating emotionally disturbed children and youth: theories and practices for teachers (pp.218-242). New York: Merrill. Northrup, J., Wacker, Wacker, D., Sasso, Sasso, G., Steege, M., Cigrand, K., Cook, J. & DeRaad, A. (1991) A brief  functional analysis of aggressive and alternative behavior in an outclinic setting.  Journal of Applied Behavior Analysis, 24, 24, 509-522. Parker, I., Georgaca, E., Harper, D., McLaughlin, T. & Stowell-Smith, M. (1995) Deconstructing psychology. Parker, psychology. London: Sage. Prendergast, M., Taylor, E., Rapoport, J.L., Bartko, J., Donnelly, M., Zametkin, A., Ahearn, M.B., Dunn, G. & Wieleberg, H.M. (1988) The diagnosis of childhood hyperactivity a U S–UK cross-national study of  29, 289-300. DSM-III and ICD-9. Journal ICD-9.  Journal of Child Psychology and Psychiatry, 29, Reid, R. (1995) Assessment of ADHD with culturally different groups: the use of behavior rating scales. School Psychology Review, 24, 24, 537-560. Reid, R. (1996) Three faces of attention deficit hyperactivity disorder.  Journal of Child and Family Studies, 5, 249-265. Reid, R., Maag, J.W. & Vasa, S.F. (1994) Attention deficit hyperactivity disorder as a disability category: a critique. Exceptional Children, 60, 60, 198-214. Reid, R. & Maag, J. (in press) Classroom-based accommodations for children with attention deficit hyperactivity disorder. disorder. Reading and Writing Quarterly. Quarterly. Sasso, G., Reimers, Rei mers, T., Cooper, L., Wacker, Wacker, D., Berg, W., Steege, M., Kel Kelly ly,, L. & Allaire, A. (1992) Use of  descriptive and experimental analyses to identify the functional properties of aberrant behavior in school settings. Journal settings. Journal of Applied Behavior Analysis, 25, 25, 809-821. Schachar, R. (1986) Hyperkinetic syndrome: historical development of the concept. In E. Taylor (Ed.) The Schachar, overactive child (pp.19-40). Philadelphia: J.B. Lippincott. Shekim, W.O., Glaser, E., Horwitz, E., Javaid, J. & Dylund, D.B. (1987) Psycho-educational correlates of  deficit disorder: new catecholamine metabolites in hyperactive children. In L. Bloomingdale (Ed.) Attention (Ed.) Attention deficit research in attention, tretment, and psychopharmacology (Vol. 3, pp.149-150). New York: Pergamon. Smelter, R.W., Rasch, B.W., Fleming, J., Nazos, P. & Baranowski, S. (1996) Is attention deficit disorder  becoming a desired diagnosis? Phi Delta Kappan, 77, 77, 6, 429-432. Still, G.F. (1902) Some abnormal psychological conditions in children. Lancet, 1, 1, 1008-1012, 1077-1082, 1163-1168. Taylor, E. (1989) On the epidemiology of hyperactivity. In T. Sagnolden & T. Archer (Eds) Attention (Eds) Attention deficit disorder: clinical and basic research (pp.31-52). Hillsdale NJ: Lawrence Erlbaum. Umbreit, J. (1995) Functional assessment and intervention in a regular classroom setting for the disruptive  behavior of a student with with attention deficit deficit hyperactivity hyperactivity disorder. disorder. Behavioral Disorders, 20, 20, 267-278. Wallis, C. (1994, July) Life in overdrive. Time Time,, pp.42-50. Wakefield, J.C. (1992) The concept of mental disorders: on the boundary between biological facts and social values. American values. American Psychologist, 47, 47, 373-388. Weinberg, W.A. & Brumback, R.A. (1992) The myth of attention deficit-hyperactivity disorder: symptoms resulting from multiple causes. Journal causes.  Journal of Child Neurology, Neurology, 7, 7, 431-445. Whalen, C.K. & Henker, B. (1980) The social ecology of psychostimulant treatment: a model for conceptual and empirical analysis. In C.K. Whalen and B. Henker (Eds)  Hyperactive children: the social ecology of identification and treatment (pp.3-51). New York: Academic Press. P ress. White, M. & Epston, D. (1990) Narrative means to therapeutic ends. ends . New York: Norton. Wicks-Nelson, R. & Israel, A.C. (1991) Behavior disorders of childhood (2nd edn). edn). Englewood Cliffs, NJ: Prentice Hall.

19

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

Zametkin, A.J. (1989) The neurobiology of attention-deficit hyperactivity disorder: a synopsis. Psychiatric P sychiatric  Annals, 19, 19, 584-586. Zametkin, A.J., Nordahl, T.E., Gross, M., King, A.C., Semple, W.E., Rumsley, J., Hamburger, S. & Cohen, R.M. (1990) Cerebral glucose metabolism in adults with hyperactivity of childhood onset. New England  Journal of Medicine, 323, 323, 1361-1366. Zametkin, A.J. & Rapoport, J.L. (1986) The pathophysiology of Attention Deficit Disorder with child psychology (Vol. 9, pp.177Hyperactivity: a review. In B. Lahey & A. Kazdin (Eds) Advances (Eds) Advances in clinical child 216). New York: Plenum. Zirkel, P. (1994, November) The approaching epidemic of attention deficit disorder. The School  Administrator,, pp.28-30.  Administrator

20

 

Educational and Child Psychology (1997) Vol. 14 (1)

Between a rock Between rock and a hard hard place: place: an Australian perspective on education of  children with ADHD Iv Ivan an M.At M. Atki kins nson on,, Jul ulie ie A. Robi Robins nson on,, Rosa Rosaly lyn n H. Shute Shute Flinders University University,, Adelaide, South Australia

 Abstract Research, clinical experience, government statistics and policies provide the basis of a brief  overview of ADHD in Australia, a description of the working context for teachers in South  Australia and an outline of one curren currentt Australian research project. A general upsurge in the numbers of prescriptions for stimulant medication has generated concerns over current diagnostic and intervention practices, highlighted by recent media reports. Stress experienced by families is exacerbated by theininadequacy inadequa cy of but services to accommoda accommodate te the needsare of attempting children with ADHD. ADHD. Teachers, operating a demanding under-resourced environment, to meet the expectations of parents and practitioners by addressing the learning and social difficulties of these children. Although Although research has generally con conceptualized ceptualized ADHD as a ‘medical’ problem, sociocultural and psychological factors must also be taken into account. One current research research project conceptualizess ADHD within a systems/goodness-of-fit conceptualize systems/goodness-of-fit framework as a means of understandin understandingg the complexities of ADHD and as a basis for effective collaborative management.

Introduction This paper is derived from a blend of published research, government statistics and anecdotal information obtained from clinical experience with families and involvement with community support groups and government departments. The first section provides a broad picture of ADHD in Australia, discussing prevalence, stimulant prescription government sponsored support and education programs. The medication second section describes and the context in which teachers encounter children c hildren with ADHD, examining the impact of ADHD in South Australian schools, relevant government education policy, parental expectations and teacher resources. The final section outlines one research project currently being undertaken in Australia comparing the knowledge, beliefs and attitudes about ADHD of parents, teachers and health professionals using a ‘goodness-of-fit’ framework.

Overview of the situation in Australia Prevalence Australian health professionals share the disagreement about the nature of ADHD seen in other Western (Adler, 1995;media Greenreports, & Chee, 1994; Hazell, 1995; national Hutchins, Oberklaid, 1995;countries Wall, 1995) and recent such as the Australian TV1993; program 4 Corners, Corners, have highlighted the debate. Some paediatricians (Green, 1994; Hutchins, 21

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

1993; Wall, Wall, 1995) have mirrored writers in the USA such as Barkley (1994), (1994) , arguing that ADHD is a genetically-based neuro-developmental disorder. Opposing this view through the Australian media, USA commentators Br Breggin eggin (1993) and Glasser (1996) have disputed its existence. This view has received partial support with some Australian practitioners who have raised questions about the incidence of the disorder (Adler, 1995; Oberklaid, 1995). One sceptical paediatrician is probably not alone in stating that: in my practice, I hardly see a child at the moment in whom the question of ADHD is not raised (Adler, 1995), and suggests Australia is seeing an ADHD epidemic. As in other Western nations, parents express impatience with such debates in statements such as “Call it what you like – I can’t cope with my child’s behaviour”. For them unresolved questions about aetiology, defining symptoms, assessment methods and preferred treatments are secondary to interventions that  bring swift amelioration of symptoms. ADHD is having a wide impact in Australia. Disruptive behaviour at home produces high levels of stress in parents and children, sometimes stretching relationships to breaking point. Pressure is placed on teachers to maintain discipline and facilitate learning despite the academic difficulties often associated with ADHD. School administrators are expected to provide adequate resources for teachers at a time when real-term funding for government schools is declining. Awith range of health pr professionals ofessionals (in (including cluding doctors doctors ‘normal’. and psychologists) is approached the expectation that they can make these children Politicians are lobbied to provide resources for counselling and support agencies for families, and for subsidized medication and disability allowances. No Australian state government records the number of children diagnosed with ADHD. However, in 1980, Glow gave an estimate of 2.3 per cent to 6 per cent. Current estimates are based on the number of prescriptions/tablets of psychostimulant drugs given for children under 18 years. In Australia, psychostimulant drugs are rarely prescribed for children child ren other than for ADHD. ADHD. However, because doctors may not prescribe for every child diagnosed, these figures provide an underestimation. These estimates, which are not equally distributed across Australian states (Hazell, 1995), may also be contaminated by regional differences in the ‘culture’ governing prescription. Despite these difficulties with the data, a clear picture is emerging: increasing numbers of children areedbeing placed on medication, is being given at younger ages, anderit of  is  bein  being g cont continu inued long longer er. . In New So South uth W Wales alesmedication th ther eree has been a six six-fo -fold ld increase incr ease in th the e numb number children receiving prescriptions in the past six years. Currently, 15,000 (0.7 per cent) of children 019 years of age are being prescribed medication (National Health & Medical Research Council (NH&MRC), 1996). The vast majority are prescribed dexamphetamine. Western Australia has recently seen a nine-fold increase in prescription rates, with about 1.8 per cent of males and 0.2 per cent of females of school age children receiving medication (Wall, 1995). Dexamphetamine is prescribed about twice as often as methylphenidate, with the increase in use of the former being greater over the past five years (W.A. Health Department, 1995). South Australia is the state with the largest recent increase in prescription rates, at least partly due to the previously low frequency. In 1991 there were only 60 children authorized as users of stimulant drugs, in 1993 there were 1255 (Drugs of Dependence Unit, S.A. Health Commission, 1993) and in 1997 it is expected that there will be 3,000 or more (S.A. Health Department, 1995), representing approximately 0.7 per cent 5- topattern 18-year-old prescriptions (65previously per cent) were for dexamphetamine.ofAthe similar existspopulation. in Victoria. Most In general, states with low prescription rates have shown the most rapid increases over the past two to three years (Hazell, 1995). 22

 

Educational and Child Psychology (1997) Vol. 14 (1)

The current ratio of prescriptions for boys and girls is approximately 4:1 in New South Wales (NH&MRC, 1996) and 9:1 in South Australia (Magarey Institute, 1995). However, prescribing of psychostimulant medication appears more likely when behaviour is severely disruptive or aggressive, and these behaviours seem see m more prevalent among boys than girls diagnosed with ADHD. It is therefore likely that prescription data particularly underestimate the prevalence of ADHD among Australian girls. Comparisons of prevalence rates across countries are difficult because of differences in datacollection methods. It seems clear, however, that the average number of school-age children prescribed psychostimulant medication in Australia (under one per cent) remains lower than the comparable USA figure (three per cent) (Murphy & Hagerman, 1992). Nevertheless, the the rapid increase has raised considerable concern over assessment and treatment practices. The medical model has dominated ADHD research and practice. This views its behavioural characteristics as dysfunctional, originating from a bio-neurological deficit, and encourages parents to take ‘a disability perspective’ (Barkley, 1994). Medicalization also seemingly allows a ‘no fault’ response (Maag & Reid, 1994) absolving child, parent and society of any responsi bility in terms of causation. While this might reduce guilt, guil t, parents may also feel powerless to effect change.

Government policies relating to ADHD  Healthcare rebates. rebates. Federal policy regarding healthcare rebates has been instrumental in fostering a medical view of ADHD. In Australia, Medicare (the National Health Scheme) restricts the provision of subsidized healthcare to medical practitioners. Furthermore, many psychologists work in psychiatric departments or mental health services service s which require them to report cases in DSM/ICD terms even if they consider these invalid/unhelpful. Access to private, non-medical practitioners such as psychologists, physiotherapists, speech and occupational therapists, is limited to the better-off. Medical practitioners generally have neither the time nor training to implement behaviour management strategies. Thus, although a combination of medical and behavioural treatment is recommended as the most effective form of  intervention (Wall, 1995; Hazell, 1995; Greene, 1995), many families have little choice since they face long waiting lists for government psychological (e.g., Child Mental Health Services) or‘free’ prohibitive costs. This effectivelyservices denies them access & toAdolescent alternative interventions forcing reliance on paediatricians, child psychiatrists or general practitioners. Psychologists sometimes express frustration that behavioural and family-based interventions are often overlooked because society ‘medicalizes’ the children’s behavioural problems. Stimulant medications. medications. In all states, stimulant medications are scheduled drugs under the Standard for the Uniform Scheduling of Drugs and Poisons (No. 10) (1995) (hereafter ‘the Standards’) developed by the NH & MRC. While each state requires health authorities to keep records of prescriptions there are interstate variations in regulations and practices such s uch as the criteria and procedures for prescribing, gathering data and maintaining records. For example, in some states, trials of stimulant medication (up to two months) may be initiated by family practitioners, while in others only licensed paediatricians can prescribe. Dexamphetamine and methylphenidate are the two most commonly prescribed stimulants. Dexamphetamine is subsidized by the Australian government for all users. Methylphenidate 23

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

is only subsidized for those on a child disability allowance. With subsidy both drugs are the same price (approx. $3 per prescription). Without the subsidy, methylphenidate varies from $50 to $90 per prescription (approx. £24-£48). Most children with ADHD are not paid a disability allowance. The resulting price difference appears to account for differential prescribing, i.e., clinicians are not necessarily prescribing on the basis of efficacy. Indeed, due to the extra paperwork involved in prescribing medications covered by the various state regulations, practitioners may be encouraged to prescribe non-stimulant medications such as Clonidine, anti-depressants or benzodiazepines. (This may further contribute to the underestimation of ADHD diagnosis based on psychostimulant prescription records.) Government support. support. The Child Disability Allowance (CDA) is a Federally funded, non meanstested, payment to parents/guardians who care for a child with a disability. Since November 1987 all disabilities for which the need for additional care at home can be substantiated are eligible. Consequently Consequently,, children with ADHD may be eligible. Although Federally funde Although funded, d, the CDA is administer administered ed by the states. Stan Standard dard applicat application ion forms and appeal processes are used, but all require medical reports and other supporting documents. Because the attitudes and beliefs be liefs about ADHD held by practitioners vary, regionregional differences in eligibility decisions have resulted. . These groupsdisplaying have developed over the pa st decade, past providing supCommunity support groups port to parents andgroups. families of children behaviour indicative of ADHD. Although initial funding was through government grants administered by local councils, economic rationalism has reduced or eliminated funding. The consequent lack of financial support has made it difficult for these groups to function effectively. Interstate communication between support groups is spasmodic. Indeed, only recently have regional groups established linkages. Local group activities range from lobbying governments to providing practical support such as child minding. Their primary aim is to educate families about ADHD and to advise, when appropriate, on actions parents can take in managing difficulties. For example, one group has compiled an information pack on ‘applying for the CDA’ and offers mediation if  applications are rejected. Many parents find these groups groups an invaluable resour resource. ce. The understanding and help received contrasts sharply with the perceived inadequacy of assistance provided by health practitioners and government agencies. g overnment responsibility responsibility.. Special education. education. Funding for special education is currently a state government Because no Federal policy exists concerning ADHD as a ‘special needs’ category, special education programs do not automatically include ADHD, and there is considerable inter/intrastate variation in the provision of educational assistance. In South Australia, for example, a diagnosis of ADHD does not automatically qualify a student for a funded Negotiated Curriculum Plan (NCP), although in some schools individual teachers tailor work to the capacities of the student. A NCP attracts extra funding for arranging appropriate modifications to a child’s learning program. Eligibility criteria differ for pre-school and school age groups, both allowing for intellectual, sensory, language and communication difficulties but only the pre-school criteria include developmental delay. To be eligible for a NCP, therefore, children with ADHD require a co-morbid diagnosis of intellectual, hearing/visual or language or communication disability. Developmental and educational assessments are performed by a schoolclinical psychologist or counsellor, in health addition to any assessment by adecision paediatrician, psychiatrist, psychologist or other practitioner, before any is made regarding alternative special education provisions. 24

 

Educational and Child Psychology (1997) Vol. 14 (1)

Working context for teachers in South Australia Background In South Australia schooling is provided by non-selective government ‘state schools’ and government-subsidized but privately operated schools, such as Catholic schools. While the number of children attending private schools is increasing, approximately approximately 75 per cent are in state schools (Australian Bureau of Statistics S.A., 1995). There are typically 25-30 students per classroom teacher in both primary and secondary schools with some classes, for reasons of preference or small enrolments, catering for more than one grade. State schools are the focus of the following discussion.

School as a context for initial diagnosis Often, behavioural difficulties are not manifest until demands of the school environment exceed the child's capability. Furthermore, difficulties are often first identified in school  because a child's behaviour is noticeably different from that of peers or is disruptive in class. A diagnosis of ADHD rrequires equires symptoms to be pr present esent before age seven (DSM-IV (DSM-IV,, 1994). Although symptoms may be present from an early age ADHD is commonly assessed/diagnosed soon after a child enters the Australian school system.

 Impact of ADHD On classroom behaviour. behaviour. Students with ADHD are reported by teachers to distract others (by swinging on chairs, making noise and fidgeting etc.). They often miss instructions thus requiring continual reminders. Some teachers indicate that children with with ADHD also have difficulty in social interactions because of an inability to read social cues or to identify, express or respond appropriately to their own or others' emotions. Teachers report that when a class includes a child with ADHD they necessarily modify their own behaviour by preparing work in more detail and adding structure and routines that facilitate more appropriate classroom behaviour. Greater use of strong but gentle guidelines and fewer spontaneous activities are required. They tend to place the child centrally and near the front of the classroom to minimize distracting stimuli (e.g., away from windows, doorways or colourful In addition, teachersthey constantly monitor their own behavioural to distractingwalls). behaviours (e.g., whether raise their voice). Teacher attitudes andresponses behavioural responses in the classroom appear to be reflected in peer reactions to the student with ADHD. ADHD therefore impacts on teachers and peers as well as the student. On academic performance. performance. Many students have learning difficulties co-morbid with ADHD (Cantwell & Baker, 1991). However, However, even in the absence of co-morbid disorders ADHD appears to impact on educational achievement. There is no relevant published Australian research but data are available from New Zealand. Of the 1037 three-year-olds who participated in the Dunedin Multidisciplinary Health and Development Study (McGee et al., al., 1991) two per cent (21) were assessed as both hyperactive and having poor language skills. Data from the 12-year follow-up indicated that early language problems contributed to poor educational outcomes for hyperactive children both in primary and high school. At age 15, 10 per cent of the hyperactive had delayed been diagnosed as having ADHD showed lower reading scores than agroup matched development group. This and suggests thatsignificantly by itself ADHD has a negative impact on academic performance. 25

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

Policies relevant to ADHD Two major policies impact on the manag management ement of ADHD in South Australian classrooms: the ‘students with disabilities’ policy and the ‘school discipline’ policy. policy. The former policy aims to facilitate a supportive, inclusive and collaborative environment for students with disabilities. However,, unless co-morbid with another disorder, ADHD attracts no additional funding outHowever side the ‘normal’ curriculum (e.g., for 1:1 tuition). Consequently, Consequently, many teachers, guidance officers (educational psychologists), students and families are becoming frustrated with the inability to accommodate needs lying outside prescribed parameters (Shute, 1995). The ‘school discipline’ policy aims to produce opportunities for students to experience success, develop an acceptance of responsibility and enable staff, parents and students to collaboratively develop behaviour codes and student development plans. It recommends use of graduated discipline steps, including giving warnings (via a card system), ‘time-out’ from class, being taken home, ‘suspension’ (day), ‘exclusion’ (3-10 weeks) and finally finall y permanent expulsion. Children with ADHD are not served well by this policy because they are unlikely to respond positively to it. Because an assessment of ADHD does not qualify a student as having ‘special needs’, the level of ongoing classroom assistance depends on resources provided within the school for children who do qualify, and the degree to which those resources are surplus to the needs of the qualifying children. Other assistance is available avail able on a one-off basis. The education department has support teams with relevant expertise (although ADHD is notare theusually specificlong focus of anylists. one team). Demand for their services far outstrips supply so there waiting Support teams provide staff with expertise in student reviews (which focus on academic performance, detection of learning disabilities and behaviour management), and include guidance officers and speech pathologists. In addition, the department operates a special education resource centre from which educational materials are obtainable. Additional resources are available from other government agencies such as Child and Adolescent Mental Health Services and Family and Community Services but ther theree are usually waiting lists. In summary, there are no policies specifically governing children with ADHD and the two policies with greatest relevance do not serve these children well (i.e., mismatch in case of discipline and omission in case of disability). The result of this system has been that inservice training regarding ADHD has been provided to teachers on an ad hoc basis with many teachers apparently obtaining information through self-generated networks.

Parental concerns A perceived inflexibility of teachers regarding discipline causes parent parentss to question their their level of competence and attitudes regarding ADHD. Furthermore, parents perceive that their children are scapegoats for others’ misbehaviour. Parents are also concerned that sharing information about their child's diagnosis may lead to social stigma and the creation of certain academic and behavioural expectations by teachers and peers. Additional concern surrounds the perceived inadequacy of the school system with inconsistencies between teachers, insufficient resources (e.g., long waiting lists for assessments, high teacherstudent ratios etc.) and inflexibility believed to inhibit appropriate interactions. Moreover, parents and doctors claim that teachers know that nothing ADHD but will notbelieve listen to parents or ‘experts’. Consequently, parents perceive theyabout are not consulted and that schools ‘don’t care’. Parents therefore often blame the school system for the difficulties of their children 26

 

Educational and Child Psychology (1997) Vol. 14 (1)

(e.g., because reading difficulties were not detected). In support, Wall (1995) argues that the school context represents represents a hostile and aversive environment for these children as evidenced by educational outcomes and subsequent occupational opportunities. However, Wall acknowledges that the fault does not necessarily lie with individual schools, principals, teachers, or allied health personnel. Rather, Rather, he berates the inadequacy of services to accommodate these children.

Draft guidelines for teachers in South Australian schools For many years disruptive behaviours, especially thosegovernment associated with ADHD, have been a source of concern in the school system. In 1996 a working party composed of representatives from the state education department, government agencies and private health practitioners solicited input from parents and researchers to develop draft guidelines for the classroom management of ADHD. These guidelines acknowledge the extent of difficulties faced by teachers, students, parents and practitioners, and provide strategies to assist teachers in individual and collaborative management. They consist of four parts. The first provides sufficient information for teachers to assist in decisions regarding student support and development. It focuses on the challenging behaviours associated with inattention, impulsivity and hyperactivity, acknowledging a wide variety of causes for these, and warns against teachers making judgements about behaviours or predisposing parents towards of a diagnostic Collaboration and manageteachers for the effective management behaviour label. is encouraged and abetween range ofparents behaviour ment techniques is suggested. The second part of the guidelines is a supplement specifically for teachers with responsibility for a child diagnosed with ADHD. It outlines diagnostic information concerning ADHD summarized from the DSM-IV (1994), and provides information about who can make a diagnosis, diag nosis, what is involved in assessment, what such assessment may mean for a student’s educational program and ways that teachers can improve academic performance. The third part is a detailed pamphlet providing information to parents outlining the roles of  parents, principals, teaching staff, students and health practitioners in schools. It emphasizes the importance of sharing perspectives and of joint planning. The final part provides draft letters for use by professionals when requesting information, or providing details to teachers about behaviour monitoring and the administration of medication. Although they will be supported with workshops and training programs, the guidelines only have the status of a working document, to be evaluated in 12 months. Even if they are a success, many of the circumstances that have led to teacher stress, student underachievement and parental dissatisfaction will remain.

Knowledge, beliefs and attitudes of teachers, parents and professionals about ADHD Systems/goodness fit perspective as a behaviour framework A systems approach of attempts to understand asfor th thee conceptualizing product of variousADHD reciprocally reciprocally influential forces. Recently, theoretical explanations have used systems/goodness-of-fit 27

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

frameworks to conceptualize the multi-dimensional nature of ADHD (Greene, 1995). The concept of ‘goodness-of-fit’ captures the degree of compatibility between a child’s capacities, motivation and behaviour style and the expectations and demands of an adult (Greene, 1996) or the characteristics of an environment. Thus ADHD symptoms might be considered products of both reciprocal interactions involving the child and the degree of compatibility  between the child's characteristics and the social aand nd physical context in which he/she operates. The educational context, for example, provides a continuous interchange between teacher, student and other elements of the school environment (e.g., peers, cl teacher, class ass size) such that each influences and is influenced by the other. The ‘goodness-of-fit’ between a child and his/her school context will be influenced by: the degree to which there is compatibility  between the teachers’ standards of of acceptable student behaviour, behaviour, pedagogical style and exposure to other stressors and the behaviours of the child (teacher-student compatibility); the concordance between the student's profile of strengths and weaknesses and the interventions  being attempted while he/she is at school (student-intervention compatibility); the congruity  between the teachers’ level of motivation and access to necessary resources and the demands of the intervention (teacher-intervention compatibility) and the consonance between the students’ strengths and weaknesses and the features of the school environment such as proximity of seating to distractions, behaviour of other students, open/structured classroom (student-class environment compatibility). A parallel network of compatibilities contributes to the ‘goodness-of-fit’ between children and their home contexts. Thus mismatches within and  between can becontext. identified, changes which compatibility the child systems and his/her An facilitating inevitable conclusion of a optimize systems perspective is between that the ‘goodness-of-fit’ between children's behaviour and their contexts differs across contexts and within a context over time. Both have implications for assessment.

 Knowledge, beliefs and attitudes Knowledge, beliefs and attitudes are characteristics of teachers, parents and professionals which may shape reciprocal interactions in which they are involved. For example, methods of  discipline might differ depending on whether a teacher believed that a student’s behaviour was not volitional or expressed wilful defiance. Only five studies (all from the USA or Canada) appear to have been published on knowledge, attitudes or on beliefs regarding ADHD and how these of contribute outcomesaand for children. Three focus teachers. One describes the k knowledge nowledge aetiology aetiology,,to assessment nd treatment of ADHD and the amount of contact teachers have with professionals (Jerome et al., al., 1994). The second describes the extent of specific training relevant to ADHD received in undergraduate and postgraduate education, the amount of contact teachers have with children diagnosed with ADHD, and knowledge of and attitudes towards stimulant medication (Kasten et al., al., 1992). The third examines the relationship between the acceptability of specific interventions, knowledge about ADHD and teaching experience (Power et al., al., 1995). The fourth examines relationships between parents’ knowledge and beliefs about ADHD and their willingness to pursue treatment (Rostain et al., al., 1993). The fifth examines the knowledge and attitudes of paediatricians and influences on diagnosis and treatment practices (Kwasman et al., al., 1995). Comparisons of the findings of these studies suggest that there may be important differences  between teachers, parents and paediatricians in their own knowledge, beliefs and attitudes concerning ADHD and in their perceptions of what others know or believe. Our current research directly compares the knowledge, beliefs and attitudes about ADHD 28

 

Educational and Child Psychology (1997) Vol. 14 (1)

held by teachers, parents and health practitioners within a systems/goodness-of-fit framework, enabling enabling the identificat identification ion of mismatches betwe between en or within groups. A mismatc mismatch h  between parents and teachers in beliefs about the contribution of classroom environments to the distractibility and impulsivity of students, or the appropriateness of disciplinary techniques may see each undermining the other in their attempts to remedy behavioural difficulties. Similarly, mismatches between teachers and health practitioners about parental influences and family environments as contributing to ADHD symptoms may influence the selection and acceptability of interventions and compliance with them. In summary, by assessing the degree of compatibility between these groups, g roups, a ‘goodness-of-fit’ approach identifies areas of collaboration that are successful and those that are not, informs the selection of interventions and may improve the efficacy of and compliance with these. In addition, the situational specificity of behaviours (e.g., fidgeting only occurs when a child is required to work in a group situation) can be identified. Thus a systems/goodness-of-fit framework provides a  basis from which strengths can be optimized and di differences fferences minimized, thereby improving the outcomes for children with ADHD.

Summary Australia is caught up in the current ADHD ‘epidemic’, with increasing numbers of children identified with problematic activity levels, impulsivity and inattention. The impact is being felt  by schools, doctors andand mental health practitioner practitioners s alike. to South teachers findfamilies, themselves between a rock a hard place, being expected meetAustralian the academic and  behavioural needs of these children despite insufficien insufficientt resources, their problems being exacerbated by economic rationalism, unhelpful education policies and differing views about the nature and management management of ADHD. A systems/goodne systems/goodness-of-fit ss-of-fit framewo framework rk can provide a  broader understanding understanding of the match between socio-cultural, psychological and biological factors contributing to a complex phenomenon and facilitate effective collaborative management.

References Prescriber, 18, 18, 3, 64. Adler, R. (1995) Stimulant treatment for ADHD: a comment. Australian comment. Australian Prescriber, American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders (4th ed.). ed.). Washington, DC: APA. Australian Bureau of Statistics (1995) Year Book: South Australia. Australia. Canberra, ACT: ACT: ABS. Barkley, R.A. (1994) Attention deficit hyperactivity disorder: workshop manual. Unpublished manuscript. Workshop Workshop presented at the Newcastle-Hunter ADD Support Group. Sydney, Sydney, Australia. Breggin, P. P. [Commentator] (1993, May) Lateline Lateline,, Sydney, NSW: ABC TV. Cantwell, D. & Baker, Baker, L. (1991) Association between attention deficit hyperactivity disorder and learning disorders. Journal disorders.  Journal of Learning Disabilities, 24, 24, 2, 88-95. Child Disability Allowance: Part 2.19 of the Social Securities Act (1987) Department of Social Security, Commonwealth Government of Australia: Author. Author. Department for Education and Children Services, South Australia (1996) Teachin Teaching g and managing school students with poor attention, impulsivity or hyperactive behaviour: a draft information paper provided to schools. Unpublished manuscript. Show, Sydney, NSW: Channel 9 TV. Glasser,, W. [Commentator] (1996, May) Midday Glasser May) Midday Show, Glow, R.A. (1980) A Validation of Connors' Glow, Connors' TQ and a cross-cultural comparison of pr prevalence evalence of  hyperactivity in children. In G. Burrows and J.Werry (Eds)  Advances in Human Psychopharmacology pp.303-320. Greenwich, Connecticut: J.A.I. Press.

29

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

Green, C. & Chee, K. (1994) Understanding ADD. ADD. Sydney: Doubleday Greene, R.W. R.W. (1995) Students with ADHD in school classrooms: teacher factors related to compatibility, compatibility, assessment and intervention. School Psychology Review, 24, 24, 1, 81-93. Hazell, P. (1995) Stimulant treatment for attention deficit hyperactivity disorder. Au disorder. Aust stra rali lian an Pr Pres escr crib iber er,, 18, 18, 3, 60-63. Lateline.. Sydney, NSW: ABC TV. Hutchins, P. P. [Commentator] (1993, May) Lateline  Jerome, L., Gordon, Gordon, M. & Hustler Hustler,, P P.. (1994) A comparison comparison of American and Canadian Canadian teachers’ knowledge and attitudes towards attention deficit hyperactivity disorder. Canadian Journal of Psychiatry, 39, 39, 9, 563-567. Kasten, E.F., Courtney, D.L. & Heron, T.E. (1992) Educators’ knowledge and attitudes regarding stimulants in the treatment of attention deficit hyperactivity disorder.  Journal of Developmental and Behavioral Pediatrics, 13, 13, 3, 215-219. Kwasman, A., Tinsley, B.J. & Lepper, H.S. (1995) Pediatricians’ knowledge and attitudes concerning diagnosis and treatment of attention deficit and hyperactivity disorders. Archives disorders.  Archives of Pediatric Adolescent  Medicine, 149, 149, 1211-1266. 1211-1266. Maag, J.W. & Reid, R. (1994) Attention deficit disorder: a functional approach to assessment and treatment. Behavioral Disorders, 20, 20, 1, 5-23. McGee, R., Partridge, F., F., Williams, Williams, S., & Silver, P. P. (1991) A twelve year follow-up of pre-school hyperactive children. Journal children. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 30, 2, 224-232. Murphy, M.A. & Hagerman, R.J. (1992) Attention deficit hyperactivity disorder in children: diagnosis, treatment and follow-up. Journal follow-up. Journal of Paediatric Health Care, 6, 1, 2-11. National Health & Medical Research Council (1996) Attention deficit hyperactivity disorder (ADHD). Consultation document. Unpublished manuscript. Oberklaid, F. [Commentator] (1995) 4 Corners. Corners. Sydney, NSW: ABC TV. Power, T.J., Hess L.E. & Bennett, D.S. (1995) The acceptability of interventions for attention deficit hyperactivity disorder among elementary and middle school teachers.  Journal of Developmental and Behavioral Pediatrics, 16, 16, 4, 238-243. Rostain, A.L., Power, T.J. & Atkins, M.S. (1993) Assessing parents’ willingness to pursue treatment for children with attention deficit hyperactivity disorder.  Journal of the American Academy of Child and  Adolescent Psychiatry, 32, 32, 1, 175-181. Shute, R.H. (1995) Inaugural Constance Davey Lecture. Australian Lecture.  Australian Journal of Guidance and Counselling, 5, 5, 1, 49-58. The Child Drug Row (1996, Saturday 22 June ) The West Australian, Australian, pp.8-9. The Magarey Institute, Child and Youth Health (1995) The health status of children and young people in South Australia : a report. report. Adelaide: Author. Author. Wall, M. (1995) Attention deficit hyperactivity disorder/conduct disorder – a major contribution to  juvenile crime and substance abuse. Unpublished submission to the Premier's Task Force on Drug Abuse, West Australia.

30

 

Educational and Child Psychology (1997) Vol. 14 (1)

Biology,, behaviour Biology behaviour and education: education: ADHD and the bio-psycho-social perspective Paul Cooper School of Education, University of Cambridge

 Abstract  ADHD is a symptom or a shift in dominant ways of understanding human behaviour. Superficially it appears to challenge the ways that educational psychologists, educational researchers and policy makers currently construe the nature of behavioural and emotional problems in school children by asserting that a significant proportion of these problems may be in  part influenced by individual biological characteristics as opposed to being of a solely psychosocial nature. To dismiss ADHD as ‘the new dyslexia’, or as simply a re-run of the crude medicalization of social problems is unlikely to best serve the interests of children with Emotional Behavioural Difficulties (EBD). The constructive route forward is for EPs and other educationists to develop an understanding of ADHD that draws together biological and psycho-social understandings in a bio-psycho-social perspective. Such a development is necessary not only in relation to the topic of ADHD but with regard to the much wider implications of contemporary developments in the biological sciences.

Why ADHD is a serious problem for individuals and society ADHD, as defined by American Psychiatric Association criteria (APA, 1994) is the most commonly diagnosed behavioural disorder among children (Barkley, 1990; Hinshaw, 1994). For a significant proportion of people ADHD persists into adulthood and is a lifelong condition. Precise figures child to 1994). adult carry overindicates, are not available, vary between 30 and 70 per centon (Hinshaw, Research however,and thatestimates persons whose behaviour and life history conform to the ADHD diagnostic criteria are at considerably greater risk than the general population for serious social and psychological ps ychological problems, such as unemployment, marital break up, substance abuse, depressive illness, social isolation and criminality (Goldstein, 1995). In the UK, the Cambridge Study of Delinquent Development found ‘hyperactivity-impulsivity-attention deficit’ to be one of six key childhood factors predictive of  offending and antisocial behaviour in childhood and adulthood (Farrington, 1990). This finding should be considered alongside research evidence which shows high levels of co-morbidity between ADHD and other adolescent behavioural problems, such as Oppositional Defiant Disorder, Conduct Disorder, antisocial and delinquent behaviour (Goldstein, 1995; Hinshaw, 1994). It should also be noted that one of the most robust findings in criminological research is the early onset of childhood antisocial behaviour and conduct disorder in the life histories of adult criminals (Smith, 1995). As amust majorbeelement the constellation childhood dysfunctional behaviour patterns ADHD seen as in a priority for action,ofboth in the interests of the children involved and society as whole. 31

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

The value of multi-modal intervention Longitudinal data on outcomes of effective intervention with children with ADHD is rare. A key study found that children’s behaviour and academic performance improved significantly and that levels of delinquency were significantly lower for this group than for the general population of children with ADHD after a three year course of multi-modal intervention (Satterfield et al., al., 1981; Satterfield et al., al., 1987). The multi-modal approach employed by Satterfield et al. involved providing a tailored programme for each child and family from a menu of interventions including: stimulant medication, tutoring, individual child therapy, parent management groups and marital therapy (Hinshaw, 1994). These intervention techniques are nearly all directed at the psycho-social aspects of ADHD,  being focused on helping individual children and their familie familiess le learn arn speci specific fic sk skills ills that will help them avoid the debilitating effects of ADHD. Specific educational interventions (see DuPaul & Stoner, 1995; Cooper & Ideus, 1996) focus on the need to provide children with ADHD with clear educational objectives that take account of their difficulties in sustaining attention and their distractibility. Emphasis is also placed on the importance of building children’s self-esteem through specific teacher interventions. Of particular interest at the present time is the possible association between ADHD and particular cognitive styles as well as high levels of creativity (Crammond, 1993; 1994). In addition to these psycho-social interventions, interventions, medication is often prescribed. prescribed. A wide range of  medications have been associated with ADHD but by far the most commonly used is the stimulant medication methylphenidate. This medication is thought to work on the brain by simulating the action of deficient neurotransmitters, and thus increasing the individual’s ability to regulate his or her impulses. The chief purpose of medication is to create circumstances in which the child is enabled to be receptive to the psycho-social measures described above. It is these psycho-social measures that are essential to the positive development of the individual with ADHD (see Barkley,, 1990; Goldstein & Goldstein, 1990; Cooper & Ideus, 1995a). In the US it is estimated that Barkley  between  betw een 60 and 90 per cent of child children ren with ADHD are treated treated with stimu stimulant lant medica medication tion (Swanson, 1992). The proportion is probably lower in the UK and Europe (Taylor, 1995).

The problem of ADHD for UK educational professionals The chief problem with ADHD is that, like many things, it has different meanings for different people. A useful concept here is that of ‘regimes of signification’. Lash (1990) defines ‘regimes of  signification’ as systems for (a) specifying relations of production of cultural objects; (b) conditions  by whi which ch obje objects cts are rec receive eived; d; (c) inst institu itutio tional nal fram framewo eworks rks for medi mediatin ating g be betwe tween en pro product duction ion and reception; (d) a particular way in which cultural objects circulate. In short a regime of signification is a process which governs the legitimization of knowledge. Different institutions will employ different regimes of signification. An important feature of such regimes is that they enable their subscribers to make judgements and decisions. The key issue here is that regimes of signification are rooted in value positions which may or may not be overt. It is suggested that if we are to come to any kind of informed judgement about an issue as complex as ADHD then we must examine the values which underpin our reaction to it. T To o avoid this process of eexamination xamination is to provide a mereme rely knee jerk response that will inevitably be dismissed as the product of prejudice and ignorance. A recent study (Cooper & Ideus, 1995b) identified eight different orientations towards the nature and causes of ADHD that are represented in the professional, academic and popular 32

 

Educational and Child Psychology (1997) Vol. 14 (1)

literature on this topic. The eight positions are: ◆

the moral-ethical orientation, orientation, which focuses on the idea that the problems associated with ADHD represent moral deficits of those displaying the behaviours;

◆

the complimentary-medical orientation which sees these problems as stemming from environmental toxins or vitamin and mineral deficiencies;

◆

the  political-ideological orientation, the political-ideological orientation, which defines ADHD in terms of a social control function, whereby the label is used to control and marginalize people by pathologizing behaviours that are legitimate responses to intolerable circumstances;

◆

the  pragmatic orientation which sees ADHD primarily as a descriptor that is often directly the pragmatic associated with interventions that are successful in alleviating the problems associated with ADHD;

◆

the social-cultural orientation which focuses on the ADHD as a social construct, and argues that the problems associated with ADHD are not so much located l ocated within the individual aass in problematic aspects of the social context or culture inhabited by the individual;

◆

the allopathic-medical orientation which asserts that ADHD is primarily a bio-medical problem in which psycho-social factors, in so far as they are implicated at all, are of secondary importance;

◆

the cognitive style orientation which focuses on the possibility that ADHD, whilst describing genuine differences between people, is not a ‘disorder’ but a range of traits indicative of  undervalued intellectual and social characteristics, such as high levels of creativity, and a preference for concreteness over abstraction in learning style;

◆

the systematic-eclectic orientation which takes elements of each of the other seven orientations and combines them in a coherent form to argue that ADHD is a bio-psycho-social issue requiring multidisciplinary understanding and intervention.

These orientations interact with one another in complex ways. In their extreme they represent arguments for and against recognition of the condition. In their moreforms moderate forms the orientations differ in terms of the kinds of interventions as well as targets for intervention. A particular and unsurprising featur featuree shared by all orientations is the way in which th their eir stance on ADHD is in each case to some degree defined with reference to the allopathic-medical orientation in which the APA APA formulation of ADHD has its origins. Each position more or less questions the validity of the scientific-medical position on philosophical, moral, scientific or social grounds. With the exception of the scientific-medical orientation itself, each orientation asserts the incompleteness, inadequacy or distorting influence of the scientific-medical model. In their extreme forms each of these positions, with the exception e xception of the scientific-medical and the systematic-eclectic orientations, can be seen to be attempting to undermine the validity ADHD to diagnosis. This process undermining has,and ultimately, ultimately , a social purpose in that itof is the calculated render the concept ofof ADHD illegitimate thus inappropriate as a source of practical help in dealing with emotional and behavioural problems. 33

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

The practical effect of such regimes of signification is demonstrated in the history of special education in the UK. The current administrative arrangements for dealing with children with SEN, as well as dominant approaches to intervention, are rooted in the historical rejection of  the medical model (Tomlinson, 1982). The individual pathology model has been largely ousted in favour of a model that emphasizes the importance of social and other environmental influences. In the area of EBD this is epitomized by the development of the ecosystemic approach (Cooper & Upton, 1990). The practical effect of this development has been to transfer responsibilities that were formerly held by physicians to educational psychologists and teachers. The great benefit of these changes has been to bring educational factors to the fore in determining appropriate intervention and placement for children with SEN. This has led to an increasing interest in the development of techniques for teaching children with diverse needs in inclusive settings. ADHD, coming as it does from a medical background, is seen by some as a threat to the progress that has been made in securing educational and social rights for previously disenfranchised groups (Cooper & Ideus, 1995c). Slee (1995) expresses this view forcefully: The monism of locating the nature of disruption in the neurological infrastructure of the child is myopic and convenient. As complex sites of interaction on a range of levels, classrooms provide opportunity for dysfunction across a number of fronts […]. The search for institutional dys function is ignored by the diagnosticians’ probes. ADDS [s [sic] ic] simply refines and extends the individualizing and depoliticizing of disruption in schools. (p.74) On a similar theme, Boreham et al. (1995) report a research study into parents’ and educational psychologists’ ways on construing EBD in which the educational psychologists p sychologists are portrayed as ‘system fixers’ demonstrating ‘a ready capacity to perceive hidden motives’ (p.20), especially in relation to the information they are given by parents and teachers about a child’s EBD’s. Their common reaction to individualized explanations of EBD is to ‘see through’ them, and to identify systemic patterns of influence on the problem in hand. The clear implication here is that the EP’s in Boreham et al.’s al.’s study, like Slee, are not prepared to entertain the possibility that there may be individual, within-child factors at work in given cases of EBD. It is suggested that this position epitomizes the dominant regime of signification s ignification in UK educational psychology psy chology.. It is further suggested that this hinders the development of effective responses to ADHD by attributing to ADHD the identity of a ‘Trojan Horse’ under the cover of which the medical profession will regain territory currently occupied by EP’s and other educationists (Cooper & Ideus, 1995c).

The need to avoid dangerous dichotomies One of the problems of being locked into a particular ‘regime of signification’ is that it encoure ncourages the dismissal of certain ce rtain items and forms of knowledge. Slee’s reaction to ADHD is to dismiss it out of hand, simply because it derives from a medical origin and implies some degree of individual impairment. For Slee, it would seem, notions of individual pathology and the idea that deviant behaviour be haviour in school is socially constructed are mutually exclusive. e xclusive. Similarly Similarly,, the EP’s in Boreham et al.’s al.’s study seem to imply that one must choose between individual and systemic explanations. Such positions, it is suggested, sugge sted, are untenable for the following reasons:

1. Biology is not destiny The fact is that certain people are placed at greater risk of developing certain forms of EBD by virtue of their personal make up, whether it be their socio-economic status, their gender gender,, their 34

 

Educational and Child Psychology (1997) Vol. 14 (1)

ethnicity or aspects of their biological predispositions. The path to deviance is influenced by a combination of these individual characteristics and the social and political politica l environment that children encounter in school and the wider community. There is clear evidence that our schools and other social institutions are often discriminatory towards ethnic minorities and females (e.g. Arnot, 1985). Similarly, Similarly, there is a tendency for our schools to reward the kinds of  pupil knowledge and styles of learning that are most readily acquired in middle class families (e.g. Willis, 1978). By the same token the biological aspect of ADHD places children who possess it at risk of behaving in i n ways that are misconstrued by parents and teachers as wilful misconduct, and thus likely to lead the child to be subject to unfair criticism and blame for not exercising sufficient control over their impulses. Children with ADHD, therefore, just like children from ethnic minorities and low SES backgrounds are placed at risk because schools are often intolerant of behaviours and social styles that fall outside of a fairly fai rly narrow band of preferred behaviours, social and learning styles.

2. Bio-medical and psycho-social understandings can combine powerfully When teachers and other educational professionals bring their existing knowledge together with that of medical scientists, the result is what Bateson (1972) would call a ‘bonus’. The  bonus is provided provided by the bringing together of two dif different ferent ideas, which when combined produce a new idea that amounts to more than the sum of the two original separate ideas. In the case of ADHD a predominantly medical perspective on the condition may emphasize the neurological aspects of aetiology and medication therapy as the most suitable response. A purely educational perspective on ADHD is more likely to emphasize the contribution that different teaching strategies and patterns of educational organization and management have on the child’s educational performance. A combined educational-medical approach to ADHD is likely to look at ways in which medical and educational approaches may complement one another. Central to such an approach would be the need to ask questions about the kinds of expectations that are being made of the child in the educational setting and the ways in which these relate to the difficulties expressed by the child. Are the demands being made by the educational setting educationally necessary or desirable, or are they placing undue strain on a child’s areas of specific weakness (e.g. their attentional capacities, level of impulse control, distractibility)? In each case, what is the precise blend of medical, educational and psychological input necessary to enable the child to participate fully and effectively in the social and educational experiences of schooling? Recent research, for example, indicates that children with attentional deficits and problems of overactivity, including in some cases, children diagnosed as having ADHD can be helped to demonstrate improvements in self controlling  behaviours and on-task behaviour through tthe he manipulation of rrecess ecess timing (Pellegrini et al., al., 1996; Pellegrini & Horvat, 1995). It would be a gross over-simplification to generalize from this research that all children with ADHD would benefit in this way from this type of intervention. The role of the interdisciplinary team is to develop ways of working that are informed by the insights of other professionals as well as the client(s). In the case of ADHD, the use of medication as an intervention in the educational context will only be justifiable when more directly educational measures have been tried and found to be unsuccessful. And even then medication is almost never seen as a sufficient intervention on its own, always requiring the accompaniment of psycho-social interventions (Barkley, 1990; Goldstein & Goldstein, 1990; Hinshaw, 1994). The appropriateness of specific educational interventions will, again, be for partly judgedanon the basisofofthe an specific informed understanding naturedisof  ADHD. Thus, example, awareness child’s difficulties of of the auditory crimination and difficulties of focusing on specific stimuli (which are common aspects of  35

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

ADHD) may suggest to a teacher that this child’s concentration and behavioural difficulties will be exacerbated by placement in groups for particular learning activities. In this case pairwork may be a preferred option.

3. Multi-dimensional problems require multi-professional co-operation Medical professionals often have little training in or knowledge of the workings of schools. As a result they may develop distorted ideas about what goes on in schools and what can be done in schools to help children with ADHD. The idea, however however,, that medical practitioners are nec nec-essarily wedded to a disease model whereby individuals are automatically pathologized is outdated and inaccurate. There is recent evidence of medical practitioners writing about EBD in systemic terms (e.g. Barker, 1990; Dare, 1990; Higgins, 1990), with the emphasis being on the ways in which apparently individual behavioural difficulties are very often the product of an interaction between individual and external factors. The emphasis in the clinical literature on ADHD on the use of family therapy underpins this point (e.g. Barkley, 1990). One of the ways in which doctors will come to learn more about the possibilities for change inherent in educational settings is by interacting in a co-operative way with teachers and other educational professionals in multidisciplinary teams, where each member is assertive of their professional expertise as well respectful of and receptive to the expertise of other professionals.

4. The ADHD diagnosis can provide a useful basis for professional-client co-operation The final point here relates to issues of what might be termed the ‘civil ‘ci vil rights of ADHD’. Notions of the stigmatizing nature of disability labels and their use as instruments of social control and suppression are increasingly anachronistic, particularly in relation to the issue of ADHD (a precursor of this is perhaps dyslexia). The fact is that ADHD sufferers sufferers are an increasingly self-defined group characterized by the desire to find a non-stigmatizing explanation and treatment for EBD’s that have been previously ignored and/or misconstrued by professionals. In these circumstances the ADHD diagnosis is seen as a definition of a problem which brings with it clear lines to follow towards a potential solution. In this way it can be contrasted with the vague and ill-defined, yet utterly stigmatizing label of EBD. Parent and adult sufferer movements such as CHADD (Children and Adults with ADD) in the US and the many recently formed groups in the UK are testimony to the way in which ADHDindiagnosis is being seen asindividuals a route towards finding solutions to problems rather than athe problem itself, in that it provides indivi duals with a basis for securing access to appropriate help and professional support. This aspect of the disability rights movement (Susman, 1995) carries with it, of course, dangers of the disorder becoming a bandwagon that will be sought by persons seeking more than their fair share of limited educational and other resources. Clearly Clearly,, the way to tackle this problem is for professionals, such as teachers and educational psychologists, to become sufficiently informed about ADHD to know the difference between genuine ADHD and ‘pseudoADHD’ (Hallowell & Ratey, 1994), and to be aware of the necessary components of a comprehensive and rigorous assessment process (e.g. Detweiler et al., al., 1995). On the positive side, this enthusiasm for the ADHD concept must be seen as helpful to professionals working with children with by EBD. It is too the case that issues surrounding EBD and indiscipline in schools are clouded feelings of often guilt and the apportioning of blame. From the decidedly unsound (current) chief inspector of schools with his inspection ‘hit squads’ to that gen36

 

Educational and Child Psychology (1997) Vol. 14 (1)

erally sound and constructive document, the Elton Report (DES, 1989), with its recommendation that teachers found to have poor classroom discipline should be sacked, there is blame and guilt attached to these issues. Sometimes the blame bla me is placed on teachers; other times it is placed on parents. The most rudimentary acquaintance with humanistic psychology tells us about the destructive effects of blame and guilt. It is not surprising, therefore, that well meaning attempts to help teachers in schools and parents in their homes to improve their behaviour management manageme nt skills often meet with that form of ‘resistance’ that is so well known to systemic theorists and therapists. ADHD, by removing the issue of culpability from certain children’s behavioural problems, opens the door for teachers, pupils and parents to attempt new ways of thinking and behaving that may lead to solutions to difficulties without the attempt being seen as an admission of guilt.

Conclusion: the need to take biology seriously In this paper I have argued that it is necessary that educational professionals take the phenomenon of ADHD seriously. Challenges to the validity of the diagnosis based on a blanket rejection of ‘the medical model’ will serve only to create a barrier between educational and medical professionals, leaving vulnerable clients (i.e. children and their parents) in an invidious ‘piggy in the middle’ position. Furthermore, such is the force and seductive power of  many current developments in the field of genetics (Cook-Deegan, 1994) that we may be on the edge of a new era of biological determinism, in which it will be a popular belief that such outcomes as low cognitive ability (Herrnstein & Murray, 1994) and adult criminality (Moir &  Jessel, 1995) are genetically determined and, therefore, controllable th through rough selective breeding and other measures designed to ‘cleanse’ the gene pool. If we as educational psychologists wish to contribute to the prevention of this new age of eugenics, we must face up to the role that biology plays in influencing human make-up, so that we can argue from an informed position that, whilst biology may create propensities for certain social and behavioural outcomes, biology is always mediated by environment and culture. Biology is not destiny but destiny  but we ignore its influence at our peril.

References American Psychiatric Association (APA) (APA) (1994) Diagnostic and statistical manual (4th edition). Washington: ashington : APA. APA. Arnot, M. (Ed.) (1985) Race and gender. gender. Oxford: Open University Press. Barker, Barker , P. P. (1990) The psychiatricofexamination childrenand with emotionaldifficulties and behavioural V. Verma (Ed.) The management children withofemotional behavioural difficulties. . London:difficulties. Routledge.In Barkley, R. (1990) At (1990) Atte tent ntio ion n Def Defic icit it Hype Hypera ract ctiv ivit ityy Dis Disor orde der: r: a hhan andb dboo ookk ooff dia diagn gnos osis is an andd ttre reat atme ment nt.. New York: Guilford. Bateson, G. (1972) Steps to an ecology of mind. mind. New York: Aronson. Boreham, N., Peers, I., Farrell, P. P. & Craven, D. (1995) Different perspectives of parents and education educational al psychologists when a child is referred for EBD. In P. Farrell (Ed.) Children with emotional and behavioural difficulties: strategies for assessment and intervention. intervention. London: Falmer. Cook-Deegan, R. (1994) The gene wars: science, politics and the human genome. genome. London: Norton and Co. Cooper, P. Cooper, P. & Ideus, K. (1995a) Chemical cosh or therapeutic tool? Towa Towards rds a balanced view of the use of  stimulant medication with children diagnosed with attention deficit/hyperactivity disorder. disorder. Therapeutic Care and Education, 4, 4, 3, 52-61. assessment.. Paper presented Cooper, P. & Ideus, K. (1995b) Attention (1995b)  Attention deficit disorder: sociocultural issues in assessment at the Annual Meeting of the American Educational Research Association, San Francisco, April. Cooper, P. & Ideus, K. (1 995c) Is attention deficit hyperactivity disorder a Trojan horse? Support for Learning, 10, 10, 1, 29-34.

37

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

Cooper, P. & Ideus, K. (1996) Attention (1996) Attention Deficit/Hyperactivity Deficit/Hyperactivity Disorder: a practical guide for teachers. teachers. London: David Fulton. Cooper, P. & Upton, G. (1990) An ecosystemic approach to emotional and behavioural difficulties in 10, 302-321. schools. Educational Psychology, 10, Crammond, B. (1993)  ADHD and creativity: two sides of the same coin? Department of Educational Psychology,, University of Georgia, Athens, Georgia. Psychology Crammond, B. (1994) The relationship between ADHD and creativity. creativity. Paper presented at the Annual Meeting of the American Educational Research Association, Association, New Orleans, April. Dare, C. (1990) The psychodynamic theory of children with emotional and behavioural difficulties. In V. V. Verma (Ed.) The management of children with emotional and behavioural difficulties. London: Routledge. Report). London: DES. DES (1989) Discipline in schools (the Elton Report). Detweiler, R., Hicks, A. & Hicks, M. (1995) The multi-modal diagnosis and treatment or ADHD. Therapeutic Care and Education, 4, 4, 2, 4-9. DuPaul, G. & Stoner, G. (1995) ADHD (1995) ADHD in the schools: schools: assessme assessment nt and interven intervention tion strategie strategiess. New York: Guilford. Farrington, D. (1990) Implications of criminal career research for the prevention of offending. Journal offending.  Journal of   Adolescence, 13, 13, 93-113. Goldstein, S. (1995) Understanding and assessing ADHD and related educational disorders. In P. Cooper issues. East & K. Ideus (Eds)  Attention Deficit Hyperactivity Disorder: educational, medical and cultural issues. Sutton: The Association of Workers for Children with Emotional and Behavioural Difficulties. children. New York: Wiley. Goldstein, S. & Goldstein, M. (1990) Managing (1990)  Managing attention disorders in children. Hallowell, E. & Ratey, Ratey, J. (1994) Drive to distraction: recognizing and coping with ADD from childhood through adulthood. London: Simon and Schuster. adulthood. Herrnestein, R. & Murray, C. (1995) The bell curve: intelligence and class structure in American life. life . New York: The Free Press. Higgins, R. (1990) Emotional and behavioural difficulties (EBD): some general points. In V. V. Verma Verma (Ed.) The management of children with emotional and behavioural difficulties difficulties.. London: Routledge. children. Thousand Oaks, CA: Sage. Hinshaw, S. (1994) Attention (1994) Attention deficit disorders and hyperactivity in children. Lash, S. (1990) The sociology of post modernism. modernism. London: Routledge. Moir, A. & Jessel, T. (1995) A (1995)  A mind to crime. crime. London: Michael Joseph and Channel Four. Pellegrini, A. & Horvat, M. (1995) A development contextualist contextualist critique critique of of attention attention deficit/hyperactivity disorder. disorder. Educational Researcher, 24, 1, 13-20. Pellegrini, A., Davis-Huberty, P. & Jones, I. (1996) The effects of recess timing on children’s playground and classroom behaviours. American behaviours. American Educational Research Journal, 32, 32, 4, 845-864. Satterfield, J., Satterfield, B. & Cantwell, D. (1981) (1981) A three year multi-modality study study of 100 hyperactive  boys. Journal  boys.  Journal of Pediatrics, 98, 98, 650-655. Satterfield, J., Satterfield, B. & Schell, A. (1987) Therapeutic interventions to prevent delinquency in hyperactive boys. Journal boys. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 26, 56-64. Slee, R. (1995) Changing theories and practices of discipline. discipline. London: Falmer. Susman, J. (1994) Disability, Disability, stigma and deviance. Social Science and Medicine, 38, 38 , 1, 15-22. Swanson, J. (1992) Research synthesis on the effects of stimulant medication on children with attention deficit disorders: a review of reviews. Syntheses on the education of children with Attention Deficit Disorder. Disorder. Washington, DC: US Department of Education. Taylor, E. (1995) Editorial. The British Medical Journal. Journal. Tomlinson, S. (1982) A (1982) A sociology of special education. education. London: Routledge. Willis, P. (1978) Learning to labour. labour. Farnborough: Saxon House.

38

 

Educational and Child Psychology (1997) Vol. 14 (1)

‘Helicopter children’ and ‘butterfly brai br ains ns’’. ADHD ADHD:: per perce cept ptio ions ns,, issu issues es and and implications Pam Maras1 & Terry err y Redmayne Redm ayne2 with Claire Claire Hall, Deborah Deborah Braithwaite Braithwaite & Philip Prior 1The

University of Greenwich, 2County Educational Psychologist for Kent

 Abstract This paper starts from the premise that ADHD may apply to a small proportion of children and  young people who experience particular difficulties that can bes bestt be described under the broad umbrella term emotional and behavioural difficulties (EBDs). We propose that just as with EBDs, there is a growing amount of folklore inherent in common perceptions of ADHD and that  perceptions are directly related to professional practice. We introduce preliminary preliminary findings from The University of Greenwich Kent EBD Project (Maras & Hall, 1996) and consider inter and intra professional relationships, perceptions, attitudes, actions, emotions and awareness in terms of ADHD specifically and EBDs generally. Implications for current, and the development of   future, policy and practice are discussed.

Background There has been considerable professional and academic debate on the ‘reality’, or not of  ADHD – as illustrated by the papers in this edition of Educational and Child Psychology. Psychology. Arguments have tended to focus on the appropriateness of medication for children ‘diagnosed’ as ‘having’ ADHD, the specificity, or not, of particular diagnostic criteria and the appropriateness of the use acronyms such as ADHD (in the singular) to describe what some say are one, and others propose are two concepts. We suggest that the ‘debate’ serves mainly to draw attention to different, sometimes competing roles of people who work with children who experience a whole range of difficulties in school of which ADHD might only be a small sample. That much of the debate and supposed disagreement has occurred mainly in academic and professional fora is in itself interesting, not least because it is encompassed in the ideology and historical development of different professional groups and as such shifts attention away from the very ‘real’ distress experienced  by children and their families, who aare re in essence at the centre of discussion. Our view has some similarities with Paul Cooper’s (also in this special edition), however we further posit that differences in ideological positions are only usefully considered in conjunction with interprofessional perceptions and relations within an organizational context.

Context and method When pupils experience difficulties there are implications for a range of individuals and pro39

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

fessional groups; from the pupils themselves who simply may not be accessing curricula or developing appropriate social and relational skills, to senior LEA management for whom effective and strategic decisions on resource, planning and service delivery are the priority. Little research to date has considered: (1) how these different needs are related; (2) how they interact; (3) whether, and if so how, they are integrated; (4) outcomes of relations, interaction and integration of professional and individual needs. As part of The Project, data were gathered on perceptions and manifestation of the concept ADHD. Findings introduced in this paper were obtained via questionnaires which included questions about ADHD which were analysed for content and theme and more structured measures that utilized five and seven point ‘Likert-type’ scales to ascertain perceptions, beliefs, practice and attitudes about the concept ADHD, and toward other professional groups. The project design adapted the ‘eco-systemic’ approach, proposed by Cooper and Upton (1990) for developing practice for behaviour in classrooms and schools, s chools, to the broader eco-system of the county within which the project was located; thus the context of the study was the local educational authority (LEA). Table 1 shows numbers and professional status of participants referred to in this paper. Figure 1 illustrates how the various groups represented within the study fit into our eco-systemic design. Table 1. Participants referred to in this paper (taken from Maras & Hall, 1996) Par ticipants

Number

Nursery and primar y teachers

68

Secondar y teachers

54

School governors

118

Managers and administrators

13

County Education Committee

9

Educational psychologists

9

Parents of pupils in PRUs

68

Government (MP’s) LEA Educ Educati ation on Committee Senior Admin. Area Admin. Parents/  Family Support Services (eg EPS, BSS, EWO) SENCO Head and Govs

Figure 1. The eco-systemic design of The University of Greenwich Kent EBD Project (Maras (Mar as & Hall Hall,, 199 1996) 6)

40

Teacher Child

Outside Agencies (eg Social Services)

 

Educational and Child Psychology (1997) Vol. 14 (1)

Relevant findings are summarized under five headings*: 1. Definitions of ADHD. 2. Perceived incidence and cause(s) of ADHD. 3. Teaching, Teaching, learning and ADHD. 4. Professional needs, working, relations and ADHD. 5. Inter-professional working and ADHD.

Definitions of ADHD Respondents were asked to define ADHD and describe its manifestations; they were also asked similar questions about EBDs. EBDs . Almost without exception respondents were more willing to supply definitions of ADHD than they were EBDs per EBDs  per se. se. Unsurprisingly, definitions reflected the descriptive nature of ADHD. For example an administrator described a child ‘with’ AD/HD as “unable to concentrate, sit still produce work”. Primary and secondary teachers’ responses indicated qualitatively different conceptualizations of the phenomena ADHD. Primary teachers described the concept as a “specific diagnosis” within the broader framework of EBDs; in contrast secondary teachers tended to indicate that they saw EBDs and ADHD as descriptors of the same thing. The view that ADHD is a subset of EBDs was reflected in responses from central administrators, for example one manager wrote that ADHD was “part of the whole EBD”. In contrast, area personnel tended to take the same line as secondary teachers that EBDs and ADHD were “one and the same thing” and that both could sometimes be seen as “labels for inappropriate or antisocial behaviour”. For example, one area administrator suggested sugges ted that both ADHD and EBDs were “current labels – in another time would have been known as naughty” whilst another wrote that “I believe here is another medical labelling labe lling phenomena which enables him (medical practitioner) to close a file and pass a problem to the LEA”. Primary teachers from grant maintained (GM) schools provided proportionally less comments about ADHD and EBDs than the other groups and their comments focused on the emotional component as well, or instead of, behavioural difficulties. On the other hand GM secondary school teachers provided proportionally more comments than other teachers and focused on behaviour significantly more often than emotion. EPs and county members were least accepting of the notion and consequential label ADHD. For example, a county member asked “is it (ADHD) just another label or clinical excuse for bad behaviour”. Parents were not asked specifically about a bout ADHD ho however wever a number indicated that generally they felt the terms EBDs and ADHD were useful ways of focusing on, and meeting, children’s specific needs.

Perceived incidence and cause(s) of ADHD Despite common assumptions that there is an increase in ADHD, there are no data on prevalence; further, estimates of prevalence have been made but it is not clear on what basis these are founded. For example, Kewley (1994) suggests that: it is likely that a significant percentage of the large group of children non-specifically classified as having emotional and behavioural problems in fact have Attention Deficit Disorder. (Kewley, 1994, p.284) *It is not our intention to report detailed statistical findings, space does not allow this, rather it is to use examples of findings from The Project to support relevant issues in the arena of ADHD. Where findings are reported as significant this can be taken to mean that they are within accepted levels of  statistical significance – that is they are unlikely to have occurred by chance.

41

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

Although not directly within the remit of The Project to comment on the prevalence of ADHD we were interested in the amount of contact respondents respondents had with pupils described as experiencing the phenomena. They were therefore therefore asked about their knowledge of, and interventions in place for pupils ‘with’ ADHD.

Perceived incidence When compared proportionally, teachers in GM secondary schools reported significantly more pupils with ADHD than did teachers in LM schools. Teachers in GM schools also used diagnostic and medical terms to describe ADHD more frequently than their colleagues in LM schools. Further, a significant number of GM secondary teachers reported growing numbers of  pupils currently undergoing the diagnostic process, for example one secondary teacher in a GM school replied that in their school there were “at least three (pupils ‘with’ ADHD) under medication and at least eight in the pipeline”. Such comments suggest a greater prevalence in older pupils, however we were concerned to note that all but one of the TIC of nursery schools described children on the role in their schools who had ‘been diagnosed’ ‘with’ ADHD and on medication.

Perceived cause(s) of ADHD As well as incidence we were also interested in the way that respondents attributed causality to ADHD, not least because such questions about EBDs elicited a diverse range of responses. Most respondents attributed a biological cause to ADHD – many related this to neurological damage and a number specified frontal lobe damage, suggesting that many had read recent literature on ADHD. Of all the groups sampled one might mi ght reasonably expect EPs to be most cognisant of such s uch terms, diagnoses and causes; all of the EPs who responded conferred with both the biological  basis and, more surprisi surprisingly ngly given suggest suggested ed disagr disagreement eement over the concep concept, t, the existen existence ce of  ADHD. Over half of the EPs did go on to suggest that additional causes such as family, home and social conditions were likely to be causal in inattention, impulsivity and hyperactivity associated with ADHD and EPs responses indicated that they were generally less accepting of the prevalence of the concept than teachers or members of other professional groups. For example, one EP wrote that ADHD “distracts from the real issues”, whilst another suggested that “it [ADHD] is another bandwagon” and another EP wrote that ADHD is “developing in a similar way (to hyperactivity) with parents wanting to label their children and so absolve themselves from the responsibility of poor management/parenting”. In terms of the impact of external (to the child) factors a striking finding was that no teachers identified, or suggested, that school or school-based strategies may be an important factor for children experiencing EBDs or described as ‘having’ ADHD. This finding was reflected in responses from other professional groups. For example, no governors referred to curriculum, learning or teaching – rather they focused on external problems such as disruption to classes, disturbance caused to other children and out of  school effects of antisocial behaviour as illustrated by the following response from a governor with responsibility for SENs who wrote that: ‘AD/HDs are generally typically badly behaved children who are difficult to control and are very hyperactive.’

Perceived volition over ADHD Mosttheir respondents, particularly teachers, suggested thatthat children have littlechildren volition with ADHD over behaviour and other difficulties; an opinion was counter to views about who experience EBDs per EBDs per se. se. A significant number of respondents from all professional groups 42

 

Educational and Child Psychology (1997) Vol. 14 (1)

indicated that EBDs were under the ‘control’ and ‘caused by’ children who experience experi ence them; this disparity between views of EBDs and ADHD is illustrated by the following quote from TIC of  a nursery school who wrote “ADHD children are unable, unlike EBDs who are unwilling”.

Teaching, learning and ADHD In The Project we were particularly concerned with the potential impact of perceptions on teaching and learning; not least because learning issues may be seen as secondary both in practice and research in SENs (Maras, 1986), particularly when policy is changing and requires diverse and often time consuming administration.

Teaching pupils ‘with’ ADHD Many of the teachers commented on the impact of a pupil “with ADHD on the classroom”. For example, a teacher from a secondary school wrote that “they (pupils ‘with’ ADHD) are a nuisance in a typical school setting”. Other teachers were much more positive about the concept suggesting that it helps plan practice, as this teacher from a primary school pointed out “ADHD is useful as it allows us to differentiate from learning difficulties”. In line with this last point nearly a quarter of the teachers who responded linked ADHD to learning, curriculum, pupils’ competence and attainment.

Learning and ADHD Such comments were completely counter to responses to similar questions about EBDs in response to which teachers focused almost solely on behaviour per behaviour per se rather than learning outcomes; indeed no teacher mentioned learning learni ng or curriculum in response to questions about EBDs. Teachers Teachers clearly are interested in learning and curriculum, it would be patronizing to say otherwise; and yet it was only in response to questions about this concept that is seemingly causing debate that teachers expressed concern about learning. We suggest that there are three inter-related reasons for this: (1) the concept of EBDs is so poorly defined that it does not provide a sufficiently coherent resource for teachers; (2) ADHD, because of its pseudo medical nature fulfils a need not met within the current term EBDs; (3) teachers are expected to be ‘experts’ on behaviour.

EBDs, ADHD and teachers as experts In the project a number of primary and secondary teachers initially deferred from answering some of the questions on ADHD as it was “a medical phenomena” and as such they “had no expertise in the area”. However, However, almost all participants did respond to all or most of the questions, indeed many of those that at first wrote that they had no medical expertise went on to describe already documented features of ADHD ADHD such as hyperactivity hyperactivity,, impulsivity etc. These last points prompt an interesting question. Could it be that claiming not to be experts (i.e. “I am not a doctor”) allowed the teachers to dissociate themselves personally and thus professionally from the label ADHD? A significant number of teachers wr wrote ote that labelling was a negative activity in respect of  EBDs, few teachers did this in respect of ADHD. T Teachers’ eachers’ responses indicated that many feel that they “are expected to be experts on behaviour” and consequently “experts on EBDs”. It is clear such expectations cause teachers concern; a number feeling increasingly less ablethat to “cope with the expectation that they would be able reported to cope with continual daily hassle of controlling naughty and unruly children”. 43

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

Professional needs, working, relations and ADHD As well as telling us something about the way teachers practise at an individual level the last few points also highlight the separateness of teachers from other professionals in education; yet teachers are operating within a system that includes an array of other professionals with a range of expertise. Of interest in the project was how these various professionals understand each others’ working practice and influence.

Relations between professional groups Many agencies and individuals can be involved with pupils described as experiencing EBDs and ADHD; both directly and individually (e.g. teachers) and indirectly (e.g. area administrators). Other professional groups can operate both at the level of individual pupils and at the more distant policy advice level (e.g. EPs). The relationship between, and attitudes toward, other agencies and professionals is an important aspect of practice: it was central to the eco-systemic research design of of The Project. Respondents were asked about their feelings toward, and attitudes about, various agencies and professionals. Questions were framed within the context of practice for pupils experiencing EBDs and participants rated their own and other professional groups on five point scales; additional qualitative data were analysed for content and theme. The inter-professional working of eight groups was considered. 1. Governors. 2. Primary school teachers. 3. Secondary school teachers. 4. TIC nursery schools. 5. TIC/heads special schools. 6. Administrators (area and county). 7. Educational psychologists. Findings are summarized below in relation to three main questions asked about: teachers, SENs, support service members, SENCOs, governors, LEA personnel and officers, educational psychologists and county members of the Education Committee, all indicated .... within each question. 1. How closely do you feel you should work w with ith ....? 2. How much influence do you think .... have? 3. How useful do you feel it is to work wit with h ....?

1. How closely do you feel you should work with ....?  As one might predict, members of each professional group felt that they should work most with other members of their own group. Members of administrative groups indicated that they should work with other administrators and schools-based professionals such as teachers indicated that they should work with other schools-based staff. EPs indicated that they should most work with SENCOs, teachers and, to a lesser extent, support staff and administrators. These findings, though significant, are of course not surprising as they most probably indicate the actual working practice of the groups involved. However, it is interesting to note that schools-based particularly teachers, were very negative about the competence and understandinggroups, of school matters of non school-based staff.

44

 

Educational and Child Psychology (1997) Vol. 14 (1)

2. How much influence do you think .... have?  Again not surprisingly, members of all groups identified teachers as having significantly more influence on practice for pupils experiencing EBDs than any other group, followed by SENCOs and to a lesser extent support services. At At the other end of the spectrum governors, governors, LEA administrators and the Education Committee were identified as having the least influence. EPs were identified as having as much influence as SENCOs and teachers by all groups except teachers – the group that EPs are most likely to have a significant amount of contact with.

3. How useful do you think the influence of .... is?  Teachers’ influence was again seen as most important by most groups including teachers. Teachers overwhelmingly reported that they needed “more recognition of their authority” and a number combined such comments with the need for more severe sanctions being made available to them. Although non-teaching respondents also indicated that teachers’ influence was the most useful, a number also expressed concern that teachers may not be adequately trained, resourced or prepared to “deal with EBDs at the coal face”. For example, an exclusions officer noted that “teachers must be provided with more training in the area of EBD – they do not appear to have the necessary knowledge to approach the difficulties they encounter in the classroom”. The need for more ‘knowledge’ and ‘training’ recurred throughout The Project. Many teachers and other respondents wrote that they did not feel they had enough information or training on ADHD. For example, an SENs manager asked “what about guidance or research from DfEE or DoH? – sitting on the fence as with speech and language”. As already noted respondents indicated that they found the term ADHD useful, it was clear that many also thought that definitions of both the concepts EBDs and ADHD were not detailed enough. A number of EPs are involved with working groups on ADHD, however most EPs indicated that they also felt there was an urgent need for review, guidance and “a county position” on ADHD and a significant number of respondents highlighted the need for research, and collaboration with health services on ADHD generally and medication specifically.

Inter-professional working and ADHD  Just as there were differences in perceptions of o other ther groups’ working working practice there wer weree also differences in the way respondents saw inter-professional working**. All of the professional groups had very strong views about other groups and these appeared to be directly related to perceptions of, and knowledge about, working practice. Teachers’ responses overwhelmingly showed that they felt that teachers should all work more closely with each other than with members of any other group. g roup. T Twenty wenty per cent of teachers extended this v view iew to working exclusively with other teachers because, as illustrated by the following teacher who wrote: “Teachers understand the issues, they know, if anyone knows, how to deal with them”. Following on from this point, a third of the teachers made negative comments about administrators generally. These reflected views that administrators were in some way “undermining (teachers) practice” for example, one secondary teacher wrote: wrote: “The influence of LEA per**A project looking at inter-professional inter-professional aspects of ADHD will begin at The University of Greenwich in November 1996 (funded by Kent Paediatric Trust).

45

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

sonnel and officers could best be used by being less worried about the evidence and more aware of classroom realities”. In addition, teachers seemed generally unaware of the roles of  administrators and non school-based personnel; for example, one primary schoolteacher wrote “other “other than things like dru drugs gs awareness it is unclear where they (LEA personnel and administrators) fit in” whilst another responded “just wh what at do they (LEA personnel and administrators) do all day while we (teachers) are at the sharp end?”. In contrast few members of other professional groups were critical of teachers. Responses from non-teachers tended to indicate that teachers “had a key role” as illustrated by the following comment from a senior manager “[Teachers] have a key development role with children and can facilitate change and enhance the self esteem of children”. The notion that “teachers are at the sharp end” recurred in teachers’ comments along with views such as “others (than teachers) occasionally drift in and out to little effect” made by a secondary teacher. As in their responses to other questions few teachers referred to children and learning in their comments about inter-professional relations. In contrast non-teaching personnel identified curriculum and learning needs as central to teachers roles, for example, a senior manager wrote “[Teachers are] key professionals who work directly with children with (and without) EBD to present curriculum in ways meaningful to children and young people”.

The role of the educational psychology service

Negative comments made by teachers about other professional groups did not extend in quite the same way to EPs. There were significantly more individual differences in the way EPs were described than any other other professional group. R Responses esponses about EPs ranged from: “EP is a good bloke but hands are held by spending restrictions on statutory assessment” to “Our only real contact (with EP) is at ISR when we find help and advice very difficult to come by – written reports are now almost non-existent as are practical ideas”. idea s”. In the same vein, all other professionals’ views on the the nature o off EP practice differed. For example, a chair of governors governors wrote “The head feels that behavioural problems do not come under the educational psychologist. I feel they should but the educational psychologist hasn’t enough time to deal with all the cases.” This last la st comment is in line with a number of responses from school-based staff  that indicated not just uncertainty about what the respondents felt “EPs should be doing” but also indicated that there was disagreement within schools and between individuals about the role of EPs. Differences of opinion between school-based personnel about EP practice were reflected in a number of comments about perceived disparities between EPs themselves. For example, a member of the education committee noted “... we hear their their private Ed Psych and the LEA Ed Psych and try to reconcile often conflicting interpretations; it (educational psychology) is an imprecise discipline”. Comments from respondents also indicated that there was some tension between how they saw EPs best working and actual EP practice. practice. On the one hand so some me respondents respondents indic indicated ated that they felt that EPs’ influence could best be employed by “more frequent contact with child and family”; whilst on the other hand others indicated that they thought EPs could best influence practice by “enlarging understanding of EBDs and EBD services” as suggested by a primary teacher. In line with this last point a number of respondents indicated that they felt EPs should be more involved in implementing interventions than they currently are.

46

 

Educational and Child Psychology (1997) Vol. 14 (1)

A few of the teachers (particular (particularly ly secondary) wer weree very negative about about the rrole ole of EPs. However,, the majority of respondents were positive about However about EP input although, as with differ different ent views about the role of EPs, there were complaints about the type of input EPs gave. As the following quote from a primary teacher indicates many respondents not only wanted more time from EPs, but they also wanted this time to be spent on more practical ‘hands-on’ tasks: “we need more of these (EPs), but in my experience the Ed. Psych. was able to talk about problem/disorder etc. But not helpful about how to deal with the problem.” This comment like many others reflected a discrepancy between EPs, who all saw themselves practising at a whole school, rather than individual child, level and a significant number of teachers who expressed a need for “more feedback” and help with information on “how best to cope with and motivate the child”. Many comments from teachers also indicated that teachers felt that they, as well as children, might benefit from input from psychological services. A number of teachers expressed a need for counselling for both teachers and pupils. For example, one secondary teacher wrote EPs should spend “more time given to counselling, less to diagnosis” and another commented “sometimes it’s the teachers that need the help, its not always just the kids, you don’t know how some of these children make us feel”. This last point reflects tensions reported elsewhere (see Maras, 1996b), along with the commonly held view reflected in the comment from a primary teacher that EPs “should be more accessible to subject teachers”.

Conclusions, implications and applications An underlying assumption tested in The Project was that the way people define pupils difficulties is influenced by, and influences their perceptions. In The Project we found that perceptions of ADHD differed just as those of EBDs  per se did, though to a much lesser extent. Participants were generally far more ‘accepting’ of the concept ADHD as a specific ‘disorder’ than they were EBDs; most respondents were able to locate ADHD in biological causes, however there were differences in the way professional groups viewed ADHD***. We suggest that to ignore underlying professional, learning and curriculum needs and focus overly on the concept ADHD per ADHD per se is at best short sighted. Although it is not clear how many pupils are currently ‘diagnosed with’ ADHD it does seem that the incidence of the concept is increasing at both the younger and older age range. We concur to some extent with the view that the development of interest in ADHD can be viewed as similar to that of specific learning difficulties – ADHD undoubtedly fulfils a need for parents and professionals that they feel is not being met in current policy and practice. However, we also take the view that such comparisons though interesting at an academic level are too simplistic to be of use in practice. Our main reason for adopting this stance is that ADHD is commonly coming to be used extensively to describe pupils whose behaviour ‘is deemed problematic’ and who might, in different circumstances, take a discipline rather than SENs route; the blurring between SENs and discipline routes is problematic and offers little in terms of coherent and effective strategies for pupils. We We suggest that a more effective way forward in organizational and practical terms ***Although there is not space to discuss them in more detail, we would like to note that in line with past work, findings from The Project show that perceptions of the importance, and problematic nature, of behaviour and emotion, differed significantly and were related to practice. There was also evidence that perceptions of boys and girls who experience ADHD may be based on stereotypic gender based notions and are reflected in the representation of boys and girls as having EBDs generally.

47

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

would be to take stock of current SENs policy with particular reference to a whole range of  difficulties that children might experience and which, in the case of ADHD, might be encompassed within the broad spectrum of EBDs. Findings from The Project show that different professional groups, parents and children are much more comfortable with the term ADHD than EBDs. We suggest that this is not because it is any more or less credible than other descriptions, rather it is because of its specificity. The educational, social, pastoral and therapeutic needs of the heterogeneous sample of children who experience emotional and behavioural difficulties in school cannot effectively be met unless practice, support and interventions are differentiated. Currently the term EBDs is used in an ad hoc way to describe the needs of pupils experiencing a multitude of difficulties, as such it is of little use as a tool for teachers or as a location for effective and strategic policy and planning. The advent of ADHD has drawn attention to the inadequacy of existing frames of reference such as EBDs. Teachers are aware of the need to differentiate, but they are currently operating within a system that does not fully support or facilitate differentiation and as such they are under-resourced and ill-prepared to do so. Current policy for EBDs is not clear and practice is informed as much by individual and group perceptions as policy related strategy. In addition, relations between various professional groups reflect differences in the understanding of the roles, and their importance. We suggest that such anomalies have a major impact on the implementation of policy, practice and interventions. The development of a typology of EBDs which encompasses ADHD and related concepts would serve as a useful starting point for effective differentiation. Data from teachers, other professionals, parents and pupils strongly support the need for a broad typology that is clearly linked to learning and curriculum delivery.

Ways forward The BPS Working Working Party has ma made de a signif significant icant and important contribution to the conceptualization and multi-dimensional formulation of ADHD in practice (BPS, 1996). The final report of the Working Party draws attention to the importance of considering the overlap of labels and the confounding impact of features such as sample selection, on studies into European and North American classifications of ADHD. It is imperative that more work is done, that the report is fully disseminated and a nd that findings are integrated into further work and future policy development. We should however not forget that whilst concepts are considered and policies formulated practice is evolving, this is both the strength and perhaps the weakness of education. Education is practice, not a set of academic arguments and ploys – it is truly dynamic and developmental; change is often arbitrarily instigated, it can be founded on research, happenstance or someone’s good (or bad) idea. W Wee suggest that methods are are explored for synchro synchro-nizing research and practice. An eco-systemic stance if utilized not just as a description or academic tool but as a working model within which practice is situated may be one way forward. ADHD would be viewed not as a discreet phenomena rather as a concept within the broader framework of EBDs generally and with particular reference to others in the eco-system including, of course, not just education but other services such as health and social. The adoption of  such a multidisciplinary perspective will best facilitate, through training, information exchange, and co-operative multi-professional working. To be effective the development of  48

 

Educational and Child Psychology (1997) Vol. 14 (1)

such a model has to be pragmatic, explicitly related to criteria for identification, dynamic enough to incorporate developing and futur futuree concepts such as ADHD, be explicitly related to practice and subject to continuous evaluation on the basis of that practice and the educational outcomes of pupils who experience difficulties in school. EPs have a unique role in relation to ADHD, particularly when the concept is considered from an eco-systemic stance; they are the professional group that interacts most with all individuals and groups in the model; they constitute an important link between the non school-based personnel, schools and of course pupils and their parents at the centre of the system. In addition, because of their professional status EPs are well equipped to forge links with agencies outside education such as health, and social services.

‘Helicopter children’ and ‘butterfly brains’  Finally, why have we included the phrases ‘helicopter children’ and ‘butterfly brains’ in the title of this paper, paper, other than as an (un)academic ploy to catch the eye of potential readers! These two terms were used on a number of occasions in response to requests for alternative descriptors of ADHD. We are not being flippant in introducing them – we do so to draw attention to the fact that, just as with EBDs, perceptions can be influenced by, and influence terms which do not meet any ‘scientific’ criteria or scrutiny but which many individuals and groups come to  believe they share a common underst understanding anding of. In terms of EBDs the expres expression sion ‘of the wall’ springs to mind as a term commonly used and believed to be a precise description. Without action similar terms will come to be common for ADHD and any future developing concepts.

Acknowledgements The important contribution of Claire Hall, main researcher on the University of Greenwich EBD Project (referred to as The Project), and Philip Prior and Deborah Braithwaite (members of The Project Steering Group), are acknowledged. We would like to point out however that opinions stated in this paper are those of the first and second authors.

References  ADHD: A psychological response to an evolving concept. The Report The British Psychological Society (1996) of the Working Party of The British Psychological Society. Society. Leicester: BPS Cooper, P. & Ideus, K. (Eds) (1994) Att (1994) Atten entio tion n Defici Deficit/H t/Hype yperac ractiv tivity ity Disord Disorder: er: educat education ional, al, medica medicall and cultur cultural al iss issues ues.. East Sutton, Kent: The Association of Workers Workers for Children with Emotional and Behavioural Difficulties. Cooper, P. & Upton, G. (1990) An eco-systemic approach to emotional and behavioural problems in schools. Educational Psychology, 10, 10, 4, 301-21. Kewley, G. (1994) In P. Cooper & K. Ideus (Eds) (1994) (1994) Attention  Attention Deficit/Hyperactivity Deficit/Hyperactivity Disorder: Disorder: educational, educational, medical and cultural issues. issues. East Sutton, Kent: The Association of Workers for Children with Emotional and Behavioural Difficulties. Maras, P. P. (1995) “What's 'e 'doing 'ere then?” The Psychologist, Psychologist, 15-16. Maras, P. (1996a) 'I'd rather have dyslexia': perceptions of EBDs. Educational and Child Psychology, 13,1, 13,1, 32-43. Maras, P. P. (1996b) 'EBDs whose special needs?' Emotional and Behavioural Difficulties 1, 1, 14-22. Kent. The Maras, P. & Hall, C. (1996) Children and young people with EBDs: towards a preventative service in Kent. final report of The University of Greenwich Kent EBD Project. London: University of Greenwich.

49

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

‘A little understood solution to a vaguel va guely y defined problem problem’: ’: parental parental perceptions of Ritalin Sarah F.Wright Department of Psychology, Psychology, Southampton University

 Abstract Prompted by national interest in Attention Deficit Hyperactivity Disorder (ADHD) and concern over the apparent lack of monitoring of children receiving Ritalin, this study investigated  parents' experiences expe riences ooff ADHD and Ritalin. It was hhypothesized ypothesized that there would be conside considerrable differences between parents in their experiences of how ADHD was managed and that the current systems of identification and treatment do not allow for adequate evaluation and monitoring, even when a need for such is perceived. Seventeen parents were interviewed at home. Results indicated that the group of children in this study appear to have relatively severe  ADHD, combined in many many cases with associated conduct disorder and specific learning disability. All the children in the study had been prescribed medication as their sole treatment. There was little multidisciplinary liaison and in many cases parents assumed responsibility for determining the optimal dose of Ritalin.

Introduction Hyperactivity and drug treatment are not new phenomena – drug treatment for hyperactivity dates back to the 1930's – and psychostimulants, most commonly Methylphenidate have  been used to varyi varying ng degree degreess since this time. A centra centrall nervou nervouss syste system m stimulant, stimul ant, Methylphenidate – Ritalin – shares many of the pharmacological effects of amphetamines. The effects are usually seen very rapidly, with dramatic improvements in attention and impulse control for the majority of children (Barkley, 1981). It has been estimated that currently between two to three per cent of children in North America, one per cent in Australia, and approximately one per 3,000 children in the UK receive medication for ADHD. Despite the efficacy of Ritalin in suppressing the symptomatology of ADHD, the use of powerful drugs to control children's behaviour and increase compliance has caused considerable apprehension. Critics have expressed concern that, although there may be children for whom treatment with Ritalin is appropriate, Ritalin is prescribed too easily and without sufficient monitoring, for children with a wide range of behavioural problems. Doubts have also been raised regarding the long-term efficacy of Ritalin. Despite the overwhelming research literature on Ritalin, the majority of studies have investigated short-term effects (Greenhill and Osman, 1991). The need for detailed monitorin monitoring g of children before and during treatment with Ritalin is clear if the interaction between child, environment environment and drug effect is to be maximally beneficial for 50

 

Educational and Child Psychology (1997) Vol. 14 (1)

the child. The need is even more paramount given that the effects of the drug are often idiosyncratic, varying from one child to another and one situation to another. However, concern has been raised that there is an absence of monitoring and that schools are not involved in the management of ADHD, with the result that Ritalin is very often being used in isolation without the support of educational educational and social program programmes mes (Cains, 1995; Sharr Sharron, on, 1995). This paper reports the results from a study carried out in one education authority authority.. The aim of  the study was to explore the experiences of parents whose children were taking Ritalin.

Method Subjects Psychiatrists were asked to nominate parents of children receiving Ritalin who would participate in the study. study. Five psychiatrists did not want to take part, one agreed to take part but sent no referrals and one sent one referral. Only three responded positively and actively referred cases. Additional cases were referred by parents or by educational psychologists. The resulting sample of 16 parents has thus been subject to a number of pre-selection criteria: parents were not randomly selected. Psychiatrists and psychologists 'chose' which parents to inform about the study; once informed, parents could 'choose' whether to take part. The author has no details of the number and experiences of those who opted not to take part; the uneven response from psychiatrists means that the sample is not geographically representative and is biased toward those areas in which co-operating psychiatrists were based.

Procedure The parent, usually the mother, was interviewed at home. In some cases both parents pa rents were interviewed. The child was not present during the interview. The interviews were semi-structured and included questions on: ADHD (onset, causes, family history, effect on the family, advice given re behaviour management); Ritalin (nature of, dosage, initial reaction, effects on child, effects of family, assumed prognosis and current reaction); management and monitoring (information given, monitoring, liaison, involvement of school, contact with other professionals).

Results Sixteen parents were interviewed. One parent had two children diagnosed as ADHD and receiving Ritalin, and she was interviewed separately about each child. In 56 per cent of cases both parents were married and living together, in 38 per cent the parents were divorced and the children lived with the mother. In one case the father had died. Parents came from a wide geographical area. The ages of the children who were the focus of the study ranged from five years tto o 15 years with a mean of 10.2 years (SD 2.7). All but one of the children were male and had at least one sibling. Sixty-nine per cent of parents reported knowing of other close family members with ADHD-like behaviours.

Treatment alternatives prior to Ritalin Parents were asked about the advice they were given to help them manage their child's c hild's behav51

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

iour before ADHD was diagnosed and Ritalin was prescribed. Ten parents (59 per cent) said they had received some advice from professionals specifically about managing behaviour difficulties. In seven cases, parents stated explicitly that the strategies suggested did not work. These included cognitive therapy and anger management (one case), behaviour management (four cases) and counselling for the child (two cases). Star charts, stickers and ‘firm but fair’ strategies were felt to be very ineffective. Three parents explicitly mentioned trying diets suggested to them by a dietician (allergy to refined sugars identified), a paediatrician (Pears & Lamb diet recommended) and a health visitor (provided list of prohibitive foods known to cause hyperactivity). The diets were tried for four months, six weeks and three months, respectively. Neither the diet excluding sugars, nor hyperactive foods made any difference, and both parents commented that in many cases behaviour was worse due to the child not being able to have many of the foods he/she enjoyed. The Pears and Lamb diet was reported to help to some extent but was impossible to maintain due to the highly restrictive diet.

Educational advice Three children (18 per cent) were in possession of a statement for emotional and behavioural difficulties. Four children also had dyslexia. One parent reported her child had attended the Dyslexia Institute twice a week for two and a half years. Eighteen parents (82 per cent) reported that their child had seen an educational psychologist (EP) before diagnosis and treatment with Ritalin. In two cases contact had resulted in formal assessment and a Statement of Special Educational Needs for Behaviour. Behaviour. For the majority of children the focus of EP involvement was classroom management strategies.

Ritalin Ritalin was prescribed for children between the ages of five and 15 years. The average age at the time of receiving the first prescription was 9.5 years old (SD 2.7). The period on Ritalin ranged from two weeks to four years with a mean of seven and a half months (SD 11.3). Response to Ritalin was overwhelmingly positive. The majority of parents reported that their child was generally calmer and that concentration was much better, that aggressive behaviour had diminished and compliance increased. Several parents also noted that their child was more affectionate. Seven parents (41 per cent) commented that although Ritalin has changed their child and definitely helped there were still difficulties with behaviour, behaviour, especially at home. All parents stressed that Ritalin had had a marked effect on behaviour and concentration at school. In terms of whether they felt that Ritalin had helped academic work, the majority of  parents felt that improved attention and concentration had had a very positive effect e ffect on work. Some parents felt that it was too early to say whether it had improved academic work as their child had not been on Ritalin for very long and still needed to catch up with missed work. Effects at School ◆ Concentration improved ◆ Attention – more focused

Greater control over behaviour Social skills have improved ◆ Fewer outbursts of temper ◆ ◆

Effects on Academic Achievement ◆ Dramatic improvement ◆ Finishing tasks more frequently

       

◆ ◆

Handwriting & drawing have improved Not marked, still needs to catch up

52

 

Educational and Child Psychology (1997) Vol. 14 (1)

The main finding to emerge from the data was that in most cases parents were given considerable freedom by the psychiatrist to manage the drug taking after a trial period in which the child was prescribed a low dose – usually five milligrams. Certain limits, for example an upper dose were set, but within these parents were largely responsible for determining both the optimal timing of the medication and the amount of Ritalin taken at different times. In all cases, the two main priorities in timing the doses of Ritalin were maximizing behaviour at school and not interfering with the child's sleep patterns. The average current dose was 30.9 mg a day (SD 13.6) with a range from 10 mg to 60 mg. The most frequently administered dose was either 20, 30 or 40 mg. These three dosage levels accounted for 53 per cent of prescribed doses. At the time of interviewing, four children (25 per cent) were receiving receiving Ritalin four times a day day,, eight (50 per cent) three times a day (am, noon, 4pm), three (18 per cent) twice a day (am, noon) and one once a day (am). Three parents explicitly mentioned that they would not give the last dose if i f the child did not have to do homework, if high levels of concentration were not needed, or if i f behaviour was not ‘stroppy’. Eighty-two per cent of children had not had a break from taking Ritalin. One child had a fortnightly two-day break when he saw his father. Another parent reported that her son did not take Ritalin if he did not need to concentrate for long periods of time. One 15-year-old child who had been receiving Ritalin on private prescription, was currently receiving Dexamphetamine as this was a cheaper alternative. He was self-medicating with an upper limit of six tablets per day.

 Monitoring  No standard monitoring practices emerged. There was considerable variation in the length of  time between visits and in who was perceived to be responsible for the monitoring. Currently, monitoring monitorin g was done in seven cases (41 per cent) by the psychiatrist, in six cases by the parents (35 per cent), in four cases by the GP (24 per cent). In two cases parents reported reported that the school was also involved. The frequency with which parents and child attended a clinic also varied. The majority attended monthly (35 per cent), with 24 per cent attending every six months, 24 per cent as needed. Twelve per cent were not attending regularly. Six parents (37 per cent) said that they were happy with the monitoring, and four expressed dissatisfaction feeling that too much responsibility was put on them both for getting the dose right and monitoring the effects.

Side effects When parents were asked about their initial concerns regarding their child taking Ritalin, four mentioned a possible adverse effect on growth. In terms of perceived effects once the child had started Ritalin, over half the parents noticed a marked effect on appetite. Six parents described it as a loss of appetite, one reported reduced appetite and another an initial loss of  appetite which subsequently wore off. One parent mentioned that her child chil d had a tendency to feel sick when the dose was increased. An effect on sleep was also mentioned by just under half of parents: either getting to sleep (three cases); awake longer at night but sleeping longer in the morning (two cases); or less disdis turbed (three cases). Two parents felt that their child was more tearful. One parent also commented that Ritalin slowed her child down to the extent he was not always ‘with it’; another that initially her child had sore eyes; in one case Ritalin had resulted in an obvious twitch. 53

 

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

Treatment alternatives during treatment with Ritalin In no case was medication combined with any other structured intervention such as behaviour or cognitive therapy. Three parents (24 per cent) reported that their child had been seen  by an educational psychologist after Ritalin was prescribed. In two case casess this was associated with formal assessment and in one one case EP involvement was specifically targeted at classroom management. One parent parent had co consulted nsulted the EP regarding behaviour management at ho home me  but the EP had not seen the child due to the reluctance on the part of the school, which was not in the LEA.

What parents found useful The range of responses highlighted the importance of having someone who listened, and someone in authority who they felt was not judging them as parents. Several parents also stressed the importance of having a diagnosis so that their child was not seen as ‘naughty’ or ‘bad’, thus transferring focus to the child rather than blaming them as parents. Just under half  of parents felt that the psychiatrist had been bee n the most helpful; others cited an educational ed ucational psychologist, a clinical psychologist, a GP, a support group, a 24-hour ADHD Helpline, a headteacher,, the drug company (CIBA). teacher

What parents would have changed

Two parents were happy with the way things had been managed. However However,, over half the parents expressed the wish that ADHD had been recognized earlier. Of these parents, some felt that an earlier diagnosis would have shifted blame from them as parents – one parent commented "we are on trial until proven innocent" – others, that it would have enabled more specific advice and support to be given to the child. Three parents would have liked more regular follow-up visits and easier access to the psychiatrist rather than being left to manage alone. Two expressed the wish for greater liaison with school. In one case the parent felt she was only contacted when things had reached a crisis point and in the other, the parent felt that because teachers did not recognize the symptoms of ADHD they found it difficult to help the child.

Degree of liaison perceived between professionals Experiences of liaison varied widely depending to a large extent on who was prescribing the Ritalin and the individual school. In a minority of cases there was good liaison with multi-professional meetings, for the majority the liaison depended to a large extent on what parents could arrange or informal links between classteacher and parent. In all cases the school was seen as very supportive and in only one case were any difficulties reported. These centred on the fact that the school were not prepared to comment on the efficacy of Ritalin as this was seen as a medical issue. In two cases, the support extended to the point that it was stated, only if the child were on Ritalin would he be able to attend.

Discussion Response to Ritalin was overwhelmingly positive in the present study. Several parents also noted improvements in family relationships, specifically that their child was more affectionate and that home life was considerably easier. Suggestions that medication is associated with 54

 

Educational and Child Psychology (1997) Vol. 14 (1)

more positive interactions within families is supported by a number of studies (Barkley, 1981; Schachar et al., al., 1987). However, the absence of objective measures of behaviour before and after treatment with Ritalin, and the effect parents' feelings and attitudes will have on their perception of their child's behaviour, are also important variables in perceived efficacy. Seven parents commented that although Ritalin had changed their child and definitely helped, there were still difficulties with behaviour, especially at home. The greater efficacy of  Ritalin at school undoubtedly reflects biochemistry biochemis try.. The stimulant is taken take n during the day and tends to be wearing off during the early evening. Rebound effects, i.e. deterioration in behaviour and mood when the medication is wearing off, have been well documented (e.g. Green, 1993). However, this finding is also consistent with the literature which suggests that medication tends to be more effective in improving concentration and attention at school than it is in improving the child's behaviour at home (Shaywitz & Shaywitz, 1991). The most frequently administered daily dose of Ritalin was 20, 30 or 40 mg. These three dosage levels represented the perceived optimal dosage for 53 per cent of children. T The he highest dose a child was on on was 60 mg a day and tthe he lowest was 10 mg. These dosage levels are  broadly consistent with those reported for a New York York study in which a total daily dose of 20 mg was the most commonly prescribed (approximately 36 per cent of all prescriptions), followed by 30 mg and 10 mg (Sherman & Hertzig, 1991). It was also apparent from interviewing parents that there was variation in the daily dose depending on circumstances. Several parents reported omitting the last dose, or adding an extra dose, depending on behaviour and situation. Experiences varied depending on the prescribing psychiatrist. However, most parents reported a trial and error process of getting the dosage right. No child arrived at the most effective dose at first attempt and parents were free within certain limits to adjust the dose as they thought appropriate. Some parents found this put considerable onus on them and would have liked more guidance from the psychiatrist, others felt happy with the situation and supported by other parents (through support groups) who they felt were in a better position to give advice on dosage than the psychiatrist as parents had had more experience. There are practitioners and lay people who find the concept of parental pa rental control of medication alarming. In the light of Weithorn's (1979) distinction between the two important aspects of  the behaviour of the hyperactive child: "(a) he or she has difficulty coping, and (b) he or she is difficult to cope with", it is important to distinguish which of these two problems will be solved through dose changes in medication for a given child. This distinction becomes even more relevant given evidence which suggests that dosages effective for improving attention control and learning are generally lower than those required to reduce inappropriate behaviour (Sprague & Sleator Slea tor,, 1977; Rapport & Kelly Kelly,, 1991). Alterations in dose could reflect the ai aim m of enhancing the child's coping strategies, in which case a lower dose may be considered appropriate, or making the child easier to cope with, in which case a higher dose may be considered necessary necessary.. If, as Greenhill and Osman (1991) caution, parents adjust the dose as needed, "they may inadvertently train themselves to administer it when they believe their child is 'bad'". There has  been very little research research which has loo looked ked directly at children's perceptions of th their eir behaviour and how these are affected by taking Ritalin. Fried (1991) suggests that most children are not aware of any changes in th themselves emselves when taking the medication, other th than an being in less

55  

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

trouble at school. The extent to which they attribute credit to the Ritalin for the perceived positive changes has also not been widely investigated. In one recent study, Pelham and Milich (1991) showed that children taking Ritalin readily took credit for any accomplishments during the time medication was active. The extent to which this is a typical response needs further investigation. A related issue is w whether hether medication should be given daily or only on school days, with  breaks when the child is away from school. In the present study study,, 82 per cent were taking Ritalin continuously. Only in one case did a child have a regular fortnightly weekend break – and this was not for medical reasons but because the child's father was not keen on medication. It has been argued that ‘drug vacations’ serve a useful purpose and enable the child's current level of ADHD symptoms to be determined (Gr (Greenhill eenhill & Osman, 1991). Given the association with appetite loss and reduced growth, Ritalin-free periods may also a lso be important opportunities for the child to catch up. Furthermore, given there is no end point signalling successful and therefore completed drug treatment, drug vacations may be the only way of  determining whether continued medication is necessary. In the present study, parents had very little knowledge of how long their child would need to continue taking Ritalin. The majority had no clear perception of how long Ritalin might be appropriate nor what the long-term outcome might be with Ritalin. This clearly highlights the lack of individual management plans in which time scales for evaluation are clearly outlined. This is a cause for concern given that research suggests that a significant proportion of children with ADHD do not ‘outgrow ‘outgrow’’ their symptoms and will need continued support of some kind (Faigel et al., al., 1985). Furthermore, given that the long-term efficacy of stimulant medication has not been established, it is worrying that children may continue to be prescribed Ritalin because there is no system for determining when medication may no longer be appropriate. The situation is further complicated by the fact that the symptoms Ritalin suppresses may change as the child gets older. How and when to terminate medication had not been systematically systematicall y explored in the literature and there is considerable uncertainty in this area. The limited research there is suggests that frequently it is the parents or the child, rather than the psychiatrist, who decides to terminate the drug, either through lack of perceived efficacy, side effects or non-compliance (Osman, 1991). The most commonly reported side effects in the present study were loss of appetite (53 per cent) and an effect on sleep (47 per cent). In the case of sleep, the effects were not necessarily negative, in some cases although the child took longer to get to sleep, resulting sleep was less disturbed and the child slept longer in the morning. These findings are in line with research findings which consistently find that insomnia and appetite loss increase in frequency with Ritalin, even at relatively low doses (Ahmann et al., al., 1993; Barkley et al., 1990; Fried, 1991). Ahmann et al. (1993) reported a relationship between dose and decrease in appetite. app etite. In the present study, one parent reported a link between dose increase and nausea for her son. The most common intervention intervention prior to the intr introduction oduction of Ritalin was advice on behaviour management. Generally behaviour management strategies were viewed as ineffective as were dietary interventions. However, However, it was clear from the present study that the order and timing of any intervention was important and had an effect on perceived efficacy efficacy.. In many cases, the strategies for managing behaviour appear to have been offered when parents were not in a

56  

Educational and Child Psychology (1997) Vol. 14 (1)

position to benefit from them. Furthermore, the prescription of a powerful drug, which had an instant and apparently lasting effect on behaviour, meant that less dramatic non-pharmacological approaches may have been unfavourably compared or not reported. This concept of  optimal timing of intervention is supported by some evidence from case studies that interventions such as drug therapy, family counselling and classroom behavioural techniques may need to be staged in order that the child and family gain maximum benefit (Fine, 1980). Eighty-two per cent of parents reported that their child had seen an educational psychologist  before diagnosis and treatment with Ritalin. This is encouraging and higher than a recent study looking at prescribing practices in the United States in which 50 per cent of children had had no contact with an educational psychologist (Kwasman et al., al., 1995). However, in the majority of cases this contact was not continued once the child was prescribed Ritalin. The findings show very clearly that once medication med ication was prescribed there was very little other co-ordinated support. The nature of the links between professionals, e.g. health and education, were very varied. Although all the schools were supportive and facilitated the actual administering of the drug during the school day, in the majority of cases there was very little formal liaison between parents, teachers, psychiatrists and GPs. Similarly, there was little evidence of systematic monitoring of the effects of Ritalin, over and above checks on weight, height and dose-related side effects made by the psychiatrist or GP.

Conclusion The current study clearly underlines the pivotal role parents are playing in the day to day monitoring of medication. Often they are responsible for determining not only the optimal timing but also the optimal dose for their child. This raises important issues. Not least how parents' own theories about their child's behaviour affect the way in which they use Ritalin. Furthermore, how a flexible parental approach to medication, affects the child's perceptions of the control he or she has over his or her own behaviour. Whatever the hypothesized relationship between parental beliefs about behaviour and medication, it is clear that decisions about timing and dosage are not taken in a vacuum, and will certainly be influenced by factors beyond the child's actual behaviour. The effect such decisions have on the child is not clear. There has been very little research looking at the effects of Ritalin from the child's perspective and the degree of control they perceive. If the situation in tthe he United States, in which drugs have sometimes become the only therapeutic resource, is to be prevented in Britain, it is essential that good co-operation is developed between professionals working in health, education and social services so that children can be offered a range of effective treatments. Very little is known about how ADHD is currently being managed in the UK. Even if medical, psychological and educational interventions are combined in an effective way to manage ADHD, there is still an element of uncertainty. No-one really knows how successful such multimodal interventions are going to be in the long term. To To date research has shown only limited gains of combining stimulant medication with either behavioural or cognitive therapy, a fact which perhaps augurs against the power of such an approach (Gittelman et al., al., 1980; Abikoff & Gittelman, 1985; Brown et al., al., 1985). However,, a multidisciplinary approach is not only about outcome, it is as much about process: However the processes of referral, assessment, monitoring and evaluation. Consistency of these processes will enable interventions, whether they be pharmacological or not, to be tailored for the child and evaluated in a systematic way. This in turn will increase their efficacy. It is only

57  

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

when alternatives to stimulant medication are planned specifically for the child with ADHD and implemented in a systematic way, that improvements will be seen. Despite the inadequacies in the present management and monitoring of drug intervention, it is not likely that medication will cease to be used. On the contrary, it is highly likely that the number of children treated will increase, as has been the pattern in the United States. Not only is there increasing recognition of ADHD in the UK, there is a growing body of literature which endorses the use of stimulant medication with children, and a concomitant number of children with ADHD taking medication in mainstream schools. It is then perhaps not surprising that within the UK the move towards multidisciplinary assessment and management has come mainly from within the educational psychology services.

Acknowledgements I would like to thank Edmund Sonuga-Barke for his support and supervision. I would also like to acknowledge all the parents who took part in the study, study, for their time, interest and willingness to share their experiences.

References Abikoff, H. & Gittelman, (1985) Psychiatry, Hyperactive useful adjunct? Archives adjunct?  Archives ofR.General 42children 42, , 953-961.treated with stimulants. Is cognitive training a Ahmann, P.A., Waltonen, S.J., Olson, K.A., Theye, F.W., Van Erem, A.J. & LaPlant, R.J. (1993) Placebocontrolled evaluation of Ritalin side effects. Pediatrics, 91, 91, 1101-1106. Barkley, R., McMurray, M., Edelbrock, C. & Robbins, K. (1990) Side effects of methylphenidate in children with attention deficit hyperactivity disorder: a systematic placebo-controlled evaluation. Pediatrics, 86, 86, 184-192. Barkley,, R.A. (1981) Hyperactive Barkley (1981) Hyperactive children: a handbook for diagnosis and treatment. treatment. New York: Guildford. Brown, R.T., Wynne, M.E. & Medenis, R. (1985) Methylphenidate and cognitive therapy: a comparison of treatment approaches with hyperactive boys. Journal boys.  Journal of Abnormal Child Psychology, 13, 13, 69-97. Cains, R.A. (1995) ADD and Ritalin. The Psychologist, February, 56. 56. Faigel, H.C., Sznajderman, S., Tishby, Tishby, O., Turel, M. & Pinns, U. (1985) Attention Deficit Disorder during adolescence. Journal adolescence.  Journal of Adolescent Health, 16, 174-184. Fine, M.J. (1980) Intervention with hyperactive children: a case study approach. a pproach. Lanca Lancaster: ster: MTP Press Press Ltd. Fried, J.E. (1991) Use of Ritalin in the practice of pediatrics. In L.L. Greenhill & B.B. Osman (Eds) Ritalin theory and patient management. management. New York: Mary Ann Liebert Inc. Publications. Gittelman-Klein, R., Abikoff, Abikoff, H., Pollack, E., Klein, D. D.F F., Katz, S. & Mates, J. (1980) A controlled trial of   behaviour modification and methylphenidate in hyperactive children. In C.K. Whalen and B. Henker (Ed.) Hyperactive (Ed.)  Hyperactive children: the social ecology of identification and treatment. treatment. New York: Academic Press. Green, C. (1993) Management of attention deficit disorder: a personal perspective.  Modern Medicine, 37, 37, 38-53. Greenhill, L.L. & Osman, B. (1991) Ritalin. Theory and patient management. management . New York: Mary Ann Liebert Inc. Publishers. Kewley,, G.D. (1995) ADD and Ritalin. The Psychologist, May, 201. Kewley 201. Kwasman, A., Tinsley, B. & Lepper, H.S. (1995) Pediatricians' knowledge and attitudes concerning diagnosis and treatment of Attention Deficit and Hyperactivity Disorders. Disorders. Archives  Archives of Pediatric Adolescent Adolescent  Medicine, 149, 149, 1211-1217. 1211-1217. Pelham, W.E. (1990) Behaviour therapy, behavioural assessment and psychostimulant medication in

58  

Educational and Child Psychology (1997) Vol. 14 (1)

treatment of attention deficit disorders: an interactive approach. In J. Swanson & L. Bloomingdale (Eds)  Attention Deficit Disorders V: current current concepts and emerging trends in the treatment of attention and behaviour  problems in children. children. London: Pergamon. Pelham, W.E. & Milich, R. (1991) Individual differenes in response to Ritalin in classwork and social  behaviour.. In L.L. Greenhill & B. Osman (Eds) Ritalin. Theory and patient management.  behaviour management. New York: Mary Ann Liebert Inc. Publishers. Rapport, M.D. & Kelly, K.L. (1991) Psychostimulant effects on learning and cognitive function: findings and implications for children with attention deficit hyperactivity disorder. Clinical Psychology Review, 11, 11, 61-92. Rapport, M.D., Kelly, K.L. & Jones, J.T. (1986) Comparing classroom and clinic measurements of  attention deficit disorder: differential, idiosyncratic and dose-response effects of methylphenidate.  Journal of Consulting and Clinical Psychology, Psychology, 54, 54, 334-341. Schachar, R.J., Taylor, E., Weiselber, M., Thorley, G. & Rutter, M. (1987) Changes in family function and relationships in children who respond to methylphenidate. Journal methylphenidate.  Journal of the American Academy of Child and  Adolescent Psychiatry, 26, 26, 728-732. Sharron, H. (1995) Behaviour drugs – headteachers speak out. Special Children, April, April, 10-13. Shaywitz, S.E. & Shaywitz, B.A. (1991) Attention Deficit Disorder: diagnosis and the role of Ritalin in management. New York: Mary management. In L.L. Greenhill & B. Osman (Eds) Ritalin. Theory and patient management. Ann Liebert Inc. Publishers. Sherman, M. & Hertzig, M.E. (1991) Prescribing practices of Ritalin: the Suffolk County, County, New York Study. Study. In L.L. Greenhill & B. Osman (Eds) Ritalin. Theory and patient management. management. New York: Mary Ann Liebert Inc. Publishers. Sprague, R.L. & Sleator, Sleator, E.K. (1977) Methylphenidate in hyperkinetic children: differences in dose effects 198, 1274-1276. on learning and social behaviour. Science, 198, Weithorn, C.J. (1979) Perspectives on drug treatment for hyperactivity. In M.J. Cohen (Ed.) Drugs and special children. children. New York: Gardner Press.

59  

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

Understanding and managing Attention Deficit Defic it Hyperactiv Hyperactivity ity Disorder: Disorder: the perspective from educational psychology M.J. M. J. Conn Connor or,, C. Epting Epting,, R. Free Freela land nd,, S. Halli Halliwe wellll and and R.J. R.J. Ca Came merron Surrey Educational Psychology Service

 Abstract Over the past decade, the level of interest in UK children with Attention Deficit Disorder has increased exponentially. This has not only been reflected in the number of articles on the topic which have appeared in professional journals for psychologists, but also in medical and psychological research where a number of issues relating to the identification and management of ADHD have been clarified. Like many problem areas for children and young people, there has been disagreement about the nature of ADHD and controversy about the help which should be provided  for these these chil children. dren. In rresponse esponse to the concer concerns ns of paren parents, ts, as well as supp supporting orting profes professionals sionals in the Education Service, a small working group of educational psychologists was set se t up to review the literature, identify resulting implications and produce guidelines for good practice for Surrey education staff. The resulting resulting ‘Guidelines’ which closely resemble the rrecommendations ecommendations of the recently published  publish ed repo report rt from The Bri British tish Psyc Psychologic hological al Socie Society ty Coun Council cil have n now ow becom becomee Coun County ty policy policy..

Introductory remarks In the USA, Attention Deficit Hyperactivity Disorder (ADHD) has long been viewed as a prerequisite of significant learning difficulties (Strauss & Lehtinen, 1947) and more recently the US Department of Education produced a memorandum to clarify the role of state and local authorities in addressing the needs of these children (US Department of Education: Office of  Special Education and Rehabilitative Services, 1991). Interest in ADHD in the UK has increased considerably during the past few years (Barkley, 1990; Anastopoulos et al., al., 1994; Taylor, 1994a; Cooper & Ideus, 1995a,b). Several professional journal issues have also been devoted to the topic, notably Exceptional Children (1993, 60, 2) and Therapeutic Care and Education (1994, 3, 4) and a Working Party report from The British Psychological Society has  been published (BPS, 1996). Pressure and support groups have also been set up in this country e.g. LADDER (the Learning, Hyperactivity and Attention Deficit Disorders Association) (see Mould, 1993) and Support for Parents of Children with ADD (UK). What is known about ADHD? How can educational psychologists assess the often complex needs of children with ADHD and what management strategies can be offered to parents, teachers and other direct contact people? In this article, articl e, we will attempt to survey research literature which has particular relevance for EPs and to describe the response of one service where guidelines for good practice have been developed.

60  

Educational and Child Psychology (1997) Vol. 14 (1)

Research review Systematic investigation of this condition began in the 1940s with an emphasis upon motor and behavioural symptoms (hyperactivity). For example, Strauss and Lehtinen (1947) referred to ‘Brain Injured Child Syndrome’, and the subsequent concept of ‘Minimal Brain Dysfunction’ was used to describe cases whose symptoms appeared similar to the effects of  central nervous system injury despite no observable evidence for such injury. It was not until the 1970s that the problem of attention as well as hyperactive behaviour was highlighted. Douglas (1972) described how the so-called hyperactive child may have deficits in sustained attention and in impulse control as much as in motor restlessness. It has become increasingly accepted that difficulties or deficits in attention may be accompanied by hypoactive, normal or hyperactive behaviour. Most of the evidence has come from US studies and points to this condition occurring in three to five per cent of the population (US DoE, 1991), 1991 ), 80 per cent of whom are boys (Barkley (Barkle y, 1990) and 60 per cent of these having associated hyperactivity (Hinshaw, 1994). A review of ADHD research by Hinshaw (1994) indicates that there is no single cause (or set of causes) which underlies the development of this disorder; aetiological features may be biological, psychological, and social (Pennington & Ozonoff, 1996; Taylor, 1994a). A major implication fr from om these reviews is the need to recognize recognize that children, justifiably justifiably diagnosed as experiencing ADHD, may have a wide range of needs, strengths, weaknesses, and backgrounds (BPS, 1996). Further, Further, assessment should highlight each child's particular profile in order to guide interventions, and early interventions are critical. For example, Taylor Taylor (1994b) suggests that, although with time there may be improvements in respect of activity or impulsivity levels, problems of antisocial behaviour and scholastic underachievement are likely. The work of Sonuga-Barke & Goldfoot (1995) reinforces the requirement for early intervention in highlighting the two-way nature of potentially negative interactions between parent and child. Parents of hyperactive children may control behaviour in ways that can be differentiated from those used by parents of ‘normal’ children, and the former may also perceive their children as delayed, relative to some overall norm. The risk is that lowered expectations or particular handling styles may exacerbate existing difficulties. Of particular interest to educational psychologists is the possible link between ADHD and specific learning difficulties. Many of the criteria for diagnosing ADHD (American Psychiatric Association, 1994) resemble those which may be applied to dyslexia viz: ◆ ◆ ◆

may fail to pay close attention to details and make careless mistakes in school work; may have difficulty in organizing tasks; may not seem to take in what is said, etc.

The probable bi-directional link between behavioural and scholastic performance means that progress in both areas may be negatively influenced by changes in expectation on the part of  teachers, peers or others who interact with the children, and by changes in self expectation. Recent research (e.g. Shachar, 1991; Hinshaw, 1994) has revealed the complex nature of the

61  

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

interactive aspects of Attention Deficit Hyperactivity Disorder, the difficulty in specifying its nature and aetiology, and the controversies about setting down a definite diagnosis in givencases (for example, there may be significant differences between children whose behavioural or attentional difficulties are observed only in one setting and those whose difficulties are evident in any setting). Shachar (1991) has summarized the key problem areas in ADHD as follows: ◆

◆ ◆ ◆ ◆

Ambiguity in the three characteristic behaviours which make up ADHD (inattention; hyperactivity; impulsivity). Behaviours like inattention and hyperactivity may have many causes. Differentiation between normal and abnormal levels of activity may be arbitrary. Age and gender appear to be related to activity and attention. Research emphasis upon samples of children referred to specialist clinics may introduce  bias elements.

Gender issues are particularly relevant since the frequency of an ADHD diagnosis may remain ‘skewed’ to those children whose disabilities or difficulties are overt and impact most immediately upon other children and their teachers, i.e. males. mal es. Girls are more likely than boys to experience an attentional difficulty without the hyperactive or acting-out behaviour and may,, therefore, not be identified as experiencing an ADHD problem (Barkley may (Barkley,, 1990). Meanwhile, controversy remains in respect of how ADHD overlaps with, impinges upon, or is synonymous with other learning difficulties. It may not follow that ADHD is a precursor of  underachievement or learning disability, but, where there is the joint problem, it is possible that learning problems and ADHD are linked through some other disability, disability, such as a speech and language disorder (see Cantwell & Baker, 1991). The problem of defining what turns out to be a heterogeneous group of children in markedly different learning and living environments has been summarized by Green (1995):  Anyone who claims that ADHD is a clear, objectively diagnosed condition must be be greeted with  great suspicion. These people have read too many books aand nd spent too littl littlee time working with children.

Managementt of ADHD Managemen As with so many other psycho-medical conditions, conditions, much effort has been devoted to diagnosis diagnosis.. However, this may only be the first step in the longer term process of specifying behavioural and learning targets, planning how to meet those targets, and maintaining liaison among parents and profession professionals als representing the education, health, social and voluntary services. Practitioners faced with requests for advice will wish to switch the focus to intervention strategies and their effectiveness rather than upon the matter of aetiology aetiology.. With regard to management of ADHD, the following themes are emerging: ◆ ◆

If causation is multi-modal, then remedial action may involve a number of types of  intervention. Such interventions would include:

62  

Educational and Child Psychology (1997) Vol. 14 (1)

—educational management; —behavioural management; —the possible (short-term) use of medication (e.g. the psychostimulant Methylphenidate, Ritalin); —consistency of actions and expectations towards the child, and the working together of parents, teachers, educational psychologists, and medical professionals. Cooper and Ideus (1995a,b) challenge the ‘traditional’ way in which emotional and behavioural difficulties have been viewed, largely a ‘within-child’ approach, and highlight the need to be aware of biological and environmental factors, and the significance si gnificance of teaching goals aand nd styles. They also highlight the risk of placing an over emphasis upon medication, with the conclusion (shared by a number of authors, e.g. Roth, 1995) that the use of medication may be a valuable component of a treatment package in providing a ‘breathing space’, or a diminution in overt behavioural symptoms, during which longer term strategies could be put in place. Such management approaches might include behaviour-modification, social skill training, structuring of teaching and learning, cognitive therapy and training/support for parents. (See The British Psychological Society Report, 1996, for a list of intervention strategies.)

ADHD in everyday life As well as interfering with their own learning, the behaviour of the pupil with ADHD affects the everyday lives of everyone in his or her living and learning environment. Likewise, parents, teachers, siblings, peers and the environment all have an impact upon the behaviour of  the child experiencing ADHD. However, it is no easy task to provide effective support and a toll is exacted on everyone's energy levels. It is important to be aware of the difficulties faced, understand these within various contexts and strive to build positive relationships so all involved feel successful. As previously noted, the child with attention deficit disorder will have difficulties in one or more of three areas: attention, impulsivity and activity activity.. In addition to being prone to high levels of physical activity, their minds often appear to be racing, jumping from one thought to another and bringing much confusion into their lives. (This can be reflected in observable difficulties with focusing, attending, organizing and following through requests from others.) Some children with ADHD appear to respond to their thoughts in an impulsive manner without reflecting on the consequences of their actions (sometimes resulting in physical harm, poor social judgement and frequent negative feedback from others). They may have difficulty concentrating on one thing or may be hyper-focused (and have difficulty breaking this intense attention). These types of difficulties and their effect on others can have negative effects on a child's self-esteem. All aspects of the child's life – peer, family, educational, and personal – suffer as the child repeatedly fails to meet either others' or his (occasionally her) own expectations. Parents of children with ADHD (see Green, 1995) are also very likely to have low levels of selfesteem. As they view other parents ‘successfully’ managing their children, they may feel frustrated when their child does not respond in the same manner. Children with ADHD are easily satiated and parents have to have a large repertoire of attention holding strategies: they also have to be hyper-vigilant in monitoring opportunities for physical harm. An added dilemma which parents of ADHD children experience is the frustration their child encounters on a daily basis and as they sit with their child struggling through homework assignments, they

63  

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

probably worry that the work may never reach the hands of the teacher who has set it! Teachers are also likely to experience a negative impact on their professional self-esteem (Burcham et al., al., 1993; Mould, 1993; Taylor, 1994b). They may feel unsuccessful as their tried and true strategies (which have taken years of experience to perfect) suddenly have little effect when applied to the child with ADHD. High levels of activity and insatiability also serve to wear down a teacher's reserves, especially when faced with 20-30 other pupils with their individual needs. The demands of the pupil with ADHD, combined with their disruptiveness through impulsive responding, reduces the opportunities for positive teacher-pupil relationships. The chaotic state of the child's desk and personal materials can increase frustration, as the teacher undertakes the ‘adventure’ of delving into the unknown in search of lost assignments. The challenge of keeping activities stimulating, yet short enough for the child to  be successful, as well as the task o off mediating difficulties between the A ADHD DHD pupil and peers, is likely to take its toll on the energy of even the most tolerant of teachers. The task for educational psychologists is to help others understand the complexities involved in the ADHD symptomatology. Working within a multimodal framework among different disciplines presents many challenges. Teasing out factors which can mask themselves as ADHD (or co-morbid symptoms) demands care and attention. When medication is seen to work it can be very hard to persuade people to maintain or develop new strategies designed to deal with underlying difficulties or to help them cope with re-emerging problems when medication is ceased. Remaining at the forefront of research and making others aware of the implications of these findings for parents and teachers are also key tasks for educational psychologists. Most importantly, the challenge for EPs is to increase understanding, improve management and to help others see the positive side of ADHD. Many of today's movers and shakers of the world may have had some early ADHD features. They have successfully met the personal, social and learning challenges and channelled their energies into both managing the present and actively planning for the future.

EPs and ADHD Educational psychologists have a powerful role to play in evaluating and developing strategies for managing the behaviour of pupils who have ADHD. Our review (SEPS, 1996a) of the current ADHD literature is full of 'good advice' to teachers such as making a special effort to 'catch children being good' g ood' and to encourage self-esteem. It becomes clear, however however,, from supporting teachers in intervening for children with ADHD, that such well intentioned general advice can leave them feeling that they have tried everything but often without success. The EP can bring a different perspective which rresults esults from an overview of all the contributing contributing factors not usually afforded to any other significant person in the child's environment. In the ADHD literature (where strategies for management can at times appear contradictory) a quote from Hinshaw & Erhardt (1991) summarizes the current state of play: ... no intervention strategies to date, whether employed singly or in combination have proved clinically sufficient and durable (for all pupils). What knowledge base should guide EP advice? Currently Currently,, there are two two promising guidelines where general agreement exists. Firstly, multimodal interventions stand a greater chance of 

64  

Educational and Child Psychology (1997) Vol. 14 (1)

success (presumably because of both a cumulative and an interactive effect). Secondly, it is only by trying out and monitoring interventions that EPs will know what to include in their personal advice. Both these strands fit well with the model of multi-professional, ongoing assessment underlying the Code of Practice (DfE, 1994), for children and young people with special educational needs. Some of the research and evaluation methods for special education in general which have  been outlined by Hegarty and Ev Evans ans (1985) are likely to be relevant to monitoring outcomes, understanding processes and identifying good practice elements. Table 1 shows an intervention schema that contains 11 elements which EPs are likely to find helpful to consider. Some domains involve other professionals/agencies, others fall more directly within the remit of education. Our experience has shown that some children may require help in a number of domains, while others have shown rapid improvement from support in just one. Table 1. Menu of intervention possibilities for teachers, parents and pupils with Attention Deficit Hyperactivity Disorder

1. zone Physical learning environment  environment (e.g. (e.g. use of quiet area, identification identification of teacher prompt prompt 2. Social learning environment  environment (e.g. (e.g. use of buddy system, system, peer group recogn recognition ition for achievement). 3. Classroom management (e.g. management (e.g. catching pupil pupil being successful, successful, use of short reprimands). 4. Differentiation Differentiation in the classroom (e.g. classroom (e.g. differentiation differentiation by task, teaching method method and assessment of outcome,). 5. Teacher-pupil behaviour plan (e.g. plan  (e.g. use of contracts, contracts, fun prompts, prompts, IEP). 6. Home-school liaison (e.g. liaison (e.g. collaborative collaborative management, home recognition recognition of school success and vice versa). 7. Parent training (e.g. training (e.g. early intervention programmes, programmes, effective effective parenting skills). 8. Self monitoring skills . 9. Self esteem enhancement . 10. Classroom monitoring of pharmacological interventions . 11. Networking with other agencies .

The Intervention Schema used in Surrey comprises a number of different interventions within each domain ranging from cognitive behaviour modification (something which does not emerge as a high scoring intervention in groups but which may nonetheless be helpful for some individuals) to process based instruction (Ashman & Conway, 1993) to behaviour management for parents (e.g. assertive discipline for parents). Working at the level of a pupil's peer group (e.g. circle time, circle of friends, prompts by peers) offers a rich intervention menu. Such a schema is an attempt to provide an overview of intervention and is open to addition and modification in the light of experience. Pharmacological intervention is included within this schema because it is something about which the EPs need to be briefed. (See for example the conflicting claims made for the effect of Ritalin in Carlson & Bunner, 1993; Kohn, 1989.) The views of EPs, which can be extremely

65  

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

influential in the decision-making of others, need to be based on published research rather than prejudice. However, as a general rule, Surrey EPs would argue that there should be no pharmacological intervention without the context of multimodal intervention and evaluation of the effects of educational intervention. From time to time, the personal hypotheses of significant people involved with a child's develde velopment can be discordant with particularly harmful effects upon any intervention that is undertaken. For example, in school staff  can be working with their hypotheses that all the unwanted behaviours in the classroom were the result of inadequate parenting and that any differentiation undertaken by the teacher is pointless. The parent The  parent may be convinced that the school view of their child is a negative one, while the pupil the  pupil becomes  becomes convinced that the whole world is against him or her. her. A shared attribution which allows joint work and coher coherent ent planning is obviously required, and a book such as All as  All Kinds of Minds (Levine, 1993) may be helpful in explaining the nature of difficulties being experienced and in modifying some of the learner's own unhelpful attributions for success and failure.

Surrey EPS policy on ADHD In Surrey, Surrey, our policy stems from the belief that while there is wide variation in attention, activity and impulsivity especially among young children, there is a small subgroup of children who have marked difficulties relating to severe inattention, over-activity and impulsivity and who pose major management and teaching challenges for teachers and parents. The literature searches carried out by the SEPS Working Group on ADHD (SEPS, 1996a) confirmed that little agreement existed among research and applied psychologists (and medics and educationalists) about the nature and aetiology of ADHD. Despite difficulties in definition and identification, we have recognized that the problems in school faced by some Surrey pupils who have ADHD features may be persistent and in some instances can have a marked effect on their academic attainments, personal esteem and social development.

Philosophy Among the group of children who are described as having ADHD, Surrey EPs accept that there is a wide spectrum of need stretching from those who may require minimal assistance at a particular point in their school career through to others who have severe and complex learning difficulties and who may need more intensive help either throughout their early school years or, occasionally, through most of their school life. Some pupils exhibit such a marked degree of inattention, overactivity and impulsivity that they under-achieve and may require support to access the curriculum. In our "Guidelines for Good Practice" (SEPS, 1996b), the working group members note that helping pupils who have ADHD to manage their problems and to make personal, social and academic progress in school is a difficult task. Multi-professional collaboration appears to produce best results (accepting that there is little evidence available as yet indicating the effectiveness of any particular teaching or management approach for ADHD). In the Surrey Guidelines, the term ‘Attention Deficit Hyperactivity Disorder (ADHD)’ has  been chosen, although this is a ‘medical’ rather than an ‘educational’ term and often implies a presumed underlying neurological dysfunction. EPs can be comfortable with this term providing that this description does not negate the importance of an educational and psycholog-

66  

Educational and Child Psychology (1997) Vol. 14 (1)

ical assessment which considers both the child's problems and the learning environment. environment. People working within education may choose to use the longer non medical term ‘children with attention difficulties, with or without over-activity and impulsivity’.

Principles Helping parents and teachers to focus both on the child's individual difficulties and the way in which the child's school or home environment interacts with those difficulties to help or hinder further progress, is seen as the most effective way of understanding the complex nature of ADHD and managing any resulting learning difficulties. Our ‘Guidelines for Good Practice’ suggest that the starting point for helping children with attention difficulties and/or over-activity and impulsivity should be the steps outlined in Section 3.62 and 3.69 of the Code of Practice on the Identification and Assessment of Special Educational Needs (DfE, 1994). Schools should have: ✦

taken action to make both the curriculum and the school day accessible to the child by alerting all teachers to the child's particular needs;

✦

formulated, monitored and evaluated, in conjunction with outside agencies, individual education plans;

✦

sought a constructive relationship with the child's parents/carers, encouraging them to participate in their child's education, including visiting the school on a regular basis;

◆

closely monitored the child's emotional and behavioural responses to his/her learning difficulties and, if necessary, provided help to reduce anxiety and enhance self-esteem;

✦

With the parents' consent, notified and sought the assistance of the school doctor and/or the the child's GP as appro appropriate. priate.

Procedures Guidelines drawn up for the Educational Psychology Service and for Surrey schools incorporate the beliefs and principles detailed above. Whilst acknowledging the fact that the use of a general label such as ADHD can be anxiety relieving to parents, teachers and pupils, the negative side of labelling is also acknowledged in placing an over-emphasis on within-child factors. Nevertheless by offering a simple explanation of a complex problem, teachers can be helped to respond with an agreed set of procedures designed to understand the child's problems, identify the child's needs and to help the child access the curriculum. For Surrey EPs, adoption of a multi-faceted approach to assessment is recommended. This includes classroom observation, looking at pupils' work portfolios, consideration of their social skills, listening and attention levels, basic attainments, verbal skills and of course a consideration of the pupil's perspective of his or her learning difficulties. Analysis of these data can provide the basis for a consultative disc discussion ussion between the EP EP,, school doctor doctor,, teachers and parents and lead to a clearer understanding of the pupil's assets and difficulties and the production of an agreed individual education plan.

67  

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

The need to demonstrate a clear link between the method of investigation, the data collected and the individual plan for each pupil is emphasized. Curriculum related assessment is recommended and a suggestion made that ‘learning environment’ measures may be of particular relevance since it can be used to consider the way the teacher is differentiating his or her teaching to take account of the pupil's difficulties. Noting and sharing good practice in different schools is encouraged in the Educational Psychology Service and Surrey EPs will be actively involved in the evaluation of these procedures within the county. The implication for major training needs for both the EPS and our Literacy Support Service are recognized and INSET programmes are being planned. Suggested assessment guidelines for schools include the introduction of a number of researchevaluated procedures to identify the needs of pupils regarded as having ADHD, for example, the DSM-IV criteria (American Psychiatric Association, 1994). Data from the recently introduced ‘Surrey Year R Screening Programme' are used to identify pupils at risk and provide accompanying programmes of support for pupils who exhibit ADHD features at a relatively early stage in their educational career. A number of important teaching teaching procedures have been outlined and these have been supplemented in an information leaflet sent to all schools detailing general, practical recommendations to enhance concentration and attention in the classroom. SEN co-ordinators are seen as having important roles, both as consultants to their teaching colleagues and other staff and as Inset organizers. Current developments include an information leaflet for parents and undertaking of liaison and training with other professionals. Amendmnent and updating of the policy p olicy will take pl place ace on an annual basis.

Final comment In the field of Attention Deficit Hyperactivity Disorder, EPs have much to offer. The EP's role as consultant and adviser allows for an overview of intervention available from no other professional source, the EP being able to work at all levels from direct observation of a pupil, to influencing the organization of the pupil's learning environment. In other words, it is highly likely that EPs stand the greatest chance of understanding the problems p roblems most clearly clearly,, finding out what works best for managing and monitoring these interventions and advising on LEA policy in this area.

Acknowledgements We would like to acknowledge the contributions of all the educational psychology staff in Surrey in shaping and formulating our new county policy on ADHD. Important comments, amendments and additions to this policy were also received from the Support for Parents of  Children with ADD (UK) group. All five authors are educational psychologists in the Surrey Educational Psychology Service and formed the working group for children who have ADHD. Mike Connor works in the Faniham, Ash and Godalming Team; Carla Epting is a member of  the Woking and Runnymede South Team; Robin Freeland is now an Independent Educational Consultant, and Sheila Halliwell is with the Tandridge, Redhill and Horley Team. Dr R.J. (Sean) Cameron, who chaired the group, is Senior EP, with responsibility for practice development in the Surrey Service.

68  

Educational and Child Psychology (1997) Vol. 14 (1)

References Anastopoulos, A., Baridey, R.A. & Shelton, T. (1994) ADHD history and diagnosis. Therapeutic Care and Education 3, 2, 96-110. American Psychiatric Association (1994) Diagnostic and and statistical manual of mental disorders disorders (DSM-IV). Washington DC. Ashman, A.F. & Conway, R.N.F. (1993) Using cognitive strategies in the classroom. classroom. London: Routledge. Barkley, R.A. (1990) Attention (1990) Attention deficit disorder. disorder. NY: Guildford. British The (1996) Attention (1996)The  Attention Hyperactivity Disorder (ADHD): a psychological responsePsychological to an evolving Society, concept . Leicester: concept. BritishDeficit Psychological Society. Society . Burcham, B., Carison, L. & Milich, R. (1993) Promising school-based practices for children with Attention Deficit Disorder. Exceptional Children, 60, 60, 2, 174-180. Cantwell, D. & Baker, L. (1991) Association between attention deficit disorder and learning disorders.  Journal of L earning Disabilities, 24, 24, 2, 88-95. Carlson, C. & Bunner, M. (1993) Effects of Methyiphenidate on academic performance of children with 22, 184-198. AD(H)D. School Psychology Review, 22, Cooper, P. & Ideus, K. (1995a) Is attention deficit hyperactivity disorder a Trojan horse? Support for Learning, 10, 10, 1, 29-34. Cooper, P. & Ideus, K. (1995b)  Attention Deficit Hyperactivity Disorder: medical, educational and cultural issues.. Maidstone, Kent: Association for Children with Emotional and Behavioural Difficulties. issues Department for Education (1994) Code of Practice on the Identification and Assessment of Special Educational Needs. Lon London don:: HMSO. HMSO. Douglas, V. (1972) Journal The problem of sustained attention and impulse control in hyperactive and normal children. Canadian of Behavioural Science, 42 , 59-282. 42, Green, C. (1995) Management of attention deficit disorder: a personal perspective.  Modern Medicine of   Australia, 37, 37, 2, 38-53. Hegarty, S. & Evans, P. (1985) Research and evaluation methods in special education. education. Windsor: NFER-Nelson. Hinshaw, S. (1994) ADD (1994) ADD and hyperactivity in children. children. Thousand Oaks, California: Sage. Hinshaw,, S. & Erhardt, D. (1991) Attention Deficit Hyperactivity Disorder. Hinshaw Disorder. In P.C. Kendal (Ed.) Child and adolescent therapy: cognitive-behavioural co gnitive-behavioural procedures. procedures. NY: Guildford. Kohn, A. (1989) Suffer the restless children. The Atlantic Monthly (November) 90-98. Levine, M. (1993) All (1993)  All kinds of minds: a young student's book about learning abilities and learning disorders. disorders. Cambridge: Educators Publishing Service Inc. Mould, S. (1993) Chaos in the classroom. Special Children (May) 8-11. Pennington, B. & Ozonoff, S. (1996) Executive functioning and developmental pathology in children with ADD. Journal ADD. Journal of Child Psychology and Psychiatry, 37, 37, 1, 51-XX. Roth, E. (1995) A clinical and cognitive approach to attention deficits. Therapeutic Care and Education, 4, 4, 1, 41-59. Shachar, R. (1991) Childhood hyperactivity. Journal hyperactivity.  Journal of Child Psychology and Psychiatry, 32, 32, 155-192. Strauss, A. & Lehtinen, L. (1947) Psychopathology and education of the brain injured child. child. New York: Grune & Stratton. Sonuga-Barke, E. & Goldfoot, M. (1995) The effect of child hyperactivity on mothers’ expectations for 21, 1, 17-29. development. Child Care, Health and Development, 21, Surrey Educational Psychology Service (1996a) Current issues, research and developments in Attention Deficit Disorder (ADD). (ADD). Kingston upon Thames: SCC Surrey Educational Psychology Service (1996b)  Attention Deficit Disorder (ADD): guidelines for good  practice.. Kingston upon Thames: SCC  practice Taylor, E. (1994a) Syndromes of attention deficity and overactivity. In M. Rutter and L. Hersov (Eds) Child and adolescent psychology: modern approaches. approaches. Oxford: Blackwell. Taylor, E. (1994b) Hyperactivity as a special educational need. Therapeutic Care and Education, 4, 4, 2, 130-144. US Department of Education: Office of Special Education and Rehabilitative Services (1991) Clarification of the Policy to address the needs of children with Attention Deficit Disorder with general and/or special education. education. Washington DC: US DoE.

69  

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

ADHD: the deve developmen lopmentt of a collaborative model of practice within North Somerset Unitary Authority G. Evans Evans,, K. Full Fuller er,, D. Hell Heller er,, C. Morg Morgad ado o, P. Salis Salisbury bury and and R. Sali Salisb sbury ury Special Educational Support and Psychology Se Services, rvices, North Somerset

 Abstractt  Abstrac This paper describes a collaborative pilot project which ran from January to July 1996 in North Somerset Unitary Authority involving psychology, education (schools) and health professionals. It aimed to design and establish a multidisciplinary protocol for the assessment and diagnosis of   Attent  Att ention ion Defi Deficit cit Hype Hyperact ractivit ivityy Dis Disorde orderr (ADHD) (ADHD) amo among ng prim primary ary scho school ol aged chi childr ldren en and to study the effectiveness of various types of intervention for the treatment of childhood ADHD. This article outlines the main findings of the pilot project drawing upon case study material, demonstrating that a more comprehensive multi-professional assessment protocol may lead to fewer children being diagnosed as having ADHD. The use of psycho-stimulant medication (Methylphenidate) combined with cognitive/behavioural interventions across home and school brought about improvements in behaviour for some of the sample. Implications for practice are discussed.

North Somerset ADHD Working Party: Gill E Ev vans Ken Fuller Dr Doug Doug He Helle llerr Cl Clar aree Mo Morrga gado do Pam Pa m Sa Salis lisbu bury ry Ruth Ru th Sa Sali lisb sbur ury y

(Principal E Ed ducational P Pssychologist) (Project Co-ordinator 1.1.96 – 31.3.96) (C (Con onsu sult ltan antt C Com ommu muni nity ty Pa Paedi ediat atri ricia cian) n) (T (Tra rain inee ee Ed Educ ucat atio iona nall Psy Psych chol olog ogis ist) t) (E (Edu ducat catio iona nall Ps Psych ychol olog ogist ist Pr Proj ojec ectt Co Co-o -ord rdin inat ator or 11.4 .4.9 .966 – 31. 31.7. 7.96 96)) (B (Beh ehav avio iour ur Su Supp ppor ortt Tea each cher er))

In 1996, psychology, education and health professionals in North Somerset ran a collaborative pilot project aimed at designing and establishing a multidisciplinary protocol for the assessment and diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) among primary school aged children and studying the effectiveness of various types of interventions for the treatment of childhood ADHD. The pilot project was conceived as a result of concerns expressed by local practitioners in education, psychology, special needs and health, that existing procedures for the assessment of  childhood ADHD were inadequate and inappropriate. It was felt that a multidisciplinary approach to the assessment, diagnosis and treatment of this disorder in children would be more appropriate and helpful to all concerned. This is echoed by the recommendations of  much recent research which states that a purely medical diagnosis should not form the sole  basis for ADHD diagnosis (Barkley (Barkley,, 1990). Concern had been expressed by headteachcrs about the legal implications of school sc hool staff being asked to administer ADHD medication to pupils in loco parentis. parentis. Dissatisfaction was also

70  

Educational and Child Psychology (1997) Vol. 14 (1)

voiced about the lack of school consultation about this important assessment and diagnostic process concerning children in their care; frustration was expressed at the perceived disenfranchisement of education from this consultation, whether intentionally or otherwise. Consequently, the pilot project framework was drawn up by a group of education and health Consequently, professionals, including the principal educational psychologist (PEP). This comprised the coordinator – an educational psychologist (EP) seconded to work part-time on the pilot, the local consultant community paediatrician (CCP), a specialist behaviour support teacher (BST) and a trainee educational psychologist (TEP) on fieldwork placement. In later phases of the pro ject, there was a change of educational psychologist as co-ordinator co-ordinator,, the other team members remaining as in the initial phase. In these latter phases, the trainee educational psychologist had only minimal involvement. The principal educational psychologist was involved and kept informed of progress throughout.

Aims of pilot project 1. To devise and pilot a comprehensive multidisciplinary assessment and diagnostic process for primary aged children who may have ADHD. 2. To lead to improved partnership between health, education (schools), psychologists and parents in the assessment and management of ADHD. 3. To To devise and pilot phased programmes of interventions where ADHD has been diagnosed and to monitor the effectiveness of various interventions. Table 1. Samp Sample le by age age/sch /school ool ye year: ar: gend gender: er: ref referrer errer Age/school year

R

1

2

3

4

5

6

Total

Number of children

1

4

5

4

2

2

2

20

Gender

Male Female

1 -

3 1

5 -

3 1

2 -

1 1

2 -

17 3

Referrer

Health Education

1 -

2 2

4 1

3 1

1 1

1 1

2 -

14 6

Assessment phase The standardized assessment procedures and instruments used The consensus in recent research indicates that the assessment of ADHD should involve gathering information about the child’s behaviour across a range of settings and from a range of  sources and individuals. In order to aid differential diagnosis, namely the separation of  ADHD diagnosis from that of similar disorders such as conduct, c onduct, oppositional defiant, anxiety or depressive disorders, information about a wide range of behavioural aspects was therefore sought. Guided by a review of recent literature, the procedures and instruments listed below were selected to be used to assess each of the 20 children in the pilot project for signs of  ADHD. In the interests of continuity and rapport establishment, the same team members generally collected all the data for a particular group of children, with the exception of the medical aspects which were all undertaken by the team consultant community paediatrician (CCP).

71  

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

Pilot Project Framew Framework ork HEALTH (GP/CMO)

EDUCATION (EP/BST)* Stage III Code of Practice

REFERRAL INITIAL ASSESSMENT (sample n = 20)

KEYWORKER (EP or BST)*

Pur pose:

–

Consultant Community Paediatrician (CCP)

MULTI-PROFESSIONAL ASSESSMENT MEETING Share As Assessment Infor mation  –  –  –

Confirm degree of diagnosis Plan Intervention Programme (home/school) Agree timescale for implementation/review

ASSESSMENT MEETING OUTCOME (n = 20) Diagnosis for ADHD not probable (n = 12)

Diagnosis for ADHD probable (n = 8)

Agree Action Plan and set review date Stage III Code of Practice (Responsibility SENCO/School EP) (no further action)

Proceed to Level One Intervention

LEVEL ONE INTERVENTION (n = 7) Durat Duration: ion: 4 weeks. Co-ord Co-ordinated inated by Ke Keywork yworker er (EP or BST) IMPLEMENTATION STRATEGIES HOME/SCHOOL  –  –

School staff Inset on ADHD Keyworker to support school staff on a fortnightly basis

 –  –  –  –

Staff/parent handout on ADHD Keyworker – 2 sessions with parents (to suppo support rt home programme) pro gramme) Keyworker – 2 sessions individual cognitive behaviour counselling counsellin g School staff member – 4 sessions with child social skills work NOTE: NO MEDICATION A AT T THIS STAGE

LEVEL ONE: REVIEW (n = 7) MEMB ME MBER ERSH SHIP IP::

Par aren ents ts/S /Sch choo ool/ l/K Keywo eywork rker er (EP/ (EP/BS BST) T)/P /Pae aedi diat atri rici cian an

PURPOSE:

– Share infor mation  – Evaluate intervention programmes home/school ho me/school  – Agree way forward Proceed to Level Two Two Intervention Programme

Modify Level One Intervention Programme Continue at Level One (i.e. no medication) Agree timescale for next review

(n = 5) (n = 2) LEVEL TWO INTERVENTION (n = 5)

(a) (b) (b) (c (c)) (d)

Continue sc school m ma anagement iin nter ve vention Cont Contin inue ue hom home em man anage ageme ment nt inte interv rvent entio ion n (co (co-or -ordi dinat nated ed by Ke Keyw ywork orker er in co cons nsul ulta tati tion on with with school and parents) and  Pr Prop opos osed ed tr tria iall of of m med edic icat atio ion n ((co co-o -ord rdin inat ated ed by cons consul ulta tant nt pa paed edia iatr tric icia ian) n) Monitoring  – agree strategies for close monitoring monitor ing (co-ordinated by keyworker)  – set review date (4 weeks after Level Two Intervention)

MEMBER MEMB ERSH SHIP IP:: PURPOSE:

LEVEL TWO INTERVENTION REVIEW to be conducted after 4 weeks (n = 5) Sc Scho hool ol/K /Key eywo work rker er/P /Par aren ents ts/C /Chi hild ld/P /Pae aedi diat atri rici cian an – Share infor mation  – Evaluate intervention programme  – Agree outcome  – Set review date

Return to Level One (i.e. no medicat medication) ion) (n = 0)

Remain on Level Two (i.e. continued use of medication) (n = 5)

*EP – Educational Psychologist; Psychologist; BST – Behaviour Support T Teacher eacher.. The findings of the pilot project will be presented in terms of the  model adopted and implications for future practice.

72  

Educational and Child Psychology (1997) Vol. 14 (1)

 Aspects of the assessment process a) An infor informal mal inter interview view with tthe he child’s par parents ents unde undertaken rtaken at tthe he family hom home, e, and use of  three different types of ratings of child's behaviour: i) Ch Chil ild d Beh Behav avio iour ur Ch Check ecklis listt (CB (CBCL) CL) – ((Ac Ache henb nbac ach h & Ede Edelbr lbroc ock, k, 19 1991 91). ). ii) Con Conner nerss P Par arent ent Rat Rating ing Sca Scale le (CP (CPRS, RS, 48) – ((Goy Goyett ettee et al., al., 1989). iii) A DSM DSM-IV -IV rrelat elated ed ch check ecklist list (dev (devised ised by th thee tea team m for the p pro rojec ject). t).  b) An informal interview with the child's class teache teacherr undertaken at the child's school, and use of three different types of ratings of the child's behaviour: i) CB CBCL CL – T Tea each cher er Re Repo port rt Fo Form rm – ((Ac Ache henb nbach ach & Edel Edelbr broc ock, k, 1991) 1991).. ii) Con Conner ners' s' T Teach eacher er R Rati ating ng S Scale cale (CT (CTRS, RS, 39) – (G (Goye oyette tte et al., al., 1989). iii) A DSM DSM-IV -IV rrelat elated ed ch check ecklist list (dev (devised ised by th thee tea team m for the p pro rojec ject). t). c) An infor informal, mal, brief in intervie terview w with th thee child under undertaken taken at th thee child's scho school ol or hom homee and use of child self report questionnaire (devised by the team for the project). d) A stru structur ctured ed direct obse observatio rvation n of the child, involv involved ed in two differ different ent classr classroom oom activi activities. ties. These were a standardized observational drawing session and either a short wordsearch or dot-to-dot activity activity,, depending on the age of the class. (Using the CBCL – Direct Observation Form: Achenbach and Edelbrock, 1986.) e) A general m medical edical exa examinati mination on of tthe he child an and d stru structur ctured ed inter interview view wi with th the ch child's ild's parents.

Results The assessment evidence for each child was collected and analysed by the project team during assessment meetings which culminated in a consensus confirmation of the likelihood of  the presence of ADHD, made on the basis of the accumulation of sufficient indications of  ADHD from the various assessment aspects. The decision was loosely based on the criteria for the disorder's classification in DSM-IV (APA, 1994), but was influenced by the wider information obtained from the multi-professional, multi-dimensional assessment. The diagnosis of ADHD was made in eight of the 20 cases where high scores were obtained on the CBCL Child Behaviour Checklist and T Teacher eacher Report Form (Ach (Achenbach enbach & Edelbrock 1991), DSM-IV related checklists and classroom observation. In the other 12 cases where the diagnosis of ADHD was not made, the profile of results across these instruments did not score consistently highly across contexts.

Table 2. Age/school year

R

1

2

3

4

5

6

Total

Diagnosis

yes

1

2

1

3

0

1

0

8

Diagnosis

no

0

2

4

1

2

1

2

12

73  

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

Table 3. Referrer

ADHD diagnosed

ADHD not diagnosed

Health Education

Male 4 1

Male 8 3

Total

Female 1 2 8

Female 1 0 12

Table 4. An overview of the assessment data leading to diagnosis or not of ADHD ADHD Diagnosis probable Yes response

ADHD Diagnosis not probable

?

No response

Yes response

?

No response

CBCL Parent Scales (high scores)

7

0

1

9

0

3

CBCL Teacher Scales (high scores)

6

0

2

3

0

8**

Conners’ Parent Scales (high scores)

6

1

0*

4

0

1**

Conners’ Teacher Scales (high scores)

3

1

0*

3

0

2**

DSM-IV related Parent Checklist

8

0

0

6

0

6

DSM-IV related Teacher Checklist

8

0

0

3

0

8**

Classroom Observation

5

0

1*

4

0

6**

Parental inter view suggests problems

5

3

0

2

7

3

Teacher inter view suggests problems

5

3

0

2

2

8

Medical repor t

4

0

4

10

0

2

Child self-repor t

4

0

4

1

3

8

Y = suggest ADHD; ADHD; N = does not sugge suggest st ADHD; ? = suggests possible possible ADHD ADHD.. *Totals *Totals <8 because of incomplete data. **T **Totals otals <12 because of incomplete data.

Discussion In each case, the evidence from the CBCL parent and teacher rating scales, together with the DSM-IV checklists completed by both parents and teachers, appeared to provide the most useful data for deciding whether there were sufficient indications of ADHD to warrant this diagnosis or not. The The CBCL data provided parental and teacher rat ratings ings of child behaviour across a range of possible problem areas for which normative, standardized information was available. Ratings from both informants were compared both with standardized norms and each other to determine the severity and setting-specificity of problems. It was also useful to have the direct comparison of the target child's scores with those of a control child from the same class, where available, on the teacher CBCL. It was considered vital that these ratings were obtained in conjunction with face-to-face parent and teacher interviews, since these provided opportunities to enquire and form impressions, albeit subjectively, about familial, developmental, medical, environmental or other factors in each child's history which might influence their behaviour. Such evidence provided valuable insights in several instances, where informants' motivation for assessing children's

74  

Educational and Child Psychology (1997) Vol. 14 (1)

 behaviour in certain ways were of concern. The aims of performing a medical physical examination were two-fold, to exclude relatively rare recognizable conditions such as Fragile-X Syndrome which might be associated with problems with attention and hyperactivity and to identify co-morbidities which might be adversely affecting the child, for example, hearing problems. As well as taking a medical history the consultant community paediatrician usually also requested that the parents completed a Conners' Parents Rating Scale, the keyworker being responsible for ensuring that the teachers completed the Conners' Teachers Rating Scale. The Conners' data was found to be useful to aid diagnosis when used in conjunction with the CBCL forms which, containing a wider range of problem scales, were considered mor moree helpful in aiding differential diagnosis. The main advantage of including the Conners as an initial assessment instrument, is that it provided a very useful baseline measurement when examining the effect of stimulant medication on behaviour of children with ADHD who progressed to phase 2 (Burcham & DeMers, 1995). Classroom observation data appeared to have little influence upon decisions made due to concerns about the reliability, reliability, validity and ssubjectivity ubjectivity of the data, des despite pite the team's attempts at standardizing the instruments and procedures. Nonetheless, this informed the team's sub jective impressions of the children concerned and helped to provide contexts for the concerns of other informants. Where such data were unavailable, decisions were made less confidently than when data were available. The child self-report data also had little influence on the decisions made, due again agai n to concerns about the validity and reliability of the instrument and procedures. However, the administration of this instrument went at least some way to acknowledging the child's views, in keeping with the Children Act (Department of Health, 1989) and additionally, additionally, provided insights into the possibility of significant learning d difficulties ifficulties in some children, which were occasionally influential in reaching a diagnosis.

Intervention phase  Intervention Level One Eight pupils were assessed as showing sufficiently significant symptoms of ADHD, both at home and at school, to be taken forward to the next phase of the project. In fact, one of these pupils was not included in the intervention results. His behaviour had become so problematic that he had been given medication before the assessment phase of the project was completed. The remaining seven pupils were then offered an intensive intervention programme over the next term. Keyworkers visited both home and school fortnightly, offering a range of strategies detailed below. (Keyworkers were either educational psychologists or specialist EBD teachers.) Table 5. Age/school year of pupils in intervention phase R

Year 1

Year 2

Year 3

Year 4

Year 5

1

2

1

3

0

1

Range and type of intervention offered by keyworker

75  

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

School a) Classr Classroom oom behav behaviour iour pro programme. gramme. Dis Discussed cussed with an and d carried out by classt classteacher eacher..  b) Lunchtime behaviour programme. Discussed and ccarried arried out by sschool chool meals supervisory assistants. c) Social sk skills ills tar target, get, e.g. playing a sim simple ple boar board d game with o others thers.. Discuss Discussed ed with an and d carried out by teacher, or delegated by teacher to another adult. d) Indivi Individual dual child sessio sessions, ns, using a range of cognitive cognitive behavi behavioural oural cou counselling nselling skil skills. ls. e) Talk and h hand-ou and-outt on ADHD to all scho school ol staf staff. f.

 Home a) Develop Developing ing an individu individual al beh behaviour avioural al pr program ogramme. me.  b) Improving parental management skills, for example: —Focusing on positive behaviour behaviour.. —Giving immediate positive feedback (plus low level negative consequences/reminders consequences/reminders). ). —Specific techniques in how to give instructions. —Handling refusals to comply comply.. —Dealing with the situation when tasks are not accomplished. Use of ‘what happened?’ rather than ‘why did you do that?’ c) Gen Genera erall sup suppor portt an and d cou counsel nselling ling.. d) Inf Inform ormatio ation n on ADH ADHD. D. After four weeks, progress was reviewed with school, parents and community paediatrician. A decision was then jointly made as to whether to move to a Level Two intervention which involved psycho-stimulant medication.

Level Two intervention – four weeks All the other behavioural and cognitive interventions begun at Level One were kept in place during this Level Two phase but psycho-stimulant medication (Methylphenidate) was introduced. Visits continued fortnightly and a close track of changes in behaviour was kept both at school and at home. At the end of this phase progress was assessed by: a)  b) c) d)

Giving a seco second nd Ach Achenbach enbach Ch Checklist ecklist to bo both th pare parents nts and teac teachers hers to com complete. plete. By collecting ev evidence idence from teachers' and parents' comments. By th thee re result sultss of be behav haviou iourr cha charts rts.. By observi observing ng changes in cl classro assroom om or famil family y enviro environment nments. s.

Table 6. Results of behavioural interventions level 1 (pre-Methylphenidate) (measured by teacher comments and behaviour charts) School Pupil Child Child Child Child

A B C D

Ch hiilld dF E C Child H

Classroom

Playground

Home

1 0 0 0

0 0 0 0

1 1 1 1

2* 0 0

2 0* N/A

1 1* 1

76  

Educational and Child Psychology (1997) Vol. 14 (1)

Key: Ke y: 0 = no effect; effect; 1 = some some effect, effect, not not consistent, consistent, or limited limited effect; effect; 2 = good good effect; effect; * = short-term  short-term  effect only 

Discussion on effectiveness of various interventions Level One Intervention . Behaviour programmes almost no effect any of  Behavioural interventions these pupilsinterventions. (except one) in school. modification This may have been partlyhad because three of theon teachers in the project felt they could only give very limited time to setting up a programme as they were in the middle of Key Stage 1 SATs. Interestingly, these children also proved the most highly resistant to star charts etc. There was also some disruption of staffing in these classes during the SATs SATs period. One teacher refused to do anything more than her normal classroom practice as she did not believe in ADHD, and one struggled on with very patchy success. Another teacher, teacher, in a Key Stage 2 class with older pupils aand nd no SA SAT Ts carried out a model programme with equally model results. However these were only short lived and other emotional factors began to emerge which cast new light on this particular pupil’s behaviour. Social skills targets – playing simple board games with others. others. These were tried by all teachers and provided a useful way of viewing some of the social difficulties that pupils had. They were very helpful when used by keyworkers who could then observe and comment on the social interactions which went on, using these in a subsequent individual, cognitive behaviour session with the project child. All children made progress in coping with turn taking, rules, failure and success, but it must be noted that many of the project children were young and would not necessarily be expected to have mature behaviours in this area. Individual cognitive therapy. therapy. What emerged most tellingly from this approach was the sheer weight of poor self-esteem which these pupils carried with them. Several of them were highly intelligent, articulate and perfectionist, hating failure of any kind and themselves because they felt they were failures. Two of the boys talked about the need for control being linked with physical strength and therefore dominance in the playground. This low self esteem and worries about failing were not always evident to the teachers as the boys' unmanageable  behaviour successfully masked their feelings. Uncovering this, and reflecting it back to the teaching staff was perhaps one of the most valuable of the interventions.

Home visiting Behavioural interventions at home At home, behavioural programmes generally had good effect but by their very nature dealt with very limited behaviours and parents felt they were not progressing because they were able to effect only the tip of the iceberg. Their energy for carrying out such programmes did therefore wane during the course of the intervention.

Counselling  What parents and carers most seemed to want was someone to talk to, with a listening ear, empathetic, and supportive. Almost none of the families seemed dysfunctional. If anything they were highly structured. In these circumstances the giving out of unconditional, positive regard by the keyworker became very important since most of the project parents felt that

77  

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

they were being blamed by the school for their child's bad behaviour. By telling them, after several visits, that we could not pinpoint any a ny particular reason or method of bringing up their children which would account for the severity of the behaviour, was often cathartic. One of the most practical results of the project was seen through advice we gave ga ve on clubs and societies in the area which the project children might join. As a result of this two children have  joined clubs outside sschool, chool, have been successful and have therefore begun to develop their social skills outside the realm of home and school.

Level Two intervention Of the seven pupils on Level One interventions, two were not moved to Level Two. One girl 'E' made very good initial progress with behavioural intervention schemes but this was short lived. This was the pupil where other emotional factors began to emerge. One boy 'F' was found, after further assessment, to have complex learning difficulties. Both pupils actually continued to have attention problems but in both cases it was felt that other factors were contributing to this and to their behavioural difficulties. Caution was paramount in all our decisions regarding Methylphenidate and medication was only agreed in cases where there seemed to be no plausible explanation for the pupil's behaviour. Five pupils from the original 20 therefore commenced a Level Two intervention.

 Main changes in behaviour at Stage 2 (post-Methylphenida (post-Methylphenidate) te) In two cases the change of behaviour during the Level Two intervention following Methylphenidate was quite dramatic. Boy 'C' had the most noticeable change. The teacher looked a different person. She described how he was now the first to finish his work, how she could now rely on him to take a message to another part of the school, how there was no need for a daily behaviour chart but simply verbal encouragement. At home, his older sister, charged with taking her brother to the Saturday cinema show, show, described how she had to keep feeling him to make sure he was there because he was sitting so still. Nor did he seem lethargic and unaware. His teacher described his quiet but active listening to others during a 30minute circle time discussion. At home, though he remained lively, his mother found him more controllable. At At school he was able to work co-operatively in a g group, roup, and function academically to his potential. Boy B' showed similar marked improvements, though not in all areas. In three other cases the results were more mixed. Child ‘A’ had short periods of very improved behaviour followed by problematic weeks. He had however shown sustained improvement at lunch times. His dosage of Methylphenidate was still under review. Child 'D' and Child 'H' showed no really remarkable changes in behaviour at school but their parents noted a num ber of signi significant ficant change changess at home. Child 'H' was the oldest of the project pupils and was able to offer a more mature reflection on the use of psycho-stimulant drugs. She played a significant role in monitoring the effects of the drug. She felt that Methylphenidate enabled enable d her to think better, and to be able to sit still and allow her body to relax – a condition she could not remember experiencing before the drug treatment. Child 'D' improved significantly in memory and attention skills. In real terms this meant that he was able to sustain a conversation beyond one exchange, and to string more than two or three words together to express himself. His parents also noted that he had begun to be able to take in instructions and benefit from their instruction. He had shown a vast improvement in his ability to be

78  

Educational and Child Psychology (1997) Vol. 14 (1)

successful with items of school work they were giving him to do at home, and to build on his learning by remembering the previous step. They had been able to take him to a pizza parlour for lunch and to feel relaxed throughout the meal. All this for them was momentous. Table 7. Results at Level Two (post-Methylphenidate) (measured by teacher comments and behaviour charts) School Pupil Child Child Child Child Child

Classroom A B C D H

1➔2 2 2 0 0

Playground 2 2 2 0 N/A

Home 1 2 2 2 2

Key: Ke y: 0 = no effect; 1 = little effect, effect, not consistent, consistent, or limited effect; 2 = good effect 

Summary of key findings  Findings 1. That a mor moree compre comprehensive hensive as assessment sessment p proto rotocol col may lead to fe fewer wer child children ren bein being g diagnosed as having ADHD. 2. That a more compreh comprehensive ensive coll collaborative aborative assessment p protoc rotocol ol involv involving ing par parents, ents, community paediatrician, schools and psychologists led to improved partnership with professionals valuing and stating a preference for multidisciplinary team decision-making. 3. For tho those se childr children en diagno diagnosed sed as AD ADHD HD that cog cognitive nitive an and d behaviou behavioural ral inter interventio ventions ns were of only limited value, pre-medication stage.* 4. That the use of psycho psycho-stim -stimulant ulant medi medicatio cation n (Methy (Methylpheni lphenidate) date) comb combined ined with cognitive/behavioural intervention across contexts (home and school) brought about significant improvements in behaviour for some of the sample.* 5. That th there ere is a key ro role le for the consultant consultant communi community ty paediatri paediatrician cian in of offering fering counselling to parents regarding the use of medication, following the Level One phase and to be available to offer regular telephone consultation so that parents can discuss dosage and any worries if the child is prescribed Methylphenidate. 6. That tthe he educat educational ional psy psychologist chologist is well placed to be the case manage managerr for the co-ordination of the assessment process and management of the intervention phase.

Implications for future practice From September 1996, North Somerset will be moving into a further pilot phase where the *It must be noted however that the sample population of children diagnosed as ADHD was small and that the intervention phase and reviews were conducted over a very short time period. These results must therefore be regarded with caution.

79  

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

patch educational psychologist, together with the school and community paediatrician will be responsible for conducting the assessment and programmes of intervention. The assessment protocol will be modified in light of the findings of the pilot and will aim to make the assessment procedures more manageable in terms of time and human resources. Clearly, there are questions to be raised as to how long does it take to undertake a really thorough diagnosis and what constitutes ‘a good enough assessment of ADHD’. What are the implications for everyday practice? It is hoped that the next phase of the pilot will go some way further in addressing these questions. In terms of intervention, how useful is the label ADHD from which to begin a problem solving approach as an ordinary patch educational psychologist responding to a pupil's difficulties. The research has shown that such a label can mask other problems of either a learning or social/emotional nature and undervalue the environmental cultural factors. However, many parents and teachers feel validated and supported by the child being diagnosed ADHD, freed from a perceived blame culture. This pilot study due to shortage of resources was unable to follow up and evaluate the progress of the 12 children who were not diagnosed as having ADHD. The responsibility for these children after the assessment phase rested with the school and school educational psychologist at stages 2/3 of the Code of Practice. Any further study will need to evaluate the children for whom a diagnosis of ADHD is not made. The team consultant community paediatrician stated that had he followed his preceding pracprac tice, working in a more professionally isolated way, rather than as a member of a multidisciplinary team he would probably have diagnosed most of the 20 cases as having ADHD. The significance of this phase of the project is thus to raise awareness of the need for comprehensive assessment and the involvement of professionals of several disciplines in this process which is not merely co-operative but collaborative (Cooper & Ideus, 1995). The pilot serves as an example of reasonably successful inter-professional collaboration, in which a consultant community paediatrican worked jointly with the educational psychology and behaviour support services to achieve a more comprehensive and satisfactory local assessment protocol for childhood ADHD. Certainly, the pilot provides support for the findings of previous research (Cohen et al., al., 1994) which suggests that prevalence of ADHD varies, depending on the clinician's diagnostic perspective and that the more comprehensive the assessment protocol, the fewer children are diagnosed as having ADHD. However, within the United Kingdom the situation with regard to the referral, assessment and diagnosis of ADHD is still very variable and the practice and interest of the team consultant community paediatrician is not necessarily reflected nationally. What is important is that there is an adequate referral system for children presenting with emotional/behavioural difficulties leading to a proper multidisciplinary assessment so that an assessment of need can be made offering appropriate intervention to support children and their key carers across the contexts of both home and school. For some children this will lead to a diagnosis of  ADHD for others it will not, but there should still be an adequate system of response and support. If parents are to have confidence in a more comprehensive assessment protocol where their

80  

Educational and Child Psychology (1997) Vol. 14 (1)

child is less likely to be labelled as ADHD yet is presenting with significant problems, unless they feel that sufficient support is available to address their child's needs the pressure for a medical diagnosis and medical intervention will continue. Despite its limitations and design weaknesses, weaknes ses, the findings of this pilot provide some support for the need for, and illustrates the feasibility of, effective e ffective inter-disciplinary collaboration with respect to ADHD assessment, diagnosis and intervention. While predictable differences of  professional opinion occurred, they were most quickly and satisfactorily resolved, leading to decisions in which the multi-disciplinary team had confidence. It is precisely this kind of collaboration which is overwhelmingly advocated by recent literature; Cooper & Ideus (1995) argue for a proper bio-psycho-sociocultural perspective to be developed and shared by all professions involved in the diagnosis and treatment of children with EBD (p.112); while McBurnett et al. (1993, p.117) conclude that: This important issue deserves the best co-ordinated efforts of mental health and education to come up with adequate but workable solutions. This pilot project was an attempt by North Somerset to go some way towards achieving this goal.

Acknowledgements Ken Fuller has now moved to Devon Educational Psychology Service. Clare Morgado has now completed her training and is an educational psychologist with Croydon LEA. Special acknowledgement should be made to Clare Morgado for her contribution to the pilot and allowing us to draw upon her M.Ed dissertation in the presentation of this article.

References Achenbach, T.M. (1986)  Manual for the child behaviour checklist-direct observation form. form. Burlington: University of Vermont. Achenback, T.M. & Edelbrock, C. (1987)  Manual for the child behaviour checklist – youth self-report. self-report. Burlington: University of Vermont. Achenbach, T.M. & Edelbrock, C. (1991) Manual (1991)  Manual for the child behaviour checklist and revised child behaviour  profile.. Burlington: University of Vermont.  profile American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders (4th edn). edn). Washington, DC: APA. Barkely, R.A. (1990) Attention (1990)  Attention Deficit Hyperactivity Disorder. A handbook for diagnosis and treatment. treatment. New York: Guildford Press. Burcham, B.G. & De Mers, S.T. (1995) Comprehensive assessment of children and youth with ADHD. Intervention in School and Clinic, 30, 30 , 211-220. Cohen, L. & Manion, L. (1994) Research methods in education. education. New York: Routledge. Cooper, P. & Ideus, K. (1995) Attention Deficit Hyperactivity Disorder: Trojan horse or gift horse? In  Attention Deficit Disorder: medical, educational and cultural issues. issues. Maidstone: Association of Workers for Children with Emotional and Behavioural Difficulties. Department of Health (1989) The Children Act. Act. London: London: HMSO. HMSO. Goyette, C.H., Conners, C.K. & Ulrich, R.F. (1989).Normative data on Revised Conners’ Parent and 6, 221-236. Teacher Rating Scales. Journal Scales. Journal of Abnormal Child Psychology, 6, McBurnett, K., Lahey, B.B. & Pfiffner, L.J. (1993) Diagnosis of attention deficit disorders in DSM-IV 60, 2, 108-117. scientific basis and implementation for education. Exceptional Children, 60, 108-117.

81  

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

Getting it all Getting all toge together: ther: dev developing a forum for a multi-agency approach to assessing and treating ADHD D.V. .V. Keen1, J. Olur Olurin in-L -Lyn ynch ch2 and K.V K. Venables3 1Doncaster

Royal Infirmary NHS Trust, 2Doncaster Child and Family Psychiatric Service, 3Doncaster Local Education Authority

 Abstract This paper describes the process of combining the perspectives of practitioners from the fields of  child medicine, child psychiatry and educational psychology, to develop a multi-agency forum addressing the needs of children with Attention Deficit Hyperactivity Disorder. Doncaster, in common with elsewhere in the UK, has experienced a considerable increase in referrals for  ADHD. Each professional group had begun separately to consider the implications of this trend  for its own and other oth er services. This pap paper er describes the attempt of some of these professionals to draw together separate practice into a more unified whole within an ADHD Forum. We do this by discussing some of the difficulties we came across, outlining the current shape that the multiagency initiative has taken and speculating as to the Forum's future development. We address the many issues that arise from working together, having discovered more questions than answers in the initial months. We are clear that there is a considerable amount of learning to do; simply writing this paper has led to the answering of some important questions, questions that have arisen because the different professions operate separately most of the time.

Why do we need to work together? ADHD is by definition a pervasive disorder that touches every aspect of the child's life (Reason et al., al., 1996). Affected children with their high incidence of other associated difficulties (including global and specific cognitive disabilities, problems of motor motor contr control, ol, conduct and emotional disorders and social interactional difficulties) have a disorder that not only constitutes a personal ‘handicap’ but is particularly notable in causing secondary dysfunction in the child's educational, family and social domains. This pervasiveness very often results in various different professionals being asked to helpmanage different problems in different different settings. A study of a cohort of children att attending ending the Doncaster Child Development Clinic (Keen et al., al., 1996) illustrates the problem. At initial presentation ADHD children had, on average, two or three associated difficulties (range 0-5 per child), two other actively involved professionals from health, education or social services (range 0-5 0- 5 per child) and been known to at least one discipline within the entire children's health and educational services for approximately half of their lifetime before the diagnosis was made.

82  

Educational and Child Psychology (1997) Vol. 14 (1)

The imperative to ‘get it all together’ in ADHD comes not only from the theoretical benefits of multi-professional working but from the practical reality that we are already working with these children separately se parately – often in relative isolation and, apparently apparently,, ineffectively ineffectively..

Why has this not happened before? A multi-professional approach tto o ADHD ADHD assessment, diagnosis, intervention and treatment should be the basis for a streamlined ‘seamless’ service. So, why has it not happened before?

Organizational and professional barriers Health and educational organizations have evolved from separate institutional bases, each with different roles and relationships to individuals, client groups and statutory processes. Within each organization, professional groups have emerged and in turn have created their own identity, culture and philosophy. The fear of losing hard won professional identities by sharing skills is familiar to those working in multidisciplinary teams. Traditional professional isolation encourages misunderstanding of other professions' p rofessions' ways of  working and mutual suspicion. It feeds the assumption as sumption that other organizations and its mem bers are static and unresponsive to outside pressures. 'W 'Wee can't work with them – they only use a medical/behavioural/psychodynamic etc approach.' There is a common misunderstanding in both educational and clinical circles that ADHD is a simplistic one-axis diagnosis. Educationalists Educationalis ts may be reminded of power struggles of the past and fear a revival of the previous dominant role of the medical profession in defining disability groups (and hence educational needs). needs ). Clinicians recall more recent constitutional vs environmental debates about the aetiology of mental illness and fear returning to 'simplistic' explanations of human behaviour. Working in an atmosphere of scepticism can encourage retreat into more comfortable familiar systems. Many health professionals work in relatively closed close d systems where assessment and a nd treatment tends to exclude educational factors and focuses on individual problems and family dynamics. Traditional Traditional hospital and clinic p practice ractice tends to draw lines around itself, creating a self sel f sufficiency that makes multi-agency work seem irrelevant and unwieldy. Concerns about medical confidentiality are not necessarily justified and can hinder valuable communication  between doctors and educationalists educationalis ts or social workers. True collaborative working can involve reappraisal of dearly held beliefs and assumptions. It may mean revisiting historical inter-agency disputes and antagonisms arising from issues drawn up years ago such as budgets, a poorly managed manag ed case, responsibilities, a breach of confidentiality and even personalities no longer on the scene. Each professional group is currently experiencing a surge in referrals of children with behavioural disorder. Establishing a more effective practice is essential if only to cope with the volume, but breaking out of existing patterns of work and departmental routines involves time for reflection. As workload pressure increases this becomes more and more difficult and it may be easier to continue in established patterns. Educational psychologists' workload pressures create a conflict between preventative inter-

83  

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

ventions with parents and teachers and working directly with children on the one hand and, statutory interventions relating to Statements of Special Educational Need on the other. This results in being less able to respond to requests by other agencies to address needs that fall outside the remit of statutory work. Where lines of communication are poor, the lack of  response may be interpreted as unwillingness to co-operate.

Systems barriers Organizational systems and arrangements can militate against joint working. For example, whether the special needs budget is centrally held or devolved to schools affects the autonomy of services like the specialist support teaching team. In Doncaster, if schools want help from this team for non-statemented children with emotional and behavioural difficulties, they must fund it from their own budget. The 1993 Education Act and its accompanying Code of Practice define many of the relationships within education and with other professional groups. Although this legislation encourages multi-professional working, there are no institutional systems described in SEN law that allows the development of avenues to make this happen apart ap art from ‘regular contact’ between a ‘designated officer of the health authority and a designated officer of the education authority’ (DfE, 1994)). There is a need to develop local networking patterns at practitioner rather than office level to create a culture of joint working. In fact, in the absence of established local multi-agency networks, schools have no option but to seek solutions to difficult behaviour just through educational channels even though early collaborative working with clinicians might be more effective. In conditions like ADHD, this may be co counterproductive. unterproductive. This has been experienced locally when Pupil Referral Units are called upon to deal with children with a variety of conditions from a purely purely educational perspective. A clinical referral is considered only when the the child once again fails in this setting, by which time because of the statutory limitations on the time spent in PRU's, the continued use of this potentially valuable resource for multi-agency treatment is denied. However, defining the point at which external specialists are consulted is problematic. The logistics of inviting in external specialists are complex and, as shown by Lewis et al. (1996), are often unwieldy and unsuccessful. Local agreement on using such inter-agency consultation for children with emotional and behavioural difficulties, requires a district-wide dissemination of  information about the nature of these difficulties, their assessment and referral patterns.

Parent/professionall barriers Parent/professiona A new arena for conflict has emerged with the apparent role rreversal eversal between parents and professionals over the issue of diagnostic labelling. Organized parental pressure has been a significant factor in the past in influencing clinical and educational professionals to move away from defining categories of handicap, abandoning the stigmatizing labels previously used in the area of special needs. Parents are now demanding diagnostic labels for children's unusual difficulties. There are a number of reasons for this change in parental expectation – a label is helpful in not only being

84  

Educational and Child Psychology (1997) Vol. 14 (1)

able to conceptualize or externalize a problem as a disorder but also in finding further information and sources of support. Parents find the genetic and familial associations of defined developmental and behavioural disorders helpful and this can free them from the guilt of a 'bad parent' label. Moreover, a label can empower parents in their search for resources. Here, diagnostic labelling can create tensions between educational and clinical colleagues, particularly if clinicians are perceived to be making diagnoses that demand significant additional educational resources, like a Statement. In ADHD the imposition of a medical diagnosis on a system that sees the problem in behavioural terms can polarize professional positions and act as a catalyst for creating high levels of conflict between parents and educational bodies.

 Moving on ADHD, as a problem common to all professional groups, has set up complex and interesting resonances within and between the professions. Because it is a 'bio-psycho-social' phenomenom, it both challenges conventional styles of working and presents new opportunities. It can  be seen either as threatening or stimulating d depending epending on persp perspective. ective. We feel it is a window of opportunity for each discipline to reappraise its relationship with and contribution to the work of others. In doing so, we can develop new styles of collaborative working in assessment and treatment. In this way we can begin to focus attention on the needs of children and their families rather than on the needs of the system.

Working towards working together  Addressing the organizational barriers An initial meeting was called by the consultant paediatrician (who was the lead clinician for the community child health services and child development centre and the designated officer for the health authority) between the heads of services for clinical psychology, educational psychology and teaching support services. The purpose was to explore differences in perception of and response to ADHD, promote awareness of the problem as it affected the clinicians, and begin a dialogue about the implications for associated professions. It was expected that this would be a difficult and delicate process. However, all the participants accepted that ADHD was here to stay and a response from each service was necessary. Agreement was reached that key professionals within each service would be supported in exploring ways of beginning to work together. This resulted in the first meeting of a multidisciplinary group with a remit to work together to create a Forum for managing children in our common care. This included consultant paediatrician, clinical psychologists from the child development centre and child and family psychiatry, educational psychologists and specialist teaching support service for emotional and  behavioural difficulties. Our initial thoughts were whether we could have arrived at this stage if the pae paediatrician diatrician had not been committed to the process. This raised questions about relative positions of power within the organizational system and a key task was for each of us to enlist sufficient management support to be able to develop our project with a degree of autonomy.

85  

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

 Addressing the professional divide We initially addressed the question of who owns the diagnosis of ADHD and who can offer help in treating it. We agreed that each profession had a valid but separate role and we needed to combine our skills to ascertain whether the cause was psychiatric e.g. emotional disorder; developmental e.g. autistic spectrum disorder; psychological e.g. behavioural learning problem; or educational e.g. an inappropriate curriculum, poor classroom management, lack of whole school policies. We found we shared an understanding that ADHD is multifaceted and treatment was most likely to succeed if it was multi-modal. This was the basis of us finding common cause with each other and deciding to explore possibilities of joint working. In this sense, we have been fortunate that our professional perspectives overlap. Others, for example those with a strong  behavioural or medical focus, might not have arrived at this conclusion. This compatible outlook has enabled us to establish a high degree of mutual trust which has meant we have shared quite openly areas of professional uncertainty and inexperience about assessment, treatment and outcomes. Having survived this process intact we progressed to share perspectives on the causes and explanation for attentional disorders, revisiting current and historic terms such as ADHD, ADD, hyperkinetic disorder, minimal brain dysfunction and their relationship with other disorders and syndromes e.g. autistic spectrum disorders, dyspraxia and specific learning disabilities. We We were surprised to find that these terms and others in common use, such as diagnosis and assessment, treatment and intervention could have different connotations for different professions. Opening up these areas for discussion at an early stage enabled us to 'clear the air' and increase sensitivity to each other’s perspectives. Although we agreed the role of the clinicians in diagnosis it became obvious that to be able to work together we needed to agree on a basis of diagnostic rigour. This has resulted in close examination of ICD 10 and DSM-IV criteria and their implication and agreement to adopt DSM-lV as something we found appropriate across professional boundaries. This helped to clarify how severe or pervasive the problem needs to be in terms of personal pe rsonal handicap or family and classroom disruption before a diagnosis was made, and formed the basis of a common agreement for us to work within a multi-agency framework. This was felt to be a prerequisite for standardizing the service given to families and to allow the child with the diagnosis to pass freely through the system without re-diagnosis at each point. It was particularly helpful for each discipline to be able to clearly state what each service needed from each other, what each service was able to offer each other and perhaps, most importantly, what each service was unable to offer in terms of resources, time, assessment and management. We had to acknowledge that different professions are exposed to different populations, and particularly that educational psychologists are presented with 'raw' problems whereas paediatricians are referred a selected population which has gone through several filters. This has considerable implications for individual workload and ability to provide a response. We also considered aspects of service similarities and differences that might facilitate or impede joint working, for example, the proposed restructuring of referral systems in the child

86  

Educational and Child Psychology (1997) Vol. 14 (1)

mental health services. Clinicians had to learn the difference between a 'statutory assessment' and a Stage 3 intervention defined in the Code of Practice. Further, we had to all agree that the LEA needs criteria on which to base its decision to make a statutory assessment and these must be educational criteria. The process of gaining insight into each other’s services and problems emphasized the absence of other key services and individuals from these initial discussions. This resulted in the inclusion of a wider circle of people such as, for example, the special needs inspector, senior nurse in Family and Child mental health, social worker from the children's health and disability team and in the near future, we would like to involve the Education Welfare Service, Youth Justice (particularly as they have now being encouraged to work with younger offenders) and community police services. This second absorption of people set up its own dynamics and to those of us involved from the start, it did seem like starting all over again. However the benefits have outweighed the disadvantages, with a wider network of services now sharing our perspective and offering support through their agencies. Bringing the issue of ADHD into the wider community has highlighted a need to di disseminate sseminate information and create a common knowledge base in the district. This also a lso has been a catalyst for beginning to tackle the immense problems around interdisciplinary training and access to protected time and funding.

 Addressing problems between parents and professions We were aware that increased activi activity ty could threaten to overwhelm our own and each other other’s ’s services, and considered the implications of various responses to the expected pressures from parents, school teachers, GPs and others. We struggled to find a balance between requiring a child to 'jump through many hoops' before a diagnosis be made (protecting the professionals) and reducing the frustration of needing multiple assessments before a diagnosis was made (protecting the child). Having previously agreed on common criteria, we were happy to agree that the child had a right to a rapid diagnostic process. An early major issue centred around the flow of information with the educationalists expressing frustration at being unaware of the work of the clinicians and vice versa. Having considered issues of confidentiality, we concluded that we could satisfactorily deal with this potential problem by obtaining parent agreement on patterns of information flow at the beginning of assessment. Besides facilitating information flow, this has significantly helped to cement relationships between parents and agencies by making clear at the outset that all the agencies are engaged in a joint venture in addressing the child's needs.

 Moving on There is now a willingness on the part of educational psychologists to attempt to match the advice given to parents and teachers on assessment and treatment of ADHD to that given by clinicians. There is now an explicit reference to educational psychologists in Statements where ADHD is mentioned, in setting up the behavioural programmes and monitoring children's p progress rogress at least termly. termly. The teaching support service are not only playing a part when children have Statements but

87  

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

also hope to offer attention training programmes and advice ad vice on behaviour management when asked by schools. The clinical psychologists offered to aid diagnosis by observing children in various settings and an ADHD parent group within the Family and Child mental health team was established. The Group uses didactic and cognitive behavioural approaches to teach parents about their child's disorder, and learn methods of managing and coping emotionally with conduct disord isordered behaviours. Through invited speakers from education, parents are encouraged to help their child by developing positive attitudes working with schools. The consultant paediatrician offered to assess ass ess and manage cases that were referred to her, initiate and monitor medication when appropriate, and undertake research in monitoring treatment and outcomes. To do this, an ADHD database linked to a district child health register has been established. This will be able to track individuals within a complex interprofessional network and to provide information on the working of the system as a whole. The database acts as a register of children with ADHD. Through it, relevant professionals can  be informed of children under tr treatment. eatment. Int Interest erest has been shown by other agencies, for example, social services and education special needs department, and anonymized information of  the treatment group e.g. age range, schools and units, exclusions, will enable services to be aware of the overall situation. An agreement to share information has influenced our working practices, with clinical assessment now regularly proceeding hand-in-hand with teacher and educational psychology observations or reports. Similarly, clinical consultation results in information to educational personnel about diagnostic and treatment intentions. An added advantage of this is that we can prevent parents being given contradictory messages and one profession inadvertently undermining another another.. This has had the result of actively enlisting the participation and co-operation of school teachers in providing high quality classroom observation to assist evaluation and response and in administering medication in school. So far, no school has raised serious objections or obstacles and many have enthusiastically responded with provision of extra support or extended periods of tolerance during trials of interventions and treatments. An unexpected but welcome bonus has been that referrals by educational professionals to clinicians are often accompanied by carefully completed behavioural rating scales or DSM-lV criteria enabling the clinical assessment process to be more focused and concise. The agreement to disseminate information has led to a collective decision to organize a multiagency/disciplinary training day to develop deve lop common understanding of ADHD, management approaches, referral pathways and treatment programmes. This is linked to a further project of developing information pamphlets for specific professional groups e.g. GPs, teachers, social workers to help professionals develop skills that dovetail together.

88  

Educational and Child Psychology (1997) Vol. 14 (1)

Developing a service through the forum We have attempted to construct a model of service delivery that is compatible with local service provision and the cultures of both health and educational processes, combining professionals currently working in a network into a core team within a Forum. The role of the ADHD Forum is three-fold. Firstly, it provides an assessment and treatment service. Secondly, it creates a central liaison point to overview and co-ordinate needs and treatment packages, assisted by the database which will monitor the child's symptoms and associated problems, interprofessional liaison, effectiveness and outcome of treatment. Thirdly, it provides outreach services to parents and professionals at every level to ensure a child can move effectively through the different facets of educational and clinical services. Active use of the database will enable the Forum to monitor the child’s symptoms and associated problems, interprofessional liaison, effectiveness and outcome of treatment and the progress of each individual through the treatment programme. In this way we can ensure agencies are working with the knowledge of each other’s involvement and raise issues of interprofessional debate. For example if a child has been diagnosed as having ADHD, is benefiting from medication and no longer showing signs of behavioural or attentional difficulty, is a Statement necessary? If behavioural programmes at school and home, and Parent Group work are being successful then is medication necessary? This central role can effect a planned response to significant anticipated changes e.g. a trial of  stopping medical treatment when intensive day centre or classroom based programmes are required or integration back into mainstream school. As the Forum represents all key professionals it is well placed to monitor and address potential conflicts that could develop between services, particularly where additional resources may be scarce e.g. respite care or additional teaching support.

Conclusion The recent plethora of media coverage will lead to an increase in awareness and deluge of  requests to diagnose ADHD. The failure of different agencies to work together together,, efficiently and professionally,, could create immense confusion, increase the workload of those professionals, professionally and most important of all, fail to serve the needs of some children and their families. Many questions have been raised in our attempt to work together together.. Do we share a common language and a common understanding? Are we able to clearly define our own roles within our own departments and work out a relationship to each other’s departments? Are we able to ensure that parents, teachers and others who deal with children with ADHD every day are given the same advice by different professionals? Are we able to take decisions that affect each other in a efficient manner? Can we ensure that the focus is not initially on an ‘instant diagnosis’ but instead on advice, programmes and resources which offer support to the child, family and school. Is it possible to ensure ensure that treatment treatment and interventions such as medication, attention training or parent support programme are agreed and progress in a co-ordinated fashion?

89  

Educational and Child Psychology (1997) ( 1997) Vol. 14 (1)

It would seem that there are many areas of potential conflict but working towards active collaboration needs imagination and some persistence. Many questions are left to resolve but our experience leaves us hopeful that we can meet the challenge to ‘get it all together’.

References Department for Education (1994) Code of Practice on the identification and assessment of Special Educational Needs. Needs. London:: HMSO. London HMSO. Keen, D., Underwood, R. & Holden, L. (1996) Unpublished data. Lewis, A., Neill, S. & Campbell, R. (1996) The implementation of the Code of Practice in primary and secondary schools.. University of Warwick. schools Reason, R. et al. (1996) ADH (1996) ADHD: D: a psycho psychologi logical cal re respon sponse se to an an evolv evolving ing concept concept.. The British Psychological Society.

90  

Educational and Child Psychology Guidelines for Authors It would be very helpful to the editors and referees if you could check your article and edit it according to the main principles below.

Title page ◆ ◆ ◆

Title to be justified left in lower case bold. Author names beneath, justified left and lower case, alphabetically by last name. An abstract of between 150-200 words.

Text ◆ ◆ ◆

 Justified left and a nd right. Double line spacing. Quotations set off from text as a block with no quote marks but indented from left. Details of source of quote to be bracketed at end.

◆

Non-discriminatory language to be used.

Headings ◆ ◆ ◆

First level headings to be in bold, lower case and justified left. Second level headings to be in italics, lower case and justified left. Third level headings to be in italics, loweer case, but with text running on, on same line.

References Names in lower case with date in brackets and publication title in italics, eg: Leach, C. (1988) Guidelines for data presentation. In R.J. Sternberg (Ed.) The psychologist’s companion,, pp113-135. Cambridge: Cambridge University Press. companion O’Connor,, M. (1986) O’Connor (1986) How  How to edit scientific books and journals journals.. Philad Philadelph elphia: ia: ISI Pr Press. ess. Lindsay,, G. & Lunt, I. (1993) The challenge of change. The Psychologist: the Bulletin of the Lindsay British Psychological Society, 6, 6, 210-213.

Word count ◆ ◆

Please ensure that at the end of the references there is a word count. Articles should not normally exceed 3,200 words.

Posting the article Please send three hard copies. Please also send one top quality hard copy of all tables and diagrams with headings. Administrative costs and time are kept to a minimum if you also send a DOS formatted 3.5in disk (with your name on it) with the file saved in two formats: ◆ the format of the software that it was produced on (please indicate with a written note); ◆ an ASCII file version. Anyone to submit an Pupil articleand for Parent consideration, to ‘guest edit’ an edition, write to wishing Simon Gibbs, Editor, Services,orThe Council Offices, Scalbyshould Road, Scarborough, N. Yorks Yorks YO13 0RA.

 

DIVISION OF EDUCATIONAL AND CHILD PSYCHOLOGY The British Psychological Society, Leicester, UK