ADHD Psychology, Co-morbidities, and Outcomes – Coursera Class Weeks 6 & 7

ADHD is complex. While defined as an executive function impairment, there are different genes, parts of the brain, brain chemicals, and behaviors involved. We know that certain drugs and behavioral interventions can relieve symptoms of ADHD, yet the medical establishment does not know what combination of interventions will promote optimal functioning in any given ADHD patient. Frequently the best course of action and medication is found through an educated trial and error method. This is stressful for both the child and the family. However, finding ways to manage and treat ADHD impairments is essential. Weeks six and seven in Pay Attention: ADHD Through the Lifespan have focused on the functional impact and complications of ADHD. It has been a bit depressing.

Disorders seen with ADHD include oppositional defiant disorder (ODD), conduct disorder (CD), anxiety disorder, mood disorders (including bipolar disorder, persistent minor depression, and major depression), learning and language disorders, Tourette syndrome, obsessive compulsive disorder (OCD), autistic spectrum disorder, fetal alcohol syndrome, sleep disorders, substance use disorders, and post-traumatic stress disorders.  Whew. The more sever the ADHD, the more likely it is to co-exist with one or more of the above disorders. Parental issues such as depression, low-income, and decreased interest in the child and a deviant child peer group will also increase the likelihood of a comorbid disorder.

Children with ADHD:

  • Are more likely to have learning issues:
    • Speech, language, reading, spelling, math, handwriting, and listening comprehension deficits can all present at higher than normal levels in children with ADHD.
    • Overall, drugs do not correct the learning problems that may be present with ADHD and parents should insist on additional educational help for their ADHD kids with learning issues. Medical interventions can make a child behave better in class but they do not make the child learn more. Specifically, reading, spelling and math issues do not improve with ADHD stimulants although the stimulants may improve handwriting and comprehension. Atomoxetine (Strattera) may sometimes help with reading abilities.
  • Have lower than average intelligence (possibly the result of poor executive function);
  • Are less self-sufficient.

Perhaps due to their initial ADHD-caused difficulties academically and socially, children with untreated ADHD can develop low self-esteem and a type of learned helplessness. They prematurely give up when faced with seeming difficult problems and don’t develop the ability to seek challenges, expect success, persist, and take failure in stride.

The behavioral and cognitive effects of ADHD can cause lifelong issues. 30% to 80% of children diagnosed with ADHD will continue to have symptoms in adolescence and up to 65% will have them as adults. ADHD may just look different as a child grows up. External manifestations such as high activity may decrease, yet internally, inattention and disorganization can persist. The world expects us to develop more and more executive function as we age and this expectation can create real issues for adolescents and adults with ADHD. When key executive functions such as self-regulation, sequencing behaviors, planning ability, organization, working memory, and internalized self-talk are impaired, personal relationships and careers suffer.

Adults with ADHD are more likely to:

  • Have an annual income of less than $25,000;
  • Be high school dropouts or if they do graduate from high school, they are less likely to graduate from college;
  • Be addicted to tobacco and/or use recreational drugs;
  • Be unemployed;
  • Be arrested;
  • Be divorced;
  • Have poor driving records, including revoked licenses, and vehicle crashes;
  • Have poor money management;
  • Have trouble organizing a household and raising children.

The lack of executive function that is a primary deficit in ADHD can cause secondary executive function problems, similar to the learned helplessness created in children with ADHD. These secondary EF problems may respond to coaching and training. People with ADHD can live in the moment and while they may know what to do, they have trouble with execution. Lecturing someone with ADHD or merely teaching them organizational skills is rarely successful. They know what is expected, they just don’t have the internal support to always follow through.

Instead of assuming individuals with ADHD will change their brain wiring and suddenly have organizational skills, it is more effective to “reverse engineer” and externalize executive functions. Technology is making this easier. Smart phones can give time reminders and have nagging due lists. ADHD coaches can help individuals learn how to break tasks into small steps, externalize sources of motivation, and post critical reminders at the point of performance. While drugs are an important treatment component for some people with ADHD, behavior training is essential. Natural settings should be restructured to externalize executive functions and then these accommodations must be maintained.

Given the increasingly high societal and economic cost of ADHD, it is distressing that the current sequester has cut programs for low income children. Early interventions for children with parental support is one of the most effective ways of preventing the negative comorbidities associated with ADHD. Individuals with ADHD have the greatest success when important people in their lives compassionately and willingly help them with their organizational needs. This is only possible if parents, educators, and spouses understand how to best support someone with ADHD.

Modern Education Reform

Our current educational system is not doing a great job of preparing students for the 21st century. We are trying a multitude of solutions to address this issue. From No Child Left Behind (which is slowly being gutted) to a re-envisioning of how technology can serve students such as Khan Academy.

One of the main issues is that there is little differentiated teaching or learning. Students are all introduced to material at the same time and taught it at the same speed, regardless of how quickly or slowly they pick up on each individual subject. Even with high achieving students, sometimes they may get stuck and need a bit of extra time to really understand a new concept. Our challenge is to create an educational system where each student is able to learn at their own pace, speeding through subjects that come easily to them and being allowed to slow down, take their time, and get additional help with the subjects that they find less intuitive. It seems we are slowly moving toward this new educational model.

As one education expert put it, in most schools, “the center of gravity is outside the child. It is in the teacher, the textbook, anywhere and everywhere you please except in the immediate instincts and activities of the child himself. . . . Now the change which is coming into our education is the shifting of the center of gravity. It is a change, a revolution, not unlike that introduced by Copernicus when the astronomical center shifted from the earth to the sun. In this case the child becomes the sun about which the appliances of education revolve; he is the center about which they are organized.”

This would all give me more hope except for one thing. The above quote was from John Dewey, philosopher and professor at the University of Chicago and Columbia University, in his book, The School and Society, published in 1900.


Gifted Kids and Online Learning

Today Ann Treacy with the Blandin Foundation wrote about an update to S. F. 1528: Teachers 21st Century Tools. This bill explicitly encourages students to take online courses and would change the Minnesota Graduation Requirements to include one digital learning course credit.

The bill lays out that the enrolling district must apply the same graduation requirements to all students whether they are traditional classroom students or online learners and must continue to provide nonacademic services to online learning students. The bill also explicitly states that while a licensed Minnesota teacher must supervise the delivery of the instruction to the online learning student, the instruction may include curriculum developed by persons other than a teacher holding a Minnesota license.

This bill seems to open the door for schools and teachers to become far more flexible in meeting the needs of gifted students. Under the bill 50% of the student’s schedule can be online courses and they can be different from the student’s current grade level. In theory, this could give gifted students who are ready to work above grade level in some subjects the opportunity to work at their ability level in all subjects. Students could work with their physical classmates at grade level for some subjects and with their virtual, online classmates and instructors above grade level for other subjects.

The availability of quality online educational programs is skyrocketing and because many of them are self-paced, they can be excellent for gifted students. Ones we have used for homeschooling our gifted kids include Khan Academy, ALEKS, and iTunes U.

All three kids use Aleks for their main math course, supplemented by parent and teachers when they get stuck. Aleks has enabled them to work at their natural pace, frequently completing 2 or 3 grade levels in a single academic year. This type of individualized pacing is virtual impossible in a regular classroom with 25 to 35 kids.

My 10-year-old is taking a biology course through iTunes U. iTunes U courses can include audio, video, textbooks, syllabi, handouts, and quizzes — providing very comprehensive treatments of course subjects. iTunes U courses have been developed by Stanford, Yale, Oxford, UC Berkeley, and the NY Public Library among others. My student finds the iTunes U course more interesting and fulfilling than science at his STEM (Science, Technology, Engineering, and Mathematics) elementary school. iTunes U lets him work at his own pace and the materials are much more detailed than those typically found in 5th grade classrooms. Even in his STEM school, the need to teach to the entire class prevented the teachers from covering subjects with the depth he hungered for.

Online learning can be one of the most effective and economical tools to help all students to reach their full potential.   As funding of gifted education programs continues to far fall below what is needed, it is a positive step for the state to explicitly recognize the value of online learning.