When a child has a language delay, people tend to accept this fact at face value: Joseph is 6 but speaks like a 3-year-old. While understandably upsetting to many parents, no one expects Joseph to speak differently before he is able. There's a scramble to start services and a patient approach while allowing language to develop.
The same attitude does not hold for attention deficit/hyperactivity disorder (ADHD). ADHD is a developmental delay in a broad skill set called executive function. A huge body of research defines it as a medical disorder; neither parents nor children benefit when people suggest otherwise.
Executive function represents our capacity to self-regulate, encompassing everything from focus and impulse control to long term planning, prioritizing, organizing our lives and emotional control. It is required for social interactions and classroom learning. Imaging studies confirm that children with ADHD experience immature brain development, showing again that it's neither a child's fault, nor a parent's, nor society's.
A child with ADHD may be 6 years old but going on 3 when it comes to self-regulation. Often parents hear, or even feel themselves: He's just lazy. He needs to get his act together. He knows better. Yet inconsistency is inherently part of ADHD, with moments of clarity balanced by a perplexing inability to hold it together over an entire day. So he probably does know better -- but without typical executive function, lacks the skills of other children his age to follow up.
Classroom Performance and Executive Function
To address ADHD only as a disorder of attention or hyperactivity also underestimates its impact on education. Impairments in executive function directly affect how children learn. In addition, up to two thirds of children with ADHD have a separate learning disability; according to Dr. William Barbaresi of Harvard, studies suggest that nearly 40% have specific deficits in reading, math and writing. For children to maintain motivation and succeed, individualized planning must take a multi-faceted view of ADHD.
While a common starting point, even the best neuropsychological or educational battery of tests does not fully capture real life. Executive function defines how we live, moment to moment, and is not consistently reflected by testing. Children with average abilities on scores like 'working memory' (the ability to hold onto and manipulate information real time) may still have difficulty in the real world. Testing suggests average skills, and yet they cannot keep track of a list of instructions in their head, or assemble an intelligible essay. More than test scores, an individual's real life experience matters most.
A useful activity for understanding ADHD can be brainstorming all the steps of executive function underlying even a basic task. What does it take to write down daily homework assignments? It requires a strategy for action (having a day planner, for example), paying attention when the assignment is put on the board and prioritizing the act of writing down your notes over any other activity at that moment. And even if you have a day planner, you have to remember where it is, find it in time to use it and track down a pencil as well.
The stress continues, as you must hold the information in your mind long enough to get it on paper while avoiding procrastination or assuming it can be written down later (both prioritizing and holding thoughts in mind rely on executive function). Then you must get the planner back in the correct place in what is probably a chaotic mess in your backpack. And that's only an abbreviated list.
We depend on executive function for activities as simple as getting out the door on time for the bus to complex activities such as planning a long-term project. A high school student of 15 with the executive function skills of a 10-year-old needs to be supported like a much younger student in order to succeed -- it is not a matter of effort alone. We can teach children what they need to know only if we see their struggles as they actually are, a frustrating and demanding developmental delay.
Executive Function and Educational Policy
Many educational choices today put children with ADHD at a further disadvantage. From classroom design to curriculum, schools place huge demands on executive function. These skewed expectations often start in kindergarten, with academic tasks assigned far beyond the development level of an average 5-year-old. Fourth grade classrooms frequently require what used to be a sixth grade level of self-regulation and planning. For a child with ADHD, already years behind peers in this area of development, the gap grows between what is expected and their actual skills.
Children with ADHD benefit from smaller, well-structured classrooms. Classes over the last generation have grown larger, with twenty-five or more students and one adult. Layout is often in desk clusters, with children sitting in a circle. And yet, it is intuitive that it is easier to attend when directly facing the teacher, without your best friend at your elbow and another across the way. Desk clusters lead to distractibility and off-task behaviors. Smaller classrooms that minimize distraction go a long way to helping children with ADHD, as well as all students.
ADHD related deficits directly impair learning, separate from classroom focus or misbehavior. Children fall behind in reading as it requires attention to details, working memory to keep track of information, efficient processing of information and countless other aspects of executive function. One study suggested half of kids with ADHD have writing disabilities; the capacity to organize information and get it onto the page relies heavily on executive functioning. Math is the same, with careless mistakes rampant and multiple executive-function driven steps inherent to solving any problem.
Traditional curricula rely on sustained instruction regarding the basic building blocks for any subject. These techniques are presently out of fashion in mainstream settings. However, if you ask experts in almost any field, they will tell you that we require automaticity of the basics before acquiring advanced skills. You can't play a Mozart sonata without first learning to play the scales fluently.
Many popular programs used in schools today rely on 'experiential learning,' playing down the crucial need for a solid academic base built through routine and memorization. And yet, as recently stated in the journal American Educator:
While experts often thrive without much guidance, nearly everyone else thrives when provided with full, explicit instructional guidance (and should not be asked to discover any essential content or skills)... Decades of research clearly demonstrate that for novices (comprising virtually all students), direct, explicit instruction is more effective and more efficient than partial guidance.
Delays in executive function skills in ADHD, meanwhile, often make assimilation of new information particularly difficult. To develop expertise in any area of academics, even more than other students children with ADHD need repetition, routine and a solid foundation of academic facts. Without it, the academic gap grows.
What do these modern curricula look like? Silent reading time is emphasized. For someone with ADHD who is distractible, impulsive and behind in reading skills, there is an unrealistic expectation they will attend, behave and basically teach themselves during this unstructured instructional time. In writing, children who struggle to organize their thoughts are asked over and over again to create coherent essays without a linear outline. In math, children still counting on their fingers are pushed to not only solve higher-level problems but to show their work, an activity which relies again on their ability to organize and get their ideas on paper.
A vicious cycle potentially develops. Until facts become hard-wired children with ADHD struggle even more than peers. Demands on executive function go up whenever facing something unfamiliar, but without an emphasis on teaching basic facts, nearly everything remains unfamiliar on some level. Already maxed out in their ability to assimilate new information, the curriculum moves forward before they are ready.
Lastly, as discussed earlier, many children with ADHD also have a learning disability. If every child with asthma had a sixty-six percent chance of having kidney disease too, would we screen them for kidney disease? Probably so. Yet, once ADHD is identified, further educational testing sometimes gets put to the side with an assumption that ADHD explains all. For children with ADHD, full educational testing is required if any academic concern seems particularly severe or if issues persist once ADHD is addressed.
Righting the Educational Ship
One of the best metaphors for ADHD is that of an iceberg. The tip signifies the best known symptoms, ranging from hyperactivity and impulsiveness to distractibility and poor focus. The rest of it, often hidden but resoundingly impairing, is the near countless facets of executive function. Disruptive behavior and trouble completing work tend to dominate the discussion when in fact most children with ADHD require far more emphasis on addressing the less obvious parts of the iceberg. Without appropriate intervention the impact on child development and education is profound, including self-esteem, motivation and a host of less quantifiable measures of well-being.
How can we best help students with ADHD succeed? A compassionate approach to parenting or teaching fully accepts a child as they are, expecting them to behave appropriately and work hard, but only within reasonable parameters. We aim to assess short-term requirements accurately while building skills for the future. Right now, today, any individual with ADHD may not have capacity to manage homework, focus, control their impulses or any of a host of other abilities that impact their lives. We best support children with ADHD by not expecting skills they simply lack to develop out of thin air, but rather by proactively creating a comprehensive educational plan.
Children with ADHD typically require an intensive short term safety net that more or less takes over executive function. Then, at whatever rate individual skills develop, we hand responsibilities back. Books including Executive Function in the Classroom and The CHADD Educator's Manual describe the academic impact of ADHD along with recommendations for intervention too detailed to list here. But the first step to meeting a child with ADHD exactly where they are in their development is acknowledging the full impact of this complex medical condition.
Follow Mark Bertin, M.D. on Twitter: www.twitter.com/markbertinmd