Epilepsia, 48 (3):464–469, 2007 Blackwell Publishing, Inc. C 2007 International League Against EpilepsyCompulsory Generic Switching of Antiepileptic Drugs: HighSwitchback Rates to Branded Compounds Compared with Other∗Frederick Andermann, † Mei Sheng Duh, ‡ Antoine Gosselin, and ‡ Pierre Emmanuel Paradis∗ Montreal Neurological Institute and Hospital, McGill University, Montr
Attention deficit / hyperactivity disorder (ad/hd) policyAttention – Deficit/Hyperactivity Disorder
Medway Education Authority Policy Framework and
for Professional Practice
C O N T E N T S
Policy Framework 2
Teaching Students with Attention Deficit Hyperactivity
Use of medication for children diagnosed as having ADHD 10
Meeting needs: successful partnership between parents and
schools in the management of children in school who have
been diagnosed as having ADHD
Letter from Health Service Providers to accompany form requesting
information from schools
Health Services Information request to schools on a child who has been
referred for attention / behavioural difficulties
The concept of AD/HD is an ‘evolving’ one. AD/HD fits into a spectrum of
neuro-developmental disorders, although there continues to be considerable
debate about its extent and prevalence.
In the interests of all school pupils and children more generally, it is important
that all who work in educational or similar settings are aware of issues around
AD/HD in order to meet the needs of those children who pass the diagnostic
criteria for this condition.
It is acknowledged that children who have been diagnosed as having AD/HD
may experience a range of barriers to learning, both socially and
educationally, not all of which may be attributable to AD/HD. Equally, some
children will experience no obvious learning needs.
Due to the complexity of the issues involved, and the differing expectations of
children in a diverse society, it is important that parents and professionals
communicate effectively to ensure that needs are met and best practice
1.2 AD/HD and its core features
AD/HD is a diagnosis applied to children who consistently show characteristic
behaviours over a period of time in different settings. The diagnostic
behaviours fall into three categories: inattention, hyperactivity and
impulsiveness. Children for who inattention is the predominant problem may
be given a diagnosis of Attention Deficit Disorder (ADD)
People who are inattentive have difficulty keeping their mind on one thing at a
time so have trouble completing tasks. Signs of inattention include:
• Becoming easily distracted by irrelevant sights or sounds
• Failing to attend to details and making careless mistakes • Being unable to listen or follow instructions • Being forgetful and frequently losing personal possessions
This refers to an excess of physical movement. Signs of hyperactivity may
• Dashing around constantly as if ‘driven by a motor’
• Restlessness when seated; squirming and fidgeting with hands and feet • Being unable to remain seated when this is appropriate
People who are excessively impulsive are unable to curb their immediate
reactions or to think before they act. Signs of impulsiveness may include:
• Being unable to take turns or wait in line
• Demanding instant gratification of wishes • Blurting out comments without thinking
Many children show similar symptoms at different stages of their lives that
may be unexceptional in developmental terms. For example, toddlers and
very young children are often very active with a short attention span and
adolescents may appear restless and disorganised.
Furthermore, many of the symptoms described above may also arise for
reasons unrelated to AD/HD, but which nonetheless indicate the child is
potentially suffering from stress (with a range of possible causes) and / or
other medical or neuro-developmental condition.
To merit a diagnosis of AD/HD, the behaviours described above must be
markedly excessive compared to an average child at the same stage of
development, be pervasive across different areas of a child’s life and a long
term problem, not just a response to a temporary situation.
Many pupils with AD/HD may have additional difficulties that can affect their
social and educational development. It should not be assumed that these are
solely attributable to AD/HD and it is important that they are also considered
as separate issues.
As with all children, information gathering should be conducted from within a
‘whole child’ perspective. Other special educational needs should be
identified such as those associated with specific learning difficulties and
emotional and behavioural needs. Other agencies may need to be consulted
if a child’s social or therapeutic needs are felt to be significant.
All the above should be taken into account when planning appropriate
1.3 When does AD/HD constitute a special educational need?
Medway LEA has structured SEN procedures in line with the Code of Practice
that apply to all children and young people equally.
These procedures are used by pre school services and schools to identify
pupils with special educational needs. The Medway SEN process therefore
provides the framework by which schools, parents, pupils and other
professionals work together to plan interventions for all pupils, including
AD/HD. A diagnosis of AD/HD in itself does not constitute a special
educational need, unless it is clear that features of the condition are acting as
a significant barrier to a child’s social and educational learning – for example
sufficient to merit specific interventions as part of an Individual Education
1.4 How is AD/HD Identified?
AD/HD is a medical diagnosis and therefore will not be ‘identified’ through the
LEA SEN Procedures. However, the assessment of educational needs that
occurs routinely as part of the SEN process as it operates within schools may
also contribute to information that supports a diagnosis of AD/HD.
Due to the potential complex interaction of various causal factors and the
variety of reasons that may underpin the observed behaviours described
above, it is important that schools and other agencies provide a broad and
holistic information base to aid medical practitioners in arriving at an
Interventions in school will depend on severity of need and the extent to which
AD/HD and associated behaviours are acting as a barrier to learning.
Interventions are discussed in more detail in the guidelines accompanying this
2.1 The LEA and Schools will act in concert to support all pupils with
special educational needs including AD/HD where appropriate by:
Advocating inclusive social and learning opportunities for children with AD/HD, as well as full access to the national curriculum Ensuring regular contact, feedback and information sharing with parents and other agencies such as Child and Adolescent Mental Health and Community Paediatric Services via a partnership approach Promoting school and other educational staff knowledge and understanding of AD/HD (e.g. through training), both as an individual and whole school issue Curriculum, intervention and provision planning that accounts for the needs of pupils with ADHD Following Code of Practice guidelines when drawing up Individual Education Plans Developing the guidelines on managing AD/HD in schools that accompany this document, as well as disseminating good practice subsequently
Ensuring that interventions, provision etc. are as far as possible based on
sound outcome research
Ensuring the views of the child and parents are taken into account as part of
any planning process
3. Ensuring and promoting quality
3.1 Individual pupils with AD/HD
Individual pupils’ needs within the social and educational environment of the
school will be discussed and monitored at In School Reviews or via the
Annual Review of their Statement of SEN if they have one. In this respect,
children with AD/HD are similar to other children with SEN.
3.2 Promoting Quality / Raising Standards
As with all children, including those whose SEN is AD/HD related, the LEA
aims to promote the highest standards in terms of enabling children to
achieve and develop both socially and educationally within an Inclusive
framework. The LEA will work in partnership with schools to raise standards
effectively as part of the overall strategy outlined in the Education
Development Plan, as well as Medway’s Behaviour Support and SEN Action
Teaching students with Attention Deficit Hyperactivity Disorder
Pupils with ADHD have learning needs that are best met through strategies
for teaching and classroom management that have relevance for all pupils.
Teachers will need to ensure that the learning environment and their teaching
style compensates for the difficulties with distractibility, limited organisational
skills and low tolerance of frustration that these children experience.
The following guidelines are based on current research literature and
suggestions about models that have been found to be useful in working with
children with ADHD. The decision to use a particular strategy must be based
on an understanding of the individual child’s educational, behavioural and
emotional needs. The professional judgement of individual teachers is valued.
Their skill in recognising pupil need and in managing an effective learning
environment with conflicting demands is recognised.
• Seat student in close proximity to teacher
• Seat peer models with good study skills next to children showing attentional difficulties and overactivity • Locate the student’s desk away from the doorway and windows to minimise auditory and visual distractions. When appropriate, place a physical divide between the child’s desk and others to reduce visual distractions • Use seats in rows, a horseshoe or a single desk at the edge of the room for the student when tasks do not require interpersonal contact to minimise the distractions of other students • Reduce the visual distractions in the area of the room for the student • Stand near the student when giving directions or instructions or presenting the lesson. Use visual aids wherever possible e.g. use his/her worksheet as the example when giving instructions
General classroom organisation
• Create an organised learning environment – establish and demonstrate a
regular classroom/lesson routine, particularly for beginnings, endings and transitions • Be clear and consistent about when pupil movement is permitted and • Use a visual signal to indicate special periods of intense independent work • Teach students how to organise their work, including page layout and organisation of folders. Allow time each lesson for this • Differentiate tasks so they are appropriate for the pupils’ abilities • Divide longer assignments into manageable sections, with clear guidelines, expectations and time scales for each section • Provide clear ‘due dates’ for the completion of assignments • Ensure homework tasks are clearly written in the child’s contact book – do not assume that the child has written the tasks clearly • Develop a clear system for keeping track of completed and uncompleted
• Provide an outline and key concepts to the lesson
• Make explicit the relevant prior learning from previous lessons • Differentiate tasks as needed to accommodation the student’s attention • Use visual and/or auditory cues as signals prior to changing a task. • Include a variety of activities during each lesson to capture attention • Plan for opportunities for the student to make frequent responses during • Where possible use multi-sensory techniques for presentation – auditory, Actively involve the student during the lesson presentation Use positive direction – explain exactly what is wanted Simplify complex directions in component parts Write tasks on the board as well as announcing orally Discuss learning objectives with the student Actively involve the child in goat setting Check that the student has heard and understands the instructions by asking them to repeat back task directions
Strategies to address specific behaviour issues
• Make the individual child’s personal lesson objectives explicit to them.
Provide rewards that have been negotiated with the child as soon after the targets have been achieved as possible • Seat the student away from distracting stimuli • Make the learning objectives explicit • Highlight the component parts of a longer assignment and assist pupil in • Include a variety of activities in each lesson • Pay careful attention to the design of worksheets – keep page format simple and avoid extraneous pictures or visual distractions that are not related directly to the task, have white space on each page, avoid hand-written text, use large type-print and a clear font • Provide alternative environments with fewer distractions for taking tests
Excessive motor activity
• Ensure the pupil has an active task within the lesson e.g. giving out books
• Provide short breaks between tasks and then re-focus attention back to • Remind pupil to check work if performance is rushed or careless • Plan for transitions between learning environments, establish explicit rules
Poor organisation and planning
• Break down long assignments into component parts – assist pupil in
settling short-term targets for longer assignments • Make the criteria for success explicit for each assignment – provide a • Prioritise activities for the student – make explicit the criteria influencing • Ensure the student is able to use a diary/calendar or other planning system to promote time management for scheduling homework assignments • Persuade parents to use organiser trays at home with days of the week marked, so books and work for school can be put together • Supervise the recording of homework tasks
• Ignore minor inappropriate behaviour
• Increase immediate rewards for good behaviour • Teach verbal mediation skills to reduce impulsive behaviour – practise a structured routine of stop, listen/look, think, answer/do
• Use positive direction to tell the student what to do, not what you don’t
• Avoid personalising the problem – focus on the behaviour • Negotiate the rules as much as possible, ensure they are simple and clear, • Give the student frequent opportunities to be rewarded • Monitor student performance and behaviour frequently and provide • Ensure there are pre-established consequences of behaviour which are explicit and enforce rules in a consistent manner
Difficulties with peers
• Organise social skills training to teach concepts of communication,
• Define the desired social behaviour target and implement a reward • Praise pupil frequently to raise his/her esteem within the class • Assign special responsibilities to pupil in the presence of peer group so others observe pupil in a positive light
• Focus on pupil’s talents, skills and accomplishments
• Praise effort as well as achievement • Notice and reward positive behaviour • Reinforce frequently when signs of frustration are noticed
Use of medication for children diagnosed as having ADHD
Ritalin (Methylphenidate) is sometimes administered to children with
significant levels of ADHD in conjunction with other non medical interventions
such as behaviour modification programmes.
It should only be used with the consent and co-operation of the child.
Ritalin is a stimulant drug that was first commercially released in 1957. There
is extensive research indicating its short term effectiveness i.e. 70 – 80 % of
children with ADHD may experience beneficial effects. There is no current
evidence to indicate that the use of Ritalin leads to dependence.
The use of Ritalin is contraindicated in children with some conditions such as
glaucoma (an eye condition). The symptoms are made worse in anxious,
agitated or depressed children. Ritalin should be used with caution with
children with controlled epilepsy, hypertension, motor tics and Tourette’s
syndrome. Some children may experience hypersensitivity to the drug or the
other components in the tablet such as lactose and gluten.
Ritalin has controlled drug status and is obtained by prescription. It comes in
10 mg tablets which can be halved.
There are no specific restrictions on it’s storage outside a hospital / pharmacy
and the usual guidelines with regard to general drug safety should apply. The
normal prescribed dosage is 1mg / 1kg body weight, but can range between
0.5 – 1.5 kg body weight.
Other drugs may be prescribed for ADHD such as Dexedrine, Clonidine and
Mode of action
Ritalin has a direct effect on attention, short term memory, vigilance, reaction
time, listening skills and ‘on-task’ behaviours.
It does not treat associated problems such as behavioural / socialisation
problems, motor clumsiness, learning difficulties or emotional immaturity. As
it improves concentration and calmness, it may indirectly have a beneficial
effect on some areas of behaviour or social interaction.
Ritalin is not a cure for ADHD and is very short acting in the body – from 2 to
4 hours – following which the ADHD symptoms return.
A response in terms of improved attention and calmness is often observable
in about 30 minutes following administration of an initial dose of Ritalin.
Children may be negative and tearful when the drug is washing out of their
Regular feedback from school and parents will help in fine tuning the optimum
level of medication required. The aim is to reduce peaks and troughs in
behaviours to enable the child to remain reasonably stable throughout the
Ritalin can help enable children with ADHD achieve more effectively
academically and in other ways, particularly when used in tandem with other
longer term interventions such as structured educational programmes, social
skills training and behavioural modification approaches.
Common side effects and drug monitoring
These may include loss of appetite, nervousness, crying, irritability, sleep
problems, headaches, rashes and stomach-aches. These usually settle
within about a week.
Children receiving Ritalin or other drugs to alleviate the symptoms of ADHD
should be supervised in a specialist ADHD clinic which will retain an
overview of the case.
Schools should play an important part in the administration and monitoring of
the effects of medication. It is important that positive comments or any
concerns about the effects of medication on a child’s functioning are
communicated to parents / carers and the medical personnel supervising the
The National Union for Teachers advises its members that a medical care
plan is drawn up and agreed on with the medical personnel, parents and the
school for every pupil who receives medication/ medical care in school.
The administration of medication by school staff takes place on a voluntary
basis. Those involved should ensure that they have appropriate information
and guidance from medical practitioners.
Meeting needs: successful partnership between parents and schools in
the management of children in school who have been diagnosed as
Is ADHD always a special educational need?
Not all children diagnosed as having ADHD will have special educational
needs above and beyond those experienced by the majority of their
The kinds of management techniques routinely used for all children may be
just as effective for children with ADHD and no specific additional
interventions will be required.
What if ADHD is having an impact on learning?
For those children where more focused interventions are indicated, examples
of good practice and commonly used approaches in school are provided in
the section entitled ‘Teaching students with ADHD’.
In some cases, children with ADHD may be on the school’s register of
children with special educational needs.
These children are likely to have their needs defined in terms of one of the
stages of needs as outlined in the DfEE’s SEN Code of Practice.
Special educational needs may relate to any behaviour, learning style,
communication need or aspect of social/emotional development that affects
the child’s ability to learn effectively and make progress.
Problems focusing or concentrating on work as a result of ADHD may be one
reason why a child is not making progress, but in many cases it may be just
one barrier to learning amongst several that a child is experiencing.
How can parents and schools work in partnership?
As with all children encountering barriers to learning, it is important that
parents and school work in partnership together to try to ensure that the
impact of whatever barriers exist are minimised as far as possible.
For children who are diagnosed as having ADHD, behavioural difficulties
associated with ADHD can often be a particular point of contention between
parents and school staff.
Because children with ADHD may in certain situations be more distractible or
impulsive, they may find it harder to conform automatically to basic class rules
or adult instructions.
It is important that this is recognised and understood by all teaching and other school staff and due allowance made. Equally, it is important to recognise that children with ADHD may be ‘naughty’ or badly behaved just like any other children and that ADHD is not used to excuse all ‘bad’ behaviour. To ensure that the potential for misunderstanding is minimised and that the child is not unfairly blamed, an open dialogue should always be encouraged between parents, the child (where appropriate) and school staff about the ways in which ADHD may influence behaviour, and the best ways in which this behaviour maybe responded to that reflect the child’s needs and developmental level. Where specific behavioural interventions may be required, parents and school staff can jointly devise appropriate responses in advance, for example as part of the discussions that take place around the development of the child’s Individual Education Plan. Apart from the kinds of good practice outlined in the section ‘Teaching students with ADHD’, effective planning between parents and schools to manage the behaviour and learning of children in school with ADHD is likely to be enhanced by: • Communication between parents and schools that is open, positive and • Emphasis on joint understanding and a blame free approach. • Close liaison with medical and other professionals where appropriate. • Sharing concerns and taking a collaborative viewpoint in trying to resolve • Making sure that management problems are highlighted early and • Ensuring that issues around medication and related issues are clearly,
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