HAYIDION The Prizmah Journal


ADHD: What Teachers Need to Know

by Melanie Fernandez Issue: Special Needs
TOPICS : Inclusivity

Every teacher has heard about attention-deficit hyperactivity disorder, even if he or she isn’t sure of the exact diagnostic criteria. Kids throw around the term “ADHD” in the same way they casually diagnose others with obsessive-compulsive disorder or schizophrenia. A well-organized child is “so OCD,” a child whose ideas seem a little unusual is a “schizo,” a child with lots of energy is “ADHD.” These schoolyard diagnoses have little in common with the real thing.

How TCIT Works

Teacher-Child Interaction Training, or TCIT, is a school-based variant of Parent-Child Interaction Therapy, or PCIT. Where PCIT seeks to improve a strained parent-child relationship and use it to reduce problem behaviors in a child, TCIT uses the disciplinary techniques and findings of PCIT to help teachers manage difficult students and classrooms.

In TCIT, clinicians train teachers on how to speak to their students and react to desired and undesired behavior. Central to TCIT are PRIDE skills that guide a teacher’s response to desired behavior, promoting positive interactions with students. These PRIDE skills are: Praise appropriate behavior; Reflect appropriate speech; Imitate and Describe appropriate behavior; and be Enthusiastic. Teachers use PRIDE on the opposite of inappropriate behavior to give concrete examples of good behavior. They also praise or describe appropriate behavior of students during another student’s misbehavior, which often motivates improvement.

Teachers also learn to state explicitly what positive or negative consequences are associated with a behavior. One key is the use of “when-then” and “if-then” statements: for example, “When you raise your hand, then I can call on you,” or “If you don’t color on your paper, then I will have to put the crayons away.” When consequences come, they are contextually relevant, so children know exactly why.

The goal of TCIT is not only a well-behaved class but a positive relationship between student and teacher that can benefit the learning process.

Trainers do live coaching of TCIT skills with teachers in class with students, and evaluate teacher-child interactions to determine the efficacy of the training based on standardized scales. TCIT has a growing evidence base.

More and more, studies are showing that the use of TCIT skills in the classroom reduces disruptive and aggressive behavior while increasing compliance. In addition, teachers report a high degree of satisfaction with the training.

The fact is that ADHD is a real psychiatric disorder with real consequences for young people. Not every high-energy or impulsive child has ADHD, and kids who do have the disorder are significantly affected by it. In fact, “clinically significant impairment” is one of the diagnostic criteria. The other criteria are inattentive, hyperactive, and impulsive symptoms—difficulty sitting still, staying focused, following directions, listening without interrupting, controlling impulses—that interfere with learning over time, as teachers are aware, but also with many other aspects of their lives.

ADHD is not a learning disorder, though it certainly affects learning. It is a complex cognitive and behavioral disorder. Clearing up this misconception is crucial to understanding both the disorder and the treatment. Children with ADHD have deficits in many of the functions (sometimes called executive functions) we develop to manage ourselves and accomplish tasks. These difficulties not only put them at a disadvantage in terms of learning; they are often associated with disruptive or problematic behavior, in school, at home, and even socially. (In fact, if children don’t show the symptoms in at least two settings, it’s not ADHD.)

Untreated, adolescents with ADHD are not only more likely to drop out of school; they are more likely to get themselves into a host of bad situations: car accidents, drug use, early pregnancy, and run-ins with the law. As adults, they have more difficulty sustaining relationships, parenting, and holding jobs.

The good news is that there are very effective new treatments for children with ADHD—not only medications, but also finely tuned behavioral therapies. By working with kids, parents, and teachers, we have developed techniques that can substantially minimize problematic behaviors and allow children to function more happily and successfully in the context of both their families and their classrooms. And because children with untreated ADHD can be difficult for teachers to manage—consuming a frustrating amount of your time and attention—techniques to help them function better are good for the rest of the class, too.

As a clinical psychologist, I focus on behavioral interventions, often in conjunction with psychiatrists, if children diagnosed with ADHD are candidates for medication as well. The medications psychiatrists sometimes prescribe, which are called psychostimulants, are not about “fixing” a child; they’re about improving and enabling his or her relationship with the world. Researchers think these compounds slightly alter brain chemistry that is atypical in children with ADHD, but they don’t change who a child is. Medication can make an inattentive child more available for instruction; an impulsive child better able to stop a behavior that might get him in trouble; a hyperactive child more aware of the needs and desires of others.

These and more are the goals of behavioral intervention. And because a child’s primary relationship is with his or her parents, the most effective way to reduce symptoms is behavioral therapy that involves that relationship.

I practice a therapy called PCIT, or Parent-Child Interaction Therapy. The specifics can be a bit daunting—it can involve one-way mirrors, and parents wear earbuds to receive instruction from therapists—but the goal is simple: repairing the relationship between parent and child by encouraging affection and trust, on the one hand, and, on the other, teaching very specific disciplinary skills that give children well-defined limits and parents tools to deal calmly with problem behaviors. This approach may sound like common sense—and it is—but the methods are cutting edge, and supported by scores of studies that support its effectiveness.

The findings from PCIT got us all thinking. If the training in our PCIT sessions can help children control their own behavior, and parents calmly manage incidents when kids need to be reined in or redirected, could it be an effective tool for teachers?

That’s the impetus behind TCIT—Teacher-Child Interaction Training. The idea here is that teachers can be trained to use the rapport-building techniques of PCIT, as well as the disciplinary ones, to make difficult classrooms easier to govern, and more ready to be taught. The benefit to students as well as to teachers in terms of their stress levels is increasingly being supported by research.

So what is your role as a teacher? It’s twofold. First of all, you may often be the person who will first notice that a child has psychiatric or learning problems. That’s because you spend so much time with each of the children in your classrooms, but also because you are often in a better position to recognize the significance of a set of behaviors. Parents generally have a sample size of one or two or three children; you have a sample of 20 or 30, and over a teaching career, hundreds of children. If you have concerns, please don’t waste any time before letting parents and other relevant individuals at your school know. Whether it’s ADHD or an anxiety disorder, the sooner a child gets treatment, the less damaging the problem will be to his or her development, and the better the prognosis.

The next step, if a child is diagnosed with ADHD or another psychiatric disorder, is to be a member of what we call the “treatment team” of significant adults in that child’s life.

What does this mean? If your student is on medication, it means making sure he or she gets it on schedule and occasionally completing short rating scales to help the treatment team keep track of how well the medication is working. If a child is undergoing PCIT or another behavioral therapy, it means being a part of that therapy in some way—meeting with parents and the child’s therapist to learn what’s working for the child. Evidence shows that consistent use by as many adults in a child’s life as possible makes behavioral techniques more effective for that child. A combination of ample positive reinforcement for desired behavior and clear, consistent consequences for undesirable behavior is surprisingly effective in helping children become more cooperative.

If you are the teacher of children being treated for ADHD, even if you’re not involved with a TCIT program, keep this in mind: the treatment is allowing them to access learning opportunities that their disorder, untreated, denies them. Treatment is also allowing them to improve their relationships with key figures in their lives—including you—but they may have some catching up to do. So be patient; help them along in a development that has, in some senses, been delayed.

And seek out new opportunities. TCIT and similar programs are still in their infancy, but a new movement is afoot among mental health professionals to strengthen the necessary and vital relationships with teachers that can help our children so much. Help us in that. If you let your voices be heard, perhaps more teachers will have access to the tools that can dramatically change a child’s trajectory. ♦

Melanie Fernandez, PhD, is a clinical psychologist at the Child Mind Institute’s ADHD and Disruptive Behavior Disorders Center (childmind.org). She can be reached at Melanie.fernandez@childmind.org.

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Special Needs

Schools increasingly need to be aware of a growing range of conditions and challenges that students confront. These challenges present school leaders with numerous considerations at various levels: funding, admissions, staffing, curriculum, health care and more. This pioneering issue serves as a roadmap for leaders as they navigate this complex terrain.

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