Planning an adult class for LD/ADHD students.

                                   Planning an adult class for LD/ADHD students.

                                               Carl Stuart

                                            Stuart Science Series

Introduction.

ADHD (Attention Deficit Hyperactivity Disorder) is one of the conditions that lead to learning disabilities (LD). However, an understanding of ADHD/LD will enable one to manage and circumvent some of the hindrances associated with the condition (Levin, 2011).

The focus of the class will be on ADHD/LD among adults. The thesis statement for this paper is that an understanding of ADHD as a neurobiological condition will enable the adult learners to manage it. This will enable the learners to overcome the fear and diffidence associated with ADHD.

Class outline.

The topic for the class is ADHD/LD and management modalities. This will be an interactive session and the participants will be allowed to ask questions about concepts that they do not understand before the class proceeds to the next concept. However, all the other questions from the participants must be reserved to the end of the class. At the end of the class, the participants must understand the concepts outlined in the class objectives. The class objectives are outlined below:

1.      To define ADHD and other related terms.

2.      To describe the classification of ADHD.

3.      To describe the signs and symptoms of ADHD.

4.      To explain the association between ADHD and LD.

5.      To state the causes of ADHD.

6.      To describe the pathophysiology of ADHD.

7.      To describe the diagnosis criteria for ADHD.

8.      To describe various management modalities for ADHD.

9.      To understand the context of ADHD within the societal milieu.

Audience.

The audiences for this class are adult learners who suffer from ADHD/LD. These special need learners have the unique features outlined hereafter.         

To start with, they are self-directed autonomous adults who have an expectation that they will be involved in the lesson (Rubin, 2011). Secondly, they have accumulated knowledge from life experiences, work and previous education; and they expect to connect the subject matter to this knowledge base (Weiner, 2011). Thirdly, they are goal-oriented and relevancy-oriented individuals who expect the subject matter to assist them to attain their goals (Rubin, 2011). Also, they are practical individuals who are more interested in the practical applicability of the concepts they are learning (Weiner, 2011). Hence, the class must have clearly defined elements and it should also be well organized. The instructor must prove the relevance of the subject content to their lives of the participants (Rubin, 2011). They must be allowed to participate in the class, in order for them to extract the maximum benefits from the class. Finally also need to be respected, and hence they must be allowed to ask questions during the lesson (Weiner, 2011).

The audiences are slow learners who require the following critical elements during the learning process: motivation, reinforcement, retention and transference (Weiner, 2011). Motivation requires the instructor to do the following: create an effective virtuous rapport with the learners, establish an appropriate tone for the class, show concern for the class needs, establish an appropriate level of difficulty for the learners, offer specific feedback and reward the participants (not by offering financial rewards) in order to ensure that the learners maintain an optimal level of interest and concentration in the subject matter (Rubin, 2011).

 Instructors must apply both negative reinforcements (to promote extinction of inappropriate behavior) and positive reinforcements in appropriate measures during the class. Reinforcement ensures that the consistent positive behavior is maintained and it also augments retention of subject matter (Rubin, 2011).

Instructors must place an emphasis on retention and practical application of the learned concepts; and hence, they must encourage the participants to practice what they have learned (Weiner, 2011). Transference is the capacity of the learner to apply concepts learned in the class in new settings (Rubin, 2011). The pragmatic benefits of the class must be demonstrated to the learners by the instructor in order to ensure that there is positive transference among the learners (Wiener, 2011). Positive transference occurs when there is association (relating the new information to the accumulated knowledge), similarity (how analogous is the new information to information in the accumulated knowledge base), critical thinking elements (how beneficial is the information in enabling one attain his/her goals) and an appropriate degree of original thinking (Rubin, 2011).

Program Planning.

The description of the program plan is described hereafter. To start with, the topic and class objectives must be identified and clearly stated. Next, the information related to the topic and objectives should be systematically organized in a logical order. The format of presentation of the systematically organized information is selected. In this case, the information will be put forward as a PowerPoint presentation. The topic will be taught in a classroom setting; and hence, there is need to locate and reserve an appropriate lecture venue.

The prerequisite for this program is that all the participants must have suffered, or are suffering, or are a caretaker of an individual suffering from ADHD. Participants are then informed about the lecture venue and the time that the class will commence. Prior to the commencement of the class, there is a 10 minutes warm-up period. The warm-up period will allow the participants to introduce themselves to each other and to the instructor; and the instructor will also introduce himself/herself to the participants.

The class then commences. The topic to be discussed is stated. Thereafter, the class objectives are outlined to the participants. They are then asked to actively participate in the class and ask questions about the concepts that they do not understand. The topic is then taught to the participants. A SCANS skills analysis of the participants will be carried out during the participants’ active participation in the class. The following competencies will be analyzed in this class: basic skills, interpersonal relationships, personal qualities and thinking skills. At the end of the class, the participants will be allowed to ask questions. After that, the instructor will ask the participants several questions about ADHD/LD.

SCANS skills is a policy formulated to ensure that the following four basic skills are imparted in the learner: basic skills (listening, reading, writing, speaking and mathematics), people skills (social, teamwork, negotiation, leadership and cultural diversity), personal qualities (self-esteem, responsibility and self-management) and thinking skills (creative thinking, visualization, problem-solving and decision making) (Smith, 2011).

Class design.

This is an in-class learning activity and the class design conforms to a classroom settings. The class design is outlined hereafter:

1.      Topic.

2.      Objectives: broad and specific objectives.

3.      Definitions.

4.      Classification of ADHD.

5.      Signs and symptoms.

6.      Association between ADHD and LD.

7.      Causes of ADHD.

8.      Pathophysiology of ADHD.

9.      Diagnosis criteria for ADHD.

10.  Management modalities and their prognosis.

11.  Context of ADHD within the societal milieu.

12.  Summary.

13.  Questions from participants.

14.  Questions from instructor.

15.  End.

This systematic class design allows for interactive participation and active learning in the class (Beal, 2012). Systematization of the information facilitates its subdivision into manageable pieces that will avert information overload in the learners, maintain interest and concentration among the learners; and also enable the instructor to narrow down his/her emphasis to the essential applicable concepts (Rubin, 2011). For instance, an ADHD patient knows that he/she must change the drugs he/she is using when a liver disease develops during the course of treatment. Moreover, he/she understand the signs and symptoms, and can thus recognize them in his/her child/children; and, then take the appropriate actions.

This systematic information will be put forward as a PowerPoint presentation to amplify aesthetic appeal and promote recall among the learners. This presentation will be done in a classroom facility.

The transfer of learning is a continuous process that occurs when contextual learning activities and behavior are related to prior knowledge or experiences. It has two components: near transfer and far transfer (Rubin, 2011). Near transfer is related to two or more contexts that share a high degree of similarity. Far transfer is related to two or more contexts that share a low degree of similarity (Beal, 2012). Transfer is essential in education as it enables the learner to associate the new concepts with the prior accumulated knowledge; and in the process improve his/her living condition/status (Rubin, 2011). The identical element theory of transfer of learning is manifested in this class design. This theory states that the extent of transfer of learning is directly proportional to the degree of similarity between the new concepts being learnt and prior experiences (Beal, 2012). In this class design, the learners are being taught about a condition that has affected them, and hence they are able to associate the new information with their prior experiences with ADHD.

Moreover, what is learnt about a particular subject facilitates the attainment of the requisite goal in related areas (Beal, 2012). Hence, this class design will enable the person suffering from ADHD to manage his/her condition appropriately.

Transfer can either be positive or negative. Positive transfer occurs when contextual learning in the classroom enables the learner to manage ADHD; while negative learning occurs when this contextual learning leaves no impact on the life of the learner (Beal, 2012). The class design aims to foster positive transfer.

The class design incorporates a session whereby questions can be asked by the participants. This question session enables the instructor to clarify issues that the participants have not understood properly. This reinforces understanding and retention of the learned concepts (Rubin, 2011). The instructor will ask the participant questions relating to ADHD in order to evaluate their level of understanding and capacity to apply the learned concepts in new settings.

There are two learning approaches that are used in this class design. The first approach is known as PQRST (preview, questions, reading, summary and test). PQRST is based on effective communication skills of the instructor (Rubin, 2012). The objectives of the class are to provide a preview of the subject to be discussed, and it will also enable the learners to formulate questions which they expect to be answered during the lesson. The recitation and exposition of the concepts by the instructor will enable the learners to understand ADHD and modalities of managing the condition. A clear understating of ADHD will enable the learners to make a summary of the key points.  

The second approach is based on condensing information, organizing summary and emphasizing the keywords and key concepts (Rubin, 2011). The systematic information presented is derived from various dissimilar sources and it has been amalgamated into a consistent, coherent and logical sequence (devoid of superfluous information) that coveys the essential attainable concepts. An organized summary assist in revision and recall. The keywords are bolded, while, the key concepts are bolded and italicized to draw an attention to them and this exploit facilitates quick recall and retention of the essential concepts.

The class presentation (adapted to Microsoft word) is provided below.

                            Attention Deficit Hyperactivity Disorder (ADHD).

I.                    Objectives:

1.      Broad objectives: To understand ADHD and its current management modalities.

2.      Specific objectives:

(a)    To define ADHD and other related terms.

(b)   To describe the classification of ADHD.

(c)    To describe the signs and symptoms of ADHD.

(d)   To explain the association between ADHD and LD.

(e)    To state the causes of ADHD.

(f)     To describe the pathophysiology of ADHD.

(g)    To describe the diagnosis criteria for ADHD.

(h)    To describe various management modalities for ADHD.

(i)      To understand the context of ADHD within the societal milieu.

II.                 Definitions.

ADHD: It is a psychiatric, developmental (involving development during childhood) and neurobiological (affecting the normal functioning of the central nervous system) disorder characterized by periods of inattention (or decreased attention) and impulsiveness (due to hyperactive) or a coexistence of the two states (Levin, 2011).

LD (Learning Disability): A condition that impedes the acquisition of basic school skills at a normal rate (Teitelbaum, 2011)..

Pathophysiology: Refers to aberrant changes that are caused by a disease or disease processes (Levin, 2011).

Neurotransmitter: A chemical compound that relays information between two or more adjacent neurons (Levin, 2011).

Co-morbidity: refers to the simultaneous coexistence of two or more diseases in the body (Levin, 2011).

Serum: The resulting fluid component of blood after the removal of clotting factors (Levin, 2011).

Prognosis: The outcome of the course of a disease. The disease either disappears completely (good prognosis) or it worsens (bad prognosis) (Levin, 2011).

III.               Classification of ADHD.

ADHD is a disruptive behavior disorder that is classified according to the preponderance of symptoms into three categories (Levin, 2011):

(a) ADHD-I: predominantly inattentive type.

(b) ADHD-HI: hyperactivity-impulsivity type.

(c) ADHD-C: combined type.

The prevalence of ADHD among children ranges from 2-18% of which 1-36% persists into adulthood. The population suffering functional impairment is probably higher because the stringent nature of the diagnosis criteria. It is associated with the following co-morbidities: anxiety disorders, mood disorders, excessive substance abuse and oppositional defiant disorder (which manifest itself as aggressive antisocial behavior or conduct) (Levin, 2011).

IV.              Signs and symptoms of ADHD.

They are categorized according to the predominant symptom.  The following are the signs and symptoms of ADHD-I: inattention to detail with resultant careless mistakes, difficulty in maintaining a consistent level of attention, difficulty in completing tasks, problems harking to verbal instructions, avoidance of mental tasks, difficulty in organizing, easy distraction and forgetfulness(Levin, 2011).

The following are the signs and symptoms of ADHD-HI: squirms and fidgets, excessive talking, inability to remain seated, inappropriate running and climbing in the workplace, handwriting difficulties, dashing during work, blurting out answers before the completion of the question, impatience, inability to await one’s turn and constant interruption/intrusion into other people’s activity(Levin, 2011).

ADHD-C involves a combination of signs and symptoms of ADHD-HI and ADHD-I. ADHD manifestation in adults takes the following forms: reduced academic performance (poor adjustment in colleges, underachievement and drop-outs), decreased work productivity (frequent absences, unemployment and frequent job changes) and strained social interactions (frequent divorce, workplace conflicts, low self-esteem and poor interpersonal skills), frequent road accidents when driving, increased substance abuse and non-compliance to prescriptions which ultimately increases the overall healthcare costs(Levin, 2011).

V.                 Association between ADHD and LD.

ADHD causes poor concentration levels, impaired recall, inability to speak coherently, poor writing skills, impaired organization of thought processes and aversion to mental tasks (Levin, 2011). Meanwhile, effective learning skills are dependent on efficient communication skills, excellent writing skills, organized thought processes, superb recall and anticipation of progressively difficult mental tasks (Teitelbaum, 2011). Hence, ADHD impairs all the mental faculties and physical attributes necessary for effective learning, and thus there is a resultant learning disability.

VI.              Causes of ADHD.

The exact causes of ADHD are currently unknown, but 8 factors do contribute to it. These factors are:

(a)    Genetics: This is based on monozygotic (from a single ovum) twin studies which have shown high heredity patterns for ADHD among twins (Levin, 2011).

(b)   Evolution: Genes responsible for ADHD remained in the gene pool because women were attracted to risk-loving males (Levin, 2011).

(c)    Environmental: Exposure of the fetus to alcohol and cigarette smoke components have been shown to cause ADHD after birth. Lead poisoning during the perinatal and infancy period has been shown to cause ADHD (Levin, 2011).

(d)   Diet: Ingestion of food containing Sodium benzoate (a food preservative) has been shown to cause ADHD-HI (Levin, 2011).

(e)    Social: Events that cause disruption of the social fabric such as divorce, adoption, crime, war and riots has been shown to cause ADHD (Levin, 2011).

(f)     Impaired neurobiological development causes neurobehavioral aberrations and ADHD (Levin, 2011).

(g)    Social construct theory: Proponents of this theory state that the diagnosis criteria is what determines if a person suffers from ADHD or not; and, thus ADHD is an invented psychiatric disorder (Levin, 2011).

(h)     Low arousal theory: People who have low arousal threshold exhibit hyperactive behavior when they are stimulated by any environmental stimuli. Lack of stimulation thus leads to inattention (Levin, 2011).

VII.            Pathophysiology of ADHD.

ADHD is caused by left frontal lobe dysfunction. This dysfunction causes a disintegration of the frontosubcortical system activities and functions. This system co-ordinates and integrates cognitive and motor functions of the body; and hence its disruption causes a disengagement of this vital co-ordination and the resultant symptoms of hyperactivity and inattention starts to manifest itself externally(Levin, 2011).

 The frontosubcortical system is made up of the caudate nucleus, anterior cingulate cortex, lateral prefrontal cortex and the putamen. The dysfunction is thought to result from hypodopaminergia (a condition where the dopamine concentration in dopaminergic neurons is low) within dopaminergic neurons (neurons that release dopamine as their primary neurotransmitter), and this condition results in reduced cerebral glucose metabolism thus adversely affecting provision of energy to functional cerebral systems (Levin, 2011).

 Dopamine is a neurotransmitter that causes stimulation within the central nervous system (brain and its associated cranial nerves) and its deficiency results in symptoms similar to depression (Levin, 2011).

VIII.         Diagnosis criteria for ADHD.

The Utah criteria is used for preliminary adult ADHD diagnosis. These criteria have three prerequisites: childhood and adult criteria must be met before a positive diagnosis is made; exclusion of transient inattentive symptoms and diagnosis is made only after all the other psychiatric conditions have been excluded (Newark, 2011).

It is imperative that a person seeks evaluation for ADHD alongside his/her child/children if the following signs and symptoms are noted: disorganization, inability to complete tasks, lack of concentration and reduced productivity (Newark, 2011).

The adult criteria used are: attention deficits, motor hyperactivity and any two of the following symptoms; labile affect (manifested by an emotionless facial expression), excessive emotional activity, frequent temper outbursts, impulsivity and disorganization (Newark, 2011).

The preliminary ADHD diagnosis made using the Utah criteria is confirmed by patient interview (which facilitates the collation of information and categorization of the type of ADHD), neuropsychological assessment (using Weschler IQ tests, Controlled Word Association Test, Stroop task and Trail making tasks), rating scales and laboratory and/or radiological examinations(Newark, 2011).

The common rating scales used are ADHD Rating Scale-IV, Brown ADD (attention deficit disorder) Scale for Adults, Adult ADHD Self Report Scale and Conner’s Adult ADHD Rating Scale (Newark, 2011).

 The common laboratory examinations done are serum lead content (as this indicates lead poisoning), full and differential blood count (due to the fact that lead poisoning alters the differential blood count) and serum vitamin B12 levels (to indicate the presence of anemia which results from hypodopaminergia) (Newark, 2011).

 The common radiological examinations are EEG (electroencephalograph), Sleep study (to examine cerebral functions) and CT (computer tomography) scan (Newark, 2011).

The diagnosis of ADHD must be done by a qualified psychiatrist who will be able to prescribe the appropriate medications and other non-pharmacological (not related to drugs) treatment modalities (Newark, 2011).

IX.              Management modalities and their prognosis.

There are two common management modalities: Pharmacological and non-pharmacological. The pharmacological treatment is further divided into two categories: stimulants and non-stimulants (Newark, 2011).

According to the low arousal theory, an adequately managed stimulation by stimulant drugs will overcome the inattention and avoid hyperactivity, thus leaving the patient in a normal state (Levin, 2011). The common stimulants used are methylphenidate and amphetamines. The starting dose of methylphenidate is 5mg (milligram) taken thrice per day; and then it is gradually increased for the next 5 weeks to a maximum of 100mg/day. The common trade names for methylphenidate are Ritalin (Ritalin LA is the extended release formulation), Strattera and Concerta XL (Newark, 2011).

The extended release formulation of methylphenidate is preferred to the short-acting daily doses. Methylphenidate has a good prognosis due to its effective therapeutic response. However, methylphenidate must not be used by persons suffering from other psychotic disorders, hypertension, heart failure, seizures, hyperthyroidism (excessive concentration of thyroid hormone in the blood which leads to aberrant body metabolism and heat intolerance) and previous myocardial infarctions. In these cases, amphetamines substitutes for methylphenidate (Newark, 2011).

Non-stimulants are used by patients who have existing co-morbid conditions. The most commonly used non-stimulants are tricyclic antidepressants, atomoxetine and bupropion. Atomoxetine is used as a substitution for methylphenidate in patients who develop liver diseases during the course of treatment. It is usually taken twice per day (morning and evening) (Newark, 2011).

Non-pharmacological treatment is categorized into three: Cognitive-behavioral therapy, family or group therapy and support groups (Newark, 2011).

The complimentary approach to management of ADHD utilizes fish oil which has nutrients that aids in the maintenance of cognitive function (Newark, 2011).

X.                 Context of ADHD within the societal milieu.

It is imperative for a person who has been diagnosed with ADHD to inform his/her family, friends and employers about it. Nowadays, stigma associated with ADHD is virtually non-existent in the society. The preliminary and definitive diagnosis report of ADHD by a certified and qualified psychiatrist will enable the patient to get the following benefits: social insurance payments mean tested payments, doctors-only medical cards which enable the patient to access long-term illness scheme, drug payment scheme, subsidized occupational therapy and social services (Levin, 2011).

Pertaining to legal matters, the patients have access to subsidized legal aid which helps him/her to prepare for the future and to write a will. The patient is also protected from discrimination by anti-discrimination legislation and employment equality legislation. The patient is also assisted to obtain vocational training, rehabilitative training and employment support (Levin, 2011).

The patient is also encouraged to join support groups which will enable him/her deal with challenges associated with ADHD (Newark, 2011).

XI.              Summary.

ADHD is a psychiatric, developmental and neurobiological disorder characterized by periods of inattention and impulsiveness or a coexistence of the two states. It causes LD.  It is classified according to the preponderance of symptoms into three categories: ADHD-I, ADHD-HI and ADHD-C. Genetics, social disruption, environmental factors, diet, low arousal theory, impaired neurobiological development, social construct theory and evolutionary factors do contribute to the development of ADHD. The underlying pathophysiology of ADHD is hypodopaminergia. Preliminary ADHD diagnosis is made using the Utah criteria while definitive diagnosis is made after patient interview, neuropsychological assessment, rating scales and laboratory and/or radiological examinations have been done. The most effective treatment for ADHD utilizes methylphenidate. Other drugs used are amphetamines and atomoxetine. There are anti-discrimination laws protecting ADHD patients, and social support groups to cater for their various challenges.

XII.            Questions from the participants.

XIII.         Questions from the instructor.

(a). Describe the classification of ADHD?

(b) Describe the signs and symptoms of ADHD?

(c) Explain the association between ADHD and LD?

(d) Describe the pathophysiology of ADHD?

(e) Describe the diagnosis criteria for ADHD?

(f) Describe the various management modalities for ADHD?

XIV. The End.

             Recommendations and conclusions.

In conclusion, the systematization of ADHD information has facilitated its subdivision into manageable pieces that can be learned by the learners without loss of interest. Also, it has enabled the instructor to narrow down his/her emphasis to the essential applicable concepts. The class design promotes a positive near transfer of learning. The class design has a session for questions, and this session facilitates understanding and retention of the learned concepts. The approaches of learning have facilitated a consistent and coherent presentation of facts which enables a clear understating of ADHD. This promotes transfer of knowledge, augments recall and facilitates transference among the learners. It is recommended that the above class design be taught in a classroom setting using a PowerPoint presentation. Also, it is recommended that each title should be in a separate slide and the two consecutive ADHD slides should be separated by a unique tantalizing picture of an individual who overcame ADHD.

                                                            Summary.

The learning process enables the participants to understand new concepts which they can apply in the betterment of their lives. For instance, an understanding of ADHD/LD will enable the learners to overcome the fear and diffidence associated with ADHD. An interactive session will enable the participants to ask questions about concepts that they have not understood. Such an interactive session will enable the instructor to meet the special needs of the participants, while concurrently assessing their SCANS skills. The systematization of information facilitates the learning process. Moreover, the learning process is facilitated by the excellent communication skills of the instructor. Positive transfer of learning, retention, positive transference and promotion of critical thinking are the desirable effects of any learning process.

                                                                         References

Newark, J. (2011). Management of Adult Attention Deficit Hyperactivity Disorder

            (ADHD).  Journal of Clinical Psychiatry, 17(3), 893-917.

Beal, P. (2012). Prerequisites of an effective class design. Journal of Higher Education, 45(9),

            654-678.

Smith, D. (2011). SCANS skills analysis. Journal of College Education, 78(5), 531-567.

Weiner, M. (2011). Adult learners in the classroom setting. Journal of Adult Education, 39(8),

289- 315.

Rubin, R. (2011). Adult learners in the Education Sector. Auckland, New Zealand: Oxford

            University  Press.

Levin, W. (2011). Understanding Attention Deficit Hyperactivity Disorder. San Francisco:

 Jossey-Bass.

Teitelbaum, Y. (2011). Effective learning skills. Journal of Pedagogy, 87(3), 595-607.