Developing ADHD care pathways

Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood disorders and can continue into young adulthood or even longer. Gareth D Morewood examines what SENCOs can learn from recent research.

ADHD may be common, but with symptoms such as ‘difficulty paying attention and controlling behaviour’ it can be a hard condition to diagnose. There are also subtypes of ADHD and a wide range of symptoms. While awareness and understanding of ADHD has improved it continues to be one of the most problematic disorders for pupils, parents and schools to manage appropriately.

Recent research into ADHD services

I was fortunate enough to speak at an ADHD education event as part of the Greater Manchester, Lancashire and South Cumbria Strategic Clinical Networks. The event was to hear about the research that formed the basis of a report called ‘Delivering Effective Services for Children and Young People with ADHD‘ from the ADHD Project Group (CAMHS Clinical Advisory Group). I was there to deliver a workshop alongside two other consultants to help implement recommendations in developing a multi-agency care pathway and in supporting clinical practice.

It was a fascinating event for lots of reasons and, for me, highlighted the significant variance in clinical commissioning across different areas of England.

What the research suggests

The following identifies information and research from the report to help SENCOs manage the way ADHD is perceived and approached in their school.

Information and signposting

The report gives information on age-appropriate diagnosis and interventions (such as medication, programmes to support families, diet, self-help strategies etc.), for example, many children enjoy and benefit from hearing the views and perspectives of other children with ADHD.

Diet

Recent studies suggest that some children with ADHD may respond to dietary interventions or removal of food colourings or polyunsaturated fatty acids supplementation. It is important to be guarded however and more research is required before these become part of routine therapeutic options (NICE, 2013; Gillies et al, 2012; Sonuga-Barke et al, 2013).

Behavioural strategies

Klassen et al (1999) suggest that whilst the size of effective behavioural management interventions are smaller than those reported for pharmacological interventions this may be due to the development of therapeutic packages that are bespoke, and therefore personalised to the specific comorbidity of an individual need.

Parent/carer based interventions

Some parent/carer based interventions demonstrate limited impact on school-aged children (Zwi et al, 2011) but do demonstrate an increased impact on ADHD symptoms for pre-school children. It is therefore important that early-intervention support is given to parents/carers to ensure increased impact. Programmes such as Triple P (Sanders, 2008) and the Incredible Years (Webster-Stratton & Reid, 2010) have been shown to be effective (NICE, 2013). The key aim of these interventions is to promote child-parent interactions and promote positive strategies and confidence.

What to read next from Optimus Education

• Working memory, ADHD and G&T: developing meta-awareness
• In-House Training course – SEND: Hidden disabilities: ADHD and autism
• Expert Answer – As a TA working with a child who has ADHD, do I have a right to know what medication the child is on?

Sleep strategies

Lack of sleep can exacerbate ADHD symptoms. A recent randomised control trial in Australia has shown promising results with a brief intervention on sleep and 5-12 year olds (Hiscock et al, 2015). A blog post from the NHS also provides useful general advice which may help parents/carers support their children.

School support

It is important that classroom and school-based strategies support the young person directly and minimise the impact of their symptoms on their learning (NICE, 2008, 2013). Access to specialist advice and support is essential. (ADHD specialist nurses, consultants, specialist teacher and support teams etc.)

Medication management

There has been a lot in the news recently about medication and ADHD. For example, a report on the call for more research into the drug Ritalin, and an article from ScienceDaily on how taking drugs for ADHD can lead to bullying. Whilst I see medication as a significant part of the support for young people with ADHD, I agree with recent findings that better designed trials are needed to assess the benefits of methylphenidate. The Voices Report (2015) by ADHD Voices provides excellent advice on common concerns that children with ADHD have about their needs and medication.

So what is important?

During some external work with a large local authority this week I was interested to find out that many SENCo colleagues were not aware of the care pathways for ADHD in their area.

Advice you can take away from this post is:

• find out the routes to support and care pathways for your area
• establish contact with key colleagues (consultants, specialist nurses etc.)
• ensure positive conversations are had with parents/carers about joined-up support and management (strategies, medication etc.)
• provide training for all school staff on positive classroom and school-based strategies.

I must give my thanks to Stockport NHS colleagues with whom I worked on the development of the ADHD Care Pathways and at the event. In particular, Dr Prathiba Chitsabesan (Project Lead & CAMHS Consultant), Dr Alison Jobling (Consultant Paediatrician) & Sally Trowse (ADHD Clinical Nurse Specialist).

Resources and references – developing ADHD care pathways

Meeting the needs of students with attachment

To meet the needs of children with attachment, we must have a realistic sense of the self and surroundings, and develop a non-confrontational attitude that provides a consistent positive role model. Some more general strategies to support students are outlined below.

• Create win-win situations – so that either ‘choice’ made by the student is a good one.
• Give clear, consistent guidelines and boundaries, yet allow some flexibility.
• Be honest and truthful, with sensitivity to the young person’s feelings.
• Give calm, measured responses in confrontational situations.
• Always endeavour to let them know it is their behaviour that isn’t liked, not them.
• Listen to them: hear what they have to say – but remember that they communicate in more ways than just verbally.
• Remember that the adult is responsible for helping young people make appropriate, positive attachments.
• Give them a safe, secure environment to express their innermost feelings, fears, hurt, etc.
• Plan with them for their adult life; help them to understand the attachment process and how they can be positive as an adult.

Why is attachment important in schools?

• There is a population of students in schools who seem unable to access learning, to engage and achieve, and to move on into adulthood with confidence; children whose diminished self-esteem and resilience are limitations on engagement in relationships and emotional and cognitive development.
• Early attachment research clearly indicated that secure attachment is the factor linked to children’s more successful engagement in school, in terms of social competence, curiosity, effective play and investigation and sympathy towards others. A secure enough start prepares the child to become the student.

Most importantly:

‘You might be the only adults who can make a difference in a child’s life’

‘You have the emotional skills and the resources to make that difference’

Attachment and the classroom

• In school, it is the teacher who is at the front line of student behaviour.
• Behind every child who misbehaves and underperforms in school there is a story; and the story is acted out in the classroom.
• Teachers are exposed to this stressful experience daily – adding to classroom tensions and challenges.
• Such powerful experiences are felt by the teacher who can begin to feel the helplessness, powerlessness and rage that some students are unable to bear and so project into others. Teachers need to be supported in such relentless encounters everyday in the classroom.

You can see my Supporting Students through Understanding Attachment guide for more information on attachment and its importance in schools.

Further reading

• Five ways to… learn about attachment theory (Optimus Education)
• Attachment theory: an introduction (Optimus Education)

Understanding and supporting students with attachment in school

In this two-part SENCology post, I will look at a complex area for SENCos: young people who have experiences of trauma or stress in early life or whilst in the womb – those with attachment needs. There is an increasing body of evidence that 21st Century children are more complex than previous generations, as reported by Special Children Magazine. In short, young people are surviving with complex needs; neonatal survival rates and advances in medicine mean that children with more complex needs are sat in our classrooms (‘the worldwide neonatal mortality rate fell by 40 per cent between 1990 and 2013’ – UNICEF).

An increasing proportion of the population are those who have experienced negative attachment during early life. As a SENCo, these young people can be extremely challenging. You will want to ensure that staff remain positive and are using a set of agreed strategies. Nevertheless, this can be very difficult when a young person is ‘testing to destruction’ their relationships with their teachers. In these two posts, I hope to offer some thoughts and advice after almost 15 years in working to support these vulnerable young people in our mainstream school environment.

So, what is Attachment?

• Attachment behaviour is there to ensure the survival of the child (originally proposed by Bowlby, 1969).
• Attachment is an affectionate bond between two individuals that endures through space and time and serves to join them emotionally.
• Attachment experiences are fundamental to emotional/social/physical/cognitive development.
• Good early attachments serve to promote resilience to later traumatic (life) experiences
• The foundation of attachment is the early main carer/child interaction.
• Its purpose is to enhance survival during infancy and promote adaptive development during the whole life span – based on the central dilemma of human life – the need for closeness and autonomy.
• Human infants are very vulnerable for a long time and need the presence and protection of carers who can assist in survival for some time.
• Being safe is the basis of survival.

You can see my Supporting Students through Understanding Attachment guide for more information on attachment and its importance in schools.

Further reading

• Understanding attachment difficulties (Optimus Education)
• The implications of attachment for behaviour and learning (Optimus Education)