PSYCHOPEDAGOGICAL INTERVENTIONS IN YOUNG SCHOOLCHILDREN WITH ADHD

PhD. PURCIA VALERIA ECATERINACounty Educational Resource and Assistance Center

"Ghe. Lazăr" National CollegeSibiu, Romania

Abstract: Attention Deficit Hyperactivity Disorder is a cerebral dysfunction frequently occurring in the case of children, being one of the most common disorders for this age. ADHD can be defined as a syndrome with an early debut (before the age of 7) and it consists of a combination of inattention, hyperactivity and impulsivity that persists in time, sometimes until adulthood. By means of the psychopedagogical intervention program we are now putting forward, we wish to offer parents and teachers information about ADHD and also provide a few simple and easy-to-use techniques which can be applied both in school and family.Keywords: ADHD, psychopedagogical intervention program, young schoolchildren, family, school.

Attention Deficit Hyperactivity Disorder, also known as minimal cerebral dysfunction, is a condition frequently occurring in children, being one of the most common disorders typical for this age. ADHD can be defined as a syndrome with an early debut (before the age of 7) characterized by a combination of inattention, hyperactivity and impulsivity that persist in time, sometimes until adulthood, occurring in individuals with normal mental development. When these symptoms become manifest they lead to difficulties in adapting to family, school and social environment. (Măgureanu, 2004) It is highly prevalent and has a strong personal and social impact, being often associated with other developmental or psychiatric disorders. It is a problem of psychic nature, which, although not permanently curable, can be kept under control. Researchers believe that a neurologically inattentive, hyperactive child is an individual with a hidden disability, who is in urgent need of intervention. (Sauvé, 2006) Irrespective of how severe the situation may be, the therapeutical strategies especially developed will help the young children to gradually lead a normal life. Through the psychopedagogical intervention program we have put forward we wanted to provide parents and teachers with information about ADHD, as well as with a few simple and easy-to-use techniques which could be applied in both school and family environment.

Research methodology

Research purpose:Studying the effectiveness of a psychopedagogical intervention to alleviate symptoms of Attention Deficit Hyperactivity Disorder in young schoolchildren. The program has been structured on three intervention axes: child-focused intervention;

family-focused intervention; teacher-focused intervention. The reason behind elaborating this program structure was to allow control and manipulation of the main levels at which the symptoms associated with Attention Deficit Hyperactivity Disorder become manifest: family level; school level; social level.

Research objectives:1. To study the effectiveness of the psychopedagogical intervention program concerning the alleviation of the major symptoms of Attention Deficit Hyperactivity Disorder in young schoolchildren: impulsivity; hyperactivity; inattention.2. To study the effectiveness of the program concerning the low level of socialization associated with Attention Deficit Hyperactivity Disorder, and to increase learning efficiency.

Research hypotheses:Getting the young schoolchildren diagnosed with ADHD involved in a psychopedagogical intervention program would lead to:1. Alleviation of the major symptoms associated with ADHD;2. Alleviation of the socialization difficulties associated with ADHD and an improvement in learning efficiency.

Methods and tools A. The interview B. The structured (quantitative) observation C. The experimentD. Raven Standard Progressive MatrixesE. Vanderbilt evaluation scales – Parent Answer Sheet Vanderbilt evaluation scales (monitoring) - Parent Answer Sheet Vanderbilt evaluation scales – Teacher Answer Sheet Vanderbilt evaluation scales (monitoring) - Teacher Answer Sheet (Wolraich, et all, 2003), adaptated by us with the author’s permission, on Romanian population, for Sibiu CountyF. The case study G. Statistico-mathematical methods

Population universeThe population on which this research was focused, and which provided the cases that lay at the basis of its elaboration, is represented by the sum total of the young schoolchildren in primary school that are on the records of the “Gh. Preda” Psychiatric Hospital of Sibiu for the February-March 2008 period, and who suffer from ADHD.

Selection of subjects For the proceedings of the research we have selected 33 cases of young schoolchildren with ADHD from the “Gh. Preda” Psychiatric Clinic of Sibiu, Department of Pediatric Psychiatry, according to the following criteria:

1. The child’s psychosocial profile: Presence of ADHD symptoms in behavior; Good level of development of the cognitive function – I.Q. higher or equal to 90 – mental age corresponding to chronological age. Low level of integration in school and social group. Low school performance.

2. Family: high interest in the child’s biopsychosocial development; quality of collaboration with school; interest in getting involved in a psychopedagogical intervention program.

3. Primary school teacher: interest shown in applying personalized educational techniques to the schoolchildren diagnosed with ADHD.

Criterion 1 – the child’s psychosociobehavioral profile Following the discussions with the specialist team from the Department of Pediatric Psychiatry concerning the schoolchildren with ADHD that were under observation and treatment, 33 children have been identified as follows: 21 pupils – 1 st grade, 6 pupils – 2nd

grade, 5 pupils – 3rd grade, 1 pupil – 4th grade. The selection of subjects has been made after interviews with the children’s parents and primary teachers, as well as according to the results obtained after the parents and primary teachers of the 33 children with ADHD filled in the Vanderbilt Scale for Primary Teachers and Parents. The scores obtained by each of the schoolchildren has been recorded in their individual charts, because of the methodological requirement of using these results in building the pre-test profile for each of the children that would eventually remain subjects of the experiment.It should be mentioned that until this stage of sampling, all the schoolchildren have met the requirements of the 1st selection criterion.

Criterion 2 – The Family The parents of the schoolchildren have been contacted, and during some meetings, have been explained the purpose, objectives and strategies of unfolding the program, along with the educational reponsibilities that they would have to undertake within the program. Also, these meetings have made it possible to evaluate the interest and resources of each family for the child’s education in general, and for the proposal of getting involved in an educational program, in particular.

It has been concluded that in the case of 6 children there is a weak response from the family regarding the collaboration for the proposed psychopedagogical program, and as a consequence, the children have been excluded from the program.that in the case of 6 children there is a weak rrr Following the interviews, 27 of the families have agreed to get involved in the program.The group under research was made up of : 18 pupils – 1st grade, 6 pupils – 2nd grade, 2 pupils – 3rd grade, 1 pupil - 4th grade.

Criterion 3 – The Primary Teacher During some meetings with the primary school teachers of the children with ADHD who remained beneficiaries of the program, they have been informed about the purpose, objectives and strategies of unfolding the program, along with the educational responsibilities they ought to undertake. All the approached primary teachers have responded positively, expressing their position of active supporters of the program.

Common problems of the selected cases:

The children selected in view of getting involved in the psychopedagogical program have been diagnosed as suffering from ADHD by the interdisciplinary team of the “Gh. Preda” Psychiatric Hospital of Sibiu, Department of Pediatric Psychiatry. Following the collecting of psychological, family, school and social data of the children, we could conclude that ADHD affects the children in all these respects. Consequently, they have a poor self-image, and strong inferiority feelings due to the difficulties they are faced with in school and in society. These difficulties have to do with a weak sensory-motion experience, partial lack of behavior control, deficient acquisition of skills needed for daily activities, as well as shortcomings in developing correct learning and social skills and abilities.

The stage of case construction Psychological profile – symptom evaluation Testing of cognitive function: It has been carried out based on the following tests: - Standard Raven Progresive Matrixes - development of cognitive function– I.Q. higher or equal to 90 in all examined subjects. -Vanderbilt ADHD Symptom Evaluation Scale for Parents and Primary Teachers

The pre-testing stage of the experiment Between March and April 2008 the aplication of the ADHD Symptom Evaluation Scale

for each of the 27 schoolchildren selected for being included in the program has been concluded, their results being recorded in their psychological charts (before becoming beneficiaries of the psychopedagogical program). 1. Evaluation of ADHD symptoms by the family (Vanderbilt ADHD Symptom Evaluation Scale for Parents) 2. Evaluation of ADHD symptoms by the primary teacher (Vanderbilt ADHD Symptom Evaluation Scale for Teachers)

The stage of experimental manipulation Full coverage of the stages of the psychopedagogical intervention program has been achieved between April and June 2008.

Stages covered for the application of the psychopedagogical intervention plan:Step 1: The parents observe the child’s behavior in the home. Step 2: The primary teacher observes the child’s behavior in school.Step 3: The parents and the primary teacher meet and talk about what they have observed concerning the child and highlight the worrying aspects that concern the child. Step 4: The parents meet the psychologist and share with him/her their observations, as well as those of the primary teacher; they also offer means of getting in contact with the child’s primary teacher: telephone number, his/her schedule in school etc.

Step 5: The psychologist innitiates an interview especially structured for the factors involved in the program: parents, child, primary teacher, from whom he/she may obtain data concerning the child’s educational and medical record. Step 6: The parents receive a number of brochures or information about ADHD, following which both them and the primary teacher fill in child behavior evaluation scales. Step 7: The scales filled in by both primary teacher and parents are examined by the psychiatrist. Step 8: Following the results obtained in the evaluation scales filled in by the parents and primary teacher, the psychiatrist determines the psychopedagogical intervention areas.Step 9: The psychologist ellaborates a psychopedagogical plan focused on the intervention areas established together with the parents and the psychiatrist. Step 10: The psychologist carries out, and the psychiatrist monitors the application of the intervention program, as well as the evolution of the child. The parents and the primary teacher fill in child behavior evaluation scales at the beginning and at the end of the psychopedagogical intervention program. (according to Feldman, 2007)

The Psychopedagogical Intervention Program

The program has taken into account the building of a home and educational environment that would favor the harmonious development of children with ADHD, by building a partnership that would involve the folowing intervention agents: The County Educational Resources and Psychopedagogical Assistance Center of Sibiu Manager – psychology professor Daniela Moldovan Psychologists / school psychologists:Valeria Purcia, Elena Morariu, Simona Crăciun, Simona Câmpean, Maria Opriş, Lidia Draghiţă, Silvana Şerb, Cătălina Nechita.The “Gh. Preda” Psychiatric Hospital of Sibiu, Department of Pediatric Psychiatry:Dr.Cornelia Acaru, primary care physician– child neuropsychiatry; Dr.Sanda Elena Barb, primary care physician - psychiatry; Dr. Angela Muntean, primary care physician – psychiatry; Răzvan Pleteriu, chief clinical psychologist, Laura Orlandea, chief clinical psychologist.The primary teachers and the parents of these children.

The interdisciplinary partnership has been designed on various intervention levels, in view of:-as full a coverage of the family, school and social levels where ADHD symptoms become manifest, as well as of the associated disorders; -identifying the basic educational principles in raising a child with ADHD;-identifying the main areas for psychopedagogical intervention in view of alleviating ADHD symptoms, as well as those of the associated disorders;-an active involvement of the intervention agents in controlling and alleviating ADHD symptoms in young schoolchildren, beneficiaries of the psychopedagogical intervention program;

Objectives of the psychopedagogical intervention program

General objective:Facillitating a global development of the children with ADHD included in the program

by means of creating a socio-educational environment adapted to their specific needs. Specific objectives:

1. Ensuring informational as well as formative aid needed by the parents of children with ADHD;2. Facillitating the professional optimization of the primary teachers working with children affected by ADHD;3. Facillitating the development of the communicative as well as of the socioaffective function in children affected by ADHD;4. Integrating the activities carried out by the members of the intervention team in a coherent educational and formative partnership to the benefit of the children who are subjects of the program.Beneficiaries of the psychopedagogical program: Children with ADHD Parents of children with ADHD Primary teachers of children with ADHDThe intervention team:Professionals: School psychologists The interdisciplinary team of the „Gh. Preda” Psychiatry Hospital of SibiuVolunteers: Parents of children with ADHD Primary teachers of children with ADHD

The unfolding of the informative/formative program for parents The program for parents has amounted to a sum total of 10 formative (weekly) sessions. The parents of children with ADHD have acted both as representatives of the family as well as beneficiaries of this formative course. Objectives:●Familiarizing the parents with: the particularities of the Attention Deficit Hyperactivity Disorder in young schoolchildren; the problems posed by ADHD; information connected with the psychology as well as with the diagostic criteria, with the particularities and difficulties that these children have to deal with along the learning and development process (in terms of behavior as well as social and school integration).●Observation and evaluation of the child’s behavior; making the parents aware of educational mistakes that may occur in the behavioral correction of a child with ADHD.●Improvement of atmosphere within the family; active listening; emotional communication; parent-child communication. ●Ways of reinforcing the parent-child relationship; focusing on the positive aspects of the child; unconditional acceptance; time dedicated to the child.● Acquisition of behavioral management notions, as well as of behavioral methods and techniques of positive disciplining by the parents; ●Rewarding of positive attitudes; designing a plan for viable behavior; types of rewards; solving problematic situations;●Co-operation with the child’s primary teacher; behavioral monitoring cards; daily plan; ●Increasing the child’s self-esteem; nurturing the child’s self-confidence; highlighting the positive achievements; increasing awareness of the distinction between the child’s behavior and person;●The influence of games in the therapy of children with ADHD; developing socialization abilities; suitable types of games and toys.

The unfolding of the informative/formative program for primary teachers

This program has amounted to a sum total of 7 of (weekly) formative sessions.

Objectives:●Familiarizing the primary teachers with the particularities of Attention Deficit Hyperactivity Disorder in young schoolchildren. Informing them about the set of problems associated with ADHD by offering them information concerning the psychological aspect and the diagnostic criteria, the particularities and difficulties that these children have to deal with along the learning and development process (in terms of behavior as well as social and school integration). ●School teaching-learning process; school adaptation; behavioral interventions; ●Well-established structure and routine; using the gradual system of structuring the class; the three „R”s: routine, regularity and repetition; careful monitoring of behavior; class management.●Acquisition of ergonomic principles and rules by the teachers that would offer the ADHD child a secure environment. ●Lessons that are as attractive as possible, getting the child involved in a work group; primary teacher-child interaction; combining verbal explanations with practical demonstrations.●Identifying behavioral problems; behavioral class management system; rewarding well-achieved tasks; ●Partnership among children; well-defined rules; co-operative learning; playing and socializing time.

Counselling children with ADHDObjectives: To enable the child to get over difficult emotional problems; To enable the child to achieve a certain congruity among thoughts, emotions and behavior; To make the child feel good about himself/herself To enable the child to accept his/her limits; To determine the child to change behavior that has negative consequences; To enable the child to function comfortably and in an adaptive manner in an external environment (both at home and in school); To create such conditions for the child that he/she could follow his/her development stages.

Result Analysis and interpretation

Age group distribution (school class) in the lot under study has been as follows: 18 pupils – 1st grade, 6 pupils – 2nd grade, 2 pupils – 3rd grade, 1 pupil – 4th grade (Fig. 1).

In this paper we have chosen to deal with the age group between 6 and 7 (1 st grade), which has turned out to be the most numerous one, further proof to a correct identification of the disorder by both parents and primary teachers mostly at the child’s entering the school system.

The next age groups are 7-8 years old (2nd grade), 8-9 years old (3rd grade). In contrast to this, the age group 10-11 years old (4 th grade) is significantly low in the studied lot.

This fact is in accordance with DSM-IV which requires that core ADHD symptoms should become manifest before the age of 7.

Figure 1 Age group distribution (school age) in the studied groupSex ratio – in the studied lot has been of 5,75:1. The distribution according to sex indicates the predominance of boys as compared to girls. These values are similar to those in the general population. (Fig.2) In children, ADHD is more frequent in males, with a sex ratio of 3,6:1. The difference between the sexes is highly significant. Girls diagnosed with ADHD are affected from a cognitive or attention point of view. (Ivanesei, 2008)

Figure 2 – Lot distribution according to sex ratio According to the degree of family disintegration (fig.3), in the group studied, 4 subjects out of 27 come from disintegrated families, however a cause-effect connection between the family environment and ADHD diagnosis could not be established.

Figure 3 – Degree of family disintegration in the studied lot

In the group analyzed according to ADHD subtypes, the combined subtype is predominant, the other ones ranking very low; a possible explanation would be that spotting children with a high degree inattention, hyperactivity and impulsivity was easier because this type of behavior can be perceived faster by parents and primary teachers. (Fig. 4). DSM trials and other subsequent clinical studies have shown that the combined type is predominant, as compared to the type where attention deficit prevales. However, because the

attention deficit subtype has the highest probability of being underdiagnosed, its prevalence cannot be deduced from clinical groups. (Iancu, 2007).

Figure 4 – Distribution of ADHD cases according to subtypes

The statistical processing – (SPSS, t test ) of data concerning the effects of the independent variable upon the dependent variables - has been carried out by means of the t test for the difference between the average of two dependent samples (pairs), by comparing the significant differences between the pair sample average data as following the results obtained from the pre-testing and the post-testing in the following tests:- Vanderbilt ADHD symptom evaluation sheet– filled in by parents - Vanderbilt ADHD symptom evaluation (monitoring) sheet– filled in by parents - Vanderbilt ADHD symptom evaluation sheet– filled in by primary teachers - Vanderbilt ADHD symptom evaluation (monitoring) sheet– filled in by primary teachers The t test concerning the difference between the average values of two dependent samples allows for the evaluation of the significance of the variation in a certain characteristic, in the same subjects, in two different situations (for example, “before” and “after” a certain condition has been acted out), or in two different contexts, irrespective of the moment when they become manifest. The advantage of this statistical model is that it captures the so-called “intrasubject” variation, because the calculation basis is represented by the difference between the two values measured for each subject separately. (Popa, 2008)Reporting the research results Considering that in all the obtained results the p value <0.05, the null hypothesis is rejected. It has been accepted as research hypothesis, that getting young schoolchildren with ADHD involved in a psychopedagogical program leads to:1. Alleviation of the major symptoms of Attention Deficit Hyperactivity Disorder:● inattention● impulsivity● hyperactivity2. Alleviation of the socialization difficulties associated with Attention Deficit Hyperactivity Disorder and an increase in learning efficiency, as observed from a sample of 27 subjects, for: Parent evaluation t.o5(26)= 9,36, p<0,05, ADHD prevalently inattentive subtypet.o5(26)= 11,19, p<0,05, ADHD prevalently hyperactive/impulsive subtype t.o5(26)= 12,23, p<0,05, ADHD combined inattentive/ hyperactive subtypet.o5(26)=6,o67, p<0,05, school efficiency / socialization Teacher evaluation t.o5(26)= 10,01, p<0,05, ADHD prevalently inattentive subtypet.o5(26)= 8,34, p<0,05, ADHD prevalently hyperactive/impulsive subtypet.o5(26)=11,13, p<0,05, ADHD combined inattentive/ hyperactive subtypet.o5(26)= 7,13, p<0,05, school efficiency / socialization

Psychometric data of the Vanderbilt Evaluation Scales

The reliability studies (by calculating the Cronbach alfa index) show a very high value (α > 0,70) for most of the sections in the scale referring to ADHD. The exception is the “anxiety/depression” section in the Vanderbuilt Evaluation Scale for Parents, where   α = 0,52. (Some authors consider as acceptable a value of 0.5 of the Cronbach alfa index in the case of scales with a small number of items: 10-15). This value is somewhat justified, since the section comprises a small number of items (7). There has been no further pressure to modify or replace the items in this section, because this paper has focused especially on the ADHD symptoms, and less on co-morbid disorders. The obtained data support the high psychometric qualities of the instrument in question. An “internally consistent” scale offers us the guarantee that the items of our instrument “go hand in hand”, that they measure the same psychological “construct”; nevertheless, this does not as yet allow us to affirm that it measures exactly what it purported to measure in the first place. (Popa, 2008) This problem has been checked through validation studies. Testing the validity by comparing the results obtained using the Vanderbuilt Evaluation Scales for ADHD to the result obtained using the CIM 10 Structured Diagnosis Interview shows that the instruments measure attributes and behavioral aspects which are similar but not identical. Research limitations ●The Vanderbuilt scales for the evaluation/monitoring of ADHD symptoms have a restrictive transcultural adaptation, for Sibiu County only;● The results obtained in this research cannot be generalized to the scale of the entire community in question. The factors that could influence it negatively are as follows: the nature and representativity of the sample; the manner of data collection; the period during which the research has been carried out; the various systematic error sources, among which the overevaluation of the obtained results by the evaluators, parents and teachers, respectively. However, this aspect may have a positive connotation, as far as the effectiveness of the proposed program, as well as the positive appreciation of results go.

Conclusions

● The processing and evaluation of the research data have revealed the effectiveness of the psychopedagogical program ellaborated by us, concerning the symptoms of attention deficit hyperkinetic disorder in young schoolchildren. ● The structure of this program (on three intervention axes: parents, primary teachers and children) has allowed for the control of the main areas of manifestation of attention deficit hyperactivity disorder (family, school and social ones), and its application has entailed significant alleviation in ADHD symptoms (attention deficit, hyperactivity, impulsivity), as well as in associated disorders (socioaffective integration, learning efficiency). ● The objectives of the program have been achieved, by developing both in parents and in primary teachers a set of educational and developmental abilities adapted to children with ADHD, as well as through their correct application by parents (in the family as well as social environment), by the primary teachers (in class), and by the school psychologists (in the school psychopedagogical counselling office), in view of relieving ADHD symptoms. ● The present paper meets the needs of school psychologists, teachers, parents and especially those of the children with ADHD, by offering a model of intervention in attention deficit hyperactivity disorder in young schoolchildren, a model which has aimed the following aspects of the problem in question:

- as full coverage as possible of the main areas of manifestation of attention deficit hyperkinetic disorder (family, school, social); - identification of the educational principles which are basic and mandatory in the raising of ADHD children; -active involvement of intervention agents (psychologists, psychiatrists, parents, teachers) in controlling and alleviating the associated ADHD symptoms, in young schoolchildren that were beneficiaries of the psychopedagoical intervention program; ● the psychopedagogical intervention programs can be an alternative for the parents that are resistant to the idea of medicating their child on an indefinite term, or for those children that develop intolerance to Strattera (atomoxetine), enabling an improvement in the lives of the children and of the family members alike. ● Behavior changing techniques, the training, educating and counselling sessions for the children, parents and teachers are enough for controling light forms of ADHD symptoms. Usually, behavioral interventions are used along with medication in the moderate and severe forms. ● The psychopedagogical therapy, initiated by specialists and later applied by the parents and teachers, represents a basic element in approaching children with ADHD. The psychopedagogical intervention program we have put forward could prove to be an effective learning tool for parents and teachers alike, by means of simple and easy-to-use techniques.

Bibliography:

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