Presentation Overview: This presentation will investigate attention deficit hyperactivity disorder (ADHD) from a neuroscience perspective in order to encourage teachers to view “deficit and disability” as variability, and to discuss how we can address variability in our teaching philosophies and pedagogies. The objective is to provide an understanding of the neurobiological basis of ADHD in order to make educators mindful of how students with ADHD function, to explain why we must change our views of what defines a “good” student if we want all children to be successful, and to discuss which types of management tools do and do not help students with ADHD succeed in the classroom. This presentation is grounded in a vignette about the struggles of teaching a child with ADHD, and the discovery that sensory stimulation engendered focus for this particular child. To address why teaching children with ADHD is challenging, the presentation moves through a description of ADHD, the role Barkley’s theory played in constructing our perceptions of ADHD, and the structural imaging data on ADHD. Next, to understand why sensory stimulation worked for the vignette child, Moderate Brain Arousal theory illuminates dopamine system dysfunction and low arousal as the cause of hyperactivity and distractibility in children with ADHD. Finally, to encourage a change in teaching philosophy and practice, the presentation concludes with implications for the classroom, and a discussion of how we might change our perception of what it means to be a “good” student to account for variability within and across learners, not just those with ADHD.
Background Research and Slide Explanations
Slide 1: Title Slide
Slide 2: ADHD in the Classroom: The Story of Sean
Any teacher knows how difficult it can be to have a child with ADHD in their classroom. It seems like the child is focused on everyone except you when you are giving a lesson, and everywhere but his book when it comes time to read. In my 2nd grade collaborative team teaching class I had a child with undiagnosed ADHD. During whole class lessons his eyes were everywhere but on me. They darted from Sara’s shoelaces to the books in the library, to students behind him, or to the marble jar beneath the whiteboard easel. His hands were constantly rubbing the carpet, playing with scraps of paper, or tying and untying book basket labels. During independent work, Sean constantly sharpened pencils, watched classmates, looked out into the hall, or crumpled the corners of his papers. It felt like we were on an emotional rollercoaster together everyday. I kept trying to find things to praise him for, trying to give him little pep talks about paying attention. He kept trying to “do the right thing,” follow directions, stay on task, but inevitably, he would become hyperactive and distracted. We went in circles all day, and in the end I think we both felt like we were disappointing each other. Sean’s problem was not a lack of motivation or effort to do well, it was his inability to attend for long enough to complete assignments or follow directions. We both had the same goal: for him to learn and feel good about himself while doing it, but we just couldn’t figure out how to get there.
Slide 3: ADHD in the Classroom: what finally worked for Sean
Half way through the year a small triumph occurred for Sean and me. I noticed on the rug that he was constantly and rigorously rubbing the carpet with his fingertips during lessons. I found some Velcro in my supply cabinet and asked Sean what he thought about me putting it under the ledge of his desk so he could feel it while he was reading or doing independent work. He gave me an approving nod, and together we stuck the Velcro under the desk. To my relief and surprise, when Sean remembered it was there, he would rub it during independent reading. In doing so he was able to focus for longer periods of time. Of course this didn’t change everything for Sean, but it changed a lot for me. I realized that instead of changing Sean to fit into the classroom environment, I needed to change my perception of what paying attention looks like, and I needed to change the environment to fit Sean.
Slide 4: Purpose of my research
I wanted to understand why the Velcro “trick” worked for Sean. So, I began with the following questions: What is ADHD? What are the theories that surround ADHD? What are the neurobiological underpinnings of ADHD? How will understanding this help me avoid the “emotional rollercoaster” route of teaching a child with ADHD? Ultimately, what are some evidence-based tools and ideas teachers can use in the classroom to make learners with ADHD successful? In addition, what do we need to change about the way we view and understand ADHD and other disabilities in order to teach all children effectively?
Slide 5: What is ADHD?
ADHD occurs in around 3-7% of children in the U.S. It is three times as prevalent in boys (Barkley, 1997). Some of the primary symptoms include inattention, distractibility, impulsivity, and hyperactivity (Sergeant 2000). In the United States, the DSM-4 is used to diagnose ADHD. There are three primary categories on the DSM-4: inattention, hyperactivity, and impulsivity. In the United States, these categories allow for three types of diagnoses: ADHD combined type, ADHD predominately inattentive type, and ADHD predominantly hyperactive-impulsive type (Castellanos & Tannock 2002). In Europe only the combined type is recognized as ADHD (Tannock 1998). This means that a child must show symptoms from all three categories to receive a diagnosis in Europe, whereas in North America, a child with just one symptom can be diagnosed. This explains why Europe shows only 1% of the childhood population as having ADHD (Sargeant 2002).
Give DSM-4 checklist from Tannock and Castellanos 2002 study for teachers to look over. Ask if any students come to mind as they skim through the diagnostic criteria and give teachers time to share these stories.
Explain that there is much variability that exists in diagnosing methods and criteria. For our purposes we are going to proceed by thinking about children like Sean. These kids may or may not be diagnosed, but they exhibit some or all of the signs of ADHD in our classrooms, and we find ourselves in day-by-day battles with them.
Slide 6: What is a “good student?”
Let’s start by talking about our ideas of what good students look and act like. At this point, have teachers talk amongst each other and then share their characteristics of a good student. Fill in the chart on the slide and discuss whether or not our idea of a child with ADHD fits this “good student” profile. This will hopefully illuminate the fact that these kids come into a place (school) where their behavior automatically makes them less than a good student in many people’s eyes. Often the emotional rollercoaster results when we try to fit them into the traditional student mold; well intentioned as we might be, it never seems to work.
Slide 7: Flow of this Presentation: Key Points
*Why Barkley’s Behavioral Inhibition Theory puts the burden of change on the child. *The neuroscience behind ADHD: structural and functional studies of differences in the brains of children with ADHD
*How Sikstrom and Soderlund’s Moderate Brain Arousal Theory can help us see why the Velcro worked and why we should put the burden of change on the classroom environment.
Slide 8: Key Points Continued
What this information means for the classroom:
*Examples of classroom interventions that don’t work for most kids.
*Examples of classroom interventions that might work if we’re thinking about Moderate Brain Arousal Theory.
*How can we change our ideas of what a “good student” is to allow all students to feel successful?
Slide 9: Barkley’s Behavioral Inhibition Theory (1997)
Barkley (1997) suggests that a deficit in behavior inhibition is at the core of ADHD. After reviewing evidence, Barkley found that children with ADHD are most likely to have deficits in behavioral inhibition, which will affect executive functions like working memory, regulation of motivation, and motor control. Barkley claims this is why they show impulsivity, cannot stay on task, and have trouble attaining goals (Barkley 1997). For the next few slides, we will unpack these terms.
Slide 10: Behavior Inhibition
Behavior inhibition is the ability to stop a response that would elicit instant feedback (positive or negative) and the ability to stop a response that has already started by self-directing to a behavior that is goal oriented (Barkley 1997). An example of a time Sean exhibited poor inhibition control was during independent reading. Any sound or movement his tablemates made would cause Sean to look around at them and then around the classroom. He was unable to inhibit his response to the noises and movements because looking around provided his body with instant gratification. In addition, even if he eventually realized he was off task, he could not re-direct himself to his reading. Sean liked reading and wanted to successfully finish his book during independent reading time. However, the goal of finishing a book provided no instant reward for Sean whereas looking around the classroom did. As Sean’s example shows, poor inhibition control eventually affects executive functions that depend on this control. We will define executive functions in the next few slides.
Slide 11: What are executive functions and why are they important in school?
Executive functions are associated with the prefrontal cortex. In a few minutes we will do a little Brain 101, so keep “prefrontal cortex” in mind. Even experts could not agree on a definition of executive functions. Eslinger noted that ten experts at the National Institute of Child Health and Human Development generated thirty-three definitions for executive functions (as cited in Tannock, 1998). This shows there is variability in how experts conceptualize these functions. Nevertheless, here are some of the terms associated with executive functions: self-regulation (of emotions, motivations, and arousal), sequencing of behavior, flexibility of thinking, response inhibition, planning and organizing, internalization of speech, and working memory (Barkley, 1997; Tannock, 1998). In Barkley’s view, the inability to inhibit a response leads to deficits in self-regulation, motor control, and working memory so we will focus on those terms.
Slide 12: Self-regulation and motor control
Self-regulation is the ability to regulate your affect, motivation, or arousal in service of a goal directed action (Barkley 1997). An inability to self-regulate will also affect one’s ability to self-direct motor control. Let’s think about Sean to visualize this executive function more vividly.
In regards to Sean’s reading time, self-regulation would have been Sean telling himself to get back to his reading after looking around at his tablemates. Sean’s inability to inhibit his “looking around the room” also made it difficult for him to self-direct his body (motor control) to go back to reading. In this scenario, Sean could not self-regulate his motivation because the reading goal was less immediate than responding to tablemates and sounds around the room.
Slide 13: Working Memory
We are going to focus in on working memory, the ability to store and manipulate information in your mind (Rose, T., Lecture at Harvard University, October 16, 2009). In Sean’s case, each time he was distracted by his tablemates, he lost the goal he was holding in mind (to finish his book before the end of independent reading, for example). This is an example of how an inability to inhibit certain behaviors becomes taxing on working memory.
It makes sense that Sean has trouble getting back to the reading goal once he is distracted because the goal has dropped out of his working memory. Next we will talk more about how a working memory deficit affects the ability to plan, organize, and hold a goal in mind. Finally, ask teachers to think about all of the working memory related tasks that we ask of children.
Slide 14: “Working Memory Task”: The Gorilla Video
I will introduce the gorilla video as a working memory task. After playing it, I will explain that most kids with ADHD see the gorilla (Rose, T., Lecture at Harvard University, October 1, 2009). Next, I will talk about what we as teachers mean by “goal oriented behavior.” When Barkley (2007) said children with ADHD have trouble with regulation of motivation, he was talking about the fact that they have difficulty staying motivated by an intangible goal. Instead, a child with ADHD is more likely to be motivated by more salient stimuli in the environment that provide instant gratification. When I think about Sean, he was always turning to instant gratification instead of working towards a long-term goal. The reading was one example of that. Barkley helps us see that kids with ADHD have trouble working towards a goal because it is difficult for them to inhibit behavior and delay gratification. On top of that, once they are distracted, the goal we gave them is no longer in their working memory (Rose, T., Lecture at Harvard University, October 16, 2009). However, there are some pieces and explanations missing from Barkley’s theory.
Slide 15: Gaps in Barkley’s Theory
Barkley’s theory gives us the impression that if children with ADHD would just learn to inhibit their behaviors, then they could achieve academic success. It puts the responsibility of change on the child. It describes the behaviors children with ADHD exhibit, but does not acknowledge that these behaviors and their effects (distraction, losing sight of goals, etc.) have an underlying cause that neuroscience can shed light on. Barkley’s theory, while it was instrumental in jumpstarting a lot of the ADHD research, leaves out the neuroscience perspective. It leaves out the answer to the question why does the child with ADHD see the gorilla? Why does Sean attend to his tablemates and not his book? Why are these things a form of instant gratification for the child? These whys are missing from Barkley’s theory. His theory helps us to identify many of the behaviors associated with ADHD. However, the absence of neuroscience, and the omission of an answer to the question, “why are these behaviors happening?” is the reason for many of our misinterpretations of the motivation behind the behaviors of children with ADHD. Sikstrom and Soderlund (2007) can answer these questions for us with Moderate Brain Arousal theory. However, before we get to that we will do a little Brain 101 and then look at some of the structural and functional studies of children with ADHD.
Slide 16: Brain 101
The brain is made up of neurons, which are specialized brain cells that receive and transmit information (Banich 2004). Neurons only account for some of the cells in your brain (there are all kids of other cells with other jobs). There are around 100 billion neurons in the brain and about 30,000 neurons could fit in the head of a pin (Rose, T., Lecture at Harvard University, September 3, 2009). Neurons communicate with electrical and chemical signals (Banich 2004). The firing of a neuron is called an action potential and it’s important to know that this firing is an all-or-nothing process. In other words, the cell either fires or does not fire (Banich 2004). Neurotransmitters like dopamine are chemicals that help neurons communicate (Banich 2004).
There are many structures in the brain, but we are going to focus on the cerebral cortex, or the outer most layer of the brain. The brain tissue of the cerebral cortex is folded continuously so that more brain tissue can fit into a smaller space (Banich 2004). We talk about the cerebral cortex in terms of four lobes: occipital, parietal, temporal, and frontal (Banich 2004). For our purposes we’ll focus on the prefrontal cortex within the frontal lobe, which is a big part of what makes humans unique. The frontal lobe houses the executive functions and allows us to organize behavior and even plan and think about consequence or rewards of future behaviors (Banich 2004). It’s important to look at the brain when we’re talking about children and development because it provides another level of analysis that can make the picture more complete.
Slides 17 and 18: Neurobiological Underpinnings of ADHD: Structural and Functional Differences
Rosemary Tannock (1998) performed a comprehensive review of structural and functional imaging studies of ADHD. Overall, structural MRI studies showed differences in prefrontal cortex, basal ganglia, and corpus callosum. Functional differences seen using event-related potentials (ERP’s) showed that children with ADHD do not perform as well as controls on sustained attention tasks (Tannock 1998).
Slide 19: Variability and Careful Interpretation!!!
Tannock (1998) mentions that we must interpret these findings with care. It is also important to note that brain imaging has limitations. Many of the images are averaged, which hides the incredible variability that exists within and across learners. Some of the differences found in the studies could be a result of averaging, small sample size, or even co-morbidity in the children with ADHD (Tannock 1998). It’s important to remember that we cannot have a “one size fits all” explanation or intervention for ADHD. In essence, many of these findings still leave us asking why.
Slide 20: We Sill Want to Know Why!
Even if the findings have some validity, they still do not help us explain behaviors and come up with strategies for helping children with ADHD in the classroom. In addition, it’s important to remember that all individuals show subtle differences in brain structure and function. We are still left wondering why children with ADHD exhibit the behaviors they do, which we can learn from Moderate Brain Arousal Theory. Knowing why will prevent us from confusing the behaviors of children with ADHD with their intentions.
Slide 21: Sikstrom and Soderlund’s MBA Theory: Dopamine
According to Sikstrom and Soderlund (2007) people with ADHD have a dysfunctional dopamine system. Dopamine is a neurotransmitter. Neurotransmitters are chemicals that help the brain communicate. They each have a unique shape. Dopamine can affect motor functioning, cognition, reward systems, the endocrine system (hormone regulation), and more. Dopamine affects many processes in the brain. Everyone has a certain level of dopamine present without stimuli from the environment. This is called your tonic level of dopamine. Children with ADHD have lower tonic levels of dopamine (Sikstrom & Soderlund, 2007). As a result, they have higher stimulus-driven dopamine release to keep their dopamine levels regulated. The video in this slide will talk a little bit about dopamine, examples of what releases dopamine, and why dopamine is important.
Slide 22:Dopamine: ADHD v. “Normal”
This slide shows two graphs from Sikstrom and Soderlund’s paper that can help people visualize what they mean by dopamine dysfunction. Graph A shows the absolute dopamine levels of children with ADHD compared to a control group. It shows that children with ADHD have much lower baseline levels of dopamine in their system than controls. Graph B shows relative total dopamine (phasic), which means dopamine in relation to stimuli. It is clear that children with ADHD have larger phasic responses than controls.
The continuously present (tonic) levels of dopamine in people with ADHD are lower than most people’s. This means that their baseline arousal level is lower as well. A person’s baseline arousal level is their normal amount of brain activity and it determines their sensitivity to the environment (Rose, T., Lecture at Harvard University, October 22, 2009). Children with ADHD require more stimuli to get to the same arousal level as normal children. As a result of being under-aroused, only very salient or novel stimuli boosts the arousal level of kids with ADHD to a normal level. For example, if we think of Sean as under-aroused during a lesson, my “teacher voice,” which he hears all day, is neither salient nor novel. However, my co-teacher stapling up self-portraits in the back of the room is extremely salient and novel for Sean, so he turns his attention to that stimulus. Next, dopamine releases in his brain as a response to this external stimulus. According to Sikstrom and Soderlund (2007), Sean’s phasic dopamine response (dopamine release in response to external stimuli) is stronger than a normal child’s to compensate for his low tonic dopamine levels. This dopamine release is a reward for his body. As a result of situations like the one I described with Sean, people with ADHD become hypersensitive to their environments. The high levels of dopamine released in response to environmental stimuli condition the body to seek out external stimuli because it is highly rewarding.
Slide 24: Stochastic Resonance
Sikstrom and Soderlund (2007) believe that there may be a way to bring kids with ADHD to a moderate arousal level so that they don’t have to constantly use environmental stimuli to achieve normal arousal. The idea is that noise (in any modality) imported through the perceptual system to the neural system can help compensate for the low levels of dopamine and under-arousal of kids with ADHD. Sikstrom and Soderlund (2007) define noise as, “continuous environmental stimuli that are irrelevant to the cognitive task” (p. 1063). They explain the use of noise to boost arousal level with stochastic resonance, a phenomenon that occurs in threshold systems. Stochastic resonance is the idea that noise in the external environment can cause detection of stimuli that are normally under detection threshold. The amount of noise is dependent on the person’s natural arousal level. In the case of children with ADHD, because their normal arousal levels are low, they require more noise than others to be at an arousal level that allows for effective cognitive functioning (Sikstrom and Soderlund, 2007). Cognitive functioning in this context refers to any mental process dealing with perception, thinking, and reasoning about ideas. It is important to keep in mind that extremely low or extremely high levels of noise can be detrimental instead of helpful.
Slide25: Why did the Velcro work and why do children with ADHD see the gorilla?
Looking back, we can see that paying attention to the gorilla or rubbing the Velcro are examples of an under-aroused child seeking out external stimuli to bring themselves to a moderate arousal level. A child with ADHD has a baseline arousal level that is lower than most other children. Therefore, a “normal” noise or movement in the environment will not get them to a normal arousal level. Instead, they seek out novel, salient stimuli like the gorilla, the Velcro, or in Sean’s case, my co-teacher stapling self-portraits to the wall. Next we will look at some other examples of how external “noise” in the environment can boost arousal levels.
Slide26: Listen to the Noise
Soderlund and Sikstrom along with Smart (2007) provided evidence for their theory by testing the effects of auditory white noise on a group of children with ADHD and a control group. Remember that noise can be the Velcro, or a song you know by heart that you don’t have to attend to, as long as it is just in the background. In the study, the noise created a positive effect for children with ADHD. During a memory recall task, children with ADHD increased their number of correct answers with noise as opposed to without noise. The task involved listening to 12 sentences and then attempting to recall as many of them as possible in 2 minutes. In addition, the control group showed impaired performance with the addition of white noise during the memory recall task. The graph helps us see that children with ADHD, who are normally under-aroused, can increase their cognitive performance with the right level of noise to bring them to a moderate arousal level.
Slide 27: Another Example of Optimal Arousal
Before the MBA theory existed, Abikoff, Courtney, Szeibel, and Koplewicz (1996) did a study on the effects of auditory stimulation on arithmetic performance in children with ADHD. They had twenty boys with ADHD and 20 control group boys work on arithmetic tasks under three different conditions: with music (high stimulation), with background speech (low stimulation), and in silence (no stimulation). They found that with music, children with ADHD increased their number of correct answers by 33%, compared with their performance during speech and 23% when compared with silent conditions. In contrast, the control group averaged 9% fewer correct answers when listening to music during arithmetic. Here we will look at a graph that shows the ADHD group did significantly better with music, but not with speech (the speech in this experiment was a news broadcast). The researchers explain this anomaly by guessing that the music was more appealing than the speech, therefore, ADHD children do better when presented with a stimulus they find more appealing. However, if we look at MBA theory, which these researchers didn’t have the benefit of doing in 1996, it sheds light on another possible explanation. In my opinion, it was more than just the fact that the music was appealing to the kids. It could be that the music provided the right level of noise to create an optimal arousal level, whereas the speech was not salient enough to boost arousal levels so it had no effect. In addition, the kids were allowed to choose their favorite music, which means they probably knew the music by heart. This means the music was a form of background noise, not something they had to focus on to understand. How can we analyze this thinking about the dopamine levels discussion we had earlier? We can also think about it in terms of Sean. What effects would the Velcro rubbing have on non-ADHD children during reading? (Let teachers discuss).
Slide 28: What Doesn’t Work: Minimizing distractions can increase hyperactivity, behavior contracts in light of MBA theory
Now that we have some background information on ADHD, let’s think about some strategies that don’t work for kids with ADHD. Therapy books such as Brain-Based Therapy by Arden and Linford make suggestions such as “minimize distractions” (2009, p. 139). The book makes several logical suggestions such as breaking down tasks and using multi-sensory instruction. However, I want to focus on the idea of minimizing distractions because it is a common suggestion and can be counterproductive in the classroom for children with ADHD when we think back to MBA theory.
When youngsters with ADHD are distracted or hyperactive, they might actually be seeking out a form of homeostasis. In attending to external stimuli, or stimuli that seem irrelevant to the task at hand, they are self-regulating their arousal level. If these kids need an external source of stimulus to boost their arousal level (and in turn their ability to focus and think about the task at hand), then putting them in an environment with no salient stimuli will only make them more hyperactive. I always thought sitting Sean front and center on the rug would help him attend to the lesson. However, it never seemed to work. He was still looking behind him, behind me, at Sara’s shoelaces, etc.
Let’s think back to our “good student” ideas. A common strategy, and one I know I’ve used, is the behavior contract. There are obviously some students for whom a behavior contract can work. However, for a child with ADHD, giving them a contract with “good student” goals like staying on task, not interrupting neighbors, or not calling out is ignoring the root of the problem. These contracts, even if managed in small increments, can be frustrating for the child and for the teacher because often times they do not develop consistent behavior. Instead they simply serve as a record of the daily battle the child faces between the need for external stimulus to boost arousal and the expectations that he “stay on task.”
Slide 29: What Will Work in the Classroom? Appealing Stimuli.
Some things that will work are things many of us already do: using color differentiation in charts and using novel stimuli to begin lessons. Let’s think of some examples of novel stimuli, such as things that move or perhaps things that appeal to modalities we don’t usually take advantage of. Let teachers brainstorm ideas.
Slide 30: What Works: Counterintuitive Strategies
There are several strategies that might have seemed counterintuitive before learning about MBA Theory. For instance, allowing a child with ADHD to listen to music while doing independent work might have seemed distracting before, but now we can see it might help kids with ADHD reach an appropriate arousal level. Keep in mind that in order for the music to be the right type of “noise,” it has to be a song or songs the child is very familiar with.
Also, sitting a child with ADHD at the front of the rug seems like it would focus him, but in reality, it limits the amount of stimuli in their environment (when I sat Sean at the front of the rug, he was constantly turning around at the slightest sound or movement anyway). So, sitting the child at the back of the rug might give them a good amount of background “noise” while at the same time keeping your lesson in the center of his visual field. The same idea applies to choosing a good desk positioning for a child with ADHD. We don’t want to sit them against a wall, but also don’t want to sit them next to a window where the stimuli might be more salient than the class work. We have to remember that finding the right amount of noise is a balancing act.
Finally, when kids with ADHD are calling out, take a minute to think about whether their “blurting out” is on topic with the lesson or not. If it is, decide how important is it to constantly remind them in front of everyone that they must raise their hand? Doing so is not only emotionally taxing for the child, but it will probably cause them to tune out the rest of the lesson.
Slide 31: Reality of the Classroom: Making goals available in the environment
We all know that we probably won’t always have a lesson that captures the attention of every student, and we won’t always be able to calibrate the right level of “noise” for all children to be at their optimal arousal level. So, thinking back to working memory, we need to make our goals clear and have them available in the environment. While it seems simple and we do it occasionally, many of us often forget to write goals on the board during independent work. Another idea is to give kids some time once they get back to their desks to write down what they need to do, or sketch it out, and ask questions if they have any. We should be explicitly teaching these kids strategies for when they get distracted and need to reorient to the task at hand.
Slide 32: What works? Adjusting to Variability.
As teachers we are skilled observers. Take time to see what works best for individual kids because there is so much variability. Velcro might not work for all kids, but I knew Sean was a particularly tactile child. You know your kids, so try to tap into that knowledge to come up with strategies that might work. Focus less on what behaviors you want to see from them, and more on what environmental changes can help them reach their learning goals.
Slide 33: How can we change our perceptions of what makes a good student?
Allow teachers to brainstorm new ideas for what makes a good student. Here are a few conversations to expect or encourage:
*We need to think about what our learning goal is, and then decide if the child’s behavior (even if it might not be a behavior we prefer) is getting in the way of the goal, or helping them accomplish the goal in a way best suited to their body. (For instance, if a child wants to stand or rock while writing, or if a child wants to feel something to get tactile stimulation while reading, these behaviors might actually be facilitating their independent work even if they don’t look “right.”)
*Things that can help children with ADHD will probably help other children as well. For instance, having the learning goal available in the environment, breaking down tasks into single-step instructions, making learning materials stimulating, and allowing kids to move around more freely.
*Is ADHD a deficit?
*What role does the environment play in our classrooms?
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