Helping Learners with ADD/ADHD to be Successful

by Sarah Jaffery, Pharm.D., PGY1 Community Pharmacy Practice Resident, University of Maryland School of Pharmacy

Most educators will agree that ensuring each student has an effective learning experience is no easy task.  This becomes all the more daunting when teaching students with learning difficulties. A well-known disorder that may act as a barrier in the learning process for students is Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD). ADD/ADHD is commonly thought of as a pediatric disorder, but up to 65% of children diagnosed with this disorder continue to have symptoms into adulthood.¹ More than 4% of adults are estimated to have ADHD.²  Although ADD/ADHD is not considered a learning disability, it can certainly have detrimental effects on daily functioning including impairments in educational performance.¹ To be an effective teacher to a student with ADD/ADHD, it is necessary to have an awareness of the medical components of this disorder, a solid foundation in behavioral management, and proficiency in instructional design.³

According to the diagnostic criteria for ADD/ADHD, adults who are not diagnosed during

childhood need to exhibit five or more inattentive and/or hyperactive-impulsive symptoms for at least six months.  These symptoms need to be severe enough to interfere with social, academic, or occupational functioning. Inattention symptoms might include difficulty remaining focused during lectures; beginning tasks but quickly losing focus and getting sidetracked; difficulty keeping materials in order; poor time management; failure to meet deadlines; and losing belongings such as school materials, wallets, keys, and paperwork. Hyperactive-impulsive symptoms include leaving one’s seat during a class; feeling restless; inability to stay still for a long period of time; talking excessively; and interrupting or taking over what others are doing.⁵ Not only do these behaviors make it more difficult for the adult with ADD/ADHD to be successful in school, but they can be disruptive to other learners too.

Several strategies can be employed to foster a more conducive learning environment for students with ADD/ADHD. These strategies require the educator to spend extra time with students to ensure everyone is on the same page and working towards the same goal. An educator may suggest the following strategies to students with ADD/ADHD at the start of a class or learning experience:³

• Sit near the front with your back to the class to keep other students out of view and thus minimize distractions
• Participate in peer tutoring and cooperative/collaborative learning
• Study in an area with minimal stimuli
• Take extra time to complete tasks and assignments
• Set specific times and routines for studying
• Report to a mentor or study buddy who encourages assignment completion and organization

Educators’ views and beliefs regarding their learners influence how they approach teaching. These views guide instructors’ ideas about which methods of teaching best suit the learner’s needs. A research report developed by the Learning & Skills Research Centre of the UK aimed to propose an alternative way for educators to think about learning and suggests a more person-centered and well-informed approach to teaching students with learning difficulties. First, a variety of teaching strategies / methods should be used - not just one. Next, there should be a focus on the purpose of learning rather than the outcome, as this takes into account the emotional and psychological aspects of learning and promotes participation. In addition, the learner’s fundamental values, stage of development, inclinations, and capabilities should be explored and should guide the teaching. Finally, to teach effectively, learning activities should take place in controlled settings (e.g. in the classroom and labs) as well as real-life (e.g. at home and on the job). This will help students test and apply the knowledge learned in a controlled setting in situations meaningful to them. Moreover, it provides opportunities for interactions with and to learn from people other than the teacher.⁴

Another strategy to help students with ADD/ADHD improve their learning capacity is teaching metacognition, or thinking about learning. Studies have shown that students who utilize metacognitive strategies tend to be better learners. Given that students with ADD/ADHD do not typically thrive in academic settings, they may benefit from training in metacognitive thinking. A study conducted in children and adults with ADD/ADHD demonstrated that training students to adopt metacognitive strategies is helpful.⁶ Students were coached to think about and monitor their learning. They were taught active reading strategies, listening skills, and organization skills, among others. There was an emphasis on being attentive when listening and studying as well as organizing and creating material to help with recall. This work resulted in positive outcomes including decreased inattention symptoms and improved academic/intellectual functioning.⁴ A more recent study explored the efficacy of a 12-week metacognitive therapy group intervention, focused on time management and organization, in adults with ADHD.⁷ Strategies used to promote metacognition in this study included teaching practical skills like using a daily planner, along with time management skills to help them organize and complete complicated projects. There were significant improvements in ADHD symptoms of those participants in the metacognitive therapy group when compared to the symptoms of participants in a control therapy group. It seems intuitive that training the brain to reflect on one’s learning, something that individuals with ADD/ADHD have difficulty doing, would be a beneficial behavioral technique.

It is clear that teaching is less effective using a one-size-fits-all approach. Creating an effective learning environment requires effort from both the educator and the student. For the educator, it is important to understand the medical aspects of ADD/ADHD as well as to be skillful in behavioral management and instructional design. If the educator has an in-depth knowledge regarding a variety of teaching approaches that can be used to meet the individual student needs, the likelihood of success is greater.

References:

1. Adler LA. Epidemiology, impairments, and differential diagnosis in adult ADHD:introduction. CNS Spectr. 2008;13:8(Suppl 12):4-5.
2. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the UnitedStates: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006. 163(4):716-732.
3. TeacherVision: Teaching Children with ADHD. [online] 1998 Sept. ERIC Clearinghouse on Disabilities and Gifted Education. (Accessed 2015 Mar 24)
4. Dee L, Devecchi C, Florian L, et al. Being, having and doing: theories of learning and adultswith learning difficulties. LSRC Research Report.
5. Rabiner D. New Diagnostic Criteria for ADHD. Attention Deficit Disorder Association. (Accessed 2015 Apr 1)
6. Thompson L and Thompson M. Neurofeedback combined with training in metacognitive strategies:effectiveness in students with ADD. Appl Psychophys Biof. 1998. 23(4):243-263.
7. Solanto MV, Marks DJ, Wassersein J, et al. Efficacy of meta-cognitive etherapy for adult ADHD. Am J Psychiatry. 2010;167(8):958-68.

Teaching Empathy

by Kumaran Ramakrishnan, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

To teach the pathophysiology of Parkinson’s, a teacher can use a lecture with a PowerPoint. The lecture can teach the pathophysiology of the disease or the therapeutic guidelines for treating the symptoms.  But how can the student learn empathy for a patient with a debilitating condition like Parkinson’s disease?  Or how to understand and relate to the patient?  Numerous articles have been published stating that empathy increases not only are the patient’s positive perception of the physician but also health outcomes. One study found that patients who’s physicians had high empathy scores were more likely to achieve better disease control as evidence by lower A1c and LDL-C measurements.¹ Similar results have been seen in patients with the other disease states such as the common cold. The Accreditation Council for Pharmacy Education (ACPE) requires schools of pharmacy to include empathy in the curriculum in order to provide high quality health care to patients with diverse backgrounds.

http://ezradew.com/wp-content/uploads/2013/12/empathy-.jpg

Unfortunately health professional students become less empathetic as they progress through school. One longitudinal study of medical students found the greatest erosion of empathy was in the third professional year.² This erosion of empathy appears to occur when students focus too much on applying their classroom-based knowledge to real patient situations.  A similar longitudinal study has not been conducted in pharmacy students, but there have been reports that interventions can increase empathy among pharmacy students at different stages in their career. 

One study conducted in the second professional year of pharmacy school, engaged students in simulation activities.  Students were asked to act as though they had lost the use of their dominant hand, vision, and speech. There were small and large group discussions after each activity to engage the students.³ The Jefferson Scale of Empathy-Health Profession (JSE-HPS) was administered before the interventions, seven days, and ninety days after these activities. The JSE is a tool designed to measure empathy in medical students, and JSE-HPS has been adapted for other health professionals.⁴ The tool is widely used in studies to measure empathy for both students and practitioners alike. The results showed that while there was an increase in the scores seven days after the activities, JSE-HPS scores returned to baseline 90 days later. When comparing the scores with a control group, there is little difference in the net increase in empathy scores.³ 

In another study, students watch a play featuring two actors — an elderly patient with a “demanding personality’ and an assistant manager who “cared more about rules and regulations than the elderly person’s concerns.” After the play, students engaged in a discussion about the stimulated encounter and how they would use the information in the future. The JSE was administered before the play, immediately after the play, seven days, and 26 days later. Similar to the previous study, while there was a significant increase between the pre-test and immediate posttest, by day 26, the scores were nearly back to baseline.⁵ 

Several other methods have been employed to teach empathy.  Students have been asked to keep a nutritional diary,⁶ participate in a 7-day active learning assignment about diaetes,⁷ and use community resources for patients with a chronic disease.⁸ All of these studies show short-term increases in empathy but scores return to pre-intervention levels in the long run. This provides a unique challenge as any method used must not only increase empathy but maintain it. A solution might be use interventions throughout the curriculum. Accrediting agencies, such as the Accreditation Council for Pharmacy Education, have incorporated empathy into their standards. The ACPE standards mention empathy has an important component of professional communication, ethical behavior, and professionalism. Since empathy is such an important trait for effective health care professionals to possess, it is essential for teachers to understand how to teach empathy.  The studies have shown that several methods, while effective in the short term, have little effect in the long term.  For students to learn empathy and be effective professionals it is important to integrate empathy exercises throughout the curriculum – not just in one isolated course. 

References:

1. Hojat M, Louis D, Markham F, Wender R, Rabinowitz C, Gonnella J.  Physicians' empathy and clinical outcomes for diabetic patients. Acad Med. 2011;86(3):359-364.
2. Hojat M1, Vergare MJ, Maxwell K, Brainard G, Herrine SK, Isenberg GA, Veloski J, Gonnella JS. The devil is in the third year: A longitudinal study of erosion of empathy in medical school. Acad Med. 2009 Nov 2009;84(11):1182-91. 
3. Lor K, Trong J, Ip E, Barnett, M. A randomized prospective study onoutcomes of an empathy intervention among second-year student pharmacists . APJE. 2015;79; Article 18. 
   
4. Fjortoft N,Van Winkle L, Mohammadreza H. Measuring empathy in pharmacy students. AJPE 2011;75: Article 109.  
5. Van Winkle L, Fjortoft N, Hojat M. Impact of aworkshop about aging on the empathy scores of pharmacy and medical students. AJPE. 2012 2012;76: Article 9. 
   
6. Whitley H. Active-learning diabetes simulation in an advanced pharmacy practice experience to develop patient empathy. APJE. 2012;76; Article 203. 
   
7. Trujillo J HY. A nutrition journal and diabetesshopping experience to improve pharmacy students’ empathy and cultural competence. APJE. 2009 37; Article 37.
8. Chen JT, LaLopa J, Dang DK. Impact of patient empathy modeling on pharmacy students caring for the underserved. AJPE. 2008,;72: Article 40.

Narrative Evaluation System

by Caroline Kim, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy 

Years ago, I attended elementary school in South Korea. My report card consisted of a letter grade accompanied by a short narrative from my teachers.  These comments stuck with me more than the grades.  They gave me insight into my performance beyond numbers.  They explained areas where I needed to improve — even if I earned a high grade — and areas where I did well despite a poor grade.  The finality of my letter grades was inescapable, but the comments were a source of motivation for further learning.

The purpose of evaluation in education is to guide student development, promote excellence, aid in defining the successful completion of a program, and provide performance evidence.¹  The traditional grading system might be effective in promoting high standards, but it fails to capture abstract details related to student performance. Traditional grading systems also provide little room for feedback to guide the future learning process.  I would argue that there is a need for a more effective method of evaluation beyond numerical and letter ‘grade’ classification systems.

The Narrative Evaluation System (NES) is a nontraditional grading system, which provides constructive feedback on student’s performance using a narrative format.  In construct, NES draws heavily from Walter Fisher’s narrative paradigm theory. ²  The theory states that narration and storytelling are the basis of all human communication. ²  In the NES system, the evaluator takes into account the objectives of the course when evaluating the strengths and weaknesses of a student’s performance.  Like traditional evaluation models, NES also recognizes noteworthy student performance.  In addition, NES encourages cooperation and collaboration by personalizing descriptions of student performance. ³ This helps to promote closer relationships between students and instructors.

NES does have some drawbacks.  NES requires a larger time commitment from educators. ³  In order to summarize student performance into a narrative, educators are required to keep detailed notes on each performance and provide suggestions on how students can improve in the future.  NES explores more dimensions of the evaluation process and educators must devote more time and energy to constructive criticism.  Simply put, NES is more difficult than  the simple categorization required in traditional grading systems.  Even after providing narrative comments, some institutions force educators to use traditional grading systems — allowing a comparison between students using the same grading scale.  The NES system supplements traditional evaluation.³   Students who have been evaluated using the narrative evaluation system often request letter grades — in one study more than two thirds did so.⁴ The most common reason for requesting letter grades was to understand the narrative evaluation by comparing their performance to grades that they are familiar.⁴ 

Very few studies have analyzed the impact of NES on future success.  One study examined whether graduates from a program that used NES remained competitive when it came to admissions into graduate and professional programs.³ When comparing students who graduated from the University of California at Santa Cruz (UCSC) — which uses a narrative grading system — with other University of California campuses which assign traditional grades, the investigators found that UCSC students generally performed as well if not better in terms of acceptance rates into graduate and professional schools.³ 

In another study, a survey of UCSC students and alumni explored their attitudes towards NES.  The survey respondents indicated they preferred NES because it pointed out strengths and weaknesses, and helped them grow personally and professionally.  They appreciated how NES promoted cooperation, scholarship, and creativity. ⁴ However, 62% of undergraduate students surveyed and 54% of alumni surveyed reported some quibbles with NES.⁴ The problems included the length of time it took to receive the narrative, failure to receive a constructive narrative, or evaluations that were similar to and provided little addition information beyond letter grades. ⁴ Despite these challenges, 82% of undergraduate students and 78% of alumni favored NES over a traditional letter grade.<sup>4 

Figure 1. This table summarizes a surveyed undergraduate and alumni opinions of NES.4</sup>

Survey Questions	Undergraduate (%)		Alumni (%)
	Yes	No	Yes	No
NES influenced decision to attend the school	58	42	48	52
Favored NES over letter grades	82	14	78	18
Requested letter grades	32	68	N/A	N/A
Believed NES worked in their favor	N/A	N/A	62	37
Experienced a problem with NES	62	38	54	46

Another study compared the effect of NES and a conventional grade system on learning and motivation.⁵  During the study students were asked to perform certain learning tasks during 3 distinct teaching sessions.  Students were randomized to receive either narrative or numerical grades when completing the learning tasks in sessions 1 and 2, and then took a post-test after session 3.⁵ Results showed that students who received narrative evaluations had the highest post-test performance.  Moreover, traditional grades depressed creativity and weakened student interests in the subject matter.⁵ 

Currently, at least seventeen colleges and universities in United States and Canada use narrative evaluation (NES).  Some have used this system for over fifty years.  NES can guide students in their learning and help them improve on their weaknesses.  The NES model provides a more complete picture of the student and helps students to distinguish themselves as individuals.  Although it may be time-consuming, educators should consider implementing NES – perhaps in conjunction with traditional grades — to enhance the learning process. 

References

1. Hanson J, Rosenber A, Lane L.Narrative Descriptions should Replace Grades and NumericalRatings for Clinical Performance in Medical Education in the United States. Frontiers in Psychology.  Nov 2013; 4: 1-10.
2. Fisher W. The Narrative Paradigm: In the Beginning. Journal of Communication. Dec 1985;35(4): 74-89.
3. Affirmation of Accreditation Self-Study Report. University of California at Santa Cruz. [Internet].  1994 Nov: 22-29. [cited 2015 Mar 8].
4. Wong M. Assessment and Evaluation of Past and Present Student Attitudes toward the UC Santa Cruz Narrative Evaluation System. University of California at Santa Cruz. [Internet]. 1992 Jun. [cited 2015 Mar 9]
5. Butler R,Nisan M. Effects of no Feedback, Task-related Comments, and Grades on Intrinsic Motivation and Performance. Journal of Educational Psychology. Jun 1986; 78(3): 210-216.

Self-Determination Theory: Supporting Students’ Intrinsic Motivation

by Adrienne Kowcz, PharmD., PGY1 Community Pharmacy Resident, University of Maryland School of Pharmacy

From day one, we are innately curious. Children constantly explores the world around them, and as we grow, we gravitate toward careers and hobbies that interest us.  We are intrinsically motivated to learn more. Educators should capitalize on this desire when designing instruction.  Unfortunately, external motivators play far too great a role in education today.² Overly prescriptive supervision and standardized evaluations can thwart the learning process, and cause learners to lose interest.

Self-determination theory (SDT) suggests that teachers can capitalize on internal motivation by supporting each student’s natural tendency to be curious and desire for autonomy.  That is, teaching should be guided by students’ interests. If we can find ways to support autonomous motivation in the delivery of instruction, we can achieve optimal learning. Although SDT has been around for 4 decades, Edward L. Deci and Richard Ryan expanded on the theory by refining the differentiation between intrinsic and extrinsic motivation as well as proposing three key intrinsic needs involved in self-determination.¹

Motivation is often examined from the perspective as to how we convince others to change their behavior. External factors, such as rewards, punishments, grades, evaluations, and other’s opinions often motivate people. However, SDT explores the intrinsic motivation, or how people are motivated from within when there is no tangible reward or external push. Deci and Ryan postulated that an individual needs intrinsic motivation as well as three intrinsic psychological needs in order to initiate these behaviors and maintain good psychological well-being and self-determination. These universal needs are autonomy, competence, and relatedness. Below is a model that depicts SDT in higher education. These components together form the self-determination model which emphasizes supporting student autonomy in order to achieve positive learning outcomes.

Autonomy relates to people feeling as though they have power over their behaviors. Giving students opportunities for growth and the ability to make their own choices, increases their sense of autonomy and reduces coercion / controlled. One study examined the learning outcomes of college students in a science course where the teachers used two different outcome expectations: one group was told they had to teach the material to others (autonomy supported) and the other group was told they had to pass an exam (controlling behavior).³ Those who had the expectation of teaching others had a deeper conceptual understanding of the material.  Autonomy can be supported in the classroom by teachers reducing the number of evaluations and encouraging active student participation, fostering positive feelings that what students say has purpose in the classroom. Also, teachers should provide a clear rationale for the learning activity. This has been shown to improve student’s effort to learn.

Competence refers to a person’s effectiveness at performing the skill or task. When someone feels competent that they can perform a task, they are more likely to continue to use what they have learned and strive to achieve more. A way to support competence in an educational setting is introducing challenging activities where students can use their previous knowledge and skill. When students perform well, providing feedback about the process can be beneficial to their growth. Not congratulating a job well done, but rather letting the student know that their effort was recognized.  In addition, providing feedback on how to master more has been shown to make students continue to strive for greater results after a compliment.⁶

Relatedness is the last need that Deci and Ryan believe should be satisfied in order to support self-determination. In a classroom, when students have a sense of belonging, that those around them truly understand and value them, they will more likely have intrinsic motivation to perform the tasks at hand. Acknowledging student’s feelings can help improve that connection. In an education setting, studies have shown that students who feel connected to teachers do better in school than those who are disconnected and do not have a relationship with someone who truly cares about them in the school.⁴ As professors, we have the ability to get to know students, as well as teach in an inviting environment where we encourage participation and provide positive feedback to encourage growth.

Creating an autonomy supporting environment is not only beneficial in the classroom, but in the clinical environment too. In the study titled Reducing the Health Risks of Diabetes: How Self-determination Theory May Help Improve Medication Adherence and Quality of Life the investigators applied the SDT model to predict medication adherence, quality of life, and physiological outcomes among patients with diabetes.⁵ Patients were surveyed assessing their perceived autonomy-support from their providers, autonomous self-regulation for medicine use, perceived competence to perform self-management, medication adherence, and quality of life. Results showed that when clinicians elicit patients’ perspectives, just as teachers elicit student’s responses, and support autonomy, patients have higher quality of life, improved medication adherence, and better health outcomes.

Regardless of setting, supporting autonomy, competence, and relatedness leads individuals — students and patients — to become better learners motivated by their internal desires. When these needs are supported, people gain self-determination and their intrinsic motivation to learn is enhanced.

References

1. Deci EL, Ryan RM. The “what” and “why” of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry 2000; 11: 227-268.
2. Williams G., Deci E. The Importance of Supporting Autonomy in Medical Education. Ann Intern Med. 1998;129:303-308.
3. Niemiec CP, Ryan, RM. Autonomy, competence and relatedness in the classroom:Applying self-determination theory to educational practice. Theory and Research in Education. 2009; 7(2): 133-144.
4. Vallerand RJ, Reid G. On the causal effects of perceived competence on intrinsic motivation: A test of cognitive evaluation theory. Journal of Sport Psychology 1984; 6: 94–102.
5. Williams, G. Patrick, H. et al. Reducing the Health Risks of Diabetes: How Self-determination Theory May Help Improve Medication Adherence and Quality of Life. Diabetes Educ 2009; 35 (3): 484-492.
6. Dweck, Carol. The power of believing that you can improve. Dec 2014. 

Embracing Mobile Technology – A Gateway to Learning

by Joanna Yala, PharmD, PGY1 Pharmacy Practice Resident, Sinai Hospital 

In an increasingly technological world, teachers and students are being pushed to adapt. Smartphones, tablets, and laptop computers are quickly replacing the conventional blackboard and chalk. I believe that transitioning from traditional note-taking and lectures to incorporating mobile devices and on-line information sharing into our classrooms can positively impact the learner’s experiences.  In this discussion it is helpful to understand what learning and memory entails. Learning is the acquisition of skill, knowledge as well as attitudes, while memory is the expression of what the learner has acquired.¹ 

As today’s technology constantly develops, we face a dilemma — risking turning away from what is already tried and tested to venturing out into the unknown and untested. As educators, we want to fulfill our duty to prepare our students with the knowledge and skills necessary to equip them for their future endeavors, but we also want to deliver the learning experiences in a controlled, safe environment. Thus, the decision for institutions to shift towards online classrooms and the use of mobile devices in tandem with the face-to-face instruction is critical.

There have been multiple studies that have evaluated the use of the mobile devices (e.g. smartphone, tablet, and computer) as an instructional tool. Social media allows a reflective output for ideas and computer applications have allowed for file-sharing.  These advances have expanded our capabilities and created virtual centers of learning.

An observational study of undergraduate students’ adoption of a mobile note-taking tool was conducted at the University of Chester in the United Kingdom.²  The software tool allowed educators to provide mobile support to students’ learning and provided an array of functions for the gathering and management of information.  The tool allowed students to easily record ideas using voice notes as well as save pictures and handwritten notes. There was positive feedback and recommendations from the test subjects reading the use of this particular platform.  Users felt the tool positively impacted their organizational skills.

In another study conducted by the Center for Teaching Excellence at the United States Military Academy, the best practices for teaching using iPads were explored.³  All the students in this setting had iPads available to them. The participants (teachers and students) deemed the devices beneficial, but the results also revealed concerns with their use such as the need to have access to the Internet, appropriate software applications for peer-to-peer and student-professor interactions, and user competency. Despite these concerns, the student interest in the subject matter seems to be one of the most important factors to consider when selecting the best teaching method. Thus, software developers have continuously tried to design applications that make the learning experience more enticing, convenient, and user-friendly.  Features common to mobile devices include capturing photos, videos of lectures, and hand-written notes as well as accessing electronic documents.

In light of the current capabilities of mobile devices as a tool to enhance instruction, I think they can be effectively used to improve learning. Studies suggest positive behavior changes when students use them for independent study under the guidance of an instructor. Social learning is also cultivated through peer-to-peer interaction with online discussion boards.

The world has evolved so much in the past two decades. Students were once dependent on every word a lecturer said, hurriedly scribbling them down in notebooks. Now we are privileged to access information with just a few taps on a screen – anywhere, anytime. By conditioning ourselves to embrace new methods of presenting and organizing information, educators can provide a gateway to limitless knowledge and possibilities.

References:

1. Kazdin A. Learning and Memory. Adapted from the Encyclopedia of Psychology [Internet]. c2000 [cited 2015 2 Feb]. 4128p.
2. Shepman, A, Rodway P, Beattie C, Lambert J. An Observational Study of Undergraduate Students’ Adoption of (mobile) Note-takingSoftware. Computers in Human Behavior. 2012 ;28 (2): 308-317.
3. Beskow D, Deb A. Increasing Learning with iPads and Social Media [Internet]. Center for Teaching Excellence, United States Military Academy, West Point, New York; 2013 [cited 2015 Feb 2]. 11p.