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Prosser, B., Reid, R., Shute, R. & Atkinson, I. (2002). Attention Deficit Hyperactivity Disorder (ADHD): Special Education and Practice in Australia. Australian Journal of Education. (in press).
Attention Deficit Hyperactivity Disorder (ADHD): Special Education Policy and Practice in Australia
Brenton Prosser
Flinders Institute for the Study of Teaching, Flinders University
Robert Reid
Department of Special Education and Communication Disorders, University of Nebraska
Rosalyn Shute
School of Psychology, Flinders University
Ivan Atkinson
School of Psychology, Flinders University
Abstract
With growing numbers of Australian children receiving Attention Deficit Hyperactivity Disorder (ADHD) diagnosis, special educators will increasingly be expected to provide interventions. We outline Australian special education policy and practice regarding ADHD in the public school context.
Drawing upon American comparisons, we consider how recent government legislation may have made the label 'disability' appear pragmatic to those seeking special education assistance, and discuss whether making ADHD an educational disability category would expand the range of interventions currently available.
Further, we note that while biological aspects of ADHD have received much attention, the important social aspects remain relatively unexplored. We propose that a socially sensitive reconceptualisation will assist special educators better meet the needs of young people with impulsive, inattentive and hyperactive behaviours.
KEY WORDS: Special Education, Attention Deficit Disorders, Hyperactivity, Labelling, Educational Policy, Educational Sociology.
Introduction
Attention Deficit Hyperactivity Disorder (ADHD) is defined by the Australian National Health and Medical Research Council (1997) as a syndrome resulting in hyperactive, impulsive and inattentive behaviours that cause social impairment in home, school and work settings. ADHD is considered a medical/psychiatric disorder; however, this runs the risk of oversimplifying a complex phenomenon. ADHD cannot be adequately viewed from a unitary perspective, because ADHD is a disorder that crosses many different domains. It is unrealistic to expect one overarching construct —no matter how broad— to have sufficient explanatory power (Whalen & Henker, 1996). For example, in addition to the medical perspective, psychological approaches must be acknowledged. Problems such as depression, anxiety, cognitive distortions, temperament, motivation, and even giftedness can produce ADHD-like behaviours (Maag & Reid, 1994; British Psychological Society [BPS], 1996; Tally-Ongan, 1997).
ADHD is now one of the most commonly diagnosed disorders amongst Australian and United States children (Gadow, 1993; Valentine, Zubrick & Sly, 1996; Prosser & Reid, 1999), and the rate of ADHD diagnoses have been increasing. Some suggest this reflects increased awareness of and necessary treatment for a medical condition. Others link increasing diagnosis to special education policy. For example, Diller (1998) argued that the U.S. increase in ADHD was a result of the Education Department's clarification of services available to diagnosed students. The former view represents the 'reductionist' or medical perspective that regards ADHD as a biological phenomenon. The latter 'sociological' perspective views ADHD as a phenomenon within a social and cultural nexus and permits understandings that are dictated by political and economic factors.
In this paper we review the present and future possibilities for special education interventions for ADHD in Australia. Firstly, we compare the Australian and overseas (especially the American) situations to outline how existing policy shapes ADHD interventions in the public school context. In the second section we argue that contemporary Australian policy may be the catalyst for the growth in calls for including ADHD as a disability category. We conclude by arguing an emphasis on the social and educational aspects will enable special educators to better meet the needs of students diagnosed with ADHD.
ADHD & Special Education Policy in U.K., U.S. and Australia
Some nations (e.g., the United Kingdom) favour psychological and educational interventions for inattentive, impulsive and hyperactive behaviours (BPS, 1996). Others, like Australia and the United States, are increasingly considering these behaviours as a disability requiring specific medical interventions.
Within the United Kingdom diagnosis is comparatively low, being based on the rigorous International Classification of Disorders (World Health Organisation, 1993) criteria. Furthermore, a child does not need a medically assigned disability label to gain access to special education assistance (Cooper & Ideus, 1995). By contrast, American legislation requires that children meet the criteria for specific learning disability categories (BPS, 1996). ADHD is not itself a disability in the U.S., but fifty percent of students with ADHD qualify for assistance due to comorbid learning disabilities and behavioural disorders (Reid, Maag, Vasa, & Wright, 1994). The needs of the remaining fifty percent can be met through legislation which ensures that all American young people with barriers to significant life activities are eligible for assistance in school (Reid & Katsiyannis, 1995).
In Australia, the federal Disability Discrimination Act refers to categories included within the DSM-IV-TR (American Psychiatric Association, 2000) as disabilities, while state legislation varies. For instance in South Australia, the Department of Education, Training and Employment (DETE) policy relies on state equal opportunity legislation, which does not recognise ADHD as a disability. Theoretically the education of South Australian students is based on curriculum needs rather than disability labels, and disability alone does not necessarily determine special education provisions (Department of Education and Childrens’ Services [DECS], 1991). However, there is reason to believe that there is a gap between policy and practice in South Australia (Atkinson, Robinson & Shute, 1997; Prosser, 2000).
While the situation for students with comorbid learning difficulties is similar to that in the U.S., significant cracks are appearing between Australian disability discrimination and equal opportunity legislation. This has placed considerable pressure on special educators as increasingly moderate or educational disabilities have been given distinct labels and used as a means to compete for finite and diminishing special education resources.
As Cooper (1994) notes, medical labels such as disability only become educationally significant when they become pragmatic in gaining special education assistance. This is exemplified by Latham and Latham's (1992) advice to U.S. advocates seeking assistance for children with ADHD. Since impairments seen to have environmental, cultural or social causes were not deemed eligible for assistance, they recommended an emphasis on the neurological basis of ADHD.
There is good reason to believe that such a reductionist view has successfully influenced institutional responses. Damico and Augustine (1995) found that an ADHD diagnosis significantly helped parents obtain additional services from schools (e.g., classroom support and concessions in examinations). Further, they found the label was usually sought only after parents became dissatisfied with school responses to their child's difficulties, and was attractive primarily because parents believed it assisted in accessing educational accommodations. Calls for such accommodations in Australia have created a challenge to existing public policy, with one highly publicised refusal for additional time in an examination by the New South Wales education department and over thirty applications for special consideration in the Victorian Certificate of Education in the last eighteen months.
United States Policy in Practice
Two U.S. federal laws concern educational services for children with disabilities. The Vocational and Rehabilitation Act of 1973 (RHA) was civil rights legislation containing a specific passage (Section 504) to terminate federal funding to institutions discriminating against individuals with disabilities. It did not establish categories, but defined disability extremely broadly. A student was considered disabled based on the school's judgement of a physical or mental impairment significantly affecting a major life activity, including learning and behavioural difficulties and poor social skills. The 1975 Education for the Handicapped Act (EHA) (Du Paul & Stoner, 1994) in practice largely subsumed and superseded Section 504. It established federally recognised categories of educational disability, and mandated specific rights, such as individualised educational plans, for children with disabilities. The categories of educational disability were narrowly drawn, and eligibility criteria expressly defined.
Both the EHA and Section 504 include a 'child-find' provision, mandating schools to make pro-active efforts to identify and serve all children with disabilities. Moreover, both laws require that assessment, accommodations and individualised educational plans be provided at no cost to parents (Latham & Latham, 1992; Macciomei, 1993). Under the EHA, funding was given to schools to ensure provision of Individualised Education Programs, while Section 504 did not provide any funding (Reid & Katsiyannis, 1995). Another difference concerned qualification for services. Under the EHA, ADHD was not expressly included as a category of disability, therefore the diagnosis did not guarantee the special education services, which parents sought increasingly from the late 1980's. Children had to qualify under the established categories, which many with ADHD did not meet. Although most would qualify for services under Section 504, many parents and educators were unaware of this (Reid & Katsiyannis, 1995).
Advocacy groups therefore began a concerted effort to have ADHD defined as a disability. In 1990 the EHA underwent a periodic re-enactment process resulting in the 1990 Individuals with Disabilities Education Act (IDEA). Parent and advocacy groups lobbied intensively to include ADHD (Diller, 1998), but were unsuccessful (Macciomei, 1993; Turnbull, 1994). However, this pressure resulted in the U.S. Education Department distributing a 1991 memo clarifying how students with ADHD could obtain assistance under the IDEA (Aleman, 1991). Students were eligible if they met the requirements for existing categories (e.g., learning disability), but could also qualify under the Other Health Impairment category if attention problems significantly affected their education. Alternatively, accommodations could be made under Section 504 of the RHA.
It is from this legislative interplay that confusion over ADHD's status as a category of educational disability originated. To many parents and special educators (unaware of legislative intricacies), it seemed that the ADHD label was an effective means to access additional educational services (Damico & Augustine, 1995; Diller, 1998). However, only about half of students with ADHD obtained assistance under the IDEA, resulting in confusion and frustration.
Schools were often reluctant to provide assistance for ADHD. DuPaul and Stoner (1994) explained this as due to a shift within educational institutions toward standardisation, outcome based assessment and limited resources. Concerns over the educational utility of medical labels saw education providers increasingly emphasise practical interventions for observable difficulties. Special educators were often caught between two compelling arguments, as parents saw ADHD as an educational disability, while education departments and schools claimed that the label was neither educationally relevant nor legally recognised.
Because many children failed to qualify under EHA or IDEA, parents and advocates sought alternative access to services, resulting in a resurgence of the long dormant Section 504 (Reid & Katsiyannis, 1995). Thus, many students gained access to educational services under Section 504's broader definitions, not because of their ADHD diagnosis (Macciomei, 1993).
The Australian Policy Situation
As in the U.S. there are no Australian ADHD-specific federal or state policies. Neither is it considered a specific learning disability (NH&MRC, 1997). While the Commonwealth Disability Discrimination Act (DDA) covers categories in the Diagnostic and Statistical Manual of Mental Disorders (APA, 2000) (thus indirectly defining ADHD as a disability), most states use their own equal opportunity legislation (which does not include ADHD as a disability) as the basis of special education policy. Some federal funding assists the states to provide education services, but primarily states must respond to demand from within their annual general education funding (Department of Employment Education Training and Youth Affairs, 1997; NH&MRC, 1997).
In short then, Australia and America are similar in that approximately fifty percent of students with ADHD should receive special education assistance under disability legislation. However, there is no Australian Section 504 equivalent covering students with significant barriers to life activities. Further, the absence of a 'child find' clause means that up to fifty percent of students with ADHD may not be receiving the assistance they require. Some families have therefore sought to gain assistance by proving their child qualifies under the DDA. This process is often prohibitively costly and diametrically opposed to the U.S. situation where schools are required both to locate and assess children with disabilities at no cost to parents. Not surprisingly parents have increasingly called for state legislation to come in line with the federal DDA (in the process including ADHD as a disability category) and shift the onus back onto the state government to provide support through special education policy.
A significant catalyst to these calls has been underlying state and federal funding cuts in public education. Departmental rhetoric claims that all students with educational needs will receive the necessary assistance without a label such as ADHD or disability. In practice however, funding reductions, along with an increasing range of competing special needs, has seen a rationalisation of resources.
While policy provides for all students with needs, in practice only those with extreme difficulties or those seen to have legitimate claims within existing policy receive assistance, and often ADHD is not deemed a high priority. In some states students need to be more than five years behind in their literacy or numeracy, or have had significant history of expulsion, before they become a priority for limited behaviour management or student disability resources. This poses a dilemma for special educators. They are aware that such delays run counter to best practice that mandates early identification and intervention. They try to strategically allocate limited human and financial resources, but often it is impossible to satisfy competing demands. This has led some advocates to consider the redefinition of ADHD as an educational disability as a means to lobby for scarce resources.
The response by state governments has largely been that students should receive assistance according to educational needs and not labels, hence making ADHD a disability would be irrelevant. However, in a political context of declining education funding and competition between service providers, increasingly only the most urgent needs are being met (Smyth & Hattam, 1998). Further, there has been an increasing emphasis on individual deficit in funding criteria (Comber, Green, Lingard & Luke, 1997; Thomson, 1997). Together these changes have resulted in an official shift of greater responsibility for the problem behaviours back onto families, for many of whom the only affordable interventions come through Medicare bulkbilling and cheap listed dexamphetamine on the Pharmaceutical Benefits Scheme (Atkinson, Robinson & Shute, 1997; Prosser & Reid, 1999).
Given the above situation, it is not surprising that there has been increasing parent, advocate and special education professional pressure for ADHD to be recognised as a disability category in state legislation. At this time ADHD is not recognised as a learning disability in any Australian state. While the Victorian Department of Education, Employment and Training bases its special education policy on the International Classification of Mental Disorders (WHO, 1993) only students with severe behavioural problems qualify for the severe emotional disorder category and are placed in specialist schools. Students with less severe problems rely on local schools to allocate resources from school global budgets according to perceived need. At this time DEET has not issued guidelines to local Victorian schools in relation to ADHD.
However, most departments of education have responded by releasing clarified guidelines similar to those of the U.S. Education Department in 1991. Largely, they identify support for students with ADHD within existing services and policy (e.g., guidance officers, federally funded literacy or numeracy programs, and behaviour management units). However, responsibility has largely remained with special education practitioners or classroom teachers. For instance, in South Australia, DETE (1999) guidelines explain that individual classroom teachers are largely responsible for building positive relationships, fostering emotional resilience, devising alternate management plans and so forth.
As is the case in most states, these guidelines are based on the argument that while ADHD is a risk factor it is not in itself grounds for additional educational assistance or specific policy. However such a position was recently rejected by the Western Australian parliamentary inquiry into ADHD. It found that a significant barrier to the effective treatment of ADHD was education departments treating ADHD as one of many disorders which may place a child at educational risk, rather than as a separate learning and behaviour category (Standing Committee on Constitutional Affairs, 1999). The Committee's recommendation to develop new policies and guidelines is currently before the Western Australian government.
It would seem that while the recommendations of most states are sound in theory, they risk falling short of the needs of students. This is because of a lack of adequate consideration of the particular behavioural and learning challenges ADHD presents to teachers in classrooms (Reid and Katsiyannis, 1995; Atkinson, Robinson & Shute, 1997). Common problems include difficulty in balancing the needs of the ADHD student with those of others in the class, the increasing administrative workload of educators, teachers being largely unaware of how to access services or teachers not being trained to implement them for students with ADHD. Without additional resources and possibly new policy, it is unlikely that these guidelines will be properly implemented.
One possible exception is New South Wales. While still not addressing the concerns raised by the Western Australian parliamentary inquiry, DET has increased special education resources significantly so that theoretically all children with barriers to learning can receive assistance. This assistance is detailed in the Department's latest guidelines (New South Wales Department of Education and Training, 1997) and takes the form of the allocation of a Learning Support Team to develop a targeted management plan (including social and behavioural interventions) for every student with learning problems resulting from ADHD.