Improving writing instruction is one of my professional growth goals this year. As a school, we are working to have 65% of our students writing at or above grade level and 90% of our students reading at or above grade level by June 2020. This summer I took some time to read 6+1 Traits of Writing: The Complete Guide for the Primary Grades by Ruth Culham, Using Picture Books to Teach Writing with the Traits by Ruth Culham and Raymond Coutu, Reading Power by Adrienne Gear, The Reading Strategies Book and The Writing Strategies Book by Jennifer Serravallo. I would highly recommend all of these books for primary teachers and beyond. I was able to select strategies for literacy instruction that aligned with our Saskatchewan Reads document and Gr. 1/2 Curriculum and our Ways to Take Action decoding strategies that our primary team uses. Please view the attached document for some of the strategies that my primary literacy cluster (co-teaching group of 2 classroom teachers, 2 SSTs, and our principal) will be utilizing:
Ethical Issues Relevant to Assessment by Kourtney J. Gorham
University of Regina
EPSY 829: Ethics and Professional Practice
The skillset and knowledgebase of psychologists is highly respected within our society, with psychological assessment often earning the highest regard (Koocher & Rey-Casserly, 2003; Turchik, Karpenko, Hammers, & McNamara, 2007). The testing business was estimated to be a 400 to 700 million dollar industry in the early 2000s and it continues to grow (Clarke, Madaus, Horn, & Ramos, 2001; Public Broadcasting Services (PBS), 2002). Psychological assessments are tools that help psychologists derive objective information about an individual’s abilities, weaknesses, interests, learning capacities, and potential diagnoses. Psychological assessments differ from informal tests and online measures because they include an in-depth assessment of the person through the referral question(s) asked and require specific procedures for how the test is managed and scored by a qualified professional (Naglieri et al., 2004). However, ethical issues can occur when the assessment is not used as intended. In these instances, the measure may overshadow the individual being assessed and/or fail to answer the referral questions (Adams & Luscher, 2003; Turchik et al., 2007). Psychologists need to use clinical judgement when deciding when and if to assess and determine if psychological assessment will lead to intervention and support rather than simply a number or score on a report.
Koocher and Rey-Casserly (2003) noted that psychological assessments can have both a negative and positive impact on people. Negative outcomes may include diagnostic labels, unanswered questions, legal trials, job loss, university admission challenges, and wait-times for assessment and services (Evans, 2011; Koocher & Rey-Casserly, 2003; Michaels, 2006). Furthermore, assessment can impact how the client views themselves and is viewed by others; stigmas and negative judgements may be formed (Michaels, 2006). Take, for instance, the misinterpretation of diagnostic labels, test scores, Intelligence Quotients (IQ), and personal descriptors that can find their way into conversations and formal documents, such as an Inclusive Intervention Plan in the school setting (Michaels, 2006). Unfortunately, both laypersons and professionals may misinterpret psychological assessment and this can negatively impact a person’s life course. It becomes easy to reduce someone to a score on a psychological report and forget the human and personal factors not accounted for in formal testing.
However, while there are negative aspects to psychological assessment, there are also many benefits. If a person is properly assessed this will increase their self-awareness about what is going on and thus, their ability to advocate for the services and supports they need. While a diagnosis can lead to a label, it also ensures that evidence-based resources, supports, and interventions are being used. Assessment also acts as a tool to determine and validate who gets certain supports in our school systems and other social programs (Dombrowski & Gischlar, 2014). It acts as a concrete way to determine funding and can connect individuals to much-needed outside agency supports.
Because psychological assessments have both negative and positive impacts on individuals, we can view them as being both ethical and unethical. Koocher & Rey-Casserly (2003) note the importance of considering all ethical aspects before, during, and after assessment. While this is no small feat, by using the ethical standards set forth by the Canadian Psychological Association’s Canadian Code of Ethics for Psychologists (2017) and the Saskatchewan College of Psychologists’ Professional Practice Guidelines (2010), psychologists in Saskatchewan can ensure they avoid ethical issues related to competency, informed consent, and confidentiality when assessing clients.
Competency is the area of expertise that a psychologist has developed through their education and supervision, as well as their own professional development pursuits (Adams & Luscher, 2003; Koocher & Rey-Casserly, 2003). Standards II.6 and II.9 of the Canadian Code of Ethics for Psychologists (2017) highlight that a psychologist must work within their area of competency (CPA, 2017). Thus, when it comes to assessment, a psychologist must first assess their own capabilities before working with the client. Self-assessments of competency also must include up-to-date knowledge of testing psychometrics. A psychologist must be trained in assessment selection, procedures, scoring, and interpretation as per the standards set forth by the Canadian Psychological Association (2017) and the Saskatchewan College of Psychologists (2010) (CPA II.9; SK 14.2). In general, a knowledgebase in validity, reliability, norms, standardization, standard error of measurement, false positives and negatives, sensitivity, specificity, test specifications, and convergent validity of multiple assessments (Adams and Luscher, 2003; Evans, 2011) is required in the broad sense and specifically in regards to each specific assessment measure to be used. Psychologists must critically select tests by weighing the pros and cons and researching them beyond the publisher’s self-reports (Evans, 2011; Koocher & Rey-Casserly, 2003).
Psychologists need to assess their own bias when selecting tests, especially when working for agencies that may prefer one assessment over another due to financial or accessibility reasons (Koocher & Rey-Casserly, 2003). Turchik et al. (2007) note that tests are frequently updated and this may cause financial barriers. There is a cascade of costs if multiple kits, testing forms, and computer interpretation programs are required or the agency serves a wide variety of needs. Furthermore, one measure may not be sufficient (Adams & Luscher, 2003). The Professional Practice Guidelines (2010) highlight the need to use the most recent edition of assessments (SK 14.5).
Both Koocher and Rey-Casserly (2003) and Simner (1994) argue that if a psychologist is not trained in testing psychometrics than they cannot critically judge the test features and thus its applicability to the situation, referral question(s), and individual. The Code of Ethics for Psychologists (2017) and the Professional Practice Guidelines (2010) note that test selection is done on a case-by-case basis, using methods that are valid to the population and questions sought (CPA II.13; CPA II.18; SK 14.3; SK 14.4). This requires careful consideration that the client’s language, race, educational level, culture, and age match the norm group, as well as the adequacy of the instrument to meet the identified need (Koocher & Rey-Casserly, 2003). It is important to note that, an assessment can be psychometrically sound but fail to meet the client’s needs and/or answer the referral question(s) (Adams & Luscher, 2003). In many cases, multicultural groups and those with disabilities have been left out of the norm groups. While adaptations can be made and reported on to accommodate this as per standard 14.3 (SKCP, 2010), these adaptations need to be reported and cannot impact the overall validity of the test (Koocher & Rey-Casserly, 2003). For instance, an interpreter or nonverbal measure may be used if a person speaks a different language but it is important to ensure comprehension of the questions asked, fidelity to the questions asked, and that the measure itself is being tested versus language (Evans, 2011; Koocher & Rey-Casserly, 2003). The Canadian Code of Ethics for Psychologists (2017) includes standards on respecting others regardless of these differences (CPA 1.1) and evaluating our own biases (CPA III.15). Ensuring our own competency and the applicability of an assessment measure is one way to ensure that these standards are met.
Informed consent is a shared decision-making process that starts from the outset and continues throughout the professional relationship (Barnett, Wise, Johnson-Greene, & Bucky, 2007). From a legal standpoint, the client must give consent voluntarily and they must comprehend and thus, have the capacity to do so (Barnett et al., 2007; Evans, 2011). This is represented in the Canadian Code of Ethics for Psychologists (2017): consent must be voluntarily given (CPA I.27), all the information that a reasonable person would need to make an informed decision must be shared and updated throughout the process (CPA I.23; CPA I.25), and the information must be presented at an attainable level for all involved (CPA I.24). From the outset, Simner (1994) recommends that the client(s) receive honest information about what the assessment process can reasonably uncover. Adams and Luscher (2003) stress the need for written and oral language that matches the client’s level of understanding. The informed consent piece is vital to ethical assessments from the outset because it allows reasonable expectations to be set, clarification of the referral questions and goals, and can be telling of the client’s desires and hopes of assessment.
Assessment of minors poses an additional challenge because minors are often referred by third-parties, such as school teams and caregivers (Koocher & Rey-Casserly, 2003). In these instances, it is the caregivers who provide consent (Adams & Luscher, 2003; Koocher & Rey-Casserly, 2003; Tan, Giovanni, Passerini, & Stewart, 2007). The Canadian Code of Ethics for Psychologists (2017) states that consent is granted from caregivers of children (CPA I.34), but active participation occurs from all involved (CPA I.19) and clarification of multiple relationships, such as third-parties (CPA I.26), is carefully established so that the psychologist knows who to serve. When it comes to assessing children, psychologists need to determine who the client is – for instance, the caregiver who pays the fees, the child who is being assessed, or the school who requires the assessment results for placement decisions – and if the goals of all parties involved align (Koocher & Rey-Casserly, 2003). Further challenges include determining if the child understands what they are consenting to (Adams & Luscher, 2003) and ensuring that they have not being coerced intentionally or unintentionally by the adult influences in their life. For psychological assessment to be ethically conducted on children, it is essential that the psychologist does not allow third-party desires to result in assessment bias (Koocher & Rey-Casserly, 2003). Adherence to the informed consent codes can help psychologists ethically conduct assessments of minors.
Confidentiality is the client’s right to privacy and autonomy. Michaels (2006) noted that assessment may uncover information that did not relate to the original purpose. There may be pressure to disclose additional information gathered to the school team (Bhola & Raguram, 2016) and pressure to change results when they are not favorable or as expected (Koocher & Rey-Casserly, 2003). In these instances, the psychologist must use clinical judgement to determine what to share and include in the report. The Professional Practice Guidelines (2010) indicate that the psychologist must work directly with the client and they are responsible for accurate interpretations based on up-to-date information, even when computer interpretation programs are used (SK 14.6; SK 14.7; SK 14.9). Koocher & Rey-Casserly (2003) also note the importance of ensuring tests were appropriately scored – especially when using computer-automated tools – and noting any limitations. Any modifications, such as errors, changes to the release of information, and omission of data that is unnecessary to share, should be noted and corrected (Koocher & Rey-Casserly, 2003). In any case, reporting should be clear and objective with a strengths-based style to ensure minimal harm to the client (Michaels, 2006). The results must be accurately reported, even when unfavorable. Tranel (1994) and Knauss (2001) recommend that when reporting results, assume anyone can read it, including the legal system, to avoid unprofessionalism and opinion-based reporting. The Canadian Code of Ethics for Psychologists (2017) is clear that the reports must be objective (CPA III.10), related only to the questions sought (CPA I.37), and regardless of the communication mode, information must be shared in a way that respects the client’s right to privacy (CPA I.41).
It is important to consider testing factors when interpreting and reporting on assessment results. Threats to internal validity must be considered, such as testing effect, maturation effect, or statistical regression effect (Neuman, 2011). External and internal factors, such as being tired, hungry, or bored, may impact a child’s performance. Furthermore, the relationship with the psychologist may not be adequate in the child’s opinion and they may not feel comfortable or able to do their best. They may perform poorly due to lack of exposure versus cognitive deficits. These factors can affect overall results and are harder to track with high-risk populations, such as children (Flanagan, Sotelo-Dynega, & Caltabiano, 2010; Russell, Norwich, & Gwernan-Jones, 2012). Tranel (1994) notes that, along with the test findings, applicable diagnoses, and relevant recommendations, a report should include background history and the setting and environmental factors noted during testing. Koocher & Rey-Casserly (2003) recommend noting any testing behaviors in the final report that may better explain the results. In fact, psychological assessment differs from other measures by how meaning is derived through accurate administration and interpretation of all relevant factors (Jacob-Timm, 1999; Knauss, 2001), including testing conditions.
Assessment reporting has both confidentiality and informed consent considerations. As per the Canadian Code of Ethics for Psychologists (2017) and the Professional Practice Guidelines (2010), it is the psychologist’s job to ensure understanding, highlight opinions in an unbiased and professional manner, and explain the assessment in a variety of culturally-appropriate ways for all parties involved (CPA II.20; CPA II.32; SK 14.1; SK 14.8). Unfortunately, often when assessing children the information is more likely to be shared with the caregivers and school team without including the child. In addition, this information can be hard to understand. Tranel (1994) notes that scores, taken out of context, have no meaning. Furthermore, reports and technical terms are not always accessible to caregivers and educators even after explanations are given. This creates an ethical challenge because the caregivers and educators are the ones who will likely be implementing the strategies with the child and need to understand the results, including what the scores and percentile ranks mean (Flanagan et al., 2010; Lefaivre, Chambers, & Fernandez, 2007). Furthermore, it is of the highest ethical standard to ensure that recommendations are being followed. An ethical challenge occurs when caregivers do not follow-through with recommendations in reports, such as not attending a doctor appointment or attending family counselling, after the psychologist has made the referral.
Another area of consideration includes keeping the tests themselves confidential. If a client has been pre-exposed to testing materials, including from previous versions of the test, this causes an internal threat to validity through testing effect and diffusion of treatment (Koocher & Rey-Casserly, 2003; LoBello & Zachar, 2007; Neuman, 2011). LoBello & Zachar (2007) found 82 psychological tests for sale on Ebay during a three month period; unfortunately, 48% had no restrictions on buyer credentials and many of the sales showed pictures of test materials that could be compromising. Similarly, Tranel (1994) found that test manuals that should only be available to licensed psychologists were accessible in bookstores and online sales. This can also become an ethical issue if tests are not disposed of appropriately (LoBello & Zachar, 2007) or if reports or tests are photocopied and/or left behind after a meeting. Adams and Luscher (2003) note that in order to protect assessment validity, clients should never take test materials home. Furthermore, assessments should be stored securely as per standard I.41 (CPA, 2017).
Psychologists may be pressured to release reports to third parties, such as schools, caregivers, insurance providers, and the legal system. This can be particularly challenging in regards to the legal system because the laws and ethics often clash and all information, scores, and notes can be subpoenaed (Koocher & Rey-Casserly, 2003; Tranel, 2003). When psychologists have client’s assessments subpoenaed these materials need to be sealed after the trial and may require publishers to fight copyright on their own behalf (Koocher & Rey-Casserly, 2003). Assessments should only be interpreted by a licensed psychologist to ensure minimum harm to the client due to copyright issues and proper interpretation of raw scores (Koocher & Rey-Casserly, 2003; LoBello & Zachar, 2007; Michaels, 2006; Tranel, 1994). Both the Canadian Code of Ethics for Psychologists (2017) and the Professional Practice Guidelines (2010) are clear that we need to protect the physical tests and methods used (SK 14.10) and testing techniques and interpretations from being misused (CPA IV.11).
The Canadian Psychological Association’s principles – Respect and Dignity of the Person, Responsible Caring, Integrity and Relationships, and Responsibility to Society – need to be at the forefront of our assessment practices. Psychological assessment can be challenging to do ethically; Kirby et al. (2009) note that only 16% of individuals receive an accurate diagnosis and out of those with an accurate diagnosis, only 16% of adults and 10% of children receive adequate supports (as cited in Mash & Wolfe, 2019). However, there are both positive and negative outcomes of psychological assessment and thus, it is not a practice we can simply discontinue. Instead, we need to use the codes and standards to guide our practice before, during, and after assessment so that we can ensure minimal harm and maximum benefit to clients. Alternatives to assessment, such as barrier-free approaches are an option but they pose their own challenges. For instance, many of our Autism Resource Centers in Saskatchewan only require a brief initial observation or a brief screener to receive supports rather than a formal assessment and diagnosis. While this speeds up the process for some children who require the supports, others are overlooked due to the lack of scope and sequence in brief screeners and the crossover of many of the diagnostic categories. Furthermore, some children are supported when they may have other conditions, such as Attention Deficit Hyperactivity Disorder (ADHD) and would be better served by other empirically supported means. While the child may not have received the diagnostic label, caregivers and educators tend to adopt these once the child is accessing services, despite formal assessment to confirm these claims. In the end, although psychological assessment can be an ethical minefield, it continues to prove valuable. If we continue to find ways to conduct assessment in adherence with the ethical codes, the answers derived will ensure maximum benefit for the clients and society that we serve.
Adams, H. E., & Luscher, K. A. (2003). Ethical considerations in psychological assessment. In O’Donohue, W. T, & Ferguson, K. E. (Eds.). Handbook of Professional Ethics for Psychologists: Issues, Questions, and Controversies (pp. 275-284). Thousand Oaks, California: Sage Publications.
Barnett, J. E., Wise, E. H., Johnson-Greene, D., & Bucky, S. F. (2007). Informed consent: Too much of a good thing or not enough? Professional Psychology, Research and Practice, 38(2): 179-186.
Bhola, P., & Raguram, A. (2016). Ethical Issues in Counselling and Psychotherapy Practice: Walking the Line. Singapore: Springer Singapore.
Canadian Psychological Association (CPA) Board of Directors (2017). Canadian Code of Ethics for Psychologists (4th ed.). Retrieved from: https://cpa.ca/docs/File/Ethics/CPA_Code_2017_4thEd.pdf
Clarke, M., Madaus, G., Horn, C., & Ramos, M. (2001). The marketplace for educational testing. National Board of Educational Testing and Public Policy 2(3), n.p. Retrieved from: https://www.bc.edu/research/nbetpp/publications/v2n3.html
Dombrowski, S. C., & Gischlar, K. L. (2014). Ethical and empirical considerations in the identification of learning disabilities. Journal of Applied School Psychology, 30(1), 68-82.
Evans, D. R. (2011). Law, standards, and ethics in the practice of psychology (3rd ed.). Toronto, Ontario: Thomson Reuters Canada Ltd.
Flanagan, D.P., Sotelo-Dynega, M., & Caltabiano, L.F. (2010). Test scores: A guide to understanding standardized test results. In Carter, A. S., Paige, L. Z., & Shaw S. (Eds.), Helping Children at Home and School III: Handouts for Children and Educators (pp. 1-4). New York: National Association of School Psychologists.
Jacob‐Timm, S. (1999). Ethically challenging situations encountered by school psychologists. Psychology in the Schools, 36(3), 205-217.
Knauss, L. (2001). Ethical issues in psychological assessment in school settings. Journal of Personality Assessment, 77(2), 231-241.
Koocher, G. P., & Rey-Casserly, C. M. (2003). Ethical issues in psychological assessment. In Graham, J. R., & Naglieri, J. A. (Eds.), Handbook of Psychology: Volume 10: Assessment Psychology (pp. 165-180). New Jersey: John Wiley & Sons Inc.
Lefaivre, M., Chambers, C. T., & Fernandez, C. V. (2007). Offering parents individualized feedback on the results of psychological testing conducted for research purposes with children: Ethical issues and recommendations. Journal of Clinical Child and Adolescent Psychology, 36(2), 242-252.
LoBello, S. G., & Zachar, P. (2007). Psychological test sales and internet auctions: Ethical considerations for dealing with obsolete or unwanted test materials. Professional Psychology: Research and Practice, 38(1), 68-70.
Mash, E.J. & Wolfe, D. A. (2019). Abnormal Child Psychology (7th Ed.). Belmont, CA: Wadsworth, Cengage Learning.
Michaels, M. (2006). Ethical considerations in writing psychological assessment reports. Journal of Clinical Psychology, 62(1), 47-58.
Naglieri, J. A., Drasgow, F., Schmit, M., Handler, L., Prifitera, A., Margolis, A., & Velasquez, R. (2004). Psychological testing on the internet: New problems, old issues. American Psychologist, 59(3), 150-162.
Neuman, W. L. (2011). Social research methods: Qualitative and quantitative approaches (7th). Toronto: Allyn & Bacon.
Public Broadcasting Services (PBS) (2002). The testing industry’s big four. Frontline, n.p. Retrieved from: https://www.pbs.org/wgbh/pages/frontline/shows/schools/testing/companies.html
Russell, G., Norwich, B., & Gwernan-Jones, R. (2012). When diagnosis is uncertain: Variation in conclusions after psychological assessment of a six-year-old child. Early Child Development and Care, 182(12), 1575-1592.
Saskatchewan College of Psychologists (SKCP) (2010). Professional Practice Guidelines (2nd ed.).Retrieved from: http://www.skcp.ca/pdf%20files/PROFESSIONAL%20PRACTICE%20GUIDELINES%20May%2017-10%20FINAL.pdf
Simner, M. (1994). Canada’s reaction to misleading advertisements for pre-school screening tests. School Psychology International, 15(3), 277-286.
Tan, J. O.A., Passerini, G. E., & Stewart, A. (2007). Special section: Consent and confidentiality in clinical work with young people. Clinical Child Psychology and Psychiatry, 12(2): 191-210.
Tranel, D. (1994). The release of psychological data to nonexperts: Ethical and legal considerations. Professional Psychology: Research and Practice, 25(1), 33-38.
Turchik, J. A., Karpenko, V., Hammers, D., & McNamara, J. R. (2007). Practical and ethical assessment issues in rural, impoverished, and managed care settings. Professional Psychology, Research and Practice, 38(2), 158-168.
This year we are trying something new – Kindergarten Home Visits! The idea emerged after our Early Years Evaluation (EYE) professional development, as one of the main topics of discussion was parental involvement and awareness. While we have home visits for those in our Pre-Kindergarten programs, some children only attend Kindergarten. Through Kindergarten Home Visits, we hope to better support our children, prepare them and their families for this major transition, and reduce the chances of, what I lovingly term, a “Kinder Surprise!”
Our home visits will include an informal interview to determine outside agency involvement and to start to get to know the child by name, need, and strength. Some of the key things we will be looking for is temperament, social opportunities, and communication abilities.
We have also created Jetting into Kindergarten bags for all of our 2019-20 students.
The bags include:
- a contact/class information brochure,
- Kindergarten readiness information,
- The Kissing Hand by Audrey Penn,
- Sask. Reads: Pause, Prompt, Praise
- Chicka Chicka Boom Boom by Bill Martin, Jr. and John Archambault,
- 10 Reasons to Read to Your Child magnets
- alphabet flashcards with game ideas,
- a name and letter printing sheet,
- fine motor lines for cutting and printing,
- play dough,
- a pencil,
- number flashcards with game ideas,
- math games with a deck of cards, two dice, and a balloon,
- and, smarties.
We will be modeling a game or two with the children during home visits so that they can share in the activities together with their families over the summer. This will better prepare the children for pre-reading, fine motor, and beginning math skills. In addition, we have a Meet the Teacher Night that all families will be encouraged to attend. Additional games and ideas will be shared to set students up for success. I’m excited to connect with the families and hope that this allows us to better serve the children that we are so lucky to teach!
I was fortunate enough to get my hands on the Canadian Red Cross Be Safe! Program. The program is aimed at children 5 to 9 years of age and teaches them personal safety, covering sensitive topics such as sexual abuse. My school division purchased the kit, which includes detailed teacher lesson plans, posters and visuals for each lesson, parent and administration information and communication packages, Trusty the puppet, stickers, the program songs on CD, and a Your Body is Yours book. The resources are in both English and French. I shared the program information packages with my administrator and connected it to the Saskatchewan Grade 1 Health curriculum outcome: USC1.3 – analyze, with support, feelings and behaviours that are important for nurturing healthy relationships at school (and home). Then I took the online educator training to better familiarize myself with the program before sharing it with my kiddos. I sent a letter home with each child so that their parents could better support them if sensitive topics came up at home. I’m not going to lie, after I sent the letter home I felt anxious and wondered what the response would be and how the program would go but…
- The program is phenomenal!
- I received ZERO complaints and instead, praise from caregivers!
- I was supported by my administrators and division to teach this important topic.
- And, most importantly, my students loved the lessons and were able to retain the information!
Let it be known, this is not a sponsored post but it may start to seem that way as I rave about this program. I believe that everyone’s favorite part of the program is the puppet, Trusty. It has helped my kids engage and connect with the topics. Now having a puppet is all the rage in Gr. 1 and students are asking their parents for their own puppets!
The lesson progression is well-timed and has so far followed the thought process of my students. It starts with comfortable topics that may have already been discussed throughout the year but adds new information of interest. For instance, the program starts with the rights and responsibility of children by introducing learners to the UN Charter of Rights and Freedoms. My students loved to learn that play and rest is their right! When asked to clean up at home, one of my students tried to use this newfound knowledge to her advantage, citing play as her right! Her mom and I had a laugh about this and then she thanked me for challenging her daughter with topics like this!
The program continues with lessons on safe and unsafe friends and adults. All of my students now understand that a safe adult has to be someone you know and trust. The program moves into body positivity and accepting diversity and my students loved reading People by Peter Spiers, focusing on the cultures and diversity that we have in our own classroom. Since teaching the lesson, I have overheard three students talking to others about why they are proud of their bodies and the cool things they can do!
These three lessons set the tone for the future lessons and help to gradually and naturally arrive at more serious topics such as public versus private. We started with public places, items, and internet safety and worked our way into private body parts. I appreciate that the program properly labels private parts of the body. I told my students that they needed to know the real names if they wanted to be farmers, doctors, nurses, teachers, moms and dads, firefighters, police officers, veterinarians, EMTs, etc. and that while we only say these words when we are hurt, are in the bathroom, and/or need help, it is important to know these terms even if they make us laugh. One of my students said it was a bit weird to hear me say those words and others were shocked that girls and boys have different body parts. But by the next day when we discussed caring for our bodies, the laughing and awkwardness had subsided.
The program teaches the personal safety strategy – Say No! Go! Tell! – and the students are able to remember this quite well. The teachers across the hall have heard us yelling ‘no’ on numerous occasions and I’m proud of how firm my students will be. We are learning that touching should always be safe. A student said to me, “Is my mom brushing my hair a safe touch because it hurts me?” Another student was able to compare this to getting a needle (necessary and from a doctor) so the class decided it was a safe touch. That is complex social thinking from a group of six and seven year olds! At the end of the lesson, a student asked if we would be talking about secrets, which just happened to be the next topic of discussion. If that’s not well-timed, I don’t know what is! Students are learning to identify their trusted people and that they are always allowed to say ‘no.’ They are able to define terms such as safety, secrets, bribery, etc. I’m so proud of the learning that has occurred.
While I felt ambivalent at the start, I am so glad that I stepped out of my comfort zone to teach this program. It has more than exceeded my expectations. But if you are not yet convinced, I will leave you with this information from the Be Safe! Kit Information Package:
The safety of our children matters. Their rights matter. Having adults that protect them matters. Our children matter!
I’m not sure who loves game-based literacy activities more – me or the kiddos! Today we enjoyed hunting for Easter eggs with sight words inside. Each student was assigned a colour so that everyone would get a chance to find eggs. Assigning colours also allowed me to put specific words inside each egg to target each of their needs. Once they read me the word I replaced the plastic egg with gum, chocolate, and candy-filled eggs. It was a win-win for all involved!
Reading instruction is often at the forefront of educational research, with research-based strategies being preferred (Browder et al., 2012; Fien et al., 2015). In 2000, the National Reading Panel outlined the science of reading instruction as “(a) vocabulary, (b) fluency, (c) comprehension, (d) phonemic awareness, and (e) phonics” (Browder et al., 2012, p. 237; National Reading Panel, 2000). In many ways, these components have always had their place in reading research, educational policies, and curriculums. However, while we have defined the components of sound reading instruction, there are still students who are failing to read at grade level and questions regarding successful reading programs for all learners. Chapman (2003) notes that “approximately 15-20% of children struggle with reading” for a variety of reasons (p. 108) and while this number varies based on population and location, it is evident that current literacy practices are not promoting success for all.
One area of debate in the literature is whether beginning reading instruction should favor sight word or decoding strategies. Through a quantitative, linear design both a “psychological-cognitive” and “language literacy-oriented” research approach will be used to focus on word reading strategies as they relate to reading comprehension (Chapman, 2003, p. 95). Sight word reading may also be termed in the literature as visual accessing (Aaron et al., 1999; Ehri, 2005; Gough, 1993), cipher reading (Gough, 1993), and/or lexical recall of the words (Aaron et al., 1999; Ryder et al., 2007). Some researches define sight words as any word that has been repeatedly read and memorized (Ehri, 2005) and others suggest sight words are limited to irregular or high frequency words (Aaron et al., 1999). Decoding strategies are often labelled as codebreaking (Gough, 1993), phonological reading (Aaron et al., 1999; Ehri, 2005), and graphophonics and/or grapheme-phoneme blending and segmenting (Aaron et al., 1999; Ehri, 2005; Eldredge et al., 1990; Weiser et al., 2011).
For the purpose of this study, the operational definition for sight word reading will be adopted from Aaron et al. (1999): “sight word reading is accomplished by addressing the orthographic representation of words” (p. 91). Gough (1993) expands this definition; a sight word “is not ‘sounded out;’ it is not read ‘phonologically.’ Its recognition is ‘direct,’ unmediated by letter-sound correspondences… [but instead] by sight” (p. 181). Decoding strategies, in contrast, are defined as “assembling the word’s pronunciation” (Aaron et al., 1999, p. 91). For the purpose of this study, decoding strategies will be operationally defined as the use of graphophonic cues – mapping the phoneme (sound) onto the grapheme (spelled representation of the word) (Saskatchewan Curriculum, 2010) – through sounding out or blending.
Review of Literature
Within the research, decoding and sight word strategies have been found to be congruent. Aaron et al. (1999) used a sample of 167 children in Grades Two through Six and 75 college students. They looked at naming time of letters in comparison to words to determine if sight word or decoding strategies were being used. They found that a switch from decoding to sight word reading was made sometime in Grade Three or Four (Aaron et al., 1999). Not only were the strategies congruent but sight words were “built on foundations of decoding skills” (Aaron et al., 1999, p. 102-3). Aaron et al. (1999) note that “sight word reading appears to be carried out by processing all the constituent letters of the word in parallel, simultaneously… [it] relies heavily on proficient decoding” (p. 115; Eldredge et al., 1990). While beginning readers often learn their first words through “selective associations” (Gough, 1993, p. 181), such as environmental print or word visualization (Ehri, 2005), this is not considered to be sight word reading. Rather, Ehri identified four stages “pre-alphabetic (environmental print), partial alphabetic (first and final sound identification), full alphabetic (decoding all of the phonemes), and consolidated alphabetic (sight word memorization) (2005, p. 173-5) – with sight word recall following the decoding stage. Thus, it can be theorized that students will be successful sight word readers if they are already successful decoders (Aaron, 1999; Uhry et al., 1997).
In Freebody’s and Byrne’s (1988) study they compared sight word and decoding strategies through regular, irregular, and nonsense individually presented words on a sample of 90 Grade Two and 89 Grade Three students in regular classrooms. They found that, while some students utilized both strategies, “one fifth attained average scores on irregular words but substantially below-average scores on nonsense words [sight word readers]… and one seventh showed the opposite pattern – average or better nonsense-word scores but poor irregular-word performance [decoders]” (p. 441). On comprehension tests, the sight word readers performed better than the decoders in Grade Two (Freebody et al., 1988). However, by Grade Three the “failure to acquire and use efficient decoding skills” decreased reading fluency and thus, comprehension scores (Freebody et al., 1988, p. 441). Therefore, over time the use of decoding strategies surpassed the use of sight word strategies. This may be explained by Gough’s (1993) finding that relying on sight word strategies is impeded by memorization and novel words. Gough explains that “while i’s easy to find a cue to distinguish one word from a few others, with each additional word it becomes harder” and sight word strategies do not help with “recognition of new words: knowing that ELEPHANT is the long word, or CAMEL is the one with humps, cannot help the child decode HORSE” (1993, p. 188). A benefit of decoding instruction is that readers have a way to access words and texts that they have not previously encountered (Eldredge et al., 1990; Ryder et al., 2007).
However, various benefits of sight word strategies are apparent in the literature. Eldredge et al. (1990) note that sight word reading allows for less “nonsense errors” but “advocates of explicit phonics approaches believe that making nonsense errors is a stage that passes” (p. 202). Sight word knowledge allows for fluent reading and thus, higher comprehension scores and vocabulary growth (Aaron et al., 1999; Eldredge et al., 1990; Ryder, 2007). This may be because “if readers attempt to decode words… their attention is shifted from the text to the word itself to identify it, and this disrupts comprehension, at least momentarily” (Ehri, 2005; Aaron et al., 1999). Sight word reading is unobtrusive and efficient (Ehri, 2004). On the other hand, Eldredge et al. (1990) note that “improved decoding skills provide the possibility for readers to give more attention to text message, resulting in better reading comprehension” (p. 202). If students have learned specific sight words, they often have proficient accuracy scores during reading benchmark assessments, making a sight word approach appealing to educators reporting reading scores.
The purpose of this study is to extend the research with a focus on beginning readers who are struggling. A 1997 study by Uhri and Shepherd looked at teaching decoding strategies as a prelude to sight word strategies for struggling readers and they found positive gains in both non-word and sight word reading scores (Uhry et al., 1997). It is important to replicate this study for learners who are experiencing difficulties “with the automatic mapping between print and speech” (Ehri, 2005, p. 172) so that our reading instruction can benefit all learners. While one strategy may not be superior to the other, Aaron (1999) notes that “efforts to improve sight-word reading skills of poor decoders through whole word methods by using flash cards or computers may not be very successful” (p. 119). In addition, “if readers do not know short vowel spellings, or they do not know that ph symbolizes /f/, then when they encounter these letters in particular words, the letters will not become bonded to their phonemes in memory” and this explicit instruction needs to occur for successful long-term reading (Ehri, 2005, p. 172; Eldredge et al., 1990; Weiser et al., 2011). It is important to determine if we are emphasizing sight word reading approaches to score higher on comprehension measures today, but overlooking the importance of decoding on reading comprehension scores over time.
The purpose of this quasi-experimental study (Creswell, 2012; Jackson et al., 2007; McMillan et al., 2010; Neuman, 2006) is to test the theory of learning to read that compares decoding to sight word instruction for Grade One students who are struggling to read (reading A to C as per Fountas and Pinnell (F&P) formative benchmarking). The independent variables are decoding and sight word reading strategies (defined above). The dependent variable of reading comprehension will be assessed through the Woodcock-Johnson Psycho-Educational Battery, Third Edition (WJ-III) Broad Reading Passage Comprehension subtest. Reading comprehension will operationally be defined as being able to orally relate “the sequence (i.e., beginning, middle, and end), the key points (who, what, when, where, and why) and the problems and solution” (Saskatchewan Curriculum, 2010, p. 27) both implicitly and explicitly stated of what one reads.
Alternative Hypothesis: Grade One struggling readers in _______ school division who participate in decoding instruction will have greater reading comprehension scores than students who participate in sight word instruction.
Null Hypothesis: There is no difference between the treatment group (decoding instruction) and the control group (sight word instruction) in terms of reading comprehension for Grade One struggling readers in _______ school division.
The participants are three classrooms of Grade One students in an elementary school in ________ school division. Their ages range from six to seven years old and the students are of different sexes, races, and socio-economic classes. Thirty students (n=30) will be receiving reading intervention with a Student Support Teacher (n=1) due to being identified as struggling readers (reading A to C on F&P formative benchmarking). Students will take part in a one-on-one pretest where they read 20 irregular words, 20 regular words, and 20 nonsense words. Students who score less than 50% correctly will be randomly assigned to the control group, focusing on sight word instruction, or the treatment group, focusing on decoding instruction. Both groups will be taught by the same trained Student Support Teacher (n=1) during a different 30 minute period each day for twelve weeks (January to March). The timespan is short to avoid maturation and potential cross-over lessons from within the regular classroom setting. Students will take a posttest on irregular words, regular words, and nonsense words. Their reading comprehension will be benchmarked using the WJ-III.
An application to the ethics board at the University of Regina will be made to grant approval to ethically conduct this research. The school division, the specific elementary school, and the participants’ caregivers will receive a formal letter explaining the purpose and benefit of the research, as well as specific details about the timespan, activities, and the use of data, paying specific attention to student anonymity (Creswell, 2012). All levels will have consent forms to sign and return in order for the research to be conducted.
|Treatment Group – Decoding||Control Group – Sight Words|
|Grapheme-Phoneme Relationships (5 minutes) – teaching phonics |
generalizations, blends, digraphs, letter
(CVC) words, and vowel teams through
the use of the Letterland program stories, songs, and actions and the Grade One
curricular list of phonics generalizations
(ee, sh, ch, ing, etc.), blends and
diagraphs (bl, br, th, wh, etc.), vowel
teams (ea, oa, oo, etc.), and the
alphabet (Saskatchewan Ministry of
Education, 2010, p. 35)
|Sight Word Naming (5 minutes) – |
teaching sight word recognition through
the Edmark program (Browder, 2012), a ‘Sight Word of the Day’ song, and word
learning through flashcard strategies and visual word boxes
|Grapheme-Phoneme Manipulation (10 minutes) – using manipulatives (ex. magnetic letters, blocks, wooden letters, etc.) to segment and blend the sounds in words |
and using Elkonin boxes to make word
|Sight Word Games (10 minutes) – |
playing sight word games, such as
Concentration and Bingo, to practice the
sight words taught that day and
|Guided Reading (10 minutes) – applying grapheme-phoneme blending in context |
to an appropriately leveled text
(approximately F&P levels A to C) (Uhry
et al., 1997; Weiser et al., 2011)
|Guided Reading (10 minutes) – applying sight word knowledge in context to an |
appropriately leveled text (approximately F&P levels A to C) (Uhry et al., 1997;
Weiser et al., 2011)
|Writing (5 minutes) – writing about what was read to encourage comprehension |
and practice segmenting and blending of phoneme-graphemes through invented
spelling (Uhry et al., 1997; Weiser et al.,
|Writing (5 minutes) – writing about what was read to encourage comprehension |
and practice sight words learned through word wall and textual cues (Uhry et al.,
1997; Weiser et al., 2011, p. 172).
Data Collection and Instruments
The students will take part in a one-on-one pretest where they read 20 irregular words, 20 regular words, and 20 nonsense words aloud (Eldredge et al., 1990; Freebody et al., 1988; Jeynes, 2008). A regular word will be defined as a word where each letter represents a common phoneme, whereas an irregular word may have silent letters, digraphs, blends, and/or vowel teams present (Freebody et al., 1988). A nonsense word will follow the grapheme-phoneme patterns of the language but result in a meaningless word, such as ‘bif.’ The same posttest will be used to determine their decoding and/or sight word strategy use after the intervention. The words will be taken from the appendix of regular, nonsense, and irregular words from Freebody’s and Byrne’s (1988) study (p. 453), keeping the grade difference in mind. The Word Attack and Letter-Word Identification subtests from the WJ-III will also be used but only during the posttest to reduce the threat of testing impact on internal validity.
Reading comprehension will be assessed using the Woodcock-Johnson Psycho-Educational Battery, Third Edition (WJ-III) by Woodcock, McGrew, and Mather (2001). The test was normed on 8,800 cases and its “internal consistency reliabilities range from .76 to .97 with a median of .87″ (Thorndike and Thorndike-Christ, 2010, p. 393). Cizek (2003) notes that the test “meets professional standards of reliability and validity for [its] intended purposes” (n.p.). The test is based on the Cattell-Horn-Carrol model of intelligence and achievement, which is commonly used in school psychology (Schrank, 2010). It is appropriate for ages 2 through 90 (Thorndike & Thorndike-Christ, 2010). The test “takes about 50 to 60 minutes to administer” if using all eleven subtests (Thorndike and Thorndike-Christ, 2010, p. 431). For the purpose of this study, the testing time will be reduced due to only using three subtests, which will help with maturation.
The Equal Variance one-tailed t-test will be used to “determine the difference between the means of the two groups” to ensure significance is based on the intervention rather than a sampling error (Mertler et al., 2010, p. 90). A repeated measure t-test will also be used to compare the results of the pre- and posttests for the same individuals (Mertler et al., 2010). The groups are equal and there is one independent and one dependent variable. Once the data is produced, it will be analyzed through the Statistical Package for the Social Sciences (SPSS) program (Creswell, 2012) in a spreadsheet format.
The p-value will be set with a <.05 level of statistical significance (Neuman, 2011). Thus, if the results are less than this, we will “reject the null hypothesis and call the findings significant” (Mertler et al., 2010, p. 93). A p-value of <.05 is common in educational psychology research and is deemed appropriate for this study to avoid a type 1 or type 2 error (Neuman, 2011).
Potential threats to internal and external validity are possible in all social research. Due the quasi-experimental nature of this study, the lack of random selection may cause an inequality between groups or selection bias from the onset (Creswell, 2012; Neuman, 2011). However, due to the ethical nature of research on students in premade classes, a true experiment with random sampling would not be applicable. Another internal threat may be testing effect since a pre- and posttest will be administered and students may remember items or simply improve their testing abilities (Creswell, 2012; Neuman, 2011). This can be solved with the Solomon-Four Group Design (Neuman, 2011). In this study, an additional posttest along with the original will be used. While we are using words from a previous research study and a standardized achievement test rather than the words taught in their classroom lessons, we cannot predetermine if students have been exposed to these words before and thus had a chance to learn them by sight. To ameliorate this, the criteria for inclusion is both struggling to read (reading F&P levels A to C) and 50% of the words stated incorrectly on the initial pretest. This should help eliminate ceiling scores. Students may also experience natural growth, testing boredom, or other natural causes that impact their results via maturation (Creswell, 2012; Neuman, 2011). A diffusion of treatment may occur if classroom instruction allows the treatment or control group to be exposed to the strategies of the other group (Neuman, 2011). The duration of the study is short so that classroom instruction will not interfere by teaching crossover items to students in the control and treatment groups and to avoid maturation. Furthermore, this study may lend itself better to a longitudinal study over a two to four year period so that the impacts of the instructional strategies can be observed overtime. A sample size of 30 was deemed acceptable as per Creswell’s (2012) recommendations for educational research. However, a larger sample size, or more importantly a more representative sample size (Neuman, 2011), may allow for more accurate generalizations.
The two overarching applications of this study for teachers will be clarity and training. Results of the study should assist teachers in planning for their classroom reading instruction (tier 1) and Student Support Teachers in planning specific reading interventions (tier 2) (Saskatchewan Provincial Reading Team, 2017). To the extent that the findings show that decoding should be emphasized for those beginning readers whom are struggling to read, teaching pedagogy may be shifted. Thus, the implication will be greater reading success for all students by “ameliorating early reading failure” (Weiser et al., 2011, p. 172) through a decoding approach. As Jeynes (2008) purported, “phonics instruction is a viable way of reducing the achievement gap” (p. 153); it is important to determine the best reading strategies through research and early intervention. This study should extend previous findings that all students “can learn decoding skills” (Browder, 2012, p. 243), albeit with explicit instruction and ample time. A change in pedagogy may also occur through teacher training in university education courses and/or professional development. The overall goal of the study is to provide concrete evidence towards a reading intervention strategy that will increase reading outcomes for all learners.
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Browder, D., Ahlgrim-Delzell, L., Flowers, C., & Baker, J. (2012). An evaluation of a multicomponent early literacy program for students with severe developmental disabilities. Remedial and Special Education, 33(4), 237-246. doi:http://dx.doi.org/10.1177/0741932510387305
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This paper explores the connection between trauma and ADHD, in terms of symptomology and etiology. Current diagnostic assessment methods for ADHD are inadequate for those who have experienced trauma. A call for more integrative, trauma-focused screening methods when diagnosing and treating ADHD is recommended.
Keywords: Acute Stress Disorder, adverse childhood experiences (ACEs),
Attention-Deficit Hyperactivity Disorder (ADHD), childhood trauma, comorbidity, complex trauma, Disinhibited Social
Engagement Disorder (DSED), evidence-based treatments, interpersonal trauma,
Posttraumatic Stress Disorder (PTSD), Reactive Attachment Disorder (RAD),
Attention-Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that manifests in early childhood and presents as predominantly inattentive (ADHD-PI), predominantly hyperactive-impulsive (ADHD-HI), or combined type (ADHD-C). The severity ranges from mild to severe based on the number of symptoms present across two or more settings, as well as the impairment these symptoms have on the individual’s overall functioning (American Psychiatric Association [APA], 2013). Mash and Wolfe (2019) note that the prevalence of an ADHD diagnosis is “about 5% to 9% of all children and adolescents 4 to 17 years old in North America” (p. 244). The DSM-5 reports rates of 5% in children due to lower worldwide occurrences (APA, 2013). However, despite varying prevalence rates, ADHD is reported in every country that studies it, across all socioeconomic statuses (SES), and amongst males and females at a 2-3:1 ratio respectively (Mash & Wolfe, 2019). ADHD is considered to be a pervasive, lifelong disorder with varying patterns of behavior and intensity based on developmental levels (Mash & Wolfe, 2019). Since ADHD is a common referral problem, it is imperative that the diagnostic screening and assessment tools used are both valid and reliable.
When diagnosing ADHD, it is important to ascertain whether the symptoms are developmentally appropriate or a result of another medical, mental, or neurodevelopmental disorder (APA, 2013). This poses a challenge because approximately “80% of clinic-referred children with ADHD have a co-occurring psychological disorder” (Mash & Wolfe, 2019, p. 244; Canadian ADHD Resource Alliance [CADDRA], 2018), with the DSM-5 highlighting Antisocial Personality Disorder (ASPD), Autism Spectrum Disorder (ASD), Conduct Disorder (CD), Disruptive Mood Dysregulation Disorder (DMDD), Intermittent Explosive Disorder (IED), Major Depressive Disorder (MDD), Obsessive-Compulsive Disorder (OCD), Oppositional Defiance Disorder (ODD), Specific Learning Disorder (SLD), and anxiety, personality, psychotic, substance use, and tic disorders as potential comorbid or differential diagnoses (APA, 2013). In addition, Bipolar Disorder (BP), Intellectual Developmental Disorder (IDD), Reactive Attachment Disorder (RAD), and neurocognitive disorders are included as differential diagnoses to be considered (APA, 2013). Accounting for potential comorbid and differential diagnoses, ensures an accurate diagnosis and treatment plan. While the DSM-5 includes many comorbid and differential diagnoses for consideration, a growing body of research highlights the need for trauma screening when diagnosing ADHD due to the relational course and symptomology.
Traumatic events may be termed in the literature as complex trauma (Conway, Oster, & Szymanski, 2011; Pottinger, 2015), interpersonal trauma (Mash & Wolfe, 2019), and/or adverse childhood experiences (ACEs) (Conway et al., 2011; Brown et al., 2017). Like ADHD, trauma does not discriminate: “in 2017, there were 59,236 child and youth victims (aged 17 years and younger) of police-reported violence in Canada… overall, 33% of children and youth victims had been subjected to violence by a casual acquaintance and 18% by a stranger” (Burczycka, Conroy, & Savage, 2018, p. 4). This is a reduction from the 85,440 substantiated cases in 2008 (Klien, Daminai-Taraba, Koster, & Campbell, 2015). These types of violence included complex and interpersonal forms of trauma, such as neglect, sexual assault, and physical and emotional abuse. These experiences in childhood can lead to diagnosable trauma- and stressor-related disorders such as Acute Stress Disorder, Disinhibited Social Engagement Disorder (DSED), Posttraumatic Stress Disorder (PTSD), and Reactive Attachment Disorder (RAD) in 10-20% of cases (APA, 2013). However, whether diagnosable or not, trauma has a negative impact on childhood development. Based on the 1998 ACEs study, 11-23% of adults have experienced childhood trauma that can “impede an individual’s ability to integrate sensory, emotional, and cognitive information” and present as hyperarousal (Conway et al., 2011, p. 61-2). Having ACE scores increases “a child’s risk for toxic levels of stress, which in turn might impair neurodevelopment, behavior, and overall physical and mental health” (Brown et al., 2017, p. 349-50). Unfortunately, while childhood trauma is far-reaching, this is not often the case for trauma screening.
The ADHD and Trauma Connection
Within the research, the connection between trauma and ADHD has been established. For instance, Ford et al. (2000) found a strong correlation between ADHD and trauma; 25% and 11% of individuals with ADHD experienced physical and sexual abuse respectively and rates of trauma rose to 91% with comorbid ODD. Weinstein, Staffelbach, and Biaggio (2000) also found a correlation between sexual abuse and ADHD. In 2006, Endo, Sugiyama, and Someya found that 14-46% of children with ADHD had experienced abuse. Similarly, Briscoe-Smith and Hinshaw (2006) found that 6 to 12 year old girls with ADHD had experienced higher rates of abuse than the general public – 14.3% to 4.5% respectively. They found that the girls with ADHD who experienced abuse often presented with externalizing symptoms and combined type ADHD. Rucklidge, Brown, Crawford, and Kaplan (2006) surveyed adults with ADHD using the Childhood Trauma Questionnaire and 56% of the individuals with ADHD self-reported childhood trauma. Conway et al. (2011) studied 79 children ages 8 to 18 from Hispanic and African-American backgrounds in an urban psychiatric hospital and found that those with ADHD experienced trauma at higher rates than the general public. Perry and Mackinnon (2012) purported that developmental adversity is a risk factor for the expression of ADHD. In 2013, Biederman et al. studied children in a pediatric setting and found that children from families with higher levels of interpersonal conflict had disproportionately higher rates of ADHD.
While these comparisons were based off of DSM-IV-R assessment criteria, recent studies using DSM-5 diagnostic criteria continue to connect ADHD to trauma. Klein et al. (2015) studied Canadian children in child protection services and found that they “are diagnosed and treated for… ADHD at higher rates than the general population” due to symptom overlap (p. 178). Fuller-Thomson and Lewis (2015) had Canadian adults self-report past childhood physical abuse, sexual abuse, and domestic violence. They found that the first two adverse experiences elevated odds of an ADHD diagnosis in both women and men, whereas domestic violence elevated odds of an ADHD diagnosis in women only. Brown et al. (2017) used a sample of 76,277 children ages 4 to 17 and found that ACE scores and ADHD were associated. Furthermore, they found a gradual relationship between the number of ACE scores and the severity of the ADHD presentation (Brown et al., 2017). In their brain neuroimaging research, Park et al. (2017) found that childhood trauma “strongly predicts the development of ADHD and influences biological processes in offspring” (p. 184). Thus, a clear relationship among trauma and ADHD continues to be substantiated in the literature, yet relatively overlooked in current DSM-5 diagnostic criteria and assessment practices.
Shared Etiology and Symptomology in ADHD and Trauma
ADHD and trauma share similar etiologies and symptomologies. While neurobiological factors rather than psychological factors are often the focus for ADHD and vice versa for trauma, a more integrative approach is preferred. Looking at neurobiological factors, Mash and Wolfe (2019) note that “ADHD appears to be related to abnormalities and developmental delays in the frontostriatal circuitry of the brain and pathways connecting this region with the limbic system, the cerebellum, the thalamus, and the default mode network” (p. 256). Trauma impacts areas of the brain connected to stress, such as the limbic and neuroendocrine systems (Mash & Wolfe, 2019). Similar deficits can be observed in the prefrontal cortex and in gray and white matter abnormalities. Spitzer, Schrager, Imagawa, and Vanderbilt (2017) studied children with PTSD and found that they had “reduced N-acetyl aspartate (NAA), indicating loss of neuronal integrity, in the medial prefrontal cortex… implying a common neuroanatomical etiology” with ADHD brain patterns (p. 345). Similarly, Perry and Mackinnon (2012) found that neglect can lead to an underdeveloped prefrontal cortex and reduced gray matter, leading to externalizing behaviors of impulsivity and reactivity or internalizing behaviors of withdrawal. Park et al. (2016) found white matter anomalies in children with ADHD and in those who had experienced childhood trauma. Furthermore, Park et al. (2017) researched catechol-o-methyltransferase genes on inhibitory deficits in children with ADHD and found “a genetic influence on the association between childhood trauma and the severity of inhibitory deficits in children with ADHD” (p. 183). While an in-depth exploration of brain functioning is beyond the scope and sequence of this research paper, it is important to note the brain connections between childhood trauma and ADHD that may result in similar behavioral presentations.
Psychological factors that are shared amongst ADHD and trauma include low SES, parental separation and divorce, parental mental illness, maternal substance use during pregnancy, and birth complications (Brown et al., 2017; Conway et al., 2011; Dubowitz et al., 2011; Gul & Gurkan, 2018; Mash & Wolfe, 2019; Richards, 2013). Mash and Wolfe (2019) recognize that “family problems may lead to greater severity of symptoms and to the emergence of co-occurring conduct problems” (p. 256), even though ADHD is generally not thought of as being caused by psychosocial factors. Furthermore, stigmatization and lack of family supports and resources can lead to mismanagement and misdiagnosis of symptoms (Fuller-Thomson & Lewis, 2015; Pottinger, 2015; Richards, 2012).
Symptoms of trauma, especially those related to PTSD, often mimic ADHD-like symptoms of hyperactivity and inattention. For instance, internalizing and externalizing behaviors such as inattention, distractibility, disruption, fidgeting, hyperactivity, restlessness, impulsivity, irritability, and poor emotional regulation may be observed in both cases (Briscoe-Smith & Hinshaw, 2006; Conway et al., 2011; Dahmen, Purtz, & Herpertz-Dahlmann, 2012; Endo et al., 2006; Ford et al., 2000; Klein et al., 2014; Park et al., 2017; Perry, 2007; Rucklidge et al., 2006; Spitzer et al., 2017; Szymanski, Sapanski, & Conway, 2011; Weinstein et al., 2000). Spitzer et al. (2017) found that when children cannot rely on a caregiver they adapt in ways that seem disruptive and “may present with signs and symptoms similar to ADHD” (p. 345). ADHD is listed as a differential or comorbid disorder in DSED due to similar impulsivity symptoms (APA, 2013). However, DSED is not listed as a differential or comorbid diagnosis for ADHD despite symptom overlap.
It has been argued that the externalizing symptoms of ADHD are easier to identify than the re-experiencing or avoidance symptoms related to PTSD and trauma, especially in young children (Ford et al., 2000; Klein et al., 2014; Spitzer et al., 2017; Szymanski et al., 2011; Young, Kenardy, & Cobham, 2011). The symptoms can impact relationships, academic performance, and executive functioning (Mash & Wolfe, 2019; Pottinger, 2015). In their study of Canadian children in the welfare system, Klein et al. (2015) found that the anxiety and hypervigilance response to trauma can mimic the hyperactivity and impulsivity found in ADHD. Furthermore, trauma-related avoidant behaviors can present like inattention in ADHD (Spitzer et al., 2017; Szymanski et al., 2011; Weinstein et al., 2000). When both disorders are present, trauma can exasperate symptoms since issues with coping and listening can further create a dysregulated affect (Szymanski et al., 2011). Because the symptoms of trauma and ADHD are closely related, a clinician may miss the signs of trauma and attribute behaviors solely to ADHD.
While the two disorders share behavioral symptoms, the treatment methods and approaches differ. The cost of ADHD in the United States varies between 12 to 17 thousand USD per person due to medical and educational needs (Klein et al., 2015; Mash & Wolfe, 2019). Thus, it is important that the treatments used are evidence-based and tailored to an accurate diagnosis so that they are both helpful and cost-effective. Treatment of ADHD often involves parent management training (PMT), educational and environmental interventions, and/or stimulant medications, such as dextroamphetamine, amphetamine-dextroamphetamine, and methylphenidate (CADDRA, 2018; Conway et al., 2011; Mash & Wolfe, 2019; Richards, 2013). Pharmacotherapy treatment is a common approach backed by the Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) study,but in complicated situations medications should be used in combination with psychoeducational interventions (Klein et al., 2014; Mash & Wolfe, 2019). ADHD treatments focus on treating the behavioral symptoms, whether through stimulant medications and/or environmental adaptations.
Treating trauma, on the other hand, focuses on the root cause(s) first and the specific behavioral symptoms second. These evidence-based treatments include Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), psychotherapy, parent management training through the Triple P Program and Project Safe Care, and/or serotonergic antidepressants for PTSD specifically (Conway et al., 2011; Mash & Wolfe, 2019; Spitzer et al., 2017). The most common approach for PTSD treatment is TF-CBT, which incorporates elements of exposure therapy, narrative writing, role-play perspective taking, parental involvement, family communication, parental training, psychoeducation, safety, and relaxation, self-regulation, and stress management skills (Mash & Wolfe, 2019; Pottinger, 2015; Weisz & Kazdin, 2017). For those diagnosed with RAD or DSED, parenting classes, environmental changes, and counselling are the preferred methods over psychopharmacological treatments (Mash & Wolfe, 2019; Perry & Mackinnon, 2012). In addition, building on protective factors such as family and social supports (Perry & Mackinnon, 2012), connecting families to support resources (Dubowitz et al., 2011), and Duty to Report protocol in childcare professions can support trauma treatment.
At best mistreatment could lead to ineffective approaches; at worst mistreatment could lead to potential harm. For instance, Klein et al. (2015) note concerns such as “prolonged exposure to unhelpful medications, stigmatization, a feeling of being misunderstood and opportunity cost in treating other problems” (p. 183). Furthermore, mistreatment neglects “the underlying emotional, personality, and interpersonal issues” that the child may have (Conway et al., 2011, p. 6). Richards purports that treating children who have experienced trauma with stimulant medication “runs the risk of colluding with an external environment which needs to change, and effectively ‘silencing’ the mechanisms a child is using to communicate that ‘all is not well'” (2013, p. 496). Because ADHD treatments focus on the behaviors, using these treatments with those who have experienced trauma does little to help the child and may overlook the relational and familial problems (Richards, 2013). Briscoe-Smith et al. (2006) found the following:
There are children with ADHD for whom abuse appears to be overlooked diagnostically, either as an etiological factor or an exacerbating variable. If such trauma is not addressed, symptoms associated with it may go unchecked and may even become worse as the child develops. The usual interventions for ADHD (behavioral modification procedures, stimulant medications) may not be the appropriate treatments for traumatized children. (p. 10)
Furthermore, if ADHD-based treatments are used without trauma supports, “symptoms and functional impairments may persist” (Klein et al., 2015, p. 181). Misdiagnosis and thus, mistreatment is predictive of negative outcomes.
If a child has ADHD but also a history of trauma, it is important not to treat each in a vacuum. Not only would the developmental course be more severe (Biederman et al., 2012; Brown et al., 2017; Ford et al., 2000; Szymanski et al., 2011), but both the trauma and ADHD symptoms would require monitoring. Brown et al. (2017) note that “cumulative exposure to traumatic experiences is associated with worse overall ADHD symptom severity” and may explain why solely using ADHD treatments does not work (p. 353). Ensuring safety and trauma symptom stabilization is recommended before treating the comorbid ADHD (Biederman et al., 2013; Perry & Mackinnon, 2012). While children who experience trauma may require medications and behavioral management strategies as part of their treatment, especially when comorbid ADHD occurs, a typical approach would be therapeutic or caused-based, followed by medications or behavior-based treatments. Further research on specific, research-based trauma and ADHD treatments is needed (Briscoe-Smith et al., 2006). Pottinger (2015) has adapted trauma-based strategies to support clients with comorbid ADHD but continued work in the field would be beneficial to ensure validity and reliability.
Moving Forward with Trauma Screening
ADHD and childhood trauma are closely related; thus, it is integral to have screening tools and methods that differentiate between the two. Unfortunately, despite research, trauma screening is not mandatory when exploring an ADHD diagnosis. Spitzer et al. (2017) found that only 44% of general practitioners screened for trauma. Furthermore, Brown et al. (2017) note that “although it has been shown that children exposed to ACEs can manifest many of the disruptive behaviors, impulsivity, and executive dysfunction characteristics of ADHD, comprehensive evaluation for traumatic stressors is not routinely performed during ADHD assessment” (p. 350). They found that only 2-4% of general practitioners routinely screened for ACEs and for one third, trauma screening was not part of their practice. The Canadian ADHD Practice Guidelines briefly mention exploring trauma histories but no specific screening tools are recommended (CADDRA, 2018). The DSM-5 recommends excluding other mental disorders and Reactive Attachment Disorder (RAD) is included as a differential diagnosis with differences in the amount of symptoms shown and attachment styles (APA, 2013). However, research by Szymanski et al. (2011) and Conway et al. (2011) shows that there is diagnostic ambiguity and confusion with determining differential diagnoses. This may be because each child differs in their behavioral presentation. Moving forward, trauma screening should become commonplace to ensure accurate diagnosis, proper care, and cost-effectiveness of treatments.
If trauma screening is to become best practice, having the appropriate tools is necessary. Currently, a pediatrician or family physician would work with an educational psychologist to diagnose ADHD (CADDRA, 2018). Often it is the caregiver or educator whom makes the initial referral and acts as a main source of screening information (Klein et al., 2015), because they have firsthand experience with the child. Since there are no definitive diagnostic tools for ADHD, clinical judgement and triangulation of assessments from multiple sources is necessary. These assessments may include parent and teacher rating scales, such as the Conners Comprehensive Behavior Rating Scales-3 (Conners CBRS-3), Vanderbilt ADHD Diagnostic Rating Scales (VADRS), ADHD Rating Scale, SNAP-IV Teacher and Parent Rating Scales, and Child Behavior Checklist (CBCL) (CADDRA, 2018; Gupta & Kar, 2010). It is important to note that none of these rating scales are intended to diagnose or screen for trauma (Spitzer et al., 2017; Weinstein et al., 2000) and rater-bias may occur (Gupta & Kar, 2010). Furthermore, Brown et al. (2017) report that:
Current rating scales and checklists focus primarily on presenting behaviors and do not query about psychosocial and environmental factors, such as exposure to traumatic stress, which might play an important role in ADHD symptom onset and progression and if identified, can help clinicians determine helpful components of multimodal therapy. (p. 350)
From a best-practice standpoint, the connection between trauma and ADHD should lend itself to clinical consideration of both concerns even when a diagnosis of ADHD seems obvious.
Moving forward, clearer diagnostic
guidelines, mandatory trauma screening protocol, and more education on the
relationship between trauma and ADHD would be beneficial. Furthermore,
including trauma as a comorbid or differential diagnosis to ADHD would help
foster accurate diagnoses. Multi-agency collaboration between child protection
workers, educators, psychologists, pharmacists, and doctors may help support
accurate diagnosis of comorbid or differential ADHD and trauma. Asking direct
questions about experiences of abuse and other trauma, probing further with
similar symptomology, exploring developmental histories, observing children in
their natural environments, and using rating scales in addition to written
self-reports and medical exams is recommended (Mash & Wolfe, 2019; Ford et
al., 2000; Richards, 2013; Weinstein et al., 2000). In addition, asking
targeted questions about onset, duration, frequency, thoughts and feelings,
environments, activities, family relationships, and the people around when
certain symptoms occur is warranted to determine patterns of ADHD-like behavior
from trauma-related symptoms. All children deserve an accurate diagnosis and
treatment plan that deals with the complexity of their lives; we need an
integrative, all-encompassing approach to diagnosing ADHD so that trauma will
not be overlooked for any child with the misfortune.
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The Saskatchewan Reads: A Companion Document to the Saskatchewan English Language Arts Curriculum – Grades 1, 2, 3 is a document that every Saskatchewan teacher should familiarize themselves with. It highlights curriculum connections, learning environments, big ideas of reading, assessment for, as, and of learning, instructional approaches, and interventions. Today I want to focus on how I use the instructional approaches in my classroom.
- Modeled Reading – “I Do”
- Shared Reading – “We Do”
- Scaffolded/Guided Reading – “We Do Together”
- Independent Reading – “You Do”
Utilizing the GRR allows the teacher to “gradually transfers increased responsibility to the students” (Saskatchewan Reads, 2019, n.p.). It is an evidence-based strategy that allows for student growth and achievement.
Modeled Reading involves verbalizing reading strategies and thought processes in a planned way while reading to the class. Basically, the teacher is repeatedly practicing the reading skill(s) that students will eventually be expected to do. This can be accomplished through various forms of literature across any subject matter. It extends beyond a simple read-aloud because reading behaviors are emphasized, modeled, and then practiced by students afterwards.
Modeled Reading in My Classroom: One of my favorite modeling lessons involves fairy tale stories. I like to use fairy tales because students are often familiar with them and there are many different versions. During a reading of the Three Little Pigs, I modeled ‘skippy frog’ (skip the tricky word, read to the end, and then go back and try again) and ‘chunky monkey’ (chunk the words into smaller parts that you know). The comprehension strategies that I focused on were retelling in order (sequencing) and using prior knowledge. I am expecting my students to start using these strategies more independently and modeling them is the first step. The next day I modeled another version of The Three Little Pigs and emphasized comparing/contrasting in addition to the other strategies.
Shared Reading involves using different genres to share in reading and strategy use. It goes beyond choral reading or round-robin reading because the students and teachers are working together and the teacher continues to model their thought process.
Shared Reading in My Classroom: My students love poems and this genre is often perfect for shared reading. We read the poem “Straw, Sticks, and Bricks” which also supported their comprehension. I modeled the poem the first day utilizing ‘stretchy snake’ (sounding out the words) and ‘flippy dolphin’ (changing the vowel sound). Then the next day we reviewed the events of the poem together and any phonics generalizations. Students then got a chance to share in the reading. Afterwards, students practiced the reading strategies that we had been focusing on with our reading strategy cards.
I also will be completing this sentence strip One Pig, Two Pigs book with the students to further practice our strategies in a shared way. Sentence strip stories lend themselves nicely to all four instructional approaches, especially when repetition occurs.
Scaffolded/Guided Reading involves targeted reading instruction in flexible groupings based on student needs. Students practice reading and reading strategies through a variety of content areas and leveled books. Instructional time and lesson focus varies based on group needs and teacher observations. This extends beyond round-robin reading because students can work at their own pace and the strategies taught apply to reading opportunities beyond that specific text.
Guided Reading in My Classroom: For Guided Reading (and Levelled Literacy Intervention), I used different levels of The Three Little Pigs based on student needs and we read them in their flexible groupings. Students got a chance to practice our previous reading and comprehension strategies, such as compare/contrast. We always read the books two days in a row before students take them home to share with their parents. On the second day, students will write about their reading to solidify their comprehension. The second reading also helps develop their confidence and fluency.
Independent Reading involves students selecting “just-right” texts and then applying their reading strategies independently. This differs from silent reading because of the discussions, written reflections, and goal-setting that occurs between students and their teacher.
Independent Reading in My Classroom: My independent reading time is scheduled alongside guided reading typically. I have a classroom library of over 500 books that students can choose from. Students read for 7-10 minutes and then conference with a peer for 3-5 minutes about what they read. They can also engage in a shared read or read-aloud at this time. I leave five minutes at the end of each guided reading lesson to check-in with students about what they read and what strategies they used. I use the attached document to conference with students about what they read and if it was the right fit. Sometimes I need to ask further comprehension questions but I like that this document ties back to our classroom anchor chart.
It can be this simple to use the four instructional approaches in your classroom! This concept can be applied to other genres, countless subjects, and any story (whether the reading materials connect or not)! I am planning to repeat this structure when reading Goldilocks and the Three Bears. Be sure to check out Saskatchewan Reads and please feel free to leave a comment about how you use the four instructional approaches in your classroom!
We have been learning about strategies to use when we are in the blue, green, yellow, and red zones. Yoga is a strategy we often use in the blue or yellow zones. One of our favorite poses is called Legs Up The Wall. In this position, students lay flat on their backs with their legs against a flat surface, like a cupboard or wall. Students can put their hands on their heads, by their sides, or on their body. Their legs can be straight up and down, bent into a butterfly pose, or open in a V-shape. The benefits of this pose include calming the nervous system, quieting the mind, reducing stress, releasing pressure and tension in the lower body, and inversion benefits without a lot of effort. It is quick and easy and students love it! One of my students told me about how she was practicing at home and her mom wondered what she was doing. While it may look silly, it is totally worth it!