h c a elPing hildren WiTh TTenTional c M hallenges in The onTessori c : i lassrooM nTroducTion by Catherine Nehring Massie Catherine Nehring Massie provides important contextual information in considering children with attentional challenges. She discusses the prevalence of attentional challenges in today’s culture and the contributing factors. She gives a general overview of the spectrum of attentional challenges and some of the indicators in children. Her history of Montessori and work with children facing attentional challenges provides a clearer understanding to the individual details and definitions as it builds upon years of work and observation. Critical to her article and those that follow is the link she draws between concentration (attention) and human development: “At- tention lays the foundation for concentrated work—normalization of the child’s personality.” By partnering Montessori with medical knowledge, fostering focus and attentional development can be better achieved. Thank you to NAMTA for inviting us to present an outline of how a medically enhanced Montessori approach may be used to strengthen the development and reduce the disability of a child with attentional challenges within an inclusive Montessori community. Together, we present an overview of how to approach the child’s challenges and challenging behaviors, and how to determine what is needed to aid their development in a significant, positive, and Catherine Nehring Massie is the director of the Frederick Country Day Montessori & Arts School. She holds an AMI elementary diploma from Bergamo, Italy, an MA in education, and Maryland certification in elementary and special education. Nehring Massie also holds special education training certificates in Orton-Gillingham tutoring for children with Dyslexia, the Dubard Association Method for children with hearing disabilities or aphasia, Montessori Applied To Children At Risk, Autism-A Montessori Approach, and Laubach Tutoring for English language learners. This talk was presented at the NAMTA conference titled Finding the Hook: Montessori Strategies to Support Concentration, October 6-9, 2016, in Columbia, MD. Massie • Helping Children with Attentional Challenges 263 lasting way. Here you will learn how varied and complex the un- derlying pathologies of attentional challenges can be and the risks of misdiagnosis in terms of intervention strategies (in other words, why differential diagnosis is so essential). You will also learn how Montessori teachers can collaborate with medical professionals to meet the needs of their attention-challenged students within a Montessori environment, as well as some relatively easy tools to provide a child with help during the (sometimes lengthy) process of resource-team building, assessment and diagnosis, and inter- vention plan development. We provide an overview of the medical landscape around attentional challenges and outline a Montessori- based approach that stresses collaboration with medical specialists to identify and address attentional challenges to allow success for these children in a Montessori classroom. If anyone is able to succeed in educating the abnormal child, this would have to be based on scientific principles, as existing pedagogy is not sufficient. (Montessori, The 1946 London Lectures 9-10) I will begin with some introductory remarks about the nature and importance of the faculty of attention and then will provide some historical background on medical-educational partnerships to therapeutically aid children with disabilities. Finally, I will introduce our two medical specialists who will provide important information for Montessori teachers seeking to aid the development of children with attentional challenges. The essenTial faculTy of aTTenTion Why is the subject of attention so timely and crucial today that it warrants an entire NAMTA conference devoted to it? We find that there are significant factors influencing today’s children’s attentional abilities originating from genetic, environmental, and cultural trends. Dr. Montessori, through her study and work with children with disabilities, recognized that attention is the prerequisite for and foundation of all learning. When you have solved the problem of controlling the atten- tion of the child you have solved the entire problem of its education. (The California Lectures of Maria Montessori 338) 264 The NAMTA Journal • Vol. 42, No. 2 • Spring 2017 We heard from keynote speaker Annette Haines about how Montessori’s educational approach is grounded in the child’s abil- ity to attend: It is the polarization of the young child’s attention that builds their capacity for concentration and that leads to the phenomena she called normalization. And yet, as we heard from keynote speaker Maggie Jackson, today’s technological culture in which many children are raised, presents a potentially dangerous assault on the development of their natural ability to attend. On top of this negative cultural influence, is the increasing number of children with attentional dysfunction stemming from neurophysi- ological or biochemical differences in how their brains work. Occu- pational therapist Barbara Luborsky and Dr. Maureen Murphy-Ryan will discuss attentional challenges from a medical perspective and how medical specialists can partner with Montessori teachers to ameliorate these challenges. ADHD Rates Are Increasing A recent study published in The Journal of Clinical Psychiatry reports a dramatic increase in the prevalence of attention deficit hy- peractivity disorder (ADHD) in the United States (Collins & Cleary). A large national survey in 2011 found that 11% (revised from 12%) of children and teenagers in the United States had a diagnosis of ADHD, a prevalence rate up 42% from 2003. This increased preva- lence reflects increased awareness of ADHD, better diagnosis, and the highly genetic heritability of this condition. How many children do you have in your class who are diagnosed or at-risk for ADHD? These children are challenging Montessori teachers worldwide, not just due to increasing prevalence but also because many parents sense that a Montessori environment will be a better place for their highly active or distractible child. Unfortunately, without an understanding of these children’s functional challenges and special educational needs, children with attentional challenges are often unsuccessful and unmanageable in a Montessori classroom. Parents are too often told that their child needs “more struc- ture” than is found in a Montessori classroom—meaning that their child needs to be in a traditional school program where children are required to sit still and attend to the words of the teacher in order to learn. Intense extrinsic motivational systems are used to Massie • Helping Children with Attentional Challenges 265 enforce compliance with attention-challenged students. A Montes- sori classroom, combined with the needed supports, can provide these challenging children a less restrictive educational environment where they can learn through movement and where they have the freedom to develop self-regulation skills so they can optimize their own working and intrinsic love of learning. When children cannoT aTTend In this workshop, you will get an understanding of the variety of causes leading to attentional dysfunction and how a diagnosis of ADHD is determined. An overview of the variety of challenging behaviors that these children exhibit will be presented along with a description of a variety of neurophysiological dysfunctions that some children struggle with daily, and the variety of detrimental, danger- ous, or deadly outcomes for which these children are at-risk. Children with attentional dysfunction can be helped to learn to concentrate, to learn compensatory strategies, to learn self-regulation, and to learn to succeed in school and in life. The particular help needed will depend on a child’s unique array of neurophysiological dysfunctions, the identification of which requires a comprehensive and multidisciplinary evaluation. Our two medical presenters, Ms. Luborsky and Dr. Murphy-Ryan, will outline the role of the occu- pational therapist and the physician/psychiatrist in these evalua- tions. Additional cognitive and psychoeducational evaluations may be needed to assess for language and learning disabilities, which can present like ADHD or accompany ADHD. The comprehensive, multidisciplinary medical evaluation is essential to make a dif- ferential diagnosis, which is required to inform correct treatment interventions and effective educational accommodation. Doctors Jean-Marc Itard, Eduoard Seguin, and Maria Montessori all confronted the sometimes nearly impenetrable wall created by inability to attend in the profoundly disabled children with whom they worked. This was the first, and probably most difficult, step in aiding a profoundly disabled child’s development—the fixing of the child’s attention. All three of these pioneers in special educa- tion recognized that to affix the child’s attention required the use of the child’s body and, in particular, the child’s hands: “The hands are the instruments of man’s intelligence” (The Absorbent Mind 27). 266 The NAMTA Journal • Vol. 42, No. 2 • Spring 2017 This principle applies to all children. Montessori applied it to her educational system to aid the development of typical children as well. In this principle, we will find powerful assistance to helping children with atypical attention. aTTenTional abiliTy falls along a sPecTruM There is a whole range of severity with respect to attentional challenges from mild to severe in terms of both hyperactivity and inattentiveness characteristics. Normal Range In the diagram on the next page, the typically developing child falls within the central range labeled Typical. This child is able to learn effectively in both traditional and Montessori educational settings. In the Casa dei Bambini, the child will develop a strong ability to at- tend and concentrate deeply, as this is Montessori’s primary focus for this age group: normalization through concentrated work. Mild Range In the diagram, we see the central range expanded to include two types of children. These types are (1) a typically developing child who has been subject to negative environmental influences (family and/or cultural) and who exhibits characteristics of atten- tion dysfunction; and (2) a child who exhibits mild attention deficits with noticeable challenges with hyperactivity and/or distractibility. These children stand out more in traditional educational settings than within the active Montessori classroom where they are allowed to move and explore. Deviations in the attention of a typical child can often be corrected during the first plane, and this is developmental aid provided by the Montessori method with its medical roots. Because Montessori education has so many therapeutic and special education features already built in, children who are mildly deviated in attentional capacity can also become successful with little additional help. Montessori teachers generally begin to see improvement in attend- ing and concentrating through the normalization process. Massie • Helping Children with Attentional Challenges 267 For a child who appears resistant to normalization, more observa- tions and experimentation with supports is called for. These normal- ization-resistant children may actually be developmentally atypical, with neurological differences falling in the mild range. Trying out a variety of functional/educational supports (such as those in the Tools for Teachers [found in appendix B at the end of this section]) can lead to identification of strategies that improve independent functioning and improve success in the Montessori environment. Moderate to Severe Range Then there are children who move out along the hyperactive/ inattentive spectrums and exhibit moderate to severe attentional challenges resulting from neurophysiological conditions. These children will need evaluation and varying levels of intervention and support. WhaT does adhd look like in a MonTessori classrooM? What behaviors do you see in your classroom indicating inat- tentiveness? Hyperactivity? Both? 268 The NAMTA Journal • Vol. 42, No. 2 • Spring 2017 Hyperactivity Running. These types of children, throughout the day, often break out into running circles around the classroom, unless prevented. This is a highly stimulating and pleasurable activity for them, which quickly turns into a game of chase, if not prevented. In addition to being a challenging behavior to stop, once started it often requires at least two adults to stop it. Other children may join in this run- ning chase game, making it even more exciting and more strongly reinforcing this behavior. Running indoors is a dangerous behavior and must be extinguished or replaced immediately. Climbing. These children use any vertical furniture available to climb on, often damaging or breaking furniture or materials in the process. These children like to climb up shelves, climb or stand on tables and chairs, climb up the bead cabinet, and/or climb unsafely on playground equipment. Hitting. These children are very impulsive and often do not understand personal space. They hit first and ask questions later, usually deeply regretting the results of their impulse (e.g., hurting a friend). Talking Out. These children talk prolifically, rapidly, and si- multaneously with others. They blurt out everything that comes to mind without reflection or pausing to hear the other person with whom they are in conversation. They frequently interrupt or talk aloud when the teacher is instructing. Poor Coordination. These children frequently have noticeable gross and small motor coordination difficulties. They frequently bump into people, bump into things, drop things, spill things, break things, trip and fall, and fall off chairs. These are not intentional, for the most part, but indicative of their neurophysiological differences. Given a lot of negative attention or admonishments for these “ac- cidents,” some children will start to do these things intentionally. Inattentive Not Choosing Work. These children usually have a very dif- ficult time choosing work. They often feel overwhelmed by all Massie • Helping Children with Attentional Challenges 269 the choices in a Montessori classroom. This creates a great deal of anxiety, and they fear being confronted by the adult with “choose a work,” which is often followed by “or I will choose for you” and this creates even more anxiety. Anxiety, then, can become a second- ary hurdle to concentrated work. Wandering. Because making choices can be very anxiety-produc- ing, these children may spend a lot of time wandering through the classroom. Wandering can include walking through other children’s work space or stepping on their work, bumping into materials (e.g., knocking down the pink tower), stopping to watch—and sometimes interfering with—another student’s work, looking out the window, daydreaming, multiple trips to the sink/restroom, or hiding in the library behind a book. Some children are not able to maintain focus long enough to choose; they simply begin thinking of something new or are attracted to something else that has caught their eye. Looking Like They Are Working. These children become adept at pretending they are working, choosing anything off the shelf to conceal that they are not engaged in work; or some sit down to work and then lose focus and start thinking about other things. They need to be observed closely to ensure they are engaging with concentration in developmental work. Poor Social Skills. Both hyperactive and inattentive types of children may struggle with poor social skills. These children often have poorly developed social skills because they have not been able to attend to, and therefore naturally absorb, the more subtle social conventions governing daily social life. They often do not respect (i.e., are not cognizant of) personal space, they impulsively interrupt others in conversation, they have not taken the time to interpret the body language or the perspective of the other person, and they have not observed the art of initiating social interaction, so they often use physical means. Hyperactive and Inattentive Combined Children who exhibit both types of behaviors described above are the most behaviorally challenging. They are often not able to function successfully in a Montessori classroom without accom- 270 The NAMTA Journal • Vol. 42, No. 2 • Spring 2017 modations, support and/or a one-on-one adult helper (preferably a behavior therapist but more commonly an untrained “shadow”). MulTiPle adhd children in one environMenT? What if there is more than one child with ADHD in a classroom? Depending on the particular children involved, this can increase the behavioral challenges exponentially. These children recognize their alikeness almost instantaneously and are attracted to each other like magnets; their energies can feed off each other and intensify. This problem is more pronounced in first-plane children, when normal- ization has not yet occurred. I have observed a three-year-old child sitting or working peacefully in the classroom, and then his friend (who is also impulsive) enters the environment and the instant that they make eye contact, it is like lightning bolts shoot between them, energizing them. All of a sudden, both are up and running through the classroom playing chase with the teachers, disrupting the work of all the children, and sometimes even stimulating typical children to join in the chase game. Soon five children are screaming and run- ning circles around the teachers! They can be best friends and worst enemies. While The essence of scientific and medical these children see kin- pedagogy: To understand, we need dred spirits in one another medicine. To aid development, we and are often drawn to need education. be friends, they also have common characteristics that antagonize each other—like impulsiveness. Disagreements, conflicts, or misunderstandings between two highly impulsive children may be frequent and can escalate rapidly and dangerously. In some cases, these electric-charged pairs may need to be placed in separate classrooms in order to be able to engage in productive activity; free play together on the playground may be all that they are able to safely handle. Dr. Theodor Hellbrügge, creator of the first inclusive-by- design Montessori school in the world, Aktion Sonnenschein, recommended that, optimally, only one of each disability type should be included in each classroom because he observed that Massie • Helping Children with Attentional Challenges 271 children with the same disability type tended to group together and isolate themselves from the rest of the classroom community. He also recommended an optimal inclusion rate of no more than 25% children with special educations needs in a classroom. While these recommendations may represent the ideal composition of a classroom, they may not represent the reality of your classroom or of many classrooms today which have three, four, or more children with serious attentional dysfunction. Weighing risks and righTs Some Montessori teachers may be wondering if they really want to have children with ADHD in their classrooms, given the challenges, risks, time, and resources involved. Depending on where you live, the answer to the question, “Why do I have to have these children in my class?” may be a legal one. The Americans with Disabilities Act (ADA) and the United Nations 2006 Convention on the Rights of Persons with Disabilities are examples of national-level and inter- national legislation with far-reaching protections for children with disabilities. The United Nations has set a high bar internationally, with 171 countries and the EU signing their treaty on the rights of persons with disabilities (but not the United States). This UN con- vention requires its members to ensure that they have an inclusive educational system at all levels, that people with disabilities have the right to the full development of their potential, and that they have a right to habilitation, rehabilitation, and early diagnosis and intervention. In the United States, under the ADA, both public and private schools are required to make an effort to accommodate the needs of children with disabilities, including ADHD. Educational access is considered a civil rights issue in the United States. Educa- tional justice means that every human being receives the help (aid) they need to get to their own unique potential. The good news is that Montessori schools are uniquely well-suited to deliver educational justice. It is possible to ac- commodate and support the needs of a child with attentional challenges in a Montessori classroom, provided that the teacher is prepared (specialized training) and that there is a partner- ship with parents and medical specialists. How we do this is the subject of these papers. 272 The NAMTA Journal • Vol. 42, No. 2 • Spring 2017