ADHD: Our Advancing Knowledge and Implications for the

Transcript ADHD: Our Advancing Knowledge and Implications for the

Speaker Background

        Registered Nurse, BSN PhD Student at OHSU  The Role of Fathers in Families with Children with ADHD Faculty Member, LEND; University of Portland Family Nurse Case Manager – ADHD research study Family Care Coordination Team - CDRC Co-editor, Pediatric Home Care 3 text rd edition, a nursing Researcher, author, and frequent public speaker on ADHD Parent of three sons with ADHD

Bridging the Gap: Education and Healthcare

 Historically, health clinicians have done a poor job of connecting with educators on ADHD  Educators are often the first to identify symptoms of ADHD  Often research does not look at practical applications in the classroom  My goal: to bridge the gap between healthcare and education and enhance outcomes for children, families AND educators

Prevalence

 US studies report 3 – 7% of all children are affected by ADHD. Has remained stable over 20 year period.

 International community has reported similar prevalence. Netherlands - low with 2%, India highest – 30%  In almost all cultures that report, the ratio of boys to girls is remarkably similar, from 2 to 1 to 3 to 1

A Brief History of ADHD

         ‘ Fidgety Phil’ – Germany mid 1848 Brain-Injured Child Syndrome Volitional Inhibition Min. Brain Damage- Post enceph.

Min. Brain Dysfunction  (1930’s) Stimulant therapies start with success (1937) Hyperkinetic Reaction Hyperactive Child Syndrome (1950’s) (1960’s) ADD ADHD, with and without hyperactivity (late 1800’s) (1902) (1922) (1980) (1987)

Current Nomenclature: Attention Deficit/Hyperactivity Disorder (ADHD)  DSM-IV, 1994 Predominantly inattentive  Inattention is predominant symptom. Activity and impulsivity similar to other children, “Daydreaming”, forgetting, misplacing, disorganized, “not listening” NOTE: this is the most commonly missed and misunderstood form of ADHD for families and teachers…particularly in girls

Current Nomenclature cont…

 Predominantly hyper-impulsive   Inattentive symptoms may not be clinically significant or under-recognized. Inattentive symptoms may appear later Combined type   Most common type “mild” cases include those that meet criteria in one type and just miss meeting enough criteria in the other DSM-IV, 1994

The Big Picture – Why ADHD?

Genetics make up the largest percentage of ADHD causes = up to 97% (80% avg.) Toxins such as tobacco, alcohol, and lead make up 2 to 10% of cases Brain Injuries 1 – 10%

ADHD and “Friends”

  Oppositional Defiant Disorder (40%) Language Disorder (30-35%)   Anxiety and Depression (20-25%) Specific Learning Disability (15-25%)   Mood disorders (15-20%) Conduct Disorder (20%)   Substance use disorder (15%) Tics (15%)

ADHD and Lifespan Risks

  Risk Behaviors - UNTREATED  200% to 300% more risk of substance abuse, car accidents/infractions, pregnancy   35% drop out of high school Up to 70% underachieve in SES   250% more risk of incarceration Hypothesized decreased life-expectancy

Disability is a CULTUAL phenomenon

Common Features – A Developmental Difference

     70% identified by caregivers by age 4 Behaviors deviant from age-based standards Teachers often the first to raise the question of a clinical problem Developmental deficit of self-control   Range from 10% to 50% Average 30% (e.g., a 10 year old behaves like a 7 year old) Development does continue, but at a greatly reduced rate compared with unaffected peers

The Compelling ‘New World’ of ADHD

Russell Barkley, 2005:

ADHD and the Nature of Self Control

     The first well-developed theory of ADHD Aims to explain ADHD from the global knowledge of multiple disciplines Describes with more clarity and consistency what ADHD really appears to be Allows for behavior prediction and testable hypotheses A different approach than previous thinking

The Frontal Lobe: “Executive Functions”

Frontal Lobe of Time Responses Working Memory Internalize Speech Self Regulation

Perception of Time

 The perception of time passing is gained by calibrating feelings of time with actual time along a developmental trajectory  Children with ADHD do not ‘feel’ the passage of time as others   3 min = 3 hours: all cues must be external and concrete Can only feel ‘now’

Inhibiting Responses

 Frontal lobe is the essential ‘human’ determinant  Evolutionary adaptation to suppress fight or flight    Allows us to utilize working memory and experience to guide present and future behavior Developmental function of frontal lobe Proficiency essential for success in most human environments

Working Memory

      The brain as a computer Frontal lobe houses ‘RAM’ Long-term memory centers house all experiences Impaired connections between working and long term memory  ‘Dial up connection vs High Speed’ Limited access to past experience in the moment, especially if in ‘stimulus crisis’ Limited capacity of working memory  Less information at one time

Internalizing Speech

    Creating self-directed (internal) speech is mediated in the frontal lobe By age 4, most children begin the process of internalizing speech By 5 th grade most have mastered the task ADHD causes two problems   Symptom of hyper-verbalism Delayed maturation of external speech to internal, self regulation

Self-Regulation

  The joint action of:     Perceiving time Inhibiting distractions Remembering past experience and future goals Internalized speech to guide self and behavior By virtue of disrupted frontal lobe neurotransmission, executive functions are impaired along a spectrum

A Typical ADHD Profile

WISC-IV (Wechsler Intelligence Scale) Verbal Comprehension Perceptual Reasoning Working Memory Processing Speed 100 (Average) 115 (Average) 77 (Below) 68 (Below)

Stimulus Preferences for ADHD Brains

  Stimuli generated EXTERNALLY, providing instantaneous feedback are relatively unimpaired and “feel good”  Imagine a child with paraplegia in a pool [freedom]  Video games, TV, Text Messaging Learning tasks requiring INTERNAL generation and delayed feedback are highly impaired due to decreased executive functions  Homework, Reading (decoding, comprehension, synthesis, working toward a distant future goal)

In a nutshell…

ADHD, now more than ever, can be best classified as:  A Disability of Performance, not of Ability  Kids do “know” but literally cannot “do” within the context of their culture and expectations.

7 x 9 = 63 “Don’t push people” vs 30 multiplication problems in 1 minute 30 minutes of incident free recess

Situational Factors Affecting Symptom Severity

           Decreased Symptoms One-to-one Fathers (men) Novelty Frequent Feedback Immediate Consequences Immediate Rewards High Salience Supervised Earlier in the Day Single Step Commands Structured time            Increased Symptoms Group Settings Mothers (women) Familiarity Infrequent Feedback Delayed Consequences Delayed Rewards Low Salience Unsupervised Later in the Day Multi-step Commands Unstructured time

Stop and ask, “Which of these apply to the school day and environment”?

Proven Interventions for ADHD

      Medication Behavior Modification Green Outdoor Spaces Physical Activity Yoga Massage     1 to 1 learning Token reward systems (until about 10 years old) Time out for behaviors Breathing and pulse monitoring

Classroom Intervention Resources - Books

 The ADHD Book of Lists. Sandra Rief (2003)  Taking Charge of ADHD: The Complete, Authoritative Guide. Russell Barkley, 2000 (revised 2005)  Classroom Management Techniques for Students With ADHD: A Step-by-Step Guide for Educators. Roger Pierangelo & George A. Giuliani (2007)

General Behavior Planning #1

 Use effective accommodations as the rule for all, rather than the exception for some

Token systems (positive rewards) that are easy to follow and manage without complex charting work for all children.

Preventing Disruptions #1

 Use physical activity with all students daily

A single, 10-minute, guided physical activity break daily will improve attentive behavior for all students, but have much larger benefit for children with attentional problems http://www.ncpe4me.com/energizers.html

Has a complete class-based program online and ready to go for K-5, middle school, and even subject specific

Effects of a Classroom-based Program on Physical Activity and On-task Behavior.

Mahar, et. al. (2006).

Preventing Disruptions #1b

 When you notice an increase in symptoms, use the outdoors to your advantage

When possible, have the child take a walk outside for a few minutes. Of course, supervision will likely be needed, but if you can swing it, have him or her take 5 minutes outdoors to center.

Do not remove recess… this decreases physical activity and increases symptoms.

Preventing Disruptions #2

 Limit group size

Many classrooms use a group work model and students don’t want to be singled out. Decrease the number of students at a table if possible. Instead of a group of 4, create a couple of groups of 2

Preventing Disruption #3

 Put the student to work for you with specific jobs.

Many kids with ADHD really rise to the occasion with helping tasks. This is a strength to be built upon. It may even help reduce your own workload and free you to help all students, including the helper.

Preventing Disruption #4 :Nutrition

 Many children with ADHD have difficulty eating lunch at school  Decreased attention span and a desire for physical activity  Decreased appetite due to medications  = poor nutrition, unrecognized hunger  Create eating groups with similar children with an adult  Allow for snack time in class near day’s end.

Preventing Disruption #5

 Anticipate transitions and prepare student ahead of time. Use many modes of cues, not just verbal

Teachers are often very gifted with this. Target ‘time blindness’ and use external time cues (sound, sight, touch) to countdown to changes. Don’t underestimate the smallness of a change for disruption [Butterfly effect]

Preventing Disruptions #6 - Use ADHD as a strength

 If a student is ‘stuck’, blurting, distracting others, etc., use distraction as a tool.

Since children with ADHD are easily distracted, use that as a tool. When a child is chatting to her tablemate, call the class attention to some other detail for a momentary pause…just a few seconds, and then bring them back to you. Have a “task jar” that you can direct a student to that contains things to do that are productive and not disruptive. Use it with all students.

Strengthening Academics #1 Math

 Eliminate timed tests

Timed tests in these ages only reinforce anxiety and negative self-concept. No evidence shows that they directly increase fluency. Timed tests ONLY work to measure the deficit of processing speed and working memory. Refocus on testing the knowledge. Refer to SE for screenings for SLD’s – math. This will also reduce post-test disruptions.

Create small test groupings (2-3) with a supervisor to redirect students while completing tests with extended time

Strengthening Academics #2 Reading

 Use desire to mentor as a strength and match student with younger children approaching the child’s ability

If a child is behind in grade level, work them into a mentoring position in another classroom for a brief period each day. They will rise to the occasion and have social success, you will get a break, and the child will be reinforcing their own skills. It will also prevent post-mentoring disruptions.

Strengthening Academics #3 – Home Connections

 Help families set a 15 - 30 min (k-5) or 60 min (6-8) commitment and have them account for the time rather than the results.

Most children with ADHD and families DO home-work…much more than other children. But the time it takes is HUGE by comparison. To enhance the big picture (lifetime love of learning and family participation) focus on the block of time as the measure.