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Adhd nowell
1. ADHD and the Processing Disorders
David D. Nowell, Ph.D.
Worcester, Massachusetts
DavidNowellSeminars
DavidNowell
www.DrNowell.com
2. ADHD and the Processing
Disorders
An overview of the day:
•Making sense of the disorders
•Skills and strategies for children
•Skills and strategies for adults
•Tools you can use now
3. ADHD and the Processing
Disorders
•Making sense of the disorders
4. ADHD and the Processing
Disorders
Sensory Processing Disorder
Central Auditory Processing Disorder
ADHD and Executive Dysfunction
56. Central Auditory Processing Disorder
• Auditory discrimination (same/different)
• Auditory closure (fill in missing bits)
• Auditory localisation (locate source of sound)
• Auditory performance with degraded acoustic
signal
• Auditory figure-ground (perceiving sounds in
background noise)
57. Central Auditory Processing Disorder
• CAPD refers to a deficit observed in one or
more of the central auditory processes
responsible for generating the auditory
evoked potentials and the following
behaviors:
– sound localization and lateralization
– auditory discrimination
– auditory pattern recognition
58. Central Auditory Processing Disorder
- Poor "communicator" (terse, telegraphic).
- Memorizes poorly.
- Hears better when watching the speaker.
- Problems with rapid speech.
- Interprets words too literally.
59. Central Auditory Processing Disorder
- Often needs remarks repeated.
- Difficulty sounding out words.
- Confuses similar-sounding words.
- Difficulty following directions in a series.
- Speech developed late or unclearly.
61. CAPD or ADHD?
• Asks for things to be repeated • Inattention
• Poor Listening skills • Academic Difficulties
• Difficulty following oral • Daydreams
instructions
• Difficulty discriminating speech • Distracted
• Difficulty hearing with • Poor Listening Skills
background noise
• Difficulty maintaining auditory • Disorganized
attention in quiet
• Academic difficulties • Asks for things to be repeated
• Slow to process information • Auditory divided attention
deficit
62. CAPD or ADHD?
• Asks for things to be repeated • Inattention
• Poor Listening skills • Academic Difficulties
• Difficulty following oral • Daydreams
instructions
• Difficulty discriminating speech • Distracted
• Difficulty hearing with • Poor Listening Skills
background noise
• Difficulty maintaining auditory • Disorganized
attention in quiet
• Academic difficulties • Asks for things to be repeated
• Slow to process information • Auditory divided attention
deficit
63. CAPD or ADHD?
• Asks for things to be repeated • Inattention
• Poor Listening skills • Academic Difficulties
• Difficulty following oral • Daydreams
instructions
• Difficulty discriminating speech • Distracted
• Difficulty hearing with • Poor Listening Skills
background noise
• Difficulty maintaining auditory • Disorganized
attention in quiet
• Academic difficulties • Asks for things to be repeated
• Slow to process information • Auditory divided attention
deficit
64. CAPD or ADHD?
• Asks for things to be repeated • Inattention
• Poor Listening skills • Academic Difficulties
• Difficulty following oral • Daydreams
instructions
• Difficulty discriminating speech • Distracted
• Difficulty hearing with • Poor Listening Skills
background noise
• Difficulty maintaining auditory • Disorganized
attention in quiet
• Academic difficulties • Asks for things to be repeated
• Slow to process information • Auditory divided attention
deficit
73. Treatment for CAPD
• Compensatory Strategies
–Metacognitive strategies include
self-instruction, cognitive problem
solving, and assertiveness training
83. Controversies
• Is ADHD over-diagnosed?
• Is ADHD a “real” condition?
• Does ADHD occur on a spectrum?
• Is ADHD a natural adaptive trait?
84. Source: Centers for Disease Control and Prevention. Prevalence of diagnosis and medication treatment for
attention-deficit/hyperactivity disorder – United States, 2003. MMWR 2005;54:[842-847].
86
85. Percent of Youth 4-17 ever diagnosed with Attention-Deficit/Hyperactivity Disorder:
National Survey of Children’s Health, 2003
> 10.1%
9.1 – 10.0%
DC
8.1 - 9.0%
7.1 - 8.0%
6.1 - 7.0%
< 6.0%
Source: Centers for Disease Control and Prevention. Prevalence of diagnosis and medication treatment for
attention-deficit/hyperactivity disorder – United States, 2003. MMWR 2005;54:[842-847].
87
86. Controversies
• Is ADHD over-diagnosed?
• Is ADHD a “real” condition?
• Does ADHD occur on a spectrum?
• Is ADHD a natural adaptive trait?
87. “a hunter in a farmer’s world”
Thom Hartmann
Hunter trait Farmer trait
• Constant monitoring • Not easily distracted
• Can act on moment’s • Steady, dependable
notice effort
• Very active when “hot • Conscious of time; able
on the trail” to pace self
• Willing to take risks • Careful, “look before
you leap”
90. ….and the rest of the criteria
B. Onset before age 7
C. Impairment in 2 or more settings
D. Significant functional impairment
E. Not better accounted for by another mental
disorder
91.
92. Functional impact
of core symptoms
• Arousal / alertness
• Mental effort
• Determination of saliency
• Focal maintenance
93. Functional impact
of core symptoms
• Arousal / alertness
• Mental effort
• Determination of saliency
• Focal maintenance
94.
95. Functional impact
of core symptoms
• Arousal / alertness
• Mental effort
• Determination of saliency
• Focal maintenance
96. Functional impact
of core symptoms
• Satisfaction control
• Previewing
• Inhibition
• Tempo control
• Self-monitoring and correcting
97. Functional impact
of core symptoms
• Satisfaction control
• Previewing .
• Inhibition
• Tempo control
• Self-monitoring and correcting
98. Functional impact
of core symptoms
• Satisfaction control
• Previewing
• Inhibition
• Tempo control
• Self-monitoring and correcting
99. Functional impact
of core symptoms
• Satisfaction control
• Previewing
• Inhibition
• Tempo control
• Self-monitoring and correcting
100. Functional impact
of core symptoms
• Satisfaction control
• Previewing
• Inhibition
• Tempo control
• Self-monitoring and correcting
101. Subtypes of ADHD
• ADHD, predominantly inattentive type
• ADHD, predominantly hyperactive type
• ADHD, combined type
• ADHD, Not Otherwise Specifed
102. Subtypes of ADHD
• ADHD, predominantly inattentive type
• ADHD, predominantly hyperactive type
• ADHD, combined type
• ADHD, Not Otherwise Specifed
103. Common comorbidities with ADHD
• Learning disorder
• Behavioral disorder
• Anxiety
• Depression
• Substance abuse
• Sensory processing and auditory processing
challenges
104. Common comorbidities with ADHD
• Learning disorder
• Behavioral disorder
• Anxiety
• Depression
• Substance abuse
• Sensory processing and auditory processing
challenges
105.
106. Common comorbidities with ADHD
• Learning disorder
• Behavioral disorder
• Anxiety
• Depression
• Substance abuse
• Sensory processing and auditory processing
challenges
119. The Executive Functions
• Initiation
• Planning
• Set-shifting
• Self-regulation
• Inhibition of response
• Directing current activity towards future goal
• X
120. The Executive Functions
• Initiation
• Planning
• Set-shifting
• Self-regulation
• Inhibition of response
• Directing current activity towards future goal
121.
122. The Executive Functions
• Initiation
• Planning
• Set-shifting
• Self-regulation
• Inhibition of response
• Directing current activity towards future goal
123. The Executive Functions
• Initiation
• Planning
• Set-shifting
• Self-regulation
• Inhibition of response
• Directing current activity towards future goal
124. The Executive Functions
• Sustaining alertness and effort
• Internalizing speech
• Prioritizing
• Sequential thinking
• Developing a plan of action
• Persevering through a plan of action
• Time management
125. The Executive Functions
• Sustaining alertness and effort
• Internalizing speech
• Prioritizing
• Sequential thinking
• Developing a plan of action
• Persevering through a plan of action
• Time management
126. The Executive Functions
• Sustaining alertness and effort
• Internalizing speech
• Prioritizing
• Sequential thinking
• Developing a plan of action
• Persevering through a plan of action
• Time management
127. The Executive Functions
• Sustaining alertness and effort
• Internalizing speech
• Prioritizing
• Sequential thinking
• Developing a plan of action
• Persevering through a plan of action
• Time management
128. The Executive Functions
• Sustaining alertness and effort
• Internalizing speech
• Prioritizing
• Sequential thinking
• Developing a plan of action
• Persevering through a plan of action
• Time management
129.
130. The Executive Functions
• Fine motor control
• Delay of gratification
• Blocking out distractions
• Weighing consequences
• Thinking before acting
• Planning for the future
• Certain aspects of memory / learning
144. Interpreting the Problem Checklist
Appendices B and C
• Items 1-8: inattention/distractibility
• Items 9-13 and 24-28: behavioral d/o
• Items 16-23: hyperactivity/impulsivity
146. Treatments With Limited Evidence
(AAP, 2001; Pelham & Fabiano, 2008)
(1) Traditional one-to-one therapy or counseling
(2) Office based "Play therapy”
(3) Elimination diets
(4) Biofeedback/neural therapy/attention (EEG) training
(5) Allergy treatments
(6) Chiropractics
(7) Perceptual or motor training/sensory integration
training
(8) Treatment for balance problems
(9) Pet therapy
(10) Dietary supplements (megavitamins, blue-green algae)
147. Evidence-Based
Treatments for Children… (Chorpita et al, 2011)
•Self – talk
•Behavioral supports + medication
•Parent training
•Physical exercise
•Biofeedback
•Contingency management
•Parent and teacher education
•Social skills training + medication
•Parent training + problem solving
•Relaxation training + exercise
•Working memory training
148. Evidence-Based Short-term
Treatments for ADHD
(1) Behavior modification
-175 studies
(2) CNS stimulant medication
>300 studies
(3) The combination of (1) and (2).
>25 studies
(Pelham & Fabiano, 2008; Greenhill & Ford,
2002; Hinshaw et al, 2002)
149. Pharmacotherapy
• Drugs approved for ADHD
– Stimulants
• Methylphenidate (e.g., Ritalin)
• Dexmethylphenidate (Focalin, Focalin XR)
• Amphetamine (Adderall, Adderall XR)
• Dextroamphetamine (Dexedrine) for layperson
Grps of 3: definition of adhd
• Pemoline (Cylert) --no longer marketed due to liver toxicity
• Methamphetamine (Desoxyn) --little used
– Atomoxetine (Strattera)
• selective norepinephrine reuptake inhibitor
X 153
150. Pharmacotherapy, continued
• Under review for ADHD indication
– Modafinil (Provigil)--stimulant
• Drugs used off label for ADHD
– Tricyclic antidepressants
– Bupropion
– Alpha-2 agonists (e.g., clonidine)
154
151. Stimulants
• Used for decades
• Available in extended release formulations
• Adverse effects: abuse/dependence (Schedule C-
II), tics, cardiovascular, CNS, growth
• Adderall XR approved for adult ADHD
155
152. Main Beneficial Short-term Effects
• 1. Decrease in classroom disruption
• 2. Improvement in teacher ratings of behavior
• 3. Improvement in compliance with adult requests
• and commands
• 4. Increase in on-task behavior and academic
• productivity and accuracy (but no long-term
• effect on academic achievement)
• 5. Improvement in peer interactions
• 6. Improvement in performance on laboratory
• measures of attention, impulsivity, and learning
(Greenhill & Ford, 2002)
153. APA Task Force on Medication and
Psychosocial Treatments in Children
and Adolescents
• Behavioral Parent Training
• Behavioral School Intervention
• Behavioral Child Intervention
• Medication--Use when needed
216. Recommendations for Teachers …
• Distinguish between medical evaluation and
educational evaluation
• Document with objective behavioral terms
the challenges you notice
• Document interventions and responses
• Speak with other teachers or last year’s
teacher – compare notes
• Recommend next-step evaluation
217. Recommendations for Teachers …
• Avoid diagnostic terms in conversation with
parents
• Leave medication decision to families and
their pediatricians
• Find common goals with parents
223. Self-Talk Proficiency
• -“How are you going to know when to be
ready?”
• -“How are you going to stop yourself from…?”
• -“What is your goal?”
• -“What do you want it to look like?”
• -“How long do you think it will take?”
233. 1. Stop What am I doing?
2. Define The main task
3. List The steps
A……
B…..
C……
4. Learn The steps
Do I know the steps?
No
Yes
5. Do It
6. Check
Am I doing what I planned to do?
Yes
No
241. Time Out
• Select target behavior
• Set place
• Determine how much time
• Dress rehearsal
• Measure the time
• Withdraw attention
• Establish the cause and effect
242. Token economy
• Good balance
• Precursor to adult reinforcement system
• Lots of work to do well
• Even more work to set up well
243.
244. Homework problems
• Fails to write down assignments
• Forgets the assignment book
• Forgets necessary materials
• Takes hours to do minutes of homework
• Hassles about when and where to do homework
• Lies about having done homework
• Needs constant supervision with homework
• Forgets to bring homework back to school
245.
246.
247. Make Real-Life More Like Video Games
• Clear expectations
• Behavioral specificity
• Build on small changes in behavior
• Irrelevant behaviors ignored
• Reward appropriate behavior and punish
inappropriate behavior – never reverse this
248. Make Real-Life More Like Video Games
• Always follow up on rules, no exceptions
• Consequences are immediate
• Punishment is mild
• Stimuli are exciting and multi-sensory
• Conduct expensive and time-consuming focus
groups to determine what really “grabs ‘em”
262. The ADHD Couple
• Need for stimulation
• Poorer impulse control
• Inattention to detail
• Fantasy projection
263. The ADHD Couple
• Remembering what drew you to your partner
• Realistic expectations
• Managing blame
• Getting to “fair”
• Feeling your contributions are valued
• Outsourcing
282. ADHD and the Processing Disorders
David D. Nowell, Ph.D.
Worcester, Massachusetts
DavidNowellSeminars
DavidNowell
David@DrNowell.com
Notas del editor
Scott peck: diagnostician. DI vs. intake, etc.NLP: distinctions.
Round pegsRespectful but not slavish.Hx:Make dx reliable across providersGuide researchMoving b/t static dsm categories and dynamic human beings.
Dx approach
8:20
Owen 7 yo boy… refuses to step up onto school bus. School psych: iqwnl, checklists ll ADHD.Neuropsych doesn’t find striking neurocognitive profile of attn/exec dysfx.CD intern finds pt inattentive (puts head on desk). In team mtg, when pressed on issue, it turns out that Owen actually performs as well on stand. Testing with head down or with enforced posture.OT suggests that his constant movement is in effort to counteract his floppy muscle tone; like a bicycle, the best way to stay upright is to keep in motion.
Tobias, 58y.o man with his son, 20 y.o. college student (psych). Son ? Adhd.Pt accountant, spvr of dept. 18 month h/o c/o re: inattention, poor focus after a reorg at work. Dx w dm um same t. Pt not compliant w b.s. checks or diet. St most helpful thing we can do is withhold a dx.
Good news ands bad news: it’s 2009.
proprioceptive
CNS Development: Sensory input contributes toDevelopmentSensory input is necessary for brainFunctionActive engagement in sensory experienceproduces an adaptive responseAdaptive responses to sensory inputs optimize function
We use our senses to interface with world around us, retreating from “too much” or “too tight” or “too loud” and seeking lights and sound and movement when we’re understimulated
Dining on raw fish stuffed with shells, families compete by walking on coals and juggling bottles of open wine; all the while air raid sirens are blaring. You don’t enjoy it. What’s your dx?
Broad. Tourette’s works because it doesn’t “try as hard.”
Neurological hard signs, soft signs, and developmental soft signs
The softest of them all!
Infants: R to loud noise, R to bells or whistles, R to lullabies, R to peek a boo, sound source locationDifferentating among people, R to lights and colors; eye contactManipulating toys, feeding, R to touch, investigating world with hands and mouthPlaying with toes, grasping objects, experimenting w diff. body positionsSitting up, lifting headSitting up, lifting head, kicking, truncal stability
A very high threshold of empirical data has been set for adding a new disorder to DSM-V in order to insure that only diagnostically valid disorders are added to the system. The types of data that would be required include 1) evidence that sensory processing disorder describes a condition that is not adequately covered by an existing DSM-IV disorder; 2) evidence supporting its diagnostic validity; 3) evidence supporting its clinical utility; and 4) evidence supporting that there is a low risk of false positive diagnoses that might result if sensory processing disorder were to be added.
The primary criterion for adding a new disorder to DSM-V is whether there is sufficient empirical evidence of its validity and clinical utility. In the case of Sensory Processing Disorder, three options for DSM-V were discussed: 1) adding it as a new disorder; 2) adding it as a subtype that would apply to disorders such as Autistic Disorder or Attention-Deficit/Hyperactivity Disorder; or 3) adding a dimensional definition to the DSM-V appendix for "criteria sets and axes needing further study" in order to stimulate additional research
Motor d/o: Decreased muscle tone Delay in motor milestones Delay in hand use and fine motor skills Delay or poorly executed self-care skills – q activity has stepsOT model of proprioception and vestibular sense
Douglas. 6 yo w h/o school avoidance. Picky eater. Wears sunglasses outdoors. ? Of adhd. w/drawn, sullen after giving up on peewee football b/c the helmet was stinky.
Carlos, 5 yo boy. …. M c/o tantrums, stubborness. Bedtimes difficult. Pushes his sister. Per OT pt performs poorly on measures of sensory modulation, esp tactile. Suggests he is easily overwhelmed.You learn that mom suspects he is in cntrol of tantruming? he negotiates. Often ? Of Primary or Secondary gain.The less cntrl he seems to have over this behavior, the more concern we have re: sensory or some other overload.
1st we need to consider construct validity b/f we “tx” a conditionIn small N studies Specific tx interventions have proven more effective than no tx, but no diff. from other alternative tx. Note problem of placebo.
adults routinely adjust for their sensory processing irregularitiesw by carefully making choices that allow them to honor their nervous systems w/o intruding on others. Swedish shoes, diesel, glare when fatigued, tight clothing, short shirtsleeves.Kids: less independent, poorer insight, poorer abstraction. OT can increase insight, normalize their sensory prefernces. Have their defensiveness in the presence of a supportive adult. K.o. like going off the high dive.
PUSHING ICE CUBE ON A TRAYFEELY GAME AROUND THE HOUSEHOT DOG IN A BLANKETTIC TAC TOE IN SHAVING CREAMBOPPING A BALLOON BUCKET BEANBAG CATCHER
CUTTING PLAY DOH WITH SCISSORS
1st we need to consider construct validity b/f we “tx” a conditionIn small N studies Specific tx interventions have proven more effective than no tx, but no diff. from other alternative tx. Note problem of placebo.
MEMORY W/ SMELLS TEXTURE MATCHINGWHAT’S IN THE SOCKHAND ON TOP
9:40 a.m.
A Central Auditory Processing Disorder (CAPD) exists when achild has apparent difficulty in processing auditory informationwhile possessing normal hearinglittle consensuson a definition, criteria for assessment and diagnosis, andthe efficacy of remediation and management.
A Central Auditory Processing Disorder (CAPD) exists when achild has apparent difficulty in processing auditory informationwhile possessing normal hearinglittle consensuson a definition, criteria for assessment and diagnosis, andthe efficacy of remediation and management.
What teacher might notice
Dr. Anthony Cacace, and his colleagues (2005) define central auditory processing disorder (CAPD) as a "modality-specific perceptual dysfunction that is not due to peripheral hearing loss" and that "should be distinguishable from cognitive, language-based, and/or supramodal attentional problems"
we might best serve the student by identifying the following:
we might best serve the student by identifying the following:
PING PONG BALL / COFFEE CANBEANS, BUTTONS IN TOOTHPASTE BOXESIPHONE VOICE RECORDER APP, VARIOUS HOUSEHOLD SOUNDSPRETENDING TO BE A RADIO WITH VOLUME KNOB WHAT’S MISSING? (TWINKLE TWINKLE…) WHAT COMES BEFORE “I BELIEVE IN YESTERDAY”HOW DOES IT END? (FAMILIAR STORY)MR POTATO HEAD W/ METAPHORS: IN ONE EAR AND OUT THE OTHER. EYES BIGGER THAN STOMACH. I’M ALL EARS. YOU TOOK THE WORDS RIGHT OUT OF MY MOUTH. YOU’RE PULLING MY LEG.
Guy berard – aitAlfred tomatis – tomatis auditory training
Environmental modifications Reduce ambient noise CARPET RUBBER TIPS ON CHAIRS CLOTH AND MAT POSTER BOARDSpreferential seating AWAY FROM SOURCES OF NOISE FANS CORRIDOORS OUTSIDE TRAFFIC Frequent checks for comprehension
Environmental modifications Reduce ambient noise CARPET RUBBER TIPS ON CHAIRS CLOTH AND MAT POSTER BOARDSpreferential seating AWAY FROM SOURCES OF NOISE FANS CORRIDOORS OUTSIDE TRAFFIC Frequent checks for comprehension
Environmental modifications Reduce ambient noise CARPET RUBBER TIPS ON CHAIRS CLOTH AND MAT POSTER BOARDSpreferential seating AWAY FROM SOURCES OF NOISE FANS CORRIDOORS OUTSIDE TRAFFIC Frequent checks for comprehension
ACTIVE LISTENING CHECKS FOR COMPREHENSION MULITISENSORY INSTRUCTION MNEMONIC DEVICES TO ASSIST MEMORY
ACTIVE LISTENING CHECKS FOR COMPREHENSION MULITISENSORY INSTRUCTION MNEMONIC DEVICES TO ASSIST MEMORY
ACTIVE LISTENING CHECKS FOR COMPREHENSION MULITISENSORY INSTRUCTION MNEMONIC DEVICES TO ASSIST MEMORY
Dx approach
Jennifer, 4 yo. Limited language. Expressive better than receptive. Makes prefernces known. Intense eye contact but ? Understanding. Plays well with cousins and sister, less well with others at daycare seting with some older children.
EXPLAIN WKSHOP’S PURPOSE, INCREASE SALIENCE, RELATE TO PRIOR K’LEDGE
By 1970, 2000 papers on the topic. Focus moves to attentionGrps of 3: definition of adhd for layperson
St’s going to happen today at 5:00You’ll never get that time back
85-x*36540 yo = 16425 28 yo = 20805 52 yo = 12045“gonna eat all the gum and candy I want”It is a most mortifying reflection for a man to consider what he has done, compared to what he might have done. ~Samuel Johnson, in Boswell's Life of Johnson, 1770
Attn is a precious commodity. Things and ppl will compete for itBest defense vs the manipulation of one’s attn is to determine for oneself how one wants to invest itSt’s going to happen today at 5:00
The full existential horror of being an adult
10:30
Distracted by whatever’s eye-catching in the moment? Or engaging in specifric and familiar activites whose fx it is to maintain sensory homeostasis?
Has trouble getting started w workWorks only on thihngs that are partic. Interesting to him/herEffort is unpredictableTx: use hi-interest topics, Premack principle, cueing, R cost (tokens)
Cant tell important from unimp.Recalls irrelevant detail rather than pertinentDistracted by irrelevant background noisesConcentrates on visual stimlui that others would ignoreTx: vary potency of stimli; highlighting certain words/phrases; explicit training in id’ing “what’s most important” (picture completion subtest)
Cassidy is working on master’s thesis. When she sits down 2 do ork, felt need to clean apt. Didn’t esp. like cleaning the apt but felt the urge whenever she needed to write. She actually fet she could not work unless e.t. in her apt was cleaned and in order.
Not a good listenerNot in volitional control of the process of focus: can overfocus, can fail to concentrate long enoughMisses key parts of directions / explanationsTx: keep verbalizations short and simple; check for understanding; use bookmarks that facilitate focus
Hard to satisfy, wants things all the time; needyRestless, craves excitementConcentrates well only on exciting stimuliPoor delayed gratificationTx: provide stimulating learning situations; do not r+ inappropriate or off-task behav.
Fails to look ahead and predict consequences, Task approach is seemingly w/o plan, w/o regard to time needed, w/o regard to resources needed. Difficulty w transitions, Difficulty foreseeing solutionsTx: train in self-talk and problem solving. R+ instances of behav,. Inhibition and planning ahead (e,.g. raising hand, packing umbrella); modeling. EG: tom, 8th grader, procrastination. TS . worked with mom, who coordinated w/ school 2 b notified of any longer term projects. LONG TERM PROJECT PLANNING SHEET. Eg report on dangerous sea animal. Brainstorm, choose, id materials needed, subgoals, assign dates, plan R+ for meeting goals.
Inappropriate behaviors, Does things the hard way, breaks things, Blurts inappropriate comments, prim. Proc.Tx: use DRO to increase soc. Appropriate behav.; be explicit; use + px (w many repetitions)EG: circle time a struggle for kristin, 2nd grader. Despite clear rules about turn taking, kristin wd blurt out while others were talking. Tchr introduced a talking stick. Then gave each child 2 chips (to ask ?s). If pt blurts, lose chip. FADE over time.
Does things slowly, or recklessly … barkley and time perceptionTrouble organizing time needs during taskDawdles, misses deadlinesLevel of activity seems inappropriate to actual urgency of taskTx: age approp. Time mgt tools; organizational charts, sub-goals, checklistst; px time estimates; beat the clock
Loses track during taskEasily derailed – responds to r+ in the moment rather than using mental representation of future r+ or p+Careless mistakesTx: give ongoing supportive feedback; encourage post-mortem reviews of behav; nag tapes
Ocd? Luvox? Cbt for ocd?
Attention deficit hyperactivity disorder or ADHD is a commonly diagnosed behavioral disorder of childhood that represents a costly major public health problem. Children with ADHD have pronounced impairments and can experience long-term adverse effects on academic performance, vocational success, and social-emotional development which have a profound impact on individuals, families, schools, and society. Despite progress in the assessment, diagnosis, and treatment of ADHD, this disorder and its treatment have remained controversial, especially the use of psychostimulants for both short- and long-term treatment.Although an independent diagnostic test for ADHD does not exist, there is evidence supporting the validity of the disorder. Further research is needed on the dimensional aspects of ADHD, as well as the comorbid (coexisting) conditions present in both childhood and adult forms.Studies (primarily short term, approximately 3 months), including randomized clinical trials, have established the efficacy of stimulants and psychosocial treatments for alleviating the symptoms of ADHD and associated aggressiveness and have indicated that stimulants are more effective than psychosocial therapies in treating these symptoms. Because of the lack of consistent improvement beyond the core symptoms and the paucity of long-term studies (beyond 14 months), there is a need for longer term studies with drugs and behavioral modalities and their combination. Although trials are under way, conclusive recommendations concerning treatment for the long term cannot be made presently.There are wide variations in the use of psychostimulants across communities and physicians, suggesting no consensus regarding which ADHD patients should be treated with psychostimulants. These problems point to the need for improved assessment, treatment, and followup of patients with ADHD. A more consistent set of diagnostic procedures and practice guidelines is of utmost importance. Furthermore, the lack of insurance coverage preventing the appropriate diagnosis and treatment of ADHD and the lack of integration with educational services are substantial barriers and represent considerable long-term costs for society.Finally, after years of clinical research and experience with ADHD, our knowledge about the cause or causes of ADHD remains largely speculative. Consequently, we have no documented strategies for the prevention of ADHD.
NeuroanatomyNeurotransmittersPhenomenology of dopamine and serotonin
Phineas gage
PLACE NAMES WHICH ARE ALSO PEOPLE’S NAMES:MADISONGEORGIACHARLOTTEINDIAPARISKENYAARIZONAADELAIDESYDNEYDALLASHOUSTONOLYMPIAJORDANBETHANY
PLACE NAMES WHICH ARE ALSO PEOPLE’S NAMES:MADISONGEORGIACHARLOTTEINDIAPARISKENYAARIZONAADELAIDESYDNEYDALLASHOUSTONOLYMPIAJORDANBETHANY
POLICE REPORT W/ ADVANCE WARNING
DECK OF CARDS20 QUESTIONS
I SPY…GEO CACHINGMAPS
If only I could be as org. as I am the day before vacation
Twins, siblings. Various genes impacting dopamine transmission. The broad selection of targets indicates that ADHD does not follow the traditional model of a "genetic disease" and should therefore be viewed as a complex interaction among genetic and environmental factors. Even though all these genes might play a role, to date no single gene has been shown to make a major contribution to ADHD
Wallman found diffs. In a dopamine transporter gene in adhd, combined type, not present with inattentive typeDecreased activity in orbital prefrontaldecreased glucose metab. In left prefrontalLack of asymmetry in b.g. (caudate and globuspallidus)
Wcst and other frontal/executive test performanceHyp: disturbance in frontal lobe fxs may be related to impulse cntrl and to the types of cog impairments common with adhd. Conclusion: inability to cntrl, direct, and sustain attn may be the core deficiency of adhd, and not impulsivity. barkley
Np testing , or imaging…..
Dopamine hypothesis first proposed 1977. Noradrenergic system also implicated
TOP DOWN BOTTOM UP
What questions do you have re: rx?
11:50
Parent training at points of needSchool staff training in in-service model, then at points of need
Moving b/t static dsm categories and dynamic human beings.Think horses, not zebras. Where possible, offer a dsm dx. E.g. NVLD … cd it be aspergers? E.g. capd… cd it be adhd inattentive type?
Why now? Changes at school or home? Family issues? Demand specificity (and then … and then)Look for patterns (persons, situations, times of day)Look for constellations (syndromes)Name it as though you’d never heard of our dx categories. “cries for no reason, lost his appetite, thinks of suicide d/o.” she’s got “fixated on routine, doesn’t like to walk down stairs, gets carsick easily, doesn’t like tags in her clothing d/o.”
Go in with LOW threshold of suspicion: “show me.”Think horses not zebras.What domains are ppl c/o ?
Sensory History Checklists and Interviews Sensory Profiles (Dunn et al, 1999, 2001) Short Sensory Profile (McIntosh, Miller,Shyu,. & Dunn, W. ,1999a). Evaluation of Sensory Processing (Parham, et al., 2003) Sensory Processing Interview and Inventory (Wilbarger, et al.) Sensory Rating Scale for Infants & YoungChildren (Provost & Oetter, 1993)
AudiologySpeech tx – primarily functional receptive language
My mom cries a lot and has dropped her hobbies….mdd?My brother won’t touch doorknobs…ocd?My son cant stand turtlenecks or tags in shirts….spd?I can go from happy one minute to sad or angry the next..bad? Ied? Mdd?
Before we jump into tx planning, we want to be as clear as possible re: case conceptualization. i.e., dx yes, but more than that “what’s the kids deal,” including consideration of fx of behavior, home environment, and medical issues.
Think of a child/student/ct… the behavioral change which would make the biggest difference……I told you of a set of strategies that could bring about IMMEDIATE behavioral change…Antecedents – human behavior change and learning can be very hard. If environmental or antecedent changes can fix the problem, we start there.
147”
Dawson p 81Setting him up for success – think about the “box” and its capacity. Don’t overload it.Change physical or soc. Environment – add bariers, <distractions, >org. structure, change social mixChange nature of tasks – reduce complexity (if > 3/10 on difficulty scale)Why do students shape up when tchr close by? >insight, activate rules, clearly they “can” – performance deficit vs skills deficit.
Which is the most important point of intervention?
Dawson p 81Setting him up for success – think about the “box” and its capacity. Don’t overload it.Change physical or soc. Environment – add bariers, <distractions, >org. structure, change social mixChange nature of tasks – reduce complexity (if > 3/10 on difficulty scale)Why do students shape up when tchr close by? >insight, activate rules, clearly they “can” – performance deficit vs skills deficit.
Child in La. In ny times article: mom, pedi, psych. “discipline”Changing antecedent can bring immediate results.
Get eye contactSpeak clearly – avoid metacommunicationsProvide behavioral infoCheck for understanding
Antecedent support for students and adults w/ processing disorders
Depression, Suicidal Ideation More Likely in Adolescents With Late vs Earlier Set Bedtimes Tx: sleep hygeine
Has trouble getting started w workWorks only on thihngs that are partic. Interesting to him/herEffort is unpredictableTx: use hi-interest topics, Premack principle, cueing, R cost (tokens)
Tx: vary potency of stimli; highlighting certain words/phrases; explicit training in id’ing “what’s most important” (picture completion subtest)
122”
EXPLAIN WKSHOP’S PURPOSE, INCREASE SALIENCE, RELATE TO PRIOR K’LEDGE
STUDY BOX
FLASHLIGHT IN THE DARKNot a good listenerNot in volitional control of the process of focus: can overfocus, can fail to concentrate long enoughMisses key parts of directions / explanationsTx: keep verbalizations short and simple; check for understanding; use bookmarks that facilitate focus
2:00
Hard to satisfy, wants things all the time; needyRestless, craves excitementConcentrates well only on exciting stimuliPoor delayed gratificationTx: provide stimulating learning situations; do not r+ inappropriate or off-task behav.
Fails to look ahead and predict consequences, Task approach is seemingly w/o plan, w/o regard to time needed, w/o regard to resources needed. Difficulty w transitions, Difficulty foreseeing solutionsTx: train in self-talk and problem solving. R+ instances of behav,. Inhibition and planning ahead (e,.g. raising hand, packing umbrella); modeling. EG: tom, 8th grader, procrastination. TS . worked with mom, who coordinated w/ school 2 b notified of any longer term projects. LONG TERM PROJECT PLANNING SHEET. Eg report on dangerous sea animal. Brainstorm, choose, id materials needed, subgoals, assign dates, plan R+ for meeting goals.
MUSICAL CHAIRS , RED LIGHT / GREEN LIGHTTx: use DRO to increase soc. Appropriate behav.; be explicit; use + px (w many repetitions)EG: circle time a struggle for kristin, 2nd grader. Despite clear rules about turn taking, kristin wd blurt out while others were talking. Tchr introduced a talking stick. Then gave each child 2 chips (to ask ?s). If pt blurts, lose chip. FADE over time.
Does things slowly, or recklessly … barkley and time perceptionTrouble organizing time needs during taskDawdles, misses deadlinesLevel of activity seems inappropriate to actual urgency of taskTx: age approp. Time mgt tools; organizational charts, sub-goals, checklistst; px time estimates; beat the clock
ALL THE THINGS YOU CAN THINK OF THAT…Tx: give ongoing supportive feedback; encourage post-mortem reviews of behav; nag tapes
ALL THE THINGS YOU CAN THINK OF THAT…Tx: give ongoing supportive feedback; encourage post-mortem reviews of behav; nag tapes
HOW DID YOU DO THAT? HOW DID YOU GET TO THE APPOINTMENT 30 MINUTES LATE?
29 times a month he made curfew. That’s great executive fx !
You can also ask about the other 2 times. What was different when you didn’t make curfew? What did you think or see or say to yourself? What did you do that led to your showing up exactly when you did?
1% of pop. BAD. BAD spectrum may be 4 – 6 %. With one BAD parent, risk is 15-30%, when both parents BAD, 50-75%. In retrospective I’views, 60% of BAD adults recall onset of sx before age 20. 40% even younger, from 13-18 yo. “narrow,” “intermediate” and “broad” BAD phenotypes. “soft BAD spectrum”
REGROUP TIMEPOST-MORTEMHOW DO YOU LOOK?BEGINNING, MIDDLE, ENDYARN ON SANDPAPER, TAKING TURNSANOTHER VIEWPOINT (ANTS, FLOWERS)
Stronger social support for being nice, developing emotional intelligence. Locker or desk mt be messy. Handwriting mt be messy. Mt be sensitive to visual stimuli and physical mvmt. Shy/wdrawn. If hyper, mt be hypertalkative and chatty.
More tasks, more diffuse
Who called the caterer? Designed and order tshirts? Considered potential hurt feelings re: invitation list. Set up the evite? Remembered that the reunion would coincide with 20th wedding reunion of one couple? Made sure the paper plates and cups match? Managed the household mood in the days leading up to the reunion?More tasksMore diffuseMore parental responsibilityLess likely to have an “executive” partnerLess likely to have assistants at workLess likely to focus on a narrow areaMore likely to feel shame about disorganization
Texts which are visually cluttered or demanding.
Individuals with disabilities educatino act of 1997Section 504 of the rehab act of 1973
BEGINNING, MIDDLE, ENDLIFELINEKIMOCHIS
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WHAT QUESTIONS ARE MATURE EXECUTIVES ASKING THEMSELVES?What are non-impaired kids doing that this pt is NOT? - screening out at the bottom-up level - screening out at higher level
What are non-impaired kids doing that this pt is NOT?You can say: “If I keep doing this it islikely my teacher/friend will……”Ask to hear what the inner voice wassaying: “Tell me what you like bestabout that!”“Tell me what you were thinking whenyou came up with that idea!”“That must have been a challenge…whatdid you tell yourself to get past it?”• -“How are you going to know when to be ready?”• -“How are you going to stop yourself from…?”• -“What is your goal?”• -“What do you want it to look like?”• -“How long do you think it will take?”• -“How much did time did it take last time?”• -“How are you going decide where to set that up?”• -“How are you going to know what you need?”• -“How are you going to know what is most important?”• -“How are you going to decide what to do first?”• -“How will you know when you are done?”• -“How will you continue when you are tired?”• -“How did that work out?”• -“How long do you think that took?”• -“How did you manage/know how to do it?”• -“Would you do anything differently?”• -“Have you done anything like this before?”• -“Was that harder or easier than….”
What are non-impaired kids doing that this pt is NOT?You can say: “If I keep doing this it islikely my teacher/friend will……”Ask to hear what the inner voice wassaying: “Tell me what you like bestabout that!”“Tell me what you were thinking whenyou came up with that idea!”“That must have been a challenge…whatdid you tell yourself to get past it?”• -“How are you going to know when to be ready?”• -“How are you going to stop yourself from…?”• -“What is your goal?”• -“What do you want it to look like?”• -“How long do you think it will take?”• -“How much did time did it take last time?”• -“How are you going decide where to set that up?”• -“How are you going to know what you need?”• -“How are you going to know what is most important?”• -“How are you going to decide what to do first?”• -“How will you know when you are done?”• -“How will you continue when you are tired?”• -“How did that work out?”• -“How long do you think that took?”• -“How did you manage/know how to do it?”• -“Would you do anything differently?”• -“Have you done anything like this before?”• -“Was that harder or easier than….”
Make task shorter, build in breaks, use salient r+ for afterwards, make steps more explicit, make task more appealing (beat the clock, write steps down on slips of paper, in jar)
2:20
BELLY COUNTSFIDGET TOYS
GUESS HOW OLD?
Token economy or response costChunking larger work into manageable units; beat the clock game; make post-homework time salientSet a clear when and whereMove towards independence; fade supervision“forgetting” homework is not a memory problem, but an organization problem
242”
He should just do it!
Victoriah’s F re: u sh just do it, tense/frustrated
HAPPENINGS BOOK (SCRAPBOOK AND HOPEBOOK)EXPANDING INTERESTSHI AND LOW OF THE DAYWAITER TAKE MY ORDER
MTBI – photo/phonophobia, headphones and sunglasses, Horseback riding (hippotherapy), trampoline, deep breathing exercises, raw carrots, have fidget objects on hand, relax with fish tank or lava light, experiment with lighting, notice reaction to smells (including “air fresheners”) in the home, massage, sauna, yoga/tai chi/martial arts, watch reaction to caffeine and etoh, vitamin b?, carefully guard sleep, plan vacations around sensory needs, be realistic re: what you can actually tolerate and manage.
Earphones, sensory diet, planning around variable noise, preferential seating, note-taker in college courses.1. Have trouble hearing clearly when it's noisy? This can be a failure of one or more of the automatic noise-suppression systems of the brain. It is reasonable to ask for a desk away from the computers or for a sound-absorbent partition. It is both polite and efficient to say, "I'm interested in what you're saying. Let's move away from this noise." A mild-gain amplifier can help you hear accurately on the phone over the noise of a busy office.2. Sometimes make "silly" mistakes or "careless" errors? Intrusions of random sounds which normal-hearing people can ignore may break your concentration so that you lose your place and skip a task (like carrying a number or writing a small word in the sentence). Take the work to a quieter place if necessary. Earplugs (sometimes in only one ear which suppresses noise less well) are a possible emergency solution. Make a deal with someone else to proofread your work.3. Miss important sounds or signals that others hear easily? Poor noise suppression and sound localization skills can cause important voices or signals to "disappear" in the general background. It will save others time if they know to tap you on the shoulder before they launch into their conversation. Telephone bells and alarms can be adjusted for volume or pitch, or a visual or tactile signal can be added.4. Get important messages wrong? Sound distortion, sequencing, auditory-visual transfer, and/or short term memory problems may be contributors. You can ask for the information in writing, double-check later with someone else who was present, or let the speaker know that she's going too fast. Even normal listeners often say, "Let me read that back -- ," or "That's '3489'?"5. Forget instructions? Inefficient short term auditory and rote memory (or habituation) may figure in this. Get in the habit of taking notes; set up a logbook for longer-term assignments; ask that the information be put in a memo. You might even carry a small tape recorder or dictaphone in some situations. If you often forget to go back to it later, put the memo or recorder where you must see it, as by your purse or underneath something you use every day.6. Only get parts of more complex directions or lengthy explanations? Here you may begin to suspect a problem with the subtleties of language - difficulty forming rapid "word pictures" to help with concept formation and memory, or failure to consider alternative word definitions so that meaning is mis-perceived. You can "freeze" it for later analysis by writing or taping. You can say "I learn better if I do it myself while you watch." Have someone else help you fill in details later.7. Have difficulty knowing "what to say when" and are puzzled by others' reactions to you? One possibility is an inefficiency in the part of the brain which registers tonality (expression in the voice) and gives us "quick fix" on the situation (sometimes referred to with rough accuracy as a "right hemisphere disorder"). A professional can help you learn other cues by which to "read" how people are feeling about what you said and how to change what you say accordingly, much as anyone would have to learn about a foreign culture. In the meantime you might explain the problem to people you trust so their feelings aren't hurt.