Transcript Presentation Slides - Fulton Psychological Group

KEY ISSUES IN THE
ASSESSMENT AND
MANANGEMENT OF ADHD
Dr. Jonine Biesman
Clinical Psychologist and Neuropsychologist
[email protected]
IMPORTANT ADHD FACTS
• AN EXECUTION/PERFORMANCE DISORDER. NOT A PROBLEM
OF SKILL OR KNOWING. A PROBLEM WITH DOING WHAT YOU
KNOW (YOU REALIZE YOU SHOULD HAVE USED WHAT YOU
KNOW BUT DID NOT). THUS, TROUBLE WITH THE WHEN AND
WHERE, NOT THE HOW AND WHAT.
• ADHD CREATES TIME PROBLEMS. CAN’T SEE INTO THE
FUTURE OR MANANGE TIME BECAUSE ARE PRONE TO LIVING
IN THE MOMENT.
• OFTEN EXISTS WITH OTHER DISORDERS (LD, ODD, CD,
MOOD, ANXIETY, SLEEP, EATING, TICS, OCD)
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ADHD FACTS (cont.)
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LARGELY A DEVELOPMENTAL DISORDER, FEWER CASES ACQUIRED
(AGE OF ONSET OF 7 NOT SO VALID).
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HUGE IMPORTANCE OF APPRECIATING SUBTYPES AND INDIVIDUAL
DIFFERENCES (DIFFERENCES IN MOTOR PLANNING ABILITIES OR
WAYS OF PROCESSING AUDITORY OR VISUAL INFORMATION)
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NEW CHANGES IN THE CONCEPTUALIZATION AND DIAGNOSTIC
CRITERIA FOR ADHD TO INCLUDE WORKING MEMORY AND
EXECUTIVE FUNCTIONING DEFICITS
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WITHIN MULITPLE SYSTEMS OF ATTENTION, IT IS ESSENTIAL TO
KNOW WHAT IS IMPAIRED AND WHAT IS SPARED.
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FOR A DIAGNOSIS, THERE MUST BE SIGNIFICANT IMPAIRMENT IN
DAILY FUNCTIONING.
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IMPORTANT ASPECTS OF ATTENTION
AND HYPERACTIVITY/IMPULSIVITY
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AROUSAL/ALERTNESS
SELECTIVE ATTENTION
DIVIDED ATTENTION
SPAN
PERSISTENCE/VIGILANCE/SUSTAINED ATTENTION
SHIFTING OF ATTENTION (ABILITY TO RE-ENGAGE WHEN
DISTRACTED)
• INHIBITION (ABILITY TO SUPPRESS DISTRACTIONS AND
IMPULSIVE DECISION-MAKING)
• WORKING MEMORY– ONLINE MEMORY, REMEMBERING TO
DO THINGS
• OTHER EXECUTIVE FUNCTIONS (SELF-REGULATION,
PLANNING, PROBLEM-SOLVING)
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LIKELY CHANGES TO
DIAGNOSIS (DSM-V)
• COMBINED TYPE ONLY BUT WITH INDICATION OF SEVERITY
• ADHD WITH OR WITHOUT CONDUCT DISORDER
• SLUGGISH COGNITIVE TEMPO (INATTENTION)
 MORE PROBLEMS WITH ACCURACY VS. PRODUCTIVITY (DISTINCT FROM
ADHD?)
 DAYDREAMING, SPACEY, STARE, HYPOACTIVE, SLOW MOVING, LETHARGIC,
MORTORICALLY AND COGNITIVELY SLUGGISH, EASILY CONFUSED,
MENTALLY FOGGY, SLOW RESPONSE SPEED AND REACTIONS, ERROR
PRONE, DECREASED FOCUS OR SELECTIVE ATTENTION, POSSIBLE
PROBLEMS WITH RETRIEVING INFORMATION, MAY BE SOCIALLY
WITHDRAWN, NO IMPULSIVITY OR DISINHIBITION, NOT MUCH EVIDENCE OF
EXECUTIVE DYSFUNCTION, MAY BE LESS REPSONSIVE TO MEDS, MORE
RESPONSIVE TO SOCIAL SKILLS
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Russell Barkley, 1998
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DEVELOPMENTAL ISSUES
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MAJORITY OF CASES GENETIC/BIOLOGICAL
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BECAUSE IS A DEVELOPMENTAL CONDITION, NEED TO COMPARE
FUNCTIONING TO A NORMATIVE SAMPLE (WHAT SHOULD WE
EXPECT AT THIS POINT IN DEVELOPMENT?)
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PRESCHOOL DURATION MAY NEED TO BE LONGER THAN 6 MONTHS
TO ASSIGN A DIAGNOSIS (GIVE PRESCHOOLERS AT LEAST A YEAR
TO GROW OUT OF WHAT MAY SIMPLY BE NORMAL AGE-RELATED
BEHAVIORS)
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HYPERACTIVITY DECREASES WITH AGE AS MOTOR RESTLESSNESS
BECOMES INTERNALIZED (MAY SEEM MORE LIKE THE NEED TO BE
BUSY ALL THE TIME)
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AS CHILDREN PROGRESS THROUGH THE GRADES, INATTENTION
AND EXECUTIVE FUNCTION SYMPTOMS HAVE THE GREATER IMPACT
ON ACADEMIC PERFORMANCE
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DEVELOPMENTAL ISSUES (cont.)
• THE TRANSITION TO MIDDLE SCHOOL IS OFTEN MET WITH
TEMPORARY DECLINE, SO IS A VERY IMPORTANT TIME
PERIOD TO MAKE SURE SUPPORTS AND INTERVENTIONS
ARE IN PLACE.
• IN ADOLESCENCE, ACADEMIC IMPAIRMENTS INCREASE.
REDUCED PRODUCITIVTY IS A SIGNIFICANT PROBLEM.
INCREASED HOMEWORK DEMANDS TAX ATTENTION AND
EXECUTIVE FUNCTIONS.
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DEVELOPMENTAL ISSUES (cont.)
EXECUTIVE FUNCTION DEFICITS AND THEIR IMPACT EMERGE
AS MOST SIGNIFICANT AS CHILDREN AGE.
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Less follow-through on promises and commitment
Impaired planning and anticipation; not ready for the future as it arrives
Reduced valuing of future rewards so less persistence toward future goals
Poor emotional regulation (anger management and frustration tolerance issues)
Decreased fluency or rapid construction of ideas
By adolescence, less productivity and accuracy, less accountability, poorer ability to handle
demands for self-regulation and time management
In adolescence and adulthood, symptoms may also manifest as inattention in traffic, higher rates
of accidents, use of nicotine, caffeine and other drugs, compromised work performance,
inattention to others’ comments and needs in social activities. BUT THERE ARE MODERATORS
AND CASES WHERE SYMPTOMS REMIT (1/6th to 1/3rd of cases).
Russell Barkley, 1998
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DEVELOPMENTAL ISSUES (cont.)
• IN SUM, ADHD IS A DEVELOPMENTAL DISORDER IMPACTING
OPTIMAL FUNCTIONING ACROSS SEVERAL AREAS –
EDUCATIONAL, OCCUPATIONAL, SOCIAL, MEDICAL, DRIVING,
SEXUAL, ETC.
• THUS, START INTERVENTIONS EARLY, SUSTAIN THEM
LONGER ACROSS THE DAY AND ACROSS DEVELOPMENT,
AND TARGET MULTIPLE DOMAINS, NOT JUST EDUCATIONAL.
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BEST PRACTICES IN THE
ASSESSMENT OF ADHD
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COMPREHENSIVE, STRENGTH-BASED APPROACH. HONOR THE INDIVIDUAL,
CAPTURE THEIR ESSENCE.
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ANSWER THE QUESTIONS CLEARLY AND WITHOUT JARGON.
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OBSERVE BEHAVIOR ACROSS SETTINGS (ESPECIALLY SCHOOL). TALK TO
TEACHERS, FIND OUT WHAT WORKS, WHAT DOESN’T. DON’T REINVENT THE
WHEEL OR MAKE SUGGESTIONS THAT ARE GENERIC. ASK TEACHERS WHAT
THEY NEED FROM THE EVALUATION AND WHAT QUESTIONS THEY HAVE.
WHERE ARE THEY GETTING STUCK?
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MANY EVALUATIONS FOR ADHD ARE CONDUCTED TO DETERMINE IF A
DIAGNOSIS EXISTS. THESE EVALUATIONS MAY BE INTERVIEW BASED, MAY
USE RATING SCALES, OR MAY BE PSYCHOEDUCATIONAL. ONLY A
NEUROPSYCHOLOGIST CAN PROVIDE THE COMPLETE PICTURE.
PSYCHOEDUCATIONAL TESTING THROUGH THE SCHOOL OR CONDUCTED
PRIVATELY IS OFTEN INSUFFICIENT. TOO MANY QUESTIONS GO
UNANSWERED AND IMPORTANT INFORMATION IS LEFT UNCOVERED.
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ASSESSMENT (cont.)
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SPEAK WITH ANY AND ALL COLLATERAL CONTACTS. REVIEW SCHOOL
RECORDS.
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CONDUCT A THOROUGH INTERVIEW WITH PARENTS INCLUDING
DEVELOPMENTAL, EDUCATIONAL, FAMILY, SOCIAL, MEDICAL HISTORIES.
SCREEN FOR ANY ISSUES THAT MAY INTERFERE WITH TREATMENT.
UNDERSTAND THE CHILD AS A WHOLE. DO NOT JUST LOOK AT NUMBERS
AND TEST RESULTS IN ISOLATION.
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DO NOT LEAVE OUT SLEEP, NUTRITION, MOTIVATION, INTERESTS,
STRENGTHS, AND INDIVIDUAL SENSORY PROFILES.
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DO NOT PUSH CHILDREN TO SIT THROUGH 3-4 HOUR TEST SESSIONS.
BREAK THEM UP AS NEEDED. ALLOW FOOD AND DRINK, FREQUENT BREAKS,
AND PLAY. BE AS PATIENT AS NEEDED AND OPTIMIZE PERFORMANCE. WE
WANT TO KNOW THE UPPER LIMITS OF CAPACITIES.
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ASSESSMENT (cont.)
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MAKE SURE TO TEST LIMITS. FIND OUT WHAT IS NEEDED TO HELP A
STUDENT SUCCEED AND WHAT IS INTERFERING. BREAKS TASKS DOWN
INTO THEIR COMPONENT PARTS TO MAKE THIS DETERMINATION.
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EVALUATE THE INDIVIDUAL’S PROCESS. THIS IS ACUTELY IMPORTANT.
KEENLY OBSERVE APPROACH TO TASKS, ERROR TYPES, PERSISTANCE,
RESPONSES TO CHALLENGES, ETC.
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MUST ASSESS DIFFERENT COMPONENTS OF ATTENTION, MEMORY, AND
LEARNING, WORKING MEMORY AND EXECUTIVE FUNCTIONS AND ANY
OTHER DOMAINS THAT ARE SUSPICIOUS INCLUDING VISUAL-MOTOR,
SENSORIMOTOR, AND AUDITORY PROCESSING.
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DIAGNOSE ADHD ONLY WHEN ALL OTHER CONDITIONS HAVE BEEN
CONSIDERED (EMOTIONAL, ENVIRONMENTAL). DETERMINE IF THERE IS
VALID “CO-MORBIDITY” OR MULTIPLE DIAGNOSES. ALWAYS DETERMINE
WHAT IS DRIVING THE ENGINE, OR MAIN CONTIBUTOR TO PRESENTING
PROBLEMS.
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ASSESSMENT (cont.)
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RECOMMENDATIONS SHOULD BE UNIQUE AND THOROUGH. THERE SHOULD
BE A CLEAR PATH FOR INTERVENTION.
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ACCESS TO THE NEUROPSYCHOLOGIST SHOULD BE ONGOING TO ANSWER
ANY QUESTIONS RELATED TO TEST RESULTS, TO ATTEND MEETINGS, OR TO
SPEAK WITH OTHER PROFESSIONALS.
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TEST RESULTS SHOULD BE DELIVERED IN A TIMELY MANNER.
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FEEDBACK SHOULD ALSO BE OFFERED TO THE STUDENT IN CHILDFRIENDLY TERMS EMPHASIZING STRENGTHS.
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EXAMPLES OF ACADEMIC
ACCOMMODATIONS
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QUIET EXAM AREAS
USE OF HEADPHONES
FREQUENT BREAKS
REDUCED HOMEWORK LOADS
PROVISION OF CLASS NOTES
ADDITIONAL TIME IF NEEDED (ON ALL STANDARDIZED EXAMS AS WELL)
VARIED TEACHING STYLES AND TEACHING WITH EXCITEMENT
ALTERNATING FUN AND BORING MATERIAL
OPPORTUNITIES FOR MULTISENSORY, EXPERIENTIAL LEARNING
ALLOW MOVEMENT AROUND THE CLASSROOM.
SUGGEST SWINGING OR CLIMBING AT RECESS
KEYBOARDING
ALLOWANCE FOR TAPING
ORGANIZATIONAL AIDS
AREA IN THE CLASSROOM TO RECONSTITUTE
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EXAMPLES OF ACADEMIC
ACCOMMODATIONS (cont.)
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DIFFICULT MATERIAL IN THE MORNING
PREFERENTIAL SEATING
PAIRING WITH ORGANIZED STUDENTS
OPPORTUNITIES TO ELEVATE GRADES
CHUNKING OF MATERIAL
REPEAT INSTRUCTIONS AS NEEDED
WEEKLY HOME-SCHOOL COMMUNICATION
REINFORCEMENT FOR ON-TASK BEHAVIORS, SELF-MONITORING AND SELFREGULATION
OPPORTUNITY FOR MASTERY EXPERIENCES WITHIN THE CLASSROOM
REFRAIN FROM SENDING HOME INCOMPLETE CLASSROOM ASSIGNMENTS
EXTERNAL TIME SIGNALS
ENCOURAGE CONTINUOUS NOTE-TAKING
ALLOW WATER, GUM, OR SUCKERS
OFFER AFTER-SCHOOL HELP
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EXAMPLES OF ACADEMIC
ACCOMMODATIONS (cont.)
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REGULAR PARENT-TEACHER MEETINGS
TARGET PRODUCTIVITY FIRST, ACCURACY LATER
PROVIDE HOMEWORK ASSIGNMENTS AND PROJECTS IN ADVANCE
ALLOW FOR SPECIAL CUSHION ON CHAIR THAT MOVES
ALLOW STUDENT TO CREATE SOME ASSIGNMENTS TO ENHANCE
MOTIVATION
EXTRA SET OF TEXT BOOKS AT SCHOOL
BOOKS ON TAPE
ABILITY TO TAKE EXAMS OVER 2 DAYS
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CURRENT TREATMENTS
(COMBINED MAY BE MOST EFFECTIVE)
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PSYCHOPHARMACOLOGICAL
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PARENT TRAINING AND EDUCATION
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FAMILY THERAPY (PROBLEM-SOLVING, COMMUNICATION)
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SUPPORT GROUPS
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SOCIAL SKILLS (BETTER WITH INATTENTION ISSUES)
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EXERCISE
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TEACHER EDUCATION AND CLASSROOM BEHAVIOR MANAGEMENT
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SELF-INSTRUCTIONAL TRAINING
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METHODS REQUIRING
FURTHER STUDY
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NEUROFEEDBACK (THE JURY IS STILL OUT. NIMH TO CONDUCT A STUDY.
NEED FOR CONTROLLED STUDIES AND META-ANALYSES)
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COGNITIVE TRAINING OF WORKING MEMORY (E.G., ROBO MEMO AT
COGMED.COM)
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DIET AND VITAMINS (ALTHOUGH GOING ORGANIC AND TAKING OMEGAS
CAN’T HURT)
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FLOORTIME (SEE ICDL.COM AND STANLEY GREENSPAN) – A DEFINITE
FAVORITE!
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MINDFUL AWARENESS
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RESOURCES
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Websites:
www.icdl.com (official website of the Interdisciplinary Council on Developmental and Learning Disorders)
www.chadd.org (official website of Children and Adults with Attention Deficit/Hyperactivity Disorder)
http://marc.ucla.edu (Mindful Awareness Research Center at UCLA)
www.abpdn.org (American Board of Pediatric Neuropsychology)
www.russellbarkley.org (Resources for Attention Deficit/Hyperactivity Disorder)
www.eeginfo.com/research (Neurofeedback resources and information)
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Print:
Parent Coaching Cards, Richfield, S.
Building Healthy Minds, Stanley Greenspan, M.D.
The Challenging Child, Stanley Greenspan, M.D.
Parenting from the Inside Out, Daniel J. Siegel, M.D; Mary Hartzell, M.Ed.
The Developing Mind, Daniel J. Siegel
The Out of Sync Child, Carol Stock Kranowitz, M.A.
Touchpoints, T. Berry Brazelton M.D; Joshua Sparrow, M.D.
The Mislabeled Child, Brock Eide, M.D., M.A; Fernette Eide, M.D.
The ADHD Report, Russell Barkley, Guilford Publications
Driven to Distraction, Edward Hallowell, M.D., John J. Ratey
Change Your Brain, Change Your Life, Daniel Amen, M.D.
Brain Lock: Free Yourself from Obsessive Compulsive Behavior, Jeffrey M. Schwartz, M.D.
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