Transcript ADHD is a well documented neurological disorder.

ADHD in the Classroom
Can anyone survive?
Quote for the Day
I was trying to daydream, but
my mind kept wandering.
Steven Wright
Planning Outline for Presentation
By the end of today’s session, this
may be how you will feel:
Information Overload
• Google for ADHD = 15,700,000 sites
• Amazon books listed on ADHD = 689 books
• Local opinions = 1 (mine)
ADHD: Living Without Brakes
(book title by M. Kutscher)
I couldn’t repair your brakes, so I made your
horn louder.
Steven Wright
Which child has ADHD?
Let’s get down to the issues.
How would you describe the ADD/ADHD child
in your classroom?
The better we can describe the behaviors, the
better we can plan interventions.
Attention
• How would you describe inattention?
• Is being inattentive the same as being
distractible?
Note: Inattention increases with difficulty of
task.
Attention
• As the child matures into adulthood,
symptoms of inattention evolve into
forgetfulness, losing things, and avoiding
menial tasks.
Impulsivity
• How would you describe impulsivity?
• What about excitability?
• What about emotional regulation?
Impulsivity
• Common characteristics within ADHD include:
– Low frustration tolerance
– Quickness to anger
– Impatience
– Being easily excitable
These characteristics tend to persist into
adulthood, even more so than hyperactivity.
Inattention
• As the child matures into adulthood,
impulsivity evolves into poor driving
performance and self-medication.
Hyperactivity
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What does hyperactivity look like?
Is being fidgety the same as being hyper?
What about sensory overload?
What about exciteability?
Hyperactivity
• Compared to inattention and impulsivity,
hyperactivity may be the least important
symptom.
• Also, hyperactivity tends to decrease as the
child ages.
Official Diagnosis
• Often fails to give close attention to details or makes careless mistakes in
schoolwork, work, or other activities.
• Often has difficulty sustaining attention in tasks or play activities.
• Often does not appear to listen when spoken to directly.
• Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (not due to oppositional
behavior of failure to understand instructions).
• Often has difficulty organizing tasks and activities.
• Often avoids, dislikes, or is reluctant to engage in tasks requiring sustained
mental effort (such as schoolwork or homework).
• Often loses things necessary for tasks or activities (for example,, toys,
school assignments, pencils, books, or tools).
• Is often easily distracted by extraneous stimuli.
• Often forgetful in daily activities.
Official Diagnosis
• Often fidgets with hands or feet or squirms in seat.
• Often leaves seat in classroom or in other situations in which remaining
seated is expected.
• Often runs about or climbs excessively in situations in which it is
inappropriate (in adolescents or adults, may be limited to subjective
feelings of restlessness).
• Often has difficulty playing or engaging in leisure activities quietly.
• Is often “on the go” or often acts as if “driven by a motor.”
• Often talks excessively.
• Often blurts out answers before questions have been completed.
• Often has difficulty awaiting turn.
• Often interrupts or intrudes on others (for example, butts into
conversations or games).
Diagnosis
• DSM-IV differentiates between three different
types of the disorder.
1. ADHD – predominately hyperactive/impulsive type
(without inattention symptoms being significant).
2. ADHD – predominately inattentive type (without
the hyperactive/impulsive symptoms being
significant).
3. ADHD – combined type (the most common).
Diagnosis
• There is a problem for researchers and
clinicians with the present diagnostic criteria
for ADHD.
• What if inattention is something entirely
separate from impulsivity and hyperactivity?
Why conduct a workshop on
ADHD?
• ADHD has long lasting and serious
consequences for the child.
• ADHD is the most common global disability
experienced in the classroom.
• There are still too many myths about ADHD.
• ADHD in the classroom can be so frustrating.
Long lasting, serious consequences:
• The national percentile score in reading
achievement in early adolescence for children
with ADHD is almost 30 points lower than for
non-ADHD age- and gender-matched controls.
Long lasting, serious consequences:
• Youths with ADHD have higher rates of
absentee days, especially after the 6th grade.
• Students with ADHD are three times as likely
to be retained in a grade by age 12.
• The school drop-out rate is twice as high for
boys with ADHD.
Long lasting, serious consequences:
• ADHD adolescent drivers have four times as
many auto accidents and three times the
number of speeding tickets as non ADHD
adolescent drivers.
• In adults, driving under the influence of ADHD
produces similar driving errors as when under
the influence of alcohol.
Long lasting, serious consequences:
• ADHD is associated with higher teen
pregnancy rates
• ADHD is associated with earlier
experimentation with drugs and alcohol.
• Girls with ADHD have a higher risk of
pathological eating behavior and a desire for
thinness.
• ADHD increases the risk for certain psychiatric
disorders.
Long lasting, serious consequences:
• Boys with ADHD are three times more likely to
be arrested or incarcerated as adults (but
there is more to this story).
• In adults, ADHD produces diverse and serious
impairments in functioning in education,
occupation, social relationships, sexual
activities, dating and marriage, parenting,
financial management, and overall mental
health.
Frequency
ADHD is the most common global
disability experienced in the
classroom.
• Nearly 7% of elementary–age children in the
United States have been diagnosed with
ADHD.
• The number of boys diagnosed with ADHD
outnumbers the girls almost 4 to 1.
Myths about ADHD
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Myth: Children grow out of it when the
reach puberty or adulthood.
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Fact: Only about a third lose their
symptoms by adulthood. Inattention and
emotional factors persist. Some symptoms
change in nature.
Myths about ADHD
• Myth: ADHD is not a real condition. It was
created by the drug companies to sell
medications.
• Fact: ADHD is a well documented neurological
disorder. (to be discussed further)
Myths about ADHD
• Myth: ADHD is over diagnosed.
• Fact: While some children may be
misdiagnosed, many children with ADHD are
never identified, especially girls.
Myths about ADHD
• Myth: We never had ADHD when I was
growing up!
• Fact: Actually the symptoms were described
in a medical document back in 1798. It has
gone by many names since then.
Myths about ADHD
• Myth: ADHD is caused by too much TV and
too much junk food, especially sugar.
• Fact: ADHD may be aggravated by these
factors, but the causes are primarily genetic
and trauma to the developing system.
Myths about ADHD
• Myth: Children who take medication for
ADHD will become addicted and will start
using other drugs.
• Fact: Medications used to treat ADHD do not
increase the risk of future drug and alcohol
abuse in early adulthood.
Myths about ADHD
• Myth: All he needs is a good whooping.
• Fact: Good discipline is essential, but
spankings are usually short lived and not
nearly as effective as structure and positive
guidance.
A Question to Ponder
Who has the hardest time in the classroom?
A. The ADHD child
B. The teacher
What is our attitude toward the ADHD
child?
Just because you are in a wheelchair
doesn’t mean you can’t walk down the
steps like everyone else!
• We struggle to understand:
– What is really due to ADHD, and what is just being
lazy, or not caring, or defiance, or …….?
– What do we have a right to expect/demand?
What is ADHD?
It is a neurological disorder characterized by
inattention, hyperactivity and impulsivity.
(see DSM-IV diagnostic criteria, Rief list 1-3)
• Note the three types:
– Predominantly hyperactive/impulsive type
– Predominantly inattentive type
– Combined type
The Brain and ADHD
• The brains of children with ADHD were 3% to
4% smaller than the brains of children without
ADHD.
The Brain and ADHD
• A recent study found a 3 year delay in brain
maturation measured by cortical thickness.
• (No wonder they can act so immature!)
• These delays in maturation were most
noticeable in brain regions related to
executive control of attention, behavioral
inhibition, working memory, evaluation of
reward contingencies, coordination of higher
order plans, and motor control.
What is ADHD?
AHDH is now perceived by many as
characterized by deficits in executive
functioning, or the management of brain
functions.
(see Rief list 1-2)
Here is where the disabilities show up.
The Major Concerns
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Deficits in executive functions
Inattention
Deficits in inhibition
Deficits in working memory
Deficits in processing speed
• http://www.aboutkidshealth.ca/ADHD/TheHigh-Risk-Triad-Inattention-Poor-WorkingMemory-and-AcademicUnderachievement.aspx?articleID=6894&cate
goryID=AD-nh1-04d
Working Memory
Phonological Task
Working Memory
Visuospatial Task
Working Memory
Visuospatial Task
Working Memory
Results for Phonological Task
Working Memory
Results for Visuospatial Task
Associated Characteristics
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Impatience
Demandingness
Low frustration tolerance
Poor listening skills
Avoidance of chores and academics
Poor task completion
Associated Characteristics
Positive Illusory Bias
Classroom Issues
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Excessive movement about the room or at seat
Excessive talking
Failure to attend or keep up
Failure to start , complete, or turn in assignments
Conflict with peers
Restricted academic performance
Argumentative
Writing Issues
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Difficulty copying from board
Slow copying from book or paper
Poor legibility of handwriting
Resistance to writing at all
– Fails to start
– Rushes through, writing anything
– Quits after brief start
Reading Issues
• Lose place (poor tracking)
• Lose train of thought
• Forget what just read, have to reread
repeatedly (impedes comprehension)
• Silent reading difficult (may subvocalize)
• Lack of fluency
• Learning deficits in reading (phonological,
processing, language)
Math Issues
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Remembering math facts
Following multiple steps
Recalling rules, procedures, directions, sequences
Poor attention to sign changes or operational
changes
Poor self-correction
Poor alignment of numbers on page
Slow processing or writing speed
Difficulty with word problems
Discipline Issues
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Needing constant redirection
Impulsiveness
Desire for attention
Feeling picked on
Anger
Few discipline options
What to do?! – What to do?!
Be Patient
Be Structured
Be Interesting
End of Part 1
The Co-conspirators
(1/2 to 2/3 have comorbid behavior disorders)
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ODD (Oppositional-Defiant Disorder)
CD (Conduct Disorder)
BPD (Bipolar Disorder)
ASD (Asperger’s Disorder)
TD (Tourette’s Disorder)
OCD (Obsessive-Compulsive Disorder)
Epilepsy
Oppositional Defiant Disorder
• Essential Feature: a recurrent pattern of negativistic, defiant,
disobedient, or hostile behavior toward authority figures.
• Characterized by:
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Losing temper
Actively refusing to comply
Deliberately annoying others
Being touchy or easily annoyed
Being angry and resentful
Being spiteful or vindictive
Conduct Disorder
• Essential Feature: repetitive and persistent pattern of
behavior in which the basic rights of others or major societal
norms or rules are violated.
• Characterized by:
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Aggression to people and animals
Destruction of property
Deceitfulness or theft
Serious violation of rules
Bipolar Disorder
• Essential feature: severe mood dysregulation
• They may cycle through moods or present a
chronic irritability
Asperger’s Syndrome
• Essential Features: severe and sustained
impairment in social interaction and the
development of restrictive, repetitive patterns
of behaviors, interests, and activities.
Difficult Combinations
• ADHD, Tourette’s, OCD
• ADHD, Asperger’s, OCD
• ADHD, ODD, and or CD
• ADHD and Epilepsy
ADHD or CD?
• Within the ADHD adults with multiple repeat
offenses and arrests, three behavior rating
items in their childhood were predictive:
• “often gets into fights with other children”
• “lies to get out of trouble”
• “takes things from other children”
More Co-conspirators
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Learning Disorders
Sensory Integration Disorders
Auditory Process Disorder (CAP-D)
Motor Deficits
Sleep Disorders
Bedwetting
Parents as Co-conspirators?
ADHD children with ADHD parents:
• Higher rates of ODD
• Higher rates of mood or anxiety disorders
Issues to Confront
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Organization
Time estimation
Volume estimation
Transitions
Motivation
Social interactions
Emotional adaptability/control
What not to do.
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5.
Tie him up and put duck tape over his mouth.
Embarrass him.
Constantly call out his name.
Be overly critical.
Repeatedly tell him to stop rather than telling
him what to do.
6. Run yelling and screaming out of the room.
What to do?! – What to do?!
Help the ADHD student organize. Develop a
system and stick with it. (Use color coding
and other organizational strategies.)
Question: Is it wrong to provide paper and
pencils for the student?
What to do?! – What to do?!
Use Visual Prompts
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About rules (color wheel, posters, lists)
About procedures/steps (printed instructions, reminders)
About content (key words, ideas)
About time (clocks, time remaining)
What to do?! What to do?!
• Use the three “P’s”
• Prepare
• Pre-teach
• Practice
What to do?! – What to do?!
Help Student Plan
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What is my task?
What materials do I need?
How will I start?
What will I do next?
How long will this take?
When should I ask for help?
What to do?! – What to do?!
Monitor & Supervise
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Redirect
Remind
Review
Reward
How do we motivate?
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Positive regard (forge a positive relationship)
Encouragement
Expectations
Guidance
Reward Systems
Social Interactions & Adaptability
• Help students learn how to shift from a
change-oriented or problem solving strategy
when a situation is controllable to a copingoriented or emotion regulation strategy when
a situation is less controllable.
Other Suggestions
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Utilize deep breathing techniques.
Exercise
Try a mirror
Nature (get outside)
Use peers
How can we help children with
ADHD?
1. Acknowledge and accept the reality
of the disorder
2. Structure, structure, structure
3. Support, guide, assist
4. Use visual supports
5. Care and embrace with compassion
REMEMBER
Patience,
Patience,
Patience
Medications for ADHD
• Originally – Dexedrine, Ritalin
• Then – Adderall, Cylert
• Then time released – Metadate, Concerta, Adderall
XR
• Something different – Strattera (norepinephrine
reuptake inhibitor)
• Most recent – Vyvanse, Guanfacine (Intuniv, Tenex)
• Patch - Daytrana
Additional Medications
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Welbutrin (antidepressant)
Clonadine (blood pressure medication)
SRI’s (anti-depressants)
Risperdal, Seraquel, Abilify (anti-psychotics)
Complications with Medications
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Rebounding
Disturbed sleep
Weight loss and delayed growth
Irritability, anger, psychotic thoughts
Heart rate increase
Anhedonia
Causes
• Genetics
• Environmental Risks
– Prenatal alcohol/drug exposure
– Oxygen deprivation
– Brain trauma
– Febrile seizures
– Lead exposure
– Maternal illness during pregnancy
• Genetics load the gun, environment pulls the
trigger.
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What about sugar?
What about food dyes and preservatives?
What about exposure to TV and video games?
What about abuse?
Don’t forget!
Patience,
Patience,
Patience