Download ADHD: Our Advancing Knowledge and Implications for the

Aaron Tabacco, RN, BSN, LEND Faculty
Child Development and Rehabilitation Center
Oregon Health and Science University
Portland, Oregon
© 2009
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 3rd edition, a nursing
text
 Researcher, author, and frequent public speaker on
ADHD
 Parent of three sons with ADHD
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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
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Brain-Injured Child Syndrome
Volitional Inhibition
Min. Brain Damage- Post enceph.
Min. Brain Dysfunction
 Stimulant therapies start with success
Hyperkinetic Reaction
Hyperactive Child Syndrome
ADD
ADHD, with and without hyperactivity
mid 1848
(late 1800’s)
(1902)
(1922)
(1930’s)
(1937)
(1950’s)
(1960’s)
(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
Other causes of attention and
hyperactivity problems – NOT ADHD
• Sleep disorders
• Depression
• Bipolar disorder
• Learning disability
• Sensory deficits
• Previous brain injury
or trauma
• Giftedness
• Language disorder
• Pervasive
developmental
disorder (autism)
 Cognitive Disability (MR)
 Migraines
 Seizures
 Anxiety
 Oppositional or
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conduct disorders
Post traumatic stress
disorder
Substance abuse
Adjustment disorders
Abuse
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
Perception
of Time
Inhibit
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 5th 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
115
77
68
(Average)
(Average)
(Below)
(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
vs
“Don’t push people”
30 multiplication
problems in 1 minute
30 minutes of incidentfree recess
Situational Factors Affecting
Symptom Severity
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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
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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
 1 to 1 learning
 Behavior
 Token reward systems
Modification
 Green Outdoor
Spaces
 Physical Activity
 Yoga
 Massage
(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.