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Slide 1 - Attention Deficit Hyperactivity Disorder (ADHD) Carrie Cadwell PsyD HSPP
Slide 2 - Attention-Deficit Hyperactivity Disorder The symptoms: Inattention- (DSM-IV-TR) Careless mistakes Poor sustained attention Doesn’t listen Poor follow through Avoids/dislikes activities with high sustained attn demands Disorganization Loses things Distractible forgetful
Slide 3 - ADHD Hyperactivity/Impulsivity- (DSM-IV-TR) Squirms/fidgets Difficulty staying seated Runs/climbs execessively Difficulty with quiet activities Driven- by- a-motor Talks excessively Blurts out answers Difficulty with waiting turn Intrudes/interrupts
Slide 4 - ADHD Some symptom onset prior to 7yo This may be more easily identified in ADHD combined or H/I type ADHD inattentive type may not onset or be identified until after 7 yo (Parker et al, 2006) There will be some individuals who will not be identified until adolescence Why? Well-structured envt, intelligent, activity level channeled in prosocial direction, mild case Some with mild cases may not be identified until college
Slide 5 - ADHD Consider: Trends across years High interest versus this is important and I need to pay attention Are there other concerns to rule out Learning/iq issues/anxiety/ODD/mood issues (emotional responders) Understand that many conditions can co-exist with ADHD Attention issues are generic, we are asking are the attention/motor/impulse issues related to ADHD
Slide 6 - ADHD What about sleep? Children with ADHD have sleep problems Some literature to suggest that children with primary sleep disorders may have ADHD features
Slide 7 - ADHD Treatment Medication consultation School Supports/Interventions Ancillary interventions Behavioral intervention Problem-solving training ADD coaching Executive functioning skill building
Slide 8 - ADHD continued.. Tip #2: “Of the treatment families with Best Suport for attention and hyperactivity problems, Medication plus Behavior Therapy showed the largest effect size on average” (source: EBS Biennial Report 2007).
Slide 9 - Attention Deficit Hyperactivity Disorder (ADHD) Tip: “The most common practice element (specific "clinical ingredient") of all "winning" treatments for attention and hyperactivity problems (27 altogether) was problem solving (44%). This was found across study groups” (source: EBS Biennial Report 2007).
Slide 10 - ADHD cont (Murray 2008) Why is combined treatment beneficial? Increases chance of “normalization” Multiple domains of impairment for which medication alone does not impact “the addition of behavioral treatments to stimulant medication appears to reduce the dosage of medication needed by 20%, potentially reducing side effects and other risks” Greater parent and teacher satisfaction with BT added
Slide 11 - ADHD cont… Parent Management Training ingredients for ADHD/ODD (Pliska et al, 2007, JAACAP) Education about ADHD Learning differential responses to misbehavior and compliance/cooperation Home token economy Use of time out Learning to manage defiance in public settings Daily school report card Anticipating and proactively preventing defiance versus reacting
Slide 12 - “the research shows that even the best behaved kid listens only about 80% of the time” (Kazdin , 2008)
Slide 13 - Precision Commands/Requests (APA-CPSE, 2009; Kazdin 2008) Preplanned!!! Think behavioral momentum 2 requests Specific Close proximity—light touch Matter of fact tone Eye contact Statement not question If complies—HUGE enthusiastic response(4:1) If noncompliant after 2 request—apply consequence
Slide 14 - Positive Behavior Strategies (APA-CPSE, 2009) coming back to the idea of skill instruction……teaching new behavioral responses means: Take advantage of the “calm” Be a “warm demander” –high expectations w warmth/caring Behavioral rehearsal Much more than just role play Heavy emphasis on “caught ya’s” Research suggests that both classrooms and home environments are often low on positive reinforcement although we tend to think we do great
Slide 15 - Positive Behavior Support Strategies (APA-CPSE, 2009) Setting the tone for teaching positive social “curriculum” 3-6 rules stated positively and clearly Thoroughly explain, repeat, integrate into all aspects Set expectations etc early and revisit as needed Apply consistently---youth need the consistent message
Slide 16 - Positive Behavior Support Strategies Ex: Menominee “Today I will work hard, play fair, and treat others with care. Today I will SHINE” Show respect Helpful In Control Nice to everyone Eager to do Best
Slide 17 - Seven Myths of Effective Parenting (Kazdin, 2008) #1 Punishment will change bad behavior Does not teach what TO do and reinforce that Caution: has side effects Brief, pseudorelief Mistake of thinking remorse after punishment equals “I got it” Resistance to punishment escalates as fast as severity of punishment (up the anty) Punishment plus lengthy lecture equals loads of negative attention
Slide 18 - Seven Myths of Effective Parenting (Kazdin, 2008) #2 More reminders lead to better behavior “I told you 50 times….” 1-2 times is more effective than 50 If I tell my child to do something 10 times why doesn’t that increase chances of success?
Slide 19 - Seven Myths of Effective Parenting (Kazdin, 2008) #3 Explaining to your child why a behavior is wrong will lead them to stop the behavior Explaining is great for understanding but it is not a sufficient condition for behavior change When is the last time that knowing you should not eat that last piece of cake ensured that you didn’t? Feedback after misbehavior is not as effective in changing behavior as feedforward/feedback with practice of positive behavior
Slide 20 - Seven Myths of Effective Parenting (Kazdin, 2008) #4 Lots of praise just spoils your child Quantity: telling the child for the 100th time today “great job” reduces its meaning and effectiveness Quality: Praise should be “clear and clean” Effective praise also uses precision command components
Slide 21 - Seven Myths of Effective Parenting (Kazdin, 2008) #5 Doing it once or twice means your child can do it regularly A handful of time does not equal consistency and frequency of behavior This myth creates the “she did it yesterday, so today she is obviously defying me, being lazy” Creates more potential for fueling conflict than resolving it
Slide 22 - Seven Myths of Effective Parenting (Kazdin, 2008) #6 My other child did not need a special training program so this child shouldn’t need it either Risk of underestimating the differences between youth #7 My child is just being manipulative - this ignores the role that caregivers play in shaping or reinforcing behaviors - behavior is like a dance
Slide 23 - ADHD in the school Advocating for a youth 504 plans vs Special Education eligibility Ideas to recommend to teachers
Slide 24 - ADHD in the school Think in terms of ( US Dept of Education; Office of Special Education Programs 2004, NASP 2002): Academic instruction Organizational/study skills Behavioral interventions Classroom accomodations
Slide 25 - ADHD in the schools (DOE, OSE 2004, NASP 2002) Academic instruction Advance organization/warning Review previous lesson Setting specific learning and behavioral interventions State needed materials Explain additional resources Simplify instructions, choices, and scheduling Be predictable Support participation Audiovisual cues Check student performance/probing questions
Slide 26 - ADHD in the school (DOE, OSE 2004, NASP 2002) Academic Instruction Cues for task focus Follow-up directions (auditory & written) Lower noise levels Shorten task duration/divide into smaller units Highlight key points Reduce/eliminate timed tests Teacher directed vs independent seat work
Slide 27 - ADHD in the schools (DOE, OSE 2004, NASP 2002) Organizational and study skills Designated advisor/coordinator Assignment notebook (home/school) Color-coded folders Homework partner Clean out desks & book bags Visual aids Visual daily activity schedule
Slide 28 - ADHD in the schools (DOE, OSE 2004, NASP 2002) Organizational/study skills cont. Adapt worksheets Note-taking skills Checklist of frequent mistakes Checklist of homework supplies Uncluttered work space Monitor homework assignments (time taken, emphasize quality not quantity)
Slide 29 - ADHD in the schools (DOE, OSE 2004, NASP 2002) Classroom accommodations Seating near teacher (proximity cues) Seating next to peer role model Low distraction work areas Using pointers/bookmarks to follow along with reading Egg timers Classroom lights/play music Proper sized furniture Task scheduling
Slide 30 - ADHD Tip: “Effective teachers praise children with ADHD frequently and look for a behavior to praise before, and not after, a child gets off task” (DOE, OSE, 2004)
Slide 31 - (APA-CPSE, 2009) Unsuccessful strategies (home or school) Use of ignoring in isolation: peer attention more powerful than teacher non-attention Punitive/harsh punishments—thinking we are “sending a message” but it is fleeting
Slide 32 - The role of choices (APA-CPSE, 2009) We all know that positive parenting advocates use of “freedom within limits”—ie reasonable choices Consider this: youth seeking control disrupt less when they choose their activity compared to when teachers present even the preferred activity but no choice