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					 Attention
   Deficit
Hyperactivity
  Disorder
 (AD/HD)
 Solutions
Personal Insight
         A teacher’s insight.
            A to Z Teacher Stuff
         At home - ADD
            My son’s perspective
         Personal experience
Take Home Messages
 AD/HD is not a disease nor is it a joke; do not
  blame the person nor trivialize the condition.
 Students with moderate to severe AD/HD are
  highly at risk for behavioral, emotional and
  academic failure.
 Those with AD/HD can and do succeed with
  proper diagnosis, intervention and support.
Goals

   1. Overview and Definitions
   2. Etiology Key Issues
   3. Scope, Prevalence and
      Comorbidity
   4. Successful Strategies (over 25!)
   5. Summary
First, An Overview…

Let’s get a critical
understanding of the
condition with its
associated features
and a discussion of
key diagnostic issues.
Clinical Definition (1 of 2)

 AD/HD is a persistent disabling
 pattern of behavior. It occurs more
 frequently and with greater
 consequences than is typically
 observed in others at a comparable
 level of development.
Clinical Definition (1 of 2)


 AD/HD is a condition
 characterized by:
         Poor short term memory
         Hyperactivity
         Impulsivity
         Poor time management
  Clinical Definition Key
All AD/HD behaviors
can be considered normal
for some people, at some
age for a certain time.
With AD/HD, these
behaviors are the rule
and not the exception and
they are age
inappropriate.

Source: DSM-IV-TR, 2000
      Clinical Qualifiers
1.        Onset before age 7 yrs.
2.        Diagnosis often delayed until problems in school
3.        In two of three settings - home, school, office
4.        Rule out other potentially ―look-alike‖ psychiatric
          disorders such an oppositional disorder, sensory
          integration disorder, central auditory processing
          disorder, learning delays, schizophrenia, stress
          disorders, psychosis or trauma.
Source: DSM-IV-TR, 2000
Diagnosis (1 of 2)

 The AD/HD diagnosis carries with it
 significant implications for
 families, educators and of course, the child.
 Only a licensed professional, such as a
 pediatrician, psychologist, neurologist, psyc
 hiatrist or clinical social worker, can make
 the diagnosis that a child, teen, or adult has
 AD/HD.
Diagnosis (2 of 2)

 Health care professionals use the
 Diagnostic and Statistical Manual
 of Mental Disorders, 4th Edition,
 Text Revised (DSM-IV-TR) as a
 guide (APA, 2000).
    AD/HD Behaviors/Symptoms
   Poor short-term memory
   Weak at following directions
   Asking another what was just said
   Looking at others to figure out what was said
   Late for time commitments
   Desk is a mess--poorly organized
   Forgetting about promises made
   Knowing what and how but not knowing
    when and where to do it--it’s appropriateness
More AD/HD
Behaviors/Symptoms

               Spacey, poor concentration
               Weak time orientation
               Cannot plan ahead
               Poor at reflecting on past
               Makes the same mistakes
                over and over
               Poor time management
Other Common Behaviors/Symptoms

•   Unable to curb their immediate reactions
   They act before thinking
   They hit or grab first, then realize it later
   Blurt out inappropriate comments
   Nearly impossible for them to wait for things--
    little or no patience
    Hyperactive-only Behaviors

 Can’t stay in their seats
 Always want to be in motion
 They can't sit still, dash around
 They squirm, wiggle and touch
   everything
 Less focus; they try to do several
  things at once
More AD/HD Milestones
(3 of 5)
1980
  APA (American Psychiatric Association)
  identified the condition as a disorder in the DSM
  III. Two behavior patterns were listed:
  Attention Deficit Disorder (ADD) and Attention
  Deficit Disorder with hyperactivity AD/HD
1983
  Amphetamines prescribed to treat AD/HD
  including Ritalin and AD/HD Adderall using
  National Rehabilitation Act, Section 504
  Most Recent AD/HD Milestones
  (5 of 5)
1994
  DSM IV) Three Subtypes Defined
1997
  Based on office visits, those diagnosed with
  AD/HD reached 3.3 million children; nearly over
  5 percent of all children (U.S. figures).
2003
  AD/HD becomes the number one diagnosed
  school age disorder in America
  Brain Differences in AD/HD Subjects

• Neurotransmitter
  imbalances
 Lower cerebral
  blood flow
  Lou, et al., (2004)

 Anatomical differences
  between healthy
  brains and those with
  AD/HD
 Castellanos, et al. (2002), Castellanos and Acosta,(2004)
Brain Differences in
AD/HD Subjects

• Magnetic Imaging Resonance (MRI)
   found a range of abnormalities in
   brain development associated with AD/HD
• Brains are 3-4% smaller in more frontal lobes, temporal
   gray matter, posterior inferior vermis, caudate nucleus
   and cerebellum.
  Castellanos F. Acosta M. (2002)
  AD/HD and Other Disorders
 25% of children diagnosed with AD/HD also
  qualify for a diagnosis of oppositional defiant or
  conduct disorder (CD).
 Nearly 20% of children with AD/HD also have
  a depressive disorder.
 More than 25% of children with AD/HD qualify
  for a diagnosis of anxiety disorder.
 Almost 33% of children with AD/HD also have
  more than one comorbid condition.
Comorbidity (appearing together)
More often than not, AD/HD presents itself with
other cognitive and behavioral issues including:
    Oppositional defiant disorder
    Conduct disorder
    Dyslexia
    Anxiety and mood disorders
    Depression
    Learning disorders
    Tourette’s disorder
    Obsessive-compulsive disorder (OCD)
   Attention Deficit Hyperactivity Disorder: A Decade of the Brain Report.96-3572, (1996).
          Bethesda, MD: National Institute of Mental Health.
Comorbidity of AD/HD Summary

 Prevalence rates of comorbid AD/HD are high.
  Estimates of various comorbid conditions in
  children with AD/HD range from 12% (learning
  disorders) to 35% (behavioral disorders) to as
  much as 92 percent in all.
  (Osman, 2000).

 Current literature indicates that approximately 40–
  60 percent of children with ADHD have at least
  one coexisting disability.
  (Jensen, et al., 2001)
  Will Children with AD/HD Outgrow It?
 50-65% of children with
  AD/HD present symptoms
  into adulthood (Korn & Weiss, 2003)
 30-40% of grownup
  AD/HD children do well.
 10-20% have significant
  impairment and disability.
 80-90% do not need
  medication as adults.
  Barkley, (2002)
AD/HD Symptoms
into Adulthood…
Adults May…
     • Experience difficulty working, finishing
        assignments or meeting deadlines
        because they cannot concentrate or are
        easily distracted.
     • Interrupt people who are speaking
        by cutting them off in the middle
        of a conversation.
     • Be restless or impatient at meetings.
     • Arrive late to work or meetings because
        of poor organizational skills or
        forgetfulness.
       (Biederman et al., 2003)
Gender and
AD/HD Issues

 Elementary age males were more than two times as
  likely as females to have been diagnosed with AD/HD
  in 2003 (9 percent versus 4 percent respectively).
 By age 14, (late adolescence), girls and women are
  identified more than boys.
 Many critics have suggested that elementary school
  seems better designed for girls, not boys.
  Biederman, et al. (2002)
     Differences by
     Ethnic Origin

 Proportionally, more Anglos are diagnosed with
  AD/HD than nonwhites.
 In 2003, 8% of non-Hispanic white children and
  6% of non-Hispanic black children had been
  diagnosed with AD/HD compared with only 4%
  of Hispanic children.
 These disparities suggest the possibility that
  income and cultural differences may affect both
  perception and analysis of the behaviors.
  Pastor and Reuben, (2005)
Risk Factors of AD/HD
 Academic
  underachievement
 Legal problems
 Substance abuse
 Social difficulties
 Risky behaviors
     How Risky is Untreated AD/HD?
 35% of students dropout with AD/HD
 5-10% will complete college
 40-50% will engage in antisocial activities
 50-70% have few or no friends
 70-80% will under-perform at work
 More likely to experience teen pregnancy and
  sexually transmitted diseases
 Greater risk for excessive speeding and
  accidents
 Higher risk for depression and personality
  disorders
Source: Barkley, (2002)
  Diagnosis and Discussion
What are potential explanations for the rapid increase
  in diagnosis of AD/HD?
 Awareness and marketing of pharmaceuticals
 Less of stigma to taking ―meds‖
 Kids grow up in a faster 24/7 world—
  it may harder to focus
 Better diagnosis and treatment by medical
  professionals
 More children in childcare, for more years
 Change in early childhood activities (more
  electronic games played that reward impulsivity)
    Validity Issues: Is AD/HD Real?
 AD/HD is a psychiatric diagnosis, not
  a disability category recognized by the
  Individuals with Disabilities Education
  Act (IDEA)
  (Salend & Rohena, 2003).

 At present, no laboratory test exists to
  determine if a child has this condition.
  You can't diagnose AD/HD with a
  urinalysis, blood test, EEG, PET, fMRI
  or SPECT scan, though these can help.
 Should students with AD/HD adapt to the
  adult world or the reverse?
         What About Simply A.D.D.?
      Students with Attention
         Deficit Disorder only
      do not have the ―hyper‖
     symptoms of movement.
  As a result, they tend to be
still impulsive, but they stay
       in their chairs. They’re
   impulsive cognitively but
   unfocused and stationary.
Etiology Possibilities

 Major changes in the last two
 generations may be a source
 for possible explanations for
 the AD/HD brain:

    1. Childrearing Tactics
    2. Nutrition Changes
    3. Stress/anxiety
    4. Screen/Computer time
Childrearing Changes
   Close, nurturing parenting is
    needed from ages 0-5 and the
    brain has higher vulnerability
    to environmental influences.
    Rice and Barone (2000)


   In 1960, an estimated 10% of all
    children were in childcare. Today,
    over 60% of all kids will spend
    time in childcare.
   NICAD (2003)
   More children watch more fast-paced TV with
    stressful, violent images. Less chaotic, less stressful
    upbringing may help the brain develop differently.
    (Christakis et al. 2004)
  Nutrition Links (1 of 2)
 Studies link excess sugar and
  poor diets with behavioral
  problems in children.
  (Jacobson, 1996 and Werbach, 1998)

 Among infants 24 months or less,
  1 in 9 have French fries daily,
  1 in 4 have hot dogs daily.
  (Fox et al., 2004)


 Children eat far more
  processed foods with
  preservatives, additives
  and trans fats than at
  any time in history.
  Nutrition Links
  (2 of 2)

 AD/HD meds such as Methylphenidate (Ritalin®)
  increase dopamine or Straterra® increase our brain’s
  norepinephrine. Diet alone may support this process.
 Specific dietary supplements may include the amino
  acid tyrosine, essential fatty acids and phospholipids.
  Tyrosine is converted into dopamine in the brain.
  (Harding et al., 2003).
Interventions:
Practical Strategies for
Parents and Teachers

   Review of both the mainstream and
   alternative treatments. Explore both
   short-term and lifelong strategies for
   successful healthy living.
                          Your Choices…
                        1. Changes within the student
   (meds, skill-building, nutrition, self-awareness, etc.)
                       2. Changes in the environment
 (more mobility, change in teachers, cooler room, etc.)
                 3. Changes in the teacher’s behavior
(more awareness, accommodations, skill-building, etc.)
             4. Changes in the overall school culture
  (awareness, greater appreciation for differences, etc.)
                                 5. Influence parenting
 (less nagging, greater support, more consistency, etc.)

  NOTE: Where do you have the most control?
       When You Treat AD/HD…
               What’s the Goal?
 To change behavior, of
      course…but how?
     All AD/HD-related
behavior change focuses
    on strengthening the
         capacity of the
 frontal lobes. This can
  be done chemically or
           behaviorally.
  Mainstream Treatments
When AD/HD is moderate to severe, the
   typical, mainstream, multimodal treatment plan
   is likely to include medication.
The typical multi-modal treatment approach
   consists of four core interventions:
1. Patient, parent, and teacher education about the
   condition
2. Medication (usually from the class of drugs called
   stimulants) or nutritional support
3. Behavioral therapy
4. Environmental supports, including an appropriate
   classroom accommodations.
Actual Mainstream Treatments Used

Medications
Medications
Medications

Some behavioral therapy is used, but many medical
  staff are untrained in a wide range of behavioral
  strategies (and follow through is problematic)
The Use of Stimulants

Effectiveness ranges from 75-95%. Why not 100%
  effectiveness?
 wrong medication
 dosage issues
 compliance issues
 improper diagnosis
 comorbidity
 contraindications
   Trial and Error
Because no single AD/HD drug always
  works for every child, doctors depend
  on parents' and teachers' input in
  prescribing medicine for AD/HD.
Often more than one drug must be tried
  before a child's behavior
  improves, and side effects always
  need to be evaluated.
Medicines are also available in longer
  acting forms, which may allow the
  child to go through a school day
  without a lunch time dose of medicine
  from the school nurse.
                        Before and After Treatment:
                           A Tale of Two Brains
     Using SPECT scans, we are
     seeing the underside of two
     brains (the top two are the
     same brain and the bottom
     two are the same brain). The
     scan on the left was taken
     before an intervention and
     the one on the bottom was
     taken a year later after meds
     and behavioral therapy. The
     dark ―holes‖ are areas of
     metabolic underactivity, not
     actual missing chunks of
     matter.
images courtesy of Daniel Amen
Most-Prescribed Stimulants
   Ritalin® -one dose lasts up to 4 hours
   Metadate® – Ritalin – once a day lasts up to 12 hrs
   Focalin® –Ritalin derivative lasts up to 4 hours
   Attenade®-Ritalin derivative-lasts 6 hours
   Straterra® –lasts for up to 12 hours
   Concerta®- once a day lasts up to 12 hours
   Dexedrine®-last 4 hours-spansule lasts 10 hours
   Adderall®- once or twice a day, lasts longer than
    Ritalin
            Most-Prescribed Stimulants

   NOTE: Many “new” AD/HD products are repackaged
   formulas
   originally used for another purpose many years
   ago.Morbidity Issues
 Safe track record for prescription
  oral stimulants
 Methylphenidate is non-lethal
  when taken orally, yet…
 When taken intravenously, effects are similar to cocaine
 Methamphetamine is a class I narcotic
  (as is morphine, opium and cocaine)
Stimulants and Substance Abuse

 A meta-analytic review of the literature shows
  there was an almost twofold decrease in the
  likelihood of substance abuse disorders for
  youths treated previously with stimulant
  medication.
   (Wilens, et al. 2003)
  Potential Stimulant Side Effect Risks (1
  of 2)
• Headache/jittery feeling
 Gastrointestinal upset
 Loss of appetite
  (anorexia)
 Emotional oversensitivity
 Irritability or tics
 Increased blood pressure
 Blood glucose changes
Potential Stimulant Side Effect Risks
(part 2 of 2) Lifestyle Effects

    Sleep difficulty and irritability
    Depression and anxiety
    Headaches
    Slowed growth rate
     (growth may be recovered after
     medication stopped)

Gogtay et al. (2002)
         Treatment Protocol

 Some children with AD/HD qualify for
  services within the public schools
 An Individualized Educational Program
  (IEP) may be developed for AD/HD
 Special education services under the
  Individuals with Disabilities Education
  Act (IDEA, 1997)
 National Rehabilitation Act, Section 504
Behavioral Modification Programs

Parental and teacher strategies typically using
  positive and negative reinforcements for
  specific behaviors.
     –Token reinforcement programs
     –Home-based contingencies
     –Use of rewards, privileges or
            restrictions
    Six Alternative Treatments
    When AD/HD is mild to
    moderate,
    these interventions may be highly
    effective without the use of
    medications.

   Nutritional Support
   Lifestyle
   Skill-Building
   Neurofeedback
   Environmental Changes
   Student Asset-Building
  Nutrition
 (part 1 of 2)

 Provide a balanced
  breakfast with extra protein
 Reduce/remove additives and dyes
  (these are common causes of the
  some AD/HD symptoms)
  Boris and Mandel (1994)

 Reduce sugars, cut high-fructose
  corn syrup--it’s in 1000’s of foods
 Remove allergens from the diet
Dopamine is a Brain Upper
and You Can Influence it!
              Dopamine is metabolized in
               the brain from the amino
               acid tryptophan (found in
               proteins).
              Classroom activators are
               winning, smiles, celebration,
               anticipation of rewards and
               repetitive gross motor
               activities.
              Energizers also release
               adrenaline, too
   Nutraceuticals
Some product types may lend
  nutritional support:
Attend® - a natural product which
  combines amino acids, and
  hormone precursors to specific
  neurotransmitters.
Tyrosine - Amino acid supplement which
  may increase alertness and focus
Other natural products such as cocoa, tea and lean
  proteins.

      NOTE: This is not an endorsement of these products
Lifestyle Changes
(1 of 2)
 Limit television and video games
 Avoid labeling and put-downs
 Encourage student to join positive
  affinity groups, clubs, teams
 Provide a variety of stimulating
  learning activities
 Reduce unnecessary academic stress
Accommodations
Specific Strategies (1 of 10)

Dealing with short-term memory issues:
 Some instructions may need to be repeated
 Break tasks into small units
 Set make able deadlines for each task
 Make lists of what you need to do
 Pre-plan the best order for doing each task
 Make a schedule for doing tasks
                    Accommodations
         Specific Strategies (2 of 10)

• Establish your routines and stick to them.
• Create high predictability through daily and
    weekly events that always happen on cue.
• Start the same way, transition the same way
    and end the same way.
• Add variation only when it’s
    acknowledged as a change.
Accommodations
Specific Strategies (3 of 10)
For organizational challenges…
 Use a calendar/planner to keep on track
 Write down things you need to remember
 Write different kinds of information in different sections
 Keep the book with you all of the time
 Post notes to yourself - tape notes on mirrors,
  refrigerator, locker
 Store similar things together/Create a routine,
  use small travel clocks
Accommodations
Specific Strategies (4 of 10)
Manage the movement!
• Include far more movement--let them stand instead
  of sit, walk instead of stand and perch instead of
  sit.
 Limit open space time, except as group activities -
  otherwise it may encourage opportunities for
  inappropriate impulsivity and movement.
 Set up a signal system so you can talk to the
  student while class is going on. There might be a
  signal that tell the student it’s time for him to go to
  the back of the room or take a walk.
Accommodations
Specific Strategies (5 of 10)
Sharpen your communication
 Externalize important information, making it easy
  for access and obvious (notes, signs, partners etc.)
 Provide clear instructions: keep oral instructions
  brief and repeat them as necessary; provide
  written instructions (and review them orally) for
  multi-step processes; break up tasks and
  homework into small steps.
  Accommodations
  Specific Strategies (6 of 10)
Manage the information flow. Show them how
  to cover up their work when they have a list.
 Provide helpful self-check criteria -- direct them
  to check their work before turning it in.
 Establish and use daily checklists for:
   homework, due dates and even
  textbooks/supplies needed
 Write out things, say them twice and let students
  write out the key words in the air for better
  attention and recall
Accommodations
Specific Strategies (7 of 10)

Increase feedback
 Focus on student successes -- build on positives,
  praise the success in every little thing.
 Acknowledge part-way progress
 Externalize sources of motivation…
  use class charts or a point system so any
  student earns points towards classroom privileges
 Use teams to improve peer feedback.
  Accommodations
  Specific Strategies (8 of 10)
Help them manage time.
 Break up the future into small,
  external chunks (calendar, post-its, etc.)
 Externalize time (use prompts,
  pointers, neighbor timekeepers, etc.)
 Don’t surprise them--give ample warnings
 Help control impulse: buddy system
   may help slow down blurting/impulsivity
Accommodations
Specific Strategies (9 of 10)
           Help manage the environment
            For some, earplugs, headsets or
             ―white noise‖ can help.
            Use a divider, a cabinet or some boxes
             to create an isolated ―student office.‖
            Keep the room a bit cooler for alertness
            Aim the student towards a less distracting
             or disruptive area or view
Accommodations
Specific Strategies (10 of 10)

 • Get the whole class involved.
 • Hold short class meetings on behavior topics
 that will help those with AD/HD (and others).
 • Do topics like ―behavior in transition‖ or
 ―respect‖ or noise levels.‖ Find out how
 students feel about it when others disrespect
 them, hit, name-call or butt in line.
 • Do only one at a time.
Parent Suggestions
Student Skill-Building (1 of 2)
 Develop their understanding of personal strengths
  and weaknesses
 Enroll your child in a martial arts program
 Promote puzzles, model-building and card games
  which require focus and concentration
 Videogames (without violence) can be helpful
 Help students learn to handle criticism more
  constructively
   Parent Suggestions
   Student Skill-Building (2 of 2)
 Teach yoga, relaxation or meditation
 Channel creative energy into the
  arts (music, drama, hands-on)
 Acknowledge and comment on
  appropriate behavior, and offer
  rewards that foster cooperation
  and social interaction
 Strongly consider neurofeedback
  training for their child.
Parent Suggestions
Environmental Changes (1 of 2)
 Give student a chance to customize his
  environment
 Change teachers or classes
 Provide consistent, immediate feedback
 Provide structured daily schedules
 Provide opportunities for movement
 Establish consistent rules, routines, and
  transitions
Parenting Suggestions Environmental
Changes (2 of 2)
               Use background music…
                it helps some to focus
               Remove any environmental
                risks (e.g. lead, asbestos)
               Study with a good friend
               Give prompts before key info
               Enroll in alternative school
               Provide positive role models
Classroom management
  • Seat the child in the back so he or she can
  stand and walk if needed.
   • Seat the child near a student role model
  and use egg timers for seatwork.
  • Use teams or study-buddies
  • Give sensory tools for using up energy
  such as squeezable items or chin-up bar.
  • Focus on the big things; avoid letting
  these students drive you crazy. Don’t
  take their behaviors personally.
             Building Student Assets (1 of 3)

           Overall Approach
 Put your efforts on internal empowerment
  rather than external control.
 Help support students in discovering their
  inner resources.
 Remember we all have differences. Focus
  on what the student can do and work to
  build on strengths.
Building Student Assets (2 of 3)

 Teach positive self-talk skills
 Help the child understand human differences
 Show them how they are different from and are
  similar to others
 Support strong self-esteem
 Use short-term contracts for behaviors
 Teach problem-solving
 Help students recognize non-verbal language and
  unwritten rules to enhance social and friendship
  skills
  Building Student Assets (3 of 3)

 Focus on the student’s interests and build passion
 Teach study skills and how to use
  clocks, calendars and Post-its
                               ®



 How to organize and to highlight information
 Teach your child to visualize and focus
 Use effective communication skills, social
  skills, peer tutoring, cooperative learning, etc.
          Nearly every
      accommodation
  you are being asked
               to make
is simply high quality
              teaching.
       It does not give
      AD/HD students
     any advantage; it
          simply levels
     the playing field.
   Adults with AD/HD

 The kids with AD/HD often have
   a parent with it, too.
 In parent conferences, keep them
  focused on task. They’ll have a
  tendency to jump around.
 Hold meetings early (if possible).
  Symptoms of AD/HD in adults are
  generally worse in the afternoon.
 Meet in a quiet place with few
  distractions, such as a conference
  room or classroom not in the teacher’s
  lounge or busy cafeteria.
Take Home Messages
 Maintain the confidentiality of students identified
  with this condition!
 AD/HD is not a disease nor is it a joke; do not
  blame the person nor trivialize the condition.
 Students with moderate to severe AD/HD are
  highly at risk for behavioral, emotional and
  academic failure.
 Those with AD/HD can and do succeed with
  proper diagnosis, intervention and support.
               ADHD Gold
 http://www.truveo.co
  m/Michael-Phelps-
  Struggled-With-
  ADHD-As-A-
  Child/id/3139888503
    Action Steps
 What have you learned?
  How might you think
  or behave differently?
    Where and when
    might you begin?
Suggested Resource
  A New View of AD/HD
         by Eric Jensen
   www.corwinpress.com
      www.amazon.com
Thank you!

				
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