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!