ADHD and the Processing Disorders               David D. Nowell, Ph.D.           Worcester, Massachusetts DavidNowellSemin...
ADHD and the Processing           DisordersAn overview of the day:  •Making sense of the disorders  •Skills and strategies...
ADHD and the Processing         Disorders•Making sense of the disorders
ADHD and the Processing           DisordersSensory Processing DisorderCentral Auditory Processing DisorderADHD and Executi...
Perspective of this workshop…..
Diagnostic Interview as “making         distinctions”
301.13, ruleout 296.89
“Top – down” dysfunction• ADHD• Executive dysfunction
“Bottom - up” dysfunction• Central auditory processing problems• Sensory processing problems
What’s the kid’s deal?
Avoiding the most common     diagnostic error
Sensory Processing Disorder
Jean Ayres
Sensory Integration Terminology    Sensory Processing             Sensory Detection            Sensory Modulation         ...
Who doesn’t love a wedding?
Is SPD a “syndrome”?
Is sensory modulationdisorder a unitaryconstruct?
Hard signs and soft signs
Developmental soft signs
Developmental considerations•   Auditory .•   Visual•   Tactile•   Proprioceptive•   Vestibular•   Motor
Sensory Processing/Integration     Disorder and DSM-V
Sensory Processing Disorder   Scientific Work Group
What’s the kid’s deal?
What’s the kid’s deal?
Regulatory-Sensory          Processing Disorders• Treatment  – “top down”  –“bottom up”
X
Regulatory-Sensory          Processing Disorders• Treatment  –“top down”  – “bottom up”
Regulatory-Sensory          Processing Disorders• Treatment  –“top down”  – “bottom up”
Role of the Mental Health Clinician in                    SPD•   Primarily “top down”•   Normalizing•   Patient and family...
Role of the Mental Health Clinician in                    SPD•   Compensatory strategies•   Self-esteem•   Planning for su...
Strengths and Weaknesses Checklist   (Sensory Processing Problems)           Appendix D
Central Auditory Processing Disorder
k /a / t
“cat”
Central Auditory Processing Disorder• Auditory discrimination (same/different)• Auditory closure (fill in missing bits)• A...
Central Auditory Processing Disorder• CAPD refers to a deficit observed in one or  more of the central auditory processes ...
Central Auditory Processing Disorder- Poor "communicator" (terse, telegraphic).- Memorizes poorly.- Hears better when watc...
Central Auditory Processing Disorder- Often needs remarks repeated.- Difficulty sounding out words.- Confuses similar-soun...
(C)APD• the research challenge of “supramodal  influences”
CAPD                  or             ADHD?• Asks for things to be repeated      • Inattention• Poor Listening skills      ...
CAPD                  or             ADHD?• Asks for things to be repeated      • Inattention• Poor Listening skills      ...
CAPD                  or             ADHD?• Asks for things to be repeated      • Inattention• Poor Listening skills      ...
CAPD                 or             ADHD?• Asks for things to be repeated     • Inattention• Poor Listening skills        ...
(C)APD• Treatment  – “top down”  – “bottom up”  X
Treatment for CAPD• Environmental modifications
Treatment for CAPD• Environmental modifications  –FM transmission  –Training the speaker to face the   listener, check for...
Treatment for CAPD• Environmental modifications  –Preferential seating  –Increased use of visual cues  –Untimed testing
Treatment for CAPD• Compensatory Strategies
Treatment for CAPD• Compensatory Strategies –Metalinguistic strategies include:  schema induction, context-derived  vocabu...
Treatment for CAPD• Compensatory Strategies –Metacognitive strategies include  self-instruction, cognitive problem  solvin...
What’s the kid’s deal?
Attention Deficit Hyperactivity           Disorder
Increase salience
Attention Deficit Hyperactivity                Disorder• History of the disorder  – Galen  – Fidgety Phil  – “abnormal def...
(85 – X) x 365
I’m gonna eat all                                                 the gum and                                             ...
Controversies• Is ADHD over-diagnosed?• Is ADHD a “real” condition?• Does ADHD occur on a spectrum?• Is ADHD a natural ada...
Source: Centers for Disease Control and Prevention. Prevalence of diagnosis and medication treatment forattention-deficit/...
Percent of Youth 4-17 ever diagnosed with Attention-Deficit/Hyperactivity Disorder:                        National Survey...
Controversies• Is ADHD over-diagnosed?• Is ADHD a “real” condition?• Does ADHD occur on a spectrum?• Is ADHD a natural ada...
“a hunter in a farmer’s world”              Thom HartmannHunter trait              Farmer trait• Constant monitoring     •...
Core symptoms• Inattention / distractibility
Core symptoms• Hyperactivity / impulsivity
….and the rest of the criteriaB.   Onset before age 7C.   Impairment in 2 or more settingsD.   Significant functional impa...
Functional impact              of core symptoms•   Arousal / alertness•   Mental effort•   Determination of saliency•   Fo...
Functional impact              of core symptoms•   Arousal / alertness•   Mental effort•   Determination of saliency•   Fo...
Functional impact              of core symptoms•   Arousal / alertness•   Mental effort•   Determination of saliency•   Fo...
Functional impact              of core symptoms•   Satisfaction control•   Previewing•   Inhibition•   Tempo control•   Se...
Functional impact              of core symptoms•   Satisfaction control•   Previewing .•   Inhibition•   Tempo control•   ...
Functional impact              of core symptoms•   Satisfaction control•   Previewing•   Inhibition•   Tempo control•   Se...
Functional impact              of core symptoms•   Satisfaction control•   Previewing•   Inhibition•   Tempo control•   Se...
Functional impact              of core symptoms•   Satisfaction control•   Previewing•   Inhibition•   Tempo control•   Se...
Subtypes of ADHD•   ADHD, predominantly inattentive type•   ADHD, predominantly hyperactive type•   ADHD, combined type•  ...
Subtypes of ADHD• ADHD, predominantly inattentive type• ADHD, predominantly hyperactive type• ADHD, combined type• ADHD, N...
Common comorbidities with ADHD•   Learning disorder•   Behavioral disorder•   Anxiety•   Depression•   Substance abuse•   ...
Common comorbidities with ADHD• Learning disorder• Behavioral disorder• Anxiety• Depression• Substance abuse• Sensory proc...
Common comorbidities with ADHD•   Learning disorder•   Behavioral disorder•   Anxiety•   Depression•   Substance abuse•   ...
NIH Consensus Statement
Executive Functioning:         An Overarching Theme• Sensory Processing Disorder• Central Auditory Processing Disorder• AD...
Introduction to Neuroanatomy…..destination: frontal lobe !
Introduction to NeuroanatomyInter-connectedness of systems• Cortico-striatal system, for example
© 2011 David D. Nowell, Ph.D. All rights5/3/2012                                              117                         ...
The Executive FunctionsX
The Executive Functions•   Initiation•   Planning•   Set-shifting•   Self-regulation•   Inhibition of response•   Directin...
The Executive Functions•   Initiation•   Planning•   Set-shifting•   Self-regulation•   Inhibition of response•   Directin...
The Executive Functions•   Initiation•   Planning•   Set-shifting•   Self-regulation•   Inhibition of response•   Directin...
The Executive Functions•   Initiation•   Planning•   Set-shifting•   Self-regulation•   Inhibition of response•   Directin...
The Executive Functions•   Sustaining alertness and effort•   Internalizing speech•   Prioritizing•   Sequential thinking•...
The Executive Functions•   Sustaining alertness and effort•   Internalizing speech•   Prioritizing•   Sequential thinking•...
The Executive Functions•   Sustaining alertness and effort•   Internalizing speech•   Prioritizing•   Sequential thinking•...
The Executive Functions•   Sustaining alertness and effort•   Internalizing speech•   Prioritizing•   Sequential thinking•...
The Executive Functions•   Sustaining alertness and effort•   Internalizing speech•   Prioritizing•   Sequential thinking•...
The Executive Functions•   Fine motor control•   Delay of gratification•   Blocking out distractions•   Weighing consequen...
The Executive Functions• Bridging the now with the past• Bridging the now with the future
Neuropsychological Model of         Executive Dysfunction• Guides your evaluation• Guides your treatment plan• Facilitates...
Literature review
Literature review• Genetic evidence
Literature review• Genetic evidence• Neuroanatomical evidence
Literature review• Genetic evidence• Neuroanatomical evidence• Neuropsychological evidence
Literature review•   Genetic evidence•   Neuroanatomical evidence•   Neuropsychological evidence•   Neurochemical evidence
Interpreting the Problem Checklist           Appendices B and C• Items 1-8: inattention/distractibility• Items 9-13 and 24...
Comprehensive Treatment
Treatments With Limited Evidence          (AAP, 2001; Pelham & Fabiano, 2008)(1) Traditional one-to-one therapy or counsel...
Evidence-Based  Treatments for Children… (Chorpita et al, 2011)•Self – talk•Behavioral supports + medication•Parent traini...
Evidence-Based Short-term       Treatments for ADHD(1) Behavior modification-175 studies(2) CNS stimulant medication>300 s...
Pharmacotherapy• Drugs approved for ADHD   – Stimulants      •   Methylphenidate (e.g., Ritalin)      •   Dexmethylphenida...
Pharmacotherapy, continued• Under review for ADHD indication   – Modafinil (Provigil)--stimulant• Drugs used off label for...
Stimulants• Used for decades• Available in extended release formulations• Adverse effects: abuse/dependence (Schedule C-  ...
Main Beneficial Short-term Effects•   1. Decrease in classroom disruption•   2. Improvement in teacher ratings of behavior...
APA Task Force on Medication and  Psychosocial Treatments in Children           and Adolescents• Behavioral Parent Trainin...
Making the diagnosis
Making the diagnosis• Get the chief complaint
Making the diagnosis• Mental status examination
ABC STAMPLICKERX
Making the diagnosis• Interview with parent / significant other
Making the diagnosis• Checklists  – Parents  – Teachers  – Others
Making the diagnosis• Looking for convergent data
O.T. Evaluation of SensoryIntegrationClinical Observations Sensory History Checklists andInterviews Assessments of Sensory...
Evaluation of CAPDAudiologistSpeech therapist
Avoiding the most common     diagnostic error
Disorder• ADHD• OCD• Motor tic disorder• Sensory processing disorder
Other options  V71.09Provisional Rule out
ADHD “look-alikes”•   Low IQ•   High IQ•   LD•   Vision/ hearing problems•   Mood disorders•   Substance abuse•   PTSD
ADHD “look-alikes”•   Sleep disorders•   Seizure disorders•   Acquired brain injury•   FAS•   Autistic-spectrum disorders•...
ADHD and the Processing         Disorders•Skills and strategies for children
The First Thing You Need to Change X
A   B   C
A      B       C    behavior
A      B         C    antecedent
A   B      CconsequencesX
A      B         C    antecedent
A   •Rules    •Expectations    •Communications
RulesA   •Waking up    •Bedtime    •Chores    •Homework    •TV / internet
ExpectationsA   •Specific    •Behavioral    •In advance
CommunicationA   •Get eye contact    •Speak clearly    •Provide behavioral info    •Check for understanding
Functional impact              of core symptoms•   Arousal / alertness•   Mental effort•   Determination of saliency•   Fo...
Functional impact              of core symptoms•   Arousal / alertness•   Mental effort•   Determination of saliency•   Fo...
Functional impact              of core symptoms•   Arousal / alertness•   Mental effort•   Determination of saliency•   Fo...
Methylphenidate Enhances theSaliency of a Mathematical Task byIncreasing Dopamine in the HumanBrainVolkow, et al. 2004
Methylphenidate Enhances theSaliency of a Mathematical Taskby Increasing Dopamine in theHuman BrainVolkow, et al. 2004
Increase salience
You lovemath….you love math.
Functional impact              of core symptoms•   Arousal / alertness•   Mental effort•   Determination of saliency•   Fo...
Functional impact              of core symptoms•   Satisfaction control•   Previewing•   Inhibition•   Tempo control•   Se...
Functional impact              of core symptoms•   Satisfaction control•   Previewing•   Inhibition•   Tempo control•   Se...
Functional impact              of core symptoms•   Satisfaction control•   Previewing•   Inhibition•   Tempo control•   Se...
Functional impact              of core symptoms•   Satisfaction control•   Previewing•   Inhibition•   Tempo control•   Se...
Functional impact              of core symptoms•   Satisfaction control•   Previewing•   Inhibition•   Tempo control•   Se...
Functional impact              of core symptoms•   Satisfaction control•   Previewing•   Inhibition•   Tempo control•   Se...
Strategic behavioral inquiry
A                       B                             C    ANTECEDENTS                BEHAVIOR                      CONSEQ...
Beginning            Middle                            End            © 2011 David D. Nowell, Ph.D. All rights5/3/2012    ...
© 2011 David D. Nowell, Ph.D. All rights5/3/2012                                              209                         ...
© 2011 David D. Nowell, Ph.D. All rights5/3/2012                                              210                         ...
© 2011 David D. Nowell, Ph.D. All rights5/3/2012                                              211                         ...
© 2011 David D. Nowell, Ph.D. All rights5/3/2012                                              212                         ...
Mood dysregulation in BAD and    executive disorders
ADHD is not    FRED-PG13X
ADHD and girls
ADHD and women
Recommendations for Teachers with   Concerns about Attention or      Processing Problems
Recommendations for Teachers …• Distinguish between medical evaluation and  educational evaluation• Document with objectiv...
Recommendations for Teachers …• Avoid diagnostic terms in conversation with  parents• Leave medication decision to familie...
Accommodationsand Modifications
IDEA and Section 504
Metacognitive Strategies• Metacognitive knowledge• Metacognitive strategiesX
A      B       C    behavior
Self-Talk Proficiency for KidsX
Self-Talk Proficiency• -“How are you going to know when to be  ready?”• -“How are you going to stop yourself from…?”• -“Wh...
Asking two questions…–Am I having fun now?–And is this what I set out to do?
Asking two questions…           1. “Am I having           fun now?”                      © 2011 David D. Nowell, Ph.D. All...
Asking two questions…                                          2. “And is this what                                       ...
Am I having fun now?Is this what I set out to do?                     Yes                                 No              ...
easy   hard
Distraction Delay Training
X
Executive Estimates TrainingX
Goal Management Training
1. Stop      What am I doing?                2. Define     The main task                 3. List      The steps           ...
SQ3R•   Survey•   Question•   Read•   Recite•   review
Dealing with difficult behavior
The Three Baskets
A   B   C
R   P
+-
R+   P+R-   P-
Time Out•   Select target behavior•   Set place•   Determine how much time•   Dress rehearsal•   Measure the time•   Withd...
Token economy•   Good balance•   Precursor to adult reinforcement system•   Lots of work to do well•   Even more work to s...
Homework problems•   Fails to write down assignments•   Forgets the assignment book•   Forgets necessary materials•   Take...
Make Real-Life More Like Video Games•   Clear expectations•   Behavioral specificity•   Build on small changes in behavior...
Make Real-Life More Like Video Games•   Always follow up on rules, no exceptions•   Consequences are immediate•   Punishme...
Error-free Learning
The “Big Five”•   Daily focus time•   Clarity regarding reinforcers•   Nutrition•   Movement•   ConnectionX
ADHD and the Processing         Disorders•Skills and strategies for adults
Is Adult ADHD a separate disorder?
DSM Criteria and Developmental             Issues
Executive Disorders and Insight
The ADHD Couple
The ADHD Couple•   Need for stimulation•   Poorer impulse control•   Inattention to detail•   Fantasy projection
The ADHD Couple•   Remembering what drew you to your partner•   Realistic expectations•   Managing blame•   Getting to “fa...
Positive characteristics of many peoplewith attentional / executive challenges             Appendix E
The ADHD Couple• Improving Dyadic Communication Skills
Executive Disorders and the Workplace
Executive Disorders and the Workplace•   Realistic expectations•   Efficiency•   Delegating•   Getting clear regarding “di...
Activity Scheduling
Chunking
The “Big Five”• Daily focus time•   Values/motivational clarity•   Nutrition•   Movement•   Connection
…the most                           important 10                           minutes of the                           day…. ...
The “Big Five”• Daily focus time• Values/motivational clarity• Nutrition• Movement• Connection
Values and Goal Clarification for the         Distracted Patient
PREFERRED  STATES    INVENTORY    David D. Nowell, Ph.D.      189 May Street   Worcester, Mass. 01602        DrNowell.com
Your #1 Organizational Tool
Learn FrenchBe a better spouseStop smoking
The “Big Five”• Daily focus time• Values/motivational clarity• Nutrition• Movement• Connection
The Sensory Defensive Adult
Adults with Auditory Processing           Challenge
A challenge….
ADHD and the Processing Disorders               David D. Nowell, Ph.D.           Worcester, Massachusetts DavidNowellSemin...
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PESI/CMI presentation "Very Best Treatment for ADHD and the Processing Disorders"

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  • Scott peck: diagnostician. DI vs. intake, etc.NLP: distinctions.
  • Round pegsRespectful but not slavish.Hx:Make dx reliable across providersGuide researchMoving b/t static dsm categories and dynamic human beings.
  • Dx approach
  • 8:20
  • Owen 7 yo boy… refuses to step up onto school bus. School psych: iqwnl, checklists ll ADHD.Neuropsych doesn’t find striking neurocognitive profile of attn/exec dysfx.CD intern finds pt inattentive (puts head on desk). In team mtg, when pressed on issue, it turns out that Owen actually performs as well on stand. Testing with head down or with enforced posture.OT suggests that his constant movement is in effort to counteract his floppy muscle tone; like a bicycle, the best way to stay upright is to keep in motion.
  • Tobias, 58y.o man with his son, 20 y.o. college student (psych). Son ? Adhd.Pt accountant, spvr of dept. 18 month h/o c/o re: inattention, poor focus after a reorg at work. Dx w dm um same t. Pt not compliant w b.s. checks or diet. St most helpful thing we can do is withhold a dx.
  • Good news ands bad news: it’s 2009.
  • proprioceptive
  • CNS Development: Sensory input contributes toDevelopmentSensory input is necessary for brainFunctionActive engagement in sensory experienceproduces an adaptive responseAdaptive responses to sensory inputs optimize function
  • We use our senses to interface with world around us, retreating from “too much” or “too tight” or “too loud” and seeking lights and sound and movement when we’re understimulated
  • Dining on raw fish stuffed with shells, families compete by walking on coals and juggling bottles of open wine; all the while air raid sirens are blaring. You don’t enjoy it. What’s your dx?
  • Broad. Tourette’s works because it doesn’t “try as hard.”
  • Neurological hard signs, soft signs, and developmental soft signs
  • The softest of them all!
  • Infants: R to loud noise, R to bells or whistles, R to lullabies, R to peek a boo, sound source locationDifferentating among people, R to lights and colors; eye contactManipulating toys, feeding, R to touch, investigating world with hands and mouthPlaying with toes, grasping objects, experimenting w diff. body positionsSitting up, lifting headSitting up, lifting head, kicking, truncal stability
  • A very high threshold of empirical data has been set for adding a new disorder to DSM-V in order to insure that only diagnostically valid disorders are added to the system. The types of data that would be required include 1) evidence that sensory processing disorder describes a condition that is not adequately covered by an existing DSM-IV disorder; 2) evidence supporting its diagnostic validity; 3) evidence supporting its clinical utility; and 4) evidence supporting that there is a low risk of false positive diagnoses that might result if sensory processing disorder were to be added.
  • The primary criterion for adding a new disorder to DSM-V is whether there is sufficient empirical evidence of its validity and clinical utility. In the case of Sensory Processing Disorder, three options for DSM-V were discussed: 1) adding it as a new disorder; 2) adding it as a subtype that would apply to disorders such as Autistic Disorder or Attention-Deficit/Hyperactivity Disorder; or 3) adding a dimensional definition to the DSM-V appendix for "criteria sets and axes needing further study" in order to stimulate additional research
  • Motor d/o: Decreased muscle tone􀂄 Delay in motor milestones􀂄 Delay in hand use and fine motor skills􀂄 Delay or poorly executed self-care skills – q activity has stepsOT model of proprioception and vestibular sense
  • Douglas. 6 yo w h/o school avoidance. Picky eater. Wears sunglasses outdoors. ? Of adhd. w/drawn, sullen after giving up on peewee football b/c the helmet was stinky.
  • Carlos, 5 yo boy. …. M c/o tantrums, stubborness. Bedtimes difficult. Pushes his sister. Per OT pt performs poorly on measures of sensory modulation, esp tactile. Suggests he is easily overwhelmed.You learn that mom suspects he is in cntrol of tantruming? he negotiates. Often ? Of Primary or Secondary gain.The less cntrl he seems to have over this behavior, the more concern we have re: sensory or some other overload.
  • 1st we need to consider construct validity b/f we “tx” a conditionIn small N studies Specific tx interventions have proven more effective than no tx, but no diff. from other alternative tx. Note problem of placebo.
  • adults routinely adjust for their sensory processing irregularitiesw by carefully making choices that allow them to honor their nervous systems w/o intruding on others. Swedish shoes, diesel, glare when fatigued, tight clothing, short shirtsleeves.Kids: less independent, poorer insight, poorer abstraction. OT can increase insight, normalize their sensory prefernces. Have their defensiveness in the presence of a supportive adult. K.o. like going off the high dive.
  • PUSHING ICE CUBE ON A TRAYFEELY GAME AROUND THE HOUSEHOT DOG IN A BLANKETTIC TAC TOE IN SHAVING CREAMBOPPING A BALLOON BUCKET BEANBAG CATCHER
  • CUTTING PLAY DOH WITH SCISSORS
  • 1st we need to consider construct validity b/f we “tx” a conditionIn small N studies Specific tx interventions have proven more effective than no tx, but no diff. from other alternative tx. Note problem of placebo.
  • MEMORY W/ SMELLS TEXTURE MATCHINGWHAT’S IN THE SOCKHAND ON TOP
  • 9:40 a.m.
  • A Central Auditory Processing Disorder (CAPD) exists when achild has apparent difficulty in processing auditory informationwhile possessing normal hearinglittle consensuson a definition, criteria for assessment and diagnosis, andthe efficacy of remediation and management.
  • A Central Auditory Processing Disorder (CAPD) exists when achild has apparent difficulty in processing auditory informationwhile possessing normal hearinglittle consensuson a definition, criteria for assessment and diagnosis, andthe efficacy of remediation and management.
  • What teacher might notice
  • Dr. Anthony Cacace, and his colleagues (2005) define central auditory processing disorder (CAPD) as a "modality-specific perceptual dysfunction that is not due to peripheral hearing loss" and that "should be distinguishable from cognitive, language-based, and/or supramodal attentional problems"
  • we might best serve the student by identifying the following:
  • we might best serve the student by identifying the following:
  • PING PONG BALL / COFFEE CANBEANS, BUTTONS IN TOOTHPASTE BOXESIPHONE VOICE RECORDER APP, VARIOUS HOUSEHOLD SOUNDSPRETENDING TO BE A RADIO WITH VOLUME KNOB WHAT’S MISSING? (TWINKLE TWINKLE…) WHAT COMES BEFORE “I BELIEVE IN YESTERDAY”HOW DOES IT END? (FAMILIAR STORY)MR POTATO HEAD W/ METAPHORS: IN ONE EAR AND OUT THE OTHER. EYES BIGGER THAN STOMACH. I’M ALL EARS. YOU TOOK THE WORDS RIGHT OUT OF MY MOUTH. YOU’RE PULLING MY LEG.
  • Guy berard – aitAlfred tomatis – tomatis auditory training
  • Environmental modifications􀂫 Reduce ambient noise CARPET RUBBER TIPS ON CHAIRS CLOTH AND MAT POSTER BOARDS􀂙preferential seating AWAY FROM SOURCES OF NOISE FANS CORRIDOORS OUTSIDE TRAFFIC􀂫 Frequent checks for comprehension
  • Environmental modifications􀂫 Reduce ambient noise CARPET RUBBER TIPS ON CHAIRS CLOTH AND MAT POSTER BOARDS􀂙preferential seating AWAY FROM SOURCES OF NOISE FANS CORRIDOORS OUTSIDE TRAFFIC􀂫 Frequent checks for comprehension
  • Environmental modifications􀂫 Reduce ambient noise CARPET RUBBER TIPS ON CHAIRS CLOTH AND MAT POSTER BOARDS􀂙preferential seating AWAY FROM SOURCES OF NOISE FANS CORRIDOORS OUTSIDE TRAFFIC􀂫 Frequent checks for comprehension
  • 􀂴 ACTIVE LISTENING􀂴 CHECKS FOR COMPREHENSION􀂴 MULITISENSORY INSTRUCTION􀂴 MNEMONIC DEVICES TO ASSIST MEMORY
  • 􀂴 ACTIVE LISTENING􀂴 CHECKS FOR COMPREHENSION􀂴 MULITISENSORY INSTRUCTION􀂴 MNEMONIC DEVICES TO ASSIST MEMORY
  • 􀂴 ACTIVE LISTENING􀂴 CHECKS FOR COMPREHENSION􀂴 MULITISENSORY INSTRUCTION􀂴 MNEMONIC DEVICES TO ASSIST MEMORY
  • Dx approach
  • Jennifer, 4 yo. Limited language. Expressive better than receptive. Makes prefernces known. Intense eye contact but ? Understanding. Plays well with cousins and sister, less well with others at daycare seting with some older children.
  • EXPLAIN WKSHOP’S PURPOSE, INCREASE SALIENCE, RELATE TO PRIOR K’LEDGE
  • By 1970, 2000 papers on the topic. Focus moves to attentionGrps of 3: definition of adhd for layperson
  • St’s going to happen today at 5:00You’ll never get that time back
  • 85-x*36540 yo = 16425 28 yo = 20805 52 yo = 12045“gonna eat all the gum and candy I want”It is a most mortifying reflection for a man to consider what he has done, compared to what he might have done.  ~Samuel Johnson, in Boswell's Life of Johnson, 1770
  • Attn is a precious commodity. Things and ppl will compete for itBest defense vs the manipulation of one’s attn is to determine for oneself how one wants to invest itSt’s going to happen today at 5:00
  • The full existential horror of being an adult
  • 10:30
  • Distracted by whatever’s eye-catching in the moment? Or engaging in specifric and familiar activites whose fx it is to maintain sensory homeostasis?
  • Has trouble getting started w workWorks only on thihngs that are partic. Interesting to him/herEffort is unpredictableTx: use hi-interest topics, Premack principle, cueing, R cost (tokens)
  • Cant tell important from unimp.Recalls irrelevant detail rather than pertinentDistracted by irrelevant background noisesConcentrates on visual stimlui that others would ignoreTx: vary potency of stimli; highlighting certain words/phrases; explicit training in id’ing “what’s most important” (picture completion subtest)
  • Cassidy is working on master’s thesis. When she sits down 2 do ork, felt need to clean apt. Didn’t esp. like cleaning the apt but felt the urge whenever she needed to write. She actually fet she could not work unless e.t. in her apt was cleaned and in order.
  • Not a good listenerNot in volitional control of the process of focus: can overfocus, can fail to concentrate long enoughMisses key parts of directions / explanationsTx: keep verbalizations short and simple; check for understanding; use bookmarks that facilitate focus
  • Hard to satisfy, wants things all the time; needyRestless, craves excitementConcentrates well only on exciting stimuliPoor delayed gratificationTx: provide stimulating learning situations; do not r+ inappropriate or off-task behav.
  • Fails to look ahead and predict consequences, Task approach is seemingly w/o plan, w/o regard to time needed, w/o regard to resources needed. Difficulty w transitions, Difficulty foreseeing solutionsTx: train in self-talk and problem solving. R+ instances of behav,. Inhibition and planning ahead (e,.g. raising hand, packing umbrella); modeling. EG: tom, 8th grader, procrastination. TS . worked with mom, who coordinated w/ school 2 b notified of any longer term projects. LONG TERM PROJECT PLANNING SHEET. Eg report on dangerous sea animal. Brainstorm, choose, id materials needed, subgoals, assign dates, plan R+ for meeting goals.
  • Inappropriate behaviors, Does things the hard way, breaks things, Blurts inappropriate comments, prim. Proc.Tx: use DRO to increase soc. Appropriate behav.; be explicit; use + px (w many repetitions)EG: circle time a struggle for kristin, 2nd grader. Despite clear rules about turn taking, kristin wd blurt out while others were talking. Tchr introduced a talking stick. Then gave each child 2 chips (to ask ?s). If pt blurts, lose chip. FADE over time.
  • Does things slowly, or recklessly … barkley and time perceptionTrouble organizing time needs during taskDawdles, misses deadlinesLevel of activity seems inappropriate to actual urgency of taskTx: age approp. Time mgt tools; organizational charts, sub-goals, checklistst; px time estimates; beat the clock
  • Loses track during taskEasily derailed – responds to r+ in the moment rather than using mental representation of future r+ or p+Careless mistakesTx: give ongoing supportive feedback; encourage post-mortem reviews of behav; nag tapes
  • Ocd? Luvox? Cbt for ocd?
  • Attention deficit hyperactivity disorder or ADHD is a commonly diagnosed behavioral disorder of childhood that represents a costly major public health problem. Children with ADHD have pronounced impairments and can experience long-term adverse effects on academic performance, vocational success, and social-emotional development which have a profound impact on individuals, families, schools, and society. Despite progress in the assessment, diagnosis, and treatment of ADHD, this disorder and its treatment have remained controversial, especially the use of psychostimulants for both short- and long-term treatment.Although an independent diagnostic test for ADHD does not exist, there is evidence supporting the validity of the disorder. Further research is needed on the dimensional aspects of ADHD, as well as the comorbid (coexisting) conditions present in both childhood and adult forms.Studies (primarily short term, approximately 3 months), including randomized clinical trials, have established the efficacy of stimulants and psychosocial treatments for alleviating the symptoms of ADHD and associated aggressiveness and have indicated that stimulants are more effective than psychosocial therapies in treating these symptoms. Because of the lack of consistent improvement beyond the core symptoms and the paucity of long-term studies (beyond 14 months), there is a need for longer term studies with drugs and behavioral modalities and their combination. Although trials are under way, conclusive recommendations concerning treatment for the long term cannot be made presently.There are wide variations in the use of psychostimulants across communities and physicians, suggesting no consensus regarding which ADHD patients should be treated with psychostimulants. These problems point to the need for improved assessment, treatment, and followup of patients with ADHD. A more consistent set of diagnostic procedures and practice guidelines is of utmost importance. Furthermore, the lack of insurance coverage preventing the appropriate diagnosis and treatment of ADHD and the lack of integration with educational services are substantial barriers and represent considerable long-term costs for society.Finally, after years of clinical research and experience with ADHD, our knowledge about the cause or causes of ADHD remains largely speculative. Consequently, we have no documented strategies for the prevention of ADHD.
  • NeuroanatomyNeurotransmittersPhenomenology of dopamine and serotonin
  • Phineas gage
  • PLACE NAMES WHICH ARE ALSO PEOPLE’S NAMES:MADISONGEORGIACHARLOTTEINDIAPARISKENYAARIZONAADELAIDESYDNEYDALLASHOUSTONOLYMPIAJORDANBETHANY
  • PLACE NAMES WHICH ARE ALSO PEOPLE’S NAMES:MADISONGEORGIACHARLOTTEINDIAPARISKENYAARIZONAADELAIDESYDNEYDALLASHOUSTONOLYMPIAJORDANBETHANY
  • POLICE REPORT W/ ADVANCE WARNING
  • DECK OF CARDS20 QUESTIONS
  • I SPY…GEO CACHINGMAPS
  • If only I could be as org. as I am the day before vacation
  • Twins, siblings. Various genes impacting dopamine transmission. The broad selection of targets indicates that ADHD does not follow the traditional model of a "genetic disease" and should therefore be viewed as a complex interaction among genetic and environmental factors. Even though all these genes might play a role, to date no single gene has been shown to make a major contribution to ADHD
  • Wallman found diffs. In a dopamine transporter gene in adhd, combined type, not present with inattentive typeDecreased activity in orbital prefrontaldecreased glucose metab. In left prefrontalLack of asymmetry in b.g. (caudate and globuspallidus)
  • Wcst and other frontal/executive test performanceHyp: disturbance in frontal lobe fxs may be related to impulse cntrl and to the types of cog impairments common with adhd. Conclusion: inability to cntrl, direct, and sustain attn may be the core deficiency of adhd, and not impulsivity. barkley
  • Np testing , or imaging…..
  • Dopamine hypothesis first proposed 1977. Noradrenergic system also implicated
  • TOP DOWN BOTTOM UP
  • What questions do you have re: rx?
  • 11:50
  • Parent training at points of needSchool staff training in in-service model, then at points of need
  • Moving b/t static dsm categories and dynamic human beings.Think horses, not zebras. Where possible, offer a dsm dx. E.g. NVLD … cd it be aspergers? E.g. capd… cd it be adhd inattentive type?
  • Why now? Changes at school or home? Family issues? Demand specificity (and then … and then)Look for patterns (persons, situations, times of day)Look for constellations (syndromes)Name it as though you’d never heard of our dx categories. “cries for no reason, lost his appetite, thinks of suicide d/o.” she’s got “fixated on routine, doesn’t like to walk down stairs, gets carsick easily, doesn’t like tags in her clothing d/o.”
  • Go in with LOW threshold of suspicion: “show me.”Think horses not zebras.What domains are ppl c/o ?
  • Sensory History Checklists and Interviews􀂄 Sensory Profiles (Dunn et al, 1999, 2001) 􀂄 Short Sensory Profile (McIntosh, Miller,Shyu,. & Dunn, W. ,1999a). 􀂄 Evaluation of Sensory Processing (Parham, et al., 2003) 􀂄 Sensory Processing Interview and Inventory (Wilbarger, et al.)􀂄 Sensory Rating Scale for Infants & YoungChildren (Provost & Oetter, 1993)
  • AudiologySpeech tx – primarily functional receptive language
  • My mom cries a lot and has dropped her hobbies….mdd?My brother won’t touch doorknobs…ocd?My son cant stand turtlenecks or tags in shirts….spd?I can go from happy one minute to sad or angry the next..bad? Ied? Mdd?
  • Before we jump into tx planning, we want to be as clear as possible re: case conceptualization. i.e., dx yes, but more than that “what’s the kids deal,” including consideration of fx of behavior, home environment, and medical issues.
  • Think of a child/student/ct… the behavioral change which would make the biggest difference……I told you of a set of strategies that could bring about IMMEDIATE behavioral change…Antecedents – human behavior change and learning can be very hard. If environmental or antecedent changes can fix the problem, we start there.
  • 147”
  • Dawson p 81Setting him up for success – think about the “box” and its capacity. Don’t overload it.Change physical or soc. Environment – add bariers, <distractions, >org. structure, change social mixChange nature of tasks – reduce complexity (if > 3/10 on difficulty scale)Why do students shape up when tchr close by? >insight, activate rules, clearly they “can” – performance deficit vs skills deficit.
  • Which is the most important point of intervention?
  • Dawson p 81Setting him up for success – think about the “box” and its capacity. Don’t overload it.Change physical or soc. Environment – add bariers, <distractions, >org. structure, change social mixChange nature of tasks – reduce complexity (if > 3/10 on difficulty scale)Why do students shape up when tchr close by? >insight, activate rules, clearly they “can” – performance deficit vs skills deficit.
  • Child in La. In ny times article: mom, pedi, psych. “discipline”Changing antecedent can bring immediate results.
  • Get eye contactSpeak clearly – avoid metacommunicationsProvide behavioral infoCheck for understanding
  • Antecedent support for students and adults w/ processing disorders
  • Depression, Suicidal Ideation More Likely in Adolescents With Late vs Earlier Set Bedtimes Tx: sleep hygeine
  • Has trouble getting started w workWorks only on thihngs that are partic. Interesting to him/herEffort is unpredictableTx: use hi-interest topics, Premack principle, cueing, R cost (tokens)
  • Tx: vary potency of stimli; highlighting certain words/phrases; explicit training in id’ing “what’s most important” (picture completion subtest)
  • 122”
  • EXPLAIN WKSHOP’S PURPOSE, INCREASE SALIENCE, RELATE TO PRIOR K’LEDGE
  • STUDY BOX
  • FLASHLIGHT IN THE DARKNot a good listenerNot in volitional control of the process of focus: can overfocus, can fail to concentrate long enoughMisses key parts of directions / explanationsTx: keep verbalizations short and simple; check for understanding; use bookmarks that facilitate focus
  • 2:00
  • Hard to satisfy, wants things all the time; needyRestless, craves excitementConcentrates well only on exciting stimuliPoor delayed gratificationTx: provide stimulating learning situations; do not r+ inappropriate or off-task behav.
  • Fails to look ahead and predict consequences, Task approach is seemingly w/o plan, w/o regard to time needed, w/o regard to resources needed. Difficulty w transitions, Difficulty foreseeing solutionsTx: train in self-talk and problem solving. R+ instances of behav,. Inhibition and planning ahead (e,.g. raising hand, packing umbrella); modeling. EG: tom, 8th grader, procrastination. TS . worked with mom, who coordinated w/ school 2 b notified of any longer term projects. LONG TERM PROJECT PLANNING SHEET. Eg report on dangerous sea animal. Brainstorm, choose, id materials needed, subgoals, assign dates, plan R+ for meeting goals.
  • MUSICAL CHAIRS , RED LIGHT / GREEN LIGHTTx: use DRO to increase soc. Appropriate behav.; be explicit; use + px (w many repetitions)EG: circle time a struggle for kristin, 2nd grader. Despite clear rules about turn taking, kristin wd blurt out while others were talking. Tchr introduced a talking stick. Then gave each child 2 chips (to ask ?s). If pt blurts, lose chip. FADE over time.
  • Does things slowly, or recklessly … barkley and time perceptionTrouble organizing time needs during taskDawdles, misses deadlinesLevel of activity seems inappropriate to actual urgency of taskTx: age approp. Time mgt tools; organizational charts, sub-goals, checklistst; px time estimates; beat the clock
  • ALL THE THINGS YOU CAN THINK OF THAT…Tx: give ongoing supportive feedback; encourage post-mortem reviews of behav; nag tapes
  • ALL THE THINGS YOU CAN THINK OF THAT…Tx: give ongoing supportive feedback; encourage post-mortem reviews of behav; nag tapes
  • HOW DID YOU DO THAT? HOW DID YOU GET TO THE APPOINTMENT 30 MINUTES LATE?
  • 29 times a month he made curfew. That’s great executive fx !
  • You can also ask about the other 2 times. What was different when you didn’t make curfew? What did you think or see or say to yourself? What did you do that led to your showing up exactly when you did?
  • 1% of pop. BAD. BAD spectrum may be 4 – 6 %. With one BAD parent, risk is 15-30%, when both parents BAD, 50-75%. In retrospective I’views, 60% of BAD adults recall onset of sx before age 20. 40% even younger, from 13-18 yo. “narrow,” “intermediate” and “broad” BAD phenotypes. “soft BAD spectrum”
  • REGROUP TIMEPOST-MORTEMHOW DO YOU LOOK?BEGINNING, MIDDLE, ENDYARN ON SANDPAPER, TAKING TURNSANOTHER VIEWPOINT (ANTS, FLOWERS)
  • Stronger social support for being nice, developing emotional intelligence. Locker or desk mt be messy. Handwriting mt be messy. Mt be sensitive to visual stimuli and physical mvmt. Shy/wdrawn. If hyper, mt be hypertalkative and chatty.
  • More tasks, more diffuse
  • Who called the caterer? Designed and order tshirts? Considered potential hurt feelings re: invitation list. Set up the evite? Remembered that the reunion would coincide with 20th wedding reunion of one couple? Made sure the paper plates and cups match? Managed the household mood in the days leading up to the reunion?More tasksMore diffuseMore parental responsibilityLess likely to have an “executive” partnerLess likely to have assistants at workLess likely to focus on a narrow areaMore likely to feel shame about disorganization
  • Texts which are visually cluttered or demanding.
  • Individuals with disabilities educatino act of 1997Section 504 of the rehab act of 1973
  • BEGINNING, MIDDLE, ENDLIFELINEKIMOCHIS
  • 147”
  • WHAT QUESTIONS ARE MATURE EXECUTIVES ASKING THEMSELVES?What are non-impaired kids doing that this pt is NOT? - screening out at the bottom-up level - screening out at higher level
  • What are non-impaired kids doing that this pt is NOT?You can say: “If I keep doing this it islikely my teacher/friend will……”Ask to hear what the inner voice wassaying: “Tell me what you like bestabout that!”“Tell me what you were thinking whenyou came up with that idea!”“That must have been a challenge…whatdid you tell yourself to get past it?”• -“How are you going to know when to be ready?”• -“How are you going to stop yourself from…?”• -“What is your goal?”• -“What do you want it to look like?”• -“How long do you think it will take?”• -“How much did time did it take last time?”• -“How are you going decide where to set that up?”• -“How are you going to know what you need?”• -“How are you going to know what is most important?”• -“How are you going to decide what to do first?”• -“How will you know when you are done?”• -“How will you continue when you are tired?”• -“How did that work out?”• -“How long do you think that took?”• -“How did you manage/know how to do it?”• -“Would you do anything differently?”• -“Have you done anything like this before?”• -“Was that harder or easier than….”
  • What are non-impaired kids doing that this pt is NOT?You can say: “If I keep doing this it islikely my teacher/friend will……”Ask to hear what the inner voice wassaying: “Tell me what you like bestabout that!”“Tell me what you were thinking whenyou came up with that idea!”“That must have been a challenge…whatdid you tell yourself to get past it?”• -“How are you going to know when to be ready?”• -“How are you going to stop yourself from…?”• -“What is your goal?”• -“What do you want it to look like?”• -“How long do you think it will take?”• -“How much did time did it take last time?”• -“How are you going decide where to set that up?”• -“How are you going to know what you need?”• -“How are you going to know what is most important?”• -“How are you going to decide what to do first?”• -“How will you know when you are done?”• -“How will you continue when you are tired?”• -“How did that work out?”• -“How long do you think that took?”• -“How did you manage/know how to do it?”• -“Would you do anything differently?”• -“Have you done anything like this before?”• -“Was that harder or easier than….”
  • Make task shorter, build in breaks, use salient r+ for afterwards, make steps more explicit, make task more appealing (beat the clock, write steps down on slips of paper, in jar)
  • 2:20
  • BELLY COUNTSFIDGET TOYS
  • GUESS HOW OLD?
  • Token economy or response costChunking larger work into manageable units; beat the clock game; make post-homework time salientSet a clear when and whereMove towards independence; fade supervision“forgetting” homework is not a memory problem, but an organization problem
  • 242”
  • He should just do it!
  • Victoriah’s F re: u sh just do it, tense/frustrated
  • HAPPENINGS BOOK (SCRAPBOOK AND HOPEBOOK)EXPANDING INTERESTSHI AND LOW OF THE DAYWAITER TAKE MY ORDER
  • “this is your 1:00”
  • “this is your 1:00”
  • “this is your 1:00”
  • Train very structured dyadic communication
  • Realistic expecationsEfficiencyDelegatingOutsourcingGetting clear re: “disability”
  • Realistic expecationsEfficiencyDelegatingOutsourcingGetting clear re:“disability”
  • Top of page 31
  • MTBI – photo/phonophobia, headphones and sunglasses, Horseback riding (hippotherapy), trampoline, deep breathing exercises, raw carrots, have fidget objects on hand, relax with fish tank or lava light, experiment with lighting, notice reaction to smells (including “air fresheners”) in the home, massage, sauna, yoga/tai chi/martial arts, watch reaction to caffeine and etoh, vitamin b?, carefully guard sleep, plan vacations around sensory needs, be realistic re: what you can actually tolerate and manage.
  • Earphones, sensory diet, planning around variable noise, preferential seating, note-taker in college courses.1. Have trouble hearing clearly when it's noisy? This can be a failure of one or more of the automatic noise-suppression systems of the brain. It is reasonable to ask for a desk away from the computers or for a sound-absorbent partition. It is both polite and efficient to say, "I'm interested in what you're saying. Let's move away from this noise." A mild-gain amplifier can help you hear accurately on the phone over the noise of a busy office.2. Sometimes make "silly" mistakes or "careless" errors? Intrusions of random sounds which normal-hearing people can ignore may break your concentration so that you lose your place and skip a task (like carrying a number or writing a small word in the sentence). Take the work to a quieter place if necessary. Earplugs (sometimes in only one ear which suppresses noise less well) are a possible emergency solution. Make a deal with someone else to proofread your work.3. Miss important sounds or signals that others hear easily? Poor noise suppression and sound localization skills can cause important voices or signals to "disappear" in the general background. It will save others time if they know to tap you on the shoulder before they launch into their conversation. Telephone bells and alarms can be adjusted for volume or pitch, or a visual or tactile signal can be added.4. Get important messages wrong? Sound distortion, sequencing, auditory-visual transfer, and/or short term memory problems may be contributors. You can ask for the information in writing, double-check later with someone else who was present, or let the speaker know that she's going too fast. Even normal listeners often say, "Let me read that back -- ," or "That's '3489'?"5. Forget instructions? Inefficient short term auditory and rote memory (or habituation) may figure in this. Get in the habit of taking notes; set up a logbook for longer-term assignments; ask that the information be put in a memo. You might even carry a small tape recorder or dictaphone in some situations. If you often forget to go back to it later, put the memo or recorder where you must see it, as by your purse or underneath something you use every day.6. Only get parts of more complex directions or lengthy explanations? Here you may begin to suspect a problem with the subtleties of language - difficulty forming rapid "word pictures" to help with concept formation and memory, or failure to consider alternative word definitions so that meaning is mis-perceived. You can "freeze" it for later analysis by writing or taping. You can say "I learn better if I do it myself while you watch." Have someone else help you fill in details later.7. Have difficulty knowing "what to say when" and are puzzled by others' reactions to you? One possibility is an inefficiency in the part of the brain which registers tonality (expression in the voice) and gives us "quick fix" on the situation (sometimes referred to with rough accuracy as a "right hemisphere disorder"). A professional can help you learn other cues by which to "read" how people are feeling about what you said and how to change what you say accordingly, much as anyone would have to learn about a foreign culture. In the meantime you might explain the problem to people you trust so their feelings aren't hurt.
  • Adhd nowell

    1. 1. ADHD and the Processing Disorders David D. Nowell, Ph.D. Worcester, Massachusetts DavidNowellSeminars DavidNowell www.DrNowell.com
    2. 2. ADHD and the Processing DisordersAn overview of the day: •Making sense of the disorders •Skills and strategies for children •Skills and strategies for adults •Tools you can use now
    3. 3. ADHD and the Processing Disorders•Making sense of the disorders
    4. 4. ADHD and the Processing DisordersSensory Processing DisorderCentral Auditory Processing DisorderADHD and Executive Dysfunction
    5. 5. Perspective of this workshop…..
    6. 6. Diagnostic Interview as “making distinctions”
    7. 7. 301.13, ruleout 296.89
    8. 8. “Top – down” dysfunction• ADHD• Executive dysfunction
    9. 9. “Bottom - up” dysfunction• Central auditory processing problems• Sensory processing problems
    10. 10. What’s the kid’s deal?
    11. 11. Avoiding the most common diagnostic error
    12. 12. Sensory Processing Disorder
    13. 13. Jean Ayres
    14. 14. Sensory Integration Terminology Sensory Processing Sensory Detection Sensory Modulation Sensory Discrimination Sensory Integration
    15. 15. Who doesn’t love a wedding?
    16. 16. Is SPD a “syndrome”?
    17. 17. Is sensory modulationdisorder a unitaryconstruct?
    18. 18. Hard signs and soft signs
    19. 19. Developmental soft signs
    20. 20. Developmental considerations• Auditory .• Visual• Tactile• Proprioceptive• Vestibular• Motor
    21. 21. Sensory Processing/Integration Disorder and DSM-V
    22. 22. Sensory Processing Disorder Scientific Work Group
    23. 23. What’s the kid’s deal?
    24. 24. What’s the kid’s deal?
    25. 25. Regulatory-Sensory Processing Disorders• Treatment – “top down” –“bottom up”
    26. 26. X
    27. 27. Regulatory-Sensory Processing Disorders• Treatment –“top down” – “bottom up”
    28. 28. Regulatory-Sensory Processing Disorders• Treatment –“top down” – “bottom up”
    29. 29. Role of the Mental Health Clinician in SPD• Primarily “top down”• Normalizing• Patient and family education• Environmental interventions
    30. 30. Role of the Mental Health Clinician in SPD• Compensatory strategies• Self-esteem• Planning for success experiences• Treating comorbidities
    31. 31. Strengths and Weaknesses Checklist (Sensory Processing Problems) Appendix D
    32. 32. Central Auditory Processing Disorder
    33. 33. k /a / t
    34. 34. “cat”
    35. 35. Central Auditory Processing Disorder• Auditory discrimination (same/different)• Auditory closure (fill in missing bits)• Auditory localisation (locate source of sound)• Auditory performance with degraded acousticsignal• Auditory figure-ground (perceiving sounds inbackground noise)
    36. 36. Central Auditory Processing Disorder• CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors: – sound localization and lateralization – auditory discrimination – auditory pattern recognition
    37. 37. Central Auditory Processing Disorder- Poor "communicator" (terse, telegraphic).- Memorizes poorly.- Hears better when watching the speaker.- Problems with rapid speech.- Interprets words too literally.
    38. 38. Central Auditory Processing Disorder- Often needs remarks repeated.- Difficulty sounding out words.- Confuses similar-sounding words.- Difficulty following directions in a series.- Speech developed late or unclearly.
    39. 39. (C)APD• the research challenge of “supramodal influences”
    40. 40. CAPD or ADHD?• Asks for things to be repeated • Inattention• Poor Listening skills • Academic Difficulties• Difficulty following oral • Daydreams instructions• Difficulty discriminating speech • Distracted• Difficulty hearing with • Poor Listening Skills background noise• Difficulty maintaining auditory • Disorganized attention in quiet• Academic difficulties • Asks for things to be repeated• Slow to process information • Auditory divided attention deficit
    41. 41. CAPD or ADHD?• Asks for things to be repeated • Inattention• Poor Listening skills • Academic Difficulties• Difficulty following oral • Daydreams instructions• Difficulty discriminating speech • Distracted• Difficulty hearing with • Poor Listening Skills background noise• Difficulty maintaining auditory • Disorganized attention in quiet• Academic difficulties • Asks for things to be repeated• Slow to process information • Auditory divided attention deficit
    42. 42. CAPD or ADHD?• Asks for things to be repeated • Inattention• Poor Listening skills • Academic Difficulties• Difficulty following oral • Daydreams instructions• Difficulty discriminating speech • Distracted• Difficulty hearing with • Poor Listening Skills background noise• Difficulty maintaining auditory • Disorganized attention in quiet• Academic difficulties • Asks for things to be repeated• Slow to process information • Auditory divided attention deficit
    43. 43. CAPD or ADHD?• Asks for things to be repeated • Inattention• Poor Listening skills • Academic Difficulties• Difficulty following oral • Daydreams instructions• Difficulty discriminating speech • Distracted• Difficulty hearing with • Poor Listening Skills background noise• Difficulty maintaining auditory • Disorganized attention in quiet• Academic difficulties • Asks for things to be repeated• Slow to process information • Auditory divided attention deficit
    44. 44. (C)APD• Treatment – “top down” – “bottom up” X
    45. 45. Treatment for CAPD• Environmental modifications
    46. 46. Treatment for CAPD• Environmental modifications –FM transmission –Training the speaker to face the listener, check for understanding, use prosody
    47. 47. Treatment for CAPD• Environmental modifications –Preferential seating –Increased use of visual cues –Untimed testing
    48. 48. Treatment for CAPD• Compensatory Strategies
    49. 49. Treatment for CAPD• Compensatory Strategies –Metalinguistic strategies include: schema induction, context-derived vocabulary building, phonological awareness, and semantic network expansion
    50. 50. Treatment for CAPD• Compensatory Strategies –Metacognitive strategies include self-instruction, cognitive problem solving, and assertiveness training
    51. 51. What’s the kid’s deal?
    52. 52. Attention Deficit Hyperactivity Disorder
    53. 53. Increase salience
    54. 54. Attention Deficit Hyperactivity Disorder• History of the disorder – Galen – Fidgety Phil – “abnormal defects in moral control” – MBD – Benzedrine – Hyperkinetic-impulsive disorder – Hyperkinetic Reaction of Childhood – Attention Deficit
    55. 55. (85 – X) x 365
    56. 56. I’m gonna eat all the gum and candy I want! © 2011 David D. Nowell, Ph.D. All rights5/3/2012 84 reserved.
    57. 57. Controversies• Is ADHD over-diagnosed?• Is ADHD a “real” condition?• Does ADHD occur on a spectrum?• Is ADHD a natural adaptive trait?
    58. 58. Source: Centers for Disease Control and Prevention. Prevalence of diagnosis and medication treatment forattention-deficit/hyperactivity disorder – United States, 2003. MMWR 2005;54:[842-847]. 86
    59. 59. Percent of Youth 4-17 ever diagnosed with Attention-Deficit/Hyperactivity Disorder: National Survey of Children’s Health, 2003 > 10.1% 9.1 – 10.0% DC 8.1 - 9.0% 7.1 - 8.0% 6.1 - 7.0% < 6.0%Source: Centers for Disease Control and Prevention. Prevalence of diagnosis and medication treatment forattention-deficit/hyperactivity disorder – United States, 2003. MMWR 2005;54:[842-847]. 87
    60. 60. Controversies• Is ADHD over-diagnosed?• Is ADHD a “real” condition?• Does ADHD occur on a spectrum?• Is ADHD a natural adaptive trait?
    61. 61. “a hunter in a farmer’s world” Thom HartmannHunter trait Farmer trait• Constant monitoring • Not easily distracted• Can act on moment’s • Steady, dependable notice effort• Very active when “hot • Conscious of time; able on the trail” to pace self• Willing to take risks • Careful, “look before you leap”
    62. 62. Core symptoms• Inattention / distractibility
    63. 63. Core symptoms• Hyperactivity / impulsivity
    64. 64. ….and the rest of the criteriaB. Onset before age 7C. Impairment in 2 or more settingsD. Significant functional impairmentE. Not better accounted for by another mental disorder
    65. 65. Functional impact of core symptoms• Arousal / alertness• Mental effort• Determination of saliency• Focal maintenance
    66. 66. Functional impact of core symptoms• Arousal / alertness• Mental effort• Determination of saliency• Focal maintenance
    67. 67. Functional impact of core symptoms• Arousal / alertness• Mental effort• Determination of saliency• Focal maintenance
    68. 68. Functional impact of core symptoms• Satisfaction control• Previewing• Inhibition• Tempo control• Self-monitoring and correcting
    69. 69. Functional impact of core symptoms• Satisfaction control• Previewing .• Inhibition• Tempo control• Self-monitoring and correcting
    70. 70. Functional impact of core symptoms• Satisfaction control• Previewing• Inhibition• Tempo control• Self-monitoring and correcting
    71. 71. Functional impact of core symptoms• Satisfaction control• Previewing• Inhibition• Tempo control• Self-monitoring and correcting
    72. 72. Functional impact of core symptoms• Satisfaction control• Previewing• Inhibition• Tempo control• Self-monitoring and correcting
    73. 73. Subtypes of ADHD• ADHD, predominantly inattentive type• ADHD, predominantly hyperactive type• ADHD, combined type• ADHD, Not Otherwise Specifed
    74. 74. Subtypes of ADHD• ADHD, predominantly inattentive type• ADHD, predominantly hyperactive type• ADHD, combined type• ADHD, Not Otherwise Specifed
    75. 75. Common comorbidities with ADHD• Learning disorder• Behavioral disorder• Anxiety• Depression• Substance abuse• Sensory processing and auditory processing challenges
    76. 76. Common comorbidities with ADHD• Learning disorder• Behavioral disorder• Anxiety• Depression• Substance abuse• Sensory processing and auditory processing challenges
    77. 77. Common comorbidities with ADHD• Learning disorder• Behavioral disorder• Anxiety• Depression• Substance abuse• Sensory processing and auditory processing challenges
    78. 78. NIH Consensus Statement
    79. 79. Executive Functioning: An Overarching Theme• Sensory Processing Disorder• Central Auditory Processing Disorder• ADHD and Executive Dysfunction
    80. 80. Introduction to Neuroanatomy…..destination: frontal lobe !
    81. 81. Introduction to NeuroanatomyInter-connectedness of systems• Cortico-striatal system, for example
    82. 82. © 2011 David D. Nowell, Ph.D. All rights5/3/2012 117 reserved.
    83. 83. The Executive FunctionsX
    84. 84. The Executive Functions• Initiation• Planning• Set-shifting• Self-regulation• Inhibition of response• Directing current activity towards future goal• X
    85. 85. The Executive Functions• Initiation• Planning• Set-shifting• Self-regulation• Inhibition of response• Directing current activity towards future goal
    86. 86. The Executive Functions• Initiation• Planning• Set-shifting• Self-regulation• Inhibition of response• Directing current activity towards future goal
    87. 87. The Executive Functions• Initiation• Planning• Set-shifting• Self-regulation• Inhibition of response• Directing current activity towards future goal
    88. 88. The Executive Functions• Sustaining alertness and effort• Internalizing speech• Prioritizing• Sequential thinking• Developing a plan of action• Persevering through a plan of action• Time management
    89. 89. The Executive Functions• Sustaining alertness and effort• Internalizing speech• Prioritizing• Sequential thinking• Developing a plan of action• Persevering through a plan of action• Time management
    90. 90. The Executive Functions• Sustaining alertness and effort• Internalizing speech• Prioritizing• Sequential thinking• Developing a plan of action• Persevering through a plan of action• Time management
    91. 91. The Executive Functions• Sustaining alertness and effort• Internalizing speech• Prioritizing• Sequential thinking• Developing a plan of action• Persevering through a plan of action• Time management
    92. 92. The Executive Functions• Sustaining alertness and effort• Internalizing speech• Prioritizing• Sequential thinking• Developing a plan of action• Persevering through a plan of action• Time management
    93. 93. The Executive Functions• Fine motor control• Delay of gratification• Blocking out distractions• Weighing consequences• Thinking before acting• Planning for the future• Certain aspects of memory / learning
    94. 94. The Executive Functions• Bridging the now with the past• Bridging the now with the future
    95. 95. Neuropsychological Model of Executive Dysfunction• Guides your evaluation• Guides your treatment plan• Facilitates family education
    96. 96. Literature review
    97. 97. Literature review• Genetic evidence
    98. 98. Literature review• Genetic evidence• Neuroanatomical evidence
    99. 99. Literature review• Genetic evidence• Neuroanatomical evidence• Neuropsychological evidence
    100. 100. Literature review• Genetic evidence• Neuroanatomical evidence• Neuropsychological evidence• Neurochemical evidence
    101. 101. Interpreting the Problem Checklist Appendices B and C• Items 1-8: inattention/distractibility• Items 9-13 and 24-28: behavioral d/o• Items 16-23: hyperactivity/impulsivity
    102. 102. Comprehensive Treatment
    103. 103. Treatments With Limited Evidence (AAP, 2001; Pelham & Fabiano, 2008)(1) Traditional one-to-one therapy or counseling(2) Office based "Play therapy”(3) Elimination diets(4) Biofeedback/neural therapy/attention (EEG) training(5) Allergy treatments(6) Chiropractics(7) Perceptual or motor training/sensory integrationtraining(8) Treatment for balance problems(9) Pet therapy(10) Dietary supplements (megavitamins, blue-green algae)
    104. 104. Evidence-Based Treatments for Children… (Chorpita et al, 2011)•Self – talk•Behavioral supports + medication•Parent training•Physical exercise•Biofeedback•Contingency management•Parent and teacher education•Social skills training + medication•Parent training + problem solving•Relaxation training + exercise•Working memory training
    105. 105. Evidence-Based Short-term Treatments for ADHD(1) Behavior modification-175 studies(2) CNS stimulant medication>300 studies(3) The combination of (1) and (2).>25 studies(Pelham & Fabiano, 2008; Greenhill & Ford,2002; Hinshaw et al, 2002)
    106. 106. Pharmacotherapy• Drugs approved for ADHD – Stimulants • Methylphenidate (e.g., Ritalin) • Dexmethylphenidate (Focalin, Focalin XR) • Amphetamine (Adderall, Adderall XR) • Dextroamphetamine (Dexedrine) for layperson Grps of 3: definition of adhd • Pemoline (Cylert) --no longer marketed due to liver toxicity • Methamphetamine (Desoxyn) --little used – Atomoxetine (Strattera) • selective norepinephrine reuptake inhibitor X 153
    107. 107. Pharmacotherapy, continued• Under review for ADHD indication – Modafinil (Provigil)--stimulant• Drugs used off label for ADHD – Tricyclic antidepressants – Bupropion – Alpha-2 agonists (e.g., clonidine) 154
    108. 108. Stimulants• Used for decades• Available in extended release formulations• Adverse effects: abuse/dependence (Schedule C- II), tics, cardiovascular, CNS, growth• Adderall XR approved for adult ADHD 155
    109. 109. Main Beneficial Short-term Effects• 1. Decrease in classroom disruption• 2. Improvement in teacher ratings of behavior• 3. Improvement in compliance with adult requests• and commands• 4. Increase in on-task behavior and academic• productivity and accuracy (but no long-term• effect on academic achievement)• 5. Improvement in peer interactions• 6. Improvement in performance on laboratory• measures of attention, impulsivity, and learning (Greenhill & Ford, 2002)
    110. 110. APA Task Force on Medication and Psychosocial Treatments in Children and Adolescents• Behavioral Parent Training• Behavioral School Intervention• Behavioral Child Intervention• Medication--Use when needed
    111. 111. Making the diagnosis
    112. 112. Making the diagnosis• Get the chief complaint
    113. 113. Making the diagnosis• Mental status examination
    114. 114. ABC STAMPLICKERX
    115. 115. Making the diagnosis• Interview with parent / significant other
    116. 116. Making the diagnosis• Checklists – Parents – Teachers – Others
    117. 117. Making the diagnosis• Looking for convergent data
    118. 118. O.T. Evaluation of SensoryIntegrationClinical Observations Sensory History Checklists andInterviews Assessments of SensoryIntegration
    119. 119. Evaluation of CAPDAudiologistSpeech therapist
    120. 120. Avoiding the most common diagnostic error
    121. 121. Disorder• ADHD• OCD• Motor tic disorder• Sensory processing disorder
    122. 122. Other options V71.09Provisional Rule out
    123. 123. ADHD “look-alikes”• Low IQ• High IQ• LD• Vision/ hearing problems• Mood disorders• Substance abuse• PTSD
    124. 124. ADHD “look-alikes”• Sleep disorders• Seizure disorders• Acquired brain injury• FAS• Autistic-spectrum disorders• Sensory processing problems – Central auditory processing – Sensory integration disorders
    125. 125. ADHD and the Processing Disorders•Skills and strategies for children
    126. 126. The First Thing You Need to Change X
    127. 127. A B C
    128. 128. A B C behavior
    129. 129. A B C antecedent
    130. 130. A B CconsequencesX
    131. 131. A B C antecedent
    132. 132. A •Rules •Expectations •Communications
    133. 133. RulesA •Waking up •Bedtime •Chores •Homework •TV / internet
    134. 134. ExpectationsA •Specific •Behavioral •In advance
    135. 135. CommunicationA •Get eye contact •Speak clearly •Provide behavioral info •Check for understanding
    136. 136. Functional impact of core symptoms• Arousal / alertness• Mental effort• Determination of saliency• Focal maintenance
    137. 137. Functional impact of core symptoms• Arousal / alertness• Mental effort• Determination of saliency• Focal maintenance
    138. 138. Functional impact of core symptoms• Arousal / alertness• Mental effort• Determination of saliency• Focal maintenance
    139. 139. Methylphenidate Enhances theSaliency of a Mathematical Task byIncreasing Dopamine in the HumanBrainVolkow, et al. 2004
    140. 140. Methylphenidate Enhances theSaliency of a Mathematical Taskby Increasing Dopamine in theHuman BrainVolkow, et al. 2004
    141. 141. Increase salience
    142. 142. You lovemath….you love math.
    143. 143. Functional impact of core symptoms• Arousal / alertness• Mental effort• Determination of saliency• Focal maintenance X
    144. 144. Functional impact of core symptoms• Satisfaction control• Previewing• Inhibition• Tempo control• Self-monitoring and correcting
    145. 145. Functional impact of core symptoms• Satisfaction control• Previewing• Inhibition• Tempo control• Self-monitoring and correcting
    146. 146. Functional impact of core symptoms• Satisfaction control• Previewing• Inhibition• Tempo control• Self-monitoring and correctingX
    147. 147. Functional impact of core symptoms• Satisfaction control• Previewing• Inhibition• Tempo control• Self-monitoring and correcting
    148. 148. Functional impact of core symptoms• Satisfaction control• Previewing• Inhibition• Tempo control• Self-monitoring and correctingX
    149. 149. Functional impact of core symptoms• Satisfaction control• Previewing• Inhibition• Tempo control• Self-monitoring and correctingX
    150. 150. Strategic behavioral inquiry
    151. 151. A B C ANTECEDENTS BEHAVIOR CONSEQUENCES STRATEGIC BEHAVIORAL INQUIRY © 2011 David D. Nowell, Ph.D. All rights5/3/2012 207 reserved.
    152. 152. Beginning Middle End © 2011 David D. Nowell, Ph.D. All rights5/3/2012 208 reserved.
    153. 153. © 2011 David D. Nowell, Ph.D. All rights5/3/2012 209 reserved.
    154. 154. © 2011 David D. Nowell, Ph.D. All rights5/3/2012 210 reserved.
    155. 155. © 2011 David D. Nowell, Ph.D. All rights5/3/2012 211 reserved.
    156. 156. © 2011 David D. Nowell, Ph.D. All rights5/3/2012 212 reserved.
    157. 157. Mood dysregulation in BAD and executive disorders
    158. 158. ADHD is not FRED-PG13X
    159. 159. ADHD and girls
    160. 160. ADHD and women
    161. 161. Recommendations for Teachers with Concerns about Attention or Processing Problems
    162. 162. Recommendations for Teachers …• Distinguish between medical evaluation and educational evaluation• Document with objective behavioral terms the challenges you notice• Document interventions and responses• Speak with other teachers or last year’s teacher – compare notes• Recommend next-step evaluation
    163. 163. Recommendations for Teachers …• Avoid diagnostic terms in conversation with parents• Leave medication decision to families and their pediatricians• Find common goals with parents
    164. 164. Accommodationsand Modifications
    165. 165. IDEA and Section 504
    166. 166. Metacognitive Strategies• Metacognitive knowledge• Metacognitive strategiesX
    167. 167. A B C behavior
    168. 168. Self-Talk Proficiency for KidsX
    169. 169. Self-Talk Proficiency• -“How are you going to know when to be ready?”• -“How are you going to stop yourself from…?”• -“What is your goal?”• -“What do you want it to look like?”• -“How long do you think it will take?”
    170. 170. Asking two questions…–Am I having fun now?–And is this what I set out to do?
    171. 171. Asking two questions… 1. “Am I having fun now?” © 2011 David D. Nowell, Ph.D. All rights5/3/2012 231 reserved.
    172. 172. Asking two questions… 2. “And is this what I set out to do?” © 2011 David D. Nowell, Ph.D. All rights5/3/2012 232 reserved.
    173. 173. Am I having fun now?Is this what I set out to do? Yes No Yes Yes Yes No No No © 2011 David D. Nowell, Ph.D. All rights5/3/2012 233 reserved.
    174. 174. easy hard
    175. 175. Distraction Delay Training
    176. 176. X
    177. 177. Executive Estimates TrainingX
    178. 178. Goal Management Training
    179. 179. 1. Stop What am I doing? 2. Define The main task 3. List The steps A…… B….. C…… 4. Learn The steps Do I know the steps? No Yes 5. Do It 6. Check Am I doing what I planned to do?Yes No
    180. 180. SQ3R• Survey• Question• Read• Recite• review
    181. 181. Dealing with difficult behavior
    182. 182. The Three Baskets
    183. 183. A B C
    184. 184. R P
    185. 185. +-
    186. 186. R+ P+R- P-
    187. 187. Time Out• Select target behavior• Set place• Determine how much time• Dress rehearsal• Measure the time• Withdraw attention• Establish the cause and effect
    188. 188. Token economy• Good balance• Precursor to adult reinforcement system• Lots of work to do well• Even more work to set up well
    189. 189. Homework problems• Fails to write down assignments• Forgets the assignment book• Forgets necessary materials• Takes hours to do minutes of homework• Hassles about when and where to do homework• Lies about having done homework• Needs constant supervision with homework• Forgets to bring homework back to school
    190. 190. Make Real-Life More Like Video Games• Clear expectations• Behavioral specificity• Build on small changes in behavior• Irrelevant behaviors ignored• Reward appropriate behavior and punish inappropriate behavior – never reverse this
    191. 191. Make Real-Life More Like Video Games• Always follow up on rules, no exceptions• Consequences are immediate• Punishment is mild• Stimuli are exciting and multi-sensory• Conduct expensive and time-consuming focus groups to determine what really “grabs ‘em”
    192. 192. Error-free Learning
    193. 193. The “Big Five”• Daily focus time• Clarity regarding reinforcers• Nutrition• Movement• ConnectionX
    194. 194. ADHD and the Processing Disorders•Skills and strategies for adults
    195. 195. Is Adult ADHD a separate disorder?
    196. 196. DSM Criteria and Developmental Issues
    197. 197. Executive Disorders and Insight
    198. 198. The ADHD Couple
    199. 199. The ADHD Couple• Need for stimulation• Poorer impulse control• Inattention to detail• Fantasy projection
    200. 200. The ADHD Couple• Remembering what drew you to your partner• Realistic expectations• Managing blame• Getting to “fair”• Feeling your contributions are valued• Outsourcing
    201. 201. Positive characteristics of many peoplewith attentional / executive challenges Appendix E
    202. 202. The ADHD Couple• Improving Dyadic Communication Skills
    203. 203. Executive Disorders and the Workplace
    204. 204. Executive Disorders and the Workplace• Realistic expectations• Efficiency• Delegating• Getting clear regarding “disability”• Managing comorbidities
    205. 205. Activity Scheduling
    206. 206. Chunking
    207. 207. The “Big Five”• Daily focus time• Values/motivational clarity• Nutrition• Movement• Connection
    208. 208. …the most important 10 minutes of the day…. © 2011 David D. Nowell, Ph.D. All rights5/3/2012 279 reserved.
    209. 209. The “Big Five”• Daily focus time• Values/motivational clarity• Nutrition• Movement• Connection
    210. 210. Values and Goal Clarification for the Distracted Patient
    211. 211. PREFERRED STATES INVENTORY David D. Nowell, Ph.D. 189 May Street Worcester, Mass. 01602 DrNowell.com
    212. 212. Your #1 Organizational Tool
    213. 213. Learn FrenchBe a better spouseStop smoking
    214. 214. The “Big Five”• Daily focus time• Values/motivational clarity• Nutrition• Movement• Connection
    215. 215. The Sensory Defensive Adult
    216. 216. Adults with Auditory Processing Challenge
    217. 217. A challenge….
    218. 218. ADHD and the Processing Disorders David D. Nowell, Ph.D. Worcester, Massachusetts DavidNowellSeminars DavidNowell David@DrNowell.com

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