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KIPP ADHD presentation Kurtz
- 2. ADHD & DisruptiveBehaviors: What to Look for in the Classroom Steven M.S. Kurtz, PhD, ABPP Senior Director ADHD & Disruptive Behavior Disorders Child Mind Institute steven.kurtz@childmind.org
- 3. Portrait of achild with ADHD
- 4. Classic Triad ofADHD Inattention Hyperactivity Impulsivity
- 5. Hyperactive/Impulsive Symptoms 1. Fidgeting and squirming 2. Leaves seat 3. Running or climbing excessively 4. Trouble playing quietly 5. “On the go” or “driven by a motor” 6. Talking excessively 7. Blurting out answers 8. Trouble taking turns 9. Interrupting or intruding
- 6. Inattentive Symptoms 1. Making careless mistakes 2. Trouble paying attention to a task 3. Not listening 4. Not following instructions 5. Trouble organizing 6. Avoiding or disliking sustained effort 7. Losing things 8. Easily distracted 9. Forgetful
- 7. Overlap of Symptomsand Diagnoses ADHD Anxiety ODD ??? Attention Concentration Anxiety Sadness Opposition Fidgetiness Impulsivity Appetite Sleep
- 8. Overlap of Symptomsand Diagnoses ADHD Anxiety ODD ??? Attention Concentration Anxiety Sadness Opposition Fidgetiness Impulsivity Appetite Sleep
- 9. Overlap of Symptomsand Diagnoses ADHD Anxiety ODD ??? Attention Concentration Anxiety Sadness Opposition Fidgetiness Impulsivity Appetite Sleep
- 10. Overlap of Symptomsand Diagnoses ADHD Anxiety ODD ??? Attention Concentration Anxiety Sadness Opposition Fidgetiness Impulsivity Appetite Sleep
- 11. Co-occurring Disorders • Oppositional defiant disorder - 40% • Anxiety or mood disorders - 25-34% • Learning disabilities - 20% • Conduct disorder- 10-60% • Tic disorders
- 12. Gender Differences andADHD • ADHD also affects girls and even adult women. • Girls with ADHD tend to be more inattentive than H/I. • Parents and teachers often overlook ADHD in girls. • Girls with untreated ADHD are at risk for low self- esteem, underachievement, depression, and anxiety. • Without treatment girls are also more likely to engage in risky behaviors like smoking and unprotected sex while in middle or high school. • Girls with ADHD often continue struggling into adulthood if they don’t receive treatment.
- 13. Areas of BrainAffected
- 14. PET Scans Approx. 3%difference in brain volumes Less asymmetrical Alan Zametkin et al., NIMH Xavier Castellanos, NYU CSC
- 15. Developmental Trends ofADHD Symptoms Impairment Hyper/Imp Age before 17 yo
- 16. Developmental Trends ofADHD Symptoms Inattention Impairment Hyper/Imp Age
- 17. Banerjee, Middleton, Faraone.Acta Paediatria, 2007, 96, 1269-1274.
- 19. Developmental Trends of H/I vs. Inattention Symptoms Sx Impairment Inattention Hyper/Imp before 17 yo
- 20. How come theycan… Watch TV for hours? Build with legos? Sit through a movie without getting up? Sit through morning meeting one day but not the next?
- 21. Refining the understandingof ADHD • Variability is the rule, not the exception • Dull, boring, repetitive tasks not of their choosing
- 22. Refining the understandingof ADHD ADHD ATTENTION SURPLUS DISORDER ATTENTION MODULATION DISORDER
- 23. Controversies in Diagnosis • Poor kids diagnoses more than wealthy kids? • Teacher/school easy way out? • Why do rates differ across countries? • False positives? – What if tomorrow 7 million new cases diabetes?
- 24. The Immediate Effectsof Not Treating ADHD • Interferes with learning and social development • Family stress • Reduces instructional time in class – Interferes with their learning and the learning of others • Drains resources • Maintains or exacerbates ADHD behaviors • We hate to see kids fail at being kids! • Same is true for undertreating
- 25. The long-term consequencesof not treating ADHD Untreated kids face: – Less schooling & poorer grades – Higher expulsion rates – Fewer friends – Lower self-esteem – Higher arrest rates – Lower occupational rank – Higher job termination rates – Riskier driving – More accidents – Relationship difficulties – Higher STD 4x
- 26. Assessment • Primary or“core” domains: the symptom triad – Attention – Activity level – Impulse control • Secondary – Compliance – Anxiety and mood – Frustration tolerance – Executive functions – Organizational skills – Learning issues – Parental functioning – Family functioning
- 27. Treatment & Intervention Whatdo we know in 2012 that we did not know in 1977? – A lot! • “If I did now for ADHD what I was taught to do in 1977 I would call it malpractice.” – That intensifying the dosing of all treatments likely affords children the best outcomes • Behavioral interventions are also dosed
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- 29. Treatment Recommendations Medicine Behavior Therapy
- 30. Treatment & Intervention •Psychopharmacology • Psychotherapy – Behavior therapy • Structuring time: down time is bad time • Maximizing predictability and routines • Increasing immediate positive attention – Parent training • Parent-Child Interaction Therapy (PCIT) • Groups – School-based interventions • Daily Report Card • Training professionals and paraprofessionals – TCIT – Organizational skills training
- 31. Treatments for ADHD • Who do we target? • What do we target? • Where do we target? • When to apply tx? – Serial vs Concurrent
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- 34. Unproved or untestedtreatments • Social skills groups* • Play therapy or talk therapy • Biofeedback • Dietary changes, elimination diets • Ginkgo biloba & other supplements • Meditation • Exercise • Metronome • Vision training • Sensory integration therapy
- 35. MTA Study: Parent-Reported Parent-Child Arguing
- 36. “MY WHAT ISDUE WHEN?” (AND, Where Is It?) ORGANIZATIONAL SKILLS TRAINING SKILLS PERFORMANCE DEFICIT DEFICIT
- 37.
- 38. 9 Principles toGuide ADHD Behavior • More immediate consequences • Increased frequency of consequences • Increased saliency of consequences • Incentives < punishments (9:1) • Act, Don’t Yak • Strive for consistency • Plan for high risk situations • Keep a disability perspective • Practice forgiveness …adapted from Barkley
- 39. Daily Report Cards(DRCs) Specific Observable Measurable Frequent & Immediate Bluegrass? Opera? Rap? Football? Wild Wadi?
- 40. Daily Report Cards(DRCs)
- 41. Daily Report Cards(DRCs)
- 42. Daily Report Cards(DRCs)
- 43. Daily Report Cards(DRCs)
- 44. Daily Report Cards(DRCs) Target Behaviors Following Directions Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A (2 Prompts) Good Risks Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Use your words Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A when frustrated Daily Percentage= # Yes = = #(Yes+No) Comments: % or better earns choice of reward from Prize List
- 46. Daily Report Card Name: ______________ Social Skill of the Day: _________________________ Day and Date: _______________________ Coping Skill of the Week: ______________________ riod: Morning and ELA and Lunch Read aloud Activity Afternoon Math Bathroom and Recess rget Behavior 1: YY will comply with directions, requests, Yes No Yes No Yes No Yes No Yes No Yes No d commands with 80% accuracy during all riods with 2 prompts. N/A N/A N/A N/A N/A N/A rget Behavior 2: hen frustrated or angry, YYY will use a Yes No Yes No Yes No Yes No Yes No Yes No ping skill and will rejoin the group within minutes with 2 prompts. N/A N/A N/A N/A N/A N/A Point System Letter Grade: ABCDF ABCDF ABCDF ABCDF ABCDF ABCDF Sticker Percentage Today’s Average Letter Grade: _____ = % Level 1 (80% - 100%) Level 2 (66% - 79%) No DRC Reward Comments: Signature: ___________________________________
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Editor's Notes
- #4 This is one artist’s portrait of a child with ADHD. Why do you think they have depicted the child this way? [Let participants share their thoughts. Previous responses have included, “the child feels like she isn’t there,” “the child feels alone,” and “the child is in trouble/time/out.”]But there is no one portrait of a child with ADHD. The caricature of a Dennis the Menace-type character is just that: a caricature. In reality, there are many ways that ADHD manifests. If you’ve seen one child with ADHD, you haven’t seen them all. You’ve only seen one.
- #6 Hyperactive or impulsive behaviors, which are often noticed first, include fidgeting, an inability to sit still, excess energy, verbal outbursts, extreme impatience, talking incessantly, and interrupting others.In school, these symptoms look like this:Switching activities frequentlyCalling out or failing to raise handsPoor frustration tolerance and impatienceActing without thinkingAggressionSocial problems (trouble taking turns and respecting space)Though all kids may exhibit these behaviors, children without ADHD can usually focus when it is necessary to accomplish a goal. Kids with ADHD can’t.
- #7 Inattentive behaviors often become noticeable only when a child enters school. He might be easily distracted, have difficulty following instructions, be unusually forgetful, struggle with organizing tasks, avoid things that involve mental exertion, and appear oblivious to what’s going on around him.Children with the predominantly inattentive subtype of ADHD are less likely to act out or have difficulties getting along with other children. They may sit quietly, but they are not paying attention to what they are doing. Because of this, the child may be overlooked, and parents and teachers may not notice that she has ADHD.In school, these inattentive behaviors may look like this:Daydreaming or “zoning out”Failing to register or recall instructions or lessonsNeglecting to pack necessary materialsFailing to write down homework assignmentsEasily distracted or off-taskFrequent mistakes“Absent-Minded Professor” syndrome
- #9 The behaviors and comprehensions of children with these issues is inconsistent and can be frustrating and confusing to parents, in that, one day the child may understand and the next, they may not.There are many reasons besides ADHD to explain why a child may be inattentive or hyperactive. This chart gives you an idea of some of the same symptoms that appear in many different disorders. Before diagnosing, mental health professionals must conduct a careful diagnostic assessment to look for other possible explanations.When conducting a diagnostic evaluation, we also consider:If the symptoms have been present for at least 6 monthsIf some symptoms were present before age 7If the symptoms are severe enough to cause significant difficulties in two or more settings, including home, school, and in relationships with peers.
- #13 Children with ADHD often have other psychiatric disorders, which are called “comorbid,” or co-occurring disorders. Any course of treatment for a child with ADHD will be more effective if all of the comorbid conditions are also addressed.
- #17 ADHD behaviors usually become apparent when a child is between 3 and 6 years of age.You may notice the hyperactive/impulsive behaviors first. These tend to wane as children get older, while the inattentive behaviors (e.g. disorganization) are more likely to persist into adulthood. Approximately 40% of those who had ADHD as kids will continue to have the disorder in adulthood.
- #23 Inattentive behaviors often become noticeable only when a child enters school. He might be easily distracted, have difficulty following instructions, be unusually forgetful, struggle with organizing tasks, avoid things that involve mental exertion, and appear oblivious to what’s going on around him.Children with the predominantly inattentive subtype of ADHD are less likely to act out or have difficulties getting along with other children. They may sit quietly, but they are not paying attention to what they are doing. Because of this, the child may be overlooked, and parents and teachers may not notice that she has ADHD.In school, these inattentive behaviors may look like this:Daydreaming or “zoning out”Failing to register or recall instructions or lessonsNeglecting to pack necessary materialsFailing to write down homework assignmentsEasily distracted or off-taskFrequent mistakes“Absent-Minded Professor” syndrome
- #26 26 million US diabetics; 7 million don’t know it
- #27 Not treating ADHD has immediate and long-term consequences.
- #35 The following treatments are what we call evidence-based, or proven to be effective based on research studies. Psychopharmacological:The most common medications prescribed for ADHD are psychostimulants. The two most widely used are methylphenidate (e.g. Ritalin) and dextroamphetamine (e.g. Adderall).Often people ask why stimulants are prescribed to kids or adults who are hyperactive. Actually, what these drugs stimulate is the brain’s production of chemicals, called neurotransmitters, that activate the areas of the brain that are responsible for attention and impulse control. They serve to focus the attention and curb the impulsivity and hyperactivity of kids with ADHD.Nonstimulant medications can also be prescribed for children who don't tolerate stimulants well. These can include atomoxetine (e.g. Strattera), Clonidine (e.g. Catapres, Nexicon), and guanfacine (e.g. Tenex).Medicating children with ADHD is a process of trial and observation, with overwhelmingly positive results—70% to 80% of kids have an excellent response to their first medication, and 15% will respond well to a second. While 20% to 30% are not helped by medication, or experience troublesome side effects, those effects are completely reversible by ending the course of treatment.Psychotherapeutic: Behavior Therapy addresses specific problem behaviors by:structuring time at homeestablishing predictability and routinesincreasing positive attentionParent training is a form of treatment that uses the family to help manage ADHD symptoms. One type of parent training is parent-child interaction therapy (PCIT), which focuses on teaching parents how to cultivate desired behaviors while minimizing the impulsive or inattentive ones. PCIT and other behavioral parent training can help children learn to control their behavior and cut down substantially on the disruptive behavior associated with ADHD.Family therapy can help parents and siblings manage ADHD-related stressSchool-based interventionsFunctional Behavioral Analysis - A strategic intervention on problem behaviorsOrganizational skills and behavior management Daily Report Cards - A report card that outlines desired behaviors without bringing attention to the negative onesChildren with ADHD often have auditory processing difficulties or poor organizational skills resulting in language difficulties. For this reason, it is best to break expectations down into easy to understand steps with simple language There is no cure for ADHD. Though many children will outgrow their diagnosis, the symptoms often persist into adulthood.
- #40 Some of these treatments are generally beneficial, such as meditation, but not specifically good for treating ADHD behaviors.Some may be proven to help other related conditions, such as biofeedback.Some diets may be generally beneficial, like minimizing caffeine intake.Other treatments may prove helpful but still lack scientific evidence from well-controlled studies.
- #47 Here’s another chart to help a child stay organized. It helps him remember to pack the items he needs for the day, including his Daily Report Card.
- #48 Here’s an example of a great daily report card. It positively states the behaviors we want from the child, rather than focusing on the behaviors we don’t wantThe desired behaviors are clearly broken downThe child is given a role as collaboratorIt offers an opportunity for the child and teacher to work togetherChecks could build up to small prizes
- #51 Here’s another chart to help a child stay organized. It helps him remember to pack the items he needs for the day, including his Daily Report Card.
- #59 Inattentive behaviors often become noticeable only when a child enters school. He might be easily distracted, have difficulty following instructions, be unusually forgetful, struggle with organizing tasks, avoid things that involve mental exertion, and appear oblivious to what’s going on around him.Children with the predominantly inattentive subtype of ADHD are less likely to act out or have difficulties getting along with other children. They may sit quietly, but they are not paying attention to what they are doing. Because of this, the child may be overlooked, and parents and teachers may not notice that she has ADHD.In school, these inattentive behaviors may look like this:Daydreaming or “zoning out”Failing to register or recall instructions or lessonsNeglecting to pack necessary materialsFailing to write down homework assignmentsEasily distracted or off-taskFrequent mistakes“Absent-Minded Professor” syndrome