Attention Deficit Hyperactivity Disorder ADHD Solutions

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• Attention Deficit Hyperactivity Disorder
  (AD/HD)Solutions

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Personal Insight

• A teachers insight.
• A to Z Teacher Stuff
• At home - ADD
• My sons perspective
• Personal experience

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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.

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Goals

• Overview and Definitions
• Etiology Key Issues
• Scope, Prevalence and Comorbidity
• Successful Strategies (over 25!)
• Summary

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First, An Overview

• Lets get a critical understanding of the
  condition with its associated features and a
  discussion of key diagnostic issues.

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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.

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Clinical Definition (1 of 2)

• AD/HD is a condition characterized by
• Poor short term memory
• Hyperactivity
• Impulsivity
• Poor time management

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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

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Clinical Qualifiers

• Onset before age 7 yrs.
• Diagnosis often delayed until problems in school
  
• In two of three settings - home, school, office
• 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

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Diagnosis (1 of 2)

• The AD/HD diagnosis carries with itsignificant
  implications for families, educators and of
  course, the child.Only a licensed professional,
  such as a pediatrician, psychologist,
  neurologist, psychiatrist or clinical social
  worker, can make the diagnosis that a child,
  teen, or adult has AD/HD.

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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).

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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--its appropriateness

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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

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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

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Hyperactive-only Behaviors

• Cant 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

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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 usingNational
  Rehabilitation Act, Section 504

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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

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Brain Differences in AD/HD Subjects

• Neurotransmitter imbalances
• Lower cerebral blood flow Lou, et al., (2004)
• Anatomical differences between healthybrains
  and those with AD/HD
• Castellanos, et al. (2002), Castellanos and
  Acosta,(2004)

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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)

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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.

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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
• Tourettes 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.

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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
  4060 percent of children with ADHD have at least
  one coexisting disability. (Jensen, et al.,
  2001)

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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)

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AD/HD Symptoms into AdulthoodAdults 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)

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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)

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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)

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Risk Factors of AD/HD

• Academic underachievement
• Legal problems
• Substance abuse
• Social difficulties
• Risky behaviors

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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)

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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 worldit may
  harder to focus
• Better diagnosis and treatment by medical
  professionals
• More children in childcare, for more years
• Change in early childhood activities
  (moreelectronic games played that reward
  impulsivity)

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Validity Issues Is AD/HD Real?

• AD/HD is a psychiatric diagnosis, nota
  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 theadult
  world or the reverse?

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What About Simply A.D.D.?

• Students with Attention Deficit Disorder onlydo
  not have the hypersymptoms of movement. As a
  result, they tend to be still impulsive, but they
  stay in their chairs. Theyre impulsive
  cognitively but unfocused and stationary.

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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

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Childrearing Changes

• Close, nurturing parenting isneeded 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)

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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
  withpreservatives, additivesand trans fats than
  atany time in history.

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Nutrition Links (2 of 2)

• AD/HD meds such as Methylphenidate (Ritalin)
  increase dopamine or Straterra increase our
  brains 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).

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InterventionsPractical Strategies for Parents
and Teachers

• Review of both the mainstream and alternative
  treatments. Explore both short-term and lifelong
  strategies for successful healthy living.

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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 teachers 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?

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When You Treat AD/HDWhats the Goal?

• To change behavior, ofcoursebut how?All
  AD/HD-related behavior change focuses on
  strengthening the capacity of the frontal
  lobes. This can be done chemically or
  behaviorally.

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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
• Patient, parent, and teacher education about the
  condition
• Medication (usually from the class of drugs
  called stimulants) or nutritional support
• Behavioral therapy
• Environmental supports, including an appropriate
  classroom accommodations.

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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)

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The Use of Stimulants

• Effectiveness ranges from 75-95. Why not 100
  effectiveness?
• wrong medication
• dosage issues
• compliance issues
• improper diagnosis
• comorbidity
• contraindications

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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.

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Before and After TreatmentA 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

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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

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Most-Prescribed Stimulants

• NOTE Many new AD/HD products are repackaged
  formulasoriginally 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)

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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)

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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

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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)

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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

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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

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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

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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--its
  in 1000s of foods
• Remove allergens from the diet

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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 releaseadrenaline, too

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Nutraceuticals

• Some product types may lend nutritional support
• Attend - a natural product which combines amino
  acids, andhormone precursors to
  specificneurotransmitters.
• 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

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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

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AccommodationsSpecific 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

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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 its acknowledged as a
  change.

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AccommodationsSpecific 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

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AccommodationsSpecific 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 its time for him to
  go to the back of the room or take a walk.

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AccommodationsSpecific 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.

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AccommodationsSpecific 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

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AccommodationsSpecific 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 anystudent earns
  points towards classroom privileges
• Use teams to improve peer feedback.

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AccommodationsSpecific 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.)
• Dont surprise them--give ample warnings
• Help control impulse buddy system may help slow
  down blurting/impulsivity

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AccommodationsSpecific Strategies (9 of 10)

• Help manage the environment 
• For some, earplugs, headsets orwhite 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 distractingor
  disruptive area or view

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AccommodationsSpecific 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 orrespect 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.

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Parent SuggestionsStudent 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

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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.

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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

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Parenting Suggestions Environmental Changes (2 of
2)

• Use background music it helps some to focus
• Remove any environmentalrisks (e.g. lead,
  asbestos)
• Study with a good friend
• Give prompts before key info
• Enroll in alternative school
• Provide positive role models

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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 energysuch as
  squeezable items or chin-up bar.
• Focus on the big things avoid lettingthese
  students drive you crazy. Dont take their
  behaviors personally.

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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.

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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

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Building Student Assets (3 of 3)

• Focus on the students 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.

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• Nearly every accommodationyou are being asked to
  makeis simply high quality teaching.It does not
  give AD/HD studentsany advantage it simply
  levelsthe playing field.

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Adults with AD/HD

• The kids with AD/HD often have a parent with it,
  too.
• In parent conferences, keep them focused on task.
  Theyll 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
  teachers lounge or busy cafeteria.

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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.

77
ADHD Gold

• http//www.truveo.com/Michael-Phelps-Struggled-Wit
  h-ADHD-As-A-Child/id/3139888503

78
Action Steps

• What have you learned?
• How might you think or behave differently?
• Where and when might you begin?

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Suggested Resource

• A New View of AD/HDby Eric Jensen
• www.corwinpress.com
• www.amazon.com

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Thank you!