KIPP ADHD presentation Kurtz

ADHD & Disruptive Behaviors:What to Look for in the Classroom

Steven M.S. Kurtz, PhD, ABPPSenior Director

ADHD & Disruptive Behavior DisordersChild Mind Institute

steven.kurtz@childmind.org

Portrait of a child with ADHD

Classic Triad of ADHD

Inattention Hyperactivity

Impulsivity

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

Inattentive Symptoms1. 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

Overlap of Symptoms and Diagnoses

ADHD Anxiety ODD ???

Attention

Concentration

Anxiety

Sadness

Opposition

Fidgetiness

Impulsivity

Appetite

Sleep

Overlap of Symptoms and Diagnoses

ADHD Anxiety ODD ???

Attention

Concentration

Anxiety

Sadness

Opposition

Fidgetiness

Impulsivity

Appetite

Sleep

Overlap of Symptoms and Diagnoses

ADHD Anxiety ODD ???

Attention

Concentration

Anxiety

Sadness

Opposition

Fidgetiness

Impulsivity

Appetite

Sleep

Overlap of Symptoms and Diagnoses

ADHD Anxiety ODD ???

Attention

Concentration

Anxiety

Sadness

Opposition

Fidgetiness

Impulsivity

Appetite

Sleep

Co-occurring Disorders

• Oppositional defiant disorder - 40%

• Anxiety or mood disorders - 25-34%

• Learning disabilities - 20%

• Conduct disorder- 10-60%

• Tic disorders

Gender Differences and ADHD• 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.

Areas of Brain Affected

PET Scans

Alan Zametkin et al., NIMH

Xavier Castellanos, NYU CSC

Approx. 3% difference in brain volumes

Less asymmetrical

Developmental Trends of ADHD Symptoms

before 17 yo

Impairm

ent

Hyper/Imp

Age

Developmental Trends of ADHD Symptoms

Impairm

ent

Hyper/Imp

Age

Impairm

ent

Inattention

Banerjee, Middleton, Faraone. Acta Paediatria, 2007,

96, 1269-1274.

before 17 yo

Sx I

mp

airm

ent

Inattention

Hyper/Imp

Developmental Trends ofH/I vs. Inattention Symptoms

How come they can…

Watch TV for hours?

Build with legos?

Sit through a movie without getting up?

Sit through morning meeting one

day but not the next?

Refining the understanding of ADHD

• Variability is the rule, not the exception

• Dull, boring, repetitive tasks not of their choosing

Refining the understanding of ADHD

ADHD

ATTENTION SURPLUS DISORDER

ATTENTION MODULATION DISORDER

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?

The Immediate Effects of 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

The long-term consequences of 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

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

Treatment & Intervention

What do 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

Treatment Recommendations

Treatment Recommendations

Medicine Behavior Therapy

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

Treatments for ADHD

• Who do we target?

• What do we target?

• Where do we target?

• When to apply tx?

– Serial vs Concurrent

Parent-Child Interaction Therapy

Teacher-Child Interaction Therapy

Unproved or untested treatments

• 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

MTA Study: Parent-Reported Parent-Child Arguing

“MY WHAT IS DUE WHEN?”(AND, Where Is It?)

ORGANIZATIONAL SKILLS TRAINING

SKILLS

DEFICIT

PERFORMANCE

DEFICIT

Oh No !!!!

9 Principles to Guide 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

Daily Report Cards (DRCs)

SpecificObservableMeasurable

Frequent & ImmediateBluegrass? Opera? Rap?

Football? Wild Wadi?

Daily Report Cards (DRCs)

Daily Report Cards (DRCs)

Daily Report Cards (DRCs)

Daily Report Cards (DRCs)

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

Daily Report Card

Name: ______________ Social Skill of the Day: _________________________

Day and Date: _______________________ Coping Skill of the Week: ______________________

Period: Morning and

Math

ELA and

Bathroom

Lunch Read aloud

and Recess

Activity Afternoon

Target Behavior 1: YYY will comply with directions, requests,

and commands with 80% accuracy during all

periods with 2 prompts.

Yes No

N/A

Yes No

N/A

Yes No

N/A

Yes No

N/A

Yes No

N/A

Yes No

N/A

Target Behavior 2:

When frustrated or angry, YYY will use a

coping skill and will rejoin the group within

10 minutes with 2 prompts.

Yes No

N/A

Yes No

N/A

Yes No

N/A

Yes No

N/A

Yes No

N/A

Yes No

N/A

Point System Letter Grade:

A B C D F

A B C D F

A B C D F

A B C D F

A B C D F

A B C D F

Sticker Percentage Today’s Average Letter Grade: _____

= %

Level 1 (80% - 100%)

Level 2 (66% - 79%) No DRC Reward

Comments:

Signature: ___________________________________

Prize Box