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Dr.ShabeerJeeva–ADHDConference25September2011

ADHD=doesnotmeanyouhavealearningdisability

• www.adhdclinicjeeva.com• Dopamine–pleasurecentreofthebrain.WhenyouareboredyouthenseekthatDopamine

stimulus.• 1in3childrenhaveADHDineverySouthAfricanclassroom.• Moreprominentinboysthaningirls.• Expressivelanguageproblems• Sleepproblems• IfoneparenthasADHD–thenchildwillhaveADHD.• BirthTraumaisalsoanindicatorofADHD.• FamouspeoplewithADHD=WillSmith,BillCosby,RichardBranson• Morelikelytohavecaraccidents,areforgetful,absentminded• ChildADHD=Alwaysfeelthattheyareintroubleandhavebadluck• TeacherplaysaroleinthebehaviouralconditioningofthechildwithADHDaswellastheir

self-concept/self-esteem• Hyperactive/Impulsive• ManychildrenwithADHDsufferfromlowself-esteem• ADHD=behaviouraldisorder• Diagnosisismadebasedonthechild’sbehaviour• 3types–hyperactive/impulsive,combined,inattentiveness(cannotpayattentiontodetails)• Majorityofchildrenhavethe‘combinedtype’symptoms• Childhastodemonstratebehaviour/symptomsthataresevereandpresentforlongerthan6

months(DSM-IVcriteria)andbeforetheageof7• Physicalconditionsneedtoberuledoutfirst,beforediagnosis• Interviewswithfamilyandteachersneedtotakeplace• Symptomsmusthavesignificantlyimpairedfunctioningforthechildin2ormoresettings• Needtoeliminateotherdisorders(depression,schizophrenia,orlearningdisabilities)• Teacherneedstoprovidesupportandstimulationforthechild• The teacher can accommodate teachingmethodology and the classroom environment to

supportthelearnerwithADHD• ADHDsymptomswillappearbeforetheageof7andcancontinueintoadulthood• 21%willskipschool–schoolisboring• Childrenneedtofeelthattheycanachievesomething.

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• AssetbasedapproachwillworkwithalearnerwithADHD(positivereinforcement)• 35%willdropoutifnotgiventherightsupport• 45%suspendedfor‘badbehaviour’

ChildhoodPhysical/MedicalRisks

• Seizures(2.5timesmorelikely)• Beingoverweight(1.5timesmorelikely)• Sleepproblems(creatingsleepingpatternsisessential)• Exerciseisimportantforassistingwithsleepproblems• Pooreroralhealthpracticesincludinglowerlikelihoodofdentalbrushingeachevening

PsychiatricDisordersassociatedwithADHD

• ODD(oppositionaldefiantdisorder)70%ofchildrenwithADHD• SuicidalIdeation• DepressionorMooddisorders• ConductDisorder• Possibilityofgreaterriskofcancer

ADHD

• Inattention,hyperactivityandimpulsivity• Mostcommontypeisthecombinedtype• Morecommoninboysthaningirls• 17%goesonintoadulthood• Occursacrossethnicitiesandgenders• Genetics!!!• 84%co-morbidity(additionalthings)inadulthood• InheritanceisNOTspecifictosubtype• GenerallyhaveahighoraboveaverageIQ• Need a full educational psychological assessment (Educational Psychologist) to assistwith

focusonspecificlearningbarriersassociatedwiththeattentiondeficit

Impulsivity

• Havetotouchthings• Cannotholdthemselvesback(impulsive)• Accidentstendtobemorefrequent• Childdoesnotliketotakeresponsibilityorownup,mayhide• Theywilltryand‘fix’theproblemfirst

Inattentive

• Pre-occupied• Losesthings• Clumsy

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• Disorganised• Tendtogiveupeasily(lackofpersistence)• “Nowwhat?”• Oftenmake smallmistakes, especiallywhen facedwith a large volume ofwork. Teachers

shouldfocusonqualityratherthanquantity.• Routineisimportant/structure• Difficultyingettingupinthemorning(canleadtofightswithparents/caregivers)• Parentsandteachersgetfrustratedwithchildastheycannotunderstandhis/herlackofsense

ofurgency.

PreandprenatalriskfactorsforADHD(LogisticRegressionModel)

• Cigaretteexposure• Alcoholexposure• Drugexposure• Lowbirthweight• Psychosocialadversity• Socio-economicstatus(highestindicatorofapredispositionforADHD)• Ageatbirth• ParentalIQ• ParentalADHD(highestindicatorofapredispositionforADHD)• ParentalCD(conductdisorder)

ADHDBrain

• Ferraribrainandbicyclebrakes• Verysensitivetoexternalstimulus• Executivefunctioningisimpaired• Difficultyinsustainingattentionforlongorextendedperiodsoftime• Youdonotoutgrowitbutyoubecomebetteratmanagingthedisorder

ClinicalPresentation

• Pre-school,asearlyasage4• Infancy(colic,decreasedsleep,cannotbesoothed,unusualgrossmotormilestones)• Latefinemotormilestones• Accidents• Needconstantsupervision• Difficultysharing,waitingturns

TeachingachildwithADHD

• Consultexperts• Haveasenseofhumour• Promotehighself-esteem• Provideorganisationaltools

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• Utilizegroupwork• Rewardsuccess• Grabthestudent’sattention• Varietyoflearningopportunities• Adaptyourmethodology• Visual/auditory/kinaestheticstimulus• Beconsistent,followdefiniterules• Allowforflexibility• Bepatient• Seatlearnerincloseproximitytoyou• Engagewithlearnerconstantly• Seekaverbal responseandconfirmthat thestudent is ‘with’youandhasunderstoodthe

contentcoveredduringthatlesson• Givebreaks!!• Opencommunicationlineswithparents• Givethestudentmoreresponsibility• DoNOTgivetheADHDlearnerasurprisetest,thestudentneedstobegivenenoughwarning

sothathe/shecanprepareadequately• Encouragesupportfromotherstudentsintheclass.• DoNOTyellorshoutatthelearner–he/sheisalreadysufferingfromalowself-esteem.• Promoteasenseofinclusivityandtoleranceforstudentswhoarefacedwithlearningbarriers.• DoNOTlabeltheADHDstudentas‘stupid’or‘defiant’or‘lazy’

Adolescence

• Moody• Liketocomplainallthetime• Feelmisunderstood• Oppositional• Anxious• Suicidal

DevelopmentalimpactofADHD(fromchildhoodthroughtoadulthood)

• Lowself-esteem• Behaviouraldisturbance• Bullying• Academicproblems

VeryimportanttotreatADHDandnotdepressionasthemedicationwillnothelpwiththetreatmentoftheattentiondeficit.Diagnosismustbecorrect,veryeasytomisdiagnoseasdepressioncanbeaco-symptomofADHD.

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• Difficultywithsocialinteractions• Legalissues(impulsivebehaviour,substanceabuse,smoking,drivingrecklessly)–increased

Dopaminelevels–pleasureseeking• Occupationalfailure(inadulthood)• Relationshipproblems(inadulthood)• Fearofjudgement

Girlsareoftenmisdiagnosedornotdiagnosedatallduringschoolyearsandthenwhenitcomestouniversitythe‘wheelsfalloff’.

Treatment=5LevelApproach

1. Diagnosis2. Education3. Structure,supportandcoaching(CBT)4. Variousformsofpsychotherapy5. Medication

Co-morbiditywithregardstolearningandtheclassroom

• Reading,writingandspellingdifficulties• Maths• Behaviour(CDandODD)• Lackofmotivation

Diagnosis

Education

Structure,supportandcoaching

Psychotherapy

Medication(ifseverecase)

Progressionfromchildhoodtoadulthood:Hyperactivitytoimpulsivitytoinattentiveness.Inattentivenessinadulthoodcanleadtoanxietyanddepression.

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TshepisoMatentjie(EducationalPsychologist&Co-ActiveCoach)

tmatent@mweb.co.za0835642273

• ADHDisnotequaltoalearningdisability/impairment!!!!!!!!!• ADHDisabarriertolearningoralearnerdifficulty• What is affected inADHD?Motor (fine and grossmotor skills), Language (expressive and

receptive language skills), Thinking (memory – short and long-term), and Behaviour(impulsivity, inattentiveness,defiance)=Executive functioning (impulsecontrol, reasoning,behaviour,planning,thinking,organising,memory,timemanagment).

• Understanding (frontal lobe),auditoryprocessing (temporal lobe), visualprocessing (visualcortex)

• Frontallobedevelopsinyourearlytwentiesthereforeadolescentsandchildrenarenaturallygoingtobeimpulsive.

• Braindevelopsfromthebacktothefront.• Developmentalstagesandageshavetobetakenintoaccountwhenassessingachildfora

learningbarrier.

Howcognitivefunctioningisimpairedwithalearnerwithalearningdisability?

• Takeslongtograspconcreteconcepts• Reliesontrialanderrorlearning• Poorretentionofpreviouslytaught/acquiredlearning• Difficultiespresentacrossthecurriculum• Performsbetterundermedication• Strugglestoworkindependently• Experiencesfrustration• Poorcomprehensioneveninmothertongue• Strugglestoorganisethoughtswhencommunication(oralandwritten)• Demonstratespoormemory• Strugglestofollowsimpleinstructions

ItisimportanttorememberthatlearnerswithADHDdoNOThavealowIQ.Withassistancehe/shewillbeabletoachievewellintheacademicenvironment.

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Reasonsforpooracademicperformance

• Behaviouraldifficulties• Inattention/hyperactivity• Disciplineproblems• Family/socialproblems• Inconsistentschoolattendance• Drug/alcoholabuse• Languageorlearningdifficulties

Intervention=sequences,succession,order,perspectiveandcomparison

• Vygotsky=ZPD(zoneofproximaldevelopment)• Linkedtoteachingandmediation• Linkedtoexperience,frustrationlevel,instructionandindependence.• Needtodetermineachild’smaximumlevelofindependentlearning.

Assistingalearnerwithalearnerdisability?

• Constantverbalandornon-verbalcueingtoattendtoinstructionsanddiscussions• Concretevisualsupportsmayalsobeneeded(symbols,pictures,signs)• Comprehensionpoor• Consistencyinunderperformance• Maybecomesociallywithdrawnorbecomesagitatedoraggressivewhennoteasily

understood

AssistingalearnerwithADHD?

• WhenworkingwithalearnerwithADHD,ratherworktowardsanassetbasedapproachandthinkaboutofwhatlevelofquestioning(Bloom’staxonomy)he/shewillbeabletofunctionatandfeelconfidentwith.

• Itisimportanttobuildself-esteemandusepositivereinforcementasatoolforteachingandlearning.

• Bloom’staxonomy(analyse,evaluate,create,apply,understandandremember).

Systemicapproachtoassessment.Thelearnermustbeassessedoveraperiodoftimeandindifferentenvironments.Onehastointerviewtheparents,teachers,siblings,andfriends.Aneco-biologicalapproachtoassessmentaswellasinterventioniscriticaltoassistingalearnerwithADHD.

Learningbarriersmayalsomanifestwith2ndlanguagelearners.Maths(wordproblems),Science,andlanguagebasedsubjects.Interventionthenneedstoincludelanguageenrichment.

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RelationshipsareaffectedwithadultswithADHD:

• Relationshipswithself• Relationshipwithlovedone• Relationshipwithauthoritylevels• Timemanagement• Organisation/procrastination• Financialmanagement

Intervention:coaching,medicationandpsychotherapy

Neuro-chemicalPatho-physiologyofADHD

Themainneurotransmittersresponsibleforbrainfunctioning:

Norepinephine(brakesoftheFerrari–helpswithimpulsivity)

• Amphetaminesandmethylyphenidateblockreuptakeofdopamind/norepinephrine• MedicationcanbehelpfulwithseverecasesofADHD

Dopamine(focusonwork,enhancessignal,improvesattention)

• Focus,on-taskbehaviour,on-taskcognition• Exerciseisagoodstimulator• Meditationisagoodstimulator• Proteinbaseddiet(holisticintervention)• ConditionedresponsetoreleaseofDopamine(addictiontocoke,coffee,nicotine,alcohol,

substances,shopping,working.

ADHDandNUTRITIONZiknonaSpelmanZikhona@wellbeingacademy.co.za

• HolisticapproachiskeytosuccessofADHDmanagement• Nutritionalstrategiesshouldbeintegratedwithbehaviourmanagement,medicaltreatment

andpsychotherapy• Dietarystrategies• Skippingbreakfastlinkedtodecreasedmentalperformance(speedofinformationretrieval)• Suppliesglucosethatbraincellsuseforenergy• LowGICarbssustainenergy levels for longer,andproteintakes longertodigesttherefore

evenslowErelease• AminoAcidsandproteinfoodsarethebuildingblocksofneurotransmitters(brainchemicals)

thatregulatemoodandcognitivefunction

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• Tryptophan(makesserotonin–calmingandrelaxingeffect)andTyrosine(makesDopamine–alertnessandsharpness)

• Essentialfattyacids(Omega3and6)helpsinregulatingnerveandbrainfunctioning• RecommendedforchildrenwithADHD• TheFeingoldDietandFoodAdditives(interventionforADHD)• Promotes elimination of most food additives and certain natural compounds called

Salicaylates• www.feingold.org• Sugarandsweeteners–shouldberemovedfromthedietandtheseprovidenonutrients,

badforteeth.• VitaminsandMineralsimportantforADHD(Zinc,MagnesiumandIron)• Neededbythebodytocarryoxygentothebrain• Irondeficiencyiscloselylinkedtochildrenwithlearningbarriers(legumes,meat,diary)• Magnesium(nuts,seeds,prunes,cheddarcheese,greenveggies)• Zinc(lowlevelsarelinkedtoashortsupplyoffattyacids)(seafood,oysters,redmeat)

AssiststhechildtoabsorbmedicationforADHD.• Herbalremedies(EveningPrimroseoil,helpsregulateourblood,hormonesandimmunity

becauseithasGamma-LinolenicAcidsGLA’s)• AcombinationoffishoilandEveningPrimroseoilwillhelpchildrenwithADHD(veryfew

sideeffects)Notmorethan9%-veryNB!!!1-2grams2timesaday.