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8/21/2019 Attention Disorders
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ttention Disorders
AD/HD and Its Relationship to
Executive FunctionsClare B. Jones, Ph.D.
Jill Fahy, M.A., CCC-SLP
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Jill Fahy,Attention Disorders, employed by Eastern Illinois University
Disclosure:Financial- Author for LinguiSystems, Inc. and receives royalty payments. In
addition, Jill Fahy received a stipend from LinguiSystems, Inc. for writingAttention
Disorders.
Nonfinancial- No relevant nonfinancial relationships exist.
LinguiSystems, Inc., publisher of products for SLPs, funded this self-study online, , .
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About the AuthorsClare B. Jones, Ph.D., was a diagnostic specialist in private practice in Scottsdale,
r zona. are rece ve er un ergra ua e egree rom ra e n vers y n es
Moines, Iowa; her masters from Cleveland State University; and her Ph.D. from theUniversity of Akron. She did post doctorate work at the University of North Carolina,
Chapel Hill. Clare was in private practice for over fifteen years and specialized in
c ren, young a u s, an a u s w spec a nee s ages zero o a u . er areas o
expertise included attention disorders, learning disabilities, and drug exposed children.
Clare authored seven books, including The Source for Brain-Based Learning and
rac ca ugges ons or , o pu s e y ngu ys ems, nc. e a so
served as editor to three books and published numerous articles. She was on the
editorial Advisory Board for the Journal of Attention Disorders and served on the
editorial Internet Board forADDitude Magazine. She also served on the Professional
v sory oar or . er am y as es a s e a sc o ars p n er memory athe University of Arizona.
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About the AuthorsJill Fahy, M.A., CCC-SLP, is assistant professor at Eastern Illinois University, in
, .
masters degree in speech pathology from the University of IllinoisUrbana-Champaign. For a number of years, Jill worked as a medical SLP, treating mostly
adults with acquired brain injuries. She specialized in the treatment of cognitive
,
those high-level deficits that impacted vocational and community independence.
Jill is co-author of The Source for Development of Executive Functions, published
by LinguiSystems, Inc. She is a nationally-known speaker on the topic of executive
function development and disorders. At Eastern Illinois University, she is a highly
sought-after diagnostician for children with disorders of right hemisphere
development and concomitant executive function deficits, primarily for Aspergers
an onver a earn ng sor er. eac es courses n acqu re anguagedisorders, and developmental disorders of executive functions and the right
hemisphere.
44
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Terminology Throughout the course, the termAD/HD will be used.
The slash ( / ) indicates with or withouthyperactivity.When the term AD/HD is used, considering it as
.
Additionally, the term executive functions will be
abbreviated to EF.
5
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Course Description
This course is desi ned to hel the SLP learn more
about AD/HD and its relationship to executivefunctions. A thorough description of the disorder is
,
research and practical suggestions for assessment,
behavior management, and adaptations for clientsages birth to adult.
6
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Learning Outcomes Participants who successfully complete this course
will be able to: Identify the operational definitions for attention and executive
functions.
Understand the criteria, core symptoms, and subtypes of
AD/HD.
.
Discuss the role of the SLP in treating individuals with
AD/HD and associated EF deficits.
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Overview: AD/HD and EFExecutive functions are a cluster of meta-cognitive skills that mediate other cognitive skills, such as perception,
, , . ,
rely on an extensive network of afferent and efferent neurons that relay information about internal states of being
and external stimuli. Executive functions can be described by the role they play in regulating and mediatingresponses, behaviors, and efforts. Although there is yet to be a general agreement upon the exact components
of executive functions, they are typically defined as processes of goal-selection, planning and organization,
initiation of efforts, persistence and flexibility of efforts, self-regulation of efforts, and inhibitory control
of disruptive or sabotaging responses. How one determines behavior, controls the timing of behaviors,
focuses attentional effort towards mental management of problem solving, self-monitors the impact of behaviors,
and adapts as necessary are all functions of the executive system.
Typical development of executive functions occurs over the first two decades of life. The role of fully developed
executive functions is to provide one with the capacity to apply knowledge to situational demands, account for and
manipulate impulse, and generate flexible solutions in both routine and novel situations. There is some suggestion
that executive functions continue to evolve throughout the lifespan, evoking such skills as wisdom and altruism.
Development of self-regulatory executive functions is delayed in individuals with AD/HD. The capacity to inhibit, to
guide and shift attention, and to make use of working memory skills are impaired, resulting in deficient self-control,self-direction, self-guidance, and problem solving. Disruption in these self-regulatory skills impedes the capacity of
an individual with AD/HD to organize his ideas and to apply knowledge for learning, working, or interacting with
others. It is the lack of inhibitory control and poor regulation that are considered hallmarks of AD/HD.
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Overview:
Etiology and Comorbidity of AD/HDAdvances in the information regarding attention deficit have come from the field of genetics and the use of neuro-
-.
also has the disorder. Specific combinations of specific genes are now clearly identified by researchers. In
addition, new research regarding the total cerebral volume of the brain recognizes that it is smaller in individualswith AD/HD.
It is also felt by most researchers that AD/HD may also be the result of an acquired insult to the brain. Disorders
of executive functions are well documented in individuals with acquired injuries to the prefrontal cortex of the
frontal lobe. The prefrontal structures of the human brain are vulnerable to the coup-contrecoup effects of
traumatic brain injury and are prone to damage from underneath where bony structures of the skull encase the
brain. Strokes, tumors, or other focal lesions to the prefrontal cortex are also known to disrupt executive
functioning. Long-lasting sequelae of disrupted prefrontal functioning often include inattention, impulsivity,
, - , , - .
Specific challenges with language, learning disabilities, and motor coordination are frequently noted
in individuals with AD/HD. Early identification of these challenges is important, as individuals with AD/HD have
higher rates of disruptive behavior disorders, are vulnerable to alcohol and drug dependence, and are at risk for
academic failure. Lan ua e la s an inte ral role in the en a ement of executive functions to su ort behavioral
regulation. The ability to engage working memory allows us to hold rules in mind while generating plans to acton those rules. The development of language also allows for the representation of direction, intention, and
predictionall of which are necessary to executive functioning. Finally, self-talk, internalized as inner speech,
is necessary to mediate behaviors in time and space through shifting, inhibition, and initiation.
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Overview:
Treatment and Management of AD/HDAD/HD is a life-span disorder and it is managed, not cured. Students with AD/HD may have the right to
classroom. They may be eligible for Federal Provisions, and these requirements can follow them through their
school years into college, and eventually into the workplace. Adults have their own unique needs regarding thediagnosis. Sophisticated levels of self-awareness are necessary for the adult to be aware of his own strengths
and weaknesses and to know when and how to compensate in order to perform at his highest level. Multiple
resources exist within communities and within the nation. A National Resource Center for Attention Disorders has
been created in Washington and a national support group, Children and Adults with Attention Deficit Disorder
(CHADD), offers educational resources, materials, networking, research information, conferences, and advocacy.
Behavioral therapy and pharmacotherapy are primary means of providing treatment for AD/HD. Historically, the
use of stimulant medication as a part of the multi-modal treatment plan continues to generate controversy.
-
symptoms in children and adults. The medication has its limits and, for some, side effects. Recent research is
finding potential in non-stimulant medications, although further research is needed. The use of medication in
a treatment plan is solely the decision of the physician and the parent, and no one single drug is beneficial for all
individuals.
Research further suggests that medication should be used in conjunction with behavior management techniques,education, and skill building (e.g., self-management, study techniques). This multi-modality approach includes a
cluster of interventions, including parent/teacher understanding and training, training of meta-cognitive skills to
support self-regulation, teaching of problem solving and social skills, and environmental modifications. Teachers
need to be aware of seating arrangements, curriculum tools, and teaching strategies that can support the AD/HD
1111
student in a classroom.
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Overview:
Role of the SLP in AD/HDA speech-language pathologist (SLP) may be involved with students with attention deficits as a member of a
,
communication disorders, or as a consultant to others. Individuals with AD/HD are at risk for challenges with
language, particularly in the areas of form, content, production, and use. They tend to have more difficulties withinternalizing language and this is often evident early in life.
,
see deficits in attention and executive control in combination with other speech and language disorders. The SLP
serves as the expert in language and communication assessment and must be able to discern the relationship
between language, attention, and executive functions. Children with AD/HD often have concomitant language
delays and learning disabilities. SLPs may offer suggestions to classroom teachers for how to focus attention;provide verbal instruction; ensure comprehension and memory; organize expressive communication; and use
language for reasoning, self-talk, and problem solving.
In the medical world, SLPs treat the meta-cognitive and cognitive disruptions resulting from secondary AD/HD
due to trauma. Treatment options are better established in the realm of acquired deficits through such approaches
as cognitive rehabilitation. These patients require skill and knowledge from the SLP to determine plans of
treatment to rehabilitate and/or compensate for inattention, impulsivity, disorganization, and impaired self-regulation associated with acquired attentional deficits.
Ultimately, the goal of any SLP working with an individual with developmental or acquired attention deficits is to
romote inde endent and efficient communication and the use of lan ua e for self-re ulation, roblem solvin ,
12
and social competence. In addition to the role of service provider, SLPs may serve as resource professionals,
consultants, diagnosticians, and counselors.
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Historical Understanding of AD/HD disorder was identified as early as the eighteenth
century
early labels for AD/HD included:
restlessness syndrome (1920s)
hyperactivity syndrome (1950s) minimal brain dysfunction (1960s-70s)
DSM Classifications
- ,
DSM-III, 1980attention deficit disorder
DSM-IV, 1994subtypes of attention deficit disorder
14
- ,
14
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Current Thinking on AD/HD AD/HD is now thought of as a disorder of the
development of executive functions.
An inability to inhibit, organize, and maintain
the problem, rather than general inattention.
Conflicting viewpoints which are not yet fullyunderstood are emerging.
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AD/HD is a Disability
In the fall of 2001 the sur eon eneral noted that
AD/HD is a neurobiological disability. AD/HD is a chronic condition.
Without treatment, AD/HD can have serious
consequences including: school failure and dro out
depression
substance abuse
of school-aged children.
Ongoing communication with school personnel is
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critical.
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American Academy of Pediatrics
Clinical Practice Guidelines
These uidelines were written in res onse to the
surgeon generals statement. The guidelines suggested that physicians:
establish treatment as a chronic condition
treat patients in collaboration with school personnel
target management outcomes
continue to evaluate if outcomes are not met and look for other
co-occurring conditions
re uire eriodic u dates from arents teachers and
the child
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The Diagnostic Statistical Manual
o en a sor ers -
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The DSM-IV Criteria for AD/HD The Diagnostic Statistical Manual of Mental
Disorders (DSM-IV) defines AD/HD by specific
criteria.
are used as the first measurement for determination
of AD/HD.
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The DSM-IV Criteria for AD/HD, continued Criteria are subdivided into three symptom types:
inattention
hyperactivity
Symptoms must be present for at least six months to
a point that is disruptive and inappropriate fordevelopmental level (DSM-IV).
The diagnosis can be with or without visible
.
In the case of the inattentive type, the brain will be very
active, racing from one idea to another, but the body
2020
.
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Additional Criteria for
AD/HD Diagnosis
S m toms must be resent in two or more settin s
(work and home). Some symptoms must be present before the age
o seven.
The individual must show clinically significant
im airment at work or school or with other eo le.
The individual must not suffer from another mental
disorder, such as a closed head injury, that could
exp a n e symp oms.
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Prevalence of AD/HD
Individuals of all intellectual levels ma be dia nosed
with AD/HD. This includes gifted, typical, or learning disabled.
s a me ca con on agnose n - o
children.
More than 60% of cases extend into adulthood.
More males than females are diagnosed with AD/HD.
childhood ratio 3:1
adult ratio may be 1:1
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Prevalence of AD/HD, continued Most females are diagnosed later in life
It may be that more females have AD/HD without
hyperactivity, which is often overlooked and not
diagnosed until later in life.
There are cultural differences in what is considered
to be normal attention
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The DSM-IV Identifies
Three Types of AD/HD
AD/HD redominantl inattentive t e
if inattentive criteria are met, but not hyperactive criteria AD/HD, predominantly hyperactive-impulsive type
if hyperactive criteria are met, but not inattentive criteria
AD/HD, combined type
Symptoms must be disruptive and inappropriate for the
childs developmental level for at least six months.
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AD/HD Predominantly Inattentive Subtype
Six or more of the followin must be resent for six
months: often ignores details, makes careless mistakes
often does not seem to listen
often does not follow through on instructions often has difficulty organizing tasks
often avoids activities that require a sustained mental effort
often loses thin s he/she needs
often gets distracted by extraneous noise
often is forgetful in daily activities
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AD/HD Hyperactive-Impulsive Subtype
Six or more of the followin must be resent for six
months: hyperactivity
often has to get out of seat
often runs about or climbs when/where not appropriate
often on the go as if driven by a motor
often talks excessively
mpu s v y
often blurts out answers to questions before questions are
completed
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often interrupts or intrudes on others
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A omparison of the Two ubtypes
w t
hyperactivity over-aroused
w t no
hyperactivity no arousal
behavior problems
cant control response
sensory problems
cant control attention
socially rejected
more aggressive
socially ignored
less aggressive
antisocial, immature apathy, lethargy
Kohner and Romero, 2001
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Growing up AD/HD With Hyperactivity
A Comparison by Age Range
Preschool Elementar Adolescence
hyper fidgety Restless
uncontrolled talking talks excessively talks out without regard for
others
begins to resist order and
routines
shows inconsistent
erformance
has problems at school
aggressive in play bossy; not a team player seems immature
attention
demanding personality appears careless poor judgment
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AD/HD Combined Subtype is the most common type
reflects a combination of both types of symptoms
inattention
may show a combination of academic and behavioral
problems typically, the inattentive type may experience more academic
problems and the hyperactive/impulsivity type may
experience more behavioral issues
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New Subtypes?
,
we may begin to identify more distinctive subtypes ofAD/HD.
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Development of Attention and
xecu ve unc ons
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What is Attention?
Attention
. . . the relationship between the environmental event and the
persons response to it.
. . . .
. . . to produce . . . an immediately available consequence . . .
(Barkley, in Lyon and Krasnegor, p. 309) In plain English
Attention is a cognitive behavior, either external or internal,
which is in response to some trigger in the immediate
environment, which causes yet another action.
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Types of Attention Focused
the act of turning ones cognitive focus toward a stimulus; the
acknowledgement of an event in the environment, or from within
the act of sustaining ones focused attention over a period of time
toward the stimulus, which may be an external or internal event
e ec ve
the act of determining which stimulus to attend to when
competing stimuli are present; selective attention should allow
or gnor ng non-re evant or stract ng nput, w c may e anexternal, or internal event
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Types of Attention, continued Alternating
the act of selectively attending over time to first one stimulus,
then another, and back again
the act of selectively attending to multiple relevant stimuli
simultaneously
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What are Executive Functions? behavior about, and upon, behavior
behaviors that link events, responses, and
consequences not otherwise related by time
equ va en o me acogn on
cognition about cognition (Flavell, et al.)
a function that selects, controls, and monitors the useof cognitive strategies
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What are Executive Functions?, continued mental processes
effortful, flexible, strategic, proactive
anticipatory, goal-oriented
delay between thought and action
attention to the future
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What is the Relationship Between
Attention and EFs? EFs require attention to form responses or behaviors
in the present or in a future time-frame
alter subsequent consequences of the original event
,
time
to demonstrate attending behavior to desired or required stimuli in the moment
attention provides a foundation for EF control
without inhibitory control, attention cannot be directed
appropriately.
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Frontal Lobe Development Massive surges in frontal lobe development take
place over the first two decades of life.
Synaptic density, myelination, and neural network
efficient, effective self-regulation.
By our mid-twenties, myelination in the frontal lobetapers off and neural connections stabilize.
Neural plasticity allows for constant growth, if
,
decline a bit in mid-life.
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Development of Executive Functions Executive functions emerge as a factor of frontal
lobe development.
Specific EF skills emerge, develop, and mature
.
EF skills are not done until the early twenties, when
independent levels of life-goal selection, delay inimmediate reward for long-term gain, and
complex/abstract problem solving are expected.
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Development of Attention and Inhibition Birth1 3 years of age
impulse-driven and
distractible early inhibitory control
cant delay gratification
maybe able to processone simple rule
simple, focused attention
emerges
continued emergence of
attention and self-control
skills-
simple shifting of attention
inhibition
shift between tasks, one
at a time
4 ears of a e
immature attentional skills
no self-correction
still impulsive, but less emerging ability to delay
41
,
minimal inhibitory control
goal for a better reward
later41
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Development of Attention and
Inhibition, continued 5 years of age 6 year of age, continued
impulsivity still declining
language still increasing processing requests and
-
language processing helps
inner speech begins 7-9 year olds
helps to balance internalneeds with external
demands
attentional skills more selective
and deliberate
more success switching
can sw c e weenmultiple sets of rules
continues to delay someinitial choices, if cued
multiple rules, demands
language is on board, if typical
continued use of silent verbal
externally 6 years of age
starts to be more self-
self-talk rapid surge in planning,
organization
42
con ro e
attention definitely better;
can resist distractions
can manage more task
parameters42
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Development of Attention and
Inhibition, continued Adolescence Early twenties
relative maturity of
attention and inhibition
working memory
EF skills come into full
maturity adapts to changes
language processing
cognitive flexibility
decision making skills
engages in goal-directed
behaviors
makes ethical, moral, legal deliberate behaviors
multi-goal oriented
efforts
decisions
avoids sabotaging our
efforts with impulsivity or
can orc es ra e an
obtain goals
multi-strategy
develo ment
implements necessaryself-control
43
parameters of our society43
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Who Makes the Diagnosis?
t icall a h sician with understandin of the childs
background history, parents histories, and information
from school
or, a psyc a r s w access o e same a ove
information
or a mental health rofessional s cholo istnurse practitioner) with access to the same above
information
w oever ma es e agnos s s ou ave access oand communication with a team of professionals,
parents, and teachers
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ow s e agnos s a e
AD/HD is rimaril an observational dia nosis.
Information is collected by a number of individualsacross a variety of situations and interactions.
There is no one particular test or tool that identifies
AD/HD.
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agnos c a ery Multi-dimensional evaluation includes:
observations
questionnaires
self-reports
clinical assessment of:
a en on
other cognitive skills (memory, perception, reasoning)
metacognitive skills (executive functions)
anguage
sensori-integration abilities
medical evaluation to rule out other primary cause of AD/HD
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Purposes of Assessment
identif a rofile of self-re ulator stren ths as well
as weaknesses
understand potential areas for intervention that may be
respons ve o suppor s
identify types of intervention that may be appropriate,
includin environmental modifications teachinstrategies, and skill development
identify degree to which individual is aware of his or
er e c s, s s, nee s, e c.
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Purposes of Assessment, continued
identif lan ua e foundation to rule out ossibilit of
needing a related service and to understand the
potential for use of self-talk to guide self-regulation
prov e careg ver an eac ers w more spec c
and focused interventions
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Questionnaires and Rating Scales
for Attention Conners Third Edition Conners 3
6-18 for teacher and parent rating scales for AD/HD
8-18 for self-report rating scale for AD/HD
onners u a ng ca es
18 and older; self-report, observer ratings
Conners Com rehensive Behavior Ratin Scales(Conners CBRS)
symptom scales for AD/HD, ODD, conduct disorder, and others
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Questionnaires and Rating Scales
for Attention, continued The ADD-H Comprehensive Teacher Rating Scale
e econ on
teacher, parent, and self-report, K-8th grade attention, hyperactivity, social skills, and oppositional
behavior
Attention-Deficit/Hyperactivity Disorder Test (ADHDT)
ages 3-23 completed by parents, teachers, or others familiar with the
child
Child Behavior Checklist and Adult Behavior Checklist
ages 1.6-5; ages 6-18; ages 18-59; ages 60-90 caregiver-teacher report form; self-report form
51
Q i i d R i S l
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Questionnaires and Rating Scales
for Attention, continued Behavioral Rating Inventory of Executive Function
Preschool Version (BRIEF)
preschool, ages 2.05.11; child/adolescent, ages 5-18; adult,a es 18-90
parent form, teacher form, self-report
ADHD Symptoms Rating Scale (ADHD-SRS)
ages - , two su sca es
Childhood History Form for Attention Disorders
histor intake form for arents
Brown Attention Deficit Disorder Scales (BADDS) children, ages 37, ages 8-12; adolescents, ages 12-18; adults,
52
ages an o er
52
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Assessment Tools for Attention Test of Ever da AttentionChildren TEACh
ages 6-16
9 subtests of attentional skills
es o ar a es o en on . . . .
ages 4-80
evaluates attention in visual and auditory informationprocessing
Conners Continuous Performance Test II Version 5
.
ages 6 and older
attention problems, especially in AD/HD population
5353
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Assessment Tools for Attention, continued Stroop Color and Word Test
ages 5-14; ages 15-90
inhibitory control, cognitive flexibility
ages 8-16
sustained attention and sequencing associated with AD/HD Color Trails Test (CTT)
ages 18 and older
54
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Assessment Tools for Attention, continued
d2 Test of Attention
ages 9-59
processing speed; complex attention
ace u ory er a on es
adults
sensitive to TBI-induced AD/HD Mesulam and Weintraub Cancellation Test
ages 17 - 79
ver a an nonver a arrays
sustained, selective attention; organization; monitoring
5555
A t T l f
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Assessment Tools for
Executive Functions Functional Assessment of Verbal Reasoning and Executive
ra eg es
Ages 18 - 79 TBI populations
er a reason ng, xecu ve unc ons, use o rea -wor as s
Behavioral Assessment of Dysexecutive Syndrome (BADS)
Ages 16 - 87
xecu ve unc ons, use o rea -wor as s
Behavioral Assessment of Dysexecutive Syndrome - Children
(BADS-C)
ges -
Executive functions, use of real-world tasks
5656
Assessment Tools for
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Assessment Tools for
Executive Functions, continued Delis-Kaplan Executive Function System (D-KEFS)
Ages 8 - 89
Executive Function components within verbal and visual tasks NEPSY II
Ages 3 - 16
Attention domain
Executive Function domain
Tower of London (TOL-DX) 2n Ed.
Ages 7 15, Ages 16 - 80
Executive planning, attention, problem solving
57
Assessment Tools for
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Assessment Tools for
Executive Functions, continued Ruff Figural Fluency Test (RFFT)
Ages 16 - 70
Nonverbal problem solving initiation, fluency, and flexibility Wisconsin Card Sorting Test (WCST)
Ages 6.5 - 89
Sensitivity to frontal lobe dysfunction, strategic planning
and shifting
5858
Non-Standardized Observation of
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Non-Standardized Observation of
Attention/EFs in Real-World Tasks Direct observation, both interactive and physical
Classroom performance
Social interaction Allow for child to independently demonstrate success and/or failure
Do not step in to be their frontal lobe!
5959
Non Standardi ed Obser ation of
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Non-Standardized Observation of
Attention/EFs in Real-World Tasks, continued
Note the following attention and executive function
components:
Ability to focus on relevant information
Abilit to inhibit distraction from extraneous stimuli
Ability to initiate/sustain efforts until task is completed
Ability to develop and engage in a sufficient plan
Ability to interpret unspoken, yet implied, requests or directives
Ability to use language as a mediating tool for self-help
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Comorbidity Speech and language disorders occur in up to 17-38% of
individuals with AD/HD.
Anywhere from 25-50% of children with AD/HDhave some kind of learning disability.
Between 42% and 61% of children with AD/HD also have
oppositional defiant disorder (ODD).
50% of those dia nosed with AD/HD ma meet criteria for disru tivebehavior disorders.
25% of individuals with AD/HD have anxiety.
- .
AD/HD occurs in 27-75% of persons with tic disorders.
6262
What Is the Link Between Attention
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What Is the Link Between Attention
and Language? Attention supports sufficient working memory stores:
Verbal working memory supports linguistic processing.
Comprehension and formulation of language relies on holding thought inworking memory.
Working memory allows for the mental manipulation of thought,
encoded in language, for the consideration of:
Past outcomes + current requirements
Viable options, which lead to
behavioral decision-making and regulation
6363
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What Is the Link Between Attention
and Language?, continued These are collectively part of the executive control of behaviors.
The internalization of language provides for inner speech.
Self-talk supports behavioral regulation and executive control.
64
What Is the Impact of AD/HD
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p
on Communication? Disrupted receptive language
Inaccurate or incomplete comprehension
Poor recall of directions, instructions, explanation
Narratives lack cohesion
Circuitous discourse
ss ng re evan e a or ma n ea
Pragmatic inappropriateness
Interruptions, disruptions
Off-topic, irrelevant comments Poor follow-up, reciprocity
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What Is the Impact of AD/HD
on Communication?, continued
S eech rate elevated
Verbal reasoning and problem solving Overlook relevant details
Draw inaccurate conclusions
Overlook potential options
e -ta or execut ve contro
Disrupted flow of inner speech
-
Inattentive efforts toward self-monitoring
Unaware of unintentional errors
6666
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What Is the Impact of AD/HD
on Communication?, continued Memory
Impacts reliability that all content was noted and stored
in memory Social competence
Inattentive to relevant nonverbal cues
Misinterpretation of social situations
Reading and writing Unintentional errors, incomplete efforts
Misunderstood content
Disorganized output
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D/HD Across
A Chronic Condition
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Chronicity of AD/HD Symptoms can be seen as early as three years of age and
c ange s g y as e c ma ures.
Children with AD/HD do not outgrow it. The disorder is chronic and exists throughout a life span.
There are an estimated 4.4 million children with AD/HD in the
United States.
These children, a es four to 17, constitute 7.8% of the eneralpopulation.
(Visser and Lesesne, 2005)
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Symptoms and Behaviors:
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Impact on Life, Independence The behaviors associated with the disorder
change as children grow older.
Core symptoms of the disorder are still recognizable. Older adolescents or adults may be more readily able to
cope with the symptoms.
Change depends on the degree to which the individual is aware
and is able to exert executive control over behaviors, efforts, work,
an soc a n erac ons.
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oc a a ura on esearc Further studies in the disorder indicate that students with AD/HD
have unique social immaturities.
They are almost two years delayed in their social maturation. This follows them throughout life.
For example, at age eight, they will act more like a six-year-old than their
same-aged peers in social situations.
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Social Interactions Most persons with AD/HD perform better in independent sports
(e.g., martial arts, swimming,
golf, biking). Children with AD/HD need to be active participants.
The position in team sports can make a difference (e.g., pitcher or
catcher would be a better position than outfield in baseball).
We need to encourage their early involvement with multi-agegroups, such as Boys and Girls Clubs or scouting. By middle
school, they will benefit from a relationship with a mentor, coach,
or tutor.
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Brain Differences in AD/HD Diffusion tensor imaging (DTI) reveals white matter differences in
the frontal cortex, basal ganglia, brainstem, and cerebellum.
Frontal lobes in children with AD/HD were 3-4% smaller than brainsof children without AD/HD.
Individuals with severe AD/HD symptoms had smaller frontal lobes,
temporal grey matter, caudate nucleus, and cerebellum.
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AD/HD without hyperactivity associated with deficits in right
Brain Differences in AD/HD, continued
posterior cortex
AD/HD with hyperactivity associated with deficits in leftanterior cortex
(American Academy of Child and Adolescent Psychiatry 54th Annual Meeting: Symposium
2. October 23-28, 2007.)
75
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Brain Differences in AD/HD, continued Adults with AD/HD have smaller volume measurements in frontal
o e orso a era pre ron a cor ex an an er or c ngu a eareas
of the brain associated with attention and executive control).
Frontal lobe was 6.3% thinner in patients with AD/HD than in
con ro s n area o e ra n assoc a e w a en on an
executive control).
Studies of dopamine indicate high levels of this neurotransmitter in
more yperac ve persons.
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Brain Differences in AD/HD, continued
Decreased glucose metabolism in left frontal and parietal
regions
Sections in the right hemisphere (globus pallidus, caudatenucleus, vermis) appear smaller in many adults with AD/HD noton me ca on (Barkley, 1990, Castellanos et al., 2002).
Overall brain size is about 5% smaller. (Swanson et al.,1998).
77
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Normal Adult Brain
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79
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Genetic Implications Heredity could be considered a risk factor.
10-35% of the immediate family members of children with ADHD are likelyto have the disorder.
Siblings of persons with ADHD are 32% more likely to have the disorderthan eo le who do not have a siblin with ADHD.
Gene mapping studies are beginning to focus on gene defectivepatterns within the total population with AD/HD and are noting:
The D4 gene is defective or a marking is noted in the inattentive type.
This differs from gene markings in the combined, aggressive, orexplosive type.
(Cook et al., 1995; Swanson et al., 1998; McCracken et al., 2000)
8080
AD/HD as a Secondary/Acquired
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Disorder Traumatic changes to the frontal lobe
Traumatic brain injury (TBI)
Primary blast injury (PBI)
Environmental exposure to neurotoxins
Fetal alcohol syndrome
Maternal crack/cocaine addiction
Depression- or anxiety-induced AD/HD
Inattention due to other disabilities
Learning disabilities
Fragile X syndrome
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Developmental Delay? There are some conclusions that AD/HD reflects
a yp ca y- eve op ng ra n u s agg ng n ma ur y.
This implies that with age, the gradual development of attention,
inhibition, organization, and other executive functions will catch
up.
This concept is yet to be fully understood or researched.
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AD/HD in Early
Childhood83
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The Infant with AD/HD Hyperactivity Mother notes child is very active in womb.
Excessive crying and colic first months
Poor sucking, little smiling
excessive crying and lack of cuddling behavior
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The Infant Without Hyperactivity Easy-going temperament
Mellow, laid-back attitude
Falls asleep often while nursing
Quiet manner
Seems to be a daydreamer
8686
Toddler Stage
f B th H ti d I tt ti
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for Both Hyperactive and Inattentive
compliance of child
High stress time for parents and lowered-
Attachment ratings at 12-18 months relate to not attending to
parent and social readiness issues
ess apt to remem er sequent a tas s e.g., earn ng p onenumber, learning home address, learning ABCs)
8787
P h l
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Preschool Zenith of parental stress occurs when the child
is between three and six years of age
Active preschoolers demonstrate: excessive activity
noncompliance
difficulty in toilet training
frequent shifting of activities in free play
early rejection by peers
8888
P h l continued
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Preschool, continued There is an increase in the number of referrals for hyperactivity in
three-to-four year olds.
This may be due to increased environmental demands on the child(e.g., large daycare situations, less managed free time) and
situations.
It may also be a result of preschool teachers being more alert to the
dia nosis. Teachers note differences in behavior in the areas
of impulsivity and independence.
8989
Common Behavior Problems in
P h l Child ith AD/HD
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Preschool Children with AD/HD Tantrums and meltdowns
Sleep, bedtime, and naptime problems
Noncompliant Short attention s an
Does not share toys
Does not play well with other children
,
(Kaiser, 2004)
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a erna eac ons Mothers of infants with this disorder:
Feel less secure in their parenting roles
Are more apt to seek help from professionals
Early mother-child conflicts predict later, serious
social issues for the child.
Mothers of toddlers with AD/HD make more corrections of their
children in social situations
than typical same-aged peers.
9191
n c ans ee o e are o
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n c ans ee o e ware o Temperament issues
Often do not like to be held
Do not seek out maternal attention when stressed
May appear angry
ommun ca on ssues High rates of language disorders
Frustration
Early differences in developing impulse control
9292
Clinicians Need to Be Aware of continued
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Attachment issues
Clinicians Need to Be Aware of, continued
Often send out negative and avoidant messages
May demonstrate ambivalence or resistance when
Develop inadequate bonding with the caregiver/ parent
May have emotional detachment
c v y eve At risk for injury
Require increased amount of supervision
The parent who is unable to control and guide may feel
like an ineffective parent
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AD/HD in School-Aged
Children94
AD/HD and the School-Aged Child:
Needs
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Needs Child with AD/HD, language disorder, and a behavior component
Is appropriate for referral to school psychology
Is appropriate for language-based interventions to support
the development of self-talk
Is appropriate for environmental modifications to support focused
attention
May also be appropriate for curricular changes to support learning
9595
What Works for the School-Aged
Child with AD/HD
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Child with AD/HD Educate others
Help the parents/family understand the disorder.
Help the teacher/educator understand the disorder.
Promote a healthy self-esteem for the child.
Find what the individual does well.
Promote success in balance with deficits.
Offer verbal praise and concrete rewards for specific accomplishments or
. Foster successful social interaction and competence.
Identify social deficits in specific situations.
.
Teach specific social skills and promote carryover.
9696
What Works for the School-Aged
Child with AD/HD, continued
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Child with AD/HD,
Discuss the use of harmaceutical intervention.
With family and physician
Prevent behavioral problems. ommun ca e expec a ons.
Be responsive to childs own needs for communication.
Give fair consequences for actions taken.
Use successful behavior modification techniques.
Positive reinforcement
Token program
Response cost
9797
What Works for the School-Aged
Child with AD/HD, continued
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Child with AD/HD Modif the environment.
Arrange the environment to encourage feelings of control
and comfort. Provide structure and routine with brevit and variet .
Organize material and content in the environment.
De-junk the environment to free it from unnecessary
distractions. Modify language when talking with child.
Give short, brief instructions with eye contact.
epea , rep rase.
Require confirmation that the child understood the message. Offer forced choice questions to promote communication
9898
of abstract concepts, feelings, emotions.
What Works for the School-Aged
Child with AD/HD, continued
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Child with AD/HD Teach language for inner speech, metacognition, and executive
control.
Teach vocabulary for wants, needs, and emotions.
Want versus feel versus know
rov e an array o emo on-wor op ons.
Teach vocabulary for thinking, planning, and deciding.
Thinking and planning verbs
Deciding verbs to reflect intent rather than impulse
Predicting and comparing syntax structures (ifthen)
Semantic knowledge to support comparing pros and cons of potential decisions
Planning and sequencing words, to offer temporal order of ideas
Self-talk hrases, such as STOP-THINK-PLAN-DO
9999
a oesn or
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a oesn or Herbal therapy
Biofeedback
Biofeedback is a laboratory procedure used to train
subjects to alter their brain activity.
as no ye een assesse or sa e y an e cacy
using standard scientific methods.
Mega-vitamin therapy
e res r c ng oo yes an sugar Occupational therapy as the onlyintervention
100100
What Are the Risks of Children Who
Receive No Support or Treatment?
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Receive No Support or Treatment? At risk of not develo in their full otential
as students or adults
At risk of behavior disorders
Are more likely to abuse drugs than children
with AD/HD who are treated
(Voeller, 2004)
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103103
Responsibilities of the Professional
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Responsibilities of the Professional The role of educating the caregiver(s) becomes the responsibility
of the clinician and/or the professional who made the diagnosis.
Parents should be given a variety of resources to review and study
and an opportunity to work with someone on learning how to
manage the disorder.
104104
e p ng am es n ers an
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e p ng am es n ers anRussell Barkle leadin researcher in the area of
attention deficit, writes:
Information is the essential linchpin in treatment. Itoesn ma er w a o er s ra eg es you use, e rs
thing you should
do is educate the family about the disorder. Education
brings about more change than
any other psychosocial intervention.(Barkley, 1990)
105105
at am es ee to now
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at am es ee to now Their family biological history
The prevalence of AD/HD in their family and
the general population
The s ecific dia nosis for their child
Strategies and skills to deal with their child
How to deal with the core symptoms
106106
Gathering Family History
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Ga e g a y s o y If the mother has AD/HD, the likelihood of her
c av ng more cu es w e sor er ncreases.
There is a high correlation of children with AD/HD having
mothers who smoked during pregnancy.
80% of all children diagnosed with AD/HD have
a mom or dad who also has it.
107107
Family Therapy as an Option
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y py p Can focus on role of educating parents and family
about features of AD/HD
May offer suggestions in effective parenting skills
Can romote attachment and bondin throu h discussion of childs
strengths, in addition to challenges
Can support development of family cohesion and problem solving
Fosters a sense of being proactive toward managing issues
108108
Supports for Families at Home
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pp Family understanding and education regarding
the disorder is critical.
Caregivers will want to help the family withor anization and structure within the home.
Make the family aware of resources available within
the community.
109109
uppor s or am es a ome, continued
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pp National support group information:
CHADD 1-800-233-4050
www.chadd.org , ,
habits parents need to encourage
in their children with AD/HD.
110
Parenting Techniques
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g q The use of ositive and su ortive arentin techni ues is
important.
Negative, critical, and demanding parenting stylesare associated with chronic and significant behavioral problemsas e c ages.
A child who is exposed to a background of poor parentingpractices is frequently hostile, avoidant,
.
111111
Actions Parents Can Take
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Read and learn more about the disorder.
Network! Learn from other parents.
Set goals! Inform! Let teachers and other famil members know about
your child. Emphasize what the child can do, not what he/shecant do.
Tell the children about their challenges! Help the children
empower themselves to make positive changes. Gather resources!
Be involved, positive, and proactive!
112112
A Suggested Time Line for
Parents of Children with AD/HDTime Line
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Time Line
understand the diagnosis
bibliotherapyinform parents
obtain resources
inform teacher stud skills mentor
confer with physician
outside activitiesstay involved in school
organizational tools
self advocacysocial skills
504 accommodations
tutoringprep for college
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Educational
Intervention
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115115
Proverbial Wisdom
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Tell a child what to think, and you make
.
Teach him how to think and ou make
all knowledge his slave.
-Henry A. Taitt
116116
IEPs and 504s The child may be eligible for an IEP or 504 accommodation plan
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The child may be eligible for an IEP or 504 accommodation plan
ase on sa y
According to IDEA, AD/HD may be eligible under categories that
may include: OHI (other health impaired)
SLD (specific learning disability)
ED (emotional disability), depending on how it manifests
Modifications may include:
Alternative methods and expectations for learning
117117
s an s, continued Accommodations do not ensure success.
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They do allow for access to the curriculum and the educational
environment.
Know the child! Evaluation helps determine what.
118
Proactively Managing IEP and 504
Accommodations Know your students and their accommodations.
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y
Keep folders of accommodations handy.
Periodically review accommodation plans
Identif otentiall successful teachin strate ies
or environmental accommodations that might be
useful to all students.
119119
Adaptations in the Classroom Students with AD/HD have difficulty processing and focusing on
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y p g g
e env ronmen o e c assroom.
Environmental accommodations that organize information help to
reduce distractions. Labeled storage and holding bins support the students efforts to
self-organize.
Predictable routines and written steps/sequences also help the
students efforts to self-regulate.
120120
Factors for Classroom Success Teachers understanding of the disorder
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g
Empathy, not sympathy
The teachers understanding of the students slower social
maturation rates
Preferential seating within the range of the teacher/model
Students with AD/HD are twice as likely to be disruptive in cluster
seating than in U-shaped or traditional rows.
Additional time for written work
121121
ypes o assroom ns ruc on Academic instruction
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Academic instruction
Educator sets learning expectations
Provides an advance organizer -
Explains what will occur in the lessons
Provides hands-on materials and resources
e av or nstruct on Educator provides a well-managed classroom
Offers a number of behavioral interventions to help students learn
to control their behaviors
Use strategies, such as positive reinforcement, response cost,and redirection as necessary
122122
Teaching the AD/HD Student Teaching the AD/HD student is most successful
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g
when the teacher uses:
Short, brief directions
Strong visual depictions
Visual gestures
Strong facial statements
Organizational strategies
Positive modeling and reinforcement
123123
Teaching the AD/HD Student, continued Students with AD/HD respond best to instruction
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p
that offers:
Brevity Activities of short duration
Variety
Diversity, change in pattern
Structure Routine, order, form(Jones, 1991)
124
Compensating for Memory Deficits in
AD/HD
,
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,not the same and the similar!
They will get anA on a spelling test Friday and not know how
to spell the words Monday.ey can remem er w a e eac er wore e rs ay o
school but not remember the teachers name.
Use mnemonics as you instruct. You can remember how to s ell the word friendb
its end, your friend will be with you to the end. Add unusual and different twists to similar tasks.
If you have a younger sister, you may hand inour books first.
125125
Compensating for Memory Deficits
in AD/HD, continued Use color and association to help with focus and
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recall.
Highlight the directions in your favorite color. Then read
them to your partner.
126126
Acknowledge the Students Needs,
an e rect A student may tell you or others in class about his disability.
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I cant do this. I have an attention disorder,
Quickly acknowledge respect for the student that he recognizes his
own challenge.
Immediately affirm that this is why an accommodation
or adaptation is being used.
Yes, you do have attention concerns, Justin, and that is why
I am asking you to color these key words to remember them.
127127
Prepare the AD/HD Student for
Transitions Students with AD/HD have difficulty shifting, adapting, and flexing
iti f f ti it t th t
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cognitive focus from one activity to the next
Teachers, instructors, or other classroom aides can offer help by:
Giving advance warnings of upcoming change
Reviewing events of the day well in advance
Posting schedules, calendars, etc., as visual cues
Using color codes or other hand signals to alert the child to
an upcoming transition
128128
Prepare the AD/HD Student for
rans t ons, continued
Using specific verb phrases to label the behavior needed to
make the transition
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make the transition:
Close notebook
Put down pencil e ou ma oo
Use verbal headlights to mark change.
Class, in five minutes we will need to end this activity. I will give
you a warning at two minutes. Be alert for my warning. Class, as you enter the classroom today, take a look at our daily
schedule. There is a change for this afternoon that I marked in
ue. ou w wan o ge ou your ue pen o mar on your
schedule for the day.
129129
Teach EF Skills to Support
omewor omp et on Goal-determination/self-talk
St t it d th i t d d t
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State or write down the purpose, or intended outcome,
of the students efforts.
What needs to be done? or What I am doing right now?
Use simple forms entitled Things I Need Before I Start.
Provide blank lines for the student to document necessary
items.
Planning and organizing efforts Teach plan-generation How many options can you
think of?
Teach plan-evaluation What is the best solution?
130130
Teach EF Skills to Support
Homework Completion, continued Task sequencing and initiation
Use simple forms with numbered blanks to support
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Use simple forms with numbered blanks to support
step-wise task execution.
Self-monitoring and task completion eac error en ca on, en error correc on.
131
Teach EF Skills to Support Reading
and Writing Goal-determination/self-talk
Read and restate written instructions on papers
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Read and restate written instructions on papers.
State/write the intended purpose of a writing assignment
Planning and organizing efforts Use graphic organizers to sort details into relevant
paragraph groups.
Use graphic organizers to represent relevant versus
rre evan e a s.
132132
Teach EF Skills to Support Reading
and Writing, continued Task sequencing and initiation
Use simple forms with numbered blanks to support
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Use simple forms with numbered blanks to support
step-wise task execution
Self-monitoring and task completion oes my wr en answer ma c e ques on
Find my mistakes. Fix my mistakes.
133
Teach EF Skills to Support Test-
Taking Success Goal-determination
Use self-talk to identify the kind of response demanded by the type of
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y p y yp
question.
Do I choose ONE answer or all possible answers? Is this ,
Attentional focus
Teach self-talk to regroup cognitive efforts
other page?
Self-monitoring skills
Teach self-talk to double check.
Does my answer match the question? Did I answer all of the question?
Did I talk about what the question asked?
134134
ommun ca on w aren s Students do best when arents and teachers
communicate on a regular basis about the students
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communicate on a regular basis about the student s
behavior and learning. se c ec s s:
To support the students transition from school to home
To ensure accurate communication between teacher, student, and
parent Send notes home.
Hi hli ht ositive behavior as well as concerns.
Reinforce successful teaching strategies, for carryover.
Email and phone calls are helpful communication tools.
135135
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Secondary Education
Transitions and Life-Preparation
136
Proverbial Wisdom
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,are preparing to fail.
- Benjamin Franklin
137137
AD/HD and Students at the
Secondary Level and Beyond All of the previous slides would apply to the older student as readily
as they do for the younger student.
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y y g
Adaptations in complexity may be appropriate.
The transition to SELF-re ulation is ke .
138138
AD/HD and Students at the
Secondary Level and Beyond, continued
Hi h school students with AD/HD still re uire su ort articularl in
self-management organization and
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self management, organization, and
study skills.
Hi h school students ma be eli ible for accommodations on a 504
plan.
This plan can accompany them into higher education and be used
as a tool to rocure services in colle e.
139139
IEPs and 504s Under Section 504, students with AD/HD are eligible for specific
accommodations within the classroom, if they are failing to learn.
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They may also be eligible for an individual educational program
(IEP) under the category of OHI, SLD, or ED, if the school teamagrees.
Eligible students may have accommodations in
School
Testing Higher education
The workplace
140140
eep va ua ons p- o- a e
The student with AD/HD will be eli ible for a varietof accommodations under the law.
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To be eligible for such accommodations, he/she must have
documented information andes ng eva ua ons a s ow e s e w ene
from these accommodations.
Up-to-date assessment and diagnostic impressions.
Advocate for these students and teach them toadvocate for themselves for best results.
141141
Classroom Adaptations for the
Secondary Student with AD/HD Preferential seating in class men or or persona coac on s e
A d ti ith kill d fi it
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Accommodations with skill deficits
Cues to aid focus (e.g., color highlighting of keywor s an p rases a s o reca
Provide a note-taker. If the student demonstrates lower scores in visual processing
-, .
Ask a student who takes excellent notes to provide a copy ofthe notes for the student with a documented disability.
Increase personal computer skills and use of electronic plannersan spe -c ec ers.
142142
Teaching Strategies for Secondary
eve u en s w
Provide them with transition tools and additional preparation time.
Keep them with the same teacher longer.
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Try block scheduling.
-
hands-on activities.
Call them by name, to refocus attention and elicit
.
Give them questions in advance.
Provide them with outlines.
143143
Prepare the Secondary Student with
or rans t on to
Life begins to expect growing independence.
EF skills are still lagging behind in this group, making social and/or
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problem solving behavior seem immature.
Pre are the student for real-world res onsibilities. Must have specific input to gain self-awareness
Must be cognizant of own strengths and weaknesses
Must begin to use compensatory strategies independently
Offer support in dealing with stress Will benefit from coping strategies, such as deep breathing
and talk therapy, to help gain self-control.
.,
144144
Prepare the Secondary Student with
or rans t on to , continued Self-Awareness
Promote specific knowledge of deficits, failures, and
break-downs
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break downs.
Promote specific knowledge of means to compensate.
Self-Organization
Work to internalize self-talk.
.
Link compensatory strategies to actual homework,
management of own room, and management of own chores,
or job.
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Prepare the Secondary Student with
AD/HD for Self-Advocacy Prepare the student for self-advocacy.
Is dependent upon self-awareness
Is dependent upon successful internalized use
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Is dependent upon successful, internalized use
of compensatory strategies s epen en upon su c en y organ ze anguage o co eren y
explain, express, convey
Is dependent upon long-term efforts to have promoted good self-
Is dependent upon having learned to inhibit impulses with appropriatewords or behaviors
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Academic/Classroom Skills for
econ ary tu ents The mechanics of classroom performance:
Note-taking
Syllabus reading
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Syllabus reading
Assimilating reading material ann ng a ea
Orchestrating a large multi-faceted project
Will benefit from long-term work on language skills designed to
e p organ ze, sor , en y re evan n orma on, conc u e e
implied, and sequence efforts
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e ng e ca on
Medication is only prescribed by the physician, not the parent,teacher, friend, or neighbor.
The physician may recommend using medication to support focus
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The physician may recommend using medication to support focus
and attention.e me ca ons prescr e are yp ca y s mu an s es gne oincrease activity in the frontal lobes ofthe brain.
not just pills but skills This pill wont work unless you do.
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Stimulants Use of stimulant medication as a part of the treatment plan for
AD/HD has been well documented.
Stimulants produce a positive effect in the majority of children with
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Stimulants produce a positive effect in the majority of children with
AD/HD, although it does not normalize behaviors (Teeter, 1998).
Stimulants serve as agonists for neurotransmitters (increase theseneurotransmitters to produce effects on behavior and cognition)
Dopamine related to the executive process, or effort to resolve
competing cognitive demands
Norepinephrine related to the alerting mechanism, or readiness to
respond (Swanson, 2003)
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ypes o mu an s
include:
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Adderall
Concerta
Daytrana
Dexadrine
oca n
Metadate
Ritalin
Wellbutrin
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Non-Stimulants for ADHD Strattera
The first non-stimulant medication for AD/HD
Approved by the FDA in 2002
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Tenex n an yper ens ve rug a mpac s mpu s v y an yperac v y
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Managing Medications in School The school nurse needs to be informed regarding
the child and the medication.
Physicians will examine sustained release and
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longer-acting medications for adolescents.aren s an c n c ans s ou no g ve oo muccredit to any medication for success.
Let children know they are responsible for their.
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Some Reported Side Effects of
Medication
Appetite and weight suppressant
Height some effect on growth
Insomnia
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Insomnia
medication wears off)
Tics
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Response to Side Effects Inform and work with the physician. May require changing dosage or medication
Ongoing assessment of the balance between
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g g
the benefit of medication and the downside Do not make changes in medication at key
transition times (e.g., finals, new school, etc.).
Kee records on an chan es ou think mi ht
be relevant for the doctor to know.
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The Role o the LP
with AD/HD
The SLP in the School
The SLP serves in the followin roles:
Provider of speech-language pathology services to
address concomitant speech, language, or other communication
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p , g g ,
disorders Consultant to educators for development of accommodations,
modifications, or teaching strategies
Participant on a school study team, an intervention team,
or a 504 committee Advocate for the student with AD/HD
Learning mentor for the student
Educator of other faculty members and/or family
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en y u en s anguage ro e
As usual, the SLP needs to identify and address any
concomitant or comorbid language disorders in children with
AD/HD.
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Inattention most frequently undermines spoken languagecomprehension, working memory, and organization of thoughts
for oral expression.
In addition to evaluating basic levels of language, pursue
assessment of higher-demand language. Narrative discourse (comprehension and production)
Literacy skills for academic success
Executive functions in naturalistic settings
Social competence/pragmatics in naturalistic settings
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Executive Functions
Children with AD/HD demonstrate deficits in metaco nitive and
executive control systems for:
Planning and organizing
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Deliberate oal-settin Deliberate initiation and inhibition
Self-awareness and regulation of efforts
Use of self-talk or inner speech as a thinking tool
The SLP must consider planning and execution skills for thesechildren, and their capacity to engage language in a beneficial
way.
Assessment and treatment of the language of thinking, planning,
and doing, is appropriate.
160160
School-Based SLP Assessment
Options for EF and Attention
The SLP may opt to evaluate attention and/or executive functions
as a part of the educational diagnostic team.
Few standardized tools are available to the SLP:
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Behavioral Rating Inventory of Executive Functions (BRIEF) Test of Everyday Attention for Children (TEA-Ch)
Many rating scales and assessment tools exist within other
professions (see slides 50-60).
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School-Based SLP Assessment
Options for EF and Attention, continued The combined effect of assessment and analysis from multiple
perspec ves o ers e mos compre ens ve ns g n o e
child with AD/HD.
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Verbal working memory subtests from standardized assessmenta er es prov e g y use u n orma on regar ng e c s
ability to
focus attention on incoming verbal information.
162
Test of Everyday Attention-Children
(TEA-Ch)
Ages 6 - 16
Assesses attentional capacities in children, adolescents
Standardized scores allow comparison of attentional domains
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Nine subtests observe: Sustained attention
Selective attention
Alternative attention
Inhibited attention
Sensitive to developmental progression of attention
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Behavior Rating Inventory of
Executive Function (BRIEF)
Rating scales based on 80 Behavioral Regulation Index
questions Never, sometimes, often
T-scores >65 significant
Regulate behavior, emotion
Inhibition, emotional control
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g Shifting, self-monitoring
Inhibition
Shifting
Emotional control
Metacognition Index (MI) Systematically solve problems
Initiate, plan, organize, execute,complete
n a on
Working memory Planning
Organization
Global Executive Composite(GEC) BRI + MI
Self-monitoring
164
Versions of the BRIEF1. Behavior Rating Inventory of Executive Function Preschool
ers on -
Ages 2.0 5.11. Parent Form, Teacher Form
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2. Behavior Rating Inventory of Executive Function (BRIEF)Ages 5 18, Parent Form, Teacher Form
3. Behavior Rating Inventory of Executive Function, Self-Report
Version (BRIEF-SR)
Ages 11 18, Parent Form, Self Form
4. Behavior Rating Inventory of Executive Function -Adult
Version (BRIEF-A)
Ages 18 90, Informant Form, Self Form
165
SLP Role in Treatment of Child with
AD/HD
The school-based SLP may determine to write goals for children
with AD/HD for a variety of reasons
Inattention disrupts verbal working memory
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Inattention disrupts language comprehension Inattention disrupts inhibition, which disrupts planning, sequencing,
evaluating, and correcting
Inattention disrupts all language modalities (reading, writing, listening,
Inattention disrupts social communication awareness and monitoring.
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Compensatory Strategies to Support
ttent on n t e c oo - ge
Teach the child to
Repeat
Request confirmation
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Restate in his/her own words Use self-talk to self-focus on the speaker
Use self-questioning to identify if information is or is not available in
working memory
ecogn ze s gns o someone ge ng rea y o spea or
offer important information Use visual cue-cards placed on childs desk to prompt attentional focus
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en on cann ng as s
Auditory scanning tasks
Listen to spoken letters, numbers, or words over a
designated number of minutes
Raise hand when target letter/word is spoken
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Visual scanning
Scan through page filled with symbols, letters, words,
Circle or cross out only the target symbol Achieve 90%+ accuracy identifying target symbol
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Attention Scanning Tasks, continued Increase time span while maintaining accuracy levels
Increase difficulty level of targets to identify
Transition from non-distracting, controlled environment to an
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unstructured, uncontrolled environment
169
en ona wareness s
Build metacognitive awareness in the child by
teaching him/her to:
Understand the skill of attentionthat listening, reading,
thinking, speaking, and writing all require fundamental
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Evaluate his/her own degree of attention to evaluate
whether he/she can remember what was just said
Reco nize when he/she is lackin in sufficient information -
to carry out the expected or required task
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Self-Talk to Cue Attention
Embed self-talk phrases to give the child a foundation for
internally monitoring his/her own attention and recall for spoken
language:
Wh t i t?
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What is next? What did she say?
Im supposed to _____, _____, and _____?
I dont remember all of it.
nee to as or more n ormat on.
Am I ready to listen?
Am I ready to work?
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amp e en on oa s or e
Client will demonstrate sustained attention for simple auditory
scanning tasks sufficient to achieve 80% accuracy for up to five
minutes, in non-distracting structured environment.
Cli t ill t i tt ti t l t fi i t il
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Client will sustain attention to complete five-minute paper-penciltask requiring use of reading comprehension and written
expression, given fewer than two prompts per task.
Client will sustain attention for simple homework sheet completion
when given fewer than two prompts, in an unstructured classroom
setting.
172172
Sample Attention Goals for SLP, continued
Client will sustain attention to five-minute conversation in structured,
non-distracting environment, following topic transitions with 80%
accuracy and fewer than two prompts
Cli t ill t i tt ti t fi i t t h l t i
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Client will sustain attention to five-minute teacher-lecture inclassroom environment, following transitions and topics with 80%
accuracy and fewer than two prompts
Client will demonstrate 80% accuracy for listening comprehension of
two-part directives, independently using compensatory attention
strategies
Client will follow three-part spoken directions with 80% accuracy,
without requiring cues for focused attention
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Sample Attention Goals for SLP, continued Client will sustain attention to three-minute verbal explanation of
aca em c con en , su c en o res a e
up to five details with 80% accuracy
Client will shift attention in the classroom from teacher
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o a e as necessary n or er o o ow spo en rec ons w
accuracy, given no repetitions
Client will sustain attention sufficient to comprehend simple short
s or es w accuracy, g ven ecrease ra e o n orma on an
repetitions as needed
Client will sustain attention sufficient to comprehend simple short
s or es w accuracy, n epen en y reques ng repe ons as
needed
174
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175
AD/HD Is a Life Span Disorder
There are ongoing strategies to help the aging
person with attention disorders.
Today state universities and colleges offer support
and guidance from on campus offices for students
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and guidance from on-campus offices for studentswith disabilities.
Adult support groups are available in most communities.
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os g c oo
Ma be eli ible to take the SAT ACT rad school tests and
vocational education tests with accommodations
May be eligible for untimed testing
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services/unique offerings
The accommodations are available at the workplace
.
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u e
Many adults use medication when performingactivities that require more concentration, but theyhave learned strategies to cope in other situations.
Adults are eligible for accommodations under ADA.
neven ma ura on eve s seem o e e er
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neven ma ura on eve s seem o e e eraccepted.
They are successful when they can match their.
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The Adult Female
Females with AD/HD have uni ue needs as the
age.
Due to estrogen changes as they mature, their
memor issues ma be more at risk durin
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memor issues ma be more at risk durinmenopause than typical females experience.
Women may benefit from working with a counselor
or thera ist as the mature.
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romo ng u onomy an wareness
All children and adults with diagnosed attention disorders need to
develop their own self-awareness about their disability.
Positive role modeling and self-accountability will
help them empower themselves
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help them empower themselves. Their challenges are not an excuse, but rather, a
conduit to change.
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or o ay
AD/HD must be understood from a develo mental and enderperspective.
Although a population of people may experience similar skilldeficits, each individual is unique in history and exposure.
This is a disorder that is managed and possibly controlled but
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This is a disorder that is managed and possibly controlled, butnot cured.
182182
For the Future
The recent information regarding a genetic basis of AD/HD
suggests the possibility in the future of more sophisticated
treatment options and earlier identification.
In addition, new pharmacology may be developed to better servethe diagnosis
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, p gy y pthe diagnosis.
More detailed subtype information will become available.
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For the Clinician
Effective management of AD/HD requires:
Understanding of the disorder
Ongoing education
Periodic evaluation
Interventions, strategies, and resources
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Interventions, strategies, and resources
Responsibility in decision-making
Positive guidance
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In Closing
Perha s the most indis ensable thind h b i d
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Perha s the most indis ensable thinwe can do as human beings, every day
of our lives, is remind ourselves and others
of our complexity, fragility, finiteness,and uniqueness.
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,
ReferencesAmerican Speech-Language-Hearing Association. (1997). Roles of audiologists and speech-
lan ua e atholo ists workin with ersons with attention deficit h eractivit disorder
(Technical Report). Available from www.asha.org/policy
Arizona Department of Education web site. (2002, February). Definition of Accommodations.
Available from www.ade.state.az/us/ess/ACCOMfin.asp
Barkley, R. (1996). Linkages between attention and executive functions in attention, memory, and
. , . ., . , . ., . . ,MD: Brookes Publishin