Upload
doandung
View
216
Download
0
Embed Size (px)
Citation preview
Intervento sui Disturbi da
Deficit di Attenzione e Iperattività
(ADHD )
Prof. Cesare Cornoldi
Lab.D.A.
Laboratorio sui Disturbi dell’Apprendimento
Galleria Berchet, 3 Padova
Direttore: Prof. Cesare Cornoldi
www.labda-spinoff.it 0498209059/3284366766
NICE Guidelines Marzo 2009
• Criteri per la considerazione di un lavoro sul
trattamento:
• gruppi randomizzati e comparabili
• (lo studio MTA era tale per cui il gruppo di
controllo, per due terzi, aveva il farmaco e il
gruppo a trattamento psicologico no)
www.labda-spinoff.it 0498209059/3284366766
• Studies involving
• participants with a mean age of 8 or 9 looked
at the effects of work with both
• the child and the parents or family
(BLOOMQUIST1991; FEHLINGS1991;PFIFFNER1997;
TUTTY2003) or just the child (ANTSHEL2003;
GONZALEZ2002).
www.labda-spinoff.it 0498209059/3284366766
• The analysis conducted here therefore suggests that CBT interventions
• for ADHD can have beneficial effects whether delivered in the absence of medication
• or as an adjunct to continued routine medication for ADHD
www.labda-spinoff.it 0498209059/3284366766
• Four studies were found that demonstrated positive
effects of psychological interventions
• on core ADHD symptoms together with ratings of
conduct, social skills or self-efficacy (FEHLINGS1991;
LONG1993; PFIFFNER1997; TUTTY2003).
• The interventions studied were either mixed CBT/social
skills interventions delivered to groups (PFIFFNER1997;
TUTTY2003) or predominantly CBT interventions
(FEHLINGS1991; LONG1993).
www.labda-spinoff.it 0498209059/3284366766
• FEHLINGS1991 involved teaching children CBT techniques to improve
behaviour
• in home settings. Time was taken to teach problem-solving techniques,
which
• included identifying the problem, goal setting, generating problem-
solving strategies,
• choosing a solution and evaluating the outcome. Active learning
methods were used
• including modelling and role play. Homework assignments were set and
related to
• individual problem situations at home. Learning gains were reinforced
with reward
• strategies such as tokens and so on. As in TUTTY2003 and PFIFFNER1997,
separate
• parent sessions were also held. Parents received education about
ADHD and training
• in CBT techniques that they were then encouraged to use to reinforce
target behaviours
• in individual homework tasks given to each child participant
www.labda-spinoff.it 0498209059/3284366766
• According to the findings of the
• economic analysis, the group clinic-based programme
was the dominant option
• among the three parent-training/education programmes, as it provided the same
• health benefits (same clinical effectiveness) at the lowest
cost (total intervention
• cost per family was £629 for the group clinic-based programme, £899 for the group
• community-based programme, and £3,839 for the
individual home-based programme).
www.labda-spinoff.it 0498209059/3284366766
Parent training (NICE) • November 18, 2008
• NICE guidelines on ADHD
• Parental training and psychological interventions are at the heart of new National Institute for
Health and Clinical Excellence (NICE) guidelines on the diagnosis and management of ADHD,
published in September.
• Specifically, drug treatment is not recommended for pre-school children with suspected ADHD,
nor for older children and adolescents with moderate ADHD. Instead, the parents of children
and adolescents with ADHD should be offered a group training programme based on the
principles of Albert Bandura's social learning theory. There should also be the option of group
psychological treatment or social skills training for the child or young person, and the option of
individual psychological therapy should be considered for older adolescents.
• The new guidelines do recommend drug treatment as the first line intervention for children and
young people with severe ADHD and for adults with ADHD. However, such treatment should
always form part of a comprehensive care package that includes psychological and
educational components. In particular, adults who don't want a drug treatment should be able
to access psychological help instead.
• Other notable aspects to the new guidance include: a call for multidisciplinary specialist ADHD
teams and/or clinics to be established; a recommendation that teachers with necessary
training should provide behavioural interventions in the classroom; an unequivocal statement
that dietary fatty acids are not recommended; and a recommendation that GPs do not initiate
drug treatments for ADHD, although they may continue prescribing and monitoring such
treatment once started by a suitably qualified expert
www.labda-spinoff.it 0498209059/3284366766
Efficacia training cognitivi • ADHD Atten Deficit Hyperact Disord. 2012;4:11-23.
• NEUROCOGNITIVE TRAINING FOR CHILDREN WITH AND WITHOUT AD/HD.
• Johnstone SJ, Roodenrys S, Blackman R, et al.
• There is accumulating evidence that computerised cognitive training of inhibitory control
and/or working memory can lead to behavioural improvement in children with AD/HD. Using a randomised waitlist control design, the present study examined the effects of combined working memory and inhibitory control training, with and without passive attention monitoring via EEG, for children with and without AD/HD. One hundred and twenty-eight children (60 children with AD/HD, 68 without AD/HD) were randomly allocated to one of three training conditions (waitlist; working memory and inhibitory control with attention monitoring; working
memory and inhibitory control without attention monitoring) and completed with pre- and post-training assessments of overt behaviour (from 2 sources), trained and untrained cognitive task performance, and resting EEG activity. The two active training conditions completed 25 sessions of training at home over a 4-5-week period. Results showed significant improvements in overt behaviour for children with AD/HD in both training conditions compared to the waitlist condition as rated by a parent and other adult. Post-training improvements in the areas of
spatial working memory, ignoring distracting stimuli, and sustained attention were reported for children with AD/HD. Children without AD/HD showed behavioural improvements after training. The improvements for both groups were maintained over the 6-week period following training. The passive attention monitoring via EEG had a minor effect on training outcomes. Overall, the results suggest that combined WM/IC training can result in improved behavioural control for children with and without AD/HD …………………..
www.labda-spinoff.it 0498209059/3284366766
Cenni di TRATTAMENTO
Il trattamento ha senso solo se coinvolge i più
importanti contesti di vita del bambino. Quindi il
trattamento coinvolgerà:
• La famiglia (Parent training)
• La scuola
• Il bambino
www.labda-spinoff.it 0498209059/3284366766
• L’intervento può sperare di avere una certa
efficacia se:
• 1) coinvolge più fronti
• 2) si inserisce su un contesto motivazionale e
attribuzionale appropriato
www.labda-spinoff.it 0498209059/3284366766
Circolare 20.3.12
(dott. Cutolo) www.labda-spinoff.it 0498209059/3284366766
Possibili Mediatori per gli Interventi a scuola
(DuPaul & Power, 2000)
• Insegnanti
• Strategie di istruzioni; Rinforzo coi gettoni
• Genitori
• Tutoring ai genitori; Rinforzi a casa
• Pari
• Tutoring dei compagni della classe
• Computer
• Esercitazioni guidate
• Sè stesso
• Auto-monitoraggio; Auto-gestione
www.labda-spinoff.it 0498209059/3284366766
Interventi a Scuola per ADHD(cont.)
Manipolare le conseguenze (Reattiva)
• Rinforzo coi gettoni
• Rimproveri verbali
• Costo della risposta
• Time Out dai Rinforzi Positivi
• Auto-gestione
www.labda-spinoff.it 0498209059/3284366766
Esempi di Strategie
Mediate dall’Insegnante www.labda-spinoff.it 0498209059/3284366766
Tecniche di insegnamento per prevenire
problemi comportamentali Ricordare agli studenti le regole
Mantenere il contatto visivo con gli studenti
Ricordare agli studenti il comportamento atteso
Muoversi per la classe per monitorare/dare feedback
Usare indizi non verbali per reindirizzare
Mantenere un ritmo veloce di istruzioni
Assicurarsi dell’avvenuta comprensione dell’attività
Controllare che i momenti di passaggio avvengano in maniera ben organizzata
Comunicare le proprie aspettative rispetto all’uso del tempo in classe
www.labda-spinoff.it 0498209059/3284366766
Componenti di un programma di
comunicazione scuola-famiglia efficace
Obiettivi giornalieri/settimanali specificati in maniera positiva
Includere sia obiettivi accademici che comportamentali
Pochi obiettivi per volta
Dare un feedback quantitativo rispetto alla performance
Feedback forniti dagli studenti o dalle lezioni
Comunicazione su base regolare (sia giornaliera che settimanale)
Contingenze a casa legate alla performance (sia a breve che a lungo termine)
www.labda-spinoff.it 0498209059/3284366766
Esempi di Strategie mediate
dai Pari www.labda-spinoff.it 0498209059/3284366766
Classwide peer tutoring
Dividere la classe in coppie
Fornire schemi accademici
Tutoring a turni
Dare immediatamente feekback e correggere
errori
Monitorare i progressi e fornire punti bonus
Registrare i punti e delineare i progressi
Cambio settimanale delle coppie
www.labda-spinoff.it 0498209059/3284366766
Effetti del CWPT sull’ADHD
(DuPaul et al., 1998)
• 18 b. con ADHD & 10 studenti di controllo (dal 1° al 5° anno)
• CWPT aumenta l’iniziativa riducendo I comportamenti off task
• 50% degli ADHD miglioramenti scolastici
• Effetti positivi per i soggetti di controllo
• Alto livello di soddisfazione di studenti e insegnanti
www.labda-spinoff.it 0498209059/3284366766
Strategie di intervento sugli ADHD
• Le linee prevalenti di intervento sugli ADHD (v.
linee guida NICE, 2012) insistono sulla necessità
di associare agli interventi autoregolativi anche
interventi centrati sulle abilità sociali
www.labda-spinoff.it 0498209059/3284366766
Tra le tecniche di insegnamento con “mediazione
sociale” proposte coi bambini ADHD ritroviamo:
►
► Peer tutoring
► Peer collaboration
Cooperative
Learning
• Interdipendenza positiva
• Interazione diretta costruttiva
•Abilità sociali
•Responsabilità individuale
•Valutazione del lavoro di
gruppo.
www.labda-spinoff.it 0498209059/3284366766
Peer tutoring
www.labda-spinoff.it 0498209059/3284366766
Individuale vs gruppo
• Van Manen (2004) ha trovato che il lavoro di
CBT individuale è più efficace di quello di
gruppo nelle misure a breve termine, ma meno
nelle misure a lungo termine. Una spiegazione
potrebbe risiedere negli effetti immediati di un
rinforzo individuale e negli effetti più profondi
del rinforzo sociale
• P. Muratori e la sua equipe hanno raccolto
risultati nella stessa direzione
www.labda-spinoff.it 0498209059/3284366766