Dr. Fralick-Ball has Asthma It will be cool in here all day SFBPsychMedEd 2010-2013

SFBPsychMedEd 2010-2013

Dr. Fralick-Ball has Asthma

It will be cool in here all day


Great Treatments for

ADHD & Processing Disorders

Take-Home Strategies that Work!

Offered for CMI by

Dr. Susan Fralick-Ball, PsyD, MSN, [email protected]


Making sense of the Disorders Skills and strategies for Children Skills and strategies for Adults Tools you can use…Now

The skills, strategies, and tools appear throughout this seminar… even more in your addendum pages

Overview of the Day


Sensory Processing Disconnections Executive Dysfunction Neuropsychological Model of Executive

Functioning (EF) ADHD Central Auditory Processing Disorder Non-Verbal Learning Disorder Mood Dysregulation in Bipolar Disorder Adult v. Child ADHD Avoiding Assessment Errors

Making Sense of the Disorders


The strategies & skills are scattered throughout the day in discussion, and text

There is little to no presenter bias for this material There is no conflict of interest between this presenter

and CMI/PESI Parents have the hardest job in the world Teachers have the second hardest job in the world This room is cool due to the presenter’s asthma; please

refrain from requesting hotel staff to change the temperature

You are taking this manual home for attaining even more information after today

The skills & strategies are all throughout the manual

Reminders… Please Read


All information comes to us through sensory input

Once the sensory stimulation is perceived,(or we become sensory aware) it is projected up and to the front of our brains via circuits or tracts

The sensory information is placed into the frontal lobes for recognition, assignment, assessment; processing – FOUNDATION LAYER #1

The frontal lobes orchestrate the sensory information and place ‘spin’ on that information as filtered through the executive functions

Motor responsiveness we call ‘behavior’ (output) are returned via the tracts and other areas of the brain and body – FOUNDATION LAYER #2

To consider the ‘process’ of ADHD, ASDs, OCD, etc. we observe the behaviors bubbling up through the foundation of SP & EF

*Foundation of Human Information Processing*


Sensory Modulation Sensory Discrimination Sensory-Based Motor Disorder

(SMD) Disorder (SDD) Disorder (SBMD)

SOR, SUR, SS Visual Postural Disorders Dyspraxia Auditory

Tactile Vestibular Proprioception Taste/Smell

Sensory Over-Responsivity Sensory Under-Responsivity Sensory Seeking/Craving

adapted from SPD Network Taxonomy

Sensory Processing Disorder (SPD)


Executive Function/Dysfunction (EF, EDf)


Basic Problems with Executive (Dys)function in ADHD are:

Working memory and recall (holding facts in mind while manipulating information; accessing facts stored in long-term memory.)

Activation, arousal, and effort (getting started; paying attention; finishing work)

Controlling emotions (ability to tolerate frustration; thinking before acting or speaking)

Internalizing language (using "self-talk" to control one's behavior and direct future actions)

Taking an issue apart, analyzing the pieces, reconstituting and organizing it into new ideas (complex problem solving).

Executive Function


A set of cognitive abilities from central processes that control and regulate other abilities and behaviors.

EF are necessary for goal-directed behavior. They include the ability to:

◦ initiate and stop actions, ◦ monitor and change behavior as needed, and ◦ plan future behavior when faced with novel tasks and

situations. ◦ anticipate outcomes and adapt to changing situations.

The ability to form concepts and think abstractly are often considered components of executive function.

Master the Neuropsychological Model of Executive Functioning (EF)


Parents and teachers are often baffled when students with ADD/ADHD, including those who are intellectually gifted, teeter on the brink of school failure.

Deficits in critical cognitive skills, known as executive dysfunction, may interfere with a student's ability to succeed in school.

Practically speaking, executive function deficits may cause problems for students with ADHD in several important areas: ◦ getting started and finishing work, ◦ remembering homework, ◦ memorizing facts, ◦ writing essays or reports, ◦ working through math problems, ◦ being on time, ◦ controlling emotions, ◦ completing long-term projects, and ◦ planning for the future.

Executive Dysfunction in ADHD


Unfortunately students with ADD or ADHD are often punished for executive function deficits, such as lack of organizational and memory skills that interfere with their ability to bring home the correct homework assignments and books.

When deficits in executive function and related learning problems are present, students can try their very best and still not succeed in school!!

Executive Dysfunction


If we break down the skills or functions into subfunctions, we might say that executive functions tap into the following abilities or skills:

Goal Plan Sequence Prioritize Organize Initiate Inhibit Pace Shift Self-monitor Emotional control Completing Working Memory

The Primary EF Subfunctions


Many students with ADD or ADHD have impaired working memory and slow processing speed, which are important elements of executive function. ◦ Not surprisingly, these skills are critical for writing essays

and working math problems.◦ Recent research has identified written expression as the

most common learning problem among students with ADHD (65 %).

Writing essays, book reports or answering questions on tests or homework is often very challenging for these students. ◦ students often have difficulty holding ideas in mind, acting

upon & organizing ideas, quickly retrieving grammar, spelling and punctuation rules from LTM, manipulating all this information, remembering ideas to write down, organizing the material in a logical sequence, and then reviewing and

correcting errors.

ADHD, EF, and Learning


Then he must hold important facts in mind while he applies the rules and shifts information back and forth between working and STM to work the problem and determine the answer.

To further complicate matters, other serious conditions may co-occur with ADD and ADHD. According to the National Institute of Mental Health MTA study on ADHD, two thirds of children with ADHD have at least one other coexisting problem, such as depression, anxiety, or SPD.

Accommodating students with complex cases of ADD/ADHD is critical!



Sometimes we forget just how complex seemingly simple tasks really are◦ Example - memorizing multiplication tables or working a

math problem: When a student works on a math problem, he

must fluidly move back and forth between analytical skills with working, STM, and LTM.

With word problems, he must hold several numbers and questions in mind while he decides how to work a problem.

He must tap into LTM to find the correct math rule to use for the problem.



Low or High IQ LDs Vision/Hearing

Deficits Mood Disorders Substance abuse PTSD Sleep Disorders Seizure Disorders

Acquired Brain Injury

Autistic-Spectrum Disorders

Sensory Processing Problems◦ Sensory integration

disorders◦ Central auditory

processing disorder

ADHD ‘Look-Alikes’


In the USA, ADHD is one of the most common causes of referrals and childhood medication in family practice, pediatric, neurology, and child psychiatry clinics.

Epidemiologic studies indicate that about 5% of children have ADHD, with boys being a large majority of these

ADHD persists into adult years in a substantial minority of cases.

Current hypotheses associate ADHD etiology with abnormalities of connections in the frontal cortex◦ It may involve faulty regulation of neurotransmitter

messenger systems, predominantly those that use dopamine and norepinephrine.

ADHD


The cardinal features of this syndrome (DSM-IV) are inattentiveness, impulsivity and motoric over-activity. ◦ In DSM-5 these features may apply to many Axis I Dx

These symptoms generally start during early grade school years; they are persistent and impair the child socially and educationally.◦ DSM-5 would ‘rate’ the difficulty with these features with

different ages and circumstances

DSM-IV subtypes of predominantly hyperactive-impulsive and predominantly inattentive ADHD have not been supported by the empirical data

ADHD


There could be a single disorder of ADHD comprising the popular conceptions of ADD and ADHD in DSM-5

New proposals are broken into the following domains:

Tends to act without thinking Is often impatient Is uncomfortable doing things slowly and

systematically Difficult to resist temptations or opportunities

ADHD and the new DSM-5


ADHD frequently co-occurs with conduct, mood, anxiety, and learning disorders. ◦ DSM-5 may be including many of these chages into the basic

ADHD Dx It often co-exists with multiple SPDs and EDfs By mid-adolescence, ADHD children originally diagnosed

with co-morbid psychiatric disorders have markedly elevated rates of antisocial, mood and anxiety disorders, more impaired intellectual and achievement scores than ADHD-only children, and high rates of social disability. ◦ Conduct disorder in childhood often predicts an antisocial

diagnosis as well as alcohol and drug dependence in adolescence and early adulthood.

◦ Major depression in childhood may predict the emergence of mania.

◦ Severe anxiety in childhood may predict more anxiety disorders in adulthood than in other ADHD children.

ADHD


Biological Explanations dominate thinking about ADHD◦ “behavioral disinhibition”◦ “failure in self-control”◦ Barkley posits that behavioral inhibition is related

to four executive neuropsychological functions carried out by the brain’s prefrontal region:

Working memory Internalization of speech Self regulation of affect, motivation, arousal Reconstitution

Biological ADHD


Working memory allows an individual to manipulate and act on events held in the mind using foresight and hindsight and gives one a sense of time in which to appropriately carry out these functions

Internalization of speech facilitates self-talk, problem solving, and an ability to reflect on one’s own behavior

Self-regulation of affect, motivation and arousal facilitates control of one’s emotions, an ability to delay gratification and engage in goal-directed activity without becoming distracted

Reconstitution allows one to analyze and synthesize one’s own behavior and communicate in an accurate and efficient manner

Biological ADHD (Executive Functioning)


fMRI conducted while subjects performed the counting Stroop task has shown that normal adults increased blood flow in the anterior cingulate cortex during this task.◦ Patients with ADHD, by contrast, failed to increase blood flow in this

structure under the same conditions During cognitive conflict, ADHD patients fail to activate the

anterior cingulate cortex than do controls PET scanning has been used to examine cerebral metabolism,

which is a measure of neuronal activity◦ Results have shown that adults with ADHD have decreased cerebral

metabolism compared with controls SPECT imaging has been used to visualize the DAT dopamine

transporter in the human brain◦ Three studies have shown that untreated adults with ADHD have increased

binding of DAT protein compared with controls◦ This increase may result in accelerated re-uptake leading to reduced

dopamine in the synaptic cleft

Imaging and ADHD


ADHD as a product of an “interactionary process” between working memory and environmental factors that is more psychological than biological in nature◦ Deficient working memory is at the core of this

disorder◦ For example, hyperactivity (often manifest as

disorganized behavior) occurs because information stored in working memory fades rapidly therefore there exists a need to increase the rate at which new stimuli or input is sought out

Biological/Psychological ADHD


Impairment in each of these executive functions is thought to lead to behaviors commonly associated with ADHD

According to Barkley: when an ability for self control is absent it “in turn impairs other important brain functions crucial for maintaining attention” and delay gratification

Biological/Psychological ADHD


Symptoms Overlap

Behaviors not Necessarily ADHD


The Sensory Processing Constellation

Depression

BS

Autism

Anxiety

OCD

FXS ADHD

Adapted from R. Ross & L. Miller. NICHD grant #1 K01 HD01201-01-A1 Wallace Research Foundation, Colorado State University

KEY:

ADHD: Attention Deficit Hyperactive Disorder

B: Bipolar Disorder

OCD: Obsessive-Compulsive Disorder

FXS: Fragile X Syndrome

S: Schizophrenia

SPD: Sensory Processing Disorder

SPD


Complex problem affecting about 5% of school-aged children.

Children can't process the information they hear in the same way as others because their ears and brain don't fully coordinate.

The way the brain recognizes and interprets sounds, most notably the sounds composing speech is altered.

Often do not recognize subtle differences between sounds in words, even when the sounds are loud and clear enough to be heard.

These kinds of problems typically occur in background noise, which is a natural listening environment.

Basic difficulty of understanding any speech signal presented under less than optimal conditions.

Central Auditory Processing Disorder (CAPD)


hearing in noisy situations following long conversations hearing conversations on the telephone learning a foreign language or challenging vocabulary words remembering spoken information (i.e., auditory memory

deficits) taking notes maintaining focus on an activity if other sounds are present

child is easily distracted by other sounds in the environment with organizational skills following multi-step directions in directing, sustaining, or dividing attention with reading and/or spelling processing nonverbal information (e.g., lack of music

appreciation)

Children with CAPD have difficulty:


ADHD behaviors seen most often include:

• Inattention • Distractibility • Hyperactivity • Restlessness • Impulsivity •Interruption/

intrusion

CAPD behaviors seen most often include:

• Difficulty hearing in background noise

• Difficulty following directions

• Poor listening skills • Academic difficulties • Poor auditory

association skills • Distractibility • Inattentiveness

“Behavioral” Comparison


Developmental disorder with manifestations in the following domains: ◦ a) somatosensory and motor functions ◦ b) visuospatial and visuoconstructive functions ◦ c) arithmetic ◦ d) social cognition◦ E) inferential reasoning.

NLD is a neurological syndrome characterized by the impairment of nonverbal or performance-based information controlled by the right hemisphere of the brain. Performance-based information governed by the R hemisphere is impaired in varying degrees, including problems with visual-spatial, intuitive, organizational, evaluative, and holistic processing functions

Non-Verbal Learning Disorder (NVLD)


Generally presents with specific assets and deficits.

The assets include:◦ Early speech and vocabulary development◦ Remarkable rote memory skills ◦ Attention to detail ◦ Early reading skills development and excellent

spelling skills. ◦ Good verbal ability to express themselves

eloquently. ◦ Strong auditory retention.

NVLD


Everyone has assets/strengths/positive points To work with a child, client, patient, etc. the

parent/teacher/therapist needs to find one of those strengths

When a problem has been identified, chipping away at the problem teaches no skills for problem solving

If a strength can be attached to the person, then every problem worked on through the asset, the person gains a working set of problem-solving skills based on something familiar and accepted by the person in therapy

This formula teaches complex problem-solving skills

Finding Assets


BPD is characterized by alternating periods of emotional highs and lows.

Ranges from mild to severe. Mood swings have long intervals to rapidly cycling. The emotional ‘highs’ include:

◦ Feelings of euphoria, optimism◦ Rapid speech, racing thoughts, agitation,↑ activity◦ Poor judgment◦ Recklessness◦ Difficulty sleeping◦ Tendency to be distracted◦ Inability to concentrate◦ Extreme irritability

Mood Dysregulation in Bipolar Disorder and EF


During periods of emotional ‘lows’, symptoms may include:◦ Persistent feelings of sadness, anxiety, guilt, or

hopelessness◦ Disturbances in sleep and/or appetite◦ Fatigue and loss of interest in daily activities◦ Difficulty concentrating◦ Recurring thoughts of suicide (generally not in

children) Some children with BPD have an underlying SPD During ‘highs’, they may experience heightened

sensory awareness or sensory feedback. During ‘lows’, the opposite is often true

Bipolar Disorder (BPD)


Most children with ADD/ADHD don’t outgrow their disorders; rather, they become disorganized, inattentive adults.

Adults with ADD?ADHD struggle daily with self-regulation: regulating their attention, regulating their impulses in talking and action, and regulating their emotions.

They have trouble staying focused, getting organized, starting and completing work, managing time and money, and remembering all the little things in daily life.

Additionally, depression, anxiety, and substance abuse are common co-conditions to adult ADD/ADHD.◦ Many adults present with these symptoms; ADHD is later found.

Adult ADHD v. Childhood ADHD


The symptoms change as someone with ADD/ADHD develops from a child into a teenager and then into an adult. While the core problems of hyperactivity, impulsiveness, and inattentiveness remain the same, the specific symptoms manifest differently. ◦ DSM-5 is looking to further refine the adult Dx to include more

inattentiveness & impulsive decision making The impairment is hallmarked with impairment of

executive functions and emotional control. Typically, the symptoms of hyperactivity decrease and

become more subtle, while problems related to concentration and organization become more dominant.

Female adult ADHD clients are often underdiagnosed and undertreated.

Adult v Child ADHD


Barkley identifies core adult ADHD as:◦ Distractibility◦ Impulsiveness, poor concentration◦ Inability to persist at tasks◦ Difficulties with working memory, organization & planning

There are high underpinnings of anxiety and depression that drive Adult ADHD

Clinicians are asked to rule out medical conditions like:◦ Hyperthyroidism◦ Seizure disorder◦ Asperger’s syndrome

Adult ADHD…


Untreated adult ADHD is often associated with:◦ Higher rates of unemployment, divorce, & arrests◦ Higher rates of STDs and unplanned pregnancies◦ Underachievement in school◦ Firing/dismissal at work◦ Behavioral problems at work◦ Job quitting due to hostility in the workplace or

boredom◦ Driving accidents, revoked/suspended driver’s

licenses, citations for speeding, reckless driving, or causing accidents

Sequelae of Adult ADHD


Hyperactivity in adults:◦ inability to relax ◦ restlessness, nervous energy ◦ talking excessively

Impulsiveness in adults:◦ volatile moods ◦ blurting out rude or insulting remarks ◦ interrupting others

Inattentiveness in adults:◦ “tuning out” unintentionally ◦ inability to focus on mundane tasks ◦ constantly losing and forgetting things

Adult v. Child ADHD


Adults with ADHD have problems in six major areas of executive functioning:◦ Activation – Problems with organization, prioritizing,

and starting tasks. ◦ Focus – Problems with sustaining focus and resisting

distraction, especially with reading. ◦ Effort – Problems with motivation, sustained effort,

and persistence. ◦ Emotion – Difficulty regulating emotions and

managing stress. ◦ Memory – Problems with short-term memory and

memory retrieval. ◦ Action – Problems with self-control and self-regulation.

Adult v. Child ADHD


Creativity – People with ADD excel at thinking outside of the box, brainstorming, and finding creative solutions to problems, more open-minded, independent, and ready to improvise.

Enthusiasm and spontaneity – People with ADD are free spirits with lively minds—qualities that makes for good company and engrossing conversation. Their enthusiasm and spontaneous approach to life can be infectious.

A quick mind - People with ADD have the ability to think on their feet, quickly absorb new information (as long as it’s interesting), and multitask with ease. Their rapid-fire minds thrive on stimulation. They adapt well to change and are great in a crisis.

High energy level – People with ADD have loads of energy. When their attention is captured by something that interests them, they can have virtually unlimited stamina and drive.

Adult ADHD Positive Traits


The strategies & skills are scattered throughout the day in discussion, and text

There is little to no presenter bias for this material There is no conflict of interest between this presenter and

CMI/PESI We have been talking about skills all morning Parents have the hardest job in the world Teachers have the second hardest job in the world This room is cool due to the presenter’s asthma; please

refrain from requesting hotel staff to change the temperature

You are taking this manual home for attaining even more information after today

The skills & strategies are all throughout the manual

Reminders… Please Read


December 12, 2011 — In light of two recent epidemiologic studies, the US Food and Drug Administration (FDA) is updating its communications with respect to medications for attention-deficit hyperactivity disorder (ADHD) on the ongoing cardiovascular safety review of medications used for treating ADHD.

The agency notes that healthcare professionals should take special note that:◦ Stimulant products and atomoxetine (i.e., Strattera) should generally

not be used in patients with serious heart problems or in patients for whom an increase in blood pressure or heart rate would be problematic.

◦ Patients treated with ADHD medications should be periodically monitored for changes in heart rate or blood pressure.

◦ Patients should continue to use their medication for the treatment of ADHD as prescribed by their healthcare professional.

Caveats to careful use of ADD/ADHD Meds


The frontal lobe contains most of the dopamine-sensitive neurons in the cerebral cortex. The dopamine system is associated with reward, attention, long-term memory, planning, and drive.

The executive functions of the frontal lobes involve the ability to recognize future consequences resulting from current actions, to choose between good and bad actions (or better and best), override and suppress unacceptable social responses, and determine similarities and differences between things or events.

Development and Neurophysiology of EF



The frontal lobes allow for high-road, or high-order processing

A Form of Processing that involves:◦ Higher◦ Rational◦ Reflective thought processes of the mind

This processing allows for:◦ Mindfulness ◦ Being flexible in our responses◦ An Integrated Sense of Self Awareness

Frontal Lobes


The frontal lobes continue to develop late in adolescence, and in fact, myleination is not complete until the fourth or fifth decade of adult life.

A number of EEG studies have found a dramatic spurt in frontal lobe maturation between the ages of 17 and 20, which can explain “late bloomers”.

Also sex hormones are relevant; there is a relationship between psychosexual development and cognitive ability.

Frontal Lobes


Frontal brain growth is shaped by what is called “pruning”.

If these connections are not utilized, they are not maintained.

It is truly a “use it or lose it” situation, This circuitry in the brain is very important, and

may actually be the cause of problems that are often misdiagnosed as a malfunction in a part of the brain.

The cortex can over-grow a problem with ADHD that is caused by another part of the brain.

Frontal Lobes


A widely accepted theory regarding the function of the brain's prefrontal cortex is that it serves as a store of short-term memory.

Implements working memory Consistent with the idea that the prefrontal

cortex functions predominantly in maintenance memory, delay-period activity in the PF has often been interpreted as a memory trace.

Involved in planning, initiation, anticipation, impulse control, and higher order thinking

Pre-Frontal Cortex (PFC)


As a member of the catecholamine family, dopamine is a precursor to norepinephrine (noradrenaline) and then epinephrine (adrenaline) in the biosynthetic pathways for these neurotransmitters.

Dopamine has many functions in the brain, including important roles in behavior and cognition, motor activity, motivation and reward, sleep, mood, attention, and learning.

Dopamine and Cognition


In the frontal lobes, dopamine controls the flow of information from other areas of the brain.

Dopamine disorders in this region of the brain can cause a decline in neurocognitive functions, especially memory, attention, and problem-solving.

Reduced dopamine concentrations in the prefrontal cortex are thought to contribute to ADD.

D1 receptors are responsible for the cognitive-enhancing effects of dopamine.

Dopamine and Cognition


Pathological states have also been associated with dopamine dysfunction, such as schizophrenia, autism, and attention deficit hyperactivity disorder in children, as well as drug abuse.

The firing of dopaminergic neurons is a motivational substance as a consequence of reward-anticipation. This hypothesis is based on the evidence that, when a reward is greater than expected, the firing of certain dopaminergic neurons increases, which consequently increases desire or motivation towards the reward.

Dopamine & Pathology


Hypothesis: Dopamine has a function of transmitting reward prediction error.

Phasic responses of dopamine neurons are observed when an unexpected reward is presented.

These responses transfer to the onset of a conditioned stimulus after repeated pairings with the reward.

Dopamine neurons are depressed when the expected reward is omitted.

Thus, dopamine neurons seem to encode the prediction error of rewarding outcomes.

In nature, we learn to repeat behaviors that lead to maximize rewards. It is therefore believed to provide a teaching signal to parts of the brain responsible for acquiring new behavior.

Dopamine & Reward


The amygdalae perform primary roles in the formation and storage of memories associated with emotional events.

It appears that teens have more trouble than adults identifying expressions of fear.

Amygdala & Control of Emotions


Children have less control over their emotions, because the axons that send information from the cortex to the limbic system are not yet fully developed.

Neurons of the prefrontal cortex that provide much of our rational control over our emotions do not mature until early adulthood.

In contrast, the amygdala is mature at birth and thus exerts a heavy influence on children.

Amygdala & Emotions


It functions as an integral part of the limbic system, which is involved with emotion formation and processing, learning, and memory.

Also, executive control needed to suppress inappropriate unconscious priming is known to involve the anterior cingulate gyrus.◦ Unconscious priming refers to exposure (unaware) to a

stimulus at time one influencing responding to a related stimulus at time two. One theory of priming is that exposure at time 1 activates parts of particular representation or associations in memory just before carrying out an action or task. The representation is already activated at time 2, reducing the time required to execute the response.

Anterior Cingulate Gyrus


Anterior Cingulate


This tiny nub of tissue acts as a memory indexer—sending memories out to the appropriate part of the cerebral hemisphere for long-term storage and retrieving them when necessary.

Information from short-term memory is stored in long-term memory by rehearsal. The repeated exposure to a stimulus or the rehearsal of a piece of information transfers it into long-term memory.

Hippocampus & Information Storage and Retrieval


Experiments also suggest that learning time is most effective if it is distributed over time. Deletion is mainly caused by decay and interference.

Emotional factors also affect long-term memory. It’s debatable whether we actually ever forget

anything or whether it becomes increasingly difficult to access certain items from memory. Having forgotten something may just be caused by not being able to retrieve it (a common problem in ADHD).

Information may not be recalled sometimes but may be recognized, or may be recalled only with prompting.

Memory Storage & Retrieval


There are two types of information retrieval: recall and recognition.

In recall, the information is reproduced from memory.

In recognition the presentation of the information provides the knowledge that the information has been seen before. ◦ Recognition is of lesser complexity, as the

information is provided as a cue. However, the recall can be assisted by the provision of retrieval cues, which enable the person to quickly access the information in memory.

Memory Storage & Retrieval


Arousal and alertness -- the prerequisites to attention

External or receptive attention: sensory processing and interpretation (executive functioning) -- as with reading

Internal or reflective attention which includes thinking about ideas, concepts, and organization of projects or tasks

Processing attention or selective attention. This includes:

◦ Focus -- tuning in to an object or topic

◦ Filtering -- signal:noise gradient -- enhancement or activation of relevant stimuli

◦ Inhibition of sensation (sensory inhibition) -- selective sensory input

External or expressive attention -- encompasses what we choose to communicate or suppress, which also evokes components of focusing, filtering, and inhibition.

Working memory -- accessing the retrieval and storage of working memory, ie, the flow of information, the content of active thought

Components of Attention


Focused attention: This is the ability to respond discretely to specific visual, auditory or tactile stimuli.

Sustained attention: This refers to the ability to maintain a consistent behavioral response during continuous and repetitive activity.

Selective attention: This level of attention refers to the capacity to maintain a behavioral or cognitive set in the face of distracting or competing stimuli. Therefore it incorporates the notion of "freedom from distractibility"

Alternating attention: It refers to the capacity for mental flexibility that allows individuals to shift their focus of attention and move between tasks having different cognitive requirements.

Divided attention: This is the highest level of attention and it refers to the ability to respond simultaneously to multiple tasks or multiple task demands.

Types of Attention


The goal of assessment is effective intervention. Neuropsychological measures assess some areas of

function/dysfunction in EF. Relevant contextual behavioral information also needs to be

gathered. Understand why , when, where the behaviors occur. Always note strengths and base interventions upon them. Gather results from excellent physical, emotional, and

social-environmental histories. Reliance on results from tests and questionnaires alone will

produce a skewed set of data.

ALL DISGNOSTIC LABELING USES THE NOMENCLATURE OF “DISORDER”

Avoiding Assessment Errors


Query about three current problems that are most debilitating: This open-ended query both establishes therapeutic rapport and allows the clinician to identify possible co-morbid conditions.

Uncover history: This step involves integration of the patient’s medical history and self-report of symptoms. The patient’s reliability can also be assessed in this step. Alternative strategies for eliciting information may be formulated as needed.

Evaluate symptom by symptom: In this step, the clinician must carefully examine each symptoms, making certain to distinguish between impairing symptoms and behaviors.

Setting pervasiveness is judged: DSM-IV criteria require significant impairment in at least two settings—in this stage, clinicians gauge the severity of impairments in different settings, taking into account the effect of social support on the patient’s level of functioning.

Test for co-morbidities: Before diagnosing ADHD, the clinician must eliminate possible alternative explanations of the patient’s impairments. When other possible disorders are identified, the clinician must determine whether they are primary or co-morbid with ADHD.

U. California, Irvine Child Devel Center QuestProbe40

Avoiding Assessment Errors


Treatment choices Understanding of prognosis and course Communication among teachers and school

personnel Communication with yourself at some future

point Communication with 3rd party payer

Your Diagnosis Facilitates:


The Daily Big Five Self-talk and Self-confidence Insights into ADHD: education & self-

monitoring Choosing the best strategies for the child Communication with the disorganized child

Skills/Strategies for Children & Adolescents


Daily focus time◦ F.A.C.T.S.™

Clarity of reinforcers◦ Know individual needs, triggers, and reinforcers to

behavior Nutrition

◦ Special diets, elimination diets, susceptibility See Symptoms of Yeast Overgrowth, next slide

Movement◦ Daily exercise

Connection◦ Improve communication

The “Big Five” Strategies


Poor attention Hyperactivity Anger Mood swings Irritability Vague, dull staring Inappropriate behavior (such as making odd noises, or

talking very loudly) Memory problems Headaches Achy joints and muscles, Ear infections, chronic congestion, coughing, and

infection Itching www.betterschoolresults.com http://www.latitudes.org/articles/hy_yeast.html http://www.nutritioninstitute.com/ADHD.html

Symptoms of Yeast Overgrowth

http://www.betterschoolresults.com/

http://www.latitudes.org/articles/hy_yeast.html


Children (and adults) with EF disorders, ADHD, LDs, etc. grow to live in the negative and believe that, ‘everything I do is wrong, too fast, too late, too many mistakes, incomplete, not thought through…”

Self-concept is a mental image we have of our bodies, brains, and personalities.

Start early and always praise effort. Respect your children and treat them with

dignity, especially during times of correction or re-direction.

Self-Talk & Self-Confidence


Self-esteem is mirrored from the parent and teacher.◦ Be the best example of self-assuredness

Quality v. quantity time spent with ADHD/EDf children is paramount to building self-assuredness.

3 cornerstones of self-esteem◦ I am lovable◦ I have abilities and gifts◦ I am worthwhile

Self-Talk and Self-Confidence


Show children physical love- hugs, holding hands Make direct eye contact when talking Be an active listener Tell children you love and respect them Spend some mutually enjoyable time together every day

(map game, tub fun…) Do special things to let your child know you are thinking of

him/her (lunch box card/note…) Watch and be with your children as they play Curb your anger; make the situation a win-win Identify your priorities Cut down on TV, video games, computer time, etc. Take an interest in your children, their opinions, likes, dislikes

11 Strategies to Create a person who knows, “I am lovable”


Be an encourager; praise and compliment freely Avoid over-protection; allow mistakes to occur and help

your child learn alternative solutions Criticize less; one criticism erases 99 praises Encourage exploration, even in the face of some risk Assign chores and responsibilities; hold your child to

completion of appropriate tasks Help your child build self skills with complex tasks Refrain from perfectionism or the expectation of it; a

better lesson is to fail and keep working on solutions Involve children in individual and team-building activities Encourage age-appropriate independence; add

responsibilities of caring for self (making her own bed, doing his own laundry…)

9 Strategies to Create a person who knows, “I am confident”


Let your child know he/she matters Pay attention to your child’s thoughts, feelings,

ideas Bring children into family discussions and

choices Always give reasons for rules Make labels taboo (stupid, slow, clumsy, pest) Refrain from punishing in anger Set realistic expectations; avoid self-worth to

become tied to perfect performance Avoid shame and guilt motivation

8 Strategies to Create a person who knows, “I am worthwhile”


Identify the target behavior(s).◦ Interrupting conversations or lessons

Select the self-monitoring system.◦ Chart, graph, etc.

Choose reinforcers and the criteria for attaining them.◦ Time to talk will be awarded after sitting down…

Teach the child to use the system.◦ Break down steps. Build upon learned responses.

Gradually fade prompts and reinforcers.◦ Once child is self-monitoring and adapting behavior

5 Base Strategies for Client Education & Self-Monitoring


Core Strategy for Self Help & Academic Help

Study Skills Program◦ Most children don’t care as much about studying as

parents and teachers do; many have few study skills◦ Develop and set up a daily assignment sheet system for

the child◦ Set up parent-teacher-child conferences to clearly

communicate daily expectations of everyone◦ Establish criteria for earning a good day on the program◦ Set up consequences for earning a good day◦ Consider using a study partner as an enhancement to the

program

Education & Self-Monitoring


Finding the Daily Assessment Sheet in your Appendices, follow the instructions for creating a daily flow sheet for your disorganized student.

Please Refer to Appendix for Study Skills Program and Daily Assignment Sheet

This Study Skills Program has been morphed into use for Adolescents and Adults out of the school situation.

Study Skills Program


Behavioral therapy is the psychosocial intervention that has the greatest amount of evidence to support its use in children with ADHD and for that reason it is prominently mentioned both within the American Academy of Child and Adolescent Psychiatry's Practice Parameters and in American Academy of Pediatrics' clinical guidelines that pertain to ADHD in children.

Although medications often grab the headlines, it is important to remember that effective and evidence-based psychosocial treatments exist for children and teenagers with ADHD.

REMEMBER THAT WHAT YOU SEE MAY NOT BE BEHAVIOR – IF IT’S SENSORY, BEHAVIORAL TREATMENT DOES NOT WORK

Meds and Therapy


Obtain a full medical-psychiatric diagnostic evaluation with neuropsychological testing.

Understand that executive functioning problems and sensory processing problems may be present in conjunction with ADHD.

Utilize the team approach to assist with behavioral change, learning techniques, psychological interventions, etc.

Working with Symptoms Overlap


General Recommendations for Teachers◦ Distinguish between medical evaluations and educational

evaluations◦ Document the challenges you notice with objective

behavioral terms◦ Document interventions and responses◦ Speak with other teachers or last year’s teacher &

compare notes◦ Recommend next-step evaluation

Avoid diagnostic terms in conversation with parents

Leave medication decisions to families and their physicians

Find common goals with parents

Teacher Friendly Classroom Worksheets


“How are you going to know when to be ready?” “How are you going to stop yourself from…?” “What is your goal?” “What do you want it to look like?” “How long do you think it will take?” “How much did time did it take last time?” “How are you going decide where to set that up?” “How are you going to know what you need?” “How are you going to know what is most important?” “How are you going to decide what to do first?” “How will you know when you are finished?” “How will you continue when you are tired?” “How did that work out?” “How long do you think that took?” “How did you manage/know how to do it?” “Would you do anything differently?” “Have you done anything like this before?” “Was that harder or easier than…?” “What worked for you?”

19 Cues to help your child/adult to know WHAT to do


The BEST strategies to help your child with ADHD, EDfs, etc. come from knowing your child and his/her strengths and sticky areas

The BEST strategies will come out of careful observation and consideration of what works well to have your child come to a positive outcome

The BEST strategies will demonstrate a collaboration with educators and other adults who add dimension to your child’s life

Choosing the BEST Strategies


Go to your child and make direct eye contact before giving an instruction.

Check for understanding: “Tell me what I want you to do.”

Give verbal directions one at a time, not in a long list. Physical contact can help the child focus. Encourage your child to talk through a situation rather

than just plunging in. Go over steps in a procedure before and during

activities, including those you and your child do together.

Express expectations in written or visual form as well as verbal, such as a chore chart or a checklist.

7 Communication Strategies for the Disorganized Child


Working with symptoms overlap Teacher-friendly classroom worksheets Identification of motivators in the

disorganized/distractible adult- getting on track

Creating a ‘good fit’ personal organization strategy for the person with EDf

Tools/Strategies You Can Use Today


6 Organizational Skills

Put an organizational system in place. Supervise your child using the system. Start small.

◦ Identify troublesome domains and work on them one at a time.

Prioritize matters. Set up prompts and reduce direct supervision

as organization improves. Model organized behavior.

The Best Skills


5 Self-Monitoring Skills

Identify the target behavior(s).◦ Interrupting conversations or lessons

Select the self-monitoring system.◦ Chart, graph, etc.

Choose reinforcers and the criteria for attaining them.◦ Time to talk will be awarded after sitting down…

Teach the child to use the system. Gradually fade prompts and reinforcers.

◦ Once child is self-monitoring and adapting behavior

The Best Skills


5 Time-Management Skills

Maintain a daily, predictable routine for the family; makes planning easier

Talk to child about how long it takes to do things; practice and time a task◦ Chores, homework, getting dressed for school, etc.

Plan a weekend or vacation activity that takes several steps; make a plan for the day

Use calendars and schedules yourself; teach and encourage child to do the same

Use timers, watches, clocks as visual cues

The Best Skills


Activity Scheduling Values & Goals Clarification Quick & Effective Daily Organization Moving Past Procrastination

Adult Skills & Strategies


Target Behaviors for Home and School Managing Children Behaviors at Home Developmental Tasks Requiring Executive Skills Atten & Related Problem Checklist for Children Atten & Related Problem Checklist Interpretation Effective Classroom and Home Strategies for Children with

ADHD Behavioral Intervention Plan Comprehensive Intervention Plan Daily School Report Card How Did I Do? School Assessment Request IDEA Request Questions & Answers: IEPs

Appendices/Strategies for Children


Developing a daily and weekly schedule of activities helps the child or adult remember that he/she can set and accomplish goals.

The scheduling is done collaboratively (teacher-student, parent-child, adult-therapist)

Goal of activity scheduling is to help the person with ADHD/EDf become more proactive in scheduling activities in advance.

Person then monitors the activities throughout the day or week, filling in a visual form with the activity LINKED to the feeling associated with that activity and level of accomplishment.

Daily Activity Schedules are set in hours, but may be broken down into smaller increments for children.

5 Adult Activity Scheduling Strategies


Understanding one’s own values is paramount to setting achievable goals

Your values are your ideas about what is most important to you in your life —what you want to live by and live for. They are the silent forces behind many of your actions and decisions.

The goal of "values clarification" is for you to become fully conscious of their influence, and to explore and honestly acknowledge what you truly value at this time in your life.

You can be more self-directed and effective when you know which values you really choose to keep and live by as an adult, and which ones will get priority over others.

Adult Values & Goals Clarification


To accomplish any work (reading a paragraph, managing a checkbook, etc) we go through 5 discrete stages:

1. Collect things that demand our attention◦ (in-basket, e-mail, Blackberry, etc

2. Process what they mean and what to do about those things◦ What is it? Actionable? Do it, delegate it, defer it

3. Organize the results◦ reviewable set of reminders, project list, calendar

4. Review the options for what we choose to do◦ Daily & weekly review, get clean, clear, current, complete

5. DO!◦ Based on context, time & energy availability, priority◦ Move Past Procrastination (find a way to get started)

5 Stages toward Ability to Master Work


Break Down the Day into Small Blocks of Time to Work on Tasks

Break Down the Work into Smaller, Manageable Chunks

Use a Timer Take Frequent Breaks Use Visual Reminders Connect with Positive Co-workers Small Healthy Snacks Throughout the Day

7 Quick, Effective Daily Organization Strategies at Work


Pre-plan the day before◦ Write down your goals/necessities that need to be accomplished the next day.

Keep this plan in a book with pages that cannot be removed. Get up and go to bed at the same times each day

◦ This sets your internal and external schedule.◦ Get to bed earlier and awaken earlier◦ Change the timing of sleep-wake pattern with a ‘dawning-alarm’

Do physical exercise◦ Helps with good rest and alertness throughout your day.

Know your triggers to stress◦ Write down your top 3 stressors that make you uneasy. Tend to those first, then

move on. Write down distracting thoughts/ideas for later

◦ Keep an ‘Idea Pad’ close by and just jot a word or two as a reminder Take a break

◦ Work hard and intently for 20-30 minutes, then get up and stretch, get a drink of water, etc. Remember to schedule recreation time in your week.

◦ Watch some mindless TV to unwind & recharge.◦ Listen to books on tape in the car

Getting the ADHD Adult on Track (Big Five Wisdom)


Details ARE important◦ Have a place for everything and keep everything in its place – this saves you

from losing your mind on daily ‘trivial’ events Do something you are good at doing

◦ Don’t spend the rest of your life trying over and over to get good at something you’re bad at doing

Pay attention to your diet◦ Eat breakfast◦ Slow down on the carbs!◦ Eat an Omega-3 rich diet

Delegate – put this reminder on every flat surface you see Find someone you trust and really listen to that person

◦ Find a lawyer, accountant, banker, physician you trust too Get yourself a ‘closer’ – someone to help you finish all those great

projects you start – until you can close for yourself Break the pattern of using previously failed strategies DO… stop procrastinating

◦ Putting off or re-prioritizing robs your time and energy. Just do it.

Getting the ADHD Adult on Track


Educate yourself about ADHD Identify your individual needs Tune up your nutrition Support your sleep Improve family/couple communication Examine your social connections Get regular exercise Support vocational success Get a complete medical evaluation

Big Picture Approach to Managing Adult ADHD


Get a hearing and vision examination Be evaluated by an adult ADHD specialist Consider environmental strategies, structure Consider coaching, counseling, or couples

counseling Tackle self-management skills Consider medication, if appropriate Monitor progress Treat co-morbidities Take care of yourself Get a fidget-toy

The Big Picture Approach to Adult ADHD


Strength and Weakness Profile Values Clarification Worksheet Attention and Related Problem Checklist for

Adults Attention and Related Problem Checklist for

Adults, Interpretation

More Appendices/Strategies for Adults


ADD/ADHD has many positive attributes The creativity that goes along with ADHD is

astounding! You always want a person who processes

this creatively in your think tank. Really connect with the person who lives

with ADD/ADHD – hang around for the downs as well as the ups.

And remember…


1. TEMPERANCE. Eat not to dullness; drink not to elevation. 2. SILENCE. Speak not but what may benefit others or yourself; avoid trifling

conversation. 3. ORDER. Let all your things have their places; let each part of your business

have its time. 4. RESOLUTION. Resolve to perform what you ought; perform without fail what

you resolve. 5. FRUGALITY. Make no expense but to do good to others or yourself; i.e., waste

nothing. 6. INDUSTRY. Lose no time; be always employed in something useful; cut off all

unnecessary actions. 7. SINCERITY. Use no hurtful deceit; think innocently and justly, and, if you

speak, speak accordingly. 8. JUSTICE. Wrong none by doing injuries, or omitting the benefits that are your

duty. 9. MODERATION. Avoid extremes; forbear resenting injuries so much as you

think they deserve. 10. CLEANLINESS. Tolerate no uncleanliness in body, clothes, or habitation. 11. TRANQUILLITY. Be not disturbed at trifles, or at accidents common or

unavoidable. 12. CHASTITY. Rarely use venery but for health or offspring, never to dullness,

weakness, or the injury of your own or another's peace or reputation. 13. HUMILITY. Imitate Jesus and Socrates.

Ben Franklin’s check against his ADD


Adam is a 36 year old divorced man who is trying to get a small delivery business off the ground. So far during his working years, he has never stayed at one job longer than 7 or 8 months. He has done all kinds of labor-intensive jobs (working in a foundry, loading dock, bakery delivery, construction), but finds working for others degrading and boring. He has been diagnosed with ADHD as a middle-school boy, and Bipolar Disorder as an adult. He has multiple parking tickets and several misdemeanor infractions on his record. His temper can be somewhat volatile.

Develop a plan of action to assist Adam with psychosocial

and vocational endeavors.

Adam


Sarah is struggling with math now that she is in high school. Algebra and geometry are her worst subjects. She puts off doing that homework, preferring to write in her journal or read her English assignments. Her parents are both architects and cannot understand why Sarah is still failing math with a tutor and remedial program at school. Sarah is often moody, sullen, and withdrawn.

Develop a plan for helping Sarah with schoolwork and emotional problems.

Sarah


Keith is in perpetual motion running, crashing, and tripping into anything or anyone in his path. Everything he does is fast – in a nanosecond. He’s now seven years old and is just beginning to stop for less than a nanosecond when his mother or other church adult asks him to slow down or gives him instructions. Keith is affable, likes to give answers (usually the first to raise his hand, stand, jump, then comes to the front of the class if not selected immediately), can play in a group or by himself, and is generally a very happy kid.

Keith


Uncombed hair going in several directions, shirt tails half in, half out, mismatched socks (and sometimes shoes), scuffed knees and elbows… a real boy. He has one vocal volume, about 20 decibels louder than the other children (even in church), and thrives on being the class clown. Keith’s mom says that if he plays really hard in the yard with running, jumping, on the swings, and rolling on the ground in the dirt, he will be able to sleep for about 7 hours that night. She has not noticed that sweet foods have much of an effect on him.

Develop a Program for Keith’s blurting out in class.

Keith


Jeff is having difficulty on many levels. He is moody and talks back to his parents, teachers and peers. From insisting on his own way in most peer interactions, his friends have stopped spending time with him. He has little regard for other people’s feelings or possessions, and often throws his books, sneakers, clothes, i-pod, game boy, and other items onto the floor in his room. His parents threaten him with punishment for not picking up his room, placing clothes in the hamper, leaving his ‘stuff’ lying around, etc. Jeff’s usual retort is, “ go ahead, I’ll just find some way to bother you when I’m being punished. I hate you!” He pulled off some of the handles on the kitchen drawers, wrote in permanent marker on the bathroom counter top, and cut clumps of hair from the family dog.

Jeff


Jeff is quite smart, yet rarely starts or completes assignments, so his grades are generally poor. This continues the downward spiral of anger and punishment with his parents. He has started and stopped several scholastic improvement programs. His teachers talk to him about doing more creative writing and with his interest in history, yet he refuses to become involved with his studies or academic groups at school. He sits in class doodling, clicking his pen, or looking out the window. He is generally not truant. He smokes in the bathrooms at school and on his walk home from school. He takes no prescription medications.

Given Jeff’s behavior, how would you develop a plan to help him in school, at home, and with peers?

Jeff


Edgar has green eyes! I’ve known him and his family for about four years and have never been able to make eye contact with him until recently. He hides behind his mom during any social contact. Minor sibling infractions (taking a sip of his milk or tussling his hair) sends him into a frenzy, then absolute silence for minutes to hours. He can be in Grand Central Station and remain focused on his puzzle or watching the fish in the tank. His mom says that he was a colicky baby, did not nurse well, slept poorly, and needed to be held and rocked more often than her other two children as babies.

Edgar


At times, when Edgar is stressed, he appears to hold his breath, stiffen his body, and twitch his fingers. He’s afraid of water, so bath time is not very pleasant; he cringes when his hair is washed or when the washcloth is full of soap. He squirms in his clothes, pulls at labels necklines, and removes his shoes as soon as he’s indoors. He is lagging on developmental and social measures. He will start first grade.

Develop an intervention plan and request school services for Edgar.

Edgar


David is an accomplished, adult computer genius, married, father of three, and grandfather of one. He is now on the faculty of a local college and always has a great story to impart about how he’s helped a floundering student. When speaking about a troubled student, David’s eyes well with tears, his voice trembles and hands shake as he relates the student’s plight. If he discusses a book passage or movie clip, joy also brings him to tears. He is often at a loss for words when expressing emotions, and will have to leave the room to compose himself. He is often disheveled in appearance, yet his wife reveals that his home study is immaculate, with books color-coded and arranged according to content. He will often interrupt or leave a conversation without apology, and displays no outward signs of affection or appropriate social physical contact (hand shake, pat on the back), yet generally stands very closely to those with whom he is conversing. He walks slightly hunched over, without any arm swing or liveliness to his gait. David is frequently late for meetings stating that he became engrossed in a book or mathematical problem and lost track of the time.

David


Thank you for attending.

Please complete your Test Questions and the Evaluation form.

CMIand I appreciate your comments.


The following pages contain multiple types of information, work sheets, skill builders, and ADHD-related help for children, teens, and adults.

Information for school settings Information for home settings Information for work settings

Any of these sheets can be adapted to fit your specific needs

Addendum

Documents

Dr. Fralick-Ball has Asthma It will be cool in here all day SFBPsychMedEd 2010-2013