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Attention Deficit HyperactivityDisorder (ADHD)

Who are children with ADHD?

https://www.youtube.com/watch?v=w4t4JFKDD6s&feature=youtu.be

Children and adolescents with Attention and / or Hyperactivity Deficits

(DDAI Italian acronym)

ADHD (English acronym Attention Deficit Hyperactivity Disorder) according to the DSM-5

ICD-10

Activity and attention disorder F90.0

Attention deficit disorder with predominant inattention F98.8

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https://www.youtube.com/watch?v=w4t4JFKDD6s&t=8s

What is ADHD?

A neurodevelopmental disorder of self-regulation of behavior that manifests itself above all with difficulty in maintaining attention, (management of cognitive effort in general), motor control and impulsive responses. In most cases it is associated with other disorders, it is disabling for the subject and creates significant social difficulties

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Brief hystory of ADHD

Still (1902): "deficit in moral control and excessivevivacity and destructiveness ..."

Levin ('30): Minimum Brain Damage

Various authors ('40): Minimal Cerebral Dysfunction

DSM-II (1968): Child's Hyperkinetic Reaction

DSM-III (1980): ADD, with or without hyperactivity

DSM-III-R (1987): ADHD (14 symptoms)

DSM-IV (1994): ADHD (18 symptoms, 3 subtypes)

DSM-5 (2013): ADHD (age onset within 12 years, adult-specific)

3 core deficits of ADHD

Inattention

Hyperactivity

Impulsiveness

Learning difficulties

Interpersonalproblem

Regulation of emotion difficulties

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ADHD Symptoms

Inattention (adult specifications):

Pay attention to details (work is inaccurate ...)

Keep the attention for a prolonged period

Avoid distractions in uninspiring tasks

Organize your activities

Coping with long tasks (revisions of documents ...)

Hyperactivity

Move excessively, even in inappropriate contexts

Often under pressure (moved by a scooter)

Continuously switching from one activity to another ....

Impulsivity

"Shoot" the answers before the question has been completed

Difficulty waiting for your turn

Stop or be intrusive towards others

Type combined ADHD-C:

inattention + hyperactivity

Prevalent inattentive ADHD-I: inattention

Prevalent hyperactiveADHD-HI: hyperactive

Subtypes of ADHD

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Entity of the ADHD problemSymptoms SDQ 6-11 years (N = 2286) Partly True

Distracted, unable to concentrate 30% 13%

He does not carry out his duties 36% 10%

Restless, hyperactive 19,5% 10%

Constantly moving 17,5% 8%

He is not able to stop and think 51% 11%

Symptoms SDQ 12-19 years (N = 991) Partly True

Distracted, unable to concentrate 33% 11,5%

He does not carry out his duties 42% 7,5%

Restless, hyperactive 18% 6%

Constantly moving 15,5% 6%

He is not able to stop and think 45% 6%

Beyond main symptoms

Poor academic performance especially in subjects requiring organization and effort (production and comprehension of texts, study, mathematics)

Difficulty in social relationships both with adults and with peers

Poor self-regulation of emotions and impulses for which they often react inadequately or commit dangerous actions

Low motivation for performing activities that require cognitive effort

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Impulsive and inattentive: difficulty or disorder?

Normality Difficulty Disorder

Difficulties are linked to adverse episodic situations or to temperamental characteristics

Behavioral signs are mainly caused by environmental factors

The difficulties are constant and interfere with the activities

Comorbidity

Children and adolescents with ADHD may also experience other psychological and psychiatric disorders at the same time (comorbidity).In 70% of cases ADHD is associated with other disorders.Comorbidity can have a more complex impact on the prognosis and management of the ADHD boy.

Oppositional Defiant Disorder and Conduct Disorder 25%

Learning Disorder 30%

Anxiety Disorder 15%

Depression 15%

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Early identification of attention and behavioral disorder

Inhibition deficit • He is unable to wait for instructions for a game or activity

• It can not block afinalistic or disturbing behavior, despite

warnings

• It is distracted by stimuli external during play and he stops

it

Behavioral inflexibility • Difficulty adapting to changes in the game (rules, mates ...)

• Difficulty to participate in group play activities

• It always emits the same behaviors, even if incorrect and not functional

to the game (it learns little from the experience)

Emotional dysregulation • He is constantly eager and intolerant

• It is easily excitable

• It is easily irritable

ICD-10 diagnostic criteria

Symptoms must:

Be present already in preschool age

To cause a clinically significant impairment of scholastic and social functioning

To be present in at least two contexts (for example, at school and at home)

Symptoms should not be explained by other psychopathological conditions: Bipolar Disorder, Anxiety Disorders, Depression, Autism, Psychosis

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Differences in DSM-5

Change of category

• DSM-IV: Disruptive Behavior Disorders

• DSM-5: Neurodevelopmental Disorders

Literature reports neuropsychological deficits, particularly Executive Funtion (attention, memory, cognitive flexibility, planning)

Age of onset

• DSM-IV: before 7 years

• DSM-5: before the age of 12

• Studies on adult ADHD: 50% onset within 7 years; 95% onset within 12 years. No differences in follow-up and treatment in patients with symptom onset <7yrs vs <12yrs

Prevalence of ADHD

According to the DSM-5: 5% in children, 2.5% in adults

According to an Italian research (North, Center, Sardinia) about 3%

1.5% combined subtype

According to the teachers, about 20% of the students are inattentive or hyperactive: in fact among this crowd there are many false positives including: other disorders (above all) and very lively children

Male ratio 2:1 females in children; 1.6:1 in adults

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Epidemiology of ADHDDevelopment of ADHD

In preschool, hyperactivity is more evident (difficult to distinguish from liveliness)

Most of the first assessment requests occur when children are 8 - 10 years old

In the preadolescence the clinical presentation changes according to the factors of improvement or aggravation

In adolescence and adulthood

30% - 40% good remission of symptoms

60% - 70% remains the disorder

About half of them have co-morbidities with Externalized (Conduct) or Internalized disorders (Anxiety or Depression)

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Causes or expression of symptoms

Distinguish the causes (determinants of the disease) from the expression of symptoms (severity and duration)

The causes of ADHD are biological (genetic or not genetic)

The expression of symptoms also depends on parental education (more or less regulated), the family environment (more or less structured and predictable), the school environment (more or less supportive)

Brain structures involved in ADHD

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3 circuits of ADHD (Sonuga-Barke et al, 2010) A TRIPLE PATHWAYHYPOTHESIS

CORTICO-DORSAL

STRIATAL

LOOP

DISTURBANCE

INHIBITORY

DEFICITS

EXECUTIVE

DEFICITS

CORTICO-VENTRAL

STRIATAL

LOOP

DISTURBANCE

IMPAIRED

SIGNAL DELAYED

REWARD

DELAY AVERSION

ADHD

CORTICO-

CEREBELLAR

LOOP

DISTURBANCE

TEMPORO-

SENSORY-MOTOR

INTEGRATI’N

DEFICITS

MOTOR

ASYNCHRONY

SIMPLIFIED FUNCTIONAL

NEUROANATOMY

DLPFC

DORSAL

STRIATUM

Caudate

Nucleus

THALAMUS

MOTOR

CORTICES

NEO

CEREBELLUM

VENTRAL

STRIATUM

Nucleus

Accumbens

OFC

AMYGDALA

ANTERIOR

CINGULATE

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Genetics• Genetics of the population

• MZ = 0.66 DZ = 0.28 h2 = 0.77

• Study summary: from 60% to 91% of explained variance

• Molecular genetics

• Why?

• Efficacy of MPH: dysregulation of Dopamine

• Brain Imaging: involvement of areas rich of Dopamine receptors

• What to study

• 5 Dopamine receptors: DRD1 ... DRD5

• 1 transporter: DAT1 (the gene is on chromosome 5)

• 5HTT serotonin genes, SNAP25 protein

Heritability 77% variance ... so familiarity is a biological risk factor (Faraone & Larsson, 2018)

6 geni Gizer et al. [2009]

1. serotonin transportergene (5HTT)

2. dopamine transportergene (DAT1)

3. D4 dopamine receptorgene (DRD4)

4. D5 dopamine receptorgene (DRD5)

5. serotonin 1B receptorgene (HTR1B)

6. Gene coding for a

synaptic vesicleregulating protein known

as SNAP25.

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• 12 independent genome-wide significant loci associated with ADHD in a GWAS meta-analysis of 55,374 individuals

• FOXP2 and other biologically informative genes…..

• The results also highlight strong overlap with the

genetics of ADHD-related traits and health risk behaviors in the population, encouraging a dimensional view of ADHD as the extreme end of a continuum of symptoms

Risk factors of ADHD

biological

environment

Individual traits

Parent traits: education, imitation, genetics

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Mercury,

Manganese

• Maternal smoking OR =

1.60 Smoking mothers 60% more likely to have ADHD

child

• 75% if they smoke more than 10 cigarettes

• 54% with less than 10

cigarettes• Interactive effect with

socio-environmental

variables or parents' personalities?

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American Journal of Psychiatry,

2003

Consumption of alcohol during pregnancy

• Variability of results: 0.88 <OR> 2.5

• Some studies do not distinguish the amount of alcohol taken

• Consumption of alcohol is associated with family psychopathology (deviance, depression) and disadvantaged socio-economic status

• The direct effect between alcohol consumption and ADHD is weak

• Contradictory results, more research is needed

Interaction gene x environment: COMT x Anxiety mother

• Maternal anxiety predicts ADHD from 4 to 15 years (9% variance explained)

• The child's genotype and maternal anxiety interact to decrease WM performance and increase

ADHD symptoms

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• The Apgar index <9 is predictive of ADHD (22% of ADHD have this risk factor)

• Birth after term is the second perinatal risk factor for predicting ADHD

From pregnancy to 18 months

• Initial sample of over 100,000 pregnant mothers

• Interviewees at 6 and 18 months of age of the child (66% of the initial sample completed the study) on child development (language, cognition, motor skills), breastfeeding, sleep, crying, temperament, sleep

• 2034 children with ADHD selected from national registers (8-12 years)

• Retrospective analysis of interviews with mothers when their children were 6 and 18 months old to reconstruct the early risk factors of ADHD

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Risk factors in ADHD childrenRetrospective analysis at 6-18 months

0

0,5

1

1,5

2

2,5

3

3,5

30min pianto giorno allattamento seno 6

mesi

ritardo linguaggio seduta a 8 mesi cammino a 11 mesi no afferrare oggetti su

richiesta

iperattivo ipoattivo bambino difficile

6 mesi 18 mesi

From risk factors, to neuropsychology and finally to symptoms

• Comparison between 251 ADHD vs 213 non-ADHD (multi-step clinical diagnosis)

• Relationship between risk factors, neuropsychological processes, ADHD symptoms

• Risk factors: pre-natal exposure, health in pregnancy, peri-natal problems

• Neuropsychological processes: Inhibition, Active working memory, Memory span, Processing speed, Response variability, Arousal, Time processing

• Analysis of the direct influence of risk factors on ADHD symptoms

• Analysis of the indirect influence of risk factors on neuropsychological processes and in turn on ADHD symptoms

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Prenatal exposure-NPS-ADHD

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Pregnancy – NPS –ADHD

Inattention Hyperactivity

Perinatal – NPS - ADHD

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Mediation model for explaining ADHD

• Partialling out age, gender, ethnicity, family income, psychopathology of parents: pre-natal exposure does not directly predict ADHD

• Exposure to substances in pre-natal times influences memory span and temporal processing, which indirectly influence inattentiveness

• The health of the pregnant mother directly influences the ADHD symptoms, even after covariates

• Difficulties in the peri-natal phase affect the neuropsychological processes of response variability and temporal processing and indirectly ADHD symptoms

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Temperament, Executive Function, ADHD

2) Response set – Nepsy-2

Touch the yellow if you hear red

Touch red if you hear yellow

Touch blue if you hear blue

Executive Function (6 years)

1) Working Memory – WISC-IV

Temperament

Questionnaire (3-4 years)

Children Behavior

Questionnaire (parents)

94 questions on 3

macrodimensions:

1. Positive affectivity

2. Negative affectivity

3. Self-regulation

Temperament Assessment

Battery (Teachers)

29 questions on 4

dimensions

1. Inhibition

2. Activity level

3. Negative emotion

4. Persistence on the task

7 years: syntoms of ADHD usingK-SADS interview to parents

Attention: visual search

Interaction Temperament and Executive Function

Working memory is a more effective mediator than inhibition and flexibility processes

Managing

frustration and anger at 3-4 years

Executive Functions 6-year

ADHD symptoms at 7 years

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Delay aversion

M & Ms under the cup

Record every 5 '' if the

child resists the

temptation to take

candy (max 45 '')

Inhibiton Attention

K-CPT: length 7.5’, press a key

every 1-3sec, all blue

balls(10% of stimuli)

• Omissions

• Commissions

• RT

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ADHD risk factors and mediation models

• To define a model of pre-school Executive Function

• To identify the relationship between biological and environmental risk factors, related to the individual characteristics of the child and parents and the preschool ADHD traits

• To study the role of mediation of executive function between risk factors and preschool ADHD symptoms

With Nicoletta Scionti, Ylenia De Palma, Sara Bossi, Giulia LuziParticipants

• 5 Kindergartens in the Province of Milan, about 250 children with typical development

• 72% acceptance: 179 children balanced by gender and age rated by their parents and teachers

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Procedure

• Children were presented with a battery for the

assessment of cognitive functioning

• Parents and teachers filled a questionnaire on

developmental steps and behavior at present

MaterialBattery to assess Cognitive Function

• The game of color and form (FE-PS)

• Day / Night (FE-PS)

• Continuous Performance Test (Corkum et al., 1995; Mahone et al., 2001)

• Truck Loading (Carlson et al., 2004)

• Statue (NEPSY-II)

• Digit span (WISC-IV)

• Progressive Colored Matrices by Raven (Giofré & Belacchi, 2015)

• The gift (Sonuga-Barke et al., 1992; 2003)

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Statue

Dimensional Change Card Sort

Gift

Truck Loading

Day/Night Stroop Test

Forward digit Span

Backward Digit Span

Inhibition

(difficulties)

Working

Memory

Updating

.80

-.45

.73

.57

.68

.51

.48

-.29

CFA 2 FACTOR

MODEL

CFI = .99; TLI = .98;

RMSEA = .020

Hyperactive

and defiant

behaviour

Inattention

«On the go» acting

Fidgets with or taps hands or feet, or squirms in seat

Leaves seat in situations when remaining seated is expected

Easily upset

Bites and beats when upset

Respond hastily to questions

Needs more supervision than other children

Plays recklessly

Has trouble wainting his/her turn

Interrupts or intrudes on other

Bully and belligerent

Doesn’t respect rules

Deliberately annoys other children

Easily distracted

Has trouble holding attention on tasks or play activities

Does not follow through on instructions

Has troubles doing activities need more steps

Fails in activities needs close attention to details

Easily gets tired of activities he/she is doing

Does not seem to listen when spoken to directly

Has trouble switching from one activity to another

Has trouble organizing task and activities

Forgets what he/she has to do during the activities

Memory troubles

Has trouble doing activities or tasks for him/herself

Has trouble putting a puzzle together with 9 pieces or more

.65

.66

.70

.32

.47

.53

.66

.78

.58

.65

.85

.78

.82

.68

.70

.77

.71

.58

.61

.69.65

.67

.58

.69

.77

.65

.48*

Teacher’s questionnaire

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ADHD

ODD

.90

.45

.55

.40

.44

.41

“On the go” acting

Impatient and restless during play

Troubles holding attention on play activities

Avoids to do tasks that require mental effort

Leaves seat in situations when he/she

should remain seated

Fidgets with or taps hands or feet, or

squirms in seat

At the dinner table plays with food and

silverware

Doesn’t finish what has began

Loses or forgets toys out

Bully

Seems immature

Easily upset

Argues with adults

Touchy or easily annoyed

Belligerant

.47

.44

.63

.37

.63

.55

.46

.46

.48

Parents’ questionnaire

Combinatory Language

Competence in third year

of life

Inattention

Inhibition

TE= -.23***

DE= -.13*

-.43**

-.08

.24**

.01

Working

Memory

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Combinatory Language

Competence in third year

of life

Hyperactivity

Defiance

Inhibition

Working

Memory

TE= -.19**

DE= -.11

.24** -.25**

-.08 .13

Gross-motor skills

competence in the first

year of life

Hyperactivity and

Defiance

Inhibition

TE = -.15*

DE= -.09

Working

Memory

-.16*

.14

-.27**

.12

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How to carry out an assessment for ADHD

The diagnosis of ADHD is clinical: the clinician decides whether or not the child has the disorder on the basis of the data collected

At least 7-10 hours of assessment is needed to outline a complete picture including:

Free or structured interviews with parents and teachers

questionnaires for parents and teachers

cognitive tests to the child (Cognitive Level, Learning, Attention, Executive Functions)

observations (during task when the child applies strategies)

interview with the child (to observe the behavior, the attitude and the awareness of the problem)

Questionnaires

• CBCL – Child Behavior Checklist (Achenbach, 2001)

• Conners Rating Scale: Parents, Teachers, Child (Short – Long) (Conners, 2007)

• Brown ADD Scale: 3-7 years for parents and teachers, 8-12 years for parents, teachers and self-report, adolescents

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https://www.youtube.com/watch?v=-eGpC8VuwII

Treatments for ADHD

Patient

Parents

Teachers

Cognitive-behavioral therapyDrug therapyCounseling

CounselingBehavioral interventions

Parent training

Counseling

Psycho-educational training

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Goal of psychological treatments

Parent training

• reduction of behavioral and emotional problems at home

• improvement of the parent-child relationship

• Behavior modification in the classroom

• reduction of behavioral and emotional problems at school

• improvement of teacher-child relationship

• Cognitive-behavioral therapy (CBT) with the child

• reduction of behavioral and emotional problems

• improvement of social and academic skills

Multimodal Treatment for ADHD - MTA

• Pharmacological therapy (Med)

• Psycho-educational therapy: Parent Training, TeacherTraining, Cognitive-behavioral therapy for children(Beh)

• Combined therapy: drug + psycho-educational therapy (Comb)

• Community therapy: Basic pediatrician (CC)

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Composite measure(Conners et al.(2001), JAACAP, 40, 159-167)

Combined Therapy is more efficacious

Normalization rates for different types of therapy

25

34

56

68

0

10

20

30

40

50

60

70

80

Percentuale

Pediatrician

(63% drug)Drug CombinedBehavioral

Therapy

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It is important to know that

• Children of the combined therapy received 20% less drug

• 63% of children of the control group were treated using drugs

• Parents in the drug therapy group received unstructured training (booklets)

• Combined therapy and psychological therapy produce the same results for: social skills, parent-child relationships, relationships with peers. For these aspects, the effectiveness was due to psychological therapy, not to medication.

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Effect size ADHD symptoms

Externalizing Impairment Parenting

Parents 0,90 0,76 0,74 0,56

Teachers 0,79 0,33 0,78 ---

Observ.clinic

Obs. school Parenting Performance

Child 0,96 0,64 5,08 0,43

Counseling: basic principles for parents

• Strengthen a positive relationship with the child

• Establish clear rules

• reward the child often without postponing

• Be consistent with the rules and their positive and negative consequences

• Try to predict the problems

• Try to keep a relaxed climate

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PARENT TRAINING is the most effective non-pharmacological intervention for

self-regulation disordersTraining for parents aiming to help them to understandwhat is happening in their family, facilitating realisticattributions about their behavior and about their child,increasing their skills in the management of dysfunctionalbehaviors

Parent training

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The first one is informative on the characteristics ofthe ADHD child on the basis of information obtainedfrom the literature

The second one is the analysis of negative andpositive thoughts about him/herself as parent andabout their child

The third one is an application of behavioralstrategies to solve problem at home

Three main ingredients Parent training - method

• Semi-structured training 8-10 sessions lasting for 90-120 minutes every 2 weeks

• Small group of parents (8-12 parents in couple)

• Discussion about important facts of the last 2 weeks

• Presentation of a strategy

• Analysis of thoughts and beliefs, observation, reward, response cost, time-out, fading, prompting, planning and routines, prolem solving

• Discussion about the possible application at home

• Homework

• Problem solving at home

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What should I think…

• Many of his disturbing behaviors are not intentional

• it does not matter to find the responsibilities, the solutions are more important

• it's not just my fault that he behaves like that

• I can not let him do what he wants

• I have to start teaching him how to behave, taking into account that it will take more time, patience ... and a counseling

Some positive behaviors• The commands must be short, simple and specific

• you need to pay close attention to positive behaviors

• gratification must be given in a broad way and immediately after the child's action

• we must ignore the slightly negative behaviors

• we must not lose control of the boy

• it is necessary to be a model and a support to solve problems

• one must be consistent in gratifications and behavioral contracts

• it is important to establish and enforce the rules of behavior: few, understandable and accepted

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Strengths and Difficulties• Strengths

• he's good at sports

• is ready in speed games

• It is intuitive

• he is sociable

• he is affectionate

• cares for family members

• participate in group activities

• it is generous

• he invented

• Difficulties

• he is distracted

• interrupts others

• it is disobedient

• it is never "never" calm

• it's hurried

• it is disorganized

• disturbs the companions

• does not respect the rules

• does not perform the tasks

• it is inconstant

Routines at home• Timetable and sleep rhythm

• Feeding hours

• Care of your person

• Homework

• Own material management

• Return times

• Behavior in public

• Table behavior

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Parent training results

2,50

3,00

3,50

4,00

4,50

5,00

Alabama Parenting

Questionnaire

pre post

* * * *

Parent report better coping strategies

with stress and related to parent-child

interactions

2,00

2,20

2,40

2,60

2,80

3,00

3,20

3,40

3,60

3,80

4,00

Parent distress parent-child interaction difficult child

Parent stress index

pre post

* * *Parents report:

1. Less supervision

2. More coherent

discipline

3. More non-

physical

punishment

4. More other

discipline

strategies

Parent training results

3,00

3,20

3,40

3,60

3,80

4,00

4,20

4,40

Satisfaction Efficacy

Sense of competence

pre post

*

Parents rate themselves as more

effective, but not more satisfied

1,60

1,65

1,70

1,75

1,80

1,85

1,90

1,95

2,00

2,05

Inattention Hyperactivity

ADHD Symptoms

pre post

* *

Parent report their children show less

ADHD symptoms

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Mediation of the Parent training effectSonuga-Barke et al 2002

• Maternal ADHD reduces the positive effect of PT

• The major severity ADHD symptoms is a negative predictive index

• The coexistence of other problems (CBCL) is a positive predictive index

• Prevent the development of secondary problems

• Reduce parental stress

• Preventing some negative development trajectories

Why a PT for preschoolers?

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Efficacy of PT for preschoolers

Mean Effect Size of ADHD

symptoms reduction is 0,61

(medium effect)

• The Parent Training and the related material must bemediated by words and concrete examples drawnfrom the stories of the parents themselves

• the parents should be helped to analyze theproblems of the child and to seek the solution

• it is necessary to favor mutual help between parents,so that a problem solved in a positive way canexercise in others the curiosity and the research of thereasons that have pushed towards the solution

Some important notes…

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TEACHER TRAINING

It is necessary to take into account:

The teacher's interpretations on problematic behaviors

The school needs (quantity of students, diversity and problems, teachers available)

The pupil's needs (cognitive profile, specific behavioral difficulties, family or social problems)

The systematic consultancy is structured in 3 phases:

1. Observation

2. Reflections on space, time and attention

3. Behavioral strategies

A starting point…

• some hyperactive students in the classroom ... .climate of poor behavioral control

• «Infect» other students ... a sense of impotence in teachers

• students who are not content "pull more and more the rope" to look for limits, boundaries, motivations to behave better

• juxtaposition of dissatisfied: students who provoke without goals, teachers who can not manage them ...

• Stress, a sense of powerlessness, lack of shared objectives ...

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A breaking point

• Isolate and define specific behaviors that create chaos and tension in the classroom (occasional observations are needed)

• Link provocative behaviors and advantages for pupils, links that are invisible to teachers (functional ABC observations are needed)

• Define simple, clear and shared rules (contrary to negative behaviors and which become common objectives)

• Agree a goal and explain how to achieve it ... respecting the rules and positive behaviors

Looking for a meaning

• Why should hyperactive pupils respect the rules?

• What are the motivations of the pupils to improve their behavior? ... .. is it more fun to provoke and break the rules?

• We need more motivation and find meaning in positive behavior

• Almost everyone must be convinced of the advantage and the consequences of compliance with the rules

• A collective award, pleasant to make everyone feel more competent is already a good reason!

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Steps of the project

1. Observation in the classroom

2. Occasional, Functional, Systematic

3. Sharing with teachers of classroom observations and definition of behavioral goals

4. Panel realization: rules, contract, points system, puzzle with final prize

5. Talking with students to share rules, positive behaviors and create a mutual respect

I keep silence during the lesson During the lesson I am sitting still

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To intervene I raise my hand

Contract and the tokens

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Teacher gives tokens for the final prize

Don’t raise hand– Don’t wait

0

10

20

30

40

50

60

70

80

90

Baseline Token 1 Token 2 Token 3 Token 4 Token 5 Token 6 Token 7 Token 8

Non alzare la mano Alzare la mano ma non aspettare

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Don’t keep silence

0

10

20

30

40

50

60

70

80

90

100

Baseline Token 1 Token 2 Token 3 Token 4 Token 5 Token 6 Token 7 Token 8

Chiacchiera Fa versi

Don’t sit still

0

50

100

150

200

250

Baseline Token 1 Token 2 Token 3 Token 4 Token 5 Token 6 Token 7 Token 8

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Raise hand

0

20

40

60

80

100

120

140

160

Positive behavior

Intervention at school for disruptive behavior

• The intervention does not focus on a single child (with ADHD or ODD) but

• It involves all pupils of the classroom

• A baseline observation is necessary: to understand the classroom, the start a project in collaboration with the children, to assess possiblechanges

• Positive behaviors could be augmented and the climate of the classroom could improve

• The final goal is to set an higher well-being at school

• For disruptive children in this context it is easier to respect the rules

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The work with the child

• It can be useful to work with the child on attention

• Need to get used to working in an organized, reflective, continuous, systematic way

• It should be gratified, supported to generalize the reflective and careful style

• He needs to improve awareness before and after the performance of activities and exercises

The work with the child

• The problem of generalization of results

• adults must be supportive models and educators

• The child and the adolescent fear judgment and deny the difficulties

• Denial of problems is contrary to emotional awareness

• Two ingredients: exercises on attention and functions + metacognition to generalize the results

• We can discuss training for children during Executive Function section

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Which therapy?

Drug therapy can be useful:

• in children with severe ADHD symptoms

• if there are no educational resources (family and school) to apply a psychological therapy

• if a crystallized situation needs to be unlocked

Psychological therapy is necessary if:

• there are social / relational problems

• it is noted that educators are motivated to "change"

• there is a long-term intervention