Very best treatment for adhd and the processing disorders tatra 2014

David D Nowell PhDwww.DrNowell.com

www.DrNowell.com

DavidNowell

DavidNowellSeminars

Overview

• Perspectives• Curious compassionate nonjudgmental evaluation• ADHDetc

– SPD– CAPD– ADHD/ADD

• Ask 2 questions• Strategic behavioral inquiry (HËDŸDT)• Tools you can use now• 75 strategies that just might change your life

Overview

• Perspectives• Curious compassionate nonjudgmental evaluation• ADHDetc

– SPD– CAPD– ADHD/ADD

• Ask 2 questions• Strategic behavioral inquiry (HËDŸDT)`• Tools you can use now• 75 strategies that just might change your life

www.slideshare.net/dnowell

PERSPECTIVES

Avoiding the most common diagnostic error

What’s wrong with this brain model?

What are our data sources?

• Record review• Interview• Collateral interview• Checklists• Mental status examination • Test scores

CURIOUS COMPASSIONATE NONJUDGMENTAL EVALUATION

Curious Compassionate Nonjudgmental Evaluation

• Skillfully eliciting the chief complaint• HËDŸDT?• Forming a diagnostic impression• Defending your diagnosis / impression

Skillfully eliciting the chief complaint

• Too much of what? Or too little of what?• Invoking the Pediatric Fairy (or the Psychiatric

Genie)

HËDŸDT?

• How exactly did you do that?– Everybody’s doing the best he/she can– Every behavior problem is either• Skills deficit• Contingency problem

Forming a diagnostic impression

• Where do you see it the most? And where do you see it the least?

• Two disorders = two stories

Documenting and communicating your conclusions

• The footprints in the butter• Defend your diagnosis

ADHDETCSPD, CAPD, ADD/ADHD, SCT

SENSORY PROCESSING DISORDERADHDetc

Sensory Processing Terminology

• Sensory detection• Sensory discrimination• Sensory modulation• Sensory integration– Performing a developmentally appropriate task in

a multi-sensory environment

Who doesn’t love a wedding?

Who doesn’t love a sensory deprivation tank?

Sensory Processing Disorder

• Persistent atypical over-responsivity or underresponsivity to sensation

SENSORY PROCESSING DISORDER

Sensory modulation

disorder

Over-responsive

Under-responsive

Sensation seeking

Sensory discrimination

disorder

Sensory-based motor disorder

Postural disorder Dyspraxia

Interventions for Sensory Processing Disorders

• Top down– Normalizing– Patient and family education– Environmental interventions– Self-esteem / success experiences– Treating comorbidities

The Sensory Defensive Adult

Consider your own self-stim strategies

• Applying lotion• Clicking pen• Sewing machine leg• Gum• Whistling

Instant study carrel

Time “in”

Place the student with tactile defensiveness at the edge of the group

Provide multiple cues for transitions

• Verbal “two minute warning” • Visual schedule• Changes in lighting• Nonverbal cues

Heavy work

CENTRAL AUDITORY PROCESSING DISORDER

ADHDetc

• Auditory discrimination (same/different)• Auditory localization (locate source of sound)• Auditory performance with degraded acousticsignal• Auditory figure-ground (perceiving sounds inbackground noise)

Central auditory processes

Central Auditory Processing Disorder

• Difficulty processing auditory information

despite normal hearing– With functional impact– Observable by SLPs, teachers, and parents

CAPD: what we notice

• Poor communicator (terse, telegraphic)• Hears better when watching the speaker• Problems when I speak to rapidly to him• She interprets words too literally• Memorizes poorly

CAPD: what we notice

• Often needs remarks repeated• Difficulty sounding out words while reading• Confuses similar-sounding words• Difficulty following directions in a series

• the research challenge of “supramodal influences”

CAPD or ADHD?

• Where do you see it the most? Where do you see it the least?

Interventions for CAPD

• Bottom up– Auditory integration training and similar programs– Environmental modifications• FM transmission• Train the speaker to face her listener, and check for

understanding• Preferential seating• Untimed testing• …..and…..

understanding• Preferential seating• Untimed testing

• Increased use of visual cues

understanding• Preferential seating• Untimed testing• Increased use of visual cues

True or False?

• Sensory Processing Disorder will be included in the DSM5

• Only individuals on the autistic spectrum engage in self-stimulating behaviors

• Speech Language Pathologists formally diagnose CAPD by way of screening tests

• CAPD and ADHD can be co-occurring conditions in some clients

• Top down– Metalinguistic strategies including schema

induction, context-derived vocabulary building, phonological awareness, and semantic network expansion

• Top down– Metalinguistic strategies including schema

induction, context-derived vocabulary building, phonological awareness, and semantic network expansion

– Metacognitive strategies including self-instruction, cognitive problem solving, and assertiveness training

Skillfully eliciting the chief complaint

• Too much of what? Or too little of what?• Invoking the Pediatric Fairy (or the Psychiatric

Genie)

HËDŸDT?

• How exactly did you do that?– Everybody’s doing the best he/she can– Every behavior problem is either• Skills deficit• Contingency problem

Forming a diagnostic impression

• Where do you see it the most? And where do you see it the least?

• Two disorders = two stories

Documenting and communicating your conclusions

• The footprints in the butter• Defend your diagnosis

Adults with Auditory Processing Challenge

Strengths and Weaknesses Checklist(Sensory Processing Problems)

Appendix A

ATTENTION DEFICIT HYPERACTIVITY DISORDER

ADHDetc

The Executive Functions

• Nonverbal working memory• Verbal working memory• Self-regulation of affect/motivation/arousal• Reconstitution

Barkley, RA, Murphy, KR., Fischer, M (2008). ADHD in Adults: What the Science Says . New York, Guilford Press.

• Sensing to the self• Speech to the self• Emotion to the self• Play to the self

Barkley, RA, (2012)

• Making movies in your head

• Talking to yourself

• Being your own boss

• Thinking and creating “what could be”

Arenas of Involvement

• Intrapersonal• Interpersonal• Environmental• Academic / symbol system

(McCloskey & Perkins, 2013)

1. 1-step errands

2. Chores with cues

3. Basic inhibition

Age-appropriate ExpectationsPreschool

1. 2-3 step directions

2. 20-30 minute assignments

3. Follow rules/inhibit/no grabbing

Age-appropriate ExpectationsKindergarten -2nd Grade

1. Simple shopping list

2. Keep track of variable daily schedule

3. Inhibit and regulate even without teacher present

4. Simple delayed gratification (phone)

Age-appropriate Expectations3rd-5th Grade

1. Complex chores

2. Organizing system

3. Time management

4. Self soothe

5. Manage conflict

Age-appropriate Expectations6th – 8th Grade

1. Independent with assignments

2. Make adjustments based on feedback

3. Inhibit reckless behavior

4. Say “no” to fun activity if other plans already made

5. Take others’ perspective

Age-appropriate ExpectationsTeenage-mid 20’s

Knock 3 years off his age

Age-appropriate ExpectationsLending Your Brain

Model and discuss attending

• Broad versus narrow• Internal versus external• Passive and active

ADHD and Brain Development

Inattentive Hyperactive Combined

Appendix B

DSM-V Changes

• Age of onset (12 years rather than 7)• Adult criteria (5 symptoms rather than 6)• Additional symptom examples provided• Strengthening of cross-situational

requirement• Provision of comorbidity with autism

ADHD and Brain Imaging

Environmental Influences

• Screens • Second-hand smoke• Toxic exposure• Sleep deprivation

Environmental Influences

• Screens • Second-hand smoke• Toxic exposure• Sleep deprivation

Functional impact of core symptoms

• Arousal / alertness• Mental effort• Determination of saliency• Focal maintenance

Sleep hygiene

• Strict bedtime• Use bed only for sleep• No caffeine after mid-afternoon• No activating media after 7pm

Establish bedtime routine

Fidget supports

Premack Principle

Reward small units of effort

• Arousal / alertness• Mental effort• Determination of saliency (what’s in it for me?)• Focal maintenance

There’s no such thing as procrastination

• “There’s just choosing….and choosing again…”

procrastinators-anonymous.org

EZ-C Reader

• Satisfaction control (“post-synaptic dopamine insensitivity”)

• Inhibition• Tempo control• Self-monitoring and correcting

Differential Reinforcement of Other

Fail-proof desk activities

Appendix C

Daily report card

Appendix D / E

Meet with your ADHD employee for regular ongoing feedback

• Satisfaction control• Inhibition• Tempo control• Self-monitoring and correcting

There’s no such thing as “disinhibited”

The “talking stick”

• Satisfaction control• Inhibition/Self-Regulation– Arousal– Motivation– Mood• ADHD or Bipolar Disorder?• Too much “push” or too little “pull”?

• Tempo control• Self-monitoring and correcting

ADHD is notFRED-PG13

• Flight of ideas• Racing thoughts• Euphoria• Decreased need for sleep• Periodicity • Grandiosity• Age of onset

1 hour 1 day 1 week 1 month 1 year

Time Horizon

Distraction delay training

COMPREHENSIVE ADHD EVALUATION

Curious Compassionate Nonjudgmental Evaluation

• Skillfully eliciting the chief complaint• HËDŸDT?• Forming a diagnostic impression• Defending your diagnosis / impression

What are our data sources?

• Record review• Interview• Collateral interview• Checklists• Mental status examination • Test scores

COMPREHENSIVE ADHD TREATMENT

Comprehensive ADHD Treatment

• Medication• Behavioral Support• Working Memory

Training• Movement• Vestibular and

Cerebellar Interventions• Neurofeedback• Breathwork /

meditation

• Creative visualization

• Mindfulness • Bodywork• Supplements / diet• Hypnosis• Coaching • Counseling

• Medication– Stimulant– Non-stimulant– “Off-label” treatment

Image: wikimedia commons

Cortico-striatal loop

Increase salience

Two weeks from now, how will you know whether it’s working?

Appendix F / G

Daily report card

Appendix D

• Behavioral Support

AANTECEDENTS

BBEHAVIOR

CCONSEQUENCE

AANTECEDEN

BBEHAVIOR

CCONSEQUENC

AANTECEDENTS

BBEHAVIOR

CCONSEQUENC

AANTECEDENTS

Set them up for success

AANTECEDENTS

Identify exceptions

Where do you see it the most?

Where do you see it the least?

•Waking up•Bedtime•Chores•Homework•TV / internet

AANTECEDENTS

Launching Pad

Expectations

•Specific•Behavioral•In advance

AANTECEDENTS

Communication

•Get eye contact•Speak clearly•Provide behavioral info•Check for understanding

AANTECEDENT

Ask for What You Want

• Talk like a behaviorist• Tell your partner what you want• Post classroom expectations visibly

(for the non-ADD partner) Ask for what you want

AANTECEDENTS

Provide prosthetic cues at the “point-of-performance” (Barkley)

• Staff mentor• “Fall-back” peer

AANTECEDENTS

Provide prosthetic cues at the “point-of-performance” (Barkley)

Appendix H

AANTECEDEN

BBEHAVIOR

CCONSEQUENC

Behavioral Support

BBEHAVIOR

“A healthy high-functioning 26 year old”

BBEHAVIOR

• Behavioral control• Choices and options• Self-regulation• Arousal• Motivation• Mood• Attention

AANTECEDEN

BBEHAVIOR

CCONSEQUENCES

Don’t reward them with stuff

Rotate rewards frequently

Determine what basic provisions are unconditional…

• Love• Respect• Safety• 3 meals• Essential clothing• Temperature-controlled environment• 30 minutes of video games

…and which are contingent• Special foods• Expensive or trendy clothing• Extra video game time

Appendix I

Clip and share horrible articles about teens falling out of the back of pickup trucks

• Review cause and effect• Discuss consequences• Emphasize behavioral agency

Working Memory Training

• CogMed• Lumosity

Movement Techniques

• Exercise• Rhythm and timing and cognition• Integrated movement • Yoga• Martial arts

Turn 30 minutes into 45

Balance screen time and “green time”

Movement Techniques

• Exercise• Rhythm and timing and cognition• Yoga• Martial arts

Bal-A-Vis-X

Vestibular and Cerebellar Exercises

• Dyslexia Dyspraxia Attention Treatment• Interactive metronome

amygdala

Prefrontalcortex

Managing our Cave(wo)man

• Meditation• Creative visualization• Mindfulness • Neurofeedback

04/11/2023 239

04/11/2023 240

04/11/2023 241

Mindfulness

Bodywork

• Massage• Chiropractic • Acupuncture• Transcranial magnetic stimulation

Supplements and Diet

• Omegas• Food additives• Food allergies• Pesticides• Dietary recommendations

Supplements and Diet

• Omegas– Zinc

• Food additives• Food allergies• Pesticides• Dietary recommendations

Nutrition essentials

• Emphasize protein at every snack and meal• Eat fewer processed foods• Choose local• Pay close attention to patterns between food

and focus/mood

Hypnosis

ADD Coaching

– May be expensive

Consider online peer support

www.reddit.com/r/ADHD/

Counseling Goals with the ADHD Client

Basic Brain Supports (without these the rest may not matter)• Sleep• Nutrition• Exercise

Family Supports (any ADHD treatment should include support for the spouse or parents)• Rules• Expectations• Communication

AANTECEDENTS

BBEHAVIOR

CCONSEQUENC

Rules,Expecations, and Communication

The Self-esteem

Abacus

Counseling Goals with the ADHD Client

Therapeutic Interventions (traditional counseling tasks)• Self-esteem• Self-efficacy

Lend-Me-Your-Brain Interventions (executive function support)• Reading skills• Study skills• Time/goal management

– Calendar– To-do list

The “Big Five”

• Daily focus time• Nutrition• Movement• Sleep• Connection

10-Minute Morning Review

…the most important 10 minutes of the day….

The “Big Five”

Barter Social/Practical Support

• Food prep for optimal nutrition• Domestic organization• Pre-tax paperwork

The “Big Five”

• Daily focus time • Nutrition• Movement• Sleep• Connection

“Exercise for focus” is different from "exercise for fitness”

The “Big Five”

Marry well and get a crackerjack assistant at work

The ADHD Couple

The ADHD Couple: The Problems

The ADD Partner May Have:• High need for stimulation• Poorer impulse control• Inattention to detail

The Non-ADD Partner May Have:

• Rigid style• Mild anxiety• Unrealistic expectations

The ADHD Couple: Counseling Goals

• Remembering what drew you to your partner• Getting to “fair”• Outsourcing / professional supports• Feeling your contributions are valued• Communication skills training

Positive characteristics of many people with attentional / executive challenges

Appendix J

The ADHD Couple: Counseling Goals

• Remembering what drew you to your partner• Getting to “fair”• Outsourcing / professional supports• Feeling your contributions are valued• Communication skills training

Allow your non-ADHD partner or roommate to tackle longer-term projects: You take on more of the easy/quick tasks.

Don’t do anything for your ADHD partner or teenager which could just as easily be managed by a machine or an app

Shower Coach

“Walk Me Up” app

MORE STRATEGIES THAT JUST MIGHT CHANGE YOUR LIFE

Tickler System

Why Don’t Nuns Worry about What to Wear?

Strategy to rule to habit

• Let’s spend 30 seconds right now determining where you’ll put your keys from now on upon entering your home.

Strategy to rule to habit

3. habit

2. rule

1. strategy

Upstairs downstairs box

60-Second Bathroom Cleaning Routine

Clear (see-through) storage

Model and practice self-talk

• “I’m checking email then returning phone calls”

• “When do I need to be ready?”• “How long will this take?”

Reck, S.G. et al (2013)

ASK TWO QUESTIONSSelf-talk proficiency

Am I having fun now?Is this important?

important?

What does dopamine feeeel like?

YesYes

Am I having fun now?Is this important?

YesYes

I’m having fun.I’m on task.

Am I having fun now?

Is this important?

YesYes

I’m having fun.I’m not on task.

Is this important?

Beware dopamine tricksters!

• Facebook• Gambling• Shopping• Video games• Free online Aramaic course

StayOnTask app

The best defense against the manipulation of our attention is to determine for ourselves – in advance - how we want to invest it.

- E. Goldberg

Key features of a great planner system

• 2 pages per day• Master to-do list• With the client at all times

Yoga / read

Staff meeting

Planningsession

Phone calls

billing

Vh: jeff w/ puritan oil

Vc: kate re: brimfield

TC umass dermatology. Spoke w/ cindy 508 8564000

What’s a To-Do list for anyway?

• The “technology”• The “practice”

• The “technology”

• The “practice”

Weekly Overview

10-Minute Morning Review

Where will I most likely feel distracted today?

What will you do today that you'll still remember one year from now??

YesYes

I’m not having fun.I’m on task.

Is this important?

Increase salience

Use extrinsic reward creatively

Emphasize the sensory details of your desired outcome

easy hard

If It’s Harder than a “3” Find Some Way to Make It Easier

Assign separate due dates for smaller parts of big projects

Barter Social/Practical Support

• Food prep for optimal nutrition• Domestic organization• Pre-tax paperwork

YesYes

I’m not having fun.I’m not on task.

Is this important?

MORE STRATEGIES THAT JUST MIGHT CHANGE YOUR LIFE

Celebrate Boxing Day

• Valentine’s Day• Memorial Day• Arbor Day• Diwali

Celebrate Boxing Day

• Valentine’s Day• Earth Day• Diwali

Using your phone’s navigator as a time-management tool

STRATEGIC BEHAVIORAL INQUIRY

Objectives of SBI

• Specific behavioral strategy• What was the feeling-goal?• Motivational level on a scale from 1-10

Benefits of SBI

• Affirms the value of clients’ unique internal experience

• Emphasizes the culture of self-regulation• Encourages metacognition

Assumptions of SBI

• Everybody’s doing the best they can• Behavior is not incomprehensible or random• Behavior follows patterns which reveal

themselves to the curious observer free of prejudice or blame or theory

How to do SBI

“How exactly did you do that?”

Personal Application

…and How Exactly Did You Do That?

Personal Application

• What bad habit persists? And How Exactly Do You Do That?

ADHD and Insight

Fall in Love with the Truth

• Self-monitor and collect data:– How long does your morning routine take,

exactly?– How much time – exactly – do you need to

complete expense forms?– How, exactly, do you follow through on

commitments to others and not to yourself?

Learn from your To-Do list

• Which things are not getting completed?• How – exactly – are these not getting

completed? How do you do that?

Clinical Application

• Who in your clinic or classroom is demonstrating remarkable “resilience” – persistence despite significant obstacles? And how, exactly, does he/she do that?

• What recurring behavioral problem is showing up in your clinic or classroom?

• Note: we aren’t asking “why did you do that,” but rather “how exactly did you do that.”

Living in The Gap

• Compassion• Self-compassion

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David D Nowell PhD

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Very best treatment for adhd and the processing disorders tatra 2014

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