Adhd nowell

ADHD and the Processing Disorders

David D. Nowell, Ph.D.

Worcester, Massachusetts

www.DrNowell.com

DavidNowellSeminars

DavidNowell

ADHD and the Processing Disorders

An overview of the day:•Making sense of the disorders•Skills and strategies for children•Skills and strategies for adults•Tools you can use now

ADHD and the Processing Disorders

•Making sense of the disorders

ADHD and the Processing Disorders

Sensory Processing DisorderCentral Auditory Processing DisorderADHD and Executive Dysfunction

Perspective of this workshop…..

Diagnostic Interview as “making distinctions”

301.13, rule out 296.89

“Top – down” dysfunction

• ADHD• Executive dysfunction

“Bottom - up” dysfunction

• Central auditory processing problems• Sensory processing problems

What’s the kid’s deal?

Avoiding the most common diagnostic error

Sensory Processing Disorder

Jean Ayres

S ensory In tegration

S ensory D iscrim ination

S ensory M odu lation

S ensory D etection

Sensory Integration Terminology

Sensory Processing

Who doesn’t love a wedding?

Is SPD a “syndrome”?

Is sensory modulation

disorder a unitary

construct?

Hard signs and soft signs

Developmental soft signs

Developmental considerations

• Auditory .• Visual• Tactile• Proprioceptive• Vestibular• Motor

Sensory Processing/Integration Disorder and DSM-V

Sensory Processing Disorder Scientific Work Group

What’s the kid’s deal?

What’s the kid’s deal?

Regulatory-Sensory Processing Disorders

• Treatment– “top down”

–“bottom up”

X

Regulatory-Sensory Processing Disorders

• Treatment

–“top down”– “bottom up”

Regulatory-Sensory Processing Disorders

• Treatment

–“top down”– “bottom up”

Role of the Mental Health Clinician in SPD

• Primarily “top down”• Normalizing• Patient and family education• Environmental interventions

Role of the Mental Health Clinician in SPD

• Compensatory strategies• Self-esteem• Planning for success experiences• Treating comorbidities

Strengths and Weaknesses Checklist(Sensory Processing Problems)

Appendix D

Central Auditory Processing Disorder

k /a / t

“cat”

• Auditory discrimination (same/different)• Auditory closure (fill in missing bits)• Auditory localisation (locate source of sound)• Auditory performance with degraded acousticsignal• Auditory figure-ground (perceiving sounds inbackground noise)

Central Auditory Processing Disorder

Central Auditory Processing Disorder

• CAPD refers to a deficit observed in one or more of the central auditory processes responsible for generating the auditory evoked potentials and the following behaviors: – sound localization and lateralization– auditory discrimination– auditory pattern recognition

Central Auditory Processing Disorder

- Poor "communicator" (terse, telegraphic). - Memorizes poorly.- Hears better when watching the speaker. - Problems with rapid speech. - Interprets words too literally.

Central Auditory Processing Disorder

- Often needs remarks repeated. - Difficulty sounding out words.- Confuses similar-sounding words.- Difficulty following directions in a series. - Speech developed late or unclearly.

(C)APD

• the research challenge of “supramodal influences”

CAPD or ADHD?

• Asks for things to be repeated• Poor Listening skills• Difficulty following oral

instructions• Difficulty discriminating speech• Difficulty hearing with

background noise• Difficulty maintaining auditory

attention in quiet• Academic difficulties• Slow to process information

• Inattention• Academic Difficulties• Daydreams

• Distracted• Poor Listening Skills

• Disorganized

• Asks for things to be repeated• Auditory divided attention

deficit

CAPD or ADHD?

• Asks for things to be repeated• Poor Listening skills• Difficulty following oral

instructions• Difficulty discriminating speech• Difficulty hearing with

background noise• Difficulty maintaining auditory

attention in quiet• Academic difficulties• Slow to process information

• Inattention• Academic Difficulties• Daydreams

• Distracted• Poor Listening Skills

• Disorganized

• Asks for things to be repeated• Auditory divided attention

deficit

CAPD or ADHD?

• Asks for things to be repeated• Poor Listening skills• Difficulty following oral

instructions• Difficulty discriminating speech• Difficulty hearing with

background noise• Difficulty maintaining auditory

attention in quiet• Academic difficulties• Slow to process information

• Inattention• Academic Difficulties• Daydreams

• Distracted• Poor Listening Skills

• Disorganized

• Asks for things to be repeated• Auditory divided attention

deficit

CAPD or ADHD?

• Asks for things to be repeated• Poor Listening skills• Difficulty following oral

instructions• Difficulty discriminating speech• Difficulty hearing with

background noise• Difficulty maintaining auditory

attention in quiet• Academic difficulties• Slow to process information

• Inattention• Academic Difficulties• Daydreams

• Distracted• Poor Listening Skills

• Disorganized

• Asks for things to be repeated• Auditory divided attention

deficit

(C)APD

• Treatment– “top down”– “bottom up”

X

Treatment for CAPD

• Environmental modifications

Treatment for CAPD

• Environmental modifications–FM transmission–Training the speaker to face the

listener, check for understanding, use prosody

Treatment for CAPD

• Environmental modifications–Preferential seating–Increased use of visual cues–Untimed testing

Treatment for CAPD

• Compensatory Strategies

Treatment for CAPD

• Compensatory Strategies–Metalinguistic strategies include:

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

Treatment for CAPD

• Compensatory Strategies–Metacognitive strategies include

self-instruction, cognitive problem solving, and assertiveness training

What’s the kid’s deal?

Attention Deficit Hyperactivity Disorder

Increase salience

Attention Deficit Hyperactivity Disorder

• History of the disorder– Galen– Fidgety Phil– “abnormal defects in moral control”– MBD– Benzedrine– Hyperkinetic-impulsive disorder– Hyperkinetic Reaction of Childhood– Attention Deficit

(85 – X) x 365

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I’m gonna eat all the gum and candy I want!

Controversies

• Is ADHD over-diagnosed?

• Is ADHD a “real” condition?

• Does ADHD occur on a spectrum?

• Is ADHD a natural adaptive trait?

86

Source: Centers for Disease Control and Prevention. Prevalence of diagnosis and medication treatment for attention-deficit/hyperactivity disorder – United States, 2003. MMWR 2005;54:[842-847].

87

Source: Centers for Disease Control and Prevention. Prevalence of diagnosis and medication treatment for attention-deficit/hyperactivity disorder – United States, 2003. MMWR 2005;54:[842-847].

Percent of Youth 4-17 ever diagnosed with Attention-Deficit/Hyperactivity Disorder: National Survey of Children’s Health, 2003

> 10.1%

9.1 – 10.0%

8.1 - 9.0%

7.1 - 8.0%

6.1 - 7.0%

< 6.0%

DC

Controversies

• Is ADHD over-diagnosed?

• Is ADHD a “real” condition?

• Does ADHD occur on a spectrum?

• Is ADHD a natural adaptive trait?

“a hunter in a farmer’s world”Thom Hartmann

Hunter trait• Constant monitoring• Can act on moment’s notice• Very active when “hot on the trail”• Willing to take risks

Farmer trait• Not easily distracted• Steady, dependable effort• Conscious of time; able to pace self• Careful, “look before you leap”

Core symptoms

• Inattention / distractibility

Core symptoms

• Hyperactivity / impulsivity

….and the rest of the criteria

B. Onset before age 7C. Impairment in 2 or more settingsD. Significant functional impairmentE. Not better accounted for by another mental

disorder

Functional impact of core symptoms

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

Functional impact of core symptoms

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

Functional impact of core symptoms

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

Functional impact of core symptoms

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

Functional impact of core symptoms

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

Functional impact of core symptoms

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

Functional impact of core symptoms

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

Functional impact of core symptoms

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

Subtypes of ADHD

• ADHD, predominantly inattentive type• ADHD, predominantly hyperactive type• ADHD, combined type• ADHD, Not Otherwise Specifed

Subtypes of ADHD

• ADHD, predominantly inattentive type• ADHD, predominantly hyperactive type• ADHD, combined type• ADHD, Not Otherwise Specifed

Common comorbidities with ADHD• Learning disorder• Behavioral disorder• Anxiety• Depression• Substance abuse• Sensory processing and auditory processing

challenges

Common comorbidities with ADHD• Learning disorder• Behavioral disorder

• Anxiety• Depression• Substance abuse• Sensory processing and auditory processing

challenges

Common comorbidities with ADHD• Learning disorder• Behavioral disorder• Anxiety• Depression• Substance abuse• Sensory processing and auditory processing

challenges

NIH Consensus Statement

Executive Functioning:An Overarching Theme

• Sensory Processing Disorder• Central Auditory Processing Disorder• ADHD and Executive Dysfunction

Introduction to Neuroanatomy

…..destination: frontal lobe !

Introduction to Neuroanatomy

Inter-connectedness of systems• Cortico-striatal system, for example

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The Executive Functions

X

The Executive Functions

• Initiation• Planning• Set-shifting• Self-regulation• Inhibition of response• Directing current activity towards future goal

• X

The Executive Functions

• Initiation• Planning• Set-shifting• Self-regulation• Inhibition of response• Directing current activity towards future goal

The Executive Functions

• Initiation• Planning• Set-shifting• Self-regulation• Inhibition of response• Directing current activity towards future goal

The Executive Functions

• Initiation• Planning• Set-shifting• Self-regulation• Inhibition of response• Directing current activity towards future goal

The Executive Functions

• Sustaining alertness and effort• Internalizing speech• Prioritizing• Sequential thinking• Developing a plan of action• Persevering through a plan of action• Time management

The Executive Functions

• Sustaining alertness and effort• Internalizing speech• Prioritizing• Sequential thinking• Developing a plan of action• Persevering through a plan of action• Time management

The Executive Functions

• Sustaining alertness and effort• Internalizing speech• Prioritizing• Sequential thinking• Developing a plan of action• Persevering through a plan of action• Time management

The Executive Functions

• Sustaining alertness and effort• Internalizing speech• Prioritizing• Sequential thinking• Developing a plan of action• Persevering through a plan of action• Time management

The Executive Functions

• Sustaining alertness and effort• Internalizing speech• Prioritizing• Sequential thinking• Developing a plan of action• Persevering through a plan of action• Time management

The Executive Functions

• Fine motor control• Delay of gratification• Blocking out distractions• Weighing consequences• Thinking before acting• Planning for the future• Certain aspects of memory / learning

The Executive Functions

• Bridging the now with the past

• Bridging the now with the future

Neuropsychological Model of Executive Dysfunction

• Guides your evaluation• Guides your treatment plan• Facilitates family education

Literature review

Literature review

• Genetic evidence

Literature review

• Genetic evidence• Neuroanatomical evidence

Literature review

• Genetic evidence• Neuroanatomical evidence• Neuropsychological evidence

Literature review

• Genetic evidence• Neuroanatomical evidence• Neuropsychological evidence• Neurochemical evidence

Interpreting the Problem Checklist

Appendices B and C

• Items 1-8: inattention/distractibility• Items 9-13 and 24-28: behavioral d/o• Items 16-23: hyperactivity/impulsivity

Comprehensive Treatment

Treatments With Limited Evidence(AAP, 2001; Pelham & Fabiano, 2008)

(1) Traditional one-to-one therapy or counseling(2) Office based "Play therapy”(3) Elimination diets(4) Biofeedback/neural therapy/attention (EEG) training(5) Allergy treatments(6) Chiropractics(7) Perceptual or motor training/sensory integration training(8) Treatment for balance problems(9) Pet therapy(10) Dietary supplements (megavitamins, blue-green algae)

Evidence-Based Treatments for Children… (Chorpita et al, 2011)

•Self – talk•Behavioral supports + medication•Parent training•Physical exercise•Biofeedback•Contingency management•Parent and teacher education•Social skills training + medication•Parent training + problem solving•Relaxation training + exercise•Working memory training

Evidence-Based Short-termTreatments for ADHD

(1) Behavior modification-175 studies

(2) CNS stimulant medication>300 studies

(3) The combination of (1) and (2).>25 studies

(Pelham & Fabiano, 2008; Greenhill & Ford, 2002; Hinshaw et al, 2002)

153

Pharmacotherapy• Drugs approved for ADHD

– Stimulants• Methylphenidate (e.g., Ritalin)• Dexmethylphenidate (Focalin, Focalin XR)• Amphetamine (Adderall, Adderall XR)• Dextroamphetamine (Dexedrine)• Pemoline (Cylert) --no longer marketed due to liver toxicity• Methamphetamine (Desoxyn) --little used

– Atomoxetine (Strattera)• selective norepinephrine reuptake inhibitor

Grps of 3: definition of adhd for layperson

X

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Pharmacotherapy, continued

• Under review for ADHD indication– Modafinil (Provigil)--stimulant

• Drugs used off label for ADHD– Tricyclic antidepressants– Bupropion – Alpha-2 agonists (e.g., clonidine)

155

Stimulants• Used for decades• Available in extended release formulations• Adverse effects: abuse/dependence (Schedule C-II), tics,

cardiovascular, CNS, growth• Adderall XR approved for adult ADHD

Main Beneficial Short-term Effects

• 1. Decrease in classroom disruption• 2. Improvement in teacher ratings of behavior• 3. Improvement in compliance with adult requests• and commands• 4. Increase in on-task behavior and academic• productivity and accuracy (but no long-term• effect on academic achievement)• 5. Improvement in peer interactions• 6. Improvement in performance on laboratory• measures of attention, impulsivity, and learning

(Greenhill & Ford, 2002)

APA Task Force on Medication andPsychosocial Treatments in Children

and Adolescents

• Behavioral Parent Training• Behavioral School Intervention• Behavioral Child Intervention• Medication--Use when needed

Making the diagnosis

Making the diagnosis

• Get the chief complaint

Making the diagnosis

• Mental status examination

ABC STAMPLICKER

X

Making the diagnosis

• Interview with parent / significant other

Making the diagnosis

• Checklists– Parents– Teachers– Others

Making the diagnosis

• Looking for convergent data

O.T. Evaluation of Sensory Integration

Clinical Observations

Sensory History Checklists and Interviews

Assessments of Sensory Integration

Evaluation of CAPD

Audiologist

Speech therapist

Avoiding the most common diagnostic error

Disorder

• ADHD• OCD• Motor tic disorder• Sensory processing disorder

Other options

V71.09Provisional

Rule out

ADHD “look-alikes”

• Low IQ• High IQ• LD• Vision/ hearing problems• Mood disorders• Substance abuse• PTSD

ADHD “look-alikes”

• Sleep disorders• Seizure disorders• Acquired brain injury• FAS• Autistic-spectrum disorders• Sensory processing problems

– Central auditory processing– Sensory integration disorders

ADHD and the Processing Disorders

•Skills and strategies for children

The First Thing You Need to Change

X

A B C

A B C

behavior

A B C

antecedent

A B C

consequencesX

A B C

antecedent

A •Rules•Expectations•Communications

ARules

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

AExpectations

•Specific•Behavioral•In advance

ACommunication

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

Functional impact of core symptoms

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

Functional impact of core symptoms

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

Functional impact of core symptoms

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

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow, et al. 2004

Methylphenidate Enhances the Saliency of a Mathematical Task by Increasing Dopamine in the Human Brain

Volkow, et al. 2004

Increase salience

math

You love math….you love math.

Functional impact of core symptoms

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

X

Functional impact of core symptoms

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

Functional impact of core symptoms

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

Functional impact of core symptoms

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

X

Functional impact of core symptoms

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

Functional impact of core symptoms

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

X

Functional impact of core symptoms

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

X

Strategic behavioral inquiry

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STRATEGIC BEHAVIORAL INQUIRY

AANTECEDENTS

BBEHAVIOR

CCONSEQUENCE

S

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Beginning Middle End

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Mood dysregulation in BAD and executive disorders

ADHD is notFRED-PG13

X

ADHD and girls

ADHD and women

Recommendations for Teachers with Concerns about Attention or Processing Problems

Recommendations for Teachers …

• Distinguish between medical evaluation and educational evaluation

• Document with objective behavioral terms the challenges you notice

• Document interventions and responses• Speak with other teachers or last year’s

teacher – compare notes• Recommend next-step evaluation

Recommendations for Teachers …

• Avoid diagnostic terms in conversation with parents

• Leave medication decision to families and their pediatricians

• Find common goals with parents

Accommodations and Modifications

IDEA and Section 504

Metacognitive Strategies

• Metacognitive knowledge• Metacognitive strategies

X

A B C

behavior

Self-Talk Proficiency for Kids

X

Self-Talk Proficiency

• -“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?”

Asking two questions…

–Am I having fun now?–And is this what I set out to do?

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Asking two questions…

1. “Am I having fun now?”

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Asking two questions…

2. “And is this what I set out to do?”

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YesYes

NoYes

YesNo

NoNo

Am I having fun now?

Is this what I set out to do?

easy hard

Distraction Delay Training

X

Executive Estimates Training

X

Goal Management Training

1. Stop What am I doing?

The main task

The steps

2. Define

3. List

4. Learn

6. Check

The steps

A……B…..

C……

Am I doing what I planned to do?

Do I know the steps?

5. Do It

Yes

No

Yes

No

SQ3R

• Survey• Question• Read• Recite• review

Dealing with difficult behavior

The Three Baskets

A B C

R P

+

-

R+ P+

R- P-

Time Out

• Select target behavior• Set place• Determine how much time• Dress rehearsal• Measure the time• Withdraw attention• Establish the cause and effect

Token economy

• Good balance• Precursor to adult reinforcement system• Lots of work to do well• Even more work to set up well

Homework problems

• Fails to write down assignments• Forgets the assignment book• Forgets necessary materials• Takes hours to do minutes of homework• Hassles about when and where to do homework• Lies about having done homework• Needs constant supervision with homework• Forgets to bring homework back to school

Make Real-Life More Like Video Games

• Clear expectations• Behavioral specificity• Build on small changes in behavior• Irrelevant behaviors ignored• Reward appropriate behavior and punish

inappropriate behavior – never reverse this

Make Real-Life More Like Video Games

• Always follow up on rules, no exceptions• Consequences are immediate• Punishment is mild• Stimuli are exciting and multi-sensory• Conduct expensive and time-consuming focus

groups to determine what really “grabs ‘em”

Error-free Learning

The “Big Five”

• Daily focus time• Clarity regarding reinforcers• Nutrition• Movement• Connection

X

ADHD and the Processing Disorders

•Skills and strategies for adults

Is Adult ADHD a separate disorder?

DSM Criteria and Developmental Issues

Executive Disorders and Insight

The ADHD Couple

The ADHD Couple

• Need for stimulation• Poorer impulse control• Inattention to detail• Fantasy projection

The ADHD Couple

• Remembering what drew you to your partner• Realistic expectations• Managing blame• Getting to “fair”• Feeling your contributions are valued• Outsourcing

Positive characteristics of many people with attentional / executive challenges

Appendix E

The ADHD Couple• Improving Dyadic Communication Skills

Executive Disorders and the Workplace

Executive Disorders and the Workplace

• Realistic expectations• Efficiency• Delegating• Getting clear regarding “disability”• Managing comorbidities

Activity Scheduling

Chunking

The “Big Five”

• Daily focus time• Values/motivational clarity• Nutrition• Movement• Connection

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…the most important 10 minutes of the day….

The “Big Five”

• Daily focus time• Values/motivational clarity• Nutrition• Movement• Connection

Values and Goal Clarification for the Distracted Patient

David D. Nowell, Ph.D.189 May Street

Worcester, Mass. 01602DrNowell.com

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The “Big Five”

• Daily focus time• Values/motivational clarity• Nutrition• Movement• Connection

The Sensory Defensive Adult

Adults with Auditory Processing Challenge

A challenge….

ADHD and the Processing Disorders

David D. Nowell, Ph.D.

Worcester, Massachusetts

David@DrNowell.com

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