Identifying and including Identifying and including students with ADHD in the students with ADHD in the

mainstream classroom; from mainstream classroom; from recognition to diagnosis – with recognition to diagnosis – with

practical strategies for the practical strategies for the classroomclassroom

ByBy

Sally TrowseSally Trowse, Specialist ADHD Nurse, Stockport , Specialist ADHD Nurse, Stockport CAMHSCAMHS

andandGareth D MorewoodGareth D Morewood, , Director of Curriculum Director of Curriculum

SupportSupport

1010thth December 2012 December 2012

What is going to happen?What is going to happen?

• Give you a context where including young Give you a context where including young people with ADHD has recorded some people with ADHD has recorded some successsuccess

• Highlight some of the barriers to inclusion Highlight some of the barriers to inclusion that need to be challengedthat need to be challenged

• Provide background and understanding Provide background and understanding from a specialist CAMHS perspectivefrom a specialist CAMHS perspective

• Offer some ideas on how to meet the Offer some ideas on how to meet the challenges facing the inclusion of young challenges facing the inclusion of young people with ADHD in mainstream schoolspeople with ADHD in mainstream schools

Does Every Child Matter?Does Every Child Matter?

• Being HealthyBeing Healthy

• Staying SafeStaying Safe

• Enjoying and AchievingEnjoying and Achieving

• Making a Positive ContributionMaking a Positive Contribution

• Economic WellbeingEconomic Wellbeing

How Many Children Have How Many Children Have AD/HD?AD/HD?• 5% of the general population5% of the general population• This is a very conservative estimateThis is a very conservative estimate• 70-80% of these children will carry the 70-80% of these children will carry the

condition on into adulthoodcondition on into adulthood• At least 1/3 will have significant problems At least 1/3 will have significant problems

with attention without being hyperactive or with attention without being hyperactive or impulsiveimpulsive

• Remaining 2/3 will have significant problems Remaining 2/3 will have significant problems with hyperactivitywith hyperactivity

• In UK only 0.03% are treatedIn UK only 0.03% are treated– Males: Females - 4:1 (9:1 – clinics)Males: Females - 4:1 (9:1 – clinics)

So what is ADHD?So what is ADHD?Now to be considered as a disorder of age-inappropriate Now to be considered as a disorder of age-inappropriate

behaviour:behaviour:

Hyperactivity-ImpulsivityHyperactivity-Impulsivity (Inhibition – Executive Function) (Inhibition – Executive Function)

• Impaired verbal and motor inhibitionImpaired verbal and motor inhibition• Impulsive decision making; cannot wait or defer gratificationImpulsive decision making; cannot wait or defer gratification• Greater disregard of future (delayed) consequencesGreater disregard of future (delayed) consequences• Excessive task-irrelevant movement and verbal behaviourExcessive task-irrelevant movement and verbal behaviour

– fidgeting, squirming, running, climbing, touching …fidgeting, squirming, running, climbing, touching …• Restlessness decreases with age, becoming more internal, Restlessness decreases with age, becoming more internal,

subjective by adulthoodsubjective by adulthood• Emotionally impulsive; poor emotional self-regulationEmotionally impulsive; poor emotional self-regulation

30% deficit of executive 30% deficit of executive functionfunction

•The ability to organize cognitive The ability to organize cognitive processes. This includes the processes. This includes the ability to plan ahead, prioritize, ability to plan ahead, prioritize, stop and start activities, shift stop and start activities, shift from one activity to another from one activity to another activity, and to monitor one's activity, and to monitor one's own behaviour.own behaviour.

Causes and Origins Causes and Origins All causes fall in the realm of biology All causes fall in the realm of biology (neurology, genetics)(neurology, genetics)

Brain Developments

Brain Structure

Family

Home & Community

ADHD

Maternal smoking/alcohol

Premature birthbirth… brain bleeding

Toxic level lead exposure

Brain hypoxiaBrain hypoxia

Head traumaHead trauma

75% family 75% family link link

Environmental risk Environmental risk factorsfactors• Accounts for 15-20% casesAccounts for 15-20% cases• Prenatal exposure to:Prenatal exposure to:

– Alcohol*Alcohol*– Cigarettes*Cigarettes*– Benzodiazepines Benzodiazepines

Obstetric complicationsObstetric complicationsPrematurity and very low birth weightPrematurity and very low birth weight

• Brain diseases/injury e.g.Brain diseases/injury e.g.– Closed head injuryClosed head injury– NeurofibromatosisNeurofibromatosis

• Severe early deprivation and institutional rearingSevere early deprivation and institutional rearing• Exposure to toxic levels of leadExposure to toxic levels of lead

Smaller, less active, less developed brain regions found on Smaller, less active, less developed brain regions found on scansscans

Anxiety/Depression

SpecificLearningDifficulty

Tourette’s

ConductDisorder

Asperger’s

Oppositional Defiant

Disorder

ASC

SpeechDisorder

ADHD

Coexisting

conditions

MTA Trial (USA)MTA Trial (USA)ADHD Alone – 31%ADHD Alone – 31%Behavioural Disorders -54%Behavioural Disorders -54%

Oppositional Defiant Disorder (40%)Oppositional Defiant Disorder (40%)Conduct Disorder (14%)Conduct Disorder (14%)

Tics – 11%Tics – 11%Anxiety Disorders – 34%Anxiety Disorders – 34%Depression – 4%Depression – 4%

Swedish Study (School-aged)Swedish Study (School-aged)Learning disability (13%)Learning disability (13%)Reading/writing disorder (40%)Reading/writing disorder (40%)Motor co-ordination disorder (47%)Motor co-ordination disorder (47%)Asperger’s (7%)Asperger’s (7%)

Coexisting conditionsCoexisting conditions

Tourettes syndromeTourettes syndrome

•What is it?

•What are tics?

•What treatment?

•What can school do?

So what might you expect?So what might you expect?InattentionInattention

Does not attendDoes not attend

Fails to finish tasksFails to finish tasks

Can’t organiseCan’t organise

Avoids sustained Avoids sustained efforteffort

Loses things, is Loses things, is ‘forgetful’‘forgetful’

Easily distractedEasily distracted

HyperactivityHyperactivity

FidgetsFidgets

Leaves seat in classLeaves seat in class

Runs/climbs Runs/climbs excessivelyexcessively

Cannot play/work Cannot play/work quietlyquietly

Always ‘on the go’Always ‘on the go’

Talks excessivelyTalks excessively

ImpulsivityImpulsivity

Talks excessivelyTalks excessively

Blurts out answersBlurts out answers

Cannot wait their turnCannot wait their turn

Interrupts othersInterrupts others

Intrudes on othersIntrudes on others

DSM-IV – Diagnostic and Statistical Manual, 4th Edition (American Psychiatric Association, 1994).ICD-10 – International Classification of Diseases, 10th Edition (World Health Organisation, 1993).

What else needs to be What else needs to be considered?considered?DurationDuration Symptom criteria must have Symptom criteria must have

been met for the past 6 months been met for the past 6 months (? 1yr+)(? 1yr+)

Age of onsetAge of onset Some symptoms must have Some symptoms must have been present before 6 - 7 years been present before 6 - 7 years of age (in childhood)of age (in childhood)

PervasivenessPervasiveness Some impairment due to Some impairment due to symptoms must have been symptoms must have been present in 2 or more settings present in 2 or more settings (e.g. school, work or home) (e.g. school, work or home)

How is ADHD clinically How is ADHD clinically defined?defined?ImpairmentImpairment symptoms must have led to symptoms must have led to

significant impairment (social, significant impairment (social, academic, or occupational)academic, or occupational)

DiscrepancyDiscrepancy symptoms are excessive in symptoms are excessive in comparison to other children of comparison to other children of the same age and IQthe same age and IQ

ExclusionExclusion symptoms must not be solely symptoms must not be solely attributable to other mental attributable to other mental health difficulties (anxiety, health difficulties (anxiety, depression, autism)depression, autism)

What characteristics may we What characteristics may we expect?expect?NEGATIVE

• Short attention span but with periods of intense focus

• Distractible• Poor planning/impulsive• Disoriented sense of time• Impatient• Day-dreamer

POSITIVE

• High levels of environmental awareness• Responds well when highly motivated• Flexible – ready to change strategy readily• Tireless when motivated• Goal orientated• Imaginative

Don’t forget about girls and Don’t forget about girls and ADHD....ADHD....• More inattentive than impulsive More inattentive than impulsive • Less ODD/CD aggression and delinquencyLess ODD/CD aggression and delinquency• More depression pre-diagnosisMore depression pre-diagnosis• More underperformance and Learning Difficulties in schoolMore underperformance and Learning Difficulties in school• ……self blame, self blame, • ……self attribution, self attribution, • ……demoralisation lead to anxiety and depression,demoralisation lead to anxiety and depression,• ……development of compensatory behaviours and development of compensatory behaviours and

strategies.strategies.• Re-think for girls… not a behaviour disorder more a life Re-think for girls… not a behaviour disorder more a life

management disordermanagement disorder

Patricia Quinn, 2009Patricia Quinn, 2009

Development of the Development of the disorder...disorder...PRESCHOOLERS (3-6 years)PRESCHOOLERS (3-6 years)

– Reduced play intensityReduced play intensityand durationand duration

– Motor restlessnessMotor restlessness

– Associated problemsAssociated problemsand implicationsand implications

• developmental deficitsdevelopmental deficits

• oppositional defiant behaviouroppositional defiant behaviour

• problems of social adaptationproblems of social adaptation

PRIMARY SCHOOL CHILDREN PRIMARY SCHOOL CHILDREN (6-12 years)(6-12 years)

– DistractabilityDistractability

– Motor restlessnessMotor restlessness

– Impulsive and disruptive behaviourImpulsive and disruptive behaviour

– Associated problems and implicationsAssociated problems and implications

• specific learning disordersspecific learning disorders

• aggressive behaviouraggressive behaviour

• low self-esteemlow self-esteem

• rejection by peers - not invited to parties rejection by peers - not invited to parties

• impaired family relationshipsimpaired family relationships

ADOLESCENTS (13-17 years)ADOLESCENTS (13-17 years)

– Difficulty in planning and organisationDifficulty in planning and organisation

– Persistent inattentionPersistent inattention

– Reduction of motor restlessnessReduction of motor restlessness

– Associated problemsAssociated problems

•aggressive, antisocial andaggressive, antisocial anddelinquent behaviourdelinquent behaviour

•alcohol and drug problems alcohol and drug problems

•emotional problemsemotional problems

•accidentsaccidents

ADULTS (18 years and older)ADULTS (18 years and older)

• Residual symptoms Residual symptoms

• Associated problemsAssociated problems

– other mental disordersother mental disorders

– antisocial behaviour/antisocial behaviour/delinquencydelinquency

– lack of achievement in academic and lack of achievement in academic and professional careerprofessional career

Risks & controls associated with ADHD in Risks & controls associated with ADHD in adolescents...adolescents...

0 10 20 30 40 50 60

Substance Abuse

Incarceration

Intentional Injury

Attempted Suicide

Repetition of year

Teen Pregnancy

Sexual Transmission of Disease

Dismissal From Job

% of Subjects

NormalADHD

NormalADHD

©Eli Lilly 1998, Barkley RA 1998

© Eli Lilly 1998, Barkley RA 1998

EFFICACY OF INTERVENTIONSEFFICACY OF INTERVENTIONSSymptomatic normalisation rates in the MTA study 1999 Symptomatic normalisation rates in the MTA study 1999 (N= 570; mainly middle school boys)(N= 570; mainly middle school boys)

EFFICACY OF INTERVENTIONSEFFICACY OF INTERVENTIONSSymptomatic normalisation rates in the MTA study 1999 Symptomatic normalisation rates in the MTA study 1999 (N= 570; mainly middle school boys)(N= 570; mainly middle school boys)

25

34

56

68

0

10

20

30

40

50

60

70

80

Nor

mal

isat

ion

rate

(%

)

Communitytreatment

MED MED +Behavioural treatment

Behavioural treatment

Swanson et al 2001

Overview AlgorithmPsychoeducation Psychopharmacotherapy QA ConclusionsEfficacy of interventions Behaviour modificationEfficacy of interventions

So what’s all this about So what’s all this about medication?medication?• StimulantsStimulants - Methylphenidate (Ritalin) - Methylphenidate (Ritalin)

– short acting (lasts up to 4 hrs) & short acting (lasts up to 4 hrs) &

– long acting long acting

(Equasym XL and Medikinet XL last up to 8 hrs) (Equasym XL and Medikinet XL last up to 8 hrs) (Concerta XL lasts up to 12 hrs)(Concerta XL lasts up to 12 hrs)

• DexamphetamineDexamphetamine

Controlled drugsControlled drugs

• NonstimulantNonstimulant - Atomoxetine (must be taken - Atomoxetine (must be taken every day 24hr effect) every day 24hr effect) non-controlled drugnon-controlled drug

How does Methylphenidate Work?Methylphenidate is thought Methylphenidate is thought

to:to:

Promote release of Promote release of dopamine &dopamine & noradrenalinenoradrenaline into the into the synapse and inhibit their synapse and inhibit their reuptake into the reuptake into the presynaptic neuron.presynaptic neuron.Modified Release Modified Release Methylphenidate:Methylphenidate:11stst phase: a sharp, initial phase: a sharp, initial rise in concentrationrise in concentration22ndnd phase: another rise phase: another rise about 3 hours later, about 3 hours later, followed by a gradual followed by a gradual declinedecline

e.g. e.g. Concerta, Equasym Concerta, Equasym XL, MethylphenidateXL, Methylphenidate

Neurochemical Neurochemical pathophysiologypathophysiology

Methylphenidate and atomoxetine block re-uptake of noradrenalineMethylphenidate and amphetamines block re-uptake of dopamine

• This has been used to treat ADHD for >50 yearsThis has been used to treat ADHD for >50 years• CNS stimulantCNS stimulant• Mechanism of action in ADHD is not completely clearMechanism of action in ADHD is not completely clear• It is believed that it increases intrasynaptic It is believed that it increases intrasynaptic

concentrations of dopamine and noradrenalin in the concentrations of dopamine and noradrenalin in the frontal cortex and sub cortical brain regions frontal cortex and sub cortical brain regions associated with motivation and reward associated with motivation and reward

(Volkow et al., 2004)(Volkow et al., 2004)• It blocks the presynaptic membrane dopamine It blocks the presynaptic membrane dopamine

transporter (DAT) and so inhibits the reuptake of transporter (DAT) and so inhibits the reuptake of dopamine and noradrenalin into the presynaptic dopamine and noradrenalin into the presynaptic neuronneuron

MethylphenidateMethylphenidate

Advances in Family TreatmentAdvances in Family Treatment(Russell Barkley, 2009)(Russell Barkley, 2009)• Parent Education About ADHDParent Education About ADHD

– The first critical step in treatmentThe first critical step in treatment– Adopt a ‘parents are shepherds’ perspectiveAdopt a ‘parents are shepherds’ perspective

• Learning the value and limitations of parent trainingLearning the value and limitations of parent training– Changes defiance and parent-child conflict, not ADHD (helping Changes defiance and parent-child conflict, not ADHD (helping

parents ‘get’ their child.)parents ‘get’ their child.)– Works best in younger children Works best in younger children

• (<11 yrs, 65-75% respond)(<11 yrs, 65-75% respond)– Modestly useful for teens Modestly useful for teens

• (25-30% show reliable change)(25-30% show reliable change)• Incorporate teen in treatment and use Problem-Solving, Incorporate teen in treatment and use Problem-Solving,

Communication Training Communication Training – (30%+ show reliable change)(30%+ show reliable change)– Best to combine it with above Parent Training to reduce drop Best to combine it with above Parent Training to reduce drop

outsouts

More Treatment Advances...More Treatment Advances...• Teacher Education About ADHDTeacher Education About ADHD

• Classroom Behaviour ManagementClassroom Behaviour Management– Design of classroomsDesign of classrooms– Very effective but no generalization or Very effective but no generalization or

maintenance after withdrawalmaintenance after withdrawal

• Special Education Services Special Education Services

• Regular Physical ExerciseRegular Physical Exercise– a coping or compensatory toola coping or compensatory tool

• Parent/Client Support GroupsParent/Client Support Groups

Unproven and Miss-Unproven and Miss-truths...truths...• Elimination Diets – removal of sugar, additives, etc. Elimination Diets – removal of sugar, additives, etc.

(weak evidence)(weak evidence)• Megavitamins, Anti-oxidants, Minerals (no compelling Megavitamins, Anti-oxidants, Minerals (no compelling

proof or have been disproved)proof or have been disproved)• Omega 3 Fatty Acids (Fish Oil) – one recent study with Omega 3 Fatty Acids (Fish Oil) – one recent study with

mixed results (effects at home on parent ratings, no mixed results (effects at home on parent ratings, no effect at school on teacher ratings)effect at school on teacher ratings)

• Sensory Integration Training (disproved)Sensory Integration Training (disproved)• Chiropractic Skull Manipulation (no proof)Chiropractic Skull Manipulation (no proof)• Play Therapy, Psycho-therapy (disproved)Play Therapy, Psycho-therapy (disproved)• Self-Control (Cognitive) Therapies for Children Self-Control (Cognitive) Therapies for Children

(disproved)(disproved)• Social Skills Therapies for Children (in clinic) Social Skills Therapies for Children (in clinic)

– Better for Inattentive (SCT) Type and Anxious CasesBetter for Inattentive (SCT) Type and Anxious Cases

ADHD – in summary...ADHD – in summary...• ADHD is probably a disorder of self-regulation ADHD is probably a disorder of self-regulation

and executive functioningand executive functioning• ADHD persists to adulthood in 65+% of casesADHD persists to adulthood in 65+% of cases• ADHD largely results from neuro-genetic ADHD largely results from neuro-genetic

factorsfactors• Impairments exist in most domains of major Impairments exist in most domains of major

life activitieslife activities• Co-morbidity is very common (80%+)Co-morbidity is very common (80%+)• Many advances in treatment occurred in the Many advances in treatment occurred in the

past decade, especially in medicationspast decade, especially in medications• ADHD can be successfully managed leading ADHD can be successfully managed leading

to improved life course and outcomesto improved life course and outcomes

Re-cap on characteristics...Re-cap on characteristics...

• InattentionInattention

• HyperactivityHyperactivity

• ImpulsivityImpulsivity

The ADHD Classroom...The ADHD Classroom...

• SeatingSeating

• Eye contactEye contact

• Small chunk tasksSmall chunk tasks

• Limit instructions/repeat back to youLimit instructions/repeat back to you

• Visual aidsVisual aids

• Keep away from stimulationsKeep away from stimulations

• RoutinesRoutines

•PraisePraise

•Class rules on wall - consistencyClass rules on wall - consistency

•Systems for tracking workSystems for tracking work

• Immediate rewardsImmediate rewards

•Avoid singling out…name the Avoid singling out…name the behaviourbehaviour

Self-help...Self-help...

On-line identification?On-line identification?

• http://pediatrics.about.com/cs/adhd/l/bl_adhd_quiz.htm

Financial support?Financial support?

• http://www.governmentallowances.co.uk/?gclid=CJ-tgrmFtqACFdkB4wodRWGpUA

Useful websites and downloads:Useful websites and downloads:

• http://www.chadd.org/

• http://www.adhdtraining.co.uk/downloads.php

Homework Homework [if we have to!!!][if we have to!!!]......• Home-school diaryHome-school diary• Bring any homework finished or unfinished into Bring any homework finished or unfinished into

school school • Home-work clubsHome-work clubs• Check that they hand homework inCheck that they hand homework in• Use an exchange system i.e. homework/stickerUse an exchange system i.e. homework/sticker• Discuss any homework issues with parents/carersDiscuss any homework issues with parents/carers• Use homework trays – three different trays, colour Use homework trays – three different trays, colour

codedcoded

- Red – did not understand it at all- Red – did not understand it at all - Amber – did it, but not fully understood- Amber – did it, but not fully understood - Green – understood it completely- Green – understood it completely

Friendships...Friendships...• Use circle time/SEAL to promote positive Use circle time/SEAL to promote positive

friendshipsfriendships• Allow the child/young person ‘cooling down’ time Allow the child/young person ‘cooling down’ time

following play timesfollowing play times• Effective use of lunchtime assistants – supervision Effective use of lunchtime assistants – supervision

and scaffold – designated places/roomsand scaffold – designated places/rooms• Organised games at break time/play timesOrganised games at break time/play times• Encourage shared tasks with peersEncourage shared tasks with peers• Model appropriate behavioursModel appropriate behaviours• Encourage and support positive friendshipsEncourage and support positive friendships• If the child/young person displays problem If the child/young person displays problem

behaviours, identify the problembehaviours, identify the problem

Inattention...Inattention...

• Inattentive BehaviourInattentive Behaviour

• What to try?What to try?

Impulsivity...Impulsivity...

• Impulsive BehaviourImpulsive Behaviour

• What to try?What to try?

Hyperactivity...Hyperactivity...

• Hyperactive BehaviourHyperactive Behaviour

• What to try?What to try?

Final thought on Final thought on medication...medication...• See medication in schools policySee medication in schools policy• If the child/young person needs to take If the child/young person needs to take

medication in school, discreetly prompt medication in school, discreetly prompt them to go to the school office [or them to go to the school office [or designated place] at the appropriate timedesignated place] at the appropriate time

• Avoid singling out the child/young person Avoid singling out the child/young person or repeatedly asking them, ‘have you had or repeatedly asking them, ‘have you had your tablet?’your tablet?’

• Doctors try and use long acting medication Doctors try and use long acting medication where possible to avoid students needing where possible to avoid students needing to take medication in schoolto take medication in school

Triangulation of support...Triangulation of support...

Final Thoughts…Final Thoughts…• ADHD is probably a disorder of self-regulation ADHD is probably a disorder of self-regulation

and executive functioningand executive functioning• ADHD persists to adulthood in 65+% of casesADHD persists to adulthood in 65+% of cases• ADHD largely results from neuro-genetic factorsADHD largely results from neuro-genetic factors• Impairments exist in most domains of major life Impairments exist in most domains of major life

activitiesactivities• Co-morbidity is very common (80%+)Co-morbidity is very common (80%+)• Many advances in treatment occurred in the Many advances in treatment occurred in the

past decade, especially in medicationspast decade, especially in medications• ADHD can be successfully managed leading to ADHD can be successfully managed leading to

improved life course and outcomesimproved life course and outcomes

Books and Further Information...Books and Further Information...www.addiss.co.uk

Teaching the tiger Teaching the tiger by Dornbush and Pruittby Dornbush and Pruitt

Attention Deficit Hyperactivity Disorder Attention Deficit Hyperactivity Disorder by Russell A. Barkleyby Russell A. Barkley

How to teach and manage children with ADHD How to teach and manage children with ADHD by Fintan O’Reganby Fintan O’Regan

Hot stuff to Help Kids Chill Out: The Anger Hot stuff to Help Kids Chill Out: The Anger Management Book Management Book by Jerry Wildeby Jerry Wilde

Stockport Multi- agency ADHD under 18 Pathway

Primary Care GP HV School Nurse Parenting team

(Referrers need to complete checklist)

Over 6 yrs – complete ADHD checklist with school inf ormation

(Community CAMHS practitioners with completed assessment)

ADHD Nurse Screening

Referral

Recognition

Consultation with ADHD nurses For unclear or complex cases SENCO / community CAMHS / GP

Social Care

Education EP SENCO (with training) SBSS/ PBSS

CAMHS Panel Complex cases

ASD symptoms go to ASD pathway within CAMHS

CAMHS (Generic or LD Team)

Paediatrics

Assessment by specialist ADHD service

Paediatrics

Less than 6 yrs - Parenting team for Webster Stratton Parenting course

oor

AGE of patient

Over 5yrs GPs may use choose and book f or paediatics

Parenting support workers

Community Learning Disability Team

Adult ADHD 16+yrs (Moving to 18 yrs) CAMHS Transition

team (New referrals f or

assessment)

Paeds up to 18 yrs

Phase 1 adult service 18+ CAMHS only Phase 2 adult service all 18+

On going care

Multi- agency working

16 – 18 yrs

I ndividual (social skills etc) and Family work

(PBSS, SBSS, Learning mentors PSA, ADHD nurse, Relate, and

CAMHS)

OT/ SALT interventions Parent partnership

Parenting Support ADHD new diagnosis course Webster Stratton parenting course Education sessions f or young people

ADHD Specialist clinics (Paeds / CAMHS) Medication monitoring School liaison GP shared care protocol

Education support SENCO (diagnosis and strategies)

Parent support group (Space) Disability database

Management

Community Learning Disability Team

And finally....And finally....Working with young people who have ADHD is Working with young people who have ADHD is

extremely challenging.extremely challenging.

Above all – remember to be Above all – remember to be

adaptable, adaptable,

innovative, innovative,

empathetic,empathetic,

and ... open minded,and ... open minded,And remember that not one strategy fits And remember that not one strategy fits

all…all…

Thanks for listening...Thanks for listening...Gareth D MorewoodGareth D Morewood

Director of Curriculum SupportDirector of Curriculum Support

www.gdmorewood.com

Sally TrowseSally TrowseSpecialist ADHD NurseSpecialist ADHD Nurse

sally.trowse@nhs.net