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PESI/CMI presentation "Very Best Treatment for ADHD and the Processing Disorders"
Citation preview
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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84
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
154
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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233
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
04/10/2023 © 2011 David D. Nowell, Ph.D. All rights reserved.
279
…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
PREFERRED STATES INVENTORY
Your #1 Organizational Tool
Learn French
Stop smoking
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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
DavidNowellSeminars
DavidNowell