Revised ADHD Training PowerPoint Presentation

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Identifying and including students with ADHD in the mainstream classroom; from recognition to diagnosis – with practical strategies for the classroom By Sally Trowse, Specialist ADHD Nurse, Stockport CAMHS and Gareth D Morewood, Director of Curriculum Support 10th December 2012

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What is going to happen? Give you a context where including young people with ADHD has recorded some success Highlight some of the barriers to inclusion that need to be challenged Provide background and understanding from a specialist CAMHS perspective Offer some ideas on how to meet the challenges facing the inclusion of young people with ADHD in mainstream schools

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Does Every Child Matter? Being Healthy Staying Safe Enjoying and Achieving Making a Positive Contribution Economic Wellbeing

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How Many Children Have AD/HD? 5% of the general population This is a very conservative estimate 70-80% of these children will carry the condition on into adulthood At least 1/3 will have significant problems with attention without being hyperactive or impulsive Remaining 2/3 will have significant problems with hyperactivity In UK only 0.03% are treated Males: Females - 4:1 (9:1 – clinics)

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So what is ADHD? Now to be considered as a disorder of age-inappropriate behaviour: Hyperactivity-Impulsivity (Inhibition – Executive Function) Impaired verbal and motor inhibition Impulsive decision making; cannot wait or defer gratification Greater disregard of future (delayed) consequences Excessive task-irrelevant movement and verbal behaviour fidgeting, squirming, running, climbing, touching … Restlessness decreases with age, becoming more internal, subjective by adulthood Emotionally impulsive; poor emotional self-regulation

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30% deficit of executive function The ability to organize cognitive processes. This includes the ability to plan ahead, prioritize, stop and start activities, shift from one activity to another activity, and to monitor one's own behaviour.

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Causes and Origins All causes fall in the realm of biology (neurology, genetics) Maternal smoking/alcohol Premature birth… brain bleeding Toxic level lead exposure Brain hypoxia Head trauma 75% family link

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Environmental risk factors Accounts for 15-20% cases Prenatal exposure to: Alcohol* Cigarettes* Benzodiazepines Obstetric complications Prematurity and very low birth weight Brain diseases/injury e.g. Closed head injury Neurofibromatosis Severe early deprivation and institutional rearing Exposure to toxic levels of lead

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

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Anxiety/ Depression Specific Learning Difficulty Tourette’s Conduct Disorder Asperger’s Oppositional Defiant Disorder ASC Speech Disorder ADHD Coexisting conditions

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MTA Trial (USA) ADHD Alone – 31% Behavioural Disorders -54% Oppositional Defiant Disorder (40%) Conduct Disorder (14%) Tics – 11% Anxiety Disorders – 34% Depression – 4% Swedish Study (School-aged) Learning disability (13%) Reading/writing disorder (40%) Motor co-ordination disorder (47%) Asperger’s (7%) Coexisting conditions

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Tourettes syndrome What is it? What are tics? What treatment? What can school do?

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So what might you expect? Inattention Does not attend Fails to finish tasks Can’t organise Avoids sustained effort Loses things, is ‘forgetful’ Easily distracted Hyperactivity Fidgets Leaves seat in class Runs/climbs excessively Cannot play/work quietly Always ‘on the go’ Talks excessively Impulsivity Talks excessively Blurts out answers Cannot wait their turn Interrupts others Intrudes 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).

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What else needs to be considered? Duration Symptom criteria must have been met for the past 6 months (? 1yr+) Age of onset Some symptoms must have been present before 6 - 7 years of age (in childhood) Pervasiveness Some impairment due to symptoms must have been present in 2 or more settings (e.g. school, work or home)

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How is ADHD clinically defined? Impairment symptoms must have led to significant impairment (social, academic, or occupational) Discrepancy symptoms are excessive in comparison to other children of the same age and IQ Exclusion symptoms must not be solely attributable to other mental health difficulties (anxiety, depression, autism)

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What characteristics may we 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

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Don’t forget about girls and ADHD.... More inattentive than impulsive Less ODD/CD aggression and delinquency More depression pre-diagnosis More underperformance and Learning Difficulties in school …self blame, …self attribution, …demoralisation lead to anxiety and depression, …development of compensatory behaviours and strategies. Re-think for girls… not a behaviour disorder more a life management disorder Patricia Quinn, 2009

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Development of the disorder... PRESCHOOLERS (3-6 years) Reduced play intensityand duration Motor restlessness Associated problemsand implications developmental deficits oppositional defiant behaviour problems of social adaptation

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PRIMARY SCHOOL CHILDREN (6-12 years) Distractability Motor restlessness Impulsive and disruptive behaviour Associated problems and implications specific learning disorders aggressive behaviour low self-esteem rejection by peers - not invited to parties impaired family relationships

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ADOLESCENTS (13-17 years) Difficulty in planning and organisation Persistent inattention Reduction of motor restlessness Associated problems aggressive, antisocial anddelinquent behaviour alcohol and drug problems emotional problems accidents

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ADULTS (18 years and older) Residual symptoms Associated problems other mental disorders antisocial behaviour/delinquency lack of achievement in academic and professional career

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Risks & controls associated with ADHD in adolescents... ©Eli Lilly 1998, Barkley RA 1998 © Eli Lilly 1998, Barkley RA 1998

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EFFICACY OF INTERVENTIONSSymptomatic normalisation rates in the MTA study 1999 (N= 570; mainly middle school boys) Communitytreatment MED MED +Behavioural treatment Behavioural treatment Swanson et al 2001 Overview Algorithm Psychoeducation Psychopharmacotherapy QA Conclusions Efficacy of interventions Behaviour modification Efficacy of interventions

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So what’s all this about medication? Stimulants - Methylphenidate (Ritalin) short acting (lasts up to 4 hrs) & long acting (Equasym XL and Medikinet XL last up to 8 hrs) (Concerta XL lasts up to 12 hrs) Dexamphetamine Controlled drugs Nonstimulant - Atomoxetine (must be taken every day 24hr effect) non-controlled drug

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How does Methylphenidate Work? Methylphenidate is thought to: Promote release of dopamine & noradrenaline into the synapse and inhibit their reuptake into the presynaptic neuron. Modified Release Methylphenidate: 1st phase: a sharp, initial rise in concentration 2nd phase: another rise about 3 hours later, followed by a gradual decline e.g. Concerta, Equasym XL, Methylphenidate

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Neurochemical pathophysiology Methylphenidate and atomoxetine block re-uptake of noradrenaline Methylphenidate and amphetamines block re-uptake of dopamine

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This has been used to treat ADHD for >50 years CNS stimulant Mechanism of action in ADHD is not completely clear It is believed that it increases intrasynaptic concentrations of dopamine and noradrenalin in the frontal cortex and sub cortical brain regions associated with motivation and reward (Volkow et al., 2004) It blocks the presynaptic membrane dopamine transporter (DAT) and so inhibits the reuptake of dopamine and noradrenalin into the presynaptic neuron Methylphenidate

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Advances in Family Treatment(Russell Barkley, 2009) Parent Education About ADHD The first critical step in treatment Adopt a ‘parents are shepherds’ perspective Learning the value and limitations of parent training Changes defiance and parent-child conflict, not ADHD (helping parents ‘get’ their child.) Works best in younger children (<11 yrs, 65-75% respond) Modestly useful for teens (25-30% show reliable change) Incorporate teen in treatment and use Problem-Solving, Communication Training (30%+ show reliable change) Best to combine it with above Parent Training to reduce drop outs

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More Treatment Advances... Teacher Education About ADHD Classroom Behaviour Management Design of classrooms Very effective but no generalization or maintenance after withdrawal Special Education Services Regular Physical Exercise a coping or compensatory tool Parent/Client Support Groups

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Unproven and Miss-truths... Elimination Diets – removal of sugar, additives, etc. (weak evidence) Megavitamins, Anti-oxidants, Minerals (no compelling proof or have been disproved) Omega 3 Fatty Acids (Fish Oil) – one recent study with mixed results (effects at home on parent ratings, no effect at school on teacher ratings) Sensory Integration Training (disproved) Chiropractic Skull Manipulation (no proof) Play Therapy, Psycho-therapy (disproved) Self-Control (Cognitive) Therapies for Children (disproved) Social Skills Therapies for Children (in clinic) Better for Inattentive (SCT) Type and Anxious Cases

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ADHD – in summary... ADHD is probably a disorder of self-regulation and executive functioning ADHD persists to adulthood in 65+% of cases ADHD largely results from neuro-genetic factors Impairments exist in most domains of major life activities Co-morbidity is very common (80%+) Many advances in treatment occurred in the past decade, especially in medications ADHD can be successfully managed leading to improved life course and outcomes

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Re-cap on characteristics... Inattention Hyperactivity Impulsivity

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The ADHD Classroom... Seating Eye contact Small chunk tasks Limit instructions/repeat back to you Visual aids Keep away from stimulations Routines

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Praise Class rules on wall - consistency Systems for tracking work Immediate rewards Avoid singling out…name the behaviour

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Self-help... On-line identification? http://pediatrics.about.com/cs/adhd/l/bl_adhd_quiz.htm Financial support? http://www.governmentallowances.co.uk/?gclid=CJ-tgrmFtqACFdkB4wodRWGpUA Useful websites and downloads: http://www.chadd.org/ http://www.adhdtraining.co.uk/downloads.php

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Homework [if we have to!!!]... Home-school diary Bring any homework finished or unfinished into school Home-work clubs Check that they hand homework in Use an exchange system i.e. homework/sticker Discuss any homework issues with parents/carers Use homework trays – three different trays, colour coded - Red – did not understand it at all - Amber – did it, but not fully understood - Green – understood it completely

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Friendships... Use circle time/SEAL to promote positive friendships Allow the child/young person ‘cooling down’ time following play times Effective use of lunchtime assistants – supervision and scaffold – designated places/rooms Organised games at break time/play times Encourage shared tasks with peers Model appropriate behaviours Encourage and support positive friendships If the child/young person displays problem behaviours, identify the problem

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Inattention... Inattentive Behaviour What to try?

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Impulsivity... Impulsive Behaviour What to try?

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Hyperactivity... Hyperactive Behaviour What to try?

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Final thought on medication... See medication in schools policy If the child/young person needs to take medication in school, discreetly prompt them to go to the school office [or designated place] at the appropriate time Avoid singling out the child/young person or repeatedly asking them, ‘have you had your tablet?’ Doctors try and use long acting medication where possible to avoid students needing to take medication in school

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Triangulation of support...

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Final Thoughts… ADHD is probably a disorder of self-regulation and executive functioning ADHD persists to adulthood in 65+% of cases ADHD largely results from neuro-genetic factors Impairments exist in most domains of major life activities Co-morbidity is very common (80%+) Many advances in treatment occurred in the past decade, especially in medications ADHD can be successfully managed leading to improved life course and outcomes

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Books and Further Information... www.addiss.co.uk Teaching the tiger by Dornbush and Pruitt Attention Deficit Hyperactivity Disorder by Russell A. Barkley How to teach and manage children with ADHD by Fintan O’Regan Hot stuff to Help Kids Chill Out: The Anger Management Book by Jerry Wilde

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And finally.... Working with young people who have ADHD is extremely challenging. Above all – remember to be adaptable, innovative, empathetic, and ... open minded, And remember that not one strategy fits all…

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Thanks for listening... Gareth D Morewood Director of Curriculum Support www.gdmorewood.com Sally Trowse Specialist ADHD Nurse sally.trowse@nhs.net