Welcome to Class # 1 [Monday July 5 th , 2010]

1. Welcome to Class # 1 [Monday July 5th, 2010] The Psychology & Education of Students with ADHD [HDP3238H]Instructor: Rosemary Tannock, PhD

2. Goals for today • Introductions • Review of Syllabus, Assignments, & case study • Housekeeping • Objectives (review of readings & didactic) • Be aware of historical changes in conceptualization of ADHD • Know core characteristics of ADHD • Be able to differentiate ADHD from other disabilities

3. Introductions • Review of syllabus, readings, assignments • Scoring Rubrics • Review the rubrics • Attach relevant rubric to your assignment • Peer evaluation rubric – circle your rating of each component. I will provide interpretive summary for sum score (score to letter-grade conversion) • Rubric for final assignment is pending today’s discussion of the assignment • Introduction to i-clickers • Closing Routine • Ticket-out-the-door face down on my desk • Return i-clickers & name card to container First, some Housekeeping

4. How do we use the i-clickers? • I ask questions on the screen during the class. • You answer using your i>clicker remote. • Audience responses are tallied. • I display a graph with the audience results on the screen. • We discuss the questions and answers.

5. How do you vote? Turn on the clicker by pressing the bottom “On/Off” button. A blue “Power” light will appear at the top of the remote.

6. How do you vote? When I ask a question (and start the timer), select A, B, C, D, or E as your vote. I may also ask you to talk about your possible choice/answer with your neighbor or in groups, prior to voting.

7. How do you know your vote was received? Check your “Vote Status” Light: Green light = your vote was sent AND received. Red flashing light = you need to vote again. **Not sure you saw the light? Just vote again. **Want to change your vote? You can vote again as long as the timer is still going.

8. Q0- Audience SurveyLet’s try the i-clickers! [NB: WHEN I start the timer, THEN press the button corresponding to your choice] Q. Do you work primarily with students in A. Elementary school B. Secondary school C. Other contexts D. I don’t work with students

9. What is ADHD? • Your perspectives (small group work) • Historical perspectives (didactic) • Current perspectives • Medical (didactic, group activity & group discussion) • Individual (Kids Behind the Label)(small group work)

10. WHAT IS ADHD? (small group activity) • Gather at your specified flip-chart • Designate one person to be recorder/reporter • Brain storm and record your responses to ‘What is ADHD” from your perspective • Identify emerging themes • Report your emergent themes to the large group

11. ADHD: Historical perspectives Tempting to infer that ADHD existed even prior to the 17th century! La purification de la Vierge Guido Reni (circa 1636) The Louvre, Paris

12. What is ADHD? 18th century perspective “On attention & its diseases” “…incapable of attending with constancy to any one object of education.” (p.271) 1798

13. Early dual conceptualizations of ADHD Poorly regulated attention (learning problems) Poorly regulated behavior (noncompliance) “Fidgety Phil” Dr. Heinrich Hoffman 1845 “Johnny-Head-In-The-Air” “ Dr. George Still 1902 “Morbid defect of moral control” Impulsive, aggressive, defiant, prone to accidents, unable to control their behavior

14. ADHD in the 1950’s-1960’s ‘minimal brain dysfunction’ Speech, Language Social interaction Emotion Mood Motor function Intellectual function Behavior

15. A mental health disorder: Childhood-onset Disruptive behavior disorder: Inattention, impulsiveness, hyperactivity World-wide recognition of ADHD Current Medical Perspective of ADHD 1994-2008

16. Criterion A: Either (1) or (2) • (1) six (or more) of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level Attention-Deficit/Hyperactivity Disorder Criteria

17. Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities • Often has difficulty sustaining attention in tasks or play activities • Often does not listen when spoken to directly • Often does not follow through on instructions and fails to finish schoolwork , chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) • Often has difficulty organizing tasks and activities • Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (eg, schoolwork, homework) • Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, tools) • Is often easily distracted by extraneous stimuli • Is often forgetful in daily activities A.1. Inattention (6 of more of these 9 symptoms

18. Criterion A: Either (1) or (2) • (1) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level Attention-Deficit/Hyperactivity Disorder Criteria

19. Hyperactivity Impulsivity • Often fidgets with hands or feet or squirms in seat • Often leaves seat in classroom or in other situations in which remaining seated is expected • Often runs about or climbs excessively in situations in which it is inappropriate • Often has difficulty playing or engaging in leisure activities quietly • Is often “on the go” or often acts as if “driven like a motor” • Often talks excessively • Often blurts out answers before questions have been completed • Often has difficulty awaiting turn • Often interrupts or intrudes on others (eg butts into conversations or games) A.2. Hyperactivity-impulsivity

20. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years • Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home) • There must be clear evidence of clinically significant impairment in social, academic or occupational functioning • The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (eg, Mood, Anxiety Dissociative or Personality Disorder) Additional DSM-IV criteria for ADHD

21. ADHD-Combined Type • If both Criteria A1 and A2 are met for the past 6 months • ADHD-Predominantly Inattentive Type • If Criterion A1 is met but Criterion A2 is not met for the past 6 months • ADHD-Predominantly Hyperactive-Impulsive Type • If Criterion A2 is met but Criterion A1 is not met for the past 6 months DSM-IV-TR Subtypes of ADHD

22. Group Discussion (5 min) What do you notice about the symptoms of ADHD? • Reflect normal behavior not atypical behavior • All symptoms are preceded by the qualifier “Often…” how often is often? • Some symptoms are ‘double-barelled’ and component parts have different meanings • Some seem similar to other symptoms • How would you differentiate between the 3 impulsivity symptoms? • Most appear to be geared towards children • Can symptoms be adapted for adolescents/adults? Medical perspectives of ADHD

23. What do ADHD symptoms look like at school? DVD Program 2: Video Clip A multi-media Professional Development Program for Teachers, developed by researchers at the Hospital for Sick Children1 in collaboration with TV-Ontario & University of Saskatchewan (video footage) with funds from NIMH, CIHR, TV-Ontario, Hospital for Sick Children & an unrestricted educational grant from Shire Biochem Inc. 1R. Tannock, B. Ferguson, P. Chaban, R. Martinussen, A. McInnes

24. What the videoclips show… • A special class for children with “behavior problems” • class designed for research • 9 children with ADHD: seated at 2 tables • None are receiving medication • 1 special education teacher & 1 educational assistant • Both trained in behavior management

25. Video-clip #1 • Teacher-directed activity • Card matching game: which card on the wall chart matches the card in teacher’s hand: tell teacher the coordinates on the wall chart (e.g., B3) • Video shows 4 boys seated at a table taking part in the activity Write down what you see your specified student doing (or not doing)

26. Classroom observations In the videoclip (card game): Q.1 which boy was the most restless? Q 2.which boy participatedthe most?

27. Video-clip #2 • Independent seat-work activity • Math fluency • Timed math task: do as many as you can in 10 minutes (we will watch 1.5 min) • work quietly, quickly, and accurately • Video shows 4 boys & 1 girl Write down what you see your specified student doing (or not doing)

28. Classroom observations • Q.1 Which student attracts the most attention from the teacher? • Q.2 Which student appears to be least productive? • Q.3 Which students is/are most productive?

29. Symptoms vary across contexts • Symptoms vary within a child minute-to-minute, day-to-day, & from one situation to another • Symptoms increase during activities with: • high cognitive demand • little active engagement

30. Often loses things necessary for tasks & activities Often ‘on the go’ or acts as if ‘driven by a motor’ Often has to hunt for needed items (pencil, book etc) Often complains that s/he can’t find the necessary items Often does not know where the needed item is (“um.. It may be in my locker, or perhaps in my knapsack, or maybe at home”) Frequently rocks chair, stands up or leans over desk, swings legs, shifts in seat, in almost constant motion How might ADHD symptoms manifest in school?

31. How might ADHD symptoms manifest in school? (small group activity) • For your designated symptoms of inattention and hyperactivity/impulsivity, describe how they might manifest at school. • Consider different situations & different classes at school • Consider how they might manifest in elementary , middle, & high school students • Report back to large group

32. What would you observe……? • Group 1 • A1.a. Fails to give close attention to details or … • A1.b. Difficulty sustaining attention.. • A2 a. Fidget or squirms • A2. b. Often leaves seat • Group 2 • A1.c. Does not listen.. • A1.d. Does not follow through on instructions…. • A2.c. Runs about or climbs • A2.d. difficulty playing quietly • Group 3 • A1.e. Difficulty organizing… • A1.f. Avoids effortful tasks.. • A2.f.talks excessively • A2.g. Blurts out answers.. • Group 4 • A1.h. Easily distracted • A1.i. forgetful daily activities • A2.h. Difficulty waiting turn • A2.i. interrupts, intrudes..

33. Classroom observation: ages 13-17 Western Australia (Carroll et al., Ed Psychol: 2006) 25% of solitary off-task behavior attributed to teacher behavior (multiple/changing instructions)40% to environmental distractions • Common Triggers: • Failure to begin assigned task • Peer-initiated

34. ADHD in the classroom (7- to 11-yr-olds ADHD-good attn On-task 68% Optimal ability 5 min ADHD-poor attn On-task 40% Optimal ability 2 min TD On-task 80%, optimal ability 7 min Increases with time on task TD On-task 80% Increases with time on task ADHD-good attn On-task 68% ADHD –poor attn On-task-40% & highly variable L H TD L H TD Rapport et al (in press ) J Attention Disorders [epub March 2 2009]

35. GROUP DISCUSSION • What is ADHD according to the youngsters interviewed for this book? • What themes emerged? • How do they map onto the DSM-IV-TR criteria for ADHD ? “Kids Behind the Label”

36. A mental health disorder: Childhood-onset Disruptive behavior disorder: Inattention, impulsiveness, hyperactivity Meta-analyses indicate a world-wide prevalence of ADHD: ~ 5 % in children & adolescents ~ 3 - 4% in adults More common in males than females (3: 1) ADHD 1994-2008

37. How many students in this class are likely to meet diagnostic criteria for ADHD?

38. Studies suggest that the symptoms of ADHD are normally distributed • Few symptoms • Some symptoms • Many symptoms • Several additional students will manifest impairing symptoms but subthreshold for a diagnosis of ADHD • Findings also indicate that even moderate levels of ADHD symptoms increase the risk for poor academic outcomes (Currie & Stabile, 2006; Rodriguez et al., 2007). Diagnosis versus Symptoms

39. Differentiating ADHD from other disorders ADHD is not…… !

40. CD ADHD • poor attention • excessive activity • impulsivity extreme antisocial behaviour: bullying, lying, stealing, cruelty Persistent negativistic behavior: argumentative, defiant, provocative, hostile Differs from: ODD

41. ADHD • poor attention • excessive activity • impulsivity Difficulty learning to read, write, process numbers, or do math, accurately and fluently, despite at least average intellectual ability and opportunity to learn. LD Differs from LD:

42. ADHD • poor attention • excessive activity • impulsivity Differs from: Autism, Asperger’s Social Communication Deficits Fixated interestsRepetitive behaviors

43. BUT…ADHD rarely occurs by itself! Carroll et al (2005) J Child Psychol Psychiat 46:524-532; Jensen et al (2001) JAACAP 40:147-158; Kessler et al (2005) Am J Psychiatry 163:716-723; Reich et al (2005) Twin Res Hum Genet 8:459-466 16

44. Case # 1: Daniel is a 7 year old boy • Since the start of the school-year, the teacher noticed that he has: • problems concentrating & rarely does his homework • disrupts the class by calling out • frequently leaves his seat to go over to another student and grabs things or pokes him • often loses his temper and gets angry • often refuses to do what the teacher asks him to do • tries to pass the blame onto others, when the teacher reprimands him • His mother reports that he is just the same at home and the problems seemed to start about 5 months ago when his father left the family

45. How likely is it that this boy’s behavior is attributable to ADHD? (by show of hands) • 1. Very likely • 2. Somewhat likely • 3. Somewhat unlikely • 4. Very unlikely Optimum response is #4, because most of the symptoms are diagnostic criteria for Oppositional Defiant Disorder (not ADHD), their onset is recent, have not persisted for at least 6 months, and coincided with a major family stressor

46. Case # 2:Danielle is a 9-year-old student… • Since the start of the school-year, the teacher noticed that Danielle … • Easily distracted by what is going on around her, • Has problems concentrating, • Makes careless mistakes in her work, • Often loses her workbooks, pencil, her library book • Generally does her homework but forgets to hand it in • Rarely puts loose worksheets into her binder and typically crams them into desk or backpack • Typically needs instructions to be repeated • Tends to annoy other girls by saying ‘ mean things” to them • Her mother says she is like this at home too,and was like it even in preschool

47. How likely is it that this girl’s behavior is attributable to ADHD? • 1. Very likely • 2. Somewhat likely • 3. Somewhat unlikely • 4. Very unlikely Optimum response is #2, because she exhibits many symptoms of Inattention, that have persisted for more than 6 months, started in preschool years, and occur in at least 2 contexts (home and school). Need diagnostic assessment to rule out other explanations & confirm ADHD

48. Weaknesses in DSM-IV diagnostic criteria for ADHD • Questionable validity of subtypes • Developmental insensitivity of symptoms & thresholds • Lack of scientific basis for age-of-onset criterion • Reliance on single informant (parent, self) • Presence of autism/PDD as diagnostic exclusion

49. Historical changes in ADHD subtyping DSM-IV subtypes of ADHD 1968 (DSM-II) No subtyping 1980 (DSM-III) Subtyping ADD (inatt + imp) ADDH (inatt, imp, hyp) 1987 (DSM-III-R) No subtyping 1994 (DSM-IV) Subtyping ADHD-PI ADHD-HI ADHD-CT INATTENTION HYPERACTIVITY- IMPULSIVITY INATTENTIVE SUBTYPE “ADD” HYPERACTIVE- IMPULSIVE SUBTYPE COMBINED TYPE “Classic ADHD”

50. Domains of clinical investigation to validate diagnostic subtypes (Cantwell:1995)