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  1. Dr. Fralick-Ball has Asthma It will be cool in here all day SFBPsychMedEd 2010-2013

  2. Great Treatments for ADHD & Processing Disorders Take-Home Strategies that Work! Offered for CMI by Dr. Susan Fralick-Ball, PsyD, MSN, CH PsychMedEd@msn.com SFBPsychMedEd 2010-2013

  3. Overview of the Day • Making sense of the Disorders • Skills and strategies for Children • Skills and strategies for Adults • Tools you can use…Now • The skills, strategies, and tools appear throughout this seminar… even more in your addendum pages SFBPsychMedEd 2010-2013

  4. Making Sense of the Disorders • Sensory Processing Disconnections • Executive Dysfunction • Neuropsychological Model of Executive Functioning (EF) • ADHD • Central Auditory Processing Disorder • Non-Verbal Learning Disorder • Mood Dysregulation in Bipolar Disorder • Adult v. Child ADHD • Avoiding Assessment Errors SFBPsychMedEd 2010-2013

  5. Reminders… Please Read • The strategies & skills are scattered throughout the day in discussion, and text • There is little to no presenter bias for this material • There is no conflict of interest between this presenter and CMI/PESI • Parents have the hardest job in the world • Teachers have the second hardest job in the world • This room is cool due to the presenter’s asthma; please refrain from requesting hotel staff to change the temperature • You are taking this manual home for attaining even more information after today • The skills & strategies are all throughout the manual SFBPsychMedEd 2010-2013

  6. *Foundation of Human Information Processing* All information comes to us through sensory input Once the sensory stimulation is perceived,(or we become sensory aware) it is projected up and to the front of our brains via circuits or tracts The sensory information is placed into the frontal lobes for recognition, assignment, assessment; processing – FOUNDATION LAYER #1 The frontal lobes orchestrate the sensory information and place ‘spin’ on that information as filtered through the executive functions Motor responsiveness we call ‘behavior’ (output) are returned via the tracts and other areas of the brain and body – FOUNDATION LAYER #2 To consider the ‘process’ of ADHD, ASDs, OCD, etc. we observe the behaviors bubbling up through the foundation of SP & EF SFBPsychMedEd 2010-2013

  7. Sensory Processing Disorder (SPD) Sensory Modulation Sensory Discrimination Sensory-Based Motor Disorder (SMD) Disorder (SDD) Disorder (SBMD) SOR, SUR, SS Visual Postural Disorders Dyspraxia Auditory Tactile Vestibular Proprioception Taste/Smell Sensory Over-Responsivity Sensory Under-Responsivity Sensory Seeking/Craving adapted from SPD Network Taxonomy SFBPsychMedEd 2010-2013

  8. Executive Function/Dysfunction (EF, EDf) SFBPsychMedEd 2010-2013

  9. Executive Function • Basic Problems with Executive (Dys)function in ADHD are: • Working memory and recall (holding facts in mind while manipulating information; accessing facts stored in long-term memory.) • Activation, arousal, and effort (getting started; paying attention; finishing work) • Controlling emotions (ability to tolerate frustration; thinking before acting or speaking) • Internalizing language (using "self-talk" to control one's behavior and direct future actions) • Taking an issue apart, analyzing the pieces, reconstituting and organizing it into new ideas (complex problem solving). SFBPsychMedEd 2010-2013

  10. Master the Neuropsychological Model of Executive Functioning (EF) • A set of cognitive abilities from central processes that control and regulate other abilities and behaviors. • EF are necessary for goal-directed behavior. • They include the ability to: • initiate and stop actions, • monitor and change behavior as needed, and • plan future behavior when faced with novel tasks and situations. • anticipate outcomes and adapt to changing situations. • The ability to form concepts and think abstractly are often considered components of executive function. SFBPsychMedEd 2010-2013

  11. Executive Dysfunction in ADHD • Parents and teachers are often baffled when students with ADD/ADHD, including those who are intellectually gifted, teeter on the brink of school failure. • Deficits in critical cognitive skills, known as executive dysfunction, may interfere with a student's ability to succeed in school. • Practically speaking, executive function deficits may cause problems for students with ADHD in several important areas: • getting started and finishing work, • remembering homework, • memorizing facts, • writing essays or reports, • working through math problems, • being on time, • controlling emotions, • completing long-term projects, and • planning for the future. SFBPsychMedEd 2010-2013

  12. Executive Dysfunction • Unfortunately students with ADD or ADHD are often punished for executive function deficits, such as lack of organizational and memory skills that interfere with their ability to bring home the correct homework assignments and books. • When deficits in executive function and related learning problems are present, students can try their very best and still not succeed in school!! SFBPsychMedEd 2010-2013

  13. The Primary EF Subfunctions • If we break down the skills or functions into subfunctions, we might say that executive functions tap into the following abilities or skills: • Goal • Plan • Sequence • Prioritize • Organize • Initiate • Inhibit • Pace • Shift • Self-monitor • Emotional control • Completing • Working Memory SFBPsychMedEd 2010-2013

  14. ADHD, EF, and Learning • Many students with ADD or ADHD have impaired working memory and slow processing speed, which are important elements of executive function. • Not surprisingly, these skills are critical for writing essays and working math problems. • Recent research has identified written expression as the most common learning problem among students with ADHD (65 %). • Writing essays, book reports or answering questions on tests or homework is often very challenging for these students. • students often have difficulty holding ideas in mind, acting upon & organizing ideas, quickly retrieving grammar, spelling and punctuation rules from LTM, manipulating all this information, remembering ideas to write down, organizing the material in a logical sequence, and then reviewing and correcting errors. SFBPsychMedEd 2010-2013

  15. ADHD, EF, and Learning • Then he must hold important facts in mind while he applies the rules and shifts information back and forth between working and STM to work the problem and determine the answer. • To further complicate matters, other serious conditions may co-occur with ADD and ADHD. According to the National Institute of Mental Health MTA study on ADHD,two thirds of children with ADHD have at least one other coexisting problem, such as depression, anxiety, or SPD. • Accommodating students with complex cases of ADD/ADHD is critical! SFBPsychMedEd 2010-2013

  16. ADHD, EF, and Learning • Sometimes we forget just how complex seemingly simple tasks really are • Example - memorizing multiplication tables or working a math problem: • When a student works on a math problem, he must fluidly move back and forth between analytical skills with working, STM, and LTM. • With word problems, he must hold several numbers and questions in mind while he decides how to work a problem. • He must tap into LTM to find the correct math rule to use for the problem. SFBPsychMedEd 2010-2013

  17. ADHD ‘Look-Alikes’ • Low or High IQ • LDs • Vision/Hearing Deficits • Mood Disorders • Substance abuse • PTSD • Sleep Disorders • Seizure Disorders • Acquired Brain Injury • Autistic-Spectrum Disorders • Sensory Processing Problems • Sensory integration disorders • Central auditory processing disorder SFBPsychMedEd 2010-2013

  18. ADHD • In the USA, ADHD is one of the most common causes of referrals and childhood medication in family practice, pediatric, neurology, and child psychiatry clinics. • Epidemiologic studies indicate that about 5% of children have ADHD, with boys being a large majority of these • ADHD persists into adult years in a substantial minority of cases. • Current hypotheses associate ADHD etiology with abnormalities of connections in the frontal cortex • It may involve faulty regulation of neurotransmitter messenger systems, predominantly those that use dopamine and norepinephrine. SFBPsychMedEd 2010-2013

  19. ADHD • The cardinal features of this syndrome (DSM-IV) are inattentiveness, impulsivity and motoric over-activity. • In DSM-5 these features may apply to many Axis I Dx • These symptoms generally start during early grade school years; they are persistent and impair the child socially and educationally. • DSM-5 would ‘rate’ the difficulty with these features with different ages and circumstances • DSM-IV subtypes of predominantly hyperactive-impulsive and predominantly inattentive ADHD have not been supported by the empirical data SFBPsychMedEd 2010-2013

  20. ADHD and the new DSM-5 • There could be a single disorder of ADHD comprising the popular conceptions of ADD and ADHD in DSM-5 New proposals are broken into the following domains: • Tends to act without thinking • Is often impatient  • Is uncomfortable doing things slowly and systematically • Difficult to resist temptations or opportunities  SFBPsychMedEd 2010-2013

  21. ADHD • ADHD frequently co-occurs with conduct, mood, anxiety, and learning disorders. • DSM-5 may be including many of these chages into the basic ADHD Dx • It often co-exists with multiple SPDs and EDfs • By mid-adolescence, ADHD children originally diagnosed with co-morbid psychiatric disorders have markedly elevated rates of antisocial, mood and anxiety disorders, more impaired intellectual and achievement scores than ADHD-only children, and high rates of social disability. • Conduct disorder in childhood often predicts an antisocial diagnosis as well as alcohol and drug dependence in adolescence and early adulthood. • Major depression in childhood may predict the emergence of mania. • Severe anxiety in childhood may predict more anxiety disorders in adulthood than in other ADHD children. SFBPsychMedEd 2010-2013

  22. Biological ADHD • Biological Explanations dominate thinking about ADHD • “behavioral disinhibition” • “failure in self-control” • Barkley posits that behavioral inhibition is related to four executive neuropsychological functions carried out by the brain’s prefrontal region: • Working memory • Internalization of speech • Self regulation of affect, motivation, arousal • Reconstitution SFBPsychMedEd 2010-2013

  23. Biological ADHD (Executive Functioning) • Working memory allows an individual to manipulate and act on events held in the mind using foresight and hindsight and gives one a sense of time in which to appropriately carry out these functions • Internalization of speech facilitates self-talk, problem solving, and an ability to reflect on one’s own behavior • Self-regulation of affect, motivation and arousal facilitates control of one’s emotions, an ability to delay gratification and engage in goal-directed activity without becoming distracted • Reconstitution allows one to analyze and synthesize one’s own behavior and communicate in an accurate and efficient manner SFBPsychMedEd 2010-2013

  24. Imaging and ADHD • fMRI conducted while subjects performed the counting Stroop task has shown that normal adults increased blood flow in the anterior cingulate cortex during this task. • Patients with ADHD, by contrast, failed to increase blood flow in this structure under the same conditions • During cognitive conflict, ADHD patients fail to activate the anterior cingulate cortex than do controls • PET scanning has been used to examine cerebral metabolism, which is a measure of neuronal activity • Results have shown that adults with ADHD have decreased cerebral metabolism compared with controls • SPECT imaging has been used to visualize the DAT dopamine transporter in the human brain • Three studies have shown that untreated adults with ADHD have increased binding of DAT protein compared with controls • This increase may result in accelerated re-uptake leading to reduced dopamine in the synaptic cleft SFBPsychMedEd 2010-2013

  25. Biological/Psychological ADHD • ADHD as a product of an “interactionary process” between working memory and environmental factors that is more psychological than biological in nature • Deficient working memory is at the core of this disorder • For example, hyperactivity (often manifest as disorganized behavior) occurs because information stored in working memory fades rapidly therefore there exists a need to increase the rate at which new stimuli or input is sought out SFBPsychMedEd 2010-2013

  26. Biological/Psychological ADHD • Impairment in each of these executive functions is thought to lead to behaviors commonly associated with ADHD • According to Barkley: when an ability for self control is absent it “in turn impairs other important brain functions crucial for maintaining attention” and delay gratification SFBPsychMedEd 2010-2013

  27. Symptoms Overlap Behaviors not Necessarily ADHD SFBPsychMedEd 2010-2013

  28. The Sensory Processing Constellation Depression SPD ADHD B S FXS Anxiety Autism OCD KEY: ADHD: Attention Deficit Hyperactive Disorder B: Bipolar Disorder OCD: Obsessive-Compulsive Disorder FXS: Fragile X Syndrome S: Schizophrenia SPD: Sensory Processing Disorder Adapted from R. Ross & L. Miller. NICHD grant #1 K01 HD01201-01-A1 Wallace Research Foundation, Colorado State University SFBPsychMedEd 2010-2013

  29. Central Auditory Processing Disorder (CAPD) • Complex problem affecting about 5% of school-aged children. • Children can't process the information they hear in the same way as others because their ears and brain don't fully coordinate. • The way the brain recognizes and interprets sounds, most notably the sounds composing speech is altered. • Often do not recognize subtle differences between sounds in words, even when the sounds are loud and clear enough to be heard. • These kinds of problems typically occur in background noise, which is a natural listening environment. • Basic difficulty of understanding any speech signal presented under less than optimal conditions. SFBPsychMedEd 2010-2013

  30. Children with CAPD have difficulty: • hearing in noisy situations • following long conversations • hearing conversations on the telephone • learning a foreign language or challenging vocabulary words • remembering spoken information (i.e., auditory memory deficits) • taking notes • maintaining focus on an activity if other sounds are present child is easily distracted by other sounds in the environment • with organizational skills • following multi-step directions • in directing, sustaining, or dividing attention • with reading and/or spelling • processing nonverbal information (e.g., lack of music appreciation) SFBPsychMedEd 2010-2013

  31. “Behavioral” Comparison • ADHD behaviors seen most often include: • • Inattention • • Distractibility • • Hyperactivity • • Restlessness • • Impulsivity • •Interruption/intrusion • CAPD behaviors seen most often include: • • Difficulty hearing in background noise • • Difficulty following directions • • Poor listening skills • • Academic difficulties • • Poor auditory association skills • • Distractibility • • Inattentiveness SFBPsychMedEd 2010-2013

  32. Non-Verbal Learning Disorder (NVLD) • Developmental disorder with manifestations in the following domains: • a) somatosensory and motor functions • b) visuospatial and visuoconstructive functions • c) arithmetic • d) social cognition • E) inferential reasoning. NLD is a neurological syndrome characterized by the impairment of nonverbal or performance-based information controlled by the right hemisphere of the brain. Performance-based information governed by the R hemisphere is impaired in varying degrees, including problems with visual-spatial, intuitive, organizational, evaluative, and holistic processing functions SFBPsychMedEd 2010-2013

  33. NVLD • Generally presents with specific assets and deficits. • The assets include: • Early speech and vocabulary development • Remarkable rote memory skills • Attention to detail • Early reading skills development and excellent spelling skills. • Good verbal ability to express themselves eloquently. • Strong auditory retention. SFBPsychMedEd 2010-2013

  34. Finding Assets • Everyone has assets/strengths/positive points • To work with a child, client, patient, etc. the parent/teacher/therapist needs to find one of those strengths • When a problem has been identified, chipping away at the problem teaches no skills for problem solving • If a strength can be attached to the person, then every problem worked on through the asset, the person gains a working set of problem-solving skills based on something familiar and accepted by the person in therapy • This formula teaches complex problem-solving skills SFBPsychMedEd 2010-2013

  35. Mood Dysregulation in Bipolar Disorder and EF • BPD is characterized by alternating periods of emotional highs and lows. • Ranges from mild to severe. • Mood swings have long intervals to rapidly cycling. • The emotional ‘highs’ include: • Feelings of euphoria, optimism • Rapid speech, racing thoughts, agitation,↑ activity • Poor judgment • Recklessness • Difficulty sleeping • Tendency to be distracted • Inability to concentrate • Extreme irritability SFBPsychMedEd 2010-2013

  36. Bipolar Disorder (BPD) • During periods of emotional ‘lows’, symptoms may include: • Persistent feelings of sadness, anxiety, guilt, or hopelessness • Disturbances in sleep and/or appetite • Fatigue and loss of interest in daily activities • Difficulty concentrating • Recurring thoughts of suicide (generally not in children) • Some children with BPD have an underlying SPD • During ‘highs’, they may experience heightened sensory awareness or sensory feedback. • During ‘lows’, the opposite is often true SFBPsychMedEd 2010-2013

  37. Adult ADHD v. Childhood ADHD • Most children with ADD/ADHD don’t outgrow their disorders; rather, they become disorganized, inattentive adults. • Adults with ADD?ADHD struggle daily with self-regulation: regulating their attention, regulating their impulses in talking and action, and regulating their emotions. • They have trouble staying focused, getting organized, starting and completing work, managing time and money, and remembering all the little things in daily life. • Additionally, depression, anxiety, and substance abuse are common co-conditions to adult ADD/ADHD. • Many adults present with these symptoms; ADHD is later found. SFBPsychMedEd 2010-2013

  38. Adult v Child ADHD • The symptoms change as someone with ADD/ADHD develops from a child into a teenager and then into an adult.  While the core problems of hyperactivity, impulsiveness, and inattentiveness remain the same, the specific symptoms manifest differently. • DSM-5 is looking to further refine the adult Dx to include more inattentiveness & impulsive decision making • The impairment is hallmarked with impairment of executive functions and emotional control. • Typically, the symptoms of hyperactivity decrease and become more subtle, while problems related to concentration and organization become more dominant. • Female adult ADHD clients are often underdiagnosed and undertreated. SFBPsychMedEd 2010-2013

  39. Adult ADHD… • Barkley identifies core adult ADHD as: • Distractibility • Impulsiveness, poor concentration • Inability to persist at tasks • Difficulties with working memory, organization & planning There are high underpinnings of anxiety and depression that drive Adult ADHD • Clinicians are asked to rule out medical conditions like: • Hyperthyroidism • Seizure disorder • Asperger’s syndrome SFBPsychMedEd 2010-2013

  40. Sequelae of Adult ADHD • Untreated adult ADHD is often associated with: • Higher rates of unemployment, divorce, & arrests • Higher rates of STDs and unplanned pregnancies • Underachievement in school • Firing/dismissal at work • Behavioral problems at work • Job quitting due to hostility in the workplace or boredom • Driving accidents, revoked/suspended driver’s licenses, citations for speeding, reckless driving, or causing accidents SFBPsychMedEd 2010-2013

  41. Adult v. Child ADHD • Hyperactivity in adults: • inability to relax • restlessness, nervous energy • talking excessively • Impulsiveness in adults: • volatile moods • blurting out rude or insulting remarks • interrupting others • Inattentiveness in adults: • “tuning out” unintentionally • inability to focus on mundane tasks • constantly losing and forgetting things SFBPsychMedEd 2010-2013

  42. Adult v. Child ADHD • Adults with ADHD have problems in six major areas of executive functioning: • Activation – Problems with organization, prioritizing, and starting tasks. • Focus – Problems with sustaining focus and resisting distraction, especially with reading. • Effort – Problems with motivation, sustained effort, and persistence. • Emotion – Difficulty regulating emotions and managing stress. • Memory – Problems with short-term memory and memory retrieval. • Action – Problems with self-control and self-regulation. SFBPsychMedEd 2010-2013

  43. Adult ADHD Positive Traits • Creativity – People with ADD excel at thinking outside of the box, brainstorming, and finding creative solutions to problems, more open-minded, independent, and ready to improvise. • Enthusiasm and spontaneity – People with ADD are free spirits with lively minds—qualities that makes for good company and engrossing conversation. Their enthusiasm and spontaneous approach to life can be infectious. • A quick mind - People with ADD have the ability to think on their feet, quickly absorb new information (as long as it’s interesting), and multitask with ease. Their rapid-fire minds thrive on stimulation. They adapt well to change and are great in a crisis. • High energy level – People with ADD have loads of energy. When their attention is captured by something that interests them, they can have virtually unlimited stamina and drive. SFBPsychMedEd 2010-2013

  44. Reminders… Please Read • The strategies & skills are scattered throughout the day in discussion, and text • There is little to no presenter bias for this material • There is no conflict of interest between this presenter and CMI/PESI • We have been talking about skills all morning • Parents have the hardest job in the world • Teachers have the second hardest job in the world • This room is cool due to the presenter’s asthma; please refrain from requesting hotel staff to change the temperature • You are taking this manual home for attaining even more information after today • The skills & strategies are all throughout the manual SFBPsychMedEd 2010-2013

  45. Caveats to careful use of ADD/ADHD Meds • December 12, 2011 — In light of two recent epidemiologic studies, the US Food and Drug Administration (FDA) is updating its communications with respect to medications for attention-deficit hyperactivity disorder (ADHD) on the ongoing cardiovascular safety review of medications used for treating ADHD. • The agency notes that healthcare professionals should take special note that: • Stimulant products and atomoxetine (i.e., Strattera) should generally not be used in patients with serious heart problems or in patients for whom an increase in blood pressure or heart rate would be problematic. • Patients treated with ADHD medications should be periodically monitored for changes in heart rate or blood pressure. • Patients should continue to use their medication for the treatment of ADHD as prescribed by their healthcare professional. SFBPsychMedEd 2010-2013

  46. Development and Neurophysiology of EF • The frontal lobe contains most of the dopamine-sensitive neurons in the cerebral cortex. The dopamine system is associated with reward, attention, long-term memory, planning, and drive. • The executive functions of the frontal lobes involve the ability to recognize future consequences resulting from current actions, to choose between good and bad actions (or better and best), overrideand suppress unacceptable social responses, and determine similarities and differences between things or events. SFBPsychMedEd 2010-2013

  47. SFBPsychMedEd 2010-2013

  48. Frontal Lobes • The frontal lobes allow for high-road, or high-order processing • A Form of Processing that involves: • Higher • Rational • Reflective thought processes of the mind • This processing allows for: • Mindfulness • Being flexible in our responses • An Integrated Sense of Self Awareness SFBPsychMedEd 2010-2013

  49. Frontal Lobes • The frontal lobes continue to develop late in adolescence, and in fact, myleination is not complete until the fourth or fifth decade of adult life. • A number of EEG studies have found a dramatic spurt in frontal lobe maturation between the ages of 17 and 20, which can explain “late bloomers”. • Also sex hormones are relevant; there is a relationship between psychosexual development and cognitive ability. SFBPsychMedEd 2010-2013

  50. Frontal Lobes • Frontal brain growth is shaped by what is called “pruning”. • If these connections are not utilized, they are not maintained. • It is truly a “use it or lose it” situation, • This circuitry in the brain is very important, and may actually be the cause of problems that are often misdiagnosed as a malfunction in a part of the brain. • The cortex can over-grow a problem with ADHD that is caused by another part of the brain. SFBPsychMedEd 2010-2013