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Understanding and Responding to Behavioural Issues of Students with ADHD, Sensory Integration Dysfunction and ODD. Prepared by Ellen Young, Krista Heisinger Frost, and Michelle Hancock. What is Neurologically-Based Behaviour (NBB)? (Paula Cook, 2011).

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    1. Understanding and Responding to Behavioural Issues of Students with ADHD, Sensory Integration Dysfunction and ODD Prepared by Ellen Young, Krista Heisinger Frost, and Michelle Hancock

    2. What is Neurologically-Based Behaviour (NBB)?(Paula Cook, 2011) • About 10 % of students can’t reliably control what they say or do. • The overarching name for the behavioural condition they exhibit is NBB • NBB is behaviour that results from cerebral processes occurring in an abnormal manner that results in information not being processed correctly in the brain. The resulting behaviour is challenging, unpredictable, inconsistent and unresponsive to ordinary discipline.

    3. 3 Indicators of NBB 1. Behaviour difficulties - atypical, inconsistent, compulsive or immune to normal behaviour management 2. Language Difficulties – problems understanding, processing, and expressing information verbally 3. Academic Difficulties – memory, fine and gross motor skills, comprehension, language and math skills deficits

    4. Common Diagnoses within NBB: • Brain injuries • Attention-Deficit Hyperactivity Disorder • Oppositional Defiant Disorder • Bipolar Disorder • Anxiety Disorders • Fetal Alcohol Spectrum Disorder • Sensory Integration Dysfunction • Autism Spectrum Disorder • Learning Disabilities

    5. Attention Deficit Hyperactivity Disorder (AD/HD) Common neurobiological condition affecting 5-8 % of school age children (Barkley, 1998) Symptoms persist into adulthood in approximately 60% of cases (4% of adults) (Kessler et al., 2006) Characterized by developmentally inappropriate levels of inattention, and/or impulsivity and/or hyperactivity Chronic, incurable condition

    6. Possible Causes of AD/HD The current model of the cause of AD/HD is rooted in the biological paradigm that emphasizes neurobiological, neuroanatomical and genetic mechanisms. Research clearly indicates genetic factor; likely multiple interacting genes (Tannock, 1998; Swanson and Castellanos, 2002) Other causal factors: low birth weight, prenatal maternal smoking, prenatal problems may also contribute (Connor, 2002)

    7. Neurology of AD/HD(Barkley, 2005) Structural differences in the brain and neurotransmitter: Dopamine and norepinephrine dysregulation (Barkley, 2005) Smaller, less active, less developed brain regions (cerebellum, prefrontal cortex, basal ganglia) Bad parenting is not a cause!

    8. Proper Steps in Diagnosis – No single test Clinical assessment of the individual’s academic, social and emotional functioning and developmental level in order to determine if DSM-IV diagnostic criteria are met History : interviews with parents, teachers, child Use rating scales and checklists (Conner’s Parent and Teacher rating scale, Barkley’s Home and School Situation Questionnaire); Continuous Performance Tests (TOVA) Physical exam (to rule out other medical problems or to determine the presence or absence of co-existing conditions)

    9. DSM IV The American Psychiatric Association's Diagnostic and Statistical Manual-IV, Text Revision (DSM-IV) is used by mental health professionals (school and clinical psychologists, clinical social workers, doctors) to help diagnose ADHD. This diagnostic standard helps ensure that people are appropriately diagnosed and treated for ADHD.

    10. The DSM-IV characterizes the following 3 subtypes of AD/HD:( • Inattentive only (AD/HD-I) (formerly known as attention-deficit disorder [ADD])—Children with this form of AD/HD are not overly active. Because they do not disrupt the classroom or other activities, their symptoms may not be noticed. Among girls with ADHD, this form is most common. Approximately 30% to 40% of children with AD/HD have this subtype. • Hyperactive/Impulsive (AD/HD-HI)—Children with this type of AD/HD show hyperactive and impulsive behavior but can pay attention. This subtype accounts for a small percentage, approximately 10%, of children with ADHD. • Combined Inattentive/Hyperactive/Impulsive (AD/HD-C)—Children with this type of AD/HD show all 3 symptoms. This is the most common type of AD/HD. The majority of children with AD/HD have this subtype, approximately 50% to 60%.

    11. Mimics • Anxiety, depression, mental retardation, sleep apnea, hypo/hyperthyroidism, Central Auditory Processing Dysfunction, severe sensory impairment, and learning disabilities may cause similar symptoms may actually be the primary diagnosis or may co-exist with AD/HD

    12. Co-Existing Conditions(Baren, 2002)

    13. Popular Misconceptions AD/HD is environmentally caused AD/HD is over diagnosed Most kids outgrow symptoms (about 1/3 do) AD/HD means inability to pay attention AD/HD kids need to put in more effort Kids notice benefits of medication Consequences change behaviour Stimulant medication leads to alcohol and substance abuse ADHD affects males more than females

    14. Importance of Early Identification and Intervention • Potential areas of impairment: • academic achievement • relationships: family and friends • low self-esteem • accidental injuries • Smoking and substance abuse • Motor vehicle accidents • Legal difficulties-delinquency • Occupational/vocational

    15. ADHD and Juvenile Criminal Justice System (Robert Eme, American School of Professional Psychology, 2008) 2, 300,000 adults and 100,000 juveniles are incarcerated in the United States At least 25% and up to 50% have ADHD This holds true for incarcerated females; may even be more likely than males to have ADHD

    16. Multi-modal Treatment: Medical, Educational and Behavioural Interventions Parent and child education about diagnosis and treatment Behaviour modification management techniques Medication Psychotherapy/Counseling (family; individual: self-esteem and coping skills) Coaching (develop better habits, social skills training) School programming (IEP, AEP, BIP) Physical Exercise Complementary and alternative medicine (CAM) for AD/HD such as elimination of: sugar, food additives, preservatives; EEG biofeedback are not supported in the literature (Rojas and Chan, 2005) Severity and type of AD/HD should be considered

    17. National Institute of Mental Health Study: Multimodal Treatment Study of Children with AD/HD (1999) • Children who were treated with medication alone (which was carefully managed and individually tailored) and children who received both medication and behavioural treatment experienced the greatest improvements in their AD/HD symptoms (attention, hyperactivity, impulsivity) • medication and behavioural treatment had added benefits for non-AD/HD symptom domains (parent-rated oppositional/aggressive symptoms, parent-child relations, teacher-rated social skills, internalizing symptoms, reading achievement)

    18. Impact of Stimulant Medication Increased: Decreased: Activity levels Impulsivity Negative behaviours Physical & verbal hostility • Attention • Concentration • Compliance • Effort on tasks • Amount and accuracy of school work

    19. Medication Impact(Dr. Russel Barkley) Working memory Self-talk, self-esteem and emotional control Verbal fluency Motor coordination, handwriting Acceptance by and interaction with peers Awareness of the game in sport Decreased punishment by others

    20. Behaviour Modification The scientific literature, the National Institute of Mental Health and other professional organizations support stimulant medication and behaviourally oriented psychosocial treatments, also called behavior therapy or behavior modification, as effective treatments for AD/HD.

    21. Behaviour modification teaches children specific techniques and skills: • children with AD/HD face problems beyond the core symptoms of inattention, hyperactivity and impulsivity • These include poor academic performance and behavior at school, poor relationships with peers and family members, and failure to obey adult requests. • to help improve their behavior • skills are reinforced by parents and teachers.

    22. Behaviour modification is often put in terms of ABCs: • Antecedents: conditions or context in which problem behavior occurs • Behaviours: responses or actions that concern teacher or parent exhibited by the student • Consequences: events and behaviours that follow the occurrence of the problem behavior

    23. Parents and teachers learn and establish programs in which: the environmental antecedents (A) and consequences (C) are modified to change the child’s target behavour (B). Treatment response is monitored via observation and measurement, and the interventions are modified when they fail to be helpful or are no longer needed.

    24. Daily school-home report-card • This tool allows parents and teacher to communicate regularly, identifying, monitoring and changing classroom problems. • It is inexpensive and minimal teacher time is required. • Can use a report-card or simply a calendar with a smile or frown for each day

    25. Teachers determine the individualized target behaviors • Teachers evaluate targets at school and send the report card home with the child. • Parents provide home-based rewards; more rewards for better performance and fewer for lesser performance. • Teachers continually monitor and make adjustments to targets and criteria as behavior improves or new problems develop. • Use the report card with other behavioral components such as commands, praise, rules, and academic programs.

    26. Behaviour Interventions • Be consistent • Use positive reinforcement • Contracts • Token programs • Response cost • Redirection • Time-out/thinking areas • Teach problem-solving skills • Communication skills • Self-advocacy skills • List-making • Teach Agenda/day-planner use

    27. 5 Effective Forms of Intervention for Peer Relationships Systematic teaching of social skills Teaching social problem solving (eg: early years: rock/paper/scissors) Teaching other behavioral skills often considered important by children, such as sports skills and board game rules Decreasing undesirable and antisocial behaviors Help to develop a close friendship

    28. Programs use methods that include: Coaching use of examples Modeling, role-playing and practice feedback, rewards and consequences, Social skills training groups are the most common intervention and the focus is on the systematic teaching of social skills.

    29. 90% of Children with ADHD have Academic Challenges Written expression Math (times tables and word problems) Spelling and Reading Overall low academic achievement scores Disorganized, incomplete homework Difficulty getting started (procrastination) Impaired sense of time (it will take me forever to do this!)

    30. Middle School: ADHD Brick Wall (Dendy, 2008) • Increased demands for executive functioning (management functions of the brain): • Organization • Memory • More complex academic work • Working independently • More homework • More complex routines (change classes/teachers)

    31. Greatest Areas of Difficulty • Difficulty following multiple-step directions • Give written directions, ask child to repeat directions, chunk work into manageable units, use graphic organizers • Completing tasks in a timely manner • Use a timer (cellphone or watch), help child develop a plan (timeline), offer incentive, allow more time • Recall of rote details • use mnemonics, color-coding, use image association • Copying and writing • allow more time, give hand-outs or note frames, chunk work, laptop: type instead of hand-writing

    32. Reframe Your ThinkingGifts of AH/HD • Students are: • Energetic • Creative • Risk-takers (in a good way) • Persuasive • Verbal • Big picture thinkers • Good long-term memory • Free thinkers • Mostly good looking

    33. References • Baren, M. (2002). ADHD in adolescents: Will you know it when you see it? Contemporary Pediatrics, 19(5), 124-143. • Barkley, R. (1998). Attention Deficit Hyperactivity Disorders: A Handbook for Diagnosis and Treatment. New York: Guilford Press. • Barkley, R. (2005). Attention Deficit Hyperactivity Disorders: A Handbook for Diagnosis and Treatment (3rd ed.). New York: Guilford Press. • Connor, D.R. (2002). Preschool Attention deficit hyperactivity disorder: A review of prevelance, diagnosis, neurobiology, and stimulant treatment. Journal of Developmental Behaviour Pediatrics 23 (1Suppl):S1-S9. • Dendy, C. Understanding the Impact of ADHD & Executive Functions on Learning and Behaviour. In: Proceedings of the ADDA 13th National Conference. Minneapolis, MN. pp. 166-83. • Eme, R. (2008). ADHD & The Criminal Justice System. In: Proceedings of the ADDA 13th National Conference. Minneapolis, MN. pp. 89-91. • Kessler, R.C., Adler, L., Barkley, R., Biederman, J. The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. Am Journal of Psychiatry (2006), 163:724-732. • MTA Cooperative Group. (1999). A 14-Month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 56, 1073-1086)

    34. References MTA Cooperative Group. (1999). Moderators and mediators of treatment responses for children with attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 56, 1088-1096) Rojas, N.L., and Chan, C. (2005). Old and new controversies in the alternative treatment of attention-deficit hyperactivity disorder. Mental Retardation and Developmental Disabilities Research Reviews, 11: 116-130. Swanson, J.M., and Castellanos, F.X. (2002). Biological Basis of ADHD-Neuroanatomy, Genetics, and Pathophysiology. In P.S. Jensen and J.R. Cooper (eds.) Attention deficit hyperactivity disorder: State of the science, best practices, pp. 7-1-7-20. Kingston, New Jersey. Tannock, R. (1998). Attention deficit hyperactivity disorder: Advances in cognitive, neurobiological, and genetic research. Journal of Child Psychology and Psychiatry, 39, 65-99.

    35. Sensory Processing DisorderorSensory Integration Dysfunction

    36. Dr. A. Jean Ayres 1920- 1989

    37. Background Information Also known as Sensory Processing Disorder Dr. A. Jean Ayres first developed the theory of Sensory Integration Dysfunction in the 1960’s Wrote two books –Sensory Integration and Learning Disorders in 1972 and Sensory Integration and the Child in 1979 Was an occupational therapist and developmental psychologist Worked at the Institute for Brain Research at the University of California at Los Angeles.

    38. What is Sensory Processing Disorder? • “Sensory integrative/ processing disorders are a set of conditions caused by an insufficient ability of the central nervous system to take in, register, modulate, perceive, and/or combine sensory experiences (input) from the environment around us.” • “The neural messages become disorganized as they travel up towards the higher brain centers. The messages may also become overly-amplified or diminished, and are hence unusable. Sensory inputs are the building blocks of learning and relating to our environment and the people in it.” Video: What is SPD?

    39. The Senses • The Five Basic Senses or “Far Senses”: • Sight • Sound • Taste • Smell • Touch -Respond to external stimuli from the environment. (Kranowitz,40,41) • Body Centered Sensory Systems or “Near Senses”: • Interoceptive- internal organs- e.g. heart rate, hunger • Tactile- info received through the skin • Vestibular- movement-pull of earth’s gravity/balance • Proprioception- info from muscles and joints

    40. Causes of SPD according to Dr. Ayres Hereditary predisposition for minimal brain dysfunction Environmental toxins – air contaminants, destructive viruses Combination of hereditary and environmental toxins Lack of oxygen at birth Children who lead deprived lives- little contact with people or things Neurological disorders Internal sensory deprivation(sensory stimulation is present in the environment but the stimulation doesn’t nourish every part of the brain) (Ayres, 54-56)

    41. The Symptoms or BehavioursExhibited Each child’s symptoms are different and unique, making it difficult to diagnose sensory processing disorder. Hyperactivity and Distractibility - activity usually not purposeful, cannot “shut out” noises, lights, etc. Behaviour Problems- not happy with self, fussy, overly sensitive; negative self concept- negative reactions from others Speech Development- speech and articulation develops slowly

    42. The Symptoms/ Behaviours Cont’d Muscle Tone and Coordination- if vestibular, proprioceptive, and tactile systems are not working well- poor motor coordination results. Learning at School- learning starts from the bottom of the brain and moves up– if the senses are disorganized then learning and behaviour problems will result Teen-age Problems- may have learned how to compensate for sensory processing disorder– if not may drop out of school ---major lack of organization. These symptoms are end products of inefficient and irregular sensory processing in the brain. (Ayres, 56-59)

    43. An Evaluation by an Occupational Therapist Considers: • Perception and registration of sensorimotor information- what the child sees, hears, touches, tastes, and smells • How movement and gravity are experienced • Gathers information through clinical observations, sensory history, and standardized tests: - “Can the child use sensorimotor experiences to learn, interact. explore, and demonstrate knowledge? - Does the child respond negatively or with extreme behaviours (flight, fright, fight responses) to unexpected or light touch, unstable surfaces, loud noises, visual distractions, or certain tastes, textures, and smells? - Can the child filter out irrelevant sensory input?” (Williams, Shellenberger, 3)

    44. The Brain’s Ability to Self Regulate Mechanisms needed to self regulate: • Modulation- neural switches can turn on or off depending on activity level • Inhibition- reduce connections between sensory intake and behavioural output • Habituation – brain tunes out familiar sensory messages • Facilitation – connections between sensory intake and behavioural output (Kranowitz, 42-44)

    45. The Alert Program for Self- Regulation • Uses the analogy of a car engine to introduce self-regulation to students • The program can be adapted to all ages • It entails three stages: 1.identifying engine speeds, 2.experimenting with changing engine speeds, and 3.regulating engine speeds; with each stage consisting of a number of steps or mile markers. • Speeds are as follows: high (hyper, overexcited), low (sluggish, spacey) and just right (easy to learn and get along with others) • There are activities that can be used for each step and each step should be modelled for the student to be able to thoroughly understand the engine levels and how to change them • Program is designed to give students the ability to self regulate their engines according to the activity they are doing. (Williams & Shellenberger)

    46. Types of SPD Sensory Modulation Dysfunction- the brain cannot regulate the amount of sensory information it allows to enter. (Hypersensitivity, hyperreactivity - registers sensations too intensely; and Hyposensitivity, hyporeactivity – not getting enough sensory information. (Kranowitz, 57-58) Developmental Dyspraxia – child is unable to mentally visualize new movements. (Vestibular, proprioception and tactile systems are impaired)

    47. Types of SPD Cont’d • Postural- Bilateral Integration Dysfunction- poor ability to use both sides of the body together; tendency not to cross the body midline; unusual fear /discomfort in certain positions (on tummy, moving backwards, going down stairs, riding on parents’ shoulders. Video: Therapy

    48. Sensory Integrative Therapy “The central idea of this therapy is to provide and control sensory input especially the input from the vestibular system, muscles and joints, and skin in such a way that the child spontaneously forms the adaptive responses that integrate those sensations.” (Ayres, 140) Most effective if child directs his own actions while therapist directs the environment. “Motor activity is valuable in that it provides the sensory input that helps to organize the learning process-just as the body movements of early animals led to the evolution of a brain that could think and read.” (Ayres, 141)

    49. The Balanced Sensory Diet Need sensory input and experiences to grow and learn A sensory diet is a planned and scheduled activity program designed and implemented by an occupational therapist to meet the child’s needs. It includes a “combination of alerting, organizing and calming techniques that lead directly to the “near” senses. (Sandra Nelson,7)