KIPP ADHD presentation Kurtz
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Transcript of KIPP ADHD presentation Kurtz
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ADHD & Disruptive Behaviors:What to Look for in the Classroom
Steven M.S. Kurtz, PhD, ABPPSenior Director
ADHD & Disruptive Behavior DisordersChild Mind Institute
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Portrait of a child with ADHD
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Classic Triad of ADHD
Inattention Hyperactivity
Impulsivity
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Hyperactive/Impulsive Symptoms
1. Fidgeting and squirming
2. Leaves seat
3. Running or climbing excessively
4. Trouble playing quietly
5. “On the go” or “driven by a motor”
6. Talking excessively
7. Blurting out answers
8. Trouble taking turns
9. Interrupting or intruding
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Inattentive Symptoms1. Making careless mistakes
2. Trouble paying attention to a task
3. Not listening
4. Not following instructions
5. Trouble organizing
6. Avoiding or disliking sustained effort
7. Losing things
8. Easily distracted
9. Forgetful
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Overlap of Symptoms and Diagnoses
ADHD Anxiety ODD ???
Attention
Concentration
Anxiety
Sadness
Opposition
Fidgetiness
Impulsivity
Appetite
Sleep
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Overlap of Symptoms and Diagnoses
ADHD Anxiety ODD ???
Attention
Concentration
Anxiety
Sadness
Opposition
Fidgetiness
Impulsivity
Appetite
Sleep
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Overlap of Symptoms and Diagnoses
ADHD Anxiety ODD ???
Attention
Concentration
Anxiety
Sadness
Opposition
Fidgetiness
Impulsivity
Appetite
Sleep
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Overlap of Symptoms and Diagnoses
ADHD Anxiety ODD ???
Attention
Concentration
Anxiety
Sadness
Opposition
Fidgetiness
Impulsivity
Appetite
Sleep
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Co-occurring Disorders
• Oppositional defiant disorder - 40%
• Anxiety or mood disorders - 25-34%
• Learning disabilities - 20%
• Conduct disorder- 10-60%
• Tic disorders
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Gender Differences and ADHD• ADHD also affects girls and even adult women.
• Girls with ADHD tend to be more inattentive than H/I.
• Parents and teachers often overlook ADHD in girls.
• Girls with untreated ADHD are at risk for low self-esteem, underachievement, depression, and anxiety.
• Without treatment girls are also more likely to engage in risky behaviors like smoking and unprotected sex while in middle or high school.
• Girls with ADHD often continue struggling into adulthood if they don’t receive treatment.
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Areas of Brain Affected
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PET Scans
Alan Zametkin et al., NIMH
Xavier Castellanos, NYU CSC
Approx. 3% difference in brain volumes
Less asymmetrical
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Developmental Trends of ADHD Symptoms
before 17 yo
Impairm
ent
Hyper/Imp
Age
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Developmental Trends of ADHD Symptoms
Impairm
ent
Hyper/Imp
Age
Impairm
ent
Inattention
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Banerjee, Middleton, Faraone. Acta Paediatria, 2007,
96, 1269-1274.
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before 17 yo
Sx I
mp
airm
ent
Inattention
Hyper/Imp
Developmental Trends ofH/I vs. Inattention Symptoms
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How come they can…
Watch TV for hours?
Build with legos?
Sit through a movie without getting up?
Sit through morning meeting one
day but not the next?
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Refining the understanding of ADHD
• Variability is the rule, not the exception
• Dull, boring, repetitive tasks not of their choosing
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Refining the understanding of ADHD
ADHD
ATTENTION SURPLUS DISORDER
ATTENTION MODULATION DISORDER
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Controversies in Diagnosis
• Poor kids diagnoses more than wealthy kids?
• Teacher/school easy way out?
• Why do rates differ across countries?
• False positives?
– What if tomorrow 7 million new cases diabetes?
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The Immediate Effects of Not Treating ADHD
• Interferes with learning and social development
• Family stress
• Reduces instructional time in class
– Interferes with their learning and the learning of others
• Drains resources
• Maintains or exacerbates ADHD behaviors
• We hate to see kids fail at being kids!
• Same is true for undertreating
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The long-term consequences of not treating ADHD
Untreated kids face:
– Less schooling & poorer grades
– Higher expulsion rates
– Fewer friends
– Lower self-esteem
– Higher arrest rates
– Lower occupational rank
– Higher job termination rates
– Riskier driving
– More accidents
– Relationship difficulties
– Higher STD 4x
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Assessment• Primary or “core” domains: the symptom triad
– Attention
– Activity level
– Impulse control
• Secondary
– Compliance
– Anxiety and mood
– Frustration tolerance
– Executive functions
– Organizational skills
– Learning issues
– Parental functioning
– Family functioning
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Treatment & Intervention
What do we know in 2012 that we did not know in
1977?
– A lot!
• “If I did now for ADHD what I was taught to do
in 1977 I would call it malpractice.”
– That intensifying the dosing of all treatments
likely affords children the best outcomes
• Behavioral interventions are also dosed
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Treatment Recommendations
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Treatment Recommendations
Medicine Behavior Therapy
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Treatment & Intervention• Psychopharmacology
• Psychotherapy– Behavior therapy
• Structuring time: down time is bad time• Maximizing predictability and routines• Increasing immediate positive attention
– Parent training• Parent-Child Interaction Therapy (PCIT)• Groups
– School-based interventions• Daily Report Card• Training professionals and paraprofessionals
– TCIT
– Organizational skills training
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Treatments for ADHD
• Who do we target?
• What do we target?
• Where do we target?
• When to apply tx?
– Serial vs Concurrent
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Parent-Child Interaction Therapy
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Teacher-Child Interaction Therapy
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Unproved or untested treatments
• Social skills groups*• Play therapy or talk therapy• Biofeedback• Dietary changes, elimination diets• Ginkgo biloba & other supplements• Meditation• Exercise• Metronome • Vision training• Sensory integration therapy
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MTA Study: Parent-Reported Parent-Child Arguing
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“MY WHAT IS DUE WHEN?”(AND, Where Is It?)
ORGANIZATIONAL SKILLS TRAINING
SKILLS
DEFICIT
PERFORMANCE
DEFICIT
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Oh No !!!!
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9 Principles to Guide ADHD Behavior
• More immediate consequences
• Increased frequency of consequences
• Increased saliency of consequences
• Incentives < punishments (9:1)
• Act, Don’t Yak
• Strive for consistency
• Plan for high risk situations
• Keep a disability perspective
• Practice forgiveness
…adapted from Barkley
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Daily Report Cards (DRCs)
SpecificObservableMeasurable
Frequent & ImmediateBluegrass? Opera? Rap?
Football? Wild Wadi?
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Daily Report Cards (DRCs)
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Daily Report Cards (DRCs)
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Daily Report Cards (DRCs)
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Daily Report Cards (DRCs)
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Daily Report Cards (DRCs)
Target Behaviors
Following Directions Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A
(2 Prompts)
Good Risks Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A
Use your words Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A
when frustrated
Daily Percentage= # Yes = =
#(Yes+No)
Comments: % or better earns choice of reward from Prize List
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Daily Report Card
Name: ______________ Social Skill of the Day: _________________________
Day and Date: _______________________ Coping Skill of the Week: ______________________
Period: Morning and
Math
ELA and
Bathroom
Lunch Read aloud
and Recess
Activity Afternoon
Target Behavior 1: YYY will comply with directions, requests,
and commands with 80% accuracy during all
periods with 2 prompts.
Yes No
N/A
Yes No
N/A
Yes No
N/A
Yes No
N/A
Yes No
N/A
Yes No
N/A
Target Behavior 2:
When frustrated or angry, YYY will use a
coping skill and will rejoin the group within
10 minutes with 2 prompts.
Yes No
N/A
Yes No
N/A
Yes No
N/A
Yes No
N/A
Yes No
N/A
Yes No
N/A
Point System Letter Grade:
A B C D F
A B C D F
A B C D F
A B C D F
A B C D F
A B C D F
Sticker Percentage Today’s Average Letter Grade: _____
= %
Level 1 (80% - 100%)
Level 2 (66% - 79%) No DRC Reward
Comments:
Signature: ___________________________________
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Prize Box
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