ATTENTION DEFICIT/ HYPERACTITY DISORDERS

WEEK 4EPSE 317

• http://www.atcweb.org/season/distracted.php

Auntie Liz’s Story Time II

• This is the story of Bertrand. (His folks call him Bertie.) He is a bright, engaging, five-year-old who is starting kindergarten at Iona Elementary School in Richmond. He loves everybody.

Bertie’s Family

• Howard: “Papa”-- is a pastor• Debbie: “Mamma”-- is at home with the

kids. She will go back to teaching when they get a bit older

• Katie: Bertie’s kid sister, three years old• Morrison: 20 years old and the

biological son of Howard and Debbie. He’s studying philosophy at the University of Toronto

• Katie and Bertie were both adopted as infants.

Last year

• Bertie was in a special needs early childhood education program. He had started a regular program but the ECE staff found him too difficult to manage.

• Needed constant supervision– Couldn’t sit still for more than 30 seconds– Ran out of the room into the playground or

hallway

This isn’t Bertie, but it gives a sense of things…

• http://www.pbs.org/wgbh/pages/frontline/video/flv/generic.html?s=frol02s3edq55&continuous=1

• Bertie is overly friendly to everyone. He greets everyone with a hug (a.k.a. flying tackle) and a barrage of questions about who they are.

• He’s a nonstop talker, has a very mature vocabulary, and uses complex sentences.

• Bertie can already read.• Debbie was reading to the kids one

day (Bertie was bouncing around, but apparently listening.)

• He interrupted, saying, “Let me read to you, Mama.” And he did.

• He now selects library books for himself and can sit for up to ten minutes reading to himself (he rocks and fidgets). He also reads to Katie.

Diagnosis?

• Bertie was seen by a paediatrician, who diagnosed ADHD, and suggested medication.

• His folks aren’t very open to medicating him, and are using fish oil supplements instead.

How to Quiet Bertie…

• Bertie’s dad has taken to taking him for long walks along the Steveston Dyke most days.

• He asks Bertie to stand with his eyes closed and listen to how many things he can hear. This works for short periods.

• Bertie likes this, and is getting very good at recognizing bird calls.

Discussion Time

• Does Bertie have ADHD?• What else might be the case?• What are the problems he’s likely to

pose?• What are the problems he’s likely to

encounter in KG? • Can he meet the learning and

behaviour expectations of KG?

ADHD Subtypes

• Predominantly hyperactive-impulsive• Predominantly inattentive• Combined hyperactive-impulsive and

inattentive

Diagnosis

• A medical diagnosis which can be further informed by psychological assessment

• Criteria for diagnosis typically used in Canada are set by the American Psychiatric Association:

DSM-IV

• Either:– A. Child presents with signs of

inattention for at least 6 months to a point that is disruptive and inappropriate for developmental level

– B: Child presents with signs of hyperactivity-impulsivity for at least 6 months to a point that is disruptive and inappropriate for developmental level

• And…

• Some signs that cause impairment were present before age 7 years

• Some impairment from the signs is present in two or more settings

• There must be clear evidence of significant impairment in social, school or work functioning

• These signs are not better accounted for by another disorder…

Inattention: the child often:• Is inattentive to details; makes careless

mistakes in schoolwork or elsewhere• has trouble keeping attention on work or play• does not seem to listen when spoken to

directly• does not follow instructions• has trouble organising activities• dislikes or avoids activities that require

sustained attention• Loses things• Easily distracted• Forgetful in daily activities.

Hyperactive: The child often

• Fidgets or squirms in seat• Gets up when remaining in seat is

expected• Runs about or climbs where

inappropriate• Has trouble playing quietly• Is often “on the go” or acts as if “driven

by a motor”• Talks excessively

Impulsive: The child often:

• Blurts out answers before questions have been finished

• Has trouble awaiting his/her turn• Interrupts or intrudes upon others

Conditions that may look like ADHD:

• FASD (more to come…)• Language disorders• Intellectual disabilities• Physical Illness• Mental illness (depression, psychosis,

anxiety disorders)• Abuse, fear• Trauma

Ministry of Education Policy re. ADHD

• Not formally recognised• Can be supported under Learning

Disability designation or under Moderate Behaviour and Mental Illness

Criteria for Moderate Behavioural Designation

(not necessarily ADHD)• Must have documentation of a behavioural, mental

health and/or psychological assessment which indicates needs related to behaviour or mental illness

• Demonstrate aggression, hyperactivity, delinquency, substance abuse, effects of child abuse or neglect, anxiety, stress related disorders, depression, etc.

• Severity of the behaviour or condition has disruptive effect on classroom learning, social relations, or personal adjustment

• Behaviour exists over extended time and in more than one setting

• Regular in-class strategies not sufficient to support behaviour needs of student; beyond common disciplinary interventions

Discussion

• Would that designation work for Bertie?– “Severity of the behaviour or condition

has disruptive effect on classroom learning, social relations, or personal adjustment”

–What supports is he likely to need, and why?

What do we do for ADHD?

• Medication– But should always be accompanied by

adaptations in programming

• Adaptations

Medication and ADHD

• Stimulant medications:• Methylphenidate (ritalin, metadate,

concerta)• Dextroamphetamine (dexedrine)• Adderal

• Antidepressants• Antipsychotics

Side effects

• Medication is a parent’s decision, but you may need to monitor for– Loss of appetite (as many as 50% of kids

on stimulant meds)– Tics– Mood changes– Excessive activity and other ‘rebound

effects’– Picking at skin– Etc…

CAUTION!!!

• Effective use of ritalin does not constitute a diagnosis of ADHD.

• “Smart” drugs…• Military use• May suppress behaviour and mask

other important problems• …and it’s not something that a

school has any business requiring a student to take.

Behavioural Supports(Attentional Problems)

• Breaks• Seating away from distractions• Minimize boredom—just because a child

has an attention disorder doesn’t mean the class isn’t dull!– If work is less than engaging, breaks become

more important.– Work needs to be at an appropriate level for

a student’s ability.• Just because a child can attend

sometimes doesn’t mean he/she can always attend.

Behavioural Supports(Hyperactivity)

• Give students opportunities and reasons to move

• Specialised seating may help—exercise ball, Move’n’sit– If you use this strategy, position student

where his/her classmates aren’t distracted.

Move’n’sit

Behavioural Support:Impulsivity

• Environmental management—monitor for safety, especially on playground & in gym.

• Model, cue for alternate to impulse– E.g., raise you hand when you ask for

responses to minimise blurting out

Discussion

• What can we do to help Bertie?• Attention supports?• Hyperactivity?• Impulsivity?• …anything else?