singapore session 2 by Rosemary Pritchard

ADHD and DCD Thinking of the whole child Professor Amanda Kirby Dyscovery Centre University of Wales, Newport,UK

The Dyscovery Centre

Aims of the talk • What is ADHD and DCD? • How is it identified- screening and diagnosis • Executive functioning - a crucial skill for life. - what is it and why is it important for all children • Intervention approaches - the evidence for working together in ADHD and DCD

Children may present in a variety of ways

ADHD and DCD • ADHD- attention deficit hyperactivity disorder • DCD- developmental co-ordination disorder • They are both developmental disorders

What is a developmental disorder? • This is one that starts in childhood- it is not acquired ( such as brain injury) • Pervasive- the impact of the difficulties are present in more than one setting • Lasts longer than 6 months • Usually some challenges continue into adulthood

Recognition of challenges Parent concerns

Delay in walking Delay in talking Fidgety Hyperactive Difficulty focusing Playing ball games Jigsaw puzzles

Teacher concerns

Fidgety Hyperactive Difficulty focusing Writing Playing ball games Copying off the board Making friends

Other concerns

Hyperactive Playing ball games Making friends

Gathering information to gain a complete picture

Working together GP

Screening tools Conners SNAP1V DCDQ

School

Screening tools Conners SNAP1V Movement ABC checklist

Educational Psychologist

Paediatrician/ CAP

Assessment for diagnosis Consider intervention

SALT

Optometry

Process for diagnosis CAP

Diagnosis of ADHD Diagnosis of ASD

Paediatrician

SALT

Differential diagnosis of SLI motor difficulties e Genetic e.g. Klinefelters, NF1 Epilepsy- e.g. BECCTS Muscular Dystrophy FAS

Educational Psychologist

Cognitive profile

Keiran

Health 3y 7m, HV

18m, P

Education

4y, P

4y, SLT 4y, EP

4y, SEN

4y, OT 4y, OT

5y, OT 5y, SLT

7y, SLT

6y, GP 7y, Physio 6y, EP

7y, CP 7y, P 7y, OT

6y, EP 8y, SLT

8y, EP 8y, SLT 9y, EP

8y, SLT

7y SLT 8y, SEN Tribunal

8y, OT 8y, OT

9y, SLT (Feeding)

10y, OT 10y, EP

9y, Physio 10y, OT

There is a need for clarity in: • Defined roles • Appropriate tools for the job • Knowledge and awareness • Pathways for referral • Terminology between professionals and parents • Embedding the research evidence into practice

Barriers to knowledge exchange • Supports/resources (e.g., time,funding, resources) • Cognitive/behavioural (e.g., knowledge,awareness, skills) • Professional (e.g.,characteristics, age/maturity of practice, peer influence), • System/process (e.g., workload, team structure, referral process) • Attitudinal/rational-emotive (e.g., perceived competence, perceived outcome expectancy, authority), • Practice guidelines/evidence (e.g., utility, access, local applicability) • Individual --client/patient/child factors(e.g.,characteristics, adherence). (Cochrane LJ, Olson CA, Murray S, Dupuis M, Tooman T, Hayes S: Gaps between knowing and doing: Understanding and assessing the barriers to optimal healthcare. J Contin Educ Health Prof 2007, 27:94-102.

Diagnosis of ADHD/DCD 1. Triggers for referral I. Delay in milestones;prematurity II. Externalising behaviour e.g. fidgety ,bored, argumentative III. Internalising behaviour e.g. withdrawn, lacks focus IV. Compared to other children e.g. in a class of similar age kids V. Family history of any developmental disorder VI. SLI delay 2. Through routine screening of all/at risk children

Screening of children for DCD and ADHD • Screening tools for DCD • e.g. DCDQ, Early years movement checklist, ADC, Movement ABC checklist, BOTBrief;DASH

• Screening tools for ADHD • E.g. Conners screening tests, SNAP1V, SDQ;ADHD-RS

BOT-2 Brief • Age range :4 years to 21 years 11 months • 12 items • 20—30 mins

Assessment for diagnosis of ADHD • • • •

Pattern of difficulties Present over time Present in more than one place Consider other co-occurring diagnoses e.g. CD, ODD,OCD, BPD , ASD, anxiety, depression • Consider other related learning difficultiesdyslexia, dyscalculia,DCD

Consider associated conditions/risk factors • Consider other reasons for inattention/hyperactivity – speech and language impairment – hearing or visual impairment, – motor

• Genetic conditions,prematurity, FAS

Reading disability( dyslexia) and ADHD • Association both ways has been noted ( Dally, 2006;McGee, 2002) • Twin study in UK • ADHD symptoms assessed at 7.8 years and 11.3 years using Conners parent rating scale • Reading assessed by teachers • ADHD- a significantly stronger predictor of reading difficulties, esp inattentive subtype ( HI and RDenvironmental influence as well) • No gender differences

Greven, Rijdsdijk, Asherons and Plomin, A longitudinal twin study on the association between ADHD symptoms and reading, 2012, JCPP

DCD Only

DCD + Dyslexia

3% 12%

19%

DCD + Dyslexia + ADHD

27% 9% 3%

19%

Ref: Kirby et al,2009

DCD + Dyslexia + ASD DCD + ADHD

DCD + ADHD + ASD DCD + ASD DCD + ASD + ADHD + Dyslexia

Other associated disorders

Oppositional Defiant Disorder 40%

Tics 11%

Conduct Disorder 14%

ADHD alone 31% Anxiety

Disorder 34%

Mood disorders

MTA Cooperative Group. Arch Gen Psychiatry 1999; 56:1088â&#x20AC;&#x201C; 1096

Dominant genes

Phenotype

Risk genes

Dyscovery Centre

Protective candidate genes

Overlap may be linked to Shared genes e.g. in ADHD and DCD 1285 twin pairs aged 5 and 16 years from the volunteer Australian Twin Registry (ATR). The DCD-fine motor and ADHD-Inattentive were most strongly linked using the DSM-IV based scale. (Martin ,Piek and Hay, 2006)

BUT it is a Gene v environment mix â&#x20AC;˘ Need to consider shared environmental influences as wellâ&#x20AC;Ś.( Burt, 2010)

TIME

ENVIRONMENTAL

BEHAVIOURAL

NEURAL

GENETIC

Turvey,2006

Assessment for diagnosis of DCD • Assessment of motor skills using a known standardised motor assessment tool e.g. BOT2/MABC-2.. Defined total lower 15th percentile, and 5th percentile in one section • Assessment of visual perception e.g. MVPT • Assessment of visual motor integration e.g. VMI( Beery) • Assessment of visual acuity

• B) meeting criteria for DSM1V /ICD10… but with modifications along EACD guidelines/UK ones • C) no presence of other motor neurological disorders e.g. CP,stroke, MD

International Classification of Functioning (WHO)

However these assessments do NOT assess for function

Need to consider assessment for : • Level of participation with others- social engagement • Self esteem • Physical activity • Independent living skills • Handwriting • Other associated difficulties e.g. anxiety/dyslexia/dyscalculia Need to use other tools such CHAS-P/CHAST/DASH

Assessment not in isolation of the family and context e.g. 35% of parents of children with ADHD have parents with ADHD Home activities and interests Other support groups

Our interpretation of different behaviours depends on our training

What is DCD?

DCD • Also known amongst other terms as Dyspraxia/Clumsy child syndrome/MBD • Prevalence: 5- 6% of individuals • Gender: 2-3:1 M:F • Difficulty with motor co-ordination affecting home and school

Motor co-ordination difficulties â&#x20AC;˘ Take one day in your life - what does not require movement?

UK Consensus (2012) agreed common descriptors aligning with DSM1V/ICD10 Developmental Co-ordination Disorder (DCD), also known as Dyspraxia in the UK, is a common disorder affecting fine or gross motor co-ordination in children and adults. This condition is formally recognised by international organisations including the World Health Organisation. DCD is distinct from other motor disorders such as cerebral palsy and stroke.

• The range of intellectual ability is in line with the general population. • Individuals may vary in how their difficulties present; these may change over time depending on environmental demands and life experience, and is lifelong. • An individual’s co-ordination difficulties may affect participation and functioning of everyday life skills in education, work and employment.

Continuing……. • Children may present with difficulties with self-care, writing, typing, riding a bike, play as well as other educational and recreational activities. • In adulthood many of these difficulties will continue, as well as learning new skills at home, in education and work, such as driving a car and DIY. • There may be a range of co-occurring difficulties which can also have serious negative impacts on daily life. These include social emotional difficulties as well as problems with time management, planning and organisation and these may impact an adult’s education or employment experiences.

DCD criteria (DSM1V) • Defining characteristics: – A MOTOR IMPAIRMENT- measured with a normative test e.g. M-ABC, BOT – B-IMPACTING on • Daily living • Academic achievement – C and D Exclusionary clauses - intelligence, CP and other pervasive disorders

Common issues Posture

Planning

Fine motor

Gross motor

Common issues

Posture

Planning

Fine motor

Gross motor

Posture and Balance

Common issues

Posture

Planning

Fine motor

Gross motor

Fine motor

Common issues

Posture

Planning

Fine motor

Gross motor

Team games e.g. Football

Common issues

Posture

Planning

Fine motor

Gross motor

Common issues

Posture

Planning

Fine motor

Gross motor

Boy, 10 years 8 years

Motor schema Movement difficulties

Planning

Mechanical

JHS

Genetic

NFI

Klinefelters syndrome

Cerebral Palsy

NDD

e.g. With Dyslexia, ADHD, ASD

Screening of children for DCD and ADHD • Screening tools for DCD • DCDQ • Early years movement checklist • Movement ABC checklist Tests • BOT-Brief (new) • DASH • ADC (16-25 years)

• Screening tools for ADHD • • • •

E.g. Conners screening tests SNAP1V SDQ (http://www.sdqinfo.org/) ADHD-RS Amanda Kirby 2012

Amanda Kirby 2012

Early years movement checklist

Amanda Kirby 2012

Need to consider the differential diagnosis What is it -----if it is not DCD?

Methods of Handwriting Speed Assessment • Speed of Handwriting – Either time limit and see how much written – Or record how long it takes to finish a task – Account for legibility as well – Different Tasks used • Cats and Dogs • The quick brown fox jumps over the lazy dog • Detailed Assessment of Speeded Handwriting (DASH) – Involves five subtasks: Copy same sentence for 2 mins either in best handwriting or as fast as possible – Write alphabet continuously for a minute – 10 minute free writing – Graphic speed task (crosses in circles) measures perceptual motor proficiency – administered individually or to a whole class

Joint Hypermobility Syndrome (JHS/BJHS)

Dyscovery Centre

Klinefelters(XXY)

KS boys demonstrated an array of motor difficulties, especially in strength and running speed. ( Ross et al, Am J Med Genet A. 2008 Mar 15;146A(6):708-19.)

NF1

NF1 and cognitive deficits • Deficits in: – visuospatial ability, – executive function, – expressive and receptive language – attentional skills • Abnormal MRI and Nf1= fine motor deficits •

Feldmann R, Denecke J, Grenzebach M, Schuierer G, Weglage J. Neurology. 2003 23;61(12):1725-8. Neurofibromatosis type 1: motor and cognitive function and T2-weighted MRI hyperintensities.

•

Hyman SL, Shores A, North KN.,Neurology. 2005 Oct 11;65(7):1037-44.The nature and frequency of cognitive deficits in children with neurofibromatosis type 1.

Structural or mechanical problems Cerebral palsy  Agenesis of the corpus callosum  Epilepsy and BECTS- post rolandic epilepsy  Cerebellar dysfunction 

CP and DCD

Agenesis of the corpus callosum

Deficits in bimanual coordination Mueller et alBehavioral Neuroscience Volume 123, 5, 2009, Pages 1000-1011

BECCTS

Benign Epilepsy of Childhood with CentrotemporalSpikes

BECCTS – Commonest childhood epilepsy – Motor cortex – Abnormal EEG pattern – Night time seizures… thought to not be as significant but may have an impact on learning – Preservation of consciousness – Pooling of saliva – Speech arrest – 75% at night One study from Italy( Scabar,2005)

6 out of 8 with MABC <1% had BECTS

Visual difficulties 

 

Visual/visual perceptual Visual acuity Visual memory

Implications of visual difficulties

Handwriting assessment

Ideomotor dyspraxia

Subtypes Symbolic / representational

Transitive

Intransitive

Nonsymbolic / nonrepresentational*

Transitive

Intransitive

Gestures Brushing your teeth; pouring a glass of lemonade; kicking a ball Waving goodbye; beckoning to come here; saluting Touching your nose; touching your left thumb to your right palm Wiggling your fingers

Correct use of dyspraxia • developmental dyspraxia should be used to describe a neurologic sign (with “clumsiness” as one possible associated symptom), not as a disorder unto itself. • it should be restricted to situations in which it can be shown that impaired execution of skilled movements or gestures is out of proportion to, and not wholly explained by, basic motor impairment or perceptuomotor (e.g. visuomotor or somatosensorimotor) impairment.

What is ADHD?

Attention Deficit Hyperactivity Disorder

Attentional difficulties (ADHD) • • • • • • •

ADHD The three core symptoms of ADHD are generally considered to be these: – Hyperactivity – Impulsivity – Attention problems

•Prevalence: 1-2% of population •Gender: 3:1 M:F

Symptom groups Inattention • Does not pay attention

• Avoids sustained effort

Hyperactivity • Fidgets

• Talks excessively†

• Leaves seat in class

• Blurts out answers

• Runs/climbs

• Cannot await turn

excessively

• Doesn‟t seem to listen • Cannot play/work when spoken to

quietly

• Fails to finish tasks

• Always „on the go‟

• Can‟t organise

• Talks excessively*

• Loses things, „forgetful‟ • Easily distracted

Impulsivity

• Interrupts others • Intrudes on others

DSM-IV ADHD diagnostic criteria • List of symptoms must be present for at least 6 months • Must have six (or more) symptoms of inattention AND/OR hyperactivity– impulsivity • Some symptoms present before 7 years of age

Diagnostic criteria for ADHD (DSM-IV). www.turnertoys.com/ADHD/APA_diagCriteria.htm

DSM-IV ADHD diagnostic criteria • Some impairment from symptoms must be present in two or more settings (e.g. school and home) • Significant impairment: social, academic or occupational • Exclude other psychiatric disorders

Different at different ages

Behavioural disturbance

Academic problems Difficulty with social interactions Self-esteem issues Legal issues, smoking and injury

Pre-school

Occupational failure Self-esteem issues Relationship problems Injury/accidents Substance abuse

Adolescent School-age

Behavioural disturbance Academic problems Difficulty with social interactions Self-esteem issues

Adult College-age

Academic failure Occupational difficulties Self-esteem issues Substance abuse Injury/accidents

Different subtypes of ADHD 1. ADHD, Combined Type: Both inattention and hyperactivity-impulsivity symptoms. 2.ADHD, Predominantly Inattentive Type: Inattention but not hyperactivity-impulsivity symptoms. ( females more likely to have this type) 3. ADHD, Predominantly Hyperactive-Impulsive Type: Hyperactivity-impulsivity but not inattention symptoms.

Amanda Kirby 2012

Long-term â&#x20AC;˘ By the age of 25, an estimated 15% of people diagnosed with childhood ADHD still have a full range of symptoms, and an estimated 65% still have symptoms which affect their daily lives.

Child with ADHD • Difficulties with concentration • Fidgety - difficulty sitting still • Difficulty completing a task - starts but does not finish • Impulsive - answering out of turn • Poor organisation • Not achieving as well academically • Dreamy • Not listening to instructions • Forgetful

ADHD in adults • • • • • • • • •

carelessness and lack of attention to detail. continually starting new tasks before finishing old ones. poor organisational skills. inability to focus, or prioritise. continually losing, or misplacing, things. forgetfulness. restlessness and edginess. difficulty keeping quiet, and speaking out of turn. blurting responses, and poor social timing when talking to others,often interrupting others. • mood swings,irritability and a quick temper.. • taking risks in activities, often with little, or no, regard for personal safety, or the safety of others.

Intervention approaches

Barriers to Intervention • including long waitlists • insufficient time to build effective consultation relationships • limited carryover • knowlegde and awareness • different communication styles

90 80 70 60 50 40 30 20 10 0

Kirby & Salmon, 2006

DCD Dyspraxia

cc ur at e

DAMP

In ac cu P ra ar te t ia lly ac cu ra te

D on â&#x20AC;&#x2122;t

kn ow

Child and adolescent Psychiatrists defining DCD/Dyspraxia/DAMP

OTsâ&#x20AC;&#x2122; definition of ADHD % 100 90 80 70 60 50 40 30 20 10 0

Accurate description

Partially accurate description

Baudinette & Kirby,2008

Inaccurate description

No response

To plan intervention requires collation of information • Their environment • The tasks they are being asked to do • Their experiences before coming into school including their social setting

Individual

Environment

Outc ome Task

Environm ent

Building a picture of the child Person Centred Planning

•Profile of strengths and difficulties •Context of home and school •Timing- pre exam, transition

Partnerships for success

ACTIVITY and PARTICIPATION

Intervention options • • • • • •

One to one Group Class Across the school At home Planning for long term

Challenges

Teaching the child â&#x20AC;˘ Task specific approaches â&#x20AC;˘ Cognitive Motor approaches

Goal

Check

Plan

Most effective approaches • Linked into every day functioning • Practicing enough (3-5 times per week) • Practicing appropriately • Providing carry over/transferability

Approaches to intervention Deficit orientated – Sensory integration • ( Ayres)

– Sensorimotor approaches • (Ayres, Bobath, Frostig)

– Process orienatated • ( kinaesthesia- Laszlo and Bairstow)

Performance orientated – Task based approaches • ( Schoemaker)

– Cognitive motor approaches • ( Polatajko)

– Ecological Intervention • (Sugden)

Task-orientated

Task Practice

Variety

Graded approach

Child and parent lead

Fun

Motivation

Self-esteem

Positive experiences

Avoiding a medical/disabled model • • • •

Inclusive approaches Seeking strengths Making adaptations Avoiding stigma

• Not a dyspraxic child

Goal setting

Parent

Teacher

Child

Short term • • • • •

Friendships Self esteem Self care Recording Team games

Long term • • • • • • • • •

Friendships Self esteem Anxiety Depression Physical fitness Limit weight gain Self organisation Independent living skills IT skills

Individual

Speed of others interacting with you e.g. yoga or football

Size of environment

Outc ome

e.g. pitch size

Number of people e.g. tennis v football team

Task

Changing environmental conditions e.g . Cross country wet weather, badminton court

Choice of activity and participation

Reaction time e.g. clay pigeon shooting

Speed of yourunner

Manual dexterity Strength e.g. .weight lifting

Sewing , violinist Use of an object e.g. tennis racquet.,cello

Flexibility or stability e.g. gymnast or footballer

Visual Accuracy e.g.

Archery , computer games

Environm ent

Individual

Speed of others interacting with you e.g. yoga or football

Size of environment

Outc ome

e.g. pitch size

Number of people e.g. tennis v football team

Task

Changing environmental conditions e.g . Cross country wet weather, badminton court

Choice of

Motivation activity andand participation interests e.g. likes horses, computers

Reaction time e.g. clay pigeon shooting

Speed of yourunner

Manual dexterity Strength e.g. .weight lifting

Sewing , violinist Use of an object e.g. tennis racquet.,cello

Flexibility or stability e.g. gymnast or footballer

Visual Accuracy e.g.

Archery , computer games

Environm ent

Intervention in ADHD

Intervention Guidelines for intervention – NICE http://www.nice.org.uk/CG72 – SIGN( Scotland) – Australian http://www.nhmrc.gov.au/guidelines/publications /ch54

What is the problem?

Problem with neurotransmission of Dopamine Dopamine is a chemical transmitter across nerves Anomalies in the brainâ&#x20AC;&#x2122;s reward system related to the neural circuits of motivation and gratification are associated with children with ADHD.

Dopamine â&#x20AC;˘ Dopamine is critical for focusing attention on environmental stimuli when it is necessary to choose between conflicting options especially when the goal may not be obvious and choices based on memory, not impulse, are required.

Where in the brain is the problem? 1.The Prefrontal cortex Marked areas: A. Spatial working memory B. Spatial working memory, performance of selfordered tasks C. Spatial, object and verbal working memory, selfordered tasks, analytic reasoning D. Object working memory, analytic reasoning 2.caudate nucleus 3.globus pallidus Image from Scientific American

Second mechanism â&#x20AC;˘ ADHD motivational levels seem to drop rapidly and there is a need for immediate reinforcements to continue persisting in their efforts. ( nucleus accumbens)

How does this work? â&#x20AC;˘ The prefrontal cortex is thought to be the brain's "command center" â&#x20AC;˘ Caudate nucleus and globus pallidus- translate the commands into actions

Therapy options as part of a total treatment programme • • • • •

Behavioural treatment Medication management Combining medication/behavioural treatment Educating parents/patient about ADHD Educational support services

Using reward approaches in class • • • • •

1. Speak it. 2. Write it. 3. Announce it. 4. Give activity rewards. 5. Give material rewards.

Immediate and not delayed…. But don’t always transfer out.

Medication Different types of medication •Short acting- every 4 hours •Long acting- last 8 or 12 hours •Need to be given every day Drug names: Stimulants: Ritalin, Concerta, Equasym, dexamphetamine AND Non stimulant : Atomoxetine ( Strattera) Varying side effects: appetite, sleep

Drug treatments (NICE guidelines)

Drug

methylphenidate

atomoxetine

School-age children or young people

Adults

Severe ADHD - offer drug treatment as first line for:

Moderate/severe impairment offer drug treatment as first line

• ADHD without significant comorbidity • ADHD with comorbid conduct disorder • Tics, Tourette’s syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion • Treatment with methylphenidate ineffective • Intolerance to low or moderate dose methylphenidate • Tics, Tourette’s syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion

Normally first choice

As for children

Mechanism of action of stimulants

Wilens T, Spencer TJ.

The Dyscovery Centre copyright Handbook of Substance 2008 Abuse: Neurobehavioral Pharmacology. 1998; 501-13.

Choosing medication • Age of the child • Stage of the child- e.g. secondary school • Side effects of medication e.g. appetite supression • Day of the child- e.g. after school activities, start time in the day • Other associated difficulties e.g. epilepsy/tics

What is executive functioning?

Executive functioning The self management system of the brain

“A cluster of skills that are necessary for efficient and effective future-orientated behaviour” (Welsh, cited in Diamantopoulou et al, 2007)

“Not accounted for by IQ” ( Martel et al, 2007) ( Barkley, Brown, Du Paul)

Involved in handling novel situations outside the domain of some of our 'automatic' psychological processes that could be explained by the reproduction of learned schemas or set behaviours.

Metaphors • • • • • •

CEO Conductor Cook Driver Chief Pilot

e.g. executive functioning Role in: • planning • setting priorities • organizing thoughts • suppressing impulses • weighing the consequences of one's actions

Prefrontal cortex

EF is a core element of developmental disorders • ADHD – all ADHD children have EF impairment to varying degrees (Barkley 2001) • ASD – Pennington and Ozonoff (1996) found children performed 1 SD below control group on EF tasks • DCD – children impaired on tests of working memory (Alloway & Temple, 2007) • Dyslexia – studies have found WM deficits that compound their phonological problems (Wolf 2010) • Dyscalculia – Askenazi & Henik (2010) found evidence of specific EFDs in university students with ‘pure’ dyscalculia

1.Self activation/Initiation • Getting going.. (Especially the boring stuff) • Procrastination • Poor time estimation

2.Working memory • The brains RAM- holding information in your mind while making links • Short term memory-what has just been said, remembering a sequence • Listening to someone talking to you while remembering you need to turn out the light before going out

3. Effort- Remembering to remember • Internal prompts • ‘…after I have finished this I need to do that...’ • Frustrating forgetting important things– seen to be lazy/can’t be bothered.. • Regulating alertness..completing tasks, sleep pattern (can’t shut off)

4.Emotional self control/Action • Thinking and not acting • Taking others perspective into account • Managing frustrations and modulating emotions • keeping things in perspective • impulsive, not considering the context, can’t adjust pace

5. Focus â&#x20AC;˘ Ability to sustain focus but be able to shift to another task â&#x20AC;˘ Reading over and over

6. Hindsight and foresight â&#x20AC;˘ Learning from past experiences and using it in the future

7.Time concepts • Time blindness • Time passing • Remembering to do the diary • Allocating time • Moving on

EF has developmental stages Building Blocks (Diamond et al,2007)

Inhibitory control

Selective attention

Working Memory

Age years

Planning

EF: â&#x20AC;˘ Is a predictor of future social competence ( Nigg et al,1999;Clark et al,2002)

â&#x20AC;˘ ADHD and poor EF- affect academic achievement (Biederman et al, 2004)

Long term.... • EF demands persist and increase into adulthood • Impact on occupational under- attainment

• Biederman (2007) 7 year follow up of children ( 9-22 years) to adulthood with ADHD – 69% had persistent EF deficits • Shur-Fen Gau et al (2009) 53 adolescents (11-16) with childhood diagnosis of ADHD compared to 53 typically developing – 81% of ADHD group had persistent ADHD diagnosis – Differences between the 2 groups in working memory, planning and problem-solving increased with the complexity of the task

Age related EF Pre- school – run an errand- go and get your shoes from upstairs – Clear dishes, do teeth

Primary school – Tidy bedroom – Queuing in the playground – Completing a homework/project – Writing a story – Saving money for a present

The Dyscovery Centre

Secondary school – Navigate around school – Assignments completed in time – Revising and doing examinations – Starting off a project – Meeting deadlines – Plan after school activities – Respond to feedback from work – Consider longer term goals – Choose not to do dangerous behaviours – Choosing what to wear

Executive Functioning skills deficits in students with DCD in higher education Data capture for the 6 EF domains (planning, organisation, impulse control, working memory, metacognition and time management) Additional 20-item list captured the use of tools - if any – to guide students to be ‘more organised’ (e.g. Using a diary, software etc..)

Analysis: Descriptive statistics to describe student sample Chi squared cross-tabulation / analysis of variance to compare diagnosis groups

Executive Functioning skills deficits in students with DCD in higher education Participants:

ď ś353 students completed the survey

Table 1

Frequency % (n)

Male % (n)

Female % (n)

Mean Age (sd)

DCD

6.1 (20)

35.0 (7)

65.0 (13)

23.90 (5.59)

Dyslexia

16.8 (55)

52.7 (29)

47.3 (26)

24.85 (8.83)

DCD and Dyslexia

4.0 (13)

38.5 (5)

61.5 (8)

25.77 (9.63)

No formal diagnosis but difficulties

56.4 (185)

59.0 (108)

41.0 (75)

26.86 (9.68)

No formal diagnosis

16.8 (55)

21.8 (12)

78.2 (43) *

27.17 (8.55)

Significantly more females with difficulties but no diagnosis

Results:

Results Using study tools Significant differences between TD and SpLD groups ( P= < 0.01) 90 80

70 60 50

SPLD % 40

TD %

30 20 10

0 never have study partner

Never use End Note/Ref manager

Don't use past papers for revision

Implications for life?

Adolescence is a time of change

The grey matter continues to thicken throughout childhood as the brain cells get extra connections. Peaks at around 11-12 years

Increased grey matter Genes

Environment

Decreased grey matter More efficient Pruning connections Ref: Giedd

Strategies for success with EF challenges 1. Understanding that this is not done â&#x20AC;&#x2DC;on purposeâ&#x20AC;&#x2122; 2. Knowing and doing are 2 different things 3. Coach the child in rehearsed behaviours 4. Remind the child with a list or schedule - practice this ++++++ 5.Check for triggers if this is not working

6.Teach the skills rather than waiting for it to occur through osmosis 7.Consider the child’s developmental level 8.Encourage automation of ‘boring’ tasks but with some pleasure stuff as well ( music)

9. Show and discuss improvements

10. Scaffold just enough support for the child to succeed

11.Use incentives along with instructions 12.Support until the child has gained mastery 13.Fade support rather than abruptly stop it 14.Move from an external to internal control â&#x20AC;&#x201C; Cueing to remind teeth cleaning The Dyscovery Centre

Allow ‘talk out loud’ • • • • •

What do I need to do What should it look like in the end How long will it take me When do I need to start I will write a list/read a recipe/make a plan • Have I other things I need to think about as well • What went wrong there, what could I have done differently

The Dyscovery Centre

Self awareness • Rate tasks. • What are your skills now? • What would a better score look like?

The Dyscovery Centre

Scaffold.. Writing an essay

The Dyscovery Centre

Teach organisation • Space • Person • Activity

Organise at school • The class environment • Desk environment • Regular short meetings

At home â&#x20AC;˘ Place at the door for everything that needs to go to school- bag packed the night before â&#x20AC;˘ Homework stationsame place, same time with kit at hand

To do list • • • •

How much Which first Rewrite it Are the relevant things on it • Electronic is betterthere is an archive...

Use learning links • Learning links • Overall term plan • Overall week to week plan • Class plan • Seeing the solution • Problem solving • Dealing with choice making • Auditing outcomes • Filing systems

Mind map of overall aims Rivers

Amazon

Geology

Mountains

Erosion

The Dyscovery Centre

Link between home and school • Homework diary • Every Friday during the year, send home a note describing the next week's schedule. This can include special events, birthdays, tests, quizzes, important assignments, trips, parents’ nights, and assemblies. • Organisational skills at home as well

Support networks • • • •

Buddy system Play dates.. But structured and not too long Circle of friends in school Buddy system for parents and a catch all

Red flags • Change in behaviourexternalising/internalising • Bullying or being bullied • Deteriorating patterns of work • Reduced scaffolding/support • Change in place • Unstructured settings • If on medication – when wears off

Useful websites • • • •

www.dyspraxiafoundation.org http://dyscovery.newport.ac.uk www.canchild.ca www.senteacher.org

Useful Websites – UK-based •www.adders.org - recommends books about educating children with ADHD •www.Addiss.co.uk - parent support information includes books written for teachers •www.janssen-cilag.co.uk - living with ADHD; site has practical advice and links for teaching children with ADHD •www.mkadhd.org.uk - the “Information” section has a good range of tips for teachers •http://premium.netdoktor.com/uk/adhd - information about ADHD, treatments and support groups •http://research-tv.warwick.ac.uk/stories/health/adhd - the latest research on ADHD from King’s College, London •www.adhdtraining.co.uk

Useful Websites – American •www.ADDinschool.com - website for teachers by teachers with hundreds of tips for teaching children with ADHD •www.glc.k12.ga.us/trc/cluster - a “Teacher Resource Center” with lots of weblinks for teachers •www.ldonline.org - website on learning disabilities which includes useful section for teachers •www.newideas.net - this is “The ADHD Information Library in America”; it includes 10 ‘easy lessons’ designed to give lots of information and understanding •www.myadhd.com – useful practical tools to help be organisedyou need to pay a nominal charge- these include timetables, help with behaviour management, assessments

The issues are ELEPHANTINE!

Beyond Ghor there was a city. All its inhabitants were blind. A king with his entourage arrived near by; he brought his army and camped in the desert. He had a mighty elephant, which he used in attack and to increase the people's awe.

The populace became anxious to see the elephant, and some sightless from among this blind community ran like fools to find it. As they did not even know the form or shape of the elephant they groped sightlessly, gathering information by touching some part of it. Each thought that he knew something, because he could feel a part.

When they returned to their fellow citizens eager groups clustered around them. Each of these was anxious, misguidedly, to learn the truth from those who were themselves astray. They asked about the form, the shape of the elephant; and listened to all that they were told. The man whose hand had reached an ear was asked about the elephant's nature. He said: "It is a large, rough thing, wide and broad, like a rug." And the one who had felt the trunk said: "I have the real facts about it. It is like a straight and hollow pipe, awful and destructive." The one who had felt its feet and legs said: "It is mighty and firm, like a pillar."

Thank you amanda.kirby@newport.ac.uk www.dyscovery.co.uk