Penny corkum 2 slides

7/5/2011

Sit Still and Learn: ADHD (and Disruptive Behaviours) Penny Corkum, PhD (Registered Psychologist) Associate Professor, Psychology Department Scientific Staff, IWK Health Centre Director of Research and Development, ADHD Clinic, CEHHA

Presentation to: Academy in School Mental Health July 11-12 & 14-15, 2011 Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Questions to be Answered What is ADHD? Is ADHD real or an excuse for bad behaviour?

How is ADHD assessed and diagnosed?

What are common features of ADHD? How is ADHD treated?

– Medication – School • Remediation • Accommodations Q&A Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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ADHD A rose by any other name would smell as sweet (Shakespeare) (Sh k )

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Current Diagnostic Criteria ADHD (DSM-IV) Three subtypes InA (6/9) HI (6/9) Combined (6/9 InA, 6/9 HI) Present in at least 2 settings Symptoms before age 7 Lasts longer than 6 months Developmentally inappropriate More frequent and severe Affects academic or social functioning Rule out other causes –

“The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder, and are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder)

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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ADHD Basics ADHD (3 subtypes) is diagnosed in ~5% of elementary school-aged children 65 80% of children diagnosed with ADHD continue to reach 65-80% diagnostic criteria in adolescents (“lifespan disorder”) Changing symptoms of ADHD Inattention: Persists across time Impulsivity: Declines (but not normalized) Hyperactivity: Declines (but not normalized) Comorbidity is high and can change overtime O l 20% off children Only hild with i h ADHD have h only l ADHD! 40% one other disorder, 30% two other disorders, 10% three + other disorders ADHD (and comorbidity) puts individual at risk for social, academic, behavioural and work problems Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

ADHD – Is It Real?

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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Biological Basis of ADHD Imaging (functional and structural) Studies fronto striatal networks Differences in fronto-striatal

Behavioural Genetics Estimated at .80 (range .50 to .98) No definite mode of inheritance has been established Most likely not a single gene locus, but rather polygenic Recent association studies implicate genes within the dopamine system in the etiology of ADHD Dopamine system innervates frontal-striatal circuits

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Assessment & Diagnosis Not all those who wander are lost (Tolkien) & Not all that looks like ADHD is ADHD

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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Assessment Rubric Kamphaus & Frick, 2002 Assess core symptoms and severity/impact Assess onset and developmental course Rule out alternative causes Rule in comorbidities

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Protocol Has To Include‌ Multiple assessment measures Standardized Testing Observation Interviews Informal Procedures

Data collected from multiple sources Home, School, Community

Multidisciplinary team Across institutions Mental Health, Health, Education Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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Problems with ADHD Assessments Over-reliance on questionnaires!

Lack of differential diagnosis Co-morbid disorders not assessed Resulting in‌ Overdiagnosis Underdiagnosis Misdiagnosis Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Role of Teachers in Diagnosis Do not diagnosis or label, but rather share your observations Help parents know how to access the diagnostic services they need & how to evaluate what is a good assessment Be an active participant in the diagnostic process Teachers are the best informants, informants so share all your knowledge with the psychologist or physician who is conducting the assessment Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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Neurodevelopmental Framework

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Alexander Luria (1902-1977) Attention – 3 units Unit 1 – Arousal/Alertness Unit 2 - Processing Unit 3 – Executive functions

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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Executive Functions in ADHD Brown, 2005 Executive Functions Activation

Focus

Effort

Executive Function Deficits

Emotion

Memory

Action

ADHD

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Neurodevelopmental Framework All Kinds of Minds Attention Hi h Order O d Cognition C iti Higher Language Memory Neuromotor Functioning g Social Cognition Spatial ordering Temporal Sequential ordering Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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Treatment

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Medication Effective in reducing core symptoms of ADHD BUT Doesn’t work with every child with ADHD Problems with acceptance and compliance Side-Effects Reduces symptoms but does not improve adaptive functioning Not a remedy!

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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Solution Focus interventions on accommodation not remediation!

Use medication as a window of opportunity not a long-term solution!

Teach the skills the child will need to be an effective learner and an full and productive participant in society Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Educational Interventions Need a framework‌cannot intervene based on the label Each framework has strengths and weakness and knowing more than one is useful; however, the framework you use needs to be geared to learning All Kinds of Minds provides an highly relevant f framework k for f understanding d t di , assessing i andd intervening with children who have attention and learning difficulties Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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Neurodevelopmental Framework All Kinds of Minds Attention Higher Order Cognition Language Memory Neuromotor Functioning Social Cognition Spatial ordering Temporal Sequential ordering Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Attention Mental Energy Processing Controls Production Controls

http://www.allkindsofminds.org/ Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Key Points Interventions need to be‌ Multifaceted Individualized Proactive Collaborative (including the youth, school, home)

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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Unsupported Treatments Dietary management (e.g., sugar, food dyes, etc.)

Nutritional or dietary supplements (e.g., (e g fatty acid) Homeopathic remedies Chiropractics Neurological treatments (e.g., biofeedback, sensory-motor integration training) Yoga, message, green outdoor settings

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Youth Focus Groups Main Findings Couldn’tt think of many good things about ADHD Couldn Mixed feelings about medication Not very knowledgeable about other treatments for ADHD Feel that others do not know about ADHD (think you are stupid, lazy, crazy, bad) Want others to know – they are not much different that others, teach us the way we learn, don’t expect us to make mistakes, don’t wait for us to mess up, treat us the same way as you treat others)

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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The Good Things To name a few …

Spontaneity Creative Risk taker Not shy Multi- tasker Enthusiastic E th i ti Fun…..

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Resources Online Resources TeachADHD http://www.aboutkidshealth.ca/teachadhd All Kinds of Minds http://www.allkindsofminds.org/ Misunderstood Minds http://www.pbs.org/wgbh/misunderstoodminds/ Totally ADHD http://totallyadd.com/ Canadian ADHD Resource Alliance http://www.caddra.ca CHADD Canada http://www.chaddcanada.org/

Local Organizations Learning Disabilities Association of Nova Scotia (902-423-2850)

Books and Videos ADD Warehouse http://addwarehouse.com

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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QUESTIONS

“CHILDREN DO WELL IF THEY CAN. IF THEY CAN’T, WE AS ADULTS NEED TO FIGURE OUT HOW WE CAN HELP” (Ross Greene)

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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