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
steven.kurtz@childmind.org
Portrait of a child with ADHD
Classic Triad of ADHD
Inattention Hyperactivity
Impulsivity
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
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
Overlap of Symptoms and Diagnoses
ADHD Anxiety ODD ???
Attention
Concentration
Anxiety
Sadness
Opposition
Fidgetiness
Impulsivity
Appetite
Sleep
Overlap of Symptoms and Diagnoses
ADHD Anxiety ODD ???
Attention
Concentration
Anxiety
Sadness
Opposition
Fidgetiness
Impulsivity
Appetite
Sleep
Overlap of Symptoms and Diagnoses
ADHD Anxiety ODD ???
Attention
Concentration
Anxiety
Sadness
Opposition
Fidgetiness
Impulsivity
Appetite
Sleep
Overlap of Symptoms and Diagnoses
ADHD Anxiety ODD ???
Attention
Concentration
Anxiety
Sadness
Opposition
Fidgetiness
Impulsivity
Appetite
Sleep
Co-occurring Disorders
• Oppositional defiant disorder - 40%
• Anxiety or mood disorders - 25-34%
• Learning disabilities - 20%
• Conduct disorder- 10-60%
• Tic disorders
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.
Areas of Brain Affected
PET Scans
Alan Zametkin et al., NIMH
Xavier Castellanos, NYU CSC
Approx. 3% difference in brain volumes
Less asymmetrical
Developmental Trends of ADHD Symptoms
before 17 yo
Impairm
ent
Hyper/Imp
Age
Developmental Trends of ADHD Symptoms
Impairm
ent
Hyper/Imp
Age
Impairm
ent
Inattention
Banerjee, Middleton, Faraone. Acta Paediatria, 2007,
96, 1269-1274.
before 17 yo
Sx I
mp
airm
ent
Inattention
Hyper/Imp
Developmental Trends ofH/I vs. Inattention Symptoms
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?
Refining the understanding of ADHD
• Variability is the rule, not the exception
• Dull, boring, repetitive tasks not of their choosing
Refining the understanding of ADHD
ADHD
ATTENTION SURPLUS DISORDER
ATTENTION MODULATION DISORDER
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?
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
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
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
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
Treatment Recommendations
Treatment Recommendations
Medicine Behavior Therapy
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
Treatments for ADHD
• Who do we target?
• What do we target?
• Where do we target?
• When to apply tx?
– Serial vs Concurrent
Parent-Child Interaction Therapy
Teacher-Child Interaction Therapy
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
MTA Study: Parent-Reported Parent-Child Arguing
“MY WHAT IS DUE WHEN?”(AND, Where Is It?)
ORGANIZATIONAL SKILLS TRAINING
SKILLS
DEFICIT
PERFORMANCE
DEFICIT
Oh No !!!!
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
Daily Report Cards (DRCs)
SpecificObservableMeasurable
Frequent & ImmediateBluegrass? Opera? Rap?
Football? Wild Wadi?
Daily Report Cards (DRCs)
Daily Report Cards (DRCs)
Daily Report Cards (DRCs)
Daily Report Cards (DRCs)
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
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: ___________________________________
Prize Box
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