Attention Disorders

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ttention Disorders

AD/HD and Its Relationship to

Executive FunctionsClare B. Jones, Ph.D.

Jill Fahy, M.A., CCC-SLP


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Jill Fahy,Attention Disorders, employed by Eastern Illinois University

Disclosure:Financial- Author for LinguiSystems, Inc. and receives royalty payments. In

addition, Jill Fahy received a stipend from LinguiSystems, Inc. for writingAttention

Disorders.

Nonfinancial- No relevant nonfinancial relationships exist.

LinguiSystems, Inc., publisher of products for SLPs, funded this self-study online, , .

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About the AuthorsClare B. Jones, Ph.D., was a diagnostic specialist in private practice in Scottsdale,

r zona. are rece ve er un ergra ua e egree rom ra e n vers y n es

Moines, Iowa; her masters from Cleveland State University; and her Ph.D. from theUniversity of Akron. She did post doctorate work at the University of North Carolina,

Chapel Hill. Clare was in private practice for over fifteen years and specialized in

c ren, young a u s, an a u s w spec a nee s ages zero o a u . er areas o

expertise included attention disorders, learning disabilities, and drug exposed children.

Clare authored seven books, including The Source for Brain-Based Learning and

rac ca ugges ons or , o pu s e y ngu ys ems, nc. e a so

served as editor to three books and published numerous articles. She was on the

editorial Advisory Board for the Journal of Attention Disorders and served on the

editorial Internet Board forADDitude Magazine. She also served on the Professional

v sory oar or . er am y as es a s e a sc o ars p n er memory athe University of Arizona.

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About the AuthorsJill Fahy, M.A., CCC-SLP, is assistant professor at Eastern Illinois University, in

, .

masters degree in speech pathology from the University of IllinoisUrbana-Champaign. For a number of years, Jill worked as a medical SLP, treating mostly

adults with acquired brain injuries. She specialized in the treatment of cognitive

,

those high-level deficits that impacted vocational and community independence.

Jill is co-author of The Source for Development of Executive Functions, published

by LinguiSystems, Inc. She is a nationally-known speaker on the topic of executive

function development and disorders. At Eastern Illinois University, she is a highly

sought-after diagnostician for children with disorders of right hemisphere

development and concomitant executive function deficits, primarily for Aspergers

an onver a earn ng sor er. eac es courses n acqu re anguagedisorders, and developmental disorders of executive functions and the right

hemisphere.

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Terminology Throughout the course, the termAD/HD will be used.

The slash ( / ) indicates with or withouthyperactivity.When the term AD/HD is used, considering it as

.

Additionally, the term executive functions will be

abbreviated to EF.

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Course Description

This course is desi ned to hel the SLP learn more

about AD/HD and its relationship to executivefunctions. A thorough description of the disorder is

,

research and practical suggestions for assessment,

behavior management, and adaptations for clientsages birth to adult.

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Learning Outcomes Participants who successfully complete this course

will be able to: Identify the operational definitions for attention and executive

functions.

Understand the criteria, core symptoms, and subtypes of

AD/HD.

.

Discuss the role of the SLP in treating individuals with

AD/HD and associated EF deficits.

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Overview: AD/HD and EFExecutive functions are a cluster of meta-cognitive skills that mediate other cognitive skills, such as perception,

, , . ,

rely on an extensive network of afferent and efferent neurons that relay information about internal states of being

and external stimuli. Executive functions can be described by the role they play in regulating and mediatingresponses, behaviors, and efforts. Although there is yet to be a general agreement upon the exact components

of executive functions, they are typically defined as processes of goal-selection, planning and organization,

initiation of efforts, persistence and flexibility of efforts, self-regulation of efforts, and inhibitory control

of disruptive or sabotaging responses. How one determines behavior, controls the timing of behaviors,

focuses attentional effort towards mental management of problem solving, self-monitors the impact of behaviors,

and adapts as necessary are all functions of the executive system.

Typical development of executive functions occurs over the first two decades of life. The role of fully developed

executive functions is to provide one with the capacity to apply knowledge to situational demands, account for and

manipulate impulse, and generate flexible solutions in both routine and novel situations. There is some suggestion

that executive functions continue to evolve throughout the lifespan, evoking such skills as wisdom and altruism.

Development of self-regulatory executive functions is delayed in individuals with AD/HD. The capacity to inhibit, to

guide and shift attention, and to make use of working memory skills are impaired, resulting in deficient self-control,self-direction, self-guidance, and problem solving. Disruption in these self-regulatory skills impedes the capacity of

an individual with AD/HD to organize his ideas and to apply knowledge for learning, working, or interacting with

others. It is the lack of inhibitory control and poor regulation that are considered hallmarks of AD/HD.

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Overview:

Etiology and Comorbidity of AD/HDAdvances in the information regarding attention deficit have come from the field of genetics and the use of neuro-

-.

also has the disorder. Specific combinations of specific genes are now clearly identified by researchers. In

addition, new research regarding the total cerebral volume of the brain recognizes that it is smaller in individualswith AD/HD.

It is also felt by most researchers that AD/HD may also be the result of an acquired insult to the brain. Disorders

of executive functions are well documented in individuals with acquired injuries to the prefrontal cortex of the

frontal lobe. The prefrontal structures of the human brain are vulnerable to the coup-contrecoup effects of

traumatic brain injury and are prone to damage from underneath where bony structures of the skull encase the

brain. Strokes, tumors, or other focal lesions to the prefrontal cortex are also known to disrupt executive

functioning. Long-lasting sequelae of disrupted prefrontal functioning often include inattention, impulsivity,

, - , , - .

Specific challenges with language, learning disabilities, and motor coordination are frequently noted

in individuals with AD/HD. Early identification of these challenges is important, as individuals with AD/HD have

higher rates of disruptive behavior disorders, are vulnerable to alcohol and drug dependence, and are at risk for

academic failure. Lan ua e la s an inte ral role in the en a ement of executive functions to su ort behavioral

regulation. The ability to engage working memory allows us to hold rules in mind while generating plans to acton those rules. The development of language also allows for the representation of direction, intention, and

predictionall of which are necessary to executive functioning. Finally, self-talk, internalized as inner speech,

is necessary to mediate behaviors in time and space through shifting, inhibition, and initiation.

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Overview:

Treatment and Management of AD/HDAD/HD is a life-span disorder and it is managed, not cured. Students with AD/HD may have the right to

classroom. They may be eligible for Federal Provisions, and these requirements can follow them through their

school years into college, and eventually into the workplace. Adults have their own unique needs regarding thediagnosis. Sophisticated levels of self-awareness are necessary for the adult to be aware of his own strengths

and weaknesses and to know when and how to compensate in order to perform at his highest level. Multiple

resources exist within communities and within the nation. A National Resource Center for Attention Disorders has

been created in Washington and a national support group, Children and Adults with Attention Deficit Disorder

(CHADD), offers educational resources, materials, networking, research information, conferences, and advocacy.

Behavioral therapy and pharmacotherapy are primary means of providing treatment for AD/HD. Historically, the

use of stimulant medication as a part of the multi-modal treatment plan continues to generate controversy.

-

symptoms in children and adults. The medication has its limits and, for some, side effects. Recent research is

finding potential in non-stimulant medications, although further research is needed. The use of medication in

a treatment plan is solely the decision of the physician and the parent, and no one single drug is beneficial for all

individuals.

Research further suggests that medication should be used in conjunction with behavior management techniques,education, and skill building (e.g., self-management, study techniques). This multi-modality approach includes a

cluster of interventions, including parent/teacher understanding and training, training of meta-cognitive skills to

support self-regulation, teaching of problem solving and social skills, and environmental modifications. Teachers

need to be aware of seating arrangements, curriculum tools, and teaching strategies that can support the AD/HD

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Overview:

Role of the SLP in AD/HDA speech-language pathologist (SLP) may be involved with students with attention deficits as a member of a

,

communication disorders, or as a consultant to others. Individuals with AD/HD are at risk for challenges with

language, particularly in the areas of form, content, production, and use. They tend to have more difficulties withinternalizing language and this is often evident early in life.

,

see deficits in attention and executive control in combination with other speech and language disorders. The SLP

serves as the expert in language and communication assessment and must be able to discern the relationship

between language, attention, and executive functions. Children with AD/HD often have concomitant language

delays and learning disabilities. SLPs may offer suggestions to classroom teachers for how to focus attention;provide verbal instruction; ensure comprehension and memory; organize expressive communication; and use

language for reasoning, self-talk, and problem solving.

In the medical world, SLPs treat the meta-cognitive and cognitive disruptions resulting from secondary AD/HD

due to trauma. Treatment options are better established in the realm of acquired deficits through such approaches

as cognitive rehabilitation. These patients require skill and knowledge from the SLP to determine plans of

treatment to rehabilitate and/or compensate for inattention, impulsivity, disorganization, and impaired self-regulation associated with acquired attentional deficits.

Ultimately, the goal of any SLP working with an individual with developmental or acquired attention deficits is to

romote inde endent and efficient communication and the use of lan ua e for self-re ulation, roblem solvin ,

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and social competence. In addition to the role of service provider, SLPs may serve as resource professionals,

consultants, diagnosticians, and counselors.

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Historical Understanding of AD/HD disorder was identified as early as the eighteenth

century

early labels for AD/HD included:

restlessness syndrome (1920s)

hyperactivity syndrome (1950s) minimal brain dysfunction (1960s-70s)

DSM Classifications

- ,

DSM-III, 1980attention deficit disorder

DSM-IV, 1994subtypes of attention deficit disorder

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- ,

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Current Thinking on AD/HD AD/HD is now thought of as a disorder of the

development of executive functions.

An inability to inhibit, organize, and maintain

the problem, rather than general inattention.

Conflicting viewpoints which are not yet fullyunderstood are emerging.

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AD/HD is a Disability

In the fall of 2001 the sur eon eneral noted that

AD/HD is a neurobiological disability. AD/HD is a chronic condition.

Without treatment, AD/HD can have serious

consequences including: school failure and dro out

depression

substance abuse

of school-aged children.

Ongoing communication with school personnel is

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American Academy of Pediatrics

Clinical Practice Guidelines

These uidelines were written in res onse to the

surgeon generals statement. The guidelines suggested that physicians:

establish treatment as a chronic condition

treat patients in collaboration with school personnel

target management outcomes

continue to evaluate if outcomes are not met and look for other

co-occurring conditions

re uire eriodic u dates from arents teachers and

the child

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The Diagnostic Statistical Manual

o en a sor ers -


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The DSM-IV Criteria for AD/HD The Diagnostic Statistical Manual of Mental

Disorders (DSM-IV) defines AD/HD by specific

criteria.

are used as the first measurement for determination

of AD/HD.

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The DSM-IV Criteria for AD/HD, continued Criteria are subdivided into three symptom types:

inattention

hyperactivity

Symptoms must be present for at least six months to

a point that is disruptive and inappropriate fordevelopmental level (DSM-IV).

The diagnosis can be with or without visible

.

In the case of the inattentive type, the brain will be very

active, racing from one idea to another, but the body

2020

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Additional Criteria for

AD/HD Diagnosis

S m toms must be resent in two or more settin s

(work and home). Some symptoms must be present before the age

o seven.

The individual must show clinically significant

im airment at work or school or with other eo le.

The individual must not suffer from another mental

disorder, such as a closed head injury, that could

exp a n e symp oms.

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Prevalence of AD/HD

Individuals of all intellectual levels ma be dia nosed

with AD/HD. This includes gifted, typical, or learning disabled.

s a me ca con on agnose n - o

children.

More than 60% of cases extend into adulthood.

More males than females are diagnosed with AD/HD.

childhood ratio 3:1

adult ratio may be 1:1

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Prevalence of AD/HD, continued Most females are diagnosed later in life

It may be that more females have AD/HD without

hyperactivity, which is often overlooked and not

diagnosed until later in life.

There are cultural differences in what is considered

to be normal attention

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The DSM-IV Identifies

Three Types of AD/HD

AD/HD redominantl inattentive t e

if inattentive criteria are met, but not hyperactive criteria AD/HD, predominantly hyperactive-impulsive type

if hyperactive criteria are met, but not inattentive criteria

AD/HD, combined type

Symptoms must be disruptive and inappropriate for the

childs developmental level for at least six months.

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AD/HD Predominantly Inattentive Subtype

Six or more of the followin must be resent for six

months: often ignores details, makes careless mistakes

often does not seem to listen

often does not follow through on instructions often has difficulty organizing tasks

often avoids activities that require a sustained mental effort

often loses thin s he/she needs

often gets distracted by extraneous noise

often is forgetful in daily activities

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AD/HD Hyperactive-Impulsive Subtype

Six or more of the followin must be resent for six

months: hyperactivity

often has to get out of seat

often runs about or climbs when/where not appropriate

often on the go as if driven by a motor

often talks excessively

mpu s v y

often blurts out answers to questions before questions are

completed

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often interrupts or intrudes on others


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A omparison of the Two ubtypes

w t

hyperactivity over-aroused

w t no

hyperactivity no arousal

behavior problems

cant control response

sensory problems

cant control attention

socially rejected

more aggressive

socially ignored

less aggressive

antisocial, immature apathy, lethargy

Kohner and Romero, 2001

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Growing up AD/HD With Hyperactivity

A Comparison by Age Range

Preschool Elementar Adolescence

hyper fidgety Restless

uncontrolled talking talks excessively talks out without regard for

others

begins to resist order and

routines

shows inconsistent

erformance

has problems at school

aggressive in play bossy; not a team player seems immature

attention

demanding personality appears careless poor judgment

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AD/HD Combined Subtype is the most common type

reflects a combination of both types of symptoms

inattention

may show a combination of academic and behavioral

problems typically, the inattentive type may experience more academic

problems and the hyperactive/impulsivity type may

experience more behavioral issues

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New Subtypes?

,

we may begin to identify more distinctive subtypes ofAD/HD.

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Development of Attention and

xecu ve unc ons

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What is Attention?

Attention

. . . the relationship between the environmental event and the

persons response to it.

. . . .

. . . to produce . . . an immediately available consequence . . .

(Barkley, in Lyon and Krasnegor, p. 309) In plain English

Attention is a cognitive behavior, either external or internal,

which is in response to some trigger in the immediate

environment, which causes yet another action.

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Types of Attention Focused

the act of turning ones cognitive focus toward a stimulus; the

acknowledgement of an event in the environment, or from within

the act of sustaining ones focused attention over a period of time

toward the stimulus, which may be an external or internal event

e ec ve

the act of determining which stimulus to attend to when

competing stimuli are present; selective attention should allow

or gnor ng non-re evant or stract ng nput, w c may e anexternal, or internal event

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Types of Attention, continued Alternating

the act of selectively attending over time to first one stimulus,

then another, and back again

the act of selectively attending to multiple relevant stimuli

simultaneously

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What are Executive Functions? behavior about, and upon, behavior

behaviors that link events, responses, and

consequences not otherwise related by time

equ va en o me acogn on

cognition about cognition (Flavell, et al.)

a function that selects, controls, and monitors the useof cognitive strategies

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What are Executive Functions?, continued mental processes

effortful, flexible, strategic, proactive

anticipatory, goal-oriented

delay between thought and action

attention to the future

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What is the Relationship Between

Attention and EFs? EFs require attention to form responses or behaviors

in the present or in a future time-frame

alter subsequent consequences of the original event

,

time

to demonstrate attending behavior to desired or required stimuli in the moment

attention provides a foundation for EF control

without inhibitory control, attention cannot be directed

appropriately.

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Frontal Lobe Development Massive surges in frontal lobe development take

place over the first two decades of life.

Synaptic density, myelination, and neural network

efficient, effective self-regulation.

By our mid-twenties, myelination in the frontal lobetapers off and neural connections stabilize.

Neural plasticity allows for constant growth, if

,

decline a bit in mid-life.

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Development of Executive Functions Executive functions emerge as a factor of frontal

lobe development.

Specific EF skills emerge, develop, and mature

.

EF skills are not done until the early twenties, when

independent levels of life-goal selection, delay inimmediate reward for long-term gain, and

complex/abstract problem solving are expected.

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Development of Attention and Inhibition Birth1 3 years of age

impulse-driven and

distractible early inhibitory control

cant delay gratification

maybe able to processone simple rule

simple, focused attention

emerges

continued emergence of

attention and self-control

skills-

simple shifting of attention

inhibition

shift between tasks, one

at a time

4 ears of a e

immature attentional skills

no self-correction

still impulsive, but less emerging ability to delay

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,

minimal inhibitory control

goal for a better reward

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Inhibition, continued 5 years of age 6 year of age, continued

impulsivity still declining

language still increasing processing requests and

-

language processing helps

inner speech begins 7-9 year olds

helps to balance internalneeds with external

demands

attentional skills more selective

and deliberate

more success switching

can sw c e weenmultiple sets of rules

continues to delay someinitial choices, if cued

multiple rules, demands

language is on board, if typical

continued use of silent verbal

externally 6 years of age

starts to be more self-

self-talk rapid surge in planning,

organization

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con ro e

attention definitely better;

can resist distractions

can manage more task

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Inhibition, continued Adolescence Early twenties

relative maturity of

attention and inhibition

working memory

EF skills come into full

maturity adapts to changes

language processing

cognitive flexibility

decision making skills

engages in goal-directed

behaviors

makes ethical, moral, legal deliberate behaviors

multi-goal oriented

efforts

decisions

avoids sabotaging our

efforts with impulsivity or

can orc es ra e an

obtain goals

multi-strategy

develo ment

implements necessaryself-control

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parameters of our society43


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Who Makes the Diagnosis?

t icall a h sician with understandin of the childs

background history, parents histories, and information

from school

or, a psyc a r s w access o e same a ove

information

or a mental health rofessional s cholo istnurse practitioner) with access to the same above

information

w oever ma es e agnos s s ou ave access oand communication with a team of professionals,

parents, and teachers

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ow s e agnos s a e

AD/HD is rimaril an observational dia nosis.

Information is collected by a number of individualsacross a variety of situations and interactions.

There is no one particular test or tool that identifies

AD/HD.

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agnos c a ery Multi-dimensional evaluation includes:

observations

questionnaires

self-reports

clinical assessment of:

a en on

other cognitive skills (memory, perception, reasoning)

metacognitive skills (executive functions)

anguage

sensori-integration abilities

medical evaluation to rule out other primary cause of AD/HD

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Purposes of Assessment

identif a rofile of self-re ulator stren ths as well

as weaknesses

understand potential areas for intervention that may be

respons ve o suppor s

identify types of intervention that may be appropriate,

includin environmental modifications teachinstrategies, and skill development

identify degree to which individual is aware of his or

er e c s, s s, nee s, e c.

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Purposes of Assessment, continued

identif lan ua e foundation to rule out ossibilit of

needing a related service and to understand the

potential for use of self-talk to guide self-regulation

prov e careg ver an eac ers w more spec c

and focused interventions

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Questionnaires and Rating Scales

for Attention Conners Third Edition Conners 3

6-18 for teacher and parent rating scales for AD/HD

8-18 for self-report rating scale for AD/HD

onners u a ng ca es

18 and older; self-report, observer ratings

Conners Com rehensive Behavior Ratin Scales(Conners CBRS)

symptom scales for AD/HD, ODD, conduct disorder, and others

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for Attention, continued The ADD-H Comprehensive Teacher Rating Scale

e econ on

teacher, parent, and self-report, K-8th grade attention, hyperactivity, social skills, and oppositional

behavior

Attention-Deficit/Hyperactivity Disorder Test (ADHDT)

ages 3-23 completed by parents, teachers, or others familiar with the

child

Child Behavior Checklist and Adult Behavior Checklist

ages 1.6-5; ages 6-18; ages 18-59; ages 60-90 caregiver-teacher report form; self-report form

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Q i i d R i S l


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for Attention, continued Behavioral Rating Inventory of Executive Function

Preschool Version (BRIEF)

preschool, ages 2.05.11; child/adolescent, ages 5-18; adult,a es 18-90

parent form, teacher form, self-report

ADHD Symptoms Rating Scale (ADHD-SRS)

ages - , two su sca es

Childhood History Form for Attention Disorders

histor intake form for arents

Brown Attention Deficit Disorder Scales (BADDS) children, ages 37, ages 8-12; adolescents, ages 12-18; adults,

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ages an o er

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Assessment Tools for Attention Test of Ever da AttentionChildren TEACh

ages 6-16

9 subtests of attentional skills

es o ar a es o en on . . . .

ages 4-80

evaluates attention in visual and auditory informationprocessing

Conners Continuous Performance Test II Version 5

.

ages 6 and older

attention problems, especially in AD/HD population

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Assessment Tools for Attention, continued Stroop Color and Word Test

ages 5-14; ages 15-90

inhibitory control, cognitive flexibility

ages 8-16

sustained attention and sequencing associated with AD/HD Color Trails Test (CTT)

ages 18 and older

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Assessment Tools for Attention, continued

d2 Test of Attention

ages 9-59

processing speed; complex attention

ace u ory er a on es

adults

sensitive to TBI-induced AD/HD Mesulam and Weintraub Cancellation Test

ages 17 - 79

ver a an nonver a arrays

sustained, selective attention; organization; monitoring

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A t T l f


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Assessment Tools for

Executive Functions Functional Assessment of Verbal Reasoning and Executive

ra eg es

Ages 18 - 79 TBI populations

er a reason ng, xecu ve unc ons, use o rea -wor as s

Behavioral Assessment of Dysexecutive Syndrome (BADS)

Ages 16 - 87

xecu ve unc ons, use o rea -wor as s

Behavioral Assessment of Dysexecutive Syndrome - Children

(BADS-C)

ges -

Executive functions, use of real-world tasks

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Executive Functions, continued Delis-Kaplan Executive Function System (D-KEFS)

Ages 8 - 89

Executive Function components within verbal and visual tasks NEPSY II

Ages 3 - 16

Attention domain

Executive Function domain

Tower of London (TOL-DX) 2n Ed.

Ages 7 15, Ages 16 - 80

Executive planning, attention, problem solving

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Executive Functions, continued Ruff Figural Fluency Test (RFFT)

Ages 16 - 70

Nonverbal problem solving initiation, fluency, and flexibility Wisconsin Card Sorting Test (WCST)

Ages 6.5 - 89

Sensitivity to frontal lobe dysfunction, strategic planning

and shifting

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Non-Standardized Observation of


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Attention/EFs in Real-World Tasks Direct observation, both interactive and physical

Classroom performance

Social interaction Allow for child to independently demonstrate success and/or failure

Do not step in to be their frontal lobe!

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Non Standardi ed Obser ation of


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Attention/EFs in Real-World Tasks, continued

Note the following attention and executive function

components:

Ability to focus on relevant information

Abilit to inhibit distraction from extraneous stimuli

Ability to initiate/sustain efforts until task is completed

Ability to develop and engage in a sufficient plan

Ability to interpret unspoken, yet implied, requests or directives

Ability to use language as a mediating tool for self-help

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Comorbidity Speech and language disorders occur in up to 17-38% of

individuals with AD/HD.

Anywhere from 25-50% of children with AD/HDhave some kind of learning disability.

Between 42% and 61% of children with AD/HD also have

oppositional defiant disorder (ODD).

50% of those dia nosed with AD/HD ma meet criteria for disru tivebehavior disorders.

25% of individuals with AD/HD have anxiety.

- .

AD/HD occurs in 27-75% of persons with tic disorders.

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What Is the Link Between Attention


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and Language? Attention supports sufficient working memory stores:

Verbal working memory supports linguistic processing.

Comprehension and formulation of language relies on holding thought inworking memory.

Working memory allows for the mental manipulation of thought,

encoded in language, for the consideration of:

Past outcomes + current requirements

Viable options, which lead to

behavioral decision-making and regulation

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and Language?, continued These are collectively part of the executive control of behaviors.

The internalization of language provides for inner speech.

Self-talk supports behavioral regulation and executive control.

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What Is the Impact of AD/HD


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p

on Communication? Disrupted receptive language

Inaccurate or incomplete comprehension

Poor recall of directions, instructions, explanation

Narratives lack cohesion

Circuitous discourse

ss ng re evan e a or ma n ea

Pragmatic inappropriateness

Interruptions, disruptions

Off-topic, irrelevant comments Poor follow-up, reciprocity

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on Communication?, continued

S eech rate elevated

Verbal reasoning and problem solving Overlook relevant details

Draw inaccurate conclusions

Overlook potential options

e -ta or execut ve contro

Disrupted flow of inner speech

-

Inattentive efforts toward self-monitoring

Unaware of unintentional errors

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on Communication?, continued Memory

Impacts reliability that all content was noted and stored

in memory Social competence

Inattentive to relevant nonverbal cues

Misinterpretation of social situations

Reading and writing Unintentional errors, incomplete efforts

Misunderstood content

Disorganized output

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D/HD Across

A Chronic Condition

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Chronicity of AD/HD Symptoms can be seen as early as three years of age and

c ange s g y as e c ma ures.

Children with AD/HD do not outgrow it. The disorder is chronic and exists throughout a life span.

There are an estimated 4.4 million children with AD/HD in the

United States.

These children, a es four to 17, constitute 7.8% of the eneralpopulation.

(Visser and Lesesne, 2005)

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Symptoms and Behaviors:


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Impact on Life, Independence The behaviors associated with the disorder

change as children grow older.

Core symptoms of the disorder are still recognizable. Older adolescents or adults may be more readily able to

cope with the symptoms.

Change depends on the degree to which the individual is aware

and is able to exert executive control over behaviors, efforts, work,

an soc a n erac ons.

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oc a a ura on esearc Further studies in the disorder indicate that students with AD/HD

have unique social immaturities.

They are almost two years delayed in their social maturation. This follows them throughout life.

For example, at age eight, they will act more like a six-year-old than their

same-aged peers in social situations.

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Social Interactions Most persons with AD/HD perform better in independent sports

(e.g., martial arts, swimming,

golf, biking). Children with AD/HD need to be active participants.

The position in team sports can make a difference (e.g., pitcher or

catcher would be a better position than outfield in baseball).

We need to encourage their early involvement with multi-agegroups, such as Boys and Girls Clubs or scouting. By middle

school, they will benefit from a relationship with a mentor, coach,

or tutor.

7272


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73


74/192

Brain Differences in AD/HD Diffusion tensor imaging (DTI) reveals white matter differences in

the frontal cortex, basal ganglia, brainstem, and cerebellum.

Frontal lobes in children with AD/HD were 3-4% smaller than brainsof children without AD/HD.

Individuals with severe AD/HD symptoms had smaller frontal lobes,

temporal grey matter, caudate nucleus, and cerebellum.

7474


75/192

AD/HD without hyperactivity associated with deficits in right

Brain Differences in AD/HD, continued

posterior cortex

AD/HD with hyperactivity associated with deficits in leftanterior cortex

(American Academy of Child and Adolescent Psychiatry 54th Annual Meeting: Symposium

2. October 23-28, 2007.)

75


76/192

Brain Differences in AD/HD, continued Adults with AD/HD have smaller volume measurements in frontal

o e orso a era pre ron a cor ex an an er or c ngu a eareas

of the brain associated with attention and executive control).

Frontal lobe was 6.3% thinner in patients with AD/HD than in

con ro s n area o e ra n assoc a e w a en on an

executive control).

Studies of dopamine indicate high levels of this neurotransmitter in

more yperac ve persons.

7676


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Brain Differences in AD/HD, continued

Decreased glucose metabolism in left frontal and parietal

regions

Sections in the right hemisphere (globus pallidus, caudatenucleus, vermis) appear smaller in many adults with AD/HD noton me ca on (Barkley, 1990, Castellanos et al., 2002).

Overall brain size is about 5% smaller. (Swanson et al.,1998).

77


78/192

Normal Adult Brain

7878


79/192

79


80/192

Genetic Implications Heredity could be considered a risk factor.

10-35% of the immediate family members of children with ADHD are likelyto have the disorder.

Siblings of persons with ADHD are 32% more likely to have the disorderthan eo le who do not have a siblin with ADHD.

Gene mapping studies are beginning to focus on gene defectivepatterns within the total population with AD/HD and are noting:

The D4 gene is defective or a marking is noted in the inattentive type.

This differs from gene markings in the combined, aggressive, orexplosive type.

(Cook et al., 1995; Swanson et al., 1998; McCracken et al., 2000)

8080

AD/HD as a Secondary/Acquired


81/192

Disorder Traumatic changes to the frontal lobe

Traumatic brain injury (TBI)

Primary blast injury (PBI)

Environmental exposure to neurotoxins

Fetal alcohol syndrome

Maternal crack/cocaine addiction

Depression- or anxiety-induced AD/HD

Inattention due to other disabilities

Learning disabilities

Fragile X syndrome

8181


82/192

Developmental Delay? There are some conclusions that AD/HD reflects

a yp ca y- eve op ng ra n u s agg ng n ma ur y.

This implies that with age, the gradual development of attention,

inhibition, organization, and other executive functions will catch

up.

This concept is yet to be fully understood or researched.

8282


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AD/HD in Early

Childhood83


84/192

8484


85/192

The Infant with AD/HD Hyperactivity Mother notes child is very active in womb.

Excessive crying and colic first months

Poor sucking, little smiling

excessive crying and lack of cuddling behavior

8585


86/192

The Infant Without Hyperactivity Easy-going temperament

Mellow, laid-back attitude

Falls asleep often while nursing

Quiet manner

Seems to be a daydreamer

8686

Toddler Stage

f B th H ti d I tt ti


87/192

for Both Hyperactive and Inattentive

compliance of child

High stress time for parents and lowered-

Attachment ratings at 12-18 months relate to not attending to

parent and social readiness issues

ess apt to remem er sequent a tas s e.g., earn ng p onenumber, learning home address, learning ABCs)

8787

P h l


88/192

Preschool Zenith of parental stress occurs when the child

is between three and six years of age

Active preschoolers demonstrate: excessive activity

noncompliance

difficulty in toilet training

frequent shifting of activities in free play

early rejection by peers

8888

P h l continued


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Preschool, continued There is an increase in the number of referrals for hyperactivity in

three-to-four year olds.

This may be due to increased environmental demands on the child(e.g., large daycare situations, less managed free time) and

situations.

It may also be a result of preschool teachers being more alert to the

dia nosis. Teachers note differences in behavior in the areas

of impulsivity and independence.

8989

Common Behavior Problems in

P h l Child ith AD/HD


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Preschool Children with AD/HD Tantrums and meltdowns

Sleep, bedtime, and naptime problems

Noncompliant Short attention s an

Does not share toys

Does not play well with other children

,

(Kaiser, 2004)

9090


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a erna eac ons Mothers of infants with this disorder:

Feel less secure in their parenting roles

Are more apt to seek help from professionals

Early mother-child conflicts predict later, serious

social issues for the child.

Mothers of toddlers with AD/HD make more corrections of their

children in social situations

than typical same-aged peers.

9191

n c ans ee o e are o


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n c ans ee o e ware o Temperament issues

Often do not like to be held

Do not seek out maternal attention when stressed

May appear angry

ommun ca on ssues High rates of language disorders

Frustration

Early differences in developing impulse control

9292

Clinicians Need to Be Aware of continued


93/192

Attachment issues

Clinicians Need to Be Aware of, continued

Often send out negative and avoidant messages

May demonstrate ambivalence or resistance when

Develop inadequate bonding with the caregiver/ parent

May have emotional detachment

c v y eve At risk for injury

Require increased amount of supervision

The parent who is unable to control and guide may feel

like an ineffective parent

9393


94/192

AD/HD in School-Aged

Children94

AD/HD and the School-Aged Child:

Needs


95/192

Needs Child with AD/HD, language disorder, and a behavior component

Is appropriate for referral to school psychology

Is appropriate for language-based interventions to support

the development of self-talk

Is appropriate for environmental modifications to support focused

attention

May also be appropriate for curricular changes to support learning

9595

What Works for the School-Aged

Child with AD/HD


96/192

Child with AD/HD Educate others

Help the parents/family understand the disorder.

Help the teacher/educator understand the disorder.

Promote a healthy self-esteem for the child.

Find what the individual does well.

Promote success in balance with deficits.

Offer verbal praise and concrete rewards for specific accomplishments or

. Foster successful social interaction and competence.

Identify social deficits in specific situations.

.

Teach specific social skills and promote carryover.

9696


Child with AD/HD, continued


97/192

Child with AD/HD,

Discuss the use of harmaceutical intervention.

With family and physician

Prevent behavioral problems. ommun ca e expec a ons.

Be responsive to childs own needs for communication.

Give fair consequences for actions taken.

Use successful behavior modification techniques.

Positive reinforcement

Token program

Response cost

9797




98/192

Child with AD/HD Modif the environment.

Arrange the environment to encourage feelings of control

and comfort. Provide structure and routine with brevit and variet .

Organize material and content in the environment.

De-junk the environment to free it from unnecessary

distractions. Modify language when talking with child.

Give short, brief instructions with eye contact.

epea , rep rase.

Require confirmation that the child understood the message. Offer forced choice questions to promote communication

9898

of abstract concepts, feelings, emotions.




99/192

Child with AD/HD Teach language for inner speech, metacognition, and executive

control.

Teach vocabulary for wants, needs, and emotions.

Want versus feel versus know

rov e an array o emo on-wor op ons.

Teach vocabulary for thinking, planning, and deciding.

Thinking and planning verbs

Deciding verbs to reflect intent rather than impulse

Predicting and comparing syntax structures (ifthen)

Semantic knowledge to support comparing pros and cons of potential decisions

Planning and sequencing words, to offer temporal order of ideas

Self-talk hrases, such as STOP-THINK-PLAN-DO

9999

a oesn or


100/192

a oesn or Herbal therapy

Biofeedback

Biofeedback is a laboratory procedure used to train

subjects to alter their brain activity.

as no ye een assesse or sa e y an e cacy

using standard scientific methods.

Mega-vitamin therapy

e res r c ng oo yes an sugar Occupational therapy as the onlyintervention

100100

What Are the Risks of Children Who

Receive No Support or Treatment?


101/192

Receive No Support or Treatment? At risk of not develo in their full otential

as students or adults

At risk of behavior disorders

Are more likely to abuse drugs than children

with AD/HD who are treated

(Voeller, 2004)

101101


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103/192

103103

Responsibilities of the Professional


104/192

Responsibilities of the Professional The role of educating the caregiver(s) becomes the responsibility

of the clinician and/or the professional who made the diagnosis.

Parents should be given a variety of resources to review and study

and an opportunity to work with someone on learning how to

manage the disorder.

104104

e p ng am es n ers an


105/192

e p ng am es n ers anRussell Barkle leadin researcher in the area of

attention deficit, writes:

Information is the essential linchpin in treatment. Itoesn ma er w a o er s ra eg es you use, e rs

thing you should

do is educate the family about the disorder. Education

brings about more change than

any other psychosocial intervention.(Barkley, 1990)

105105

at am es ee to now


106/192

at am es ee to now Their family biological history

The prevalence of AD/HD in their family and

the general population

The s ecific dia nosis for their child

Strategies and skills to deal with their child

How to deal with the core symptoms

106106

Gathering Family History


107/192

Ga e g a y s o y If the mother has AD/HD, the likelihood of her

c av ng more cu es w e sor er ncreases.

There is a high correlation of children with AD/HD having

mothers who smoked during pregnancy.

80% of all children diagnosed with AD/HD have

a mom or dad who also has it.

107107

Family Therapy as an Option


108/192

y py p Can focus on role of educating parents and family

about features of AD/HD

May offer suggestions in effective parenting skills

Can romote attachment and bondin throu h discussion of childs

strengths, in addition to challenges

Can support development of family cohesion and problem solving

Fosters a sense of being proactive toward managing issues

108108

Supports for Families at Home


109/192

pp Family understanding and education regarding

the disorder is critical.

Caregivers will want to help the family withor anization and structure within the home.

Make the family aware of resources available within

the community.

109109

uppor s or am es a ome, continued


110/192

pp National support group information:

CHADD 1-800-233-4050

www.chadd.org , ,

habits parents need to encourage

in their children with AD/HD.

110

Parenting Techniques


111/192

g q The use of ositive and su ortive arentin techni ues is

important.

Negative, critical, and demanding parenting stylesare associated with chronic and significant behavioral problemsas e c ages.

A child who is exposed to a background of poor parentingpractices is frequently hostile, avoidant,

.

111111

Actions Parents Can Take


112/192

Read and learn more about the disorder.

Network! Learn from other parents.

Set goals! Inform! Let teachers and other famil members know about

your child. Emphasize what the child can do, not what he/shecant do.

Tell the children about their challenges! Help the children

empower themselves to make positive changes. Gather resources!

Be involved, positive, and proactive!

112112

A Suggested Time Line for

Parents of Children with AD/HDTime Line


113/192

Time Line

understand the diagnosis

bibliotherapyinform parents

obtain resources

inform teacher stud skills mentor

confer with physician

outside activitiesstay involved in school

organizational tools

self advocacysocial skills

504 accommodations

tutoringprep for college

113113


114/192

Educational

Intervention


115/192

115115

Proverbial Wisdom


116/192

Tell a child what to think, and you make

.

Teach him how to think and ou make

all knowledge his slave.

-Henry A. Taitt

116116

IEPs and 504s The child may be eligible for an IEP or 504 accommodation plan


117/192

The child may be eligible for an IEP or 504 accommodation plan

ase on sa y

According to IDEA, AD/HD may be eligible under categories that

may include: OHI (other health impaired)

SLD (specific learning disability)

ED (emotional disability), depending on how it manifests

Modifications may include:

Alternative methods and expectations for learning

117117

s an s, continued Accommodations do not ensure success.


118/192

They do allow for access to the curriculum and the educational

environment.

Know the child! Evaluation helps determine what.

118

Proactively Managing IEP and 504

Accommodations Know your students and their accommodations.


119/192

y

Keep folders of accommodations handy.

Periodically review accommodation plans

Identif otentiall successful teachin strate ies

or environmental accommodations that might be

useful to all students.

119119

Adaptations in the Classroom Students with AD/HD have difficulty processing and focusing on


120/192

y p g g

e env ronmen o e c assroom.

Environmental accommodations that organize information help to

reduce distractions. Labeled storage and holding bins support the students efforts to

self-organize.

Predictable routines and written steps/sequences also help the

students efforts to self-regulate.

120120

Factors for Classroom Success Teachers understanding of the disorder


121/192

g

Empathy, not sympathy

The teachers understanding of the students slower social

maturation rates

Preferential seating within the range of the teacher/model

Students with AD/HD are twice as likely to be disruptive in cluster

seating than in U-shaped or traditional rows.

Additional time for written work

121121

ypes o assroom ns ruc on Academic instruction


122/192

Academic instruction

Educator sets learning expectations

Provides an advance organizer -

Explains what will occur in the lessons

Provides hands-on materials and resources

e av or nstruct on Educator provides a well-managed classroom

Offers a number of behavioral interventions to help students learn

to control their behaviors

Use strategies, such as positive reinforcement, response cost,and redirection as necessary

122122

Teaching the AD/HD Student Teaching the AD/HD student is most successful


123/192

g

when the teacher uses:

Short, brief directions

Strong visual depictions

Visual gestures

Strong facial statements

Organizational strategies

Positive modeling and reinforcement

123123

Teaching the AD/HD Student, continued Students with AD/HD respond best to instruction


124/192

p

that offers:

Brevity Activities of short duration

Variety

Diversity, change in pattern

Structure Routine, order, form(Jones, 1991)

124

Compensating for Memory Deficits in

AD/HD

,


125/192

,not the same and the similar!

They will get anA on a spelling test Friday and not know how

to spell the words Monday.ey can remem er w a e eac er wore e rs ay o

school but not remember the teachers name.

Use mnemonics as you instruct. You can remember how to s ell the word friendb

its end, your friend will be with you to the end. Add unusual and different twists to similar tasks.

If you have a younger sister, you may hand inour books first.

125125

Compensating for Memory Deficits

in AD/HD, continued Use color and association to help with focus and


126/192

recall.

Highlight the directions in your favorite color. Then read

them to your partner.

126126

Acknowledge the Students Needs,

an e rect A student may tell you or others in class about his disability.


127/192

I cant do this. I have an attention disorder,

Quickly acknowledge respect for the student that he recognizes his

own challenge.

Immediately affirm that this is why an accommodation

or adaptation is being used.

Yes, you do have attention concerns, Justin, and that is why

I am asking you to color these key words to remember them.

127127

Prepare the AD/HD Student for

Transitions Students with AD/HD have difficulty shifting, adapting, and flexing

iti f f ti it t th t


128/192

cognitive focus from one activity to the next

Teachers, instructors, or other classroom aides can offer help by:

Giving advance warnings of upcoming change

Reviewing events of the day well in advance

Posting schedules, calendars, etc., as visual cues

Using color codes or other hand signals to alert the child to

an upcoming transition

128128

Prepare the AD/HD Student for

rans t ons, continued

Using specific verb phrases to label the behavior needed to

make the transition


129/192

make the transition:

Close notebook

Put down pencil e ou ma oo

Use verbal headlights to mark change.

Class, in five minutes we will need to end this activity. I will give

you a warning at two minutes. Be alert for my warning. Class, as you enter the classroom today, take a look at our daily

schedule. There is a change for this afternoon that I marked in

ue. ou w wan o ge ou your ue pen o mar on your

schedule for the day.

129129

Teach EF Skills to Support

omewor omp et on Goal-determination/self-talk

St t it d th i t d d t


130/192

State or write down the purpose, or intended outcome,

of the students efforts.

What needs to be done? or What I am doing right now?

Use simple forms entitled Things I Need Before I Start.

Provide blank lines for the student to document necessary

items.

Planning and organizing efforts Teach plan-generation How many options can you

think of?

Teach plan-evaluation What is the best solution?

130130

Teach EF Skills to Support

Homework Completion, continued Task sequencing and initiation

Use simple forms with numbered blanks to support


131/192


step-wise task execution.

Self-monitoring and task completion eac error en ca on, en error correc on.

131

Teach EF Skills to Support Reading

and Writing Goal-determination/self-talk

Read and restate written instructions on papers


132/192

Read and restate written instructions on papers.

State/write the intended purpose of a writing assignment

Planning and organizing efforts Use graphic organizers to sort details into relevant

paragraph groups.

Use graphic organizers to represent relevant versus

rre evan e a s.

132132

Teach EF Skills to Support Reading

and Writing, continued Task sequencing and initiation



133/192


step-wise task execution

Self-monitoring and task completion oes my wr en answer ma c e ques on

Find my mistakes. Fix my mistakes.

133

Teach EF Skills to Support Test-

Taking Success Goal-determination

Use self-talk to identify the kind of response demanded by the type of


134/192

y p y yp

question.

Do I choose ONE answer or all possible answers? Is this ,

Attentional focus

Teach self-talk to regroup cognitive efforts

other page?

Self-monitoring skills

Teach self-talk to double check.

Does my answer match the question? Did I answer all of the question?

Did I talk about what the question asked?

134134

ommun ca on w aren s Students do best when arents and teachers

communicate on a regular basis about the students


135/192

communicate on a regular basis about the student s

behavior and learning. se c ec s s:

To support the students transition from school to home

To ensure accurate communication between teacher, student, and

parent Send notes home.

Hi hli ht ositive behavior as well as concerns.

Reinforce successful teaching strategies, for carryover.

Email and phone calls are helpful communication tools.

135135


136/192

Secondary Education

Transitions and Life-Preparation

136

Proverbial Wisdom


137/192

,are preparing to fail.

- Benjamin Franklin

137137

AD/HD and Students at the

Secondary Level and Beyond All of the previous slides would apply to the older student as readily

as they do for the younger student.


138/192

y y g

Adaptations in complexity may be appropriate.

The transition to SELF-re ulation is ke .

138138

AD/HD and Students at the

Secondary Level and Beyond, continued

Hi h school students with AD/HD still re uire su ort articularl in

self-management organization and


139/192

self management, organization, and

study skills.

Hi h school students ma be eli ible for accommodations on a 504

plan.

This plan can accompany them into higher education and be used

as a tool to rocure services in colle e.

139139

IEPs and 504s Under Section 504, students with AD/HD are eligible for specific

accommodations within the classroom, if they are failing to learn.


140/192

They may also be eligible for an individual educational program

(IEP) under the category of OHI, SLD, or ED, if the school teamagrees.

Eligible students may have accommodations in

School

Testing Higher education

The workplace

140140

eep va ua ons p- o- a e

The student with AD/HD will be eli ible for a varietof accommodations under the law.


141/192

To be eligible for such accommodations, he/she must have

documented information andes ng eva ua ons a s ow e s e w ene

from these accommodations.

Up-to-date assessment and diagnostic impressions.

Advocate for these students and teach them toadvocate for themselves for best results.

141141

Classroom Adaptations for the

Secondary Student with AD/HD Preferential seating in class men or or persona coac on s e

A d ti ith kill d fi it


142/192

Accommodations with skill deficits

Cues to aid focus (e.g., color highlighting of keywor s an p rases a s o reca

Provide a note-taker. If the student demonstrates lower scores in visual processing

-, .

Ask a student who takes excellent notes to provide a copy ofthe notes for the student with a documented disability.

Increase personal computer skills and use of electronic plannersan spe -c ec ers.

142142

Teaching Strategies for Secondary

eve u en s w

Provide them with transition tools and additional preparation time.

Keep them with the same teacher longer.


143/192

Try block scheduling.

-

hands-on activities.

Call them by name, to refocus attention and elicit

.

Give them questions in advance.

Provide them with outlines.

143143

Prepare the Secondary Student with

or rans t on to

Life begins to expect growing independence.

EF skills are still lagging behind in this group, making social and/or


144/192

problem solving behavior seem immature.

Pre are the student for real-world res onsibilities. Must have specific input to gain self-awareness

Must be cognizant of own strengths and weaknesses

Must begin to use compensatory strategies independently

Offer support in dealing with stress Will benefit from coping strategies, such as deep breathing

and talk therapy, to help gain self-control.

.,

144144


or rans t on to , continued Self-Awareness

Promote specific knowledge of deficits, failures, and

break-downs


145/192

break downs.

Promote specific knowledge of means to compensate.

Self-Organization

Work to internalize self-talk.

.

Link compensatory strategies to actual homework,

management of own room, and management of own chores,

or job.

145145


AD/HD for Self-Advocacy Prepare the student for self-advocacy.

Is dependent upon self-awareness

Is dependent upon successful internalized use


146/192

Is dependent upon successful, internalized use

of compensatory strategies s epen en upon su c en y organ ze anguage o co eren y

explain, express, convey

Is dependent upon long-term efforts to have promoted good self-

Is dependent upon having learned to inhibit impulses with appropriatewords or behaviors

146146

Academic/Classroom Skills for

econ ary tu ents The mechanics of classroom performance:

Note-taking

Syllabus reading


147/192

Syllabus reading

Assimilating reading material ann ng a ea

Orchestrating a large multi-faceted project

Will benefit from long-term work on language skills designed to

e p organ ze, sor , en y re evan n orma on, conc u e e

implied, and sequence efforts

147147


148/192


149/192

149149

e ng e ca on

Medication is only prescribed by the physician, not the parent,teacher, friend, or neighbor.

The physician may recommend using medication to support focus


150/192

The physician may recommend using medication to support focus

and attention.e me ca ons prescr e are yp ca y s mu an s es gne oincrease activity in the frontal lobes ofthe brain.

not just pills but skills This pill wont work unless you do.

150150

Stimulants Use of stimulant medication as a part of the treatment plan for

AD/HD has been well documented.

Stimulants produce a positive effect in the majority of children with


151/192

Stimulants produce a positive effect in the majority of children with

AD/HD, although it does not normalize behaviors (Teeter, 1998).

Stimulants serve as agonists for neurotransmitters (increase theseneurotransmitters to produce effects on behavior and cognition)

Dopamine related to the executive process, or effort to resolve

competing cognitive demands

Norepinephrine related to the alerting mechanism, or readiness to

respond (Swanson, 2003)

151151

ypes o mu an s

include:


152/192

Adderall

Concerta

Daytrana

Dexadrine

oca n

Metadate

Ritalin

Wellbutrin

152152

Non-Stimulants for ADHD Strattera

The first non-stimulant medication for AD/HD

Approved by the FDA in 2002


153/192

Tenex n an yper ens ve rug a mpac s mpu s v y an yperac v y

153153

Managing Medications in School The school nurse needs to be informed regarding

the child and the medication.

Physicians will examine sustained release and


154/192

longer-acting medications for adolescents.aren s an c n c ans s ou no g ve oo muccredit to any medication for success.

Let children know they are responsible for their.

154154

Some Reported Side Effects of

Medication

Appetite and weight suppressant

Height some effect on growth

Insomnia


155/192

Insomnia

medication wears off)

Tics

155155

Response to Side Effects Inform and work with the physician. May require changing dosage or medication

Ongoing assessment of the balance between


156/192

g g

the benefit of medication and the downside Do not make changes in medication at key

transition times (e.g., finals, new school, etc.).

Kee records on an chan es ou think mi ht

be relevant for the doctor to know.

156156


157/192

The Role o the LP

with AD/HD

The SLP in the School

The SLP serves in the followin roles:

Provider of speech-language pathology services to

address concomitant speech, language, or other communication


158/192

p , g g ,

disorders Consultant to educators for development of accommodations,

modifications, or teaching strategies

Participant on a school study team, an intervention team,

or a 504 committee Advocate for the student with AD/HD

Learning mentor for the student

Educator of other faculty members and/or family

158158

en y u en s anguage ro e

As usual, the SLP needs to identify and address any

concomitant or comorbid language disorders in children with

AD/HD.


159/192

Inattention most frequently undermines spoken languagecomprehension, working memory, and organization of thoughts

for oral expression.

In addition to evaluating basic levels of language, pursue

assessment of higher-demand language. Narrative discourse (comprehension and production)

Literacy skills for academic success

Executive functions in naturalistic settings

Social competence/pragmatics in naturalistic settings

159159

Executive Functions

Children with AD/HD demonstrate deficits in metaco nitive and

executive control systems for:

Planning and organizing


160/192

Deliberate oal-settin Deliberate initiation and inhibition

Self-awareness and regulation of efforts

Use of self-talk or inner speech as a thinking tool

The SLP must consider planning and execution skills for thesechildren, and their capacity to engage language in a beneficial

way.

Assessment and treatment of the language of thinking, planning,

and doing, is appropriate.

160160

School-Based SLP Assessment

Options for EF and Attention

The SLP may opt to evaluate attention and/or executive functions

as a part of the educational diagnostic team.

Few standardized tools are available to the SLP:


161/192

Behavioral Rating Inventory of Executive Functions (BRIEF) Test of Everyday Attention for Children (TEA-Ch)

Many rating scales and assessment tools exist within other

professions (see slides 50-60).

161161

School-Based SLP Assessment

Options for EF and Attention, continued The combined effect of assessment and analysis from multiple

perspec ves o ers e mos compre ens ve ns g n o e

child with AD/HD.


162/192

Verbal working memory subtests from standardized assessmenta er es prov e g y use u n orma on regar ng e c s

ability to

focus attention on incoming verbal information.

162

Test of Everyday Attention-Children

(TEA-Ch)

Ages 6 - 16

Assesses attentional capacities in children, adolescents

Standardized scores allow comparison of attentional domains


163/192

Nine subtests observe: Sustained attention

Selective attention

Alternative attention

Inhibited attention

Sensitive to developmental progression of attention

163

Behavior Rating Inventory of

Executive Function (BRIEF)

Rating scales based on 80 Behavioral Regulation Index

questions Never, sometimes, often

T-scores >65 significant

Regulate behavior, emotion

Inhibition, emotional control


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g Shifting, self-monitoring

Inhibition

Shifting

Emotional control

Metacognition Index (MI) Systematically solve problems

Initiate, plan, organize, execute,complete

n a on

Working memory Planning

Organization

Global Executive Composite(GEC) BRI + MI

Self-monitoring

164

Versions of the BRIEF1. Behavior Rating Inventory of Executive Function Preschool

ers on -

Ages 2.0 5.11. Parent Form, Teacher Form


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2. Behavior Rating Inventory of Executive Function (BRIEF)Ages 5 18, Parent Form, Teacher Form

3. Behavior Rating Inventory of Executive Function, Self-Report

Version (BRIEF-SR)

Ages 11 18, Parent Form, Self Form

4. Behavior Rating Inventory of Executive Function -Adult

Version (BRIEF-A)

Ages 18 90, Informant Form, Self Form

165

SLP Role in Treatment of Child with

AD/HD

The school-based SLP may determine to write goals for children

with AD/HD for a variety of reasons

Inattention disrupts verbal working memory


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Inattention disrupts language comprehension Inattention disrupts inhibition, which disrupts planning, sequencing,

evaluating, and correcting

Inattention disrupts all language modalities (reading, writing, listening,

Inattention disrupts social communication awareness and monitoring.

166166

Compensatory Strategies to Support

ttent on n t e c oo - ge

Teach the child to

Repeat

Request confirmation


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Restate in his/her own words Use self-talk to self-focus on the speaker

Use self-questioning to identify if information is or is not available in

working memory

ecogn ze s gns o someone ge ng rea y o spea or

offer important information Use visual cue-cards placed on childs desk to prompt attentional focus

167167

en on cann ng as s

Auditory scanning tasks

Listen to spoken letters, numbers, or words over a

designated number of minutes

Raise hand when target letter/word is spoken


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Visual scanning

Scan through page filled with symbols, letters, words,

Circle or cross out only the target symbol Achieve 90%+ accuracy identifying target symbol

168168

Attention Scanning Tasks, continued Increase time span while maintaining accuracy levels

Increase difficulty level of targets to identify

Transition from non-distracting, controlled environment to an


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unstructured, uncontrolled environment

169

en ona wareness s

Build metacognitive awareness in the child by

teaching him/her to:

Understand the skill of attentionthat listening, reading,

thinking, speaking, and writing all require fundamental


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Evaluate his/her own degree of attention to evaluate

whether he/she can remember what was just said

Reco nize when he/she is lackin in sufficient information -

to carry out the expected or required task

170170

Self-Talk to Cue Attention

Embed self-talk phrases to give the child a foundation for

internally monitoring his/her own attention and recall for spoken

language:

Wh t i t?


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What is next? What did she say?

Im supposed to _____, _____, and _____?

I dont remember all of it.

nee to as or more n ormat on.

Am I ready to listen?

Am I ready to work?

171171

amp e en on oa s or e

Client will demonstrate sustained attention for simple auditory

scanning tasks sufficient to achieve 80% accuracy for up to five

minutes, in non-distracting structured environment.

Cli t ill t i tt ti t l t fi i t il


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Client will sustain attention to complete five-minute paper-penciltask requiring use of reading comprehension and written

expression, given fewer than two prompts per task.

Client will sustain attention for simple homework sheet completion

when given fewer than two prompts, in an unstructured classroom

setting.

172172

Sample Attention Goals for SLP, continued

Client will sustain attention to five-minute conversation in structured,

non-distracting environment, following topic transitions with 80%

accuracy and fewer than two prompts

Cli t ill t i tt ti t fi i t t h l t i


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Client will sustain attention to five-minute teacher-lecture inclassroom environment, following transitions and topics with 80%

accuracy and fewer than two prompts

Client will demonstrate 80% accuracy for listening comprehension of

two-part directives, independently using compensatory attention

strategies

Client will follow three-part spoken directions with 80% accuracy,

without requiring cues for focused attention

173173

Sample Attention Goals for SLP, continued Client will sustain attention to three-minute verbal explanation of

aca em c con en , su c en o res a e

up to five details with 80% accuracy

Client will shift attention in the classroom from teacher


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o a e as necessary n or er o o ow spo en rec ons w

accuracy, given no repetitions

Client will sustain attention sufficient to comprehend simple short

s or es w accuracy, g ven ecrease ra e o n orma on an

repetitions as needed

Client will sustain attention sufficient to comprehend simple short

s or es w accuracy, n epen en y reques ng repe ons as

needed

174


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175

AD/HD Is a Life Span Disorder

There are ongoing strategies to help the aging

person with attention disorders.

Today state universities and colleges offer support

and guidance from on campus offices for students


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and guidance from on-campus offices for studentswith disabilities.

Adult support groups are available in most communities.

176176

os g c oo

Ma be eli ible to take the SAT ACT rad school tests and

vocational education tests with accommodations

May be eligible for untimed testing


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services/unique offerings

The accommodations are available at the workplace

.

177177

u e

Many adults use medication when performingactivities that require more concentration, but theyhave learned strategies to cope in other situations.

Adults are eligible for accommodations under ADA.

neven ma ura on eve s seem o e e er


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neven ma ura on eve s seem o e e eraccepted.

They are successful when they can match their.

178178

The Adult Female

Females with AD/HD have uni ue needs as the

age.

Due to estrogen changes as they mature, their

memor issues ma be more at risk durin


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memor issues ma be more at risk durinmenopause than typical females experience.

Women may benefit from working with a counselor

or thera ist as the mature.

179179

romo ng u onomy an wareness

All children and adults with diagnosed attention disorders need to

develop their own self-awareness about their disability.

Positive role modeling and self-accountability will

help them empower themselves


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help them empower themselves. Their challenges are not an excuse, but rather, a

conduit to change.

180180


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or o ay

AD/HD must be understood from a develo mental and enderperspective.

Although a population of people may experience similar skilldeficits, each individual is unique in history and exposure.

This is a disorder that is managed and possibly controlled but


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This is a disorder that is managed and possibly controlled, butnot cured.

182182

For the Future

The recent information regarding a genetic basis of AD/HD

suggests the possibility in the future of more sophisticated

treatment options and earlier identification.

In addition, new pharmacology may be developed to better servethe diagnosis


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, p gy y pthe diagnosis.

More detailed subtype information will become available.

183183

For the Clinician

Effective management of AD/HD requires:

Understanding of the disorder

Ongoing education

Periodic evaluation

Interventions, strategies, and resources


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Interventions, strategies, and resources

Responsibility in decision-making

Positive guidance

184184

In Closing

Perha s the most indis ensable thind h b i d


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Perha s the most indis ensable thinwe can do as human beings, every day

of our lives, is remind ourselves and others

of our complexity, fragility, finiteness,and uniqueness.

185185

,

ReferencesAmerican Speech-Language-Hearing Association. (1997). Roles of audiologists and speech-

lan ua e atholo ists workin with ersons with attention deficit h eractivit disorder

(Technical Report). Available from www.asha.org/policy

Arizona Department of Education web site. (2002, February). Definition of Accommodations.

Available from www.ade.state.az/us/ess/ACCOMfin.asp

Barkley, R. (1996). Linkages between attention and executive functions in attention, memory, and

. , . ., . , . ., . . ,MD: Brookes Publishin

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Attention Disorders

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