Adult ADHD… - Allegany College of Maryland

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SFBPsychMedEd 2010-2013
Offered for CMI by
Dr. Susan Fralick-Ball, PsyD, MSN, CH
[email protected]
SFBPsychMedEd 2010-2013
Making sense of the Disorders
 Skills and strategies for Children
 Skills and strategies for Adults
 Tools you can use…Now
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The skills, strategies, and tools appear
throughout this seminar… even more
in your addendum pages
SFBPsychMedEd 2010-2013
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Sensory Processing Disconnections
Executive Dysfunction
Neuropsychological Model of Executive
Functioning (EF)
ADHD
Central Auditory Processing Disorder
Non-Verbal Learning Disorder
Mood Dysregulation in Bipolar Disorder
Adult v. Child ADHD
Avoiding Assessment Errors
SFBPsychMedEd 2010-2013
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The strategies & skills are scattered throughout the
day in discussion, and text
There is little to no presenter bias for this material
There is no conflict of interest between this presenter
and CMI/PESI
Parents have the hardest job in the world
Teachers have the second hardest job in the world
This room is cool due to the presenter’s asthma;
please refrain from requesting hotel staff to change
the temperature
You are taking this manual home for attaining even
more information after today
The skills & strategies are all throughout the manual
SFBPsychMedEd 2010-2013
All information comes to us through sensory input
Once the sensory stimulation is perceived,(or we become sensory aware) it
is projected up and to the front of our brains via circuits or tracts
The sensory information is placed into the frontal lobes for recognition,
assignment, assessment; processing – FOUNDATION LAYER #1
The frontal lobes orchestrate the sensory information and place ‘spin’ on
that information as filtered through the executive functions
Motor responsiveness we call ‘behavior’ (output) are returned via the tracts
and other areas of the brain and body – FOUNDATION LAYER #2
To consider the ‘process’ of ADHD, ASDs, OCD, etc. we observe the
behaviors bubbling up through the foundation of SP & EF
SFBPsychMedEd 2010-2013
Sensory Modulation
(SMD)
SOR, SUR, SS
Sensory Over-Responsivity
Sensory Under-Responsivity
Sensory Seeking/Craving
Sensory Discrimination
Disorder (SDD)
Visual
Auditory
Tactile
Vestibular
Proprioception
Taste/Smell
Sensory-Based Motor Disorder
Disorder (SBMD)
Postural Disorders
Dyspraxia
adapted from SPD Network Taxonomy
SFBPsychMedEd 2010-2013
SFBPsychMedEd 2010-2013
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Basic Problems with Executive (Dys)function in ADHD are:
Working memory and recall (holding facts in mind while
manipulating information; accessing facts stored in long-term
memory.)
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Activation, arousal, and effort (getting started; paying attention;
finishing work)
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Controlling emotions (ability to tolerate frustration; thinking
before acting or speaking)
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Internalizing language (using "self-talk" to control one's behavior
and direct future actions)
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Taking an issue apart, analyzing the pieces, reconstituting and
organizing it into new ideas (complex problem solving).
SFBPsychMedEd 2010-2013
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A set of cognitive abilities from central processes
that control and regulate other abilities and
behaviors.
EF are necessary for goal-directed behavior.
They include the ability to:
◦ initiate and stop actions,
◦ monitor and change behavior as needed, and
◦ plan future behavior when faced with novel tasks and
situations.
◦ anticipate outcomes and adapt to changing situations.
The ability to form concepts and think abstractly
are often considered components of executive
function.
SFBPsychMedEd 2010-2013
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Parents and teachers are often baffled when students with
ADD/ADHD, including those who are intellectually gifted,
teeter on the brink of school failure.
Deficits in critical cognitive skills, known as executive
dysfunction, may interfere with a student's ability to
succeed in school.
Practically speaking, executive function deficits may cause
problems for students with ADHD in several important
areas:
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getting started and finishing work,
remembering homework,
memorizing facts,
writing essays or reports,
working through math problems,
being on time,
controlling emotions,
completing long-term projects, and
planning for the future.
SFBPsychMedEd 2010-2013
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Unfortunately students with ADD or ADHD
are often punished for executive function
deficits, such as lack of organizational and
memory skills that interfere with their ability
to bring home the correct homework
assignments and books.
When deficits in executive function and
related learning problems are present,
students can try their very best and still not
succeed in school!!
SFBPsychMedEd 2010-2013
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If we break down the skills or functions into subfunctions,
we might say that executive functions tap into the
following abilities or skills:
Goal
Plan
Sequence
Prioritize
Organize
Initiate
Inhibit
Pace
Shift
Self-monitor
Emotional control
Completing
Working Memory
SFBPsychMedEd 2010-2013
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Many students with ADD or ADHD have impaired
working memory and slow processing speed,
which are important elements of executive
function.
◦ Not surprisingly, these skills are critical for writing
essays and working math problems.
◦ Recent research has identified written expression as the
most common learning problem among students with
ADHD (65 %).
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Writing essays, book reports or answering
questions on tests or homework is often very
challenging for these students.
◦ students often have difficulty holding ideas in mind,
acting upon & organizing ideas, quickly retrieving
grammar, spelling and punctuation rules from LTM,
manipulating all this information, remembering ideas to
write down, organizing the material in a logical
sequence, and then reviewing and
correcting errors.
SFBPsychMedEd 2010-2013
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Then he must hold important facts in mind while
he applies the rules and shifts information back
and forth between working and STM to work the
problem and determine the answer.
To further complicate matters, other serious
conditions may co-occur with ADD and ADHD.
According to the National Institute of Mental
Health MTA study on ADHD, two thirds of
children with ADHD have at least one other
coexisting problem, such as depression, anxiety,
or SPD.
Accommodating students with complex cases of
ADD/ADHD is critical!
SFBPsychMedEd 2010-2013
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Sometimes we forget just how complex seemingly
simple tasks really are
◦ Example - memorizing multiplication tables or working a
math problem:
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When a student works on a math problem, he must
fluidly move back and forth between analytical
skills with working, STM, and LTM.
With word problems, he must hold several numbers
and questions in mind while he decides how to
work a problem.
He must tap into LTM to find the correct math rule
to use for the problem.
SFBPsychMedEd 2010-2013
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Low or High IQ
LDs
Vision/Hearing
Deficits
Mood Disorders
Substance abuse
PTSD
Sleep Disorders
Seizure Disorders
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Acquired Brain
Injury
Autistic-Spectrum
Disorders
Sensory Processing
Problems
◦ Sensory integration
disorders
◦ Central auditory
processing disorder
SFBPsychMedEd 2010-2013
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In the USA, ADHD is one of the most common
causes of referrals and childhood medication in
family practice, pediatric, neurology, and child
psychiatry clinics.
Epidemiologic studies indicate that about 5% of
children have ADHD, with boys being a large
majority of these
ADHD persists into adult years in a substantial
minority of cases.
Current hypotheses associate ADHD etiology with
abnormalities of connections in the frontal cortex
◦ It may involve faulty regulation of neurotransmitter
messenger systems, predominantly those that use
dopamine and norepinephrine.
SFBPsychMedEd 2010-2013
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The cardinal features of this syndrome (DSM-IV)
are inattentiveness, impulsivity and motoric
over-activity.
◦ In DSM-5 these features may apply to many Axis I Dx
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These symptoms generally start during early
grade school years; they are persistent and
impair the child socially and educationally.
◦ DSM-5 would ‘rate’ the difficulty with these features
with different ages and circumstances
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DSM-IV subtypes of predominantly hyperactiveimpulsive and predominantly inattentive ADHD
have not been supported by the empirical data
SFBPsychMedEd 2010-2013
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There could be a single disorder of ADHD
comprising the popular conceptions of ADD and
ADHD in DSM-5
New proposals are broken into the following
domains:
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Tends to act without thinking
Is often impatient
Is uncomfortable doing things slowly and
systematically
Difficult to resist temptations or opportunities
SFBPsychMedEd 2010-2013
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ADHD frequently co-occurs with conduct, mood,
anxiety, and learning disorders.
◦ DSM-5 may be including many of these chages into the
basic ADHD Dx
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It often co-exists with multiple SPDs and EDfs
By mid-adolescence, ADHD children originally
diagnosed with co-morbid psychiatric disorders have
markedly elevated rates of antisocial, mood and
anxiety disorders, more impaired intellectual and
achievement scores than ADHD-only children, and
high rates of social disability.
◦ Conduct disorder in childhood often predicts an antisocial
diagnosis as well as alcohol and drug dependence in
adolescence and early adulthood.
◦ Major depression in childhood may predict the emergence
of mania.
◦ Severe anxiety in childhood may predict more anxiety
disorders in adulthood than in other ADHD children.
SFBPsychMedEd 2010-2013
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Biological Explanations dominate thinking
about ADHD
◦ “behavioral disinhibition”
◦ “failure in self-control”
◦ Barkley posits that behavioral inhibition is related to
four executive neuropsychological functions carried
out by the brain’s prefrontal region:
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Working memory
Internalization of speech
Self regulation of affect, motivation, arousal
Reconstitution
SFBPsychMedEd 2010-2013
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Working memory allows an individual to manipulate
and act on events held in the mind using foresight
and hindsight and gives one a sense of time in which
to appropriately carry out these functions
Internalization of speech facilitates self-talk, problem
solving, and an ability to reflect on one’s own
behavior
Self-regulation of affect, motivation and arousal
facilitates control of one’s emotions, an ability to
delay gratification and engage in goal-directed
activity without becoming distracted
Reconstitution allows one to analyze and synthesize
one’s own behavior and communicate in an accurate
and efficient manner
SFBPsychMedEd 2010-2013
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fMRI conducted while subjects performed the counting
Stroop task has shown that normal adults increased blood
flow in the anterior cingulate cortex during this task.
◦ Patients with ADHD, by contrast, failed to increase blood flow in
this structure under the same conditions
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During cognitive conflict, ADHD patients fail to activate the
anterior cingulate cortex than do controls
PET scanning has been used to examine cerebral
metabolism, which is a measure of neuronal activity
◦ Results have shown that adults with ADHD have decreased
cerebral metabolism compared with controls
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SPECT imaging has been used to visualize the DAT
dopamine transporter in the human brain
◦ Three studies have shown that untreated adults with ADHD have
increased binding of DAT protein compared with controls
◦ This increase may result in accelerated re-uptake leading to
reduced dopamine in the synaptic cleft
SFBPsychMedEd 2010-2013
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ADHD as a product of an “interactionary
process” between working memory and
environmental factors that is more
psychological than biological in nature
◦ Deficient working memory is at the core of this
disorder
◦ For example, hyperactivity (often manifest as
disorganized behavior) occurs because information
stored in working memory fades rapidly therefore
there exists a need to increase the rate at which
new stimuli or input is sought out
SFBPsychMedEd 2010-2013
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Impairment in each of these executive
functions is thought to lead to behaviors
commonly associated with ADHD
According to Barkley: when an ability for self
control is absent it “in turn impairs other
important brain functions crucial for
maintaining attention” and delay gratification
SFBPsychMedEd 2010-2013
Symptoms
Overlap
Behaviors not
Necessarily
ADHD
SFBPsychMedEd 2010-2013
SPD
Depression
B
S
Autism
FXS
OCD
Anxiety
ADHD
KEY:
ADHD: Attention Deficit Hyperactive Disorder
B: Bipolar Disorder
OCD: Obsessive-Compulsive Disorder
FXS: Fragile X Syndrome
S: Schizophrenia
SPD: Sensory Processing Disorder
Adapted from R. Ross & L. Miller. NICHD grant #1 K01 HD01201-01-A1 Wallace Research Foundation,
Colorado State University
SFBPsychMedEd 2010-2013
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Complex problem affecting about 5% of school-aged
children.
Children can't process the information they hear in
the same way as others because their ears and brain
don't fully coordinate.
The way the brain recognizes and interprets sounds,
most notably the sounds composing speech is
altered.
Often do not recognize subtle differences between
sounds in words, even when the sounds are loud and
clear enough to be heard.
These kinds of problems typically occur in
background noise, which is a natural listening
environment.
Basic difficulty of understanding any speech signal
presented under less than optimal conditions.
SFBPsychMedEd 2010-2013
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hearing in noisy situations
following long conversations
hearing conversations on the telephone
learning a foreign language or challenging vocabulary
words
remembering spoken information (i.e., auditory memory
deficits)
taking notes
maintaining focus on an activity if other sounds are
present child is easily distracted by other sounds in the
environment
with organizational skills
following multi-step directions
in directing, sustaining, or dividing attention
with reading and/or spelling
processing nonverbal information (e.g., lack of music
appreciation)
SFBPsychMedEd 2010-2013
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ADHD behaviors seen
most often include:
• Inattention
• Distractibility
• Hyperactivity
• Restlessness
• Impulsivity
•Interruption/intrusion
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CAPD behaviors seen
most often include:
• Difficulty hearing in
background noise
• Difficulty following
directions
• Poor listening skills
• Academic difficulties
• Poor auditory
association skills
• Distractibility
• Inattentiveness
SFBPsychMedEd 2010-2013
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Developmental disorder with manifestations in the
following domains:
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a) somatosensory and motor functions
b) visuospatial and visuoconstructive functions
c) arithmetic
d) social cognition
E) inferential reasoning.
NLD is a neurological syndrome characterized by the
impairment of nonverbal or performance-based
information controlled by the right hemisphere of the brain.
Performance-based information governed by the R
hemisphere is impaired in varying degrees, including
problems with visual-spatial, intuitive, organizational,
evaluative, and holistic processing functions
SFBPsychMedEd 2010-2013
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Generally presents with specific assets and
deficits.
The assets include:
Early speech and vocabulary development
Remarkable rote memory skills
Attention to detail
Early reading skills development and excellent
spelling skills.
◦ Good verbal ability to express themselves
eloquently.
◦ Strong auditory retention.
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SFBPsychMedEd 2010-2013
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Everyone has assets/strengths/positive points
To work with a child, client, patient, etc. the
parent/teacher/therapist needs to find one of those
strengths
When a problem has been identified, chipping away
at the problem teaches no skills for problem solving
If a strength can be attached to the person, then
every problem worked on through the asset, the
person gains a working set of problem-solving skills
based on something familiar and accepted by the
person in therapy
This formula teaches complex problem-solving skills
SFBPsychMedEd 2010-2013
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BPD is characterized by alternating periods of
emotional highs and lows.
Ranges from mild to severe.
Mood swings have long intervals to rapidly cycling.
The emotional ‘highs’ include:
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Feelings of euphoria, optimism
Rapid speech, racing thoughts, agitation,↑ activity
Poor judgment
Recklessness
Difficulty sleeping
Tendency to be distracted
Inability to concentrate
Extreme irritability
SFBPsychMedEd 2010-2013
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During periods of emotional ‘lows’, symptoms
may include:
◦ Persistent feelings of sadness, anxiety, guilt, or
hopelessness
◦ Disturbances in sleep and/or appetite
◦ Fatigue and loss of interest in daily activities
◦ Difficulty concentrating
◦ Recurring thoughts of suicide (generally not in children)
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Some children with BPD have an underlying SPD
During ‘highs’, they may experience heightened
sensory awareness or sensory feedback.
During ‘lows’, the opposite is often true
SFBPsychMedEd 2010-2013
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Most children with ADD/ADHD don’t outgrow their
disorders; rather, they become disorganized,
inattentive adults.
Adults with ADD?ADHD struggle daily with selfregulation: regulating their attention, regulating their
impulses in talking and action, and regulating their
emotions.
They have trouble staying focused, getting organized,
starting and completing work, managing time and
money, and remembering all the little things in daily
life.
Additionally, depression, anxiety, and substance
abuse are common co-conditions to adult
ADD/ADHD.
◦ Many adults present with these symptoms; ADHD is later
found.
SFBPsychMedEd 2010-2013
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The symptoms change as someone with ADD/ADHD
develops from a child into a teenager and then into
an adult. While the core problems of hyperactivity,
impulsiveness, and inattentiveness remain the same,
the specific symptoms manifest differently.
◦ DSM-5 is looking to further refine the adult Dx to include
more inattentiveness & impulsive decision making
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The impairment is hallmarked with impairment of
executive functions and emotional control.
Typically, the symptoms of hyperactivity decrease and
become more subtle, while problems related to
concentration and organization become more
dominant.
Female adult ADHD clients are often underdiagnosed
and undertreated.
SFBPsychMedEd 2010-2013
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Barkley identifies core adult ADHD as:
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Distractibility
Impulsiveness, poor concentration
Inability to persist at tasks
Difficulties with working memory, organization &
planning
There are high underpinnings of anxiety and depression
that drive Adult ADHD
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Clinicians are asked to rule out medical conditions
like:
◦ Hyperthyroidism
◦ Seizure disorder
◦ Asperger’s syndrome
SFBPsychMedEd 2010-2013
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Untreated adult ADHD is often associated
with:
Higher rates of unemployment, divorce, & arrests
Higher rates of STDs and unplanned pregnancies
Underachievement in school
Firing/dismissal at work
Behavioral problems at work
Job quitting due to hostility in the workplace or
boredom
◦ Driving accidents, revoked/suspended driver’s
licenses, citations for speeding, reckless driving, or
causing accidents
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SFBPsychMedEd 2010-2013
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Hyperactivity in adults:
◦ inability to relax
◦ restlessness, nervous energy
◦ talking excessively
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Impulsiveness in adults:
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Inattentiveness in adults:
◦ volatile moods
◦ blurting out rude or insulting remarks
◦ interrupting others
◦ “tuning out” unintentionally
◦ inability to focus on mundane tasks
◦ constantly losing and forgetting things
SFBPsychMedEd 2010-2013
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Adults with ADHD have problems in six major
areas of executive functioning:
◦ Activation – Problems with organization, prioritizing, and
starting tasks.
◦ Focus – Problems with sustaining focus and resisting
distraction, especially with reading.
◦ Effort – Problems with motivation, sustained effort, and
persistence.
◦ Emotion – Difficulty regulating emotions and managing
stress.
◦ Memory – Problems with short-term memory and
memory retrieval.
◦ Action – Problems with self-control and self-regulation.
SFBPsychMedEd 2010-2013
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Creativity – People with ADD excel at thinking outside of
the box, brainstorming, and finding creative solutions to
problems, more open-minded, independent, and ready to
improvise.
Enthusiasm and spontaneity – People with ADD are free
spirits with lively minds—qualities that makes for good
company and engrossing conversation. Their enthusiasm
and spontaneous approach to life can be infectious.
A quick mind - People with ADD have the ability to think
on their feet, quickly absorb new information (as long as
it’s interesting), and multitask with ease. Their rapid-fire
minds thrive on stimulation. They adapt well to change
and are great in a crisis.
High energy level – People with ADD have loads of energy.
When their attention is captured by something that
interests them, they can have virtually unlimited stamina
and drive.
SFBPsychMedEd 2010-2013

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




The strategies & skills are scattered throughout the
day in discussion, and text
There is little to no presenter bias for this material
There is no conflict of interest between this presenter
and CMI/PESI
We have been talking about skills all morning
Parents have the hardest job in the world
Teachers have the second hardest job in the world
This room is cool due to the presenter’s asthma;
please refrain from requesting hotel staff to change
the temperature
You are taking this manual home for attaining even
more information after today
The skills & strategies are all throughout the manual
SFBPsychMedEd 2010-2013
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December 12, 2011 — In light of two recent epidemiologic
studies, the US Food and Drug Administration (FDA) is
updating its communications with respect to medications
for attention-deficit hyperactivity disorder (ADHD) on the
ongoing cardiovascular safety review of medications used
for treating ADHD.
The agency notes that healthcare professionals should
take special note that:
◦ Stimulant products and atomoxetine (i.e., Strattera) should
generally not be used in patients with serious heart problems or in
patients for whom an increase in blood pressure or heart rate
would be problematic.
◦ Patients treated with ADHD medications should be periodically
monitored for changes in heart rate or blood pressure.
◦ Patients should continue to use their medication for the treatment
of ADHD as prescribed by their healthcare professional.
SFBPsychMedEd 2010-2013
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The frontal lobe contains most of the dopaminesensitive neurons in the cerebral cortex. The
dopamine system is associated with reward,
attention, long-term memory, planning, and
drive.
The executive functions of the frontal lobes
involve the ability to recognize future
consequences resulting from current actions, to
choose between good and bad actions (or better
and best), override and suppress unacceptable
social responses, and determine similarities and
differences between things or events.
SFBPsychMedEd 2010-2013
SFBPsychMedEd 2010-2013
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The frontal lobes allow for high-road, or
high-order processing
A Form of Processing that involves:
◦ Higher
◦ Rational
◦ Reflective thought processes of the mind
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This processing allows for:
◦ Mindfulness
◦ Being flexible in our responses
◦ An Integrated Sense of Self Awareness
SFBPsychMedEd 2010-2013
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The frontal lobes continue to develop late in
adolescence, and in fact, myleination is not
complete until the fourth or fifth decade of
adult life.
A number of EEG studies have found a
dramatic spurt in frontal lobe maturation
between the ages of 17 and 20, which can
explain “late bloomers”.
Also sex hormones are relevant; there is a
relationship between psychosexual
development and cognitive ability.
SFBPsychMedEd 2010-2013
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Frontal brain growth is shaped by what is called
“pruning”.
If these connections are not utilized, they are not
maintained.
It is truly a “use it or lose it” situation,
This circuitry in the brain is very important, and
may actually be the cause of problems that are
often misdiagnosed as a malfunction in a part of
the brain.
The cortex can over-grow a problem with ADHD
that is caused by another part of the brain.
SFBPsychMedEd 2010-2013
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A widely accepted theory regarding the function
of the brain's prefrontal cortex is that it serves as
a store of short-term memory.
Implements working memory
Consistent with the idea that the prefrontal
cortex functions predominantly in maintenance
memory, delay-period activity in the PF has often
been interpreted as a memory trace.
Involved in planning, initiation, anticipation,
impulse control, and higher order thinking
SFBPsychMedEd 2010-2013
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As a member of the catecholamine family,
dopamine is a precursor to norepinephrine
(noradrenaline) and then epinephrine
(adrenaline) in the biosynthetic pathways for
these neurotransmitters.
Dopamine has many functions in the brain,
including important roles in behavior and
cognition, motor activity, motivation and
reward, sleep, mood, attention, and learning.
SFBPsychMedEd 2010-2013
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In the frontal lobes, dopamine controls the flow
of information from other areas of the brain.
Dopamine disorders in this region of the brain
can cause a decline in neurocognitive functions,
especially memory, attention, and problemsolving.
Reduced dopamine concentrations in the
prefrontal cortex are thought to contribute to
ADD.
D1 receptors are responsible for the cognitiveenhancing effects of dopamine.
SFBPsychMedEd 2010-2013
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Pathological states have also been associated
with dopamine dysfunction, such as
schizophrenia, autism, and attention deficit
hyperactivity disorder in children, as well as drug
abuse.
The firing of dopaminergic neurons is a
motivational substance as a consequence of
reward-anticipation. This hypothesis is based on
the evidence that, when a reward is greater than
expected, the firing of certain dopaminergic
neurons increases, which consequently increases
desire or motivation towards the reward.
SFBPsychMedEd 2010-2013
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Hypothesis: Dopamine has a function of transmitting
reward prediction error.
Phasic responses of dopamine neurons are observed when
an unexpected reward is presented.
These responses transfer to the onset of a conditioned
stimulus after repeated pairings with the reward.
Dopamine neurons are depressed when the expected
reward is omitted.
Thus, dopamine neurons seem to encode the prediction
error of rewarding outcomes.
In nature, we learn to repeat behaviors that lead to
maximize rewards. It is therefore believed to provide a
teaching signal to parts of the brain responsible for
acquiring new behavior.
SFBPsychMedEd 2010-2013
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The amygdalae
perform primary
roles in the
formation and
storage of memories
associated with
emotional events.
It appears that teens
have more trouble
than adults
identifying
expressions of fear.
SFBPsychMedEd 2010-2013
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Children have less control over their
emotions, because the axons that send
information from the cortex to the limbic
system are not yet fully developed.
Neurons of the prefrontal cortex that provide
much of our rational control over our
emotions do not mature until early
adulthood.
In contrast, the amygdala is mature at birth
and thus exerts a heavy influence on children.
SFBPsychMedEd 2010-2013
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It functions as an integral part of the limbic
system, which is involved with emotion formation
and processing, learning, and memory.
Also, executive control needed to suppress
inappropriate unconscious priming is known to
involve the anterior cingulate gyrus.
◦ Unconscious priming refers to exposure (unaware) to a
stimulus at time one influencing responding to a related
stimulus at time two. One theory of priming is that
exposure at time 1 activates parts of particular
representation or associations in memory just before
carrying out an action or task. The representation is
already activated at time 2, reducing the time required
to execute the response.
SFBPsychMedEd 2010-2013
SFBPsychMedEd 2010-2013
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This tiny nub of tissue acts as a memory
indexer—sending memories out to the
appropriate part of the cerebral hemisphere
for long-term storage and retrieving them
when necessary.
Information from short-term memory is
stored in long-term memory by rehearsal.
The repeated exposure to a stimulus or the
rehearsal of a piece of information transfers it
into long-term memory.
SFBPsychMedEd 2010-2013
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Experiments also suggest that learning time is
most effective if it is distributed over time.
Deletion is mainly caused by decay and
interference.
Emotional factors also affect long-term memory.
It’s debatable whether we actually ever forget
anything or whether it becomes increasingly
difficult to access certain items from memory.
Having forgotten something may just be caused
by not being able to retrieve it (a common
problem in ADHD).
Information may not be recalled sometimes but
may be recognized, or may be recalled only with
prompting.
SFBPsychMedEd 2010-2013
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There are two types of information retrieval:
recall and recognition.
In recall, the information is reproduced from
memory.
In recognition the presentation of the
information provides the knowledge that the
information has been seen before.
◦ Recognition is of lesser complexity, as the
information is provided as a cue. However, the
recall can be assisted by the provision of retrieval
cues, which enable the person to quickly access the
information in memory.
SFBPsychMedEd 2010-2013
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Arousal and alertness -- the prerequisites to attention
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External or receptive attention: sensory processing and interpretation
(executive functioning) -- as with reading
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Internal or reflective attention which includes thinking about ideas,
concepts, and organization of projects or tasks
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Processing attention or selective attention. This includes:
◦ Focus -- tuning in to an object or topic
◦ Filtering -- signal:noise gradient -- enhancement or activation of relevant stimuli
◦ Inhibition of sensation (sensory inhibition) -- selective sensory input
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External or expressive attention -- encompasses what we choose to
communicate or suppress, which also evokes components of focusing,
filtering, and inhibition.
Working memory -- accessing the retrieval and storage of working memory,
ie, the flow of information, the content of active thought
SFBPsychMedEd 2010-2013
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Focused attention: This is the ability to respond discretely to
specific visual, auditory or tactile stimuli.
Sustained attention: This refers to the ability to maintain a
consistent behavioral response during continuous and
repetitive activity.
Selective attention: This level of attention refers to the
capacity to maintain a behavioral or cognitive set in the face
of distracting or competing stimuli. Therefore it incorporates
the notion of "freedom from distractibility"
Alternating attention: It refers to the capacity for mental
flexibility that allows individuals to shift their focus of
attention and move between tasks having different cognitive
requirements.
Divided attention: This is the highest level of attention and it
refers to the ability to respond simultaneously to multiple
tasks or multiple task demands.
SFBPsychMedEd 2010-2013
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The goal of assessment is effective intervention.
Neuropsychological measures assess some areas of
function/dysfunction in EF.
Relevant contextual behavioral information also needs to
be gathered.
Understand why , when, where the behaviors occur.
Always note strengths and base interventions upon them.
Gather results from excellent physical, emotional, and
social-environmental histories.
Reliance on results from tests and questionnaires alone
will produce a skewed set of data.
ALL DISGNOSTIC LABELING USES THE NOMENCLATURE OF
“DISORDER”
SFBPsychMedEd 2010-2013
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Query about three current problems that are most debilitating:
This open-ended query both establishes therapeutic rapport and
allows the clinician to identify possible co-morbid conditions.
Uncover history: This step involves integration of the patient’s
medical history and self-report of symptoms. The patient’s
reliability can also be assessed in this step. Alternative strategies
for eliciting information may be formulated as needed.
Evaluate symptom by symptom: In this step, the clinician must
carefully examine each symptoms, making certain to distinguish
between impairing symptoms and behaviors.
Setting pervasiveness is judged: DSM-IV criteria require
significant impairment in at least two settings—in this stage,
clinicians gauge the severity of impairments in different settings,
taking into account the effect of social support on the patient’s
level of functioning.
Test for co-morbidities: Before diagnosing ADHD, the clinician
must eliminate possible alternative explanations of the patient’s
impairments. When other possible disorders are identified, the
clinician must determine whether they are primary or co-morbid
with ADHD.

U. California, Irvine Child Devel Center QuestProbe40
SFBPsychMedEd 2010-2013
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Treatment choices
Understanding of prognosis and course
Communication among teachers and school
personnel
Communication with yourself at some future
point
Communication with 3rd party payer
SFBPsychMedEd 2010-2013
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The Daily Big Five
Self-talk and Self-confidence
Insights into ADHD: education & selfmonitoring
Choosing the best strategies for the child
Communication with the disorganized child
SFBPsychMedEd 2010-2013
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Daily focus time
◦ F.A.C.T.S.™
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Clarity of reinforcers
◦ Know individual needs, triggers, and reinforcers to
behavior
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Nutrition
◦ Special diets, elimination diets, susceptibility
 See Symptoms of Yeast Overgrowth, next slide
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Movement
◦ Daily exercise
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Connection
◦ Improve communication
SFBPsychMedEd 2010-2013
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Poor attention
Hyperactivity
Anger
Mood swings
Irritability
Vague, dull staring
Inappropriate behavior (such as making odd noises, or
talking very loudly)
Memory problems
Headaches
Achy joints and muscles,
Ear infections, chronic congestion, coughing, and
infection
Itching
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www.betterschoolresults.com
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http://www.latitudes.org/articles/hy_yeast.html
http://www.nutritioninstitute.com/ADHD.html
SFBPsychMedEd 2010-2013
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Children (and adults) with EF disorders,
ADHD, LDs, etc. grow to live in the negative
and believe that, ‘everything I do is wrong,
too fast, too late, too many mistakes,
incomplete, not thought through…”
Self-concept is a mental image we have of
our bodies, brains, and personalities.
Start early and always praise effort.
Respect your children and treat them with
dignity, especially during times of correction
or re-direction.
SFBPsychMedEd 2010-2013
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Self-esteem is mirrored from the parent and
teacher.
◦ Be the best example of self-assuredness
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Quality v. quantity time spent with ADHD/EDf
children is paramount to building selfassuredness.
3 cornerstones of self-esteem
◦ I am lovable
◦ I have abilities and gifts
◦ I am worthwhile
SFBPsychMedEd 2010-2013
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Show children physical love- hugs, holding hands
Make direct eye contact when talking
Be an active listener
Tell children you love and respect them
Spend some mutually enjoyable time together every
day (map game, tub fun…)
Do special things to let your child know you are
thinking of him/her (lunch box card/note…)
Watch and be with your children as they play
Curb your anger; make the situation a win-win
Identify your priorities
Cut down on TV, video games, computer time, etc.
Take an interest in your children, their opinions,
likes, dislikes
SFBPsychMedEd 2010-2013
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Be an encourager; praise and compliment freely
Avoid over-protection; allow mistakes to occur and
help your child learn alternative solutions
Criticize less; one criticism erases 99 praises
Encourage exploration, even in the face of some risk
Assign chores and responsibilities; hold your child to
completion of appropriate tasks
Help your child build self skills with complex tasks
Refrain from perfectionism or the expectation of it; a
better lesson is to fail and keep working on solutions
Involve children in individual and team-building
activities
Encourage age-appropriate independence; add
responsibilities of caring for self (making her own
bed, doing his own laundry…)
SFBPsychMedEd 2010-2013
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Let your child know he/she matters
Pay attention to your child’s thoughts,
feelings, ideas
Bring children into family discussions and
choices
Always give reasons for rules
Make labels taboo (stupid, slow, clumsy, pest)
Refrain from punishing in anger
Set realistic expectations; avoid self-worth to
become tied to perfect performance
Avoid shame and guilt motivation
SFBPsychMedEd 2010-2013
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Identify the target behavior(s).
◦ Interrupting conversations or lessons
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Select the self-monitoring system.
◦ Chart, graph, etc.
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Choose reinforcers and the criteria for attaining
them.
◦ Time to talk will be awarded after sitting down…
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Teach the child to use the system.
◦ Break down steps. Build upon learned responses.
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Gradually fade prompts and reinforcers.
◦ Once child is self-monitoring and adapting behavior
SFBPsychMedEd 2010-2013
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Core Strategy for Self Help & Academic Help
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Study Skills Program
◦ Most children don’t care as much about studying as
parents and teachers do; many have few study skills
◦ Develop and set up a daily assignment sheet system for
the child
◦ Set up parent-teacher-child conferences to clearly
communicate daily expectations of everyone
◦ Establish criteria for earning a good day on the program
◦ Set up consequences for earning a good day
◦ Consider using a study partner as an enhancement to
the program
SFBPsychMedEd 2010-2013
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Finding the Daily Assessment Sheet in your
Appendices, follow the instructions for
creating a daily flow sheet for your
disorganized student.
Please Refer to Appendix for Study Skills
Program and Daily Assignment Sheet
This Study Skills Program has been morphed
into use for Adolescents and Adults out of
the school situation.
SFBPsychMedEd 2010-2013
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Behavioral therapy is the psychosocial intervention that
has the greatest amount of evidence to support its use in
children with ADHD and for that reason it is prominently
mentioned both within the American Academy of Child and
Adolescent Psychiatry's Practice Parameters and in
American Academy of Pediatrics' clinical guidelines that
pertain to ADHD in children.
Although medications often grab the headlines, it is
important to remember that effective and evidence-based
psychosocial treatments exist for children and teenagers
with ADHD.
REMEMBER THAT WHAT YOU SEE MAY NOT BE BEHAVIOR –
IF IT’S SENSORY, BEHAVIORAL TREATMENT DOES NOT
WORK
SFBPsychMedEd 2010-2013
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Obtain a full medical-psychiatric diagnostic
evaluation with neuropsychological testing.
Understand that executive functioning
problems and sensory processing problems
may be present in conjunction with ADHD.
Utilize the team approach to assist with
behavioral change, learning techniques,
psychological interventions, etc.
SFBPsychMedEd 2010-2013
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General Recommendations for Teachers
◦ Distinguish between medical evaluations and
educational evaluations
◦ Document the challenges you notice with objective
behavioral terms
◦ Document interventions and responses
◦ Speak with other teachers or last year’s teacher &
compare notes
◦ Recommend next-step evaluation
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Avoid diagnostic terms in conversation with
parents
Leave medication decisions to families and their
physicians
Find common goals with parents
SFBPsychMedEd 2010-2013
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“How are you going to know when to be ready?”
“How are you going to stop yourself from…?”
“What is your goal?”
“What do you want it to look like?”
“How long do you think it will take?”
“How much did time did it take last time?”
“How are you going decide where to set that up?”
“How are you going to know what you need?”
“How are you going to know what is most important?”
“How are you going to decide what to do first?”
“How will you know when you are finished?”
“How will you continue when you are tired?”
“How did that work out?”
“How long do you think that took?”
“How did you manage/know how to do it?”
“Would you do anything differently?”
“Have you done anything like this before?”
“Was that harder or easier than…?”
“What worked for you?”
SFBPsychMedEd 2010-2013
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The BEST strategies to help your child with
ADHD, EDfs, etc. come from knowing your
child and his/her strengths and sticky areas
The BEST strategies will come out of careful
observation and consideration of what works
well to have your child come to a positive
outcome
The BEST strategies will demonstrate a
collaboration with educators and other adults
who add dimension to your child’s life
SFBPsychMedEd 2010-2013
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Go to your child and make direct eye contact before
giving an instruction.
Check for understanding: “Tell me what I want you to
do.”
Give verbal directions one at a time, not in a long list.
Physical contact can help the child focus.
Encourage your child to talk through a situation
rather than just plunging in.
Go over steps in a procedure before and during
activities, including those you and your child do
together.
Express expectations in written or visual form as well
as verbal, such as a chore chart or a checklist.
SFBPsychMedEd 2010-2013
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Working with symptoms overlap
Teacher-friendly classroom worksheets
Identification of motivators in the
disorganized/distractible adult- getting on
track
Creating a ‘good fit’ personal organization
strategy for the person with EDf
SFBPsychMedEd 2010-2013
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6 Organizational Skills
Put an organizational system in place.
Supervise your child using the system.
Start small.
◦ Identify troublesome domains and work on them one at
a time.
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Prioritize matters.
Set up prompts and reduce direct supervision as
organization improves.
Model organized behavior.
SFBPsychMedEd 2010-2013
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5 Self-Monitoring Skills
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Identify the target behavior(s).
◦ Interrupting conversations or lessons
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Select the self-monitoring system.
◦ Chart, graph, etc.
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Choose reinforcers and the criteria for attaining
them.
◦ Time to talk will be awarded after sitting down…
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Teach the child to use the system.
Gradually fade prompts and reinforcers.
◦ Once child is self-monitoring and adapting behavior
SFBPsychMedEd 2010-2013
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5 Time-Management Skills
Maintain a daily, predictable routine for the
family; makes planning easier
Talk to child about how long it takes to do
things; practice and time a task
◦ Chores, homework, getting dressed for school, etc.
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Plan a weekend or vacation activity that takes
several steps; make a plan for the day
Use calendars and schedules yourself; teach and
encourage child to do the same
Use timers, watches, clocks as visual cues
SFBPsychMedEd 2010-2013
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Activity Scheduling
Values & Goals Clarification
Quick & Effective Daily Organization
Moving Past Procrastination
SFBPsychMedEd 2010-2013
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Target Behaviors for Home and School
Managing Children Behaviors at Home
Developmental Tasks Requiring Executive Skills
Atten & Related Problem Checklist for Children
Atten & Related Problem Checklist Interpretation
Effective Classroom and Home Strategies for Children
with ADHD
Behavioral Intervention Plan
Comprehensive Intervention Plan
Daily School Report Card
How Did I Do?
School Assessment Request
IDEA Request
Questions & Answers: IEPs
SFBPsychMedEd 2010-2013
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Developing a daily and weekly schedule of activities
helps the child or adult remember that he/she can set
and accomplish goals.
The scheduling is done collaboratively (teacherstudent, parent-child, adult-therapist)
Goal of activity scheduling is to help the person with
ADHD/EDf become more proactive in scheduling
activities in advance.
Person then monitors the activities throughout the
day or week, filling in a visual form with the activity
LINKED to the feeling associated with that activity and
level of accomplishment.
Daily Activity Schedules are set in hours, but may be
broken down into smaller increments for children.
SFBPsychMedEd 2010-2013
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Understanding one’s own values is paramount to
setting achievable goals
Your values are your ideas about what is most
important to you in your life —what you want to live
by and live for. They are the silent forces behind
many of your actions and decisions.
The goal of "values clarification" is for you to become
fully conscious of their influence, and to explore and
honestly acknowledge what you truly value at this
time in your life.
You can be more self-directed and effective when you
know which values you really choose to keep and live
by as an adult, and which ones will get priority over
others.
SFBPsychMedEd 2010-2013
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To accomplish any work (reading a paragraph,
managing a checkbook, etc) we go through 5 discrete
stages:
1. Collect things that demand our attention
◦ (in-basket, e-mail, Blackberry, etc
2. Process what they mean and what to do about
those things
◦ What is it? Actionable? Do it, delegate it, defer it
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3. Organize the results
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4. Review the options for what we choose to do
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5. DO!
◦ reviewable set of reminders, project list, calendar
◦ Daily & weekly review, get clean, clear, current, complete
◦ Based on context, time & energy availability, priority
◦ Move Past Procrastination (find a way to get started)
SFBPsychMedEd 2010-2013
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Break Down the Day into Small Blocks of Time
to Work on Tasks
Break Down the Work into Smaller,
Manageable Chunks
Use a Timer
Take Frequent Breaks
Use Visual Reminders
Connect with Positive Co-workers
Small Healthy Snacks Throughout the Day
SFBPsychMedEd 2010-2013
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Pre-plan the day before
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Get up and go to bed at the same times each day
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Do physical exercise
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Know your triggers to stress
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Write down distracting thoughts/ideas for later
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Take a break
◦ Write down your goals/necessities that need to be accomplished the next
day. Keep this plan in a book with pages that cannot be removed.
◦ This sets your internal and external schedule.
◦ Get to bed earlier and awaken earlier
◦ Change the timing of sleep-wake pattern with a ‘dawning-alarm’
◦ Helps with good rest and alertness throughout your day.
◦ Write down your top 3 stressors that make you uneasy. Tend to those first,
then move on.
◦ Keep an ‘Idea Pad’ close by and just jot a word or two as a reminder
◦ Work hard and intently for 20-30 minutes, then get up and stretch, get a
drink of water, etc. Remember to schedule recreation time in your week.
◦ Watch some mindless TV to unwind & recharge.
◦ Listen to books on tape in the car
SFBPsychMedEd 2010-2013
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Details ARE important
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Do something you are good at doing
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Pay attention to your diet
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◦ Have a place for everything and keep everything in its place – this saves
you from losing your mind on daily ‘trivial’ events
◦ Don’t spend the rest of your life trying over and over to get good at
something you’re bad at doing
◦ Eat breakfast
◦ Slow down on the carbs!
◦ Eat an Omega-3 rich diet
Delegate – put this reminder on every flat surface you see
Find someone you trust and really listen to that person
◦ Find a lawyer, accountant, banker, physician you trust too
Get yourself a ‘closer’ – someone to help you finish all those
great projects you start – until you can close for yourself
Break the pattern of using previously failed strategies
DO… stop procrastinating
◦ Putting off or re-prioritizing robs your time and energy. Just do it.
SFBPsychMedEd 2010-2013
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Educate yourself about ADHD
Identify your individual needs
Tune up your nutrition
Support your sleep
Improve family/couple communication
Examine your social connections
Get regular exercise
Support vocational success
Get a complete medical evaluation
SFBPsychMedEd 2010-2013
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Get a hearing and vision examination
Be evaluated by an adult ADHD specialist
Consider environmental strategies, structure
Consider coaching, counseling, or couples
counseling
Tackle self-management skills
Consider medication, if appropriate
Monitor progress
Treat co-morbidities
Take care of yourself
Get a fidget-toy
SFBPsychMedEd 2010-2013
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Strength and Weakness Profile
Values Clarification Worksheet
Attention and Related Problem Checklist for
Adults
Attention and Related Problem Checklist for
Adults, Interpretation
SFBPsychMedEd 2010-2013
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ADD/ADHD has many positive attributes
The creativity that goes along with ADHD is
astounding!
You always want a person who processes this
creatively in your think tank.
Really connect with the person who lives with
ADD/ADHD – hang around for the downs as
well as the ups.
SFBPsychMedEd 2010-2013
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1. TEMPERANCE. Eat not to dullness; drink not to elevation.
2. SILENCE. Speak not but what may benefit others or yourself; avoid trifling
conversation.
3. ORDER. Let all your things have their places; let each part of your business
have its time.
4. RESOLUTION. Resolve to perform what you ought; perform without fail
what you resolve.
5. FRUGALITY. Make no expense but to do good to others or yourself; i.e.,
waste nothing.
6. INDUSTRY. Lose no time; be always employed in something useful; cut off
all unnecessary actions.
7. SINCERITY. Use no hurtful deceit; think innocently and justly, and, if you
speak, speak accordingly.
8. JUSTICE. Wrong none by doing injuries, or omitting the benefits that are
your duty.
9. MODERATION. Avoid extremes; forbear resenting injuries so much as you
think they deserve.
10. CLEANLINESS. Tolerate no uncleanliness in body, clothes, or habitation.
11. TRANQUILLITY. Be not disturbed at trifles, or at accidents common or
unavoidable.
12. CHASTITY. Rarely use venery but for health or offspring, never to
dullness, weakness, or the injury of your own or another's peace or
reputation.
13. HUMILITY. Imitate Jesus and Socrates.
SFBPsychMedEd 2010-2013
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Adam is a 36 year old divorced man who is trying to
get a small delivery business off the ground. So far
during his working years, he has never stayed at one
job longer than 7 or 8 months. He has done all kinds
of labor-intensive jobs (working in a foundry, loading
dock, bakery delivery, construction), but finds
working for others degrading and boring. He has
been diagnosed with ADHD as a middle-school boy,
and Bipolar Disorder as an adult. He has multiple
parking tickets and several misdemeanor infractions
on his record. His temper can be somewhat volatile.
Develop a plan of action to assist Adam with
psychosocial and vocational endeavors.
SFBPsychMedEd 2010-2013
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Sarah is struggling with math now that she is in
high school. Algebra and geometry are her worst
subjects. She puts off doing that homework,
preferring to write in her journal or read her
English assignments. Her parents are both
architects and cannot understand why Sarah is
still failing math with a tutor and remedial
program at school. Sarah is often moody, sullen,
and withdrawn.
Develop a plan for helping Sarah with schoolwork
and emotional problems.
SFBPsychMedEd 2010-2013
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Keith is in perpetual motion running, crashing, and
tripping into anything or anyone in his path.
Everything he does is fast – in a nanosecond. He’s
now seven years old and is just beginning to stop
for less than a nanosecond when his mother or
other church adult asks him to slow down or gives
him instructions. Keith is affable, likes to give
answers (usually the first to raise his hand, stand,
jump, then comes to the front of the class if not
selected immediately), can play in a group or by
himself, and is generally a very happy kid.
SFBPsychMedEd 2010-2013
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Uncombed hair going in several directions, shirt
tails half in, half out, mismatched socks (and
sometimes shoes), scuffed knees and elbows… a
real boy. He has one vocal volume, about 20
decibels louder than the other children (even in
church), and thrives on being the class clown.
Keith’s mom says that if he plays really hard in the
yard with running, jumping, on the swings, and
rolling on the ground in the dirt, he will be able to
sleep for about 7 hours that night. She has not
noticed that sweet foods have much of an effect on
him.
Develop a Program for Keith’s blurting out in class.
SFBPsychMedEd 2010-2013
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Jeff is having difficulty on many levels. He is moody
and talks back to his parents, teachers and peers.
From insisting on his own way in most peer
interactions, his friends have stopped spending time
with him. He has little regard for other people’s
feelings or possessions, and often throws his books,
sneakers, clothes, i-pod, game boy, and other items
onto the floor in his room. His parents threaten him
with punishment for not picking up his room, placing
clothes in the hamper, leaving his ‘stuff’ lying
around, etc. Jeff’s usual retort is, “ go ahead, I’ll just
find some way to bother you when I’m being
punished. I hate you!” He pulled off some of the
handles on the kitchen drawers, wrote in permanent
marker on the bathroom counter top, and cut clumps
of hair from the family dog.
SFBPsychMedEd 2010-2013
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Jeff is quite smart, yet rarely starts or completes
assignments, so his grades are generally poor. This
continues the downward spiral of anger and
punishment with his parents. He has started and
stopped several scholastic improvement programs.
His teachers talk to him about doing more creative
writing and with his interest in history, yet he refuses
to become involved with his studies or academic
groups at school. He sits in class doodling, clicking
his pen, or looking out the window. He is generally
not truant. He smokes in the bathrooms at school
and on his walk home from school. He takes no
prescription medications.
Given Jeff’s behavior, how would you develop a plan to
help him in school, at home, and with peers?
SFBPsychMedEd 2010-2013
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Edgar has green eyes! I’ve known him and his
family for about four years and have never
been able to make eye contact with him until
recently. He hides behind his mom during any
social contact. Minor sibling infractions (taking
a sip of his milk or tussling his hair) sends him
into a frenzy, then absolute silence for minutes
to hours. He can be in Grand Central Station
and remain focused on his puzzle or watching
the fish in the tank. His mom says that he was
a colicky baby, did not nurse well, slept poorly,
and needed to be held and rocked more often
than her other two children as babies.
SFBPsychMedEd 2010-2013
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At times, when Edgar is stressed, he appears to
hold his breath, stiffen his body, and twitch his
fingers. He’s afraid of water, so bath time is not
very pleasant; he cringes when his hair is washed
or when the washcloth is full of soap. He squirms
in his clothes, pulls at labels necklines, and
removes his shoes as soon as he’s indoors. He is
lagging on developmental and social measures. He
will start first grade.
Develop an intervention plan and request school
services for Edgar.
SFBPsychMedEd 2010-2013
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David is an accomplished, adult computer genius,
married, father of three, and grandfather of one. He is
now on the faculty of a local college and always has a
great story to impart about how he’s helped a
floundering student. When speaking about a troubled
student, David’s eyes well with tears, his voice trembles
and hands shake as he relates the student’s plight. If he
discusses a book passage or movie clip, joy also brings
him to tears. He is often at a loss for words when
expressing emotions, and will have to leave the room to
compose himself. He is often disheveled in appearance,
yet his wife reveals that his home study is immaculate,
with books color-coded and arranged according to
content. He will often interrupt or leave a conversation
without apology, and displays no outward signs of
affection or appropriate social physical contact (hand
shake, pat on the back), yet generally stands very
closely to those with whom he is conversing. He walks
slightly hunched over, without any arm swing or
liveliness to his gait. David is frequently late for
meetings stating that he became engrossed in a book or
mathematical problem and lost track of the time.
SFBPsychMedEd 2010-2013
Please complete your Test Questions and the
Evaluation form.
CMIand I appreciate your comments.
SFBPsychMedEd 2010-2013
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The following pages contain multiple types of
information, work sheets, skill builders, and
ADHD-related help for children, teens, and
adults.
Information for school settings
Information for home settings
Information for work settings
Any of these sheets can be adapted to fit your
specific needs
SFBPsychMedEd 2010-2013

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