Addressing Barriers to Learning: Helping Students Cope with Disruptive Behaviors (ADHD, ODD, CD)

1. Addressing Barriers to Learning: Helping Students Cope with Disruptive Behaviors (ADHD, ODD, CD) Mental Health in the Schools: Module II

2. QUESTION: WHAT DO THESE DISORDERS LOOK LIKE IN THE CLASSROOM?

3. Fidgets Squirms in seat Easily distracted Difficulty waiting turn Blurts out answers Difficulty following directions Difficulty sustaining attention Shifts quickly and often between activities Forgetful Avoidance of tasks that require sustained attention Poor organization Interrupts/intrudes Restlessness Talks excessively ADHD: Core Symptoms

4. Subtypes of ADHD (DSM-IV) • ADHD, Combined Type • ADHD, Primarily Hyperactive-Impulsive Type • ADHD, Primarily Inattentive Type

5. New Thinking (Barkley, 2008) • DSM-V will probably not have ADHD, Primarily Inattentive Type – another disorder altogether (not impulsive, sluggish cognitive tempo, hesitant, shy, socially anxious)

6. Definition: ADHD • ADHD is a developmental disorder, or a disorder of age-inappropriate behavior, that is characterized by difficulties with persistence toward a goal, working memory, impulsiveness, and inhibition. Onset is during childhood.

7. What causes ADHD? • Multiple causes • Not parenting skills • Not social factors • All reliably supported causes fall in the realm of biology (neurology, genetics) • 25-35% attributed to acquired brain injuries • 65-75% due to genetics/ heredity

8. Argues Loses temper, angry Defies rules Easily annoyed, deliberately annoys Resentful Spiteful, vindictive Non-compliant Blames others Oppositional Defiant Disorder (ODD)

9. ODD AGGRESSIVE PURPOSELY ANNOYS DENIES BEHAVIOR MORE DIFFICULT TO MANAGE ABILITY TO CONTROL ACTIVITY LEVEL ADHD-HYPERACTIVE IMPULSIVE NOT PURPOSEFUL SHOWS REMORSE INABILITY TO CONTROL ACTIVITY LEVEL ODD VS. ADHD-HYPERACTIVE

10. Conduct Disorder (CD) • Aggression to people and animals (bullies, fights, weapons) • Destruction of property (fire setting, vandalism) • Deceitfulness or theft (lies, forgery) • Serious violations of rules (stays out at night, runs away, truant)

11. Relationship between ADHD/ ODD/ CD • ADHD can cause ODD – negative cycle of coercive behavior • 50% of ODD alone goes away in 2 years; if ODD is comorbid, it is more resistant and a precursor to CD • CD is a precursor to Antisocial Personality Disorder

12. MEDICATION • STIMULANTS • Methylphenidate: Ritalin, Concerta, Medadate CD, Daytrana • Amphetamine: Dexedrine, Adderall, Vyvanse • STRATERRA (ATOMOXETINE) • ANTI-HYPERTENSIVES • Guanfacine, Guanfacine XR, Clonidine

13. Why use medication? • Results of hundreds of studies indicate that stimulant medication and Atomoxetine (Strattera) are the most effective treatments available for ADHD. • Safety is well established. • Medication treatment improves 70-90% of clinical cases and normalizes 50-60% of such cases.

14. Why use medication? Cont. • Medications are convenient to administer, with the least effort. • Can be used for years, even into adulthood. • Active in community settings where no caregivers may be present to provide active treatment (unsupervised activities, driving alone or with friends, free time in schools, bus rides, etc.)

15. Stimulants • Most well studied drugs in psychiatry. • Used for more than 40 years, 350+ studies, and thousands of cases. • What’s new? • Extended release delivery systems • The 5 P’s- Pills, pumps (Concerta), pellets, patches, pro-drug (Vyvanse™)

16. Behavioral Benefits of Stimulants • Increased concentration and persistence • Decreased impulsivity and hyperactivity • Increased work productivity • Decreased likelihood of grade retention • Decreased days absent from school • Increased reading achievement by age 18 • Better emotional control • Decreased aggression and defiance • Decreased antisocial activities

17. Benefits of Stimulants (cont.) • Improved compliance and rule following • Better working memory and internalizing language • Improved handwriting and motor control • Improved self-esteem • Improved attention and reaction time during driving performance

18. Benefits of Stimulants (cont.) • Note on use of stimulants in preschoolers • Stimulant medication is considered safe to use with preschoolers; however, preschoolers exhibit a decreased degree of change relative to older children. • Additionally, preschoolers exhibit an increased risk of side effects (e.g., insomnia, poor appetite, and weight loss)

19. Side Effects of Stimulants • Largely benign; <5% discontinue use due to adverse events. • Mild Weight Loss (mean= 1-4 lbs.) • Growth effects are short term and limited to first 3 years of therapy • Most common: • Insomnia (50% +) • Loss of appetite (50% +) • Headaches (20-40%) • Stomach Aches (20-40%)

20. Strattera (Atomoxetine) • Effective for kids, teens, and adults;no abuse potential. • Reduces ADHD, ODD, and aggression • Also, treats anxiety • Less insomnia • Takes 3-4 weeks to get the full result

21. MANAGEMENT OF ADHD BEHAVIORS • Planning and Organization • Attention to task • Work completion • Impulsivity • Social Skills

22. CLEAR RULES AND EXPECTATIONS FAIR AND LOGICAL CONSEQUENCES STUDENT PARTICIPATION IN ESTABLISHING CONSEQUENCES/ REWARDS ROLE MODEL LOOK FOR STUDENT STRENGTHS FLEXIBILILTY WHAT IS YOUR ROLE AS A TEACHER?

23. Basic Considerations for Classroom Management • Decrease total workload (How much work does the student need to do to show he knows and/or is proficient in the task?) • Give smaller amounts of work at a time • Target productivity first, accuracy later

24. More Basic Considerations • Use the traditional desk arrangement • Seat the student close to teaching area • Keep homework to 10 minutes per grade level • Do not retain • Establish a school ADHD liaison

25. Classroom Management Tips • Allow some restlessness at work area • Build in frequent exercise breaks • Organize by using color-coded binders • Use white erase boards for question and answer times instead of hands in the air

26. Classroom Management Tips, cont’d • Always be thinking “How do I involve this child within my lesson plan” • Schedule more difficult subjects in AM • Intersperse low with high appeal activities • Be more animated and theatrical • Require continuous note taking

27. 18 Great Ideas • Know that parents are Shepherds, not Engineers • Reduce Delays, Externalize Time • Externalize Important Information • Externalize Motivation (Think Win/Win) • Externalize Problem-Solving • Use immediate Feedback

28. 18 Great Ideas, cont’d • Increase frequency of consequences • Increase accountability to others • Use more salient and artificial rewards • Change rewards periodically • Touch more, talk less • Act, Don’t Yak • Use rewards before punishment

29. 18 Great Ideas cont. • Keep your sense of humor • Anticipate problem settings (make a plan) • Keep a sense of priorities • Maintain a Disability Perspective • Practice Forgiveness (student, self, parents, others)

30. Punishment cont. • Loss of tokens /Response Cost • Moral essays/Reflection papers • Establish a “Chill Out” location • Formal time out in class or private room • In-school suspension or go to IBS class

31. The Punishment Hierarchy ADHD children are punished 2 to 8 times more than other children SO: Swift justice is the key to discipline “Do a Task” – variation of time out -have desk in back of class with worksheets -child told what they did wrong and given a number -child goes to desk and completes number of worksheets assigned

32. Peer Tutoring Children are more sensitive to other children so peer tutoring can be effective. Teach new concepts and skills to class Break class into dyads Have one student tutor and quiz the other Alternate student/tutor roles Re-organize into new dyads weekly

33. WHAT WORKS? WHAT DOESN’T? STRATEGY INFORMATION SHARE

34. CASE STUDY

35. AVAILABLE SCHOOL-BASED SUPPORT SERVICES