By Sally Trowse , Specialist ADHD Nurse, Stockport CAMHS and Gareth D Morewood , Director of Curriculum Support 10 th

1. Identifying and including students with ADHD in the mainstream classroom; from recognition to diagnosis – with practical strategies for the classroom By Sally Trowse, Specialist ADHD Nurse, Stockport CAMHS and Gareth D Morewood, Director of Curriculum Support 10th December 2012

2. What is going to happen? • Give you a context where including young people with ADHD has recorded some success • Highlight some of the barriers to inclusion that need to be challenged • Provide background and understanding from a specialist CAMHS perspective • Offer some ideas on how to meet the challenges facing the inclusion of young people with ADHD in mainstream schools

3. Does Every Child Matter? • Being Healthy • Staying Safe • Enjoying and Achieving • Making a Positive Contribution • Economic Wellbeing

4. How Many Children Have AD/HD? • 5% of the general population • This is a very conservative estimate • 70-80% of these children will carry the condition on into adulthood • At least 1/3 will have significant problems with attention without being hyperactive or impulsive • Remaining 2/3 will have significant problems with hyperactivity • In UK only 0.03% are treated • Males: Females - 4:1 (9:1 – clinics)

5. So what is ADHD? Now to be considered as a disorder of age-inappropriate behaviour: Hyperactivity-Impulsivity (Inhibition – Executive Function) • Impaired verbal and motor inhibition • Impulsive decision making; cannot wait or defer gratification • Greater disregard of future (delayed) consequences • Excessive task-irrelevant movement and verbal behaviour • fidgeting, squirming, running, climbing, touching … • Restlessness decreases with age, becoming more internal, subjective by adulthood • Emotionally impulsive; poor emotional self-regulation

6. 30% deficit of executive function • The ability to organize cognitive processes. This includes the ability to plan ahead, prioritize, stop and start activities, shift from one activity to another activity, and to monitor one's own behaviour.

7. Causes and Origins All causes fall in the realm of biology (neurology, genetics) Maternal smoking/alcohol Premature birth… brain bleeding Toxic level lead exposure Brain hypoxia Head trauma 75% family link

8. Environmental risk factors • Accounts for 15-20% cases • Prenatal exposure to: • Alcohol* • Cigarettes* • Benzodiazepines • Obstetric complications • Prematurity and very low birth weight • Brain diseases/injury e.g. • Closed head injury • Neurofibromatosis • Severe early deprivation and institutional rearing • Exposure to toxic levels of lead

9. Smaller, less active, less developed brain regions found on scans

11. Anxiety/ Depression Coexisting conditions ASC Asperger’s Specific Learning Difficulty Conduct Disorder ADHD Tourette’s Oppositional Defiant Disorder Speech Disorder

12. Coexisting conditions • MTA Trial (USA) • ADHD Alone – 31% • Behavioural Disorders -54% • Oppositional Defiant Disorder (40%) • Conduct Disorder (14%) • Tics – 11% • Anxiety Disorders – 34% • Depression – 4% • Swedish Study (School-aged) • Learning disability (13%) • Reading/writing disorder (40%) • Motor co-ordination disorder (47%) • Asperger’s (7%)

13. Tourettes syndrome What is it? What are tics? What treatment? What can school do?

14. So what might you expect? Inattention Does not attend Fails to finish tasks Can’t organise Avoids sustained effort Loses things, is ‘forgetful’ Easily distracted Hyperactivity Fidgets Leaves seat in class Runs/climbs excessively Cannot play/work quietly Always ‘on the go’ Talks excessively Impulsivity Talks excessively Blurts out answers Cannot wait their turn Interrupts others Intrudes on others DSM-IV – Diagnostic and Statistical Manual, 4th Edition (American Psychiatric Association, 1994). ICD-10 – International Classification of Diseases, 10th Edition (World Health Organisation, 1993).

15. What else needs to be considered? Duration Symptom criteria must have been met for the past 6 months (? 1yr+) Age of onset Some symptoms must have been present before 6 - 7 years of age (in childhood) Pervasiveness Some impairment due to symptoms must have been present in 2 or more settings (e.g. school, work or home)

16. How is ADHD clinically defined? Impairmentsymptoms must have led to significant impairment (social, academic, or occupational) Discrepancy symptoms are excessive in comparison to other children of the same age and IQ Exclusion symptoms must not be solely attributable to other mental health difficulties (anxiety, depression, autism)

17. What characteristics may we expect? • NEGATIVE • Short attention span • but with periods of intense focus • Distractible • Poor planning/impulsive • Disoriented sense of time • Impatient • Day-dreamer • POSITIVE • High levels of environmental awareness • Responds well when highly motivated • Flexible – ready to change strategy readily • Tireless when motivated • Goal orientated • Imaginative

19. Don’t forget about girls and ADHD.... • More inattentive than impulsive • Less ODD/CD aggression and delinquency • More depression pre-diagnosis • More underperformance and Learning Difficulties in school • …self blame, • …self attribution, • …demoralisation lead to anxiety and depression, • …development of compensatory behaviours and strategies. • Re-think for girls… not a behaviour disorder more a life management disorder Patricia Quinn, 2009

20. Development of the disorder... PRESCHOOLERS (3-6 years) • Reduced play intensityand duration • Motor restlessness • Associated problemsand implications • developmental deficits • oppositional defiant behaviour • problems of social adaptation

21. PRIMARY SCHOOL CHILDREN (6-12 years) • Distractability • Motor restlessness • Impulsive and disruptive behaviour • Associated problems and implications • specific learning disorders • aggressive behaviour • low self-esteem • rejection by peers - not invited to parties • impaired family relationships

22. ADOLESCENTS (13-17 years) • Difficulty in planning and organisation • Persistent inattention • Reduction of motor restlessness • Associated problems • aggressive, antisocial anddelinquent behaviour • alcohol and drug problems • emotional problems • accidents

23. ADULTS (18 years and older) • Residual symptoms • Associated problems • other mental disorders • antisocial behaviour/delinquency • lack of achievement in academic and professional career

24. Normal DismissalFromJob ADHD SexualTransmission ofDisease TeenPregnancy Repetitionofyear Normal AttemptedSuicide ADHD IntentionalInjury Incarceration SubstanceAbuse 0 10 20 30 40 50 60 % of Subjects Risks & controls associated with ADHD in adolescents... © Eli Lilly 1998, Barkley RA 1998 ©Eli Lilly 1998, Barkley RA 1998

25. EFFICACY OF INTERVENTIONSSymptomatic normalisation rates in the MTA study 1999 (N= 570; mainly middle school boys) MED +Behavioural treatment Communitytreatment Behavioural treatment MED Swanson et al 2001 Overview Efficacy of interventions Psychoeducation Psychopharmacotherapy Behaviour modification Algorithm QA Conclusions Efficacy of interventions

26. So what’s all this about medication? • Stimulants- Methylphenidate (Ritalin) • short acting (lasts up to 4 hrs) & • long acting (Equasym XL and Medikinet XL last up to 8 hrs) (Concerta XL lasts up to 12 hrs) • Dexamphetamine Controlled drugs • Nonstimulant - Atomoxetine (must be taken every day 24hr effect) non-controlled drug

27. How does Methylphenidate Work? • Methylphenidate is thought to: • Promote release of dopamine &noradrenaline into the synapse and inhibit their reuptake into the presynaptic neuron. • Modified Release Methylphenidate: • 1st phase: a sharp, initial rise in concentration • 2nd phase: another rise about 3 hours later, followed by a gradual decline • e.g. Concerta, Equasym XL, Methylphenidate

28. Neurochemical pathophysiology Methylphenidate and atomoxetine block re-uptake of noradrenaline Methylphenidate and amphetamines block re-uptake of dopamine

29. Methylphenidate • This has been used to treat ADHD for >50 years • CNS stimulant • Mechanism of action in ADHD is not completely clear • It is believed that it increases intrasynaptic concentrations of dopamine and noradrenalin in the frontal cortex and sub cortical brain regions associated with motivation and reward (Volkow et al., 2004) • It blocks the presynaptic membrane dopamine transporter (DAT) and so inhibits the reuptake of dopamine and noradrenalin into the presynaptic neuron

30. Advances in Family Treatment(Russell Barkley, 2009) • Parent Education About ADHD • The first critical step in treatment • Adopt a ‘parents are shepherds’ perspective • Learning the value and limitations of parent training • Changes defiance and parent-child conflict, not ADHD (helping parents ‘get’ their child.) • Works best in younger children • (<11 yrs, 65-75% respond) • Modestly useful for teens • (25-30% show reliable change) • Incorporate teen in treatment and use Problem-Solving, Communication Training • (30%+ show reliable change) • Best to combine it with above Parent Training to reduce drop outs

31. More Treatment Advances... • Teacher Education About ADHD • Classroom Behaviour Management • Design of classrooms • Very effective but no generalization or maintenance after withdrawal • Special Education Services • Regular Physical Exercise • a coping or compensatory tool • Parent/Client Support Groups

32. Unproven and Miss-truths... • Elimination Diets – removal of sugar, additives, etc. (weak evidence) • Megavitamins, Anti-oxidants, Minerals (no compelling proof or have been disproved) • Omega 3 Fatty Acids (Fish Oil) – one recent study with mixed results (effects at home on parent ratings, no effect at school on teacher ratings) • Sensory Integration Training (disproved) • Chiropractic Skull Manipulation (no proof) • Play Therapy, Psycho-therapy (disproved) • Self-Control (Cognitive) Therapies for Children (disproved) • Social Skills Therapies for Children (in clinic) • Better for Inattentive (SCT) Type and Anxious Cases

33. ADHD – in summary... • ADHD is probably a disorder of self-regulation and executive functioning • ADHD persists to adulthood in 65+% of cases • ADHD largely results from neuro-genetic factors • Impairments exist in most domains of major life activities • Co-morbidity is very common (80%+) • Many advances in treatment occurred in the past decade, especially in medications • ADHD can be successfully managed leading to improved life course and outcomes

34. Re-cap on characteristics... • Inattention • Hyperactivity • Impulsivity

35. The ADHD Classroom... • Seating • Eye contact • Small chunk tasks • Limit instructions/repeat back to you • Visual aids • Keep away from stimulations • Routines

36. Praise • Class rules on wall - consistency • Systems for tracking work • Immediate rewards • Avoid singling out…name the behaviour

37. Self-help... On-line identification? • http://pediatrics.about.com/cs/adhd/l/bl_adhd_quiz.htm Financial support? • http://www.governmentallowances.co.uk/?gclid=CJ-tgrmFtqACFdkB4wodRWGpUA Useful websites and downloads: • http://www.chadd.org/ • http://www.adhdtraining.co.uk/downloads.php

38. Homework [if we have to!!!]... • Home-school diary • Bring any homework finished or unfinished into school • Home-work clubs • Check that they hand homework in • Use an exchange system i.e. homework/sticker • Discuss any homework issues with parents/carers • Use homework trays – three different trays, colour coded - Red – did not understand it at all - Amber – did it, but not fully understood - Green – understood it completely

39. Friendships... • Use circle time/SEAL to promote positive friendships • Allow the child/young person ‘cooling down’ time following play times • Effective use of lunchtime assistants – supervision and scaffold – designated places/rooms • Organised games at break time/play times • Encourage shared tasks with peers • Model appropriate behaviours • Encourage and support positive friendships • If the child/young person displays problem behaviours, identify the problem

40. Inattention... • Inattentive Behaviour • What to try?

41. Impulsivity... • Impulsive Behaviour • What to try?

42. Hyperactivity... • Hyperactive Behaviour • What to try?

43. Final thought on medication... • See medication in schools policy • If the child/young person needs to take medication in school, discreetly prompt them to go to the school office [or designated place] at the appropriate time • Avoid singling out the child/young person or repeatedly asking them, ‘have you had your tablet?’ • Doctors try and use long acting medication where possible to avoid students needing to take medication in school

44. Triangulation of support...

45. Final Thoughts… • ADHD is probably a disorder of self-regulation and executive functioning • ADHD persists to adulthood in 65+% of cases • ADHD largely results from neuro-genetic factors • Impairments exist in most domains of major life activities • Co-morbidity is very common (80%+) • Many advances in treatment occurred in the past decade, especially in medications • ADHD can be successfully managed leading to improved life course and outcomes

46. Books and Further Information... www.addiss.co.uk Teaching the tiger by Dornbush and Pruitt Attention Deficit Hyperactivity Disorder by Russell A. Barkley How to teach and manage children with ADHD by Fintan O’Regan Hot stuff to Help Kids Chill Out: The Anger Management Book by Jerry Wilde

49. And finally.... Working with young people who have ADHD is extremely challenging. Above all – remember to be adaptable, innovative, empathetic, and ... open minded, And remember that not one strategy fits all…

50. Thanks for listening... Gareth D Morewood Director of Curriculum Support www.gdmorewood.com Sally Trowse Specialist ADHD Nurse sally.trowse@nhs.net