Strategies to improve ADHD symptoms - PowerPoint Presentation

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Strategies to improve ADHD symptoms

Kevin M. Antshel, Ph.D.

Associate Professor of Psychiatry / Licensed Psychologist

Director, ADHD Lifespan Treatment, Education & Research Program

SUNY – Upstate Medical UniversitySlide2

Outline

10 principles of ADHD treatment

Strategies designed to improve executive functions

Strategies designed to improve working memorySlide3

Essential Principles of ADHD Treatment

PRINCIPLE #1

: There are

no

magic cures for ADHDSlide4

Essential Principles of ADHD Treatment

PRINCIPLE #2

:

For children and adolescents with ADHD, medication

can

helpSlide5

Essential Principles of ADHD Treatment

PRINCIPLE #3

: Too

little or too much treatment

(medical

or otherwise

)

both

have side- effectsSlide6

Essential Principles of ADHD Treatment

PRINCIPLE

#4

: Strategies are effective

only if the

setting allows

for

their consistent implementationSlide7

The Essential Needs of

a Child with ADHD

Clearly specified rules, expectations and instructions

Frequent, immediate, and consistent feedback on behavior and redirection to task

Reasonable and meaningful consequences for both

adherence and

nonadherence

Adults who will deal with his/her problems based on knowledge, compassion, and respect

Programming and adult intervention designed to compensate for the child's impulsiveness, inattention, distractibility, limited organizational skills, and low frustration tolerance

A well-integrated and functioning team of parents, teachers, administrators and clinicians who communicate often and work together to create a structured and supportive environmentSlide8

Essential Principles of ADHD Treatment

PRINCIPLE

#5

: There's nothing better

than a

good teacher Slide9

Incentive Exists If . . .

1. The task at hand is more compelling than almost anything else around at that moment

and/or

2. There is some predictable and meaningful

reinforcement for

compliance with clearly-stated rules and/or some predictable and meaningful punishment for

nonadherence

with

clearly stated rules.Slide10

Principle #6

There is no better treatment than an accurate diagnosis.

Not all inattention is ADHD

Are there other

comorbid

conditions? Slide11

Principle #7

One size does not fit all.

What

treatment, by

whom

, is most effective for

this

individual with

these

specific problems, and under

which

set of circumstances?Slide12

MTA – Cost / benefit analysis

Jensen et al., 2005Slide13

Principle #8

Combined treatment should be recommended for ADHD + [

insert diagnosis here

].Slide14

Principle #9

Parent training is a front-line behavioral intervention.

Differential reinforcement of other behaviors (

DRO

),

time out

&

response cost

are

empirically supported treatment components

For behavioral treatment to work best, it must be

intensive

&

across settingsSlide15

Principle #10

Know what is most likely a waste of time and money.

Unsupported and / or discredited treatments

Removal of sugar from child's diet

Removal of food additives, dyes, etc.

Megavitamin therapy

Caffeine

Removal of fluorescent lights

Sensory motor integration

Biofeedback training /relaxation exercises

Treatment for inner ear disturbances

Vision training

Social skills trainingSlide16

Implications for Treatment

Teaching skills is inadequate

The key is to design prosthetic environments around the individual to compensate for their EF deficits

Therefore, effective treatments are always those at the “point-of-performance”

The EF deficits are neuro-genetic in origin

Therefore, medications may be essential for most (but not all) cases – meds are neuro-genetic therapies

But some evidence suggests some EFs may also be partly responsive to direct training

While ADHD creates a diminished capacity: Does this excuse accountability?

(No! The problem is with time and timing, not with consequences)Slide17

More Treatment Implications

Behavioral treatment is essential for restructuring natural settings to assist the EFs

They provide artificial prosthetic cues to substitute for the working memory deficits (signs, lists, cards, charts, posters)

They provide artificial prosthetic consequences in the large time gaps between consequences (accountability) (i.e., tokens, points, etc.)

But their effects do not generalize or endure after removal because they primarily address the motivational deficits in ADHD

The compassion and willingness of others to make accommodations are vital to success

A chronic disability perspective is most usefulSlide18

How do we compensate for EF deficits?

By Reverse Engineering the EFs

Externalize important information at key points of performance

Externalize time and time periods related to tasks

Break up future tasks into many small steps

Externalize sources of motivation

Externalize mental problem-solvingSlide19

Externalizing Working Memory

Use externally (outside the individual) represented forms of information to remind the individual what is to be done at the point of performance

This can be done by using sticky notes, cues, cards, lists, posters, signs, and other prompts of critical reminders at the point of performance

For older kids and adults, also use personal journals, digital recording devices, Watch-Minder watches, day planners, personal organizers, computer organizersSlide20

Externalizing Time and the Future

Make time physical, external, and obvious

timers, clocks, counters, and anything else that can signal time’s passing

Break down future projects and goals into small pieces and do a piece a day (or more frequently).

Bring the Es, Rs, & Os of life close togetherSlide21

Make Motivation External

Identify tasks and settings in which consequences are too delayed or nonexistent

Put artificial consequences into these large gaps in time

Tokens, points, prizes, praise, privileges

Increase accountability to others – more frequent check-ins with others to see that work is being done, goals are being metSlide22

Make Problem-Solving Manual

When tasks normally require mental problem-solving (manipulating mental information, generating multiple ideas, etc.) make the mental information external, physical, or manual

For math, use marbles, number lines, an abacas, etc. and calculators

For words, use cards, paper, computer word processing programsSlide23

Memory Improvement TechniquesSlide24

Attention ----> Encoding ----> Storage ----> RetrievalSlide25

Attention

(Concentration of Effort)Slide26

Effort

Interest

-- The brain prioritizes by

meaning, value

and

relevance

.

To have

meaning

, you must understand what you are learning.

In order to remember something thoroughly, you must be interested in it and think that it has

value

and

relevance

in your life.

Ways to create interest in a class in which you are confused or bored:

Find a study partner.

Get to know the teacher / professor better.

Do some extra practice or research. (We tend to be uninterested in things we are not good at.)

Teach an assignment to someone else.

Seek a way to make the information personal. Slide27
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Effort (cont’d)

Techniques to help improve attention:

Use a concentration check sheet. When you feel yourself wandering from the subject, put a check on this sheet. Do this every time you find yourself not concentrating. You will program your mind to pay attention.

When reading an assignment

talk back to

the writer.

When listening to a lecture, ask frequent questions.Slide29
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Background Knowledge

The more we know about something, the easier it is to learn more

.

Before you read an assignment, preview it. Survey the title and headings. Read the summary. Familiarize yourself with the study questions. Think about and try to recall what you already know about the subject.

Then

read the assignment.

The more you know about the subject, the easier it will be to take notes during the lecture. Before you go to class, do all homework assignments and readings.

Do extra research. Explore the internet. Create ways to experience the subject.Slide31
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Imagery can help encoding

Most of us remember what we see much larger (and better) than what we read or hear. We, therefore, need to make an effort visualize everything we learn.

No matter how abstract, determine a way to visualize each new concept :

Will it convert to a chart or graph?

Can I draw it out?.

Can I make a mental video of the process? (If you used a mnemonic devise to learn something, you might make a mental video of the word or sentence.)

Do I know what each person I am learning about looks like? (If can't find out, make it up!) Slide34
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Practice should be activeSlide36
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Active Practice

The 

more senses

we use the stronger the 

neural trace

.    

The more 

feedback

we get, the 

faster

and more accurate our learning is.   

Practice

Fallacy of total time hypothesis

Spacing effect – allows consolidation

Active practice works for several reasons:

When you know you are going to recite something

in your own words

, you pay more attention.

You get immediate feedback. You know if you are able to explain something in your own words out loud, you understand it.

Some tips for active practice

:

Make use of

flashcard

of anything you need to learn.

When you finish reading a paragraph in your reading assignment, stop and recite. You will soon see that understanding what you read and explaining it out loud are very different.

Find a partner and ask each other questions and answer out loudSlide38

Active Practice (cont’d)

Association

is central to the process of encoding and retrieval.

Optimal learning occurs when the brain’s multiple maps work in synchronization or network with each other.

By recalling something you already know and making a link to the "brain file" that contains that information, you should be able to remember new information more efficiently. Ask yourself:

Is this like something I already know?

Is the number similar?

Is the sound similar?

Can I use it for something similar?

If I were filing it in my brain "filing cabinet", it there an existing file I can use instead of creating a new one?

How do you remember: your pin number? your telephone number? where you parked your car? your instructors name? the name of the person you just met? Slide39

Organization

When information is poorly encoded there is no hope for data recovery.

Alphabetize.

Use a mnemonic device (e.g., HOMES: Huron, Ontario, Michigan, Erie, Superior).

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Time

Learning is a biological process that literally changes the configuration of the brain. This takes time.

New information takes time to soak in. We are usually bombarded with much more information than we can remember. We must, therefore, allow time for consolidation to take place. In fact, we must

cause

consolidation to take place. Ways to consolidate:

Taking notes in class

Asking questions in class

Reviewing Notes

Stopping after each paragraph you read and writing a question in the margin which identifies what the paragraph is about

Visualizing

Reciting

Making flash cards

Designing practice tests

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Time (cont’d)

Using distributed practice optimizes our learning.

Distributed practice allows time for things to consolidate and for you to build a basic background. It also uses what we know about the nature of short-term memory.

Here are a few tips:

Take 10 minute breaks after each hour of study and review what you just learned before you begin again.

Have a scheduled time to study each subject.

Make use of daylight hours and time that you normally waste.

Use flash cards

Study immediately before and after classes .

Short sessions, more often, create growth of dendrites and connections exponentially.

Studies of biological cycles confirm that the body is going to take “down time” whether we give it or not.Slide43

We tend to remember things at the beginning of a list or study session and things at the end.Slide44

State dependent learning

Retrieval is enhanced if variables (e.g., mood, environment, etc.) are highly similar between encoding and retrieval.Slide45
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MetacognitionSlide48

Metacognition

Metamemory

MetacomprehensionSlide49
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Model predicting recall. (DeMarie & Ferron, 2003)