Modern models and management of learning and organisation problems in children and adolescents : evidence into practice

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Modern models and management of learning and
organisation problems in children and
adolescents evidence into practice

• Dr Paul Hutchins
• Child Development Unit
• Childrens Hospital Education Research
  InstituteThe Childrens Hospital at Westmead
  NSW Australia
• paulh_at_chw.edu.au

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Issues of Current Interest

• Interaction between communication behaviour
• Overlaps of language learning organisation
• Dyslexia dyspraxia ADHD autism
  anxiety
• ADHD working memory executive function
• a learning disability seen/described as behaviour
  disorder
• Evidence-based Assess abstract pragmatic
  ?EEG
• Medication extended- release RitalinLA
  Concerta
• Atomoxetine Newest patches guanfacine
• Topical / fashionable Interventions
• FastforWord Neurofeedback Sensory Profile
  Omega 3
• Age Preschool Intellect GT IH CNS Tics Fits
  ABI
• Adult continuity and transition
• GUIDELINES

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HOW IS LANGUAGE POSSIBLE ?

• "The speed and naturalness with which most
  children pick up spoken and written language can
  fool us into underestimating the enormity of the
  intellectual task which faces them, and thus the
  enormity of the task facing those who have to
  solve learning problems when they arise.
• David Crystal

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Having imagination , it takes you an hour to
write a paragraph that, if you were
unimaginative, would take you only a minute . Or
you might not write the paragraph at all.
Franklin P Adams US writer , poet, translator
and editor. 1881-1960 )
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Impact of language function

• play behave and learn at language level
• Language disorder is living in foreign language
  
• predictable effect on social skills
• Social poor with language / or intrinsic lack
  social empathy / social instinct
• Visual strengths may mislead oral vs written
• Rote-learned restricted rituals
  ?anxiety

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CRUCIAL QUESTIONS

• DOES LANGUAGE WORK
• DO READING SPELLING WORK
• DOES LANGUAGE REALLY WORK
• DOES ORGANISATION WORK
• IS BEHAVIOUR THE RESULT
• IS THE BEHAVIOUR SYMPTOM AT THE LEVEL AND
  QUALITY OF LANGUAGE FUNCTIONS
• and PREDICTABLE FOR THE DEMAND

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NATURE OF DISORDERS -QUALITY IS THE KEY

• LANGUAGE IMPAIRMENT 10 DEFICITS/ DYSLEXIA
• content context complexity
• ADHD 8 DISORGANISATION
• fine tuning fluency feedback
• speed capacity EXECUTIVE FUNCTION
• adaptability flexibility WORKING
  MEMORY
• DYSPRAXIA / DCD 5-10 PLANNING
  SEQUENCING
• restricted repertoire inconsistent
  repetition speed
• INTELLECT GIFTED 3 superior 1 highly sup ALL
  OLDER
• INTELLECTUAL DISABILITY 3 mild 1 mod ALL
  YOUNGER
• AUTISTIC SPECTRUM 1 DISTANCE SAMENESS
• failure of social symbols / instinct
  rigidity
• fail to generalise

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Learning disorders how common?

• Specific learning disability 1 in 10
• Specific Language Difficulty 1 in 10
• Specific Language Disorder 1 in 30
• Intellectual Disability 1 in 30
• Specific motor difficulty 1 in 20
• DCD / Dyspraxia 1 in 50
• ADHD 1 in 20
• Inattentive ADHD 1 in 40
• Autism 1 in 150
• Selective mutism 1 in 150

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Recent Epidemiology

• NSW 14.000 in primary schools 2 waves
• Specific Learning Difficulties ?????? 18
• Communication Disorders 13
• English as second language ESL 6 -9
• McKinnon McCleod 2007
• 10.000 children Speech sound disorder 1
  Stutter 0.3
• McKinnon McCleod Reilly 2007
• HONG KONG DATA
• Shanghai Childrens Medical Centre Zhijuan Jin
  Xingming Jin
• Preschool development of Mandarin and identify
  risk

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auditory processing disorder/ training Dawes P
Bishop D Int J Lang Comm Dis 2009 44 440-
465retune ears - Cochrane Collaboration no
evidence

• Fast ForWord Tallal 1973 - poor rapid processing
  - dyslexia
• Computer modulation other
• Scientific Learning Corporation claim 18 to 24
  months gain in 4-6 weeks very few peer reviewed
  
• Merzenich improve fMRI Brain heals itself
  Doidge
• META-ANALYSIS Strong G et al JCPP 2011
  52224-235
• 79 to 13 to 6 studies RCT 60 -454 subjects
  6-11 yrs
• Single word read Passage Compr Rec Expr
  Language 8 pooled effect sizes not differ from
  zero 4 negative
• McArthur G (2008) 6 wks improve poor auditory
  process not Specific language or reading
• Conventional therapies can improve vocabulary
  knowledge

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Risks for language disorder ( and other
disorders)

• FAMILY HISTORY socio-economic
• Cultural and Linguistic diversity CALD
• hearing impairment sensory middle ear ?
• preterm VLBW ELBW nb. Survival
• intellectual disability nb. scatter not uniform
• autism spectrum / Asperger
• Mental Health disorder 40 overlap
• seizure disorders acquired neurology
• genetic e.g. XY !!! XXY Fra X VCFS

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Communication disorders Outcome

• Comprehension biggest risk
• Language impairment beyond 5.5 yrs
• Severity in preschool increases risk
• Adolescent outcome (Snowling M et al 2006)
• SLI have more ADHD
• Social receptive expressive Attention expr
  
• At 19 yrs 71 with LI _at_5 yrs had LD (Beitchman
  2002)
• Language and literacy link
• Tannock 2006 review
• http//literacyencyclopedia.ca/index.php?faitems.
  showtopicId5

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Robert 2 .5 yrs

• Active in utero
• Mother ADHD dyslexia
• Active from day 1
• No sense of danger
• 2 yrs no words 60 dB hearing loss
• 3 yrs active
• 4 yrs medication to enable preschool and therapy
• 6 yrs LD decoding story speech
• 10 yrs special education dex clonidine
• 12 yrs sports and class captain
• 14 yrs high school entry supported now
  slipping

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Sarah 3.5 yrs

• Global delay DQ 60
• language disorder DQ 40
• Active
• Special preschool language therapy
• medication essential
• special class /school still illiterate
• Brother PIQ 130 VIQ 85 presents at 11 years
• language learning disability continues in job /
  TAFE
• age 15years reads _at_ 6yr level

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Carlos 6.5yrs

• no skills no remorse
• active
• NESB
• marital dysfunction
• father illiterate/ alcohol
• always slow speech play
• PIQ 80 ( 95 - 45)VIQ 48 ( language 3.2 yrs)
• special class family behaviour support

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RAYMOND 6 yrs

• IQ 55 sociable language 2 yr level
• Denied Support Class
• Settled term 1 some play draw
• Term 2 went abroad for 2 months
• HI IA aloof ? resist even 1 to 1
• ?need medication
• SUPPORT CLASS signs visuals
• SETTLED quickly

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TOM 9.6.93

• Cricket is when you make a pitch and you get two
  sets of stumps and hit them down on the flat end
  at each side. then you get a cricket ball and a
  bat then you get the ball and throw it and the
  person with the bat hits the ball and that is
  what cricket is
• Sentence someone tells you a bit of a word
• paragraph something half of a sentence or a
  full sentence

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Impact of SLI in adolescence

• reasoning , analysis, narrative
• language of new subjects and countries
• amount / complexity / memory/write
• verbal and social pragmatics
• inference , intuition , humour , sarcasm
• jargon / fashions / music/ games
• negotiation extrapolation
• introspection values individuation
• RELATIONSHIPS CHOICES OUTCOMES

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ADAM age 18 years

• English is one of my most difficult subjects . I
  often know the answers but dont know how to
  express it in words.This gets in the way during
  exams for other subjects. My organisation and
  study skills are not well developed . I have a
  keen interest in computers. but find my learning
  disability prevents me from getting the marks
  that I want.

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IMPACT OF LANGUAGE IMPAIRMENT( cohorts of
Beitchman Bishop)

• Language / Specific LD / ADHD interwoven
• Impact especially in adolescence
• Outcomes in learning , attention , self-esteem ,
  socialisation , employment
• Persisting Language disorder at 15 yrs has
  problems with attention ( especially if
  expressive language ) and social skills
  Snowling, Bishop et al JCPP 47(8), 759-765,
  2006
• Psychiatry Clinics and Language Clinics 40
  overlap
• Many undiagnosed for the other (Cohen N 2003 )
  
• Juvenile Justice 45 SLI ADHD LD(IH)
• Cultural and Linguistic Diversity
• Talk-based therapies for behaviour emotion

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REPORTS CONTENT

• LANGUAGE AGE LEVEL(S)
• EXPLAIN DIFFERENCE LANGUAGE and SPEECH
• QUALITY not just WNL scores
• Scatter and inconsistency
• Functional language TOPS TOAL
• Inference relevance problem solving
• Executive function memory
  attention
• Sense of time and sequence
• Word finding
• EXAMPLES of tests ADVICE for class
• Teach and expect at language level
• Especially visuals , small amounts ,
  clarification, extra time to process and to write
  

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ASSESSMENT guides INTERVENTIONBASIC QUALITY
e.g. TOPS TOAL

• Semantics comprehension context word-finding
• Syntax essays time sequence
• Pragmatics relevance feelings inference
• Metalinguistics figurative humour ambiguity
• Auditory processing
• Metacognition relevance problem solving
• eg Pip Greathead
• www.addiss.co.uk /language disorders.htm
• http//members.tripod.com/Caroline_Bowen/urls.htm

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MAIN ACCOMMODATIONSspecific substantiated
sustained support

• CONTENT
• Understanding research reasoning
  structure
• OUTPUT
• essays extra time computer
  reader writer
• MEDIUM
• MCQ aural tape video then book
  cartoon
• THERAPY language behaviour relaxation
• HIGH SCHOOL 6 YEARS TO DEFINE REFINE
• boxofideas.org Spldtransitions.co.uk

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SPECIFIC LEARNING DIFFICULTY

• Language levels
• Literacy levels? Phonological awareness
• Higher language NOT only phonics
• Word finding
• executive function working memory
• OVERLAP WITH ADHD
• Think motor output ?DYSPRAXIA
• Planning of complex movements
• Dyslexia and Language impairment same or
  different
• Bishop Snowling 2004 Psychol Bull, 130 ,858-886
• Genes language and language disorders
• Smith SD 2007 MRDD Rsearch reviews 13, 96-105
• Genes and reading and maths disorders and ADHD
• Wilcutt EG et al 2010 J Dev Behav Pediatr 231
  533-544

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AD/HD - MODERN EVIDENCE and GUIDELINES

• Australia (2010 ) NHMRC Guidelines
• Hong Kong Child Neurology ( 2007)
• UK ADHD guidelines NICE ( 2008)
• European 2004 and 2009
• Systematic review 13 items 4 countries Europe
• De Siexas and Muller European Psychiatry 2009
• Scotland (2009 ) ww.sign.ac.uk/pdf/sign112.pdf
• American Academy Child Adolesc Psychiatry 2007
  

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Recent Guidelines and reviews - Australian

• Guidelines for Stimulants NSW 1989 onwards - Feb
  2008
• Talk Time Teamwork 1995 NSW Dept of Education
• ADHD in Preschoolers 2004
• National Prescribing Service 2008
• NHMRC Redeveloped Guidelines ADHD ( 2010)
• http//www.nhmrc.gov.au/publications/synopses/adhd
  _draft.htm
• Western Australia Practice guidelines and
  service plan 2009
• Prescribers survey and audit w.cec.health.nsw.go
  v.au/pdf/specialreports/adhd_080211.pdf
• Childrens Hospital Education Research Institute
  Conferences
• cheri.com.au/MotorDifficulties.htm
• cheri.com.au/MakingsenseofAutismStrategiesthatSucc
  eed.htm
• cheri.com.au/PuttingEvidenceintoPracticetoReachTea
  chADHD.htm

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NHMRC Draft Guidelines ( 2010) Strengths
Specific Content

• Wide consultation
• I/A common co morbid
• Early assess LD anxiety
• High-level collaboration
• Preschool supports
• School funding change
• Impact on families NB FH
• Out of home Justice issues
• Adult management
• GP co-prescribe
• National data and policy
• MPH IR - ER - ATX
• Education of all essential

• Extensive references
• Diagnostic tools
• ASQ in PSK
• Importance language dysfunction
• Intell Disab Autism CNS genetics
• School approaches
• ADHD is in Disab Discrim Act
• Tertiary Student needs research
• Training and resources funding
• CAM discussed
• Adult work life assessment
• Drive with medication

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AD/HD CONSENSUS EVIDENCE

• Neurobiological disorder
• Strong genetic influence
• Spectrum inattentive more common
• Usually with language speech and motor disorders
  
• Overlap with autism, intellectual disability
  anxiety
• Long-term course secondary disability
• Severe hyperactivity poorer outcome
• Multimodal treatment essential
• Learning behaviour medication
• INDIVIDUALISED SYMPTOMS and MANAGEMENT

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CORE of ADHD (threshold genes environs)
www.drthomasebrown.com

• How the brain controls thinking learning and
  behaviour
• executive functioning planning and prioritising
  to a goal
• working memory hold in mind while
  processing
• attention focus sustain
  switch speed
• inhibition monitor select regulate action and
  emotion
• A neurodevelopmental learning difference/
  disorder described/ defined/ interpreted as a
  behaviour disorder
• complex language understanding and use
• motor planning visuo-spatial poor time
  sense sequences
• are most vulnerable in complex outputs
• extended writing social interactions
  deadlines work
• Castellanos FX Sonuga-Barke EJS,Milham MP Tannock
  R(2006) Trends in Cognitive sciences.
  10(3),117-123

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Types of ADHD IMPULSIVE INATTENTIVE

• INHIBITION
• motor
• boys gtgtgt girls
• language/speech disorder
• social rejection
• BEHAVIOUR
• aggression
• Early referral
• family discord
• Persistence
• MEDICATION Behaviour

• ORGANISING
• memory/planning
• boys gt girls
• subtle language / speech
• social reticence
• LEARNING
• anxiety/sadness
• Late referral
• family stress
• Adjustment
• Organisation Medication

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ADHD Social difficulty

• impulsivity immaturity
• comprehension perception
• sense of consequences
• time sequences
• inner language misinterpretation
• insatiability overfocussed
• anxiety self esteem sensitivity

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ADHD and Learning Difficulty Overlaps Genes
environment

• ADHD and specific learning difficulty coexist
• Reading disorder ( RD ) and maths disorder (MD)
• Each is familial and heritable
• Co-occur more than by chance
• Multiple genetic and environmental risks interact
• Slow Processing speed common genetic risk
• Wilcutt EG et al 2010 J Dev Behav Pediatr 231
  533-544

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Language impairment and ADHD

• Implied meanings ( Brock Knapp 96)
• Cause effect in narrative ( Lorch et al 2004)
• Poor inference ( McInnes et al 2003)
• Verbal WM ( Castellanos and Tannock 2002)
• Visual spatial WM ( Martinussen and Tannock 2005)
• IA subtle complex HI expressive and clarity
  
• Cohen et al (2000) JCPP
  41, 353-362
• Poorest outcome age 7 with RecepexprHA
• Beitchman et al
  1996
• Persisting Language disorder at 15 yrs has
  problems with attention ( esp. expressive
  language ) and social skills
• Snowling, Bishop et al JCPP 47(8),
  759-765, 2006

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Working Memory concept impact ??train it

• Working Memory more impact on academic outcomes
  than IQ
• ( T
  Alloway ( 2010) S Gathercole)
• scatter on WISC-IV ? valid
• Is WM big enough / fast enough in G and T
• High IQ and ADHD ( Brown Reichel Quinlan 2007)
• Youth and Adult ADHD compare to controls
• Working Memory Processing Speed ( cf. VCI or
  POI)
• ADHD -1sd 80 -2sd 40 Normal -1sd 30 -2sd 4
  
• Story Memory Index (cf. VCI)
• ADHD -1sd 86 -2sd 37 Normal -1sd 15 -2sd
  2.5
• Self Report Exec Fn Youth 65-75 N 5-8
  Adults 70-90 N 5-7
• High IQ and ADHD ( Antshiel et al 2008 and 2007)
  49 ADHD 92 non-ADHD
• At 5 yrs ADHD diagnosis persist 78 (others
  subthresh) 23 no medic high IQ stable
• More repeat grades co morbid close rels ADHD
  mood anxiety behave peers parents

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Mark

• 4 y ? ASD language poor puzzle no VG
• 8 y comprehend 4y PIQ 140 language . therapy
• 9 y medication essay converse
• 10 y Maths national competition
• 14 y depression - SSRI help
• 18 y HSC International Maths competition
• 21 y Univ HD Maths Comp Ph D Nerds
  FC
• Poor organisation Poor insight e g birthday
• Some empathy ?Asperger SSRI still helps
• 24 y Ph D deadline has friends/ gfriend at
  home
• Mother I am still his frontal lobe ? How
  long

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ADHD and AUTISM

• ADHD not if PDD /autism present in DSM-1V
  (CHANGE!)
• Clinical symptom overlap 50 - 70
• Children Communic. Checklist Guerts 2004 JCPP 45
  1437-53
• ADHD developmentally inappropriate for autism
• Genes overlap 41 ASD ?ADHD 22 ADHD ?ASD
  Ronald A et al JCPP 2007
• Use of medication in both Autism and ADHD
• Wisniewski T 2007 J Ped Neurol 5, 189-197
• Categories of special education ? Increase
  diagnosis
• 2005 J Paed Ch Health 41 Dossetor 405, Skellern
  407
• Www.mindroom.org.spaw2/uploads/files/gillberg_s_17
  .ppt
• Gargaro B et al Neuroscience and behavioral
  review 2010

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LUKE 6 years

• Autism aloof draw drains hyperlexia
• Auditory sensitive roaming
• Anxious SSRI less obsessive
• At School is constantly moving ? H/I
• Paed tried RitalinLA then tic for 16 hours
• Earphones help while building site in action

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USING MEDICATION science success safety

• establish understanding education
  collaboration
• TALK TIME TEAMWORK
• Use appropriate medication
• are target symptoms / expectations clear ?
• Refine teaching and behaviour and therapy
  supports
• Individualise medication dose to child and
  curriculum

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Stimulant Medication Dexamphetamine 5 mg
Methylphenidate 10 mg Non Stimulant
Atomoxetine ( Strattera ) NA inhibitor similar
effects

• NEW types Slow release Concerta Equasym
  atomoxetine
• Pro drug lisdexamphetamine Patches
  guanfacine
• Dopamine /noradrenaline stimulate organisation
• Effective 70 to 92
• 10 single medication 10 no response
• Normalise behaviour and classroom performance
• language and learning memory and planning
• self esteem family/ peer relations
• RIGOROUS CONTROL PROCESSES
• Adverse effects lt10 appetite sleep mood ?
  Growth
• Can use in preschool seizures tics /
  Tourette
• Media misinformation and mischief extreme
  opinions

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Stimulants benefits for language e.g listening
comprehension inference visp spatial WM
McInnes A, Tannock et al. J Ch Adol
Psychopharm 17(1)35-49 2007 patients
say research finds

• Listen better longer more
• Start persist switch
• Clearer and more thoughts
• Conversation logical
• Creativity
• Argue better !
• Inference and relevance
• More information (WM)
• Speech clearer

• Naming speed Bedard 2004
• Verbal Working memory
• Visual Spatial WM
• Oral narrative Francis 2003
• Patient Clinical tests
• Divergent thinking
• Convergent thinking
• Listening comprehension (CELF)
• Reading comprehension
• Reading and spelling
• Syllable rate

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OTHER MEDICATIONS

• Less effect on core ADHD more side effects
• little science less RESTRICTED
  PRESCRIBING
• Clonidine - impulsivity oppositional ? sleep
  
• Tricyclics - anxiety Inattentive gt impulse
• Sertraline - depression/obsessionality
• Fluoxetine -
• Risperidone - aggression Conduct disorder
• Carbamazepine - aggression

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Tuning Medication to Teaching
ADHD SYMPTOMS
STIMULANT DOSE
DOSE TIMING
Homework
7 am
11 am
1 p.m.
4 p.m.
9 p.m.
DOSE TIMING
ADHD SYMPTOMS
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AD/HD Complementary Approaches

• Most have little research
• Omega 3 and 6 Fatty Acids
• EEG neurofeedback
• Heinrich (2007), J Ch Psychol Psychiatr, 48
  316.
• Memory Training Klingberg
• Food additives ? act via histamine degrade gene
• Stevenson J (2010) Child and Adolescent Mental
  Health, 15 130133

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ADHD and Omega fatty Acids

• Anecdotal more research support
• Omega 3 to Omega 6 balance
• Benefits on motor skills and behaviour 20
• Compare with medication in different groups
• Population placebo study
• Kirby A et al (2010) Res in Develop Disab, 31
  718-730
• Clinical study 25 had 25 to 47 gain
• Johnson M 2009 J Attention Dis 12 394-401

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AD/HD and Memory Training

• Working memory impairment is a key deficit in
  ADHD
• Working memory can be directly improved by
  specifically targeted training
• Reduces symptoms of inattention, and improves
  related cognitive abilities
• Training effect involves plasticity of parietal
  and frontal regions
• Klingberg T ,Trends in Cognitive Sciences, Volume
  14, Issue 7, 317-324, 17 June 2010
• sadd.nl/wallpapers20canada/TorkelKlingberg.pdf.

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CRUCIAL QUESTIONS

• DOES LANGUAGE WORK
• DO READING SPELLING WORK
• DOES LANGUAGE REALLY WORK
• DOES ORGANISATION WORK
• IS BEHAVIOUR THE RESULT

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ADHD LANGUAGE and LEARNING

• Always assess basic and higher language in ADHD
• Teacher not assume in ADHD without language or
  reading difficulty that student does comprehend
  everything
• Target academic cognitive language problems
• AND behaviour
• Synchronise medication to academic demands
  support
• When you meet ONE of the labels of
• ADHD LD Language Disorder or Motor Disorder
• GET INFORMATION ABOUT THEM ALL

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Creativity or
Confusion - a point of view and context of load
expectation

• Lateral thinking/ solving
• Imagination/innovation
• Intuition / empathy
• Energy / spontaneity
• Charm / charisma
• Focus / commitment
• Intensity / persistence
• Enthusiasm / passion
• Vision / ambition

• Distractibility/inconsistency
• Inaccuracy /irreverence
• Intrusion / introversion
• Activity / impulsivity
• Superficiality
• Insatiable / inflexible
• Compulsion / zeal
• Arrogance / idiosyncrasy
• Risk-taking / egocentricity