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

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


1
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
    Institute The Childrens Hospital at Westmead
    NSW Australia
  • paulh_at_chw.edu.au

2
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

3
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4
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5
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6
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

7
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 )
8
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

9
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

10
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

11
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

12
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

13
auditory processing disorder/ training Dawes P
Bishop D Int J Lang Comm Dis 2009 44 440-
465 retune 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

14
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

15
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

16
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

17
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

18
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

19
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

20
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

21
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

22
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.

23
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

24
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

25
ASSESSMENT guides INTERVENTION BASIC 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

26
MAIN ACCOMMODATIONS specific 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

27
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

28
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

29
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

30
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

31
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

32
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

33
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

34
ADHD Social difficulty
  • impulsivity immaturity
  • comprehension perception
  • sense of consequences
  • time sequences
  • inner language misinterpretation
  • insatiability overfocussed
  • anxiety self esteem sensitivity

35
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

36
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

37
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

38
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

39
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

40
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

41
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

42
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

43
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

44
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

45
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
46
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

47
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

48
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.

49
CRUCIAL QUESTIONS
  • DOES LANGUAGE WORK
  • DO READING SPELLING WORK
  • DOES LANGUAGE REALLY WORK
  • DOES ORGANISATION WORK
  • IS BEHAVIOUR THE RESULT

50
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

51
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
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