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Understanding and Responding to Behavioural Issues of Students with ADHD, Sensory Integration Dysfunction and ODD

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Title: Understanding and Responding to Behavioural Issues of Students with ADHD, Sensory Integration Dysfunction and ODD


1
Understanding and Responding to Behavioural
Issues of Students with ADHD, Sensory Integration
Dysfunction and ODD
  • Prepared by Ellen Young, Krista Heisinger Frost,
    and Michelle Hancock

2
What is Neurologically-Based Behaviour
(NBB)?(Paula Cook, 2011)
  • About 10 of students cant reliably control
    what they say or do.
  • The overarching name for the behavioural
    condition they exhibit is NBB
  • NBB is behaviour that results from cerebral
    processes occurring in an abnormal manner that
    results in information not being processed
    correctly in the brain. The resulting behaviour
    is challenging, unpredictable, inconsistent and
    unresponsive to ordinary discipline.

3
3 Indicators of NBB
  • 1. Behaviour difficulties - atypical,
    inconsistent, compulsive or immune to normal
    behaviour management
  • 2. Language Difficulties problems
    understanding, processing, and expressing
    information verbally
  • 3. Academic Difficulties memory, fine and gross
    motor skills, comprehension, language and math
    skills deficits

4
Common Diagnoses within NBB
  • Brain injuries
  • Attention-Deficit Hyperactivity Disorder
  • Oppositional Defiant Disorder
  • Bipolar Disorder
  • Anxiety Disorders
  • Fetal Alcohol Spectrum Disorder
  • Sensory Integration Dysfunction
  • Autism Spectrum Disorder
  • Learning Disabilities

5
Attention Deficit Hyperactivity Disorder (AD/HD)
  • Common neurobiological condition affecting 5-8
    of school age children (Barkley, 1998)
  • Symptoms persist into adulthood in approximately
    60 of cases (4 of adults) (Kessler et al.,
    2006)
  • Characterized by developmentally inappropriate
    levels of inattention, and/or impulsivity and/or
    hyperactivity
  • Chronic, incurable condition

6
Possible Causes of AD/HD
  • The current model of the cause of AD/HD is rooted
    in the biological paradigm that emphasizes
    neurobiological, neuroanatomical and genetic
    mechanisms.
  • Research clearly indicates genetic factor likely
    multiple interacting genes (Tannock, 1998
    Swanson and Castellanos, 2002)
  • Other causal factors low birth weight, prenatal
    maternal smoking, prenatal problems may also
    contribute (Connor, 2002)

7
Neurology of AD/HD(Barkley, 2005)
  • Structural differences in the brain and
    neurotransmitter Dopamine and norepinephrine
    dysregulation (Barkley, 2005)
  • Smaller, less active, less developed brain
    regions (cerebellum, prefrontal cortex, basal
    ganglia)
  • Bad parenting is not a cause!
  • http//www.youtube.com/watch?vu82nzTzL7Tofeature
    related

8
Proper Steps in Diagnosis No single test
  • Clinical assessment of the individuals academic,
    social and emotional functioning and
    developmental level in order to determine if
    DSM-IV diagnostic criteria are met
  • History interviews with parents, teachers,
    child
  • Use rating scales and checklists (Conners Parent
    and Teacher rating scale, Barkleys Home and
    School Situation Questionnaire) Continuous
    Performance Tests (TOVA)
  • Physical exam (to rule out other medical problems
    or to determine the presence or absence of
    co-existing conditions)

9
DSM IV
  • The American Psychiatric Association's Diagnostic
    and Statistical Manual-IV, Text Revision (DSM-IV)
    is used by mental health professionals (school
    and clinical psychologists, clinical social
    workers, doctors) to help diagnose ADHD. This
    diagnostic standard helps ensure that people are
    appropriately diagnosed and treated for ADHD.

10
The DSM-IV characterizes the following 3 subtypes
of AD/HD(http//www.nichq.org/toolkits_publicati
ons/complete_adhd/01ADHD20Introduction.pdf)
  • Inattentive only (AD/HD-I) (formerly known as
    attention-deficit disorder ADD)Children with
    this form of AD/HD are not overly active. Because
    they do not disrupt the classroom or other
    activities, their symptoms may not be noticed.
    Among girls with ADHD, this form is most common.
    Approximately 30 to 40 of children with AD/HD
    have this subtype.
  • Hyperactive/Impulsive (AD/HD-HI)Children with
    this type of AD/HD show hyperactive and impulsive
    behavior but can pay attention. This subtype
    accounts for a small percentage, approximately
    10, of children with ADHD.
  • Combined Inattentive/Hyperactive/Impulsive
    (AD/HD-C)Children with this type of AD/HD show
    all 3 symptoms. This is the most common type of
    AD/HD. The majority of children with AD/HD have
    this subtype, approximately 50 to 60.

11
Mimics
  • Anxiety, depression, mental retardation, sleep
    apnea, hypo/hyperthyroidism, Central Auditory
    Processing Dysfunction, severe sensory
    impairment, and learning disabilities may cause
    similar symptoms may actually be the primary
    diagnosis or may co-exist with AD/HD

12
Co-Existing Conditions(Baren, 2002)
13
Popular Misconceptions
  • AD/HD is environmentally caused
  • AD/HD is over diagnosed
  • Most kids outgrow symptoms (about 1/3 do)
  • AD/HD means inability to pay attention
  • AD/HD kids need to put in more effort
  • Kids notice benefits of medication
  • Consequences change behaviour
  • Stimulant medication leads to alcohol and
    substance abuse
  • ADHD affects males more than females

14
Importance of Early Identification and
Intervention
  • Potential areas of impairment
  • academic achievement
  • relationships family and friends
  • low self-esteem
  • accidental injuries
  • Smoking and substance abuse
  • Motor vehicle accidents
  • Legal difficulties-delinquency
  • Occupational/vocational

15
ADHD and Juvenile Criminal Justice System
(Robert Eme, American School of Professional
Psychology, 2008)
  • 2, 300,000 adults and 100,000 juveniles are
    incarcerated in the United States
  • At least 25 and up to 50 have ADHD
  • This holds true for incarcerated females may
    even be more likely than males to have ADHD

16
Multi-modal Treatment Medical, Educational and
Behavioural Interventions
  • Parent and child education about diagnosis and
    treatment
  • Behaviour modification management techniques
  • Medication
  • Psychotherapy/Counseling (family individual
    self-esteem and coping skills)
  • Coaching (develop better habits, social skills
    training)
  • School programming (IEP, AEP, BIP)
  • Physical Exercise
  • Complementary and alternative medicine (CAM) for
    AD/HD such as elimination of sugar, food
    additives, preservatives EEG biofeedback are not
    supported in the literature (Rojas and Chan,
    2005)
  • Severity and type of AD/HD should be considered

17
National Institute of Mental Health Study
Multimodal Treatment Study of Children with AD/HD
(1999)
  • Children who were treated with medication alone
    (which was carefully managed and individually
    tailored) and children who received both
    medication and behavioural treatment experienced
    the greatest improvements in their AD/HD symptoms
    (attention, hyperactivity, impulsivity)
  • medication and behavioural treatment had added
    benefits for non-AD/HD symptom domains
    (parent-rated oppositional/aggressive symptoms,
    parent-child relations, teacher-rated social
    skills, internalizing symptoms, reading
    achievement)

18
Impact of Stimulant Medication
  • Increased
  • Decreased
  • Attention
  • Concentration
  • Compliance
  • Effort on tasks
  • Amount and accuracy of school work
  • Activity levels
  • Impulsivity
  • Negative behaviours
  • Physical verbal hostility

19
Medication Impact(Dr. Russel Barkley)
  • Working memory
  • Self-talk, self-esteem and emotional control
  • Verbal fluency
  • Motor coordination, handwriting
  • Acceptance by and interaction with peers
  • Awareness of the game in sport
  • Decreased punishment by others

20
Behaviour Modification
  • The scientific literature, the National Institute
    of Mental Health and other professional
    organizations support stimulant medication and
    behaviourally oriented psychosocial treatments,
    also called behavior therapy or behavior
    modification, as effective treatments for AD/HD.

21
Behaviour modification teaches children specific
techniques and skills
  • children with AD/HD face problems beyond the core
    symptoms of inattention, hyperactivity and
    impulsivity
  • These include poor academic performance and
    behavior at school, poor relationships with peers
    and family members, and failure to obey adult
    requests.
  • to help improve their behavior
  • skills are reinforced by parents and teachers.

22
Behaviour modification is often put in terms of
ABCs
  • Antecedents conditions or context in which
    problem behavior occurs
  • Behaviours responses or actions that concern
    teacher or parent exhibited by the student
  • Consequences events and behaviours that follow
    the occurrence of the problem behavior

23
Parents and teachers learn and establish programs
in which
  • the environmental antecedents (A) and
    consequences (C) are modified to change the
    childs target behavour (B).
  • Treatment response is monitored via observation
    and measurement, and the interventions are
    modified when they fail to be helpful or are no
    longer needed.

24
Daily school-home report-card
  • This tool allows parents and teacher to
    communicate regularly, identifying, monitoring
    and changing classroom problems.
  • It is inexpensive and minimal teacher time is
    required.
  • Can use a report-card or simply a calendar with a
    smile or frown for each day

25
Teachers determine the individualized target
behaviors
  • Teachers evaluate targets at school and send the
    report card home with the child.
  • Parents provide home-based rewards more rewards
    for better performance and fewer for lesser
    performance.
  • Teachers continually monitor and make adjustments
    to targets and criteria as behavior improves or
    new problems develop.
  • Use the report card with other behavioral
    components such as commands, praise, rules, and
    academic programs.

26
(No Transcript)
27
Behaviour Interventions
  • Be consistent
  • Use positive reinforcement
  • Contracts
  • Token programs
  • Response cost
  • Redirection
  • Time-out/thinking areas
  • Teach problem-solving skills
  • Communication skills
  • Self-advocacy skills
  • List-making
  • Teach Agenda/day-planner use

28
5 Effective Forms of Intervention for Peer
Relationships
  • Systematic teaching of social skills
  • Teaching social problem solving (eg early years
    rock/paper/scissors)
  • Teaching other behavioral skills often considered
    important by children, such as sports skills and
    board game rules
  • Decreasing undesirable and antisocial behaviors
  • Help to develop a close friendship

29
Programs use methods that include
  • Coaching
  • use of examples
  • Modeling, role-playing and practice
  • feedback, rewards and consequences,
  • Social skills training groups are the most common
    intervention and the focus is on the systematic
    teaching of social skills.

30
90 of Children with ADHD have Academic
Challenges
  • Written expression
  • Math (times tables and word problems)
  • Spelling and Reading
  • Overall low academic achievement scores
  • Disorganized, incomplete homework
  • Difficulty getting started (procrastination)
  • Impaired sense of time (it will take me forever
    to do this!)

31
Middle School ADHD Brick Wall (Dendy, 2008)
  • Increased demands for executive functioning
    (management functions of the brain)
  • Organization
  • Memory
  • More complex academic work
  • Working independently
  • More homework
  • More complex routines (change classes/teachers)

32
Greatest Areas of Difficulty
  • Difficulty following multiple-step directions
  • Give written directions, ask child to repeat
    directions, chunk work into manageable units, use
    graphic organizers
  • Completing tasks in a timely manner
  • Use a timer (cellphone or watch), help child
    develop a plan (timeline), offer incentive, allow
    more time
  • Recall of rote details
  • use mnemonics, color-coding, use image
    association
  • Copying and writing
  • allow more time, give hand-outs or note frames,
    chunk work, laptop type instead of hand-writing

33
Reframe Your ThinkingGifts of AH/HD
  • Students are
  • Energetic
  • Creative
  • Risk-takers (in a good way)
  • Persuasive
  • Verbal
  • Big picture thinkers
  • Good long-term memory
  • Free thinkers
  • Mostly good looking

34
References
  • Baren, M. (2002). ADHD in adolescents Will you
    know it when you see it? Contemporary Pediatrics,
    19(5), 124-143.
  • Barkley, R. (1998). Attention Deficit
    Hyperactivity Disorders A Handbook for Diagnosis
    and Treatment. New York Guilford Press.
  • Barkley, R. (2005). Attention Deficit
    Hyperactivity Disorders A Handbook for Diagnosis
    and Treatment (3rd ed.). New York Guilford
    Press.
  • Connor, D.R. (2002). Preschool Attention deficit
    hyperactivity disorder A review of prevelance,
    diagnosis, neurobiology, and stimulant treatment.
    Journal of Developmental Behaviour Pediatrics 23
    (1Suppl)S1-S9.
  • Dendy, C. Understanding the Impact of ADHD
    Executive Functions on Learning and Behaviour.
    In Proceedings of the ADDA 13th National
    Conference. Minneapolis, MN. pp. 166-83.
  • Eme, R. (2008). ADHD The Criminal Justice
    System. In Proceedings of the ADDA 13th National
    Conference. Minneapolis, MN. pp. 89-91.
  • Kessler, R.C., Adler, L., Barkley, R., Biederman,
    J. The prevalence and correlates of adult ADHD in
    the United States Results from the National
    Comorbidity Survey Replication. Am Journal of
    Psychiatry (2006), 163724-732.
  • MTA Cooperative Group. (1999). A 14-Month
    randomized clinical trial of treatment strategies
    for attention-deficit/hyperactivity disorder.
    Archives of General Psychiatry, 56, 1073-1086)

35
References
  • MTA Cooperative Group. (1999). Moderators and
    mediators of treatment responses for children
    with attention-deficit/hyperactivity disorder.
    Archives of General Psychiatry, 56, 1088-1096)
  • Rojas, N.L., and Chan, C. (2005). Old and new
    controversies in the alternative treatment of
    attention-deficit hyperactivity disorder. Mental
    Retardation and Developmental Disabilities
    Research Reviews, 11 116-130.
  • Swanson, J.M., and Castellanos, F.X. (2002).
    Biological Basis of ADHD-Neuroanatomy, Genetics,
    and Pathophysiology. In P.S. Jensen and J.R.
    Cooper (eds.) Attention deficit hyperactivity
    disorder State of the science, best practices,
    pp. 7-1-7-20. Kingston, New Jersey.
  • Tannock, R. (1998). Attention deficit
    hyperactivity disorder Advances in cognitive,
    neurobiological, and genetic research. Journal of
    Child Psychology and Psychiatry, 39, 65-99.

36
Sensory Processing DisorderorSensory
Integration Dysfunction
37
Dr. A. Jean Ayres 1920- 1989
38
Background Information
  • Also known as Sensory Processing Disorder
  • Dr. A. Jean Ayres first developed the theory of
    Sensory Integration Dysfunction in the 1960s
  • Wrote two books Sensory Integration and Learning
    Disorders in 1972 and Sensory Integration and the
    Child in 1979
  • Was an occupational therapist and developmental
    psychologist
  • Worked at the Institute for Brain Research at the
    University of California at Los Angeles.

39
What is Sensory Processing Disorder?
  • Sensory integrative/ processing disorders are a
    set of conditions caused by an insufficient
    ability of the central nervous system to take in,
    register, modulate, perceive, and/or combine
    sensory experiences (input) from the environment
    around us.
  • The neural messages become disorganized as they
    travel up towards the higher brain centers. The
    messages may also become overly-amplified or
    diminished, and are hence unusable. Sensory
    inputs are the building blocks of learning and
    relating to our environment and the people in
    it.
  • Video What is SPD?

40
The Senses
  • Body Centered Sensory Systems or Near Senses
  • Interoceptive- internal organs- e.g. heart rate,
    hunger
  • Tactile- info received through the skin
  • Vestibular- movement-pull of earths
    gravity/balance
  • Proprioception- info from muscles and joints
  • The Five Basic Senses or Far Senses
  • Sight
  • Sound
  • Taste
  • Smell
  • Touch
  • -Respond to external stimuli from the
    environment.
  • (Kranowitz,40,41)

41
Causes of SPD according to Dr. Ayres
  • Hereditary predisposition for minimal brain
    dysfunction
  • Environmental toxins air contaminants,
    destructive viruses
  • Combination of hereditary and environmental
    toxins
  • Lack of oxygen at birth
  • Children who lead deprived lives- little contact
    with people or things
  • Neurological disorders
  • Internal sensory deprivation(sensory stimulation
    is present in the environment but the stimulation
    doesnt nourish every part of the brain) (Ayres,
    54-56)

42
The Symptoms or BehavioursExhibited
  • Each childs symptoms are different and unique,
    making it difficult to diagnose sensory
    processing disorder.
  • Hyperactivity and Distractibility - activity
    usually not purposeful, cannot shut out noises,
    lights, etc.
  • Behaviour Problems- not happy with self, fussy,
    overly sensitive negative self concept- negative
    reactions from others
  • Speech Development- speech and articulation
    develops slowly

43
The Symptoms/ Behaviours Contd
  • Muscle Tone and Coordination- if vestibular,
    proprioceptive, and tactile systems are not
    working well- poor motor coordination results.
  • Learning at School- learning starts from the
    bottom of the brain and moves up if the senses
    are disorganized then learning and behaviour
    problems will result
  • Teen-age Problems- may have learned how to
    compensate for sensory processing disorder if
    not may drop out of school ---major lack of
    organization.
  • These symptoms are end products of inefficient
    and irregular sensory processing in the brain.
    (Ayres, 56-59)

44
An Evaluation by an Occupational Therapist
Considers
  • Perception and registration of sensorimotor
    information- what the child sees, hears, touches,
    tastes, and smells
  • How movement and gravity are experienced
  • Gathers information through clinical
    observations, sensory history, and standardized
    tests
  • - Can the child use sensorimotor
    experiences to learn, interact. explore, and
    demonstrate knowledge?
  • - Does the child respond negatively
    or with extreme behaviours (flight, fright, fight
    responses) to unexpected or light touch, unstable
    surfaces, loud noises, visual distractions, or
    certain tastes, textures, and smells?
  • - Can the child filter out irrelevant
    sensory input?
  • (Williams, Shellenberger, 3)

45
The Brains Ability to Self Regulate
  • Mechanisms needed to self regulate
  • Modulation- neural switches can turn on or off
    depending on activity level
  • Inhibition- reduce connections between sensory
    intake and behavioural output
  • Habituation brain tunes out familiar sensory
    messages
  • Facilitation connections between sensory intake
    and behavioural output
  • (Kranowitz, 42-44)

46
The Alert Program for Self- Regulation
  • Uses the analogy of a car engine to introduce
    self-regulation to students
  • The program can be adapted to all ages
  • It entails three stages 1.identifying engine
    speeds, 2.experimenting with changing engine
    speeds, and 3.regulating engine speeds with each
    stage consisting of a number of steps or mile
    markers.
  • Speeds are as follows high (hyper,
    overexcited), low (sluggish, spacey) and just
    right (easy to learn and get along with others)
  • There are activities that can be used for each
    step and each step should be modelled for the
    student to be able to thoroughly understand the
    engine levels and how to change them
  • Program is designed to give students the ability
    to self regulate their engines according to the
    activity they are doing.
  • (Williams Shellenberger)

47
Types of SPD
  • Sensory Modulation Dysfunction- the brain
    cannot regulate the amount of sensory information
    it allows to enter. (Hypersensitivity,
    hyperreactivity - registers sensations too
    intensely and Hyposensitivity, hyporeactivity
    not getting enough sensory information.
    (Kranowitz, 57-58)
  • Developmental Dyspraxia child is unable to
    mentally visualize new movements. (Vestibular,
    proprioception and tactile systems are impaired)

48
Types of SPD Contd
  • Postural- Bilateral Integration Dysfunction- poor
    ability to use both sides of the body together
    tendency not to cross the body midline unusual
    fear /discomfort in certain positions (on tummy,
    moving backwards, going down stairs, riding on
    parents shoulders.
  • Video Therapy

49
Sensory Integrative Therapy
  • The central idea of this therapy is to provide
    and control sensory input especially the input
    from the vestibular system, muscles and joints,
    and skin in such a way that the child
    spontaneously forms the adaptive responses that
    integrate those sensations. (Ayres, 140)
  • Most effective if child directs his own actions
    while therapist directs the environment.
  • Motor activity is valuable in that it provides
    the sensory input that helps to organize the
    learning process-just as the body movements of
    early animals led to the evolution of a brain
    that could think and read. (Ayres, 141)

50
The Balanced Sensory Diet
  • Need sensory input and experiences to grow and
    learn
  • A sensory diet is a planned and scheduled
    activity program designed and implemented by an
    occupational therapist to meet the childs needs.
  • It includes a combination of alerting,
    organizing and calming techniques that lead
    directly to the near senses. (Sandra Nelson,7)
  • http//home.comcast.net/momtofive/SIDWEBPAGE2.htm

51
Five Important Caveats
  • Carol Kranowitz (1998) writes it is important to
    remember these five caveats
  • The child with sensory dysfunction does not
    necessarily exhibit every characteristic. Thus
    the child with vestibular dysfunction may have
    poor balance but good muscle tone.
  • Sometimes the child will show characteristics of
    a dysfunction one day but not the next. For
    instance, the child with proprioceptive problems
    may trip over every bump in the pavement on
    Friday yet score every soccer goal on Saturday.
    Inconsistency is a hallmark of neurological
    dysfunction.

52
Caveats Contd
  • 3. The child may exhibit characteristics of a
    particular dysfunction yet not have that
    dysfunction. For example, the child who
    typically withdraws from being touched may seem
    to be hypersensitive to tactile stimulation but
    may, have an emotional problem.
  • 4. The child may be both hypersensitive and
    hyposensitive. For example, the child may be
    extremely sensitive to light touch, jerking away
    from a soft pat on the shoulder, while being
    rather indifferent to the deep pain of an
    inoculation.

53
Caveats Contd
  • 5. Everyone has some sensory integration
    problems now and then, because no one is well
    regulated all the time. All kinds of stimuli can
    temporarily disrupt normal functioning of the
    brain, either by overloading it with, or
    depriving it of, sensory stimulation.
    (Kranowitz, 61)

54
Is SPD a Real Diagnosis?
  • Yes, it is a real diagnosis even though-
  • not enough significant scientific research
    through controlled studies to quantify, prove, or
    predict the symptoms and life course of this
    disorder.
  • Research by the SPD Foundation indicates that 1
    in every 20 children experiences symptoms of
    Sensory Processing Disorder that are significant
    enough to affect their ability to participate
    fully in every day life.
  • (http//www.sensorycritters.com/SI_Information.htm
    l.)

55
The Diagnostic and Statistical Manual -5th
Edition (DSM-V)
  • With extensive research and advocacy from the
    Sensory Processing Disorder Foundation, the
    American Psychiatric Association which publishes
    the Diagnostic and Statistical Manual -5th
    Edition (DSM-V) continues to consider the
    addition of Sensory Processing Disorder to the
    DSM-V.
  • The new DSM-V will be published in 2013.
  • http//summit-education.com/dsm-v/spd-and-the-dsm-
    v-doreit-s-bialer/

56
References
  • Ayres, Jean A. (1979). Sensory integration and
    the child. Los Angeles, CA Western Psychological
    Services.
  • Kranowitz, Carol S. (1998). The out-of-sync
    child Recognizing and coping with sensory
    integration dysfunction. New York, NY The
    Berkley Publishing Group.
  • Kranowitz, Carol S. (2003). The out of-sync
    child has fun activities for kids with sensory
    integration. New York, NY The Berkley Publishing
    Group
  • Mucklow, Nancy. (2009). The sensory team
    handbook. Kingston, ON Michael Grass House.
  • Nelson, Sandra. Sensory integration dysfunction
    The misunderstood, misdiagnosed and unseen
    disability. http//home.comcast.net/momfive/SIDWE
    BPAGE2.htm
  • 11/03/2011

57
References
  • Prainito Pediatric Therapy. What is sensory
    integration?
  • http//prainitopediatrictherapy.com/prainitopediat
    rictherapysensoryintegration.aspx 13/02/2011
  • Sensory processing disorder...Is SPD a real
    diagnosis?
  • http//www.sensorycritters.com?SI_Information.html
    11/03/2011
  • Sensory processing disorder checklist Signs and
    symptoms of dysfunction.
  • http//www.sensory-processing-disorder.com/sensory
    -processing-disorder-checklist.html 11/02/2011
  • Sensory processing disorder checklist.
    http//www.spdfoundation.net/library/checklist.htm
    l 11/03/2011
  • Williams, M. and Shellenberger, S. (1994). How
    does your engine run? A leaders guide to the
    alert program for self-regulation. Albuquerque,
    NM Therapy Works Inc.

58
Oppositional-Defiant Disorder (ODD)
59
DSM-IV Characteristics of ODD
  • Oppositional Defiant Disorder
  • A. A pattern of negativistic, hostile, and
    defiant behavior lasting at least 6 months,
    during which four (or more) of the following are
    present
  • (1)  often loses temper
  • (2)  often argues with adults
  • (3)  often actively defies or refuses to comply
    with adults' requests or rules
  • (4)  often deliberately annoys people
  • (5)  often blames others for his or her mistakes
    or misbehavior
  • (6)  is often touchy or easily annoyed by others
  • (7)  is often angry and resentful
  • (8)  is often spiteful or vindictive

60
DSM-IV Characteristics, ctd
  • Note Consider a criterion met only if the
    behavior occurs more frequently than is typically
    observed in individuals of comparable age and
    developmental level.
  • B. The disturbance in behavior causes clinically
    significant impairment in social, academic, or
    occupational functioning.
  • C. The behaviors do not occur exclusively during
    the course of a Psychotic or Mood Disorder.
  • D. Criteria are not met for Conduct Disorder,
    and, if the individual is age 18 years or older,
    criteria are not met for Antisocial Personality
    Disorder.

61
Risk Factors
  • mother smoked during pregnancy
  • poor socioeconomic environment
  • parents display maladaptive behaviour (includes
    general family instability, alcoholism, drug
    addiction, criminality)
  • childhood abuse (including childhood sexual
    abuse) or exposure to violence between parents
  • cognitive ability (IQ)
  • association with peers who engage in deviant
    behaviour during early adolescence
  • Genetic link possible but not proven

62
Case Study Kendra
  • Openly defiant, rude meets criteria (and
    diagnosis is in place)
  • Peers exclude her (group work, classroom seating,
    frequently bounces from one social group to the
    other)
  • Parents divorced lives with Mom
  • Mother does not return phone calls or emails from
    the teacher
  • Referral to Divisional Psychologist was only
    first requested in Grade 9

63
Case Study, ctd
  • Missed 24 classes in first semester Mom called
    the school to excuse all absences
  • Got into a fight at school (smashed a girls cell
    phone, so the girl smashed Kendras face into the
    floor) signs of CD are already appearing
  • What is wrong with the system that a child would
    be so far-gone by the time they reach high
    school?

64
What Causes ODD?
  • Possible pathway to ODD starts during infancy
  • Some infants have a difficult temperament (about
    15) think reciprocity infant or not, it is
    difficult for many parents/caregivers to show
    constant love for a baby who is seldom happy
  • If primary caregiver (usually Mom) is
    rejecting/cold and inconsistent with the child, a
    disorganized pattern of attachment develops
    (child mistrusts primary caregiver)

65
Pathway to ODD, ctd
  • Though children can develop late attachment (age
    4-6), almost ALL children who have experienced
    very poor caregiving in the first years of life
    will develop adjustment problems.
  • So then, by the time the child arrives at school,
    a great deal of damage has already been done
  • If ODD is left untreated, it often progresses
    into Conduct Disorder and possibly Antisocial
    Personality Disorder huge risk factors for
    criminality in adulthood.

66
Caveat
  • There is no known cause for ODD.
  • Research indicates that such a pathway as the one
    just described seems to be more common, but it is
    not the only pathway to ODD.
  • ODD without diagnosis of another disorder is more
    likely to be attributable to a pathway such as
    the one described.

67
Treatment Options
  • Research is unanimous treatment is MUCH more
    effective when the parents are supportive of the
    childs treatment, and are willing to change
    themselves
  • Often, ODD is encouraged unwittingly by the
    parents
  • For instance, the child is throwing a tantrum
    parents give in to the request just to get him to
    stop child has learned to throw tantrums to get
    his way

68
Types of Treatment
  • ODD appears to be acquired through environmental
    factors this is likely the reason why most
    research favours therapeutic techniques to treat
    ODD rather than medication.
  • HOWEVER ODD is often comorbid with other
    disorders (usually AD/HD, but sometimes autism
    and depressive or anxiety disorders) so these
    underlying conditions must be treated before ODD
    can be attended to.

69
What Happened with Kendra?
  • She does not have an EA for any of her classes
    (Level 1 funding only)
  • Past teachers have described coping techniques
    such as ignoring in order to deal with Kendra
    through the years.
  • She has been on the wait-list for the
    Divisional Psychologist since Nov. 2010
  • Her academic skills are below-level
  • She indicated to one teacher that she hopes to
    drop out of school as soon as she turns 16.

70
Working within a Flawed System
  • The public can be quick to condemn teachers and
    assign blame for students problems however,
    parents need to work with us rather than against
    us if we want to see real change
  • Our school system is not horrible but I believe
    our preschool care system is.
  • I wondered why I keep hearing about Germany
    (lowest dropout rate) and Finland (best academic
    results) in the news and did some digging

71
Germany and Finland a quick tangent
  • As it turns out, maternity leave in both of these
    countries is among the best in the world.
  • Both countries have a paid leave (just under 1
    year each) followed by an optional, additional
    unpaid leave for up to the time the child turns
    three
  • Canada has 15 weeks maternity followed by 37
    weeks parental leave
  • The USA has 0 weeks paid leave and a maximum
    legislated twelve weeks off work with no pay for
    mat leave

72
But I digress
  • There are certainly patterns that emerge when
    comparing countries preschool care to school
    performance, but this is simply an observation
    an interesting thought for future study and
    public policy reforms

73
So What CAN We Do?
  • What can be done with a student like Kendra, with
    a mother who refuses to work together with her
    childs teachers?
  • The vice-principal suggested allowing Kendra to
    take breaks from the classroom she does this
    during every class now and leaves for 15 minutes
    at a time is this to her advantage?
  • The Special Education teacher who completed one
    classroom visit with one of Kendras teachers
    suggested the teacher show the child as much love
    as possible

74
What Can Be Done, Ctd
  • The literature suggests the following strategies
    for teachers
  • Seating place student in a location where
    distracting stimuli are least present
  • Use daily schedules to eliminate the childs
    opportunity for idle time
  • Give instructions clearly and simply, standing in
    front of the blank overhead screen to eliminate
    background distractions
  • Structure every moment of the day

75
More Strategies
  • Manage the daily antecedents
  • Know what they are usually
  • Being told no
  • Being told to stop doing something
  • Hearing a sharp directive to begin doing
    something
  • Seeing any facial expression/gesture that conveys
    disapproval
  • Having idle time
  • Individual children also have their own
    antecedents get to understand what these are
    and avoid them if possible

76
Strategies, Ctd
  • Antecedents to enhance allowing choice and
    foreshadowing activities.
  • Continue to try to involve the parents, BUT DO SO
    IN A NONJUDGMENTAL WAY. If you convey any
    judgment toward the parent, this will only serve
    to drive them away even if the child developed
    ODD as a direct result of their personal
    qualities as a parent
  • They certainly didnt do it on purpose!
  • They feel frustrated themselves at being unsure
    how to help their child

77
Some Idealistic Realism
  • Governmental reforms are not the easiest or most
    likely resolution to the disjuncture between the
    quality of childcare prior to age 5 and entry
    into the public school system.
  • Resource Teachers/Guidance Counsellors/School
    Administration could consider contacting
    daycares near the school to host a 1-hour evening
    session to talk about positive parenting
    strategies this is part of being a leader.

78
Other Ideas
  • Schools need to do more to encourage parents to
    come in to meet the teachers why not a Fun
    Fair, a barbecue, etc. The relationship with
    parents is absolutely crucial to the success of
    students with severe behaviour disorders
  • Teachers we cannot diagnose, we cannot suggest
    conditions we can report symptoms. So why not
    keep a selection of brochures available in the
    classroom then at parent-teacher night, parents
    may feel more inclined to grab some reading
    material than to feel as though theyre being
    judged on the quality of their parenting

79
Lastly
  • More needs to be done during teacher training
    programs to prepare new teachers for these
    realities. Teachers who dont immediately return
    to school for a PBDE are missing out on a lot of
    important information!
  • References see hard copy of final assignment

80
Diagnostic Criteria for ADHD
  • 5 symptom-related criteria for diagnosis
  • Use modified version of DSM-IV for general public
    found on Center for Disease Control and
    Prevention website
  • (http//www.cdc.gov/ncbddd/adhd/diagnosis.html)

81
A. Either 1 (Inattention) or 2
(Hyperactivity-impulsivity)
82
(1) Inattention
  • six (or more) of the following symptoms of
    inattention have persisted for at least 6 months
    to a degree that is maladaptive and inconsistent
    with developmental level

83
(1) Inattention
  • (a) often fails to give close attention to
    details or makes careless mistakes in schoolwork,
    work, or other activities
  • (b) often has difficulty sustaining attention in
    tasks or play activities
  • (c) often does not seem to listen when spoken to
    directly
  • (d) often does not follow through on instructions
    and fails to finish schoolwork, chores, or duties
    in the workplace (not due to oppositional
    behavior or failure to understand instructions)
  • (e) often has difficulty organizing tasks and
    activities

84
(1) Inattention continued
  • (f) often avoids, dislikes, or is reluctant to
    engage in tasks that require sustained mental
    effort (such as schoolwork or homework)
  • (g) often loses things necessary for tasks or
    activities (e.g., toys, school assignments,
    pencils, books, or tools)
  • (h) is often easily distracted by extraneous
    stimuli
  • (i) is often forgetful in daily activities

85
(2) Hyperactivity-impulsivity
  • six (or more) of the following symptoms of
    hyperactivity-impulsivity have persisted for at
    least 6 months to a degree that is maladaptive
    inconsistent with developmental level

86
Hyperactivity
  • (a) often fidgets with hands or feet or squirms
    in seat
  • (b) often leaves seat in classroom or in other
    situations in which remaining seated is expected
  • (c) often runs about or climbs excessively in
    situations in which it is inappropriate (in
    adolescents or adults, may be limited to
    subjective feelings of restlessness)
  • (d) often has difficulty playing or engaging in
    leisure activities quietly
  • (e) is often "on the go" or often acts as if
    "driven by a motor"
  • (f) often talks excessively

87
Impulsivity
  • (g) often blurts out answers before questions
    have been completed
  • (h) often has difficulty awaiting turn
  • (i) often interrupts or intrudes on others (e.g.,
    butts into conversations or games)

88
B. Some hyperactive-impulsive or inattentive
symptoms that caused impairment were present
before age 7 years.C. Some impairment from the
symptoms is present in two or more settings
(e.g., at school or work and at home).D.
There must be clear evidence of clinically
significant impairment in social, academic, or
occupational functioning.
89
E. The symptoms do not occur exclusively during
the course of
  • a Pervasive Developmental Disorder
  • Schizophrenia, or other Psychotic Disorder
  • are not better accounted for by another mental
    disorder (e.g., Mood Disorder, Anxiety Disorder,
    Dissociative Disorder, or a Personality Disorder).
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