Understanding and Understanding and Responding to Responding to

Behavioural Issues of Behavioural Issues of Students with ADHD, Students with ADHD, Sensory Integration Sensory Integration

Dysfunction and ODD Dysfunction and ODD Prepared by Ellen Young, Prepared by Ellen Young,

Krista Heisinger Frost, and Krista Heisinger Frost, and Michelle HancockMichelle Hancock

What is Neurologically-What is Neurologically-Based Behaviour (NBB)?Based Behaviour (NBB)?

(Paula Cook, 2011)(Paula Cook, 2011)• About 10 % of students can’t reliably control what About 10 % of students can’t reliably control what

they say or do.they say or do.• The overarching name for the behavioural The overarching name for the behavioural

condition they exhibit is NBBcondition they exhibit is NBB• NBB is behaviour that results from cerebral NBB is behaviour that results from cerebral

processes occurring in an abnormal manner that processes occurring in an abnormal manner that results in information not being processed results in information not being processed correctly in the brain. The resulting behaviour is correctly in the brain. The resulting behaviour is challenging, unpredictable, inconsistent and challenging, unpredictable, inconsistent and unresponsive to ordinary discipline.unresponsive to ordinary discipline.

3 Indicators of NBB3 Indicators of NBB

1. Behaviour difficulties - atypical, 1. Behaviour difficulties - atypical, inconsistent, compulsive or immune to inconsistent, compulsive or immune to normal behaviour managementnormal behaviour management

2. Language Difficulties – problems 2. Language Difficulties – problems understanding, processing, and understanding, processing, and expressing information verballyexpressing information verbally

3. Academic Difficulties – memory, fine 3. Academic Difficulties – memory, fine and gross motor skills, comprehension, and gross motor skills, comprehension, language and math skills deficitslanguage and math skills deficits

Common Diagnoses Common Diagnoses within NBB:within NBB:

• Brain injuriesBrain injuries• Attention-Deficit Attention-Deficit

Hyperactivity Hyperactivity Disorder Disorder

• Oppositional Oppositional Defiant DisorderDefiant Disorder

• Bipolar DisorderBipolar Disorder

• Anxiety DisordersAnxiety Disorders• Fetal Alcohol Fetal Alcohol

Spectrum DisorderSpectrum Disorder• Sensory Integration Sensory Integration

DysfunctionDysfunction• Autism Spectrum Autism Spectrum

DisorderDisorder• Learning Learning

DisabilitiesDisabilities

Attention Deficit Attention Deficit Hyperactivity Disorder Hyperactivity Disorder

(AD/HD)(AD/HD)• Common neurobiological condition Common neurobiological condition

affecting 5-8 % of school age children affecting 5-8 % of school age children (Barkley, 1998)(Barkley, 1998)

• Symptoms persist into adulthood in Symptoms persist into adulthood in approximately 60% of cases (4% of adults) approximately 60% of cases (4% of adults) (Kessler (Kessler et alet al., 2006)., 2006)

• Characterized by developmentally Characterized by developmentally inappropriate levels of inattention, and/or inappropriate levels of inattention, and/or impulsivity and/or hyperactivityimpulsivity and/or hyperactivity

• Chronic, incurable conditionChronic, incurable condition

Possible Causes of AD/HDPossible 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; Research clearly indicates genetic factor; likely multiple interacting genes (Tannock, likely multiple interacting genes (Tannock, 1998; Swanson and Castellanos, 2002)1998; Swanson and Castellanos, 2002)

• Other causal factors: low birth weight, Other causal factors: low birth weight, prenatal maternal smoking, prenatal prenatal maternal smoking, prenatal problems may also contribute (Connor, 2002)problems may also contribute (Connor, 2002)

Neurology of AD/HDNeurology of AD/HD(Barkley, 2005)(Barkley, 2005)

• Structural differences in the brain and Structural differences in the brain and neurotransmitter: neurotransmitter: Dopamine and Dopamine and norepinephrine dysregulation norepinephrine dysregulation (Barkley, (Barkley, 2005)2005)

• Smaller, less active, less developed brain Smaller, less active, less developed brain regions (cerebellum, prefrontal cortex, regions (cerebellum, prefrontal cortex, basal ganglia)basal ganglia)

• Bad parenting is not a cause!Bad parenting is not a cause!• http://www.youtube.com/watch?v=u82nzT

zL7To&feature=related

Proper Steps in Diagnosis – No Proper Steps in Diagnosis – No single testsingle test

• Clinical assessment of the individual’s academic, Clinical assessment of the individual’s academic, social and emotional functioning and developmental social and emotional functioning and developmental level in order to determine if DSM-IV diagnostic level in order to determine if DSM-IV diagnostic criteria are metcriteria are met

• History : interviews with parents, teachers, childHistory : interviews with parents, teachers, child• Use rating scales and checklists (Conner’s Parent Use rating scales and checklists (Conner’s Parent

and Teacher rating scale, Barkley’s Home and and Teacher rating scale, Barkley’s Home and School Situation Questionnaire); Continuous School Situation Questionnaire); Continuous Performance Tests (TOVA)Performance Tests (TOVA)

• Physical exam (to rule out other medical problems Physical exam (to rule out other medical problems or to determine the presence or absence of co-or to determine the presence or absence of co-existing conditions)existing conditions)

DSM IVDSM IV

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

The DSM-IV characterizes the following 3 subtypes of AD/HD:

(http://www.nichq.org/toolkits_publications/complete_adhd/01ADHD%20Introduction.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%.

MimicsMimics

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

Comorbidity % among teens with ADHD

% in general teen population

Learning disability

20-60 5-15

Bipolar disorder 6-10 3-4Major depression

9-32 3-5

Anxiety disorder 10-40 3-10Conduct disorder

20-56 Unknown

ODD 20-67 2-16

Co-Existing ConditionsCo-Existing Conditions(Baren, 2002)(Baren, 2002)

Popular MisconceptionsPopular Misconceptions• AD/HD is environmentally causedAD/HD is environmentally caused• AD/HD is over diagnosedAD/HD is over diagnosed• Most kids outgrow symptoms (about 1/3 do)Most kids outgrow symptoms (about 1/3 do)• AD/HD means inability to pay attentionAD/HD means inability to pay attention• AD/HD kids need to put in more effortAD/HD kids need to put in more effort• Kids notice benefits of medicationKids notice benefits of medication• Consequences change behaviourConsequences change behaviour• Stimulant medication leads to alcohol and Stimulant medication leads to alcohol and

substance abusesubstance abuse• ADHD affects males more than femalesADHD affects males more than females

Importance of Early Identification Importance of Early Identification and Interventionand Intervention

• Potential areas of impairment: Potential areas of impairment: – academic achievementacademic achievement– relationships: family and friendsrelationships: family and friends– low self-esteemlow self-esteem– accidental injuriesaccidental injuries– Smoking and substance abuseSmoking and substance abuse– Motor vehicle accidentsMotor vehicle accidents– Legal difficulties-delinquencyLegal difficulties-delinquency– Occupational/vocationalOccupational/vocational

ADHD and Juvenile Criminal ADHD and Juvenile Criminal Justice System Justice System

(Robert Eme, American School of Professional (Robert Eme, American School of Professional Psychology, 2008)Psychology, 2008)

• 2, 300,000 adults and 100,000 2, 300,000 adults and 100,000 juveniles are incarcerated in the juveniles are incarcerated in the United StatesUnited States

• At least 25% and up to 50% have At least 25% and up to 50% have ADHDADHD

• This holds true for incarcerated This holds true for incarcerated females; may even be more likely females; may even be more likely than males to have ADHDthan males to have ADHD

Multi-modal Treatment: Multi-modal Treatment: Medical, Educational and Behavioural Medical, Educational and Behavioural

InterventionsInterventions• Parent and child education about diagnosis and treatmentParent and child education about diagnosis and treatment• Behaviour modification management techniquesBehaviour modification management techniques• Medication Medication • Psychotherapy/Counseling (family; individual: self-esteem Psychotherapy/Counseling (family; individual: self-esteem

and coping skills)and coping skills)• Coaching (develop better habits, social skills training)Coaching (develop better habits, social skills training)• School programming (IEP, AEP, BIP)School programming (IEP, AEP, BIP)• Physical Exercise Physical Exercise • Complementary and alternative medicine (CAM) for AD/HD Complementary and alternative medicine (CAM) for AD/HD

such as elimination of: sugar, food additives, preservatives; such as elimination of: sugar, food additives, preservatives; EEG biofeedback EEG biofeedback are not supportedare not supported in the literature (Rojas in the literature (Rojas and Chan, 2005)and Chan, 2005)

• Severity and type of AD/HD should be consideredSeverity and type of AD/HD should be considered

National Institute of Mental National Institute of Mental Health Study: Health Study: Multimodal Treatment Multimodal Treatment

Study of Children with AD/HD (1999)Study of Children with AD/HD (1999)• Children who were treated with Children who were treated with medication alonemedication alone

(which was carefully managed and individually tailored) (which was carefully managed and individually tailored) and children who received and children who received both medication and both medication and behavioural behavioural treatment experienced the greatest treatment experienced the greatest improvements in their AD/HD symptoms (attention, improvements in their AD/HD symptoms (attention, hyperactivity, impulsivity)hyperactivity, impulsivity)

• medication and behavioural medication and behavioural treatment had added treatment had added benefits for non-AD/HD symptom domains (parent-rated benefits for non-AD/HD symptom domains (parent-rated oppositional/aggressive symptoms, parent-child oppositional/aggressive symptoms, parent-child relations, teacher-rated social skills, internalizing relations, teacher-rated social skills, internalizing symptoms, reading achievement)symptoms, reading achievement)

Impact of Stimulant Impact of Stimulant MedicationMedication

Increased:Increased:• AttentionAttention• ConcentrationConcentration• ComplianceCompliance• Effort on tasksEffort on tasks• Amount and accuracy Amount and accuracy

of school workof school work

Decreased:Decreased:• Activity levelsActivity levels• ImpulsivityImpulsivity• Negative behavioursNegative behaviours• Physical & verbal Physical & verbal

hostilityhostility

Medication ImpactMedication Impact(Dr. Russel Barkley)(Dr. Russel Barkley)

• Working memoryWorking memory• Self-talk, self-esteem and emotional Self-talk, self-esteem and emotional

controlcontrol• Verbal fluencyVerbal fluency• Motor coordination, handwritingMotor coordination, handwriting• Acceptance by and interaction with Acceptance by and interaction with

peerspeers• Awareness of the game in sportAwareness of the game in sport• Decreased punishment by othersDecreased punishment by others

Behaviour ModificationBehaviour 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.

Behaviour modification teaches Behaviour modification teaches children specific techniques and skills:children specific techniques and skills:

• children with AD/HD face problems beyond children with AD/HD face problems beyond the core symptoms of inattention, the core symptoms of inattention, hyperactivity and impulsivityhyperactivity and impulsivity

• These include poor academic performance These include poor academic performance and behavior at school, poor relationships and behavior at school, poor relationships with peers and family members, and failure with peers and family members, and failure to obey adult requests. to obey adult requests.

• to help improve their behaviorto help improve their behavior• skills are reinforced by parents and skills are reinforced by parents and

teachers. teachers.

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

Parents and teachers learn and establish programs in which:

• the environmental antecedents (A) and consequences (C) are modified to change the child’s 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.

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

Teachers determine the Teachers determine the individualized target behaviorsindividualized target behaviors

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

Subjects Science

Math LA SS Gym

Class participation

Completes assigned work in class

Follows class rules

Gets along with others

Completes homework

Teacher Initials

Behaviour InterventionsBehaviour Interventions

• Be consistentBe consistent• Use positive Use positive

reinforcementreinforcement• ContractsContracts• Token programsToken programs• Response costResponse cost• RedirectionRedirection• Time-out/thinking Time-out/thinking

areasareas

• Teach problem-Teach problem-solving skillssolving skills

• Communication Communication skillsskills

• Self-advocacy Self-advocacy skillsskills

• List-makingList-making• Teach Agenda/day-Teach Agenda/day-

planner useplanner use

5 Effective Forms of Intervention for Peer Relationships

1. Systematic teaching of social skills2. Teaching social problem solving (eg:

early years: rock/paper/scissors) 3. Teaching other behavioral skills often

considered important by children, such as sports skills and board game rules

4. Decreasing undesirable and antisocial behaviors

5. Help to develop a close friendship

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.

90% of Children with ADHD have 90% of Children with ADHD have Academic ChallengesAcademic Challenges

• Written expressionWritten expression• Math (times tables and word problems)Math (times tables and word problems)• Spelling and ReadingSpelling and Reading• Overall low academic achievement scoresOverall low academic achievement scores• Disorganized, incomplete homeworkDisorganized, incomplete homework• Difficulty getting started (procrastination)Difficulty getting started (procrastination)• Impaired sense of time (it will take me Impaired sense of time (it will take me

forever to do this!)forever to do this!)

Middle School: ADHDMiddle School: ADHD Brick Wall Brick Wall (Dendy, 2008)(Dendy, 2008)

• Increased demands for executive functioning Increased demands for executive functioning (management functions of the brain):(management functions of the brain):– OrganizationOrganization– MemoryMemory– More complex academic workMore complex academic work– Working independentlyWorking independently– More homeworkMore homework– More complex routines (change classes/teachers)More complex routines (change classes/teachers)

Greatest Areas of DifficultyGreatest Areas of Difficulty• Difficulty following multiple-step directionsDifficulty following multiple-step directions

– Give written directions, ask child to repeat Give written directions, ask child to repeat directions, chunk work into manageable directions, chunk work into manageable units, use graphic organizersunits, use graphic organizers

• Completing tasks in a timely manner Completing tasks in a timely manner – Use a timer (cellphone or watch), help child Use a timer (cellphone or watch), help child

develop a plan (timeline), offer incentive, develop a plan (timeline), offer incentive, allow more timeallow more time

• Recall of rote detailsRecall of rote details– use mnemonics, color-coding, use image use mnemonics, color-coding, use image

associationassociation

• Copying and writingCopying and writing– allow more time, give hand-outs or note frames, allow more time, give hand-outs or note frames,

chunk work, laptop: type instead of hand-writingchunk work, laptop: type instead of hand-writing

Reframe Your ThinkingReframe Your ThinkingGifts of AH/HDGifts of AH/HD

• Students are:Students are:– EnergeticEnergetic– CreativeCreative– Risk-takers (in a Risk-takers (in a

good way)good way)– PersuasivePersuasive

– VerbalVerbal– Big picture thinkersBig picture thinkers– Good long-term Good long-term

memorymemory– Free thinkersFree thinkers– Mostly good Mostly good

lookinglooking

ReferencesReferences• Baren, M. (2002). ADHD in adolescents: Will you know it when you see Baren, M. (2002). ADHD in adolescents: Will you know it when you see

it? it? Contemporary PediatricsContemporary Pediatrics, 19(5), 124-143. , 19(5), 124-143. • Barkley, R. (1998). Attention Deficit Hyperactivity Disorders: A Barkley, R. (1998). Attention Deficit Hyperactivity Disorders: A

Handbook for Diagnosis and Treatment. New York: Guilford Press.Handbook for Diagnosis and Treatment. New York: Guilford Press.• Barkley, R. (2005). Attention Deficit Hyperactivity Disorders: A Barkley, R. (2005). Attention Deficit Hyperactivity Disorders: A

Handbook for Diagnosis and Treatment (3Handbook for Diagnosis and Treatment (3rdrd ed.). New York: Guilford ed.). New York: Guilford Press.Press.

• Connor, D.R. (2002). Preschool Attention deficit hyperactivity disorder: Connor, D.R. (2002). Preschool Attention deficit hyperactivity disorder: A review of prevelance, diagnosis, neurobiology, and stimulant A review of prevelance, diagnosis, neurobiology, and stimulant treatment. treatment. Journal of Developmental Behaviour Pediatrics Journal of Developmental Behaviour Pediatrics 23 23 (1Suppl):S1-S9.(1Suppl):S1-S9.

• Dendy, C. Understanding the Impact of ADHD & Executive Functions on Dendy, C. Understanding the Impact of ADHD & Executive Functions on Learning and Behaviour. In: Proceedings of the ADDA 13th National Learning and Behaviour. In: Proceedings of the ADDA 13th National Conference. Minneapolis, MN. pp. 166-83.Conference. Minneapolis, MN. pp. 166-83.

• Eme, R. (2008). ADHD & The Criminal Justice SystemEme, R. (2008). ADHD & The Criminal Justice System. In: . In: Proceedings Proceedings of the ADDA 13of the ADDA 13thth National Conference. Minneapolis, MN. pp. 89-91. National Conference. Minneapolis, MN. pp. 89-91.

• Kessler, R.C., Adler, L., Barkley, R., Biederman, J. The prevalence and Kessler, R.C., Adler, L., Barkley, R., Biederman, J. The prevalence and correlates of adult ADHD in the United States: Results from the correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. National Comorbidity Survey Replication. Am Journal of Psychiatry Am Journal of Psychiatry (2006), 163:724-732.(2006), 163:724-732.

• MTA Cooperative Group. (1999). A 14-Month randomized clinical trial of MTA Cooperative Group. (1999). A 14-Month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. treatment strategies for attention-deficit/hyperactivity disorder. Archives of General PsychiatryArchives of General Psychiatry, 56, 1073-1086), 56, 1073-1086)

ReferencesReferences

• MTA Cooperative Group. (1999). Moderators and mediators of MTA Cooperative Group. (1999). Moderators and mediators of treatment responses for children with treatment responses for children with attention-deficit/hyperactivity disorder. attention-deficit/hyperactivity disorder. Archives of General Archives of General PsychiatryPsychiatry, 56, 1088-1096), 56, 1088-1096)

• Rojas, N.L., and Chan, C. (2005). Old and new Rojas, N.L., and Chan, C. (2005). Old and new controversies in the alternative treatment of attention-controversies in the alternative treatment of attention-deficit hyperactivity disorder. deficit hyperactivity disorder. Mental Retardation and Mental Retardation and Developmental Disabilities Research ReviewsDevelopmental Disabilities Research Reviews, 11: 116-130., 11: 116-130.

• Swanson, J.M., and Castellanos, F.X. (2002). Biological Swanson, J.M., and Castellanos, F.X. (2002). Biological Basis of ADHD-Neuroanatomy, Genetics, and Basis of ADHD-Neuroanatomy, Genetics, and Pathophysiology. In P.S. Jensen and J.R. Cooper (eds.) Pathophysiology. In P.S. Jensen and J.R. Cooper (eds.) Attention deficit hyperactivity disorder: State of the Attention deficit hyperactivity disorder: State of the science, best practicesscience, best practices, pp. 7-1-7-20. Kingston, New Jersey., pp. 7-1-7-20. Kingston, New Jersey.

• Tannock, R. (1998). Attention deficit hyperactivity Tannock, R. (1998). Attention deficit hyperactivity disorder: Advances in cognitive, neurobiological, and disorder: Advances in cognitive, neurobiological, and genetic research. genetic research. Journal of Child Psychology and Journal of Child Psychology and PsychiatryPsychiatry, 39, 65-99., 39, 65-99.

Sensory Processing Sensory Processing DisorderDisorder

oror

Sensory Integration Sensory Integration DysfunctionDysfunction

Dr. A. Jean Ayres 1920- Dr. A. Jean Ayres 1920- 19891989

Background InformationBackground Information

• Also known as Sensory Processing DisorderAlso known as Sensory Processing Disorder• Dr. A. Jean Ayres first developed the theory Dr. A. Jean Ayres first developed the theory

of Sensory Integration Dysfunction in the of Sensory Integration Dysfunction in the 1960’s1960’s

• Wrote two books –Wrote two books –Sensory Integration and Sensory Integration and Learning Disorders Learning Disorders in 1972 and in 1972 and Sensory Sensory Integration and the Child Integration and the Child in 1979in 1979

• Was an occupational therapist and Was an occupational therapist and developmental psychologistdevelopmental psychologist

• Worked at the Institute for Brain Research Worked at the Institute for Brain Research at the University of California at Los at the University of California at Los Angeles.Angeles.

What is Sensory Processing What is Sensory Processing

DisorderDisorder??• ““Sensory integrative/ processing disorders are Sensory integrative/ processing disorders are a set of conditions caused by an insufficient a set of conditions caused by an insufficient ability of the central nervous system to take in, ability of the central nervous system to take in, register, modulate, perceive, and/or combine register, modulate, perceive, and/or combine sensory experiences (input) from the sensory experiences (input) from the environment around us.”environment around us.”

• ““The neural messages become disorganized as The neural messages become disorganized as they travel up towards the higher brain they travel up towards the higher brain centers. The messages may also become centers. The messages may also become overly-amplified or diminished, and are hence overly-amplified or diminished, and are hence unusable. Sensory inputs are the building unusable. Sensory inputs are the building blocks of learning and relating to our blocks of learning and relating to our environment and the people in it.”environment and the people in it.”

Video: What is SPD?

The SensesThe Senses

• The Five Basic The Five Basic Senses or “Far Senses or “Far Senses”:Senses”:– SightSight– SoundSound– TasteTaste– SmellSmell– Touch Touch

-Respond to external -Respond to external stimuli from the stimuli from the environment. environment.

(Kranowitz,40,41)(Kranowitz,40,41)

• Body Centered Body Centered Sensory Systems Sensory Systems or “Near Senses”:or “Near Senses”:– Interoceptive- Interoceptive-

internal organs- e.g. internal organs- e.g. heart rate, hungerheart rate, hunger

– Tactile- info received Tactile- info received through the skinthrough the skin

– Vestibular- Vestibular- movement-pull of movement-pull of earth’s earth’s gravity/balancegravity/balance

– Proprioception- info Proprioception- info from muscles and from muscles and jointsjoints

Causes of SPD according to Dr. Causes of SPD according to Dr. AyresAyres

• Hereditary predisposition for minimal brain Hereditary predisposition for minimal brain dysfunctiondysfunction

• Environmental toxins – air contaminants, destructive Environmental toxins – air contaminants, destructive virusesviruses

• Combination of hereditary and environmental toxinsCombination of hereditary and environmental toxins• Lack of oxygen at birth Lack of oxygen at birth • Children who lead deprived lives- little contact with Children who lead deprived lives- little contact with

people or thingspeople or things• Neurological disordersNeurological disorders• Internal sensory deprivation(sensory stimulation is Internal sensory deprivation(sensory stimulation is

present in the environment but the stimulation present in the environment but the stimulation doesn’t nourish every part of the brain) (Ayres, 54-doesn’t nourish every part of the brain) (Ayres, 54-56) 56)

The Symptoms or The Symptoms or BehavioursBehavioursExhibited Exhibited Each child’s symptoms are different and Each child’s symptoms are different and

unique, making it difficult to diagnose unique, making it difficult to diagnose sensory processing disorder.sensory processing disorder.

• Hyperactivity and Distractibility - Hyperactivity and Distractibility - activity activity usually not purposeful, cannot “shut out” noises, usually not purposeful, cannot “shut out” noises, lights, etc.lights, etc.

• Behaviour Problems- Behaviour Problems- not happy with self, not happy with self, fussy, overly sensitive; negative self concept- fussy, overly sensitive; negative self concept- negative reactions from othersnegative reactions from others

• Speech Development- Speech Development- speech and speech and articulation develops slowlyarticulation develops slowly

The Symptoms/ The Symptoms/ Behaviours Cont’dBehaviours Cont’d• Muscle Tone and Coordination- Muscle Tone and Coordination- if vestibular, if vestibular,

proprioceptive, and tactile systems are not working proprioceptive, and tactile systems are not working well- poor motor coordination results.well- poor motor coordination results.

• Learning at School- Learning at School- learning starts from the learning starts from the bottom of the brain and moves up– if the senses are bottom of the brain and moves up– if the senses are disorganized then learning and behaviour problems disorganized then learning and behaviour problems will resultwill result

• Teen-age Problems- Teen-age Problems- may have learned how to may have learned how to compensate for sensory processing disorder– if not compensate for sensory processing disorder– if not may drop out of school ---major lack of organization.may drop out of school ---major lack of organization.

These symptoms are end products of inefficient and These symptoms are end products of inefficient and irregular sensory processing in the brain. (Ayres, irregular sensory processing in the brain. (Ayres, 56-59)56-59)

An Evaluation by an An Evaluation by an Occupational Therapist Occupational Therapist

Considers:Considers: 1.1. Perception and registration of sensorimotor Perception and registration of sensorimotor

information- what the child sees, hears, touchesinformation- what the child sees, hears, touches, , tastes, and smellstastes, and smells

2.2. How movement and gravity are experiencedHow movement and gravity are experienced3.3. Gathers information through clinical Gathers information through clinical

observations, sensory history, and standardized observations, sensory history, and standardized tests:tests:

- “Can the child use sensorimotor experiences to - “Can the child use sensorimotor experiences to learn, interact. explore, and demonstrate knowledge?learn, interact. explore, and demonstrate knowledge?

- Does the child respond negatively or with extreme - Does the child respond negatively or with extreme behaviours (flight, fright, fight responses) to unexpected behaviours (flight, fright, fight responses) to unexpected or light touch, unstable surfaces, loud noises, visual or light touch, unstable surfaces, loud noises, visual distractions, or certain tastes, textures, and smells?distractions, or certain tastes, textures, and smells?

- Can the child filter out irrelevant sensory input?”- Can the child filter out irrelevant sensory input?” (Williams, Shellenberger, 3)(Williams, Shellenberger, 3)

The Brain’s Ability to The Brain’s Ability to Self RegulateSelf Regulate

Mechanisms needed to self regulate:Mechanisms needed to self regulate:• Modulation- neural switches can turn Modulation- neural switches can turn

on or off depending on activity levelon or off depending on activity level• Inhibition- reduce connections between Inhibition- reduce connections between

sensory intake and behavioural outputsensory intake and behavioural output• Habituation – brain tunes out familiar Habituation – brain tunes out familiar

sensory messagessensory messages• Facilitation – connections between Facilitation – connections between

sensory intake and behavioural outputsensory intake and behavioural output(Kranowitz, 42-44)(Kranowitz, 42-44)

The Alert Program for The Alert Program for Self- RegulationSelf- Regulation

• Uses the analogy of a car engine to introduce self-regulation to Uses the analogy of a car engine to introduce self-regulation to studentsstudents

• The program can be adapted to all agesThe program can be adapted to all ages• It entails three stages: 1.identifying engine speeds, It entails three stages: 1.identifying engine speeds,

2.experimenting with changing engine speeds, and 3.regulating 2.experimenting with changing engine speeds, and 3.regulating engine speeds; with each stage consisting of a number of steps engine speeds; with each stage consisting of a number of steps or mile markers.or mile markers.

• Speeds are as follows: high (hyper, overexcited), low (sluggish, Speeds are as follows: high (hyper, overexcited), low (sluggish, spacey) and just right (easy to learn and get along with others)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 There are activities that can be used for each step and each step should be modelled for the student to be able to thoroughly should be modelled for the student to be able to thoroughly understand the engine levels and how to change themunderstand the engine levels and how to change them

• Program is designed to give students the ability to self regulate Program is designed to give students the ability to self regulate their engines according to the activity they are doing.their engines according to the activity they are doing.

(Williams & Shellenberger)(Williams & Shellenberger)

Types of SPDTypes of SPD

• Sensory Modulation Dysfunction- the brain Sensory Modulation Dysfunction- the brain cannot regulate the amount of sensory cannot regulate the amount of sensory information it allows to enter. information it allows to enter. (Hypersensitivity, hyperreactivity - (Hypersensitivity, hyperreactivity - registers sensations too intensely; and registers sensations too intensely; and Hyposensitivity, hyporeactivity – not Hyposensitivity, hyporeactivity – not getting enough sensory information. getting enough sensory information. (Kranowitz, 57-58)(Kranowitz, 57-58)

• Developmental Dyspraxia – child is unable Developmental Dyspraxia – child is unable to mentally visualize new movements. to mentally visualize new movements. (Vestibular, proprioception and tactile (Vestibular, proprioception and tactile systems are impaired) systems are impaired)

Types of SPD Cont’dTypes of SPD Cont’d

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

Video: Therapy

Sensory Integrative Sensory Integrative Therapy Therapy

• ““The central idea of this therapy is to provide and The central idea of this therapy is to provide and control sensory input especially the input from control sensory input especially the input from the vestibular system, muscles and joints, and the vestibular system, muscles and joints, and skin in such a way that the child spontaneously skin in such a way that the child spontaneously forms the adaptive responses that integrate those forms the adaptive responses that integrate those sensations.” (Ayres, 140)sensations.” (Ayres, 140)

• Most effective if child directs his own actions Most effective if child directs his own actions while therapist directs the environment.while therapist directs the environment.

• ““Motor activity is valuable in that it provides the Motor activity is valuable in that it provides the sensory input that helps to organize the learning sensory input that helps to organize the learning process-just as the body movements of early process-just as the body movements of early animals led to the evolution of a brain that could animals led to the evolution of a brain that could think and read.” (Ayres, 141) think and read.” (Ayres, 141)

The Balanced Sensory The Balanced Sensory DietDiet

• Need sensory input Need sensory input and experiences to and experiences to grow and learngrow and learn

• A sensory diet is a A sensory diet is a planned and planned and scheduled activity scheduled activity program designed program designed and implemented and implemented by an occupational by an occupational therapist to meet therapist to meet the child’s needs.the child’s needs.

• It includes a It includes a “combination of “combination of alerting, organizing alerting, organizing and calming and calming techniques that lead techniques that lead directly to the “near” directly to the “near” senses. (Sandra senses. (Sandra Nelson,7)Nelson,7)

http://home.comcast.net/~momtofive/SIDWEBPAGE2.htm

Five Important CaveatsFive Important Caveats

• Carol Kranowitz (1998) writes it is important Carol Kranowitz (1998) writes it is important to remember these five caveats:to remember these five caveats:

1.1.““The child with sensory dysfunction does not The child with sensory dysfunction does not necessarily exhibit every characteristic. Thus necessarily exhibit every characteristic. Thus the child with vestibular dysfunction may the child with vestibular dysfunction may have poor balance but good muscle tone.”have poor balance but good muscle tone.”

2.2.““Sometimes the child will show Sometimes the child will show characteristics of a dysfunction one day but characteristics of a dysfunction one day but not the next. For instance, the child with not the next. For instance, the child with proprioceptive problems may trip over every proprioceptive problems may trip over every bump in the pavement on Friday yet score bump in the pavement on Friday yet score every soccer goal on Saturday. every soccer goal on Saturday. Inconsistency is a hallmark of Inconsistency is a hallmark of neurological dysfunction.”neurological dysfunction.”

Caveats Cont’dCaveats Cont’d

3. “The child may exhibit characteristics of a 3. “The child may exhibit characteristics of a particular dysfunction yet not have that particular dysfunction yet not have that dysfunction. For example, the child who dysfunction. For example, the child who typically withdraws from being touched typically withdraws from being touched may seem to be hypersensitive to tactile may seem to be hypersensitive to tactile stimulation but may, have an emotional stimulation but may, have an emotional problem.”problem.”

4. “The child may be both hypersensitive and 4. “The child may be both hypersensitive and hyposensitive. For example, the child may hyposensitive. For example, the child may be extremely sensitive to light touch, be extremely sensitive to light touch, jerking away from a soft pat on the jerking away from a soft pat on the shoulder, while being rather indifferent to shoulder, while being rather indifferent to the deep pain of an inoculation.” the deep pain of an inoculation.”

Caveats Cont’dCaveats Cont’d

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

Is SPD a Real Diagnosis?Is SPD a Real Diagnosis?

• Yes, it is a real diagnosis even though-Yes, it is a real diagnosis even though- not enough significant scientific research through not enough significant scientific research through

controlled studies to quantify, prove, or predict controlled studies to quantify, prove, or predict the symptoms and life course of this disorder.the symptoms and life course of this disorder.

• ““Research by the SPD Foundation indicates that Research by the SPD Foundation indicates that 1 in every 20 children experiences symptoms of 1 in every 20 children experiences symptoms of Sensory Processing Disorder that are significant Sensory Processing Disorder that are significant enough to affect their ability to participate fully enough to affect their ability to participate fully in every day life.”in every day life.”

((http://www.sensorycritters.com/SI_Information.html.).)

The Diagnostic and The Diagnostic and Statistical Manual -5Statistical Manual -5thth

Edition (DSM-V)Edition (DSM-V)• ““With extensive research and advocacy With extensive research and advocacy

from the Sensory Processing Disorder from the Sensory Processing Disorder Foundation, the American Psychiatric Foundation, the American Psychiatric Association which publishes the Association which publishes the Diagnostic and Statistical Manual -5Diagnostic and Statistical Manual -5thth Edition (DSM-V) continues to consider the Edition (DSM-V) continues to consider the addition of “Sensory Processing Disorder” addition of “Sensory Processing Disorder” to the DSM-V.” to the DSM-V.”

• The new DSM-V will be published in 2013.The new DSM-V will be published in 2013.• http://summit-education.com/dsm-v/spd-an

d-the-dsm-v-doreit-s-bialer/

ReferencesReferencesAyres, Jean A. (1979). Ayres, Jean A. (1979). Sensory integration and the child. Sensory integration and the child.

Los Angeles, CA: Western Psychological Services.Los Angeles, CA: Western Psychological Services.Kranowitz, Carol S. (1998). Kranowitz, Carol S. (1998). The out-of-sync child: The out-of-sync child:

Recognizing and coping with sensory integration Recognizing and coping with sensory integration dysfunction.dysfunction. New York, NY: The Berkley Publishing New York, NY: The Berkley Publishing Group.Group.

Kranowitz, Carol S. (2003). Kranowitz, Carol S. (2003). The out –of-sync child has fun: The out –of-sync child has fun: activities for kids with sensory integration. activities for kids with sensory integration. New York, New York, NY: The Berkley Publishing GroupNY: The Berkley Publishing Group

Mucklow, Nancy. (2009). Mucklow, Nancy. (2009). The sensory team handbook. The sensory team handbook. Kingston, ON: Michael Grass House.Kingston, ON: Michael Grass House.

Nelson, Sandra. Nelson, Sandra. Sensory integration dysfunction: “The Sensory integration dysfunction: “The misunderstood, misdiagnosed and unseen disability. misunderstood, misdiagnosed and unseen disability. http://home.comcast.net/~momfive/SIDWEBPAGE2.htm

11/03/2011

ReferencesReferences

Prainito Pediatric Therapy. Prainito Pediatric Therapy. What is sensory integration?What is sensory integration? http://prainitopediatrictherapy.com/prainitopediatrictherapysensoryintegration.aspx

13/02/2011 13/02/2011Sensory processing disorder...Is SPD a real diagnosis?Sensory processing disorder...Is SPD a real diagnosis?http://www.sensorycritters.com?SI_Information.html 11/03/2011 11/03/2011Sensory processing disorder checklist: Signs and symptoms of Sensory processing disorder checklist: Signs and symptoms of

dysfunction.dysfunction.http://www.sensory-processing-disorder.com/sensory-processing-disorder-checklist.html

11/02/2011 11/02/2011 Sensory processing disorder checklist. Sensory processing disorder checklist.

http://www.spdfoundation.net/library/checklist.html 11/03/201111/03/2011

Williams, M. and Shellenberger, S. (1994). Williams, M. and Shellenberger, S. (1994). “How does your “How does your engine run?” A leader’s guide to the alert program for self-engine run?” A leader’s guide to the alert program for self-regulation. regulation. Albuquerque, NM: Therapy Works Inc. Albuquerque, NM: Therapy Works Inc.

Oppositional-Defiant

Disorder (ODD)

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

DSM-IV Characteristics, ct’d

• 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.

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

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

Case Study, ct’d

• Missed 24+ classes in first semester; Mom called the school to “excuse” all absences

• Got into a fight at school (smashed a girl’s cell phone, so the girl smashed Kendra’s 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?

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)

Pathway to ODD, ct’d• 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.

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.

Treatment Options

• Research is unanimous – treatment is MUCH more effective when the parents are supportive of the child’s 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

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.

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.

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

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

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

So What CAN We Do? • What can be done with a student like

Kendra, with a mother who refuses to work together with her child’s 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 Kendra’s teachers suggested the teacher show the child as much love as possible

What Can Be Done, Ct’d

• 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

child’s 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

More Strategies• Manage the daily antecedents

1. Know what they are – usually:a) Being told “no”b) Being told to stop doing somethingc) Hearing a sharp directive to begin doing

somethingd) Seeing any facial expression/gesture that

conveys disapprovale) Having idle time f) Individual children also have their own

antecedents – get to understand what these are and avoid them if possible

Strategies, Ct’d• 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:

1) They certainly didn’t do it on purpose!2) They feel frustrated themselves at being

unsure how to help their child

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.

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 they’re being judged on the quality of their parenting

Lastly…

• More needs to be done during teacher training programs to prepare new teachers for these realities. Teachers who don’t immediately return to school for a PBDE are missing out on a lot of important information!

• References – see hard copy of final assignment

Diagnostic Criteria for Diagnostic Criteria for ADHDADHD

• 5 symptom-related criteria for 5 symptom-related criteria for diagnosisdiagnosis

• Use modified version of DSM-IV for Use modified version of DSM-IV for general public found on Center for general public found on Center for Disease Control and Prevention Disease Control and Prevention websitewebsite

(http://www.cdc.gov/ncbddd/adhd/(http://www.cdc.gov/ncbddd/adhd/diagnosis.html)diagnosis.html)

A. Either 1 A. Either 1 (Inattention) (Inattention)

or 2 (Hyperactivity-or 2 (Hyperactivity-impulsivity):impulsivity):

(1) Inattention:(1) Inattention:

• six (or more) of the following six (or more) of the following symptoms of inattention have symptoms of inattention have persisted for at least 6 months to a persisted for at least 6 months to a degree that is maladaptive and degree that is maladaptive and inconsistent with developmental inconsistent with developmental level:level:

(1) Inattention:(1) Inattention:

• (a) often fails to give close attention to details or (a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or makes careless mistakes in schoolwork, work, or other activitiesother activities

• (b) often has difficulty sustaining attention in tasks (b) often has difficulty sustaining attention in tasks or play activitiesor play activities

• (c) often does not seem to listen when spoken to (c) often does not seem to listen when spoken to directlydirectly

• (d) often does not follow through on instructions and (d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the fails to finish schoolwork, chores, or duties in the workplace workplace (not due to oppositional behavior or (not due to oppositional behavior or failure to understand instructions)failure to understand instructions)

• (e) often has difficulty organizing tasks and activities(e) often has difficulty organizing tasks and activities

(1) Inattention continued(1) Inattention continued

• (f) often avoids, dislikes, or is reluctant to engage (f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort in tasks that require sustained mental effort (such as schoolwork or homework)(such as schoolwork or homework)

• (g) often loses things necessary for tasks or (g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, activities (e.g., toys, school assignments, pencils, books, or tools)books, or tools)

• (h) is often easily distracted by extraneous (h) is often easily distracted by extraneous stimulistimuli

• (i) is often forgetful in daily activities(i) is often forgetful in daily activities

(2) Hyperactivity-impulsivity:(2) Hyperactivity-impulsivity:

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

::

HyperactivityHyperactivity• (a) often fidgets with hands or feet or squirms in seat(a) often fidgets with hands or feet or squirms in seat• (b) often leaves seat in classroom or in other (b) often leaves seat in classroom or in other

situations in which remaining seated is expectedsituations in which remaining seated is expected• (c) often runs about or climbs excessively in (c) often runs about or climbs excessively in

situations in which it is inappropriate (in adolescents situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of or adults, may be limited to subjective feelings of restlessness)restlessness)

• (d) often has difficulty playing or engaging in leisure (d) often has difficulty playing or engaging in leisure activities quietlyactivities quietly

• (e) is often "on the go" or often acts as if "driven by a (e) is often "on the go" or often acts as if "driven by a motor"motor"

• (f) often talks excessively(f) often talks excessively

ImpulsivityImpulsivity

• (g) often blurts out answers before (g) often blurts out answers before questions have been completedquestions have been completed

• (h) often has difficulty awaiting turn(h) often has difficulty awaiting turn• (i) often interrupts or intrudes on (i) often interrupts or intrudes on

others (e.g., butts into conversations others (e.g., butts into conversations or games)or games)

B. Some hyperactive-impulsive or B. Some hyperactive-impulsive or inattentive symptoms that caused inattentive symptoms that caused impairment were present before age 7 impairment were present before age 7 years.years.

C. Some impairment from the symptoms is C. Some impairment from the symptoms is present in two or more settings (e.g., at present in two or more settings (e.g., at school [or work] and at home).school [or work] and at home).

D. There must be clear evidence of clinically D. There must be clear evidence of clinically significant impairment in social, academic, significant impairment in social, academic, or occupational functioning.or occupational functioning.

E. The symptoms do not occur E. The symptoms do not occur exclusively during the course of:exclusively during the course of:

• a Pervasive Developmental Disordera Pervasive Developmental Disorder• Schizophrenia, or other Psychotic Schizophrenia, or other Psychotic

DisorderDisorder• are not better accounted for by are not better accounted for by

another mental disorder (e.g., Mood another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Anxiety Disorder, Disorder, Dissociative Disorder, or a Dissociative Disorder, or a Personality Disorder).Personality Disorder).