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
What is Neurologically-Based
Behaviour (NBB)?
(Paula Cook, 2011)
• About 10 % of students can’t 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 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
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
Attention Deficit Hyperactivity
Disorder (AD/HD)
• Common neurobiological condition affecting 58 % 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
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)
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?v=u82nzTzL7
To&feature=related
Proper Steps in Diagnosis – No single test
• Clinical assessment of the individual’s 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 (Conner’s Parent and
Teacher rating scale, Barkley’s 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)
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.
The DSM-IV characterizes the following 3 subtypes of AD/HD:
(http://www.nichq.org/toolkits_publications/complete_adhd/01ADHD%2
0Introduction.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%.
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
Co-Existing Conditions
(Baren, 2002)
Comorbidity
% among teens % in general
with ADHD
teen population
20-60
5-15
Learning
disability
Bipolar disorder 6-10
3-4
Major
9-32
depression
Anxiety disorder 10-40
3-5
Conduct
disorder
ODD
20-56
Unknown
20-67
2-16
3-10
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
Importance of Early Identification and
Intervention
• Potential areas of impairment:
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academic achievement
relationships: family and friends
low self-esteem
accidental injuries
Smoking and substance abuse
Motor vehicle accidents
Legal difficulties-delinquency
Occupational/vocational
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
Multi-modal Treatment:
Medical, Educational and Behavioural Interventions
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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
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 (parentrated oppositional/aggressive symptoms, parent-child
relations, teacher-rated social skills, internalizing
symptoms, reading achievement)
Impact of Stimulant Medication
Increased:
• Attention
• Concentration
• Compliance
• Effort on tasks
• Amount and accuracy of
school work
Decreased:
• Activity levels
• Impulsivity
• Negative behaviours
• Physical & verbal hostility
Medication Impact
(Dr. Russel Barkley)
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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
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.
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.
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 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.
Subjects
Class
participation
Completes
assigned
work in class
Follows class
rules
Gets along
with others
Completes
homework
Teacher
Initials
Science
Math
LA
SS
Gym
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/dayplanner use
5 Effective Forms of Intervention
for Peer Relationships
1. Systematic teaching of social skills
2. 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 Academic
Challenges
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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!)
Middle School: ADHD
Brick Wall
(Dendy, 2008)
• Increased demands for executive functioning
(management functions of the brain):
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Organization
Memory
More complex academic work
Working independently
More homework
More complex routines (change classes/teachers)
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
Reframe Your Thinking
Gifts of AH/HD
• Students are:
– Energetic
– Creative
– Risk-takers (in a good
way)
– Persuasive
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Verbal
Big picture thinkers
Good long-term memory
Free thinkers
Mostly good looking
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), 163:724-732.
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)
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 ADHDNeuroanatomy, 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.
Sensory Processing Disorder
or
Sensory Integration
Dysfunction
Dr. A. Jean Ayres 1920- 1989
Background Information
• Also known as Sensory Processing Disorder
• Dr. A. Jean Ayres first developed the theory of
Sensory Integration Dysfunction in the 1960’s
• 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.
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?
The Senses
• The Five Basic Senses
or “Far Senses”:
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Sight
Sound
Taste
Smell
Touch
-Respond to external
stimuli from the
environment.
(Kranowitz,40,41)
• Body Centered Sensory
Systems or “Near
Senses”:
– Interoceptive- internal
organs- e.g. heart rate,
hunger
– Tactile- info received
through the skin
– Vestibular- movementpull of earth’s
gravity/balance
– Proprioception- info from
muscles and joints
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 doesn’t
nourish every part of the brain) (Ayres, 54-56)
The Symptoms or Behaviours
Exhibited
Each child’s 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
•
The Symptoms/ Behaviours
Cont’d
Muscle Tone and Coordination- if vestibular,
proprioceptive, and tactile systems are not working wellpoor 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)
An Evaluation by an Occupational
Therapist Considers:
1. Perception and registration of sensorimotor informationwhat the child sees, hears, touches, tastes, and smells
2. How movement and gravity are experienced
3. 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)
The Brain’s 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)
The Alert Program for SelfRegulation
• 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)
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)
Types of SPD Cont’d
• Postural- Bilateral Integration Dysfunctionpoor 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
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)
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 child’s
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/SIDWEBP
AGE2.htm
Five Important Caveats
• Carol Kranowitz (1998) writes it is important to
remember these five caveats:
1. “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.”
2. “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.”
Caveats Cont’d
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.”
Caveats Cont’d
• 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)
Is SPD a Real Diagnosis?
• Yes, it is a real diagnosis even thoughnot 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.html.)
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-thedsm-v-doreit-s-bialer/
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/SIDWEBPAGE2.htm
11/03/2011
References
Prainito Pediatric Therapy. What is sensory integration?
http://prainitopediatrictherapy.com/prainitopediatrictherapysensoryinteg
ration.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-processingdisorder-checklist.html 11/02/2011
Sensory processing disorder checklist.
http://www.spdfoundation.net/library/checklist.html 11/03/2011
Williams, M. and Shellenberger, S. (1994). “How does your engine run?” A
leader’s guide to the alert program for self-regulation. Albuquerque, NM:
Therapy Works Inc.
OppositionalDefiant 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)
b)
c)
d)
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
e) 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 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.ht
ml)
A. Either 1 (Inattention)
or 2 (Hyperactivityimpulsivity):
(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:
(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
(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
(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:
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
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)
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.
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).