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Presenter: Dr. Vince Monastra

Clinical Director, FPI Attention Disorders Clinic

Endicott, NY 13760

Email: poppidoc@aol.com

Website: www.drvincemonastra.com

Radio: Get Focused. Blogtalkradio

BCIA Webinar: October 5th, 2018

* V.J. Monastra (2005; 2014)Parenting Children with ADHD: 10 Lessons That Medicine Cannot Teach (APA Books)

*V.J. Monastra (2006).Unlocking the Potential of Patients with ADHD: A Model for Clinical Practice (APA Books)

*V.J. Monastra (2015).Teaching Life Skills to Children & Teens with ADHD: A Guide for Parents & Counselors (APA Books).

� ADHD: Is it Medical or Motivational?

� Medical Conditions That Mimic ADHD

� ADHD: Fact vs Fiction

� The Neurological Foundation of ADHD

� Medications for ADHD: How Do They Work?

� Implications for Educators

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� 1900-1915: Children with an atypical degree of inattention, impulsivity and hyperactivity are considered to be suffering from a condition stemming from with a defect of cognitive functions, moral consciousness, or inhibitory volition (G.E. Still)

� Dr. Still believed these “amoral” children had some type of “organic” predisposition…in fact he would not consider them to have this condition if they simply had not been adequately trained by their parents

� Debate begins…How can you tell if a child has these symptoms because of medical causes or poor parenting?

1917-18: Encephalitis Epidemic. Children who survived were left with significant attention and behavioral control problems. Term used:

Post-encephalitic brain disorder.

1920’s-30’s. Conditions like measles, lead toxicity, epilepsy, head injury also caused similar symptoms.

Conclusion of the time: Children with persistent symptoms of inattention, impulsivity, hyperactivity had “minimal brain disorder”…of some type (even when evidence of damage was lacking)

� Late 1930’s-1950’s. Children being evaluated with pneumoencephalograms develop severe headaches. Amphetamines (benzadrine) were found to reduce these headaches…and also to produce a noticeable improvement in attention, behavioral control, and academic performance.

� No abnormalities were typically found on the PEG scan. So…how did this medication help?

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� 1960’s-1970’s.

Psychological Studies: clarify the various types of functional problems found in children with problems of attention and behavioral control.

Neurological Studies: examined incidence of head trauma, poisoning, seizures and other medical conditions in children with these problems in order to determine causes

� Dr. Virginia Douglas (McGill University) clarifies the importance of attention deficits in children with behavioral control problems.

� Term Attention Deficit Disorder adopted by the American Psychiatric Association

� Medications for ADHD (methylphenidate) are developed and demonstrate efficacy. Cause is still unclear.

� Behavior Therapy proposes that psychiatric disorders can be treated by understanding the antecedents and consequences of behavior. Functional Behavioral Analysis begins to be adopted in clinics and schools. Without effective medical treatment, these programs fail.

� Stimulant medications continue to be prescribed without clear understanding of the underlying causes of ADHD. Serious adverse effects occur and parents become increasingly fearful of using medications.

� Dietary allergies proposed as a cause (<1% have this)

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� Neuroimaging (QEEG, fMRI, PET Scans, SPECT) and genetic techniques improve.

� Underlying causes of persistent symptoms of inattention, impulsivity, and hyperactivity are clarified.

� The neuroanatomical foundation of ADHD is established…and an understanding of the pharmacokinesis of medications for ADHD emerges

� Inattention: “Often”� Fails to give close attention to details

� Has difficulty sustaining attention in tasks (like focusing during lectures, conversations, reading)

� Does not seem to listen� Does not follow through on instructions� Has difficulty organizing tasks� Avoids tasks that require sustained mental effort

� Loses things; Is easily distracted; Is forgetful

� Hyperactivity/Impulsivity: “Often”� Fidgets� Leaves seat in situations where remaining seated is expected

� Runs about or climbs where it is inappropriate� Unable to play quietly� Is “on the go” or seems “driven by a motor”� Talks excessively� Blurts out answers before a question is completed� Has difficulty waiting turn� Interrupts or intrudes on others

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� Patient has demonstrated at least 6 symptoms of inattention or at least 6 symptoms of hyperactivity/impulsivity for at least 6 months

* Patients 17+ need to show at least 5 symptoms

� The degree of symptoms (severity/frequency) is atypical for age

� Symptoms negatively impacts on social and academic/occupational activities

� Onset: Some symptoms were present before 12

� Several symptoms are present in 2 settings

� Symptoms interfere with, or reduce the quality of, social, academic or occupational functioning

� Symptoms not due to another psychiatric or medical condition

� Anemia

� Hypoglycemia; diabetes� Thyroid Disorders� Sleep Disorders (deficits; apnea)

� Deficiencies: zinc, magnesium, calcium, Vitamin D, B, Essential Fatty Acids

� Visual problems (acuity; tracking; convergence)

� Allergies (e.g. gluten, wheat, dyes, nuts, corn, dairy)

� Inadequate protein consumption at breakfast/lunch

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DisorderDisorderDisorderDisorder General Pop. General Pop. General Pop. General Pop. ADHDADHDADHDADHD

Conduct Disorder 1-10% 15-56%O.D.D. 2-16% 23-63%Anxiety Disorders 5-15% 20-50%Mood Disorders 10-25% 15-75%Learning Disorders 2-10% 40-60%SUD 20-25% 40-50%Tic Disorders 4-18% 4-18%Eating Disorders 1-3% 11-17%Autistic Spectrum <1 % <1%

� Clinical Interview

� Completion of behavioral rating scales to determine the number and frequency of core ADHD symptoms, as well as, other psychiatric disorders in multiple social settings

� Computerized Tests of Attention (IVA; TOVA)

� Quantitative EEG (only test approved by FDA)

� Medical screening to rule out other conditions associated with “ADHD” symptoms

1. The child must be hyperactive to have ADHD.

Fiction: There are three subtypes of ADHD: Inattentive PresentationHyperactive/Impulsive PresentationCombined Presentation

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2. If behavioral rating scales do not indicate an atypically high frequency of ADHD symptoms at home and at school, the child does not have ADHD.

Fiction: The degree of inter-rater reliability of rating scales is approximately 33% and the DSM-V only requires that “some symptoms” are evident in 2 or more settings.

3. Children will grow out of ADHD.

Fiction: Approximately 50% of children with

ADHD will continue to have symptoms that

interfere with functioning during adulthood.

4. If a child can focus on video games, Legos, Harry Potter books, or other activities, they can’t have ADHD

Fiction: Hyperfocus is a common characteristic

of patients with ADHD. That’s why they are

often successful in high interest activities but

can struggle to learn basic math, reading and

writing skills.

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5. Inconsistent Parenting and ineffective teachers cause ADHD.

Fiction: Certain Parenting and teaching styles

can be problematic, but ADHD is an inherited

condition. Occurs in ~5% of population

75% of monozygotic twins; 35% of dizygotic

10-35% of sibs; If parent has ADHD, odds are

approximately 50% that they will have a child

with ADHD

6. There is no reason for a physician to screen for other medical conditions prior to starting treatment for ADHD.

Fiction: According to the DSM-V: “Visual and hearing impairments, metabolic abnormalities, sleep disorders, nutritional deficiencies and epilepsy should be considered as possible influences on ADHD symptoms”

� 7. There is no medical test that has been approved for use in the diagnosis of ADHD

Fiction: In July of 2013, the FDA approved a QEEG test, based on the research of Dr. Monastra and Dr. Lubar. This test examines the degree of cortical “slowing” in children. This “biomarker” has been found in 80-90% of patients with ADHD.

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Key Findings

Patients diagnosed with ADHD exhibit:*decreased glucose metabolism on PETprefrontal cortex & basal ganglia

*decreased cerebral blood flow on SPECTright lateral prefrontal cortex, temporal cortex,and cerebellum

See Reviews: Barkley, 2006; Monastra, 2008

Key Findings: MRI/fMRI

*Decreased anatomical size (~5-10%) and evidence of asymmetrical development in:

a) Basal ganglia and cerebellum

(associated with behavioral inhibition)

b) Anterior cingulate gyrus, right frontal region, anterior and posterior regions of the corpus callosum and caudate (attention)

*See Reviews: Barkley (2006) & Monastra (2008)

X = -8

4.5

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0

Z

VALUE

FMRI data – Experimental group

Time 2

Go/NoGo task

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X = 31

4.5

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0

Z

VALUE

X = -34

FMRI data – Experimental group

Go/NoGo task

Time 2

� At present, genetic abnormalities have been identified on chromosomal regions that program the development of the following structures

� Dopamine Receptors (~16% fewer receptors)� Dopamine Reuptake Transporters (~70 % more)

� Norepinephrine Receptors

� Norepinephrine Reuptake Transporters* See Reviews: Barkley (2006) & Monastra (2008)

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� Children with ADHD have inherited the “smart” brain or “energy saver” brain.

� If the situation that they are in is important, interesting, life threatening, or fun…their brains will “outperform” most others (hyperfocus).

� If the situation is not important, interesting, life threatening or fun, their brains will quickly disregard…and either hibernate until something interesting comes along, or seek a more stimulating situation.

Adapted from Wilens and Spencer. Child Adolesc Psych Clin N Am. 2000;9:573.

NT Transporter(reuptake pump)

Presynaptic Neuron

Postsynaptic Neuron

Neurotransmitter Transporter

Neurotransmitter Output

Storage VesicleAMP

H

= NT = neurotransmitter; dopamine or norepinephrine

AMPH = amphetamineMPH = methylphenidate

� Stimulants: Ritalin, Ritalin-LA, Methylphenidate, Concerta, Metadate-CD, Focalin (XR), Methylin, Quillivant-XR, Daytrana: DSRI

� Stimulants: Adderall(XR), Vyvanse, mixed amphetamine salts: DRI & NRI, Increase release of dopamine and norepinephrine as well.

� Strattera: NRI

� Anti-hypertensives: clonidine, guanfacine, Intuniv: occupy adrenalin receptors

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1. Stimulants:

Loss of appetite, weight loss, sleep problems,

irritability, tics

2. Strattera:

Sleep problems, anxiety, fatigue, upset stomach,

dizziness, dry mouth, depression

3. Anti-hypertensives:

Sleepiness, headache, rarely causes low blood

pressure

� 1. Enduring symptoms of inattention, impulsivity, & hyperactivity can be caused by a variety of medical conditions, ADHD is only one of the possible causes. Effective intervention hinges on determining the specific medical causes of symptoms in a specific child.

� 2. Teachers can greatly help in the diagnostic process by being aware that there are multiple potential medical multiple potential medical multiple potential medical multiple potential medical causes of symptoms of ADHDcauses of symptoms of ADHDcauses of symptoms of ADHDcauses of symptoms of ADHD and sharing that perspective with parents. Most parents are turned off by a teacher suggesting a child has ADHD. Encourage the parent to get a medical evaluation of their child to figure out if there is “some kind” of medical problem causing the symptoms (ADHD is only 1 of the possibilities

� 3. ADHD is caused by neurological and associated neurochemical “differences”. Unless these factors are treated, the problems will continue

� 4. Parents are highly unlikely to initiate and sustain treatment based on a brief interview and completion of rating scales (only 10-40% will).

� 5. Direct assessment of attention (CPT’s/QEEG’s) combined with thorough medical evaluation to rule out other relevant conditions increases initiation and retention (>95%)

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� 6. The need for intensive educational support often reflects inadequate medical diagnosis and care. Rule of thumb: The amount of Rule of thumb: The amount of Rule of thumb: The amount of Rule of thumb: The amount of support needed in school is inversely related support needed in school is inversely related support needed in school is inversely related support needed in school is inversely related to the adequacy of medical care. to the adequacy of medical care. to the adequacy of medical care. to the adequacy of medical care.

� 7. Failure to respond to medication often reflects insufficient medical screening, lack of academic support at school, inadequate diet, insufficient sleep and/or inattention to motivational issues

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� Presented by Madison-Oneida BOCES

August 5, 2015

� Speaker:

Dr. Vince Monastra

FPI Attention Disorders Clinic

94 Marshall Dr., Endicott, NY 13760

607-785-0400

poppidoc@aol.com

www.drvincemonastra.com

� At present, evidence has identified genetic abnormalities on chromosomal regions that program the development of the following structures

� Dopamine Receptors (16% fewer)� Dopamine Reuptake Transporters (70% more)� Norepinephrine Receptors� Norepinephrine Reuptake Transporters� Adrenalin ReceptorsResult: Dysregulation of arousal in brain regions responsible for attention & behavioral control;80-90% show “underarousal”10-20% show “overarousal”

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1. Students with ADHD will attend in contexts that are important…interesting…life threatening…or fun

2. Learning requires motivation…without a reason to learn, students with ADHD will not attend or learn

3. Kids learn best from people who they admire, respect, and like…and SEEM TO LIKE AND RESPECT US!!!!

4. Get to know each child’s name, face, and interests as early in the year as possible. Look for common interests with you and other kids in class.

5. Look for opportunities during breaks to share the gift of your time, positive attention and interest. Kids with ADHD do a lot of things “wrong” and will start to “tune out” if all they hear is what they are doing wrong.

� Kids with ADHD WILL ATTEND if the situation is important, interesting, or fun… So …

1. Plan your activities so that at least YOU have an idea that the topic is important, interesting or fun.

2. SELL IT. If you don’t come across like something awesome is about to happen, why WOULD they pay attention to you.

3. Explain the rules to kids before the activity, so that they know what will happen if they do not follow directions and complete the task. Color Charts can help provide clarity to the child

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� Children need to eat protein at breakfast and lunch in order to sustain attention, reduce irritability, and remain in control

� Primary Grades (10-15 grams per meal)

� Middle School (15-20 grams per meal)

� High School/College (20+ grams per meal)

� Instruct children in protein sources, assign homework to monitor their intake, and encourage parents to provide protein snacks for children who are not hungry in the morning

� 20 minutes of sustained activity that raises heart rate above threshold can also improve attention and reduce hyperactivity for 1-2 hrs.

� To establish threshold/max heart-rate:

Step 1: Subtract the child’s age from 220

Step 2: Multiple number by 0.6 (threshold)

Step 3: Subtract age from 200; X 0.8 (Max)

Class Friendly Exercises: Planks; Superman; Sit ups; Run in Place. Kids often enjoy setting goals, challenging each other. Consider having one movement break like this in the morning.

� Children in the primary and intermediate grades will struggle to attend with less than10 hours sleep

� Teens will struggle to attend when sleep decreases much below 9 hours. Students evaluated after less than 8 hours of sleep do not pass the tests of attention administered at my clinic.

� In your “classroom notes” to parents share this type of information. Suggest that electronic devices be turned off 1.5 hours before bedtime. High definition light sources reduce the activity of the pineal gland, which produces the “put your brain to sleep” hormone: melatonin.

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� When the child is “off-task” get them involved in a leadership role, or pair with a “focused” child. If you’ve “lost them”, figure the kid needs an alternative activity…

� Ask them to help you get something

� Get them a drink

� Ask them to help set up the next activity

� Give them a challenge on the task (use a stop watch

� Take them aside and see if they’ve got an idea on what could make the activity more fun

� Move with the ADHD child…insisting that they go to time out, leave an area, etc. is not likely to work. If possible, walk with them away from the class.

� During conversation with the child, emphasize the notion that they’re just having a tough moment…and encourage them to sip some water, take some breaths, etc. and re-group. Talk to the “GOOD KID” Inside.

� Without threatening them, play a version of “good cop/bad cop”, just gently reminding them what kinds of things could happen if they “can’t get it together”…again remembering that a really “GOOD KID” lives inside.

� Positive PracticePositive PracticePositive PracticePositive Practice: Requiring the child to practice the desired skill extra times if they are “off-task” or are non-compliant

� Positive PunishmentPositive PunishmentPositive PunishmentPositive Punishment: Requiring the child to perform some type of task or action to “make up” for disrupting the class or not working

� Time Stands StillTime Stands StillTime Stands StillTime Stands Still: Letting the child know that until they complete the required task, as well as any other “make-up” tasks, they will not be able to engage in “fun” activities at school.

� These tasks can be performed in school or at home if the child simply does not respond to your preventive strategies.

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� Until the medical causes of the child’s ADHD behavior are identified and treated, motivational interventions will yield inconsistent results.

� Collaboration with parents and physicians to obtain thorough medical evaluation to identify causes of persistent ADHD symptoms is probably one of the most important roles a teacher will play.

Prior to Diagnosis� Get to know your students before the school year begins.

� Be friendly, interested, and enthusiastic…kids with ADHD attend better to adults who are interesting, fun, and clear about their expectations.

� Share your observations about attention/behavioral control problems with parents early in the year. Use class-wide monitoring systems

� Offer to help by sharing your knowledge with the child’s doctor (e.g. via letter).

� Defer diagnosis to physician, psychologist, etc. It is helpful when teachers point out that there are a number of possible causes for inattention, hyperactivity, impulsivity and stress the importance of asking a doctor for an evaluation to help figure out what’s going on. Do not say that you think a child has ADHD (BIG TURN OFF)

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� Students with ADHD have a wide range of functional problems that can and do impede learning and adversely affect educational performance including:

� Organization

� Classroom Functioning

� Social Skills

� Mood/Behavioral Control

� Reading, Math, and Writing Skills (fluency)

Fact is used to compare students with peers on

Seven areas of potential impairment

OrganizationOrganizationOrganizationOrganization…does the child

*arrive to class on time

*have the necessary materials

*bring homework assignments to class

*records homework assignments

*brings home the materials necessary to complete homework

Does the student…

*sit in seat, does not disrupt class

*follow written directions

*follow verbal directions

*accurately copy notes from boards

*complete “seat work” during the allowed time

*take accurate notes from lectures

*participate appropriately in class discussions

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Does the student…

*maintain eye contact while speaking; listening

*engage in social conversations with peers

*maintain a conversation that is of interest to others

*get invitations from peers to join social activities

*get involved in school-based extracurricular activities (sports, music, drama, clubs)

Does the student

*tolerate frustration without getting “upset”

*comply with rules

*seem anxious or worried

*seem sad or depressed

*become verbally aggressive with peers or staff

*become physically aggressive with peers/staff

How does the student compare on

*reading speed and accuracy

*ability to comprehend the literal meaning

*ability to reach conclusions based on inference

*ability to prepare outlines/study guides based on reading of textbook

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How does the student compare on

*knowledge of math facts (+, -, X, Division)

*computational accuracy

*ability to understand word problems and calculate the correct answer

*ability to explain “HOW” they solved a particular problem

How does the student compare on

*writing speed

*writing legibility

*spelling

*punctuation/grammar

*ability to write answers requiring 1sentence

*ability to write short responses (1-2 par.)

*ability to write compositions (3+ paragraphs)

� Advocate for your student to receive those accommodations and support services that will help them succeed in your class. Do not ignore teasing, shunning, and other aggressive behaviors that can (and have) led to social isolation and violence in students

� Obtain written permission from parents/guardians so that you can share your observations with the child’s treatment providers (prevent disconnect). No different from field trips. Doctors HIGHLY VALUE your perspective!!!!! You don’t have to do it alone!

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� 1. Monitor assignments and agenda� 2. Monitor book bag packing at end of day

� 3. Reduce the number of repetitive assignments

� 4. Use of class-wide Color Chart system, with daily reports regarding listening, completion of seat work, remaining seated, controlling inappropriate verbal & physical behavior

� Monitoring + Feedback Improves Home Reinforcement and Motivation. Without timely information parents cannot reinforce/punish

1. Reinforce use of an agenda

2. Collaborate with in-school case manager or resource room teacher to provide weekly progress notes regarding behavior and missing assignments. CLOSE THE LOOP! Require students to complete all missing assignments (even if they won’t be given credit)

� 3. Just like college, provide your students with advance notice of coming assignments.

� 4. Provide at least two periods for review/homework during the school day

� 5. Consider the strengths of the student and promote involvement in vocational courses for students with clear academic weaknesses in core academic areas

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� 6. Encourage use of word processor +/or voice recognition software.

� 7. Assist the student in developing study and note-taking skills.

� 8. AVOID DEBATINGYou do not need to defeat the studentin a class debate. Establish a “safe place (in IEP/504 Plan) and encouragethe student to go there (non-confrontational): APPEAL TO THE HEALTHY KID INSIDE

� 9. Help Connect Isolated Kids with School Activities

� Mathematical Problems:

Kids with ADHD have great difficulty with working memory and expressing math processes “verbally”.“Visual Math Practice”Use of number lines, multiplication tables, calculatorsSongs and playful repetition: Computerized Math gamesAIS ClassesResource Room

� Reading Comprehension Problems:

BE ATTENTIVE TO VISUAL PROBLEMS: About 20% of patients have undiagnosed Visual Tracking/Convergence Disorders.

“Read with a Purpose”

Assistive Technology: Electronic Versions

Text-Reading Software

AIS Classes

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Written Expression:

� Working Memory Problems REALLY Impact ability to write even the simplest assignments.

� Foundation Steps include:Retrieving within categories (Scattegories; Word Fluency Games)

Teaching simple 4-sentence, paragraph structure

Expanding to simple 3 paragraph data-based writing

Consider evaluation by speech/language therapist to rule out/treat pragmatic language disorder

� Ask parents to provide healthy, protein-based snack for morning (in case child is too tired to eat breakfast)

� Pair with peer to model and teach organizational and study skills (class-wide).

� Use AARP; PTA to establish a “homework” club or review class

� Establish non-aggression pact in class:no one has the right to tease, shun or act aggressively to classmates or teachers. Apologies and Amends

� Teach problem-solving skills in the classroom � Identify needs/fears

KEYS:

1. Accept that ADHD is a “real” medical condition but is only one of multiple conditions that can cause problems of attention and behavioral control

2. Don’t pass the problem on from year to year: Collaborate with each other to determine the cause(s) of a person’s inattention and impaired behavioral control

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� 3. Establish a system that provides permission for parents, teachers, physicians, and other care providers to communicate. If problems with attention and behavioral control persist despite the best efforts of qualified teachers, odds are the causes are MEDICAL!!!

� 4. Establish sufficient academic support and accommodation

� 5. Develop in-school “review/practice” periods to complete “homework”

� 6. Recognize and address motivational issues via a system that uses meaningful consequences not “takaways” or “gimme’s”

� Students with chronic attention and behavioral control problems are highly likely to be suffering from an undiagnosed medical condition. Help them get to a doctor who can figure out what the cause is.

� The Goal: To help children successfully navigate the tides of 13 academic years and end up believing that they are capable, that they have talents, and they can have a successful future.

� Remember: Treating children with ADHD is not just about preventing “drop outs”, drug abuse, and criminal behavior. Some of the most talented people of all time (e.g. Thomas Edison) had significant attention problems. They succeeded because they had a parent or teacher who REALIZED THEIR ABILITIES, not just their “dis” abilities.