esu grad student seminar
TRANSCRIPT
1Case Study: Wendy G:
Background Age 23
Senior at KU, Special Ed major, 130+ hours Youngest of three Childhood illnesses Bullied in middle school Mother is cancer survivor History of ADHD, anxiety
Medication 504 accommodations Including post-secondary
2KU Student Services
18 months prior
“Summarv and Conclusions“Wendy is a 22-year, 9-month old Caucasian female who
was referred by the KU student disabilities resource center, for an updated evaluation of her abilities and achievement. The present evaluation shows that Wendy's cognitive abilities fall into the average range, with high average verbal skills, average perceptual reasoning skills and working memory, and low average processing speed.
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4“Wendy's academic achievement compared to similarly-aged peers falls into the average range, with average math and reading skills, superior written language skills, and low average oral language skills.
5
The results of the present evaluation show that Wendy does not currently meet the diagnostic criteria for a specific learning disorder in any particular academic area. However, she does experience several significant symptoms and deficits that interfere with her learning.
6• Finally, Wendy exhibits symptoms of inattention, both according to her and her mother. Wendy's report of these inattention symptoms is consistent with behavioral observations of her short attention span and break requirements. • Furthermore, her report of attention problems confirms prior
evaluations' conclusions that she did indeed met diagnostic criteria as a child and continues to experience these symptoms. Though this report of symptoms is somewhat below the diagnostic requirements, she is still significantly impaired. This is partially due to her utilization of the accommodations she receives.
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“Because she is able to meet expectations with the help of these accommodations, her symptoms are less problematic in her academic work.
8
“Wendy's report, her mother's report, behavioral observations and evaluation results, and her current success with her educational accommodations suggest that other key areas make learning success difficult for Wendy. First, she has a history of impairment with some specific perceptual processes that make transferring visual material from one space to another particular difficult for her. This is further supported by her lower performance on the Coding subtest of the WAIS-IV.
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“Second, Wendy experiences low average processing speed; she is very slow and deliberate in her work, making tasks that require her to work under a time limit particularly difficult. Both Wendy and her mother report that she has learned to plan far in advance when working on tasks so that she can finish them on time, and she benefits from extended time on tests now.
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“Third, while Wendy's reading achievement does fall in the average range when compared to her age-mates, when compared to grade-mates, she falls below average in comprehension. While Wendy is able to keep up with her peers, she seems to require more time when reading.
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“Additionally, Wendy exhibited a deficit in oral language abilities, suggesting that she struggles to manage verbal directions when that is the only format they are presented in, despite her strength in working with verbal materials.
12
Altogether, these functional impairments in perceptual abilities, understanding nonverbal cues, specific skill deficits, and attentional problems equate impairment for Wendy in academic and testing situations. Because she has a disorder of learning that is not confined to a specific area but still affects her performance in some specific situations, a diagnosis of Learning Disorder, Not Otherwise Specified is recommended.
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“Furthermore, Wendy has previously met the Attention Deficit Hyperactivity Disorder diagnosis and still continues to experience a range of impairing symptoms that affect her academic work and daily life management.
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“While attention and learning struggles may pose difficulties for Wendy's success, she has some important strengths in her favor. First, she has clear strengths in verbal and writing abilities. Additionally, Wendy possesses a determined and motivated work ethic that has helped her persevere in the past and will continue to aid her in reaching her academic and professional goals.
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“Furthermore, Wendy has a strong support network of friends and family that will continue to be important in helping her succeed. She does not exhibit symptoms consistent with any other emotional or psychological disorders, and she has successfully coped with several stressful life events.
16Cognitive
17
18
19Dx/Rx
20“Recommendations
“1. Wendy may wish to give a copy of this evaluation to staff at the disabilities resource center to determine if she is eligible for any additional supportive educational services from his school or for testing accommodations.
[Ed – clearly cut and paste]
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2. Because Wendy has benefited from the following accommodations and she continues to struggle with attention, perceptual processes, and handwriting, it would be in her best interest to continue to have these accommodations, including:
extended test taking time; test-taking in smaller, quieter rooms; note-taking help from classmates; use of a laptop for note-taking and writing assignments; and being allowed to forgo using "bubble" formatted tests and
responding in an alternate way.
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“3. Should Wendy feel that her attentional difficulties are increasingly difficult to control, she should contact her physician or a psychiatrist to explore medication options, as she may benefit from pharmacological interventions as she did when she was a child.
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Myths
24Somewhat True
Myths have basis in historical facts ‘The World is Flat.’ ‘The Sun Revolves Around the Earth.’ ‘Witches Made of Wood’ ‘Test scores = Learning’
Myths help make confusing concepts easy to understandEven if wrong
If I’m wrong …Email me with better research
20 ADHD Myths
Origins: Fueled by medical model of illness, treatment, recovery. Huge $$ Involved
$250B IndustryInsurance reimbursement
25
Except
Minimal evidence that ADHD kids are ill, Nor that medical treatment leads to recovery
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Some Kids’ Brains Are Just Wired Differently
Actual: All kids’ brains are wired
differently
27
Myth or Fact?
Experts Now Have A Much More Sophisticated Understanding
… of how a brain works, and which treatments most effective.
Actual No agreement at the national level on definitions and
guidelines for mental health categoriesAPA conflict with NIMH
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Myth or Fact?
Mental Health Obstacles Like ADHD And Depression Are Caused By Chemical Imbalances In The Brain
29
Myth or Fact?
Mental Health Obstacles Like ADHD And Depression Are Caused By Chemical Imbalances In The Brain
Actual: ‘Chemical imbalance’ is a marketing metaphor. Unlikely a chemically imbalanced brain would survive.
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ADHD Is Caused By
Parents Teachers Doctors Politicians Drug Companies Kids
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Myth or Fact?
ADHD Is Caused By
Actual: Lacking a clear definition amongst experts, defining a
cause remains elusive Some experts define ADHD as a patient who responds
well to ADHD treatment.Gualtieri, C. T., & Johnson, L. G. (2005). ADHD: Is
objective diagnosis possible?. Psychiatry (Edgmont), 2(11), 44.
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ADHD Occurs 3x More Often In Boys
Actual: Boys more likely ‘combined’ ADHD
Therefore noticed and diagnosed Girls more likely ‘inattentive’
Identified later Girls more likely misunderstood
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Myth or Fact?
ADHD Rates Are Consistent Across North America
34
Myth or Fact?
ADHD Rates Consistent?
Journal of the American Academy of Child and Adolescent Psychiatry Volume 53, (January 2014)
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Experts Create Treatment Plans For Doctors,
… using new discoveries invented by scientists working drug companies’ labs.
Actual: Protocols exist, but vary by specialty
And seldom followed in community care. Barkley, R. A. (2005). Attention-deficit hyperactivity
disorder: A handbook for diagnosis and treatment (Vol. 1). Guilford Press.
36
Myth or Fact?
ADHD Drugs May Lead To Addiction
Actual: College-age diversion to recreational use is problematic No proof of extreme addiction risk
Although mechanism is similar to cocaineNote that meth still legal –
37® (methamphetamine hydrochloride) Was frequently prescribed in the US through early
70s.
37
Myth or Fact?
Your Doctor Has Been Trained
… To Provide Long-Term Treatment To Enhance Kids’ Well-Being
Actual: Pediatricians have minimal feedback on college students’
challenges Doctors workshops sponsored by pharmaceutical
companies Most doctors now employees
Paid per ‘encounter’ (ICD10)
38
Myth or Fact?
Doctors are Trained To Provide Medical Solutions
… To identify non-medical problems like inefficient learning skills
Actual: Most doctor visits for ADHD initiated by teacher complaint Doctors rely on teacher/parent behavior surveys
Miss non-behavioral elements Doctors often report feeling ‘pressured’ Report feeling frustrated with ‘specialist’ evaluations
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Myth or Fact?
MD’s Burnout Rate 40
Source: Medscape 2014
Early Detection And Expert Medical Treatment … GUARANTEES MOST ADHD CHILDREN WILL SUCCEED DESPITE THEIR ILLNESSES
41
Myth or Fact?
Medical Treatment Guarantees Most Will Succeed?
Actual: “We had thought that children medicated longer would
have better outcomes. That didn’t happen to be the case. There were no beneficial effects, none. In the short term, [medication] will help the child behave
better, in the long run it won’t. And that information should be made very clear to
parents.”
MTA Investigator William Pelham, University at Buffalo
Daily Telegraph, “ADHD drugs could stunt growth, “ Nov. 12, 2007.
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1,379 Canadian Youth
14 studies that lasted a minimum of three months, Canadian investigators concluded that there is “little evidence for improved academic performance” with stimulants.
Source: R. Sachar, “Attention-deficit hyperactivity disorder,” Canadian Journal of Psychiatry 47(2002):337-348.
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2005 Oregon Public Health
In a 2005 review of 2,287 studies at Oregon Health and Science University:
“no good quality evidence on the use of drugs to affect outcomes relating to global academic performance, consequences of risky behaviors, social achievements, etc.”
Source: McDonagh, “Drug class review on pharmacologic treatment for ADHD,” 2006. http://www.ohsu.edu/drugeffectiveness
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2012 New York Times
“Attention-deficit drugs increase concentration in the short term, which is why they work so well for college students cramming for exams.
But when given to children over long periods of times, they neither improve school achievement nor reduce behavior problems
. . . to date, no study has found any long-term benefit of attention-deficit medication on academic performance, peer relationships, or behavior problems, the very things we would want most to improve.”
--Alan Sroufe, professor emeritus of psychology at the University of Minnesota Source: New York Times, “Ritalin Gone Wrong,” January 28, 2012.
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2013 Wall Street Journal
7/8/2013
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In Support
2012: Shire Pharmaceuticals funded a study, led by its medical director, that reviewed studies of long-term outcomes (>2yrs) for ADHD. (Shire manufactures Vyvanse, Adderall XR and Intuniv)
Reported 29 studies of favorable outcomes for treated ADHD in the literature, on some measure or another, when compared to patients who weren’t treatedVs. 20 reports of no benefit or worse outcomes for treated ADHD.
Authors concluded: “Treatment for ADHD improved long-term outcomes compared with untreated ADHD.”
Source: M. Shaw. “A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder.” BMC Medicine10 (2012):99.
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Girls With ADHD Fare Better Than Boys?(MYTH)
48
Myth or Fact?
Girls With ADHD Versus Boys’ Outcomes
Actual:
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No Long Term Risks From ADHD MedsONCE A CHILD STOPS TAKING MEDS
50
Myth or Fact?
Actual:
Stimulants can induce mania and psychosis In a Canadian study, six percent of ADHD children treated with stimulants
for an average of 21 months developed psychotic symptoms. In a study of 195 bipolar children, Demitri Papolos found that 65% had
“hypomanic, manic and aggressive reactions to stimulant medications.” University of Cincinnati reported that 21 of 34 adolescent patients
hospitalized for mania had been on stimulants “prior to the onset of an affective episode.”
Source: Cherland, “Psychotic side effects of psychostimulants,” Canadian Journal of Psychiatry 44 (1999):811-13. Papolos, “Bipolar disorder, co-occuring conditions, and the need for extreme caution before initiating drug treatment.” Bipolar Child Newsletter 1 (Nov. 1999). DelBello, “Prior stimulant treatment in adolescents with bipolar disorder,” Bipolar Disorders 3 (2001):53-57.
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The FDA Guarantees That A New Drug Is Safe And Effective For Treating A Specific Illness
52
Myth or Fact?
The FDA Guarantees That A New Drug Is Safe And Effective For Treating A Specific Illness Children on SSDI for mental health issues
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The FDA Guarantees That A New Drug Is Safe And Effective For Treating A Specific Illness
Actual: Long-Term Risks With SSRIs in Children
Conversion to bipolar diagnosis.Apathy SyndromeCognitive ImpairmentSexual dysfunction in adulthood
Source: Faedda, “Pediatric onset bipolar disorder,” Harvard Review of Psychiatry 3 (1995):171-95. Geller, “Bipolar disorder at prospective follow-up of adults who had prepubertal major depressive disorder,” Amer J of Psychiatry 158 (2001):125-7.
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The SSRI-to-Bipolar Pathway
In first pediatric trial of Prozac, 6% of treated children suffered a manic episode; none in placebo group.
In study of antidepressant-induced mania for all ages, Yale University investigators found the risk highest in those under 13 years of age.
Harvard University researchers find that 25% of children treated for depression convert to bipolar within four years.
Washington University researchers report that within 10 years, 50% of prepubertal children treated for depression convert to bipolar illness.
Source: Emslie, “A double-blind, randomized, placebo-controlled trial of fluoxetine in children and adolescents with depression,” Arch of General Psychiatry 54 (1997):1031-37. Martin, “Age effects on antidepressant-induced manic conversion,” Arch of Pediatrics & Adolescent Medicine 158 (2004):773-80. Faedda, “Pediatric onset bipolar disorder,” Harvard Review of Psychiatry 3 (1995): 171-95. Geller, “Bipolar disorder at prospective follow-up of adults who had prepubertal major depressive disorder,” Amer J of Psychiatry 158 (2001):125-7.
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Nonprofit Groups Serve As Watchdogs To Protect The Interests Of Children And Families
For example, CHADD and NAMI
Actual: CHADD initially chartered with grant from industry
receiving $18mil in funding last five yearsAt least $5 million from directors
Source IRS 990 for 2012
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Myth or Fact?
In-School Options
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Schools Are Required By Law To Provide ‘504’ Accommodations To Kids With Documented Health Issues, Including ADHD.
True Examples
Extra time on testsShortened homework assignmentsTests read out loudPreferential seating near teacher
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Myth or Fact?
504 Accommodations Have Been Proven To ‘Level The Playing Field’ For Kids With Learning Issues
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Myth or Fact?
Effect Sizes
27 review articles149 strategies111 related to ADHD symptoms68 accommodations (vs mods or Rx)
To analyze 201 studies for ES 9 accommodations
Harrison, J. R., Bunford, N., Evans, S. W., & Owens, J. S. (2013). Educational Accommodations for Students With Behavioral Challenges A Systematic Review of the Literature. Review of Educational Research, 83(4), 551-597.
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ADHD Students Benefit From 504 Accommodations
Actual: “Multiple accommodations are being recommended without any evidence
of effectiveness. This approach … costs students in terms of their potential long-term outcomes, … costs teachers' effort and time providing services unlikely to work, and … costs districts and communities the resources used to provide these
strategies Harrison, J. R., Bunford, N., Evans, S. W., & Owens, J. S. (2013). Educational
Accommodations for Students With Behavioral Challenges A Systematic Review of the Literature. Review of Educational Research, 83(4), 551-597.
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Classroom Teachers Are Trained In The Pros And Cons Of The Long Term Use Of Stimulant Meds …
64Myth or Fact?
Classroom Teachers And Reading Specialists Receive Extensive Training In Developmental Neuroscience
Actual: 1 reference to cognitive skills in 1 course offered by KU
School of Education in 2014. New teachers themselves now graduating from an education
system that values nothing more than improving test scores Historic fad of ‘Brain-based learning’
Workshop information simplistic to wrongVeteran teachers/administrators tend to dismiss
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66
Review Wendy’s Report
67 The present evaluation shows that Wendy's cognitive abilities fall into the average range, with high average verbal skills, average perceptual reasoning skills and working memory, and low average processing speed.
68Cognitive
69
The results of the present evaluation show that Wendy does not currently meet the diagnostic criteria for a specific learning disorder in any particular academic area. However, she does experience several significant symptoms and deficits that interfere with her learning.
70T-Scores
71
72
• Though this report of symptoms is somewhat below the diagnostic requirements, she is still significantly impaired. • This is partially due to her utilization of the
accommodations she receives. • Because she is able to meet expectations with the help of
these accommodations, her symptoms are less problematic in her academic work.
73
…. her current success with her educational accommodations suggest that other key areas make learning success difficult for Wendy.
First, she has a history of impairment with some specific perceptual processes that make transferring visual material from one space to another particular difficult for her.
Second, Wendy experiences low average processing speed; she is very slow and deliberate in her work, making tasks that require her to work under a time limit particularly difficult.
… and she benefits from extended time on tests now.
74
…. her current success with her educational accommodations suggest that other key areas make learning success difficult for Wendy.
First, she has a history of impairment with some specific perceptual processes that make transferring visual material from one space to another particular difficult for her.
Second, Wendy experiences low average processing speed; she is very slow and deliberate in her work, making tasks that require her to work under a time limit particularly difficult.
… and she benefits from extended time on tests now.
75
Third, … she seems to require more time when reading. Additionally, Wendy exhibited a deficit in oral language
abilities, suggesting that … she struggles to manage verbal directions when that is
the only format they are presented in, … despite her strength in working with verbal materials.
76
Altogether, these functional impairments in perceptual abilities, understanding nonverbal cues, specific skill deficits, and attentional problems
equate impairment for Wendy in academic and testing situations.
… a diagnosis of Learning Disorder, Not Otherwise Specified is recommended.
… previously met the Attention Deficit Hyperactivity Disorder diagnosis and still continues to experience a range of impairing symptoms that affect her academic work and daily life management.
77
Altogether, these functional impairments in perceptual abilities, understanding nonverbal cues, specific skill deficits, and attentional problems
equate impairment for Wendy in academic and testing situations.
… a diagnosis of Learning Disorder, Not Otherwise Specified is recommended.
… previously met the Attention Deficit Hyperactivity Disorder diagnosis and still continues to experience a range of impairing symptoms that affect her academic work and daily life management.
78
• While attention and learning struggles may pose difficulties for Wendy's success, she has some important strengths in her favor. First, she has clear strengths in verbal and writing abilities. • Additionally, Wendy possesses a determined and
motivated work ethic that has helped her persevere in the past and will continue to aid her in reaching her academic and professional goals.
79
She does not exhibit symptoms consistent with any other emotional or psychological disorders, and she has successfully coped with several stressful life events.
80Dx/Rx
81Recommendations
1 .. copy of this evaluation to staff at the disabilities resource center to determine if she is eligible for any additional supportive educational services from his school
or for testing accommodations.
2. Because Wendy has benefited … and she continues to struggle with attention, perceptual processes, and handwriting,
it would be in her best interest to continue to have these accommodations, including: extended test taking time; test-taking in smaller, quieter rooms; note-taking help from classmates; use of a laptop for note-taking and writing assignments; and being allowed to forgo using "bubble" tests
82
3. Should Wendy feel that her attentional difficulties are increasingly difficult to control, she should contact her physician or a psychiatrist to explore medication options, as she may benefit from pharmacological interventions as she did when she was a child.
832 ½ Semesters Later
84Clinical Supervisor Concerns
“Needs much guidance for teaching; spent a large amount of time gathering materials and going over things with Wendy
“Hard time remembering things “Procedures and routines are hard for her “Difficulty seeing the big picture-how everything we do in
the classroom is connected
85
“Didn't have materials done when said she was going to; “Parents asking why lesson plans were not posted “Forgets a lot of what was discussed “Needs prompts constantly “When teaches something, often has to be re-taught
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“Not an independent thinker “Classroom management is a concern “Concerns with treatment of some students that Wendy
feels are not showing her respect “Constantly does same instructional strategies over and
over-does not vary
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“Wastes a lot of instructional time “Not always prepared “Concerns about Wendy taking over the full class “Not aware of surroundings and location of things “Not connecting the "why" you are doing things
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“Spent a lot of time with her and Wendy still is not prepared or forgets the elements of the discussion
“Little initiative “Must be hand fed everything and has difficulty thinking
on her own “No original ideas
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“Does not do much with the resources provided “False sense of success
90Positives
“Wendy is trying very hard. “She does have a difficult time remembering everything. She is trying to
think through --write more down to practice- so that she can have more eye contact and the lesson will flow a little more naturally.
“She is eager to try things and this class is exceptionally polite and well-behaved, so they really do listen well for her.
“Making decisions --about pacing, about what to cut and what to add, about what would be interesting for the children and would hold their attention well --are difficult for her. She really does best if she knows exactly what to do and has, perhaps had it modeled for her.
91
“She seems very bright in many ways. Hopefully, some practice will make her feel more comfortable.
Children on SSDI for mental health issues 92
93
Time for Good News
94
Channel 9 video here
95Eudaimonia Wellbeing
Vs hedonic wellbeing C. D. Ryff
1. Autonomy
2. Personal growth
3. Self-acceptance
4. Purpose in life
5. Environmental mastery
6. Positive relations with others.
96
SCOPES Study Skills Coaching
97Unique SCOPES Factors
Coactive Target clients’ perceived
challenges Using clients’ existing
strengths* To seek epicenter of clients’
emotional energy and authenticity
By providing framework
Through non-judgmental Socratic interaction
Didactic Predetermined optimal
outcomes Prevention (or
remediation) of failures To win
By “expert” efficacy analysis
And enforcing clients’ compliance
* - We consider one’s capacity for growth a strength (vs a rationale for avoidance)
98SCOPES ROOTS
Harvard in-house ADHD student support model (Safren) Adapted to coaching model grades 6 and up
Alpha test in paper/pencil format (4/12)Rollout online screening format (9/12)
99CURRENT OPERATING MODEL
Phase 1: Prescreening Risk FactorsGrades 6-12: parents’ survey --- College: self-surveyOnline, self-scoringHigh comorbidity low EF with LD, ADHD, RD, GAD
Phase 2: Online students self-assess academic strengths and challenges
Phase 3: Weekly coactive coachingTypically requires 60-90’ per week (more at startup)
Phase 4: Clients determine support levels
100
Phase 1 (grades 6-12):
Parents’ prescreeningOnline 10-15 minutesSelf-scoring (autoreply)Screening results: Green, yellow, red lights
Discourage Red Lights from continuing with SCOPES High comorbidity low EF with
LD, ADHD, RD, GAD, etcRefer highest risk to appropriate MHP
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Phase 1 (College):
Students self-screen and self-score Similar narrative for red/yellow/green
Presume self-care for referral follow through
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Phase 2: Strengths Profile
Students Self-assess Online survey Strengths and challenges
Overweighted to planning and mindset topicsUnderweighted to content-specific concerns (eg math)
Client option to analyze and coach at home $39 fee*
Option for Heartscope Analysis Support ($99)* Fee currently waived to promote data collection
103
Phase 3: Weekly Coactive Coaching
Typically requires 60-90’ per week Although startup sessions often longer
Parents’ option to implement at home No additional fees … (Future intention to promote blog and e-zine support)
In-house coaching option (local clients)Weekly 1:1 coach-client sessionsMeet at Heartscope Parent(s) present session 1 only
Students self-report results of subsequent sessionsSession 1: ‘Roles Agreement’ signed, parent, student coach
Clarifying no homework help
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Phase 4: Clients Self-Sufficient
Clients determine support level requiredSession frequencyTopicsEnvision future options for online support
Email … Text … SkypeEnvision future ‘Pay-it-Forward’
SCOPES recipients encouraged to coach younger students and/or peers.
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Sample Activity: 6 Sources of Motivation
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Long-term Heartscope Goals
1. SCOPES available to all college students nationally Effective Affordable Expanding evidence base Collaborative relationships with other local student support service providers
2. Income stream funds research for SCOPES interventions Middle/High school … Full SES range … Innovative parent support options
3. SCOPES catalyzes fundamental change Higher % college entrants graduate in 4 years Qualitatively better personal student experiences Improved self-regulation and self-appraisal in new graduates Greater productivity and economic benefit to students and community
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Short Term ESU Options
1. On-campus student coaching
2. Emporia-area middle/high school coaching
3. Direct-coach model
4. Train the trainer model Grad students oversee
Peer coach development Parent coach development
(clarify teachers as coaches…)
