Attention, Memory and Learning

1. Attention, Memory and Learning ADHD Related disorders What does this mean to educators?

2. As you begin… This is a lengthy presentation – you might want to look at it in sections. There is considerable information on the anatomical connections related to ADHD. It might be a good idea to review the anatomy of the brain to know the locations of the areas mentioned. Where mentioned, some abbreviations are explained.

3. ADHD There are three types of attention deficits, yet they are all called ADHD in the diagnostic literature: ADHD primarily inattentive type ADHD primarily impulsive type ADHD combined type What is important to remember is that not all individuals with ADHD are overly active, disruptive or aggressive.

4. Let’s start with some of the neurology This section will address the anatomical and pharmacological aspects of understanding how ADHD has been studied.

5. Neurology—Revealed by aMRI and fMRI—Underlying ADHD • Frontal (and all subdivision!) • Striatal (emphasis on caudate) • Cerebellar (most distinctive) • Underactivated caudate and MPH response of caudate most consistent findings aMRI=anatomical magnetic resonance image fMRI=functional magnetic resonance image MPH= methylphenidate, a stimulant medication (ex., Ritalin, Concerta)

6. Shapes of caudate and anteroventral putamen are compressed such that volume is diminished in 8-12 year old boys with ADHD. Mostofsky/Denckla group

7. fMRI shows normal sensitivity to rewards in children with ADHD, although conduct disorder (not ADHD) is associated with diminished activation of the reward circuitry of the orbitofrontal cortex. Rubia et al

8. Between 12 and 16 years, children with ADHD Rx with stimulants show cortical thickness (for age) closer to typically developing peers than did those not treated. Shaw et al

9. “Attention-deficit/hyperactivity disorder is characterized by a delay in cortical maturation.” • This is the title of the publication by Shaw P, Eckstrand K, Sharp W, Blumenthal J, Lerch JP, Greenstein D, Clasen L, Evans A, Giedd J, Rapoport JL, 2007 PNAS, 104:19649-19654 • Cortical growth-to-max trajectories measured on aMRIs

10. Multifactorial Cognitive Etiology Model of ADHD • “Impulsive cognitive style is attributive to an additive or interactive dysfunciton in multiple (but probably related) cognitive systems and their closely related mediating neural networks” (Sergeant et al., 2003; Willcutt et al., 2005)

11. Compensatory Neural Activity Revealed by fMRI with ADHD • Caudate activation deficiency implies deficient coding of event probability • Anomalous activity of right posterior superior temporoparietal region (possible awareness of motor action is compensatory?) • MPH modulation limited to regional and task specificity, not a “cure-all.”

12. Non-Pharmacological Rx for ADHD: More Research-based Rationale I • Cognitive control status is not correlated with symptom severity of ADHD but… • ADHD symptom severity isMPH-responsive • Closely related cognitive control tasks are differently impaired with ADHD

13. Non-Pharmacological Rx for ADHD: More Research-based Rationale II • Two closely related cognitive control tasks: • Interference suppression: NOT MPH-responsive • Response inhibition: YES, MPH-responsive • Rapid naming (fluency measure) is improved but NOT normalized by MPH

14. Now we move to Executive Function Executive function (EF) and executive dysfunction (EDF) are important to the learning process because they represent the integration of the skills of planning, organization, impulse control, spatial and visual processing, and creativity. In the case of EDF, it may impact how students can demonstrate what they know if the format of tasks do not coincide with their ability to draw on prior knowledge, apply knowledge to the task required, focus on the task and disregard distractions, and present the final product.

15. I-S-I-S • A feature of executive function is the ability to do the following… • Initiate activities by organizing for the task • Sustain attention to the task • Inhibit the impulse to attend to distractions • Shift attention to new information while still retaining what has already been presented You do it every day…when you work, read or drive…in just about all conversations, and when you read power points!

16. EF Popularized As Neuropsychology of ADHD • Executive Function (EF) is domain of direct interest, implicates “Frontal” circuits • All EFs flow (linearly, developmentally) from the primary one, INHIBITION • Others view INHIBITION and RESPONSE PREPARATION as “two sides of the same coin” • Add “Sustain,” “Initiate” and “Shift”

17. Emphasis Shift: Not Just Inhibition is Deficient with ADHD • Speed of Motor Output • Timing of Motor Output • VARIABILITY of Motor Output • These now “Motor Endophenotype”

18. Current Concerns About What Sufficiently Characterizes ADHD • Does the “traditional triad” cover the syndrome? • Is “hyperactivity” too superficial or redundant? • Isn’t “inattention” misleading? (better choice “attention mis-allocation”)

19. Is EDF “diagnostic” of ADHD? • No! Most with ADHD show EDF but reverse is not true! • EDF is NOT a diagnosis but a “processing problem” (educators’ terminology) • EF has “server loops” from other “posteriorly based” systems (also described as “ingredients”)

20. What Is Seen Clinically As EDF? • Observations of “I-S-I-S” • Excess-for-age extraneous overflow • Poor visual-motor organization • Lack of strategies or plans of search

21. How Do We Assess EF/EDF? • Indirectly in younger children using “neighborhood signs” of motor control/inhibition • Directly, if at least 8 years old, Delis-Kaplan Executive Function System • Still need vigilance for “ingredients”

22. Definitions – “Plain” • Inhibition (“No-go” side of “Go/No-go”) • Response Preparation (called “Intention” by neurologists) • Delayed Responding (made possible by Inhibition) • Working Memory

23. Working Memory Analyses • What fills the delay in the delayed response situation made possible by inhibition of responding • Working memory in the Central Executive sense must be served by (and mediated through) either a “phonological” (i.e., verbal) loop or a “visuospatial” (i.e., mind’s eye) loop

24. More Crucial Components of EF • Sustain and Shift (1/2 of “ISIS”) • Plan (time-manage, sequence actions) • Organize (arrange environment, materials, pieces of complex products)

25. Implicit EF Deficits • Initiation • Inhibition • Affect/motivation modulation • Goal setting • Planning, (sequencing, spatial and temporal organization, prioritizing) • Monitor/adjust actions and consequences

26. Social Interpersonal Motor Self Intrapersonal Object “WHAT” Executive Function Executive Function Auditory Nonverbal Music/ Sounds /Tone of Voice Spatial “WHERE” Symbolic/ Analytic Language

27. Treatments and Interventions Many school aged children and adolescents are prescribed medications (described here), but not all individuals with ADHD respond to this treatment. This is where it is important to note the combination of pharmacological and behavioral protocols in planning for learning.

28. TREATMENT IMPLICATIONS • Stimulants are neither cure nor curse (not so good, not so bad as is said). • More formulations now exist, use of which involves “the art of medicine.” • Individualize medication for “target symptoms, target times.” • Stimulants outperform non-drug interventions but combination is best and permits lower drug doses.

29. Combined Medical and Behavioral Rx Superior to Medical For • Oppositional/aggressive • Internalizing • Social skills • Reading achievement • Parent-child relations

30. TREATMENT DESCRIPTIONS (OTHER THAN STIMULANTS) • “ABC” of applied behavior analysis (synonyms: behavior modification, contingency management). • Antecedent – Behavior - Consequence • Valence of contingency should be POSITIVE.

31. MORE ON TREATMENT OF ADHD (NONPHARMACOLOGIC) • Antecedents need to be manipulated so that home and school “engineer for success.” • Tutoring, coaching, motor skills building are examples of Antecedent manipulations (and are cognitive). • Cognitive, in the psychiatric sense, is not therapeutically effective (e.g., “I must not run”).

32. What does this mean to educators? Students with ADHD and connected disorders in reading, writing and math, often struggle with the academic demands of learning – keeping to a schedule, applying visual or auditory skills to tasks, working with others cooperatively, keeping materials organized, making transitions, etc.

33. Academic Difficulty Learning Disability EF Deficit

34. Reading Comprehension and ADHD • Brock & Knapp (1996) • 4th, 5th, and 6th graders with and without ADHD • All subjects had normal decoding skills • Both groups had similar word attack, reading speed, and vocabulary skills. • BUT… • The ADHD group had reading comprehension deficits.

35. Reading Comprehension and ADHD • Tannock and colleagues • Children with ADHD (without decoding or language problems) have difficulty organizing, sequencing, and self-monitoring retelling of stories they have read • Also have difficulty with making inferences from what they have read • BUT…can answer factual questions well

36. What to Do? Interventions for Reading Comprehension • FIRST…Evaluate • Make sure common lower level skill deficits are not the cause (i.e., decoding) • Examine oral language skills (syntax, semantics) • Examine EF: • Inferential Language • Self-monitoring • Organizing material • Use of strategies

37. What to Do? Interventions for Reading Comprehension • Teaching of strategies, e.g. • Comprehension monitoring (“metacognitive awareness”) • Graphic organizers • Question generation (who, what, why, where) • Knowledge of story structure • Summarizing • Mental imagery • Reciprocal teaching (summarize, question, clarification, prediction) • Teacher first models, then gradually takes away support/modeling

38. Written Expression • Heterogeneous; intersection of many skills: • Handwriting • Spelling • Punctuation • Expressive Language (Vocabulary, Grammar) • Working Memory, Self-Monitoring, Organization, and Planning (Executive Function)

39. Why is Writing Often Challenging for Children with ADHD? • Motoric requirements (handwriting) • Children with ADHD typically have graphomotor issues • Graphomotor/motor substantial predictor of overall written productivity (Berninger et al., 1992) • Requirements for working memory, self-monitoring, planning and organization • Areas of impairment in ADHD

40. What to Do? • FIRST, evaluate…exactly which issues is the child having difficulty with? • Handwriting • Spelling • Punctuation • Expressive Language • Organization/Planning

41. What to Do? • Organize and plan—initially be stand-in frontal lobe! • Use graphic organizers • Teach use of different graphic organizers for different types of writing • Compare/contrast, narrative, description, etc. • Gradual decrease of support • Knowing DOES NOT equal doing

42. What to Do? • Separate out handwriting and writing • Dictate • Learn keyboarding • Gradually merge processes so child can organize and write on own.

43. Warning…objects may not always be what they seem It is worth knowing that what may appear to be ADHD may actually be anxiety It is important to know exactly what has been evaluated and determined in a child’s record so that mis-assignment of a diagnosis is not done

44. Roles of ADHD or “false” ADHD (often Anxiety) • Executive Function (usually but not always impaired with ADHD) is powerful factor in LD • Anxiety impairs Executive Function (EF) also • Life is not simple, so BOTH ADHD and Anxiety may undermine EF • Children with weak EF may “grow into” LDs (written expression and reading comprehension)

45. Treatment of LD Substantially Determined by ADHD/EdF • Stimulant meds: neither curse nor cure but reliable only for inhibitory component of EdF (where “d” is for “dys”____) • Home and School environment changes are more important but less accessible! • “A” in ABC of applied behavior analysis needs greater emphasis: proactive antecedents

46. One Important “anti-A,” the “Inclusion Delusion” How can in-class special help work when most LD is based upon weak speech-sound processing and/or weak attentional control?

47. Therapeutic Needs (Nothing New) • “A” in “ABC” can mean cheerful, positive, encouraging adults! • Special teaching is best done one-on-one (but negative irritable teacher won’t do!) • Special teaching means flexible, individually “customized” plans, not pre-packaged or scripted “one size fits all.”

48. Now…consider the TBQ The Big Question from this material requires you to think about this information and that of prior sessions on development and learning disorders. Considering the demands of inclusion, what do you see as the major challenge of distinguishing knowing from doing in the design of instruction for students with disorders of memory and attention? Identify one accommodation you would use with such students. (If you are not a teacher, consider an intervention or accommodation you would want to see used with a child you know).