Strategies to improve ADHD symptoms

1. Strategies to improve ADHD symptoms Kevin M. Antshel, Ph.D. Associate Professor of Psychiatry / Licensed Psychologist Director, ADHD Lifespan Treatment, Education & Research Program SUNY – Upstate Medical University

2. Outline • 10 principles of ADHD treatment • Strategies designed to improve executive functions • Strategies designed to improve working memory

3. Essential Principles of ADHD Treatment PRINCIPLE #1: There are no magic cures for ADHD

4. Essential Principles of ADHD Treatment PRINCIPLE #2: For children and adolescents with ADHD, medication can help

5. Essential Principles of ADHD Treatment PRINCIPLE #3: Too little or too much treatment (medical or otherwise) both have side- effects

6. Essential Principles of ADHD Treatment PRINCIPLE #4: Strategies are effective only if the setting allows for their consistent implementation

7. The Essential Needs of a Child with ADHD • Clearly specified rules, expectations and instructions • Frequent, immediate, and consistent feedback on behavior and redirection to task • Reasonable and meaningful consequences for both adherence and nonadherence • Adults who will deal with his/her problems based on knowledge, compassion, and respect • Programming and adult intervention designed to compensate for the child's impulsiveness, inattention, distractibility, limited organizational skills, and low frustration tolerance • A well-integrated and functioning team of parents, teachers, administrators and clinicians who communicate often and work together to create a structured and supportive environment

8. Essential Principles of ADHD Treatment PRINCIPLE #5: There's nothing better than a good teacher

9. Incentive Exists If . . . 1. The task at hand is more compelling than almost anything else around at that moment and/or 2. There is some predictable and meaningful reinforcement for compliance with clearly-stated rules and/or some predictable and meaningful punishment for nonadherence with clearly stated rules.

10. Principle #6 • There is no better treatment than an accurate diagnosis. • Not all inattention is ADHD • Are there other comorbid conditions?

11. Principle #7 • One size does not fit all. • What treatment, by whom, is most effective for thisindividual with these specific problems, and under which set of circumstances?

12. MTA – Cost / benefit analysis Jensen et al., 2005

13. Principle #8 • Combined treatment should be recommended for ADHD + [insert diagnosis here].

14. Principle #9 • Parent training is a front-line behavioral intervention. • Differential reinforcement of other behaviors (DRO), time out & response cost areempirically supported treatment components • For behavioral treatment to work best, it must be intensive & across settings

15. Principle #10 • Know what is most likely a waste of time and money. • Unsupported and / or discredited treatments • Removal of sugar from child's diet • Removal of food additives, dyes, etc. • Megavitamin therapy • Caffeine • Removal of fluorescent lights • Sensory motor integration • Biofeedback training /relaxation exercises • Treatment for inner ear disturbances • Vision training • Social skills training

16. Implications for Treatment • Teaching skills is inadequate • The key is to design prosthetic environments around the individual to compensate for their EF deficits • Therefore, effective treatments are always those at the “point-of-performance” • The EF deficits are neuro-genetic in origin • Therefore, medications may be essential for most (but not all) cases – meds are neuro-genetic therapies • But some evidence suggests some EFs may also be partly responsive to direct training • While ADHD creates a diminished capacity: Does this excuse accountability? • (No! The problem is with time and timing, not with consequences)

17. More Treatment Implications • Behavioral treatment is essential for restructuring natural settings to assist the EFs • They provide artificial prosthetic cues to substitute for the working memory deficits (signs, lists, cards, charts, posters) • They provide artificial prosthetic consequences in the large time gaps between consequences (accountability) (i.e., tokens, points, etc.) • But their effects do not generalize or endure after removal because they primarily address the motivational deficits in ADHD • The compassion and willingness of others to make accommodations are vital to success • A chronic disability perspective is most useful

18. How do we compensate for EF deficits?By Reverse Engineering the EFs • Externalize important information at key points of performance • Externalize time and time periods related to tasks • Break up future tasks into many small steps • Externalize sources of motivation • Externalize mental problem-solving

19. Externalizing Working Memory • Use externally (outside the individual) represented forms of information to remind the individual what is to be done at the point of performance • This can be done by using sticky notes, cues, cards, lists, posters, signs, and other prompts of critical reminders at the point of performance • For older kids and adults, also use personal journals, digital recording devices, Watch-Minder watches, day planners, personal organizers, computer organizers

20. Externalizing Time and the Future Make time physical, external, and obvious • timers, clocks, counters, and anything else that can signal time’s passing Break down future projects and goals into small pieces and do a piece a day (or more frequently). Bring the Es, Rs, & Os of life close together

21. Make Motivation External • Identify tasks and settings in which consequences are too delayed or nonexistent • Put artificial consequences into these large gaps in time • Tokens, points, prizes, praise, privileges • Increase accountability to others – more frequent check-ins with others to see that work is being done, goals are being met

22. Make Problem-Solving Manual • When tasks normally require mental problem-solving (manipulating mental information, generating multiple ideas, etc.) make the mental information external, physical, or manual • For math, use marbles, number lines, an abacas, etc. and calculators • For words, use cards, paper, computer word processing programs

23. Memory Improvement Techniques

24. Attention ----> Encoding ----> Storage ----> Retrieval

25. Attention (Concentration of Effort)

26. Effort Interest -- The brain prioritizes by meaning, value and relevance. To have meaning, you must understand what you are learning. In order to remember something thoroughly, you must be interested in it and think that it has value and relevance in your life. Ways to create interest in a class in which you are confused or bored: • Find a study partner. • Get to know the teacher / professor better. • Do some extra practice or research. (We tend to be uninterested in things we are not good at.) • Teach an assignment to someone else. • Seek a way to make the information personal.

28. Effort (cont’d) Techniques to help improve attention: • Use a concentration check sheet. When you feel yourself wandering from the subject, put a check on this sheet. Do this every time you find yourself not concentrating. You will program your mind to pay attention. • When reading an assignment talk back to the writer. • When listening to a lecture, ask frequent questions.

30. Background Knowledge The more we know about something, the easier it is to learn more. • Before you read an assignment, preview it. Survey the title and headings. Read the summary. Familiarize yourself with the study questions. Think about and try to recall what you already know about the subject. Then read the assignment. • The more you know about the subject, the easier it will be to take notes during the lecture. Before you go to class, do all homework assignments and readings. • Do extra research. Explore the internet. Create ways to experience the subject.

33. Imagery can help encoding • Most of us remember what we see much larger (and better) than what we read or hear. We, therefore, need to make an effort visualize everything we learn. • No matter how abstract, determine a way to visualize each new concept : • Will it convert to a chart or graph? • Can I draw it out?. • Can I make a mental video of the process? (If you used a mnemonic devise to learn something, you might make a mental video of the word or sentence.) • Do I know what each person I am learning about looks like? (If can't find out, make it up!)

35. Practice should be active

37. Active Practice • The more senses we use the stronger the neural trace.     • The more feedback we get, the faster and more accurate our learning is.    • Practice • Fallacy of total time hypothesis • Spacing effect – allows consolidation • Active practice works for several reasons: • When you know you are going to recite something in your own words, you pay more attention. • You get immediate feedback. You know if you are able to explain something in your own words out loud, you understand it. • Some tips for active practice: • Make use of flashcard of anything you need to learn. • When you finish reading a paragraph in your reading assignment, stop and recite. You will soon see that understanding what you read and explaining it out loud are very different. • Find a partner and ask each other questions and answer out loud

38. Active Practice (cont’d) • Association is central to the process of encoding and retrieval. • Optimal learning occurs when the brain’s multiple maps work in synchronization or network with each other. • By recalling something you already know and making a link to the "brain file" that contains that information, you should be able to remember new information more efficiently. Ask yourself: • Is this like something I already know? • Is the number similar? • Is the sound similar? • Can I use it for something similar? • If I were filing it in my brain "filing cabinet", it there an existing file I can use instead of creating a new one? • How do you remember: your pin number? your telephone number? where you parked your car? your instructors name? the name of the person you just met?

39. Organization • When information is poorly encoded there is no hope for data recovery. • Alphabetize. • Use a mnemonic device (e.g., HOMES: Huron, Ontario, Michigan, Erie, Superior).

41. Time • Learning is a biological process that literally changes the configuration of the brain. This takes time. • New information takes time to soak in. We are usually bombarded with much more information than we can remember. We must, therefore, allow time for consolidation to take place. In fact, we must cause consolidation to take place. Ways to consolidate: • Taking notes in class • Asking questions in class • Reviewing Notes • Stopping after each paragraph you read and writing a question in the margin which identifies what the paragraph is about • Visualizing • Reciting • Making flash cards • Designing practice tests

42. Time (cont’d) • Using distributed practice optimizes our learning. • Distributed practice allows time for things to consolidate and for you to build a basic background. It also uses what we know about the nature of short-term memory. • Here are a few tips: • Take 10 minute breaks after each hour of study and review what you just learned before you begin again. • Have a scheduled time to study each subject. • Make use of daylight hours and time that you normally waste. • Use flash cards • Study immediately before and after classes . • Short sessions, more often, create growth of dendrites and connections exponentially. • Studies of biological cycles confirm that the body is going to take “down time” whether we give it or not.

43. We tend to remember things at the beginning of a list or study session and things at the end.

44. State dependent learning • Retrieval is enhanced if variables (e.g., mood, environment, etc.) are highly similar between encoding and retrieval.

47. Metacognition

48. Metacognition Metamemory Metacomprehension

50. Model predicting recall. (DeMarie & Ferron, 2003)