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1 Can good academic attainment ever be achieved by children with ADHD? Prof Maurice Place Prof Maurice Place Copies of this presentation can be found at: Meeting funded and organised by Shire Pharmaceuticals Item code: UK/EQU/09/0127 Date of preparation: September 2009

2 Disclosure: Currently member of the speakers panel of AstraZeneca AstraZeneca Eli Lilly Eli Lilly Janssen Cilag Janssen Cilag Shire Shire

3 What are the Academic and Educational Characteristics of Children with ADHD? Children with ADHD show significant academic underachievement poor academic performance educational problems ( Hinshaw, 1992; Fergusson & Horwood 1995; Rapport et al 1999; Sayal 2008; Galéra et al 2009)

4 What are the Academic and Educational Characteristics of Children with ADHD? IQ - compared with controls score on average within the normal range (Biederman et al 1996) BUT score significantly lower on reading and arithmetic achievement tests than controls. (Biederman et al 1996) Children with ADHD are 4 to 5 times more likely need special educational services. (LeFever et al 2002; Jensen et al 2004)

5 Academic difficulties begin early in life. Symptoms are common in children aged 3 to 6 years, (Gadow et al 2001) preschool children with ADHD are more likely to be behind in basic academic readiness skills. (Mariani & Barkley 1997; DuPaul, et al 2001) have impaired handwriting performance characterized by illegible written material and/or inappropriate speed of execution ( Racine et al 2008) What are the Academic and Educational Characteristics of Children with ADHD?

6 In adolescence: achieve lower ratings on all school subjects have lower class rankings perform poorly on standardized academic achievement tests (Gittelman et al 1985; Barkley et al 1990; Weiss et al 1999). x2 likely to repeat a grade (Currie & Stabile 2006; Beiderman et al 2006) x2 - 4 to have lower than expected grades (Todd et al 2002) What are the Academic and Educational Characteristics of Children with ADHD?

7 School histories indicate persistent problems in social participation more years to complete high school lower rates of college attendance lower rates of college graduation (Mannuza et al 1993; Weiss et al 1999; Barkley 2002). What are the Academic and Educational Characteristics of Children with ADHD?

8 In College relative to other students have lower GPAs more academic concerns depressive symptoms social concerns emotional instability and substance use. BUT most said were coping. (Blase et al 2009) What are the Academic and Educational Characteristics of Children with ADHD?

9 longitudinal studies into young adulthood Initial symptoms of hyperactivity distractibility impulsivity aggression tend to decrease in severity over time BUT remain present and increased in comparison to controls (Weiss et al 1999). What are the Academic and Educational Characteristics of Children with ADHD?

10 26 ADHD individuals and 31 controls (paired for gender, age, & intelligence) Using mathematics and language scores academic underachievement was 2.98 times higher in students with ADHD (Pastura et al 2009)

11 Ethnically diverse cohort of 823 assessed at 6 years for behavioural problems and IQ and at 17 years of age for academic achievement in math and reading, and other parameters. Attention problems predicted maths and reading achievement with little benefit from intervention. Whereas reducing externalizing and internalizing problems materially reduced academic problems. (Breslau et al 2009)

12 3 main groups of outcome as young adults: (1) approximately 25% eventually function comparably to matched normal controls (2) the majority show continuing functional impairment, limitations in learning and applying knowledge restricted social participation, particularly poor progress through school (3) less than 25% develop significant, severe problems, including psychiatric and/or antisocial disturbance (Hechtman 2000) What are the Academic and Educational Characteristics of Children with ADHD?

13 Academic difficulties associated with inattention are cross-cultural and not specific to the Western countries. (Norvilitis et al 2010)

14 Girls do it different Girls do it different male-to-female ratio – child clinic-referred (10 to 1) child community (3 to 1) adults (3 to 2) (Keissler et al 2006)

15 Girls do it different Girls do it different Girls with ADHD more likely to have inattentive type less likely to have a learning disability, less likely to have problems in school or in their spare time. (Biederman et al 2002; Graetz et al 2005) more speech and language problems (Hinshaw 2002) more personality disorders (Burket et al 2005)

16 Girls do it different Girls do it different In addition, girls with ADHD less risk for conduct disorder, substance misuse oppositional defiant disorder (Biederman et al 2002) but substance misuse is only one that is attributable to gender + ADHD, others are gender only (Biederman & Faraone 2004) Inattentive girls more likely to present with anxiety disorder (Levy et al 2005)

17 The Impact of Medication

18 medication improves academic productivity as indicated by improvements in the quality of note-taking scores on quizzes and worksheets the amount of written-language output homework completion. (Evans et al. 2001) methylphenidate-induced dopamine increases the interest and motivation to do maths tasks (Volkow et al 2004) The Impact of Medication

19 However, stimulants are not associated with normalization of skills in the domain of learning and applying knowledge. (Rapport et al 1994) The Impact of Medication

20 1195 children were tested at 5 points: compared the academic performance of treated with untreated children at each testing node. medicated gained 2.9 points in mathematics performance between the first and final testing reading performance medicated gained 5.4 points above unmedicated Despite this improvement the performance of the medicated children with ADHD lagged their peers without ADHD. (Scheffler et al 2009) Early Childhood Longitudinal Study

21 177 ADHD effectively medicated vs 95 untreated ADHD and 101 normal controls. Neuro Cognitive Index - computed as the average of the z scores of five domains (memory, psychomotor speed, reaction time, complex attention, and shifting attention flexibility) untreated ADHD patients perform 15% lower than normals. However, treated ADHD patients perform 10% lower than normals. (Gualtieri & Johnson 2008)

22 Consistently in longitudinal studies subjects consistently demonstrate poor outcomes compared with controls whether or not they receive medication. (Gittelman et al 1985; Barkley et al 1990; Hechtman & Greenfield 2003; Fischer et al 2002; Loe & Feldman 2007; Powers et al 2008) The Impact of Medication

23 and in UK studies: Despite medication, ADHD association with poor attainment in GCSEs (Daley et al 2009)

24 "Given their well-established benefit for increasing attention and concentration, it seems counterintuitive that ADHD medications are not more effective in improving academic and occupational attainment," (Advokat 2009)

25 There are Brain Changes ADHD associated with decreased frontal lobe gray and white matter volumes Affected areas suggest problem in development of pre-motor and pre-frontal cortices. (Mostofsky et al 2002)

26 Children with ADHD show decrease in total cerebral volume of about 8% volume reduction throughout the cortex, significant reduction in all four lobes bilaterally. ADHD group also showed a decrease in surface area of over 7% bilaterally, and a significant decrease in cortical folding bilaterally (Wolosin et al 2009)

27 Boys with ADHD show significantly smaller basal ganglia volumes and compressed basal ganglia shapes. Volume compression bilaterally in caudate head and body anterior putamen left anterior globus pallidus right ventral putamen. No volume or shape differences in girls with ADHD. (Qiu et al 2009)

28 Amygdala volumes in patients with ADHD bilaterally smaller than in patients with depression and healthy controls. In ADHD, more hyperactivity and less inattention were associated with smaller right amygdala volumes (Frodl et al 2009)

29 There is also delayed cortical maturation ….especially in the frontal cortex

30 (Shaw et al 2007)

31 BUT evidence is of multiple and persistent neural processing deficits in ADHD NOT simply a developmental lag (Doehnert et al 2010)

32 Post-hoc comparisons suggested that comorbid ODD or CD do not greatly alter the extent of regional pathology in ADHD. (McAlonan et al 2007)

33 ADHD & Functionality

34 People with ADHD have difficulties with: planning, organization, reasoning, response inhibition, decision-making, set-shifting working memory (Tranel et al.1994; Pennington and Ozonoff 1996; Barkley 1997; Geurts et al 2004) abilities that are mediated by the prefrontal cortex and its extensive interconnections with other brain regions (Tranel et al. 1994).

35 Neuroimaging studies have shown deficits in Executive Functioning in ADHD probably related to structure and function of pre-frontal cortex and frontostriatal pathways (Seidman et al. 2005; Jurado & Rosselli 2007)

36 ADHD symptom severity is associated with magnitude of impairment in executive functions BUT this relationship can be obscured by the presence of comorbid disruptive disorders. (Barnett et al 2009)

37 Medication gives higher scores on neuropsychological measures of attention but differences not found for other measures of executive function. (Biederman et al 2008) SO medication helps with concentration aspect but not the more central aspects of functioning… especially working memory

38 Short-term memory Short-term memory is the term for short-term storage of information with no manipulation or organizational element Working memory Working memory is the structures and processes used for temporarily storing manipulating information and manipulating information.

39 How Memory Works Sensory inputs are held through transient functional changes in the strength of pre-existing synaptic connections The basal ganglia and pre-frontal cortex analyze sensory inputs and decide if they're worth remembering If So create stable and permanent changes in neural connections throughout the brain by the synthesis of new protein and the growth of new connections. Especially during sleep (Diekelman & Born 2010)

40 highly heritable (Campbell et al., 1997) Independent of socio-economic status (Engel et al., 2008) Working Memory Capacity & Learning

41 Professionals use working memory for… Getting to work on time Meeting deadlines at work Multi-tasking and prioritizing Working effectively in pressure situations Remembering important names and phone numbers Interaction with co-workers Writing emails, memos, or summaries

42 Indicators that a working memory needs improving Frequently late to work Underestimates time required to complete a task Problems breaking a project down into manageable steps or dealing with more than one task at a time Cant concentrate under pressure; prone to panicking Cant remember clients names or numbers after meeting them or hanging up the phone Difficulty creating neat and coherent emails, memos, or summaries

43 Associated with reading and mathematics ability (Gathercole & Pickering, 2000; Geary et al., 2004) Important for successful learning in individual classroom activities (Gathercole & Alloway, 2008) Working Memory Capacity & Learning


45 Message from the research: low working memory = educational underachievement Working Memory Capacity & Learning

46 assessed using simple cognitive tasks Automated Working Memory Assessment (Alloway, 2008) 4 aspects of memory verbal and visuo-spatial storage (simple span) verbal and visuo-spatial processing and storage (complex span) Working Memory

47 verbal short term memory – ability to hold verbal information in memory for a short period …eg new telephone number …problems mean slow to acquire new vocabulary verbal working memory – to hold and manipulate verbal information …links to academic ability including literacy and numeracy visuo-spatial short term memory – holding visuo-spatial information ….problems with mathematics, and word problems. visuo-spatial working memory – to hold and manipulate visuo-spatial information …links to academic ability including literacy and numeracy and is predictor of poor scholastic attainment. Working Memory

48 Working memory comparisons (Holmes et al 2009)

49 Computerised training programme developed by Klingberg et al. (2002) Used with children with ADHD who are not medicated for their symptoms (Klingberg et al., 2002;2005) Improving Working Memory

50 Participants 42 children, aged 8-11 years, with low working memory Identified via routine screening of 345 children on two verbal wm tasks (Listening Recall and Backward Digit Recall) Scores <86 on both tasks (bottom 15 th centile) Two groups Adaptive, standard version of training programme training at maximum span level Non-adaptive, control condition training at fixed span level of 2 Hartlepool Study (1) (Holmes et al 2009)

51 Working Memory Training working on memory tasks on a computer 20 minutes everyday for 20-25 days

52 Robo Memo

53 * Results from non-adaptive

54 Results from adaptive **

55 Results from adaptive Follow up **

56 Pre-trainingPost-training 6mth follow- up MeasureMSDM M Verbal IQ 88.7311.1490.8611.5292.789.10 Performance IQ 88.0513.0990.6812.9687.119.07 Reading 83.6812.3583.0015.0682.8314.1 Mathematics 84.2712.2885.6812.70 89.94*9.88 Following inst. 14.454.0218.27**4.3716.5*3.82 No significant improvements for non-adaptive group IQ, Reading & Maths Scores - adaptive

57 Impact of Medication & Robo Memo on Working Memory Participants: 25 children (21 boys, 4 girls), clinical diagnosis of ADHD-C receiving quick release stimulant medication (methylphenidate n=22, dexamfetamine n=3) aged 8-11 years diagnosis for at least 6 months no co morbid ASD (Holmes et al 2010) Hartlepool Study (2)

58 Research on Working Memory & Medication Stimulant medication improves working memory function in individuals with ADHD – mainly visuo-spatial simple span tasks (Bedard et al., 2004)

59 Effects of medication on working memory **

60 Effects of medication and training on working memory ** *

61 On Meds Post training (+ on meds) Inattentivity (teacher)69.84 (23.33)58.21 (20.27)** Hyperactivity (teacher)81.15 (21.69)70.31 (23.87)* Working memory problems (child)17.60 (5.72)13.25 (6.00)** Effects of training on behaviour ratings

62 Effect of medication on IQ

63 Sustainability of training effects – 6 mth follow-up **

64 Working Memory Intervention Significant gains in non-trained working memory tasks, which extended across all four aspects of working memory. Substantial increases in scores (low-average to average range). Significant reduction in ratings of problem behaviours No effect on IQ Unlikely to result from practice effect Comparison group showed no test re-test effect Consistent gains in both the repeated and non- repeated AWMA tasks in the ADHD group

65 SO: Working memory deficits associated with ADHD can be overcome by two different interventions RoboMemo intervention led to more generalized gains in WM, and reductions in problem behaviours Medication led to specific gains in visuo-spatial WM, and improves concentration and improves academic productivity (Holmes et al., 2010)

66 How is training enhancing working memory? changes in the density of prefrontal & parietal cortical dopamine D1 receptors. (McNab et al., 2009) may stimulate the development of WM strategies that compensate for weaknesses in basic processes (Holmes et al., 2010)

67 The Research Team Joni Holmes Senior Lecturer in Experimental Psychology Maurice Place Professor of Child & Family Psychiatry Torkel Klingberg Professor in Cognitive Neuroscience Joe Elliott Professor of Education Sue Gathercole Professor of Cognition & Neuropsychology

68 Can good academic attainment ever be achieved by children with ADHD? Prof Maurice Place Prof Maurice Place Copies of this presentation can be found at:

69 General classroom advice

70 children with ADHD are more likely to complete more problems and complete them accurately when high levels of engaging stimuli are included within the task. (Jitendra et al 2008) Pacing of tasks with periods to release energy Clarity of goals Instant feedback Novel & rapidly changing rewards Time out DOES NOT work

71 1.Draw or create vivid pictures depicting information that needs to be memorized. Since memory is enhanced by exaggeration, emotion, action, and color, the more ridiculous and detailed the image, the better. 2.Teach memory strategies. Such as mnemonics e.g. Dead Monsters Smell Bad (steps for long division: divide, multiply, subtract, bring down). 3. Create acrostics or whole sentences. Every Good Boy Does Fine is an excellent way to help recall the sequence of lines in the treble clef (EGBDF). 4. Try melody and rhythm to teach a series or sequence. There are raps, rhymes, and songs to help attention deficit students memorize multiplication tables, days of the week, etc. 5. Use songs specially created to teach content. Musically Aligned ( creates music and lyrics geared to teach a science curriculum. For physical science, there are songs like Electromagnets and Heat, Light, and Motion. For teaching concepts in life science, there are Food Chain Gang and Decomposers. 6. After the lesson, have ADHD students list the things they remember. Ask them to do so as fast as they can, to increase memory recall. (Sandra Rief 2009)

72 Improved by reading interventions focused on basic skills e.g., decoding – such as activities to promote phonological awareness and alphabetic understanding (Blachman et al 2000). and maths strategies e.g. problem solving using schema-based instruction (Jitendra et al 2007). And strengthened by Peer mediated interventions Computer assisted instruction (Jitendra et al 2008) Task modification and varying classroom function (Daley & Birchwood 2010) Teaching parents homework strategies (Raggi & Chronis 2006).

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