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ASD AND AD/HD SIMILARITIES & DIFFERENCES Dr Angel Adams, PhD Chartered Clinical Psychologist Director: Prosocial Psychology Services www.prosocial.co.uk.

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Presentation on theme: "ASD AND AD/HD SIMILARITIES & DIFFERENCES Dr Angel Adams, PhD Chartered Clinical Psychologist Director: Prosocial Psychology Services www.prosocial.co.uk."— Presentation transcript:

1 ASD AND AD/HD SIMILARITIES & DIFFERENCES Dr Angel Adams, PhD Chartered Clinical Psychologist Director: Prosocial Psychology Services

2 ADHD AND ASD ARE BOTH LIFE SPAN DISORDERS AND ARE ON A SPECTRUM OF SEVERITY

3 THEY ARE TWO DIFFERENT NEURODEVELOPMENTAL DISORDERS WITH OVERLAPPING FEATURES A CHILD CAN HAVE BOTH DIAGNOSES

4 ASD TRUMPS ADHD AND IS THUS A ONE-WAY CO-MORBIDITY

5 ADHD and AUTISM AFFECTS THE BRAIN IN DIFFERENT WAYS Frontal Lobes Involved in planning functions Judgement Sense of time Attention Organisation Self-regulation Hippocampus Memory & learning area Temporal Lobe Auditory, speech & memory centers Amygdala Primitive emotional center Cerebellum Involved in motor skills & shifting attention from one task to another

6 DEFINITIONS ADHD: Developmental impairment of the executive functions of the brain. (Barkley,2007) ASD: Neurologically-based social-communication disorder and information processing disorder which also impairs executive functioning. (Frith U (Ed), 1991; Ozonoff S, Pennington BF, Rogers SJ, 1991)

7 ADHD A disorder of age-inappropriate symptoms in: – Inattention Poor persistence of responding Impaired resistance to distraction, Deficient task re-engagement following disruption – Hyperactivity-Impulsivity (Disinhibition) Impaired motor inhibition, Poor sustained inhibition Excessive and often task-irrelevant motor and verbal behavior Restlessness decreases with age, becoming more internal, subjective by adulthood Primary deficits in response inhibition, affect modulation, working memory deficits and delay of gratification

8 ASD Initiating and sustaining connection with peer relationships and social reciprocity Nonverbal communication: eye contact, facial expression, vocal inflection and gestures that help regulate social interaction Use of language, especially in a social context Dealing with transitions/changes and need for sameness Spontaneous make-believe play or social imitative skills Complex fine motor skill tasks Sensory perception and co-ordination A disorder of age-inappropriate symptoms in:

9 Co-morbidities with ADHD Oppositional Defiant Disorder (40-80%; odds ratio of 11) –ADHD contributes to and likely causes ODD –Some ODD is related to disrupted parenting Which can arise from parental ADHD –Predicts persistence of ADHD Conduct Disorder (20-56%)/ Psychopathy (20%) –If starts early, represents a unique family subtype More severe, more persistent antisocial behavior Worse family psychopathology Less responsive to treatment than late onset –If starts late (>12), more related to social disadvantage, family disruption, & deviant peers –Father desertion, parent divorce more common –Major depression more likely to co-exist –School drop out and teen pregnancy more likely R Barkley, (2007)

10 Co-morbidities ADHD Anxiety Disorders (10-39%) Related in part to poor emotion regulation –But some legitimate anxiety disorders are likely –Most common are simple phobias or separation anxiety; GAD becomes more common with age –Often show lower levels of impulsiveness (better course & outcomes?) –Anxiety disorders more likely in parents and family Major Depression (0-45%; 27% by age 20) –Likely genetic linkage to ADHD –Also related to presence of CD in child & family –Often manifest low self-esteem in childhood –MDD onset may not be until adolescence or later –Associated with increased suicidal ideation (4x) and attempts (2x) Bipolar Disorder (0-27%; likely 6-10% max.) –Some cases are misdiagnosed (ADHD/ODD) –Requires substitution of severe irritability for mania and chronic for episodic course –Significant family history of bipolar disorder –Probably a one-way comorbidity (like Tourette’s Syndrome) -R Barkley, (2007)

11 Co-morbidities ASD Children, adolescents and adults with ASD experience high levels of anxiety more similar to children with diagnosed anxiety disorders than to non- anxious children -Kim et al., 2000; Sofronoff & Russell, (2005) 84.1% of children with PDD met the full criteria of at least one anxiety disorder: phobia panic disorder separation anxiety disorder avoidant disorder overanxious disorder obsessive compulsive disorder PTSD -Muris et al (1998) Anxiety disorders and depression become more pronounced in late adolescence and early adult life. -Tantam & Prestwood, (1999) Both ADHD and ASD can lead to self-medication with drugs and alcohol In teens especially if undiagnosed and untreated.

12 Co-morbidities with ASD Bipolar disorder Bowel disorders Depression and anxiety Fragile X Syndrome Global Learning disabilities Neuroinflammation and immune disorders OCD Seizures 1 Tuberous Sclerosis Hyperactivity and attention abnormalities 26% clinic samples of children with autism met criteria for ADHDH and 33% for ADD. -Goldstein and Scwebach (2004) Developmental receptive language disorder Dyspraxia Dyslexia Phenylketonuria (untreated) Rett’s syndrome Williams’ syndrome

13 DIFFERENCES AND SIMILARITIES

14 ADJUSTING TO CHANGES AND TRANSITIONS ASD Prefer sameness due to cognitive deficits which limit abilities to adapt spontaneously More apt to experience change as anxiety- provoking Become overstimulated ADHD Prefer change and novelty, but have difficulty realigning behavior in changing circumstances. Describe changes as exciting Like highly stimulating

15 INATTENTION AND DITRACTIBILITY ASD Problems with planning and flexibility of their attention rather than sustained attention and distractibility Distracted by objects and movement of objects. Attend to atypical stimuli and, therefore, appear quite inattentive. Prone to “tune out” due primarily to difficulties in mentally imposing organization on their environment. Idiosyncratic focus of attention Attend more to inanimate and spatial characteristics of environmental stimuli, rather than social features ADHD Also distracted by trivial visual and auditory stimuli but apt to be MORE distracted by the activities of other people. Attend to stimuli that most kids would find compelling. “Tune out” because of mental fatigue, have missed too many bits and pieces of information to make sense of the input, etc.

16 REPETITVE ANNOYING BEHAVIOURS ASD Restless due to sensory irritants such as bright lights, loud noises, uncomfortable clothes etc. Often represent a self- stimulatory behavior and more often has an odd quality. Fidgeting maybe related to stereotypical movements SIB (head banging, hair pulling) AD/HD Often represents a discharge of energy to permit greater mental awareness Foot tapping, pencil gnawing Fidgeting is about motor overflow Distracted and restless due to boredom.

17 RESPONSES TO INCENTIVES/REINFORCEMENT ASD More difficult to find out exactly WHAT they find reinforcing (may be somewhat unusual). Often prefer to stick with the same reinforcer, and then after many trials, may suddenly find it no longer rewarding. ADHD More typically respond to reinforcers that “make sense” and are consistent with rewards that most other children desire Need reinforcers/incentives/feedback immediately Need to change reinforcers more frequently NEED TO EXTERNALISE MOTIVATION

18 BOTH CAN HYPERFOCUS ADHD kids can think, remember, focus, sit still, and learn from experiences under certain unique conditions: NOVEL AND FASINATING SCARY THRILLING AND INTIMIDATING ONE to ONE HIGHLY STIMULATING

19 RESPONSES TO RULES ASD Desire rules. Rules help them to bring order to what they perceive as a chaotic environment. Often the “little policemen” may be unnecessarily rigid or persnickety as to the details of a rule. Rules in the game are more important than the social aspect of games Moralistic Quality ADHD Not so fond of rules, may have difficulty conforming to rules due to impulsivity. May stretch the rules as much as possible Need structure and routine but also need flexibility at home and school when it comes to their disability

20 LANGUAGE & COMMUNICATION ASD Excessive talking related to preoccupation with area of special interest and is wanting in terms of meaning. Nonverbals like facial expression, often do not match inner feeling states. Interrupting more associated with lack of social understanding cues and perspective taking (where ADHD is behavioural inhibition). Pervasive problems in pragmatics – using language to accomplish a practical goal. Speech usually marked by unusual prosody and inflection. Sometimes do not understand jokes, irony or metaphors Literal use of language ADHD Social chatting / thinking out loud May go from one topic to another, but intent to communicate is clear and within normal limits. Usually inner feeling states are apparent –trouble modulating or suppressing expression of emotion. Typically do not show a significant problem in pragmatics, may be skilled at “wearing down” adults using language. Unusual speech patterns not associated with core diagnostic features. Often the class clown and loves jokes

21 SOCIAL SKILLS and RELATIONSHIPS ASD More odd in appearance and perservarative talking. Social relatedness problems arise from difficulties dealing with nonverbals to regulate social interactions. Do not “get it.” A college professor with AS remarked that her quest to understand human interactions made her “feel like an anthropologist from Mars” (Sacks, l993, p.112). Skill deficit (They don’t know) ADHD Seen as intrusive, noisy, overwhelming due to excessive talking, touching everything, Social relations disrupted by problems with impulsivity, turn- taking, etc. which can disrupt the flow of social relationships. Have a better grasp of nonverbal communication but have difficulties with response inhibition which prevent competent execution of their knowledge. Performance deficit (Can’t do what they know)

22 SOCIAL SKILLS and RELATIONSHIPS ASD Often target of bullying and teasing Is naïve Often egocentric May not like physical contact Talk at peers instead of to them Can be insensitive and lack tact Can misinterpret social cues Poor judgment in “social distance” Has well-developed speech but poor communication Can be taken advantage of Not always wanting to be part of the social world ADHD Problems in unstructured times, fighting, bullying and being teased or bullied. Social relations disrupted by problems with impulsivity, turn- taking, etc. which can disrupt the flow of social relationships. Have a better grasp of nonverbal communication but may have difficulties with response inhibition which prevent competent execution of their knowledge. Social and boundary problems Great desire to be part of the social world

23 SOCIAL SKILLS and RELATIONSHIPS ASD Have trouble building and sustaining friendships, and are frequently ignored by their peers TOM -Concurrent difficulty realizing that behavior affects how other people think or feel (as a result the child with ASD may be misunderstood as having little conscience) – a reduced motivation to please others Difficulty understanding the emotions of others leading to the appearance of lacking empathy Lack of emotion Personal self-care and hygiene problems Will strike out more due to sensory issues Meltdowns (rigidity confusion fear sensory) ADHD Have trouble building and sustaining friendships, and are frequently rejected by their peers Even after brief periods of social interaction the negative attributions of their peers remain stable across time, despite overt behavioural improvement Hyperemotional Hypersensitive to criticism Anger management problems (Disinhibition)

24 MY FUTURE by JOSHUA MUGGLETON My future, my present, my past, are all controlled The horror, the memories of my past, stop me from resting What happened is seared on my mind Never to forget the pain of school The memories haunts me, in my dreams The memories torments me in my thoughts The memories kills me in my hopes The memories chokes me in my life Part of my sanity, lies in the school yard Screaming in agony in what it has to endure. What is left of my sanity, weeps for the rest In drowning sorrow, and merciless hate The memories follow me, a shadow of my being When I run, it runs with me, when I hide, it hides with me When I travel, it travels with me, when I speak, it speaks with me The Hyde to my Jeckyll, the devil to my angel, the darkness to my light The strength of the memories, the pain, is unimaginable Harnessed, it fuels my fire for change, For speaking out for those who can't Living my life to make a difference The strength of my memories, the pain, is unimaginable Let loose, it controls me, and I relive the horror I feel nothing but indescribable hate for so many people and places It removes any joy in my life, because the places still stand, and the people still laugh In my mind, a never ending war is fought The Angel, against the devil The armies fight, day and night, and no winner will ever be determined But I feel every blow, every wound, every death, as if it were my own. Some nights, I cry myself to sleep, at the memories of what happened Some days, I can do naught but feel a burning hate for what happened. Some nights, I go to sleep with a smile, for the change it made me make Some days, I can do naught but feel elated, for the lives I have changed These memories, are as valuable as diamonds Yet as valuable as a rotting fish These memories are as desired as fame, fortune, glory Yet as desired as manure I am taught to forgive, to move on Yet how can I move on from this? I may have left the school But the school has not left me

25 CO-ORDINATION ASD Sloppy handwriting, motor planning deficits, fine motor deficits. Difficulties with gross motor skills (sometimes with islands of competence) but often seen as clumsy or accident prone Difficulties in sports (also team aspect) ADHD May or may not have motor planning/fine motor deficits. Handwriting sloppy often due to a tendency to rush through. Often accident prone because they assume a fast pace of activity, act without fully thinking through possible consequences. Gross motor immaturities may or may not be present. Difficulties participating in sports may emerge due to problems sustaining attention (as in football) or due to response inhibition which reduces the capacity to contain emotion and work as a team.

26 COGNITIVE MARKERS ASD Prone to Cognitive rigidity Tend to see parts over wholes Difficulty experiencing the whole without full attention to the constituent parts Often proficient academic skills maths, vocabulary, memory. Difficulty distinguishing pretend form real, fact form fiction Re-experiencing the feeling of an event and encoding it with what happened, to come up with a unique, personal meaning They know but don't remember Poor Episodic memory ADHD Thinking is more chaotic See the big picture Not good at details Poor on measures of inhibition Think outside the box Poor marks most often arise out of careless errors in computation and short-term memory problems. IQ lowered by 10 points ADHD considered an educational disability “No problems with Autobiographical Memory” Short-term memory is often a problem

27 INTERVENTIONS There needs to be a balance between treating co-occurring conditions, short-term compensations to address immediate needs, and long-term remediation to address the aspects of ASD & ADHD which profoundly affect quality of life.

28 INTERVENTIONS FOR ADHD Parent Education Psychopharmacology Parent Training in Child Management –Children (<11 yrs., 65-75% respond) –Adolescents (25-30% show reliable change) Family Therapy for Teens: Problem- Solving, Communication Training (30% show change) –Best to combine it with BMT to reduce drop outs –CBT & Coaching

29 KNOWLEDGE AND EDUCATION ADHD is a Chronic Condition (I.e. diabetes) An educational disability “ Parents are Shepherds ” Model Change Expectations (30% rule) Modify Settings: Points of Performance Encourage Acceptance & Advocacy Encourage routine aerobic exercising

30 Empirically Proven Treatment Teacher Education About ADHD Teacher Training in Classroom Behavior Management Special Education Services Regular Physical Exercise Residential Treatment (5-8%) Parent/Family Services (25+%) Parent/Client Support Groups (ADDISS, ADDERS, Independents)

31 Evidence based treatment for ASD. Applied behavior analysis (ABA) School intervention Early intervention programs will teach early communication and social interaction skills that also target specific deficits in learning, language, imitation, attention, motivation, compliance, and initiative of interaction. Speech and language Occupational and physical therapy along with social play interventions. Dietary interventions Medication CBT for higher end Social stories TEACCH Parent education and support groups Parent management training RDItm

32 INTERVENTIONS FOR ASD More psychoeducation than with a typical child Will often enjoy acquiring new information Use visual aids such as rope or thermometer to demonstrate variations Start with positive emotions Increase vocabulary related to emotions in a meaningful way

33 INTERVENTIONS FOR ASD Comic Strip Conversations (Gray, 1998) – using cartoon strips to illustrate specific interactions – allows an accurate record of what occurred – includes the perspective of others – asks for motivations and thoughts of others – emotions can be conveyed using colour – will focus a restless client – provides a concrete record –

34 WHAT IS CBT? Six Components Assessment of nature and degree of problem (anxiety, anger, sadness) Affective education Cognitive restructuring Stress management Self-reflection Schedule of activities/rehearsal Developed and refined over several decades Research has established CBT as an effective method to change the way a person thinks about and responds to emotions such as anxiety, sadness, anger Focuses on aspects of cognitive deficiency in terms of maturity, complexity and expression of emotions Cognitive distortion in terms of dysfunctional thinking and incorrect assumptions

35 CBT Adapted to AS Cognitive Profile Identify key elements of a specific emotion via affective education Emotion recognition Meaningful measurement of emotion Concrete and visual Cognitive restructuring Gathering evidence, challenging distortions and dysfunctional beliefs Practice Extending repertoire of responses -Sofronoff (2004). Counseling adolescents. In L. Baker and L.Welkovitz (eds), Asperger’s syndrome: Intervening in schools, clinics and communities. -

36 CBT and Asperger Syndrome Very useful for young people with AS who have impaired ToM abilities Difficulty understanding, expressing and managing emotions Theoretical model of CBT consistent with current Theoretical models of human emotions Becoming more consciously aware of one’s emotional state Knowing how to respond to emotion Becoming more sensitive to how others are feeling -Ekman, (2003)

37 CBT & ADHD Very useful for children, adolescents, and adults (often combined with coaching for adults). Assists them in understanding their irrational thoughts and the emotions that accompany these cognitions Helps with comorbid anxiety and depression Overgeneralising the negative Blaming themselves or others Comparing themselves to their peers ( who do not have ADHD) Help with time management and organisational issues Help with goal setting Help with emotional response inhibition (putting on the brakes) Problem solving

38 Journals “ Competency" journal “My Accomplishments". Anger management Anxiety management Self-esteem portrait Once a consensus is reached on how the child wishes to have him/ herself depicted, focus is on special interests and talents, pets, family members. Use photographs

39 BRAVE BOOK When the child does something courageous in the classroom or at home, it is recorded, and includes as much information as possible. (How long he stayed upstairs by himself, what he did to deal with his fears (e.g. listed to music, went on his computer). This can be assisted by a token or point reward system. At school it could include times that he initiated joined/accepted interaction or with other children in a positive way. This can be photographed using a small digital or throwaway camera. He needs to see himself in these positive situations to help record the memory in a positive way.

40 USE A POWER SYMBOL AS ALLY A positive metaphor such as a Roman soldier, A respected character in history that the child feels has power and who he can identify with. Worries/fear that cause the child to withdraw, cry or become agitated can be assuaged by using “externalising language" by adapting the hero figure as a way that he can get rid of the unwanted behaviour. The child’s parents and teachers can help together in getting rid of the worry by 'ganging up' on it and using his positive symbol (e.g., “we can beat him!”). Outsmarting the worry means to do something positive to get rid of it and to “trick” it into not taking control of the child’s behaviour.

41 Externalising the problems You can also draw the fear using a cartoon silly feature. Shrek or the Lion in the wizard of Oz.

42 EXTERNALISING THE SYMPTOMS the Pink Mink (Anger or impulsivity)

43 EXTERNALISING THE SYMPTOMS NESSIE ’ S MESSY THOUGHTS

44 STINGERS (Hurtful words)

45 Self-control Competency Book Journaling Rehearsing Spotlighting sense of self-control via successes Learning from the consequences Photos taken at school Videotaping Mentor

46 Self-control Competency Book Help from my buddy in the playground

47 Self-control Competency Book Extract from his diary (with permission) from the last 2 weeks “ I did feel angry inside as everyone was having a go at me saying “ You are so rubbish at swimming”. I wanted to hit back but I didn’t. I just left the changing room and went outside. I remembered all the things I am good at and that I don’t like swimming anyway. I was sad in me but I did not let it out. Later I told mum and I had chocolate milk to make me feel better and proud that I did it on my own. I am strong really”.

48 SELF-ESTEEM PORTRAIT

49 MY SCHOOL WALL - Laminate a colored poster board and put up in the kitchen or room. Change the theme-color each month. Regularly put up the class list, weekly Day 1-5 schedule, & monthly calendar and refer to them daily/as needed. Add photos of school activities, students with names, social stories, crafts made at school, etc. Each month is a "fresh start" with a new board.

50 FEELINGS BOOK Thanks to Andrew ( great artist!)

51 TICKLING

52 ME AND MY GIRLFRIEND

53 Questions ” competency book Books can be made specifically for a problem: For example, this book would highlight when the child gets anxious or obsessive and allows others (parents, siblings) who don’t want to talk anymore or answer any more questions. The child would then use the book to answer his own questions based on his knowledge of what he has experienced and learned before. A parent can also role model when they might want to ask questions but they don’t. For example, “I really want to talk about _____, but I know that no one else wants to talk about that.”

54 Take more photos! Make memory books and journals together Children with AS are known to have phenomenal rote memory for facts and numbers, but poor personal episodic memory (poor recall for events experienced by themselves), but they will be better able to recall events with another person and will be more motivated to return if the experience is pleasurable!

55 “Episodic Memory affords individuals the possibility to apprehend their subjective experiences throughout time... It is the kind of memory that renders possible conscious recollection of happenings and events from one's personal past and mental projection of anticipated events into one's subjective future. It allows people to update information critical to …dealing with meaningful changes in their world.” Endel Tulving

56 DIARIES Happiness diary (Attwood, 2003) Personalised record that the young person can create Used to repair negative feelings Concrete example that the young person has good things in their life May work better than positive self talk

57 SOCIAL STORIES (Gray, 1994) Social stories are tailored to the needs of each individual child. This makes his life and his parents’ perceptions of their child visual and language-based. Used to promote social understanding in a specific situation Written to a formula Allows young person to work out for themselves what they need to do Non-threatening, non-critical Can incorporate visuals

58 Emotional Toolbox (Attwood, (2003) Physical tools Relaxation tools Social tools Thinking tools May be visual Other tools Special interest Inappropriate tools

59 Antidotes to Poisonous Thoughts (Attwood, 2003) Identify negative thoughts What purpose do these serve? Can we develop antidotes to these? What would they be? When can they be used?

60 USE OF DECLARATIVE LANGUAGE AVOID INSTRUMENTAL INTERACTIONS AS MUCH AS POSSIBLE

61 DECLARATIVE LANGUAGE Sharing Emotion and Experiences Comparing Attributes Reminiscing Reflecting Brainstorming Affirming Coordinating action Repairing misunderstandings

62 Declarative language Intent: in declarative communication is to share experiences or make a comment. A response is invited but not demanded. Imperative communication: we need specific information from someone or a particular response is expected.

63 Imperative language Requesting- something you want Responding- with the correct answer to a question Obtaining- needed information Controlling- the communication environment to eliminate uncertainty and surprise Making demands and commands

64 Declarative language Declarative language invites a response. Therefore, it takes away the pressure to respond. Look at the cognitive deficit of “right and wrong thinking.” When an individual with ASD hears a question, they perceive that there is a right or wrong answer and therefore it makes it a pressured situation and they are less likely to respond.

65 Declarative Language Application A way to increase the child’s desire to communicate and to use it in new ways by: Using 80% declarative and 20% imperative language to: –Encourage relationship development –Engages the prefrontal cortex –Encourages reciprocal conversation Increase your non-verbal communication and use far fewer words.

66 Examples That ’ s so funny! vs. Did you like that? I want to give you a big hug. vs. Come here and give me a hug Johnny is leaving now vs. Say “ good-bye ” to Johnny I wonder what is going to happen next? vs. What is going to happen next? Brrr its cold out vs. Put on your coat! Blue is my favorite color vs.What colour is that?

67 AUDIENCE PARTICIPATION Spend a few minutes having a conversation with only imperatives. Talk to the person next to you using only questions or demands. Spend a few minutes having a conversation with only declaratives. Talk to the person next to you using only experience sharing, open ended statements.

68 REDUCE INSTRUMENTAL INTERACTION Gradually reduce screen time (that is passive, addictive, non-interactive, not stretching the brain, leaves child isolated.) While interacting reduce objects that are self- entertaining to the child Reduce competitive interactions as appropriate Reduce games and interactions that are performance oriented Introduce more cooperative games and interactions

69 Ideas for increasing self-esteem Plan for ‘down time’ for your child and allow time for relaxing as opposed to over scheduling time. A child's choice of how to spend ‘down time’ is important in developing self-reliance. Create a workable routine (bedtime, mealtimes etc.) Young children need routines to help them to feel secure and competent. Keep exceptions to a minimum, and explain any necessary changes. Allow opportunities for a child to contribute to the family Give your child a job that only he/she does for the family. Even a small job can create a feeling of competence and build confidence. Pretend that you can’t do something (which you know the child can) and make declarative language in your comments. (E.g. You fixed that very well. The choice of colour you chose was spot on. You did your homework right away tonight, and now you get more free time, wise choice! )

70 Great Ideas for Management Parents are Shepherds, Not Engineers Reduce Delays, Externalize Time Externalize Important Information Externalize Motivation (Think win/win) Externalize Problem-Solving Use Immediate Feedback Increase Frequency of Consequences Increase Accountability to Others Use More Salient & Artificial Rewards NEVER go back on what you have said will be the consequence (EMPTY THREATS CAN CREATE A MONSTER) for your child, unless it is for a mighty good reason or unless you have a more appropriate consequence. (Barkley 2007)

71 Externalising time “The use of timers has revolutionised the process of getting dressed for school in the mornings, much less stressful now! His teacher has also given him one to use when he gets changed for P.E and she's been amazed at the difference it makes. I hope it will lead to staff using the timer for other things he does at school”. Mother of 7 year old son with ADD

72 Externalising time Make time physical via clocks, watches, calendars. There are electric timers with red/yellow/green lights Kitchen timers are great because you can spring load and wind them up and put right at the point of performance. Teachers can use interactive whiteboards/smartboards, where there is a digital timer that moves across the screen indicating what the total time is to complete the task is. If you give an ADHD child an assignment to do at their desk, it has a time limit, thus you need to put a timer on that desk because what do they do with the time they have? Waste it, because they don’t realize they’re wasting it. They think they have all the time in the world. When they finally realise that time is gone, they scrabble to do everything at the last minute, and it becomes chaotic. With a timer and a reward or consequence at the end, well you will most likely see a different phenomenon altogether.

73 Externalising time Classroom Time Timer

74 More of the Great Ideas  Change Rewards Periodically  Touch More, Talk Less  Act, Don ’ t Yak  Keep Your Sense of Humor  Use Rewards Before Punishment  Anticipate Problem Settings - Make A Plan  Keep A Sense of Priorities  Maintain a Disability Perspective  Practice Forgiveness (Child, Self, Others) R Barkley, 2007

75 Great Ideas For School Important to have close communication with school and home Use a checklist system for parents that records when a student achieves a goal or objective, such as arriving on time, being prepared, and completing classroom work. For each subject, the child should write down the homework and then show it to the teacher so that it can be checked for correctness. At the end of the class, repeat the homework assignment out loud as a reminder. Parents will then use the checklist to ensure the child completes the homework.

76 Great Ideas For School (From R Barkley) Each teacher rates each behaviour at end of each class; 1=Excellent (+25), 2=Good (+15), 3=Fair (+5), 4=Poor (-15), 5=Very Poor (-25) A Daily Behaviour Card

77 Is helpful to others and shows he cares by his actions Comments: Reacts in an appropriate way when others try to wind him/her up Comments: Communicates with mature language, kind words, complements others Comments: Respects Others’ Personal Space and belongings in class or in the playground Comments: Remembers to not talk when the teacher is talking. Comments: SKILLS CHECKLIST Date

78 Self-Evaluation One student designed his own chart to monitor himself and to decrease the number of times he interrupted the teacher in the classroom. He then evaluated it himself as to how many interruptions he recorded and then had his teacher simply check whether or not his estimate matched the teacher ’ s perception at the end of the class. His reward for 0- 2 times (no more) on all classrooms was to earn time to play this favorite computer game at home.

79 Making Commands Effective Heavily Praise High Compliance Commands Initially Use Imperatives, Not Questions Go to Child, Touch, & Use Eye Contact Child Recites Request Make Complex Tasks Simpler Ones Make Chore Cards for Multi-Step Tasks –List all steps involved in task on 3x5 file card –Stipulate a time period on the card

80 More on Effective Commands Reduce Time Delays for Consequences Use Timers at Points of Performance Don’t Assign Multiple Tasks at Once Praise the Initiation of Compliance Reward Throughout the Task Child Evaluates Performance at End Ignore unwanted behaviour


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