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Session 1 Professor Amanda Kirby Dyscovery Centre University of Wales, Newport Aims of the session • What is ADHD and DCD (dyspraxia) and how do they present ? • What are the implications for school and home? • How can parents and professionals work effectively around the clock to maximise the child's skills in primary school • Considering transitions The Dyscovery Centre
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ADHD and DCD
Session 1
Professor Amanda KirbyDyscovery Centre
University of Wales, Newport
Aims of the session• What is ADHD and DCD
(dyspraxia) and how do they present ?
• What are the implications for school and home?
• How can parents and professionals work effectively around the clock to maximise the child's skills in primary school
• Considering transitions
The Dyscovery Centre
ADHD and DCD
• ADHD- attention deficit hyperactivity disorder
• DCD- developmental co-ordination disorder
• They are both developmental disorders
• Pervasive
• Developmental
• Likely to continue to have some impact into adulthood
Start from any point and you will end up seeing overlap
Behaviour
ADHD
DCD
ADHD and DCD are both
Commonly overlap with one another35-50% of the time
Children with ADHD and DCD may often have to varying degrees:
• Dyslexia- reading difficulties
• Dyscalculia- mathematics difficulties
• ASD- social and communication difficulties
• Specific language difficulties
• … increased risk of anxiety and depression
• … lowered self esteem
ADHD & ASD –21% of children with severe ADHD met full criteria for Asperger’s syndrome and 36% showed‘autistic traits’
(Fitzgerald and Corvin, 2001; Lecavalier, 2006; Fombonne et al, 2001)
DCD & ADHD –30-35% of children have ADHD and DCD
(Kirby and Salmon, 2008; Gillberg and Rasmussen, 2010)
ADHD, DCD, Dyslexia & ASD –Extensive evidence of overlap between all four disorders
(Kaplan et al 1998)
Dyslexia &ADHD – in about 35% -40% of cases
(Willcutt, Pennington, Olson et al (2007) showed a shared genetic basis)
SLI & DCD –60% of children with specific language impairment showed motor difficulties as well
(Missiuna and Gaines, 2007)
SLI & Dyslexia•Greater risk of later dyslexia difficulties in adulthood
–( Pennington and Bishop , 2009)
Despite this knowledge we still separate
children into different labels
Children can present in a variety of
ways
ADHD
Attention
Deficit
Hyperactivity
Disorder
ADHD
The three core symptoms of ADHD are generally considered to be these:
– Hyperactivity
– Impulsivity
– Attention problems
• Prevalence: 1-2% of population
• Gender: 3:1 M:F
• Genetically based condition
ADHD is not new
• Described by George Still in 1902
• He described 43 children from his practice
who were “often aggressive, defiant, resistant to discipline, excessively emotional or passionate, who showed little inhibitory volition, had serious problems with sustained attention and could not learn from the consequences of their actions; though their intellect was normal.”
The Dyscovery Centre copyright
2008
Fidgety Phillip
Dr. Heinrich Hoffmann in 1844 is the first known description of Attention-deficit/ hyperactivity disorder,
But fidgety Phil,He won't sit still;He wriggles,And giggles,And then, I declare,Swings backwards and forwards,And tilts up his chair,Just like any rocking-horse-"Philip! I am getting cross!"
Johnny Head in the air
Symptom groups
Inattention Hyperactivity Impulsivity
• Does not pay
attention
• Avoids sustained
effort
• Doesn’t seem to listen
when spoken to
• Fails to finish tasks
• Can’t organise
• Loses things,
‘forgetful’
• Easily distracted
• Fidgets
• Leaves seat in class
• Runs/climbs
excessively
• Cannot play/work
quietly
• Always ‘on the go’
• Talks excessively*
• Talks excessively†
• Blurts out answers
• Cannot await turn
• Interrupts others
• Intrudes on others
Other associated disorders
Oppositional
Defiant
Disorder
40%Tics
11%
Conduct
Disorder
14%
ADHD
alone
31% Anxiety
Disorder
34%
MTA Cooperative Group. Arch Gen Psychiatry 1999; 56:1088–1096
Mood
disorders
DSM-IV ADHD diagnostic criteria
• List of symptoms must be present for at least 6 months
• Must have six (or more) symptoms of inattention AND/OR hyperactivity–impulsivity
• Some symptoms present before 7 years of age
Diagnostic criteria for ADHD (DSM-IV). www.turnertoys.com/ADHD/APA_diagCriteria.htm
DSM-IV ADHD diagnostic criteria
• Some impairment from symptoms must be present in two or more settings (e.g. school and home)
• Significant impairment: social, academic or occupational
• Exclude other psychiatric disorders
Child with ADHD
• Difficulties with concentration• Fidgety - difficulty sitting still• Difficulty completing a task - starts but does not
finish• Impulsive - answering out of turn• Poor organisation• Not achieving as well academically• Dreamy• Not listening to instructions• Forgetful
ADHD in adults• carelessness and lack of attention to detail.
• continually starting new tasks before finishing old ones.
• poor organisational skills.
• inability to focus, or prioritise.
• continually losing, or misplacing, things.
• forgetfulness.
• restlessness and edginess.
• difficulty keeping quiet, and speaking out of turn.
• blurting responses, and poor social timing when talking to others,often interrupting others.
• mood swings,irritability and a quick temper..
• taking risks in activities, often with little, or no, regard for
personal safety, or the safety of others.
Different at different ages
Pre-school Adolescent Adult
School-age College-age
Behavioural
disturbance
Behavioural disturbance
Academic problems
Difficulty with social
interactions
Self-esteem issues
Academic problems
Difficulty with social interactions
Self-esteem issues
Legal issues, smoking
and injury
Academic failure
Occupational difficulties
Self-esteem issues
Substance abuse
Injury/accidents
Occupational failure
Self-esteem issues
Relationship problems
Injury/accidents
Substance abuse
Long-term
• By the age of 25, an estimated 15% of people diagnosed with childhood ADHD still have a full range of symptoms, and an estimated 65% still have symptoms which affect their daily lives.
What is Developmental Coordination Disorder (DCD)?
DCD
• Also known amongst other terms as Dyspraxia/Clumsy child syndrome
• Prevalence: 5- 6% of individuals ( Lingham et al, ALSPAC, 2009)
• Gender: 2-3:1 M:F
Motor co-ordination difficulties
Take one day in your life -what does not require movement?
UK Consensus (2012) agreed common descriptors aligning with DSM1V/ICD10
Developmental Co-ordination Disorder (DCD), also known as Dyspraxia in the UK, is a common disorder affecting fine or gross motor co-ordination in children and adults.
This condition is formally recognised by international organisations including the World Health Organisation. DCD is distinct from other motor disorders such as cerebral palsy and stroke.
• The range of intellectual ability is in line with the general population.
• Individuals may vary in how their difficulties present; these may change over time depending on environmental demands and life experience, and is lifelong.
• An individual’s co-ordination difficulties may affect participation and functioning of everyday life skills in education, work and employment.
Continuing…….
• Children may present with difficulties with self-care, writing, typing, riding a bike, play as well as other educational and recreational activities.
• In adulthood many of these difficulties will continue, as well as learning new skills at home, in education and work, such as driving a car and DIY.
• There may be a range of co-occurring difficulties which can also have serious negative impacts on daily life. These include social emotional difficulties as well as problems with time management, planning and organisation and these may impact an adult’s education or employment experiences.
DCD criteria (DSM1V)
• Defining characteristics:
– A MOTOR IMPAIRMENT- measured with a normative test e.g. M-ABC, BOT
– B-IMPACTING on
• Daily living
• Academic achievement
– C and D Exclusionary clauses - intelligence, CP and other pervasive disorders
Missiuna, C. et al. CMAJ 2006;175:471
Concerns typically noted by parents of children with DCD at different ages
Common issues
Posture Planning Fine motor Gross motor
DCD: In childhood
3-4 years
Parents often report “something different”
• Frequent tripping when running
• Difficulty sitting at table & chair
• Unable to hop on one foot
• Fist grip of crayon
• Poor spoon feeding
• Unable to throw ball with direction
• Unable to catch 12” ball
• Not exploring playground equipment
• Not alternating steps on descent of stairs
• Can’t do up zips
• Can’t cut along a line
6 years
• Fearful and/or avoids active play
• Inaccurate throw & catch
• Cannot skip
• Awkward/tense pencil grasp
• Poor legibility/speed of handwriting
• Avoids fine motor tasks e.g. crafts, creative
8 years
• Dislikes sports & active recreation
• Can’t keep up with written work
• Gap between verbal & written work is obvious
• Limited social engagement
• Aware of difficulties
10-12 years
• Writing at speed
• Self organisation
• Organisation of work
• Still slow getting dressed/shoes etc
• Social interaction with peers- emotional mismatch
• Mathematics associated
Emerging adulthood lasts a bit longer
“I was later than most of my peers in starting to experiment, starting just a few weeks before my 18th birthday. I didn't really have a lot of people to go out with, and I didn't usually enjoy it when I did because it simply seemed to be a less controlled extension of the social dynamics of school... i.e. I was outcast to varying degrees. Now, at university, I definitely don't drink more than some, but I'd say I was about average for my peer group at the moment”
What difficulties with ‘emerging adults’ with DCD have?
• Less self care issues unless under time pressure
• Writing at speed and neatly• Self organisation• Time management• Avoiding sports• Weight gain• Driving• Less mature • Less social experiences
Practical strategies for home and
school
“When it comes to the future, there are three kinds of people: those who let it happen, those who make it happen, and those who wonder what happened.”
M.A.T.C.H. the activity to the individual
Modify the task
Alter expectations
Teach strategies
Change the environment
Help by understanding
M.A.T.C.H. strategies available from CanChild website http://www.canchild.ca/
Intervention
• Practising what you can’t do
• Doing what you want to do
• Doing what you need to do
• Avoiding what is difficult and is likely to persist and adapting
• Seeking out strengths
Pragmatic approach
How much time have you got
What is important for now
What is important for the future
Listen to the voice of the child and what is important for them
Practise enough and in context
Hours practised per day
Start with the basics
Think of ‘hot spots’ in the day or with people
Think about what has triggered problems in the past and now
“ Every time” he does xxx....
Self care
Challenges Responses• Putting out clothes the
night before
• Alternative fastenings-velcro etc
• Timer for teeth cleaning
• Wet wipes and practice- be explicit
• Adapted cutlery/stable position
• Verbal prompts
Teeth cleaning/bottom
wiping/personal hygiene
Shoe lace tying- never too late
Avoid mealtime angst
Practice processes-tuck in, napkin
Think about the length of time
Organisation
• Same place
• Same time
• All equipment ready
• Home- school diary
• Create a plan
• Use an essay planner
• Parent buddy
Sleep habits
Social currency
Family
Friends
Teachers
Strangers
Social currency
Creating
Social networks
Social rules
Seek out social opportunities similar to peers
• Sport
• Music
• Cooking
• Martial arts
• Gym
• Local clubs
• With family
• Appropriate thrill seeking if this is important
Preparing for school
• What needs to be prepared for.....
Responses• List of what to do
• Night before by the front door
• List in bag/kitchen etc
• Timer with an alarm
• Practice new journeys
• Practice sorting.. To do lists
Challenges
Preparing for school
• Lunch box/lunch money
• Lunch choices
• List of items – for the day
• Labelled clothes
• Right and left shoes
• Preparing for periods
• Pack for sport
• Good rucksack
Map of the School, pictures of pupils and teachers
Using colours, key features, reference points
MATCH- IT
Lunch and break times/unstructured times
• Encourage lunch time clubs where there are “ formalised” opportunities for socialising
• Peer mentor schemes
• Play ‘what if’
• Play’ canteen chaos game’
• Get weekly menu from school
Toilets
In the canteen/lunchtime
• Queuing and choosing
• Paying
• Using cutlery
• Spills
• Where to sit
In class
Challenge
• Recording from the board
• Listening
• Planning out tasks
• Using tools- scissors /rulers
• Maths
• Posture
• Position
• Task
• Motivation
Response
• Facing the front
• Angle board
• Adapted tools
• ICT
• Minimise writing
• Being able to ask again
• Time out/toilet
Position can make a difference
Think environment
Study carelle
Headphones- quiet, specific music
Visual timetable
Allow movement breaks
• Ask the child to do some chores in class-tidy up a corner
• Send on a chore
• Warning cards if need a stretch
• Get all children to have a stretch
Work on core stability
Improving posture
Different writing tools
Rulers
Scissors
Improve literacy, recording skills
• Reading/Spelling skills• Use of IT to assist/avoid/compensate• Speech to text. Dragondictate free
app on I Phones• Use spellcheckers• Text to speech software- such as
Kindles, ebooks, audiobooks, Claroread, readplease.com
• Wordbar• Put together a glossary of terms
Mathematics
– Language of maths
– Visualisation of maths
– Learning times tables
– Recording in class
– Using tools
Jonny went down the street and had
£3.20, He had to buy six apples at
20p each and 4 pears at 10p. What
change did he have?
Learn functional maths
Cookery
Weights and measures
Shape- geometry
Half and quarters
Language
Planning
Motor skills
“The clock represents our commitments, appointments, schedules, goals and activities – what we do with and how we manage our time.
The compass represents our vision, values, principles, mission, conscience, direction –what we feel is important and how we lead our lives.”
"The struggle comes when we sense a gap between the clock and the compass – when what we do doesn’t contribute to what is most important in our lives.”
Stephen Covey
Time reminders
Think about ‘in
time’ concepts
Get keyboard skills sorted
Lower case keyboard
software
Changing colour
background Screenruler
Speech-to-text Text-to-speech
http://www.readwritethink.org/files/resources/i
nteractives/essaymap/
Mind mapping -www.ikonmap.com
www.ghotit.com
Literacy based difficulties
Suitable reading materials
Rising Stars
Barrington Stoke
Homework- school approaches
• Consistency between home and school
• Colour coding and filing systems
• PA system of checks at start and end of day
• Home-school diary
• Parent buddy system
Think of the whole family
• Siblings
• Family occasions
• Times of transition
Cohesion and conflict in families
Physical fitness
• Cardiovascular fitness
• Obesity
Unstructured times
• Create a time table
• Provide a framework to the week
• Consider opportunities for practising skills –led by individual/child goals
Plan holidays
• Calendar
• Travel time
• Smells, tastes
• Climate
Seek out hobbies for confidence
• Swimming• Horse riding• Trampolining• Canoeing• Music- drums• Photography• Cookery• Rambling• Badminton• Fencing• Archery• Golf• Gym work• Orienteering• Wall climbing
CAPACITY THEORY
Individual
Task
Outcome
Environment
Individual strengths
and difficulties
Motor skills
Social and communica
tion
( reading, speaking,
understanding )
Vision and
hearing
Executive functioning
Individual
Task
Outcome
Environment
TASK
Do
Avoid
Adapt
Individual
Task
Outcome
Environment
Grading for success
Transition
“A passage from one form, state, style, or place to another”
• We know when
• We usually know where
• We know the curriculum in school
• We know most of the issues
• We don’t always consider them in enough time
Times of change can create tipping points
• Plan for transition points early
• Change of teachers
• Change of children
• Moving from school to school
• New family members
• Examinations
Transition
• Primary → Secondary transition is a key rite of passage for children and parents
• Internal and external changes are maximal
• Internal - puberty, growth, emotional upheaval
• External - larger school, new friends, more teachers, faster pace , greater self-organisation, more movement etc., less parent-teacher contact
preparation transfer induction consolidation
Four phases of transition
John
10 years old• He is in his last year in a small primary school. • He has problems with writing at speed, copying
from the board. He interrupts others when he is unsure.
• Slow changing for PE. He does not like football. • He has started to find maths hard to do. • He gets fidgety when sitting for a long time.• He has been bullied in the past. He is on School
Action.• He takes ADHD medication three times daily. • He has a diagnosis of ADHD and DCD• He will need to get a bus to his new school• Only one of his friends is going to the same
school.
Recognise the increased demand in
secondary school
– Navigate around school– Assignments to time– Revise and do examinations– Manage projects– Remembering to take the right books to class– Getting homework completed on time.. And given in– Plan after school activities– Respond to feedback from work- manage
frustrations– Consider longer term goals– Choose not to do dangerous behaviours– Dealing with lunch money for the week
New for John
• Needs to catch a bus and pay for it• Wearing a uniform with a tie.. • Coping with toilets• No lockers in his school• Playing rugby and doing up rugby boot laces• Use a protractor in mathematics• Make new friends – different location• Have more and all new teachers – with different teaching
styles• Having to write faster in class• Needing to get around a new school• Meeting new pupils• More school rules• Using the Canteen AND……………………………….
John arrives
• Misses his bus going to school• Late for rugby as slower to change• Can’t undo his trousers fast enough and wets himself• Does not know what to take home for homework and packs the
wrong book• Loses his locker key and the note from the teacher about an inset
day• Has to find his way to the school office for his medication at
lunchtime• Wanders around the playground fiddling with a toy he likes and older
boys start laughing at him• Distressed by the canteen noise and does not know how to
queue/pay/where to sit/pay –he wanders off without lunch• Lost his homework book in the first few days - unsure what lesson is
next• Does not have correct homework down as writing is slow at the end
of class- gets into trouble• Told to stay behind as he has not completed his work in time• +++++++++++++++++++++++++++
Adolescence as well
as transition
The grey matter continues to thicken throughout childhood as the brain cells get
extra connections.
Peaks at around 11-12 years
Increased grey matter
Decreased grey matter
More efficient
connections
Genes Environment
Ref: Giedd
Pruning
Use it or lose it phase
• If a teen is doing music or sports or academics, those are the cells and connections that will be hard-wired.
• If they're lying on the couch or playing video games, those are the cells and connections that are going to survive.
• Changes can be seen.... taxi drivers/pianists
Gut or head- making a decision
• Adolescents rely heavily on the amygdala-do then think
• Adults rely more on the frontal lobes-think then do
Advice to parents
• Revise over summer holidays in a fun, interactive way – Teacher bingo– Pelmanism– Map quiz
• Practice scenarios- queuing, paying, choosing.• Consider personal risk - as may be an
intellectual/emotional mismatch• Understanding of rules - explain implied rules
as well as explicit
Advice to parents
• Study skills – scaffold, set up a study area• Increase opportunity for social interactions -
drama, chess, sports• Learn socially appropriate behaviour from
appropriate age - need to model behaviours with peers not parents… going shopping for clothes etc.
• Sleep patterns established before school starts
www.move627.org
Guidance on each scenario
Mapping SEN routes to identification
Mapping SEN
Useful websites
• www.dyscovery.org• www.boxofideas.org• www.adhdtraining.co.uk• www.spldtransitions.co.uk
