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7/5/2011

Acknowledgement to the following for many slides: Attention-Deficit/Hyperactivity Disorder (ADHD) At the Leading Edge Program Directors: Emmett Francoeur, MD, FRCPC Associate Professor, McGill University Director, Child Development Program, McGill University Health Center Westmount, Quebec

Samuel Chang, MD, FRCPC Clinical Associate Professor, University of Calgary Director, Adolescent Substance Abuse & Psychiatric Disorders Clinic Psychiatrist, Foothills Medical Centre Calgary, Alberta

Grazyna Jackiewicz, MD, FRCPC Assistant Professor, Pediatrics, McMaster University Consulting Pediatrician in Developmental/Behavioural Pediatrics, American Board Certified Chedoke Developmental/ Behavioural Clinic, Hamilton, Ontario Private Practice, Niagara Falls, Ontario

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

SOCIETAL IMPORTANCE Prevalence Developmental Sequencing E Economics i Multijurisdictional Agency Involvement Multimodal Management Prevention Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

COSTS OF ADHD - $US -2004 Overall Healthcare costs related to ADHD in children

Criminality Costs of ADHD vs Control /child

$2.8 Billion

$12,868 vs

$498

Accident-specific direct medical costs ADHD vs Control /child $642 vs $194

Excess costs to the economy due to ADHD

$3.46 Billion

Cost Effectiveness and Resource Allocation. Matza LS, Paramore, C, Prsad, M. 2005-06-09. www.resource-allocation.com/content/3/1/5

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7/5/2011

Multiple Contributing Factors to Disruptive Behavioral Disorders Heredity (Parental ADHD, ASPD) Intrauterine (alcohol, nicotine, lead, teratogens, ?pesticides, ?other environmental chemicals) Birth Trauma (prematurity, hypoxia, low birth weight) Negative temperament (child and/or parent) Insecure attachment—Disorganized, Avoidant Family distress, disorganization, chaos and dysfunction Physical abuse Modeling Ineffective and damaging child management strategies Iatrogenic Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Oppositional Defiant Disorder (ODD) 4+ symptoms, lasting at least 6 months, no CD often loses temper often argues with adults often actively defies or refuses to comply with adults' requests or rules often deliberately annoys people often blames others for his or her mistakes or misbehavior is often touchy or easily annoyed by others is often angry and resentful is often spiteful or vindictive Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

ODD Statistics Average onset: 7 years of age Prevalence: range 2-10% Sex ratio: Latency-age: 2 boys:1 girl Adolescence: 1 boy:1 girl

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7/5/2011

ODD – The Four Causes of Defiance Negative Child Temperament & ADHD Negative Parent Temperament Ineffective Child Management g by y Parent Highly inconsistent & indiscriminate Use of harsh, extreme punishment Excessive reliance on talking & yelling Tit-for-tat interaction style

Parent and family stress events Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

The Non Compliance Cycle Parent commands

Parent Parent Repeats Repeats command command

Other Other interactions interactions Compliance

Loop repeats 3 to 7 times Compliance

Parent Parent threatens threatens

Loop repeats 3 to 7 times Compliance

Parent ?

Aggression Aggression

Acquiescence Acquiescence

Presentation by Barkley R. Original research, by Patterson G (?)

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Managing ODD Manage pre-existing disorders, especially ADHD Children are in charge of choices; adults are in charge of consequences Parents are Shepherds, Not Engineers Train parents in child behavior management skills – IWK has unified approach – Incredible Years – Dorothy Stratton Note later slide on overall management program for Disruptive Behavioral Disorders

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7/5/2011

Conduct Disorder (CD) 3+ symptoms over past 12 months with 1 in past 6 months Aggression to people and animals bullies, threatens or intimidates others often initiates physical fights has used a weapon p that could cause serious pphysical y harm to others (e.g. a bat, brick, broken bottle, knife or gun) physically cruel to people or animals steals from a victim while confronting them (e.g. assault) forces someone into sexual activity Destruction of Property deliberately engaged in fire setting with the intention to cause damage deliberately destroys other's property Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Conduct Disorder (CD) Deceitfulness, lying, or stealing has broken into someone else's building, house, or car lies to obtain goods, or favors or to avoid obligations steals items without confronting a victim (e.g. shoplifting, but without breaking and entering) Serious violations of rules often stays out at night despite parental objections runs away from home often truant from school (prior to 13 years of age)

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Statistics Average Onset: Childhood Onset = <10 years Adolescent Onset = >10 years

Prevalence: Latency-age: 2-8% boys; 0-2% girls Adolescence: 3-10% boys; 1-7% girls

Sex ratio: More boys than girls (during latency-age, ? During adolescence) Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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Important Distinctions Delinquency versus ODD/CD Overt versus covert behaviours Instrumental versus hostile aggression Reactive versus proactive aggression Direct versus indirect aggression Early versus late onset Callous unemotional Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Links between ADHD, ODD & CD With ADHD, 40% have ODD and 14% CD With ODD, 25% develop CD (M>F) With CD, 80% of youth meet criteria for ODD The 25% of children with ODD who will develop CD have earlier onset of ODD. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Developmental Sequence of Disruptive Behaviour Rejection by peers and teachers

Noncompliance

Coercive Parent-child interaction

Coercive Peer & teacher interaction

Association with delinquent peers

Minor delinquency

Association with more delinquent peers

Serious delinquency

Poor school performance

Early Childhood

Middle Childhood

Early Adolescence

Middle/ Late Adolescence

The sequence outlined should not be interpreted as a causal model; there is no evidence that one event in the sequence is the cause of another.

Forehand R, Wierson M. Behavior Therapy, 24: 117-141.

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7/5/2011

CD: Perceptual and Attributional Processes PERCEPTUALATTRIBUTIONAL PROCESSES

KNOWLEDGE STRUCTURES

EARLY EXPERIENCES

Hostile world schema Self-defensive goals

Physical abuse Aggressive models Insecure attachments

BEHAVIOUR

Hypervigilance to hostile cues Hostile attributional bias

Aggressive Behaviour

CONDUCT PROBLEMS

Model of the development of aggression and conduct problems

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Three Pathways to Boys’ Problem Behaviour and Delinquency % BOYS

AGE OF ONSET

% BOYS

AGE OF ONSET

Few Few

Late Late

VIOLENCE (rape, attack VIOLENCE Strong (rape,arm) attack Strong arm)

MOD. To SERIOUS MOD. To DELINQUENCY SERIOUS (fraud, burglary, DELINQUENCY (fraud, burglary, Serious theft) Serious theft)

PROPERTY DAMAGE (vandalism, fire setting)

PHYSICAL FIGHTING (physical fighting, fighting PHYSICAL FIGHTING Gang fighting) (physical fighting,

PROPERTY DAMAGE (vandalism, fire setting)

Gang fighting)

AUTHORITY AVOIDANCE AUTHORITY (truancy, AVOIDANCE (truancy, Running away, Running away, Staying late) Staying out out late)

MINOR AGGRESSION (bullying, annoying others) MINOR AGGRESSION (bullying, annoying others)

MINOR COVERT BEHAVIOR (shoplifting, frequent lying)

OVERT PATHWAY OVERT PATHWAY

MINOR COVERT BEHAVIOR (shoplifting, frequent lying)

COVERT PATHWAY) DEFIANCE/ DISOBEDIENCE

COVERT PATHWAY)

DEFIANCE/ DISOBEDIENCE

Early Early

Many

STUBBORN BEHAVIOUR STUBBORN BEHAVIOUR AUTHORITY CONFLICT PATHWAY (before age 12)

Many

Loeber R &Hay. Three developmental pathways to serious disruptive behaviours.

AUTHORITY CONFLICT PATHWAY (before age 12)

Academy in School Mental Health &Hay. Three developmental pathways toMental serious disruptive Presented by: SunLoeber Life RFinancial Chair in Adolescent Health behaviours.

The Benefits of Treatment? One Study Retrospective study of 25 adolescents age 15 at a Toronto residential setting: Start of problems: Age 4.7 years First intervention age 6.48 years Average number of CD symptoms: 5 Age 16 15.6 Agencies Average 8 months / agency 18.9 interventions Average 7 months / intervention Number of schools – 6.88 Average number of CD symptoms: 10.16

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7/5/2011

The Importance of School and Teachers Assets:  100s for comparison standards and a structured environment Early Identification  Written observations of behavior, compliance and peer functioning  Observations for learning strategies and for learning disabilities Questionnaires and rating scales Positive relationship with child Positive relationship with parents Observations of response to behavioural interventions and teaching strategies CAUTION:  Less Teacher Contact in Junior and Senior High School

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Effective Interventions Contingency Management Programs Parent Management Training Cognitive-Behavioural Skills Training Stimulant Medication Basic Principles Families and Schools Together (FAST Track) Multi-Systemic Therapy (MST)

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Managing Disruptive Behavioral Disorders 1. Program Infrastucture 2. Assess and Manage 3. Skill Building 4. Classical Therapy 5. School Preparation 6. Child Management Training 7. In the Community . 8. Case Conferencing Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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7/5/2011

Key Goal of Working with DBD Prevent the progression through: Attention-Deficit /Hyperactivity Disorder to Oppositional Defiant Disorder to Conduct Disorder to Antisocial Personality Disorder

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Resources Support Groups Look for support groups in your area on the CADDAC website (www.caddac.ca) Websites Canadian ADHD Resource Alliance (CADDRA) – www.caddra.ca Centre for ADD/ADHD Advocacy, Canada (CADDAC) – www.caddac.ca Attention Deficit Disorder Association (ADDA) - www.add.org Answers to your questions about ADHD (PO Quinn,K Nadeau) - www.ADDvance.com Online catalogue of ADHD resources – www.addwarehouse.com www addwarehouse com Quebec-based Dr Annick Vincent's ADHD website - www.attentiondeficit-info.com Children and Adults with Attention Deficit Hyperactivity Disorder – www.chadd.org Connecting doctors, parents and teachers – www.myadhd.com Online planner - www.skoach.com Totally ADD – www.totallyadd.com Canadian DVDs on ADHD Portrait of AttentionDeficit / Hyperactivity Disorder Dr. Annick Vincent ADHD Across The Lifespan, Timothy S. Bilkey, Ontario; www.bilkeyadhdclinic.com Various DVDs for patients, parents and educators CADDAC, Toronto: www.caddac.ca Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

Books Adler &Florence(2006) Scattered Minds: Hope and Help for Adults with ADHD, NY, Putnam. Barkley, R. A. (2000). Taking Charge of ADHD: The Complete Authoritative Guide for Parents, New York: Guilford Press. Barkley, R.A., Murphy, K.R. & Fischer, M. (2008) ADHD in Adults: What the Science Says, New York: Guilford Publications Bergh, RM (2004). Explaining ADHD: A Paediatrician Talks to Parents, Ottawa: Nicro Pub. Brown, T. E. (2000). Attention-Deficit Disorders and Comorbidities in Children, Adolescents and Adults, Adults Washington DC: American Psychiatric Press. Press Brown, T. E. (2005) Attention Deficit Disorder: the Unfocused Mind in Children and Adults, New Haven, CT: Yale University Press Hallowell, E. M., and Ratey, J. J. (2005). Delivered from Distraction. NY: Ballantine Books. Kelly, K., and Ramundo, P. (1996). You Mean I'm not Lazy, Stupid or Crazy? A Fireside Book. New York: Simon & Schuster. Kolberg J & Nadeau KG (2002) ADD-Friendly ways to Organize Your Life. NY: Routledge Kutscher, ML. ( 2003) ADHD Book: Living Right Now! White Plains, NY: Neurology Press Moghadam, H. (2006). Attention Deficit-Hyperactivity Disorder. Calgary, AB: Detselig Ent. Moulton Sarkis, S. (2005) 10 Simple Solutions to Adult ADD. Oakland: New Harbinger Publications, Inc. Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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Books Nadeau K(1996)Adventures in Fast Forward: Life, Love and Work for the ADD Adult.NY:Brunner/Mazel. Nadeau K(1997)ADD in the Workplace:Choices, Changes and Challenges.NY: Brunner/Mazel. Nadeau, K. G., Littman, E. B., and Quinn, P. (1999). Understanding Girls with AD/HD. Silver Spring: Advantage Books. Nadeau, K. G., Littman, E. B., and Quinn, P. (2002). Understanding Women with AD/HD. Silver Spring: Advantage Books. Nadeau, K. (1998) Help4ADD@High School. Silver Spring : Advantage Books Nadeau K (2006) Survival Guide for College Students with ADHD or LD. NY: Magination P Pera G. (2008) Is it You, Me, or Adult ADD? Stopping the Roller Coaster When Your Partner has -- Surprise! -- Attention Deficit Disorder, San Francisco, 1201 Alarm Press. Phelan, T. W. (2003). 1-2-3 Magic. Glen Ellyn, Illinois: Parent Magic inc. Ph l T. Phelan, T W. W (2000). (2000) All about b Attention A Deficit D f Disorder: D d Symptoms, S Diagnosis D andd Treatment: Children and Adults. Glen Ellyn, Illinois: Parent Magic inc. Pinsky SC (2006) Organizing Solutions for People with Attention Deficit Disorder-Tips and Tools to Help you Take Charge of Your Life and Get Organized, Glouchester, Fair Winds P. Quinn, P.O., Ratey, N.A., Maitland, T.L. (2000) Coaching College Students with AD/HD, Issues and Answers. Washington D.C. : Advantage Books Safren, S. A., Sprich S., Perlman C.A., Otto, M. W. (2005) Mastering Your Adult ADHD, A Cognitive Behavioral Treatment Program, Client Workbook, New York: Oxford. Solden, S. (1995). Women with Attention Deficit Disorder: Embracing Disorganization at Home and in the Workplace. Grass Valley: Underwood Books. Tuckman, A. (2009) More Attention, Less Deficit: Success Strategies for Adults with ADHD, Specialty Press/A.D.D. Warehouse, U.S. Vincent A (2008). My Brain Needs Glasses: Living with Hyperactivity. QC: Impact!Éditions. Vincent A (2008). My Brain Still Needs Glasses: AD/HD in Adults. QC: Impact!Éditions. Wender PH (2002) ADHD: Attention-Deficit Hyperactivity Disorder in Children and Adults. OUP

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

QUESTIONS Q

“CHILDREN DO WELL IF THEY CAN. IF THEY CAN’T, WE AS ADULTS NEED TO FIGURE OUT HOW WE CAN HELP” (Ross Greene)

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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Dr wade junek 3 slides