School Neuropsychology of Behaviour and Psychopathology

James B. Hale, PhD, MEd, ABPdN, ABSNP Professor of Education and Medicine University of Calgary [email protected]

Kelly Ryan Hicks, M.Sc. Registered Psychologist School Psychologist, Calgary Board of Education

Manitoba Association of School Psychologists 14-15 November 2013 The Strange Case of Phineas Gage • Phineas Gage was a railroad foreman who had a tamping pole blown through his orbital and dorsolateral prefrontal regions • He was walking and talking a few minutes after the injury, but vomited sending more brain tissue to the floor, with swelling leading to coma • Recovery was slow; mood was variable, and he was disinhibited, contentious, and socially inept, so “no longer Gage” • Frontal lobes and limbic system “Seat of Personality” and psychopathology (not far off!) Physiological Basis of Psychopathology

• Eysenck (1967) Theory of Autonomic Arousal: Internalizing and externalizing dimensions  Internalizers have cortical overarousal; Cope by limiting environmental stimuli  Externalizers have cortical underarousal; Cope by seeking environmental stimuli Hemispheric Functions and Psychopathology

• Sackheim (1982) review of hemispheric functions and psychopathology Left hemisphere lesions/anesthetization and catastrophic/depressive reactions Right hemisphere lesions/anesthetization and euphoric/indifferent reactions • Davidson’s (2000) work in brain functioning in typical populations Left hemisphere activation = Positive affect; The “approach” hemisphere Right hemisphere activation = Negative affect, The “avoidant” hemisphere • Implications for discordant-divergent (new relationships) and concordant-convergent (known relationships) thought Cortical-Subcortical Circuits and the Third Axis

Motor Oculo- Working memory, memory Cingulate motor encoding & retrieval

Basal Plan, organize, strategize, Ganglia/ implement, monitor, Thalamus evaluate, modify, and & change behaviour

Cerebellum Attention, concentration, activity, and impulse control Anterior Cingulate Circuit and Psychopathology • Cognitive Functions – arousal, motivation, performance monitoring, switching, behavioral initiation, posterior-anterior communication  online data processing manager (like RAM) • Dysfunction Psychopathologies – depression, bipolar, ADHD, schizophrenia, autism • Associated Neuropsychological Deficits – Internal state executive skills: Apathy or poor motivation Poor response control and shifting/switching behavior Difficulty with decision-making Lack of enjoyment – anhedonia Poor response to reinforcement Slow processing speed Limited idea generation and creativity Dorsolateral Prefrontal Circuit and Psychopathology • Cognitive Functions – planning, organizing, strategizing, monitoring, evaluating, shifting, and changing behavior; working memory, memory encoding and retrieval; strategy generation and hypothesis testing • Dysfunction Psychopathologies – depression, schizophrenia, ADHD, autism • Associated Neuropsychological Deficits – External task-oriented executive skills: Difficulty with hypothesis generation and problem solving Limited or excessive interest in environment Poor sustained attention Mental inflexibility Decreased verbal and design fluency Encoding and/or retrieval from long-term memory deficits Poor planning, organization, and checking behavior Orbital Prefrontal Circuit and Psychopathology • Cognitive Functions – indirect influence on tasks; emotional and behavioral self-regulation, inhibition, empathy, social control, integrating emotions into contextually relevant behavior • Dysfunction Psychopathologies – obsessive compulsive disorder, anxiety disorder, bipolar disorder, conduct disorder • Associated Neuropsychological Deficits – Internal state executive skills: Perseveration or disinhibition Tactlessness Irritability Sexual deviance (extreme interest or disinterest) Antisocial or asocial behaviors Inappropriate feelings (e.g., sadness or euphoria) Orbital Prefrontal Circuit and Theory of Mind

• Theory of Mind – the ability to take the perspective of others or feel empathy • Does empathy only require perception, or does it also require Action? • Posterior systems linked to affect perception Parietal lobe and “mirror” neurons Temporal lobe and face recognition • Why then is theory of mind linked to the frontal systems? Pars opercularis and imitation Medial orbital cortex and theory of mind • Are posterior systems related to affect perception, while anterior systems related to empathy? The Often Neglected Cerebellum: Motor Functioning or The Mini Brain? • Cerebellum is “mini-brain” involved in most cognition • Ipsilateral “check and balance” for cortical functions • Important for fine motor and gross motor control • Higher level functions include timing, precision, learning, coordination, amplification of mental activity or “scripts” • Cerbellar vermis and frontal-subcortical interpretative axis, damage leads to “cognitive- affective syndrome” • Koziol, Budding, and Hale (2013) argue cerebellar automaticity functions could play into routinized psychopathology (e.g., personality disorders) The Third Axis: Regulating Brain Function

Superior -Executive Regulation and Supervision

Inferior -Executive Efficiency -Precision in Motor and Language Action Emotion and Behavior: Cortical-Subcortical Interactions

• Limbic system for emotion Prefrontal registration and awareness cortex • Right hemisphere and emotion processing, perception of facial affect, prosody, and mirror neurons • Orbital prefrontal for emotion regulation and theory of mind for empathy • Should cortical disorders be treated with cognitive behavior therapy, but Limbic subcortical disorders be system treated with behavioural therapy? Cerebellum The Three Axes Interpretation Left Hemisphere -Routinized/Detailed/Local -Convergent/Concordant -Crystallized Abilities Posterior -Sensory Input -Comprehension Anterior/Superior -Executive Regulation and Supervision Right Hemisphere -Motor Output -Novel/Global/Coarse -Divergent/Discordant -Fluid Abilities

Inferior -Executive Efficiency -Precision of action  Executive functions are essential for all academics and adaptive behavior! Differential Diagnosis of Childhood Psychopathologies: Hale’s Balance Theory Frontal-Subcortical Circuits and Psychopathology: Regions of Interest

DLPFC = Dorsolateral Prefrontal Cortex; OFC = Orbital Frontal Cortex; SMA = Supplementary Motor Area; FEF = frontal eye fields; ACG = Anterior Cingulate Gyrus; CB = Cerbellum; CC = Corpus Callosum; Basal Ganglia: CN = Caudate Nucleus; PU = Putamen; GP = Globus Pallidus (from Roth & Saykin, 2004) Balance Theory and Psychopathology (Hale et al., 2009)

Inattention/ Inattention/ Distractibility Fixation Brain Impulsive Repetitive Behavior Behavior Manager Hyperactivity Hypoactivity

Circuit Circuit Underactivity Overactivity

Regulation problem of cortical-subcortical circuits Rubia (2002) fMRI ADHD vs. Schizophrenia: Hypoactive and Hyperactive in Response

Significant differences in MR signal response between ADHD, Schizophrenia, and Controls . Yellow = increased MR signal in controls ; Blue = increased MR signal in schizophrenia.

Rubia (2002). The dynamic approach to neurodevelopmental psychiatric disorders: use of fMRI combined with neuropsychology to elucidate the dynamics of psychiatric disorders, exemplified in ADHD and schizophrenia . Behavioral Brain Research, 130, 47-56. Balance Theory and Internalizing Comorbidity

• If one circuit is dysfunctional, does the other provide compensatory balance? • Example: Anxiety comorbid with depression? What about anxiety with depression and poor response inhibition? • Decreased dorsolateral and increased amygdala in depression (Siegle et al., 2007) • Increased orbital frontal, amygdala, and anterior cingulate in GAD (McClure et al., 2007) So what IS ADHD? You’ll like Mr. Woolford, he has an Attention-Deficit Disorder.

The question is WHAT TYPE of attention-deficit disorder? Using Neuroimaging Techniques to Examine Psychopathology in Children Anxiety Disorder Neuroimaging Findings Anxiety Disorder Study Sample Characteristics Clinical Group Circuit Findings Krain et al., 2008 Generalized anxiety Increased frontal-limbic region activation that disorder/ social phobia reported higher intolerance of uncertainty and control groups McClure et al., 2007 Generalized anxiety Increased activation in ventral prefrontal, anterior disorder & control cingulate, and amygdala groups Monk et al., 2006 Generalized anxiety Increased activation in right ventrolateral prefrtonal disorder and control assocaited in response to angry faces and attention bias groups away, but reduced anxiety  compensatory response Obsessive Compulsive Disorder Study Sample Characteristics Clinical Group Circuit Findings Szeszesko et al., 2004 Children with OCD and Increased cingulate gray matter volume controls Viard et al., 2005 Adolescents with OCD & Abnormal activation in parietal, temporal & control group precuneus regions; hyperactivity in anterior cingulate & left parietal subregions Woolley et al, 2008 Adolescent males with Reduced activation in right orbitofrontal cortex, OCD & control group thalamus, cingulate & basal ganglia during response inhibition Yucel et al., 2007 Adolescents with OCD Hyperactivation of medial frontal cortex and controls compensatory for reduced dorsal anterior cingulated Nakao et al., 2005 Patients with OCD pre Hyperactivity in orbital frontal and cingulate and post-treatment reduced with SSRI medication treatment Rosenberg & Children with OCD and Increased ventral prefrontal Keshavan, 1998 controls Mood Disorder Neuroimaging Findings

Major Depressive Disorder

Study Sample Characteristics Clnical Group Circuit Findings

Forbes et al., 2006 Youth with MDD, anxiety Decreased amygdala and orbital frontal cortex in response to disorder, & control group reward, inconsistent with anxiety group Grimm et al., 2008 MDD (unmedicated) & Hypoactivity in left dorsolateral, hyperactivity in right control group dorsolateral prefrontal correlated with depression severity Steingard et al., 2002 Adolescents with MDD & Decreased white matter/increased gray matter in frontal lobe control group Wagner et al., 2005 MDD (unmedicated) & Hyperactivity in rostral anterior cingulate gyrus & left control group dorsolateral prefrontal cortex in during Interference phase Bipolar Disorder

Study Sample Characteristics Clinical Group Circuit Findings

Adler et al. 2005 Children with Bipolar Children with comorbid ADHD showed decreased Disorder with and without ventrolateral and cingulated activity. ADHD Blumberg et al., 2003 Adolescents with Bipolar Increased left putamen & thalamus; depressive symptoms Disorder & control group and ventral striatum positively correlated. Adler et al., 2005 Youth with BD + ADHD & BD Decreased activation of ventrolateral prefrontal cortex & groups anterior cingulated (BD + ADHD group). Chang et al., 2004 Youth with Bipolar Disorder Increased activation in anterior cingulated, left dorsolateral and controls prefrontal, right inferior, and right insula. Gruber et al. 2003 Bipolar Disorder and Increased dorsolateral and decreased cingulated. Controls Nelson et al., 2007 Adolescents with Bipolar Increased left dorsolateral prefrontal and premotor activity Disorder and controls interfere with flexibility. Rich et al., 2006 Adolescents with Bipolar Greater putamen, accumbens, amygdala, and ventral Disorder and controls prefrontal with emotional face processing. Effected Systems in ADHD: Cingulate and Superior Longitudinal Fasiculus White Matter Deficiency

Diffusion Tensor Imaging: ADHD < Controls in fractional anisotropy (white matter integrity) findings for anterior cingulate and superior longitudinal fasciculus, R more deficient than L Makris et al., (2008). Attention and Executive Systems Abnormalities in Adults with Childhood ADHD: A DT-MRI Study of Connections. Cerebral Cortex, 18, 1210-1220. Dickstein et al. (2006) Activation Likelihood Estimation (ALE) Meta-Analysis

• ADHD < controls in right dorsolateral, inferior frontal/orbital, cingulate, striatum, thalamus, and parietal regions • For response inhibition, inferior frontal/orbital, anterior cingulate, and precentral gyrus underactive in ADHD • Overactivation in several regions (left insula, occipital, middle frontal gyrus, right precentral gyrus) may reflect compensatory strategy to overcome underactive regions • ADHD is not just right frontal-striatal hypoactivity, but hyperactivity of compensatory regions as well • Result suggest balance of dysfunction and compensatory activity

Dickstein et al., (2006). The neural correlates of attention deficit hyperactivity disorder: An ALE meta-analysis. Journal of Child Psychology and Psychiatry, 47, 1051-1062. Are Oppositional Defiant Disorder/Conduct Disorder Findings Different from ADHD? • De Brito et al. (2009) – increased grey matter in conduct disorder in several areas (ratio of white-grey matter important?) • Sterzer et al. (2005) – hypoactivation in response to negative pictures in the dorsal anterior cingulate and left amygdala in CD • Rubia et al. (2008) – “Pure” ADHD had reduced ventrolateral and increased cerebellum in sustained attention, while “pure” CD showed decreased anterior cingulate, insula, and hippocampus; reward condition, they showed right orbital frontal hypoactivity • ADHD is ventral-lateral and cerebellar, while CD is orbital-paralimbic? Externalizing Disorders Neuroimaging Findings Attention-Deficit/Hyperactivity Disorder Study Sample Characteristics Clinical Group Circuit Findings

Booth et al., 2005 Children with ADHD & Decreased activation in inferior, middle, superior & control group medial fronto-striatal regions, caudate nucleus & globus pallidus Cao et al., 2008 Adolescent males & Decreased activation in frontal (middle & superior control group frontal gyrus), putamen, & inferior parietal lobe Durston et al., 2003 Children with ADHD and ADHD underactivated ventrolateral prefrontal, controls anterior cingulate, and caudate during response inhibition Pliszka et al., 2006 ADHD treatment naïve & ADHD treatment naïve less cingulate and left previously medicated ventrolateral activation during impulsive responding groups, & control group than controls Rubia et al., 2005 ADHD adolescents & ADHD less right inferior frontal activation during matched controls inhibition Scheres et al., 2007 ADHD adolescents and Reduced ventral striatum activity during reward matched controls anticipation Schultz et al., 2004 Male adolescents with Increased left & right ventrolateral inferior frontal ADHD & control group gyrus, left & right frontopolar regions of the middle frontal gyrus, right dorsolateral middle frontal gyrus, left anterior cingulate gyrus, & left medial frontal gyrus Tamm et al., 2004 Children with ADHD and Hypoactivation of anterior cingulated and controls hyperactivation temporal compensatory regions

Vaidya et al., 1998 Children with ADHD and Frontal activity possible compensation for striatal controls hypoactivity normalized with stimulant treatment Autism Neuroimaging Findings • Koshino et al. (2005) – autism use right parietal but controls use left parietal for verbal working memory task, and (2008) autism less left frontal and right temporal for face working memory, plus processing faces as objects, suggesting asocial face processing style • Luna et al. (2002) – autism showed lower dorsolateral and posterior cingulate functioning during spatial working memory task, suggesting poor executive control and communication across hemispheres rather than “pure” spatial deficit • Pierce et al. (2001) – autism face processing outside the fusiform region, including the primary occipital region and prefrontal cortex, suggesting they process faces as objects, or parts of objects, not as faces • Dapretto et al. (2005) – autism showed less activity in pars opercularis (mirror neurons area), important for imitation and empathy (theory of the mind) • Allen & Courchesne (2003) significantly more motor activation (neocerebellum) and less attention activation (vermis) in cerebellum Is Asperger Syndrome on the “Spectrum”?

• In 1944, Hans Asperger described “autistic psychopathy” cases with “normal” intelligence with peculiar social skills, pedantic speech, and preference for routinized activities • Myklebust (1975) – Social judgment and reciprocity impaired due to misperception of external cues and internal experiences • Denckla (1983) – Right hemisphere developmental learning disability: Affects cognition, academic and psychosocial functions • Rourke (1989) – Nonverbal learning disabilities due to white matter syndrome, poor visual-spatial- motor, and novel problem solving, both internalizing and externalizing psychopathology Is Asperger Syndrome on the “Spectrum”? • O’Neill (1999) describes Asperger’s as “little professors who can’t understand social cues”  don’t understand gist of social discourse • Klin et al. (1996) compared neuropsychological profiles and found Asperger > autism on verbal measures, reverse was true for nonverbal (visuospatial, visuomotor, and visual memory), concluding profile in Asperger’s was similar to NVLD and distinct from high functioning autism. • Volkmar et al. (2000) describe “Robert”, good reader but eccentric and clumsy, high anxiety levels, and poor social and adaptive functioning, found right hemisphere white matter lesion • Bryan & Hale (2001) – Discordant/Divergent processes affect nonverbal (spatial-holistic) and verbal (implicit language) functioning Specific Learning Disabilities and Psychopathology Psychopathology in Specific Learning Disabilities • Byron Rourke’s “nonverbal” SLD; right hemisphere dysfunction and the “White Matter Model” of psychopathology Prosody, implicit language, neglect of self and environment, limited recognition of faces/social cues, integration of complex stimuli poor Results in both internalizing and externalizing psychopathology (under socialized delinquency?), no distinction of anterior/posterior • Verbal/Left Hemisphere Dysfunction? Rourke says no, but early childhood internalizing problems and delinquents show LEFT hemisphere dysfunction (Moffit, 1993, Forrest, 2004) Could shift from internalizing to externalizing reflect environmental causes (e.g. socialized delinquency)? Differentiating Right Hemisphere Functions Right Posterior Region Right Anterior Region • Attention to Environment • Sustained Attention • Attention to Self (Body • Planning Awareness) • Strategizing • Spatial/Holistic Processing • Evaluating • Left Hand Sensory Feedback • Flexibility/Shifting • Object Recognition • Immediate Learning • Facial Perception • Working Memory • Affect Recognition • Memory Retrieval • Contextual Comprehension • Novel Problem Solving • Implicit Comprehension • Divergent Thought • Discordant Comprehension • Implicit Expression • Receptive Prosody • Expressive Prosody • Social Comprehension • Social Adaptability

ADHD-Inattentive Type? ADHD-Combined Type? Asperger Syndrome? SLD Psychopathology Study Participants Hain, Hale, & Glass-Kendorski (2010) • 155 children, age 6 to 16 (M = 10.86, SD = 2.80), with SLD by school district and Concordance-Discordance Model criteria • 42 excluded for not meeting processing asset and deficit (e.g., Hale et al., 2006) Results • WISC-IV, BASC-2 TRS, and achievement scores in average range with mild impairments, but heterogeneity masked significant profile differences • Average linkage within groups variant of the unweighted pair-group method arithmetic average (UPGMA) revealed six neurocognitive SLD subtypes: Visual/Spatial (V/S) (n = 14) Fluid Reasoning (FR) (n = 10) Crystallized/Language (C/L) (n = 15) Processing Speed (PS) (n = 30) Executive/Working Memory (E/WM) (n = 19) High Functioning/Inattentive (HF/I) (n = 25)

Preliminary Study of SLD Subtypes and Psychopathology • Participants and Methods • 124 students ages 6-11 • All underwent comprehensive evaluations in two Canadian school districts • Students were divided into three groups based on concordance-discordance methods (CDM) to determine significant patterns of processing strengths and weaknesses

• C-DM identified three specific subtype groups: Working Memory (n = 24), Processing Speed (n = 32), and No SLD Disability (n = 32) subtypes • Specific LD subtype domains were examined further, comparing subtype groups to specific cognitive, academic, and psychosocial domains CDM-Determined SLD WISC-IV Cognitive Results CDM-Determined LD Psychosocial Dimensions: Eternalizing Behaviors

No LD WMI PSI F P n = 15 n = 17 n = 18

Externalizing M 59.00 56.29 58.72 .25 .784 SD 14.27 11.13 11.50

Hyperactivity M 59.93 60.82 59.33 .05 .950 SD 15.36 14.01 12.21

Aggression M 60.93 54.59 58.50 .93 .401 SD 17.38 11.36 10.95

Conduct Problems M 54.27 52.06 56.67 .79 .460 SD 10.53 8.37 12.96 CDM–Determined SLD Psychosocial Dimensions: Internalizing Behaviors

No LD WMI PSI F P n = 15 n = 17 n = 18 Internalizing M 58.47 55.47 64.17 1.89 .162 SD 11.67 11.36 16.34 Anxiety M 55.87 57.18 59.44 .32 .730 SD 11.77 12.82 14.47 Depression M 61.80 59.71 69.17 1.59 .215 SD 14.61 14.26 19.63 Somatization M 52.27 69.17 55.17 2.07 .138 SD 10.93 19.63 16.33 Withdrawal M 57.13 57.18 68.61ab 4.98 .011 SD 12.29 11.06 13.43 Note. a Greater than No LD group; b Greater than WMI group CDM-Determined SLD Psychosocial Dimensions: Adaptive Skills

No LD WMI PSI F P n = 15 n = 17 n = 18 Overall Adaptive Skills M 43.67 41.53 36.22a 5.68 .006 SD 8.14 7.10 4.29 Adaptability M 45.20 45.24 37.89ab 2.58 .087 SD 12.73 11.26 8.90 Social Skills M 46.13 44.47 38.56a 3.94 .026 SD 9.90 8.52 6.34 Leadership M 45.93 42.63 40.89a 3.45 .040 SD 6.89 5.52 4.13 Functional Communication M 43.87 38.81 36.94a 3.68 .033 SD 7.14 6.38 8.54 Note. a Greater than No LD group; b Greater than WMI group Relevance of School Neuropsychological Assessment for Intervention Recognizing Brain Functioning in the Classroom

Brain Area Possible Effects of Left Possible Effects of Right Hemisphere Damage? Hemisphere Damage? Occipital Lobe Slow reading, poor spelling with Limited comprehension and letter substitutions, difficulty with writing when visual imagery visual discrimination of details required, object recognition limited Dorsal Stream Poor left/right orientation, sound- Poor handwriting and math from symbol association (i.e., alphabetic spatial deficits; poor awareness of principle), and letter reversals self and environment during social Ventral Stream Difficulty recognizing sight words, Difficulty with sight words and poor reading fluency; object perception of affect and faces* naming limited Lateral/Medial Can’t remember facts and words Limited understanding of Temporal Lobe due to difficulty with long-term context, metaphor, multiple memory, poor categorization word meanings, and humor* Superior Temporal Frequent requests for repetition, Poor perception of rate and Lobe poor word reading, poor auditory pitch or prosody, difficulty with and phonological processing complex sentence processing* Anterior Parietal Poor right hand grasping, writing Poor left hand grasping and limited Lobe too light or dark, complains after bimanual coordination skills writing that “hand hurts”

*BOLDED Items reflect processes that could lead to psychosocial concerns Recognizing Brain Functioning in the Classroom

Brain Area Possible Effects of Left Possible Effects of Right Hemisphere Damage Hemisphere Damage Occipital-temporal- Difficulty connecting sounds Poor math problem solving and parietal crossroads (phonemes) with symbols comprehension of implicit (graphemes); difficulty connecting language, complex language, and Wernicke’s numbers with quantity and math poetry, difficulty with new Area algorithms, limited comprehension learning and integrating of explicit language different types of information; poor understanding of humor Posterior Frontal Difficulty with dressing, drawing, Difficulty with learning new motor Lobe and handwriting; limited or no skills and sports requiring fine motor skill automaticity motor, difficulty with using both hand simultaneously Broca’s Area Halting speech with little output Poor verbal prosody and word and difficulty with articulation substitutions; verbose, but and syntax, even impulse control limited pragmatics Dorsolateral-Dorsal Poor encoding for storage, Poor retrieval from long term Cingulate limited decision making, rigid memory, sustained attention, and inflexible thinking, difficulty and novel problem solving; with concordant and convergent difficulty with thought discordant/divergent thought Orbital-Ventral Depressive symptoms and Disinhibition and indifference, Cingulate avoidance/withdrawal, excessive aggression and or conduct emotional control problems Comprehensive Evaluation for Disability Determination and Service Delivery

The Cognitive Hypothesis Testing Model

Theory 1. Presenting Problem 5. Cognitive Strengths/Weaknesses 9. Intervention Consultation Interpretation 13. Continue/Terminate/Modify Hypothesis

4. Interpret IQ or Demands Analysis 2.Intellectual/Cognitive Problem 8. Interpret Constructs/Compare 6. Choose Related Construct Test 12. Determine Intervention Efficacy Data Collection 10. Choose Plausible Intervention

3. Administer/Score Intelligence Test 7. Administer/Score Related Construct Test 11. Collect Objective Intervention Data

Source: Hale, J. B., & Fiorello, C. A. (2004). School Neuropsychology: A Practitioner’s Handbook. New York, NY: Guilford Press. Choosing Tier 3 Interventions for ADHD and Other Psychopathologies Affecting Attention • Determine whether a what problem (cortical-cognitive behaviour therapy? metacognitive strategies?), a when problem (basal ganglia-social skills? role playing?) or a how problem (cerebellar-behavioural intervention?) GOAL: Move from subcortical to cortical! • Medication likely for cortical and/or subcortical problems, consider agonist vs. antagonist issues and cortical hyperactivity/hypoactivity • Adaptive strategies (self-monitoring, metacognitive strategies, problem-solving, conflict resolution, social skills, planners, organizers, routines, response inhibition, flexible brainstorming, empathy instruction, working memory, computer games) • Importance of monitoring treatment response Instructional Strategies for Children with Psychopathology

– Keeping lesson objectives clear – Deliver the lesson at a brisk pace – Encourage collaboration among students – Use meaningful materials and manipulatives – Prompt student answers after five seconds of wait time – Vary the tone of your voice and model enthusiasm – Break up long assignments by "chunking" content – Encourage regular student responding – Reduce amount of work on assignments for good performance – Provide extended time on assignments and exams – Ensure success in responding, assignments, and exams

Barkley, 2006; DuPaul & Stoner, 2004; Majewicz-Hefley & Carlson, 2007; Toplak et. al., 2008; Barkley, Edwards, Laneri, Fletcher, & Metevia, 2001; Klingberg & Forssberg, 2002; Lonigan, Elbert, & Johnson, 1998 Executive Deficits: Metacognition and Learning Strategies “‘The individual's own awareness and consideration of his or her cognitive processes and strategies” (Flavell 1979)

• Learning strategies: Paired Associates, Rehearsal, Mnemonics, Visualization, Notetaking, Self-Talk, Brainstorming, Checking, Scaffolding, Outlining • Ask metacognitive questions during the day (thinking about your thinking!) • Give kids models to help them evaluate their work • Teach a problem-solving procedure • Give assignments that require evaluative skills • Demonstrate “thinking aloud” during lessons • Working memory training (e.g., CogMed)? • Attention training?

Barkley, 2006; DuPaul & Stoner, 2004; Majewicz-Hefley & Carlson, 2007; Toplak et. al., 2008; Barkley, Edwards, Laneri, Fletcher, & Metevia, 2001; Klingberg & Forssberg, 2002; Lonigan, Elbert, & Johnson, 1998 Working Memory Training and Improved Cognitive Functioning

Takeuchi et al., 2010 • N-Back task • Increased working memory performance • Changes in regions near intraparietal sulcus & anterior corpus callosum • Amount of training correlated with increased fractional anisotropy (changes in white matter) CogMed: Working Memory Training (Brehmer et al., 2011)

• Working Memory training and adults • Improved working memory performance with CogMed training • Decreased activity in frontal and parietal areas • Increased activity in subcortical regions (thalamas & caudate) • Suggests more efficient working memory and cortical-subcortical circuit functions Coping with ADHD Behavior Problems: Proactive or Reactive?  Scheduling  “On task” behaviors decrease during day, more academic instruction mornings and more non-academic afternoon activities  Productive Physical Movement  Allow opportunities for movement (e.g., office trip, sharpen pencil, stand at desk, assist with class duties, movement in assignments)  Choice Making  Provide student with menu of potential tasks to choose  Alter Environment  Provide control through preferential seating or teacher proximity  Task Duration  Brief assignments and immediate feedback, long assignments broken down into smaller parts  Prompt Appropriate Classroom Behavior  Visual, auditory, verbal, or physical cues  Specific Rules and Reminders Barkley, 2006; DuPaul & Stoner, 2004; Majewicz-Hefley & Carlson, 2007; Toplak et. al., 2008; Barkley, Edwards, Laneri, Fletcher, & Metevia, 2001; Klingberg & Forssberg, 2002; Lonigan, Elbert, & Johnson, 1998 Changes in Brain Functioning with Psychological and Medication Interventions

• Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder (Freyer et al. 2011; O’Neill et al., 2011) – Decreased activation in orbitofrontal cortex and right putamen – Metabolic changes in anterior cingulate and thalamus • Social Skills Therapy for Autism (Bolte et al., 2006) – Increased activation in parietal and occipital lobe – Suggests a compensatory mechanism for emotion recognition • Medication Treatment for Attention-Deficit/Hyperactivity Disorder (Pliszka et al. 2006; Hale et al., 2011) – Normalized cingulate functioning following medication treatment, even without medication – Only children with ADHD and executive dysfunction show stimulant response, best dose for cognitive functioning lower than best dose for behaviour Coping with ADHD Behavior Problems: Proactive or Reactive?  Differential Reinforcement  DRO – Other behavior  DRA – Alternative behavior  DRI – Incompatible behavior  Time Out  Time out from learning  extinction of negative attention  Duration is equivalent to student’s age  Do not remove student or allow other reinforcing activities  Token Economy/Contingency Contracting  Students earn tokens or points for meeting behavioral expectations and lose points for poor behavior  Points can be exchanged for privileges  Effective at home and school  Tokens- chips, class money, stickers  Self Management  Requires students to monitor and/or evaluate their own behavior over time  Teacher identifies target behaviors expected, provides scale with criteria for self- ratings, and teaches student to chart behavior Barkley, 2006; DuPaul & Stoner, 2004; Majewicz-Hefley & Carlson, 2007; Toplak et. al., 2008; Barkley, Edwards, Laneri, Fletcher, & Metevia, 2001; Klingberg & Forssberg, 2002; Lonigan, Elbert, & Johnson, 1998 Choosing Therapeutic Interventions Based on Neuropsychological Functioning Executive Problem (e.g., Cognitive Behavior Therapy, Learning Strategy Instruction)

Superior -Executive Regulation and Supervision

Inferior -Executive Efficiency -Precision in Motor and Language Action

Automatized Behaviors (e.g., operant conditioning, desensitization) Get Parents Involved! • Home based reinforcement program • Allows child to earn privileges at home based on positive school behaviour • Home-school report card - accomplished through notes between teacher and parent • Contingency contract specifies academic performance and classroom behavior expected and privileges that can be earned • Most effective if earned daily rather than weekly • Start with criteria that is easy to accomplish and slowly build to more challenging goals Conducting Executive Function Interventions Relevance of School Neuropsychological Assessment for Intervention: Hale et al. (2011) ADHD Study Executive Impairment Determines ADHD Medication Response: Implications for Academic Achievement James B. Hale, Linda Reddy, Margaret Semrud-Clikeman, Lisa A. Hain, James Whitaker, Jessica Morley, Kyle Lawrence, Alex Smith, and Nicole Jones

Abstract Methylphenidate (MPH) often ameliorates attention-deficit/hyperactivity disorder (ADHD) behavioral dysfunction according to indirect informant reports and rating scales. The standard of care behavioral MPH titration approach seldom includes direct neuropsychological or academic assessment data to determine treatment efficacy. Documenting “cool” executive-working memory (EWM) and “hot” self-regulation (SR) neuropsychological impairments could aid in differential diagnosis of ADHD subtypes and determining cognitive and academic MPH response. In this study, children aged 6 to 16 with ADHD inattentive type (IT; n = 19) and combined type (n = 33)/hyperactive-impulsive type (n = 4) (CT) participated in a double-blind placebo-controlled MPH trials with baseline and randomized placebo, low MPH dose, and high MPH dose conditions. EWM/SR measures and behavior ratings/classroom observations were rank ordered separately across conditions, with nonparametric randomization tests conducted to determine individual MPH response. Participants were subsequently grouped according to their level of cool EWM and hot SR circuit dysfunction. Robust cognitive and behavioral MPH response was achieved for children with significant baseline EWM/SR impairment, yet response was poor for those with adequate EWM/SR baseline performance. Even for strong MPH responders, the best dose for neuropsychological functioning was typically lower than the best dose for behavior. Findings offer one possible explanation for why long-term academic MPH treatment gains in ADHD have not been realized. Implications for academic achievement and medication titration practices for children with behaviorally diagnosed ADHD will be discussed.

© Hammill Institute on Disabilities 2010 http://journaloflearningdisabilities.sagepub.com Medication Treatment and ADHD

• Approximately 2,000,000 treated with stimulants • Medication effective in 70 to 90% • Medication wakes the “brain manager” (i.e., reduces frontal- striatal hypoactivity) • Dopamine agonists (e.g., stimulants) affect striatum • Norepinephrine agonists (e.g., Strattera) affect prefrontal cortex • Improves classroom behavior, performance, and interactions • Few serious side effects (appetite, sleep, irritability, and headache – not common and typically decrease) • Best dose for behavior may be higher than best dose for cognition • Behavioral diagnosis and titration limit treatment efficacy Double-Blind Placebo Protocol (Hoeppner et al. 1997; Hale et al. 1998; 2005; 2007, in press)

• Children diagnosed and referred by physician, diagnosis independently confirmed by psychologist • Weekly neuropsychological testing, parent and teacher behavior ratings, and classroom observation for 4 weeks • Baseline; then randomized placebo, low and high dose conditions • Child, parent, teacher, and graduate research assistant blind • Physician, psychologist, and pharmacist not blind (safety) • Data rank ordered across conditions • Nonparametric randomization tests determine separate cognitive and behavioral response • Results graphically depicted and reported to referring physicians for subsequent clinical decision-making Hale-Denckla Cancellation Task X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Trail-Making Test Part B “Blue” Stroop “Red” Color-Word Test “Green” “Blue” “Green” “Red” “Green” “Red” “Blue” “Red”“Blue” “Blue” “Green” “Red” “Green” “Red”“Blue” “Green” Drug Trial Example: Lisa • Lisa was a 6 year, 10 month-old friendly and outgoing girl who thrived on adult attention • Academic and social concerns in the first grade included: Inattentive, easily distracted, fidgety, and frequently off task Attentional difficulties during whole-group instruction and independent work Poor writing skills, including difficulties with grammar and illegible handwriting Noncompliant behavior with teacher Limited social skills and frequent conflicts with peers • Recurrent discussions and removal of privileges did not help • Comprehensive neuropsychological evaluation revealed cognitive, neuropsychological, academic and behavioral data consistent with ADHD • Following consultation with parents, pediatrician referred Lisa for double-blind placebo controlled trial of methylphenidate Neuropsychological Medication Trial Results for Lisa Baseline Placebo 5 mg MPH 10 mg MPH1 Auditory- Go-No Go 17 (4) 21 (3) 27 (1) 26 (2) Verbal/ Motor SRTM Word Storage 41 (3.5) 41 (3.5) 53 (1) 48 (2) Measures SRTM Consistent Retrieval 24(3) 21 (4) 43 (1) 36 (2) Stroop Color Word Correct 14 (4) 17 (1) 15 (3) 16 (2)

Stroop Errors 4 (3) 4 (3) 2 (1) 4 (3) 1Order = Baseline TOMAL Digits Backward 10 (4) 12 (3) 20 (1) 14 (2) 10mg MPH Placebo Visual- Hale-Denckla Cancellation Correct 13 (4) 18 (3) 26 (1.5) 26 (1.5) 5mg MPH Motor MeasuresHale-Denckla Cancellation Time 172 (2) 199 (4) 163 (1) 191 (3) Trails B Errors 6 (4) 3 (3) 1 (1) 2 (2) Trails B Time 534 (4) 56 (2) 44 (1) 60 (3) Conners’ CPT-II Omissions 65 (4) 62 (3) 55 (1) 60 (2) Conners’ CPT-II Commissions 60 (3) 64 (4) 43 (2) 34 (1) Conners’ CPT-II Reaction Time 41 (3) 47 (1) 54 (2) 63 (4) Conners’ CPT-II RT Block Change 57 (3) 61 (4) 44 (2) 41 (1) Conners’ CPT-II RT ISI Interval 57 (3) 69 (4) 51 (2) 42 (1) MEAN RANK 3.43 3.03 1.43 2.10 Behavioural Medication Trial Results for Lisa Baseline Placebo 5 mg MPH 10 mg MPH1 Parent CPRS-R:L Oppositional 60 (3.5) 52 (1) 56 (2) 60 (3.5) Ratings CPRS-R:L Cognitive Problems 89 (4) 81 (2) 72 (1) 87 (3) CPRS-R:L Hyperactivity Index 87 (4) 84 (3) 80 (2) 70 (1) CPRS-R:L DSM-IV Inattentive 90 (4) 80 (2) 74 (1) 84 (3) CPRS-R:L DSM-IV Hyperactive-Impulsive 83 (2) 90 (4) 89 (3) 75 (1) HSQ-R Mean Score 7.4 (3.5) 7.5 (3.5) 7.4 (2) 6.9 (1) SERS Parent 0 3 0 21 Teacher CTRS-R:L Oppositional 65 (3.5) 58 (1) 63 (2) 65 (3.5) Ratings CTRS-R:L Cognitive Problems 89 (3.5) 81 (2) 76 (1) 89 (3.5) CTRS-R:L Hyperactivity Index 77 (4) 74 (3) 71 (2) 70 (1) CTRS-R:L DSM-IV Inattentive 82 (4) 72 (2) 66 (1) 74 (3) CTRS-R:L DSM-IV Hyperactive-Impulsive 73 (2) 80 (4) 79 (3) 65 (1) SSQ-R Mean Severity 6.5 (4) 6.0 (2) 6.3 (3) 4.6 (1) APRS Learning 18 (2.5) 18 (2.5) 16 (4) 22 (1) APRS Impulse Control 15 (3) 15 (3) 15 (3) 18 (1) APRS Academic Performance 22 (2) 21 (3) 18 (4) 28 (1) SERS Teacher 7 11 12 18 Classroom RAT Off-Task 28 (2) 35 (4) 10 (1) 33 (3) Observations RAT Fidgeting 33 (3) 38 (4) 28 (2) 15 (1) RAT Plays with Objects 20 (3) 25 (4) 5 (1) 10 (2) RAT Vocalizes 13 (3.5) 10 (2) 13 (3.5) 3 (1) RAT Out of Seat 3 (2) 5 (3) 10 (4) 0 (1) MEAN RANK 3.19 2.76 2.26 1.79 Lisa’s Response to Stimulant Medication

4.0 Cognitive Response Behavioural Response 3.0

2.0 Mean Rank Mean 1.0

0.0 Baseline Placebo 5mg MPH 10mg MPH Note. Lower Ranks = Better Performance and Behavior; Order of Conditions = Baseline, 10mg MPH, Placebo, 5mg MPH Frontal-Subcortical Impairment and Diagnosis

14

Inattentive Type

12 Combined Type

10

8

6 # of Participants 4

2

0 None (+1 SD or more) Low (+.99 to 0) Moderate (0 to -.99) High (-1 SD or less) Medication Response for No Impairment Group 3.5

3.0

2.5

2.0

1.5 Mean Rank Mean

1.0 Cognitive Response (NS) Behavioural Response (B>P,L,H) .5

0 Baseline Placebo Low Dose High Dose Note. Lower Ranks = Better Performance and Behaviour Medication Response for Low Impairment Group 3.5

3.0

2.5

2.0

1.5 Mean Rank Mean

1.0 Cognitive Response (B,P>L,H; L>H) Behavioural Response (B>P,L,H; P,L>H) .5

0 Baseline Placebo Low Dose High Dose Note. Lower Ranks = Better Performance and Behaviour Medication Response for Moderate Impairment Group 3.5

3.0

2.5

2.0

1.5 Mean Rank Mean

1.0 Cognitive Response (B,P>L,H) Behavioural Response (B>P,L,H; P>L,H) .5

0 Baseline Placebo Low Dose High Dose Note. Lower Ranks = Better Performance and Behaviour Medication Response for High Impairment Group 3.5

3.0

2.5

2.0

1.5

1.0 Cognitive Response (B,P>L,H) Behavioural Response (B,P>L,H) .5

0 Baseline Placebo Low Dose High Dose Note. Lower Ranks = Better Performance and Behaviour Medication Response by Subtype and Impairment Group

No MPH Response 10 Cog or Beh MPH Response Cog and Beh MPH Response 8

6

4

2

0

Inattentive Combined Type Type ADHD ADHD Solution: Should We Put Ritalin in the Water Supply?

Question is not WHETHER medication should be used for ADHD, but rather WHOM do we use it for, HOW do we monitor it, and WHAT dose should we use (in conjunction with other interventions)… SNAP-FIT (Student Neuropsychological Assessment Profiles for Innovative Teaching) Kai Case Study Together, we can help all children learn and behave!

“Open exploration of multiple viewpoints breathes life into discipline; alternatively, ignoring or minimizing that discourse only suffocates it” (Hale, 2007) THANK YOU! QUESTIONS? COMMENTS?

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