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Multimodal Intervention 6/28/2020 ADHD 360 Optimizing & Supporting the ADHD Brain Success with ADHD Learning Series #3 Dr. Caroline Buzanko [email protected] drcarolinebuzanko.com 1 Overview • Multimodal intervention • Executive functions • Considerations • Environmental interventions • Personal Interventions • Optimizing Efs • Teen Considerations • Medication overview 2 Multimodal Intervention Behaviour Management Psychological Support Education (individual/ family) Accommodations Effective Medical & Environmental Management Manipulation Intervention 3 3 1 6/28/2020 Play! Imagination crucial for problem-solving, loving life, and excelling 4 4 Instructional Goal-setting Peer tutoring Self- strategies Contingency monitoring contracting Token system Reinforcement Parent tutoring 5 Designing Interventions: Considerations • Individualized • Assessment data • Look at problem in context • Creativity • Doable • Ongoing evaluation • Collaboration • Multidisciplinary • Multimodal • Maintained • Research 6 2 6/28/2020 ADHD: A Disorder of Executive Functions 7 7 Executive Functions (EF) •Consider now with future anticipation and past experience to develop a plan to choose what to do next 8 EF: Review • High-level cognitive functions • Help us to decide what tasks we will pay attention to and which ones we will choose to do • Help us to: • Plan and organize tasks • Sustain attention/mental effort • Persist at a task • Manage emotions and thoughts • Regulate our behaviour • Maintenance 9 3 6/28/2020 Planning Meta- Organization cognition EF Achieve Goals Working Time Mgmt Memory 10 EF Cont’d… Response Inhibition Self- Persistence regulation Behaviour Guide Task Flexibility Initiation 11 Know ADHD… & EF impairments… how it affects kids & reasonable expectations 12 12 4 6/28/2020 Remember: EF do not fully develop until adulthood Developmental progression is external to internal 13 13 Considerations Developmental Transitions External Mental Others Self Temporal Now Anticipated Future Immediate Delayed Gratification 14 Intervention Recommendations • Prompts of critical reminders at the point of Externalize Working performance Memory Externalize Time and • Break future projects and goals into small pieces • Make time physical Future • Increase accountability to others • Identify tasks where feedback is too delayed Externalize Motivation • Work collaboratively with child and parents at every stage • Make tasks more interesting, incentives more rewarding • “Physicalize” tasks that require mental problem Make Problem-Solving solving Manual 15 5 6/28/2020 • EF • In early development, imperfect and inconsistent • “Surrogates” Remember! • Direct • Structure • Long-term treatment • Secondary by-products • Effective treatments within NATURAL environment: “point of performance” 16 Spoon Theory: EF Resources 17 Reserve and replenish their resources as much as possible! 18 6 6/28/2020 Interventions: Level of Environment Create EF Friendly Environment! 19 When things are going good = conditions are met to support EF 20 Environment: o Kids with EF deficits do not do well in sedentary conditions o Participatory teaching methods o Active learning style 21 21 7 6/28/2020 EF-friendly teaching practices Fun and engaging Teach multiple modalities Student choice for task medium (e.g., skits, aural, graphic) Structured teaching (especially of strategies) Active and interactive learning (high response opportunities) Make learning relevant to real life Multisensory 22 22 Good Not so good • Engaging (interests) • Boring • Immediate consequences • Delayed consequences • Frequent feedback • Infrequent feedback • Personally important • Low importance • Early • Late in the day • Supervised • Unsupervised • 1:1 • Group situations • Structured • Unstructured • Clear expectations • Uncertainty • Close to needed materials • Need to search for materials • Quiet/low arousal • Loud/high arousal 23 Create the right conditions for success o Optimize timing of tasks o Optimize tasks • Make them engaging • Shorter, explicit, closed ended, provide choice • Scoring rubrics • Match capacity • More structured social activities 24 8 6/28/2020 Environment o Change the physical environment o Remove (e.g., reduce number of children, distractions) o Add (e.g., increase supervision, organizing structures) o Match expectations to skills 25 Environment Structure the environment to promote learning (and reduce off-task or disruptive behaviour) o Placement of chairs/desks o Clarity of visuals o Minimal visual clutter o Good lighting o Handouts vs. board o How long is a task o Time of day o Size of groups o What else is happening in the environment o Water and snacks available 26 Environment o Provide cues for them to cue themselves (e.g., visual, verbal) o Think about prerequisites • Working memory – still need to externalize • Self-monitoring 27 9 6/28/2020 Individualizing the Environment • Dry-erase board • Repeat backs • Bubble stickers • Recordings • Play-doh • Videos • Teach within activity • Music level • Exercise • Modify Tactile- Visual learner Auditory learner Kinesthetic learner 28 28 Important to match expectations to what they can do 29 29 Environment • Focus on automatization of skill to increase internal control • Consistent, structured learning opportunities with consistent practice (e.g., role-play two- sided cue card) • Avoid verbal dependency (i.e., reminders) 30 30 10 6/28/2020 Environment • Must have buy-in: LOADS of reinforcement immediately - start small so reinforcement can be accessed fast 31 31 OtherBe flexible. ideas Kids for help an EF-friendly environment Don’t remove Find acceptable ways create niche extracurricular as for children to stand environment and punishment and move accommodations Periods of Frequent breaks. concentration are Maximize controlled Novelty. Allow choices followed by periods of movement creativity or movement Green Break Remove temptations More structure 32 32 Never take away recess. Give more! Movement increases blood flow to the brain. Improves performance, creativity, attention, and focus. 33 3 3 33 11 6/28/2020 Be Explicit!!!!!!!!!!!! (Don’t assume anything) 34 The Role of Emotions 35 35 Brain in high stress state = amygdala kicks in and becomes a stop sign for information 36 12 6/28/2020 Intense emotions Impulsivity Rigidity No self-reflection Unable to take perspectives 37 37 . Can’t learn . Can’t remember . Brain seeks pleasure (stop trying/putting in effort) . Reactive response (fight/flight/freeze) 38 • Boring • No personal relevance • Previous failure • Perception of falling behind • Too easy • Perceive too difficult • Takes too long • Anxious • Fear • Social rejection/acceptance • Not wanting to disappoint • Grades • Parents 39 39 13 6/28/2020 Risk-taking Essential for learning 40 • Have to process not just the answer, but also the question – twice the processing effort • What book are we reading today? • Who wrote it? Pace? • Laugh = consequence What could we do to help create success? 41 41 Avoid overload • Still need to learn how to handle it, but try to predict overload • When overloaded • Less able to handle information that can otherwise understand when calm • Lose behavioural control – more repetitive, anxious, impulsive, inattentive 42 42 14 6/28/2020 Avoid overload • Do best with one predictable detail at a time • Make things as predictable as possible (while working on flexibility) • Choices • Fixed routines • Preview new situations • Structure nonroutine or chaotic situations with a specific plan, job, or rules • Predict potential problems • Regular breaks and downtimes + as needed • Teach new skills in small groups 43 43 Start the day off right Begin day with relaxation and focusing exercise 44 • Increase accountability to others Intervention • Reduce delay in Recommendations: feedback Externalize Motivation • Work collaboratively • Make tasks more interesting, incentives more rewarding 45 15 6/28/2020 Motivate Developmentally Appropriate Immediate Specific Value Effort Increase appreciation 46 Subjects 1 2 3 4 5 6 7 Motivation Participation Completes Suggestions classwork • Increase praise, approval, Follows rules appreciation Completes • Token boards to organize homework consequences Helps a peer • Group rewards • Daily report card Teacher initials 47 1-mminute manager – frequent check-in’s Increase praise, approval, appreciation Token boards to organize consequences Motivation Tone-tape with self-rewards Suggestions Daily report card ***Offer lot’s of support! - CPS – problem solve together 48 16 6/28/2020 Important! Kids with ADHD release dopamine at low rates = unable to apply themselves to tasks that are not intrinsically interesting Work cut short without When incentive is low, they immediate rewards are unable to switch off the Forget rules in the moment part of the brain involved in mind wandering Caught up in predominant emotion 49 Important! Kids with ADHD release dopamine at low rates = BUT, when unable to apply motivation is high, themselves to brain activity is the tasks that are not intrinsically same as all other kids interesting 50 50 Task Incentive 51 17 6/28/2020 Therefore, when teaching something new or wanting them to follow your request, INCENTIVES (or buy-in) are needed 52 Incentive Task 53 PASS THE BALL – student with ball tosses ball to another student who is the next one to answer a You’re only question from the teacher limited by your own creativity! TEAM PLAY – Make an academic activity a friendly competition 54 54 18 6/28/2020 Teach + MOTIVATE – this is key!!!!!!! 1. Positive attitude 2. Statements
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