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From ABC to ADHDEric Tridas, MDAprilil 3 & 4A4, 2009The Hawai’i Branch of theInternational Dyslexia Association

The Developmental WebDevelopmental al EmotionalSocialSoca Interactionte act oHealthBehavioral &CognitiveMedicalEnvironmental

Developmental WebContributing Factorsto Clinical Presentation

Developmental ProfileVISUALPROCESSINGAUDITORYINPUTLONG NEUSSHORT TERMATTENTIONNCOGNITIVEETACTILE-KINESTHETIC

Visual Perceptual Problems KEDLIKETHIS! ORI FTH EWOR DSBE GINA NDEN DI NPLACESTH ATDON’NTM AKES ENSET OY OU? TAHW FI EHT SRETTEL EREW DESREVER, orOUT FO ODRER w re o n al paT oset aelv e g e.e ds m c er hhd t

Language Processing PhonologySemanticsMorphologyS tSyntaxDiscourseMetalinguisticsPragmatics

Tactile-kinesthetic Processing Impacts Fine Motor Function– Progresses in a proximal-distal fashion– Affected by: Sense of body position or movementVisual spatialpprocessingpgVerbal-motor integrationMotor planningMotor sequentialqmemoryyMonitoringToneCoordination

Memory Short Term Active working Long Term

Short Term Memory Holds information for a few seconds Limited storage capacity Depends on:– VolumeV l– Modality Visual,Vil AAuditory,ditTTactiletil - KinestheticKith ti– Attention

Working Memory Intermediate durationg an idea in mind while developing,p g Holdingelaborating, clarifying, using it––––Recalling answers while thinking of the questionComplex math problemsReading (summarizing/comparing while decodingS l ti colorSelectingl whilehil rememberingb i whath t you aredrawing

Working Memory Factors affecting it:– Attention– Rate– Volume– Automaticity of skill

Long Term Memory Unlimited storage capacity Long duration Retrieval affected by:– RelevancyR loff stimulusti l– Frequency of use– StrategySt tforf memorizationi ti (consolidation)(lid ti )

Output Oral– Casual– Benefits from tone, gestures, etc. Written– Very formal– Depends on fine motor / graphomotorfunction Motor sequences, pencil grip, spatialorganization

Fine Motor Function Progresses in a proximal-distal fashion Affected by:––––––––Sense of body position or movementVisual spatial processingVerbal motor integrationVerbal-motorMotor planningMotor sequential memoryMonitoringToneCoordination

Behavioral ENIAATTENTION

Medical FactorsCHRONIC HEALTHPROBLEMSASSOCIATED HEALTHPROBLEMSIATROGENIC HEALTHPROBLEMS

Environmental MPERAMENTPHYSICAL FACILITYCURRICULUM DEMANDSTEACHERShouse

Developmental WebManagement

Educational ManagementEducational TherapySpeech & Language TherapyOccupational lumeRateTechnologyComplexity

Psychological ManagementADULT FOCUSEDBehavioral TherapyCHILD FOCUSEDCognitive Therapy

Medical ManagementMEDICATIONSURGERY

Environmental ManagementHOMESCHOOL

DyslexiaEtiology

Phonological Processing

Phonology Phoneme:––––Building block of wordsS ll t unitSmallestit off speechhThere are 40 - 52 phonemes in the English languageAre put together to form words Words can be broken down into their elementalsounds allowing us to decipher words Deficits in phonology strongly correlate withreading problems

Phonologic System Processing and production of speechsounds Earliest language system to develop It is natural – does not have to be taught It is the foundation of language

Phonological Processing gicalMemory

Fluency The ability to read text– Quickly– Accurately– With good understanding The hallmark of a good reader Is the bridgeg between decodingg andcomprehension It is acquiredqword-by-wordy

Dyslexia Etiology Language problem specific to thePhonologic Module– Functional part of the brain where Sounds of language (phonemes) are puttogether to form words Words are broken down into their elementalsounds (phonemes) Discriminates words from noise– Learning to read is not a natural biologicalprocess

Dyslexia: NeurobiologyPhoneme ProcessingSSpeechVisual Word - FluencyTypical ReadersDyslexic Readers

TypicalypReaders:Elision versus RepetitionleftEden et al., 2004right

Dyslexia: NeurobiologyControlEden et al. Nature 1996Dyslexic

Reading: NeurobiologyPhonological processingPhoneme Processingcatkæt

Reading: NeurobiologyVisual - FluencyVisual Word - Fluencycat

Reading Disability(D x F) C ReadingD DecodinggF FluencypC ComprehensionM. Joshi; IDA National Conference November 2004

Reading on Meaning

Early IdentificationWhat to look for

Early Signs of Dyslexia By age of onset:–––––Delay in speakingDifficulty in pronunciationInsensitivity to rhymePoor word retrieval or word findingNaming the letters and their sounds

Early Signs of Dyslexia Infants and toddlers– Delay in speaking First word by 1 yearPhrases by 18 - 24 monthsParents may ascribe it to family history– Speech delay and dyslexia are familial

Early Signs of Dyslexia Preschool years– Difficulty in pronunciation No “baby talk” by 5 or 6 years of ageTypical problems:– What to listen for» Omission of initial sounds: lephant for elephant,chi-en for chicken» Inverting sounds: aminal for animal

Early Signs of Dyslexia Preschool years– Insensitivity to rhyme Unable to recite nursery rhymes– Children that remember nursery rhymes tend to begoodd readersd Unable to differentiate between similar anddifferent words– Can not focus on parts of the words» What rhymes with: food, talk

Early Signs of Dyslexia Poor word retrieval or word finding– Talking around a word (circumlocution)– Uses words like “stuff” or “things”

Early Signs of Dyslexia Naming the letters and their sounds– Before entering Kindergarten Knows the names of upper and lower case letters– Before entering 1st grade Knows the names and sounds of letters Alphabetic principle– Sequence of letters number and sequence of sounds MatchesM t h bbeginningi i soundsd off wordsd Pronounces beginning sounds of words Counts phonemes in small words

Early Signs of Dyslexia Typical development– 4 – 6 y/o aware that words come apart– 6 y/o 70% can count phonemes in small words Early signs of dyslexia– After 1 year of reading instruction (end of 1stgrade) can’tcan t separate sounds of spoken word

Common Signs of Dyslexia Problems with:– Phoneme segmentation– Phoneme deletion– Specific word retrieval (i(i.e.e tornado forvolcano, prostitute for prosecute)– Rapid word retrieval

History Screening: Infancy Single words by 1 yr Phrases by 2 yrs FamilyF il hihistorytoff llanguage orreading problemsY N

History Screening: PreschoolEnd of K – 4 Omission of soundsY N – Eliminates initial sounds(i.e., lephant for elephant) Inverts sounds( i l ffor animal)(aminali l) Insensitivity to rhyme– Can’t memorize nursery rhymes– Can’tC ’t ttellll if wordsd rhymeh Does not know lower case alphabet

History Screening: KindergartenBy the end of year CAN NOT: Name upper and lower casealphabet Name most letter sounds Match beginning sounds to words Pronounce beginning sounds ofwordsYN

History Screening:st1GradeBy the end of year CAN NOT: Can separate and / or countsounds in a word FindFi d ththe righti ht wordsdYN

Screening Test: End ofst1Grade Alphabetic principle– Names beginning letters of words– Names beginning sounds of words– Names ending letters of words– Names ending sounds of words– Can tell # of sounds in a wordPF

Screening Test: K.5 and Rhymingst1GradePF – Say a word that rhymes with Food Walk– Can recite a rhyme

History Screening: Infancy Single words by 1 yr Phrases by 2 yrs FamilyF il hihistorytoff llanguage orreading problemsY N

History Screening: PreschoolEnd of K – 4YN Omission of sounds – EliEliminatesi t initiali iti l soundsd(i.e., -lephant for elephant, chi-en for chicken) Inverts sounds(aminal for animal) Insensitivity to rhyme– Can’t tell if words rhyme Does not know lower case alphabet

History Screening: KindergartenBy the end of year CAN NOT: Name upper and lower casealphabet Name most letter sounds Match beginning sounds to words Pronounce beginning sounds ofwordsYN

History Screening:st1GradeBy the end of year CAN NOT: Can separate and / or countsounds in a word FindFi d ththe righti ht wordsdYN

Screening Test: End ofst1Grade Alphabetic principle– Reads the words accurately– Names beginning letters of words– Names beginning sounds of words– Names ending letters of words– Names ending sounds of words– Can tell # of sounds in a wordPF

Screening Test: K.5 and Rhymingst1GradePF – Say a word that rhymes with Food Walk

InterventionWhat to do about it.

Research Based Reading Instruction Essential Components– Phonemic awareness Recognize,gremember and manipulatepindividual sounds– Phonics and word recognition Sound – symbol relationship, word meaning– Reading Fluency Read with sufficient speed an accuracy to supportcomprehension– Vocabulary development Individual word meanings– Reading comprehension Verbal reasoning, background knowledge, comprehensiongstrategies

Reading Instruction Other components– Basic writing skills Compose English with accuracy, fluency andclarity of expression– Comprehending and using language The ability to listen and understand themeaningi off whath t someone isi sayingi

Effective Reading Instruction Explicit– Clearly and directly explained not left to discovery Systematic– The speech sounds, spelling patterns, sentence structures, textgenre and language conventions Cumulative– ContinualC til reviewione skillkill bbuildsild on anotherth Multisensory Sequential and Incremental– ManageableMbl stepst Data driven– Emphasis, speed of instruction and support are determined bystudent'sstudents progress

Dyslexia: Management Critical to start before 3rd grade It is almost impossible to remediateafter 4th grade

Earlyl Interventioni IS Urgent 10TH %ile 5th Grade reader 50,000 words/year 50TH %ile 5th grade reader 600,000 words/year Average students receiveapproximately 10 TIMES asmuchh practiceti ini a yearAnderson, Wilson & Fielding 1998

ain activationprofile becomesnormal followingsuccessful remedialtrainingSimos, Fletcher, et al. Neurology,2002Post-testing

What About Attention?ADHD:What it is and what is not!

ADHD: Historical TimelineHyperkineticHki ti RReactiontiof Childhood (DSM-II)Attention Deficit HyperactivityDisorder (DSM-III-R)Minimal Brain Damage1902193019601968198019871994Minimal Brain DysfunctionyADHD-like syndromefirst describedAttention Deficit Disorder or Hyperactivity (DSM-III)Attention Deficit/Hyperactivity Disorder (DSM(DSM-IV)

DiagnosticgCriteria for ADHD:DSM-IV Persistent symptoms of inattention and/or impulsivity andhyperactivity Onset of symptoms before age 7 Impairmentpin 2 or more settingsg ((eg,g, school,, work,, home)) Evidence of clinically significant impairment in social,academic,, or occupationalpfunctioningg Symptoms not a result of other disordersDiagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision.Washington, DC: American Psychiatric Association; 2000.

DSM-IV DiagnosticgCriteriaSymptoms for ADHD Inattention ( 6)– IIs carelessl– Has difficultysustainingg attentionin activity– Does not listen– Does not followthrough with tasks– Is disorganized–AAvoids/dislikesid /di lik ttaskskrequiring sustainedmental effort– Loses important items– Is easilyy distracted– Is forgetful in dailyactivitiesDiagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision.Washington, DC: American Psychiatric Association; 2000.

DSM-IV DiagnosticgCriteriaSymptoms for ADHD (cont’d) Hyperactivity ( 6)–––––Squirms and fidgetsCannot stay seatedRuns/climbs excessivelyCannot play/work quietlyIs on the go/drivenby a motor– Talks excessively Impulsivity— Blurts out answers— Cannot wait turn— Intrudes/interrupts othersDiagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision.Washington, DC: American Psychiatric Association; 2000.