Disturbi da Deficit di Attenzione e Iperattività · Deficit di Attenzione e Iperattività (ADHD )...

Intervento sui Disturbi da

Deficit di Attenzione e Iperattività

(ADHD )

Prof. Cesare Cornoldi

Lab.D.A.

Laboratorio sui Disturbi dell’Apprendimento

Galleria Berchet, 3 Padova

Direttore: Prof. Cesare Cornoldi

www.labda-spinoff.it 0498209059/3284366766

http://www.labda-spinoff.it/



NICE Guidelines Marzo 2009

• Criteri per la considerazione di un lavoro sul

trattamento:

• gruppi randomizzati e comparabili

• (lo studio MTA era tale per cui il gruppo di

controllo, per due terzi, aveva il farmaco e il

gruppo a trattamento psicologico no)





• Studies involving

• participants with a mean age of 8 or 9 looked

at the effects of work with both

• the child and the parents or family

(BLOOMQUIST1991; FEHLINGS1991;PFIFFNER1997;

TUTTY2003) or just the child (ANTSHEL2003;

GONZALEZ2002).





• The analysis conducted here therefore suggests that CBT interventions

• for ADHD can have beneficial effects whether delivered in the absence of medication

• or as an adjunct to continued routine medication for ADHD





• Four studies were found that demonstrated positive

effects of psychological interventions

• on core ADHD symptoms together with ratings of

conduct, social skills or self-efficacy (FEHLINGS1991;

LONG1993; PFIFFNER1997; TUTTY2003).

• The interventions studied were either mixed CBT/social

skills interventions delivered to groups (PFIFFNER1997;

TUTTY2003) or predominantly CBT interventions

(FEHLINGS1991; LONG1993).





• FEHLINGS1991 involved teaching children CBT techniques to improve

behaviour

• in home settings. Time was taken to teach problem-solving techniques,

which

• included identifying the problem, goal setting, generating problem-

solving strategies,

• choosing a solution and evaluating the outcome. Active learning

methods were used

• including modelling and role play. Homework assignments were set and

related to

• individual problem situations at home. Learning gains were reinforced

with reward

• strategies such as tokens and so on. As in TUTTY2003 and PFIFFNER1997,

separate

• parent sessions were also held. Parents received education about

ADHD and training

• in CBT techniques that they were then encouraged to use to reinforce

target behaviours

• in individual homework tasks given to each child participant





• According to the findings of the

• economic analysis, the group clinic-based programme

was the dominant option

• among the three parent-training/education programmes, as it provided the same

• health benefits (same clinical effectiveness) at the lowest

cost (total intervention

• cost per family was £629 for the group clinic-based programme, £899 for the group

• community-based programme, and £3,839 for the

individual home-based programme).





Parent training (NICE) • November 18, 2008

• NICE guidelines on ADHD

• Parental training and psychological interventions are at the heart of new National Institute for

Health and Clinical Excellence (NICE) guidelines on the diagnosis and management of ADHD,

published in September.

• Specifically, drug treatment is not recommended for pre-school children with suspected ADHD,

nor for older children and adolescents with moderate ADHD. Instead, the parents of children

and adolescents with ADHD should be offered a group training programme based on the

principles of Albert Bandura's social learning theory. There should also be the option of group

psychological treatment or social skills training for the child or young person, and the option of

individual psychological therapy should be considered for older adolescents.

• The new guidelines do recommend drug treatment as the first line intervention for children and

young people with severe ADHD and for adults with ADHD. However, such treatment should

always form part of a comprehensive care package that includes psychological and

educational components. In particular, adults who don't want a drug treatment should be able

to access psychological help instead.

• Other notable aspects to the new guidance include: a call for multidisciplinary specialist ADHD

teams and/or clinics to be established; a recommendation that teachers with necessary

training should provide behavioural interventions in the classroom; an unequivocal statement

that dietary fatty acids are not recommended; and a recommendation that GPs do not initiate

drug treatments for ADHD, although they may continue prescribing and monitoring such

treatment once started by a suitably qualified expert





Efficacia training cognitivi • ADHD Atten Deficit Hyperact Disord. 2012;4:11-23.

• NEUROCOGNITIVE TRAINING FOR CHILDREN WITH AND WITHOUT AD/HD.

• Johnstone SJ, Roodenrys S, Blackman R, et al.

• There is accumulating evidence that computerised cognitive training of inhibitory control

and/or working memory can lead to behavioural improvement in children with AD/HD. Using a randomised waitlist control design, the present study examined the effects of combined working memory and inhibitory control training, with and without passive attention monitoring via EEG, for children with and without AD/HD. One hundred and twenty-eight children (60 children with AD/HD, 68 without AD/HD) were randomly allocated to one of three training conditions (waitlist; working memory and inhibitory control with attention monitoring; working

memory and inhibitory control without attention monitoring) and completed with pre- and post-training assessments of overt behaviour (from 2 sources), trained and untrained cognitive task performance, and resting EEG activity. The two active training conditions completed 25 sessions of training at home over a 4-5-week period. Results showed significant improvements in overt behaviour for children with AD/HD in both training conditions compared to the waitlist condition as rated by a parent and other adult. Post-training improvements in the areas of

spatial working memory, ignoring distracting stimuli, and sustained attention were reported for children with AD/HD. Children without AD/HD showed behavioural improvements after training. The improvements for both groups were maintained over the 6-week period following training. The passive attention monitoring via EEG had a minor effect on training outcomes. Overall, the results suggest that combined WM/IC training can result in improved behavioural control for children with and without AD/HD …………………..





Cenni di TRATTAMENTO

Il trattamento ha senso solo se coinvolge i più

importanti contesti di vita del bambino. Quindi il

trattamento coinvolgerà:

• La famiglia (Parent training)

• La scuola

• Il bambino





• L’intervento può sperare di avere una certa

efficacia se:

• 1) coinvolge più fronti

• 2) si inserisce su un contesto motivazionale e

attribuzionale appropriato





Circolare 20.3.12

(dott. Cutolo) www.labda-spinoff.it 0498209059/3284366766




Possibili Mediatori per gli Interventi a scuola

(DuPaul & Power, 2000)

• Insegnanti

• Strategie di istruzioni; Rinforzo coi gettoni

• Genitori

• Tutoring ai genitori; Rinforzi a casa

• Pari

• Tutoring dei compagni della classe

• Computer

• Esercitazioni guidate

• Sè stesso

• Auto-monitoraggio; Auto-gestione





Interventi a Scuola per ADHD(cont.)

Manipolare le conseguenze (Reattiva)

• Rinforzo coi gettoni

• Rimproveri verbali

• Costo della risposta

• Time Out dai Rinforzi Positivi

• Auto-gestione





Esempi di Strategie

Mediate dall’Insegnante www.labda-spinoff.it 0498209059/3284366766




Tecniche di insegnamento per prevenire

problemi comportamentali Ricordare agli studenti le regole

Mantenere il contatto visivo con gli studenti

Ricordare agli studenti il comportamento atteso

Muoversi per la classe per monitorare/dare feedback

Usare indizi non verbali per reindirizzare

Mantenere un ritmo veloce di istruzioni

Assicurarsi dell’avvenuta comprensione dell’attività

Controllare che i momenti di passaggio avvengano in maniera ben organizzata

Comunicare le proprie aspettative rispetto all’uso del tempo in classe





Componenti di un programma di

comunicazione scuola-famiglia efficace

Obiettivi giornalieri/settimanali specificati in maniera positiva

Includere sia obiettivi accademici che comportamentali

Pochi obiettivi per volta

Dare un feedback quantitativo rispetto alla performance

Feedback forniti dagli studenti o dalle lezioni

Comunicazione su base regolare (sia giornaliera che settimanale)

Contingenze a casa legate alla performance (sia a breve che a lungo termine)





Esempi di Strategie mediate

dai Pari www.labda-spinoff.it 0498209059/3284366766




Classwide peer tutoring

Dividere la classe in coppie

Fornire schemi accademici

Tutoring a turni

Dare immediatamente feekback e correggere

errori

Monitorare i progressi e fornire punti bonus

Registrare i punti e delineare i progressi

Cambio settimanale delle coppie





Effetti del CWPT sull’ADHD

(DuPaul et al., 1998)

• 18 b. con ADHD & 10 studenti di controllo (dal 1° al 5° anno)

• CWPT aumenta l’iniziativa riducendo I comportamenti off task

• 50% degli ADHD miglioramenti scolastici

• Effetti positivi per i soggetti di controllo

• Alto livello di soddisfazione di studenti e insegnanti





Strategie di intervento sugli ADHD

• Le linee prevalenti di intervento sugli ADHD (v.

linee guida NICE, 2012) insistono sulla necessità

di associare agli interventi autoregolativi anche

interventi centrati sulle abilità sociali





Tra le tecniche di insegnamento con “mediazione

sociale” proposte coi bambini ADHD ritroviamo:

►

► Peer tutoring

► Peer collaboration

Cooperative

Learning

• Interdipendenza positiva

• Interazione diretta costruttiva

•Abilità sociali

•Responsabilità individuale

•Valutazione del lavoro di

gruppo.





Peer tutoring





Individuale vs gruppo

• Van Manen (2004) ha trovato che il lavoro di

CBT individuale è più efficace di quello di

gruppo nelle misure a breve termine, ma meno

nelle misure a lungo termine. Una spiegazione

potrebbe risiedere negli effetti immediati di un

rinforzo individuale e negli effetti più profondi

del rinforzo sociale

• P. Muratori e la sua equipe hanno raccolto

risultati nella stessa direzione





Disturbi da Deficit di Attenzione e Iperattività · Deficit di Attenzione e Iperattività (ADHD )...

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Transcript of Disturbi da Deficit di Attenzione e Iperattività · Deficit di Attenzione e Iperattività (ADHD )...