 But it's not supposed to take anything away from our seminar presentation today. Wendy, we usually record this for broader impacts and publications so that those who can't be with us this morning can also get the benefit of the wisdom that we share. So I'm very delighted to introduce Wendy Altonurando, who is the program director for the CHOC UCI, that's the Children's Hospital of Orange County National Children's UCI, initiative for the development of attention and readiness. We, in our classes, cite statistics all the time about how ADD is going up in the population, I don't really know what. But we're very lucky that some people are at least trying to do something about it. So we'll hear from Wendy today what they see with us. We are queada. Queada has been doing, in our community, to address this problem. So please help join me in welcoming Wendy. Good afternoon. I thank you so much for the invitation from the School of Public Health. As was mentioned, my name is Wendy Altonurando. I'm the program manager with FIDAR. And FIDAR is the CHOC UCI Irvine Initiative for the Development of Attention and Readiness. We will definitely get into what all of that means. But today I'm here to speak with you all about ADHD and how we've actually converted somewhat of a community health model. So essentially using a public health model to deal with mental health concerns. I know usually when you think about public health, you don't really think about mental health. So we're going to take a look at that. And also we'll save some questions, fresh and answer them before. After this presentation. So just a brief overview of ADHD. The prevalence rates normally for school-age population is between 3 and 8%. And we primarily work with preschool-age children. So in the typical classroom of 20 children, you'll find that one of those kids has ADHD. Although all of them may look like they have ADHD. And we'll talk about the symptoms in a little bit. But again, I think all of us have always said, oh, he has ADHD or this person has ADHD because they move around a lot or they can't sit still or they blur out. But again, the real problem isn't necessarily the symptom. It's more so the impairment. And it's definitely present more often in boys sending girls. You typically have a 3 to 1 ratio. So 75% of the cases will be males. And also 75% of these children will retain the symptoms into adolescence and then into adulthood. So for the DSM, which I think many of you know, there's a DSM-5 coming out. So some of the criteria for diagnosing ADHD will change in DSM-5 into 2012. But for now DSM-4, in order to be diagnosed with ADHD, would have to have 6 out of 9 symptoms present either in the inattention subcategory or in the hyperactivity-impulsivity category. And symptoms are typically present before the age of 7. And our program, because we primarily focus on preschool age children, that's essentially the public health law, prevention and early intervention. So trying to catch these children at an earlier age so we can get them to be appropriate. So the impairment from symptoms are usually present in two settings. Typically you'll find this for a preschool age child at school, at home, towards the babysitter. We definitely want to be able to see that the impairment isn't necessarily just at home, that we don't just have the parent's point of view, but that we also have the teacher's point of view, the daycare worker's point of view to make sure that in every single study they're presenting the exact same symptoms. And we're going to further about what our program does to try and figure out if we give this child the appropriate guidance. So arm the parents with parenting strategies and give the children the type of social skills that they need to more appropriately behave in a typical classroom setting then we'll know that they're capable of actually sitting still in every situation non-decentral. So here are some examples of ADHD symptoms for inattention. And again, this does not include all of them, it's just a little bit of a taster. So often does not pay close attention to details or makes careless mistakes, has trouble paying attention to tasks or play activities, often does not seem to listen and spoken to directly, often does not follow through on instructions. And again, that often is a key word because in order to be diagnosed you would have to have these symptoms for at least a period of six months. And typically this is done because let's say for example if you have a child who just recently, two weeks ago, started running them up, starts running around like crazy and nobody can make them sit still. Then those type of factors you'll have to see, did something happen in the home? Was someone living there who maybe moved out? Was grandma living there and now she's not there anymore? Children have a very unique way of presenting different feelings whether it be depression, anger. So some of those will present themselves into these type of symptoms and that's why we have to make sure that they may occur for at least a period of six months. Activity, again I think this one's pretty self-explanatory, often fidgets with hands and feet, squirms in their seat when sitting is expected. So typical classroom behavior, we expect them to be seated, paying attention, if they're not doing that then we'll take notice for further action. Often gets up from seat when remaining in seat is expected. Again for impulsivity, often blurts out answers before questions are finished, often has trouble waiting their turn and often interrupts or intrudes others. So again these symptoms you may be able to say well every preschool child does this at one point or another but again what we're looking at is the often portion of it. How often have they done it in the past six months? Has it been recurring often? That's when you're going to the need for an evaluation. So this is a very very very old slide but I figured why reinvent perfection, right? So this was originally made when our program first started. So we started our program in 2001 and the reason it started was that one of the problems Dr. Jim Swanson saw and Jim Swanson I'm not sure, I heard everybody knows Mary and Mary works for NCS, National Children's Study. So Dr. Jim Swanson is a principal investigator at the National Children's Study and he was also our director. So he had this vision, he figured there was a very long wait list for children to be evaluated by their primary care physician. Children who had ADHD and let's say for example if you went to go visit, I don't know if anybody knows Dr. Lerner but he's a developmental behavioral pediatrician at UC Irvine. So that's his basic vision. He was our first pediatrician who was with the Kredaard Clinic. So there was a long wait list and again most pediatricians are not equipped to make an ADHD diagnosis because it's behavioral, it's not clinical. Although now there are different studies that have presented which will lead us to more of a clinical diagnosis. So at that time really the only option was to provide medication if a child was diagnosed and some children will respond just fine while others it may not be so helpful. So typically what happens in that situation is the parents are sent to a parenting class and the children in addition to medication will also be sent to a social skills group to continue with the other one. So Kredaard's solution was to provide service before diagnosis. Also at that time there were a lot of false positives. A lot of children over-medicated, children who were maybe misdiagnosed and then of course a lot of over-diagnosis maybe ADHD. So at that time they figured why not provide the, back to the public health model, the prevention and early intervention before sending these children off for a diagnosis. So in this top picture that's our parenting classes that we provide all over Orange County and in that bottom picture we have children in social skills groups. So we figured provide the intervention if the parent's parenting classes so that they're better able to manage their child's behavior and then also provide the children with a structured setting where we're able to define whether or not they do have a tension or behavior problem. How has the medication changed since 2001? That is, what's the limitation of the medication in part of the rationale for looking at it? Well, there's a lot of evolution in the medication that you have of longer medication that lasts for 16 hours instead of just eight. So that may have been the problem but in reality behavioral intervention is still a huge option because a lot of parents don't want to medicate their children. They don't want to give them that label. They prefer to provide them with other solutions instead of putting that. So by doing so we would attempt to shorten the waiting list at the doctor's office instead of a six month waiting list a child can go in to see their pediatrician at any point in time but again for the evaluation for ADHD we're aiming at the possibility that that wouldn't be necessary for most of the children coming through the program. So originally we had intended for 20% of the children who came through our program to still need an evaluation and now we find that only about 7% go on to further evaluation. So again that decrease that we expected to happen from misdiagnosis or overdiagnosis of ADHD we assume has been short to the use of our program. So providing the parents with more options they can either go with medication or they can go with behavioral intervention again providing parents with parenting strategies and then also providing the children with social skills. So here we go. To give you the QR method. So that was the vision and then now we have a grant from the Children of Families Commission of Orange County so that's Prop 10. Anybody who smokes, thank you very much. They provide 50 cents of every cigarette packet to the first five of California and first five then distributes to each county depending on the birth rate. So thankfully for Orange County we've still got a lot of births coming in so back in maybe around 2000 people were asked to submit requests for proposals for any type of program that would help children between needs of zero and five. So the RFP for our program was submitted and accepted and we were granted funding and it still continues to this day. So again the primary purpose is service before diagnosis and again prevention early intervention really using the public health model of getting into the community trying to decrease all barriers to access barriers to transportation and barriers to language primarily. The QR name means to care for in Spanish and again Dr. Swanson when we originally dreamt of the vision of QR and service before diagnosis model he figured that mental health resources would be underutilized in the Hispanic community and in Orange County at the time there was a huge growth and I think there's still a lot of presence of the Hispanic population so he figured why not make the name a Spanish name make it more inviting and again removing the stigma from mental health because now we're using a public health model which is readily available in the community so currently we travel to any site in Orange County that has a space available for parenting classes as far up north as the Habra and Brea as far down south as San Juan Capistrano we travel everywhere we go and the requirements are fairly simple a family simply needs to have an Orange County address and the child they must have a child and the child must be between the ages of birth and five so no income requirements no other requirements necessary Is there a reason that you do not have or do you have free parenting classes like for pregnant women or like to prep for that early early age development is that a part of it or did you just try to do zero to five? Well originally the RFP was specifically for zero to five and we started off with only parenting classes for parents of preschoolers ages three to five but we've now actually grown quite a bit so for example our first class right from the start which is for parents of children ages birth through one we do have a lot of parenting moms and in fact we provide services to teen moms who are pregnant and have children so we don't really deny services to someone who is pregnant is there in the area that has the availability and capacity to attend the class the more they'll want to participate so our three core services are parenting classes, children's social skills groups and teacher trainings are all done in the community so the parenting classes as I mentioned we started off with the preschoolers because of the ADHD issue and then we sort of moved on to becoming a parenting program so we started off with COPE which is that third bullet down that line community parent education and that's specifically for parents of children ages three to five then we followed up with COPE with toddler so we actually went up the ladder there for parents of children ages one to three and those parenting classes primarily cover the social and emotional developments of toddlers then right from the start which covers parenting for parents of children ages birth through one that is primarily focusing on the bond that a parent would have with their child so in reverse order and I'll talk about COPE right now in a minute but that was our core service the COPE parenting program and that actually came from McMaster University up in Canada Dr. Chuck Cunningham and the model that he used again very representative of something that you would need in public health where there's very little resistance you provide the parents in a group setting so every we'll have about five to six tables, round tables designed for discussion format and each table will have maybe about six parents so we'll show the videos of parents making parenting errors and then we turn it back to the class so we're just facilitating we're not teaching and we ask the class what would you do differently in this situation or what advice can you offer the parent again removing all the resistance that one would have if as a teacher I were to say this is what you have to do in order for your child to behave removing that and making the parent the expert so we want them to participate and through that course of participation there's also that aha moment of I should be doing this too it's not necessarily just what I'm saying here I should actually be practicing that at home so they do have homework that they take home practice with your child during the week and we'll talk about the topics in a bit but again the format itself is really what lends to the public health model of being in the community and participating as your very own little community in each classroom so again when I speak of the topics later on in the class I'll be speaking of the COPE model but the COPE model well the COPE you would tell their behavior and write from the start really a spin-off of COPE because they use the exact same model to bring parents together and identify different ways in which they can deal with their child's behavior but again all based on the facilitator guiding them to the topics that we've already another course service is the Children's Social Skills Group for preschoolers again this is only for the COPE past participants and in this class we have a very structured format about 5 social skills providers and a maximum of 18 children so we want to give the children as much opportunity as possible to really take away the social skills that are being taught in the class so again the classes meet for a period of 10 weeks one time per week for 2 hours so a total of 20 hours of instruction time and for the kids everything is based on a reinforcement system so we want the child who may have attention problems may have behavior problems they don't necessarily have to be diagnosed with ADHD we want them to feel great when they come to the class even if a child who is fidgety sits still for 1 second we're there to praise so good job for sitting still if you get a point so typically the children have a little cup with their picture on it and every time they do something sitting still using their calm body saying please and thank you they will get a point into their cup and at the end of the night every child will get at least one point so then they get to trade them in for snacks and every child gets that reward we also provide trainings for teachers and providers anybody who is working with children ages 0 and 5 and again this is done all throughout the county one of the things that we encounter especially with preschool teachers is that you have so many regulations coming in from the federal government from the state a child has to know 15 letters they have to know all of their colors so when it comes to behavior that usually gets pushed into the back burner so we try to give the teachers as many tools as possible so that they can appropriately deal and manage those behaviors in the classroom because sometimes that's not really something they have time for for the coat background again community parent education non-digactic group models and again it's a very participatory but if a parent decides that today is not the day to talk we don't force anybody to speak it's a group format and every group has their leader which before that night will take notes in a larger classroom again it reduces parental resistance we really want the parents to feel like they're in charge so that when they go home they're able to practice those strategies because they feel confident in themselves the telling class offered in the community again to reduce those barriers to access as well as barriers to transportation barriers to language and 15 to 20 families per group which we are average because it's a 10 week session it requires some commitment and so far we've operated in two languages English and Spanish and we did try to make it available in Vietnamese but when we met with community leaders they figured that the model of empowering parents wouldn't really be the best fit for them so again this is trial and error and actually provide parenting classes for older kids which is apparently something that in their culture they prefer to have when the child is acting out they didn't think that it was a problem it's more so when they turn into teenagers and they start talking back that they wanted some strategies to deal with that sorry could you point it on the Vietnamese cultural attribute of modern art experience I don't want to give them any questions but they want to be empowered well I guess it's more so based on authority they want the teacher to be the authority figure so they don't want to have they don't want to be vocal or classroom they just want the full classroom instruction and they'll take notes as opposed to our model which is really requiring a lot of participation from parents cultural topics very very basic parenting skills praise and positive attention plan ignoring especially when you have tantrums again we discuss ignoring the behavior not the child the minute the child stops their tantruming then the parent is back at the site of the child transitional warnings that's usually parent's favorite in five minutes it's going to be time to think of your toys or the when then statement when you're not picking up your toys then you can go outside planning ahead for children who have attention or behavior problems really the best thing to do is to keep structure with them and planning ahead does a good job of that because you're reiterating once and twice and three times over again what it is that you're going to do next so planning planning planning letting them know this afternoon we're going to go to the grocery store and you know you said you were going to help me out writing a list and then on throughout the day continue to do that token economies again goes back to the rewards chart there can be any type of system where you provide the child with points for tokens or something just to to keep them motivated time out and as we'll see with the data a lot of parents come in saying oh I use time out all the time that doesn't necessarily mean that it's effective it just means that they use it a lot so some parents come in thinking that they're using time out you know might put the child in their room and as the discussion goes along throughout the class we realize that there are certain things that you can do to make time out of it putting them in their room is probably not the best option so their time out use decreases towards the end of the techniques and that's a good thing because we really want to focus on the first topics which are all about prevention and early intervention with any behavior that you have with the child you'll have an antecedent then you have the behavior then you have the consequence so once you start looking at these topics you'll see that a lot of these can be done before the behavior occurs so if you praise your child constantly for putting away their toys more than likely you're going to keep up that behavior so the consequence which results in the time out losing privileges that's really what we want the parents to leave as a last resort we want to tease all of the positives establish that foundation and then if need be then you go into the consequences and losing privileges again it's really taking away any type of privilege that you may have for example going to the park today and that's if the child didn't put away his toys then let's say today you won't go to the park in case problem solving that goes through all of the sessions that we've discussed in the class and that's set at the end of the 10 sessions and at that time we do the final review and parents will try to figure out if all of their questions have been answered and if they haven't then you move into doing a very thorough problem solving agenda yes so you mentioned service before diagnosis and so one of the things that I'm wondering is is this a blanket prevention program or are you using a targeted strategy I mean in terms of in terms of which kids are going to get the intervention oh no really what we try to do with the program is try to have a net and we'll bring in any child who wants to participate no limitation as to whether they're diagnosed or not but again most of the kids that do come through our program have attention or behavior problems so it is more of a a net that we cast it's not specific to any particular child because we don't have that requirement because of our kinders but the idea primarily was to try and identify children who have attention or behavior problems that may go on to be diagnosed with ADHD and have you found that there are reliable markers there have you been able to find which kids sort of reliably are able to go on to diagnosis well in the social skills group we have our social skills coordinator sitting right up front he can't say anybody has questions after but in our social skills groups we we do provide very brief screening for example we have the forgotten screening a measure of typical development for that child and once we screen the child that report is given back to the parents and there's a cutoff score for each age range so for the three-year-old it might be 70 so for the four-year-old it might be 77 and we'll let the parents know in a report format whether or not their child fell below the cutoff score or above so let's say the cutoff score is 75 and the child about a 70 there was a lot of impairment but we want to provide that parent with the information they need to determine whether or not they want to seek out an evaluation we're assuming that they come to the program because they might have been referred by a doctor referred by a preschool teacher who's already identified some problems or maybe they've just noted some problems already but again it's primarily trying to cast out the net and I'll give you an example we've had siblings who come in let's say a three-year-old with a five-year-old and mom says my five-year-old I know he has attention problems and we'll see them in the structured classroom setting again our social skills groups will say he's fine he's able to pay attention he finishes his task yes he might be fidgety but he's able to continue through his task the three-year-old then we'll find maybe he doesn't have any information for his age and again going through those screenings then we provide the parents more information so that they can see that the five-year-old maybe doesn't need to go on to an evaluation of the three-year-old might and again these are just we don't refer any parents to go on to an evaluation we simply provide them the information that was conducted in the class so the screenings and then we also have it's called the our child impairment scale because again the importance of the ADHD symptoms is the symptoms that are showing it's more so the impairment that's occurring so with the quidar child impairment scale after every session the social skills providers that were with the kids they go over each child and they describe any observations that were made strictly observations no diagnosis we noticed that Wendy was fidgety during circle time what was going on around her were there other kids was she sitting next to Millie was really chatting what were the environmental factors and then we'll compile a report at the end of the ten weeks again letting the parent know which sections there were issues in and to what degree so again a child might appear to be in a tent and we might say well we're going for the light so we think she's not paying attention but after you read the book can you say what was it about oh it was about some pain when they went to the snow and they had a lot of fun so although it appears that they're not paying attention they clearly are so again truly the impairment was not necessarily the symptom so with the CCIS we focus on the observations that were made so we noticed that he couldn't really sit still and these activities and of course week to week those social skills providers will get together and try to formulate a plan for the following so that they can fight or help the child and then of course that information is then given about to the parents I'm not sure if that answered your question or I just rambled yeah so you focus on impairment and symptom related impairment using like contextually sensitive measure right where you're looking at what's going on okay and to give you some information as to who is actually participating in the program this is data from 2 years worth so again most of the kiddos that are coming through our program are males 64% of the preschool age were boys ethnicity 73% were Hispanic that doesn't necessarily mean that they went to a Spanish speaking class they kind of attended an English speaking class Caucasian 15% other or unknown 8% Asian 3% and African American 1% age primarily we have 4 year olds coming through and again relating back to the ADHD symptom criteria we really wanted to see the 2 different environments so now we have the home environment and presumably so when the 4 year olds will have the preschool environment so that they can take that information back to the pediatrician along with the pre-doored information that the child is participating in parent education pretty much across the board but most of them did not complete high school or have their high school diploma and then very few went on to have their bachelor's degree parent marital status 70% were married 14% living together and very few separated divorced or unknown and the unknown isn't that they didn't know each other that's just maybe an anti-king or a grandpa came they didn't really know the marital status so attendance for the most part we have one parent attending especially in the morning sessions we have just the mom coming in and again that can be a whole other presentation as to in the Spanish speaking groups in the mornings we typically have all moms they are holding down their house co-class demand 60% of our classes are now provided in Spanish and again that's really just because that's who calls us we really haven't had to seek out sites to provide the classes to we're usually receiving the phone calls again we're embedded in the community we spread the word and we conduct a lot of outreach events and health fairs so there's the need in the county 60% of our classes and the average number of families per group again in our Spanish groups has consistently been a bit higher 23 families compared to our English groups 16 families which is suddenly on the rise I think our demand for English groups is slowly shifting back up so we'll see how that pans out Hope for Spanish speakers again with the public health model I think there's always that need to translate or adjust to different cultures so I wanted to present this here the homework we originally started again was translated into Spanish and we used lower literacy levels just based on the demographics of the parents who were participating in our program the videos were also redone using Hispanic actors again we really wanted to focus on removing the mental health stigma and having parents participate and feel comfortable and knowing that I can relate to this because there's someone like me who's here as well as a facilitator all of our facilitators are bilingual and bicultural the ones who are in the Spanish speaking classes and changes in curriculum we removed some of the role playing in the English groups we have two parents pair up and actually role play one person as a child one person as a parent and that didn't really work so well in the Spanish groups we've had a lot of dads who just sit so we figured that's one of the adjustments that we have to make culturally in order for parents to feel comfortable and want to continue attending the class and again in the Spanish groups the facilitator is still seen as an authority figure but I think when you observe one of these classes you really see that people want to participate they don't have any data pertaining to that we sort of figured that most of the parents who attend the classes really don't have a support system so when they come to the classes and they have their own little community in the group that becomes their support system so they're more comfortable and they want to share and recruiting for co-classes this is mostly for our Spanish groups again because it's really a lot of community involvement we have on-site facilitator or communities this could be at an elementary school a preschool a family resource center we've gone to churches we pretty much have a steady group over at the Irvine University School District as well as the Children's Hospital of Ontario but primarily when you have that stronger context someone who actually knows the families who can talk to them about the program talk to the teachers about the program then we get a better recruitment we present parent meetings that's usually also very helpful and families for the most part are referred by teachers again, physicians and community resources and we distribute flyers everywhere we go so again we want to bring everybody, it's not necessarily someone who has a childhood potential or may have problems although that's primarily who we're trying to identify as I mentioned with the siblings the three-year-old and the five-year-old some parents may not know that their child might have attention or behavior problems and a lot of what we're finding now is actually that there's a lot of children with speech or language delays and again if a child can't verbalize what they want to say what are they going to do they're going to physically show you and that might translate into a lack of children who have siblings who have been diagnosed or older siblings who have been diagnosed I'm wondering if there's some wrongs in common so like genetics we don't personally keep track of them although we have had some families who return again they came in the older child is six and now they have a four-year-old who they want to take the class for because they just really like the program or maybe they were referred by a teacher or somebody else again but that's not the nature right, yeah very few pieces so in order to measure the effectiveness of our parenting program and again then determine whether or not parents are using the strategies and going back to our theory maybe a lot of these children just needed that structure and were being misdiagnosed or overdiagnosed we want to see the pre and post measures for our parenting classes to see whether they're using those strategies so we have two that we use the first is the swan rating scale so again our visionary Dr. Swanson also created this ADHD rating scale the Parenting Strategies Assessment that was created in-house and that's pretty much just a pre and post of the strategies that are presented throughout the 10 weeks in class so the swan questions one through nine measure the inattention items so again those that I presented in the beginning doesn't pay attention to detail appears to kind of use around questions 10 through 18 measure hyperactivity so blurts out the answer before a pierce fidgety when they're in the chair when they're supposed to be seated and this was reworded from the original again to be applicable for the preschool age child and was also translated into Spanish for our use to see but I just wanted to give you the idea that this is used in the library scale and it just lists out the 18 items and hyperactivity and the parent will then go on to respond whether their child for example number one attends to details and avoids making careless mistakes whether they're far below other children below other children slightly below other children average slightly above other children or far above other children so how often do they do this and we're asking them to take a look at the last week how often do they do this and the last week when compared to other children so parents it is difficult because they're not really around with their kids but just say you know typical behavior sometimes a child pays attention sometimes they don't so that would be our average so if a child is always seated ready to go and pays attention they'll be more of course a right side of the scale and if a child just never pays attention they'll probably be rated closer to the left side of the scale for pre and post means I wanted to show you the difference between the English and the Spanish groups and again all of them more significantly in attention for example we saw an increase which is good in this case because as I mentioned we want them to be closer to the right side of the scale that means that they're paying attention appropriately when needed that means that they're not flirting out the answer so again all of the symptoms that we have for ADHD in those items we're seeing a shift to the positive so we're seeing better behavior as the parents reported so all of these were significant to change and hyperactivity same idea we went shift to the right and are not appearing as hyperactive and again we want to attribute that to the classes that the parents learn the strategies to better manage their child's behavior so now their perception of their child is that they're going to be great and the parenting strategies assessment again this was created in-house by our psychologists and based strictly on the pope strategies that we discussed the pope topics and it measures the frequency and utility of all the strategies so again the parenting skill prays a positive attention then we'll ask in the past week how many times did you use this skill A, not at all, B, 1, 2, 3 times C, 4, 6 times B, more than 6 times and the very last column is how helpful did you find this skill so someone can pray all day give their child a hug that kisses if the child doesn't care then it's not really useful for the parent to get that measure see how often are they using these strategies and again how successful is it for them B, in the Spanish side we have on the left side everything changed significantly with the exception of time out and losing privileges and again part of what we attribute to that is that parents either came in thinking that they knew how to use time out and then realized well there is a structure to it I was using it appropriately or they came in again maybe not using time out or using it and because we've discussed so many other positive strategies they're using those which is really what we want what we want to use all of the prevention strategies first then if all else fails move into the consequences of time out so I was for the Spanish troops and for the English troops again same two and then also one then sequence and planning those we didn't see a significant difference but there was sub change I'm sorry is that this is after how many 10 weeks 10 weeks to our sessions so total of 20 hours and so here is the usefulness of strategies so the usefulness of time out wasn't significantly different and also physical punishment that's one of the things that we we actually pride ourselves in is that physical punishment decreases substantially but again they don't find it useful anymore so that's a good thing for the English troops again physical punishment is a really nice use between the Spanish and English classes the Spanish again reported better behavior and their English counterparts but they still saw significant positive changes in both attention and the level of activity of their child and for the PSA significant increase in use of all code strategies for Spanish-speaking families again with the exception of time out and greater gains were made by Spanish-speaking families compared to the English but again the English also saw better behavior from their children and again use of physical punishment decreased for both groups so as a conclusion code groups were both useful for English and Spanish speakers alike and the modifications to the Spanish code classes again maybe they helped because we saw more of a significant change in those classes so again with the premise of our program which was to provide the parents with as many strategies as possible to better manage their child's behavior we now find that only 7% of families go on to request further evaluation for their child changing from that 20% that we originally saw so still they need to give the child that structured format at home and then again also helping the teachers, we worked a lot with the Orange County Department of Education who tried to meet that proposal and school teachers as possible so we're hoping that that kind of makes their way as a child transition from school to home that they're being received for the same type of structure and strategies right and they'll send them on for further evaluation and these are based on that the classes have to they're hoping that they will be able to control them now for one boy to stay I ended up in first or second grade because I'm a teacher he can control they don't want to sit down so according to some of the regulations of Spain you cannot really work inside the land you're asking what could the teacher do for example what could the teacher do for parents what does who control the child because the child can pass oh well that's that's primarily why our program focuses on children who need his births through 5 so that we're able to capture how many children as possible before they get to that age and again for children typical diagnosis usually occurs before the age of 7 but we would assume that before they get to the age of 7 they've either been through our program or that a teacher has referred them to their primary composition to get a diagnosis but there are a lot of cases who actually do fall through the cracks if our funding works in our model was intended for parents of children who need a 7 to 12 who have ADHD so again given enough funding we'd be able to provide parenting classes up until the age of 12 so there are no similar code programs for the elite group right do you follow this data on diagnosis in our county? yeah I mean it's pretty typical again we only focus on preschool age child children and it's one out of every 20 sorry I wanted to ask about funding so I know you get funding and I'm just asking what other sources of funding so far we're in the works for a couple of grants one of the grants that we have is the Early Head Start grants so that's federal funding and we've partnered up with Wrenches Nantango Community College District to provide the coping with trauma behavior classes and also teacher trainings there but then we're also in the works with the county for Prop 63 again mental health that's the area where we fall into for behavioral health so there's a couple of different things but for the most part yes the funding is slowly but steadily decreasing for there was a research group here a while back that was studying phantasyte the shaking baby syndrome parents and they were following the time trends what time of day this happened but at the time I think ADHD research was really not well known and the diagnosis this was 70s but are there now connections between what we see in the mobility and diagnosis so I can one can think that in this behaving my the parent is not still my response in your comment physical punishment declining made me think that that would be a very good strategy reducing yeah actually the primary focus for the class originally was for maternal depression so we're hoping again that they form that support group within the class and are able to bond with their baby at the same time it seems like it's pretty kind of parallel with a lot of the interventions in for often do you see that I mean is there some sort of overlap I guess on the you know with the spectrum of ADHD and you guys then refer to those yes you know we do have a couple of kids that come through that maybe go on to be diagnosed with autism and yes with the symptoms of autism and ADHD there is definitely a lot of overlap there's a lot of children that have that dual diagnosis for the most part most children who already have already been diagnosed with autism aren't necessarily able to participate in our program because we do have three requirements for the social skills groups they have to be 3, 4 or 5 they have to be body trained and again they have to move over to county so that body training for a 3, 4 or 5 world with autism usually doesn't happen before that age so by process of elimination they're not able to participate in the program because they're not body trained but with typical ABA for autism it's definitely a one on one situation whereas we have a group a group dynamic going on in the social skills classes and the reason why we do that is because a child with ADHD is definitely going to learn from their peers and that's what we want we want them to say okay well we have Eric and he got a point so I want to sit still too even if it's for one second the modeling definitely helps whereas with autism depending on how far along the spectrum they are it may not be as beneficial for them they'll definitely get that long so do you find yourself referring other, I mean because I imagine a lot of parents would be a lot more likely to take service for ADHD and they may need a little more hesitant thinking the fact that the child is autism so you find that out you do find some children who are going in for those services the parenting strategies that we discuss in the class are definitely very basic so we do have parents who maybe have a child who is already diagnosed and even though the child isn't able to participate in the social skills the parents will still come to the parenting class so it does happen and as far as referral goes again if a parent feels that there's a need for an evaluation if they haven't already been diagnosed with autism I think most of you received that larger brochure so one of those programs and there is for OC Kids and they're a neurodevelopmental center and they focus primarily on diagnosing children with both autism and ACEs so we'll definitely give them that information and then Help We Grow is also in there currently the funding was for 0-5 so they give you any type of resources that you want for a child 0-5 but they've also received additional funding so I think they're trying to expand and they still take requests for children to leave Any more questions? Thank you very much