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RETHINKING ADHD TREATMENT

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Title: RETHINKING ADHD TREATMENT


1
Managing Inattentive, Hyperactive, and Impulsive
Behaviors in the Classroom
Catharine Weiss, Ph.D. Nancy Lever, Ph.D.
Center for School Mental Health Department of
Psychiatry, University of Maryland,
Baltimore cweiss_at_psych.umaryland.edu nlever_at_psych.
umaryland.edu
2
Have you ever
  • Thought a student was lazy because they wouldnt
    start or complete work that you knew they could
    do?
  • Stopped teaching over and over to keep a student
    on task?
  • Noticed a child who sits quietly but is not able
    to follow the lesson?
  • Been frustrated by a student who keeps getting
    up, touching or playing with anything and
    everything in sight?
  • Struggled to work with a student who talked
    incessantly or interrupted you and blurted out
    random comments?
  • Felt powerless with a student who acts without
    regard to consequences and instigates fights with
    other students?

3
What could be contributing to and/or co-occurring
with these behaviors?
4
Session Overview
  • What is ADHD?
  • Best Practice Strategies and Resources
  • Case Examples
  • Discussion

5
Most Common ADHD Myths
  • ADHD isn't a real medical disorder.
  • Children given ADHD accommodations are given an
    unfair advantage.
  • Children with ADHD often outgrow the condition.
  • ADHD affects only boys.
  • ADHD is the result of bad parenting.
  • ADHD children on medication will abuse drugs as
    teenagers.
  • People with ADHD are stupid and lazy.
  • From www.additudemag.com

6
Attention-Deficit/ Hyperactivity Disorder Some
Basics
  • Neurobiological disorder disorder in brain
    development or brain functioning
  • Affects ability to regulate behavior and
    attention
  • Genetic link 30-40 have relatives diagnosed
    with the disorder
  • Most common childhood disorder approximately
    2-9 of youth
  • 3 times more common in males

7
ADHD Diagnosis
  • Symptoms for at least 6 months to a degree that
    it is maladaptive and INCONSISTENT with
    developmental level
  • Some symptoms that caused impairment present
    prior to age 7
  • Difficulties in two or more settings
  • Clear evidence of impairment in school, work, or
    social functioning

8
  • I was trying to daydream, but my mind kept
    wandering.
  • - Steven Wright, comedian

9
ADHD Core Symptoms
INATTENTION
  • Fails to give close attention to details
  • Has difficulty sustaining attention
  • Does not seem to listen when spoken to
  • Does not follow through on instructions or finish
    tasks
  • Has difficulty organizing tasks and activities
  • Avoids or dislikes tasks requiring sustained
    attention
  • Loses necessary things
  • Is easily distracted by extraneous stimuli
  • Is often forgetful

6 or more, occurring very often (DSM-IV)
10
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11
ADHD Core Symptoms
HYPERACTIVITY/IMPULSIVITY
  • Fidgets with hands or feet or squirms
  • Leaves seat inappropriately
  • Runs or climbs inappropriately (or subjective
    feelings of restlessness)
  • Difficulty engaging quietly in leisure activities
  • "On the go" or "driven by a motor"
  • Talks excessively
  • Blurts out answers
  • Difficulty awaiting turn
  • Interrupts or intrudes

6 or more, occurring very often (DSM-IV)
12
DSM-IV ADHD SUBTYPES
  • PREDOMINANTLY
  • PREDOMINANTLY
  • COMBINED TYPE

INATTENTIVE
HYPERACTIVE/IMPULSIVE
INATTENTIVE

HYPERACTIVE/IMPULSIVE
13

ADHD Associated Difficulties
  • Trouble with academic performance
  • Frequent classroom disruptions
  • Disturbed social relationships with family,
    adults, and peers
  • Angry and defiant behavior
  • Learning disabilities (20-30)
  • Coexisting disabilities (40-60)

14
Specific Educational Outcomes
  • Youth with ADHD are more likely to
  • Be retained
  • Be placed in special education
  • Be suspended and expelled
  • Drop out of school
  • Have lower grades

15

ADHD at Different AgesPreschool
  • High motor activity always on the go, climbing
    on things, getting into things
  • Decreased or restless sleep
  • High curiosity
  • Vigorous, often destructive play
  • High attention needs
  • More intense temper tantrums
  • Require closer, more frequent monitoring
  • Disobedience

16
ADHD at Different Ages School-Age
  • Academic difficulties difficult homework time
  • School complaints of disruptive behavior
  • Difficulties with chores and responsibilities
  • Low frustration tolerance
  • Social difficulties conflict and rejection
  • May have low self-esteem

17
ADHD at Different Ages Adolescence
  • Approximately 70-80 still display symptoms
  • Continued academic difficulties, disorganized,
    incomplete assignments
  • At risk for earlier sexual behavior and
    cigarette smoking
  • Higher rates of risky driving, substance abuse,
    and risky sexual behaviors

18
ADHD at Different Ages Adulthood
  • More subtle presentation
  • Difficulties initiating and organizing daily
    tasks
  • Inconsistent performance and trouble with
    deadlines
  • Restlessness, trouble relaxing
  • Socially inappropriate
  • Frequently have comorbid diagnoses

19
What Doesnt Work for ADHD?
  • Treatments with little or no evidence of
    effectiveness include
  • Special elimination diets
  • Vitamins or other health food remedies
  • Psychotherapy or psychoanalysis
  • Biofeedback
  • Play therapy
  • Chiropractic treatment
  • Sensory integration training
  • Social skills training
  • Self-control training

20

More Favorable Situations
  • New tasks
  • Situations with immediate rewards and
    consequences
  • One-on-one attention
  • Early in the day
  • Structured time
  • Single-step commands

21

Evidence-Based Treatment
  • Cognitive Behavioral Interventions
  • Parent training and implementing behavioral
    modification at home
  • Teacher training behavioral modification at
    school
  • Medication

22
A Student Perspective on ADDFrom adders.org -
Creative ADDers
  • I am more than my ADD
  • By Robert
  • I am more than my ADDI have feet, arms,
    legsbut most of all a heart and a soulYou may
    think, "so irresponsible is he""so insensitive
    is he""how careless to be"Maybe this is all you
    see.but there is more to memore to me than my
    ADDI love music, writing, poetryI get angry,
    tired, happy,sad, just like everybody else.I
    take responsibility for my actionsas hairbrained
    as they may be (or not)but there is more to me
    than my ADD

23
Acting Out Cycle
Peak
Acceleration
De-escalation
Agitation
Trigger
Recovery
Calm
Adapted from The Iris Center
http//iris.peabody.vanderbilt.edu
24
  • QTIP
  • (Quit Taking it Personally)

25
ADHD Practice Elements
  • Praise
  • Ignoring/Differential Reinforcement
  • Commands/Limit Setting
  • Time Out
  • Tangible Rewards

26
Praise
  • Verbal praise, Encouragement
  • Attention
  • Affection
  • Physical proximity

27
Giving Effective Praise
  • Be honest, not overly flattering
  • Be specific
  • Make eye contact give undivided attention
  • No back-handed compliments (i.e., I like the
    way you are working quietly, why cant you do
    this all the time?)
  • Give praise immediately
  • Remember to praise the absence of a behavior

28
Ignoring and Differential Reinforcement
  • Selectively
  • Ignore mild unwanted behaviors
  • AND
  • Attend to alternative positive behaviors

29
How to Ignore
  • Visual cues
  • Look away once child engages in undesirable
    behavior
  • Do not look at the child until behavior stops
  • Postural cues
  • Turn the front of your body away from the
    location of childs undesirable behavior
  • Do not appear frustrated (e.g., hands on hip)
  • Do not vary the frequency or intensity of your
    current activity (e.g., talking faster or louder)

30
How to Ignore
  • Vocal cues
  • Maintain a calm voice even after your child
    begins undesirable behavior
  • Do not vary the frequency or intensity of your
    voice (e.g., dont talk faster or shout over the
    child)
  • Social cues
  • Continue your intended activity even after your
    child begins undesirable behavior
  • Do not panic once childs begins inappropriate
    behavior (i.e., do not draw more attention to
    child)

31
When to Ignore
  • When to ignore undesirable behavior
  • Child interrupts conversation or class
  • Child blurts out answers before question
    completed
  • Child tantrums
  • Do not ignore undesirable behavior that could
    potentially harm the child or someone else

32
Differential Reinforcement
  • Step One Ignore (stop reinforcing) the childs
    undesirable behavior
  • Step Two Reinforce the childs desirable
    behavior in a systematic manner
  • The desirable behavior should be a behavior that
    is incompatible with the undesirable behavior

33
Differential Reinforcement
  • Define the behavior of concern (target)
  • Determine how often the target behavior occurs
  • Determine how often to reward the child for
    alternative behavior
  • Fixed interval reward every X minutes
  • Determine how to reward the child for alternative
    behavior
  • Praise, attention, points or chips

34
Differential Reinforcement of Target Behavior
  • Target behavior Interrupting
  • Alternative behavior Working by himself
  • Reward schedule 10 minutes
  • If child goes 10 minutes without interrupting,
    the child receives reinforcement
  • If child interrupts before 10 minutes is up, the
    child does not receive reinforcement
  • Re-set schedule once child interrupts

35
Differential Reinforcement
  • Systematically delay reinforcement once child
    responds to initial schedule
  • Target behavior Interrupting
  • 1st reinforcement schedule 5 times per class
  • 2nd reinforcement schedule 3 times
  • 3rd reinforcement schedule 1 time

36
Challenges with Ignoring and Differential
Reinforcement
  • Extinction burst
  • Behavior will get worse before it gets better
    (child will work harder to gain attention)
  • Indiscriminant reinforcement
  • Reward only the alternative (desirable) behavior,
    so you dont reward other unwanted behaviors by
    mistake

37
Improving Commands/Limit Setting with Youth
  • Only give commands that you intend to back up
    with consequences (positive and negative)
  • Do not present commands as questions or favors
  • Break down multi-component commands
  • Make clear what you want them to do, not just
    what you do not want

38
Steps to Making Effective Commands
  1. Make eye contact with the child before giving
    command
  2. Reduce other distractions while giving commands
  3. Ask the child to repeat the command
  4. Monitor after giving the command to ensure
    progress
  5. Immediately praise child when s/he starts to
    comply

39
Consequences and Time Outs
  • Do in private, stay calm
  • Time outs
  • Cool off space that can be monitored
  • Effective if problem behavior is strengthened by
    peer attention
  • Not effective if goal of behavior is to avoid work

40
Tangible Rewards
  • Children and adolescents with ADHD do not respond
    to natural (intrinsic) rewards as well as typical
    youth
  • Can use token systems, behavior charts, or
    immediate rewards

41
Setting up a School-Home Contract
  • School staff track the childs behavior and
    reports it to family daily, who reward the child
  • Effective because both the parent and staff are
    involved and can reward for positive behavior
  • If the parent cant be involved, the rewards may
    be given only at school

42
School-Home Contract
  • Typically referred to as a daily report card
  • Purpose To identify, monitor and change
    classroom problems and facilitate home-school
    communication and collaboration
  • Takes time on the front end, but found to reduce
    classroom disruption time

43
Daily Report Card Steps (http//ccf.buffalo.edu/pd
f/school_daily_report_card.pdf)
  • Select areas for improvement
  • Involve staff who work with student
  • Involve the student and family in identifying
    areas for improvement
  • Examples of key domains- peer relations, academic
    work, classroom rule following, adult
    relationships

44
Daily Report Card Steps (http//ccf.buffalo.edu/pd
f/school_daily_report_card.pdf)
  • Define target behaviors
  • Must be clearly defined and measurable
  • Number of targets depends on age and ability. Be
    realistic.
  • Examples of behaviors-completes assigned tasks,
    speaks respectfully to the teacher, participates
    in class lesson, walks in hallway appropriately

45
Daily Report Card Steps(Continued)
  • Decide on criteria for evaluating target behavior
  • Estimate how often the behavior occurs now
  • Set a reasonable criterion for success (child can
    earn between 75-90 of the time)
  • Remember the goals need to be feasible to both
    the teacher and the child
  • Set criteria to be met for each part of the day
    versus the whole day (e.g., class period)

46
Daily Report Card Steps(Continued)
  • Explain report card and set up rewards with
    child/family
  • The goal is to help the child to be successful
  • Ideally rewards should be natural and easy to
    implement
  • More preferred rewards can be earned for longer
    term performance
  • Need a menu of rewards
  • Kids need both in school and home rewards
  • Kids need to have success at the start and
    regularly thereafter

47
Daily Report Card Steps(Continued)
  • Monitor and modify the program
  • Gradually make the criteria harder
  • If child fails to meet the criteria, consider how
    to best modify
  • Praise child sincerely for success and
    matter-of-factly for missed targets
  • Parent and teacher signatures and comments

48
Sample Daily Report Card
49
Behavioral Consequences Benefits of Whole
Classroom Approach (e.g., PBIS)
  • Reduces sense of unfairness ADHD children
    receiving special treatment
  • Multiple ADHD children in classroom may strain
    individual approach
  • Benefits whole class environment

50
Classroom-Wide Peer Tutoring
  • Create and distribute scripts (worksheets)
  • Teach any new concepts and skills to class
  • Break class into dyads
  • Each takes turns tutoring and quizzing the other
  • Praise or points awarded
  • Errors are immediately corrected
  • Circulate and coach dyads

51
Good Behavior Game
  • An approach to the management of classrooms
    behaviors that rewards children for positive
    behaviors during classtime.
  • Class divided into two teams
  • A point is given to a team for any inappropriate
    behavior displayed by one of its members
  • The team with the fewest number of points each
    day wins a group reward. If both do well, can
    share in reward

52
Steps to the Good Behavior Game
  • Decide when to schedule the game
  • Clearly define what negative behaviors will be
    scored during the game
  • Leaving ones seat
  • Talking out
  • Disruptive behavior
  • Decide on rewards and schedule of rewards
  • Daily versus weekly
  • Introduce the game to the class
  • Implement the game

53
Core Concepts from Good Behavior Game
  • Class working in teams
  • Clearly defined expectations
  • Can target specific behaviors
  • Rewards for positive behavior
  • Can adjust expectations over time related to
    student success
  • Used only for short periods of time, particularly
    most critical instructional time
  • Can also reframe to reward positive behaviors
  • Raising hand, staying in seat, completing
    assignments

54
Classroom Modifications
  • Brief, clear, and frequent instructions
  • Preferential seating, removal of distracters
  • Reduced workloads, break tasks into smaller units
  • Stimulating activities, matched at their level
  • One-on-one attention close supervision
  • Choice in activities
  • Highlighting Directions with Color
  • Computer Assisted Learning
  • Schedule more difficult activities in AM
  • Anticipate problem times and activities

55
Classroom Modifications
  • Motivational Strategies
  • More frequent feedback
  • More immediate feedback, positive reinforcement,
    and valued rewards
  • Highly salient and meaningful consequences
  • Reinforcing accuracy not speed
  • Daily report card systems, home notes
  • Group rewards
  • Change rewards regularly with student input

56
What Would You Do with Wayne?
  • 6 years old, 1st grade
  • Bright affect, very likeable
  • Off-task 80-90 of the time very short attention
    span, daydreaming, rocking, humming, singing,
    talking to peers, out of seat, distracted by all
    activity in the room
  • Trouble completing work, sometimes refuses to
    finish assignments, forgetful
  • Can verbalize that he has trouble with activity
    and attention

57
What would you do with Shannon?
  • 17 years old, 11th grade
  • Seems anxious, disconnected from peers
  • Late for school most days
  • Locker and backpack disorganized
  • Inconsistent in her completion of homework
  • Failing English and Science Classes
  • Teachers see her as lazy and unmotivated
  • Easily distracted in class, daydreams, makes
    careless mistakes
  • Easily frustrated, gives up if cannot get a
    concept immediately

58
Resources
  • The Attention Deficit Information Network
    www.addinfonetwork.com
  • Children and Adults with Attention-Deficit/Hyperac
    tivity Disorder (CHADD) www.chadd.org
  • National Resource Center on ADHD help4adhd.org
  • University of Buffalo, Center for Children and
    Families http//wings.buffalo.edu/adhd

59
Resources
  • National Institutes of Mental Health
    www.nimh.nih.gov
  • School Mental Health Resources
  • www.schoolmentalhealth.org
  • Childrens Mental Health Disorder Fact Sheet for
    the Classroom (Minnesota Association for
    Childrens Mental Health)
  • http//www.macmh.org/publications/fact_sheets/ADHD
    .pdf

60
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