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Information about ADHDintheClassroom1

Published on January 29, 2008

Author: Toni


Slide1:  Laura G. Anthony, Ph.D. Center for School Mental Health Analysis and Action Department of Psychiatry, University of Maryland, Baltimore 737 W. Lombard Street, Baltimore, MD 21201 410-706-0980 Helping Children with ADHD and Disruptive Behaviors in the Classroom Make sure it is ADHD! :  Make sure it is ADHD! Mood/Anxiety Problems PDD Spectrum Evidence-Based Treatment of ADHD:  Evidence-Based Treatment of ADHD Medication Treatment :  Medication Treatment Robust positive effects of stimulant medication (70% of children) on ADHD core symptoms and positive effects on some associated problems (aggression, peer relations, reduced compliance) A handful of studies have documented decreases in negative (but not increases in positive) mother-child interaction with stimulant medication. Slide5:  “Outcomes in ADHD may be governed less by the severity of a child’s symptoms and more by the manner in which the child and significant persons in the child’s environment react and respond to these symptoms” (Greene and Ablon, 2001). Importance of Context Slide6:  EFFECTIVE IMPLEMENTATION OF EVIDENCE-BASED NON-MEDICATION TREATMENTS What works for ADHD?:  What works for ADHD? All of the evidence-based practice elements for use in ADHD have their basis in Clinical Behavior Therapy. We will first cover the basic premises behind behavior therapy, then cover the specifics of effective interventions for ADHD What doesn’t work for ADHD?:  What doesn’t 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 Clinical Behavior Therapy: Theory:  Clinical Behavior Therapy: Theory Proposed Mechanism: Individuals with ADHD have difficulty understanding the consequences of their actions. Approach: Application of the principles of social learning theory to modify children’s behavior by training parents and teachers to manipulate environmental antecedents, consequences and contingencies. The ABC Model:  The ABC Model Contingencies An example: The ABC Model:  An example: The ABC Model The ABC Model:  The ABC Model Contingencies Teacher makes eye contact with student, says, “Take out your math books.” Basic Principles:  Basic Principles Clear and brief rules Swift consequences Frequent consequences Powerful consequences Rich incentives Change rewards Expect failures Anticipate Slide14:  Treatment Target: Difficult Relations with Adults Less compliant and cooperative More demanding Less independent More emotional and conflicted interchange Adults are more negative and directive with child or adolescent with ADHD Treatment Target: Classroom Behavior Problems:  Treatment Target: Classroom Behavior Problems Difficulties in completing independent seat work Talking with classmates at inappropriate times Frequent out-of-seat behavior Organizational difficulties Praise:  Praise Training teachers to praise correctly increases compliance in youth with ADHD/DBD Praise can include Verbal praise, Encouragement Attention Affection Physical proximity Giving effective praise:  Giving effective praise Be honest, not overly flattering Be specific No “back-handed compliments” (i.e., “I like the way you are working quietly, why can’t you do this all the time?”) Give praise immediately Ignoring and Differential Reinforcement:  Ignoring and Differential Reinforcement Train staff and teachers to selectively Ignore mild unwanted behaviors AND Attend to alternative positive behaviors Teaching to ignore:  Teaching to ignore Teach staff and teachers how and when to ignore undesirable behavior Ignoring can include Visual cues Postural cues Vocal cues Social cues How to ignore:  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 child’s 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) When to ignore:  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 Differential reinforcement:  Differential reinforcement Teach how and when to differentially reinforce desirable behavior Step One: Ignore (stop reinforcing) the child’s undesirable behavior Step Two: Reinforce the child’s desirable behavior in a systematic manner The desirable behavior should be a behavior that is incompatible with the undesirable behavior Differential reinforcement:  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 Differential Rreinforcement of target behavior:  Differential Rreinforcement of target behavior Target behavior: Interrupting Alternative behavior: Working by himself Reward schedule: 5 minutes If child goes 5 minutes without interrupting, the child receives reinforcement If child interrupts before 5 minutes is up, the child does not receive reinforcement Re-set schedule once child interrupts Differential reinforcement:  Differential reinforcement Teacher systematically delays reinforcement once child responds to initial schedule Target behavior: Interrupting 1st reinforcement schedule: 5 minutes 2nd reinforcement schedule: 6 minutes 3rd reinforcement schedule: 7.5 minutes Problems with ignoring and differential reinforcement :  Problems with ignoring and differential reinforcement Extinction burst Warn staff and teachers that the behavior will get worse before it gets better (child will work harder to gain their attention) If you put your money in a vending machine, and the soda doesn’t come out, what do you do? You probably press the button a few more times, maybe you even try pressing harder Indiscriminant reinforcement Train teachers to reward only the alternative (desirable) behavior, so they don’t reward other unwanted behaviors by mistake Improving commands/limit setting:  Improving commands/limit setting Training for teachers to give commands in the most effective way Effective commands increase compliance in children and adolescents with ADHD/DBD (and in others, too!) Improving commands/limit setting with children:  Improving commands/limit setting with children Teach parents and teachers: To only give commands that they intend to back up with consequences (positive and negative) Not to present commands as questions or favors Not give too many commands at once Improving commands/limit setting with adolescents:  Improving commands/limit setting with adolescents Teach parents and teachers: To consider the intent of their command Do they have the time/energy to follow through? Do they have consequences for noncompliance? To avoid ambiguity when issuing commands To not respond to compliance with gratitude Improving commands/limit setting with adolescents, con’t.:  Improving commands/limit setting with adolescents, con’t. Teach parents and teachers: To praise teens for appropriate behavior To tell teen what to do, rather than what not to do To eliminate other distractions while giving commands To break down multi-step commands To use aids for commands that involve time Classroom Management: Working on Behavioral Consequences:  Classroom Management: Working on Behavioral Consequences Reinforcement: immediate rewards for positive behavior Tangible token for following rules and instructions Labeled praise Punishment: Mild aversive consequences for off-task, non-compliant behavior Tangible token for disruptive behavior Salient warning of consequence with choice Tangible rewards:  Tangible rewards Children and adolescents with ADHD do not respond to natural (intrinsic) rewards as well as typical youth The training of parents and teachers in the use of tangible rewards is effective in increasing desired behaviors Can use token systems, behavior charts, or immediate rewards Response Cost:  Response Cost Using a point or token system in school in which negative behaviors result in the loss of points or tokens. Training parents and teachers to use response cost is effective in reducing undesired behavior and noncompliance Response Cost with Children:  Response Cost with Children Train teachers: To develop list of undesirable behavior to be fined by reward system To deduct points/chips for undesirable behavior Teacher and child have chosen to reduce whining If child whines, teacher deducts three points Penalties increase based on severity of behavior Response Cost with Adolescents:  Response Cost with Adolescents Train teachers: To now use behavioral contract with the teen for “fines” Teen agrees to not swear If teen swears, teen loses Internet privilege at school To begin with 1 week “training period,” during which teacher labels misbehavior every time it happens and warns of new fines Response Cost with Adolescents:  Response Cost with Adolescents Train teachers: To avoid “punishment spiral” When teacher fines teen for misbehavior, the teen responds with more misbehavior Teen continues to lose privileges, then loses motivation Rule: fine teen no more than twice, then direct teen to “cool off” away from the situation Response Cost with Adolescents:  Response Cost with Adolescents Encourage teacher to act as “judge and jury” when teen lies The teen should remain above suspicion Response cost allows teacher to discipline/educate instead of just punish Emphasis of response cost is on “Warm” – positive, loving “Firm” – specific, immediate, and consistent Classroom Management: What Helps it Work?:  Classroom Management: What Helps it Work? Immediate and frequent reinforcement Student is an active participant in developing the reinforcement system. “Priming” periods at the beginning of the day. Response Cost: Cost should be mild (e.g., loss of privilege, losing points in token system) and should not be overused Include academic performance (e.g., accurate work completion) in behavior plan. Cooperative teacher Setting up a school-home contract:  Setting up a school-home contract The teacher tracks the child’s behavior and reports it to the parent daily, who rewards the child Pretty easy for the teacher This is particularly effective because both the parent and teacher are involved If the parent can’t be involved, the rewards may be given at school School-Home Contract:  School-Home Contract Daily report card, based on a written contract, coupled with home-based reward system List of a few target behaviors, homework and test grades and homework assignments Choose one target that the child will be successful with most of the time Parent and teacher signatures and comments See samples provided School Home Contract:  School Home Contract Jeffrey Smith promises to stay out of fights on the schoolyard. Each day he does as agreed, he can expect the following actions to take place. From the teacher: Praise One point for each day of appropriate behavior. When ten points are earned, Jeffrey may spend an extra hour on the computer. A note home to parents telling them of Jeffrey’s successful day. From the parents: Praise One point for each day of appropriate behavior. When ten points are earned Jeffrey may invite a friend to dinner and a movie. General Education Classroom:  General Education Classroom Brief, clear, and frequent instructions Include academic performance (e.g., accurate work completion) in behavior plan. Daily report card system Parallel teaching—increase engagement Strategic attention, frequent feedback Post schedules and rules Increase novelty and interest level of tasks “Direct Instruction” techniques General Education Classroom: “504” Plan Accommodations:  General Education Classroom: “504” Plan Accommodations Preferential seating Increased time on tests Reduced homework load Extra supervision Select appropriate group partners Verbal and visual cuing Help with organizational skills ADHD and Test Accommodations:  ADHD and Test Accommodations If ADHD meets the requirements of the Americans with Disabilities Act (impairment that substantially limits a major life activity), then testing accommodations can be requested: Extended time Separate testing room Breaks during the test Behavioral Consequences: Benefits of Whole Classroom Approach (e.g., PBIS):  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 Classroom Management: Evaluation:  Classroom Management: Evaluation Classroom-based contingency management procedures have led to improvement in: Task-related attention Academic productivity and accuracy Interactions with peers and adults Positive reinforcement and response cost procedures necessary Proactive Interventions: Classroom-Wide Peer Tutoring:  Proactive Interventions: Classroom-Wide Peer Tutoring Students in classroom paired and take turns being the tutor Tutors provided with “scripts” Praise or points awarded Errors are immediately corrected Teacher monitors and awards points to pairs Evaluation Enhanced task attention and academic accuracy Practical and highly acceptable Little generalization to other classroom activities Proactive Interventions: Coaching:  Proactive Interventions: Coaching Student teams with adult or peer to develop goals and methods to evaluate. Brief sessions involve: Reviewing and evaluating goals Anticipate barriers to achieving objectives Plan steps and when they should be accomplished Evaluation Promising for adolescents who have shown progress in other structured interventions and who are motivated by attention from others (Dawson, P., & Guare, R. (1998). Coaching the ADHD Student. North Tonawanda, NY: Multi Health Systems) Reducing Teacher Burden :  Reducing Teacher Burden Increase Knowledge Improve attitude to actively work with ADHD students (e.g., treatable, not curable) More difficult for ADHD student to do same work More difficult for ADHD student to behave at appropriate level School behavior and performance mainly a result of school-based interventions rather than individual/family interventions Reducing Teacher Burden:  Reducing Teacher Burden Ongoing Collaboration In-service and videos not enough Help in implementing behavioral programs “Master teachers” Individualized programs Engagement Reducing Teacher Burden:  Reducing Teacher Burden Communicating Developing trust Reduce emphasis on “family problems” as causal Importance of concern; parents know it’s a tough job Support and support groups Slide52:  Systemic Interventions Develop consistent guidelines for assessment and intervention in school system Mount a public awareness campaign Disseminate and use “best practices” information, including communication Include ADHD and mental health issues in the training of new teachers Develop new community resources for children with ADHD (camps, after-school programs) Resources:  Resources The Attention Deficit Information Network Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) National Attention Deficit Disorder Association Resources :  Resources National Information Center for Children and Youth with Disabilities National Institutes of Mental Health

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