Evidence-based practices for students with adhd Alyssa n. suess, ph.d, bcba-d Licensed psychologist, behavior analyst Trinity health

Introduction Licensed Psychologist and BCBA-D Graduated from the University of Iowa Trained with Dr. David Wacker Specialized in the assessment and treatment of problem behavior Currently work in a community-based clinic in ND Behavior therapy Psychological testing

Presentation Outline Overview of ADHD Executive functioning deficits and overarching principles to manage symptoms in the classroom Preventative strategies to reduce attentional deficits and hyperactivity Behavior management to reduce problem behavior Additional strategies for teens

What is adhd? Attention Deficit Hyperactivity Disorder Neurodevelopmental disorder Developmental delays or neuropsychological deficits Attentional deficits Hyperactivity-Impulsivity ADHD symptoms Become apparent in childhood (often before age 16) Persistent across development Persistent across many but not all situations

Symptoms of ADHD Inattention: Hyperactivity-Impulsivity: Fails to give close attention to details Makes careless mistakes Cannot sustain attention Fails to listen Does not follow instructions Fails to finish work Cannot keep work organized Avoids effortful tasks Loses things Easily distracted Forgetful Hyperactivity-Impulsivity: Fidgets or squirms in chair Leaves seat at inappropriate times Runs and climbs on things when inappropriate Cannot play quietly “On the go” or “drive by a motor” Talkative Blurts out answers Difficult waiting for a turn Interrupts others

Environmental factors that effect severity of symptoms Boring Mastered or highly familiar tasks Delayed consequences Infrequent feedback Independent work Large groups Lack of supervision Require waiting Occur late in the afternoon or evening Restriction of movement

Symptoms of ADHD DSM-5 Diagnostic Criteria: Symptoms must occur frequently and be excessive for the child’s age Need to exhibit at least 6 inattentive and/or hyperactivity/impulsivity symptoms Symptoms must be present prior to age 12 Symptoms must persist for at least 6 months Symptoms must be apparent in at least 2 settings (e.g., home or school) Symptoms must cause impairment in functioning (e.g., academic concerns, social impairment)

Adhd facts 5 to 8% of children and 4 to 7% of teens have ADHD Sex ratio of ADHD is 3-4:1 (males to females) in children Symptomatology similar across genders Prevalence of ADHD declines with age Inattentive symptoms become more apparent in teens Higher likelihood of comorbidity than peers

What does not cause ADHD Poor parenting Dietary substances (e.g., sugar, food coloring) Iron deficiencies Excessive screen time

How do symptoms affect student’s behavior and performance?

Executive functioning deficits Goal directed persistence and resistance to distraction Difficulty sustaining attention Difficulty persisting toward the future or focusing on future events Working memory Inability to hold information in memory or remembering what is supposed to be done Inhibition Respond impulsively through actions, verbal behavior, decision making Difficulty delaying gratification Quick emotional reactions and difficulty with self-regulation Planning and problem solving Difficulty constructing and executing a plan to solve problems

Effects on Daily Functioning Self-resistance poor self-control, poor delay to gratification, difficulty inhibiting one’s own desires Self-management to time Poor time-management and organization Self-motivation Difficulty initiating and sustaining motivation Self-organization and problem solving Disorganized and forgetful Self-regulation of emotions Poor inhibition of emotional responses, impatient, frustrated

Overarching principles to manage deficits in executive functioning Externalize information Externally represent or remove gaps in time Externalize motivation Make problem-solving manual Intervene in natural settings Approach ADHD and its executive function deficits as a chronic condition

Externalize information Regulating behavior via processing internal information is impaired Do not nag to try harder but rather externally represent information that is often represented internally Addition of visual cues in the natural environment Acts as a reminder on what should be done Visually display rules of classroom Use a visual schedule or to-do list Use visual cue to signal where to stand in line Use an alarm to signal to stay on-tasks

Externally represent or remove gaps in time Time management difficulties within and across activities Helps us understand why students with ADHD make certain decisions Maximize immediate rewards and escape/avoid aversive circumstances without concern about the delayed negative consequence Need to eliminate time gaps or make time externally represented Provide immediate consequences

Externally represent or remove gaps in time Antecedent Behavior Consequence

Externally represent or remove gaps in time Antecedent Instructed to complete math worksheet Behavior Completed math worksheet Did not complete math worksheet Consequence Token provided as a reinforcer for task completion Token removed for noncompliance

Externally represent or remove gaps in time Time management difficulties within and across activities Helps us understand why students with ADHD make certain decisions Maximize immediate rewards and escape/avoid aversive circumstances without concern about the delayed negative consequence Need to eliminate time gaps or make time externally represented Provide immediate consequences Use a timer to signal the length of time for activities Break assignments up into smaller parts

Externalize motivation Deficits with executive functioning cause a lack of motivation Not effective to complain about a lack of motivation Not effective to let student fail and experience consequences Need to build in external sources of motivation (rewards) Natural reinforcers Artificial reinforcers paired with back-up reinforcers Rewards are analogous to prosthetic devices

make problem-solving manual Mental problem-solving is difficult for children with ADHD It important to make the problem physical to allow for manipulation Use manipulatives for math Use index cards for writing Adding visual cues to problem-solving makes problem-solving a manual task rather than mental task

intervene in natural settings Interventions for students with ADHD must occur in the natural setting (e.g., classroom) Not effective to only provide one-on-one or small group instruction as an accommodation to target executive functioning deficits

approach adhd as a chronic condition Consider ADHD as a chronic condition similar to diabetes Strategies need to be maintained over a long period of time Setbacks will occur (e.g., strategies no longer are effective, crises arise, etc.) Continuing strategies Modifying strategies Implementing new strategies

Antecedent-based strategies for managing adhd in the classroom

Classroom Environment Establish behavioral control at the start of the academic year Focus on behavior management first Rules and instructions must be… Clear Brief and concise Presented externally (i.e., visually display rules) Free Play (rules listed) Desk Work (rules listed) Lecture Time (rules listed)

Classroom Environment Establish behavioral control at the start of the academic year Focus on behavior management first Rules and instructions must be… Clear Brief and concise Presented externally (i.e., visually display rules) Free Play (rules listed) Desk Work (rules listed) Lecture Time (rules listed)

Classroom environment Use a traditional desk arrangement (i.e., all desks facing forward) Place the student close to the teaching area Increases treatment adherence Allow some restlessness at the student’s work area Stress ball or large exercise ball Give frequent but brief physical or exercise breaks Passing out papers or running errands for the teacher Avoid taking away recess or gym time for problem behavior

teaching practices Gain and maintain the student’s attention Be more animated or dramatic when teaching Touch the student lightly when talking to him Keep instruction brief Use participatory teaching Give the student something active to do during teaching Have the student prestate work goals Student has a say in work production Gives small break and allows for frequent check-ins Color-coding of texts Draw the student’s attention to key concepts or directions

teaching practices Require continuous note taking Helps with sustaining attention and working memory Allow using a computer for assignment completion High occurrence of fine motor problems Reduces problem behavior Better attention to computer programs Utilize peer tutoring Better concentration and learns the material quicker than from lectures

structure of work periods Schedule the most difficult subjects in the morning Maximizes student’s ability to attend to the material Decrease the student’s total workload No “busy work” “How much work is needed to demonstrate mastery?” Target productivity first Number of problems attempted and then accuracy second Assign assignments that are short with clear goals or directions Intersperse frequent quizzes to provide feedback Use color-coded binders Helps with organization and being prepared for class Consider creating a “homework” binder

structure of work periods Give smaller quotas of work at a time with frequent breaks Break assignment into small parts Helps to sustain attention Alternate high and low preferred activities Maintain interest as a way to decrease distractibility and classroom disruptions Homework Reduce or eliminate homework for elementary students Little research to support benefits of homework 10 minutes of homework per grade level Give out weekly homework assignments for older students Do not send unfinished work home for parents to do Unfinished work shows that the problem lies at school in the classroom

behavioral programming for students with adhd

Teacher Identifies Problem with Student’s Behavior Conduct Functional Assessment Informal Assessment Behavioral Interview Descriptive Assessment ABC Data Scatter Plot Experimental Assessment Functional Analysis Least to Most Intrusive or Time Intensive

Functional behavior assessment Purpose is to determine the purpose (function) the inappropriate behavior serves the student Evaluate data on events that precede (antecedents) and follow (consequences) the target behavior Helps us determine intervention strategies that will be effective Randomly choose intervention strategies can make behavior worse

Antecedent Behavior Consequence Effect Student A is given work to complete at desk Student off-task and engaging in disruptive behavior Peers laugh and teacher sends student to hallway without work task No problem behavior during desk work Student B is given work to complete at desk Problem behavior occurs again during desk work

Antecedent Behavior Consequence Effect Student A is given work to complete at desk Student off-task and engaging in disruptive behavior Peers laugh and teacher sends student to hallway without work task No problem behavior during desk work Student B is given work to complete at desk Problem behavior occurs again during desk work

Antecedent Behavior Consequence Effect Student A is given work to complete at desk Student off-task and engaging in disruptive behavior Peers laugh and teacher sends student to hallway without work task No problem behavior during desk work Student B is given work to complete at desk Problem behavior occurs again during desk work

Antecedent Behavior Consequence Effect Function Student A is given work to complete at desk Student off-task and engaging in disruptive behavior Peers laugh and teacher sends student to hallway without work task No problem behavior during desk work Attention Student B is given work to complete at desk Problem behavior occurs again during desk work Escape

“ONE SIZE DOES NOT FIT ALL!” Antecedent Behavior Consequence Effect Function Student A is given work to complete at desk Student off-task and engaging in disruptive behavior Peers laugh and teacher sends student to hallway without work task No problem behavior during desk work Attention Student B is given work to complete at desk Problem behavior occurs again during desk work Escape

Function Positive Reinforcement Negative Reinforcement Demand/Activity Attention Tangible Sensory Negative Reinforcement Demand/Activity

Behavior management program Reinforcement program should be implemented before a punishment program Punishment only tells a student what not to do rather than what to do Behavioral program needs to be implemented long-term Problem behavior improves and then worsens Problem behavior worsens at the onset of treatment Good sign treatment is working if problem behavior worsens Persist and continue to implement treatment consistently for at least 3 weeks

Behavior management program Principles of reinforcement important for students with ADHD Immediately Delays degrade efficacy Frequently Intermittently throughout activities Do not wait until end of school day Higher magnitude Choose meaningful reinforcers Praise alone will not be effective Conduct preference assessments Rotate reinforcers within and across days

Function: To gain attention Function: To gain tangible Intervention Function: To gain attention Function: To gain tangible Function: To escape demand Differential Reinforcement of Alternative Behavior (DRA) Raise hand Ask for a turn Ask for a break Differential Reinforcement of Other Behavior (DRO) Sitting quietly for 5 minutes Standing in line appropriately for an average of 2 minutes Working on task at the end of 10 minutes Noncontingent reinforcement (NCR) Schedule times during the day to receive peer and/or teacher attention Schedule times during the day to engage with desired activities Schedule work breaks throughout the school day Extinction Do not provide attention for inappropriate attention seeking behaviors Do not provide access to desired items for problem behavior Do not allow a break for noncompliant behavior Time-Out Removed from situation (e.g., hallway) Removed from situation (e.g., chair) [AVOID USING]

Differential Reinforcement of Alternative Behavior (DRA) Reinforce occurrences of alternative (desired) behavior and withhold reinforcement following occurrence of target problem behavior (extinction)

DRA Applications Attention: Child called on for raising hand; no teacher response if the child yells Tangible: Child gets computer time for appropriately asking; computer withheld for problem behavior Escape: Child gets a work break for asking nicely for a break; no break provided if problem behavior occurs. Child earns “skip work” coupon for compliance; no coupon earned for problem behavior

Differential Reinforcement of Other Behavior (DRO) Reinforcement delivered contingent on problem behavior not occurring during specific interval of time 49

DRO Applications Attention: Child earns a coupon to be the teacher’s special helper if she sits quietly during the first 5 minutes of circle time Tangible: Child earns computer time if he stands in line appropriately for an average of 2 minutes Escape: Child given brief break from work if on-task at end of 10 minute work activity

Noncontingent Reinforcement (NCR) Reinforcer delivered independent of behavior Scheduled times for the child to access reinforcement Reinforcement delivered regardless of behavior “Free” and “frequent” availability of reinforcement may decrease motivation to engage in problem behavior Can be considered an antecedent strategy 51

NCR Applications Attention: Schedule times during the day for the child to receive peer and/or teacher attention Tangible: Schedule times during the day for the child to engage with desired activities Escape: Schedule work breaks throughout the school day

Extinction Involves withholding or terminating the reinforcer that maintains problem behavior Understanding functional contingencies critical Ignoring problem behavior which results in a decrease in problem behavior Very common treatment component DRA Often not used in isolation 53

Extinction Applications Attention: Do not provide attention for inappropriate attention seeking behaviors Tangible: Do not provide access to desired items for problem behavior Escape: Do not allow a break for noncompliant behavior 54

Timeout Removal from activity to deny access to reinforcement Schools often do not use “timeout” Student removed from play area Student placed in hallway

Timeout applications Attention: Place the student in the hallway for engaging in disruptive behaviors during class Tangible: Place the student in a designated chair when she engages in problem behavior when she cannot have access to desired item Escape: Avoid using! Often countertherapeutic

Token economy Provides students with “tokens” for demonstrating target behaviors (e.g., compliance) Tokens are secondary reinforcers and exchanged for primary reinforcers (e.g., computer time, work pass)

Token economy Determine behaviors to be reinforced (target behaviors) Choose type of tokens to be earned (e.g., stickers, poker chips, point card) Determine the number of tokens to be earned for each target behavior Create a list of primary reinforcers including the value of each reinforcer Practice token exchange Must be able to earn tokens frequently and exchange tokens on a daily basis

daily behavior card Allows the teacher and parents to communicate regularly about the student’s behavior Provides an opportunity for the student monitor her own behavior

daily behavior card Teacher creates small card with activities or days of week listed Behavior goals are listed on card Card is placed on the student’s desk or in a planner Child earns sticker, smiley face, or number rating next to the behavior goal Immediate feedback is important! External rewards might be needed in order to motivate child

behavior contracting Contract established between the teacher and student Outlines expected behaviors, rewards for exhibiting the target behaviors, and consequences for problem behavior Create new contract weekly

behavior contracting Meet with student to discuss academic and behavior goals Clear goals to reduce negotiation Determine the rewards earned for meeting goals Specify when the student will earn the rewards Specify punishment for problem behavior Loss of points or tokens Response cost procedure (e.g., additional work tasks) Signatures from the teacher and student Make contract visible to student

teen management Psychotropic medication may be needed More expectations with executive functioning Less structure and supervision Designate an adult mentor who meets with the student daily Require use of a homework sheet or planner Consider providing an extra set of books for home Allow the student to type assignments

teen management Digitally record lessons for review Schedule harder classes in the morning or early afternoon Allow the student to listen to music while working Require note taking Use peer tutoring or a study buddy Have regular parent-teacher meetings

Summary Executive functioning deficits Sustaining and persisting towards the future Difficulties holding information in their memory Lack the ability to inhibit emotions and actions Difficulties with problem solving Externalize, Externalize, and Externalize! Antecedent strategies to prevent problems If disruptive behaviors then treatment matched to function

Contact Information: Alyssa Suess alyssa.suess@trinityhealth.org