ADHD Practice Elements Developed by the Center for School Mental Health with support provided in part from grant 1R01MH A1 from the National Institute of Mental Health and Project # U45 MC00174 from the Office of Adolescent Health, Maternal, and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services

Specific interventions to help the student with ADHD Psycho-education with parent Psycho-education with parent Parent praise Parent praise Commands/limit setting Commands/limit setting Tangible rewards Tangible rewards Response cost Response cost Parent monitoring Parent monitoring Time out Time out Ignoring or DRO Ignoring or DRO

Parent Psychoeducation Engage and empower parents by teaching them about ADHD Engage and empower parents by teaching them about ADHD Establish relationship with parents as partner in treatment process Establish relationship with parents as partner in treatment process Look at how ADHD influences parent-child interaction (bi-directional) Look at how ADHD influences parent-child interaction (bi-directional)

Parent Psychoeducation Review information about ADHD Review information about ADHD Symptoms Symptoms Causes Causes Diagnostic criteria (3 sub-types) Diagnostic criteria (3 sub-types) Treatment modalities Treatment modalities

Emphasize caretaker role in development and treatment of ADHD Emphasize caretaker role in development and treatment of ADHD Problems in parenting and parenting styles may make ADHD worse Problems in parenting and parenting styles may make ADHD worse Establishing behavioral interventions at home or at school require caretaker involvement Establishing behavioral interventions at home or at school require caretaker involvement Knowledge enables parents to more effectively advocate for better services Knowledge enables parents to more effectively advocate for better services Parent Psychoeducation

 More effective if therapist devotes more than one session to psychoeducation More effective if therapist educates parents about ADHD across multiple settings (home, school, playground, etc) More effective if therapist educates parents about ADHD across multiple settings (home, school, playground, etc)

Resources for Parent Psychoeducation Center for Children and Families Center for Children and Families “What Parents and Teachers Should Know about ADHD” “What Parents and Teachers Should Know about ADHD” Children and Adults with Attention- Deficit/Hyperactivity Disorder (CHADD) Children and Adults with Attention- Deficit/Hyperactivity Disorder (CHADD) Fact sheets for parents Fact sheets for parents

Resources for Parent Psychoeducation National Initiative for Children’s Healthcare Quality National Initiative for Children’s Healthcare Quality “How to Establish a School-Home Daily Report Card” “How to Establish a School-Home Daily Report Card” Vanderbilt Assessment Scales (parent and teacher version) Vanderbilt Assessment Scales (parent and teacher version) ADHD Resources Available on the Internet ADHD Resources Available on the Internet “Working with Your Child’s School” “Working with Your Child’s School”

Parent praise Training parents to praise correctly increases compliance in youth with ADHD Training parents to praise correctly increases compliance in youth with ADHD Praise can include Praise can include Verbal praise, Encouragement Verbal praise, Encouragement Attention Attention Affection Affection Physical proximity Physical proximity

Giving effective praise Be honest, not overly flattering Be honest, not overly flattering Be specific Be specific No “back-handed compliments” (i.e., “I like the way you are playing quietly, why can’t you do this while I’m on the phone?”) No “back-handed compliments” (i.e., “I like the way you are playing quietly, why can’t you do this while I’m on the phone?”) Give praise immediately Give praise immediately

Training parents to praise children Barkley manual, Step 2 (Defiant Children) Barkley manual, Step 2 (Defiant Children) Teach parents to set up “special time” to pay attention to their child during play Teach parents to set up “special time” to pay attention to their child during play Teach parents to narrate their child’s play Teach parents to narrate their child’s play Teach parents not to ask many questions nor give any commands Teach parents not to ask many questions nor give any commands Teach parents to ignore misbehavior during this playtime Teach parents to ignore misbehavior during this playtime Teach parents how to praise and praise lavishly during this time Teach parents how to praise and praise lavishly during this time

Training parents to praise teens Barkley manual, Step 3 (Defiant Teens) Barkley manual, Step 3 (Defiant Teens) Encourage parents to set aside 15 minutes a few times a week to pay attention to their adolescent Encourage parents to set aside 15 minutes a few times a week to pay attention to their adolescent Teach parents to pay attention to what their teen is doing, and show interest in a relaxed way Teach parents to pay attention to what their teen is doing, and show interest in a relaxed way Teach parents not to ask questions nor give any instructions Teach parents not to ask questions nor give any instructions Teach parents to ignore if the teenager reacts with sarcasm, coolness or suspicion Teach parents to ignore if the teenager reacts with sarcasm, coolness or suspicion Teach parents to praise well and often Teach parents to praise well and often

Improving commands/limit setting Training for parents and teachers to give commands in the most effective way Training for parents and teachers to give commands in the most effective way Effective command increase compliance in children and adolescents with ADHD (and in others, too!) Effective command increase compliance in children and adolescents with ADHD (and in others, too!)

Improving commands/limit setting with children Barkley Step 3 (Defiant Children) Barkley Step 3 (Defiant Children) Teach parents and teachers: Teach parents and teachers: To only give commands that they intend to back up with consequences (positive and negative) To only give commands that they intend to back up with consequences (positive and negative) Not to present commands as questions or favors Not to present commands as questions or favors Not give too many commands at once Not give too many commands at once

Improving commands/limit setting with children Teach parents and teachers: Teach parents and teachers: To make eye contact with the child before giving command To make eye contact with the child before giving command To reduce other distractions while giving commands To reduce other distractions while giving commands To ask the child to repeat the command To ask the child to repeat the command To watch the child for one minute after giving the command to ensure compliance To watch the child for one minute after giving the command to ensure compliance To immediately praise child when s/he starts to comply To immediately praise child when s/he starts to comply

Improving commands/limit setting with adolescents Barkley, Defiant Teens, Step 4 Barkley, Defiant Teens, Step 4 Teach parents and teachers: Teach parents and teachers: To consider the intent of their command To consider the intent of their command Do they have the time/energy to follow through? Do they have the time/energy to follow through? Do they have consequences for noncompliance? Do they have consequences for noncompliance? To avoid ambiguity when issuing commands To avoid ambiguity when issuing commands To not respond to compliance with gratitude To not respond to compliance with gratitude

Improving commands/limit setting with adolescents Teach parents and teachers: 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

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

Setting up a reward system for children at home Barkley, Defiant Children, Step 4 Barkley, Defiant Children, Step 4 Determine family’s readiness to implement Determine family’s readiness to implement Tailor the program to family’s ability-simplify it for overwhelmed or stressed families Tailor the program to family’s ability-simplify it for overwhelmed or stressed families Use poker chip system with younger children (4-7), point system with older children (8 and up) Use poker chip system with younger children (4-7), point system with older children (8 and up)

Setting up a reward system for children at home Set a positive tone for the program Set a positive tone for the program “We are going to make sure that you get rewarded for all of the good stuff you do at home” “We are going to make sure that you get rewarded for all of the good stuff you do at home” Parent(s) buys chips and makes a bank, or sets up a chart or notebook for tracking points Parent(s) buys chips and makes a bank, or sets up a chart or notebook for tracking points The parent(s) and child together (with your help) make up a list of rewards The parent(s) and child together (with your help) make up a list of rewards There should be everyday rewards, like TV or computer time, and longer term rewards, like going to a movie or earning a new video game) There should be everyday rewards, like TV or computer time, and longer term rewards, like going to a movie or earning a new video game)

Setting up a reward system for children at home Help the parent(s) and child make a list of jobs or problem areas Help the parent(s) and child make a list of jobs or problem areas Determine how much each is worth Determine how much each is worth Add up how much the child might earn in a day Add up how much the child might earn in a day Harder jobs should earn more Harder jobs should earn more Bigger rewards should cost more Bigger rewards should cost more Make sure the child has some success in the beginning Make sure the child has some success in the beginning

Setting up a reward system for children at home Discuss the concept of bonus chips to reward helpful or other positive behaviors, even if they aren’t on the list Discuss the concept of bonus chips to reward helpful or other positive behaviors, even if they aren’t on the list Chips and points are only given if the child complies after the first command Chips and points are only given if the child complies after the first command Don’t take away chips or points (response cost) Don’t take away chips or points (response cost) All caregivers should use the same system All caregivers should use the same system Remind parents to praise while giving the points Remind parents to praise while giving the points

Setting up a reward system for children at school Barkley, Defiant Children, Step 8, Daily School Report Card Barkley, Defiant Children, Step 8, Daily School Report Card The teacher tracks the child’s behavior and reports it to the parent daily, who rewards the child The teacher tracks the child’s behavior and reports it to the parent daily, who rewards the child This is particularly effective because both the parent and teacher are involved 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 If the parent can’t be involved, the rewards may be given at school

Setting up a reward system for children at school Choose a few target behaviors at school Choose a few target behaviors at school Choose one that the child will be successful with most of the time Choose one that the child will be successful with most of the time Set up a system for school report card or school/home note system Set up a system for school report card or school/home note system See samples on page See samples on page Pick from the targets given, or create your own with the blank samples Pick from the targets given, or create your own with the blank samples

Setting up a reward system for adolescents at home Barkley, Defiant Teens, Step 5 Barkley, Defiant Teens, Step 5 Use a point system (see previous slides) for 13/14 and under Use a point system (see previous slides) for 13/14 and under Set up basically the same way as with children Set up basically the same way as with children Warn parents to expect resistance, their teen is used to getting all of their privileges for free! Make sure parents don’t give in. Warn parents to expect resistance, their teen is used to getting all of their privileges for free! Make sure parents don’t give in. Make sure parents only choose privileges they can control Make sure parents only choose privileges they can control

Setting up a reward system for adolescents at home Barkley, Defiant Teens, Step 5 Barkley, Defiant Teens, Step 5 Use a behavior contract for teens 14/15 and older Use a behavior contract for teens 14/15 and older See sample contract on page 208 See sample contract on page 208 Begin with only “do” behaviors (clean up room, set table, get ready for school on time) Begin with only “do” behaviors (clean up room, set table, get ready for school on time) “Don’t” behaviors are dealt with under response cost in next section “Don’t” behaviors are dealt with under response cost in next section

Setting up a reward system for adolescents at school Barkley, Defiant Teens, Step 9 Barkley, Defiant Teens, Step 9 Establish a homework contract (see sample on page 121) Establish a homework contract (see sample on page 121) This can be adapted for other behavioral goals This can be adapted for other behavioral goals Can also set up guidance counselor, tutor or peer as “coach” for organizational skills or other targets Can also set up guidance counselor, tutor or peer as “coach” for organizational skills or other targets Rewards for teen’s participation can be made part of the home contract, or part of a school reward system Rewards for teen’s participation can be made part of the home contract, or part of a school reward system

Response Cost Using a point or token system in which negative behaviors result in the loss of points or tokens. Using a point or token system 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 Training parents and teachers to use response cost is effective in reducing undesired behavior and noncompliance

Response Cost with Children Barkley, Defiant Children Step 4 & 8 Barkley, Defiant Children Step 4 & 8 Train parents and teachers: Train parents and teachers: To develop list of undesirable behavior to be fined by reward system To develop list of undesirable behavior to be fined by reward system To deduct points/chips for undesirable behavior To deduct points/chips for undesirable behavior Parent and child have chosen to reduce whining Parent and child have chosen to reduce whining If child whines, parent deducts three points If child whines, parent deducts three points Penalties increase based on severity of behavior Penalties increase based on severity of behavior

Response Cost with Children Train parents and teachers: Train parents and teachers: To avoid “punishment spiral” To avoid “punishment spiral” When parent fines child for misbehavior, the child may respond with more misbehavior When parent fines child for misbehavior, the child may respond with more misbehavior Child continues to lose points, then loses motivation for the point system Child continues to lose points, then loses motivation for the point system Rule: Parent fines child once through point system, then sends child to time out if undesirable behavior continues Rule: Parent fines child once through point system, then sends child to time out if undesirable behavior continues

Response Cost with Adolescents Barkley, Defiant Teens Step 6 Barkley, Defiant Teens Step 6 To train parents and teachers: To train parents and teachers: To now use behavioral contract with the teen for “fines” To now use behavioral contract with the teen for “fines” Teen agrees to not swear Teen agrees to not swear If teen swears, teen loses Internet privilege If teen swears, teen loses Internet privilege

Response Cost with Adolescents Train parents and teachers: Train parents and teachers: To begin with 1 week “training period,” during which parent labels misbehavior every time it happens and warns of new fines To begin with 1 week “training period,” during which parent labels misbehavior every time it happens and warns of new fines To avoid “punishment spiral” To avoid “punishment spiral” When parent fines teen for misbehavior, the teen responds with more misbehavior When parent fines teen for misbehavior, the teen responds with more misbehavior Teen continues to lose privileges, then loses motivation Teen continues to lose privileges, then loses motivation Rule: Parent fines teen no more than twice, then directs teen to “cool off” away from the situation Rule: Parent fines teen no more than twice, then directs teen to “cool off” away from the situation

Response Cost with Adolescents Encourage parents to act as “judge and jury” when teen lies Encourage parents to act as “judge and jury” when teen lies The teen should remain above suspicion The teen should remain above suspicion Response cost allows parents to discipline/educate instead of just punish Response cost allows parents to discipline/educate instead of just punish Emphasis of response cost is on Emphasis of response cost is on “Warm” – positive, loving “Warm” – positive, loving “Firm” – specific, immediate, and consistent “Firm” – specific, immediate, and consistent

Parent Monitoring Give parents a structured way to monitor their child’s behavior Give parents a structured way to monitor their child’s behavior Measurement of the target behavior should be repeated Measurement of the target behavior should be repeated Can use either informal or formal measures Can use either informal or formal measures

Parent Monitoring Informal measures Informal measures Daily homework log Daily homework log Behavior chart as part of a reward system Behavior chart as part of a reward system Home Situations Checklist (Barkley, Defiant Children) Home Situations Checklist (Barkley, Defiant Children)

Parent Monitoring Formal measures Formal measures Vanderbilt Scales (from your Resource Toolkit or on the web) Vanderbilt Scales (from your Resource Toolkit or on the web) Disruptive Behavior Disorders Scale (in Barkley or on the web) Disruptive Behavior Disorders Scale (in Barkley or on the web)

Time Out Time out is the removal of a child or adolescent from all reinforcement for a specified period of time after a targeted misbehavior Time out is the removal of a child or adolescent from all reinforcement for a specified period of time after a targeted misbehavior It is an effective intervention, but only if it is used correctly and is not used too often It is an effective intervention, but only if it is used correctly and is not used too often

Using Time Out with Children at Home Barkley, Defiant Children, Step 5 Barkley, Defiant Children, Step 5 Teach parents to give an effective command (Step 3) Teach parents to give an effective command (Step 3) Teach parents to count out loud (initially) from 5 to 1 Teach parents to count out loud (initially) from 5 to 1 Teach parents to give a time out warning if the child has not complied Teach parents to give a time out warning if the child has not complied After warning, count from 5 to 1 again After warning, count from 5 to 1 again

Using Time Out with Children at Home Teach parents to guide child to time out chair IMMEDIATELY Teach parents to guide child to time out chair IMMEDIATELY Teach parents to place the child in the chair “Stay there until I tell you to get up” Teach parents to place the child in the chair “Stay there until I tell you to get up” Teach parents not to argue or interact with the child in any way Teach parents not to argue or interact with the child in any way Teach parents to not come back until the child is calm. Once the child is calm and the time is served, the child must correct the misbehavior Teach parents to not come back until the child is calm. Once the child is calm and the time is served, the child must correct the misbehavior

Using Time Out with Children at Home Teach the parents that the child should now go and comply with the previous command, or correct the misbehavior Teach the parents that the child should now go and comply with the previous command, or correct the misbehavior Teach the parent to now praise compliance, and to praise the next behavior that the child does well Teach the parent to now praise compliance, and to praise the next behavior that the child does well

Time Out Tips with Children The first time out may be difficult The first time out may be difficult Prepare parents for a worst case scenario of a complete struggle. Prepare parents for a worst case scenario of a complete struggle. Reassure parents that this is how the child learns time out and correcting misbehavior. Reassure parents that this is how the child learns time out and correcting misbehavior. Make sure the time out area is away from anything interesting or fun Make sure the time out area is away from anything interesting or fun Remind parents not to “make up for” the time out (i.e., saving dessert for them) Remind parents not to “make up for” the time out (i.e., saving dessert for them)

Using Time Out with Adolescents Barkley, Defiant Teens, Step 8 Barkley, Defiant Teens, Step 8 “Grounding” = “house arrest” “Grounding” = “house arrest” NO access to privileges (phone, TV, etc) NO access to privileges (phone, TV, etc) Parent must be home to enforce Parent must be home to enforce Most effective with younger teens Most effective with younger teens May include “work detail” (cleaning out basement, scrubbing bathroom floor) May include “work detail” (cleaning out basement, scrubbing bathroom floor)

Ignoring and Differential Reinforcement Train parents and teachers to selectively Train parents and teachers to selectively Ignore mild unwanted behaviors Ignore mild unwanted behaviorsAND Attend to alternative positive behaviors Attend to alternative positive behaviors

Teaching parents and teachers to ignore Teaching parents and teachers how and when to ignore undesirable behavior Teaching parents and teachers how and when to ignore undesirable behavior Ignoring can include Ignoring can include Visual cues Visual cues Postural cues Postural cues Vocal cues Vocal cues Social cues Social cues

How to ignore Visual cues Visual cues Look away once child engages in undesirable behavior Look away once child engages in undesirable behavior Do not look at the child until behavior stops Do not look at the child until behavior stops Postural cues Postural cues Turn the front of your body away from the location of child’s undesirable behavior 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 appear frustrated (e.g., hands on hip) Do not vary the frequency or intensity of your current activity (e.g., chopping faster, hammering harder) Do not vary the frequency or intensity of your current activity (e.g., chopping faster, hammering harder)

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

When to ignore  When to ignore undesirable behavior Child interrupts conversation or class Child interrupts conversation or class Child blurts out answers before question completed Child blurts out answers before question completed Child continuously talks during dinner Child continuously talks during dinner Child tantrums while at the grocery store Child tantrums while at the grocery store Do not ignore undesirable behavior that could potentially harm the child or someone else Do not ignore undesirable behavior that could potentially harm the child or someone else

Differential reinforcement Teach parents and teachers how and when to differentially reinforce desirable behavior Teach parents and teachers how and when to differentially reinforce desirable behavior Step One: Ignore (stop reinforcing) the child’s undesirable behavior Step One: Ignore (stop reinforcing) the child’s undesirable behavior Step Two: Reinforce the child’s desirable behavior in a systematic manner 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 The desirable behavior should be a behavior that is incompatible with the undesirable behavior

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

Reinforcement of target behavior Target behavior: Interrupting Target behavior: Interrupting Alternative behavior: Playing by himself Alternative behavior: Playing by himself Reward schedule: 5 minutes Reward schedule: 5 minutes If child goes 5 minutes without interrupting, the child receives reinforcement 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 If child interrupts before 5 minutes is up, the child does not receive reinforcement Re-set schedule once child interrupts Re-set schedule once child interrupts

Differential reinforcement Parent or teacher systematically delays reinforcement once child responds to initial schedule Parent or teacher systematically delays reinforcement once child responds to initial schedule Target behavior: Interrupting Target behavior: Interrupting 1 st reinforcement schedule: 5 minutes 1 st reinforcement schedule: 5 minutes 2 nd reinforcement schedule: 6 minutes 2 nd reinforcement schedule: 6 minutes 3 rd reinforcement schedule: 7.5 minutes 3 rd reinforcement schedule: 7.5 minutes

Problems with ignoring and differential reinforcement Extinction burst Extinction burst Warn parents and teachers that the behavior will get worse before it gets better (child will work harder to gain their attention) Warn parents 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 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 Indiscriminant reinforcement Train parents to reward the alternative (desirable) behavior, so they don’t reward other unwanted behaviors by mistake Train parents to reward the alternative (desirable) behavior, so they don’t reward other unwanted behaviors by mistake