Laura G. Anthony, Ph.D. Children’s National Medical Center Pediatric Neuropsychology Nancy Lever, Ph.D. Center for School Mental Health Analysis and Action Department of Psychiatry, University of Maryland, Baltimore Best Practices: Strategies for Addressing ADHD & Disruptive Behavior Disorders

Maryland School Mental Health Alliance School Mental Health Integration Grant

History Commitment from key local, state, and national partners to collaborate and form an Alliance to advance school-mental health system integration in Maryland Commitment from key local, state, and national partners to collaborate and form an Alliance to advance school-mental health system integration in Maryland Strong support for children’s mental health and school mental health in the state Strong support for children’s mental health and school mental health in the state A strong PBIS structure within the state and an interest in enhancing mental health support and resources for red and yellow zone youth A strong PBIS structure within the state and an interest in enhancing mental health support and resources for red and yellow zone youth Notified of award in September 2005 Notified of award in September of 20 funded projects (84 total applicants)

Maryland School Mental Health Alliance (MSMHA) Maryland State Department of Education Maryland State Department of Education Center for School Mental Health Analysis and Action - University of Maryland Center for School Mental Health Analysis and Action - University of Maryland Center for Prevention and Early Intervention - Johns Hopkins University Center for Prevention and Early Intervention - Johns Hopkins University Governor’s Office for Children Governor’s Office for Children Maryland Assembly on School-Based Health Care Maryland Assembly on School-Based Health Care Maryland Coalition of Families for Children’s Mental Health Maryland Coalition of Families for Children’s Mental Health Maryland Department of Juvenile Services Maryland Department of Juvenile Services Mental Hygiene Administration Department of Health and Mental Hygiene Mental Hygiene Administration Department of Health and Mental Hygiene Mental Health Association of Maryland Mental Health Association of Maryland

Primary Grant Objectives 1. To further build a systematic state initiative for school mental health (SMH) 2. To improve outcomes related to red and yellow zone youth in PBIS schools through: Helping school staff to better identify and refer students who could benefit from mental health services Helping school staff to better identify and refer students who could benefit from mental health services Enhancing mechanisms for effective communication between schools and the mental health system to help better integrate quality mental health care for students Enhancing mechanisms for effective communication between schools and the mental health system to help better integrate quality mental health care for students Developing training and resources to assist school staff with creating environments that support academic, social, and emotional learning for children with more intensive mental health needs Developing training and resources to assist school staff with creating environments that support academic, social, and emotional learning for children with more intensive mental health needs

Make sure it is ADHD! Mood/Anxiety Problems PDD Spectrum

Evidence-Based Treatment of ADHD

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) 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. A handful of studies have documented decreases in negative (but not increases in positive) mother-child interaction with stimulant medication.

“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

What works for ADHD? All of the evidence-based practice elements for use in ADHD have their basis in Clinical Behavior Therapy. 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 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? Treatments with little or no evidence of effectiveness include Treatments with little or no evidence of effectiveness include Special elimination diets Special elimination diets Vitamins or other health food remedies Vitamins or other health food remedies Psychotherapy or psychoanalysis Psychotherapy or psychoanalysis Biofeedback Biofeedback Play therapy Play therapy Chiropractic treatment Chiropractic treatment Sensory integration training Sensory integration training Social skills training Social skills training Self-control training Self-control training

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 Contingencies

An example: The ABC Model

The ABC Model Contingencies Teacher makes eye contact with student, says, “Take out your math books.”

Basic Principles Clear and brief rules Clear and brief rules Swift consequences Swift consequences Frequent consequences Frequent consequences Powerful consequences Powerful consequences Rich incentives Rich incentives Change rewards Change rewards Expect failures Expect failures Anticipate Anticipate

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 Difficulties in completing independent seat work Difficulties in completing independent seat work Talking with classmates at inappropriate times Talking with classmates at inappropriate times Frequent out-of-seat behavior Frequent out-of-seat behavior Organizational difficulties Organizational difficulties

Praise Training teachers to praise correctly increases compliance in youth with ADHD/DBD Training teachers to praise correctly increases compliance in youth with ADHD/DBD 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 working quietly, why can’t you do this all the time?”) 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 Give praise immediately

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

Teaching to ignore Teach staff and teachers how and when to ignore undesirable behavior Teach staff 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., talking faster or louder) Do not vary the frequency or intensity of your current activity (e.g., talking faster or louder)

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 tantrums Child tantrums 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 how and when to differentially reinforce desirable behavior Teach 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

Differential Reinforcement of target behavior Target behavior: Interrupting Target behavior: Interrupting Alternative behavior: Working by himself Alternative behavior: Working 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 Teacher systematically delays reinforcement once child responds to initial schedule 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 staff and teachers that the behavior will get worse before it gets better (child will work harder to gain their attention) 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 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 teachers to reward only the alternative (desirable) behavior, so they don’t reward other unwanted behaviors by mistake Train teachers to reward only the alternative (desirable) behavior, so they don’t reward other unwanted behaviors by mistake

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

Improving commands/limit setting with 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 adolescents 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, con’t. 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

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

Response Cost with Children Train teachers: Train 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 Teacher and child have chosen to reduce whining Teacher and child have chosen to reduce whining If child whines, teacher deducts one point If child whines, teacher deducts one point Penalties increase based on severity of behavior Penalties increase based on severity of behavior

Response Cost with Adolescents Train teachers: Train teachers: To use behavioral contract with the teen for “fines” To use behavioral contract with the teen for “fines” Teen agrees to not swear Teen agrees to not swear If teen swears, teen loses 15 minutes of internet privilege at school If teen swears, teen loses 15 minutes of 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 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 Train teachers: Train teachers: To avoid “punishment spiral” To avoid “punishment spiral” When teacher fines teen for misbehavior, the teen responds with more misbehavior When teacher 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: fine teen no more than twice, then direct teen to “cool off” away from the situation Rule: fine teen no more than twice, then direct teen to “cool off” away from the situation

Response Cost with Adolescents Encourage teacher to act as “judge and jury” when teen lies Encourage teacher to act as “judge and jury” when teen lies The teen should remain above suspicion The teen should remain above suspicion Response cost allows teacher to discipline/educate instead of just punish Response cost allows teacher 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

Setting up a school-home contract 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 Pretty easy for the teacher Pretty easy for the teacher 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

School-Home Contract Daily report card, based on a written contract, coupled with home-based reward system 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 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 Choose one target that the child will be successful with most of the time Parent and teacher signatures and comments Parent and teacher signatures and comments See samples provided 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 Brief, clear, and frequent instructions Brief, clear, and frequent instructions Include academic performance (e.g., accurate work completion) in behavior plan. Include academic performance (e.g., accurate work completion) in behavior plan. Daily report card system Daily report card system Parallel teaching—increase engagement Parallel teaching—increase engagement Strategic attention, frequent feedback Strategic attention, frequent feedback Post schedules and rules Post schedules and rules Increase novelty and interest level of tasks Increase novelty and interest level of tasks “Direct Instruction” techniques “Direct Instruction” techniques

Behavioral Consequences: Benefits of Whole Classroom Approach (e.g., PBIS) Reduces sense of “unfairness;” ADHD children receiving special treatment Reduces sense of “unfairness;” ADHD children receiving special treatment Multiple ADHD children in classroom may strain individual approach Multiple ADHD children in classroom may strain individual approach Benefits whole class environment Benefits whole class environment

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  Students in classroom paired and take turns being the tutor Tutors provided with “scripts” Tutors provided with “scripts” Praise or points awarded Praise or points awarded Errors are immediately corrected Errors are immediately corrected Teacher monitors and awards points to pairs Teacher monitors and awards points to pairs Evaluation Evaluation Enhanced task attention and academic accuracy Enhanced task attention and academic accuracy Practical and highly acceptable Practical and highly acceptable Little generalization to other classroom activities Little generalization to other classroom activities

Proactive Interventions: Coaching  Student teams with adult or peer to develop goals and methods to evaluate. Brief sessions involve: Reviewing and evaluating goals Reviewing and evaluating goals Anticipate barriers to achieving objectives Anticipate barriers to achieving objectives Plan steps and when they should be accomplished Plan steps and when they should be accomplished Evaluation 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) 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 Increase Knowledge Increase Knowledge Improve attitude to actively work with ADHD students (e.g., treatable, not curable) 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 do same work More difficult for ADHD student to behave at appropriate level 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 School behavior and performance mainly a result of school-based interventions rather than individual/family interventions

Reducing Teacher Burden Ongoing Collaboration Ongoing Collaboration In-service and videos not enough In-service and videos not enough Help in implementing behavioral programs Help in implementing behavioral programs “Master teachers” “Master teachers” Individualized programs Individualized programs Engagement Engagement

Reducing Teacher Burden Communicating Communicating Developing trust Reduce emphasis on “family problems” as causal Importance of concern; parents know it’s a tough job Support and support groups Support and support groups

Systemic Interventions Develop consistent guidelines for assessment and intervention in school system Develop consistent guidelines for assessment and intervention in school system Mount a public awareness campaign Mount a public awareness campaign Disseminate and use “best practices” information, including communication Disseminate and use “best practices” information, including communication Include ADHD and mental health issues in the training of new teachers Include ADHD and mental health issues in the training of new teachers Develop new community resources for children with ADHD (camps, after-school programs) Develop new community resources for children with ADHD (camps, after-school programs)

Resources The Attention Deficit Information Network The Attention Deficit Information Network Children and Adults with Attention- Deficit/Hyperactivity Disorder (CHADD) Children and Adults with Attention- Deficit/Hyperactivity Disorder (CHADD) National Attention Deficit Disorder Association National Attention Deficit Disorder Association Maryland School Mental Health Alliance Maryland School Mental Health Alliance

Resources National Information Center for Children and Youth with Disabilities National Information Center for Children and Youth with Disabilities National Institutes of Mental Health National Institutes of Mental Health