Help for the Wiggling and Off-Task Interventions Jodi A. Polaha, Ph.D. Assistant Professor, Pediatrics Munroe-Meyer Institute, UNMC Director, Hastings Behavioral Health Clinic

New Conceptualization of ADHD Russell Barkley, Ph.D. “ADHD is a delay in the development of behavioral inhibition.”

Behavioral Inhibition System Effects executive functioning. Processing Input Output Sensing Executing

Behavioral Inhibition System Effects executive functioning. Processing Input Output Sensing Executing A problem of PERSISTENCE and MOTIVATION.

What we know works: 4 Drug Therapy 4 Behavior Therapy 4 Combined Behavioral/Drug Treatments

What we know DOESN’T work: 4 Play therapy 4 Individual or family counseling (without altering the environment) 4 Social skills/Self-monitoring/organizational planning.

Not enough evidence to say : 4 Dietary management 4 Megavitamin therapy 4 Sensory integration therapy/chiropractics 4 Biofeedback

What we know works: 4 Drug Therapy 4hundreds of studies (N > 5000) 4 Behavior Therapy 448 classroom studies (N > 900) 480 parent/home studies (N > 5,000) 4 Combined Behavioral/Drug Treatments 410 classroom studies (N > 800)

Medications for ADHD 4 Stimulants Ritalin, Adderall, Cylert, Dexedrine

Medications for ADHD 4 Stimulants Ritalin, Adderall, Cylert, Dexedrine 4 Tri-Cyclic Antidepressants Imipramine

Medications for ADHD 4 Stimulants Ritalin, Adderall, Cylert, Dexedrine 4 Tri-Cyclic Antidepressants Imipramine 4 Clonidine

What Medications Can Do Manage symptoms 4 Decrease activity level 4 Decrease impulsivity 4 Increase attention or “focus”

What Medications Can Do Improve associated features 4 Decrease “defiance” 4 Decrease aggression 4 Suppress negative social skills

What Medications Can’t Do 4 Teach new, appropriate behaviors Compliance/rule-following Self-management

What Medications Can’t Do 4 Teach new, appropriate behaviors Compliance/rule-following Self-management 4 Teach content previously missed Academic work Social skills

What Medications Can’t Do 4 Teach new, appropriate behaviors Compliance/rule-following Self-management 4 Teach content previously missed Academic work Social skills 4 “Cure” ADHD

Stimulant Medications: Considerations 4 Effective for 70-75% 4 Higher doses associated with more side effects 4 Positive effects are lost when drug discontinued

Stimulant Medications: Contraindications 4 Under six years of age 4 High anxiety level 4 Thought disorder 4 History of tics or Tourette’s Syndrome 4 Risk of drug abuse 4 Unacceptably high levels of negative side effects

Behavioral Inhibition System Effects executive functioning. Processing Input Output Sensing Executing A problem of PERSISTENCE and MOTIVATION.

Behavioral Inhibition System “Temporal Myopia” NOW Response event horizon (Dr. R. Barkley) 5-7 yrs hours 8-12 years - 24 hours year days 30+ years weeks

Behavioral Inhibition System “Temporal Myopia” NOW Event Response event horizon (Dr. R. Barkley)

Behavioral Inhibition System “Temporal Myopia” NOW Event Response event horizon (Dr. R. Barkley)

Behavior Therapy for ADHD Components 4 Highly Structured

Behavior Therapy for ADHD Components 4 Highly Structured 4 Immediate Feedback reinforcer or reward for appropriate behavior punishment for inappropriate behavior

Behavior Therapy for ADHD Components 4 Highly Structured 4 Immediate Feedback reiforcer or reward for appropriate behavior punishment for inappropriate behavior 4 Salient/Meaningful Feedback

School Behavior Intervention Examples: 1. The Attention Training System (ATS) 2. Home School Note

School Behavior Intervention: The Attention Training System (ATS) 1. Technology Teacher Module Student Module

School Behavior Intervention: The Attention Training System (ATS) 1. Technology Teacher Module Student Module 2. Immediate feedback

School Behavior Intervention: The Attention Training System (ATS) 1. Technology Teacher Module Student Module 2. Immediate feedback 3. Meaningful consequences

School Behavior Intervention: The Attention Training System (ATS) 1. Technology Teacher Module Student Module 2. Immediate feedback 3. Meaningful consequences 4. Structured “time”

School Behavior Intervention The ATS: Lisa Days % Time Off Task No ATSATSNo ATSATS

School Behavior Intervention The ATS: Troy Days % Time Off Task No ATS ATS Meds Only

School Behavior Intervention Home School Notes Address Problems With 4Academic effort 4In-class behaviors 4Assignment completion

School Behavior Intervention Home School Notes Procedures 4 Identify target behaviors.

School Behavior Intervention Home School Notes Academic Behaviors 3 Working on assignments 3 Completing homework 3 Handing in assignments 3 All work up to date 3 On time for class

School Behavior Intervention Home School Notes Academic Behaviors 3 Working on assignments 3 Completing homework 3 Handing in assignments 3 All work up to date 3 On time for class Social Behaviors 3 Out of seat 3 Talking without permission 3 Disrespectful behavior 3 Bothering peers 3 Following instructions 3 Hands to self

School Behavior Intervention Home School Notes Procedures 4 Identify target behaviors. 4 Design school note form.

School Behavior Intervention Home School Notes

Procedures 4 Identify target behaviors. 4 Design school note form. 4 Identify reinforcers and consequences.

School Behavior Intervention Home School Notes Reinforcer Examples 4 Wear an outfit of your choice to school. 4 Get out of a chore. 4 TV/nintendo/telephone/computer time. 4 Allowance. 4 Token toward weekend activity.

School Behavior Intervention Home School Notes Procedures 4 Identify target behaviors. 4 Design school note form. 4 Identify reinforcers and consequences. 4 Establish criterion for reinforcement.

School Behavior Intervention Home School Notes Procedures 4 Identify target behaviors. 4 Design school note form. 4 Identify reinforcers and consequences. 4 Establish criterion for reinforcement. 4 Increase criterion as progress is made.

School Behavior Intervention Home School Notes Procedures 4 Identify target behaviors. 4 Design school note form. 4 Identify reinforcers and consequences. 4 Establish criterion for reinforcement. 4 Increase criterion as progress is made. 4 Plan for generalization and maintenance.

School Behavior Intervention Home School Notes What makes it effective: 4 Frequent, immediate feedback (school). 4 Highly structured (short time).  Salient consequences (home).

Home Behavior Intervention Examples 4 Time Out 4 Job Card Grounding

Home Behavior Intervention: Time Out Putting child in: 4 Locate away from attention/fun. 4 Place within 5 seconds. 4 Be brief, unemotional.

Home Behavior Intervention: Time Out Putting child in: 4 Locate away from attention/fun. 4 Place within 5 seconds. 4 Be brief, unemotional. While in: 4 Avoid talk or eye contact. 4 Continue to monitor.

Home Behavior Intervention: Time Out Putting child in: 4 Locate away from attention/fun. 4 Place within 5 seconds. 4 Be brief, unemotional. While in: 4 Avoid talk or eye contact. 4 Continue to monitor. After: 4 Be brief, unemotional. 4 Have child do behavior that got him/her placed in time out. 4 Show approval for appropriate behavior within five minutes.

Home Behavior Intervention: Job Card Grounding Components 4 List of rules

Home Behavior Intervention: Job Card Grounding Examples of Rules 1. Do your chores 2. Follow instructions 3. Tell us where you are going

Home Behavior Intervention : Job Card Grounding Components 4 List of rules 4 List of odd jobs

Home Behavior Intervention: Job Card Grounding Odd Job Examples 1. Dust baseboards/ceilings 2. Sweep out garage 3. Wipe down inside refrigerator

Home Behavior Intervention: Job Card Grounding Components 4 List of rules 4 List of odd jobs 4 List of rewards

Home Behavior Intervention: Job Card Grounding GROUNDING MEANS 4 No television, telephone, stereo, video games 4 No friends over/go to friends 4 No snacks, naps 4 No outside social activities 4 No toys

Home Behavior Intervention: Job Card Grounding GROUNDING DOES NOT MEAN 4 Nagging 4 Reminding 4 Discussing 4 Explaining

Home Behavior Intervention: Job Card Grounding Other Guidelines 4 Check jobs when completed and praise.

Home Behavior Intervention: Job Card Grounding Other Guidelines 4 Check jobs when completed and praise. 4 Child determines how long he/she is grounded.

Home Behavior Intervention: Job Card Grounding Other Guidelines 4 Check jobs when completed and praise. 4 Child determines how long he/she is grounded. 4 Maximum 2 cards at a time.

Home Behavior Intervention: Job Card Grounding Other Guidelines 4 Check jobs when completed and praise. 4 Child determines how long he/she is grounded. 4 Maximum 2 cards at a time. 4 Make sure groundings are DULL.

Home Behavior Intervention: Job Card Grounding Other Guidelines 4 Check jobs when completed and praise. 4 Child determines how long he/she is grounded. 4 Maximum 2 cards at a time. 4 Make sure groundings are DULL. 4 Reward for having 2 or less cards/day.

Home Behavior Interventions What makes them effective: 4 Frequent, immediate feedback. 4 Highly structured. 4 Salient consequences.

Behavioral Interventions: Key Points l Behavioral interventions consist of training parents and teachers to implement behavioral interventions with children.

Behavioral Interventions: Key Points l Behavioral interventions consist of training parents and teachers to implement behavioral interventions with children. l Best to wait on medication start until after committed effort to establish behavioral intervention.

Behavioral Interventions: Key Points l Behavioral interventions consist of training parents and teachers to implement behavioral interventions with children. l Best to wait on medication start until after committed effort to establish behavioral intervention. l ADHD is chronic; treatment must be lengthy, intensive, and used throughout the child’s environment.

Behavioral Interventions: Key Points l Behavioral interventions consist of training parents and teachers to implement behavioral interventions with children. l Best to wait on medication start until after committed effort to establish behavioral intervention. l ADHD is chronic; treatment must be lengthy, intensive, and used throughout the child’s environment. l Behavioral treatment is labor intensive for teachers and parents.