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

2. 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

3. 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

5. 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

6. 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

7. 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

8. 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)

9. 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

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

12. How do symptoms affect student’s behavior and performance?

13. 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

14. 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

15. 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

16. 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

17. 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

18. Externally represent or remove gaps in time
Antecedent
Behavior
Consequence

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. Antecedent-based strategies for managing adhd in the classroom

26. 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)

27. 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)

28. 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

29. 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

30. 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

31. 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

32. 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

33. behavioral programming for students with adhd

34. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. “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

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

44. 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

45. 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

46. 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]

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

48. 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

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

50. 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

51. 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

52. 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

53. 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

54. 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

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

56. 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

57. 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)

58. 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

59. 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

60. 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

61. 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

62. 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

63. 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

64. 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

65. 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

66. Contact Information: Alyssa Suess