1. What Can SBHC Providers Do to Address ADHD?

2. Goals Help SBHC Providers: Maximize use of evidence based treatment strategies for students diagnosed with ADHD Understand the resources available to create a behavior program Understand the resources available to use medications Understand the resources available to create quality monitoring programs

3. Overview Introductions ADHD – What works and what doesn’t work Screening and Assessment Review Practice Skills for Home-based Interventions Classroom Management Strategies Medication Management Case Examples – if time permits!

4. ADHD Definition (DSM-IV) “A persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals of comparable level of development”

5. DSM IV-ADHD Three main types – Attention Deficit Hyperactivity Disorder, Predominantly Inattentive Type – Attention Deficit Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type – Attention Deficit Hyperactivity Disorder, Combined

6. ADHD DSM-IV Diagnosis 6 or more inattentive items 6 or more hyperactive/impulsive items Persistent for at least 6 months Clinically significant impairment in social, academic, or occupational functioning Inconsistent with developmental level Some symptoms that caused impairment before age 7 Impairment is present in two or more settings (school, home, work)

7. ADHD: Common School Response Identification and Referral: – Inattention/Hyperactivity/Disruptive Behavior seen as Intentional Defiance  Discipline Referral – Discipline – Criticism, Detention, Suspension – MH Intervention??? Referral to PCP for medication Often with NO environmental (school/home) intervention

8. ADHD is treated by Primary Care Providers – such as SBHCs Extensive research - MTA Evidence based therapies with clear guidelines – NICHQ: http://www.nichq.org/areas_of_focus/adhd_topic.htm l http://www.nichq.org/areas_of_focus/adhd_topic.htm l – Texas Department of State Health Services http://www.dshs.state.tx.us/WorkArea/DownloadAss et.aspx?id=8592 http://www.dshs.state.tx.us/WorkArea/DownloadAss et.aspx?id=8592

9. SBHCs are Optimally Situated Behavioral and medical providers Access to schools – teachers, admin. Goal of SBHCs is to increase parent involvement – necessary for ADHD rx Chronic disease model (like asthma)

11. ADHD Team A team with time - champions NO NEW TOOLS Clarify roles and tasks Map resources Set goals – keep them simple – NICHQ QI ADHD measures

12. Roles Connect with parents, teachers, administration, students and providers Educate each about ADHD in an accessible and culturally appropriate manner Deliver evidence based practices Prescribe medication Monitor medication Monitor process and outcomes

13. Monitor/evaluate symptoms (side effects) Tools/collaboration With parent/Guardian, Teacher, Student MH and medical clinicians create/revise Treatment plan -behavior -medication

14. Step 4 Medication Management (as appropriate) Step 3 Behavioral Interventions * Home and School * Step 2 Screening and Assessment * Involving Family and School * (ongoing) Step 1 Appropriate Identification and Referral

15. Step 1 Identification & Referral Provide Training and Materials for Teachers and Parents on ADHD signs/symptoms Include ADHD and mental health issues in the training of new teachers Develop an effective referral process, including referral feedback, for teachers and school staff

16. Parent Teacher Training Resources Texas Dept. of State Health Services http://www.dshs.state.tx.us/mhsa/patient-family-ed/ http://www.dshs.state.tx.us/mhsa/patient-family-ed/ CHADD – the What We Know sheets include clear explanations for provider and parent http://www.help4adhd.org/en/about/wwk http://www.help4adhd.org/en/about/wwk Maryland Public Schools http://www.msde.maryland.gov/MSDE/divisions/studentsch oolsvcs/student_services_alt/ADHD/ http://www.msde.maryland.gov/MSDE/divisions/studentsch oolsvcs/student_services_alt/ADHD/

17. Step 2 Screening & Assessment SBHC Providers can conduct interviews and administer screening tools and assessments to assist in the diagnosis of ADHD

18. Is It ADHD? Mood/Anxiety Problems PDD Spectrum

19. Structured Interview Form Disruptive Behavior Disorders Structured Parent Interview – Based on DSM criteria – FREE! – available at http://ccf.buffalo.edu/pdf/DBD_interiew.pdf http://ccf.buffalo.edu/pdf/DBD_interiew.pdf Subscales for: – ADHD, ODD, CD

20. Resources for Free and Validated Screening Tools: NICHQ Parent/Teacher Disruptive Behavior Disorders Rating Scale http://ccf.buffalo.edu/pdf/DBD_rating_scale.pdf http://ccf.buffalo.edu/pdf/DBD_rating_scale.pdf Parent and Teacher report – 45 items. Subscales for: ADHD, ODD, CD

22. Diagnosis Beware previous labels Childhood is constant change – continuous assessment Not sure you have the right label? “Not Otherwise Specified” while you observe/gather information

23. Interventions with little or NO evidence of effectiveness as the primary treatment of ADHD: Special elimination diets Vitamins or other health food remedies Psychotherapy or psychoanalysis Biofeedback Play therapy Chiropractic treatment Sensory integration training Social skills training Self-control training

24. Step 3 Behavioral Interventions “According to the research, Behavior Therapy and Management, both in the classroom and at home, are the best-supported non-drug treatments” Hawaii Department of Health, Child and Adolescent Mental Health Division. (2004). Evidence Based Services Committee Biennial Report: Summary of Effective Interventions for Youth with Behavioral and Emotional Needs.

25. What Do We Mean By Behavior Management? Why children with ADHD misbehave – correcting misperceptions Identifying and removing barriers to effective child management Paying attention to and reinforcing child’s good behavior (improving emotional relationship)

26. Behavior Management of ADHD Issuing effective commands (compliance training) Use of time-out Reinforcement and response cost system (tokens or points) for appropriate/inappropriate behaviors Extension to school and public settings - behavior report card

27. Importance of Context “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)

28. Bright Futures – www.brightfutures.org/mentalhealth/pdf/tools.html www.brightfutures.org/mentalhealth/pdf/tools.html Tools for students, clinicians and families

29. Several Empirically-Supported Behavior Protocols Exist: Defiant Children (Russell Barkley) Helping the Noncompliant Child (Rex Forehand) Videotape Parent Modeling (Carolyn Webster- Stratton)

30. Praise Training parents and teachers to praise correctly increases compliance in youth with ADHD/DBD – Praise can include Verbal praise, Encouragement Attention Affection Physical proximity

31. Giving Effective Praise Be honest, not overly flattering 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?”) Give praise immediately

32. Ignoring & Differential Reinforcement Train parents and teachers to selectively – Ignore mild unwanted behaviors AND – Attend to alternative positive behaviors

33. Teaching to Ignore Teach parents and teachers how and when to ignore undesirable behavior – Ignoring can include Visual cues Postural cues Vocal cues Social cues

34. Improving Commands/Limit Setting Training for parents and teachers to give commands in the most effective way Effective commands increase compliance in children and adolescents with ADHD (and in others, too!)

35. Improving Commands/Limit Setting with Children Teach parents and teachers: – To only give commands that they intend to back up with consequences (positive and negative) – Not to present commands as questions or favors – Not give too many commands at once

36. Improving Commands/Limit Setting with Adolescents Teach parents and teachers: – To consider the intent of their command Do they have the time/energy to follow through? Do they have consequences for noncompliance? – To avoid ambiguity when issuing commands – To not respond to compliance with gratitude

37. Improving Commands/Limit Setting with Adolescents (cont) 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

38. Tangible Rewards 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 – Can use token systems, behavior charts, or immediate rewards

39. School-Home Contract 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 – Choose one target that the child will be successful with most of the time – Parent and teacher signatures and comments

40. 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:

41. 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 – 1point for each day of appropriate behavior. When 10 points are earned Jeffrey may invite a friend to dinner and a movie

42. General Education Classroom Brief, clear, and frequent instructions Include academic performance (e.g., accurate work completion) in behavior plan. Daily report card system Parallel teaching—increase engagement Strategic attention, frequent feedback Post schedules and rules Increase novelty and interest level of tasks “Direct Instruction” techniques

43. Step 4 Medication Management 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)

44. Medication Should Not Be a Substitute For: Parent/Teacher training Behavior modification Appropriate educational curricula Appropriate school placement Adequate teaching skills Family treatment

45. Stimulants They work immediately Up to 70% response rate Need to be monitored and titrated No response – reconsider the diagnosis

46. Algorithms and Tactics Article describing the new ADHD algorithms - Journal of the American Academy of Child and Adolescent Psychiatry in June 2006 (Pliszka S, Crismon ML, et al.)

48. Discussion, Consent/Assent Clarify prognosis, alternative treatments, potential side effects The student and parent decide whether or not to try medication – not the provider or the school Warn students and families that we use a “try and see method” Address myths and stigma

49. Monitor Determine GOALS (target behavior) together – see NICHQ mgt plan Ensure adequate dose and duration before changing or adding Monitor with user friendly tools Less is more – don’t scare them away with side effects The idea is to assist self control for this chronic disease

50. Be Prepared For Concerns Possible questions – Over treatment – Under treatment – Misdiagnoses – Misuse of medications Myths and misperceptions – Medication makes you a zombie – Medication leads to addiction

51. Resources Children and Adults with Attention- Deficit/Hyperactivity Disorder (CHADD) www.chadd.org www.chadd.org National Attention Deficit Disorder Association www.add.org www.add.org University of Buffalo, Center for Children and Families http://wings.buffalo.edu/adhd/http://wings.buffalo.edu/adhd/

52. Resources National Information Center for Children and Youth with Disabilities www.nichy.orgwww.nichy.org National Institutes of Mental Health www.nimh.nih.gov www.nimh.nih.gov And don’t forget the ones previously noted