An ADHD Primer: Treatment for Educators Jill Zaruba, OT Columbus Community Hospital Tawnya Meadows, Ph.D. Munroe-Meyer Institute, UNMC.

An ADHD Primer:Treatment for Educators

Jill Zaruba, OTColumbus Community Hospital

Tawnya Meadows, Ph.D.Munroe-Meyer Institute, UNMC

Not recommended!

What we know works:

Drug TherapyBehavior TherapyCombined Behavioral/Drug

Treatments

APA Task Force on Evidence-Based Treatments, JCCAP, Pelham, Wheeler, & Chronis, 1998

American Academic of Pediatrics

AAP Guidelines

1. Establish a management program that recognizes ADHD as a chronic condition (strength of evidence: good; strength of recommendation: strong).

AAP Guidelines

2. Clinician, parents, and child, in collaboration with school should specify appropriate target outcomes to guide management (strength of evidence: good; strength of recommendation: strong).

AAP Guidelines

3. Recommend stimulant medication and/or behavior therapy as appropriate (strength of evidence: strong).

AAP Guidelines

4. When management has not met target, clinicians should evaluate the original diagnosis, treatments, adherence and coexisting conditions (evidence: weak; recommendation: strong).

AAP Guidelines

5. Periodically provide systematic follow-up to monitor targets and adverse effects by gaining information from child, parents, and teachers (evidence: fair; recommendation: strong).

What we know DOESN’T work:

Play therapyIndividual or family counseling (without altering

the environment)Social skills/self-monitoring/organizational

planning Dietary managementMegavitamin therapySensory integration therapy/chiropracticsEEG Biofeedback

• Optometric vision training

• Anti-motion-sickness medication

• Treatment for candida yeast infection

• Applied kinesiology (realigning bones in the skull)

What we know works:

CNS Stimulant Medicationso 250 studies (N > 5000)

Behavior Therapyo 48 classroom studies (N > 900)o 80 parent/home studies (N > 5,000)

Combined Behavioral/Drug Treatments

o 25 studies (N > 800)

Behavior Therapy for ADHD

ComponentsHighly structured

Behavior Therapy for ADHD

ComponentsHighly structuredImmediate feedback

reinforcer or reward for appropriate behavior

consequence for inappropriate behavior

Behavior Therapy for ADHD

ComponentsHighly structuredImmediate feedback

reinforcer or reward for appropriate behavior

consequence for inappropriate behaviorSalient/meaningful feedback

Behavior Therapy for ADHD

ComponentsHighly structuredImmediate feedback

reinforcer or reward for appropriate behavior

consequence for inappropriate behaviorSalient/meaningful feedbackProgramming at home and school

School Behavior Intervention

Examples:1. The Attention Training System

(ATS)2. Home School Note3. Self-monitoring

4. Accommodations

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 feedback3. Meaningful consequences

School Behavior Intervention:

The Attention Training System (ATS)

1. Technology Teacher Module Student Module

2. Immediate feedback3. Meaningful consequences4. Structured “time”

School Behavior Intervention

The ATS: Lisa

0102030405060708090100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Days

%TimeOff

Task

No ATS ATS No ATS ATS

School Behavior Intervention

The ATS: Troy

0102030405060708090100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Days

%TimeOff

Task

No ATS No ATS No ATS

ATS ATS Meds Only

School Behavior InterventionHome School Notes

Address Problems WithAcademic effortIn-class behaviorsAssignment completion

School Behavior InterventionHome School Notes

ProceduresIdentify target behaviors

School Behavior InterventionHome School Notes

Academic Behaviors Working on

assignments Completing homework Handing in

assignments All work up to date On time for class

Social Behaviors Out of seat Talking without

permission Disrespectful behavior Bothering peers Following instructions Hands to self

School Behavior InterventionHome School Notes

ProceduresIdentify target behaviorsDesign school note form

School Behavior InterventionHome School Notes

GOAL:8 of 12 YES

Desk neat and organized

Homework written neatly, accurately in book by class bell

Class assignment neat and 80% accurate or better

Math L. Arts History Science

Yes No Yes No Yes No Yes No

Yes No Yes No Yes No Yes No

Yes No Yes No Yes No Yes No

School Behavior InterventionHome School Notes

ProceduresIdentify target behaviorsDesign school note formIdentify reinforcers and

consequences

School Behavior InterventionHome School Notes

Reinforcer ExamplesWear an outfit of your choice to

schoolGet out of a choreTV/video games/telephone/computer

timeAllowanceToken toward weekend activity

School Behavior InterventionHome School Notes

ProceduresIdentify target behaviorsDesign school note formIdentify reinforcers and

consequencesEstablish criterion for reinforcement

School Behavior InterventionHome School Notes

ProceduresIdentify target behaviorsDesign school note formIdentify reinforcers and

consequencesEstablish criterion for reinforcementIncrease criterion as progress is

made

School Behavior InterventionHome School Notes

Procedures Identify target behaviorsDesign school note form Identify reinforcers and consequencesEstablish criterion for reinforcement Increase criterion as progress is madePlan for generalization and maintenance

School Behavior InterventionHome School Notes

What makes it effective:Frequent, immediate feedback

(school).Highly structured (short time).Salient consequences (home).

Self-Monitoring

• Gives motivated student sense of responsibility

• Less work for teacher

• Provides parent/physician with information

Date:

Cross off each picture each time you talk without raising your hand or having permission. Teacher will cross off two pictures if you don’t.

Teenagers with ADHD

• 80% still need medication (NIMH)

• Use a planner

• Keep a routine

• Study skills

• Sleep, Sleep, Sleep

Accommodations

• Seat placement (front is not always best)

• Small group activities

• Encourage students to pause before answering questions

• Keep assignments short or break them into sections

• Close supervision with frequent, positive, (subtle) cues to stay on task