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Laura G. Anthony, Ph.D.
Children’s National Medical Center
Pediatric [email protected]
Nancy Lever, Ph.D.
Center for School Mental Health Analysis and Action
Department of Psychiatry, University of Maryland, Baltimore
Best Practices: Strategies for Best Practices: Strategies for Addressing ADHD & Disruptive Addressing ADHD & Disruptive
Behavior DisordersBehavior Disorders
Maryland School Mental Health Alliance
School Mental Health Integration Grant
HistoryHistory
Commitment from key local, state, and national partners to Commitment from key local, state, and national partners to collaborate and form an Alliance to advance school-mental collaborate and form an Alliance to advance school-mental health system integration in Maryland health system integration in Maryland
Strong support for children’s mental health and school Strong support for children’s mental health and school mental health in the statemental health in the state
A strong PBIS structure within the state and an interest in A strong PBIS structure within the state and an interest in enhancing mental health support and resources for red and enhancing mental health support and resources for red and yellow zone youth yellow zone youth
Notified of award in September 2005Notified of award in September 20051 of 20 funded projects (84 total applicants)1 of 20 funded projects (84 total applicants)
Maryland School Mental Health Maryland School Mental Health Alliance (MSMHA)Alliance (MSMHA)
Maryland State Department of EducationMaryland State Department of Education
Center for School Mental Health Analysis and Action - University of MarylandCenter for School Mental Health Analysis and Action - University of Maryland
Center for Prevention and Early Intervention - Johns Hopkins UniversityCenter for Prevention and Early Intervention - Johns Hopkins University
Governor’s Office for ChildrenGovernor’s Office for Children
Maryland Assembly on School-Based Health CareMaryland Assembly on School-Based Health Care
Maryland Coalition of Families for Children’s Mental HealthMaryland Coalition of Families for Children’s Mental Health
Maryland Department of Juvenile ServicesMaryland Department of Juvenile Services
Mental Hygiene Administration Department of Health and Mental HygieneMental Hygiene Administration Department of Health and Mental Hygiene
Mental Health Association of MarylandMental Health Association of Maryland
Primary Grant ObjectivesPrimary Grant Objectives
1. To further build a systematic state initiative for school mental 1. To further build a systematic state initiative for school mental health (SMH)health (SMH)
2. To improve outcomes related to red and yellow zone youth in PBIS 2. To improve outcomes related to red and yellow zone youth in PBIS schools through:schools through:
Helping school staff to better identify and refer students who Helping school staff to better identify and refer students who could benefit from mental health servicescould benefit from mental health services
Enhancing mechanisms for effective communication between Enhancing mechanisms for effective communication between schools and the mental health system to help better integrate schools and the mental health system to help better integrate quality mental health care for studentsquality mental health care for students
Developing training and resources to assist school staff with Developing training and resources to assist school staff with creating environments that support academic, social, and creating environments that support academic, social, and emotional learning for children with more intensive mental emotional learning for children with more intensive mental health needshealth needs
Make sure it is ADHD! Make sure it is ADHD!
Mood/Anxiety Problems
PDD Spectrum
Evidence-Based Treatment of Evidence-Based Treatment of ADHDADHD
Medication Treatment Medication Treatment
Robust positive effects of stimulant Robust positive effects of stimulant medication (70% of children) on ADHD core medication (70% of children) on ADHD core symptoms and positive effects on some symptoms and positive effects on some associated problems (aggression, peer associated problems (aggression, peer relations, reduced compliance)relations, reduced compliance)
A handful of studies have documented A handful of studies have documented decreases in negative (but not increases in decreases in negative (but not increases in positive) mother-child interaction with positive) mother-child interaction with stimulant medication.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?What works for ADHD?
All of the evidence-based practice All of the evidence-based practice elements for use in ADHD have their elements for use in ADHD have their basis in Clinical Behavior Therapy. basis in Clinical Behavior Therapy. We will first cover the basic premises We will first cover the basic premises
behind behavior therapy, then cover the behind behavior therapy, then cover the specifics of effective interventions for specifics of effective interventions for ADHDADHD
What doesn’t work for What doesn’t work for ADHD?ADHD?
Treatments with little or no evidence of Treatments with little or no evidence of effectiveness includeeffectiveness include Special elimination dietsSpecial elimination diets Vitamins or other health food remediesVitamins or other health food remedies Psychotherapy or psychoanalysisPsychotherapy or psychoanalysis BiofeedbackBiofeedback Play therapyPlay therapy Chiropractic treatmentChiropractic treatment Sensory integration trainingSensory integration training Social skills trainingSocial skills training Self-control trainingSelf-control training
Clinical Behavior Therapy: Clinical Behavior Therapy: TheoryTheory
Proposed Mechanism:Proposed Mechanism: Individuals with Individuals with ADHD have difficulty understanding ADHD have difficulty understanding the consequences of their actions.the consequences of their actions.
Approach:Approach: Application of the principles Application of the principles of of social learning theorysocial learning theory to modify to modify children’s behavior by training parents children’s behavior by training parents and teachers to manipulate and teachers to manipulate environmental antecedents, environmental antecedents, consequences and contingencies. consequences and contingencies.
The ABC ModelThe ABC Model
Behavior
Consequences
Antecedents
Contingencies
An example: The ABC ModelAn example: The ABC Model
BehaviorStudent ignoresbell while rest of
class takes out mathbooks
ConsequencesTeacher yells at
student
Antecedent9:30 bell signals
beginningof math period
The ABC ModelThe ABC Model
BehaviorStudent takes out
math book
ConsequenceTeacher smiles
at student
Antecedent9:30 bell signals
beginningof math period
Contingencies
Teacher makes eye contact with student, says, “Take out your math books.”
Basic PrinciplesBasic Principles Clear and brief rulesClear and brief rules Swift consequencesSwift consequences Frequent consequencesFrequent consequences Powerful consequencesPowerful consequences Rich incentivesRich incentives Change rewardsChange rewards Expect failuresExpect failures AnticipateAnticipate
Treatment Target:Treatment Target:Difficult Relations with AdultsDifficult Relations with Adults
Less compliant and cooperativeLess compliant and cooperative More demandingMore demanding Less independentLess independent More emotional and conflicted More emotional and conflicted
interchangeinterchange Adults are more negative and Adults are more negative and
directive with child or directive with child or adolescent with ADHDadolescent with ADHD
Treatment Target: Classroom Treatment Target: Classroom Behavior ProblemsBehavior Problems
Difficulties in completing Difficulties in completing independent seat workindependent seat work
Talking with classmates at Talking with classmates at inappropriate timesinappropriate times
Frequent out-of-seat behaviorFrequent out-of-seat behavior Organizational difficultiesOrganizational difficulties
PraisePraise
Training teachers to praise Training teachers to praise correctly increases compliance in correctly increases compliance in youth with ADHD/DBDyouth with ADHD/DBD Praise can include Praise can include
Verbal praise, EncouragementVerbal praise, Encouragement AttentionAttention AffectionAffection Physical proximityPhysical proximity
Giving effective praiseGiving effective praise
Be honest, not overly flatteringBe honest, not overly flattering Be specificBe specific No “back-handed compliments” (i.e., No “back-handed compliments” (i.e.,
“I like the way you are working “I like the way you are working quietly, why can’t you do this all the quietly, why can’t you do this all the time?”)time?”)
Give praise immediatelyGive praise immediately
Ignoring and Differential Ignoring and Differential ReinforcementReinforcement
Train staff and teachers to Train staff and teachers to selectivelyselectively Ignore mild unwanted behaviorsIgnore mild unwanted behaviors
ANDAND
Attend to alternative positive Attend to alternative positive behaviorsbehaviors
Teaching to ignoreTeaching to ignore
Teach staff and teachers how and Teach staff and teachers how and when to ignore undesirable when to ignore undesirable behaviorbehavior Ignoring can includeIgnoring can include
Visual cuesVisual cues Postural cuesPostural cues Vocal cues Vocal cues Social cuesSocial cues
How to ignoreHow to ignore
Visual cuesVisual cues Look away once child engages in undesirable Look away once child engages in undesirable
behaviorbehavior Do not look at the child until behavior stopsDo not look at the child until behavior stops
Postural cuesPostural cues Turn the front of your body away from the Turn the front of your body away from the
location of child’s undesirable behaviorlocation 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 Do not vary the frequency or intensity of your
current activity (e.g., talking faster or louder)current activity (e.g., talking faster or louder)
When to ignoreWhen to ignore
When to ignore undesirable behavior When to ignore undesirable behavior Child interrupts conversation or classChild interrupts conversation or class Child blurts out answers before question Child blurts out answers before question
completedcompleted Child tantrumsChild tantrums
Do Do notnot ignore undesirable behavior ignore undesirable behavior that could potentially harm the child that could potentially harm the child or someone elseor someone else
Differential reinforcementDifferential reinforcement
Teach how and when to differentially Teach how and when to differentially reinforce desirable behaviorreinforce desirable behavior Step One: Ignore (stop reinforcing) the Step One: Ignore (stop reinforcing) the
child’s undesirable behaviorchild’s undesirable behavior Step Two: Reinforce the child’s desirable Step Two: Reinforce the child’s desirable
behavior in a systematic mannerbehavior in a systematic manner The desirable behavior should be a behavior The desirable behavior should be a behavior
that is incompatible with the undesirable that is incompatible with the undesirable behaviorbehavior
Differential reinforcementDifferential reinforcement
Define the behavior of concern Define the behavior of concern (target)(target) Determine how often the target behavior Determine how often the target behavior
occursoccurs Determine how often to reward the child Determine how often to reward the child
for alternative behaviorfor alternative behavior Fixed interval – reward every X minutesFixed interval – reward every X minutes
Determine how to reward the child for Determine how to reward the child for alternative behavioralternative behavior
Praise, attention, points or chipsPraise, attention, points or chips
Differential Reinforcement of Differential Reinforcement of target behaviortarget behavior
Target behavior: InterruptingTarget behavior: Interrupting Alternative behavior: Working by Alternative behavior: Working by
himselfhimself Reward schedule: 5 minutesReward schedule: 5 minutes
If child goes 5 minutes without interrupting, If child goes 5 minutes without interrupting, the child receives reinforcementthe child receives reinforcement
If child interrupts before 5 minutes is up, the If child interrupts before 5 minutes is up, the child does not receive reinforcementchild does not receive reinforcement
Re-set schedule once child interruptsRe-set schedule once child interrupts
Differential reinforcementDifferential reinforcement
Teacher systematically delays Teacher systematically delays reinforcement once child responds to reinforcement once child responds to initial scheduleinitial schedule Target behavior: InterruptingTarget behavior: Interrupting 11stst reinforcement schedule: 5 minutes reinforcement schedule: 5 minutes 22ndnd reinforcement schedule: 6 minutes reinforcement schedule: 6 minutes 33rdrd reinforcement schedule: 7.5 minutes reinforcement schedule: 7.5 minutes
Problems with ignoring and Problems with ignoring and differential reinforcementdifferential reinforcement
Extinction burstExtinction burst Warn staff and teachers that the behavior Warn staff and teachers that the behavior
will get worse before it gets better (child will will get worse before it gets better (child will work harder to gain their attention)work harder to gain their attention)
If you put your money in a vending machine, and If you put your money in a vending machine, and the soda doesn’t come out, what do you do? You the soda doesn’t come out, what do you do? You probably press the button a few more times, probably press the button a few more times, maybe you even try pressing hardermaybe you even try pressing harder
Indiscriminant reinforcementIndiscriminant reinforcement Train teachers to reward only the alternative Train teachers to reward only the alternative
(desirable) behavior, so they don’t reward (desirable) behavior, so they don’t reward other unwanted behaviors by mistakeother unwanted behaviors by mistake
Improving commands/limit Improving commands/limit settingsetting
Training for teachers to give Training for teachers to give commands in the most effective waycommands in the most effective way
Effective commands increase Effective commands increase compliance in children and compliance in children and adolescents with ADHD/DBD (and in adolescents with ADHD/DBD (and in others, too!)others, too!)
Improving commands/limit Improving commands/limit setting with childrensetting with children
Teach parents and teachers:Teach parents and teachers: To only give commands that they intend To only give commands that they intend
to back up with consequences (positive to back up with consequences (positive and negative)and negative)
Not to present commands as questions Not to present commands as questions or favorsor favors
Not give too many commands at onceNot give too many commands at once
Improving commands/limit Improving commands/limit setting with adolescentssetting with adolescents
Teach parents and teachers:Teach parents and teachers: To consider the intent of their commandTo 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 commandsTo avoid ambiguity when issuing commands To not respond to compliance with gratitudeTo not respond to compliance with gratitude
Improving commands/limit Improving commands/limit setting with adolescents, con’t.setting with adolescents, con’t.
Teach parents and teachers:Teach parents and teachers: To praise teens for appropriate behaviorTo praise teens for appropriate behavior To tell teen what To tell teen what toto do, rather than what do, rather than what
notnot to do to do To eliminate other distractions while To eliminate other distractions while
giving commandsgiving commands To break down multi-step commandsTo break down multi-step commands To use aids for commands that involve To use aids for commands that involve
timetime
Tangible rewardsTangible rewards
Children and adolescents with ADHD do Children and adolescents with ADHD do not respond to natural (intrinsic) not respond to natural (intrinsic) rewards as well as typical youthrewards as well as typical youth
The training of parents and teachers in The training of parents and teachers in the use of tangible rewards is effective the use of tangible rewards is effective in increasing desired behaviorsin increasing desired behaviors Can use token systems, behavior charts, or Can use token systems, behavior charts, or
immediate rewardsimmediate rewards
Response CostResponse Cost
Using a point or token system in Using a point or token system in school in which negative behaviors school in which negative behaviors result in the loss of points or tokens.result in the loss of points or tokens.
Training parents and teachers to use Training parents and teachers to use response cost is effective in reducing response cost is effective in reducing undesired behavior and undesired behavior and noncompliancenoncompliance
Response Cost with ChildrenResponse Cost with Children
Train teachers:Train teachers: To develop list of undesirable behavior to To develop list of undesirable behavior to
be fined by reward systembe fined by reward system To deduct points/chips for undesirable To deduct points/chips for undesirable
behaviorbehavior Teacher and child have chosen to reduce Teacher and child have chosen to reduce
whiningwhining If child whines, teacher deducts one pointIf child whines, teacher deducts one point Penalties increase based on severity of behaviorPenalties increase based on severity of behavior
Response Cost with Response Cost with AdolescentsAdolescents
Train teachers:Train teachers: To use behavioral contract with the teen To use behavioral contract with the teen
for “fines”for “fines” Teen agrees to not swearTeen agrees to not swear If teen swears, teen loses 15 minutes of If teen swears, teen loses 15 minutes of
internet privilege at schoolinternet privilege at school To begin with 1 week “training period,” during To begin with 1 week “training period,” during
which teacher labels misbehavior every time which teacher labels misbehavior every time it happens and warns of new finesit happens and warns of new fines
Response Cost with Response Cost with AdolescentsAdolescents
Train teachers:Train teachers: To avoid “punishment spiral”To avoid “punishment spiral”
When teacher fines teen for misbehavior, When teacher fines teen for misbehavior, the teen responds with more misbehaviorthe teen responds with more misbehavior
Teen continues to lose privileges, then loses Teen continues to lose privileges, then loses motivation motivation
Rule: fine teen Rule: fine teen no more than twiceno more than twice, then , then direct teen to “cool off” away from the direct teen to “cool off” away from the situationsituation
Response Cost with Response Cost with AdolescentsAdolescents
Encourage teacher to act as “judge and Encourage teacher to act as “judge and jury” when teen liesjury” when teen lies The teen should remain above suspicionThe teen should remain above suspicion
Response cost allows teacher to Response cost allows teacher to discipline/educate instead of discipline/educate instead of justjust punish punish
Emphasis of response cost is onEmphasis of response cost is on ““Warm” – positive, lovingWarm” – positive, loving ““Firm” – specific, immediate, and consistentFirm” – specific, immediate, and consistent
Setting up a school-home Setting up a school-home contractcontract
The teacher tracks the child’s The teacher tracks the child’s behavior and reports it to the parent behavior and reports it to the parent daily, who rewards the childdaily, who rewards the child Pretty easy for the teacherPretty easy for the teacher
This is particularly effective because This is particularly effective because both the parent and teacher are both the parent and teacher are involvedinvolved
If the parent can’t be involved, the If the parent can’t be involved, the rewards may be given at schoolrewards may be given at school
School-Home ContractSchool-Home Contract
Daily report card, based on a written Daily report card, based on a written contract, coupled with home-based contract, coupled with home-based reward systemreward system List of a few target behaviors, homework List of a few target behaviors, homework
and test grades and homework assignments and test grades and homework assignments Choose one target that the child will be Choose one target that the child will be
successful with most of the time successful with most of the time Parent and teacher signatures and Parent and teacher signatures and
commentscomments See samples providedSee samples provided
School HomeSchool Home Contract 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 General Education ClassroomClassroom
Brief, clear, and frequent instructionsBrief, clear, and frequent instructions Include academic performance (e.g., Include academic performance (e.g.,
accurate work completion) in behavior accurate work completion) in behavior plan.plan.
Daily report card systemDaily report card system Parallel teaching—increase engagementParallel teaching—increase engagement Strategic attention, frequent feedbackStrategic attention, frequent feedback Post schedules and rulesPost schedules and rules Increase novelty and interest level of Increase novelty and interest level of
taskstasks ““Direct Instruction” techniquesDirect Instruction” techniques
Behavioral Consequences: Behavioral Consequences: Benefits Benefits of Whole Classroom Approach (e.g., of Whole Classroom Approach (e.g.,
PBIS)PBIS) Reduces sense of “unfairness;” Reduces sense of “unfairness;”
ADHD children receiving special ADHD children receiving special treatmenttreatment
Multiple ADHD children in Multiple ADHD children in classroom may strain individual classroom may strain individual approachapproach
Benefits whole class environmentBenefits whole class environment
Classroom Management: EvaluationClassroom Management: Evaluation
Classroom-based contingency Classroom-based contingency management procedures have led to management procedures have led to improvement in:improvement in: Task-related attentionTask-related attention Academic productivity and accuracyAcademic productivity and accuracy Interactions with peers and adultsInteractions with peers and adults
Positive reinforcement and response Positive reinforcement and response cost procedures necessarycost procedures necessary
Proactive Interventions: Proactive Interventions: Classroom-Wide Peer TutoringClassroom-Wide Peer Tutoring
Students in classroom paired and take Students in classroom paired and take turns being the tutorturns being the tutor Tutors provided with “scripts”Tutors provided with “scripts” Praise or points awardedPraise or points awarded Errors are immediately correctedErrors are immediately corrected Teacher monitors and awards points to pairsTeacher monitors and awards points to pairs
EvaluationEvaluation Enhanced task attention and academic Enhanced task attention and academic
accuracyaccuracy Practical and highly acceptablePractical and highly acceptable Little generalization to other classroom Little generalization to other classroom
activitiesactivities
Proactive Interventions: Proactive Interventions: CoachingCoaching
Student teams with adult or peer to Student teams with adult or peer to develop goals and methods to evaluate. develop goals and methods to evaluate. Brief sessions involve:Brief sessions involve: Reviewing and evaluating goalsReviewing and evaluating goals Anticipate barriers to achieving objectivesAnticipate barriers to achieving objectives Plan steps and when they should be Plan steps and when they should be
accomplishedaccomplished EvaluationEvaluation
Promising for adolescents who have shown Promising for adolescents who have shown progress in other structured interventions and progress in other structured interventions and who are motivated by attention from others who are motivated by attention from others ((Dawson, P., & Guare, R. (1998). Dawson, P., & Guare, R. (1998). Coaching the ADHD StudentCoaching the ADHD Student. . North Tonawanda, NYNorth Tonawanda, NY: : Multi Health Systems)Multi Health Systems)
Reducing Teacher Burden Reducing Teacher Burden
Increase KnowledgeIncrease Knowledge Improve attitude to actively work with Improve attitude to actively work with
ADHD students (e.g., treatable, not ADHD students (e.g., treatable, not curable)curable)
More difficult for ADHD student to do same More difficult for ADHD student to do same workwork
More difficult for ADHD student to behave More difficult for ADHD student to behave at appropriate levelat appropriate level
School behavior and performance mainly a School behavior and performance mainly a result of school-based interventions rather result of school-based interventions rather than individual/family interventionsthan individual/family interventions
Reducing Teacher BurdenReducing Teacher Burden
Ongoing CollaborationOngoing Collaboration In-service and videos not enoughIn-service and videos not enough Help in implementing behavioral Help in implementing behavioral
programsprograms ““Master teachers”Master teachers” Individualized programsIndividualized programs EngagementEngagement
Reducing Teacher BurdenReducing Teacher Burden
Communicating Communicating Developing trustDeveloping trust Reduce emphasis on “family Reduce emphasis on “family
problems” as causalproblems” as causal Importance of concern; Importance of concern;
parents know it’s a tough jobparents know it’s a tough job Support and support groupsSupport and support groups
Systemic Systemic InterventionsInterventions
Develop consistent guidelines for Develop consistent guidelines for assessment and intervention in school assessment and intervention in school systemsystem
Mount a public awareness campaignMount a public awareness campaign Disseminate and use “best practices” Disseminate and use “best practices”
information, including communicationinformation, including communication Include ADHD and mental health issues in Include ADHD and mental health issues in
the training of new teachersthe training of new teachers Develop new community resources for Develop new community resources for
children with ADHD (camps, after-school children with ADHD (camps, after-school programs)programs)
ResourcesResources
The Attention Deficit Information Network The Attention Deficit Information Network www.addinfonetwork.comwww.addinfonetwork.com
Children and Adults with Attention-Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) Deficit/Hyperactivity Disorder (CHADD) www.chadd.orgwww.chadd.org
National Attention Deficit Disorder National Attention Deficit Disorder Association Association www.add.orgwww.add.org
Maryland School Mental Health Alliance Maryland School Mental Health Alliance www.msmha.orgwww.msmha.org
Resources Resources
National Information Center for National Information Center for Children and Youth with Disabilities Children and Youth with Disabilities www.nichy.orgwww.nichy.org
National Institutes of Mental Health National Institutes of Mental Health www.nimh.nih.govwww.nimh.nih.gov