Treating Adhd, Predominantly Inattentive Type With


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  • Treating Adhd, Predominantly Inattentive Type With

    1. 1. Treating ADHD, Predominantly Inattentive Type with Integrated Psychosocial Treatment Linda Pfiffner, Ph.D. Children’s Center at Langley Porter University of California, San Francisco
    2. 2. What is ADHD-I? <ul><li>Case Description: “Kayla” </li></ul><ul><li>8 y/o girl, 3 rd grade, private school </li></ul><ul><li>Referred due to concerns about attention: “mind floats,” lives in fantasy world, organizational problems, needs to be redirected. Also concerns about social interaction problems. </li></ul><ul><li>Family background: lives with her biological mother and sister; parents are divorced. History of ADHD, behavior problems, depression in family. Mother works full-time. </li></ul><ul><li>Birth, medical and developmental history: “normal”, but slightly late in some fine and gross motor skills. </li></ul>
    3. 3. <ul><li>School History </li></ul><ul><li>Problems with attention, focus and completing tasks began during first grade and have worsened each year. </li></ul><ul><li>Teacher comments: </li></ul><ul><ul><li>Capable, but works slowly </li></ul></ul><ul><ul><li>Doesn’t use class time well, “mostly in her own world” </li></ul></ul><ul><ul><li>Concentration problems worse as day progresses or if activity is lengthy </li></ul></ul><ul><ul><li>Lack of attention leads to missing directions </li></ul></ul><ul><ul><li>Needs 1:1 or small group to stay on task and achieve </li></ul></ul><ul><ul><li>Work is often sloppy, messy, incomplete, not turned in </li></ul></ul><ul><ul><li>Academic ability– on grade level </li></ul></ul><ul><ul><li>Very imaginative, artistic </li></ul></ul><ul><ul><li>Few behavior problems </li></ul></ul>
    4. 4. <ul><li>Peer Relations </li></ul><ul><li>“ Immature,” fits in better with younger children </li></ul><ul><li>Has a few friends but does not seek new friends </li></ul><ul><li>Makes up stories </li></ul><ul><li>Can be bossy </li></ul><ul><li>Some teasing by peers </li></ul><ul><li>Teacher describes as “eccentric” </li></ul><ul><li>Home Behavior </li></ul><ul><li>Daily routine activities and homework are an ordeal. </li></ul><ul><li>Takes “forever” to get things done </li></ul><ul><li>Lots of frustration and conflict over need for reminders and not completing tasks </li></ul><ul><li>Needs constant supervision </li></ul><ul><li>Affects getting ready in am, homework, chores, bedtime </li></ul><ul><li>High levels of mother-daughter conflict, but evidence of loving relationship </li></ul>
    5. 5. Teacher Ratings <ul><li>Teacher CSI : ADHD IA: 8/9 often or very often, H/I: 0/9 </li></ul><ul><li>SCT : 11/15 often or very often </li></ul><ul><li>APRS : 50% work completed, “often” completes work in careless fashion, “often” requires assistance to complete work, quality of work is “more successful than poor” </li></ul><ul><li>Peer Relations Scale : often chosen late, never sought after by peers, none would like for a best friend, none would wish she was not in class </li></ul><ul><li>School Situations Q = moderate-severe in 4/8 areas </li></ul><ul><li>SSRS : SS Scale: 79, AC=88, PB=130 </li></ul>
    6. 6. Parent Interview and Ratings <ul><li>Parent KSADS and CSI : IA: 9/9, H/I=2/9, past sep anx disorder. </li></ul><ul><li>Home Sit. Q .: moderate in 10/13 areas </li></ul><ul><li>HPC : “very often” 17/20 items </li></ul><ul><li>SSRS : SS Scale: 67, PB Scale=134 </li></ul><ul><li>PSI : P-C Dys Interaction: 99%, Difficult Child: 97%, Total Stress: 97% </li></ul><ul><li>ABAS : Gen Adaptive Composite: 72 </li></ul>
    7. 7. Test Results <ul><li>Behavioral Observations : cheerful, rapport each to establish, somewhat slow to respond, compliant and friendly </li></ul><ul><li>WASI : FSIQ=108, Verb=114, Perf=102 </li></ul><ul><li>WIAT II : WR=93, MR=106, S=96 </li></ul><ul><li>MASC : T=65, elevated </li></ul><ul><li>CDI : T=47, normal range </li></ul><ul><li>DSM-IV Diagnosis: ADHD-I </li></ul>
    8. 8. Life in families with ADHD-I <ul><li>Homework vacillates between a struggle and a crisis </li></ul><ul><li>Routine activities and chores are forgotten </li></ul><ul><li>Getting ready in the morning is a formidable challenge </li></ul><ul><li>Dawdling and procrastination means things are done at the last minute </li></ul><ul><li>Bedrooms and play areas usually messy and disorganized—clothes laying in the same spot they were dropped; toys, papers, books, and magazines in disarray. </li></ul><ul><li>Lots of time spent looking for “lost” things </li></ul><ul><li>“ Off in own world,&quot; not listening and not following through </li></ul>
    9. 9. School (cont.) <ul><ul><li>Academic underachievement, learning disabilities (McBurnett et al., 1999; Carlson & Mann, 2000) </li></ul></ul><ul><ul><li>These problems may be less extreme in early elementary years, but as demands for independence increase with each grade, these problems can be quite severe by middle and high school. </li></ul></ul>
    10. 10. Peer Relations in ADHD-I Carlson & Mann, 2000; Maedgen & Carlson, 2000; Blachman & Hinshaw, 2002 <ul><li>Tend to be passive and withdrawn </li></ul><ul><li>Often play by themselves; play with others for only short periods of time. </li></ul><ul><li>Often shy, not “tuned in” to group conversation. </li></ul><ul><li>Poor tracking and processing of social cues, </li></ul><ul><li>Not well-accepted by peers: teased, unpopular, neglected rather than openly rejected. </li></ul><ul><li>Deficits in knowing what to do when interacting with others, not just a performance problem. </li></ul>
    11. 11. DSM-IV ADHD-I Must occur OFTEN, cause IMPAIRMENT, X 2 settings <ul><li>Inattentive (6+) </li></ul><ul><ul><li>Fails to give attention to details/makes careless mistakes </li></ul></ul><ul><ul><li>Difficulty sustaining attention </li></ul></ul><ul><ul><li>Seems not to listen </li></ul></ul><ul><ul><li>Fails to finish tasks </li></ul></ul><ul><ul><li>Difficulty organizing </li></ul></ul><ul><ul><li>Avoids tasks requiring sustained attention </li></ul></ul><ul><ul><li>Loses things </li></ul></ul><ul><ul><li>Easily distracted </li></ul></ul><ul><ul><li>Forgetful </li></ul></ul><ul><li>Hyper/Impulsive (5-) </li></ul><ul><ul><li>Fidgets or squirms in seat </li></ul></ul><ul><ul><li>Difficulty remaining seated when asked to </li></ul></ul><ul><ul><li>Runs about or climbs on things when asked not to </li></ul></ul><ul><ul><li>Difficulty playing quietly </li></ul></ul><ul><ul><li>Acts “on the go” or “driven by a motor” </li></ul></ul><ul><ul><li>Talks excessively </li></ul></ul><ul><ul><li>Blurts out answers </li></ul></ul><ul><ul><li>Difficulty awaiting turn in group activities </li></ul></ul><ul><ul><li>Interrupts people, butts into others’ activities </li></ul></ul>
    12. 12. Sluggish Cognitive Tempo (McBurnett et al., 2001; Carlson et al., 2002 <ul><li>Daydreams </li></ul><ul><li>Sluggish or drowsy </li></ul><ul><li>Confused or in a fog </li></ul><ul><li>Absent-minded </li></ul><ul><li>Apathetic or unmotivated </li></ul><ul><li>Stares blankly </li></ul><ul><li>Underactive or unmotivated </li></ul><ul><li>Forgetful </li></ul>
    13. 13. Attention Problems in ADHD-I vs. ADHD-C <ul><li>ADHD-I more severe alertness/orientation problems than ADHD-C (McBurnett et al., 2001). </li></ul><ul><li>ADHD-I more problems in focused or selective attention; ADHD-C more problems with persistence, working memory and behavioral inhibition (Barkley, 1997). </li></ul><ul><li>Both types share deficits on tests of frontal lobe functions, but additional problems in perceptual-motor speed and slow processing specific to ADHD-I (e.g., Barkley et al., 1992) </li></ul>
    14. 14. Work Style in ADHD-I vs. ADHD-C (Booth et al., 2001; Carlson et al., 2002) <ul><li>ADHD-I and ADHD-C- </li></ul><ul><ul><li>lower motivation for learning </li></ul></ul><ul><ul><li>less interest in challenging tasks </li></ul></ul><ul><ul><li>less persistent and more easily discouraged </li></ul></ul><ul><li>ADHD-I prefer cooperative work setting; ADHD-C prefer more competitive environment. </li></ul><ul><li>ADHD-I motivated to please teacher, make good grades more so than for own curiosity, interest or internal drive. </li></ul><ul><li>ADHD-C more likely to value being perceived as high performing and successful than those with ADHD-I. </li></ul>
    15. 15. Comorbid Disorders Carlson & Mann, 2000 <ul><li>Oppositional Defiant Disorder and Conduct Disorder — less in ADHD-I than ADHD-C </li></ul><ul><li>Anxiety and Depression — comparable or more in ADHD-I than ADHD-C </li></ul><ul><li>Learning Disorders — comparable or more in ADHD-I than ADHD-C (esp. math achievement) </li></ul>
    16. 16. Tailoring psychosocial treatment to ADHD-I <ul><li>Academic impairment -- necessitates close involvement with school; direct intervention for homework. </li></ul><ul><li>Work style issues – use non-competitive external rewards for specific goals; accommodations to tasks and assignments to address slow processing speed </li></ul><ul><li>Social difficulties -- teach and practice specific skills; provide opportunities and reinforcement for approaching and interacting with peers. </li></ul>
    17. 17. Tailoring Tx (cont.) <ul><li>Lack of independence in daily living tasks -- most efficiently increased with routines, parent monitoring and reinforcement. </li></ul><ul><li>Fewer disruptive behavior problems -- Limit setting strategies (time-out) less useful. Instead, positive reinforcement targeting specific goals and routines indicated. </li></ul>
    18. 18. Why psychosocial treatment? <ul><li>Medication may be less helpful for ADHD-I than ADHD-C. (Barkley et al, 1991; Greenhill et al, 2000) </li></ul><ul><li>Social impairment in ADHD-I (social passivity/withdrawal, lack of social knowledge) likely to be more amenable to PST than ST (Pfiffner et al, 2000) </li></ul><ul><li>ST side effects of social withdrawal (Granger et al., 1996) may be less acceptable in children who already have social withdrawal problems </li></ul><ul><li>ST often does not normalize functioning; the inclusion of PST may be necessary to produce “excellent” treatment response </li></ul><ul><li>Parents show a significant preference for behavioral treatments over pharmacological treatment alone (Pelham, 1999) </li></ul><ul><li>These factors suggest that psychosocial interventions may be even more important for this subtype. </li></ul>
    19. 19. Life Skills Training for ADHD-Inattentive Type <ul><li>Exploratory/Developmental 3 year grant funded by NIMH (2002-2005) </li></ul><ul><li>Treatment incorporates rehabilitation approaches based on similarities between ADHD-I and mild brain injuries (e.g., sluggish cognitive tempo, forgetfulness) </li></ul><ul><li>Emphasizes adaptive skills, functional competence, compensatory strategies </li></ul><ul><li>Uses cues, prompts, routines </li></ul><ul><li>Involves teachers and parents to provide necessary environmental supports at school and at home </li></ul>
    20. 20. Child Life Skills Program <ul><li>Study Screening and Assessment Process : </li></ul><ul><ul><li>Telephone screenings (parent, teacher) </li></ul></ul><ul><ul><li>Agreement from school to participate </li></ul></ul><ul><ul><li>Standardized rating scales completed by parent and teacher (symptoms, impairment) </li></ul></ul><ul><ul><li>Clinic visit for family: </li></ul></ul><ul><ul><ul><li>Clinical Interview </li></ul></ul></ul><ul><ul><ul><li>KSADS Diagnostic Interview </li></ul></ul></ul><ul><ul><ul><li>WASI and WIAT II screener </li></ul></ul></ul><ul><ul><ul><li>Child self-report: MASC, CDI </li></ul></ul></ul><ul><ul><ul><li>Parent-completed: PSI, APQ </li></ul></ul></ul>
    21. 21. Child Life Skills Program <ul><li>Study design: </li></ul><ul><ul><li>28 children (age 7-11) randomly assigned to: </li></ul></ul><ul><ul><ul><li>Life Skills Training program, or </li></ul></ul></ul><ul><ul><ul><li>Assessment only group (“Treatment as usual”) </li></ul></ul></ul><ul><li>DSM-IV Diagnoses: </li></ul><ul><ul><ul><li>ADHD-I only: 61% </li></ul></ul></ul><ul><ul><ul><li>Comorbid ODD: 32% </li></ul></ul></ul><ul><ul><ul><li>Comorbid anxiety disorder: 21% </li></ul></ul></ul><ul><ul><ul><li>Comorbid depressive disorder: 4% </li></ul></ul></ul><ul><li>Parent and teacher ratings gathered at pre-treatment, post-treatment and follow-up </li></ul>
    22. 22. Participant Characteristics Standard deviation (SD) in parentheses. 102.9 (12.0) 104.6 (12.3) WASI Full Scale IQ 97.8 (16.1) 101.0 (11.8) 100.3 (12.4) 110.1 (22.1) 107.4 (11.1) 107.3 (8.4) WIAT II Math Reasoning Word Reading Spelling 29% 7% 29% 7% 29% 47% 13% 13% 0% 27% Ethnicity Caucasian Latino Asian African American Mixed 21% : 79% 20% : 80% No. of Parents one : two 14% : 50% : 7% : 29% 33% : 27% : 33% : 7% Grade 2 nd : 3 rd : 4 th : 5 th 57% : 43% 53% : 47% Sex male : female 9.4 (1.1) 8.9 (1.1) Age Assessment Only (n=13) Life Skills Program (n=15)
    23. 23. Child Life Skills Program <ul><li>Treatment Components : </li></ul><ul><ul><li>Child </li></ul></ul><ul><ul><ul><li>Weekly Child Group meetings (90 min.) for eight weeks, concurrent with Parent Group meetings. </li></ul></ul></ul><ul><ul><ul><li>Four family meetings with study therapists </li></ul></ul></ul><ul><ul><li>Parent </li></ul></ul><ul><ul><ul><li>Weekly Parent Group meetings (90 min.) for eight weeks, concurrent with Child Group meetings </li></ul></ul></ul><ul><ul><ul><li>Four family meetings with study therapists </li></ul></ul></ul><ul><ul><li>Teacher </li></ul></ul><ul><ul><ul><li>Five consultations with study therapists, families attend part of meetings </li></ul></ul></ul>
    24. 24. Child Component – Skills Taught: <ul><li>Independence Modules </li></ul><ul><ul><li>Homework/study skills </li></ul></ul><ul><ul><li>Self-care skills </li></ul></ul><ul><ul><li>Getting chores done </li></ul></ul><ul><ul><li>Routines, organization and time tools </li></ul></ul><ul><ul><li>Public Situations </li></ul></ul><ul><li>Social Skills Modules </li></ul><ul><ul><li>Friendship-making </li></ul></ul><ul><ul><li>Handling teasing </li></ul></ul><ul><ul><li>Assertion </li></ul></ul><ul><ul><li>Accepting </li></ul></ul><ul><ul><li>Being a good sport </li></ul></ul><ul><ul><li>Problem-solving </li></ul></ul>
    25. 25. Structure of each Child Group: <ul><ul><li>Review homework, previous skills taught, stars earned at home and school </li></ul></ul><ul><ul><li>Present “skill of the week” </li></ul></ul><ul><ul><li>Skill game </li></ul></ul><ul><ul><li>Role Plays </li></ul></ul><ul><ul><li>Independence Stations and/or free play to practice new skills </li></ul></ul><ul><ul><li>Reinforcement </li></ul></ul><ul><ul><li>Review and meet with parents </li></ul></ul>
    26. 26. Parent Component— Skills Taught: <ul><ul><li>Positive communication (attending, praising, quality time) </li></ul></ul><ul><ul><li>Use of more powerful reinforcement programs to support daily living skills (e.g., star systems, home challenge) </li></ul></ul><ul><ul><li>Use of effective instructions and commands </li></ul></ul><ul><ul><li>Prudent discipline (planned ignoring, response cost) </li></ul></ul>
    27. 27. Parent Component (cont.) <ul><ul><li>Using routines and plans to promote success </li></ul></ul><ul><ul><ul><li>Morning and evening routines </li></ul></ul></ul><ul><ul><ul><li>Homework </li></ul></ul></ul><ul><ul><ul><li>Playdate plan </li></ul></ul></ul><ul><ul><ul><li>Chores </li></ul></ul></ul><ul><ul><li>Child “skill of the week” also reviewed with parents to promote generalization </li></ul></ul><ul><ul><ul><li>Social skills </li></ul></ul></ul><ul><ul><ul><li>Independence Modules </li></ul></ul></ul>
    28. 28. Outline of session content <ul><li>Week 1 </li></ul><ul><li>Child Group Session 1 </li></ul><ul><ul><li>Friendship-making Skills </li></ul></ul><ul><ul><li>Good Sportsmanship </li></ul></ul><ul><li>Parent Group Session 1 </li></ul><ul><ul><li>Overview of ADHD, Child Life Skills Program </li></ul></ul><ul><ul><li>Behavioral Model of Child Behavior </li></ul></ul><ul><ul><li>Attending and Quality Time </li></ul></ul><ul><ul><li>Positive Attention and Verbal Praise </li></ul></ul><ul><li>Teacher Component (Orientation) </li></ul><ul><ul><li>Overview of Child Life Skills Program, behavioral intervention, classroom accommodations </li></ul></ul><ul><ul><li>Classroom Challenge overview </li></ul></ul>
    29. 29. <ul><li>Week 2 </li></ul><ul><li>Child Group Session 2 </li></ul><ul><ul><li>What’s my job? Intro to routines </li></ul></ul><ul><ul><li>Morning routine planning </li></ul></ul><ul><ul><li>Accepting </li></ul></ul><ul><li>Parent Group Session 2 </li></ul><ul><ul><li>Rewarding behavior with praise, activities and privileges </li></ul></ul><ul><ul><li>Token Economy </li></ul></ul><ul><ul><li>Effective use of Positive Reinforcement (novelty, consistency, specificity) </li></ul></ul><ul><ul><li>Effective Communication with school and teacher (Classroom challenge) </li></ul></ul>
    30. 30. <ul><li>Week 3 </li></ul><ul><li>Individual Family Session 1 </li></ul><ul><ul><li>Review of home programs </li></ul></ul><ul><ul><li>Individualized feedback and assistance </li></ul></ul><ul><ul><li>Review classroom challenge </li></ul></ul><ul><li>Parent/Teacher/Child Meeting 1 </li></ul><ul><ul><li>Discuss and develop classroom challenge </li></ul></ul><ul><ul><li>Review homework routine, modify as needed </li></ul></ul>
    31. 31. <ul><li>Week 4 </li></ul><ul><li>Child Group Session 3 </li></ul><ul><ul><li>Homework and study skills </li></ul></ul><ul><ul><li>Remembering important things </li></ul></ul><ul><li>Parent Group Session 3 </li></ul><ul><ul><li>Strategies for Handling Homework Problems </li></ul></ul><ul><ul><li>Review Teacher Homework Expectations </li></ul></ul><ul><ul><li>Discuss a Script for Parent-Teacher Meetings </li></ul></ul><ul><ul><li>Plan Homework Program </li></ul></ul>
    32. 32. <ul><li>Week 5 </li></ul><ul><li>Child Group Session 4 </li></ul><ul><ul><li>Homework and study skills practice </li></ul></ul><ul><ul><li>Assertive Behavior </li></ul></ul><ul><li>Parent Group Session 4 </li></ul><ul><ul><li>Effective vs. Ineffective Commands </li></ul></ul><ul><ul><li>How to Structure Antecedents to Improve Peer Relations </li></ul></ul><ul><ul><li>Practice Homework Routine </li></ul></ul>
    33. 33. <ul><li>Week 6 </li></ul><ul><li>Individual Family Session 2 </li></ul><ul><ul><li>Review and Troubleshoot Home Programs </li></ul></ul><ul><ul><li>Individualized Feedback and Assistance </li></ul></ul><ul><ul><li>Practice Using Script for Parent-Teacher Meetings </li></ul></ul><ul><ul><li>Review classroom challenge </li></ul></ul><ul><li>Parent/Teacher/Child Meeting 2 </li></ul><ul><ul><li>Review classroom challenge, modify as needed </li></ul></ul><ul><ul><li>Review homework routine, modify as needed </li></ul></ul><ul><ul><li>Review accommodations </li></ul></ul>
    34. 34. <ul><li>Week 7 </li></ul><ul><li> Child Group Session 5 </li></ul><ul><ul><li>Dealing with Teasing </li></ul></ul><ul><ul><li>Let’s Make a Plan! </li></ul></ul><ul><ul><li>Parent Group Session 5 </li></ul></ul><ul><ul><li>Reducing Problem Behavior by Planned Ignoring </li></ul></ul><ul><ul><li>Effective Strategies for Changing Antecedents </li></ul></ul><ul><ul><li>Applying Antecedents to Evening Routine or Other Activity </li></ul></ul><ul><li> Parent/Teacher/Child Meeting 3 </li></ul><ul><ul><li>Review classroom challenge, modify as needed </li></ul></ul><ul><ul><li>Review homework routine, modify as needed </li></ul></ul><ul><ul><li>Review accommodations, modify as needed </li></ul></ul>
    35. 35. <ul><li>Week 8 </li></ul><ul><li>Individual Family Session 3 </li></ul><ul><ul><li>Troubleshoot and Individualize Other Home Programs </li></ul></ul><ul><ul><li>Review Parent-Teacher Meetings </li></ul></ul><ul><ul><li>Review classroom challenge </li></ul></ul><ul><li>AND </li></ul><ul><li>Child Group Session 6 </li></ul><ul><ul><li>Study Skills and Homework Practice </li></ul></ul><ul><ul><li>Problem Solving and Organization </li></ul></ul><ul><li>Parent Group Session 6 </li></ul><ul><ul><li>Response Cost (and Fines) </li></ul></ul><ul><ul><li>Using Punishment Effectively </li></ul></ul><ul><ul><li>Approaches to Problem Solving and Organization with my Child </li></ul></ul>
    36. 36. <ul><li>Week 9 </li></ul><ul><li>Child Group Session 7 </li></ul><ul><ul><li>Time Management Tools </li></ul></ul><ul><ul><li>Do it Now! Overcoming Procrastination </li></ul></ul><ul><li>Parent Group Session 7 </li></ul><ul><ul><li>Improving My Child’s Organization and Time Management Skills </li></ul></ul><ul><ul><li>Planning Activities in Advance </li></ul></ul><ul><ul><li>Promoting Independence in Public Places </li></ul></ul><ul><li>Parent/Teacher/Child Meeting 4 </li></ul><ul><ul><li>Review classroom challenge, modify as needed </li></ul></ul><ul><ul><li>Review homework routine, modify as needed </li></ul></ul><ul><ul><li>Review accommodations, modify as needed </li></ul></ul><ul><li>Individual Family Session 4 (if needed) </li></ul>
    37. 37. Week 10 <ul><li>Child Group Session 8 </li></ul><ul><li>Review all skills taught </li></ul><ul><li>Select “personal challenge” </li></ul><ul><li>Parent Group Session 8 </li></ul><ul><li>Review all skills taught </li></ul><ul><li>Discuss strategies for maintaining gains working with new teachers </li></ul><ul><li>Being prepared for future problems </li></ul><ul><li>Plus monthly family meetings until follow-up </li></ul>
    38. 38. Sample Home Challenge Name: Date:
    39. 39. Sample home target behaviors <ul><ul><li>Complete morning routine: (e.g., get up w/o complaining, get dressed-all items, put backpack by front door) </li></ul></ul><ul><ul><li>Complete H/W assignment independently (e.g., start with one page, increase with success; strategies for going on when stuck) </li></ul></ul><ul><ul><li>Complete chores </li></ul></ul><ul><ul><li>Complete evening routine independently (e.g., bathe, dressed, clothes in hamper, brush teeth in x mins). </li></ul></ul>
    40. 40. Name: Date: Home Challenge
    41. 41. <ul><ul><li>Orientation meeting with teacher and therapist </li></ul></ul><ul><ul><ul><li>Overview of ADHD-I and the Child Life Skills Program </li></ul></ul></ul><ul><ul><ul><li>Overview of behavioral interventions and classroom-based accommodations for ADHD-I </li></ul></ul></ul><ul><ul><ul><li>Overview of Daily Report Card (“Classroom Challenge”) </li></ul></ul></ul><ul><ul><li>Four meetings between teacher, therapist and family; focus on: </li></ul></ul><ul><ul><ul><li>Homework Plan </li></ul></ul></ul><ul><ul><ul><li>Classroom Challenge </li></ul></ul></ul><ul><ul><ul><li>Classroom-based accommodations </li></ul></ul></ul>Teacher Component
    42. 42. Homework Expectations <ul><li>When, what and how is homework assigned? </li></ul><ul><li>Should parent help child with homework or correct homework? </li></ul><ul><li>How important is neatness? </li></ul><ul><li>How long should it take? </li></ul><ul><li>Is homework meant for practicing skills or is there some other purpose? </li></ul>
    43. 43. Homework plan <ul><ul><li>Own desk </li></ul></ul><ul><ul><li>Organize space with paper sorter, etc. </li></ul></ul><ul><ul><li>Lighting </li></ul></ul><ul><ul><li>Prioritize, break down h/w </li></ul></ul><ul><ul><li>H/W sheet checked each day </li></ul></ul><ul><ul><li>Built in breaks </li></ul></ul><ul><ul><li>Closely supervised H/W, incidental teaching, not just giving answers </li></ul></ul>
    44. 44. Sample Classroom Challenge Name: Date:
    45. 45. Steps to set up Classroom Challenge <ul><li>Select target behaviors </li></ul><ul><li>List target behaviors on the CC Card </li></ul><ul><li>Discuss logistics during school day </li></ul><ul><li>Discuss logistics when at home </li></ul>
    46. 46. Sample target behaviors <ul><li>Academics/ Study habits: </li></ul><ul><li>completes assigned work accurately </li></ul><ul><li>has materials necessary for task </li></ul><ul><li>completes and returns homework </li></ul><ul><li>keeps desk area organized/neat </li></ul><ul><li>starts work with X or fewer reminders </li></ul><ul><li>Peers: </li></ul><ul><li>plays with other children </li></ul><ul><li>shows good sportsmanship </li></ul><ul><li>Rules/behavior: </li></ul><ul><li>accepts consequences </li></ul><ul><li>follows rules/directions </li></ul>
    47. 47. Steps (cont.) <ul><li>Identify reinforcers for the child to earn at home </li></ul><ul><li>Discuss baseline ratings & Match Game </li></ul><ul><li>Review plan & do a “walk-through” of procedure with child </li></ul><ul><li>Schedule Follow-up meeting for 1-2 weeks after CC begins </li></ul>
    48. 48. Communication styles for working with attention problems <ul><li>Giving directions </li></ul><ul><li>Praise </li></ul><ul><li>Corrective feedback </li></ul>
    49. 49. Give clear directions: Stay clam. Use a nonverbal sign to tell students it’s time to be quiet. Too emotional “ Pleeeeeze! Be quiet!!!” “ If you don’t finish your work you will lose your recess.” A threat in an emotional way can provoke many ADHD students “ Do you want to lose your recess?” Give time, such as 5-10 seconds in between each direction. Too many directions at once. “ Okay class. It’s time to get back to work. Turn to page 5 of your book and you will find an experiment to do. All of the materials are on the back counter. Make sure you answer all questions. When you’re done you can start your math, but first turn in your completed work.” Be direct. “You have a direction to listen the first time.” Unanswerable question “ Why can’t you ever listen the first time?” “ Jason, please collect the papers.&quot; Implies a choice “ Jason, would you collect all of the papers?” Better Problem Statement
    50. 50. Effective and Ineffective Praise You should always keep your desk that clean!! Your desk is spotless!! Finally you remembered your homework. I like the way you remembered your homework today. I hope you can put your things away like this all the time. It’s so helpful when you have your things away on time. You ignored Sally’s teasing right now. I just hope you don’t get back at her when I leave. You made a super effort at ignoring Sally’s teasing. Why can’t your desk look like this all of the time? Your desk looks very organized.
    51. 51. Prudent and Imprudent Feedback I told you before recess to clean up your mess. I noticed that you want to go to recess anyway. You have to remember to clean up before recess. I gave you a direction to clean up. If you don’t start right away, you will start losing recess time. How many times do I have to tell you to stop talking? Other students can’t concentrate when you are so loud. You know the quiet rule. You’re going to have to learn how to follow it. Stop talking to Sammy or you will have to go to your seat. Brian, why aren’t you working? Brian, please go to work. Imprudent Prudent
    52. 52. Classroom Accommodations for Attentional Problems <ul><li>For problems following instructions and directions : </li></ul><ul><li>Keep instructions brief (one or two parts), specific, and step-by-step. </li></ul><ul><li>For problems completing assignments and tasks : </li></ul><ul><li>Reduce length of assignment (break into smaller parts). </li></ul><ul><li>Allot extra time for work completion. </li></ul><ul><li>Give assignments one at a time, rather than all at once. </li></ul><ul><li>Set time limits or “challenges” for completion of tasks. </li></ul><ul><li>Include some method of checking work. </li></ul>
    53. 53. Classroom Accommodations (cont.) <ul><li>For problems with organization, planning, or beginning assignments or tasks : </li></ul><ul><li>Encourage child to make “to do” lists and use organizer notebooks or folders. Monitor these regularly. </li></ul><ul><li>Teach child to organize assignments by completion; notes according to chronological order, etc. </li></ul><ul><li>Teach outlining and note-taking skills (e.g., by providing outlines for child to complete). </li></ul><ul><li>Praise child for getting started on a task. </li></ul>
    54. 54. Classroom Accommodations (cont.) <ul><li>For problems staying focused and on task : </li></ul><ul><li>Seat child away from doors, windows, areas of frequent activity or noise, and disruptive students. </li></ul><ul><li>Place child near teacher’s desk to help teacher monitor more closely whether child is paying attention to oral instructions and completing work. </li></ul><ul><li>Provide “quiet zone” (e.g., desk with study carrel located in a corner) in which child can sit while taking tests, or at times when distracted or having trouble concentrating. </li></ul>
    55. 55. Classroom Accommodations (cont.) <ul><li>Cue child when it is important to pay attention by putting important information on chalkboard or introducing it with verbal prompts (for example, “This is important”). </li></ul><ul><li>Cue child in advance about times or tasks where independence is needed, and encourage non-disruptive activities while waiting (for example, reading, journal writing, doodling, note taking). </li></ul><ul><li>Instruct child to move on to another task when work finished early or to continue on easier parts of an assignment or task while waiting for assistance. </li></ul>
    56. 56. Classroom Accommodations (cont.) <ul><li>For problems working independently : </li></ul><ul><li>Reward child for finishing small portions of an assignment on his/her own; gradually increase the requirement as s/he is successful. </li></ul><ul><li>Set time limits or “challenges” for completion of tasks. </li></ul>
    57. 57. Kayla Home program <ul><li>H/W: moved work station into bedroom; too noisy in kitchen area due to remodeling. Made sure desk area stocked and clean/organized </li></ul><ul><li>To remember assignments and bring back, CC and prompting most helpful </li></ul><ul><li>AM routine: added checklists and daily rewards; get up earlier- reward with shower in am. </li></ul><ul><li>Commands—distant commands decreased </li></ul>
    58. 58. <ul><li>Playdates– </li></ul><ul><ul><li>during playdates would withdraw into own activity and engage in parallel play. Parent monitored more often and found alternatives for interactive play </li></ul></ul><ul><ul><li>Selected specific girls for playdates </li></ul></ul><ul><ul><li>Planned activities in advance </li></ul></ul>
    59. 59. Kayla: School program <ul><li>Listening target: implies social behavior of less chatting, more eye contact. Teacher took the time to define and troubleshoot. Used praise. </li></ul><ul><li>H/W target– implies remembering to get it home. Needed reminders/cues. Tried: </li></ul><ul><ul><li>Visual sticker in cubby </li></ul></ul><ul><ul><li>Hawaiian dress key chain on backpack (laminated)—jingly noise helped the most </li></ul></ul><ul><ul><li>Self-monitoring: “whats the first thing I need to do when I get to the classroom” </li></ul></ul><ul><ul><li>Teacher posted homework sign for all </li></ul></ul>
    60. 60.  
    61. 61. Dennis, 9 years, 3 rd grade <ul><li>Getting started target: due to spacing out, forgetting instructions. Teacher agrees to accommodate cross checking that he understood instructions </li></ul><ul><li>Organization target: mastered in 2 weeks </li></ul><ul><li>Completing work: half of problems assigned to the rest of class—skill development still accomplished with half the problems. </li></ul><ul><li>Child identified problems to work on, he helped set the goal which increased motivation </li></ul>
    62. 62.  
    63. 63. Tips for making a DRC work <ul><li>Define target behaviors very specifically </li></ul><ul><ul><li>Organized desk– give examples of criteria </li></ul></ul><ul><ul><li>Vague targets (paying attention) hard to track </li></ul></ul><ul><li>Include “easy” target behavior </li></ul><ul><li>Change target behaviors or requirements if not working; take flexible approach </li></ul>
    64. 64. Tips (cont.) <ul><li>Be encouraging and positive; use praise </li></ul><ul><li>Integrate self-monitoring, “Match Game” </li></ul><ul><li>Make homework expectations clear </li></ul><ul><li>Maintain close communication between home and school </li></ul>
    65. 65. Troubleshooting a program <ul><li>Are target behaviors clear to the child (and teacher) and appropriate? </li></ul><ul><li>Does child understand the program? </li></ul><ul><li>Does child remember the target behaviors during the day? </li></ul><ul><li>Are the criteria realistic? </li></ul><ul><li>Is the child getting sufficient feedback during day about his/her progress? </li></ul><ul><li>Is child interested in the rewards? Are more immediate rewards at school needed? </li></ul>
    66. 66. Progress during Teacher/Family meetings, Sample Case: ADHD-I+LD <ul><li>Meeting 1: </li></ul><ul><ul><li>Pxs: distractibility and not completing work </li></ul></ul><ul><ul><li>When distracted go to “secret spot” </li></ul></ul><ul><ul><li>Complete all in-class assignment during class time </li></ul></ul><ul><li>Meeting 2: </li></ul><ul><ul><li>Modify in-class assignments to writing only </li></ul></ul><ul><ul><li>Decrease doodling on h/w (parent reluctant to set higher expectations) </li></ul></ul><ul><li>Meeting 3: </li></ul><ul><ul><li>Good progress, mostly 2’s on CC </li></ul></ul><ul><ul><li>Secret spot not used, add ignoring to CC </li></ul></ul><ul><ul><li>Add completion of h/w problem in homework clinic </li></ul></ul>
    67. 67. <ul><li>Meeting 4: </li></ul><ul><ul><li>Mostly 2’s on CC for writing assignments </li></ul></ul><ul><ul><li>Ignoring a px, modify to before lunch, using sign (could use response cost) </li></ul></ul><ul><ul><li>Not doing h/w problem in h/w clinic– teacher had not communicated with homework clinic staff </li></ul></ul>
    68. 68. Progress during family meetings Sample case: ADHD-I+LD <ul><li>Meeting 1: </li></ul><ul><ul><li>Px with am routine, hard to get out of bed </li></ul></ul><ul><ul><li>Dad doing h/w for her; pessimistic </li></ul></ul><ul><ul><li>Set up HC targeting h/w and am program, use stickers for daily reward and weekly video </li></ul></ul><ul><li>Meeting 2: </li></ul><ul><ul><li>Not much improvement in h/w </li></ul></ul><ul><ul><li>Modify after school routine: dad picks up 30 min early, small snack, start h/w earlier, make sure rewards given (parent did not believe in incentives) </li></ul></ul>
    69. 69. <ul><li>Meeting 3: </li></ul><ul><ul><li>Program is working: Dad goes through h/w instructions, but she does it without Dad’s help. </li></ul></ul><ul><ul><li>Earning daily and weekly rewards </li></ul></ul><ul><ul><li>Dad says still distractible. Get a desk and put in her room. </li></ul></ul><ul><li>Meeting 4: </li></ul><ul><ul><li>Desk has greatly helped decrease distractions </li></ul></ul><ul><ul><li>Routine and rewards working, earning free time </li></ul></ul><ul><ul><li>Using incidental teaching (not giving the answers) </li></ul></ul><ul><ul><li>For am, using alarm clock and stars </li></ul></ul><ul><li>Parents did not think much could change, but small modification made a big difference. She is happy on playground, increased confidence, doing better with social entry, less snippy with peers, and has playdates for first time. </li></ul>
    70. 70. Mean scores for Child Life Skills and Assessment Only groups at baseline and post-treatment, Parent Report
    71. 71. Mean scores for Child Life Skills and Assessment-Only groups at baseline and post-treatment, Parent Report
    72. 72. Mean scores for Child Life Skills and Assessment Only groups at baseline and post-treatment, Teacher Report
    73. 73. Parent Consumer Satisfaction Ratings <ul><ul><li>Attention Difficulties: 90% improved or much improved </li></ul></ul><ul><ul><li>Change in Target Behaviors: </li></ul></ul><ul><ul><li>88% improved or much improved </li></ul></ul><ul><ul><ul><ul><li>Morning routine </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Social Skills </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Homework </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Classroom </li></ul></ul></ul></ul><ul><ul><li>Home and School Challenge: 100% helpful or very helpful </li></ul></ul><ul><ul><li>Usefulness of Skills Taught: 95% useful or extremely useful </li></ul></ul><ul><ul><li>Satisfaction With Treatment: 100% satisfied or very satisfied </li></ul></ul>
    74. 74. Teacher Consumer Satisfaction Ratings <ul><ul><li>Classroom Challenge: 100% helpful or very helpful </li></ul></ul><ul><ul><li>Effort required to participate: 88% not too much </li></ul></ul><ul><ul><li>Continued use of Classroom Challenge: </li></ul></ul><ul><ul><ul><ul><ul><li> 80% likely or very likely </li></ul></ul></ul></ul></ul><ul><ul><li>Recommendation of the program to other parents and teachers: </li></ul></ul><ul><ul><li> 93% recommend or strongly recommend </li></ul></ul><ul><ul><li>Use of program to treat attentional/academic/social skills problems: 100% appropriate or very appropriate </li></ul></ul>
    75. 75. Child Consumer Satisfaction Ratings <ul><li>(Ratings on 5- point scale: not at all, a little, somewhat, pretty much, a lot) </li></ul><ul><li>How much did you like the group? 90% pretty much or a lot </li></ul><ul><li>How much did you learn in group? 90% pretty much or a lot </li></ul><ul><li>How much did the Home Challenge help you do better at home? </li></ul><ul><li>85% pretty much or a lot </li></ul><ul><li>How much did the School Challenge help you do better at school? </li></ul><ul><li>80% pretty much or a lot </li></ul><ul><li>How much would you like to continue in the group? </li></ul><ul><li>80% pretty much or a lot </li></ul><ul><li>Note: for all questions, one child rated “sometimes” </li></ul>
    76. 76. Common Issues <ul><li>Family fails to do homework </li></ul><ul><ul><li>Does not understand </li></ul></ul><ul><ul><li>Too angry </li></ul></ul><ul><ul><li>Disagrees with need </li></ul></ul><ul><ul><li>Too much effort </li></ul></ul><ul><ul><li>No time (and didn’t get needed supplies) </li></ul></ul><ul><ul><li>Forgot </li></ul></ul><ul><li>Kitchen-sinking, hard to stay on topic </li></ul><ul><li>Child “tests” the system </li></ul><ul><li>Siblings </li></ul><ul><li>Teacher/school not supportive or parents and teacher fail to communicate </li></ul>
    77. 77. Common Issues (cont.) <ul><li>Resistance to using rewards: re-name, hear about success from other parents, use small, practical rewards </li></ul><ul><li>Managing parent affect and emotion: increase awareness, coping strategies </li></ul><ul><li>Anxiety and perfectionism in implementing program: lower the threshold for success, step back, be more supportive and “catch them being good” </li></ul>
    78. 78. What was most helpful? <ul><li>Using consequences rather than repeating directions over and over. </li></ul><ul><li>Attending and praising </li></ul><ul><li>Setting time limits, using a timer </li></ul><ul><li>Ignoring outbursts </li></ul><ul><li>Using varying levels of rewards: cuddle time, computer time, having friend over, dessert choice, movie, lunch date with mom, bike to park </li></ul><ul><li>Using job jar for infractions (home tasks) </li></ul><ul><li>Applying the program consistently </li></ul>
    79. 79. <ul><li>Giving immediate commands (e.g., “do xyz”, rather than “when this is over can you do this?”) </li></ul><ul><li>Playdates: </li></ul><ul><ul><li>Plans important—activity, length, practice setting up, use telephone, coaching before child came, rewarding afterwards </li></ul></ul><ul><li>Using a chart </li></ul><ul><li>Having a defined program allowed for more couple’s time without constant discussion of parenting/child. </li></ul>
    80. 80. What did parents like about the program? <ul><li>Groups </li></ul><ul><li>Children in own peer group made it fun </li></ul><ul><li>Relating to other parents </li></ul><ul><li>Feeling supported, individualized advice, sharing info </li></ul><ul><li>Group size great </li></ul><ul><li>Therapists addressed concerns well, responsive to feedback </li></ul><ul><li>Educating parents (informative), increased awareness of parenting </li></ul><ul><li>Program </li></ul><ul><li>Separate family and teacher components, holistic approach </li></ul><ul><li>Positive reinforcement and praise for target behs, home and classroom challenges </li></ul><ul><li>Rewards program for children </li></ul><ul><li>Organized (structured), common sense approach that values the child </li></ul><ul><li>Parenting Help </li></ul><ul><li>Parenting tips, ABC, social skills for children </li></ul><ul><li>Immediate change in child’s beh </li></ul><ul><li>Learning that children need limits </li></ul>
    81. 81. What did teachers like about the program? <ul><li>Effort </li></ul><ul><li>Quick and efficient, meetings were short and productive </li></ul><ul><li>Easy target behaviors to work on </li></ul><ul><li>Minimal effort </li></ul><ul><li>Teacher-Child Relationship </li></ul><ul><li>Daily feedback, classroom challenge – helped student and teacher focus on behaviors </li></ul><ul><li>One-on-one work </li></ul><ul><li>Hands-on nature </li></ul><ul><li>Seeing child pleased with ratings </li></ul><ul><li>Made teacher pay close attention to child </li></ul><ul><li>Gets student involved in own decision-making </li></ul><ul><li>School/Family Relations </li></ul><ul><li>Educating, involving both teachers and parents </li></ul>
    82. 82. Barriers to treatment <ul><li>Parent psychopathology </li></ul><ul><li>Low SES (transportation, childcare px, no job/$ neighborhood factors) </li></ul><ul><li>No coverage for mental health services </li></ul><ul><li>Marital conflict (and inconsistent parenting) </li></ul><ul><li>School not willing or able to participate </li></ul><ul><li>Insular family, lack of social support </li></ul><ul><li>Language and/or learning px in parent </li></ul>
    83. 83. Methods for tailoring behavioral intervention <ul><li>Parenting skills: Group vs. family format </li></ul><ul><li>Child skills: Group vs. individual, need to teach basics to parents/teachers </li></ul><ul><li>School: List accommodations, request 504 or IEP (if comorbidities present) to formalize. Daily report card almost always helpful during school-age years. </li></ul>
    84. 84. Reference for Child Life Skills Program <ul><li>Pfiffner, L.J. (2003). Psychosocial treatment for ADHD-Inattentive Type. The ADHD Report , 11 , 1-8. </li></ul>