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

Not recommended!

What we know works:  Drug Therapy  Behavior Therapy  Combined 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 therapy  Individual or family counseling (without altering the environment)  Social skills/self-monitoring/organizational planning  Dietary management  Megavitamin therapy  Sensory integration therapy/chiropractics  EEG 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 Medications o250 studies (N > 5000)  Behavior Therapy o48 classroom studies (N > 900) o80 parent/home studies (N > 5,000)  Combined Behavioral/Drug Treatments o25 studies (N > 800)

Behavior Therapy for ADHD Components  Highly structured

Behavior Therapy for ADHD Components  Highly structured  Immediate feedback  reinforcer or reward for appropriate behavior  consequence for inappropriate behavior

Behavior Therapy for ADHD Components  Highly structured  Immediate feedback  reinforcer or reward for appropriate behavior  consequence for inappropriate behavior  Salient/meaningful feedback

Behavior Therapy for ADHD Components  Highly structured  Immediate feedback  reinforcer or reward for appropriate behavior  consequence for inappropriate behavior  Salient/meaningful feedback  Programming at home and school

School Behavior Intervention Examples: 1. The Attention Training System (ATS) 2.Home School Note 3.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 feedback 3. Meaningful consequences

School Behavior Intervention: The Attention Training System (ATS) 1. Technology Teacher Module Student Module 2. Immediate feedback 3. Meaningful consequences 4. Structured “time”

School Behavior Intervention The ATS: Lisa Days % Time Off Task No ATSATSNo ATS AT S

School Behavior Intervention The ATS: Troy Days % Time Off Task No ATS ATS Meds Only

School Behavior Intervention Home School Notes Address Problems With  Academic effort  In-class behaviors  Assignment completion

School Behavior Intervention Home School Notes Procedures  Identify target behaviors

School Behavior Intervention Home 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 Intervention Home School Notes Procedures  Identify target behaviors  Design school note form

School Behavior Intervention Home 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 MathL. ArtsHistoryScience Yes No

School Behavior Intervention Home School Notes Procedures  Identify target behaviors  Design school note form  Identify reinforcers and consequences

School Behavior Intervention Home School Notes Reinforcer Examples  Wear an outfit of your choice to school  Get out of a chore  TV/video games/telephone/computer time  Allowance  Token toward weekend activity

School Behavior Intervention Home School Notes Procedures  Identify target behaviors  Design school note form  Identify reinforcers and consequences  Establish criterion for reinforcement

School Behavior Intervention Home School Notes Procedures  Identify target behaviors  Design school note form  Identify reinforcers and consequences  Establish criterion for reinforcement  Increase criterion as progress is made

School Behavior Intervention Home School Notes Procedures  Identify target behaviors  Design school note form  Identify reinforcers and consequences  Establish criterion for reinforcement  Increase criterion as progress is made  Plan for generalization and maintenance

School Behavior Intervention Home 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