Laura G. Anthony, Ph.D.

Children’s National Medical Center

Pediatric Neuropsychologylanthony@cnmc.org

Nancy Lever, Ph.D.

Center for School Mental Health Analysis and Action

Department of Psychiatry, University of Maryland, Baltimore

nlever@psych.umaryland.edu

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