School Based Treatment for Adolescents with ADHD: The

Challenging Horizons Program

Steven W. Evans (Chair)

James Madison University

Jennifer Axelrod (Discussant)

Center for School Mental Health Assistance

Treating Adolescents with ADHD in the Schools

Steven W. Evans, Ph.D.

Michelle Quick, B.A.

Margaret Nemeth, Ed.S.

James Madison University

Loyola University

Indiana University of Pennsylvania

CHProgram.jmu.edu

Adolescents with ADHD

While there is considerable treatment outcome literature on children with ADHD, there is very little treatment outcome research focusing on adolescents with ADHD

Important developmental changes and changes in context make effectiveness of child interventions uncertain with adolescents– e.g. parent training, note taking– Secondary schools vs. elementary schools

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School Based Mental Health

Clinic based treatments are not likely to be effective with adolescents with ADHD– Generalization– Counseling and CBT not likely to be effective

Manifestations of ADHD impair functioning at school– Academic– Social– Disruptive behavior

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School Based Mental Health – 2

One of most frequent recommendations to achieve generalization is to put services where problems are exhibited

Increases access to care for psychosocial and educational interventions

Puts services in community where adolescents live

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Challenging Horizons Program

Students attend CHP at a local middle school from 3:00 to 5:15 on Mondays, Tuesdays, & Thursdays

Each child is assigned a primary counselor who works with him/her individually, develops (with supervisor) treatment plans, and is liaison with teachers.

Family counselor supervises primary clinician and liaison/counselor with parents

– Send home bi-weekly reports– Phone communication– Parent training– Individual counseling

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CHP Parent Meetings

Last Monday of every month parents meet in library– Collect assessment data– Present/discuss information on ADHD– Practice skills with students– Eat pizza dinner & child care– Children work on homework in cafeteria, eat dinner,

and play in gym after homework completion

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CHP Treatments

Behavioral– Verbal reinforcement and punishment– Point systems– Time Outs– Daily/weekly report cards

Educational– Organization– Study Skills– Homework Management– Note Taking

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CHP Treatment Modalities

Counseling Relationship Group Therapy

– Interpersonal Skills Group– Education Group

Individual Treatment– Supportive counseling– Collaborative development of treatment plans– Individualized behavior plans

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CHP Treatment Model

Develop, modify, and evaluate treatments in CHP

When interventions achieve desired behavioral outcome, interventions are exported to teachers and parents

Results:– Parents and teachers do not need to be involved in

the trial and error portion of treatment development– Interventions are demonstrated effective prior to

expecting others to invest in them

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Measures

Monthly parent and teacher ratings of symptoms and functioning

Parent and self ratings of social functioning Grades 88 min of observation data per week (44 min

in science & 44 min in math class) Individualized data collection resulting from

treatment plan

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Treatment Development Process

Given lack of treatment literature on adolescents with ADHD, started CHP in 1999 with 4 students in public middle school

Over years treatment manual evolved as data and experience indicated some interventions worked and others did not

Goal: Identify collection of effective interventions that could be integrated into middle school for teachers, counselors, administrators, and others to implement

Interventions Targeting AcademicImprovement in the Challenging

Horizons ProgramJessica M. Allen1, B.A.

Joshua M. Langberg2, M.A.

Corinne Maiorana1

James Madison University1, University of South Carolina2

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Why target Academic Functioning?

Adolescents with ADHD exhibit significant school problems.– Poor organization– Low grades– High rate of suspension– As many as 58% will be retained at least one grade

and they are ten times more likely not to complete high school (Barkley, et al., 1990; Barkley, Fischer, Edelbrock, Smallish, 1991).

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Why Target Academic Functioning?

Approximately 25% of adolescents with ADHD are diagnosed with learning disabilities (Barkley, DuPaul, & McMurray, 1990).

35% to 39% of all adolescents in special education are estimated to have ADHD (Pelham, Evans, Gnagy, & Greenslade, 1992).

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Why Target Academic Functioning?

Due to the severity of academic difficulties in adolescents with ADHD, the development of efficacious treatments targeting academic functioning has been encouraged (NIH consensus development panel members, 2000).

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Educational Interventions

Education Group– Note taking instruction and practice in class– Study skills– Written language

Individual education (with counselor)– Organization of materials– Tracking assignments– Homework Completion

Homework management

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Education Group

Four phases, each one focusing on application and/or instruction of skills.

Consists of an instruction component and an application component.

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Education Group Phases

Instruction Application

Phase 1 Note-taking from Class

N/A

Phase 2 Note-taking from Text

Note-taking from Class

Phase 3 Study Skills Note-taking from Text

Phase 4 Written Language Study Skills

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Individual Education - Organization

Demonstration of organization in notebooks, bookbags, and lockers.

Students experiencing difficulty in this area should work with their primary counselor to set up an organizational system with weekly locker/notebook checks.

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Individual Education – Assignment Tracking

Assignments checked as soon as student arrives at program.

Write upcoming assignments or “no homework” where applicable.

If the student experiences difficulty in this area, they may be required to obtain teacher initials for each class.

Can be phased out after improvement in this area.

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Individual Education – Homework Completion

After all organizational tasks have been checked, students work on homework (hardest assignments first).

If the student claims not to have any homework, the primary counselor should work with the student on studying for an upcoming test.

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Homework Management Plan

Implemented in the home setting. Can be individualized to meet each individual

family’s needs. Mandatory study time.

– Parent assigns academic tasks if the child hasn’t brought anything home.

– Privileges contingent on completion.– Child can participate in activities not listed in the

plan.

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Homework Management Plan – Assignment Notebook

The degree to which the student accurately recorded assignments and obtained teacher initials may dictate the amount of privileges he or she receives after completing the mandatory study time.

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Outcomes

Large gains in classroom functioning and academics during the first year (1999-2000) of CHP (Evans, et al., in press).

Little progress in exhibiting note-taking and study skills in class or at home.

Interventions targeting the accurate recording of assignments, completion of homework, and organization of materials appeared to account for much of the overall improvement.

During the second year of CHP (2000-2001) the amount of time practicing the note-taking, study skills, and writing skills were increased.

The application component of Education group grew out of the need for generalization.

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Participants

18 Participants Age range: 11-14 All participants involved in the Challenging

Horizons Program were diagnosed with ADHD-Combined or ADHD-Inattentive types.

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Mean Number of D’s and F’s Per Semester

0

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6

First Semester Second Semester

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CHP

Community Control

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Parent Ratings of Academic Functioning

3

3.5

4

4.5

5

5.5

6

Parent rating pre Parent rating post

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CHP

Community Control

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Teacher Ratings of Academic Functioning

2

2.5

3

3.5

4

4.5

teacher rating pre teacher rating post

Pro

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CHP

Community Control

Development of Social Skills Interventions for the Challenging

Horizons Program

Veronica L. Raggi, B.S. and Sheryle A. Moore, B.S.

James Madison University

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Social Deficits

More than 50% of ADHD children have significant problems in social relationships with other children

Children with ADHD are often less compliant with parental requests, more off-task and negative, and typically more demanding of help and attention than non-diagnosed children

(Pelham & Bender, 1982; Hinshaw & Melnick, 1995; Milich, et al, 1982;

Barkley & Cunningham, 1980; Campbell, 1975; Befera & Barkley, 1985)

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Impairment in Relationships with Peers

more aggressive, disruptive, intrusive and noisy than non-diagnosed children

less reciprocity in social exchanges talk more but less efficient in organizing and

communicating information to peers less liked by their peers and often have few

friends(Cunningham & Siegel, 1987; Landau & Milich, 1988; Barkley, 1988)

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Development of Social Skills Training and Interventions

Original CHP interventions (1999-2001)– Interpersonal Skills component

focused on conversational skills, problem solving strategies

– Cognitive-behavioral componentfocused on low self-esteem and poor motivation,

the role of self-statements and their connection to mood

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Outcome Results (1999-2001)

The overall multivariate effect was not significant, F(6,23) = .51, p >.05  

Parent ratings on the IRS showed improvement in the CHP group in the medium to large effect size range

Teacher ratings showed deterioration in functioning over time for both groups

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Effect Sizes for CHP versus Control on the Parent version of the Impairment

Rating Scale

-0.1

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

Relationship w ith Peers Relationship w ith Parent Self-Esteem Relationship w ith Siblings

Impairment Rating Scale Category

Eff

ect

Siz

e

CHP

Control

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Nature of ADHD Deficits

Represents a deficit in the brain’s behavioral inhibition system (BIS)

Executive functions disrupted:– emotional self-control – objectivity and social perspective taking– problem solving and self-questioning – moral reasoning– sensitivity to response feedback – inhibition of task-irrelevant responses

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Theory of Social Deficits

Adolescents with ADHD do not recognize long-term contingencies associated with their behavior

They over-respond to potential immediate reinforcement without inhibiting behavior as a result of likely punishment

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Major Goals for Social Skills Training and Interventions

Recognize the social contingencies present in their environment and connect those contingencies with their own behavior

Identify the effects of their behavior on their real self (how others perceive them)

Learn how to bring their real self closer to their ideal self (how they want others to perceive them)

Use and apply problem solving steps to make better decisions in response to real life events

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Development of Social Skills Training and Interventions

Modified CHP social skills interventions– Recreation Time

Sports Rules Matching Game Behavior Calls

– Individual Social Skills Goals Developed with the primary counselor

– Interpersonal Skills Group

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Interpersonal Skills Group

Phase I- Psycho-Educational Component– Purpose

Participants learn basic concepts necessary for understanding the connections between contingencies and behavior

– Basic Concepts Ideal Self, Real Self, Contingencies, Reinforcement,

Punishment– Techniques

Role Playing, Games, Instruction

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Interpersonal Skills Group

Phase II- Three Activities– Social Problem Solving Instruction

Students learn six problem solving steps; steps are then applied to their own social problems

– Skill Development Leader reviews progress on individual goals for each child

– Social Contingencies Assessment Students identify the social contingencies that result from

behaviors, videotaped at the program

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Interpersonal Skills Group

Review videos of social interactions

Directions for Future Research

Amy L. Williams, B.S.

Zewe Serpell, Ph.D.

Jennifer Capito & Lindsay BarnettJames Madison University

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After-School Model

Development Laboratory– Assess effectiveness of various interventions and

procedures Modifications made to manual as necessary

Additional Staff Requirement– Entire program coordinated and run by graduate

and undergraduate student staff– Completely separate from existing school curriculum

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Fully Integrated Model

Long-Term Goal– Develop a program that facilitates widespread

usage.– After-school model not feasible without additional

resources.

Recent Funding– Currently in year 1 of a 6 year project– Re-package interventions for use by existing

school personnel during normal school day.

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Elements of Fully Integrated Model

Currently Existing Elements– Psychosocial Protocol

Essentially the same interventions, just different providers.

Additional Elements – Medication Protocol

Effectiveness of combined treatment.

– Web Based Communication System Need for enhanced collaboration.

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Community Development Teams

Purpose and Use– Created to enhance feasibility, transportability, and

acceptability of program.– Monthly meetings and online discussions to provide

feedback, ideas, etc… Reflect Three Elements of Model

– Psychosocial, Medication, Web Composition of Members

– Varies according to needs of the team.

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Psychosocial Development Team

Team Members– Director of special education, teachers (regular & special

education), school counselors, & parents

Current Progress– Determination of interventions and providers.

Who is best suited to implement the intervention? Where in the school schedule does the intervention fit? Who is best suited for home follow up? What are the training and resource needs? What are potential challenges and obstacles to implementation?

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Psychosocial (Cont.)

Outcome Goals– Manual

Individual Modules IEP Goals

– Training Materials Interactive video and text Good and bad examples of

implementation

Note Taking from TextPresenting ProblemsGoals MethodsPre-Instruction Phase Instruction PhaseMastery CriteriaTroubleshootingExpectations (time frame)Additional OptionsMaterials Needed

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Medication Development Team

Team Members– Physicians, family and school counselors, regular

and special education teachers, and parents Current Progress

– Assessment of psychosocial treatment effectiveness.

What indicates a need for medication?

– Determination of medication benefit. What is the best medication and best dosage?

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Medication (Cont.)

Outcome Goals– Treatment Algorithm

Diagnostic Assessment, Family Evaluation, and Documentation of Prior Medication

Psychosocial ProtocolPsychosocial Assessment

Continue Psychosocial

Review, Assess, and Adjust Psychosocial

Begin Medication

Medication Assessment

Determination of Med Benefit Prescribe Medication

If Yes

If No

Stimulant B Alt. Med C Alt. Tx. Protocol

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Web Development Team

Team Members– District web specialist, school counselors, teachers (regular

and special education), and parents

Current Progress– Two completed sites

Public Website (Description) Development Team Website (Description)

– One site currently in progress Student Participant Site Security, accessibility, and information display

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Home I Client Login I Glossary I Contacts

Search for:

•Med Protocol

•Child’s Progress in Protocol

•Medical Information

Last Updated: 2/20/03

E-mail

Doctor

Start Search

Clear

Web (Cont.)

Outcome Goals - Secure page, treatment plan, data entry and display, and online communication.

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Program Feasibility

Primary Objective– Create a program that is both useful and can be

used by school personnel.

Assessment of Feasibility Perceptions– Acceptability (valid intervention)– Practicality (easily integrated into school day)– Obstacles to Implementation

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Feasibility (Cont.)

Method of Assessment– Focus groups at 5 area middle schools– Presentation of 2 delivery models (after-school and

fully integrated)– Completion of questionnaire

Use of Information– Facilitate transition from development lab to school

setting

DiscussantJennifer Axelrod, Ph.D.

Associate Director

CSMHA

Assistant Professor of Psychiatry