ADHD Practice Elements

1. ADHD Practice Elements Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1 from the National Institute of Mental Health and Project # U45 MC00174 from the Office of Adolescent Health, Maternal, and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services

2. Specific interventions to help the student with ADHD • Psycho-education with parent • Parent praise • Commands/limit setting • Tangible rewards • Response cost • Parent monitoring • Time out • Ignoring or DRO

3. Parent Psychoeducation • Engage and empower parents by teaching them about ADHD • Establish relationship with parents as partner in treatment process • Look at how ADHD influences parent-child interaction (bi-directional)

4. Parent Psychoeducation • Review information about ADHD • Symptoms • Causes • Diagnostic criteria (3 sub-types) • Treatment modalities

5. Parent Psychoeducation • Emphasize caretaker role in development and treatment of ADHD • Problems in parenting and parenting styles may make ADHD worse • Establishing behavioral interventions at home or at school require caretaker involvement • Knowledge enables parents to more effectively advocate for better services

6. Parent Psychoeducation • More effective if therapist devotes more than one session to psychoeducation • More effective if therapist educates parents about ADHD across multiple settings (home, school, playground, etc)

7. Resources for Parent Psychoeducation • Center for Children and Families • “What Parents and Teachers Should Know about ADHD” • Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) • Fact sheets for parents

8. Resources for Parent Psychoeducation • National Initiative for Children’s Healthcare Quality • “How to Establish a School-Home Daily Report Card” • Vanderbilt Assessment Scales (parent and teacher version) • ADHD Resources Available on the Internet • “Working with Your Child’s School”

9. Parent praise • Training parents to praise correctly increases compliance in youth with ADHD • Praise can include • Verbal praise, Encouragement • Attention • Affection • Physical proximity

10. Giving effective praise • Be honest, not overly flattering • Be specific • No “back-handed compliments” (i.e., “I like the way you are playing quietly, why can’t you do this while I’m on the phone?”) • Give praise immediately

11. Training parents to praise children • Barkley manual, Step 2 (Defiant Children) • Teach parents to set up “special time” to pay attention to their child during play • Teach parents to narrate their child’s play • Teach parents not to ask many questions nor give any commands • Teach parents to ignore misbehavior during this playtime • Teach parents how to praise and praise lavishly during this time

12. Training parents to praise teens • Barkley manual, Step 3 (Defiant Teens) • Encourage parents to set aside 15 minutes a few times a week to pay attention to their adolescent • Teach parents to pay attention to what their teen is doing, and show interest in a relaxed way • Teach parents not to ask questions nor give any instructions • Teach parents to ignore if the teenager reacts with sarcasm, coolness or suspicion • Teach parents to praise well and often

13. Improving commands/limit setting • Training for parents and teachers to give commands in the most effective way • Effective command increase compliance in children and adolescents with ADHD (and in others, too!)

14. Improving commands/limit setting with children • Barkley Step 3 (Defiant Children) • Teach parents and teachers: • To only give commands that they intend to back up with consequences (positive and negative) • Not to present commands as questions or favors • Not give too many commands at once

15. Improving commands/limit setting with children • Teach parents and teachers: • To make eye contact with the child before giving command • To reduce other distractions while giving commands • To ask the child to repeat the command • To watch the child for one minute after giving the command to ensure compliance • To immediately praise child when s/he starts to comply

16. Improving commands/limit setting with adolescents • Barkley, Defiant Teens, Step 4 • Teach parents and teachers: • To consider the intent of their command • Do they have the time/energy to follow through? • Do they have consequences for noncompliance? • To avoid ambiguity when issuing commands • To not respond to compliance with gratitude

17. Improving commands/limit setting with adolescents • Teach parents and teachers: • To praise teens for appropriate behavior • To tell teen what to do, rather than what not to do • To eliminate other distractions while giving commands • To break down multi-step commands • To use aids for commands that involve time

18. Tangible rewards • Children and adolescents with ADHD do not respond to natural (intrinsic) rewards as well as typical youth • The training of parents and teachers in the use of tangible rewards is effective in increasing desired behaviors • Can use token systems, behavior charts, or immediate rewards

19. Setting up a reward system for children at home • Barkley, Defiant Children, Step 4 • Determine family’s readiness to implement • Tailor the program to family’s ability-simplify it for overwhelmed or stressed families • Use poker chip system with younger children (4-7), point system with older children (8 and up)

20. Setting up a reward system for children at home • Set a positive tone for the program • “We are going to make sure that you get rewarded for all of the good stuff you do at home” • Parent(s) buys chips and makes a bank, or sets up a chart or notebook for tracking points • The parent(s) and child together (with your help) make up a list of 10-15 rewards • There should be everyday rewards, like TV or computer time, and longer term rewards, like going to a movie or earning a new video game)

21. Setting up a reward system for children at home • Help the parent(s) and child make a list of jobs or problem areas • Determine how much each is worth • Add up how much the child might earn in a day • Harder jobs should earn more • Bigger rewards should cost more • Make sure the child has some success in the beginning

22. Setting up a reward system for children at home • Discuss the concept of bonus chips to reward helpful or other positive behaviors, even if they aren’t on the list • Chips and points are only given if the child complies after the first command • Don’t take away chips or points (response cost) • All caregivers should use the same system • Remind parents to praise while giving the points

23. Setting up a reward system for children at school • Barkley, Defiant Children, Step 8, Daily School Report Card • The teacher tracks the child’s behavior and reports it to the parent daily, who rewards the child • This is particularly effective because both the parent and teacher are involved • If the parent can’t be involved, the rewards may be given at school

24. Setting up a reward system for children at school • Choose a few target behaviors at school • Choose one that the child will be successful with most of the time • Set up a system for school report card or school/home note system • See samples on page 244-246 • Pick from the targets given, or create your own with the blank samples

25. Setting up a reward system for adolescents at home • Barkley, Defiant Teens, Step 5 • Use a point system (see previous slides) for 13/14 and under • Set up basically the same way as with children • Warn parents to expect resistance, their teen is used to getting all of their privileges for free! Make sure parents don’t give in. • Make sure parents only choose privileges they can control

26. Setting up a reward system for adolescents at home • Barkley, Defiant Teens, Step 5 • Use a behavior contract for teens 14/15 and older • See sample contract on page 208 • Begin with only “do” behaviors (clean up room, set table, get ready for school on time) • “Don’t” behaviors are dealt with under response cost in next section

27. Setting up a reward system for adolescents at school • Barkley, Defiant Teens, Step 9 • Establish a homework contract (see sample on page 121) • This can be adapted for other behavioral goals • Can also set up guidance counselor, tutor or peer as “coach” for organizational skills or other targets • Rewards for teen’s participation can be made part of the home contract, or part of a school reward system

28. Response Cost • Using a point or token system in which negative behaviors result in the loss of points or tokens. • Training parents and teachers to use response cost is effective in reducing undesired behavior and noncompliance

29. Response Cost with Children • Barkley, Defiant Children Step 4 & 8 • Train parents and teachers: • To develop list of undesirable behavior to be fined by reward system • To deduct points/chips for undesirable behavior • Parent and child have chosen to reduce whining • If child whines, parent deducts three points • Penalties increase based on severity of behavior

30. Response Cost with Children • Train parents and teachers: • To avoid “punishment spiral” • When parent fines child for misbehavior, the child may respond with more misbehavior • Child continues to lose points, then loses motivation for the point system • Rule: Parent fines child once through point system, then sends child to time out if undesirable behavior continues

31. Response Cost with Adolescents • Barkley, Defiant Teens Step 6 • To train parents and teachers: • To now use behavioral contract with the teen for “fines” • Teen agrees to not swear • If teen swears, teen loses Internet privilege

32. Response Cost with Adolescents • Train parents and teachers: • To begin with 1 week “training period,” during which parent labels misbehavior every time it happens and warns of new fines • To avoid “punishment spiral” • When parent fines teen for misbehavior, the teen responds with more misbehavior • Teen continues to lose privileges, then loses motivation • Rule: Parent fines teen no more than twice, then directs teen to “cool off” away from the situation

33. Response Cost with Adolescents • Encourage parents to act as “judge and jury” when teen lies • The teen should remain above suspicion • Response cost allows parents to discipline/educate instead of just punish • Emphasis of response cost is on • “Warm” – positive, loving • “Firm” – specific, immediate, and consistent

34. Parent Monitoring • Give parents a structured way to monitor their child’s behavior • Measurement of the target behavior should be repeated • Can use either informal or formal measures

35. Parent Monitoring • Informal measures • Daily homework log • Behavior chart as part of a reward system • Home Situations Checklist (Barkley, Defiant Children)

36. Parent Monitoring • Formal measures • Vanderbilt Scales (from your Resource Toolkit or on the web) • Disruptive Behavior Disorders Scale (in Barkley or on the web)

37. Time Out • Time out is the removal of a child or adolescent from all reinforcement for a specified period of time after a targeted misbehavior • It is an effective intervention, but only if it is used correctly and is not used too often

38. Using Time Out with Children at Home • Barkley, Defiant Children, Step 5 • Teach parents to give an effective command (Step 3) • Teach parents to count out loud (initially) from 5 to 1 • Teach parents to give a time out warning if the child has not complied • After warning, count from 5 to 1 again

39. Using Time Out with Children at Home • Teach parents to guide child to time out chair IMMEDIATELY • Teach parents to place the child in the chair “Stay there until I tell you to get up” • Teach parents not to argue or interact with the child in any way • Teach parents to not come back until the child is calm. Once the child is calm and the time is served, the child must correct the misbehavior

40. Using Time Out with Children at Home • Teach the parents that the child should now go and comply with the previous command, or correct the misbehavior • Teach the parent to now praise compliance, and to praise the next behavior that the child does well

41. Time Out Tips with Children • The first time out may be difficult • Prepare parents for a worst case scenario of a complete struggle. • Reassure parents that this is how the child learns time out and correcting misbehavior. • Make sure the time out area is away from anything interesting or fun • Remind parents not to “make up for” the time out (i.e., saving dessert for them)

42. Using Time Out with Adolescents • Barkley, Defiant Teens, Step 8 • “Grounding” = “house arrest” • NO access to privileges (phone, TV, etc) • Parent must be home to enforce • Most effective with younger teens • May include “work detail” (cleaning out basement, scrubbing bathroom floor)

43. Ignoring and Differential Reinforcement • Train parents and teachers to selectively • Ignore mild unwanted behaviors AND • Attend to alternative positive behaviors

44. Teaching parents and teachers to ignore • Teaching parents and teachers how and when to ignore undesirable behavior • Ignoring can include • Visual cues • Postural cues • Vocal cues • Social cues

45. How to ignore • Visual cues • Look away once child engages in undesirable behavior • Do not look at the child until behavior stops • Postural cues • Turn the front of your body away from the location of child’s undesirable behavior • Do not appear frustrated (e.g., hands on hip) • Do not vary the frequency or intensity of your current activity (e.g., chopping faster, hammering harder)

46. How to ignore • Vocal cues • Maintain a calm voice even after your child begins undesirable behavior • Do not vary the frequency or intensity of your voice (e.g., don’t talk faster or shout over the child) • Social cues • Continue your intended activity even after your child begins undesirable behavior • Do not panic once child’s begins inappropriate behavior (i.e., do not draw more attention to child)

47. When to ignore • When to ignore undesirable behavior • Child interrupts conversation or class • Child blurts out answers before question completed • Child continuously talks during dinner • Child tantrums while at the grocery store • Do not ignore undesirable behavior that could potentially harm the child or someone else

48. Differential reinforcement • Teach parents and teachers how and when to differentially reinforce desirable behavior • Step One: Ignore (stop reinforcing) the child’s undesirable behavior • Step Two: Reinforce the child’s desirable behavior in a systematic manner • The desirable behavior should be a behavior that is incompatible with the undesirable behavior

49. Differential reinforcement • Define the behavior of concern (target) • Determine how often the target behavior occurs • Determine how often to reward the child for alternative behavior • Fixed interval – reward every X minutes • Determine how to reward the child for alternative behavior • Praise, attention, points or chips

50. Reinforcement of target behavior • Target behavior: Interrupting • Alternative behavior: Playing by himself • Reward schedule: 5 minutes • If child goes 5 minutes without interrupting, the child receives reinforcement • If child interrupts before 5 minutes is up, the child does not receive reinforcement • Re-set schedule once child interrupts