School Based Treatment for Adolescents with ADHD: The Challenging Horizons Program

1. 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

2. 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

3. 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 CHProgram.jmu.edu

4. 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 CHProgram.jmu.edu

5. 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 CHProgram.jmu.edu

6. 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 CHProgram.jmu.edu

7. 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 CHProgram.jmu.edu

8. CHP Treatments • Behavioral • Verbal reinforcement and punishment • Point systems • Time Outs • Daily/weekly report cards • Educational • Organization • Study Skills • Homework Management • Note Taking CHProgram.jmu.edu

9. CHP Treatment Modalities • Counseling Relationship • Group Therapy • Interpersonal Skills Group • Education Group • Individual Treatment • Supportive counseling • Collaborative development of treatment plans • Individualized behavior plans CHProgram.jmu.edu

10. 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 CHProgram.jmu.edu

11. 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 CHProgram.jmu.edu

12. 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 CHProgram.jmu.edu

13. Interventions Targeting AcademicImprovement in the ChallengingHorizons Program Jessica M. Allen1, B.A. Joshua M. Langberg2, M.A. Corinne Maiorana1 James Madison University1, University of South Carolina2

14. 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). CHProgram.jmu.edu

15. 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). CHProgram.jmu.edu

16. 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). CHProgram.jmu.edu

17. 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 CHProgram.jmu.edu

18. Education Group • Four phases, each one focusing on application and/or instruction of skills. • Consists of an instruction component and an application component. CHProgram.jmu.edu

19. Education Group Phases CHProgram.jmu.edu

20. 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. CHProgram.jmu.edu

21. 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. CHProgram.jmu.edu

22. 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. CHProgram.jmu.edu

23. 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. CHProgram.jmu.edu

24. 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. CHProgram.jmu.edu

25. 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. CHProgram.jmu.edu

26. Participants • 18 Participants • Age range: 11-14 • All participants involved in the Challenging Horizons Program were diagnosed with ADHD-Combined or ADHD-Inattentive types. CHProgram.jmu.edu

27. Mean Number of D’s and F’s Per Semester CHProgram.jmu.edu

28. Parent Ratings of Academic Functioning CHProgram.jmu.edu

29. Teacher Ratings of Academic Functioning CHProgram.jmu.edu

30. Development of Social Skills Interventions for the Challenging Horizons Program Veronica L. Raggi, B.S. and Sheryle A. Moore, B.S. James Madison University

31. 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) CHProgram.jmu.edu

32. 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) CHProgram.jmu.edu

33. Development of Social Skills Training and Interventions • Original CHP interventions (1999-2001) • Interpersonal Skills component • focused on conversational skills, problem solving strategies • Cognitive-behavioral component • focused on low self-esteem and poor motivation, the role of self-statements and their connection to mood CHProgram.jmu.edu

34. 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 CHProgram.jmu.edu

35. Effect Sizes for CHP versus Control on the Parent version of the Impairment Rating Scale CHProgram.jmu.edu

36. 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 CHProgram.jmu.edu

37. 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 CHProgram.jmu.edu

38. 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 CHProgram.jmu.edu

39. 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 CHProgram.jmu.edu

40. 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 CHProgram.jmu.edu

41. 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 CHProgram.jmu.edu

42. Interpersonal Skills Group • Review videos of social interactions CHProgram.jmu.edu

43. Directions for Future Research Amy L. Williams, B.S. Zewe Serpell, Ph.D. Jennifer Capito & Lindsay Barnett James Madison University

44. 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 CHProgram.jmu.edu

45. 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. CHProgram.jmu.edu

46. 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. CHProgram.jmu.edu

47. 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. CHProgram.jmu.edu

48. 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? CHProgram.jmu.edu

49. Psychosocial (Cont.) • Outcome Goals • Manual • Individual Modules • IEP Goals • Training Materials • Interactive video and text • Good and bad examples of implementation Note Taking from Text • Presenting Problems • Goals • Methods • Pre-Instruction Phase • Instruction Phase • Mastery Criteria • Troubleshooting • Expectations (time frame) • Additional Options • Materials Needed CHProgram.jmu.edu

50. 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? CHProgram.jmu.edu