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What Can SBHC Providers Do to Address ADHD?

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What Can SBHC Providers Do to Address ADHD?. Goals Help SBHC Providers:. Maximize use of evidence based treatment strategies for students diagnosed with ADHD Understand the resources available to create a behavior program Understand the resources available to use medications

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slide1

What Can SBHC Providers

Do to Address ADHD?

goals help sbhc providers
Goals Help SBHC Providers:
  • Maximize use of evidence based treatment strategies for students diagnosed with ADHD
  • Understand the resources available to create a behavior program
  • Understand the resources available to use medications
  • Understand the resources available to create quality monitoring programs
overview
Overview
  • Introductions
  • ADHD – What works and what doesn’t work
  • Screening and Assessment
  • Review Practice Skills for Home-based Interventions
  • Classroom Management Strategies
  • Medication Management
  • Case Examples – if time permits!
adhd definition dsm iv
ADHD Definition (DSM-IV)
  • “A persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals of comparable level of development”
dsm iv adhd
DSM IV-ADHD
  • Three main types
    • Attention Deficit Hyperactivity Disorder, Predominantly Inattentive Type
    • Attention Deficit Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type
    • Attention Deficit Hyperactivity Disorder, Combined
adhd dsm iv diagnosis
ADHD DSM-IV Diagnosis
  • 6 or more inattentive items
  • 6 or more hyperactive/impulsive items
  • Persistent for at least 6 months
  • Clinically significant impairment in social, academic, or occupational functioning
  • Inconsistent with developmental level
  • Some symptoms that caused impairment before age 7
  • Impairment is present in two or more settings (school, home, work)
adhd common school response
ADHD: Common School Response
  • Identification and Referral:
    • Inattention/Hyperactivity/Disruptive Behavior seen as Intentional Defiance  Discipline Referral
    • Discipline – Criticism, Detention, Suspension
    • MH Intervention???
      • Referral to PCP for medication
      • Often with NO environmental (school/home) intervention
adhd is treated by primary care providers such as sbhcs
ADHD is treated by Primary Care Providers – such as SBHCs
  • Extensive research - MTA
  • Evidence based therapies with clear guidelines
    • NICHQ: http://www.nichq.org/areas_of_focus/adhd_topic.html
    • Texas Department of State Health Services http://www.dshs.state.tx.us/WorkArea/DownloadAsset.aspx?id=8592
sbhcs a re optimally s ituated
SBHCs are Optimally Situated
  • Behavioral and medical providers
  • Access to schools – teachers, admin.
  • Goal of SBHCs is to increase parent involvement – necessary for ADHD rx
  • Chronic disease model (like asthma)
adhd team
ADHD Team
  • A team with time - champions
  • NO NEW TOOLS
  • Clarify roles and tasks
  • Map resources
  • Set goals – keep them simple
    • NICHQ QI ADHD measures
roles
Roles
  • Connect with parents, teachers, administration, students and providers
  • Educate each about ADHD in an accessible and culturally appropriate manner
  • Deliver evidence based practices
  • Prescribe medication
  • Monitor medication
  • Monitor process and outcomes
step 1 identification referral
Step 1Identification & Referral
  • Provide Training and Materials for Teachers and Parents on ADHD signs/symptoms
  • Include ADHD and mental health issues in the training of new teachers
  • Develop an effective referral process, including referral feedback, for teachers and school staff
parent teacher training resources
Parent Teacher Training Resources
  • Texas Dept. of State Health Services http://www.dshs.state.tx.us/mhsa/patient-family-ed/
  • CHADD – the What We Know sheets include clear explanations for provider and parent http://www.help4adhd.org/en/about/wwk
  • Maryland Public Schoolshttp://www.msde.maryland.gov/MSDE/divisions/studentschoolsvcs/student_services_alt/ADHD/
step 2 screening assessment
Step 2Screening & Assessment
  • SBHC Providers can conduct interviews and administer screening tools and assessments to assist in the diagnosis of ADHD
is it adhd
Is It ADHD?

Mood/AnxietyProblems

PDD Spectrum

structured interview form
Structured Interview Form
  • Disruptive Behavior Disorders Structured Parent Interview
    • Based on DSM criteria
    • FREE! – available at http://ccf.buffalo.edu/pdf/DBD_interiew.pdf
  • Subscales for:
    • ADHD, ODD, CD
resources for free and validated screening tools
Resources for Free and Validated Screening Tools:
  • NICHQ
  • Parent/Teacher Disruptive Behavior Disorders Rating Scale http://ccf.buffalo.edu/pdf/DBD_rating_scale.pdf

Parent and Teacher report – 45 items.

Subscales for: ADHD, ODD, CD

diagnosis
Diagnosis
  • Beware previous labels
  • Childhood is constant change – continuous assessment
  • Not sure you have the right label? “Not Otherwise Specified” while you observe/gather information
interventions with little or no evidence of effectiveness as the primary treatment of adhd
Interventions with little or NO evidence of effectiveness as the primary treatment of ADHD:
  • Special elimination diets
  • Vitamins or other health food remedies
  • Psychotherapy or psychoanalysis
  • Biofeedback
  • Play therapy
  • Chiropractic treatment
  • Sensory integration training
  • Social skills training
  • Self-control training
step 3 behavioral interventions
Step 3 Behavioral Interventions
  • “According to the research, Behavior Therapy and Management, both in the classroom and at home, are the best-supported non-drug treatments”

Hawaii Department of Health, Child and Adolescent Mental Health Division. (2004). Evidence Based Services Committee Biennial Report: Summary of Effective Interventions for Youth with Behavioral and Emotional Needs.

what do we mean by behavior management
What Do We Mean By Behavior Management?
  • Why children with ADHD misbehave – correcting misperceptions
  • Identifying and removing barriers to effective child management
  • Paying attention to and reinforcing child’s good behavior (improving emotional relationship)
behavior management of adhd
Behavior Management of ADHD
  • Issuing effective commands (compliance training)
  • Use of time-out
  • Reinforcement and response cost system (tokens or points) for appropriate/inappropriate behaviors
  • Extension to school and public settings - behavior report card
importance of context
Importance of Context

“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)

slide28
Bright Futures –www.brightfutures.org/mentalhealth/pdf/tools.html
  • Tools for students, clinicians and families
several empirically supported b ehavior protocols e xist
Several Empirically-Supported Behavior Protocols Exist:
  • Defiant Children (Russell Barkley)
  • Helping the Noncompliant Child (Rex Forehand)
  • Videotape Parent Modeling (Carolyn Webster-Stratton)
praise
Praise
  • Training parents and teachers to praise correctly increases compliance in youth with ADHD/DBD
    • Praise can include
      • Verbal praise, Encouragement
      • Attention
      • Affection
      • Physical proximity
giving effective praise
Giving Effective Praise
  • Be honest, not overly flattering
  • Be specific
  • No “back-handed compliments” (i.e., “I like the way you are working quietly, why can’t you do this all the time?”)
  • Give praise immediately
ignoring differential reinforcement
Ignoring & Differential Reinforcement
  • Train parents and teachers to selectively
    • Ignore mild unwanted behaviors

AND

    • Attend to alternative positive behaviors
teaching to ignore
Teaching to Ignore
  • Teach parents and teachers how and when to ignore undesirable behavior
    • Ignoring can include
      • Visual cues
      • Postural cues
      • Vocal cues
      • Social cues
improving commands limit setting
Improving Commands/Limit Setting
  • Training for parents and teachers to give commands in the most effective way
  • Effective commands increase compliance in children and adolescents with ADHD (and in others, too!)
improving commands limit setting with children
Improving Commands/Limit Setting with 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
improving commands limit setting with adolescents
Improving Commands/Limit Setting with Adolescents
  • 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
improving commands limit setting with adolescents cont
Improving Commands/Limit Setting with Adolescents (cont)
  • 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
tangible rewards
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
school home contract
School-Home Contract
  • Daily report card, based on a written contract, coupled with home-based reward system
    • List of a few target behaviors, homework and test grades and homework assignments
    • Choose one target that the child will be successful with most of the time
    • Parent and teacher signatures and comments
school home contract1
School HomeContract

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:

slide41

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
    • 1point for each day of appropriate behavior. When 10 points are earned Jeffrey may invite a friend to dinner and a movie
general education classroom
General Education Classroom
  • Brief, clear, and frequent instructions
  • Include academic performance (e.g., accurate work completion) in behavior plan.
  • Daily report card system
  • Parallel teaching—increase engagement
  • Strategic attention, frequent feedback
  • Post schedules and rules
  • Increase novelty and interest level of tasks
  • “Direct Instruction” techniques
step 4 medication management
Step 4Medication Management
  • Robust positive effects of stimulant medication (70% of children) on ADHD core symptoms and positive effects on some associated problems (aggression, peer relations, reduced compliance)
medication should not be a substitute for
Medication Should Not Be aSubstitute For:
  • Parent/Teacher training
  • Behavior modification
  • Appropriate educational curricula
  • Appropriate school placement
  • Adequate teaching skills
  • Family treatment
stimulants
Stimulants
  • They work immediately
  • Up to 70% response rate
  • Need to be monitored and titrated
  • No response – reconsider the diagnosis
algorithms and tactics
Algorithms and Tactics
  • Article describing the new ADHD algorithms - Journal of the American Academy of Child and Adolescent Psychiatry in June 2006 (Pliszka S, Crismon ML, et al.)
discussion consent assent
Discussion, Consent/Assent
  • Clarify prognosis, alternative treatments, potential side effects
  • The student and parent decide whether or not to try medication – not the provider or the school
  • Warn students and families that we use a “try and see method”
  • Address myths and stigma
monitor
Monitor
  • Determine GOALS (target behavior) together – see NICHQ mgt plan
  • Ensure adequate dose and duration before changing or adding
  • Monitor with user friendly tools
  • Less is more – don’t scare them away with side effects
  • The idea is to assist self control for this chronic disease
be prepared for concerns
Be Prepared For Concerns
  • Possible questions
    • Over treatment
    • Under treatment
    • Misdiagnoses
    • Misuse of medications
  • Myths and misperceptions
    • Medication makes you a zombie
    • Medication leads to addiction
resources
Resources
  • Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) www.chadd.org
  • National Attention Deficit Disorder Association www.add.org
  • University of Buffalo, Center for Children and Families http://wings.buffalo.edu/adhd/
resources1
Resources
  • National Information Center for Children and Youth with Disabilities www.nichy.org
  • National Institutes of Mental Health www.nimh.nih.gov
  • And don’t forget the ones previously noted
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