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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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What Can SBHC Providers Do to Address ADHD?

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What can sbhc providers do to address adhd

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



  • 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


  • 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


  • A team with time - champions


  • Clarify roles and tasks

  • Map resources

  • Set goals – keep them simple

    • NICHQ QI ADHD measures



  • 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



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:


  • Parent/Teacher Disruptive Behavior Disorders Rating Scalehttp://ccf.buffalo.edu/pdf/DBD_rating_scale.pdf

    Parent and Teacher report – 45 items.

    Subscales for: ADHD, ODD, CD



  • 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)

What can sbhc providers do to address adhd

  • 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)



  • 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


    • 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:

What can sbhc providers do to address adhd

  • 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



  • 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



  • 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



  • 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/



  • 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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