Addressing the Treatment Needs of Adolescents with ADHD

1. Addressing the Treatment Needs of Adolescents with ADHD Steven W. Evans, Ph.D. Alvin V. Baird Centennial Chair in Psychology James Madison University

2. Overview • Brief description of disorder and evaluation as pertains to adolescents • Review individual interventions that comprise CHP • Present CHP outcome data • Future Directions

3. Core Symptoms • Inattention • Impulsivity • Hyperactivity

4. Difficulty Sustaining Attention • Takes 3 hours to complete 20 minutes of homework or chores • Adolescent claims to be bored in spite of numerous recreation and task opportunities • Cursory review of material when studying • Overwhelmed with large tasks (often avoids starting) • Disorganized rooms, desks, lockers, bookbags

5. Impulsivity • Blurting & inappropriate “humorous” comments • Raising hand to answer before completing question • Responding to questions with tangential information • Easily agitated • Driving, drugs & alcohol, sexual relations, delinquency

6. Hyperactivity • Childhood overactivity usually diminished • Excessive talking • Fidgety behavior • Restless

7. Diagnosis and Assessment • Gather information from adults in the natural environment regarding (a) degree to which the child displays developmentally inappropriate levels of the core symptoms (inattention, impulsivity, hyperactivity) and (b) associated impairment. • Structured interviews • Rating Scales (mother and teacher; weight on teacher; gather multiple informants if discrepancies) • Symptoms (DBD, ADHD RS, SNAP) • Impairment (IRS) • Observations (clinic? classroom? home?)

8. Middle School Teacher Agreement(Evans et al. in press) Teacher Rating ICC n ADHD – RS Total .35c 176 ADHD – RS Inattention .30c 176 ADHD-RS Hyperactivity .36c 176 IRS Relationship with Peers .23a 176 IRS Relationship with Teacher .05 176 IRS Academic Progress .36c 176 IRS Effect on Class .28a 176 IRS Self-Esteem .18a 167 IRS Overall Severity .33c 174 Note. a - p < .01, c - p < .0001, ADHD-RS – Attention Deficit Hyperactive Disorder-Rating Scale, IRS – Impairment Rating Scale.

9. Middle School Teacher Ratings on ADHD RS

10. Middle School Teacher Ratings on IRS – Academic Progress

11. Theory • Primary source of teacher information is reputation • Students selectively decline in classes depending on relationship with teacher, class environment, & difficulty • Over course of year diminished functioning occurs in increasingly more classes so agreement increases

12. GPA in Community Control Sample of Middle School Youth with ADHD

13. Implications • Time of year greatly influences ratings • Changes in behavior should be measured within classroom • When collecting data for diagnosis there will be considerable disagreement • Weight worse cases • Take average • Examine persistence of pattern over time

14. Presenting Problems School • School functioning • Disruptive behavior in classrooms, hallways, cafeterias, buses • Fighting • Defiance • Noncompliance & lack of conforming to rules • Verbal abuse and inappropriate comments • Problems organizing materials • Difficulty tracking and completing assignments • Ineffective study skills • Poor writing skills

15. Presenting Problems Social • Poor interpersonal skills • Predominantly inattentive type • Social behavior deficits • Isolation & social withdrawal • Poor conversation initiation & maintenance • Awkward social interactions • Combined type • Social behavior excesses • Annoying & alienating verbal behavior • Persistence in spite of social punishment

16. Presenting Problems Family • Families of youth with ADHD have more conflicts than families without an adolescent with ADHD • Parent-adolescent dyads demonstrated more negative and controlling verbal behavior than control dyads • Divorce three times more common in families of adolescents with ADHD than control families • Families moved more often and fathers changed jobs more often than controls (Barkley et al., 1990; Barkley et al., 1991)

17. Paths of Family Influence Parental Drinking Parental Stress Child Behavior Problems Maladaptive Parenting Parental Negative Affect

18. Caregiver Strain • Examination of change in caregiver strain over time in relation to change in symptoms and impairment • Does improvement at any level lead to hope and reduction in self-reported strain? • Do parents habituate to problems and reduce strain or become increasingly sensitized to problems and increase strain? • Approximately 70 parents of middle school aged youth with ADHD • Static levels of oppositional behavior best predictor of current level of strain and change • Some parents reporting low levels of ODD in child show a reduction in strain while those reporting high levels of ODD tend to report increased strain. • Oppositional behavior is a critically important treatment target of middle school aged youth

19. Change in Caregiver Strain after 1 year in relation to parent report of oppositional and defiant behavior

20. Challenging Horizons Program

21. Accommodations: Helpful or Harmful?? • How much do we lower the bar and how much do we teach them how to jump higher? • List of “effective” secondary school accommodations: Are these helpful (Robin, 1998)? • Shortening homework assignments • Supplying daily assignment book & reminding students to use it • Giving full credit for late assignments • Permit extra time during tests and give breaks • Allow open book examinations • Provide students with teacher prepared notes from class • Give permission to tape-record lecture • Train in time management

22. CHP – After School Model • Began in November 1999 at JMU • Operates at school between 2 and 4 times per week • Two hours & 15 minutes after school • Focus is improving academic and social impairment • JMU students serve as counselors • NIMH funded developmental clinical trial

23. Organization Belongings Assignments Study skills Note taking Memorization techniques Test preparation Classroom behavior Disruptive behavior Following directions Social functioning Coaching Sports skills Applied practice Family Family Check-Up Homework management CHP Interventions

24. Organization

26. Organization Intervention • 79% of students (22/28) were considered responders to the intervention (White, Evans et al. 2006) • Of the responders, three trends emerged: • Immediate Responders • Slow but Steady Responders • Honeymoon Responders • Currently examining potential moderators of treatment response (ADHD symptom severity, anxiety, depression, ODD, attendance)

27. Organization Intervention Student A: Immediate Responder

28. Organization Intervention Student B: Slow but Steady Responder

29. Organization Intervention Student C: Honeymoon Responder

30. Organization Intervention Student D: Non-responder

31. Assignment Notebook Tracking Patterns of Responding

32. Study Skills

33. The Challenge Children with ADHD Face When Studying • Learning begins with attention – you must attend to the material and then process (elaborate) at deeper levels • To get beyond this hurdle, children with ADHD need explicit instruction in practical and efficient study strategies

34. Study Strategies that RARELY or NEVER Work… • ‘Magic Number’ Strategies – “If I write each word five times, I’ll remember them” • Doing Time – “If I look at the material from now until 8pm, I’ll remember it” • Massed Practice – “If I ‘pull an all-nighter’ before the test, I’ll pass it” • Better Choices for studying include…..

35. Flashcards(Challenging Horizons Program Treatment Manual, 2004) • Flashcards • Excellent study technique for learning terms and definitions (e.g., social studies, science) • Term on one side, SHORT definition on other • Putting the definition in own terms assures mental elaboration. Without this, learning might not occur • “Beat the Clock” – once a student can go through cards without making an error at a rate of 10-15 cards per minute or better, studying is complete

36. Acronyms & Acrostics(Challenging Horizons Program Treatment Manual, 2004) • Transforming lists into words and sentences that are easier to remember. ??? Ex. HOMES – Great Lakes (Huron, Ontario, Michigan, Erie, Superior) Ex. My Very Educated Mother Just Served Us Nine Pizzas

37. Application • Teaching strategies to children with ADHD does not ensure that they will be able to successfully implement them on their own. • Setting up an application system: • Child is required to show use of strategies in their school work. • Reward can be given for successful use. • i.e. show test that received “A” and corresponding set of flashcards they used to study.

38. Consulting with Teachers • Because much of the impairment associated with ADHD emerges in the school setting, participation of teachers is an important key in the treatment of many children. • Teachers are in a good position to implement these academic interventions. • Mutual relationship between parent and teacher: how can parent help teacher and maintain their end of the intervention?

39. Taking Notes • One study demonstrating the benefits of teaching middle school students with ADHD to take notes in class (Evans, Pelham, & Grudberg, 1995). • Reported benefits to taking notes, having notes, and the combination • Increased on-task behavior • Improved scores on homework and tests

40. Teaching Note Taking to Middle School Youth with ADHD • In the context of classroom presentations • Present class material and use “think aloud” technique to teach note taking • Organize information into main ideas and details • Reword into phrases and symbols • Abbreviate the second time forward • Fade “think aloud” instruction and increase class participation • Check products and give feedback • Percent main ideas & details • Format and legibility

41. Note Taking from Text • Use same procedures to learn to take notes from text • Read a paragraph from text and “think aloud” relevant notes • Teach the “What might be on the test?” rule • Create flash cards for vocabulary and use notes for content

42. Summarizing • Many children with ADHD may benefit from taking notes; however, they may gain little by having notes to study • Summarizing • Students learn to present information to parents from notes • Parents taught to ask questions • Summaries may be written or verbal (verbal is much preferred by students) • Implementation of notes interventions

43. Classroom Behavior

44. Behavior Report Cards(Challenging Horizons Program Treatment Manual, 2004) • Structured rating system for target behaviors • Daily Behavior Report Card • Determine behavioral goals within specific setting (e.g., one classroom, cafeteria, school bus) • Rate adolescent during a “baseline” period • Develop report card with teen • Reinforcers for meeting goals • Punishment for poor ratings • Assess progress over time • Phase out behaviors on report card upon “mastery” • Can also be managed at school with some modification

45. Daily Report Card for English Teacher (Evans & Youngstrom 2006) Monday’s Date _______________________ Student – Polly Instructions: Please circle either the “yes” or “no” corresponding to each of the three target behaviors and the day of the week. This report should be faxed to Polly’s mother at work every Friday before 5:00 pm.

46. CHP Daily Behavior Report Cards for Assignment Notebook Complies with verbal requests after one or fewer repetitions BKS BKS Interacts nicely with siblings BKS BKS Speaks respectfully to adults BKS BKS 1 = Needs Much Improvement, 2 = Some Difficulty, 3 = Good Job, 4 = Great Job!

47. DRC w/increased criteria DRC + Medication DRC Alone DRC + Medication DRC Baseline (Evans & Youngstrom 2006)

48. Behavior Report Cards • Sample Rewards • Stay up ___ minutes past normal bedtime • TV/video game/phone time for ___ minutes • Snacks/dessert • Telephone use • Weekend privileges • Allowed to go to a friend’s house • Internet access • Earn a day off from chores • Larger rewards could be earned on a weekly or long-term basis (e.g. special dinner, sleepover, tickets to a baseball game)

49. Matching Game • Quick procedure targeting classroom behaviors (e.g., on-task, disruptive, bringing materials) • Students and teachers develop goals that are listed in the child’s assignment notebook • Student rates his/her own behavior on these goals at end of class then takes assignment notebook to teacher • Teacher checks recorded assignment and rates student • Parents provide contingencies for matches and improved ratings.

50. Small Trial with Matching Game (Creasy, Evans et al.) • Twice daily classroom activity for five days in summer day camp for youth with ADHD (JumpStart) • Eleven middle school aged students with ADHD randomly assigned to receive matching game or not • Daily ratings on following rules and on-task behavior by teacher and observer blind to condition (1-5 scale with 5 = best)