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Managing Inattentive, Hyperactive, and Impulsive Behaviors in the Classroom . Catharine Weiss, Ph.D. & Nancy Lever, Ph.D. Center for School Mental Health Department of Psychiatry, University of Maryland, Baltimore cweiss@psych.umaryland.edu nlever@psych.umaryland.edu. Have you ever….

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slide1

Managing Inattentive, Hyperactive, and Impulsive Behaviors in the Classroom

Catharine Weiss, Ph.D. & Nancy Lever, Ph.D.

Center for School Mental Health

Department of Psychiatry, University of Maryland, Baltimore

cweiss@psych.umaryland.edu

nlever@psych.umaryland.edu

have you ever
Have you ever…
  • Thought a student was lazy because they wouldn’t start or complete work that you knew they could do?
  • Stopped teaching over and over to keep a student on task?
  • Noticed a child who sits quietly but is not able to follow the lesson?
  • Been frustrated by a student who keeps getting up, touching or playing with anything and everything in sight?
  • Struggled to work with a student who talked incessantly or interrupted you and blurted out random comments?
  • Felt powerless with a student who acts without regard to consequences and instigates fights with other students?
session overview
Session Overview
  • What is ADHD?
  • Best Practice Strategies and Resources
  • Case Examples
  • Discussion
most common adhd myths
Most Common ADHD Myths
  • ADHD isn't a real medical disorder.
  • Children given ADHD accommodations are given an unfair advantage.
  • Children with ADHD often outgrow the condition.
  • ADHD affects only boys.
  • ADHD is the result of bad parenting.
  • ADHD children on medication will abuse drugs as teenagers.
  • People with ADHD are stupid and lazy.

From: www.additudemag.com

attention deficit hyperactivity disorder some basics
Attention-Deficit/ Hyperactivity Disorder: Some Basics
  • Neurobiological disorder: disorder in brain development or brain functioning
  • Affects ability to regulate behavior and attention
  • Genetic link: 30-40% have relatives diagnosed with the disorder
  • Most common childhood disorder; approximately 2-9% of youth
  • 3 times more common in males
adhd diagnosis
ADHD Diagnosis
  • Symptoms for at least 6 months to a degree that it is maladaptive and INCONSISTENT with developmental level
  • Some symptoms that caused impairment present prior to age 7
  • Difficulties in two or more settings
  • Clear evidence of impairment in school, work, or social functioning
adhd core symptoms
ADHD: Core Symptoms

INATTENTION*

  • Fails to give close attention to details
  • Has difficulty sustaining attention
  • Does not seem to listen when spoken to
  • Does not follow through on instructions or finish tasks
  • Has difficulty organizing tasks and activities
  • Avoids or dislikes tasks requiring sustained attention
  • Loses necessary things
  • Is easily distracted by extraneous stimuli
  • Is often forgetful

*6 or more, occurring very often (DSM-IV)

slide11

ADHD: Core Symptoms

HYPERACTIVITY/IMPULSIVITY*

  • Fidgets with hands or feet or squirms
  • Leaves seat inappropriately
  • Runs or climbs inappropriately (or subjective feelings of restlessness)
  • Difficulty engaging quietly in leisure activities
  • "On the go" or "driven by a motor"
  • Talks excessively
  • Blurts out answers
  • Difficulty awaiting turn
  • Interrupts or intrudes

*6 or more, occurring very often (DSM-IV)

slide12

DSM-IV ADHD SUBTYPES

  • PREDOMINANTLY
  • PREDOMINANTLY
  • COMBINED TYPE

INATTENTIVE

HYPERACTIVE/IMPULSIVE

INATTENTIVE

+

HYPERACTIVE/IMPULSIVE

slide13

ADHD: Associated Difficulties

  • Trouble with academic performance
  • Frequent classroom disruptions
  • Disturbed social relationships with family, adults, and peers
  • Angry and defiant behavior
  • Learning disabilities (20-30%)
  • Coexisting disabilities (40-60%)
specific educational outcomes
Specific Educational Outcomes

Youth with ADHD are more likely to:

  • Be retained
  • Be placed in special education
  • Be suspended and expelled
  • Drop out of school
  • Have lower grades
slide15

ADHD at Different Ages:Preschool

  • High motor activity: always on the go, climbing on things, getting into things
  • Decreased or restless sleep
  • High curiosity
  • Vigorous, often destructive play
  • High attention needs
  • More intense temper tantrums
  • Require closer, more frequent monitoring
  • Disobedience
slide16

ADHD at Different Ages: School-Age

  • Academic difficulties; difficult homework time
  • School complaints of disruptive behavior
  • Difficulties with chores and responsibilities
  • Low frustration tolerance
  • Social difficulties; conflict and rejection
  • May have low self-esteem
slide17

ADHD at Different Ages: Adolescence

  • Approximately 70-80% still display symptoms
  • Continued academic difficulties, disorganized, incomplete assignments
  • At risk for earlier sexual behavior and cigarette smoking
  • Higher rates of risky driving, substance abuse, and risky sexual behaviors
slide18

ADHD at Different Ages: Adulthood

  • More subtle presentation
  • Difficulties initiating and organizing daily tasks
  • Inconsistent performance and trouble with deadlines
  • Restlessness, trouble relaxing
  • Socially inappropriate
  • Frequently have comorbid diagnoses
slide19

What Doesn’t Work for ADHD?

  • Treatments with little or no evidence of effectiveness include
    • 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
slide20

More Favorable Situations

  • New tasks
  • Situations with immediate rewards and consequences
  • One-on-one attention
  • Early in the day
  • Structured time
  • Single-step commands
slide21

Evidence-Based Treatment

  • Cognitive Behavioral Interventions
    • Parent training and implementing behavioral modification at home
    • Teacher training behavioral modification at school
  • Medication
a student perspective on add from adders org creative adders
A Student Perspective on ADD*From adders.org - Creative ADDers
  • I am more than my ADD

By Robert

I am more than my ADDI have feet, arms, legsbut most of all a heart and a soulYou may think, "so irresponsible is he""so insensitive is he""how careless to be"Maybe this is all you see.but there is more to memore to me than my ADDI love music, writing, poetryI get angry, tired, happy,sad, just like everybody else.I take responsibility for my actionsas hairbrained as they may be (or not)but there is more to me than my ADD

acting out cycle
Acting Out Cycle

Peak

Acceleration

De-escalation

Agitation

Trigger

Recovery

Calm

Adapted from The Iris Center: http://iris.peabody.vanderbilt.edu

slide24
QTIP

(Quit Taking it Personally)

adhd practice elements
ADHD Practice Elements
  • Praise
  • Ignoring/Differential Reinforcement
  • Commands/Limit Setting
  • Time Out
  • Tangible Rewards
praise
Praise
  • Verbal praise, Encouragement
  • Attention
  • Affection
  • Physical proximity
giving effective praise
Giving Effective Praise
  • Be honest, not overly flattering
  • Be specific
  • Make eye contact; give undivided attention
  • 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
  • Remember to praise the absence of a behavior
ignoring and differential reinforcement
Ignoring and Differential Reinforcement
  • Selectively
    • Ignore mild unwanted behaviors

AND

    • Attend to alternative positive behaviors
how to ignore
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., talking faster or louder)
how to ignore30
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)
when to ignore
When to Ignore
  • When to ignore undesirable behavior
    • Child interrupts conversation or class
    • Child blurts out answers before question completed
    • Child tantrums
  • Do not ignore undesirable behavior that could potentially harm the child or someone else
differential reinforcement
Differential Reinforcement
  • 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
differential reinforcement33
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
differential reinforcement of target behavior
Differential Reinforcement of Target Behavior
  • Target behavior: Interrupting
  • Alternative behavior: Working by himself
  • Reward schedule: 10 minutes
    • If child goes 10 minutes without interrupting, the child receives reinforcement
    • If child interrupts before 10 minutes is up, the child does not receive reinforcement
    • Re-set schedule once child interrupts
differential reinforcement35
Differential Reinforcement
  • Systematically delay reinforcement once child responds to initial schedule
    • Target behavior: Interrupting
    • 1st reinforcement schedule: 5 times per class
    • 2nd reinforcement schedule: 3 times
    • 3rd reinforcement schedule: 1 time
challenges with ignoring and differential reinforcement
Challenges with Ignoring and Differential Reinforcement
  • Extinction burst
    • Behavior will get worse before it gets better (child will work harder to gain attention)
  • Indiscriminant reinforcement
    • Reward only the alternative (desirable) behavior, so you don’t reward other unwanted behaviors by mistake
improving commands limit setting with youth
Improving Commands/Limit Setting with Youth
  • Only give commands that you intend to back up with consequences (positive and negative)
  • Do not present commands as questions or favors
  • Break down multi-component commands
  • Make clear what you want them to do, not just what you do not want
steps to making effective commands
Steps to Making Effective Commands
  • Make eye contact with the child before giving command
  • Reduce other distractions while giving commands
  • Ask the child to repeat the command
  • Monitor after giving the command to ensure progress
  • Immediately praise child when s/he starts to comply
consequences and time outs
Consequences and Time Outs
  • Do in private, stay calm
  • Time outs
    • Cool off space that can be monitored
    • Effective if problem behavior is strengthened by peer attention
    • Not effective if goal of behavior is to avoid work
tangible rewards
Tangible Rewards
  • Children and adolescents with ADHD do not respond to natural (intrinsic) rewards as well as typical youth
  • Can use token systems, behavior charts, or immediate rewards
setting up a school home contract
Setting up a School-Home Contract
  • School staff track the child’s behavior and reports it to family daily, who reward the child
  • Effective because both the parent and staff are involved and can reward for positive behavior
  • If the parent can’t be involved, the rewards may be given only at school
school home contract
School-Home Contract
  • Typically referred to as a daily report card
    • Purpose: To identify, monitor and change classroom problems and facilitate home-school communication and collaboration
    • Takes time on the front end, but found to reduce classroom disruption time
daily report card steps http ccf buffalo edu pdf school daily report card pdf
Daily Report Card Steps (http://ccf.buffalo.edu/pdf/school_daily_report_card.pdf)
  • Select areas for improvement
    • Involve staff who work with student
    • Involve the student and family in identifying areas for improvement
    • Examples of key domains- peer relations, academic work, classroom rule following, adult relationships
daily report card steps http ccf buffalo edu pdf school daily report card pdf44
Daily Report Card Steps (http://ccf.buffalo.edu/pdf/school_daily_report_card.pdf)
  • Define target behaviors
    • Must be clearly defined and measurable
    • Number of targets depends on age and ability. Be realistic.
    • Examples of behaviors-completes assigned tasks, speaks respectfully to the teacher, participates in class lesson, walks in hallway appropriately
daily report card steps continued
Daily Report Card Steps(Continued)
  • Decide on criteria for evaluating target behavior
    • Estimate how often the behavior occurs now
    • Set a reasonable criterion for success (child can earn between 75-90% of the time)
    • Remember the goals need to be feasible to both the teacher and the child
    • Set criteria to be met for each part of the day versus the whole day (e.g., class period)
daily report card steps continued46
Daily Report Card Steps(Continued)
  • Explain report card and set up rewards with child/family
    • The goal is to help the child to be successful
    • Ideally rewards should be natural and easy to implement
    • More preferred rewards can be earned for longer term performance
    • Need a menu of rewards
    • Kids need both in school and home rewards
    • Kids need to have success at the start and regularly thereafter
daily report card steps continued47
Daily Report Card Steps(Continued)
  • Monitor and modify the program
    • Gradually make the criteria harder
    • If child fails to meet the criteria, consider how to best modify
    • Praise child sincerely for success and matter-of-factly for missed targets
  • Parent and teacher signatures and comments
behavioral consequences benefits of whole classroom approach e g pbis
Behavioral Consequences: Benefits of Whole Classroom Approach (e.g., PBIS)
  • Reduces sense of “unfairness;” ADHD children receiving special treatment
  • Multiple ADHD children in classroom may strain individual approach
  • Benefits whole class environment
classroom wide peer tutoring
Classroom-Wide Peer Tutoring
  • Create and distribute scripts (worksheets)
  • Teach any new concepts and skills to class
  • Break class into dyads
  • Each takes turns tutoring and quizzing the other
    • Praise or points awarded
    • Errors are immediately corrected
  • Circulate and coach dyads
good behavior game
Good Behavior Game
  • An approach to the management of classrooms behaviors that rewards children for positive behaviors during classtime.
    • Class divided into two teams
    • A point is given to a team for any inappropriate behavior displayed by one of its members
    • The team with the fewest number of points each day wins a group reward. If both do well, can share in reward
steps to the good behavior game
Steps to the Good Behavior Game
  • Decide when to schedule the game
  • Clearly define what negative behaviors will be scored during the game
    • Leaving one’s seat
    • Talking out
    • Disruptive behavior
  • Decide on rewards and schedule of rewards
    • Daily versus weekly
  • Introduce the game to the class
  • Implement the game
core concepts from good behavior game
Core Concepts from Good Behavior Game
  • Class working in teams
  • Clearly defined expectations
  • Can target specific behaviors
  • Rewards for positive behavior
  • Can adjust expectations over time related to student success
  • Used only for short periods of time, particularly most critical instructional time
  • Can also reframe to reward positive behaviors
    • Raising hand, staying in seat, completing assignments
slide54

Classroom Modifications

  • Brief, clear, and frequent instructions
  • Preferential seating, removal of distracters
  • Reduced workloads, break tasks into smaller units
  • Stimulating activities, matched at their level
  • One-on-one attention; close supervision
  • Choice in activities
  • Highlighting Directions with Color
  • Computer Assisted Learning
  • Schedule more difficult activities in AM
  • Anticipate problem times and activities
slide55

Classroom Modifications

  • Motivational Strategies
    • More frequent feedback
    • More immediate feedback, positive reinforcement, and valued rewards
    • Highly salient and meaningful consequences
    • Reinforcing accuracy not speed
    • Daily report card systems, home notes
    • Group rewards
    • Change rewards regularly with student input
slide56

What Would You Do with Wayne?

  • 6 years old, 1st grade
  • Bright affect, very likeable
  • Off-task 80-90% of the time; very short attention span, daydreaming, rocking, humming, singing, talking to peers, out of seat, distracted by all activity in the room
  • Trouble completing work, sometimes refuses to finish assignments, forgetful
  • Can verbalize that he has trouble with activity and attention
slide57

What would you do with Shannon?

  • 17 years old, 11th grade
  • Seems anxious, disconnected from peers
  • Late for school most days
  • Locker and backpack disorganized
  • Inconsistent in her completion of homework
  • Failing English and Science Classes
  • Teachers see her as lazy and unmotivated
  • Easily distracted in class, daydreams, makes careless mistakes
  • Easily frustrated, gives up if cannot get a concept immediately
resources
Resources
  • The Attention Deficit Information Network www.addinfonetwork.com
  • Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) www.chadd.org
  • National Resource Center on ADHD help4adhd.org
  • University of Buffalo, Center for Children and Families http://wings.buffalo.edu/adhd
resources59
Resources
  • National Institutes of Mental Health www.nimh.nih.gov
  • School Mental Health Resources
  • www.schoolmentalhealth.org
  • Children’s Mental Health Disorder Fact Sheet for the Classroom (Minnesota Association for Children’s Mental Health)
  • http://www.macmh.org/publications/fact_sheets/ADHD.pdf