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addressing the treatment needs of adolescents with adhd

Addressing the Treatment Needs of Adolescents with ADHD

Steven W. Evans, Ph.D.

Alvin V. Baird Centennial Chair in Psychology

James Madison University

overview
Overview
  • Brief description of disorder and evaluation as pertains to adolescents
  • Review individual interventions that comprise CHP
  • Present CHP outcome data
  • Future Directions
core symptoms
Core Symptoms
  • Inattention
  • Impulsivity
  • Hyperactivity
difficulty sustaining attention
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
impulsivity
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
hyperactivity
Hyperactivity
  • Childhood overactivity usually diminished
  • Excessive talking
  • Fidgety behavior
  • Restless
diagnosis and assessment
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?)
middle school teacher agreement evans et al in press
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.

theory
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
implications
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
presenting problems school
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
presenting problems social
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
presenting problems family
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)

paths of family influence
Paths of Family Influence

Parental

Drinking

Parental

Stress

Child

Behavior

Problems

Maladaptive

Parenting

Parental

Negative

Affect

caregiver strain
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
slide19
Change in Caregiver Strain after 1 year in relation to parent report of oppositional and defiant behavior
accommodations helpful or harmful
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
chp after school model
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
chp interventions
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
organization intervention
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)
organization intervention27
Organization Intervention

Student A: Immediate Responder

organization intervention28
Organization Intervention

Student B: Slow but Steady Responder

organization intervention29
Organization Intervention

Student C: Honeymoon Responder

organization intervention30
Organization Intervention

Student D: Non-responder

the challenge children with adhd face when studying
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
study strategies that rarely or never work
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…..
flashcards challenging horizons program treatment manual 2004
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
acronyms acrostics challenging horizons program treatment manual 2004
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

application
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.
consulting with teachers
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?
taking notes
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
teaching note taking to middle school youth with adhd
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
note taking from text
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
summarizing
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
behavior report cards challenging horizons program treatment manual 2004
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
slide45

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.

chp daily behavior report cards for assignment notebook
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!

slide47

DRC w/increased criteria

DRC + Medication

DRC Alone

DRC + Medication

DRC

Baseline

(Evans & Youngstrom 2006)

behavior report cards
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)
matching game
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.
small trial with matching game creasy evans et al
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)
on task ratings by teacher

Group

5.00

Control

Treatment

4.80

4.60

4.40

4.20

4.00

3.80

1

2

3

4

5

6

7

8

9

10

Session #

On-Task Ratings by Teacher
on task ratings by observer blind to condition

Group

5.00

Control

Treatment

4.80

4.60

4.40

4.20

4.00

3.80

1

2

3

4

5

6

7

8

9

10

Session

On-Task Ratings by Observer Blind to Condition
current strategies for social functioning
Current Strategies for Social Functioning
  • Treatment Development
    • Teaching Vocabulary
      • Social reinforcement & social punishment
      • Ideal self & real self
        • Friendly, athletic, smart, funny, responsible, etc.

Social Punishment

Social Reinforcement

Friendly

Unfriendly

Real Self

Ideal Self

current strategies
Current Strategies
  • Coaching in social activities
    • Establish ideal self list/goals
    • Conduct developmentally appropriate social activities
    • Counselors observe with goals in hand
    • Give feedback in relation to goals (every 3 – 7 minutes)
    • Plan specific behaviors for next few minutes
    • Establishes repertoire for achieving goals and language for prompts
    • No intervention level outcome data – yet!
contexts
Contexts
  • Peers
  • Teachers
  • Employers
  • Police Officers
  • Romantic Relationships
homework management plan
Homework Management Plan

Serenity Prayer

God, grant me the serenity to accept

the things I can not change

Courage to change the things that I can

And the wisdom to know the difference.

homework management plan59
Homework Management Plan
  • Accept the things I can not change:
    • Not knowing what is due when
    • Making sure the required materials are brought home
    • Not knowing the subject material
  • Change the things that I can:
    • Amount of time spent on academic work
    • Academic productivity
  • Key is wisdom to know the difference
web based hmp intervention
Web-Based HMP Intervention
  • Parents learn procedures through written and video instruction on the Internet
  • Clinician telephone contact
  • Currently being developed and piloted (Creasy & Evans)
chp after school study design
CHP-After School Study Design
  • Recruit middle school students from two schools for two years
  • Randomly assign 7 students to treatment and 4 to community care from each school each year (total – 28 treatment & 16 control)
  • Evaluate participants at baseline (August – November), post-treatment (May-June) and follow-up (November).
  • Collect monthly ratings on all participants from teachers and parents

Funding provided by a research grant from the National Institute of Mental Health

treatment procedures
Treatment Procedures
  • Baseline Evaluation
  • Family Check-Up
  • Begin CHP in January 2 times per week for 2 hours and 15 minutes per meeting
  • Provide family follow-up and teacher consultation in addition to services after school
  • Conclude CHP in May
chp integrated study design
CHP-Integrated Study Design
  • Recruit 2 cohorts of 6th graders from 4 schools and follow them for 3yrs
  • Assign 2 schools to treatment & 3 to control
  • Evaluate participants every 6 months for duration of funding (i.e., 1st cohort 6th-8th grade)
  • Collect monthly ratings on all participants from teachers and parents

Funding Provided by the Virginia Tobacco Settlement Foundation

overview of treatment procedures
Overview of Treatment Procedures

Collect monthly ratings of symptoms and impairment from parents & teachers

Initiate school-based psychosocial treatment

Parents offered choice of increasing psychosocial treatment or adjusting/ initiating medication treatment

If ratings exceed threshold, then call parents

If not….

If select medication, initiate medication assessment with physician

If select psychosocial, then increase psychosocial treatment related to reported problem area

psychosocial treatment
Psychosocial Treatment
  • Mentor (care-coordinator)
  • 15 CHP psychosocial interventions described in treatment manual and interactive CD-ROM.
  • Teacher training (2) & ongoing consultation (approx. 5 times a week; average of 8 hrs/wk)
sample characteristics
Sample Characteristics

N=79 (42 treatment, 37 control)

  • all students met diagnostic criteria for ADHD
  • 62% had one or more comorbid conditions (ODD, CD, anxiety, depression)
  • Mean age 11.93 yrs at the start of participation
  • 94% Caucasian, 77% male
  • 51% household income <$40,000
psychosocial treatment76
Psychosocial treatment
  • Parents opted for psychosocial adjustments on 92% of their opportunities to alter treatment
  • Mentor reports indicate that slightly less than half:
    • were likely to implement more than 2 interventions at a time (47%)
    • make adjustments based on parent or consultant feedback (41%)
    • implement interventions as described in the manual (43%)
analyses findings
Analyses & Findings
  • long-term effects examined 1st (looking for lack of equivalence between groups)
  • outcome measures (hyperactivity/ impulsivity, inattention, social impairment, academic functioning) modeled separately using Hierarchical Linear Modeling
  • School and med effects examined as possible moderators/ mediators
summary of findings
Summary of Findings
  • neither parent nor teacher ratings of academic functioning revealed any cumulative benefit, but grades improved?
    • Teacher data (including ratings of classroom disruption) yielded conflicting findings with no clear patterns
  • cumulative benefits of CHP treatment appear for parent ratings of ADHD symptoms and social functioning, grade point average, and substance use.
estimated change over time in gpa by group within 6 th grade year evans serpell schultz pastor
Estimated change over time in GPA by group within 6th grade year (Evans, Serpell, Schultz & Pastor)
conclusions
Conclusions
  • Comprehensive school-based services can benefit middle school aged children with ADHD
  • There is no need to rely on unproven accommodations that primarily serve to lower the expectations
  • Patience & Persistence
future directions
Future Directions
  • Improve interventions aimed at families
    • Parent – School collaboration
    • Family treatment
  • Examine integrated and after-school model as possible complementary systems
  • Continue to evaluate individual interventions within CHP to improve outcomes
    • Social functioning
    • Academic competencies