School-based Support for Students with ADHD: Is There Life After Ritalin?

1. School-based Support for Students with ADHD:Is There Life After Ritalin? George J. DuPaul, Ph.D. School Psychology Program Lehigh University Bethlehem PA 18015

2. Conclusions • ADHD has enormous impact on school functioning • Medication is effective for changing behavior, but not necessarily for academic performance • Individually tailored school-based interventions have potential for building upon medication effects • Must go beyond “one size fits all”

3. DSM-IV CRITERIA FOR ADHD • Significant problems with inattention • Significant problems with hyperactivity-impulsivity • Symptoms present for at least 6 months • Symptoms that caused impairment before age 7 • Some impairment in two or more settings • Impairment in social, academic, or occupational functioning • Not due to another disorder • Subtypes: Combined, Predominantly Inattentive, Predominantly Hyperactive-Impulsive

4. PREVALENCE AND SEX RATIOS • Occurs in 3 to 5 % of children • Ratio of males:females is 3:1 in community and 6:1 in clinic referrals • Makes up high percentage of referrals for academic and behavior difficulties • Found in all countries and ethnic groups with varying prevalence - highest in US

5. PROBLEMS ASSOCIATED WITH ADHD • Conduct problems (e.g., oppositional behavior, lying, stealing, and fighting) • Academic underachievement • Specific learning disabilities • Peer relationship problems

6. Model for School-based Assessment of ADHD (DuPaul & Stoner, 2003) • Screening • Multi-method Assessment • Interpretation of Results • Intervention Planning & Design • Intervention Evaluation

7. SCREENING: QUESTIONS TO BE ADDRESSED • Does this student have a problem related to possible ADHD? • Is further assessment of ADHD required?

8. SCREENING METHODS • Parent and/or teacher ratings of ADHD-related behaviors • Brief interview with teacher and/or parent

9. MULTIMETHOD ASSESSMENT: QUESTIONS TO BE ADDRESSED • What is the extent and nature of the ADHD-related problems? • What factors (e.g., organismic and environmental) maintain these problems? • What is the frequency, duration, and/or intensity of the problem behaviors? • In what settings do the ADHD-related behaviors occur?

10. MULTIMETHOD ASSESSMENT STRATEGIES • Parent and teacher interviews • Reviews of school records • Behavior rating scales • Observations of school behavior • Academic performance data • Functional behavioral assessment

11. INTERPRETATION: QUESTIONS TO BE ADDRESSED • Does the child exhibit a significant number of behavioral symptoms of ADHD ? • Are behaviors occurring significantly more frequently than children of the same gender and age? • At what age did these begin and are these behaviors chronic and evident across many situations? • Is the child’s functioning significantly impaired? • Are there other possible problems or factors that could account for symptoms?

12. INTERPRETATION OF RESULTS • Number of ADHD symptoms • Deviance from age and gender norms • Age of onset and chronicity • Pervasiveness across situations • Degree of functional impairment • Rule out alternative hypotheses

13. Developmental Trends for ADHD Symptoms: Boys

14. Developmental Trend for ADHD Symptoms: Girls

15. Teacher-rated Inattention as a Function of Age & Ethnicity

16. Teacher-rated HypImp as a Function of Age & Ethnicity

17. ALTERNATIVE HYPOTHESES FOR ADHD BEHAVIOR • Environmental factors • Antecedent/consequent events • Placement in curriculum • Psychosocial stressors • Within-child factors • Academic skills deficits • Other forms of emotional or behavioral disturbance

18. DIFFERENTIAL DIAGNOSIS • Disorders to be “ruled out”: • Separation Anxiety Disorder • Other Anxiety Disorders • Depression/affective disorders • Tourette’s Disorder • Disorders which frequently co-occur with ADHD: • Oppositional Defiant Disorder • Conduct Disorder • Learning Disabilities

19. LD VS. ADHD • Lacks early childhood history of hyperactivity • “ADHD” behaviors arise in middle childhood • “ADHD” behaviors appear to be task- or subject-specific • Not socially aggressive or disruptive • Not impulsive or disinhibited

20. INTERVENTION PLANNING: QUESTIONS TO BE ADDRESSED • What are the behavioral objectives? • What are the student’s strengths and weaknesses? • What are the optimum intervention strategies? • What additional resources are available to address the child’s ADHD-related problems?

21. INTERVENTION PLANNING • Severity of ADHD-related behaviors • Functional assessment of behavior • Presence of associated disorders • Response to prior interventions • Availability of community resources

22. Possible Functions of ADHD Behavior • Avoid/escape effortful tasks • Obtain peer attention • Obtain teacher attention • Obtain tangible object • Sensory stimulation

23. Design Interventions Based on Functional Assessment • Descriptive analysis • Identify antecedents, consequences, sequential conditions • Direct observation, teacher interview, parent interview, student interview • Experimental Analysis • Develop hypotheses related to function of behavior • Test hypotheses using direct observation • Develop intervention plan based on results of experimental analyses

24. INTERVENTION EVALUATION: QUESTIONS TO BE ADDRESSED • Are changes occurring in the target and collateral behaviors? • Are the treatment changes socially valid and clinically significant? • Are target behaviors normalized? • Are “side-effects” present?

25. INTERVENTION EVALUATION • Periodic collection of assessment data (e.g., teacher ratings, observations, academic performance measures) • Consumer satisfaction ratings • Comparison with normal peers • Revision of treatment plan based on assessment data

26. What are the most common school difficulties associated with ADHD? • High rates of disruptive behavior • Low rates of engagement with academic instruction and materials • Inconsistent completion and accuracy on schoolwork • Poor performance on homework, tests, & long-term assignments • Difficulties getting along with peers & teachers

27. Project PASS: Initial Group Differences • 1st through 4th grade students in public elementary schools in eastern PA • N = 87 children with ADHD • N = 38 normal controls • 20 min observations in math and reading using the BOSS (Shapiro, 1996) • Woodcock-Johnson Reading & Math subtests (WJ-III) • Teacher ratings on the Academic Competency Evaluation Scale (ACES; DiPerna & Elliott)

28. Project PASS: Classroom Behavior in Reading

29. Project PASS: Classroom Behavior in Math

30. Project PASS: WJ-III Achievement Test Scores

31. Project PASS: ACES Teacher Ratings

32. Kindergarten Subjects Compared to District Norms on DIBELS OnRF

33. Letter Naming Fluency: Kindergarten Benchmark Scores

34. Comparison of Kindergarten Subjects and Peers on Benchmarks

35. Comparison of First Grade Subjects and Peers on Benchmarks

36. Most Common Interventions for Children with ADHD • Psychotropic Medication (e.g., CNS stimulants such as methylphenidate) • Home-based contingency management (behavioral parent training) • School-based contingency management interventions (e.g., token reinforcement) • Academic tutoring • Daily report card or school-home notes

37. MEDICATIONS FOR ADHD • Stimulant Medications • Methylphenidate (Ritalin, Concerta, Metadate) • Dextroamphetamine (Dexedrine) • Adderall • Tricyclic Antidepressants • Desipramine (Norpramine);Imipramine (Tofranil) • Other Antidepressants • Bupropion (Wellbutrin); Fluoxetine (Prozac) • Other Medications • Clonidine (Catapres) • Atomoxetine (Strattera)

38. BEHAVIORAL EFFECTS OF STIMULANTS • Increased Attention and Concentration • Decreased Impulsivity • Decreased Task-Irrelevant Activity Level • Decreased Aggressiveness • Increased Compliance • Improved Handwriting and Fine Motor Skill • Improved Peer Relations and Social Status • Possible enhancement of academic productivity

39. SIDE EFFECTS OF STIMULANT DRUGS • Insomnia & Decreased Appetite (50-60%) • Headaches and Stomachaches (20-40%) • Prone to Crying (10%) • Nervous Mannerisms (10%) • Tics (<5%) and Tourette’s (Very Rare) • Overfocused behavior; Cognitive toxicity • Mild Weight Loss (A Few Pounds First 1-2 Years); No effect on Skeletal Growth • Mild Increases in Heart Rate and Blood Pressure • Cylert Affects Liver Functioning; Needs Monitor

40. Problems with Currently Available Research Literature • Limited data on school-based interventions in gen. ed. settings • “One size fits all” approach is typical • Emphasis on reduction of disruptive behavior rather than improvement in social behavior or academic skills • Few studies of adolescents • Focus on short-term outcomes & limited data on generalization of effects

41. Multimodal Treatment Study (MTA) • N = 579 children from Gr. 1-5 (M age = 8.5) randomly assigned to tx groups • Medication management (n = 144), Behavioral tx (n = 144), Combined tx (n = 145), and Community Care Control Group (n = 146) • 14 mos of tx (manualized) at mult. sites • Multiple assessment measures collected on three occasions

42. MTA Psychosocial Interventions • Parent Training • 27 group sessions over 14 mos • School Intervention • Child-Based Treatment: Summer Treatment Program • Comprehensive behavior mod. Program • Peer interventions • Sports skills training • Daily report cards • Individualized programs, as necessary

43. MTA School Intervention Component • Teacher consultation • Biweekly meetings with teachers over 14 mos • Daily Report Card implemented • Basic behavioral principles and classroom interventions as necessary (e.g., token economy); Stage II tx (response cost) as necessary • Paraprofessional Program (UCI model) • Para spent half day in classroom for 12 weeks in fall of 2nd school year • Implemented behavior modification procedures including daily report card & merit badge system for social skills

44. MTA Study (cont.) • Reductions in symptoms in all groups • Combined tx & medication greater symptom reduction than BT & control • Combined tx > BT & control in reduction of agg./ODD symptoms & improved social skills, parent-child relations, and reading achievement • Medication > BT in most cases; however meds still active while BT had been faded • Predictors of individual response? • Effects of school intervention component?

45. School-based Intervention for ADHD: A Meta-analysis (DuPaul & Eckert, 1997)

46. School-based Intervention for ADHD: Effects on Behavior

47. School-based Intervention for ADHD: Effects on Academics

48. Balanced “Game” Plan • Too often rely solely on defense (reactive) strategies • Need a strong “offense” (proactive) and a strong “defense” (reactive) • Intervention plan should always include both proactive & reactive procedures (emphasis on positive)

49. School-Based Interventions for ADHD • Manipulating Antecedents (Proactive) • Post Rules • Instructional Modifications • Workload Adjustment • Providing Choices • Peer Tutoring

50. School-Based Interventions for ADHD (cont.) • Manipulating Consequences (Reactive) • Token Reinforcement • Verbal Reprimands • Response Cost • Time Out from Positive Reinforcement • Self-Management