What Can SBHC Providers What Can SBHC Providers Do to Address ADHD?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

OverviewOverview• 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-ADHDDSM 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 DiagnosisADHD 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 ADHD: Common School ResponseResponse• 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 ADHD is treated by Primary Care Providers – such as SBHCsProviders – 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 are Optimally SituatedSBHCs 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 TeamADHD Team• A team with time - champions• NO NEW TOOLS • Clarify roles and tasks• Map resources• Set goals – keep them simple–NICHQ QI ADHD measures

RolesRoles• 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 1Step 1Identification & ReferralIdentification & 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 ResourcesParent 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 Schools http://www.msde.maryland.gov/MSDE/divisions/studentschoolsvcs/student_services_alt/ADHD/

Step 2Step 2Screening & AssessmentScreening & Assessment

• SBHC Providers can conduct interviews and administer screening tools and assessments to assist in the diagnosis of ADHD

Is It ADHD?Is It ADHD?

Mood/Anxiety Problems

PDD Spectrum

Structured Interview FormStructured 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 Resources for Free and Validated Screening Tools:Validated Screening Tools:• NICHQ• 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

DiagnosisDiagnosis• 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 Interventions with little or NO evidence of effectiveness as the effectiveness as the primary treatmentprimary treatment of of ADHD: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 Step 3 Behavioral InterventionsBehavioral 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 What Do We Mean By Behavior Management?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 ADHDBehavior 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 ContextImportance 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)

• Bright Futures –www.brightfutures.org/mentalhealth/pdf/tools.html

• Tools for students, clinicians and families

Several Empirically-Supported Several Empirically-Supported Behavior Protocols Exist:Behavior Protocols Exist:

• Defiant Children (Russell Barkley)• Helping the Noncompliant Child (Rex Forehand)• Videotape Parent Modeling (Carolyn Webster-

Stratton)

PraisePraise• 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 PraiseGiving 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 Ignoring & Differential ReinforcementReinforcement

• Train parents and teachers to selectively– Ignore mild unwanted behaviors

AND

–Attend to alternative positive behaviors

Teaching to IgnoreTeaching 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 Improving Commands/Limit SettingSetting• 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 Improving Commands/Limit Setting with ChildrenSetting 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 Improving Commands/Limit Setting with AdolescentsSetting 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 Improving Commands/Limit Setting with Adolescents (cont)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 RewardsTangible 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 ContractSchool-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 School HomeHome Contract Contract

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:

• 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 ClassroomGeneral 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 4Step 4Medication ManagementMedication 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 aMedication Should Not Be aSubstitute For:Substitute For:

• Parent/Teacher training• Behavior modification• Appropriate educational curricula• Appropriate school placement• Adequate teaching skills• Family treatment

Stimulants Stimulants • They work immediately• Up to 70% response rate• Need to be monitored and titrated• No response – reconsider the diagnosis

Algorithms and TacticsAlgorithms 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/AssentDiscussion, 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

MonitorMonitor• 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 ConcernsBe 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

ResourcesResources• 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/

Resources Resources

• 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