191© Springer International Publishing Switzerland 2015B. K. Schultz, S. W. Evans, A Practical Guide to Implementing School-Based Interventions for Adolescents with ADHD, DOI 10.1007/978-1-4939-2677-0

Appendices

Appendix A: Initial Appraisal Form

Student Name _________________________ Date Completed ___________________

Age __________ Birthdate ___________ Grade__________

List the names and ages of all of the child’s siblings

Names Ages

Living at home? (yes or no –

if no indicate where living)

List the names of all parents, step-parents, and other care-takers

Names Relationship to

child

Living at home? (yes or no – if no

indicate where living)

192 Appendices

List and describe any clubs, teams, or organizations that the child participates in now or has

participated in during the last year.

What are the child’s three favorite things to do?

How does the child spend unstructured time? Be specific, what did he/she do last weekend or

yesterday evening?

Who are the child’s two best friends and when was the last time he/she spent time with them

outside of school?

193Appendices

What are the child’s best and worst subjects? Why?

List the child’s current teachers and the subjects that they teach.

What is the child’s schedule?

Why does the child believe that he is involved in CHP?

194 Appendices

Does s/he have any goals that you can help him/her with?

Main Findings

1

2

3

4

5

195Appendices

Appendix B: Assignment Notebook Tracking Intervention Record

Instructions: Record the number of assignments and teacher initials obtained each day, over the number expected.

196 Appendices

Appendix C: Organization Intervention Monitoring Record

Get organized! Be able to find your assignments and turn them in! Be able to locate your notes to study for tests! Open your binder and go down the checklist: for each item, write a Y (for yes) if you meet the question fully or an N (for no) if you do not meet the question fully. When finished checking divide the number of Y’s recorded by 11 and record this in the last space as the percentage of your binder that’s orga-nized.

197Appendices

BIN

DER

Is y

our a

ssig

nmen

t not

eboo

k se

cure

d by

thre

e rin

gs so

that

it is

the

first

thin

g yo

u se

e w

hen

you

open

you

r bin

der?

Is th

ere

a fo

lder

for e

ach

clas

s yo

u ar

e ta

king

atta

ched

by

thre

e ri

ngs?

(1.

Mat

h, 2

. Sci

ence

, 3. E

nglis

h/R

eadi

ng, 4

. Soc

ial S

tudi

es, 5

. P.E

./Hea

lth, 6

. ot

here

xtra

curr

icul

ar c

ours

es)

Are

the

note

s fro

m e

ach

subj

ect o

rgan

ized

from

old

est t

o ne

wes

tbeh

ind

the

subj

ect f

olde

r and

sec

ured

by

the

thre

e-ri

ngsi

n th

e bi

nder

?

Is th

ere

a po

cket

for p

aper

s you

r par

ents

nee

d to

see,

and

onl

y th

ese

pape

rs

are

in it

?

Are

all

the

pape

rs th

at a

re in

the

bind

er sc

hool

rela

ted?

(no

draw

ings

, scr

ap

pape

r, et

c.)

Is th

e H

omew

ork

Fold

er a

ttach

ed b

y th

ree

rings

beh

ind

your

ass

ignm

ent

note

book

?

Is y

our b

inde

r fre

e of

loos

e pa

pers

(are

all

pape

rs se

cure

d in

fold

er p

ocke

ts o

r at

tach

ed b

y th

ree

rings

)?

With

in e

ach

subj

ect f

olde

r: A

re a

ll no

n-ho

mew

ork

pape

rs fo

r tha

t sub

ject

in

the

right

poc

ket o

f the

fold

er?

Are

all

pape

rs in

the

corr

ect s

ectio

n of

the

bind

er?

(no

pape

rs in

the

wro

ng

sect

ion)

Wha

t per

cent

of y

our b

inde

r is

orga

nize

d? D

ivid

e th

e nu

mbe

r of Y

’s b

y 9

and

then

mul

tiply

by

100.

198

Appendix C: Organization Intervention Monitoring Record (Continued)

Don’t forget your bookbag and locker! Organize them too! Open your bookbag and locker and go down the checklist: for each item, write a Y (for yes) if you meet the question fully or an N (for no) if you do not meet the question fully. When finished checking, divide the number of Y’s recorded by 4 for the bookbag and record this in the last space as the percentage of your bookbag that’s organized. Repeat this for the locker and divide the number of Ys by 3 and record.

Appendices

199

BO

OK

BA

G

Do

you

have

the

book

s you

nee

d to

com

plet

e to

mor

row

’s

hom

ewor

k?

You

don

’t ha

ve b

ooks

in y

our b

ook

bag

that

you

don

’t ne

ed to

co

mpl

ete

hom

ewor

k du

e in

the

next

3 d

ays o

r lon

g-te

rm

assi

gnm

ents

?

Is y

our b

ookb

ag fr

ee fr

om u

nnec

essa

ry c

loth

ing?

Is y

our b

ookb

ag fr

ee fr

om lo

ose

pape

rs a

nd o

bjec

ts (p

ens,

toys

, m

agaz

ines

, etc

)?

Perc

enta

ge o

f crit

eria

met

(# o

f Ys/

4)*1

00

LOC

KER

Are

the

book

s nea

tly st

acke

d (o

r she

lved

) with

the

spin

es fa

cing

ou

t so

that

you

can

eas

ily g

rab

one

in b

etw

een

clas

ses o

r afte

r sc

hool

?

Is y

our l

ocke

r fre

e of

loos

e ob

ject

s (pa

pers

, pen

cils

, pen

s, to

ys,

mag

azin

es, t

rash

, etc

.)?

Is y

ou lo

cker

free

from

unn

eces

sary

clo

thin

g?

Perc

enta

ge o

f crit

eria

met

(# o

f Ys/

3)*1

00

Appendices

200

Appendix D: ISG Card

Client & Counselor Ratings Circle One

Student ID:

Date:

Counselor:

Behavior is opposite of goal No Evidence

Behavior matches the desired goal

-3 -2 -1 0 +1 +2 +3 N/A

Note. Clients are asked for their self-ratings and these are recorded in the small boxes within each cell before the counselor shares his/her ratings, which are recorded in the large boxes within each cell.

Appendices

201

Appendix E: ISG Master Tracking Form

Instruction At the end of each ISG session, record the date. Then compute the stu-dent’s average score for each goal and record in the appropriate box. If the student has achieved a staff AND student score greater than or equal to 2 for any of his/her goals, record “Y” in the corresponding box. If the student has not achieved a staff AND student score of greater than or equal to 2, then record “N” in the correspond-ing box. Once three consecutive “Y’s” have been obtained for a single goal, then the student has mastered this goal. Please record the date that the student masters each goal. The student can proceed to phase three of the intervention once he/she has mastered one goal.

Date

AverageIdeal SelfGoal #1

AverageIdeal SelfGoal #2

AverageIdeal SelfGoal #3

Achieved2 or 3 onGoal #1(Y/N)

Achieved2 or 3 onGoal #2(Y/N)

Achieved2 or 3 onGoal #3(Y/N)

Appendices

202 Appendices

Appendix F: Behavior Contract for Homework Management

1. My goal for the next report card is:

2. I will work on my homework at this time:

3. I will work on my homework for this amount of time each day:

4. What will happen if I’m not working during homework time?

5. I understand that even if I do not have homework, I will use

the homework time to study for tests and quizzes, or as an

alternative:

Additional Terms:

By signing this contract, I ______________________ (print name) understand the terms

that are described above. This agreement will start today and will be renegotiated

when I receive my next report card / mid-term report, and changes will depend on

how I am doing at that time.

Student Signature: __________________________________ Date: ______________

Parent Signature: ___________________________________ Date: ______________

203Appendices

Appendix G: Common Interview Questions for Consultees

1. What are this child’s strengths? What are this child’s weaknesses? 2. What are some things you are doing now that help this student work up to

potential? 3. Describe one area where this student could improve. (GET SPECIFIC EXAM-

PLES by asking, “What does he do that makes you describe him/that way?”) 4. When does problem behavior occur? During what time of day is it most

problematic? 5. Where does the problem behavior usually take place (e.g., classroom, gym,

hallway, bus)? What are the characteristics of that setting (e.g., individual seat work, group task, number of other students and adult’s present, seating arrangement)?

6. How often does the problem behavior occur (i.e., frequency)? 7. How long does the problem behavior last (i.e., duration)? 8. What is usually happening just before the problem behavior begins (anteced-

ents, triggers)? (e.g., Is the student interacting with a peer, being reprimanded, being told to do or not to do something, a transition)

9. How do you typically respond to the problem behavior?10. What are the consequences associated with the problem behavior (e.g., student

is removed from task, reprimanded, punished, ignored, sent to office, threat-ened by consequences, denied privileges, parent is called, note is sent home)?

11. How do other students react to the problem behavior (e.g., leave student alone, criticize student, laugh at student?

12. What are some positive strategies that have been helpful in reducing the prob-lem behavior?

204 Appendices

Appendix H: Consultation and Performance Feedback Template

Challenging Horizons Program

Teacher: Child ID: Date of Consultation:

Consultant: ********************************************************************************* Intervention:

Summary of Student Progress since Last Consultation Session: 1. Areas of Student success:

2. Areas of Student non-success:

3. Review Graphs for each interven�on (a�ach copies to this document)

4. Problem Solving Ideas (if applicable):

5. Ac�on Steps:

205

A Practical Guide to Implementing School-Based Interventions for Adolescents with ADHD

Brandon K. Schultz, Steven W. Evans

This innovative volume details counseling interventions for secondary students with attention deficit hyperactivity disorder (ADHD) and its associated academic and conduct problems, particularly focusing on youth at risk for developing seri-ous disruptive behaviors. It addresses the continuing debate over counseling for youths with ADHD by identifying key elements common to reputable therapies and suggesting a framework for their successful implementation. The core of the book discusses the Challenging Horizons Program (CHP), a behavior- and solu-tions-focused approach to counseling adolescents with ADHD that has been studied extensively for more than 15 years. Based on the quality of research, the CHP has been included in the National Registry of Evidence-based Programs and Practices maintained by the US Substance Abuse and Mental Health Services Administration (SAMHSA). Excerpts from actual sessions illustrate typical therapist-client inter-actions in the CHP, and sample modules from the program’s treatment literature expand the book’s descriptions of effective hands on interventions.

Counseling skills featured in this book include:

• Bridging the research-into-practice divide.• Establishing a therapeutic alliance with students with ADHD.• Developing and implementing interventions for memory, organization, and plan-

ning.• Enhancing young clients’ social skills.• Enlisting family members in the intervention process.• Working directly with teachers to improve student behaviors.

A Practical Guide to Implementing School-Based Interventions for Adolescents with ADHD is an essential resource for researchers, clinicians and related profes-sionals, and graduate students in such disciplines as school and clinical child psy-chology, social work, educational psychology, psychotherapy and counseling, and learning and instruction.

© Springer International Publishing Switzerland 2015B. K. Schultz, S. W. Evans, A Practical Guide to Implementing School-Based Interventions for Adolescents with ADHD, DOI 10.1007/978-1-4939-2677-0

207

Index

© Springer International Publishing Switzerland 2015B. K. Schultz, S. W. Evans, A Practical Guide to Implementing School-Based Interventions for Adolescents with ADHD, DOI 10.1007/978-1-4939-2677-0

AAcademic interventions, 87, 88

executive functions (EF), 90, 91, 92identifying academic goals, 88, 89, 90memory, 92, 93, 94, 95, 96, 97organization, 98, 99, 100, 101planning, 102, 103, 104

ADHD See Attention-Deficit Hyperactivity Disorder (ADHD), 4

Assignment tracking, 29, 72, 102Attention-Deficit Hyperactivity Disorder

(ADHD), 23, 24, 25, 29, 31biological causes of, 34causes of, 32counseling for, 3, 4, 6, 16diagnosis of, 27, 38, 40interventions for, 4, 16manifestations of, 25model of, 33persistent, 38, 39symptoms, 23, 28, 31theories of, 32, 90

BBehavioral consultation, 42, 45, 160, 169

advantages of, 161in schools, 160techniques of, 160

Behavior contracting, 147, 156elements of, 140

CChallenging Horizons Program

future directions for, 189interventions, 189research and practices, 190

Challenging Horizons Program (CHP), 3, 14, 18, 23, 47, 48, 50, 100, 133, 160

Common factors, 7, 8, 12, 13, 15, 16, 19quality of, 19

Conduct Disorder (CD), 23, 33, 39, 40, 100Conduct problems, 6, 12, 26, 39, 40, 79, 80,

81, 85, 87, 90, 140, 156comorbid, 40development of, 41

Counseling adolescentswith ADHD, 79

DDSM-5, 23, 24, 39

EEducation and community mental health

quality assurance challenges of, 188Evidence-based interventions, 81, 163Evidence-based practices, 4, 5, 6, 81

FFamilies of adolescents, 16, 140

with ADHD, 63, 140

HHomework Management Plan (HMP), 141,

154, 155

IInterpersonal Skills Group\t See ISG, 113ISG

counseling challenges in, 130, 131individual applications of, 131, 132, 133interview, 116, 117overview, 114, 115

208 Index

vocabulary, 117ideal-self, 117punishment, 118real-self, 117, 118reinforcement, 118

MMnemonic strategies, 93, 104

NNote-taking intervention, 166, 181

OOppositional Defiant Disorder (ODD), 23, 33,

39, 40Organization checklists, 99, 100, 177

PPerformance feedback, 133, 169, 173, 174,

179, 180, 182implementation of, 175, 176research on, 174, 175

RResearch-practice debate, 6, 11, 17

consequences of, 15, 16, 17Research-practice gap, 7, 80

SSchool consultation, 44

behavioral consultation, 160advantages of, 161

building a mentorship, 169, 170common challenges in, 171, 172interviewing the mentor, 170, 171introducing CHP interventions, 173

challenges of, 161, 162performance feedback, 173, 174

implementation of, 175, 176, 177research on, 174, 175

problem-solving process, 162evaluating outcomes, 168, 169forgoing the consultative relationship,

162, 163, 164identifying the problem, 164, 165, 166,

167implementing an intervention, 168selecting an intervention, 167, 168

School mental health servicesmodel quality assurance program for, 188

Social performance deficits, 28, 113, 133Social skill deficits, 28, 43, 115Solution-focused counseling, 62, 79, 80, 84,

94key ingredients of, 69, 70, 71, 72, 73research on, 74, 75, 76

Stages of change, 64, 65, 67, 76Study skills, 31, 92, 93, 104, 165, 179, 181

TTherapeutic alliance, 8, 13, 15, 19, 61, 76, 81,

125, 133