School-based Interventions for Students with ADHD

George J. DuPaul, Ph.D.

School Psychology Program

Lehigh University

Bethlehem PASeptember 2015

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Agenda Brief overview of treatment for ADHD

Overview of school-based interventions

Principles underlying school-based interventions

Behavioral classroom strategies

Academic support

Home-school communication

Self-regulation strategies

Integrating medication & school-based intervention

Guiding principles for school-based intervention

Wrap-up & discussion

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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

School-Based Interventions for Students with ADHD

Behavioral classroom strategies

Academic support

Home-school communication

Self-regulation strategies

4DuPaul & Stoner (2014)

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School-based Interventions: Core Principles

Balanced treatment plan

Use multiple mediators (not just reliance

on classroom teacher)

Consider behavioral function

Link intervention design to assessment

data

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Balance between Proactive and Reactive Strategies

Proactive strategies involve doing something before behavior occurs to reduce probability of problems occurring

Reactive strategies involve doing something afterbehavior occurs to either reduce or increase probability of future occurrence

Too often rely solely on reactive strategies

Need to increase focus on being preventive and proactive

Intervention plan should always include both proactive & reactive procedures (emphasis on positive)

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School-Based Interventions for ADHD

Manipulating Antecedents (Proactive)

– Post Rules

– Instructional Modifications

– Workload Adjustment

(Accommodation)

– Providing Choices

– Peer Tutoring

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School-Based Interventions for ADHD (cont.)

Manipulating Consequences (Reactive)

– Token Reinforcement

– Verbal Reprimands

– Response Cost

– Time Out from Positive

Reinforcement

– Self-Management

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Possible Mediators for School-Based Interventions

Teacher-mediated

– Instructional strategies; Token reinforcement

Parent-mediated

– Parent tutoring; Home-based reinforcement

Peer-mediated

– Classwide peer tutoring

Computer-assisted

– Drill-and-practice

Self-mediated

– Self-monitoring; Self-management

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Possible Functions of ADHD Behavior

Avoid/escape effortful tasks

Obtain peer attention

Obtain teacher attention

Obtain tangible object

Sensory stimulation

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Link Interventions to Behavioral FunctionAvoid/escape effortful tasks

Increase stimulation value of task and/or provide brief “attention breaks”

Obtain peer attention

Provide peer attention following appropriate behavior (e.g., peer tutoring)

Obtain teacher attention

Provide attention following appropriate behavior while ignoring inappropriate behavior (or time out from positive reinforcement)

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TEACHING TECHNIQUES TO PREVENT BEHAVIOR PROBLEMS

Remind students of rules

Maintain eye contact with students

Remind students about expected behaviors

Circulate thru classroom to monitor/provide feedback

Use nonverbal cues to redirect

Maintain brisk pace of instruction

Insure understanding of activities

Manage transitions in well-organized manner

Communicate expectations about use of class time

See Paine et al. (1983)

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TOKEN REINFORCEMENT

Establish behavioral or academic goals

Choose several target situations

Break situation (task) into smaller units

Tokens (points, stickers) provided immediately

Tokens turned in for privileges at end of day

Could also incorporate response cost, if necessary

STUDENT CONTRACT

Specify several short-term objectives

Identify possible contingencies– Positive for reaching goal

– Aversive for rule violations

Determine time period for meeting goals

Include both short and long-term payoffs

Agreement by both student and teacher (counselor) to follow through

Periodic revisions of contract as necessary

Academic Support

Explicit instruction in academic skills

Peer tutoring

Computer-assisted instruction

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CLASSWIDE PEER TUTORING

Divide classroom into pairs

Provide academic scripts

Take turns tutoring

Immediate feedback & error correction

Teacher monitors progress & provides bonus

points

Points tallied & progress charted

Pairs change weekly

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CWPT Effects on ADHD (DuPaul et al., 1998)

18 ch. w/ADHD & 10 comparison students (1st to 5th grade gen. ed.)

CWPT increased active engagement w/ reduction of off-task behavior

50% of ADHD improved academically

Positive effects for comparison peers

High rates of student and teacher satisfaction

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COMPONENTS OF EFFECTIVE HOME-SCHOOL COMMUNICATION PROGRAM

Daily/weekly goals specified in a positive manner

Both academic and behavioral goals included

Small number of goals at a time

Quantitative feedback about performance

Feedback provided by subject or class period

Communication is made on a regular basis (either daily or weekly)

Home-based contingencies tied to performance (both short-term and long-term)

Barkley & Murphy (2006)

Daily Report Card Example

Behaviors to be rated: 1 2 3 4 5 6 7

Class participation

Classwork performance

Follows class rules

Gets along well

w/others

Quality of HW

Teacher’s initials

Comments on back

Class Periods/Subjects

HOME-SCHOOL PROGRAM (cont.)Parental cooperation solicited prior to

implementation

– Student input into goals and

contingencies

Goals/procedures modified as necessary

Associated with reduction in rule

violations and greater academic

productivity (see Owens et al., 2012)

More information:

http://ccf.buffalo.edu/pdf/school_daily_rep

ort_card.pdf

http://www.directbehaviorrattings.com

HOME-SCHOOL PROGRAM (cont.)Probability of positive tx response higher

for younger children (K-3) who have

never repeated a grade (Owens, 2013)

Largest improvement obtained in 1st

month (ES = .78) with gradual reduction

in incremental benefit over time (Owens,

2013)

Thus, program should be tried for at least

one month before discontinuing

Self-Regulation Strategies for ADHD

Self-monitoring

Self-evaluation & self-reinforcement

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Self-monitoring of organizational skills

Adolescents with ADHD typically have

difficulties in class prep. and HW

For some students, problems related to

poor attention to detail and low

motivation to complete mundane tasks

Possible students can be trained to

monitor own behaviors (e.g., being

ready for class)

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Self-monitoring of org. skills: Controlled case study (Gureasko,DuPaul, & White, 2006) Three 7th grade students with ADHD

All had significant problems being prepared for class

Checklist of preparatory behaviors developed with teachers (% steps)

Training in self-monitoring (4 days)

Self-monitoring followed by fading

Gains in organizational skills maintained without treatment

Replicated with additional 6 middle school students and extended effects to homework performance (Gureasko-Moore et al., 2007)

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SELF-EVALUATION PROGRAM

Initially incorporates external and internal evaluation but works toward complete self-monitoring and evaluation

Teacher and student independently “grade” student performance regarding behavior and academics for specified work period

– Established performance criteria

– Points earned for performance

– Bonus points for “matching” ratings

– Penalities for “inflated” ratings

– Points turned in for school based or home based privileges

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Sample Self-Evaluation Criteria

5 = Excellent

– Followed all rules for entire interval; Work 100% correct

4 = Very Good

– Minor infraction of rules; Work at least 90% correct

3 = Average

– No serious rule offenses; Work at least 80% correct

2 = Below Average

– Broke rules to some degree: Work 60 to 80% correct

1 = Poor

– Broke rules almost entire period; Work 0 to 60% correct

0 = Unacceptable

– Broke rules entire period; No work completed

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SELF-EVALUATION (cont.)

Gradual weaning from external ratings

– Longer work periods to be rated

– Periodic, random “matching” challenges

– Eventual reliance on self-ratings only

Factors to consider:

– Practical constraints

– “Drift” of student ratings

– Prepare student using external system

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Integrating Interventions

Research indicates that combined medication and behavioral intervention is optimal for many children with ADHD

Possible reduction in “dosage” of complementary treatments

– Examples: MTA study; classroom intervention study (Fabiano et al., 2007)

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Frequency of Classroom Rule Violations (Fabiano et al., 2007)

0

5

10

15

20

25

30

35

40

45

50

Placebo .15 mg/kg .30 mg/kg .60 mg/kg

Medicat ion

Fre

qu

en

cy

No BMOD

Low BMOD

High BMOD

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Percentage of Seatwork Completed (Fabiano et al., 2007)

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Interventions for Students with ADHD: Guiding Principles

Stimulant medication is single most effective treatment for reducing ADHD symptoms

Psychosocial (behavioral) treatments at home & school address impairments in functioning

Intervention design linked directly to assessment data (e.g., functional behavioral assessment)

School-based interventions associated with moderate to large effects on academic & behavioral outcomes

Academic interventions for academic outcomes

Behavioral, self-regulation, and academic interventions for behavioral outcomes

Multiple mediators beyond classroom teacher should be involved

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Guiding Principles for Intervention (cont.)

Intervening as early as possible is important,

especially in key functioning areas (e.g., reading)

All behavior serves a purpose; intervention should

lead to functionally equivalent behavior

Aim for balance between proactive and reactive

strategies

Typically no single intervention is sufficient; multi-

component and multi-setting intervention is presumed

more effective

Whenever possible, school-based interventions

should be tried before medication and/or educational

accommodations

Questions and Discussion

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References

Barkley, R. A., & Murphy, K. R. (2006). Attention-

deficit hyperactivity disorder: A clinical workbook (3rd

ed.). New York: Guilford Press.

DuPaul, G. J., Ervin, R. A., Hook, C. L., & McGoey,

K. E. (1998). Peer tutoring for children with attention

deficit hyperactivity disorder: Effects on classroom

behavior and academic performance. Journal of

Applied Behavior Analysis, 31, 579–592.

DuPaul, G.J. & Stoner, G. (2014). ADHD in the

Schools: Assessment and intervention strategies (3rd

ed.). NY: Guilford.

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References

Fabiano, G.A., Pelham, Jr., W.E., Gnagy, E.M.,

Burrows-MacLean, L., Coles, E.K., Chacko,

A….Robb, J.A. (2007). The single and combined

effects of multiple intensities of behavior modification

and methylphenidate for children with attention deficit

hyperactivity disorder. School Psychology Review,

36, 195-216.

Gureasko-Moore, S., DuPaul, G. J., & White, G. P.

(2006). The effects of self-management in general

education classrooms on the organizational skills of

adolescents with ADHD. Behavior Modification, 30,

159–183.

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References

Gureasko-Moore, S., DuPaul, G., & White, G. (2007).

Self-management of classroom preparedness and

homework: Effects on school functioning of

adolescents with attention-deficit hyperactivity

disorder. School Psychology Review, 36, 647-664.

Owens, J.S., Holdaway, A.S., Zoromski, A.K., Evans,

S.W., Himawan, L.K., Girio-Herrera, E., & Murphy,

C.E. (2012). Incremental benefits of a daily report

card intervention over time for youth with disruptive

behavior. Behavior Therapy, 43, 848-861.

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References

Paine, S. C., Radicchi, J., Rosellini, L. C.,

Deutchman, L., & Darch, C. B. (1983). Structuring

your classroom for academic success. Champaign,

IL: Research Press.

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