addressing the treatment needs of adolescents with adhd
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Addressing the Treatment Needs of Adolescents with ADHD. Steven W. Evans, Ph.D. Alvin V. Baird Centennial Chair in Psychology James Madison University. Overview. Brief description of disorder and evaluation as pertains to adolescents Review individual interventions that comprise CHP - PowerPoint PPT PresentationTRANSCRIPT
Addressing the Addressing the Treatment Needs of Treatment Needs of
Adolescents with ADHDAdolescents with ADHD
Addressing the Addressing the Treatment Needs of Treatment Needs of
Adolescents with ADHDAdolescents with ADHD
Steven W. Evans, Ph.D.
Alvin V. Baird Centennial Chair in Psychology
James Madison University
Steven W. Evans, Ph.D.
Alvin V. Baird Centennial Chair in Psychology
James Madison University
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
Inattention
Impulsivity
Hyperactivity
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
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
Childhood overactivity usually diminished
Excessive talking
Fidgety behavior
Restless
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)
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.
Middle School Teacher Ratings on ADHD RS
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Sept Oct Nov Dec Jan Feb Mar Apr
Total
Inatt.
Hyp.
Middle School Teacher Ratings on IRS – Academic Progress
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Sept Oct Nov Dec Jan Feb Mar Apr
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
GPA in Community Control Sample of Middle School Youth with ADHD
1.6
1.7
1.8
1.9
2
2.1
2.2
1st 2nd 3rd 4th 5th 6thReport periods
GP
A
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
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
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
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)
Parental Drinking
Parental Negative
Affect
ChildBehaviorProblems
ParentalStress
MaladaptiveParenting
Paths of Family Influence
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
Change in Caregiver Strain as a function of ODD/CD
-50
-40
-30
-20
-10
0
10
20
30
0 5 10 15 20 25 30 35
ODD/CD
Ch
an
ge i
n C
are
giv
er
Str
ain
Change in Caregiver Strain after 1 year in relation to parent report of oppositional and defiant behavior
Challenging Horizons Program
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
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
Organization
BINDER DATE-
Is your assignment notebook secured by three rings so that it is the first thing you see when you open your binder?
Is your binder free of loose papers (are all papers secured in folder pockets or attached by three rings)?
Is the Homework Folder attached by three rings behind your assignment notebook?
Inside the homework folder: are homework assignments need for even days in the even day pocket?
Inside the homework folder: are homework assignments need for odd days in the odd day pocket?
Is there a pocket for papers you parents need to see, and only these papers are in it?
Is there a folder for each class you are taking attached by three rings? (1. Math, 2. Science, 3. English/Reading, 4. Social Studies, 5. P.E./Health, 6. other extracurricular courses)
Within each subject folder: Are all non-homework papers for that subject in the right pocket of the folder?
Are the notes from each subject organized from oldest to newest behind the subject folder and secured by the three-rings in the binder?
Are all papers in the correct section of the binder? (no papers in the wrong section)
Are all the papers that are in the binder school related? (no drawings, scrap paper, etc.)
What percent of your binder is organized? Divide the number of Y’s by 11 and then multiply by 100.
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 Intervention
Student A: Immediate Responder
Student 15r2 Means - Binder
y = 0.0239x + 0.7453
0%
20%
40%
60%
80%
100%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Week
Perc
en
tag
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et
Organization InterventionStudent B: Slow but Steady Responder
Student 80l2 Means - Binder
y = 0.029x + 0.5404
0%
20%
40%
60%
80%
100%
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Week
Perc
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tag
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Organization InterventionStudent C: Honeymoon Responder
Student 7q38 Means - Binder
y = 0.0198x + 0.7511
0%
20%
40%
60%
80%
100%
1 2 3 4 5 6 7 8 9 10 11 12
Week
Perc
en
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et
Organization InterventionStudent D: Non-responder
Student 5g13 Means - Binder
y = 0.0143x + 0.3248
0%
20%
40%
60%
80%
100%
1 2 3 4 5 6 7 8 9 10 11 12
Week
Perc
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Figure 1. Immediate Responders
y = 0.011x + 0.8553
0%
20%
40%
60%
80%
100%
1 3 5 7 9 11 13 15 17 19 21
Week
Perc
enta
ge
Crite
ria M
et
Figure 2. Slow-But-Steady Responders
y = 0.0248x + 0.1603
0%
20%
40%
60%
80%
100%
1 3 5 7 9 11 13 15 17 19 21 23
Week
Perc
enta
ge
Crit
eria
Met
Figure 3. Non-Responders
y = -0.0116x + 0.6788
0%
20%
40%
60%
80%
100%
1 3 5 7 9 11 13 15 17 19 21 23
Week
Perc
enta
ge
Crit
eria
Met
Assignment Notebook Tracking Patterns of Responding
Study Skills
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…
‘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 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)
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
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
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
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
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
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
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
Classroom Behavior
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
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.
Monday Tuesday Wednesday Thursday Friday
Polly spoke only at appropriate times in class in accordance with classroom rules. Yes
NoYesNo
YesNo
YesNo
YesNo
Polly completed and turned in all work due today. Yes
NoYesNo
YesNo
YesNo
YesNo
More than half of Polly’s contributions to classroom discussions were relevant and non-redundant. Yes
NoYesNo
YesNo
YesNo
YesNo
Monday
Behavior 1:Tuesday Wednesday
1 2 3 4 1 2 3 4 1 2 3 4
Behavior 2:
1 2 3 4 1 2 3 4 1 2 3 4
Behavior 3:
1 2 3 4 1 2 3 4 1 2 3 4
CHP Daily Behavior Report Cards for Assignment Notebook
1 = Needs Much Improvement, 2 = Some Difficulty, 3 = Good Job, 4 = Great Job!
Complies with verbal requests after Complies with verbal requests after one or fewer repetitions one or fewer repetitions
Interacts nicely with siblings
Speaks respectfully to adultsSpeaks respectfully to adults
BKS
BKS
BKS
BKS
BKS
BKS
0
10
20
30
40
50
60
70
80
90
100
1/8/
2006
1/15
/200
6
1/22
/200
6
1/29
/200
6
2/5/
2006
2/12
/200
6
2/19
/200
6
2/26
/200
6
3/5/
2006
3/12
/200
6
3/19
/200
6
3/26
/200
6
4/2/
2006
4/9/
2006
4/16
/200
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4/23
/200
6
Mondays of Week
Per
cen
t o
f D
ays
Mar
ked
Yes
Followed classroom rules aboutspeakingTurned in all work completed
Quality contributions to class
BaselineDRC
DRC w/increased criteria
DRC + Medication
DRC Alone
DRC + Medication
(Evans & Youngstrom 2006)
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
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.)
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)
10987654321
Session #
5.00
4.80
4.60
4.40
4.20
4.00
3.80
Treatment
Control
Group
On-Task Ratings by Teacher
10987654321
Session
5.00
4.80
4.60
4.40
4.20
4.00
3.80
Treatment
Control
Group
On-Task Ratings by Observer Blind to Condition
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.
Ideal SelfReal Self
FriendlyUnfriendly
Social ReinforcementSocial Punishment
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
Peers Teachers Employers Police Officers Romantic Relationships
Family
Homework Management Plan
Serenity PrayerGod, grant me the serenity to
acceptthe things I can not change
Courage to change the things that I can
And the wisdom to know the difference.
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
HMP Pilot StudyStudent A
Math Grade Assessment
0
1
2
3
4
5
6
Sept Oct Nov Jan Feb Mar Apr May
Quality of Assignments
Turned in On-Time
HMP Pilot StudyStudent B
Math Grade Assessment
0
1
2
3
4
5
6
Sept Oct Nov J an Feb Mar Apr May
Quality of Assignments
Turned in On-Time
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 Outcome Data
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
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
GPA by Group by Six Weeks
Parent Ratings of ADHD Symptoms (DBD)
Parents’ Ratings of Child’s Impact on Family
Parents’ Ratings of Child’s Social Functioning
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
Collect monthly ratings of symptoms and impairment from parents & teachers
If ratings exceed threshold, then call parents
Parents offered choice of increasing psychosocial treatment or adjusting/ initiating medication treatment
If select medication, initiate medication assessment with physician
If select psychosocial, then increase psychosocial treatment related to reported problem area
If not….
Initiate school-based 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 CharacteristicsN=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 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
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 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.
Changes in Parent Ratings Over 3 Years (Evans, Serpell, Schultz & Pastor)
50.00
55.00
60.00
65.00
70.00
75.00
80.00
0 180 360 540 720 900
Days Since Initial Visit
BA
SC
Ina
tten
tion
Sta
ndar
d S
core
Control Treatment
Between Group Effect Sizes over Time (Evans, Serpell, Schultz & Pastor)
Denominator for
Outcome Measure Scale Effect Sizes 0 180 360 540 720 900
ADHD Symptoms BASC - Hyperactivity 10.00 0.53 0.64 0.74 0.84 0.95 1.05
DBD - Hyperactivity 6.75 0.27 0.35 0.42 0.50 0.57 0.65
BASC - Inattention 10.00 -0.10 0.07 0.24 0.41 0.59 0.76
DBD - Inattention 6.05 0.02 0.14 0.26 0.38 0.50 0.62
Social Functioning IRS 2.15 -0.19 -0.07 0.05 0.17 0.28 0.40
BASC 10.00 0.20 0.21 0.21 0.22 0.23 0.24
SSRS 15.00 0.27 0.31 0.36 0.41 0.46 0.51
School Functioning IRS - Parent 1.92 -0.14 -0.15 -0.15 -0.16 -0.16 -0.17
Days Since Initial Measurement Occasion
Estimated change over time in GPA by group within 6th grade year (Evans, Serpell, Schultz & Pastor)
1
1.25
1.5
1.75
2
2.25
2.5
2.75
3
1 2 3 4 5 6
Six Week Grading Period
GP
A
Control Treatment
Survival Analysis: Ever Tried Tobacco
Survival Analysis: Ever Drank with Friends
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
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