TeachersandParentsasPartners:HowitworksforStudentswith

ADHD

MatthewJ.GormleyPaulDizona4.25.2018

Agenda

• ADHDBackground• TeachersandParentsasPartners(TAPP)• Overviewofcurrentstudy• Procedures• Results• Keytakeawaysandfuturedirections

WhohasworkedwithorknownachildwithADHD?

HowmanypeoplechildrenhaveADHD?

• Mostcommonmentalhealthdiagnosisamongschool-agedchildren

• Estimatesrangebasedonmethod– StrictCriteria:• 5-7%ofschoolagedchildren

– Parentreporteddiagnosis:• 9.4%ages2-17

– 2.4%ages2-5– 9.6%ages6-11

Thatis:

• 6.1millionnationwide

• 3,820inLPS

• 1or2studentsperclassroominLPS• LPSreportedmedianelementaryclassroomhas20students

http://home.lps.org/hr/

Whoismostlikelytobediagnosed• Males(atleast2xmorelikely)• Childrenlivinginpoverty(22%morelikely)• Childrenlivinginaruralarea(30%morelikely)• AfricanAmericans(27%morelikely)*• Childrenwithpublicinsurance(64%morelikely)

– 2xmorelikelyifpublicandprivateinsurance

• LivingintheMidwest(49%morelikely)

Danielsonetal.,2018

WhatcomestomindwhenthinkingofachildwithADHD?

WhatisADHD?

Inattention• Lowattentiontodetail• Difficultysustainingattention• Doesnotseemtolisten• Strugglestofollowthrough• Disorganized• Avoidssustainedmentaleffort• Loosesimportantitems• Easilydistracted• Forgetful

Hyperactivity-Impulsivity• Fidgets• Leavesseat• Runs/Climbsexcessively• Difficultyplayingquietly• Always“onthego”• Talksexcessively• Blurtsoutanswers• Difficultyawaitingturn• Interrupts/intrudesonothers

Developmentallyinappropriatelevelsofinattentionand/orhyperactivity/impulsivity

ADHD– FunctionalImpairment• AcademicUnderachievement– Lowergrades– Morecoursefailure– Greaterratesofretention

• BehavioralDifficulties– OfficeDisciplinaryreferrals– Suspensions/Expulsions

• SocialDifficulties– Peerrejection– Riskyhealthbehaviors

Thegoodnews…

• Wehaveeffectivetreatments!– PsychostimulantMedications• Ritalin,Vyvanse,Concerta,Strattera

– PsychosocialInterventions• BehavioralParentandTeacherTraining

– Tokeneconomies,school-homenotes

– Combinedtreatment• Facilitateslowerdosesofbothcomponents• Evidencesuggestsbehavioralinterventionsfirst

Pelhametal.,2016

Thebadnews…

• Interventionimprovementsdonotlast– Immediatewithmedication

– Slowerwithpsychosocialinterventions• Fewstudieslookatlong-termchanges• Within~24months,allimprovementsfadeaway

Somemoregoodnews…

• TeachersandParentsasPartners(TAPP)– Evidence-basedintervention– Recentevidencesuggestingmaintenanceata1-yearfollowup• However,thiswasnotspecifictostudentswithADHD

– SmallstudieshaveshownTAPPiseffectiveforstudentswithADHDintheshortterm

SowhatisTAPP?

• Brief(8-12week)strengths-basedproblemsolvingprocedure

• Bringstogetheraparent,ateacher,andaconsultant

• Facilitatesparent-teacherpartnershipstohelpastudentsucceed

BuildingonStrengthsPlanningforSuccessPlanImplementation

CheckingandReconnecting

Parent(s) Teacher

Consultant

TAPPGoals

• Improvecommunication• Addressdifficultiesacrosssettings• Promotesharedownership• Establish(orstrengthen)home-schoolpartnershipsandimprovethefamily-schoolrelationship– Mutualefforttowardasharedgoal– Fundamentalphilosophy,attitude,andbeliefthatfamiliesandeducatorsareessentialforachild’sprogress

Ultimately

• Identifyanddefinespecificneedsofastudentathomeandschool

• Buildonexistingstrengthstoproduceimprovedfunctioningforthestudent

• Planforgeneralizationandmaintenance

Insummary

• ADHDispervasive,detrimental,andexpensive• Wehavetreatmentsthatwork;however,effectsgenerallydonotlast

• TAPPoffersadvantagesoverprevioustreatments,andpriorworkshowsithasbeeneffectiveforstudentswithADHD(insmallstudies),andthattreatmenteffectspersist

Thecurrentproject

• EvaluateifTAPPiseffectiveforstudentswithADHDusingdatafromalargerandomizedcontroltrial

• Determineifthe1-yearoutcomesofTAPPareanydifferentforstudentswithADHD

PrimaryMeasures• BehavioralAssessmentSystemforChildren– 2– AttentionProblems– Hyperactivity– BehavioralSymptomsIndex

• SocialSkillsImprovementSystem– SocialSkills– ProblemBehaviors

• Completed4timesduringthestudyperiodbyparentsandteachers

OutcomeVariables

• ADHDSymptoms– BASCAttentionProblems– BASCHyperactivity

• BehaviorProblems– BASCBehavioralSymptomsIndex

• SocialFunctioning– SSiS SocialSkills– SSiS ProblemBehaviors

Participants• 267K-3rd gradestudentsfrom152classroomsin45ruralschoolsinthreeMidwesternstatesrecruitedover5years– 24%female– 6.9yearsoldonaverage– 86%non-HispanicCaucasian

• Theirparents– 90%female– 34yearsoldonaverage– 90%non-HispanicCaucasian

Participants

• Theirteachers– 97%female– 41yearsoldwith15yearsteachingexperienceonaverage

– 100%non-HispanicCaucasian• Consultants– 14Master’slevelclinicians– 93%female– 30yearsoldonaverage– 100%non-HispanicCaucasian

Design

• “Five-cohortcluster-randomized”design• TeacherswererandomizedtoTAPPorTreatmentasUsual– Anystudentparticipant(upto3perclassroom)wouldbeinthesamegroupastheirteacher

• Fourassessmentpoints– Pre-treatment(T1)– Post-treatment(~12weekslater;T2)– Follow-up1(Beginningofnextschoolyear;T3)– Follow-up2(~12monthsaftertreatment;T4)

InterventionGroupsTAPP

• BuildingonStrengths– Identify/defineinterfering

behavior

• PlanningforSuccess– Co-constructanintervention

planforhomeandschool

• PlanImplementation– Doit!

• CheckingandReconnecting– Reviewprogressandgoals

BusinessasUsual• “Traditional”schoolsupport

– OfficeReferrals– RemovalfromClassroom– Pull-outforspecialeducation

• Parent-initiatedcommunitysupports– Counseling– OT/PT

NosignificantdifferencesinSpecialEducationoroutsideServiceuse

TAPPInterventions• Collaborativelydevelopedbyparents,teachers,andconsultants

• Oneoffourtypesofintervention– Positivereinforcement/consequences

• Attention/rewards– Environmentalstructuring&antecedentcontrol

• Structuredprompts,precisionrequests– Skillstraining

• Socialskillstraining/behavioralrehearsal– Reductivetechniques

• Removingprivileges

DataAnalysis

• “Repeatedmeasuresmultilevelpiecewisegrowthmodel”– SASv9.4usingPROCMIXED(Snijders &Bosker,2011)

• Controlsformissingdata,thetimethestudentenrolledintheproject,andnesting*– Nestingrecognizesthateachstudentisunique,asiseveryclassroom

Results

• ADHDStatus– 22%ofthissamplemetresearchcriteriaforADHD• ClinicallysignificantparentANDteacherratingsontheBASCHyperactivityand/orAttentionProblems

• SignificantDifferencesforparentrated:– BehavioralSymptomsIndex– Hyperactivity

BehavioralSymptomsIndex

50

55

60

65

70

75

Baseline PostInt PostFollow-up

Control,NoADHD Treatment,NoADHD Control,withADHD Treatment,withADHD

T-Score

At-RiskRange

N.S.

N.S.

Hyperactivity

50

55

60

65

70

75

Baseline PostInt PostFollow-up

Control,NoADHD Treatment,NoADHD Control,withADHD Treatment,withADHD

T-Score

At-RiskRange

N.S.

KeyTakeaways

• TAPPiseffectiveforyoungstudentswithADHD– CoresymptomofADHD– BehavioralFunctioning

• Unfortunately,theeffectofTAPPdoesnotpersistforstudentswithADHDovera12-monthperiod

KeyTakeaways

• Thisfindingisinlinewithpreviousliteraturelookingatmaintenanceoftreatmentgains

• ADHDischronicandpervasive

• One-timeinterventionislikelyinsufficient– Atleasttheinterventionswecurrentlyhave

Limitations

• Underpowered– Only46studentswithADHDtocompare

• StudentswerenotformallyassessedforADHD• Didnotfindchangesforteacherratings

FutureDirections

• TAPP-Vertical–Maintainandtransfertheparent-teacherpartnershipacrossgrade-level(vertical)transitions

– Provideconsistent(butflexible)supportovertime– Ensureinterventionisdevelopmentallymatchedtotheneedsofthestudent• ConsideringthechronicnatureofADHD,programingforincreasingparticipationasthestudentages– Keepingtheultimategoalinmind

Thankyou!

Questions?