Effective Treatments for ADHD PowerPoint Presentation

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Effective Treatments for ADHD in school settings Gregory A. Fabiano, Ph.D. University at Buffalo Department of Counseling, School, and Educational Psychology Fabiano@buffalo.edu

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Attention-deficit hyperactivity disorder (ADHD) ADHD is characterized by developmentally inappropriate levels of: Inattention Hyperactivity Impulsivity ADHD behaviors are developmentally inappropriate, pervasive, chronic, and result in considerable impairment in social and academic functioning.

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History of ADHD Heinrich Hoffman, a German psychiatrist, authored a widely-published children’s book of short stories in 1844. “Fidgety Phillip” “Johnny Look-in-the-Air” “The Story of Cruel Frederick” The Story of Little Suck a Thumb” The Dreadful Story of Pauline and the Matches” Thome & Jacobs, 2004

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Prevalence

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Fabiano et al., under review

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Impact of ADHD - Impairment

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Domains of Impairment Peer relationships Adult relationships Sibling relationships Academic Progress Self-esteem Group functioning Associated problems

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Impairment Ratings – Academic Progress Parent ratings Teacher ratings Fabiano et al., 2006

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Impairment Ratings – School Functioning Relationship with Teacher Classroom Functioning Fabiano et al., 2006

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Impact of ADHD - Costs

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Educational Costs (Robb et al, under review) Costs of Special education* $3230 Disciplinary referrals** $ 740 Retention $ 110 Special schools $ 780 Total: $4900 *Does not include Section 504 Accommodation Plans/OHI classifications not used pre-1992 **Likely under-estimated

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Costs in the Aggregate (assuming prevalence of 5% and 60 million school aged children--2000 census--2005 dollars) Health and Mental Health $11.6 billion Education $14.7 billion Crime and Delinquency $11.4 billion Parental work loss $ 2.3 billion Total $40 billion Range $34.1--$53.7 Pelham, Foster, & Robb, in press; Robb et al., under review

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Annual Cost of Other Disorders in U.S. Depression: $44 billion Stroke: $53.6 billion ADHD (child, $80 billion adolescent, adult) Alzheimer’s $100 billion Alcohol abuse/dep $180 Drug abuse/dep $180

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Effective School-Based Interventions for ADHD

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Evidence-Based ADHD Treatments Behavior Modification Classroom Contingency Management Behavioral Parent Training Peer Interventions in Recreational Settings Stimulant Medication DuPaul & Eckert, 1997; Fabiano, et al., 2009; Greenhill & Ford, 2002; Hinshaw et al., 2002; Pelham & Fabiano, 2008; Pelham, Wheeler, & Chronis, 1998

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ADHD Treatment Effect Sizes

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ADHD Treatment Effects in Schools

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

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

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

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ADHD and Special Education

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Interface between ADHD and Special Education A considerable number of children with ADHD receive special education in schools. Difficult to describe precisely due to no “ADHD” category Majority of children in Other Health Impaired and Emotionally/Behaviorally disturbed categories. About 20% of children in Learning Disabled Category Bussing et al., 2002; Reid et al., 1994; Schnoes et al., 2006

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What are placements for children in Special Education with ADHD 63% of time is spent in a general education setting. Approximately 60-70% of children spend the majority of their time in general education settings. Schnoes et al., 2006

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Percent of Services Received by Children with ADHD in Special Education - WNY Fabiano et al., unpublished data

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Accommodations for children with ADHD Fabiano et al., in preparation

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Interventions for children with ADHD Schnoes et al., 2006

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What interventions are not received? Only between 27-37% of students with ADHD have a behavioral management program written into their IEP. Two-thirds to three-quarters of children with ADHD do not have the evidence-based interventions for ADHD – school-based contingency management approaches – listed in the IEP. Daily progress monitoring 72% of children with ADHD are reported to have progress monitored by a special educator, but typically with long lags between assessments (i.e., weeks or months) Fabiano et al., in preparation; Schnoes et al., 2006

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Enhancing the Effectiveness of Special Education Services for Children with ADHD Using a Daily Report Card Program Institute of Education Sciences Grant # R324J06024

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Contributors Co-Investigators William E. Pelham, Jr. Daniel A. Waschbusch Greta M. Massetti Martin Volker Christopher J. Lopata Clinicians Justin Naylor Meaghan Summerlee Rebecca Vujnovic Research Assistants Tarah Carnefix Melissa Robins Jenna Rennemann

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Participants

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What is a Daily Report Card (DRC)? The DRC is an operationalized list of a child’s target behaviors Specific criteria Immediate feedback Communication tool Home-based privileges contingent on meeting DRC goals

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Why Use a DRC? Lack of evidence based interventions specified in the IEP’s of students diagnosed with ADHD (Niemic, Fabiano, Pelham, & Fuller, 2002) The DRC is an evidence-based intervention for ADHD in schools (Pelham & Fabiano, 2008; DuPaul & Eckert, 1997; DuPaul & Stoner, 2004; Pelham, Wheeler, & Chronis, 1998; Evans, 2006) Time & cost effective for teachers Students receive immediate feedback Explicit feedback from the teacher may also serve as an antecedent to future appropriate behavior (Sugai & Colvin, 1997)

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Why Use a DRC? Provides daily communication Important for an intervention to facilitate communication (Pisecco, et al, 1999) May contribute to amenable parent-teacher relationships (Dussault, 1996). May enhance relationships between teacher, parent and child (e.g., Pianta, 1996; Pisecco, Huzinec, Curtis & Matthews, 1999) Allow for continued progress monitoring & monitoring outcomes (e.g., Chafouleas, Riley-Tillman, & McDougal, 2002; DuPaul & Stoner, 2003; Evans et al., 1995; Pelham, Fabiano, & Massetti, 2005; Riley-Tillman, Chafouleas, & Breisch, 2007)

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Select Areas for Improvement & Defining Goals Review the student’s IEP Involve all school staff who work directly with the student Key domains Improving peer relations Improving academic productivity Improving classroom rule-following Identify specific behaviors to facilitate progress toward goals

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Defining DRC Goals: From IEP Goal to DRC Target IEP: Student will decrease verbal outbursts during lessons with 95% success over 10 months DRC: Raises hand to speak with __ or fewer prompts IEP: Student will refrain from making inappropriate noises during teacher directed lessons with 90% success over 10 months DRC: Makes __ of fewer inappropriate noises IEP: Student will comply with teacher directives and requests with 100% success over 10 months DRC: Follows directions with __ or fewer reminders IEP: Student will arrive to class with all necessary materials required DRC: Has materials necessary for class according to checklist IEP: Student will remain on task during class instruction DRC Options: Starts work with __ or fewer reminders Completes __ assignment(s) within specified time IEP: Student will demonstrate proficiency in 3rd grade reading curriculum DRC Options: Completes assigned reading tasks at 80% accuracy or better Returns completed reading homework done with 80% accuracy

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Creating the DRC

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Assist Parents in Establishing Reward Menu Sample Child Reward Form Child’s Name: Michael Date: Daily Rewards: Level 3 (50-74% positive marks): 15 min. of T.V. or pick 1 snack Level 2 (75-89% positive marks): 30 min. of T.V. or both of Level 3 Level 1 (90-100% positive marks): 45 min. of T.V. or choose dessert and stay up 15 extra min. Weekly Rewards: Level 3 (50-74% positive marks): Choose dinner on Saturday Level 2 (75-89% positive marks): Go out to lunch with Mom or Dad Level 1 (90-100% positive marks): Sleepover and movie with friend

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Clinician met with teacher and set up targets. The student began bringing home the Daily Report Card on 10/23 During the December consultation visit, teachers and consultant agreed to modify one of the targets from 2, to no more than 1 reminder for being off-task Clinician observed that the student was not responding to the new criteria. Parent contact was made to discuss altering the reward menu During the January consultation, target was changed from 2 to no more than 1 interruptions per class. Clinician observed that the student was not meeting criteria over multiple days. Home work incompletion and impulsively yelling out were identified as the behaviors that were currently problematic. Clinician worked with parent on adjusting the home work routine and teachers developed an in-class reward system to address “yelling out” behavior Student’s behavior was maintained throughout the remainder of the school year. Clinician met with the teacher and supported parents in problem-solving homework concerns

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Results

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Intervention Integrity All DRC group participants completed the study/ Three Monitoring families dropped out after group assignment 94% of consultation meetings occurred as intended Teachers completed 74% (SD=21%) of the DRCs. Parents reviewed/returned/rewarded 64% of the DRCs

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Primary Outcomes Measures Blinded observations of classroom behavior Academic Achievement Testing Teacher Rating of IEP goal attainment

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Blinded Observations of Classroom Behavior p < .001; f2= .20

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Academic Achievement Testing Broad Math scores were significantly improved over time (p < .001), whereas Basic Reading scores were not (p > .05). There was no time x group interaction.

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d=.09 d=.11

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Teacher Ratings of IEP Goal Attainment Each teacher was asked to rate whether the child had attained idiographic IEP goals and objectives.

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For these analyses, there was a significant difference between groups, t (55, one-tailed) = -1.98, p = .027. d = .53

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Secondary Outcome Measures

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ADHD, ODD, CD Symptoms d=.43 d=.58 d=.28

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Impairment Rating Scale d=.72 d=.64

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Academic Performance Rating Scale d=.66 d=.71

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Teacher Satisfaction d=.66 d=.46 d=.59

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Conclusion One of the longest controlled intervention studies for ADHD (9 months) and one of the first to focus on ADHD and special education. Children in the intervention group were: Observed to be less disruptive Rated as more academically productive Improved in functional domains No difference between groups in academic achievement The intervention was rated as palatable to teachers