ADHD

All About ADHD by Thomas W. Phelan

Chapter 1. "[M]any children with ADHD can pay attention (or sit still) for limited periods of time. I have found they may be able to do this when they are in situations that have one or more of four particular characteristics. These characteristics are: (a) novelty, (b) high interest value, (c) intimidation, (d) one-on-one with an adult. This temporary ability of children with ADHD to sit still and concentrate can amaze people who have previously only seen these kids in their hyperactive mode. It can also produce plenty of missed diagnoses! Examples of these special situations? The first two weeks of a school year (novelty), watching TV or playing video games (high interest value), a visit to a pediatrician's office (intimidation), going to a ball game alone with Mom or Dad (one-on-one), and psychological testing (all four!)."

Chapter 8. "Two factors make counseling children with ADHD difficult. First of all, the very characteristics that characterize ADHD can also make these kids poor candidates for counseling. Are you a good counseling candidate, for example, if you don't want to see a therapist, blame everyone else for your problems, don't pay attention well during a session, and, finally, forget everything that was discussed after you get home? Probably not. // Second, research has shown that the core symptoms of ADHD -- impaired concentration, impulsivity, and hyperactivity -- simply do not respond to counseling or psychotherapy. You just can't make these things change through talking therapies... Yet it is essential for kids with ADHD (and their parents) to see some professionals periodically as they are growing up. The visits certainly do not need to be weekly, and what is actually done during the visits may not really qualify as counseling or psychotherapy in the strict sense. The counselor is really more of a monitor or treatment supervisor, and he or she may serve several functions. These include moral support, continuing education about ADHD, medication, problem prevention, and the fine tuning of the overall treatment plan."

Chapter 8. "Comorbid DSM-5 disorders that may actually improve therapy prospects for kids with ADHD include depression and the anxiety disorders. We know that these conditions can respond quite favorably to talk therapies (as well as certain medications). On the other hand, the disorders that make for poorer therapeutic prospects include oppositional defiant and conduct disorders."

Chapter 9, CBT. "I often view the counseling process less as psychotherapy and more as education, moral support, mediation, and monitoring... Is it possible to train kids with ADHD to reduce their symptoms of hyperactivity, inattentiveness, and impulsivity in a way that improves their self-control?" Research has been done -- CBT trainings focusing on self-instruction (e.g., "If I hit her, I'll get in trouble"). "This approach took the point of view that the child's difficulties with self-control resulted from a lack of an internal language." But the results of this training were disappointing. "One of the primary problems was that children with ADHD 'forgot to remember' to use the strategy. Even though children were able to repeat the process back to the trainer, when the time came to actually use the tactic, the new strategy was the furthest thing from their mind. This type of forgetfulness is common in kids with ADHD." / More research was conducted on training focused on teaching "self-monitoring and related self-reinforcement approaches." "Although positive effects often occurred in the treatment settings, these effects did not generalize to classroom different from the one in which the tactics were first learned. Some type of environmental management skill seemed to be necessary. In other words, adults had to help kids with generalization, or the new training would not take effect." More recent trainings have attempted to train kids to improve their executive functioning by improving their working memory. These results have been no more successful.[1]

Chapter 9, Social Skills Training. "When it was first attempted, social skills training employed systematic approaches, which provided for the introduction and mastery of individual skills in a supportive environment. The goal was the generalization of these skills to other settings." Some social skills training programs lasted 8-15 weeks. Results were "disappointing." "Ironically, in the groups themselves, kids with ADHD were pretty good when it came to defining skills, describing bad behaviorr, generating new behavioral alternatives, and role-playing. As it was with the CBT techniques, however, in their every day lives, these children just didn't seem to remember to use the new thoughts and skills that had been discussed and suggested to them -- even if it was still the same day![2]

Chapter 9, Explanation. "Children with ADHD do not seem to generalize learning from a training situation to other real-life situations." Many believe that kids with ADHD have a performance deficit, not a knowledge deficit. The "basic symptoms of ADHD -- inattentiveness, hyperactivity, and impulsivity -- take over in the heat of the current moment. Kids with ADHD do better in training situations because both behavior management and medication "are being used in the situations where improvements in ADHD-like behavior are desired." Medication "can help to reduce their intrusive and irritating actions and to increase their ability to listen and think before acting. And when a behavior management program is in place, and a child with ADHD knows exactly how and when the adults in the situation are going to respond to this behavior, he will often do better. But the adults have to be there!"

Chapter 10, So What Does Work? "Over the years, controlled research has repeatedly confirmed the value of three kids of interventions for children with ADHD: behavior management training for parents, medication for children with ADHD, and specific classroom interventions to help children with ADHD in school. These strategies work, but it's important to remember what 'work' means. Work does not mean cure. Instead, work means that while these treatments are in place, ADHD symptoms and impairments are suppressed (often a lot), so that kids, parents, and teachers have enjoyable, successful days."

Chapter 11. "The final behavior management challenge is the point of performance problem. Because of the ever-present symptoms of inattention, impulsivity, and hyperactivity, it's very hard to teach a child with ADHD a behavior or skill and then expect them to remember it on their own and apply it in a new situation. The therapies that work best -- parent training, classroom management, and medication -- provide direction and assistance to kids at the time and place in which the child has to perform."

[1] Abikoff, H. (1987). An evaluation of cognitive behavior therapy for hyperactive children. In Advances in clinical child psychology (pp. 171-216). Springer, Boston, MA. /  Abikoff, H. (1991). Cognitive training in ADHD children: Less to it than meets the eye. Journal of learning Disabilities, 24(4), 205-209. / Kendall, P. C. (1993). Cognitive-behavioral therapies with youth: guiding theory, current status, and emerging developments. Journal of Consulting and Clinical Psychology, 61(2), 235. / Bloomquist, M. L., August, G. J., & Ostrander, R. (1991). Effects of a school-based cognitive-behavioral intervention for ADHD children. Journal of Abnormal Child Psychology, 19(5), 591-605.

[2] De Boo, G. M., & Prins, P. J. (2007). Social incompetence in children with ADHD: Possible moderators and mediators in social-skills training. Clinical psychology review, 27(1), 78-97.

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From BH: I am passing along some interventions that help children with similar attentional concerns. That being said, it sounds like you are already doing so many of these things! It appears the CBT interventions I was talking about may be a better fit for clinical settings. The research supports these classroom interventions, the daily report card, and other behavioral reinforcement strategies more than anything. Also, social skills interventions may be effective for him, specifically in the areas of communication, dealing with conflict, active listening strategies etc. The self monitoring strategies I talked about would also be great. https://education.wm.edu/centers/ttac/documents/packets/adhd.pdf;
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998237/

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Pelham and Fabiano (2008) reviewed the literature on ADHD interventions since 1998, and Evans, Owens, and Bunford (2014) revieweed the literature between 1998 and 2013.

The researchers primarily focused on two main interventions: behavior management interventions (BM) and training interventions (TI). BM interventions "involve training parents, teachers or program staff to modify the behavioral contingencies in the environments within which the children function and outcomes are measured." Training interventions involve teaching children skills -- usually social skills in a clinical setting -- but not "manipulating contingencies in the environments where the behavior change is intended to occur." Most training interventions are cognitive-behavioral interventions.

[BM = behavior management or behavior therapy = changing the child's behavior by modifying his/her physical/social environment.]

Behavior management interventions have consistently been shown to be effective at reducing symptoms and/or improving functioning. Examples of successful BM programs for parents include the Community-Oriented Parenting Education (COPE) program and the Defiant Children program, Second Edition; an example of a successful BM program in the classroom is the Daily Report Card (DRC) intervention in combination with ongoing teacher consultation. Training interventions, on the other hand, do "not have adequate evidence to be considered well-established or probably efficacious."

Corcoran and Walsh (2016) note that medication has been shown to be incredibly efficacious. In one study, "[t]he impact of medication compared to placebo was 0.78 for teacher report (a large effect size) and 0.54 for parent report (a moderate effect size)."Most common medication: CNS (central nervous system) stimulants (e.g., Adderall, Dexedrine, Ritalin).

The American Academy of Pediatrics recommends a combination of medication and behavior therapy for most children: just behavior therapy for preschoolers, medication and behavior therapy for children and adolescents, noting that behavior therapy tends to be less efficacious for adolescents.

Corcoran, J., & Walsh, J. (2016). Clinical assessment and diagnosis in social work practice. Oxford University Press.

Evans, S. W., Owens, J. S., & Bunford, N. (2014). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology, 43(4), 527-551.

Fabiano, G. A., Vujnovic, R. K., Pelham, W. E., Waschbusch, D. A., Massetti, G. M., Pariseau, M. E., ... & Greiner, A. R. (2010). Enhancing the effectiveness of special education programming for children with attention deficit hyperactivity disorder using a daily report card. School Psychology Review, 39(2), 219.

Pelham Jr, W. E., & Fabiano, G. A. (2008). Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology, 37(1), 184-214.

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Barkley, R. (2016). Managing ADHD in schools: The best evidence-based methods for teachers. Eau Claire, WI: Pesi Publishing and Media. 

ADHD is a neurodevelopmental disorder, meaning that the brain's development of neurological pathways has been impaired. "Such brain maldevelopment seems to arise largely from genetics but can also occur as a consequence of damage [experienced by the child] at any time during development but most often during prenatal brain formation."

Barkley conceptualizes ADHD symptoms as involving deficits in the following executive functions:

• Goal-directed persistence and resistance to distraction. ADHD kids struggle to sustain attention. "They pay attention to what is happening now just fine but not to what they need to be doing to be ready for what is coming next." The distractions might come from inside their minds.
• Working memory. ADHD kids "cannot hold as much information in mind or for as long as other students. They are also less likely to call up such information from memory and keep it consciously in mind when" changing activities. They can try to hold this information in mind but will be easily distracted. "The mental chalkboard of working memory is wiped clean by distraction, and so the child is now off doing something other than what he or she is supposed to be doing." 
• Impulsive. ADHD kids are physically and verbally impulsive, and they are more likely to choose immediate gratification or rewards. 
• Planning. ADHD kids struggle "to construct and execute the steps of a plan necessary to attain a goal." 

People with executive functioning deficits have problems with (1) self-control (live in the moment, want what they want now), (2) time-management (planning one's goals over time), (3) self-motivation (difficult to persevere through boring tasks or tasks with no immediate gratification), (4) organization.

ADHD symptoms tend to be worse in settings/tasks that require self-regulation and executive functioning:

• Are boring.
• Involve delayed consequences or infrequent feedback, require waiting. 
• Require working independently. 
• Lack supervision.
• Involve groups of children. 
• Involve supervisors who "talk and reason too much but rarely act to control misbehavior."
• Occur later in the day (due to fatigue in self-control). 
• Restrict movement.

Best situations involve "fun activities, highly stimulating or interesting tasks (e.g., video games), lots of movement, frequent rewards or feedback, highly supervised settings, working in small teams with peers rather than independently, working one-on-one with an adult, highly novel settings, where supervisors speak briefly but back up their rules with consequences, and where there is little or no pressure to wait for things." 

How to effectively managed ADHD executive functioning deficits:

1. Externalize Information -- e.g., write down rules, have student repeat rules (b/c they have poor working memory). Ideas: (1) Print classroom rules on posters in front of room. (2) Make three-sided stop sign > red = lecture, yellow = desk work, green = free play. (3) "Place laminated, color-coded card sets on desks with a set of rules for each subject or class activity," (4) "Have child restate rules at start of each activity," (5) "Have child use soft, vocal self–instruction during work." 
2. Externalize Time -- (b/c ADHD kids have trouble telling how much time has passed and how much is left). Can use Time Timer or download classroom timer. 
3. Consequences -- must be given immediately and frequently. 

School Situations Questionnaire. 

Classroom management considerations:

1. Reduce workload -- no busy work.
2. Give small quotas of work at a time with frequent breaks. 
3. Target productivity first and accuracy second -- start by rewarding child for each problem attempted. 
4. Basics -- preferential seating, allow child to move at desk, frequent movement breaks. 
5. Get color-coded binders to keep materials organized. 
6. Let student practice drills on computer -- ADHD kids pay more attention to computers. 
7. Discourage impulsive answering giving students mini whiteboards.
8. Alternate low-appeal activities w/ high-appeal activities. 
9. Schedule the most difficult activities early in day (due to fatigue). 
10. Allow computer use, as ADHD struggle w/ fine motor skills. 
11.  Require continuous note-taking, as this helps them sustain attention and helps w/ working memory. 
12. Peer Tutorng -- ADHD kids work better in dyads >> instruct class; break into dyads; have one student be tutor (he/she teaches partner what teacher just taught, then quizzes peer); alternate tutors.

Rewards. ADHD kids have less self-motivation than peers. They need immediate, extrinsic rewards. Frequent praise. Token economy. 

Tone-Tape: "A best seller, this wonderful, easy-to-use program helps children pay attention in school or when doing homework. It features an endless cassette tape which plays an audible tone at variable intervals. The student listens for the beep while attending to classwork. When the beep sounds, the student checks on a self-recording sheet whether he or she was paying attention to his or her work. Can be used individually, in small groups, or with an entire class. The program is based on research studies that have shown that self-recording of attention improves on-task behavior.The program comes with an endless cassette signaling tape, instruction manual, and self-recording forms for students."

Attention Training System: "This sensible approach to enhancing attention involves a small battery-operated electronic counter which is placed on the student’s desk. The ATS automatically awards the child a point every sixty seconds. If the student wanders off task, the teacher uses remote control to deduct a point and activate a small warning light on the student’s module. The ATS delivers unobtrusive but effective feedback, functions during regular classroom activities, circumvents the problem of treatment generalization, and has been shown to be as effective as stimulant medication in increasing attentiveness. Each teacher can control four student modules."

Daily Behavior Report Cards: Must be daily reported to parents; parents reward good behavior at home. After teacher has completed card for a few weeks, you can start having student list score and then compare their score to the teacher's.

Building Self-Awareness:

• MotivAider: "Reminds students to stay on task! A battery-operated, pocket-sized device called a MotivAider® can be set to automatically provide children with private reminders or cues to engage in specific desired behavior. A gentle vibration that lasts only for a couple of seconds reminds the child to pay attention, keep on working, raise hand before talking, etc. The MotivAider® sees to it that a child receives enough of the right reminders to make a specific improvement in behavior. Includes MotivAider® and manual specifically designed for classroom use."
• Turtle. When teacher says "Turtle," student (a) stops what she's doing, (b) looks around classroom, (c) she asks herself aloud, "What was I told to do?" (d) she provides answer and returns to task. When student gets back on-task, teacher gives student a turtle sticker or turtle stamp on hand. Stamps/tokens can be exchanged for prizes/privileges. 
• Older Children. Teacher uses "nonverbal confidential cues to signal them to stop and self-monitor their current actions." E.g., if teacher drops paperclip by student's desk. 

Transition Planning: 

1. Before starting a new activity, the teacher asks the student to STOP. (Or teacher can provide child with note card stating rules.)
2. Teacher reviews 2-3 rules child must obey in new situation.
3. Child repeats rules to teacher.
4. Teacher explains reward for obeying rules and punishment for not obeying rules.
5. Teacher gives student immediate instructions to do -- e.g., "Go to your desk, get out your math book, and turn to chapter X and start reading."
6. Teacher gives frequent rewards during activity.
7. Teacher speaks briefly with student after activity to evaluate success or failure.

Discipline:

• "Use mild, private, brief, direct reprimands" ("go to child, touch him on the arm or shoulder, make a brief corrective statement or instruction, and have the student repeat it back").
• Immediacy is the key to discipline (not severity). 
• Response cost -- but don't go overboard with taking away tokens, or incentive program will lose power. 

Coaching Method for teens.

1. Student goes to Coach first thing in morning. Gets new behavior report card, reviews daily assignment sheet for recording homework, organizes materials for classes, receives motivational pep talk. 
2. Teen returns to Coach at lunch. Coach reviews behavior report card, daily assignment sheet, helps student get organized for afternoon classes.
3. Student checks in with Coach at end of day >> review report card, daily assignment sheet, help organize materials going home. 

More for Teens. (1) Bucks for B's: Parents pay kids for good grades -- e.g., every paper w/ a C earns $.25, every paper w/ a B earns $.50. (2) Schedule hard classes in late morning or early afternoon. (3) Alternate hard and fun classes. (4) Giving extra time on tests doesn't help. What does help is allowing students to take a break during test. Can use stopwatch >> stop time when student takes break. (5) Allow students to listen to music during independent work time. (6) SQ4R Method to help w/ reading.