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

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0.4

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0.8

Sept Oct Nov Dec Jan Feb Mar Apr

Total

Inatt.

Hyp.

Middle School Teacher Ratings on IRS – Academic Progress

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0.1

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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

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ODD/CD

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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

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Organization InterventionStudent B: Slow but Steady Responder

Student 80l2 Means - Binder

y = 0.029x + 0.5404

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Organization InterventionStudent C: Honeymoon Responder

Student 7q38 Means - Binder

y = 0.0198x + 0.7511

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Organization InterventionStudent D: Non-responder

Student 5g13 Means - Binder

y = 0.0143x + 0.3248

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Figure 1. Immediate Responders

y = 0.011x + 0.8553

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1 3 5 7 9 11 13 15 17 19 21

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Figure 2. Slow-But-Steady Responders

y = 0.0248x + 0.1603

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Figure 3. Non-Responders

y = -0.0116x + 0.6788

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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

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Mondays of Week

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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

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1

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Sept Oct Nov Jan Feb Mar Apr May

Quality of Assignments

Turned in On-Time

HMP Pilot StudyStudent B

Math Grade Assessment

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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