adhd management strategies behavioral interventions

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         CT A Good T eachin g Conf erenc e – South March 19, 2011 Sandra Rief, Presenter www.sandrarief.com

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  • ADHD: Management Strategies & ADHD: Management Strategies & ADHD: Management Strategies & ADHD: Management Strategies & Behavioral InterventionsBehavioral InterventionsBehavioral InterventionsBehavioral Interventions

    CTA Good Teaching Conference South

    March 19, 2011

    Sandra Rief, Presenterwww.sandrarief.com

  • 3 Types of AD/HD

    1. The predominantly inattentive type

    2. The predominantly hyperactive & impulsivetype

    3. The combined type

  • Descriptions of AD/HD

    AD/HD is characterized by developmentally inappropriate degrees of: inattention, impulsivity, and sometimes hyperactivity.

    S. Rief, 2011

  • AD/HD Descriptions

    Neurobiological inefficiency (underactivity) in the attention/inhibitory center of the brain

    A disorder involving delayed development of executive functions/self-regulation.

    S. Rief, 2011

  • The management functions (overseers) of the brain

    The range of central control processes in the brain

    Cognitive processes and self-directed actions we use to engage in goal-directed behavior

    What are Executive Functions?

    S. Rief, 2011

  • Executive Function AnalogyDr. Thomas Brown

    EF is the conductors role in orchestra.

    EF impairment = a poor or absent conductor

  • Inhibition

    Working memory

    Organizing, planning, and prioritizing

    Time awareness & management

    Arousal & Activation (initiation)

    Sustaining focus, alertness, and effort

    Self-regulation (emotional control, motivation)

    Goal-directed persistence

    Self-monitoring, metacognition

    EF Components

    S. Rief, 2011

  • Advances in Theory

    Increasingly, AD/HD is being conceptualized as a disorder of inhibition, self-regulation, executive functioning.

    S. Rief, 2011

  • Common School Performance Difficulties in Students with AD/HD

    Poor planning, organization, time management, study skills

    Some academic weaknesses particularly in written language

    Minimal/inconsistent production & output (both in-class assignments & homework)

    S. Rief, 2011

  • Common School Performance Difficulties in Students with AD/HD

    Forgetfulness/memory-related issues

    Difficulty following rules

    Behavioral & social difficulties affecting interpersonal relationships

    Unable to sustain effort for long-term goals (need short term goals/rewards)

    S. Rief, 2011

  • Things to Keep in Mind About AD/HD

    Disorder in performance, output, and production

    Approximately 30% delay in self-control/ inhibition, and executive functions

    High rate of coexisting conditions (comorbidity)

    S. Rief, 2011

  • AD/HD & Coexisting Conditions Learning disabilities (LD) 30-60%

    Oppositional Defiant Disorder 40-65%

    Anxiety Disorder 25%-35%

    Conduct Disorder 10%-25%children;

    25%-50% of teens

    Depression 10%-47%

    Bipolar 1%-20%

    Tourettes 7% (but 60% of

    those with Tourettes

    also have ADHD)

    S. Rief, 2011

  • AD/HD Research Indicates

    Heredity is number 1 cause of ADHD.

    Multiple genes are involved in ADHD.

    S. Rief, 2011

  • AD/HD Research Indicates

    Diminished activity & lower metabolism in certain brain regions

    Chemical imbalance/deficiency in neurotransmitters

    S. Rief, 2011

  • AD/HD Research Indicates

    Not enough neurotransmitters (dopamine and norepinephrine) in all the brain circuits.

    These brain chemicals are not being released and reloaded effectively.

    S. Rief, 2011

  • Research-Validated Treatments for AD/HD

    1. Medication therapy (stimulants)2. Behavioral therapy

    S. Rief, 2011

  • An Optic View of ADHDIf corrective lenses did not existNo well-meaning parent could hope to resistA pill that enabled their child to see -And increase that childs abilityFor better sight and clear vision -No, this would not be a tough decision.

    Then why wouldnt the same analogyApply to the problem of ADHD?For brains are a lot like eyes, I believeThey both need to focus in order to see!Medication as treatment might be preventedIf ADHD lenses were someday invented.

    K. Easter, 2005

  • Behavioral Treatment & Management of AD/HD

    Increased frequency and amount of feedback and reinforcement

    Behavior modification techniques

    Individualized interventions (e.g., daily report cards, contracts, self-monitoring and self-regulation strategies)

    Rief, S. (2008). The ADD/ADHD Checklist, 2nd edition. San Francisco: Jossey-Bass.

  • Treatment Components

    Medical

    Education re. ADHD

    Psychosocial(behavioral)

    Academic Supports/AccommodationsS. Rief, 2011

  • Getting Started & Staying OnGetting Started & Staying OnGetting Started & Staying OnGetting Started & Staying On----TaskTaskTaskTask Read directions together; get them started.

    Accessible materials

    Create a checklist.

    Frequent check-in times

    Divide assignment/task into parts.

    Set mini-goals for what to accomplish with rewards.

    S. Rief, 2011

  • Combat Attention-Busters

    Distractions (environmental and internal)

    Boredom (add novelty)

    Fatigue (movement breaks)

    S. Rief, 2011

  • Chronic intense need students

    At-risk students

    Normative/withoutserious problem behavior

    Tertiary preventionIndividual student System (~5%)

    Secondary preventionAt Risk system (~15%)

    Primary preventionUniversal interventionsSchool-wide/classroomsystems (~80%)

    SWPBS www.pbis.org & Behavioral RtI Model

  • Reverse the praise deficit.

    It takes changing the interactions:

    3:1(minimally)

    S. Rief, 2011

  • Recognition, Acknowledgement, and Specific Praise

    I really appreciate how you ______.

    I appreciate the self-control you are using.

    I noticed how hard you were working on ____.

    I see the effort you are showing.

    Thank you for the good choice you just made.

    S. Rief, 2011

  • Group Positive Reinforcement Systems

    Social reinforcers Earning minutes/time for choice activities Marbles/Popcorn kernels, etc. in jar

    S. Rief, 2011

  • Group Positive Reinforcement Systems

    Team management table points

    Token economy

    (e.g., points, tickets, class currency)

    Lottery grid

    Chart moves

    S. Rief, 2011

  • Group Reinforcement Contingencies

    No problems reported at recess No more than one name on board for

    classroom rule violations during certain time frame

    X amount of time with no incidences of (specific behavior)

    S. Rief, 2011

  • Universal Interventions

    Effective academic support Social skills teaching Explicit teaching of school behavior

    expectations Active supervision and monitoring in

    common areas Positive reinforcement for all students Firm, fair, and corrective discipline Effective classroom management

    Sprague, Bernstein, Munkres, et. al., (2003) Best Behavior

  • STARS

    Safety first

    Teamwork

    Always Respectful

    Ready to learn

    Sharing and caringS. Rief, 2011

  • Best Behavior 3 School-wide Rules

    Be SafeBe RespectfulBe Responsible

    J. Sprague, L. Bernstein, A. Munkres, A. Golly, R. March University of Oregon The Institute on Violence and Destructive Behavior

  • Inhibition StrategiesInhibition StrategiesInhibition StrategiesInhibition Strategies Have student repeat directions, restate in own words before beginning tasks.

    Praise for remembering to raise hand and wait to be called on.

    Role play and rehearse appropriate way to stand and wait in line and other problematic situations.

    S. Rief, 2011

  • Inhibition StrategiesInhibition StrategiesInhibition StrategiesInhibition Strategies

    Teach techniques to try to self-regulate impulsive behavior such as: taking a deep breath and counting silently to 10 before responding.

    S. Rief, 2011

  • Inhibition StrategiesInhibition StrategiesInhibition StrategiesInhibition Strategies Create a voice volume scale (0 = silence; 2-3 = partner talk).

    Use hand signals or other visual cue to indicate wait and dont interrupt.

    Teach problem-solving strategies and how to weigh pros and cons before making a decision or taking an action.

    S. Rief, 2011

  • Inhibition StrategiesInhibition StrategiesInhibition StrategiesInhibition Strategies

    Remind student prior to entering challenging environments or situations about expected behavior.

    In cooperative groups give 3-5 tokens for each student in the group, with rule that they can only speak when using one of their tokens.

    S. Rief, 2011

  • Common Antecedents to Misbehavior

    Physically Based

    Environmentally Based

    Related to Specific Time

    Performance/Skill Demand

    Specific Person(s)

    S. Rief, 2011

  • Prevent Problems:Alter the Antecedents

    Provide closer monitoring and supervision.

    Increase cueing & prompts.

    Address skill deficits.

    Provide accommodations & supports.

    Prepare for transitions.

    Adjust the environmental factors.

    Rief, S. (2003). The ADHD Book of Lists. San Francisco: Jossey-Bass.

  • Environmental Accommodations Preferential Seating (location & alternatives

    to chair)

    Standing work stations

    Office area/study carrel, 2-desks

    Adding structure and organization

    Visual supports & prompts

    Rief, S. (2003). The ADHD Book of Lists. San Francisco: Jossey-Bass.

  • Visual Cues

    1. May talk with teacher permission only.2. May leave seat with teacher permission only.

    1. May use 12 whisper.2. May leave seat when needed (e.g., to turn in work)

    1. May talk quietly with other students.2. May leave seat to work with other students.

    S. Rief, 2011

  • Non-Verbal Signals

    Private signals (hand motions)

    Reminder notes and messages

    S. Rief, 2011

  • Making Mistakes

    If I make a mistake on my work, it is all right.Everyone makes mistakes.

    After making a mistake, I can go back and fix the mistake.

    I will try to remember not to make the same mistake twice.

    If I do make the same mistake again, I can go back until I get it right.

    Thats how I learn.Thats how others learn, too.

    John Kistler, contribution to The Original Social Story Book, Carol Gray, et. Al)

  • The Value of Mistakes

    Einstein flunked grade-school mathematics.

    Edison tried over 9,000 kinds of filaments before he found one that would work in a lightbulb.

    Walt Disney went bankrupt five times before he built Disneyland.

  • www.whytry.org

    for teaching social-emotional skills

    Why Try Inc.

  • Menu of Creative + Reinforcers Work on board/overhead Choice of seat/special chair Messenger/Mail carrier Sharpen pencils, staple

    papers, clean board Library pass Pet or plant caretaker Decorating room/board Listen to music Reduced homework Reading to someone Time to read or be read to No homework pass Time on computer or use

    of other technology

    Special pens, paper, materials, equipment

    Pop bubble wrap Tell a joke Puzzles Cartoons/Drawing Talking periods Dancing, Exercising Arts & Crafts, Projects Hoola hoops, jump ropes Sports equipment Board games/class games Musical instrument Activity/Learning Center

    S. Rief, 2011

  • Daily Report Card Information

    12 page packet developed by Dr. William Pelham, Jr., et al.

    www.ccf.buffalo.edu/resources_downloads.php

  • Target Goals & Rewards

    Goal: Working efficiently for a 20-minute period of

    time.

    Set timer in two 10-minute sessions (or four 5 min)

    S. Rief, 2011

  • Reaction to a Reaction

    We are training children not to be reactive without thinking.

    Adults must show the same capability.

  • With Challenging Kids

    Dont take it personally.

    Dont threaten.

    Dont provide an audience.

    Dont engage in power struggles.

    Rief, S. (2008). The ADD/ADHD Checklist, 2nd edition.

  • Emotional Control & FlexibilityEmotional Control & FlexibilityEmotional Control & FlexibilityEmotional Control & Flexibility

    Watch for warning signs of over-stimulation or frustration & intervene :

    diverting attention redirecting cues/signals reminding about rewards/consequences assigning a silent or calm activity ( journaling, drawing)

    providing opportunity to change environment

    S. Rief, 2011

  • Emotional ControlEmotional ControlEmotional ControlEmotional Control

    When student shows sign of losing control:

    - Lower and calm your voice.- Maintain a calm, patient tone.- Offer choices to student (going to

    designated cool-down area, cue to use one of the calming techniques taught).

    S. Rief, 2011

  • Emotional ControlEmotional ControlEmotional ControlEmotional Control Teach to use positive self-talk: I am calm and in control. I can handle this situation.

    Teach, model, and practice appropriate strategies for anger management, stress reduction, and conflict resolution.

    S. Rief, 2011

  • Emotional ControlEmotional ControlEmotional ControlEmotional Control

    Provide visual cue cards to remind student of appropriate behaviors and steps to take when feeling upset/angry/frustrated.

    Teach awareness of emotions with scales (My anger levelMy worry level).

    S. Rief, 2011

  • Emotional Control & FlexibilityEmotional Control & FlexibilityEmotional Control & FlexibilityEmotional Control & Flexibility

    Provide advance notice of upcoming changes in activities, routines, schedules.

    Anticipate frustrating/anxiety-provoking situations and provide support (e.g., social stories www.thegraycenter.org )

    S. Rief, 2011

  • To Aid Calming

    Physical activities (brisk walk)

    Take a break area (low stimulation area,

    non-punitive)

    Self-regulation techniques (counting

    backwards, relaxation techniques like

    stretching, deep breathing, visualization)

    Rief, S. (2005). How to Reach & Teach Children with ADD/ADHD, 2nd edition.

  • Self-Regulation Strategies

    Fidget toys

    Self-monitoring

    Rief, S. (2005). How to Reach & Teach Children with ADD/ADHD, 2nd edition.

  • Self-Monitor Your Behavior

    On-task (Im focused on doing my work.)

    Paying attention (I am listening and following along)

    In my seat

    Remembering to raise hand

    Being respectful to teacher (no arguing, rude voice, or talking back)

    S. Rief, 2011

  • Organization & Homework Support

    Require backpack and either 3-ring binder or alternative of accordion file.

    Use of simple pocket folder for younger students

    S. Rief, 2011

  • Organization & Homework Support

    Consistent use of planner/agenda, calendar, or assignment sheet

    S. Rief, 2011

  • Organization & Homework Support

    Walk through the recording of assignments.

    Provide a second set of books for home.

    S. Rief, 2011

  • Organization & Homework Support

    Be responsive to parent feedback and frustration about homework difficulties.

    Use a monitoring form to track and communicate between home and school.

    Rief, S. (2008). The ADD/ADHD Checklist: A Practical Reference for Parents & Teachers, 2nd ed.

  • LongLongLongLong----Term Projects: The EF Term Projects: The EF Term Projects: The EF Term Projects: The EF NightmareNightmareNightmareNightmare

    Planning

    Organizing

    Getting started

    Estimating time

    Self-monitoring

    Meeting deadlines

    S. Rief, 2011

  • Time Awareness & SelfTime Awareness & SelfTime Awareness & SelfTime Awareness & Self----MonitoringMonitoringMonitoringMonitoring

    Write begin/end time on paper.

    Student tracks length of time it takes to complete assignments.

    S. Rief, 2011

  • Working Memory Strategies & Accommodations

    Provide written reminders and instructions.

    Post assignments and other important information in a consistent location.

    Provide to-do lists, task cards, and visual reminders of expectations.

    Create checklists for procedures and routines.

    Use technology to compensate (electronic devices, email homework).

    S. Rief, 2011

  • MetacognitionMetacognitionMetacognitionMetacognitionSelf-Awareness

    Self-Assessment

    Self-Monitoring

    S. Rief, 2011

  • Recommended Websites Children & Adults with Attention-Deficit/Hyperactivity Disorder www.chadd.org

    National Resource Center on AD/HD www.help4adhd.org

    Attention Deficit Disorder Association www.add.org

    LD Online www.ldonline.org

    Learning Disabilities Association of America www.ldanatl.org

    Great Schools www.greatschools.org formerly Schwab Learning

    S. Rief, 2011

  • Recommended Websites

    www.ccf.buffalo.edu/resources_downloads.php(Dr. William Pelham, Jr. site lots of management tools)

    www.russellbarkley.net (Dr. Barkleys official website)www.sandrarief.com (Sandras website)

    www.helpforadd.com (David Rabiners website)

    S. Rief, 2011

  • The content of this session and slides come from the following books & resources by Sandra:

    BOOKS published by Jossey-Bass:

    The ADD/ADHD Checklist: A Practical Reference for Parents & Teachers, 2nd edition (2008)How to Reach & Teach Children with ADD/ADHD, 2nd edition (2005)The ADHD Book of Lists: A Practical Guide for Helping Children & Teens with Attention Deficit Disorders (2003)

    DVDs produced by ERS (www.sandrarief.com )ADHD & LD: Powerful Teaching Strategies & Accommodations (with RTI)Successful Schools: How to Raise Achievement & Support At-Risk Students

    LAMINATED CARDS published by National Professional Resources Section 504: Classroom Accommodations (4-page laminated card)ADHD & LD: Classroom Strategies At Your Fingertips (6-page laminated card, also available in Spanish)Executive Functions: Practical Applications in the Classroom (4-page card)