Treating Adhd, Predominantly Inattentive Type With

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Treating ADHD, Treating ADHD, Predominantly Inattentive Predominantly Inattentive Type with Type with Integrated Psychosocial Integrated Psychosocial Treatment Treatment Linda Pfiffner, Ph.D. Linda Pfiffner, Ph.D. Children’s Center at Langley Porter University of California, San Francisco

Transcript of Treating Adhd, Predominantly Inattentive Type With

Page 1: Treating Adhd, Predominantly Inattentive Type With

Treating ADHD, Predominantly Treating ADHD, Predominantly Inattentive Type with Inattentive Type with

Integrated Psychosocial Integrated Psychosocial TreatmentTreatment

Linda Pfiffner, Ph.D.Linda Pfiffner, Ph.D.

Children’s Center at Langley PorterUniversity of California, San Francisco

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What is ADHD-I?What is ADHD-I? Case Description: “Kayla”Case Description: “Kayla”

8 y/o girl, 38 y/o girl, 3rdrd grade, private school grade, private school

Referred due to concerns about attention: “mind Referred due to concerns about attention: “mind floats,” lives in fantasy world, organizational floats,” lives in fantasy world, organizational problems, needs to be redirected. Also concerns problems, needs to be redirected. Also concerns about social interaction problems.about social interaction problems.

Family background: lives with her biological mother Family background: lives with her biological mother and sister; parents are divorced. History of ADHD, and sister; parents are divorced. History of ADHD, behavior problems, depression in family. Mother behavior problems, depression in family. Mother works full-time.works full-time.

Birth, medical and developmental history: “normal”, Birth, medical and developmental history: “normal”, but slightly late in some fine and gross motor skills. but slightly late in some fine and gross motor skills.

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School HistorySchool History Problems with attention, focus and completing Problems with attention, focus and completing tasks began during first grade and have tasks began during first grade and have worsened each year. worsened each year. Teacher comments:Teacher comments:– Capable, but works slowlyCapable, but works slowly– Doesn’t use class time well, “mostly in her own Doesn’t use class time well, “mostly in her own

world”world”– Concentration problems worse as day progresses or Concentration problems worse as day progresses or

if activity is lengthyif activity is lengthy– Lack of attention leads to missing directionsLack of attention leads to missing directions– Needs 1:1 or small group to stay on task and achieveNeeds 1:1 or small group to stay on task and achieve– Work is often sloppy, messy, incomplete, not turned Work is often sloppy, messy, incomplete, not turned

inin– Academic ability– on grade levelAcademic ability– on grade level– Very imaginative, artisticVery imaginative, artistic– Few behavior problemsFew behavior problems

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Peer RelationsPeer Relations ““Immature,” fits in better with younger children Immature,” fits in better with younger children Has a few friends but does not seek new friendsHas a few friends but does not seek new friends Makes up stories Makes up stories Can be bossy Can be bossy Some teasing by peers Some teasing by peers Teacher describes as “eccentric”Teacher describes as “eccentric”

Home BehaviorHome Behavior Daily routine activities and homework are an ordeal.Daily routine activities and homework are an ordeal. Takes “forever” to get things doneTakes “forever” to get things done Lots of frustration and conflict over need for reminders Lots of frustration and conflict over need for reminders

and not completing tasksand not completing tasks Needs constant supervisionNeeds constant supervision Affects getting ready in am, homework, chores, bedtimeAffects getting ready in am, homework, chores, bedtime High levels of mother-daughter conflict, but evidence of High levels of mother-daughter conflict, but evidence of

loving relationshiploving relationship

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Teacher RatingsTeacher Ratings

Teacher CSITeacher CSI: ADHD IA: 8/9 often or very often, H/I: 0/9: ADHD IA: 8/9 often or very often, H/I: 0/9 SCTSCT: 11/15 often or very often: 11/15 often or very often APRSAPRS: 50% work completed, “often” completes work in : 50% work completed, “often” completes work in

careless fashion, “often” requires assistance to complete careless fashion, “often” requires assistance to complete work, quality of work is “more successful than poor” work, quality of work is “more successful than poor”

Peer Relations ScalePeer Relations Scale: often chosen late, never sought : often chosen late, never sought after by peers, none would like for a best friend, none after by peers, none would like for a best friend, none would wish she was not in classwould wish she was not in class

School Situations QSchool Situations Q= moderate-severe in 4/8 areas= moderate-severe in 4/8 areas SSRSSSRS: SS Scale: 79, AC=88, PB=130: SS Scale: 79, AC=88, PB=130

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Parent Interview and RatingsParent Interview and Ratings

Parent KSADS and CSIParent KSADS and CSI: IA: 9/9, H/I=2/9, : IA: 9/9, H/I=2/9, past sep anx disorder.past sep anx disorder.

Home Sit. QHome Sit. Q.: moderate in 10/13 areas.: moderate in 10/13 areas HPCHPC: “very often” 17/20 items: “very often” 17/20 items SSRSSSRS: SS Scale: 67, PB Scale=134: SS Scale: 67, PB Scale=134 PSIPSI: P-C Dys Interaction: 99%, Difficult : P-C Dys Interaction: 99%, Difficult

Child: 97%, Total Stress: 97%Child: 97%, Total Stress: 97% ABASABAS: Gen Adaptive Composite: 72: Gen Adaptive Composite: 72

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Test ResultsTest Results

Behavioral ObservationsBehavioral Observations: cheerful, : cheerful, rapport each to establish, somewhat slow to rapport each to establish, somewhat slow to respond, compliant and friendlyrespond, compliant and friendly

WASIWASI: FSIQ=108, Verb=114, Perf=102: FSIQ=108, Verb=114, Perf=102 WIAT IIWIAT II: WR=93, MR=106, S=96: WR=93, MR=106, S=96 MASCMASC: T=65, elevated: T=65, elevated CDICDI: T=47, normal range: T=47, normal range

DSM-IV Diagnosis: ADHD-IDSM-IV Diagnosis: ADHD-I

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Life in families with ADHD-ILife in families with ADHD-I Homework vacillates between a struggle and a crisis Homework vacillates between a struggle and a crisis Routine activities and chores are forgotten Routine activities and chores are forgotten Getting ready in the morning is a formidable challengeGetting ready in the morning is a formidable challenge Dawdling and procrastination means things are done at Dawdling and procrastination means things are done at

the last minute the last minute Bedrooms and play areas usually messy and Bedrooms and play areas usually messy and

disorganized—clothes laying in the same spot they were disorganized—clothes laying in the same spot they were dropped; toys, papers, books, and magazines in dropped; toys, papers, books, and magazines in disarray. disarray.

Lots of time spent looking for “lost” thingsLots of time spent looking for “lost” things ““Off in own world," not listening and not following throughOff in own world," not listening and not following through

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School (cont.)School (cont.)

– Academic underachievement, learning Academic underachievement, learning disabilities disabilities (McBurnett et al., 1999; Carlson & Mann, 2000)(McBurnett et al., 1999; Carlson & Mann, 2000)

– These problems may be less extreme in early These problems may be less extreme in early elementary years, but as demands for elementary years, but as demands for independence increase with each grade, these independence increase with each grade, these problems can be quite severe by middle and problems can be quite severe by middle and high school. high school.

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Peer Relations in ADHD-IPeer Relations in ADHD-ICarlson & Mann, 2000;Carlson & Mann, 2000; Maedgen & Carlson, 2000;Maedgen & Carlson, 2000;

Blachman & Hinshaw, 2002Blachman & Hinshaw, 2002

Tend to be passive and withdrawn Tend to be passive and withdrawn Often play by themselves; play with others for only short Often play by themselves; play with others for only short

periods of time. periods of time. Often shy, not “tuned in” to group conversation.Often shy, not “tuned in” to group conversation. Poor tracking and processing of social cues, Poor tracking and processing of social cues, Not well-accepted by peers: teased, unpopular, neglected Not well-accepted by peers: teased, unpopular, neglected

rather than openly rejected. rather than openly rejected. Deficits in knowing what to do when interacting with others, Deficits in knowing what to do when interacting with others,

not just a performance problem. not just a performance problem.

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DSM-IV ADHD-I DSM-IV ADHD-I Must occur OFTEN, cause IMPAIRMENT, X 2 settingsMust occur OFTEN, cause IMPAIRMENT, X 2 settings

Inattentive (6+)Inattentive (6+) Fails to give attention to Fails to give attention to

details/makes careless details/makes careless mistakesmistakes

Difficulty sustaining Difficulty sustaining attentionattention

Seems not to listenSeems not to listen Fails to finish tasksFails to finish tasks Difficulty organizingDifficulty organizing Avoids tasks requiring Avoids tasks requiring

sustained attentionsustained attention Loses thingsLoses things Easily distractedEasily distracted ForgetfulForgetful

Hyper/Impulsive (5-)Hyper/Impulsive (5-) Fidgets or squirms in seatFidgets or squirms in seat Difficulty remaining seated Difficulty remaining seated

when asked towhen asked to Runs about or climbs on Runs about or climbs on

things when asked not tothings when asked not to Difficulty playing quietlyDifficulty playing quietly Acts “on the go” or “driven by Acts “on the go” or “driven by

a motor”a motor” Talks excessivelyTalks excessively Blurts out answersBlurts out answers Difficulty awaiting turn in Difficulty awaiting turn in

group activitiesgroup activities Interrupts people, butts into Interrupts people, butts into

others’ activitiesothers’ activities

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Sluggish Cognitive TempoSluggish Cognitive Tempo(McBurnett et al., 2001; Carlson et al., 2002(McBurnett et al., 2001; Carlson et al., 2002

Daydreams Daydreams Sluggish or drowsySluggish or drowsy Confused or in a fogConfused or in a fog Absent-mindedAbsent-minded Apathetic or unmotivatedApathetic or unmotivated Stares blanklyStares blankly Underactive or unmotivatedUnderactive or unmotivated ForgetfulForgetful

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Attention Problems in Attention Problems in ADHD-I vs. ADHD-CADHD-I vs. ADHD-C

ADHD-I more severe alertness/orientation ADHD-I more severe alertness/orientation problems than ADHD-C (McBurnett et al., 2001).problems than ADHD-C (McBurnett et al., 2001).

ADHD-I more problems in focused or selective ADHD-I more problems in focused or selective

attention; ADHD-C more problems with attention; ADHD-C more problems with persistence, working memory and behavioral persistence, working memory and behavioral inhibition (Barkley, 1997).inhibition (Barkley, 1997).

Both types share deficits on tests of frontal lobe Both types share deficits on tests of frontal lobe functions, but additional problems in perceptual-functions, but additional problems in perceptual-motor speed and slow processing specific to motor speed and slow processing specific to ADHD-I (e.g., Barkley et al., 1992)ADHD-I (e.g., Barkley et al., 1992)

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Work Style in ADHD-I vs. ADHD-C Work Style in ADHD-I vs. ADHD-C (Booth et al., 2001; Carlson et al., 2002)(Booth et al., 2001; Carlson et al., 2002)

ADHD-I and ADHD-C-ADHD-I and ADHD-C-– lower motivation for learning lower motivation for learning – less interest in challenging tasks less interest in challenging tasks – less persistent and more easily discouraged less persistent and more easily discouraged

ADHD-I prefer cooperative work setting; ADHD-C prefer ADHD-I prefer cooperative work setting; ADHD-C prefer more competitive environment. more competitive environment.

ADHD-I motivated to please teacher, make good grades ADHD-I motivated to please teacher, make good grades more so than for own curiosity, interest or internal drive. more so than for own curiosity, interest or internal drive.

ADHD-C more likely to value being perceived as high ADHD-C more likely to value being perceived as high performing and successful than those with ADHD-I.performing and successful than those with ADHD-I.

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Comorbid DisordersComorbid DisordersCarlson & Mann, 2000Carlson & Mann, 2000

Oppositional Defiant Disorder and Conduct Oppositional Defiant Disorder and Conduct Disorder — less in ADHD-I than ADHD-CDisorder — less in ADHD-I than ADHD-C

Anxiety and Depression — comparable or more in Anxiety and Depression — comparable or more in ADHD-I than ADHD-CADHD-I than ADHD-C

Learning Disorders — comparable or more in Learning Disorders — comparable or more in ADHD-I than ADHD-C (esp. math achievement)ADHD-I than ADHD-C (esp. math achievement)

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Tailoring psychosocial treatment Tailoring psychosocial treatment to ADHD-Ito ADHD-I

Academic impairmentAcademic impairment -- necessitates close -- necessitates close involvement with school; direct intervention for involvement with school; direct intervention for homework.homework.

Work style issuesWork style issues– use non-competitive external – use non-competitive external rewards for specific goals; accommodations to tasks and rewards for specific goals; accommodations to tasks and assignments to address slow processing speedassignments to address slow processing speed

Social difficultiesSocial difficulties-- teach and practice specific skills; -- teach and practice specific skills; provide opportunities and reinforcement for approaching provide opportunities and reinforcement for approaching and interacting with peers.and interacting with peers.

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Tailoring Tx (cont.)Tailoring Tx (cont.)

Lack of independence in daily living tasksLack of independence in daily living tasks-- most -- most efficiently increased with routines, parent monitoring and efficiently increased with routines, parent monitoring and reinforcement. reinforcement.

Fewer disruptive behavior problemsFewer disruptive behavior problems-- Limit setting -- Limit setting strategies (time-out) less useful. Instead, positive strategies (time-out) less useful. Instead, positive reinforcement targeting specific goals and routines reinforcement targeting specific goals and routines indicated.indicated.

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Why psychosocial treatment?Why psychosocial treatment?

Medication may be less helpful for ADHD-I than ADHD-C. Medication may be less helpful for ADHD-I than ADHD-C. (Barkley et al, 1991; Greenhill et al, 2000)(Barkley et al, 1991; Greenhill et al, 2000)

Social impairment in ADHD-I (social passivity/withdrawal, Social impairment in ADHD-I (social passivity/withdrawal, lack of social knowledge) likely to be more amenable to PST lack of social knowledge) likely to be more amenable to PST than ST than ST (Pfiffner et al, 2000)(Pfiffner et al, 2000)

ST side effects of social withdrawal ST side effects of social withdrawal (Granger et al., 1996)(Granger et al., 1996) may may be less acceptable in children who already have social be less acceptable in children who already have social withdrawal problemswithdrawal problems

ST often does not normalize functioning; the inclusion of PST ST often does not normalize functioning; the inclusion of PST may be necessary to produce “excellent” treatment responsemay be necessary to produce “excellent” treatment response

Parents show a significant preference for behavioral Parents show a significant preference for behavioral treatments over pharmacological treatment alone treatments over pharmacological treatment alone (Pelham, (Pelham, 1999)1999)

These factors suggest that psychosocial interventions may be These factors suggest that psychosocial interventions may be even more important for this subtype.even more important for this subtype.

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Life Skills Training for Life Skills Training for ADHD-Inattentive TypeADHD-Inattentive Type

Exploratory/Developmental 3 year grant funded by NIMH Exploratory/Developmental 3 year grant funded by NIMH (2002-2005)(2002-2005)

Treatment incorporates rehabilitation approaches based Treatment incorporates rehabilitation approaches based on similarities between ADHD-I and mild brain injuries on similarities between ADHD-I and mild brain injuries (e.g., sluggish cognitive tempo, forgetfulness)(e.g., sluggish cognitive tempo, forgetfulness)

Emphasizes adaptive skills, functional competence, Emphasizes adaptive skills, functional competence, compensatory strategiescompensatory strategies

Uses cues, prompts, routinesUses cues, prompts, routines

Involves teachers and parents to provide necessary Involves teachers and parents to provide necessary environmental supports at school and at homeenvironmental supports at school and at home

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Child Life Skills ProgramChild Life Skills Program Study Screening and Assessment ProcessStudy Screening and Assessment Process ::

Telephone screenings (parent, teacher)Telephone screenings (parent, teacher)Agreement from school to participateAgreement from school to participateStandardized rating scales completed by parent and teacher Standardized rating scales completed by parent and teacher

(symptoms, impairment)(symptoms, impairment)Clinic visit for family:Clinic visit for family:

Clinical InterviewClinical Interview KSADS Diagnostic InterviewKSADS Diagnostic Interview WASI and WIAT II screenerWASI and WIAT II screener Child self-report: MASC, CDIChild self-report: MASC, CDI Parent-completed: PSI, APQParent-completed: PSI, APQ

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Child Life Skills ProgramChild Life Skills Program Study design:Study design:

28 children (age 7-11) randomly assigned to:28 children (age 7-11) randomly assigned to:

Life Skills Training program, orLife Skills Training program, or

Assessment only group (“Treatment as usual”)Assessment only group (“Treatment as usual”)

• DSM-IV Diagnoses: DSM-IV Diagnoses: ADHD-I only: 61%ADHD-I only: 61% Comorbid ODD: 32%Comorbid ODD: 32% Comorbid anxiety disorder: 21%Comorbid anxiety disorder: 21% Comorbid depressive disorder: 4%Comorbid depressive disorder: 4%

• Parent and teacher ratings gathered at pre-treatment, Parent and teacher ratings gathered at pre-treatment, post-treatment and follow-uppost-treatment and follow-up

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Participant CharacteristicsParticipant Characteristics

Life Skills Program (n=15)Life Skills Program (n=15) Assessment Only (n=13)Assessment Only (n=13)

AgeAge 8.9 (1.1)8.9 (1.1) 9.4 (1.1)9.4 (1.1)

Sex Sex male : femalemale : female 53% : 47%53% : 47% 57% : 43%57% : 43%

Grade Grade 22nd nd : 3: 3rd rd : 4: 4thth : 5 : 5thth 33% : 27% : 33% : 7%33% : 27% : 33% : 7% 14% : 50% : 7% : 29%14% : 50% : 7% : 29%

No. of Parents No. of Parents one : twoone : two 20% : 80%20% : 80% 21% : 79%21% : 79%

EthnicityEthnicity

CaucasianCaucasian

LatinoLatino

AsianAsian

African AmericanAfrican American

MixedMixed

47%47%

13%13%

13%13%

0%0%

27%27%

29%29%

7%7%

29%29%

7%7%

29%29%

WIAT IIWIAT II

Math ReasoningMath Reasoning

Word ReadingWord Reading

SpellingSpelling

110.1 (22.1)110.1 (22.1)

107.4 (11.1)107.4 (11.1)

107.3 (8.4)107.3 (8.4)

97.8 (16.1)97.8 (16.1)

101.0 (11.8)101.0 (11.8)

100.3 (12.4)100.3 (12.4)

WASI WASI

Full Scale IQFull Scale IQ 104.6 (12.3)104.6 (12.3) 102.9 (12.0)102.9 (12.0)

Standard deviation (SD) in parentheses.

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Child Life Skills ProgramChild Life Skills Program Treatment ComponentsTreatment Components::

ChildChild Weekly Child Group meetings (90 min.) for eight Weekly Child Group meetings (90 min.) for eight

weeks, concurrent with Parent Group meetings. weeks, concurrent with Parent Group meetings. Four family meetings with study therapistsFour family meetings with study therapists

ParentParent Weekly Parent Group meetings (90 min.) for eight Weekly Parent Group meetings (90 min.) for eight

weeks, concurrent with Child Group meetingsweeks, concurrent with Child Group meetings Four family meetings with study therapistsFour family meetings with study therapists

TeacherTeacher Five consultations with study therapists, families Five consultations with study therapists, families

attend part of meetingsattend part of meetings

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Child Component – Skills Taught:Child Component – Skills Taught:

Independence ModulesIndependence Modules• Homework/study skillsHomework/study skills• Self-care skillsSelf-care skills• Getting chores doneGetting chores done• Routines, organization Routines, organization

and time toolsand time tools• Public SituationsPublic Situations

Social SkillsSocial Skills ModulesModules• Friendship-making Friendship-making • Handling teasingHandling teasing• AssertionAssertion• Accepting Accepting • Being a good sportBeing a good sport• Problem-solvingProblem-solving

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Structure of each Child Group:Structure of each Child Group:

Review homework, previous skills taught, stars earned Review homework, previous skills taught, stars earned

at home and schoolat home and school Present “skill of the week”Present “skill of the week” Skill gameSkill game Role PlaysRole Plays Independence Stations and/or free play to practice new Independence Stations and/or free play to practice new

skillsskills ReinforcementReinforcement Review and meet with parentsReview and meet with parents

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Parent Component— Parent Component— Skills Taught:Skills Taught:

Positive communication (attending, praising, Positive communication (attending, praising, quality time)quality time)

Use of more powerful reinforcement programs to Use of more powerful reinforcement programs to support daily living skills (e.g., star systems, support daily living skills (e.g., star systems, home challenge)home challenge)

Use of effective instructions and commandsUse of effective instructions and commands

Prudent discipline (planned ignoring, response Prudent discipline (planned ignoring, response cost)cost)

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Parent Component (cont.)Parent Component (cont.)Using routines and plans to promote successUsing routines and plans to promote success

Morning and evening routinesMorning and evening routines HomeworkHomework Playdate planPlaydate plan ChoresChores

Child “skill of the week” also reviewed with Child “skill of the week” also reviewed with parents to promote generalizationparents to promote generalization

Social skillsSocial skills Independence ModulesIndependence Modules

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Outline of session contentOutline of session contentWeek 1Week 1

Child GroupChild Group Session 1 Session 1• Friendship-making SkillsFriendship-making Skills• Good SportsmanshipGood Sportsmanship

Parent Group Parent Group Session 1Session 1• Overview of ADHD, Child Life Skills ProgramOverview of ADHD, Child Life Skills Program• Behavioral Model of Child BehaviorBehavioral Model of Child Behavior• Attending and Quality TimeAttending and Quality Time• Positive Attention and Verbal PraisePositive Attention and Verbal Praise

Teacher Component (Orientation)Teacher Component (Orientation)• Overview of Child Life Skills Program, behavioral intervention, Overview of Child Life Skills Program, behavioral intervention,

classroom accommodationsclassroom accommodations• Classroom Challenge overviewClassroom Challenge overview

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Week 2Week 2

Child Group Child Group Session 2Session 2• What’s my job? Intro to routinesWhat’s my job? Intro to routines• Morning routine planningMorning routine planning• AcceptingAccepting

Parent Group Parent Group Session 2Session 2• Rewarding behavior with praise, activities and privilegesRewarding behavior with praise, activities and privileges• Token EconomyToken Economy• Effective use of Positive Reinforcement (novelty, consistency, Effective use of Positive Reinforcement (novelty, consistency,

specificity)specificity)• Effective Communication with school and teacher (Classroom Effective Communication with school and teacher (Classroom

challenge)challenge)

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Week 3Week 3

Individual Family Session 1Individual Family Session 1• Review of home programsReview of home programs• Individualized feedback and assistanceIndividualized feedback and assistance• Review classroom challengeReview classroom challenge

Parent/Teacher/Child Meeting 1Parent/Teacher/Child Meeting 1• Discuss and develop classroom challengeDiscuss and develop classroom challenge• Review homework routine, modify as neededReview homework routine, modify as needed

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Week 4Week 4

Child Group Child Group Session 3Session 3• Homework and study skillsHomework and study skills• Remembering important thingsRemembering important things

Parent Group Parent Group Session 3Session 3• Strategies for Handling Homework ProblemsStrategies for Handling Homework Problems• Review Teacher Homework ExpectationsReview Teacher Homework Expectations• Discuss a Script for Parent-Teacher MeetingsDiscuss a Script for Parent-Teacher Meetings• Plan Homework ProgramPlan Homework Program

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Week 5Week 5

Child Group Child Group Session 4Session 4• Homework and study skills practiceHomework and study skills practice• Assertive BehaviorAssertive Behavior

Parent Group Parent Group Session 4Session 4• Effective vs. Ineffective CommandsEffective vs. Ineffective Commands• How to Structure Antecedents to Improve Peer How to Structure Antecedents to Improve Peer

RelationsRelations• Practice Homework RoutinePractice Homework Routine

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Week 6Week 6

Individual Family Session 2Individual Family Session 2• Review and Troubleshoot Home ProgramsReview and Troubleshoot Home Programs• Individualized Feedback and AssistanceIndividualized Feedback and Assistance• Practice Using Script for Parent-Teacher MeetingsPractice Using Script for Parent-Teacher Meetings• Review classroom challengeReview classroom challenge

Parent/Teacher/Child Meeting 2Parent/Teacher/Child Meeting 2• Review classroom challenge, modify as neededReview classroom challenge, modify as needed• Review homework routine, modify as neededReview homework routine, modify as needed• Review accommodationsReview accommodations

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Week 7Week 7 Child Group Child Group Session 5Session 5• Dealing with TeasingDealing with Teasing• Let’s Make a Plan!Let’s Make a Plan!

Parent GroupParent Group Session 5 Session 5• Reducing Problem Behavior by Planned IgnoringReducing Problem Behavior by Planned Ignoring• Effective Strategies for Changing AntecedentsEffective Strategies for Changing Antecedents• Applying Antecedents to Evening Routine or Other ActivityApplying Antecedents to Evening Routine or Other Activity

Parent/Teacher/Child Meeting 3Parent/Teacher/Child Meeting 3• Review classroom challenge, modify as neededReview classroom challenge, modify as needed• Review homework routine, modify as neededReview homework routine, modify as needed• Review accommodations, modify as neededReview accommodations, modify as needed

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Week 8Week 8Individual Family Session 3Individual Family Session 3• Troubleshoot and Individualize Other Home ProgramsTroubleshoot and Individualize Other Home Programs• Review Parent-Teacher MeetingsReview Parent-Teacher Meetings• Review classroom challengeReview classroom challenge

ANDANDChild Group Child Group Session 6Session 6• Study Skills and Homework PracticeStudy Skills and Homework Practice• Problem Solving and OrganizationProblem Solving and Organization

Parent Group Parent Group Session 6Session 6• Response Cost (and Fines)Response Cost (and Fines)• Using Punishment EffectivelyUsing Punishment Effectively• Approaches to Problem Solving and Organization with my ChildApproaches to Problem Solving and Organization with my Child

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Week 9Week 9Child Group Child Group Session 7Session 7• Time Management ToolsTime Management Tools• Do it Now! Overcoming ProcrastinationDo it Now! Overcoming Procrastination

Parent Group Parent Group Session 7Session 7• Improving My Child’s Organization and Time Management SkillsImproving My Child’s Organization and Time Management Skills• Planning Activities in AdvancePlanning Activities in Advance• Promoting Independence in Public PlacesPromoting Independence in Public Places

Parent/Teacher/Child Meeting 4Parent/Teacher/Child Meeting 4• Review classroom challenge, modify as neededReview classroom challenge, modify as needed• Review homework routine, modify as neededReview homework routine, modify as needed• Review accommodations, modify as neededReview accommodations, modify as needed

Individual Family Session 4 (if needed)Individual Family Session 4 (if needed)

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Week 10Week 10

Child Group Child Group Session 8Session 8

Review all skills taughtReview all skills taught

Select “personal challenge”Select “personal challenge”

Parent Group Parent Group Session 8Session 8

Review all skills taughtReview all skills taught

Discuss strategies for maintaining gains working with new Discuss strategies for maintaining gains working with new

teachersteachers

Being prepared for future problemsBeing prepared for future problems

Plus monthly family meetings until follow-upPlus monthly family meetings until follow-up

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Sample Home ChallengeSample Home Challenge

Day Target

Behaviors Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Home Target

Behavior

Social Skill

Classroom Challenge

TOTAL ___

“stars” ___

“stars” ___

“stars” ___

“stars” ___

“stars” ___

“stars” ___

“stars”

Weekly Total

____ “stars”

Name: Date:

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Sample home target behaviorsSample home target behaviors

– Complete morning routine: (e.g., get up w/o Complete morning routine: (e.g., get up w/o complaining, get dressed-all items, put backpack by complaining, get dressed-all items, put backpack by front door)front door)

– Complete H/W assignment independently (e.g., start Complete H/W assignment independently (e.g., start with one page, increase with success; strategies for with one page, increase with success; strategies for going on when stuck)going on when stuck)

– Complete chores Complete chores – Complete evening routine independently (e.g., bathe, Complete evening routine independently (e.g., bathe,

dressed, clothes in hamper, brush teeth in x mins).dressed, clothes in hamper, brush teeth in x mins).

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Name:Name: Date:Date:

Home ChallengeHome Challenge

Day Target Behaviors Sun Mon Tues Wed Thurs Fri Sat

Morning Routine: 1. Out of bed by 6:45 2. Dressed by 7:00 3. Breakfast by 7:15 4. Ready to leave by 7:30

Social Skills 1. Friendship skills 2. Accepting

(during playdates)

Classroom Challenge

DAILY STAR TOTAL

Weekly Total

____ “stars”

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Orientation meeting with teacher and therapistOrientation meeting with teacher and therapistOverview of ADHD-I and the Child Life Skills Overview of ADHD-I and the Child Life Skills

ProgramProgramOverview of behavioral interventions and classroom-Overview of behavioral interventions and classroom-

based accommodations for ADHD-Ibased accommodations for ADHD-IOverview of Daily Report Card (“Classroom Overview of Daily Report Card (“Classroom

Challenge”)Challenge”)

Four meetings between teacher, therapist and family; Four meetings between teacher, therapist and family; focus on:focus on:Homework PlanHomework PlanClassroom ChallengeClassroom ChallengeClassroom-based accommodationsClassroom-based accommodations

Teacher ComponentTeacher Component

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Homework ExpectationsHomework Expectations

When, what and how is homework assigned? When, what and how is homework assigned? Should parent help child with homework or correct Should parent help child with homework or correct

homework? homework?

How important is neatness? How important is neatness?

How long should it take? How long should it take?

Is homework meant for practicing skills or is there some Is homework meant for practicing skills or is there some other purpose? other purpose?

Page 43: Treating Adhd, Predominantly Inattentive Type With

Homework planHomework plan

– Own deskOwn desk– Organize space with paper sorter, etc.Organize space with paper sorter, etc.– LightingLighting– Prioritize, break down h/wPrioritize, break down h/w– H/W sheet checked each dayH/W sheet checked each day– Built in breaksBuilt in breaks– Closely supervised H/W, incidental teaching, Closely supervised H/W, incidental teaching,

not just giving answersnot just giving answers

Page 44: Treating Adhd, Predominantly Inattentive Type With

Sample Classroom ChallengeSample Classroom Challenge

Time Target Behaviors Before Recess Before Lunch End of School

Gets started on work

Keeps desk organized

Completes work with accuracy

Daily Total

= _____ “stars”

Point Scale 0 = Needs Improvement 1 = Okay 2 = Super Job

Teacher Signature: ______________________________

Name: Date:

Page 45: Treating Adhd, Predominantly Inattentive Type With

Steps to set up Steps to set up Classroom ChallengeClassroom Challenge

Select target behaviorsSelect target behaviors

List target behaviors on the CC CardList target behaviors on the CC Card

Discuss logistics during school dayDiscuss logistics during school day

Discuss logistics when at homeDiscuss logistics when at home

Page 46: Treating Adhd, Predominantly Inattentive Type With

Sample target behaviorsSample target behaviors

Academics/ Study habits:Academics/ Study habits: completes assigned work accuratelycompletes assigned work accurately has materials necessary for taskhas materials necessary for task completes and returns homeworkcompletes and returns homework keeps desk area organized/neatkeeps desk area organized/neat starts work with X or fewer remindersstarts work with X or fewer remindersPeers:Peers: plays with other childrenplays with other children shows good sportsmanshipshows good sportsmanshipRules/behavior:Rules/behavior: accepts consequencesaccepts consequences follows rules/directionsfollows rules/directions

Page 47: Treating Adhd, Predominantly Inattentive Type With

Steps (cont.)Steps (cont.)

Identify reinforcers for the child to earn at homeIdentify reinforcers for the child to earn at home

Discuss baseline ratings & Match GameDiscuss baseline ratings & Match Game

Review plan & do a “walk-through” of procedure Review plan & do a “walk-through” of procedure with childwith child

Schedule Follow-up meeting for 1-2 weeks after Schedule Follow-up meeting for 1-2 weeks after CC beginsCC begins

Page 48: Treating Adhd, Predominantly Inattentive Type With

Communication styles for working Communication styles for working with attention problemswith attention problems

Giving directionsGiving directions

PraisePraise

Corrective feedbackCorrective feedback

Page 49: Treating Adhd, Predominantly Inattentive Type With

Give clear directions:Give clear directions:StatementStatement ProblemProblem BetterBetter

““Jason, would you collect all Jason, would you collect all of the papers?”of the papers?”

Implies a choiceImplies a choice ““Jason, please collect the Jason, please collect the papers."papers."

““Why can’t you ever listen the Why can’t you ever listen the first time?”first time?”

Unanswerable questionUnanswerable question Be direct. “You have a direction Be direct. “You have a direction to listen the first time.”to listen the first time.”

““Okay class. It’s time to get Okay class. It’s time to get back to work. Turn to page 5 back to work. Turn to page 5 of your book and you will find of your book and you will find an experiment to do. All of an experiment to do. All of the materials are on the back the materials are on the back counter. Make sure you counter. Make sure you answer all questions. When answer all questions. When you’re done you can start you’re done you can start your math, but first turn in your math, but first turn in your completed work.”your completed work.”

Too many directions at Too many directions at once.once.

Give time, such as 5-10 Give time, such as 5-10 seconds in between each seconds in between each direction.direction.

““Do you want to lose your Do you want to lose your recess?”recess?”

A threat in an emotional A threat in an emotional way can provoke many way can provoke many ADHD studentsADHD students

““If you don’t finish your work you If you don’t finish your work you will lose your recess.”will lose your recess.”

““Pleeeeeze! Be quiet!!!”Pleeeeeze! Be quiet!!!” Too emotionalToo emotional Stay clam. Use a nonverbal Stay clam. Use a nonverbal sign to tell students it’s time to sign to tell students it’s time to be quiet.be quiet.

Page 50: Treating Adhd, Predominantly Inattentive Type With

Effective and Ineffective PraiseEffective and Ineffective Praise

You should always keep your desk that clean!!Your desk is spotless!!

Finally you remembered your homework.I like the way you remembered your homework today.

I hope you can put your things away like this all the time.It’s so helpful when you have your things away on time.

You ignored Sally’s teasing right now. I just hope you don’t get back at her when I leave.You made a super effort at ignoring Sally’s teasing.

Why can’t your desk look like this all of the time?Your desk looks very organized.

Page 51: Treating Adhd, Predominantly Inattentive Type With

Prudent and Imprudent FeedbackPrudent and Imprudent Feedback

PrudentPrudent ImprudentImprudent

Brian, please go to work.Brian, please go to work. Brian, why aren’t you working?Brian, why aren’t you working?

Stop talking to Sammy or Stop talking to Sammy or you will have to go to you will have to go to your seat.your seat.

How many times do I have to tell you to How many times do I have to tell you to stop talking? Other students can’t stop talking? Other students can’t concentrate when you are so loud. You concentrate when you are so loud. You know the quiet rule. You’re going to have know the quiet rule. You’re going to have to learn how to follow it.to learn how to follow it.

I gave you a direction to I gave you a direction to clean up. If you don’t clean up. If you don’t start right away, you will start right away, you will start losing recess time.start losing recess time.

I told you before recess to clean up your I told you before recess to clean up your mess. I noticed that you want to go to mess. I noticed that you want to go to recess anyway. You have to remember recess anyway. You have to remember to clean up before recess.to clean up before recess.

Page 52: Treating Adhd, Predominantly Inattentive Type With

Classroom Accommodations for Classroom Accommodations for Attentional ProblemsAttentional Problems

For problems following instructions and directionsFor problems following instructions and directions: : Keep instructions brief (one or two parts), specific, and Keep instructions brief (one or two parts), specific, and

step-by-step.step-by-step.

For problems completing assignments and tasksFor problems completing assignments and tasks: : Reduce length of assignment (break into smaller parts).Reduce length of assignment (break into smaller parts). Allot extra time for work completion.Allot extra time for work completion. Give assignments one at a time, rather than all at once.Give assignments one at a time, rather than all at once. Set time limits or “challenges” for completion of tasks.Set time limits or “challenges” for completion of tasks. Include some method of checking work. Include some method of checking work.

Page 53: Treating Adhd, Predominantly Inattentive Type With

Classroom Accommodations Classroom Accommodations (cont.)(cont.)

For problems with organization, planning, or beginning For problems with organization, planning, or beginning assignments or tasksassignments or tasks: :

Encourage child to make “to do” lists and use organizer Encourage child to make “to do” lists and use organizer notebooks or folders. Monitor these regularly.notebooks or folders. Monitor these regularly.

Teach child to organize assignments by completion; Teach child to organize assignments by completion; notes according to chronological order, etc.notes according to chronological order, etc.

Teach outlining and note-taking skills (e.g., by providing Teach outlining and note-taking skills (e.g., by providing outlines for child to complete).outlines for child to complete).

Praise child for getting started on a task.Praise child for getting started on a task.

Page 54: Treating Adhd, Predominantly Inattentive Type With

Classroom Accommodations Classroom Accommodations (cont.)(cont.)

For problems staying focused and on taskFor problems staying focused and on task: :

Seat child away from doors, windows, areas of frequent Seat child away from doors, windows, areas of frequent activity or noise, and disruptive students. activity or noise, and disruptive students.

Place child near teacher’s desk to help teacher monitor Place child near teacher’s desk to help teacher monitor more closely whether child is paying attention to oral more closely whether child is paying attention to oral instructions and completing work.instructions and completing work.

Provide “quiet zone” (e.g., desk with study carrel located Provide “quiet zone” (e.g., desk with study carrel located in a corner) in which child can sit while taking tests, or at in a corner) in which child can sit while taking tests, or at times when distracted or having trouble concentrating.times when distracted or having trouble concentrating.

Page 55: Treating Adhd, Predominantly Inattentive Type With

Classroom Accommodations Classroom Accommodations (cont.)(cont.)

Cue child when it is important to pay attention by putting Cue child when it is important to pay attention by putting important information on chalkboard or introducing it with important information on chalkboard or introducing it with verbal prompts (for example, “This is important”).verbal prompts (for example, “This is important”).

Cue child in advance about times or tasks where Cue child in advance about times or tasks where independence is needed, and encourage non-disruptive independence is needed, and encourage non-disruptive activities while waiting (for example, reading, journal activities while waiting (for example, reading, journal writing, doodling, note taking).writing, doodling, note taking).

Instruct child to move on to another task when work Instruct child to move on to another task when work finished early or to continue on easier parts of an finished early or to continue on easier parts of an assignment or task while waiting for assistance.assignment or task while waiting for assistance.

Page 56: Treating Adhd, Predominantly Inattentive Type With

Classroom Accommodations Classroom Accommodations (cont.)(cont.)

For problems working independentlyFor problems working independently::

Reward child for finishing small portions of an Reward child for finishing small portions of an assignment on his/her own; gradually increase the assignment on his/her own; gradually increase the requirement as s/he is successful.requirement as s/he is successful.

Set time limits or “challenges” for completion of tasks.Set time limits or “challenges” for completion of tasks.

Page 57: Treating Adhd, Predominantly Inattentive Type With

Kayla Home programKayla Home program

H/W: moved work station into bedroom; too noisy H/W: moved work station into bedroom; too noisy in kitchen area due to remodeling. Made sure in kitchen area due to remodeling. Made sure desk area stocked and clean/organizeddesk area stocked and clean/organized

To remember assignments and bring back, CC To remember assignments and bring back, CC and prompting most helpfuland prompting most helpful

AM routine: added checklists and daily rewards; AM routine: added checklists and daily rewards; get up earlier- reward with shower in am.get up earlier- reward with shower in am.

Commands—distant commands decreasedCommands—distant commands decreased

Page 58: Treating Adhd, Predominantly Inattentive Type With

Playdates–Playdates–– during playdates would withdraw into own activity and during playdates would withdraw into own activity and

engage in parallel play. Parent monitored more often engage in parallel play. Parent monitored more often and found alternatives for interactive playand found alternatives for interactive play

– Selected specific girls for playdatesSelected specific girls for playdates– Planned activities in advancePlanned activities in advance

Page 59: Treating Adhd, Predominantly Inattentive Type With

Kayla: School programKayla: School program

Listening target: implies social behavior of less chatting, Listening target: implies social behavior of less chatting, more eye contact. Teacher took the time to define and more eye contact. Teacher took the time to define and troubleshoot. Used praise.troubleshoot. Used praise.

H/W target– implies remembering to get it home. Needed H/W target– implies remembering to get it home. Needed reminders/cues. Tried:reminders/cues. Tried:– Visual sticker in cubbyVisual sticker in cubby– Hawaiian dress key chain on backpack (laminated)—jingly noise Hawaiian dress key chain on backpack (laminated)—jingly noise

helped the mosthelped the most– Self-monitoring: “whats the first thing I need to do when I get to the Self-monitoring: “whats the first thing I need to do when I get to the

classroom”classroom”– Teacher posted homework sign for allTeacher posted homework sign for all

Page 60: Treating Adhd, Predominantly Inattentive Type With

 

NAME KAYLA DATE:__________

CLASSROOM CHALLENGE

TIME TARGET BEHAVIORS Before Recess Before Lunch End of School

Attentive listening during instruction. 0 1 2 0 1 2 0 1 2

Turn in homework every day 0 1 2 0 1 2 0 1 2

BONUS 1: Take classroom challenge home. 0 1

BONUS 2: Teacher and child match scores. 0 1

DAILY TOTAL = ______ “stars”

POINT SCALE 0 =Needs Improvement 1 =Okay 2 =Super Job

Teacher Signature: _________________________________________

Page 61: Treating Adhd, Predominantly Inattentive Type With

Dennis, 9 years, 3Dennis, 9 years, 3rdrd grade grade

Getting started target: due to spacing out, Getting started target: due to spacing out, forgetting instructions. Teacher agrees to forgetting instructions. Teacher agrees to accommodate cross checking that he understood accommodate cross checking that he understood instructionsinstructions

Organization target: mastered in 2 weeksOrganization target: mastered in 2 weeks Completing work: half of problems assigned to the Completing work: half of problems assigned to the

rest of class—skill development still accomplished rest of class—skill development still accomplished with half the problems.with half the problems.

Child identified problems to work on, he helped set Child identified problems to work on, he helped set the goal which increased motivationthe goal which increased motivation

Page 62: Treating Adhd, Predominantly Inattentive Type With

 

NAME DENNI S DATE:__________

CLASSROOM CHALLENGE

TIME TARGET BEHAVIORS Before Recess Before Lunch End of School

1. Get started right away on in-class assignments. 0 1 2 0 1 2 0 1 2

2. Put loose papers in accordion file.

0 1 2 0 1 2 0 1 2

3. Identify a set number of in-class problems and complete them in assigned time period.

0 1 2 0 1 2 0 1 2

BONUS 1: Take classroom challenge home. 0 1

BONUS 2: Teacher and child match scores. 0 1

DAILY TOTAL = ______ “stars”

POINT SCALE 0 =Needs Improvement 1 =Okay 2 =Super Job

Teacher Signature: _________________________________________

Page 63: Treating Adhd, Predominantly Inattentive Type With

Tips for making a DRC workTips for making a DRC work

Define target behaviors very specificallyDefine target behaviors very specifically– Organized desk– give examples of criteriaOrganized desk– give examples of criteria– Vague targets (paying attention) hard to trackVague targets (paying attention) hard to track

Include “easy” target behaviorInclude “easy” target behavior

Change target behaviors or requirements if Change target behaviors or requirements if not working; take flexible approachnot working; take flexible approach

Page 64: Treating Adhd, Predominantly Inattentive Type With

Tips (cont.)Tips (cont.)

Be encouraging and positive; use praiseBe encouraging and positive; use praise

Integrate self-monitoring, “Match Game”Integrate self-monitoring, “Match Game”

Make homework expectations clearMake homework expectations clear

Maintain close communication between home and Maintain close communication between home and schoolschool

Page 65: Treating Adhd, Predominantly Inattentive Type With

Troubleshooting a programTroubleshooting a program

Are target behaviors clear to the child (and teacher) and Are target behaviors clear to the child (and teacher) and appropriate?appropriate?

Does child understand the program?Does child understand the program? Does child remember the target behaviors during the Does child remember the target behaviors during the

day?day? Are the criteria realistic?Are the criteria realistic? Is the child getting sufficient feedback during day about Is the child getting sufficient feedback during day about

his/her progress?his/her progress? Is child interested in the rewards? Are more immediate Is child interested in the rewards? Are more immediate

rewards at school needed?rewards at school needed?

Page 66: Treating Adhd, Predominantly Inattentive Type With

Progress during Teacher/Family Progress during Teacher/Family meetings, Sample Case: meetings, Sample Case:

ADHD-I+LDADHD-I+LD Meeting 1:Meeting 1:

– Pxs: distractibility and not completing workPxs: distractibility and not completing work– When distracted go to “secret spot”When distracted go to “secret spot”– Complete all in-class assignment during class timeComplete all in-class assignment during class time

Meeting 2:Meeting 2:– Modify in-class assignments to writing onlyModify in-class assignments to writing only– Decrease doodling on h/w (parent reluctant to set higher Decrease doodling on h/w (parent reluctant to set higher

expectations)expectations) Meeting 3:Meeting 3:

– Good progress, mostly 2’s on CCGood progress, mostly 2’s on CC– Secret spot not used, add ignoring to CCSecret spot not used, add ignoring to CC– Add completion of h/w problem in homework clinicAdd completion of h/w problem in homework clinic

Page 67: Treating Adhd, Predominantly Inattentive Type With

Meeting 4: Meeting 4: – Mostly 2’s on CC for writing assignmentsMostly 2’s on CC for writing assignments– Ignoring a px, modify to before lunch, using sign Ignoring a px, modify to before lunch, using sign

(could use response cost)(could use response cost)– Not doing h/w problem in h/w clinic– teacher Not doing h/w problem in h/w clinic– teacher

had not communicated with homework clinic had not communicated with homework clinic staffstaff

Page 68: Treating Adhd, Predominantly Inattentive Type With

Progress during family meetingsProgress during family meetingsSample case: ADHD-I+LDSample case: ADHD-I+LD

Meeting 1:Meeting 1:– Px with am routine, hard to get out of bed Px with am routine, hard to get out of bed – Dad doing h/w for her; pessimisticDad doing h/w for her; pessimistic– Set up HC targeting h/w and am program, use Set up HC targeting h/w and am program, use

stickers for daily reward and weekly videostickers for daily reward and weekly video Meeting 2:Meeting 2:

– Not much improvement in h/wNot much improvement in h/w– Modify after school routine: dad picks up 30 min Modify after school routine: dad picks up 30 min

early, small snack, start h/w earlier, make sure early, small snack, start h/w earlier, make sure rewards given (parent did not believe in incentives)rewards given (parent did not believe in incentives)

Page 69: Treating Adhd, Predominantly Inattentive Type With

Meeting 3:Meeting 3:– Program is working: Dad goes through h/w instructions, but she Program is working: Dad goes through h/w instructions, but she

does it without Dad’s help. does it without Dad’s help. – Earning daily and weekly rewardsEarning daily and weekly rewards– Dad says still distractible. Get a desk and put in her room.Dad says still distractible. Get a desk and put in her room.

Meeting 4:Meeting 4:– Desk has greatly helped decrease distractionsDesk has greatly helped decrease distractions– Routine and rewards working, earning free timeRoutine and rewards working, earning free time– Using incidental teaching (not giving the answers)Using incidental teaching (not giving the answers)– For am, using alarm clock and starsFor am, using alarm clock and stars

Parents did not think much could change, but small modification Parents did not think much could change, but small modification made a big difference. She is happy on playground, increased made a big difference. She is happy on playground, increased confidence, doing better with social entry, less snippy with peers, confidence, doing better with social entry, less snippy with peers, and has playdates for first time. and has playdates for first time.

Page 70: Treating Adhd, Predominantly Inattentive Type With

Measure CLS Program (n=15)

Assessment Only (n=13)

BL Post-treatment

BL Post-treatment

Effect Sizes (d)

DSM-IV Inattention Symptom Count ** Symptom Severity***

6.1 1.9

2.3 1.2

6.9 2.1

5.8 1.9

1.2 1.3

Sluggish Cognitive Tempo Scale***

1.3

0.7

1.2

1.3

1.3

SSRS Social Skills* Problem Behaviors

90.1 107.1

98.1 97.8

91.4 110.7

93.3 105.1

-.2 .5

Homework Problems Checklist***

49.8

34.9

49.5

50.7

1.6

Child Life Skills Scale***

43.8

55.93

46.2

48.4

-1.0

Child Organization Scale (Parent Form) (n=8 all grps)

41.5

37.9

38.8

39.0

-.3

Child Organization Scale (Child Form) (n=8 all grps)

85.3

85.3

92.0

84.8

-.04

ANCOVAs performed for each measure with baseline scores serving as covariate.

*p= .10 **p < .05 ***p < .01

Mean scores for Child Life Skills and Assessment Only Mean scores for Child Life Skills and Assessment Only groups at baseline and post-treatment, Parent Reportgroups at baseline and post-treatment, Parent Report

Page 71: Treating Adhd, Predominantly Inattentive Type With

Measure CLS Program (n=8)

Assessment Only (n=8)

BL Post-Treatment

BL Post-Treatment

Effect Sizes (d)

Alabama Parenting Involvement Positive Parenting Poor Monitoring Inconsistent Discipline Corporal Punishment

33.6 22.3 20.1 16.1 7.5

34.8 23.9 20.4 13.6 8.1

33.4 22.6 16.6 13.6 7.5

32.3 22.1 17.4 13.5 7.6

-.6 -.6 -1.1 -.04 -.5

Parenting Stress Index Defensive Responding Parental Distress Parent-Child Dysfunctional Interaction* Total

54.0 35.0

72.4 70.4

58.0 34.9

71.1 57.3

45.4 30.3

54.8 45.8

39.1 34.3

54.5 50.0

-.6 -.02

-.5 -.2

Clinical Global Impression Parent** Interviewer***

N/A

mild mild

N/A

moderate

severe

ANCOVAs performed for each measure with baseline scores serving as covariate. *p= .10 **p < .05 ***p < .01

Mean scores for Child Life Skills and Assessment-Only Mean scores for Child Life Skills and Assessment-Only groups at baseline and post-treatment, Parent Reportgroups at baseline and post-treatment, Parent Report

Page 72: Treating Adhd, Predominantly Inattentive Type With

Measure CLS Program (n=15)

Assessment Only (n=13)

BL Post-Treatment

BL Post-Treatment

Effect Sizes (d)

DSM-IV Inattention Symptom Count Symptom Severity

5.9 1.8

3.6 1.5

7.0 2.3

5.8 1.9

1.2 .6

Sluggish Cognitive Tempo Scale

1.4

1.2

1.6

1.4

.4

SSRS Social Skills Problem Behaviors Academic Competence

88.2 106.8 91.5

91.5 103.2 94.6

86.8 114.8 88.9

88.2 109.2 89.8

-.3 .5 -.4

Academic Performance Rating Scale*

14.4

16.4

12.6

13.5

-.9

Peer Relations Scale 2.0 2.0 2.2 2.2 .4

Clinical Global Impression Teacher Interviewer*

N/A

mild mild

N/A

moderate moderate

ANCOVAs performed for each measure with baseline scores serving as covariate.

*p= .10

Mean scores for Child Life Skills and Assessment Only groups Mean scores for Child Life Skills and Assessment Only groups at baseline and post-treatment, Teacher Reportat baseline and post-treatment, Teacher Report

Page 73: Treating Adhd, Predominantly Inattentive Type With

Parent Consumer Parent Consumer Satisfaction RatingsSatisfaction Ratings

• Attention Difficulties: Attention Difficulties: 90% improved or much improved90% improved or much improved

• Change in Target Behaviors:Change in Target Behaviors:

88% improved or much88% improved or much

improvedimproved Morning routineMorning routine Social SkillsSocial Skills HomeworkHomework ClassroomClassroom

• Home and School Challenge: Home and School Challenge: 100% helpful or very helpful100% helpful or very helpful

• Usefulness of Skills Taught:Usefulness of Skills Taught: 95% useful or extremely useful95% useful or extremely useful

• Satisfaction With Treatment:Satisfaction With Treatment: 100% satisfied or very satisfied100% satisfied or very satisfied

Page 74: Treating Adhd, Predominantly Inattentive Type With

Teacher Consumer Teacher Consumer Satisfaction RatingsSatisfaction Ratings

• Classroom Challenge: Classroom Challenge: 100% helpful or very helpful100% helpful or very helpful

• Effort required to participate: Effort required to participate: 88% not too much88% not too much

• Continued use of Classroom Challenge:Continued use of Classroom Challenge:

80% likely or very likely80% likely or very likely

• Recommendation of the program to other parents andRecommendation of the program to other parents and teachers: teachers:

93% recommend or strongly 93% recommend or strongly recommendrecommend

• Use of program to treat attentional/academic/social skills problems: Use of program to treat attentional/academic/social skills problems: 100% appropriate or very appropriate100% appropriate or very appropriate

Page 75: Treating Adhd, Predominantly Inattentive Type With

Child Consumer Child Consumer Satisfaction RatingsSatisfaction Ratings

(Ratings on 5- point scale: not at all, a little, somewhat, pretty much, a lot)(Ratings on 5- point scale: not at all, a little, somewhat, pretty much, a lot)

How much did you like the group? How much did you like the group? 90% pretty much or a lot90% pretty much or a lot

How much did you learn in group?How much did you learn in group? 90% pretty much or a lot90% pretty much or a lot

How much did the Home Challenge help you do better at home?How much did the Home Challenge help you do better at home?85% pretty much or a lot85% pretty much or a lot

How much did the School Challenge help you do better at school?How much did the School Challenge help you do better at school?80% pretty much or a lot80% pretty much or a lot

How much would you like to continue in the group?How much would you like to continue in the group?80% pretty much or a lot80% pretty much or a lot

Note: for all questions, one child rated “sometimes”Note: for all questions, one child rated “sometimes”

Page 76: Treating Adhd, Predominantly Inattentive Type With

Common IssuesCommon Issues

Family fails to do homeworkFamily fails to do homework– Does not understandDoes not understand– Too angryToo angry– Disagrees with needDisagrees with need– Too much effortToo much effort– No time (and didn’t get needed supplies)No time (and didn’t get needed supplies)– ForgotForgot

Kitchen-sinking, hard to stay on topicKitchen-sinking, hard to stay on topic Child “tests” the systemChild “tests” the system SiblingsSiblings Teacher/school not supportive or parents and teacher fail Teacher/school not supportive or parents and teacher fail

to communicateto communicate

Page 77: Treating Adhd, Predominantly Inattentive Type With

Common Issues (cont.)Common Issues (cont.)

Resistance to using rewards: re-name, hear about Resistance to using rewards: re-name, hear about success from other parents, use small, practical rewardssuccess from other parents, use small, practical rewards

Managing parent affect and emotion: increase awareness, Managing parent affect and emotion: increase awareness, coping strategies coping strategies

Anxiety and perfectionism in implementing program: lower Anxiety and perfectionism in implementing program: lower the threshold for success, step back, be more supportive the threshold for success, step back, be more supportive and “catch them being good”and “catch them being good”

Page 78: Treating Adhd, Predominantly Inattentive Type With

What was most helpful?What was most helpful?

Using consequences rather than repeating directions over Using consequences rather than repeating directions over and over.and over.

Attending and praisingAttending and praising Setting time limits, using a timerSetting time limits, using a timer Ignoring outburstsIgnoring outbursts Using varying levels of rewards: cuddle time, computer Using varying levels of rewards: cuddle time, computer

time, having friend over, dessert choice, movie, lunch date time, having friend over, dessert choice, movie, lunch date with mom, bike to parkwith mom, bike to park

Using job jar for infractions (home tasks)Using job jar for infractions (home tasks) Applying the program consistentlyApplying the program consistently

Page 79: Treating Adhd, Predominantly Inattentive Type With

Giving immediate commands (e.g., “do xyz”, rather Giving immediate commands (e.g., “do xyz”, rather than “when this is over can you do this?”)than “when this is over can you do this?”)

Playdates:Playdates:– Plans important—activity, length, practice setting up, Plans important—activity, length, practice setting up,

use telephone, coaching before child came, rewarding use telephone, coaching before child came, rewarding afterwardsafterwards

Using a chartUsing a chart Having a defined program allowed for more Having a defined program allowed for more

couple’s time without constant discussion of couple’s time without constant discussion of parenting/child.parenting/child.

Page 80: Treating Adhd, Predominantly Inattentive Type With

What did parents like about the What did parents like about the program?program?

GroupsGroups Children in own peer group made it funChildren in own peer group made it fun Relating to other parentsRelating to other parents Feeling supported, individualized advice, sharing infoFeeling supported, individualized advice, sharing info Group size greatGroup size great Therapists addressed concerns well, responsive to feedback Therapists addressed concerns well, responsive to feedback Educating parents (informative), increased awareness of parenting Educating parents (informative), increased awareness of parenting ProgramProgram Separate family and teacher components, holistic approachSeparate family and teacher components, holistic approach Positive reinforcement and praise for target behs, home and classroom Positive reinforcement and praise for target behs, home and classroom

challengeschallenges Rewards program for childrenRewards program for children Organized (structured), common sense approach that values the childOrganized (structured), common sense approach that values the childParenting HelpParenting Help Parenting tips, ABC, social skills for childrenParenting tips, ABC, social skills for children Immediate change in child’s beh Immediate change in child’s beh Learning that children need limitsLearning that children need limits

Page 81: Treating Adhd, Predominantly Inattentive Type With

What did teachers like about the What did teachers like about the program? program?

EffortEffort Quick and efficient, meetings were short and productiveQuick and efficient, meetings were short and productive Easy target behaviors to work onEasy target behaviors to work on Minimal effortMinimal effort

Teacher-Child RelationshipTeacher-Child Relationship Daily feedback, classroom challenge – helped student and teacher focus on Daily feedback, classroom challenge – helped student and teacher focus on

behaviorsbehaviors One-on-one workOne-on-one work Hands-on natureHands-on nature Seeing child pleased with ratingsSeeing child pleased with ratings Made teacher pay close attention to childMade teacher pay close attention to child Gets student involved in own decision-makingGets student involved in own decision-making

School/Family RelationsSchool/Family Relations Educating, involving both teachers and parentsEducating, involving both teachers and parents

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Barriers to treatmentBarriers to treatment

Parent psychopathologyParent psychopathology Low SES (transportation, childcare px, no job/$ Low SES (transportation, childcare px, no job/$

neighborhood factors)neighborhood factors) No coverage for mental health servicesNo coverage for mental health services Marital conflict (and inconsistent parenting)Marital conflict (and inconsistent parenting) School not willing or able to participateSchool not willing or able to participate Insular family, lack of social supportInsular family, lack of social support Language and/or learning px in parentLanguage and/or learning px in parent

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Methods for tailoring behavioral Methods for tailoring behavioral interventionintervention

Parenting skills: Group vs. family formatParenting skills: Group vs. family format Child skills: Group vs. individual, need to Child skills: Group vs. individual, need to

teach basics to parents/teachersteach basics to parents/teachers School: List accommodations, request 504 School: List accommodations, request 504

or IEP (if comorbidities present) to formalize. or IEP (if comorbidities present) to formalize. Daily report card almost always helpful Daily report card almost always helpful during school-age years.during school-age years.

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Reference for Child Life Skills Reference for Child Life Skills ProgramProgram

Pfiffner, L.J. (2003). Psychosocial treatment Pfiffner, L.J. (2003). Psychosocial treatment for ADHD-Inattentive Type. for ADHD-Inattentive Type. The ADHD The ADHD ReportReport, , 1111, 1-8., 1-8.