Effective Treatments for ADHD in school settings

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Effective Treatments for ADHD in school settings

• Gregory A. Fabiano, Ph.D.
• University at Buffalo
• Department of Counseling, School, and Educational
  Psychology
• Fabiano_at_buffalo.edu

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Attention-deficit hyperactivity disorder (ADHD)

• ADHD is characterized by developmentally
  inappropriate levels of
• Inattention
• Hyperactivity
• Impulsivity
• ADHD behaviors are developmentally inappropriate,
  pervasive, chronic, and result in considerable
  impairment in social and academic functioning.

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History of ADHD

• Heinrich Hoffman, a German psychiatrist, authored
  a widely-published childrens book of short
  stories in 1844.
• Fidgety Phillip
• Johnny Look-in-the-Air
• The Story of Cruel Frederick
• The Story of Little Suck a Thumb
• The Dreadful Story of Pauline and the Matches

Thome Jacobs, 2004
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Prevalence
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Fabiano et al., under review
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Impact of ADHD - Impairment
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Domains of Impairment

• Peer relationships
• Adult relationships
• Sibling relationships
• Academic Progress
• Self-esteem
• Group functioning
• Associated problems

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Impairment Ratings Academic Progress

• Parent ratings

• Teacher ratings

Fabiano et al., 2006
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Impairment Ratings School Functioning

• Relationship with Teacher

• Classroom Functioning

Fabiano et al., 2006
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Impact of ADHD - Costs
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Educational Costs (Robb et al, under review)

• Costs of
• Special education 3230
• Disciplinary referrals 740
• Retention 110
• Special schools 780
• Total 4900

Does not include Section 504 Accommodation
Plans/OHI classifications not used
pre-1992 Likely under-estimated
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Costs in the Aggregate(assuming prevalence of 5
and 60 million school aged children--2000
census--2005 dollars)

• Health and Mental Health 11.6 billion
• Education 14.7 billion
• Crime and Delinquency 11.4 billion
• Parental work loss 2.3 billion
• Total 40 billion
• Range 34.1--53.7

Pelham, Foster, Robb, in press Robb et al.,
under review
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Annual Cost of Other Disorders in U.S.
Depression 44 billion Stroke 53.6
billion ADHD (child, 80 billion adolescent,
adult) Alzheimers 100 billion Alcohol
abuse/dep 180 Drug abuse/dep 180
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Effective School-Based Interventions for ADHD
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Evidence-Based ADHD Treatments

• Behavior Modification
• Classroom Contingency Management
• Behavioral Parent Training
• Peer Interventions in Recreational Settings
• Stimulant Medication

DuPaul Eckert, 1997 Fabiano, et al., 2009
Greenhill Ford, 2002 Hinshaw et al., 2002
Pelham Fabiano, 2008 Pelham, Wheeler,
Chronis, 1998
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ADHD Treatment Effect Sizes
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ADHD Treatment Effects in Schools
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Frequency of Classroom Rule Violations
Fabiano, Pelham, et al., (2007)
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Frequency of Classroom Rule Violations
Fabiano, Pelham, et al., (2007)
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Frequency of Classroom Rule Violations
Fabiano, Pelham, et al., (2007)
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ADHD and Special Education
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Interface between ADHD and Special Education

• A considerable number of children with ADHD
  receive special education in schools.
• Difficult to describe precisely due to no ADHD
  category
• Majority of children in Other Health Impaired and
  Emotionally/Behaviorally disturbed categories.
• About 20 of children in Learning Disabled
  Category

Bussing et al., 2002 Reid et al., 1994 Schnoes
et al., 2006
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What are placements for children in Special
Education with ADHD

• 63 of time is spent in a general education
  setting.
• Approximately 60-70 of children spend the
  majority of their time in general education
  settings.

Schnoes et al., 2006
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Percent of Services Received by Children with
ADHD in Special Education - WNY
Fabiano et al., unpublished data
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Accommodations for children with ADHD
Fabiano et al., in preparation
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Interventions for children with ADHD
Schnoes et al., 2006
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What interventions are not received?

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

Fabiano et al., in preparation Schnoes et al.,
2006
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Enhancing the Effectiveness of Special Education
Services for Children with ADHD Using a Daily
Report Card Program
Institute of Education Sciences Grant R324J06024
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Contributors

• Co-Investigators
• William E. Pelham, Jr.
• Daniel A. Waschbusch
• Greta M. Massetti
• Martin Volker
• Christopher J. Lopata

• Clinicians
• Justin Naylor
• Meaghan Summerlee
• Rebecca Vujnovic
• Research Assistants
• Tarah Carnefix
• Melissa Robins
• Jenna Rennemann

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Participants
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What is a Daily Report Card (DRC)?

• The DRC is an operationalized list of a childs
  target behaviors
• Specific criteria
• Immediate feedback
• Communication tool
• Home-based privileges contingent on meeting DRC
  goals

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Why Use a DRC?

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

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Why Use a DRC?

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

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Select Areas for Improvement Defining Goals

• Review the students IEP
• Involve all school staff who work directly with
  the student
• Key domains
• Improving peer relations
• Improving academic productivity
• Improving classroom rule-following
• Identify specific behaviors to facilitate
  progress toward goals

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Defining DRC Goals From IEP Goal to DRC Target

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

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Creating the DRC
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Assist Parents in Establishing Reward Menu
Sample Child Reward Form Childs Name
Michael Date Daily Rewards Level 3
(50-74 positive marks) 15 min. of T.V. or pick
1 snack Level 2 (75-89 positive marks) 30
min. of T.V. or both of Level 3 Level 1
(90-100 positive marks) 45 min. of T.V. or
choose dessert and stay up 15 extra min.
Weekly Rewards Level 3 (50-74 positive
marks) Choose dinner on Saturday Level 2
(75-89 positive marks) Go out to lunch with
Mom or Dad Level 1 (90-100 positive
marks) Sleepover and movie with friend
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During the December consultation visit, teachers
and consultant agreed to modify one of the
targets from 2, to no more than 1 reminder for
being off-task
Students behavior was maintained throughout the
remainder of the school year. Clinician met with
the teacher and supported parents in
problem-solving homework concerns
During the January consultation, target was
changed from 2 to no more than 1 interruptions
per class.
Clinician observed that the student was not
meeting criteria over multiple days. Home work
incompletion and impulsively yelling out were
identified as the behaviors that were currently
problematic.
Clinician observed that the student was not
responding to the new criteria. Parent contact
was made to discuss altering the reward menu
Clinician met with teacher and set up targets.
The student began bringing home the Daily Report
Card on 10/23
Clinician worked with parent on adjusting the
home work routine and teachers developed an
in-class reward system to address yelling out
behavior
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Results
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Intervention Integrity

• All DRC group participants completed the study/
  Three Monitoring families dropped out after group
  assignment
• 94 of consultation meetings occurred as intended
• Teachers completed 74 (SD21) of the DRCs.
• Parents reviewed/returned/rewarded 64 of the DRCs

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Primary Outcomes Measures

• Blinded observations of classroom behavior
• Academic Achievement Testing
• Teacher Rating of IEP goal attainment

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Blinded Observations of Classroom Behavior
p lt .001 f2 .20
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Academic Achievement Testing

• Broad Math scores were significantly improved
  over time (p lt .001), whereas Basic Reading
  scores were not (p gt .05).
• There was no time x group interaction.

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d.09
d.11
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Teacher Ratings of IEP Goal Attainment

• Each teacher was asked to rate whether the child
  had attained idiographic IEP goals and
  objectives.

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d .53
For these analyses, there was a significant
difference between groups, t (55, one-tailed)
-1.98, p .027.
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Secondary Outcome Measures
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ADHD, ODD, CD Symptoms
d.43
d.58
d.28
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Impairment Rating Scale
d.72
d.64
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Academic Performance Rating Scale
d.66
d.71
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Teacher Satisfaction
d.66
d.46
d.59
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Conclusion

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