Help for the Wiggling and Off-Task Interventions Jodi A. Polaha, Ph.D. Assistant Professor,...

Help for the Wiggling and Off-TaskInterventions

Jodi A. Polaha, Ph.D.Assistant Professor, Pediatrics

Munroe-Meyer Institute, UNMCDirector, Hastings Behavioral Health Clinic

New Conceptualization of ADHDRussell Barkley, Ph.D.

“ADHD is a delay in the development of behavioral inhibition.”

Behavioral Inhibition System

Effects executive functioning.

ProcessingInput OutputSensing Executing




A problem of PERSISTENCE and MOTIVATION.

What we know works:

Drug Therapy Behavior Therapy Combined Behavioral/Drug Treatments

What we know DOESN’T work:

Play therapy Individual or family counseling (without

altering the environment) Social skills/Self-monitoring/organizational

planning.

Not enough evidence to say :

Dietary management Megavitamin therapy Sensory integration therapy/chiropractics Biofeedback

What we know works:

Drug Therapy hundreds of studies (N > 5000)

Behavior Therapy 48 classroom studies (N > 900) 80 parent/home studies (N > 5,000)

Combined Behavioral/Drug Treatments 10 classroom studies (N > 800)

Medications for ADHD

StimulantsRitalin, Adderall, Cylert, Dexedrine



Tri-Cyclic AntidepressantsImipramine



Tri-Cyclic AntidepressantsImipramine

Clonidine

What Medications Can Do

Manage symptoms Decrease activity level Decrease impulsivity Increase attention or “focus”

What Medications Can Do

Improve associated features Decrease “defiance” Decrease aggression Suppress negative social skills

What Medications Can’t Do

Teach new, appropriate behaviorsCompliance/rule-following

Self-management



Self-management Teach content previously missed

Academic work

Social skills



Self-management Teach content previously missed

Academic work

Social skills “Cure” ADHD

Stimulant Medications: Considerations

Effective for 70-75% Higher doses associated with more side

effects Positive effects are lost when drug

discontinued

Stimulant Medications:Contraindications

Under six years of age High anxiety level Thought disorder History of tics or Tourette’s Syndrome Risk of drug abuse Unacceptably high levels of negative side

effects




A problem of PERSISTENCE and MOTIVATION.


“Temporal Myopia”

NOW

Response

Response

Response

Response

event horizon

(Dr. R. Barkley)

5-7 yrs. - 12 hours

8-12 years - 24 hours

12-18 year - 2-3 days

30+ years - 8-12 weeks


“Temporal Myopia”

NOW

Event

Event

Event

Event

Event

EventResponse

Response

Response

Response

event horizon

(Dr. R. Barkley)

Behavior Therapy for ADHD

Components Highly Structured


Components Highly Structured Immediate Feedback

reinforcer or reward for appropriate behavior

punishment for inappropriate behavior


Components Highly Structured Immediate Feedback

reiforcer or reward for appropriate behavior

punishment for inappropriate behavior Salient/Meaningful Feedback

School Behavior Intervention

Examples:

1. The Attention Training System (ATS)

2. Home School Note

School Behavior Intervention:The Attention Training System (ATS)

1. Technology

Teacher Module

Student Module


1. Technology

Teacher Module

Student Module

2. Immediate feedback


1. Technology

Teacher Module

Student Module


3. Meaningful consequences


1. Technology

Teacher Module

Student Module


3. Meaningful consequences

4. Structured “time”

School Behavior InterventionThe ATS: Lisa

0102030405060708090

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Days

%TimeOff

Task

No ATS ATS No ATS ATS

School Behavior InterventionThe ATS: Troy

0102030405060708090

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Days

%TimeOff

Task

No ATS No ATS No ATSATS ATS Meds Only

School Behavior InterventionHome School Notes

Address Problems WithAcademic effort In-class behaviorsAssignment completion


Procedures Identify target behaviors.


Academic Behaviors Working on assignments Completing homework Handing in assignments All work up to date On time for class


Academic Behaviors Working on assignments Completing homework Handing in assignments All work up to date On time for class

Social Behaviors Out of seat Talking without permission Disrespectful behavior Bothering peers Following instructions Hands to self


Procedures Identify target behaviors. Design school note form.


Procedures Identify target behaviors. Design school note form. Identify reinforcers and consequences.


Reinforcer Examples Wear an outfit of your choice to school. Get out of a chore. TV/nintendo/telephone/computer time. Allowance. Token toward weekend activity.


Procedures Identify target behaviors. Design school note form. Identify reinforcers and consequences. Establish criterion for reinforcement.


Procedures Identify target behaviors. Design school note form. Identify reinforcers and consequences. Establish criterion for reinforcement. Increase criterion as progress is made.


Procedures Identify target behaviors. Design school note form. Identify reinforcers and consequences. Establish criterion for reinforcement. Increase criterion as progress is made. Plan for generalization and maintenance.


What makes it effective: Frequent, immediate feedback (school). Highly structured (short time). Salient consequences (home).

Home Behavior Intervention

Examples Time Out Job Card Grounding

Home Behavior Intervention:Time Out

Putting child in: Locate away from attention/fun. Place within 5 seconds. Be brief, unemotional.



While in: Avoid talk or eye contact. Continue to monitor.



While in: Avoid talk or eye contact. Continue to monitor.

After: Be brief, unemotional. Have child do behavior that got him/her placed in time out. Show approval for appropriate behavior within five minutes.

Home Behavior Intervention:Job Card Grounding

Components List of rules


Examples of Rules

1. Do your chores

2. Follow instructions

3. Tell us where you are going

Home Behavior Intervention :Job Card Grounding

Components List of rules List of odd jobs


Odd Job Examples

1. Dust baseboards/ceilings

2. Sweep out garage

3. Wipe down inside refrigerator


Components List of rules List of odd jobs List of rewards


GROUNDING MEANS No television, telephone, stereo, video games No friends over/go to friends No snacks, naps No outside social activities No toys


GROUNDING DOES NOT MEAN Nagging Reminding Discussing Explaining


Other Guidelines Check jobs when completed and praise.


Other Guidelines Check jobs when completed and praise. Child determines how long he/she is

grounded.



grounded. Maximum 2 cards at a time.



grounded. Maximum 2 cards at a time. Make sure groundings are DULL.



grounded. Maximum 2 cards at a time. Make sure groundings are DULL. Reward for having 2 or less cards/day.

Home Behavior Interventions

What makes them effective: Frequent, immediate feedback. Highly structured. Salient consequences.

Behavioral Interventions: Key Points

Behavioral interventions consist of training parents and teachers to implement behavioral interventions with children.



Best to wait on medication start until after committed effort to establish behavioral intervention.




ADHD is chronic; treatment must be lengthy, intensive, and used throughout the child’s environment.




ADHD is chronic; treatment must be lengthy, intensive, and used throughout the child’s environment.

Behavioral treatment is labor intensive for teachers and parents.

Help for the Wiggling and Off-Task Interventions Jodi A. Polaha, Ph.D. Assistant Professor,...

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