Karin Vander Ploeg Booth, MD, gives a presentation on Behavioral and Educational Aspects of ADHD Management.
KARIN VANDER PLOEG BOOTH: Hello. I'm Karin Vander Ploeg Booth. I'm an assistant professor of pediatrics at the University of Chicago Medicine, in the section of developmental and behavioral pediatrics. Today I want to spend some time talking about the behavioral and educational aspects of ADHD management. I have a lot of objectives for our talk. I'm hoping to discuss two important aspects of ADHD management, including behavior management and educational interventions, review the evidence for behavior management in ADHD, go over some recommendations for environmental modification and some high yield behavior techniques, discuss the process for helping parents request 504 accommodations and/or an IEP through schools, and review some examples of effective ADHD accommodations at school. There's some main points I hope you'll leave with after our talk. I hope you'll know that there's good evidence for behavioral interventions in ADHD, that most behavioral techniques are not complicated-- although implementing them in a whole family system can be, that there are many effective educational interventions for ADHD, and that clinicians can help parents advocate for their children. For ADHD management we need a comprehensive management program that recognizes ADHD as the chronic condition that it is-- much like asthma, diabetes, or any other chronic condition. We need to have parent and child education, school supports, linkages to community supports. We need to specify appropriate target outcomes in various domains of functioning, and provide systematic follow up, preferably from multiple sources of information. There are three treatment modalities that have been validated in the short term. There's medication that's been found highly effective in studies. Stimulants are the best studied and validated. Behavior modification has been well studied and validated, particularly parent training. And combined medication and behavioral treatments are effective in short term studies. Behavioral management in ADHD has a lot of evidence. There is a well known, multi-center trial called the MTA study, or the Multi-modal Treatment of ADHD study, and in this study intensive behavior therapy was comparable to community medical management. There were improvements in parent teacher ratings of ADHD, there was improvement in parent teacher ratings of ODD symptoms. However, combination and medical management branches of treatments were superior. It's important to note that in this study, the behavior management was very time and effort intensive, and some parents and teachers are just not willing or able, sometimes, to implement a complicated behavioral intervention. Some kids benefit more than others from behavioral interventions for ADHD. Kids with ADHD and anxiety disorders-- but not ODD or conduct disorder-- in the MTA, responded equally well to behavioral or medication management. And then combined treatment-- the arm of combined treatment in this study-- showed that the combined treatment was better than community care or behavior management alone. Interestingly, it was the same as just medical therapy alone for the core ADHD symptoms or ODD symptoms, but combined treatment was better for internalizing symptoms, such as depression and anxiety, was better for teacher-rated social skills, parent-child relations, and improved reading skills, for some reason. Kids with multiple comorbidities did better with a combined treatment modality, especially kids with anxiety and ODD or conduct disorder. Some families and children did better. Families on public aid had better school outcomes with combined interventions. Kids who were African American also did better with combined interventions. But some families and children didn't do as well. The pre-treatment levels of parental depression and anxiety, as well as significant poverty, were associated with high treatment failure and a significant drop out rate during treatment. So where do you start if you have a child in your clinical practice, they have ADHD, and you want to start intensive behavioral modification-- or behavior modification at all-- where do you start? There's a number of reading resources that I'll talk about minute for parents and families to help get them started. Families-- parents-- can be referred for parent training if they're interested. There's a number of centers in the Chicagoland area who offer this kind of training. And then it's easy in clinic to discuss a few simple things to implement at home, and I'm going to talk at length about some environmental modifications and some high yield behavior techniques. There is a resource for clinicians put out by the AAP, and was recently updated just within the last couple of years, that has a lot of different resources for all the aspects of treatment of ADHD-- but that includes behavioral interventions. Some very good parent resources include some books that are commonly used. There's Taking Charge of ADHD-- The Complete Authoritative Guide for Parents by Russell Barkley. He's a psychologist who's been doing this all of his career. Lynn Clark, another psychologist, has written a book called SOS-- Help For Parents that's not specific to ADHD, but goes through a variety of different behavioral interventions that can be effective for a variety of behaviors. There's numerous brochures and handouts in that toolkit we just talked about. And then there's some very high quality websites that can give information to parents and other interested parties. We know that most of our families are on the web, and so I think it's always good to give them the sites that you think are particularly valid and useful. But as far as things you can get started with parents right from your office-- environmental modifications are very high yield and very important. When you have a child who's internally disorganized from ADHD, they need more external organization, so increased structure and routines is very helpful for these children-- doing homework at roughly the same time every day, having your meals at roughly the same time every day, having in the morning routine look more or less the same, the evening routine look more or less the same day to day to day. It's helpful for children to reduce distractions. Homework shouldn't be done at the kitchen table if there's going to be siblings and dogs running through, and somebody on the phone and someone on the computer. They need their own spot where there will not be many external distractions if they're internally distracted themselves. Other organizational strategies that are very helpful are to walk children with ADHD through preparing materials and clothes in advance. Then you're not trying to hit the door with a backpack unpacked, someone trying to decide still what to wear for the day. You've prepared these things in advance. It's helpful to have a specific place for materials. Children with ADHD lose things a lot, so if they know where they're supposed to go, that helps prevent this. So if all of our homework supplies go in the same sort of canister, and that's on the table, that's really useful. And then reminder lists can be really helpful for children with ADHD. What does it mean to get ready in the morning? It means brush your teeth, wash your face, put your clothes on, go downstairs for breakfast, listed out. It's very helpful. We do want to remember, though, that ADHD can be hard on families. Parent-child and sibling-child interactions in a family of a child with ADHD are more stressful and negative overall. Parents and siblings of children with ADHD are more likely to have their own psychological distress and/or own psychiatric disorders. And so we may need family therapy in addition to behavior management, and in addition to some of these high yield techniques. So we'll just keep that in the back of our minds if families continue to really struggle. A few more practical techniques for parents. One of the things that it's very easy to talk parents through is how to give an effective command. Now if there's parents in the audience, you may know how you give commands. You may give them like I do-- from the kitchen, yelling upstairs-- guys, you need to brush your teeth. You need to get on your jammies. I'll meet you in for books, but only if you do it in five minutes. It's not an effective command. I have not ensured that I have my children's attention. I've given more than one command at a time. So an effective command is when you're sure you have the child's attention. You turn off the TV if it's behind you, so that they're not looking anywhere but you. You stand right in front of them so you know they're listening-- then it's a question of obedience, not not hearing you-- and you give one command. And so the command should be turn off the television. Then when they turn off the television it's go upstairs. And then they're upstairs, and you say time to brush your teeth. So there's one command at a time. They can keep track of one command at a time, and it's very clear what you meant. There also needs to be more frequent feedback for children with ADHD. They need that feedback. And so we don't want to praise homework behavior only if they've completed all of their homework, which may take 45 minutes. Want to make sure that 10 minutes in, the child's getting some recognition that they're on task and doing what they're supposed to. And so that can be as simple as a hand on the shoulder; you're doing a great job. I see you've really gotten a lot done-- but more frequent than at the end of a very long task. For children with ADHD, we need to break down their tasks. They do not understand big, big, big tasks, such as clean your room. So it's better to say put away your clothes, make your bed, and straighten your desk. Remember, we talked about effective commands, though, so it's better even still to write those down, so they haven't forgotten the third step by the time they get to it. And then, really important to decrease TV time for children with ADHD. TV is very disorganizing for the child's brain who has ADHD. There is very, very, very constant feedback and lots of changing, and that is not good for the ADHD brain. A few more parent strategies. We want to make sure that parents are paying attention to positive behavior. We talked a few slides ago about how hard ADHD can be on this relationship. If parents are always telling children to be quiet and sit down and do what you're supposed to, and they're not always meeting with a lot of success, sometimes most interactions can become negative, and we need to increase some of those positive interactions and some attention to positive behavior. And this doesn't have to be some big deal. You don't need to jump up and down and cheer for the most routine things, but a little bit of verbal praise, a hand on the shoulder, a child knows that what they're doing is the positive behavior that we want. What's important here is to avoid backhanded compliments. So again, when things have gotten hard, what can happen is parents may say, thanks for doing that when I asked-- for once. That's not a compliment anymore. That's not praise. That's not positive feedback. That was a chance to get in a little dig about past behavior. And so we want to be sure that our positive feedback remains positive. We also want to increase the time together spent doing pleasurable things. So again, if this has become hard and a conflictual relationship, we want to be sure we're building on that a little bit. This doesn't have to be long-- 10 or 15 minutes a day is a lot to get this on the right start, preferably not doing something like TV, because that's not really spending time together, and we just talked about decreasing TV time, but can be time taking a walk around the block. Playing is really good. All kids like it, and parents can lighten up. Mostly that's going to be positive. Board games, all kinds of things may work. But sometimes you have to take families through what might be fun if it's become really difficult together. And then kids with ADHD should have an extracurricular that they can feel good about. So often school is hard, maybe there's been lots of conflict at home, and so they need some area that they feel like they're successful in and they can do well in. So whether this is drama-- kids with ADHD don't have a lot of impulse control, so sometimes they're outstanding actresses. So that can be a good possibility. Sports are also useful to get some of that energy out. And so as far as behavior management, the couple main points to take home is that there's good evidence for behavioral interventions in ADHD. Most behavioral things I just talked about are not complicated. Neither is the more intensive stuff. But implementing them in a family system where things are busy can be tricky, and so then parents and families may need to be referred for more intensive supports outside of what you can recommend in clinic. So moving on just a little bit, we're going to change directions to that educational aspect of ADHD management. So we're going to talk about educational support and school efficacy. There's a couple of educational interventions that can be done for children with ADHD. There's 504 accommodations and individualized education plans, and I'll talk about what each of those mean and how you might choose either one of those. Section 504 is from the Rehabilitation Act. The Section 504 in that act requires schools to provide accommodations so that a child can function in his or her class. And so this first came out from some of the physical problems of childhood. So these had to be accommodations that helped a child be able to get to the second floor if they used a wheelchair, if that's what needed to happen in their school setting. So to qualify, children must be determined to have a physical or mental impairment that substantially limits one or more major life activity, including learning and behavior. They need to have a record of having such impairment, or be regarded as having such impairment. That's the language of the Act. And children with ADHD meet these criteria. We know that ADHD often affects their learning and behavior, and that'll be true in a school setting as well. So how do you get a child qualified under Section 504 for accommodations or modifications? Only the school can determine a child's qualification, so parents must submit a written request asking for an evaluation to determine if their child's ADHD results in significant impact on his or her learning or behavior. That being said, physicians can provide the documentation saying that they have described a child as meeting the diagnostic criteria for ADHD. And that often will help the school fairly readily say that the child meets these qualifications. There's a number of things that can be done under Section 504 for accommodations, including the same environmental modifications that we talked about at home. The same things will be useful at school. So increasing structure, routine-- making it very clear what the school day is going to be, making sure that most days look like the others, or at least that most Mondays look like most Mondays, so children understand what's going to happen. Reducing distractions is a little trickier in a classroom of 20 to 30, but things can be done. Preferential seating can be helpful-- so close to the teacher, where you can at least quickly look at her. She can give you some verbal feedback. She can give you some touch feedback if you're off task. Not sitting by the window, where things are going to be really interesting and distracting; not by the door; and not in the back with the disruptive peers, but preferably by the teacher, away from other distractions. There's organizational strategies that can be put in place, specific places for materials again, so go through the child's desk with them periodically so it's not a disaster. They know where things are. Reminder lists for the usual routines of the day in school. And then a homework notebook is really important for children with ADHD. So somebody should check that too, to make sure that the child's written down everything they need to do. It could be the teacher, or maybe everyone has a homework buddy and you just exchange notebooks across the aisle, so everyone's is getting checked to make sure they wrote everything down. And then ensuring that a child has everything they need to do their homework. So really common for kids with ADHD to get home, to need to do an assignment and to have that book be at school. So just a little bit of check-in to make sure that they have everything they need so they can be successful with their night's homework. And then there's some more accommodations that can target inattention. So almost every child, but particularly children with ADHD, benefit from multi-modal presentation of information. So oral directions, but also written on the blackboard or on the worksheet. Oral and written assignments. It's useful to check in with a child during seat work. So if a child's supposed to be working quietly on their own for a half hour, coming by and making sure they're on task or that they've been doing what they need to do. Can be useful to request modifications of assignments. Some schools just give a tremendous amount of homework every single night-- many, many, many math problems-- and often a child could learn from half as many. So could they do odd problems instead, so that if they get off task or if they aren't sustaining attention, it doesn't take them two hours, it just takes one? There can be breaking down of larger assignments. So children with ADHD, it's really hard on them to say you have a report due in two weeks. So instead it may be, in two days I need you give me some ideas for your report. Two days after that, I want you to give me an outline of how you're going to structure that. Two days after that, tell me how you're doing on your research. Two days after that, let me see your rough draft-- so that they're not having a big, big assignment out there without the smaller breaks in between. Redirection cues are useful. Again, if the child's sitting right by the teacher, she can just touch the desk or touch their arm or something to get them back on task if she notices they're spacing out. And then children with ADHD benefit from untimed testing, especially for some of those high stake tests, like the state achievement tests or SATs or ACTs. So in case they've lost focus, they have some extra time to get themselves back on task to work through the rest of the test, and they're not penalized for that in the same way. And then there's some accommodations that can target hyperactivity or just behavior challenges that can come with ADHD. Again, most children probably benefit from movement breaks, but especially children with ADHD. So could they be sent on quick errands? Could they be the child that brings the attendance slip to the principal, or different things like that? Let him or her help pass out the papers for the day. You can allow the use of fidgets. So there are some of-- maybe an exercise ball, or sometimes kids have rubber bands between the two legs of their chair where they can put their feet on there and kind of wiggle them-- something where they can fidget and have movement happen during the school day that's not disruptive to everyone in the classroom. And then it's really useful for children to have a daily behavior report card. So we talked about the fact that frequent feedback is useful. So maybe we divide the day into chunks-- maybe we do morning and afternoon-- and you have a few different behaviors you're working on with your teacher and talking about together how you're doing. So for example, maybe in the morning we're working on these things-- keeping your hands to yourself, raising your hand to speak in circle time, remaining in your seat. And so at the end of circle time in the morning you can get together with your teacher and say how did I do? I think I did pretty excellent. She can be like, no, no, no, remember-- and so you've gotten some of that feedback. Or you could do the same thing in the afternoon with different behaviors. So ideally the child rates themselves so they develop some internal monitoring of their behavior, and reviews it with a teacher at the end of that period of time. Parents should review it too. That way parents know how school's going. They can reinforce the children for good behavior or talk about how to change their behavior if it has not been ideal. There's also the IDEA accommodations for children with ADHD. These are a little bit more intensive, and we'll talk about these in detail. So this is the Individuals with Disabilities Education Act. Part B of it was enacted in 1990 and reauthorized in '97 and 2004. It's a more comprehensive program, but has stricter eligibility criteria. So to be eligible for IDEA accommodations children must have a disability that adversely affects their educational performance and must need special education in order to receive an appropriate education. So different than just modifying things in the classroom or making some accommodations, but must also need some special education supports. Qualifying conditions for this include autism, deafness or blindness, hearing impairments of other kinds, mental retardation, multiple disabilities, orthopedic impairment, serious emotional disturbance, specific learning disability-- which children with ADHD may have comorbid to their ADHD-- speech or language impairment, traumatic brain injury, visual impairment, or other health impairment. And this is where children with ADHD most often end up. They have another health impairment, their ADHD, which is affecting their educational achievement. So if they don't meet specific criteria for a learning disability this is how they will qualify. So how can IDEA help? It does require a school to provide comprehensive testing to determine eligibility. So it can help determine if there's also a learning disability, or if it's just the inattention that's affecting that child's ability to acquire the knowledge they need and to perform in the way they should for their age. If a child's determined to meet eligibility criteria, it requires development of an IEP, or an Individualized Education Plan, with clearly measurable goals. Students are also granted safeguards and protections such as not having children be suspended for some behavior if it's associated with her ADHD. So if this child very impulsively threatens to hurt another student, maybe they don't have the same hard-line approach because the impulsivity is part of their disability. So how can clinicians help guide parents regarding what to request from the school and how to do it? So in primary care, you have some data available to you-- and we don't expect you to be able to do full IQ testing or academic testing or other things. But we have some things we can look at-- Illinois state achievement test scores, other benchmark measures to show how a child's doing compared to peers. Is the child on grade level for basic skills, at least? You'll get some sense of reading and some sense of math. You can look at the grades and try to get some sense of what's bringing the grades down. Are there missing assignments? Are tests just really hard? Does the child not understand the concepts? If the child just says I don't get it, then maybe you really want to push for a whole IEP development and testing. And then you can look at the teacher's ratings of academic performance on Vanderbilt rating scales or other rating scales. So teachers themselves may say, yeah, this child's really underperforming in this specific area of learning. If a child's falling below grade level on basic skills or failing core subjects, then it's reasonable to request a full case study or an IEP evaluation. If not, it's reasonable to start with requesting 504 accommodations and then see if some of those middle grades or poorer grades improve with these interventions, or if you're choosing to do additional intervention with medications with those. There are some resources in that AAP toolkit I talked about in the behavior management section. This is under Treatment and Medication. There's clinician tools for physicians-- what every pediatrician needs to know about ADHD in school. There's parent tools, such as homework tips for parents. And under additional parent tools there's some nice informational brochures. Why is my child having so much trouble in school? And then for the child themself, why am I having so much trouble in school? Goes through why is ADHD affecting you so badly. And then I think it's always good to give parents additional reading resources, as we talked about. Many of our families are on the web, so good for them to know what are some really good resources. The CHADD website is made by children and adults who they themselves have ADHD, or they're the parents of children with ADHD. They have lots of good information. The Families and Advocates Partnership for Education Project has really nice information for families. And the National Dissemination Center for Children with Disabilities website's also really helpful. So those main points I was hoping that we would remember from today's discussion of educational interventions is that there are many effective educational interventions for ADHD, and clinicians can help parents advocate for their children. Thank you.
