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Class # 10 ( Wed August 4th ): RTI Level - 3 Interventions for ADHD

Class # 10 ( Wed August 4th ): RTI Level - 3 Interventions for ADHD. Class#1: Historical & current concepts of ADHD; ADHD diagnostic criteria Class #2 : Developmental / Lifespan and sex differences in ADHD Class #3: Neurobiology of ADHD

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Class # 10 ( Wed August 4th ): RTI Level - 3 Interventions for ADHD

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  1. Class # 10(WedAugust 4th):RTI Level-3 Interventions for ADHD Class#1: Historical & current concepts of ADHD; ADHD diagnostic criteria Class #2: Developmental / Lifespan and sex differences in ADHD Class #3: Neurobiology of ADHD Class #4: Working memory & other cognitive problems in ADHD Class #5: Academic problems in ADHD Class #6: Assessment tools for ADHD Class #7: RTI Level-1 Interventions for ADHD Class #8: RTI Level-2 Interventions for ADHD

  2. Plan for today • Case study presentations/peer assessment • Carren, Sonia • Didactic presentation: • Level-3 Interventions for ADHD • Small-group activity • Problem-solving problematic behavior and poor academic functioning: Case study-Riley

  3. Academic Systems Behavioral Systems • Intensive, Individual Interventions • Individual Students • Assessment-based • High Intensity • Of longer duration • Targeted Group Interventions • Some students (at-risk) • High efficiency • Rapid response • Targeted Group Interventions • Some students (at-risk) • High efficiency • Rapid response • Universal Interventions • All students • Preventive, proactive • Universal Interventions • All settings, all students • Preventive, proactive 80-90% 80-90% Multi-tier Model • Intensive, Individual Interventions • Individual Students • Assessment-based • Intense, durable procedures 1-5% 1-5% 5-10% 5-10%

  4. Iclicker -RTI-Level 3 Prevention • Which one of the following statements best describes Level-3 Prevention? • Individualized evidence-based instruction of increased intensity compared to level-2 interventions • Adult-led individualized evidence-based instruction for students who do not respond to effective Level-2 prevention • Individualized instruction that targets the student’s areas of need with more frequent (weekly) progress monitoring

  5. Level-3 Interventions for ADHD

  6. Is Brain-Training an effective intervention for ADHD? 1. Does ”Brain-Gym” meet criteria for a Level-3 intervention” (Spaulding et al 2010) YES NO Unsure Did not read

  7. Is Brain-Training an effective intervention for ADHD? Does Computerized Working Memory Training meet criteria for a Level-3 intervention? (klingberg et al 2005) YES NO Unsure Did not read

  8. Computerized Training of WorkingMemory • 40 min training / day • 5 days/week, 5 weeks • Adaptive algorithm • Internet based feedback Developed with the company Cogmed A side-trip to Cogmed…

  9. 14 children (3 girls); ADHD combined type; pre-post design • Treatment • Verbal and non-verbal working memory trials • Adaptation of difficulty level • Control • Verbal and non-verbal working memory trials • Easy trials • RESULTS:Improvement in: • Non-trained VSWM task (span-board) • Problem solving (RPM) • Response inhibition (Stroop) • Recorded head movements

  10. J Am Acad Child Adolesc Psychiatry, 2005 53 children with ADHD (9 girls; 38 combined type) no meds • 90 trials/day • 6 different WM tasks (predominantly VS) • 5 days/week, 5 weeks • Treatment 25.2 days • Control 26.6 days • Treatment • Verbal and non-verbal working memory trials • Adaptation of difficulty level • Control • Verbal and non-verbal working memory trials • Easy trials

  11. Span-board Klingberg et al. (2005) JAACAP

  12. Digit-span ”2 8 4 7 2 9” Klingberg et al. (2005) JAACAP

  13. Inattentive symptoms (DSM-IV) pre post change (SD)

  14. Subjects • 345, 9-10 year old children screened with WM tests • <15th percentile included • N = 42 • Randomized, controlled, blinded design • Intervention • Training group, (Klingberg, 2005) (n=22) • Control group (easy WM tasks) (n=20) • Both groups receive 25 days of training over 5-6 weeks

  15. Holmes, Gathercole & Dunning 2009.

  16. Results Holmes, Gathercole & Dunning 2009.

  17. 9 students (8-10 yrs old; low SES) 8 completed the training • 40-45 min daily, pull-out, • individual monitoring by assistant • daily tangible reinforcement • Pre-post design • Results • ADHD symptoms ES = 1.02 • WM digit span ES = .93

  18. Increased activity in caudate after WM training in updating Dahlin et al 2008

  19. Our studies of working memory training • Adolescents with severe LD/ADHD attending Trillium School (OPDS) (n=100) • Randomized controlled trial • Cogmed WM training RM / Academy of Math • 20 sessions: 45 min daily, across 5 weeks • Outcome measures • Near-transfer – other WM tasks • Far-transfer – ADHD symptoms, other cognitive tasks, weekly school report, academic achievement

  20. Our studies of working memory training - 2 • University students registered with Disability Services (ADHD/LD) n=60 • Randomized controlled trial • Cogmed WM training QM/ waitlist control • 20 sessions: 45 min daily, across 5 weeks • Outcome measures • Near-transfer – other WM tasks • Far-transfer – ADHD symptoms, daily cognitive problems (CFQ) other cognitive tasks, academic achievement

  21. Challenges we are facing • Student engagement/motivation • Scheduling the training sessions • Scheduling pre-, post-, follow-up assessments • Coordination of multiple players • school/disability services staff, JVS coach, research team BUT, we are about half-way point in studies, preliminary results are promising…..not spectacular

  22. Training of working memory:conclusions • Improves non-trained measures of WM capacity • Klingberg et al. 2002, Klingberg et al. 2005, Gibson et al. 2007, Lucas et al. 2008 • Westerberg et al. 2007, Westerberg et al. (2008); Holmes et al. (2009) • Decreases inattentive symptoms in everyday life • Klingberg et al. 2005, Gibson et al. 2007, Lucas et al. 2008 • Westerberg et al. 2007; Westerberg et al. 2008 • Is associated with plasticity of parietal and prefrontal cortex • Olesen et al. 2004; Westerberg and Klingberg 2007; McNab et al. (submitted)

  23. Level-3 Interventions for ADHD

  24. Self-management strategies • Implemented by student • Designed to increase self-control of behavior • Self-monitoring • Self-evaluation • Self-reinforcement • Self-monitoring + self-reinforcement(Reid, Trout, Schwartz,;Exceptional Children, 71:361-377, 2005)

  25. Self-management in general educational classrooms for adolescents with ADHDGureasko-Moore, DuPaul, White: Behav Mod 30:159-183, 2006) • Organizational demands of middle/high school • Change classrooms & teachers • Multi-user desk & classroom • Listening & reading for learning; homework for self-evaluation of learning • Implications for student with ADHD? • Based on functional assessment

  26. Self-management in general educational classrooms for adolescents with ADHDGureasko-Moore, DuPaul, White: Behav Mod 30:159-183, 2006) • Sample: 3 7th-grade males with ADHD, receiving stimulant medication • Continued to be insufficiently prepared for class • Often late, did not have pencil/notebook, did not complete assigned tasks consistently • Baseline observation & ratings of 6 classroom preparation behaviors • Training: 20 min, 3 consecutive days during homeroom period • Day 1: Tutor gave each student an explanation & rationale for self-management: included description of baseline observation results; explanation of importance of responsibility for one’s own behavior; specific responsibilities to be maintained for being considered prepared for class. Introduced to self-management plan • Day 2: Students were taught & the started self-management plan using a) student log; and b) self-monitoring checklist. • Day 3 (?): Students taught goal setting & self-evaluation (document in student log what did * did not do & what could do to accomplish goals) • Monitoring: daily meeting with student • until student demonstrated 100% of target behaviors on 4/5 consecutive days • Fading: meetings every-other day (criterion as above) • Maintenance: Meeting 1x/week

  27. Self-Monitoring Checklist (Gureasko-Moore et al, 2006)

  28. Self-management in general educational classrooms for adolescents with ADHDGureasko-Moore, DuPaul, White: Behav Mod 30:159-183, 2006) • Multiple-baseline design with 3 students showed beneficial effects (other research approaches?) • Benefits of self-management • Students take responsibility for own actions • Students in control of intervention • Likelihood of promoting generalization across classes/teachers • Challenges • Initial time to train, monitor, & evaluate intervention • Requires specialist’s knowledge of functional assessment & behavior management techniques • school psychologist, school counselor, or teacher • Limitations?

  29. Results No change in academic grades

  30. We have a long-way to go kin terms of establishing effective Tier 2 and Tier 3 interventions for ADHD! Summary: Level-3 Interventions for ADHD: • Cognitive • Computerized working memory training is promising but efficacy & effectiveness not yet established • Academic • Rarely investigated with ADHD • Reading comprehension – CSR • Behavior • Self-management is promising but efficacy & effectiveness not yet established

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