Catharine Weiss, Ph.D. & Nancy Lever, Ph.D. Center for School Mental Health Department of Psychiatry, University of

1. Managing Inattentive, Hyperactive, and Impulsive Behaviors in the Classroom Catharine Weiss, Ph.D. & Nancy Lever, Ph.D. Center for School Mental Health Department of Psychiatry, University of Maryland, Baltimore cweiss@psych.umaryland.edu nlever@psych.umaryland.edu

2. Have you ever… • Thought a student was lazy because they wouldn’t start or complete work that you knew they could do? • Stopped teaching over and over to keep a student on task? • Noticed a child who sits quietly but is not able to follow the lesson? • Been frustrated by a student who keeps getting up, touching or playing with anything and everything in sight? • Struggled to work with a student who talked incessantly or interrupted you and blurted out random comments? • Felt powerless with a student who acts without regard to consequences and instigates fights with other students?

3. What could be contributing to and/or co-occurring with these behaviors?

4. Session Overview • What is ADHD? • Best Practice Strategies and Resources • Case Examples • Discussion

5. Most Common ADHD Myths • ADHD isn't a real medical disorder. • Children given ADHD accommodations are given an unfair advantage. • Children with ADHD often outgrow the condition. • ADHD affects only boys. • ADHD is the result of bad parenting. • ADHD children on medication will abuse drugs as teenagers. • People with ADHD are stupid and lazy. From: www.additudemag.com

6. Attention-Deficit/ Hyperactivity Disorder: Some Basics • Neurobiological disorder: disorder in brain development or brain functioning • Affects ability to regulate behavior and attention • Genetic link: 30-40% have relatives diagnosed with the disorder • Most common childhood disorder; approximately 2-9% of youth • 3 times more common in males

7. ADHD Diagnosis • Symptoms for at least 6 months to a degree that it is maladaptive and INCONSISTENT with developmental level • Some symptoms that caused impairment present prior to age 7 • Difficulties in two or more settings • Clear evidence of impairment in school, work, or social functioning

8. “I was trying to daydream, but my mind kept wandering.” - Steven Wright, comedian

9. ADHD: Core Symptoms INATTENTION* • Fails to give close attention to details • Has difficulty sustaining attention • Does not seem to listen when spoken to • Does not follow through on instructions or finish tasks • Has difficulty organizing tasks and activities • Avoids or dislikes tasks requiring sustained attention • Loses necessary things • Is easily distracted by extraneous stimuli • Is often forgetful *6 or more, occurring very often (DSM-IV)

11. ADHD: Core Symptoms HYPERACTIVITY/IMPULSIVITY* • Fidgets with hands or feet or squirms • Leaves seat inappropriately • Runs or climbs inappropriately (or subjective feelings of restlessness) • Difficulty engaging quietly in leisure activities • "On the go" or "driven by a motor" • Talks excessively • Blurts out answers • Difficulty awaiting turn • Interrupts or intrudes *6 or more, occurring very often (DSM-IV)

12. DSM-IV ADHD SUBTYPES • PREDOMINANTLY • PREDOMINANTLY • COMBINED TYPE INATTENTIVE HYPERACTIVE/IMPULSIVE INATTENTIVE + HYPERACTIVE/IMPULSIVE

13. ADHD: Associated Difficulties • Trouble with academic performance • Frequent classroom disruptions • Disturbed social relationships with family, adults, and peers • Angry and defiant behavior • Learning disabilities (20-30%) • Coexisting disabilities (40-60%)

14. Specific Educational Outcomes Youth with ADHD are more likely to: • Be retained • Be placed in special education • Be suspended and expelled • Drop out of school • Have lower grades

15. ADHD at Different Ages:Preschool • High motor activity: always on the go, climbing on things, getting into things • Decreased or restless sleep • High curiosity • Vigorous, often destructive play • High attention needs • More intense temper tantrums • Require closer, more frequent monitoring • Disobedience

16. ADHD at Different Ages: School-Age • Academic difficulties; difficult homework time • School complaints of disruptive behavior • Difficulties with chores and responsibilities • Low frustration tolerance • Social difficulties; conflict and rejection • May have low self-esteem

17. ADHD at Different Ages: Adolescence • Approximately 70-80% still display symptoms • Continued academic difficulties, disorganized, incomplete assignments • At risk for earlier sexual behavior and cigarette smoking • Higher rates of risky driving, substance abuse, and risky sexual behaviors

18. ADHD at Different Ages: Adulthood • More subtle presentation • Difficulties initiating and organizing daily tasks • Inconsistent performance and trouble with deadlines • Restlessness, trouble relaxing • Socially inappropriate • Frequently have comorbid diagnoses

19. What Doesn’t Work for ADHD? • Treatments with little or no evidence of effectiveness include • Special elimination diets • Vitamins or other health food remedies • Psychotherapy or psychoanalysis • Biofeedback • Play therapy • Chiropractic treatment • Sensory integration training • Social skills training • Self-control training

20. More Favorable Situations • New tasks • Situations with immediate rewards and consequences • One-on-one attention • Early in the day • Structured time • Single-step commands

21. Evidence-Based Treatment • Cognitive Behavioral Interventions • Parent training and implementing behavioral modification at home • Teacher training behavioral modification at school • Medication

22. A Student Perspective on ADD*From adders.org - Creative ADDers • I am more than my ADD By Robert I am more than my ADDI have feet, arms, legsbut most of all a heart and a soulYou may think, "so irresponsible is he""so insensitive is he""how careless to be"Maybe this is all you see.but there is more to memore to me than my ADDI love music, writing, poetryI get angry, tired, happy,sad, just like everybody else.I take responsibility for my actionsas hairbrained as they may be (or not)but there is more to me than my ADD

23. Acting Out Cycle Peak Acceleration De-escalation Agitation Trigger Recovery Calm Adapted from The Iris Center: http://iris.peabody.vanderbilt.edu

24. QTIP (Quit Taking it Personally)

25. ADHD Practice Elements • Praise • Ignoring/Differential Reinforcement • Commands/Limit Setting • Time Out • Tangible Rewards

26. Praise • Verbal praise, Encouragement • Attention • Affection • Physical proximity

27. Giving Effective Praise • Be honest, not overly flattering • Be specific • Make eye contact; give undivided attention • No “back-handed compliments” (i.e., “I like the way you are working quietly, why can’t you do this all the time?”) • Give praise immediately • Remember to praise the absence of a behavior

28. Ignoring and Differential Reinforcement • Selectively • Ignore mild unwanted behaviors AND • Attend to alternative positive behaviors

29. How to Ignore • Visual cues • Look away once child engages in undesirable behavior • Do not look at the child until behavior stops • Postural cues • Turn the front of your body away from the location of child’s undesirable behavior • Do not appear frustrated (e.g., hands on hip) • Do not vary the frequency or intensity of your current activity (e.g., talking faster or louder)

30. How to Ignore • Vocal cues • Maintain a calm voice even after your child begins undesirable behavior • Do not vary the frequency or intensity of your voice (e.g., don’t talk faster or shout over the child) • Social cues • Continue your intended activity even after your child begins undesirable behavior • Do not panic once child’s begins inappropriate behavior (i.e., do not draw more attention to child)

31. When to Ignore • When to ignore undesirable behavior • Child interrupts conversation or class • Child blurts out answers before question completed • Child tantrums • Do not ignore undesirable behavior that could potentially harm the child or someone else

32. Differential Reinforcement • Step One: Ignore (stop reinforcing) the child’s undesirable behavior • Step Two: Reinforce the child’s desirable behavior in a systematic manner • The desirable behavior should be a behavior that is incompatible with the undesirable behavior

33. Differential Reinforcement • Define the behavior of concern (target) • Determine how often the target behavior occurs • Determine how often to reward the child for alternative behavior • Fixed interval – reward every X minutes • Determine how to reward the child for alternative behavior • Praise, attention, points or chips

34. Differential Reinforcement of Target Behavior • Target behavior: Interrupting • Alternative behavior: Working by himself • Reward schedule: 10 minutes • If child goes 10 minutes without interrupting, the child receives reinforcement • If child interrupts before 10 minutes is up, the child does not receive reinforcement • Re-set schedule once child interrupts

35. Differential Reinforcement • Systematically delay reinforcement once child responds to initial schedule • Target behavior: Interrupting • 1st reinforcement schedule: 5 times per class • 2nd reinforcement schedule: 3 times • 3rd reinforcement schedule: 1 time

36. Challenges with Ignoring and Differential Reinforcement • Extinction burst • Behavior will get worse before it gets better (child will work harder to gain attention) • Indiscriminant reinforcement • Reward only the alternative (desirable) behavior, so you don’t reward other unwanted behaviors by mistake

37. Improving Commands/Limit Setting with Youth • Only give commands that you intend to back up with consequences (positive and negative) • Do not present commands as questions or favors • Break down multi-component commands • Make clear what you want them to do, not just what you do not want

38. Steps to Making Effective Commands • Make eye contact with the child before giving command • Reduce other distractions while giving commands • Ask the child to repeat the command • Monitor after giving the command to ensure progress • Immediately praise child when s/he starts to comply

39. Consequences and Time Outs • Do in private, stay calm • Time outs • Cool off space that can be monitored • Effective if problem behavior is strengthened by peer attention • Not effective if goal of behavior is to avoid work

40. Tangible Rewards • Children and adolescents with ADHD do not respond to natural (intrinsic) rewards as well as typical youth • Can use token systems, behavior charts, or immediate rewards

41. Setting up a School-Home Contract • School staff track the child’s behavior and reports it to family daily, who reward the child • Effective because both the parent and staff are involved and can reward for positive behavior • If the parent can’t be involved, the rewards may be given only at school

42. School-Home Contract • Typically referred to as a daily report card • Purpose: To identify, monitor and change classroom problems and facilitate home-school communication and collaboration • Takes time on the front end, but found to reduce classroom disruption time

43. Daily Report Card Steps (http://ccf.buffalo.edu/pdf/school_daily_report_card.pdf) • Select areas for improvement • Involve staff who work with student • Involve the student and family in identifying areas for improvement • Examples of key domains- peer relations, academic work, classroom rule following, adult relationships

44. Daily Report Card Steps (http://ccf.buffalo.edu/pdf/school_daily_report_card.pdf) • Define target behaviors • Must be clearly defined and measurable • Number of targets depends on age and ability. Be realistic. • Examples of behaviors-completes assigned tasks, speaks respectfully to the teacher, participates in class lesson, walks in hallway appropriately

45. Daily Report Card Steps(Continued) • Decide on criteria for evaluating target behavior • Estimate how often the behavior occurs now • Set a reasonable criterion for success (child can earn between 75-90% of the time) • Remember the goals need to be feasible to both the teacher and the child • Set criteria to be met for each part of the day versus the whole day (e.g., class period)

46. Daily Report Card Steps(Continued) • Explain report card and set up rewards with child/family • The goal is to help the child to be successful • Ideally rewards should be natural and easy to implement • More preferred rewards can be earned for longer term performance • Need a menu of rewards • Kids need both in school and home rewards • Kids need to have success at the start and regularly thereafter

47. Daily Report Card Steps(Continued) • Monitor and modify the program • Gradually make the criteria harder • If child fails to meet the criteria, consider how to best modify • Praise child sincerely for success and matter-of-factly for missed targets • Parent and teacher signatures and comments

48. Sample Daily Report Card

49. Behavioral Consequences: Benefits of Whole Classroom Approach (e.g., PBIS) • Reduces sense of “unfairness;” ADHD children receiving special treatment • Multiple ADHD children in classroom may strain individual approach • Benefits whole class environment

50. Classroom-Wide Peer Tutoring • Create and distribute scripts (worksheets) • Teach any new concepts and skills to class • Break class into dyads • Each takes turns tutoring and quizzing the other • Praise or points awarded • Errors are immediately corrected • Circulate and coach dyads