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Help for the Wiggling and Off-Task Interventions

Help for the Wiggling and Off-Task Interventions. Jodi A. Polaha, Ph.D. Assistant Professor, Pediatrics Munroe-Meyer Institute, UNMC Director, Hastings Behavioral Health Clinic. New Conceptualization of ADHD Russell Barkley, Ph.D.

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Help for the Wiggling and Off-Task Interventions

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  1. Help for the Wiggling and Off-TaskInterventions Jodi A. Polaha, Ph.D. Assistant Professor, Pediatrics Munroe-Meyer Institute, UNMC Director, Hastings Behavioral Health Clinic

  2. New Conceptualization of ADHDRussell Barkley, Ph.D. “ADHD is a delay in the development of behavioral inhibition.”

  3. Behavioral Inhibition System Effects executive functioning. Processing Input Sensing Executing Output

  4. Behavioral Inhibition System Effects executive functioning. Processing Input Sensing Executing Output A problem of PERSISTENCE and MOTIVATION.

  5. What we know works: • Drug Therapy • Behavior Therapy • Combined Behavioral/Drug Treatments

  6. What we know DOESN’T work: • Play therapy • Individual or family counseling (without altering the environment) • Social skills/Self-monitoring/organizational planning.

  7. Not enough evidence to say : • Dietary management • Megavitamin therapy • Sensory integration therapy/chiropractics • Biofeedback

  8. 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)

  9. Medications for ADHD • Stimulants Ritalin, Adderall, Cylert, Dexedrine

  10. Medications for ADHD • Stimulants Ritalin, Adderall, Cylert, Dexedrine • Tri-Cyclic Antidepressants Imipramine

  11. Medications for ADHD • Stimulants Ritalin, Adderall, Cylert, Dexedrine • Tri-Cyclic Antidepressants Imipramine • Clonidine

  12. What Medications Can Do Manage symptoms • Decrease activity level • Decrease impulsivity • Increase attention or “focus”

  13. What Medications Can Do Improve associated features • Decrease “defiance” • Decrease aggression • Suppress negative social skills

  14. What Medications Can’t Do • Teach new, appropriate behaviors Compliance/rule-following Self-management

  15. What Medications Can’t Do • Teach new, appropriate behaviors Compliance/rule-following Self-management • Teach content previously missed Academic work Social skills

  16. What Medications Can’t Do • Teach new, appropriate behaviors Compliance/rule-following Self-management • Teach content previously missed Academic work Social skills • “Cure” ADHD

  17. Stimulant Medications: Considerations • Effective for 70-75% • Higher doses associated with more side effects • Positive effects are lost when drug discontinued

  18. 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

  19. Behavioral Inhibition System Effects executive functioning. Processing Input Sensing Executing Output A problem of PERSISTENCE and MOTIVATION.

  20. Behavioral Inhibition System “Temporal Myopia” event horizon 5-7 yrs. - 12 hours Response Response 8-12 years - 24 hours NOW Response 12-18 year - 2-3 days Response 30+ years - 8-12 weeks (Dr. R. Barkley)

  21. Behavioral Inhibition System “Temporal Myopia” event horizon Response Event Response Event Event NOW Response Event Response Event Event (Dr. R. Barkley)

  22. Behavioral Inhibition System “Temporal Myopia” event horizon Response Event Response Event Event NOW Response Event Response Event Event (Dr. R. Barkley)

  23. Behavior Therapy for ADHD Components • Highly Structured

  24. Behavior Therapy for ADHD Components • Highly Structured • Immediate Feedback reinforcer or reward for appropriate behavior punishment for inappropriate behavior

  25. Behavior Therapy for ADHD Components • Highly Structured • Immediate Feedback reiforcer or reward for appropriate behavior punishment for inappropriate behavior • Salient/Meaningful Feedback

  26. School Behavior Intervention Examples: 1. The Attention Training System (ATS) 2. Home School Note

  27. School Behavior Intervention:The Attention Training System (ATS) 1. Technology Teacher Module Student Module

  28. School Behavior Intervention:The Attention Training System (ATS) 1. Technology Teacher Module Student Module 2. Immediate feedback

  29. School Behavior Intervention:The Attention Training System (ATS) 1. Technology Teacher Module Student Module 2. Immediate feedback 3. Meaningful consequences

  30. School Behavior Intervention:The Attention Training System (ATS) 1. Technology Teacher Module Student Module 2. Immediate feedback 3. Meaningful consequences 4. Structured “time”

  31. School Behavior InterventionThe ATS: Lisa No ATS ATS No ATS ATS % Time Off Task Days

  32. School Behavior InterventionThe ATS: Troy No ATS No ATS ATS No ATS ATS Meds Only % Time Off Task Days

  33. School Behavior InterventionHome School Notes Address Problems With • Academic effort • In-class behaviors • Assignment completion

  34. School Behavior InterventionHome School Notes Procedures • Identify target behaviors.

  35. Academic Behaviors Working on assignments Completing homework Handing in assignments All work up to date On time for class School Behavior InterventionHome School Notes

  36. 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 School Behavior InterventionHome School Notes

  37. School Behavior InterventionHome School Notes Procedures • Identify target behaviors. • Design school note form.

  38. School Behavior InterventionHome School Notes

  39. School Behavior InterventionHome School Notes Procedures • Identify target behaviors. • Design school note form. • Identify reinforcers and consequences.

  40. School Behavior InterventionHome School Notes 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.

  41. School Behavior InterventionHome School Notes Procedures • Identify target behaviors. • Design school note form. • Identify reinforcers and consequences. • Establish criterion for reinforcement.

  42. School Behavior InterventionHome School Notes Procedures • Identify target behaviors. • Design school note form. • Identify reinforcers and consequences. • Establish criterion for reinforcement. • Increase criterion as progress is made.

  43. School Behavior InterventionHome School Notes 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.

  44. School Behavior InterventionHome School Notes What makes it effective: • Frequent, immediate feedback (school). • Highly structured (short time). • Salient consequences (home).

  45. Home Behavior Intervention Examples • Time Out • Job Card Grounding

  46. Home Behavior Intervention:Time Out Putting child in: • Locate away from attention/fun. • Place within 5 seconds. • Be brief, unemotional.

  47. 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.

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

  49. Home Behavior Intervention:Job Card Grounding Components • List of rules

  50. Home Behavior Intervention:Job Card Grounding Examples of Rules 1. Do your chores 2. Follow instructions 3. Tell us where you are going

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