Transcript ATS
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. “ADHD is a delay in the development of behavioral inhibition.” Behavioral Inhibition System Effects executive functioning. Input Sensing Executing Output Processing Behavioral Inhibition System Effects executive functioning. Input Sensing Executing Output Processing 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 Stimulants Ritalin, Adderall, Cylert, Dexedrine Medications for ADHD Stimulants Ritalin, Adderall, Cylert, Dexedrine Tri-Cyclic Antidepressants Imipramine Medications for ADHD Stimulants Ritalin, Adderall, Cylert, Dexedrine Tri-Cyclic Antidepressants Imipramine 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 behaviors Compliance/rule-following Self-management What Medications Can’t Do Teach new, appropriate behaviors Compliance/rule-following Self-management Teach content previously missed Academic work Social skills What Medications Can’t Do Teach new, appropriate behaviors Compliance/rule-following 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 Behavioral Inhibition System Effects executive functioning. Input Sensing Executing Output Processing A problem of PERSISTENCE and MOTIVATION. Behavioral Inhibition System “Temporal Myopia” event horizon 5-7 yrs. - 12 hours Response Response 8-12 years - 24 hours NOW Response Response 12-18 year - 2-3 days 30+ years - 8-12 weeks (Dr. R. Barkley) Behavioral Inhibition System “Temporal Myopia” event horizon Response Response Event Event NOW Response Response Event Event Event Event (Dr. R. Barkley) Behavioral Inhibition System “Temporal Myopia” event horizon Response Response Event Event NOW Response Response Event Event Event Event (Dr. R. Barkley) Behavior Therapy for ADHD Components Highly Structured Behavior Therapy for ADHD Components Highly Structured Immediate Feedback reinforcer or reward for appropriate behavior punishment for inappropriate behavior Behavior Therapy for ADHD 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 School Behavior Intervention: The Attention Training System (ATS) 1. Technology Teacher Module Student Module 2. Immediate feedback School Behavior Intervention: The Attention Training System (ATS) 1. Technology Teacher Module Student Module 2. Immediate feedback 3. Meaningful consequences School Behavior Intervention: The Attention Training System (ATS) 1. Technology Teacher Module Student Module 2. Immediate feedback 3. Meaningful consequences 4. Structured “time” School Behavior Intervention The ATS: Lisa No ATS 100 90 80 70 60 % 50 Time 40 Off 30 Task 20 10 0 1 2 3 ATS 4 5 6 7 No ATS 8 ATS 9 10 11 12 13 14 15 16 17 18 19 Days School Behavior Intervention The ATS: Troy No ATS ATS No ATS ATS No ATS Meds Only 100 90 80 70 60 % 50 Time 40 Off Task 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Days School Behavior Intervention Home School Notes Address Problems With Academic effort In-class behaviors Assignment completion School Behavior Intervention Home School Notes Procedures Identify target behaviors. School Behavior Intervention Home School Notes Academic Behaviors Working on assignments Completing homework Handing in assignments All work up to date On time for class School Behavior Intervention Home School Notes 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 Intervention Home School Notes Procedures Identify target behaviors. Design school note form. School Behavior Intervention Home School Notes School Behavior Intervention Home School Notes Procedures Identify target behaviors. Design school note form. Identify reinforcers and consequences. School Behavior Intervention Home 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. School Behavior Intervention Home School Notes Procedures Identify target behaviors. Design school note form. Identify reinforcers and consequences. Establish criterion for reinforcement. School Behavior Intervention Home School Notes Procedures Identify target behaviors. Design school note form. Identify reinforcers and consequences. Establish criterion for reinforcement. Increase criterion as progress is made. School Behavior Intervention Home 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. School Behavior Intervention Home School Notes 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. 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. 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. Home Behavior Intervention: Job Card Grounding Components List of rules Home Behavior Intervention: Job Card Grounding 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 Home Behavior Intervention: Job Card Grounding Odd Job Examples 1. Dust baseboards/ceilings 2. Sweep out garage 3. Wipe down inside refrigerator Home Behavior Intervention: Job Card Grounding Components List of rules List of odd jobs List of rewards Home Behavior Intervention: Job Card Grounding GROUNDING MEANS No television, telephone, stereo, video games No friends over/go to friends No snacks, naps No outside social activities No toys Home Behavior Intervention: Job Card Grounding GROUNDING DOES NOT MEAN Nagging Reminding Discussing Explaining Home Behavior Intervention: Job Card Grounding Other Guidelines Check jobs when completed and praise. Home Behavior Intervention: Job Card Grounding Other Guidelines Check jobs when completed and praise. Child determines how long he/she is grounded. Home Behavior Intervention: Job Card Grounding Other Guidelines Check jobs when completed and praise. Child determines how long he/she is grounded. Maximum 2 cards at a time. Home Behavior Intervention: Job Card Grounding Other Guidelines Check jobs when completed and praise. Child determines how long he/she is grounded. Maximum 2 cards at a time. Make sure groundings are DULL. Home Behavior Intervention: Job Card Grounding Other Guidelines Check jobs when completed and praise. Child determines how long he/she is 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. 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. 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. 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. Behavioral treatment is labor intensive for teachers and parents.