Post on 02-Jan-2016
description
School Based Treatment for Adolescents with ADHD: The
Challenging Horizons Program
Steven W. Evans (Chair)
James Madison University
Jennifer Axelrod (Discussant)
Center for School Mental Health Assistance
Treating Adolescents with ADHD in the Schools
Steven W. Evans, Ph.D.
Michelle Quick, B.A.
Margaret Nemeth, Ed.S.
James Madison University
Loyola University
Indiana University of Pennsylvania
CHProgram.jmu.edu
Adolescents with ADHD
While there is considerable treatment outcome literature on children with ADHD, there is very little treatment outcome research focusing on adolescents with ADHD
Important developmental changes and changes in context make effectiveness of child interventions uncertain with adolescents– e.g. parent training, note taking– Secondary schools vs. elementary schools
CHProgram.jmu.edu
School Based Mental Health
Clinic based treatments are not likely to be effective with adolescents with ADHD– Generalization– Counseling and CBT not likely to be effective
Manifestations of ADHD impair functioning at school– Academic– Social– Disruptive behavior
CHProgram.jmu.edu
School Based Mental Health – 2
One of most frequent recommendations to achieve generalization is to put services where problems are exhibited
Increases access to care for psychosocial and educational interventions
Puts services in community where adolescents live
CHProgram.jmu.edu
Challenging Horizons Program
Students attend CHP at a local middle school from 3:00 to 5:15 on Mondays, Tuesdays, & Thursdays
Each child is assigned a primary counselor who works with him/her individually, develops (with supervisor) treatment plans, and is liaison with teachers.
Family counselor supervises primary clinician and liaison/counselor with parents
– Send home bi-weekly reports– Phone communication– Parent training– Individual counseling
CHProgram.jmu.edu
CHP Parent Meetings
Last Monday of every month parents meet in library– Collect assessment data– Present/discuss information on ADHD– Practice skills with students– Eat pizza dinner & child care– Children work on homework in cafeteria, eat dinner,
and play in gym after homework completion
CHProgram.jmu.edu
CHP Treatments
Behavioral– Verbal reinforcement and punishment– Point systems– Time Outs– Daily/weekly report cards
Educational– Organization– Study Skills– Homework Management– Note Taking
CHProgram.jmu.edu
CHP Treatment Modalities
Counseling Relationship Group Therapy
– Interpersonal Skills Group– Education Group
Individual Treatment– Supportive counseling– Collaborative development of treatment plans– Individualized behavior plans
CHProgram.jmu.edu
CHP Treatment Model
Develop, modify, and evaluate treatments in CHP
When interventions achieve desired behavioral outcome, interventions are exported to teachers and parents
Results:– Parents and teachers do not need to be involved in
the trial and error portion of treatment development– Interventions are demonstrated effective prior to
expecting others to invest in them
CHProgram.jmu.edu
Measures
Monthly parent and teacher ratings of symptoms and functioning
Parent and self ratings of social functioning Grades 88 min of observation data per week (44 min
in science & 44 min in math class) Individualized data collection resulting from
treatment plan
CHProgram.jmu.edu
Treatment Development Process
Given lack of treatment literature on adolescents with ADHD, started CHP in 1999 with 4 students in public middle school
Over years treatment manual evolved as data and experience indicated some interventions worked and others did not
Goal: Identify collection of effective interventions that could be integrated into middle school for teachers, counselors, administrators, and others to implement
Interventions Targeting AcademicImprovement in the Challenging
Horizons ProgramJessica M. Allen1, B.A.
Joshua M. Langberg2, M.A.
Corinne Maiorana1
James Madison University1, University of South Carolina2
CHProgram.jmu.edu
Why target Academic Functioning?
Adolescents with ADHD exhibit significant school problems.– Poor organization– Low grades– High rate of suspension– As many as 58% will be retained at least one grade
and they are ten times more likely not to complete high school (Barkley, et al., 1990; Barkley, Fischer, Edelbrock, Smallish, 1991).
CHProgram.jmu.edu
Why Target Academic Functioning?
Approximately 25% of adolescents with ADHD are diagnosed with learning disabilities (Barkley, DuPaul, & McMurray, 1990).
35% to 39% of all adolescents in special education are estimated to have ADHD (Pelham, Evans, Gnagy, & Greenslade, 1992).
CHProgram.jmu.edu
Why Target Academic Functioning?
Due to the severity of academic difficulties in adolescents with ADHD, the development of efficacious treatments targeting academic functioning has been encouraged (NIH consensus development panel members, 2000).
CHProgram.jmu.edu
Educational Interventions
Education Group– Note taking instruction and practice in class– Study skills– Written language
Individual education (with counselor)– Organization of materials– Tracking assignments– Homework Completion
Homework management
CHProgram.jmu.edu
Education Group
Four phases, each one focusing on application and/or instruction of skills.
Consists of an instruction component and an application component.
CHProgram.jmu.edu
Education Group Phases
Instruction Application
Phase 1 Note-taking from Class
N/A
Phase 2 Note-taking from Text
Note-taking from Class
Phase 3 Study Skills Note-taking from Text
Phase 4 Written Language Study Skills
CHProgram.jmu.edu
Individual Education - Organization
Demonstration of organization in notebooks, bookbags, and lockers.
Students experiencing difficulty in this area should work with their primary counselor to set up an organizational system with weekly locker/notebook checks.
CHProgram.jmu.edu
Individual Education – Assignment Tracking
Assignments checked as soon as student arrives at program.
Write upcoming assignments or “no homework” where applicable.
If the student experiences difficulty in this area, they may be required to obtain teacher initials for each class.
Can be phased out after improvement in this area.
CHProgram.jmu.edu
Individual Education – Homework Completion
After all organizational tasks have been checked, students work on homework (hardest assignments first).
If the student claims not to have any homework, the primary counselor should work with the student on studying for an upcoming test.
CHProgram.jmu.edu
Homework Management Plan
Implemented in the home setting. Can be individualized to meet each individual
family’s needs. Mandatory study time.
– Parent assigns academic tasks if the child hasn’t brought anything home.
– Privileges contingent on completion.– Child can participate in activities not listed in the
plan.
CHProgram.jmu.edu
Homework Management Plan – Assignment Notebook
The degree to which the student accurately recorded assignments and obtained teacher initials may dictate the amount of privileges he or she receives after completing the mandatory study time.
CHProgram.jmu.edu
Outcomes
Large gains in classroom functioning and academics during the first year (1999-2000) of CHP (Evans, et al., in press).
Little progress in exhibiting note-taking and study skills in class or at home.
Interventions targeting the accurate recording of assignments, completion of homework, and organization of materials appeared to account for much of the overall improvement.
During the second year of CHP (2000-2001) the amount of time practicing the note-taking, study skills, and writing skills were increased.
The application component of Education group grew out of the need for generalization.
CHProgram.jmu.edu
Participants
18 Participants Age range: 11-14 All participants involved in the Challenging
Horizons Program were diagnosed with ADHD-Combined or ADHD-Inattentive types.
CHProgram.jmu.edu
Mean Number of D’s and F’s Per Semester
0
1
2
3
4
5
6
First Semester Second Semester
Me
an
Nu
mb
er
of
Ds
or
Fs
CHP
Community Control
CHProgram.jmu.edu
Parent Ratings of Academic Functioning
3
3.5
4
4.5
5
5.5
6
Parent rating pre Parent rating post
Rat
ing
of
Pro
ble
m 6
= E
xtr
em
e P
rob
lem
CHP
Community Control
CHProgram.jmu.edu
Teacher Ratings of Academic Functioning
2
2.5
3
3.5
4
4.5
teacher rating pre teacher rating post
Pro
ble
m R
atin
g6
= e
xtr
em
e p
rob
lem
CHP
Community Control
Development of Social Skills Interventions for the Challenging
Horizons Program
Veronica L. Raggi, B.S. and Sheryle A. Moore, B.S.
James Madison University
CHProgram.jmu.edu
Social Deficits
More than 50% of ADHD children have significant problems in social relationships with other children
Children with ADHD are often less compliant with parental requests, more off-task and negative, and typically more demanding of help and attention than non-diagnosed children
(Pelham & Bender, 1982; Hinshaw & Melnick, 1995; Milich, et al, 1982;
Barkley & Cunningham, 1980; Campbell, 1975; Befera & Barkley, 1985)
CHProgram.jmu.edu
Impairment in Relationships with Peers
more aggressive, disruptive, intrusive and noisy than non-diagnosed children
less reciprocity in social exchanges talk more but less efficient in organizing and
communicating information to peers less liked by their peers and often have few
friends(Cunningham & Siegel, 1987; Landau & Milich, 1988; Barkley, 1988)
CHProgram.jmu.edu
Development of Social Skills Training and Interventions
Original CHP interventions (1999-2001)– Interpersonal Skills component
focused on conversational skills, problem solving strategies
– Cognitive-behavioral componentfocused on low self-esteem and poor motivation,
the role of self-statements and their connection to mood
CHProgram.jmu.edu
Outcome Results (1999-2001)
The overall multivariate effect was not significant, F(6,23) = .51, p >.05
Parent ratings on the IRS showed improvement in the CHP group in the medium to large effect size range
Teacher ratings showed deterioration in functioning over time for both groups
CHProgram.jmu.edu
Effect Sizes for CHP versus Control on the Parent version of the Impairment
Rating Scale
-0.1
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Relationship w ith Peers Relationship w ith Parent Self-Esteem Relationship w ith Siblings
Impairment Rating Scale Category
Eff
ect
Siz
e
CHP
Control
CHProgram.jmu.edu
Nature of ADHD Deficits
Represents a deficit in the brain’s behavioral inhibition system (BIS)
Executive functions disrupted:– emotional self-control – objectivity and social perspective taking– problem solving and self-questioning – moral reasoning– sensitivity to response feedback – inhibition of task-irrelevant responses
CHProgram.jmu.edu
Theory of Social Deficits
Adolescents with ADHD do not recognize long-term contingencies associated with their behavior
They over-respond to potential immediate reinforcement without inhibiting behavior as a result of likely punishment
CHProgram.jmu.edu
Major Goals for Social Skills Training and Interventions
Recognize the social contingencies present in their environment and connect those contingencies with their own behavior
Identify the effects of their behavior on their real self (how others perceive them)
Learn how to bring their real self closer to their ideal self (how they want others to perceive them)
Use and apply problem solving steps to make better decisions in response to real life events
CHProgram.jmu.edu
Development of Social Skills Training and Interventions
Modified CHP social skills interventions– Recreation Time
Sports Rules Matching Game Behavior Calls
– Individual Social Skills Goals Developed with the primary counselor
– Interpersonal Skills Group
CHProgram.jmu.edu
Interpersonal Skills Group
Phase I- Psycho-Educational Component– Purpose
Participants learn basic concepts necessary for understanding the connections between contingencies and behavior
– Basic Concepts Ideal Self, Real Self, Contingencies, Reinforcement,
Punishment– Techniques
Role Playing, Games, Instruction
CHProgram.jmu.edu
Interpersonal Skills Group
Phase II- Three Activities– Social Problem Solving Instruction
Students learn six problem solving steps; steps are then applied to their own social problems
– Skill Development Leader reviews progress on individual goals for each child
– Social Contingencies Assessment Students identify the social contingencies that result from
behaviors, videotaped at the program
CHProgram.jmu.edu
Interpersonal Skills Group
Review videos of social interactions
Directions for Future Research
Amy L. Williams, B.S.
Zewe Serpell, Ph.D.
Jennifer Capito & Lindsay BarnettJames Madison University
CHProgram.jmu.edu
After-School Model
Development Laboratory– Assess effectiveness of various interventions and
procedures Modifications made to manual as necessary
Additional Staff Requirement– Entire program coordinated and run by graduate
and undergraduate student staff– Completely separate from existing school curriculum
CHProgram.jmu.edu
Fully Integrated Model
Long-Term Goal– Develop a program that facilitates widespread
usage.– After-school model not feasible without additional
resources.
Recent Funding– Currently in year 1 of a 6 year project– Re-package interventions for use by existing
school personnel during normal school day.
CHProgram.jmu.edu
Elements of Fully Integrated Model
Currently Existing Elements– Psychosocial Protocol
Essentially the same interventions, just different providers.
Additional Elements – Medication Protocol
Effectiveness of combined treatment.
– Web Based Communication System Need for enhanced collaboration.
CHProgram.jmu.edu
Community Development Teams
Purpose and Use– Created to enhance feasibility, transportability, and
acceptability of program.– Monthly meetings and online discussions to provide
feedback, ideas, etc… Reflect Three Elements of Model
– Psychosocial, Medication, Web Composition of Members
– Varies according to needs of the team.
CHProgram.jmu.edu
Psychosocial Development Team
Team Members– Director of special education, teachers (regular & special
education), school counselors, & parents
Current Progress– Determination of interventions and providers.
Who is best suited to implement the intervention? Where in the school schedule does the intervention fit? Who is best suited for home follow up? What are the training and resource needs? What are potential challenges and obstacles to implementation?
CHProgram.jmu.edu
Psychosocial (Cont.)
Outcome Goals– Manual
Individual Modules IEP Goals
– Training Materials Interactive video and text Good and bad examples of
implementation
Note Taking from TextPresenting ProblemsGoals MethodsPre-Instruction Phase Instruction PhaseMastery CriteriaTroubleshootingExpectations (time frame)Additional OptionsMaterials Needed
CHProgram.jmu.edu
Medication Development Team
Team Members– Physicians, family and school counselors, regular
and special education teachers, and parents Current Progress
– Assessment of psychosocial treatment effectiveness.
What indicates a need for medication?
– Determination of medication benefit. What is the best medication and best dosage?
CHProgram.jmu.edu
Medication (Cont.)
Outcome Goals– Treatment Algorithm
Diagnostic Assessment, Family Evaluation, and Documentation of Prior Medication
Psychosocial ProtocolPsychosocial Assessment
Continue Psychosocial
Review, Assess, and Adjust Psychosocial
Begin Medication
Medication Assessment
Determination of Med Benefit Prescribe Medication
If Yes
If No
Stimulant B Alt. Med C Alt. Tx. Protocol
CHProgram.jmu.edu
Web Development Team
Team Members– District web specialist, school counselors, teachers (regular
and special education), and parents
Current Progress– Two completed sites
Public Website (Description) Development Team Website (Description)
– One site currently in progress Student Participant Site Security, accessibility, and information display
CHProgram.jmu.edu
Home I Client Login I Glossary I Contacts
Search for:
•Med Protocol
•Child’s Progress in Protocol
•Medical Information
Last Updated: 2/20/03
Doctor
Start Search
Clear
Web (Cont.)
Outcome Goals - Secure page, treatment plan, data entry and display, and online communication.
CHProgram.jmu.edu
Program Feasibility
Primary Objective– Create a program that is both useful and can be
used by school personnel.
Assessment of Feasibility Perceptions– Acceptability (valid intervention)– Practicality (easily integrated into school day)– Obstacles to Implementation
CHProgram.jmu.edu
Feasibility (Cont.)
Method of Assessment– Focus groups at 5 area middle schools– Presentation of 2 delivery models (after-school and
fully integrated)– Completion of questionnaire
Use of Information– Facilitate transition from development lab to school
setting
DiscussantJennifer Axelrod, Ph.D.
Associate Director
CSMHA
Assistant Professor of Psychiatry