Attention Deficit Hyperactivity Disorder(ADHD): A Review...
Transcript of Attention Deficit Hyperactivity Disorder(ADHD): A Review...
Attention Deficit Hyperactivity
Disorder(ADHD): A Review of Selected
Research for Practitioners
Jan Montgomery-Pierce, MS, BCBA, LBA
Florida Institute of Technology
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Why this Presentation on ADHD?
• Provide Behavior Analysts ADHD research
overview
• Professional interest (work with foster care
system and children diagnosed with ADHD
in Florida from 1997 to 2008)
• Research and involvement as FABA
President (2010) into mental health
collaboration
• Personal interest (family members
diagnosed) 2
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JABA Articles – Selected Mental Health
Diagnoses (1980 – 2010)
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ADHD
Other
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JABA Articles - Selected Mental Health
Diagnoses (2000 - 2010)
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2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Freq
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Year
ADHD
Other
How Diagnosed?
Clinical Assessment of ADHD
• Clinical Interview:
– Developmental, social, educational and
behavioral history
• Common Checklists and Rating Scales:
– Conners' Parent Rating Scales
– Child Behavior Checklist - wide range of
symptoms (Achenbach)
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Clinical Assessment of ADHD
• Common Checklists and Rating Scales
(continued):
– Conners' Teacher Rating Scales
– Child Behavior Checklist/Teacher Report
Form (Achenbach)
– Child Attention Problems (CAP) Rating
Scale monitors behavioral changes when
child is taking medicine to treat ADHD.
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DSM-IV TR (2000) Diagnostic Criteria for
ADHD
A. 6 or more symptoms of Inattention or
Hyperactivity-Impulsivity*
• Inattention*: careless mistakes, difficulty
sustaining attention, does not seem to
listen, does not follow through, difficulty
organizing, avoids, dislikes, tasks that
require sustained mental effort, loses
things, easily distracted, forgetful – * includes “often” in these descriptions
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DSM-IV Diagnostic Criteria for ADHD
(continued)
• Hyperactivity*: fidgets with hands or feet or
squirms in seat, leaves seat, runs about or
climbs excessively, has difficulty playing or
engaging in leisure activities quietly, ‘on
go’ or often acts as if ‘driven by a motor,’
talks excessively
• Impulsivity*: Blurts out answers before
questions have been completed, difficulty
awaiting turn, interrupts/intrudes on others * includes “often” in these descriptions
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B. Onset of these symptoms before age 7
C. Clinically significant impairment in social,
academic, or occupational functioning
B. Impairment present in 2 or more settings
C. No co-occurrence of another mental
disorder (that could better account for
these symptoms)
– From DSM IV TR(2000)
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DSM-IV TR Diagnostic Criteria for ADHD
(continued)
Upcoming Change in ADHD Diagnostic
Criteria
• One of major changes to come in ADHD
diagnosis in approximately May of 2013
DSM V is that it will read “before the age of
12” rather than “7”
• Potential to increase the number of children
diagnosed with this disorder
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Prevalence of ADHD
• Diagnosis from 2003–2007 increased 21.8
percent among children aged 4–17 years,
representing 5.4 million children. *
• It also affects estimated 4.4 percent of
adults in United States in a given year.**
• Rates of ADHD diagnosis increased
average of 3% per year from 1997 to 2006
& average of 5.5% per year from 2003 -
2007.
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ADHD
• “There are no laboratory tests, neurological
assessments, or attentional assessments
that have been established as diagnostic in
clinical assessment of Attention-
Deficit/Hyperactivity Disorder.”
– (DSM-IV-TR, page 88)
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Correlational Effects
• Drug and alcohol abuse
• Failure in school
• Problems keeping a job
• Trouble with the law
• About half of children with ADHD may
continue with troublesome symptoms of
inattention or impulsivity as adults.
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Parent Report
• Medication Treatment
– As of 2007, parents of 2.7 million youth
ages 4-17 years (66% of those with a
current diagnosis) report their child was
receiving medication treatment for the
disorder.
– Children aged 11-17 years of age were
more likely than those 4-10 years of age
to take medication, & boys are 2.8 times
more likely to take medication than girls 14
Parent Report
• Peer Relationships
– Parents of children with a history of
ADHD report almost 3 times as many
peer problems as those without a history
of ADHD
– Parents report that children with history of
ADHD are almost 10 times as likely to
have difficulties that interfere with
friendships
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ASR
• In 2007, about what percentage of parents
reported their ADHD diagnosed child was
receiving medication?
1. 100%
2. 0%
3. No parents reported
4. 66%
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ASR
• In 2007, about what percentage of parents
reported their ADHD diagnosed child was
receiving medication?
1. 100%
2. 0%
3. No parents reported
4. 66%
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ASR
• About how many children have been
diagnosed with ADHD according to figures
from 2007?
1. One million
2. Five million
3. 20 million
4. 50 million
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ASR
• About how many children have been
diagnosed with ADHD according to figures
from 2007?
1. One million
2. Five million
3. 20 million
4. 50 million
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Why Behavior Analysis and ADHD?
Is it Neurobiological?
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According to the National Institute for Mental
Health (NIMH) and other sources…
• “Convergent data from neuroimaging,
neuropsychology, genetics and
neurochemical studies consistently point to
the involvement of the frontostriatal network
as a likely contributor to the
pathophysiology of ADHD.”
– Italics and underline mine.
– Curatolo, et al. (2010). The
neurobiological basis of ADHD.
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Differing Views in Behavior Analysis
Neurobiological Basis?
POSITION A:
– “There is no compelling evidence for a
neurobiological basis of ADHD… no
consistent causal neurobiological variable
has ever been identified and no
neuroimaging or continuous performance
methods have ever proven useful in
diagnosis given high rates of false
positives and negatives.”
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Differing Views (continued)
POSITION A (continued): “In practice, looking at ADHD as a medical issue, medication is prescribed by a doctor, but it serves only as a crutch without mending the bone - take the crutch away and the patient falls down (is this ultimately truly ethical patient care, and might this neurobiological conceptualization of ADHD distract the helping community from getting right to effective behavioral treatment that teaches new skills with lasting impact?)”
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Differing Views in Behavior Analysis
Neurobiological Basis?
POSITION B:
– “I would simply refer everyone to our best
source of information on ADHD or any
other mental health or clinical disorder,
which is NIMH and CDC (Center for
Disease Control).”
(in referencing that there “IS” compelling evidence
for a neurobiological basis with stimulant medications
viewed as a viable and effective alternative for the
majority of children with true ADHD symptoms)
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Differing View (continued)
Position B:
”Although there may be anatomical and biochemical differences between those with & without ADHD, the plasticity of nervous system suggests these can be altered by experience.
It is reasonable to assume behavioral inhibition may be taught
By teaching multiple exemplars of behavioral inhibition, a pattern of generalized self-control may emerge”
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Russell Barkley, Ph.D.
Neuropsychological Model of ADHD
• Principal impairment:
– Primary deficit in behavioral inhibition
– Secondary Deficits in Executive Functions
leading to Impulsive Bx and Lack of Self-
Control
• According to Barkley, the core symptom of
ADHD is impulsivity
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Neuropsychological Model of ADHD
• Russell Barkley, Ph.D. :
• Implications for treatment of “impulsivity”
– As a neurodevelopmental disorder, his
recommendation is that it will best be
managed medically
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Shur-Fen Gau, S. (2006) Journal of Sleep
Research
Purpose: 6-month rates of sleep-related
problems & association with daytime
inadvertent napping, inattention,
hyperactivity/impulsivity, & oppositional
symptoms in children & teens
Participants: School-based sample of 2463
1st - 9th graders
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Shur-Fen Gau, S. (2006) Journal of Sleep
Research
• Instruments:
– Sleep Habits Questionnaire, Chinese
Health Questionnaire, & Chinese
versions of the Conners’ Parent &
Teacher Rating Scales-Revised: Short
forms.
• Informants:
– mothers & teachers
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Shur-Fen Gau, S. (2006) Journal of Sleep
Research
• Findings:
– Sleep deprivation & disruption impaired
executive functioning, resulting in similar
cognitive, behavioral profile of children
with ADHD.
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Shur-Fen Gau, S. (2006) Journal of Sleep
Research
• Findings (continued):
– Supported by reduction in ADHD
symptoms following tx of sleep problems
– Findings imply importance of assessment
of sleep problems in children with ADHD-
related symptoms in addition to
symptoms of ADHD.
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Age Sleep Age Sleep
Up to 18 mos. 16.5 hours 6 years 10.75 hours
2 years 13 hours 9 years 10 hours
3 years 12 hours 12 years 9.25 hours
4 years 11.5 hours 15 years 8.75 hours
5 years 11 hours 18 years 8.25 hours
Sleep (average requirements)
ASR
• The current clinical assessment for ADHD
involves:
1. Blood testing
2. Urine testing
3. Neuro imaging
4. Genetic testing
5. Rating scales and/or checklists
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ASR
• The current clinical assessment for ADHD
involves:
1. Blood testing
2. Urine testing
3. Neuro imaging
4. Genetic testing
5. Rating scales and/or checklists
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ASR
• According to the Neuropsychological Model
of ADHD, the core symptom is:
1. Lack of focus
2. Impulsivity
3. Nervousness
4. Oppositional behaviors
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ASR
• According to the Neuropsychological Model
of ADHD, the core symptom is:
1. Lack of focus
2. Impulsivity
3. Nervousness
4. Oppositional behaviors
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ADHD and Medication
NIMH Funded Research and
Follow-ups
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Brand Names Other Meds
Concerta Dextroamphetamine
Metadate Dexedrine
Methylin
Ritalin Dextroamphetamine
sachharate/sulfate- Adderall Daytrana- transdermal patch
Focalin- New Ritalin derivative Pemoline- Cylert
(needs liver function tests due to
toxicity) Attenade- Newest Ritalin
derivative
Methylphenidate and Other Meds
(meth il fen' i date)
Multimodal Treatment Study of Children
with ADHD (MTA) 1999
• MTA Cooperative Group’s 3 questions:
1. How do long-term medication and
behavioral treatments compare with
one another?
2. Are there additional benefits when they
are used together?
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Multimodal Treatment Study of Children
with ADHD (MTA) 1999
3. What is effectiveness of systematic,
carefully delivered treatments vs
routine community care?
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Multimodal Treatment Study of Children
with ADHD (MTA) 1999
• Four Treatment Groups – Random
Assignments of 579 children
1. Medication alone
2. Intensive Behavioral Treatment alone
3. Combined medication and Behavioral
Treatment
4. Community based care (control group)
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Overall Findings: MTA Study (1999)
• Results:
– All treatment found to be effective on an
absolute basis as compared to control
– Medication or Medication plus Behavioral
tx were nearly equally effective and
superior to:
• Behavioral Treatment alone
• Community based controls
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Overall Findings: MTA Study
14 Month Endpoint
• % Normalized at 14 month endpoint
compared to Classroom Controls
– Classroom Controls 88%
– Combination 68%
– Medicine 56%
– Behavior 34%
– Community based care 25%
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NIMH Multimodal Treatment Study of
ADHD Follow-up: Changes in
Effectiveness and Growth After End of
Treatment (2004)
• From 14 - 24 months ADHD Symptom
Ratings Results
– Groups as a whole with greatest
improvement at end of treatment phase
(Comb and MedMgt) deteriorated during
follow-up phase, but other 2 groups (Beh
and CC) did not
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MTA Follow-up: Changes in Effectiveness
and Growth After End of Treatment (2004)
• Subgroup that consistently reported
medication use showed reduced height
gain compared with…
• Subgroup that never reported medication
use which actually grew faster than
predicted by population norms.
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MTA Follow-up: Changes in Effectiveness
and Growth After End of Treatment (2004)
• Restated long-standing view that stimulant
meds provide symptomatic relief as long as
administered but limited carryover effects
when stopped *
• Effect of Bx smaller than effect of meds but
was maintained, suggests that
generalization occurred, perhaps because
parents continued to implement learned
practices.
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Swanson et al. (2007) Growth Rates
Findings:
– Children with combined type ADHD were
larger as a group before med treatment
however showed stimulant meds related
decreases in growth rates after start of
treatment (reviewed last here at 36
months)
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Swanson et al. (2007) Growth Rates
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4.21
3.04
0
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Consistent vs… Newly vs. Not*
Centimeters shorter than comparison group at 36 month follow-up
Swanson et al. (2007) Growth Rates
(Summary)
• Greater med use produced better outcome
at 14, and 24 month assessment points, but
at 36 month assessment point- no
significant effect of med use from overall
baseline to 36 month follow-up.
• Post hoc analysis of 24 - 36 month change
in symptom severity showed that med use
over this follow up interval was related to
deterioration rather than benefit.
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Swanson et al. (2007) Growth Rates
• Conclusions (continued):
– Doesn’t support hypothesis of growth
rebound
– Doesn’t support hypothesis of delayed
maturation as stimulant naïve children
had heights and weights above rather
than below average at study initiation
– loss of relative superiority being related to
maintenance of tx not confirmed*
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ASR
• Which of the following is NOT a common
medication used to treat ADHD symptoms?
1. Concerta
2. Metadate
3. Viagra
4. Ritalin
5. Daytrana
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ASR
• Which of the following is NOT a brand
name for Methylphenidate?
1. Concerta
2. Metadate
3. Viagra
4. Ritalin
5. Daytrana
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ASR
• At the 14 month follow-up of the MTA study,
what group showed the highest percentage
of “normalization”?
1. Combination
2. Medicine
3. Behavior
4. Community based care
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ASR
• At the 14 month follow-up of the MTA study,
what group showed the highest percentage
of “normalization”?
1. Combination
2. Medicine
3. Behavior
4. Community based care
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ASR
• At 24 months after the MTA study, which
groups deteriorated (ADHD symptoms)
during the follow-up phase?
1. Combination & Behavior
2. Medicine & Community based care
3. Behavior & Medicine
4. Combination and Medicine
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ASR
• At 24 months after the MTA study, which
groups deteriorated (ADHD symptoms)
during the follow-up phase?
1. Combination & Behavior
2. Medicine & Community based care
3. Behavior & Medicine
4. Combination and Medicine
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Behavior Analysis Defining Impulsivity
• Choosing a smaller/lower quality reward
available immediately over a larger/higher
quality reward available after a delay.
• Choosing a smaller/lower quality reward
available for less effort than a larger/higher
quality reward available for greater effort.
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Impulsiveness in ADHD:
Behaviorally Speaking
• Children with ADHD prefer immediate
rewards over delayed rewards.
• Children with ADHD prefer rewards
that require less effort than rewards
that require greater effort.
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Behavioral/Medication Studies - ADHD
• Neef et al. (2005b). Medication effects on
impulse control/self control measured by
variables of reinforcement
• Neef et al. (2005a). Extension with tighter
control
• LaRue et al. (2008). Medication effects on
value of school social interaction
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Neef et al. (2005a, 2005b) JABA
• 58 children – between groups design
• 4 children - double-blind, placebo-
controlled, counterbalanced reversal design
• used computer-based math problems to
assess impulsivity
• Compared those with ADHD who were &
were not receiving medication & with
typically developing children without ADHD.
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Neef et al. (2005 a & b) JABA
• Responding favored problem alternatives
that produced immediate reinforcement
across medication & placebo conditions.
• Supports Barkley - ADHD mainly a problem
of self control but both studies inconsistent
with findings in the research literature on
ADHD that medication improves impulse
control (Barkley, 1997).
• Suggests meds may have little effect on
objective measures of impulsivity.
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LaRue et al. (2008) JABA
• Purpose:
– To evaluate a clinic-based assessment
for determining reinforcing value of social
play for preschool children with a
diagnosis of ADHD
– To determine if procedures could be
useful for further evaluation of
medication effects on these behaviors.
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LaRue et al. (2008) JABA
• Subjects: 5 children 4- 6 years old, all prior
diagnosis of ADHD
• Alternating courses of placebo and
stimulant meds were provided by child
psychiatrist.
• Reinforcer Assessment: Children placed
criterion # blocks in a bucket to earn 1 of 3
coupons for “alone play” , “play with friends”
and a “quiet time”
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LaRue et al. (2008) JABA
• 1 ALWAYS selected play with friends
• 2 gradual increase in play with friends
regardless of med dosage
• 1 gradual increase in play with friends with
meds, gradual decrease at placebo dosage
• 1 decrease in play with friends as meds
increased with increase in play alone choice
Stimulant meds may decrease or increase
value of social activity for some children &
with some doses.
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LaRue et al. (2008) JABA
– If decreased, may be contraindicated for
children who exhibit social deficits prior to
meds
– If increased value, may make social skills
training easier
Take Home: Individualized assessment may
be necessary to identify idiosyncratic
responses to stimulant meds across children
and med doses.
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ASR
Which of the following was found in Neef et
al. (2005 a & b) with children diagnosed with
ADHD?
1. Medication assisted children in waiting for
reinforcement.
2. Children preferred largest rewards later.
3. Children were most influenced by
immediacy.
4. None of these.
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ASR
Which of the following was found in Neef et
al. (2005 a & b) with children diagnosed with
ADHD?
1. Medication assisted children in waiting for
reinforcement.
2. Children preferred largest rewards later.
3. Children were most influenced by
immediacy.
4. None of these.
67
ASR
LaRue et al. (2008) found that children on
medication for symptoms of ADHD were
more likely to choose to:
1. Play with friends
2. Play alone
3. Have a quiet time
4. Some chose play with friends and some
chose play alone
68
ASR
LaRue et al. (2008) found that children on
medication for symptoms of ADHD were
more likely to choose to:
1. Play with friends
2. Play alone
3. Have a quiet time
4. Some chose play with friends and
some chose play alone
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Behavioral/Medication Studies - ADHD
• Kelley, Fisher, Lomas, & Sanders. (2006) .
Medication & behavioral treatment -effects
on compliance
• Mace et al. (2009) combination
meds/function based treatment needed
• Gulley et al. (2003) optimal treatment
modification (meds &/or behavioral)
through sequential evaluation
• Kayser et al. (1997) behavioral treatment
instead of meds?
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Kelley et al. (2006) JABA
Medication’s effect on compliance
• Single subject design 11-year-old boy
diagnosed with intellectual disability &
ADHD
• 20 mg of Adderall© or placebo alternated
in double-blind fashion in reversal design.
• Continuous demands during 10 minute
sessions
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Kelley et al. (2006) JABA
• 2 response options—destructive &
appropriate bx— concurrently programmed
to contact reinforcement during both drug &
placebo conditions.
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Kelley et al. (2006) JABA
• Results:
– More likely to engage in compliance for
reinforcement with meds than placebo
– Presence of meds biased responding
toward appropriate bx
– However, high levels of destructive bx &
low levels of compliance occurred during
prior functional analysis with med.
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Kelley et al. (2006) JABA
• So, behavioral treatment and meds were
both necessary to maintain low levels of
destructive bx and high levels of
compliance.
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Mace et al. (2009) JABA
• Subject:
– 16 year old boy diagnosed with ADHD &
moderate intellectual disabilities
– ½ days received 36 mg of Concerta XL
and half days received quasiplacebo
– Single-blind placebo controlled study
75
Mace et al. (2009) JABA
• 4 conditions:
– high & low preference activity
– divided attention
– low attention
• Target behaviors:
– Activity engagement & Activity changes –
– rude vocalizations or gestures,
inappropriate touching and physical
aggression 76
Mace et al. (2009) JABA
• Results:
– Meds improved all undesirable behaviors
– Activity engagement was higher and
activity changes occurred less often with
meds
– High-preference leisure activity evoked
more activity engagement & fewer activity
changes than the low-preference
assignment regardless of med condition
77
Mace et al. (2009) JABA
• Discussion:
– Meds reduced undesirable behaviors in
several conditions but were STILL at
unacceptable levels while attention was
divided between adults & not directed
towards child.
78
ASR
In Kelley et al. (2006), low levels of
destructive bx and high levels of compliance
were obtained by:
1. Behavioral treatment alone
2. Medication alone
3. Meds and behavioral treatment
4. Neither meds nor behavioral treatment
79
ASR
• In Kelley et al. (2006), low levels of
destructive bx and high levels of
compliance were obtained by:
1. Behavioral treatment alone
2. Medication alone
3. Meds and behavioral treatment
4. Neither meds nor behavioral treatment
80
ASR
In Mace et al. (2009) what is true about the
environmental conditions effect on behavior?
1. Medications reduced undesirable
behaviors to acceptable levels in all
conditions.
2. Medications reduced undesirable
behaviors to acceptable levels in no
conditions
3. Medication reduced undesirable
behaviors to acceptable levels in some
conditions 81
ASR
In Mace et al. (2009) what is true about the
environmental conditions effect on behavior?
1. Medications reduced undesirable
behaviors to acceptable levels in all
conditions.
2. Medications reduced undesirable
behaviors to acceptable levels in no
conditions
3. Medication reduced undesirable
behaviors to acceptable levels in some
conditions 82
Gulley et al. (2003) JABA
• Participants:
– 4-year-old boy, 7-year-old girl, & 6-year-
old girl all diagnosed with ADHD,
prescribed stimulant medication
• Target Bx:
– Out-of-seat behavior, inappropriate
vocalizations & playing with objects,
aggression, destruction of materials, &
throwing objects also target bx for one
child 83
Gulley et al. (2003) JABA
• Behavioral treatments: DRA, DRA +
response cost & DRA + time-out evaluated
as behavioral tx. Treatments selected
based on empirical support in literature &
inclusion in MTA study.
• Medication treatments: MPH based on
weight for each child initially prescribed (10
– 15 mg)
84
Gulley et al. (2003) JABA
• Sequential evaluation:
– Showed a change in dosage of
medication was necessary for 1 child &
necessary change in the behavioral tx
was necessary for 2 of 3 children.
85
Gulley et al. (2003) JABA
• Results:
– Individualized behavioral treatment
decreased disruptive behavior equivalent
to MPH for all 3 participants &
demonstrated the need to evaluate
behavioral treatments & med dosages on
individual basis.
86
Kayser et al. (1997) JABA
• Participant:
– 6-year-old boy - diagnosed with ADHD
on MPH medication for 3 years
• Referring physician requested evaluation
of effects of MPH & specifically asked for a
behavioral intervention to replace MPH.
87
Kayser et al. (1997) JABA
Problem behaviors: Aggression, SIB &
Sleep Disturbances (rocking)
• Escape identified as potential function
Targeted tasks: writing tasks, mathematical
problems, and reading
• MPH and behavioral treatment studied with
ABCB reversal design
88
Kayser et al. (1997) JABA
• Intervention:
– Math problem worksheet with:
a) Sequential prompting procedure,
b) Attention and preferred activities on a
FR1 schedule on compliance
c) For Sleep: Escape extinction - No
specific procedures were used to
increase his sleep; nursing staff simply
put child to bed on a regular schedule
89
Kayser et al. (1997). JABA
90
Kayser, et al. (1997). JABA
91
American Academy of Pediatrics (2011)
• Recommendations for treating children
diagnosed with ADHD consist of use of both
psycho-stimulants & behavioral interventions
(over age 6) to help control symptoms.
• Recommendations for use of both psycho-
stimulants and behavioral interventions are
consistent with majority of literature
available on tx of ADHD.
92
American Academy of Pediatrics (2011)
Although best practice indicates a combination
is best, in applied practice treatment for
symptoms of ADHD typically consists of
psycho-stimulants alone according to the
literature…
93
Medication/Behavior Treatment Issues
Just Meds Both Just Beh
Numerous discussions on both sides due to
side effects and efficacy. Ultimately it comes
down to individual child, guardian and
treatment team as to what decision will be
acceptable in terms of benefit/cost ratio.
Behavior Analysts must speak/work in terms
of our area of expertise – specific
observable, measurable behaviors! 94
ASR
• In Kayser, et al. (1997), the percentage of
sleep increased due to:
1. Child was taken off MPH
2. Child was placed on MPH
3. Child was placed on structured sleep
schedule
4. Could be 1 and/or 3
95
ASR
• In Kayser, et al. (1997), the percentage of
sleep increased due to:
1. Child was taken off MPH
2. Child was placed on MPH
3. Child was placed on structured sleep
schedule
4. Could be 1 and/or 3
96
Behavioral Focus Studies - ADHD
• Kodak, Kodak, Grow, & Northup (2004) function based treatment for elopement
• Stahr, Cushing, Lane, Fox, (2006) Efficacy of a function based intervention for off task behavior
• McDowell, & Keenan (2001) increased fluency for endurance
• Azrin, et al. (2006) activity as reinforcement
• Bloh (2009) increasing self-control & generalization
97
Kodak, et al. (2004) JABA
• Participant:
– 5 year old diagnosed with ADHD
• Elopement:
– running more than 1 m away from
designated area during kickball game on
open field
• Functional analysis:
– indicated that elopement was reinforced
by attention 98
Kodak, et al. (2004) JABA
• Treatment:
– consisted of NCA and time-out contingent
on elopement.
• NCA:
– consisted of praise and tickles & was
provided approximately every 15s.
• Time-out:
– consisted of 30 s in penalty box
99
Kodak, et al. (2004) JABA
100
Stahr et al. (2006) Journal of Positive
Behavior Interventions
• 9 year old boy - ADHD diagnosis & speech & language impairment
• Welbutrin medication for anxiety related diagnosis
• Descriptive functional assessment completed for “off-task” behavior & inappropriate requests for help during Language & Math classes - indicated maintained by attention & escape from tasks .
101
Stahr et al. (2006) Journal of Positive
Behavior Interventions
• Function-based intervention:
communication system, self-monitoring
component & extinction
• Taught:
A. Child to seek assistance unobtrusively
B. Child to regulate own bx
C. Teachers, paraeducator & therapist to
ignore undesirable bx
102
Stahr et al. (2006) Journal of Positive
Behavior Interventions
• Results:
– Increased task engagement &
completion, & appropriate requests,
– Decreased off task, inappropriate
requests
103
McDowell, & Keenan (2001) JABA
• Participant:
– 9 year-old-boy diagnosed with ADHD & 5
mg of MPH 3x per day
• Dependent variables:
– number of letter sounds identified
correctly and incorrectly per minute and
the time spent on task.
104
McDowell, & Keenan (2001) JABA
• Baseline: 4 ten minute sessions, 26 cards
letters A-Z, on floor randomly. Cards
contained upper & lowercase letter & word
& picture that began with letter. No
practice/instruction, just feedback at end
• Intervention: Fluency goals & practicing
all letter sounds with teacher feedback &
error-correction procedure before timing
corrects/incorrects 105
McDowell, & Keenan (2001) JABA
• The intervention resulted in an immediate
increase in correct responses & a decrease
in incorrect responses.
• Child remained on task for 100% of these
sessions. Time on task increased from 50-
60% at baseline to 100% when fluent in
task
106
McDowell, & Keenan (2001) JABA
107
McDowell, & Keenan (2001) JABA
108
Azrin et al. (2006) Behavior Modification
• Age-appropriate reinforcers found to be
effective in promoting attentiveness and
calmness in children with ADHD diagnosis
• Subject:
– 4 year old boy with diagnosis ADHD
comorbid with autism, no meds
• DV:
– “attentive calmness”
109
Azrin et al. (2006) Behavior Modification
• IV:
– Scheduled period of physical activity as
reinforcer for attentive calmness
• Results:
– Attentive Calmness increased from an
average 3 seconds to 60 seconds.
110
Azrin et al. (2006) Behavior Modification
111
Bloh (2009) Assessing Self-Control
Training in Children with ADHD. The
Behavior Analyst Today
First, a few words:
“Self-Control” vs “Self Management”
• Participants: Three boys 10 – 14
diagnosed with ADHD
• Natural baseline:
– Asked to wait as long as possible before
consuming preferred edible
112
Bloh (2009) The Behavior Analyst Today
• Choice baseline:
– Participant asked to choose between his
small immediate (one bite-size
Snickers®/ Starburst®) and a large
delayed reinforcer (two Snickers®/
Starbursts®).
• Self-Control Training:
– “Do you want [small item] now, or would
you like [large item] in a little while?”
113
Bloh (2009) The Behavior Analyst Today
Self Control Training: Incremental delays
increased every session. During the delay
concurrent activity involved symmetry
matching (pictures to their word equivalents).
Generalization Setting: individualized…
• Replicated findings of increased self-
control through progressive delays &
participation in concurrent activities.
114
ASR
• McDowell, & Keenan (2001) found that
practicing letter skills before timings for
correct and incorrect letter sounds in
combination with reinforcement for meeting
or beating past results produced:
1. Increases in fluency and time on task
2. Increases in fluency but not time on task
3. Increase in time on task but not fluency
4. No increases in time on task or fluency
115
ASR
• McDowell, & Keenan (2001) found that
practicing letter skills before timings for
correct and incorrect letter sounds in
combination with reinforcement for meeting
or beating past results produced:
1. Increases in fluency and time on task
2. Increases in fluency but not time on task
3. Increase in time on task but not fluency
4. No increases in time on task or fluency
116
ASR
• Azrin et al. (2006) successfully used what
as a reinforcer for “attentive calmness”?
1. Grab bag with small toys and edibles
2. Activity on playground
3. NCA
4. Candy Bars
117
ASR
• Azrin et al. (2006) successfully used what
as a reinforcer for “attentive calmness”?
1. Grab bag with small toys and edibles
2. Activity on playground
3. NCA
4. Candy Bars
118
Social Skills in Children Diagnosed With
ADHD
• Children diagnosed with ADHD often exhibit
inattentive, impulsive, & inappropriate social
bx (e.g., bossy, uncooperative) associated
with negative peer relations including social
rejection.
• Research states SS may be more resistant
to treatments of meds and traditional
behavioral interventions
119
Behavioral Focus Studies - ADHD
• Social Skills:
– Hupp, Reitman, Northup, O'Callaghan &
LeBlanc (2002) Delayed Rewards &
Tokens to improve Social Skills
– O‘Callaghan, Reitman, Northup, Hupp &
Murphy (2003) Social Skills Generalization
– Also LaRue, et al. (2008) Medications
effects on school social interaction in
children with ADHD.
120
Hupp et al. (2002) Behavior Modification
• 5 children aged 4 – 7 years, diagnosed with
ADHD, 3 on stimulant medication
• Purpose:
1. Replicate previous studies on
sportsmanlike bx with stronger design
2. Tokens vs Delayed rewards comparison
3. Tracking 3 on meds vs placebos for
effect on targeted bx
121
Hupp et al. (2002) Behavior Modification
• Design:
– multiple baseline reversal design
• (compared to A-B prior design)
• Sportsmanlike Bx:
– praising, applauding, high fiving or other
ways of “encouraging” players
122
Hupp et al. (2002) Behavior Modification
• Findings:
1. Replication: all 5 children showed
increases in sportsmanlike bx overall
2. Delayed rewards did NOT increase
sportsmanlike bx while tokens plus
praise plus delayed reward DID.
3. Meds did not increase sportsmanlike bx
(but decreased disruptive bx in
classroom)
123
Hupp et al. (2002) Behavior Modification
• Drawback:
– No fading or generalization due to short
summer program, no generalization
demonstrated
124
O‘Callaghan et al. (2003) Behavior
Therapy
• Problem:
– Social Skills (SS) programs lacking in
Generalization
• Purpose:
– replicate a program for increasing
sportsmanlike and attentive behaviors in
ADHD-diagnosed children
– demonstrate generalization of these
behaviors to a nontraining setting.
125
O'Callaghan et al. (2003) Behavior
Therapy
• Participants:
– 2 boys, 2 girls diagnosed with ADHD with
low levels of sportsmanlike & attentive
behavior at 6 week summer camp
126
O'Callaghan et al. (2003) Behavior
Therapy
• Dependent Variables:
– Sportsmanlike*
– Attentive bx -"ready position." (a)
standing within 10 feet of the base, (b)
head & eyes facing toward home plate,
and (c) both hands on knees or thighs
* Defined as in Hupp et al., (2002) study
127
O'Callaghan et al. (2003) Behavior
Therapy
• Design:
– Multiple-baseline-across-participants
• Training:
– Kickball diamond set up
– Experimenter & research assistant as
coaches
– Training in morning, games in afternoon
128
O'Callaghan et al. (2003) Behavior
Therapy
• Training sessions:
– Modeling appropriate social skills
followed by feedback and reinforcement
for performance.
• Token economy system like Hupp, et al.
(2005).
• Generalization Sessions:
– Started when target bx’s occurred at 75%
training intervals for 6 consecutive data
points 129
O‘Callaghan et al. (2003) Behavior
Therapy
• Stokes and Baer (1977)
Examples:
• Train with Multiple exemplars. Rotate
trainers, staff & peers participating in
training setting
• Program Common Stimuli:
– Occasionally use same trainers in games
as used in training
130
O‘Callaghan et al. (2003) Behavior Therapy
More examples:
Use Indiscriminable contingencies:
schedule of token reinforcement faded on
intermittent schedule
Training loosely: introduce and withdraw
programming techniques in training session
131
O'Callaghan et al. (2003) Behavior
Therapy
• Regular game data were collected at a
separate location during a scheduled
"recess" time near the end of the camp
day.
• No token economy in place
132
O'Callaghan et al. (2003)
Behavior Therapy • Results:
– In training setting, increase (˜80%) in
attentive & sportsmanlike bx with token
system
– Increased rates of SS in training sessions
maintained even as reinforcement
schedules thinned & faded completely
133
O'Callaghan et al. (2003) Behavior
Therapy
• Generalization programming produced
significant gains in game setting for all
children,
• Response variability and no one generalization programming technique
yielded consistent results for all children.
• But, efforts to systematically program for
social skills generalization resulted in
increases of 40% to 50% without arbitrary
contingencies in generalization setting.
134
ASR
• In Hupp et al. (2002) which of the following
increased sportsmanlike behavior?
1. Medications
2. Tokens plus praise plus delayed reward
3. Delayed rewards
4. All of the above
135
ASR
• In Hupp et al. (2002) which of the following
increased sportsmanlike behavior?
1. Medications
2. Tokens plus praise plus delayed
reward
3. Delayed rewards
4. All of the above
136
Behavioral Focus Studies – ADHD
• Instructional Control:
– Neef et al. (2004) modeling vs
instructions on sensitivity to
reinforcement schedules
– Falcomata et al. (2008) Contingency
Specifying. (CS) vs Incomplete
Instructions (II)
137
Neef et al. (2004) JABA
• Participants:
– 3 typically developing children & 3
children with ADHD whose academic
responding showed insensitivity to
reinforcement schedules
– Children were tasked with earning X
points in Y time to obtain 1 of 5 preferred
prizes according to VI VI schedules
(solving computer math problems)
138
Neef et al. (2004) JABA
• No Instruction Baseline:
– Children attempt contacting reinforcement
with VI schedules to complete math
problems
– All 6 exhibited undermatching i.e. less
time on schedule that provided most
reinforcement
139
Neef et al. (2004) JABA
• Modeling:
– Experimenter chose schedules and
performed problems as talked out loud to
obtain points to exchange for
reinforcement
• Instructions:
– Experimenter gave the participant
specific instructions for earning the most
points with concurrent schedules in effect
140
Neef et al. (2004) JABA
• Results:
– No difference in children with & without
ADHD
– Instruction & modeling interventions quickly
produced patterns of response allocation
to maximize reinforcement
– Responding established by modeling more
sensitive to change in reinforcement
schedules (less rigid–better generalization)
141
Falcomata et al. (2008) JABA
142
Setting: University Lab school or elementary
school
Participants:
- Three, 7 year-old boys diagnosed with
ADHD
Dependent Variable:
- Latency from instruction to inappropriate
vocalizations or out of seat behavior
Falcomata et al. (2008) JABA
143
• Design:
- Alternating treatments across
reinforcement, extinction, &
reinforcement + increasing response
requirements conditions to evaluate
effects of Contingency-Specifying
Instructions (CSIs) & Incomplete
Instructions (IIs).
Falcomata et al. (2008) JABA
• Reinforcement
– CSI sessions during reinforcement were
initiated with instruction, “Sit and wait
quietly, and you might get a coupon”
– II sessions during reinforcement were
identical to CSI sessions during
reinforcement except that therapist
provided instruction, “Sit and wait quietly.”
144
Falcomata et al. (2008) JABA
Extinction
• CSI sessions during extinction same as CSI
sessions during reinforcement but no
reinforcement if child met goal
• II sessions during extinction were same as
CSI sessions during extinction except that
the therapist provided instruction, ‘‘Sit and
wait quietly.’’
145
Falcomata et al. (2008) JABA
• For 2/3 children sessions during
reinforcement + increasing response
requirement were same as sessions during
reinforcement except as each participant
reached target goal, goal was increased
systematically in each condition.
146
Falcomata et al. (2008) JABA
• Results:
– Instructional control was achieved with
CSI, which resulted in maintenance of
appropriate bx in absence of
reinforcement for all 3 children
– Instructional control not achieved with II.
147
Falcomata et al. (2008) JABA
Take Home: CSIs may be useful:
• To maintain appropriate classroom
behavior without reinforcement as a goal.
• When there are challenges to treatment
integrity
• If consequences for appropriate behavior
are likely to be inconsistent.
148
ASR
• In Neef, et al. (2004), which of the following
was more flexible in the allocation of
responding when reinforcement schedules
changed?
1. Instructions
2. Modeling
3. Instructions & Modeling
4. Neither were flexible
149
ASR
• In Neef, et al. (2004), which of the following
was more flexible in the allocation of
responding when reinforcement schedules
changed?
1. Instructions
2. Modeling
3. Instructions & Modeling
4. Neither were flexible
150
ASR
In Falcomata et al. (2008) when no
reinforcement was provided, which
technique yielded instructional control?
1. Contingency specifying instructions
2. Incomplete instructions
3. Both
4. Neither
151
ASR
In Falcomata et al. (2008) when no
reinforcement was provided, which
technique yielded instructional control?
1. Contingency specifying instructions
2. Incomplete instructions
3. Both
4. Neither
152
Behavioral Focus Studies - ADHD
• Variables Impacting Performance:
– Northup, Kodak, Grow, Lee, & Coyne
(2004) “Type” of instructions as
procedural variable
– Belke, & Garland (2007) Magnitude of
Reinforcement
– Powell & Nelson (1997) Choice effects
153
Northup et al. (2004) JABA
Influence of instructions on FA
• Participant: 5-year-old girl at a summer
program for children diagnosed with ADHD
• Target behaviors:
– Inappropriate vocalizations,
– out-of-seat behavior, destruction,
aggression
154
Northup et al. (2004) JABA
• Functional analysis:
– An initial assessment consisted of
attention (reprimand), escape, and control
conditions alternated in a multi-element
design.
155
Northup et al. (2004) JABA
Control: therapist helped child complete
simple puzzles child chose. NCA provided
approximately every 30 s as praise &
approving statements.
Initial Attention & Escape: Therapist
presented task and said ‘‘stay in your seat
and work quietly. If you [any target behavior] I
will have to remind you.’’ ( if target then ‘‘You
need to work quietly’’).
156
Northup et al. (2004) JABA
• Escape:
– ‘‘If you [any target behavior] you might
need to take a break.’’
– If target behavior, then said‘‘take a break’’
(turned chair, 30 seconds)
– Due to High Rates of Target Bx in Escape
condition, 2 additional conditions
conducted
157
Northup et al. (2004) JABA
• Time-out:
– “If you [any target behavior] you will be in
time-out” & said “time-out” in neutral tone
contingent on target bx
• No instructions:
– No additional instructions were given in
no-instructions condition, & therapist
made no comment following target bx.
158
Northup et al. (2004) JABA
159
Belke & Garland (2007) JEAB
Magnitude of Reinforcement?
Subjects: 2 groups of mice
– Selectively bred (based on high daily
wheel running rates) versus Control mice
• Studied Lever-pressing response reinforced
by brief opportunity to run 90 s, 30 min,
and 90 s
• Trials ending after obtaining 20 reinforcers
or after 1 hour.
160
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
90 Second 30 minute 90 second
% M
ice O
bta
inin
g 2
0 R
ein
forc
ers
Wheel Running Reinforcer Duration
Selected vs Control Mice
Contol
Selected
161
Belke & Garland (2007) JEAB
Belke & Garland (2007) JEAB
• Why important? High-running mice share
features common to ADHD.
– Hyperactive vs. nonselected mice, even
when in cages without wheels
– Ritalin, improves hyperactivity in
selected mice
– Selected mice show a particular learning
deficit vs. controls - may be function of
inattention.
162
Belke & Garland (2007) JEAB
• Importance (continued)
– Reduced dopamine function & altered
activity in prefrontal cortex that occur in
ADHD have been observed in selected
mice
Take Home? Seems to agree with
research that children diagnosed with
ADHD have higher reward threshold
relative to typically developing children…
163
Powell & Nelson (1997) JABA
Choice Effects?
Participant: 7-year-old boy diagnosed with
ADHD on 15 mg of Ritalin © daily
Classroom setting
Undesirable Behavior: Noncompliance,
away from desk, disturbing others, staring off
& not doing work
ABAB Design: used to evaluate effects of
choice making on undesirable bx
164
Powell & Nelson (1997) JABA
• Baseline no-choice phases:
– Worked on same assignment as class.
• Choice phases:
– Choice of 3 language arts assignments
from class.
• No-choice condition:
– Not given a choice of academic
assignments.
165
Powell & Nelson (1997) JABA
166
ASR
• The Belke & Garland (2007) study with
mice may imply that magnitude of reward
necessary for a child with ADHD is:
1. The same as for a child without ADHD
2. Less than for a child without ADHD
3. Greater than for a child without ADHD
4. No correlation with a child without ADHD
167
ASR
• The Belke & Garland (2007) study with
mice may imply that magnitude of reward
necessary for a child with ADHD is:
1. The same as for a child without ADHD
2. Less than for a child without ADHD
3. Greater than for a child without ADHD
4. No correlation with a child without ADHD
168
Behavioral Focus Studies - ADHD
• Peer Mediated Treatment:
– Grauvogel-MacAleese & Wallace (2010)
extension on peer mediated treatment
– Flood, Wilder, Flood, & Masuda (2002)
extension of peer mediated treatment
169
Grauvogel-MacAleese & Wallace (2010)
JABA
Peer Mediated Treatment
• 3 boys with ADHD, ages 6, 8 & 10, and
• 3 male peers ages 7, 9 & 10
• Target Behavior: “Off-task behavior”
• talking about subjects unrelated to
homework, leaving or falling out of his
seat, wandering around room, leaving
the homework area, hiding behind
objects and crawling under tables
170
Grauvogel-MacAleese & Wallace (2010)
JABA
• Multiple baseline design across
participants, with a reversal for one
participant used to evaluate treatment
• Correct response: Scored when peer
gave attention contingent on off-task bx
during peer-attention condition, provided
attention noncontingently during control
condition, & ignored off-task bx & provided
attention for on-task bx during treatment
sessions. 171
Grauvogel-MacAleese & Wallace (2010)
JABA
• Incorrect response:
– Scored if peer delivered attention when
he should not have or if he ignored
prompt to deliver attention.
172
Grauvogel-MacAleese & Wallace (2010)
JABA
• During treatment:
– Peer provided statements of praise and
help if participant was on task.
• If participant engaged in off-task bx, peer
discontinued praise & help until participant
was on task again (i.e., extinction).
• Baseline & treatment:
– Homework worksheet assigned by
teacher.
173
Grauvogel-MacAleese & Wallace (2010)
JABA
174
Flood et al. (2002) JABA
Peer Mediated Treatment
• Participants: 3, 10-year-old children
diagnosed with ADHD
• Dependent variables: Off-task behavior
and # math problems completed
• Functional Analysis: Showed all exhibited
elevated levels of off-task behavior in alone
and peer-attention conditions.
175
Flood et al. (2002) JABA
Treatment:
• Children told they & confederate peer
(CP) would work on math & CP gave
continuous social approval if child on-task
• If off-task behavior, CP prompted child to
engage in on-task behavior
• If child did not resume on-task behavior,
CP withdrew eye contact & verbal
interaction until child resumed on-task bx
(the extinction component of DRA) 176
Flood et al. (2002) JABA
177
ASR
• In Grauvogel-MacAleese & Wallace (2010),
peers of children diagnosed with ADHD
implemented ________ successfully?
1. Differential Reinforcement & time-out
2. Differential Reinforcement & extinction
3. Shaping & time-out
4. Shaping & extinction
178
ASR
• In Grauvogel-MacAleese & Wallace (2010),
peers of children diagnosed with ADHD
implemented successfully:
1. Differential Reinforcement & time-out
2. Differential Reinforcement &
extinction
3. Shaping & time-out
4. Shaping & extinction
179
ASR
In Flood, et al. (2002), DRA plus prompting
resulted in successful reduction of off-task
behavior for:
1. All three children
2. No children
3. 2 of the three children
4. 1 of the three children
180
ASR
In Flood, et al. (2002), DRA plus prompting
resulted in successful reduction of off-task
behavior for:
1. All three children
2. No children
3. 2 of the three children
4. 1 of the three children
181
Barry & Haraway (2005)
Self-Management and ADHD: A Literature
Review. The Behavior Analyst Today
• Behavioral self management including self-
monitoring, self-regulation, self-control, self-
talk, and reinforced self-evaluation
• Review of 3 cognitive behavioral studies
(with inconclusive results*)
182
Barry & Haraway (2005) The Behavior
Analyst Today
Review 8 published studies of behavioral self-management with children diagnosed with ADHD in school settings (1992 – 2004)
Behavioral “self-management” included reinforcement, response costs, contingency management of bx with self-monitoring, behavioral goals, operational definitions of behaviors, data based self-assessment, & data recording with reliability measures
183
Barry & Haraway (2005) The Behavior
Analyst Today
From the reviews, components of behavioral
self-management that may contribute to
beneficial effects:
a. Immediate auditory and/or written
prompts for self-recording
b. Individual or group contingency
reinforcement,
c. Child choice of reinforcement,
d. Daily practice & instruction,
184
Barry & Haraway (2005) The Behavior
Analyst Today
(continued):
e. Operational definitions of behaviors &
goals
f. Reliability of (compare teacher &
student info)
g. Specific skill instruction
h. Monitored acquisition of skill
i. Possible combo of tx with meds
185
Barry, & Haraway (2005) The Behavior
Analyst Today
• Considerations:
– Generalization of tx problematic
– Maintenance issues with behavioral
change with ADHD population - Long
term support strategies needed?
– Given numbers with ADHD prescribed
meds, parents and professionals,
including physician working with child,
collaborate to coordinate & monitor
interventions. 186
ADHD Summary
• First:
• Neurodevelopmental?
• Collection of categories/behaviors that
significant persons or professionals in the
life of an individual have noticed/reported
with the intent of obtaining a diagnosis to
obtain assistance
187
ADHD Summary
So regardless of position on neurobiological
or not, behavior analysts and the Center for
Disease Control and the National Institute of
Mental Health are in agreement that
behavioral techniques can make a distinct
and significant positive impact on the
behaviors exhibited by children diagnosed
with ADHD and should be included as part
of best practice treatment.
188
ADHD Summary
• Second:
– Behavior analytic techniques with or
without medications… focus on
behaviors and teamwork with other
professionals involved
189
ADHD Summary
• Third:
– There may be some “person variables”
specific to individuals diagnosed with
ADHD such as:
• Stronger preference for immediate vs
delayed rewards
• Sensitivity to larger quantity of reinforcer
190
ADHD Summary
Other studies with children diagnosed with
ADHD have used behavioral techniques that
were shown to be effective regardless of
whether the child was diagnosed with ADHD
or not - e.g., like children with or without
ADHD diagnoses able to generalize problem
solving best with strategies (modeling) vs.
specific tactics (instructions)
191
ADHD Summary
• Take Home:
– The scientifically based behavioral
techniques of influencing behavior
including functional assessments and
research based interventions are similar
if not identical to the behavioral
techniques used with other diverse
populations including children who are
typically developing and those with
developmental disabilities. 192
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