School-based Support for Students with ADHD:

Is There Life After Ritalin?

George J. DuPaul, Ph.D.School Psychology Program

Lehigh UniversityBethlehem PA 18015

Conclusions

• ADHD has enormous impact on school functioning• Medication is effective for changing behavior, but not

necessarily for academic performance• Individually tailored school-based interventions have

potential for building upon medication effects• Must go beyond “one size fits all”

DSM-IV CRITERIA FOR ADHD

Significant problems with inattentionSignificant problems with hyperactivity-impulsivity Symptoms present for at least 6 monthsSymptoms that caused impairment before age 7Some impairment in two or more settings Impairment in social, academic, or occupational

functioningNot due to another disorderSubtypes: Combined, Predominantly Inattentive,

Predominantly Hyperactive-Impulsive

PREVALENCE AND SEX RATIOS

Occurs in 3 to 5 % of childrenRatio of males:females is 3:1 in community

and 6:1 in clinic referralsMakes up high percentage of referrals for

academic and behavior difficultiesFound in all countries and ethnic groups

with varying prevalence - highest in US

PROBLEMS ASSOCIATED WITH ADHD

Conduct problems (e.g., oppositional behavior, lying, stealing, and fighting)

Academic underachievement

Specific learning disabilities

Peer relationship problems

Model for School-based Assessment of ADHD (DuPaul &

Stoner, 2003)• Screening• Multi-method Assessment• Interpretation of Results• Intervention Planning & Design• Intervention Evaluation

SCREENING: QUESTIONS TO BE ADDRESSED

• Does this student have a problem related to possible ADHD?

• Is further assessment of ADHD required?

SCREENING METHODS

• Parent and/or teacher ratings of ADHD-related behaviors

• Brief interview with teacher and/or parent

MULTIMETHOD ASSESSMENT: QUESTIONS

TO BE ADDRESSED• What is the extent and nature of the ADHD-

related problems?

• What factors (e.g., organismic and environmental) maintain these problems?

• What is the frequency, duration, and/or intensity of the problem behaviors?

• In what settings do the ADHD-related behaviors occur?

MULTIMETHOD ASSESSMENT STRATEGIES

Parent and teacher interviewsReviews of school recordsBehavior rating scalesObservations of school behaviorAcademic performance dataFunctional behavioral assessment

INTERPRETATION: QUESTIONS TO BE

ADDRESSED• Does the child exhibit a significant number of

behavioral symptoms of ADHD ?• Are behaviors occurring significantly more frequently

than children of the same gender and age?• At what age did these begin and are these behaviors

chronic and evident across many situations?• Is the child’s functioning significantly impaired?• Are there other possible problems or factors that could

account for symptoms?

INTERPRETATION OF RESULTS

• Number of ADHD symptoms• Deviance from age and gender norms• Age of onset and chronicity• Pervasiveness across situations• Degree of functional impairment• Rule out alternative hypotheses

Developmental Trends for ADHD Symptoms: Boys

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ALTERNATIVE HYPOTHESES FOR ADHD

BEHAVIOR• Environmental factors

– Antecedent/consequent events– Placement in curriculum– Psychosocial stressors

• Within-child factors– Academic skills deficits– Other forms of emotional or behavioral

disturbance

DIFFERENTIAL DIAGNOSIS

• Disorders to be “ruled out”:– Separation Anxiety Disorder– Other Anxiety Disorders– Depression/affective disorders– Tourette’s Disorder

• Disorders which frequently co-occur with ADHD:– Oppositional Defiant Disorder– Conduct Disorder– Learning Disabilities

LD VS. ADHD

• Lacks early childhood history of hyperactivity• “ADHD” behaviors arise in middle childhood• “ADHD” behaviors appear to be task- or subject-specific• Not socially aggressive or disruptive• Not impulsive or disinhibited

INTERVENTION PLANNING: QUESTIONS TO BE

ADDRESSED• What are the behavioral objectives?• What are the student’s strengths and

weaknesses?• What are the optimum intervention

strategies?• What additional resources are available to

address the child’s ADHD-related problems?

INTERVENTION PLANNING

• Severity of ADHD-related behaviors• Functional assessment of behavior• Presence of associated disorders• Response to prior interventions• Availability of community resources

Possible Functions of ADHD Behavior

Avoid/escape effortful tasksObtain peer attentionObtain teacher attentionObtain tangible objectSensory stimulation

Design Interventions Based on Functional Assessment

Descriptive analysis– Identify antecedents, consequences, sequential conditions– Direct observation, teacher interview, parent interview, student

interview Experimental Analysis

– Develop hypotheses related to function of behavior– Test hypotheses using direct observation

Develop intervention plan based on results of experimental analyses

INTERVENTION EVALUATION: QUESTIONS

TO BE ADDRESSED• Are changes occurring in the target and

collateral behaviors?• Are the treatment changes socially valid

and clinically significant?• Are target behaviors normalized?• Are “side-effects” present?

INTERVENTION EVALUATION

• Periodic collection of assessment data (e.g., teacher ratings, observations, academic performance measures)

• Consumer satisfaction ratings• Comparison with normal peers• Revision of treatment plan based on assessment

data

What are the most common school difficulties associated

with ADHD?• High rates of disruptive behavior• Low rates of engagement with academic

instruction and materials• Inconsistent completion and accuracy on

schoolwork• Poor performance on homework, tests, & long-

term assignments• Difficulties getting along with peers & teachers

Project PASS: Initial Group Differences

• 1st through 4th grade students in public elementary schools in eastern PA

• N = 87 children with ADHD• N = 38 normal controls• 20 min observations in math and reading using the

BOSS (Shapiro, 1996)• Woodcock-Johnson Reading & Math subtests (WJ-

III)• Teacher ratings on the Academic Competency

Evaluation Scale (ACES; DiPerna & Elliott)

Project PASS: Classroom Behavior in Reading

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Most Common Interventions for Children with ADHD

• Psychotropic Medication (e.g., CNS stimulants such as methylphenidate)

• Home-based contingency management (behavioral parent training)

• School-based contingency management interventions (e.g., token reinforcement)

• Academic tutoring• Daily report card or school-home notes

MEDICATIONS FOR ADHD Stimulant Medications

– Methylphenidate (Ritalin, Concerta, Metadate)– Dextroamphetamine (Dexedrine)– Adderall

Tricyclic Antidepressants – Desipramine (Norpramine);Imipramine (Tofranil)

Other Antidepressants– Bupropion (Wellbutrin); Fluoxetine (Prozac)

• Other Medications– Clonidine (Catapres)– Atomoxetine (Strattera)

BEHAVIORAL EFFECTS OF STIMULANTS

Increased Attention and ConcentrationDecreased ImpulsivityDecreased Task-Irrelevant Activity LevelDecreased Aggressiveness Increased Compliance Improved Handwriting and Fine Motor Skill Improved Peer Relations and Social StatusPossible enhancement of academic productivity

SIDE EFFECTS OF STIMULANT DRUGS

Insomnia & Decreased Appetite (50-60%) Headaches and Stomachaches (20-40%) Prone to Crying (10%) Nervous Mannerisms (10%) Tics (<5%) and Tourette’s (Very Rare) Overfocused behavior; Cognitive toxicity Mild Weight Loss (A Few Pounds First 1-2 Years); No

effect on Skeletal Growth Mild Increases in Heart Rate and Blood Pressure Cylert Affects Liver Functioning; Needs Monitor

Problems with Currently Available Research Literature

• Limited data on school-based interventions in gen. ed. settings

• “One size fits all” approach is typical• Emphasis on reduction of disruptive behavior

rather than improvement in social behavior or academic skills

• Few studies of adolescents• Focus on short-term outcomes & limited data on

generalization of effects

Multimodal Treatment Study (MTA)

• N = 579 children from Gr. 1-5 (M age = 8.5) randomly assigned to tx groups

• Medication management (n = 144), Behavioral tx (n = 144), Combined tx (n = 145), and Community Care Control Group (n = 146)

• 14 mos of tx (manualized) at mult. sites• Multiple assessment measures collected on three

occasions

MTA Psychosocial Interventions

• Parent Training– 27 group sessions over 14 mos

• School Intervention• Child-Based Treatment: Summer Treatment

Program– Comprehensive behavior mod. Program– Peer interventions– Sports skills training– Daily report cards– Individualized programs, as necessary

MTA School Intervention Component

• Teacher consultation– Biweekly meetings with teachers over 14 mos– Daily Report Card implemented– Basic behavioral principles and classroom interventions as

necessary (e.g., token economy); Stage II tx (response cost) as necessary

• Paraprofessional Program (UCI model)– Para spent half day in classroom for 12 weeks in fall of 2nd

school year– Implemented behavior modification procedures including

daily report card & merit badge system for social skills

MTA Study (cont.)• Reductions in symptoms in all groups• Combined tx & medication greater symptom

reduction than BT & control• Combined tx > BT & control in reduction of

agg./ODD symptoms & improved social skills, parent-child relations, and reading achievement

• Medication > BT in most cases; however meds still active while BT had been faded

• Predictors of individual response?• Effects of school intervention component?

School-based Intervention for ADHD: A Meta-analysis (DuPaul & Eckert, 1997)

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Balanced “Game” Plan• Too often rely solely on

defense (reactive) strategies

• Need a strong “offense” (proactive) and a strong “defense” (reactive)

• Intervention plan should always include both proactive & reactive procedures (emphasis on positive)

School-Based Interventions for ADHD

Manipulating Antecedents (Proactive)– Post Rules– Instructional Modifications– Workload Adjustment– Providing Choices– Peer Tutoring

School-Based Interventions for ADHD (cont.)

Manipulating Consequences (Reactive)– Token Reinforcement– Verbal Reprimands– Response Cost– Time Out from Positive Reinforcement– Self-Management

SCHOOL-BASED INTERVENTIONS FOR

ADOLESCENTS WITH ADHD Manipulating Antecedents (Proactive)

– Note-taking/Study Skills Instruction– Workload Adjustment– Providing Choices– School-based Case Manager

Manipulating Consequences (Reactive)– Behavioral Contract– Discipline Hierarchy– Self-Management Program

Possible Mediators for School-Based Interventions

(DuPaul & Power, 2000)• Teacher-mediated

– Instructional strategies; Token reinforcement• Parent-mediated

– Parent tutoring; Home-based reinforcement• Peer-mediated

– Classwide peer tutoring• Computer-assisted

– Drill-and-practice• Self-mediated

– Self-monitoring; Self-management

Link Interventions to Behavioral Function

Avoid/escape effortful tasks Increase stimulation value of task and/or provide brief

“attention breaks”Obtain peer attention

Provide peer attention following appropriate behavior (e.g., peer tutoring)

Obtain teacher attentionProvide attention following appropriate behavior while

ignoring inappropriate behavior (or time out from positive reinforcement)

TEACHING TECHNIQUES TO PREVENT BEHAVIOR

PROBLEMSRemind students of rulesMaintain eye contact with studentsRemind students about expected behaviorsCirculate thru classroom to monitor/provide feedbackUse nonverbal cues to redirectMaintain brisk pace of instruction Insure understanding of activitiesManage transitions in well-organized mannerCommunicate expectations about use of class time

TOKEN REINFORCEMENT Establish behavioral or academic goals Choose several target situations Break situation (task) into smaller units Tokens (points, stickers) provided immediately Tokens turned in for privileges Factors to consider:

– Practicality for teachers– What to use for rewards– “Satitation” effect– Expansion to additional situations– Gradual “weaning” process– Reactions of other students

“DEAD PERSON’S RULE” If a dead person can do it, it’s not a good target

behavior for interventionExamples: sit still, stay on-task, don’t call out,

don’t fightAppropriate target behaviors involve active

respondingExamples: completion of tasks, accuracy on work,

participating in class discussions, getting along with others

STUDENT CONTRACTSpecify several short-term objectives Identify possible contingencies

– Positive for reaching goal– Aversive for rule violations

Determine time period for meeting goals Include both short and long-term payoffsAgreement by both student and teacher

(counselor) to follow throughPeriodic revisions of contract as necessary

RESPONSE COST Apparatus or materials needed Description of system

– Review rules with student– Positive reinforcement following “on-task” behavior– “Fines” following “off-task” behavior– Unpredictability of contingencies– Turn in points for privileges

Classroom situations where system is useful Factors to consider

– Explanation of system to student– Reactions of other students– Practicality for teachers– “Weaning”

Parent Tutoring

• Strong evidence that parental support of learning enhances academic ach.

• Several tutoring models (e.g., Reading to Read)• CWPT Model :

– Individually-paced– Frequent, imm. feedback w/error corr.– Emphasis on positive reinforcement– Time-efficient

Parent Tutoring: Controlled Case Study (Hook & DuPaul, 1999)

• 4 students (3 boys, 1 girl) with ADHD from 2nd & 3rd grade (w/ reading diff.)

• Teachers provided parents with reading passages for tutoring sessions

• Student read aloud for 5 min w/imm. error correction & praise for accuracy

• At 5-min mark, student instructed to start over & read same section x 10-min

• 1-min “reading check” w/same passage

Parent Tutoring Case Study (cont.)

• 2-3 parent tutoring sessions per week for 4 to 8 weeks

• All 4 children showed gains in reading at home based on CBM probes

• Variable changes in school-based reading performance

• Children cooperative with procedures & parents involved in their education

• Promising tx for some child. w/ ADHD

COMPONENTS OF EFFECTIVE HOME-SCHOOL

COMMUNICATION PROGRAMDaily/weekly goals specified in a positive manner

Both academic and behavioral goals includedSmall number of goals at a timeQuantitative feedback about performanceFeedback provided by subject or class periodCommunication is made on a regular basis (either

daily or weekly)Home-based contingencies tied to performance

(both short-term and long-term)

HOME-SCHOOL PROGRAM (cont.)

Parental cooperation solicited prior to implementation– Student input into goals and contingencies

Goals/procedures modified as necessary

Peer Mediated Interventions

• Playground monitors (Cunningham et al.)• Peer monitoring plus self-evaluation• Peer tutoring

– Classwide Peer Tutoring– Reciprocal Peer Tutoring

• Cooperative Learning

CLASSWIDE PEER TUTORING

Divide classroom into pairsProvide academic scriptsTake turns tutoring Immediate feedback & error correctionTeacher monitors progress & provides bonus

pointsPoints tallied & progress chartedPairs change weekly

CWPT Effects on ADHD (DuPaul et al., 1998)

• 18 ch. w/ADHD & 10 comparison students (1st to 5th grade gen. ed.)

• CWPT increased active engagement w/ reduction of off-task behavior

• 50% of ADHD improved academically• Positive effects for comparison peers• High rates of student and teacher

satisfaction

Coaching Teens with ADHD(Guare & Dawson, 1995)

Phase I– Identify long-term goals– Determine goal criteria– Delineate barriers to reaching goals

Phase II (Coaching sessions)– Review– Evaluate– Anticipate– Plan

Adult vs. peer coaching? Outcomes systematically evaluated

Computer-Assisted Instruction

• 1. Delivery of instruction (e.g., aid to acquisition of new material)

• 2. Drill-and-practice (e.g., fluency and retention of already-instructed material)

• May be effective for both purposes with more evidence for drill-and-practice

• ?Effects due to higher stimulation value of material, self-paced, & provision of frequent, immediate feedback?

CAI: Controlled Case Study(Ota & DuPaul, 2002)

• 3 students with ADHD in 4th-6th grade at a private school for children with LD

• All with math skill acquisition difficulty • All three students receiving medication• Math Blaster software introduced sequentially

across students while assessing on-task and math skills (CBA)

• Gains in on-task behavior and slope of math skill acquisition (for 2 out of 3)

CAI: Replication in Public School Setting (Mautone,

DuPaul, & Jitendra, in submission)• 3 2nd through 4th grade children in general education

or special education classrooms• All met research criteria for ADHD & none being

treated with psychostimulants• Baseline= typical math instruction & work• CAI = Math Blaster software 15 min X 3 days per

week• Multiple baseline across participants design• Math fluency, direct observations of behavior, &

consumer satisfaction ratings were measures

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Baseline Computer-assisted Instruction

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Observation Data

Baseline Computer-assisted Instruction

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Results - CBM

DCPM DIPM

Baseline CAI Baseline CAI

Brian -.1 .27 1.35 .22

Greg .23 1.15 -.15 -.34

Chris -.2 .38 -.15 -.02

Linear Regression Coefficients for Digits Correct and Digits Incorrect

Results - Behavior

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Baseline CAI Baseline CAI

Brian -.19 -.32 4.15 -.49

Greg -2.98 .0007 -1.19 3.02

Chris -.51 1.48 -8.97 4.69

Linear Regression Coefficients for Active Engaged and Off-task Behavior

Results – Acceptability

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Self-monitoring of organizational skills

• Adolescents with ADHD typically have difficulties in class prep. and HW

• For some students, problems related to poor attention to detail and low motivation to complete mundane tasks

• Possible students can be trained to monitor own behaviors (e.g., being ready for class)

Self-monitoring of org. skills: Controlled case study

(Gureasko,DuPaul, & White in press)

• Three 7th grade students with ADHD• All had significant problems being prepared for

class• Checklist of preparatory behaviors developed with

teachers (% steps)• Training in self-monitoring (4 days)• Self-monitoring followed by fading• Gains in organizational skills maintained without

treatment

SELF-MANAGEMENT PROGRAM

Initially incorporates external and internal evaluation but works toward complete self-monitoring and evaluation

Teacher and student independently “grade” student performance regarding behavior and academics for specified work period– Established performance criteria– Points earned for performance– Bonus points for “matching” ratings– Penalities for “inflated” ratings– Points turned in for school based or home based privileges

Sample Self-Management Criteria

5 = Excellent– Followed all rules for entire interval; Work 100% correct

4 = Very Good– Minor infraction of rules; Work at least 90% correct

3 = Average– No serious rule offenses; Work at least 80% correct

2 = Below Average– Broke rules to some degree: Work 60 to 80% correct

1 = Poor– Broke rules almost entire period; Work 0 to 60% correct

0 = Unacceptable– Broke rules entire period; No work completed

SELF-MANAGEMENT (cont.) Gradual weaning from external ratings

– Longer work periods to be rated– Periodic, random “matching” challenges– Eventual reliance on self-ratings only

Factors to consider:– Practical constraints– “Drift” of student ratings– Prepare student using external system

School Services for Students with ADHD

Qualifies for special education on basis of having another disability (e.g., LD)

Qualifies for special education on basis of “other health impairment”

Qualifies for accommodations on basis of Section 504

PSYCHOSOCIAL INTERVENTION STUDIES AT

LEHIGH UNIVERSITY PROJECT PASS (1st through 4th grade students)

http://www.lehigh.edu/~inpass/inpass.htmlProject Coordinator: Rosemary Gruber, M.Ed. (610) 758-6384Email: rog5@lehigh.edu

PROJECT ACHIEVE (3 & 4 year olds)http://www.lehigh.edu/~inachiev/inachiev.htmlProject Coordinator: Suzanne Irvine, M.S.W. (610) 758-3123Email: sli2@lehigh.edu

Project PASS (2000-2005)• Goal: Empirically examine effects on academic and

behavior outcomes of two consultation-based approaches to designing academic interventions for students with ADHD

• 1st through 4th graders with ADHD (N=160) randomly assigned to individualized academic intervention (IAI) or generic academic intervention (GAI)

• Sample of similar aged normal controls (N=80) to examine ADHD vs. normal trajectories on dependent variables

Project PASS (cont.)

• Consultation provided for 1.5 school years • Outcomes assessed at 5 time points (including 1

year follow-up)• Dependent measures include achievement tests,

teacher reports of goal attainment, curriculum-based measurement, teacher ratings of behavior and academic performance, parent ratings of behavior, consumer satisfaction ratings from teachers

IAI Consultation -- Problem Identification

(Kratochwill & Bergan, 1990; Witt, Daly, & Noell, 2000)

• Teacher Education on ADHD• Academic area(s) of concern

– Setting with most and least difficulties– Intensity/Severity of problems– Antecedent conditions

• Teacher asks question• Teacher presents item• Teacher shows or models how to do an item• Teacher prompts the student

IAI Consultation - Problem Identification

• Child’s typical response to antecedents• Consequent conditions• Patterns to academic behavior problems?• Goal-setting and prioritizing• Specifics of lesson to be observed for Functional

Academic Assessment• Agree on additional observational procedures

based on data-driven hypotheses

IAI Consultation --Functional Academic Assessment

• Classroom observation– Information about teacher routine that occurs– Student, teacher, and peer behaviors

• Review student work products in comparison to peers

• Basic Skills Assessment (CBA data)

Linking Assessment to Intervention: Hypotheses for

Academic DeficitsDaly, Witt, Martens, & Dool, 1997; Witt et al., 2000

• MOTIVATION (e.g., There are no incentives to do the work)

• PRACTICE (e.g., The opportunities to do the work are too infrequent )

• INSTRUCTION (e.g., Nobody has shown the student how to do the task, or not enough practice is provided. )

IAI Consultation: Problem Analysis

• Review all data and determine adequacy of baseline data collection

• Based on desired performance versus actual performance, which areas are of most concern?

• Goals from PII still appropriate?• Discussion of possible interventions, tightly linked to

assessment results

IAI Consultation: Problem Analysis

• If conflicting hypotheses --> Hypothesis testing

• Determine specifics of intervention plan• Consultant may train the teacher and/or the

student(s) on intervention implementation• Progress monitoring every week• Treatment integrity and feedback biweekly

Interventions for Students with ADHD: Guiding Principles

• Intervention design linked directly to assessment data (e.g., FBA, CBA)

• Consultative problem-solving process integral to intervention design

• Intervene at “point of performance”• Go beyond “train and hope”• Intervention evolves based on ongoing

assessment

Guiding Principles for Intervention (cont.)

• Don’t place entire onus on classroom teacher; look to other possible treatment mediators

• All behavior serves a purpose; intervention should lead to functionally equivalent behavior

• Aim for balance between proactive and reactive strategies

• Typically no single intervention is sufficient; multi-component and multi-setting intervention is presumed more effective

Conclusions

• ADHD has enormous impact on school functioning

• Medication is effective for changing behavior, but not necessarily for academic performance

• Individually tailored school-based interventions have potential for building upon medication effects

• Must go beyond “one size fits all”

Classroom Interventions for ADHD (DuPaul & Stoner, 1999)

• Response Cost• CWPT

ADHD INATTENTIVE TYPE VS. COMBINED TYPE

• Lethargy, staring, and daydreaming less likely in combined type

• Lacks impulsive, disinhibited, or aggressive behavior

• Greater risk for anxiety symptoms• Greater family history of anxiety disorders

and LD

ADHD VS. ANXIETY DISORDERS

• Not overly concerned with competence• Not anxious or nervous• Exhibit little or no fear• Have no difficulty separating from parents• Infrequently experience nightmares• Inconsistent performance• Not concerned with future• Are not socially withdrawn• May be aggressive• May be able to pay attention if work is stimulating

DEPRESSION VS. ADHD

• Not usually as motorically active• Marked changes in affect/mood• Concentration problems have acute onset

possibly following stress event• Changes in eating and sleeping habits• Loss of interest or pleasure in most

activities

ODD/CD VS. ADHD

• Lacks impulsive, disinhibited behavior• Able to complete tasks requested by others• Resists initiating response to demands• Lacks poor sustained attention and marked

restlessness• Often associated with parental child

management deficits or family dysfunction

ADHD INATTENTIVE TYPE VS. COMBINED TYPE

• Lethargy, staring, and daydreaming less likely in combined type

• Lacks impulsive, disinhibited, or aggressive behavior

• Greater risk for anxiety symptoms• Greater family history of anxiety disorders

and LD

ADHD VS. ANXIETY DISORDERS

• Not overly concerned with competence• Not anxious or nervous• Exhibit little or no fear• Have no difficulty separating from parents• Infrequently experience nightmares• Inconsistent performance• Not concerned with future• Are not socially withdrawn• May be aggressive• May be able to pay attention if work is stimulating

DEPRESSION VS. ADHD

• Not usually as motorically active• Marked changes in affect/mood• Concentration problems have acute onset

possibly following stress event• Changes in eating and sleeping habits• Loss of interest or pleasure in most

activities

ODD/CD VS. ADHD

• Lacks impulsive, disinhibited behavior• Able to complete tasks requested by others• Resists initiating response to demands• Lacks poor sustained attention and marked

restlessness• Often associated with parental child

management deficits or family dysfunction

Discussion

• How does your school district presently identify students with ADHD?

• How could present identification procedures be improved?

• What factors limit the assessment of students with ADHD in school settings?

• What could be done to address these limiting factors?