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Educational Interventions & Other Behavioral Techniques for Attention-Deficit/Hyperactivity Disorder (ADHD)
Lewis Mehl-Madrona, M.D., Ph.D
Introduction: In recent years the traditional therapy of choice for children with ADHD has been a prescription for the stimulant Ritalin. However, the medical and educational community have begun to express concern about the sheer numbers of young children being diagnosed as ADHD and administered drug therapy. Behavioral programs have often accompanied drug therapy in the traditional treatment of childhood ADHD. These programs historically were focused on classical conditioning procedures of rewards and punishments. In other words, children were required to conform to the traditional educational setting and they were considered successful to the extent that they were capable of "fitting in". As a balance to traditional cognitive behavioral therapy (CBT) for children with ADHD, here we intend to present interesting new and emerging ideas as well as reinforcement of practices that make common sense from a wellness perspective of the whole child. More often than not, no one therapy, treatment or intervention will alleviate ADHD symptoms in a child. Rather, it is a combination of tools and positive interventions that can make remarkable differences in these children and their lives in our society as it is. Environmental Supports for Children with ADHD: ADHD and the School Environment * The ideal classroom for a child with ADHD is one in which classroom rules and expectations are clearly defined; the environment is organized; and routines are structured. * A child with ADHD should not be isolated in the classroom but seating should be preferential with the child located front and center near the teacher. Fellow students who would present as good behavioral role models should be seated close by. * A study area with reduced stimuli and traffic should be placed in the room and available for use by all the students, not just the child with ADHD. * Close attention to schedules and routines should be given so that the fluctuation in energy presented by the child can be accommodated. For instance, it would be unwise to spend too much time in low energy activities. A mixture of low and high-energy activities would be more desirable. Activities, though, should generally be stimulating, interesting and meaningful and involve a lot of hands-on projects vs. seat and board work or lecture. ADHD and the Home Environment The home environment can also be structured to provide optimum support to the child with ADHD. Family and household rules should be clear and well defined as well as consistently applied. Predictable routines often help structure time for the child with ADHD. A quiet, organized study area, free of distractions, should be present. Set times and routines should be established for study and review of work by the parent. The child's family responsibilities should also be well defined and it may be necessary to break chores or tasks into very small sequential steps. Plans should be reviewed with the child and they should be prepared for any out of the ordinary changes to routine. Instructional Strategies for ADHD : 1. Giving Directions: Directions need to be given clearly, concisely and through multiple channels. For instance, the teacher should clearly state the directions as well as have written directions or a pictorial list of directions available. Complex directions need to be simplified. Teachers should patiently repeat directions if this is necessary. Make sure the student understands the directions before proceeding to the task. Ask them to repeat the directions back. 2. Assistance: The teacher can help the child with ADHD feel comfortable asking for assistance. One way to do so it to institute a classroom wide method that all students can use rather than singling out the child with ADHD. Develop and discuss with the student private cues that can be used when the student gets off task. For instance, the teacher can quietly touch the student's arm to remind him/her to refocus on the task. 3. Assignments: Make sure that the student is writing down assignments correctly each day. If a student is too young or is not capable, the teacher should assist in providing a record of assignments to go home with the student. Assignments may need broken into smaller segments or steps to complete vs. an entire project. Make sure that the assignment is actually one that the student has the capacity to perform. Some assignments may need further modified or adapted for the student. 4. Test Taking: Students with ADHD may need extended time to complete tests. Once more, be sure that test directions are understood and that the child is capable of what is being asked of him/her. Some children may need modifications in the way a test is delivered. For instance, the test perhaps should be given orally or perhaps the student can respond orally instead of in writing. Unique and individual needs should be considered at all times. Teaching Self-Monitoring: Students with ADHD can often participate in planning for improvements in their own behavior, thus allowing them to hopefully experience more ownership for change and also pride in accomplishing improvements. First students need to be aware of the problem behaviors and the control they can exhibit to improve the situation. To begin assisting a student with self-monitoring, teachers need to select a behavior and precisely explain to the student the nature of the problem and what exactly would consistute improvement. The teacher can then assist the student by developing a rating scale to rate behavior and document improvement. The student will need to learn how to use the rating scale and the scale should be age appropriate. Teachers can demonstrate how they would rate the behavior and verbalize aloud their process of decision-making. Learning to use the rating tool with some reliable accuracy will be a precursor to implement the self-monitoring program. Make decisions on the time interval by which the child will record their "data" or rating of the target behavior. However, be careful to insure that whatever time interval is set that the child is capable of being successful. An example used in one resource gave the example of a child using sarcastic remarks. If the child is known to use sarcastic remarks about once every 20 minutes, the teacher would want to set the time interval for 15 minutes, thus enhancing a child's chance of experiencing successful control. Self-monitoring can be gradually faded out for the behavior as progress is noted. However, in some cases formal self-monitoring may be desirable for some time to come. Positive Behavioral Intervention and Support: Positive Behavioral Support is different than traditional "behavior modification". One key reason for the difference is that with Positive Behavioral Support we ask the question, "why?" Why is the child's work so sloppy? Why is the child seemingly never in his seat? Why is this child having problems making friends? The adults in the situation observe the behaviors and observe the child in numerous settings in order to develop ideas on the function that the behavior is serving for the child. Positive Behavioral Support has a focus on changing the environment and responses in order to enhance a child's experience of feeling successful and teaching important skills that reduce the function of the problem behavior. Positive Behavioral Support is not one approach focused solely on reducing a problem behavior, rather, it garners a collective team vision and collaboration, creating a multifaceted approach to improve the circumstances for the child, their school and community. Positive Behavioral Support was initially developed as an alternative to aversive procedures for those with the most severe and extreme behavioral challenges. However, more recently, it has been used successfully with a wide range of students and contexts and has been extended to apply to entire school environments, not just individuals. According to the Beach Center for Children, the following are general key steps to implementing Positive Behavioral Supports: 1. Ensuring a fit with your values: This is not a one-size-fits-all, simplistic plan. There is no "recipe" or quick fix. 2. Putting together a collaborative team: No one person alone can create a solution but many ideas and perspectives can lend themselves toward creating better futures. 3. Creating a vision: This involves imagining what an ideal life and positive future would look like for the focus individual. Such a vision should incorporate the individuals personal preferences, talents, gifts, abilities and relationships. 4. Completing a functional assessment: This is a structured method of gathering and testing information about the function that the behavior may have in the individuals' life. 5. Developing strategies: 1. Teaching new skills 2. Appreciating positive behavior 3. Changing systems According to the O.S.E.P. Technical Assistance Center on Positive Behavioral Interventions and Supports: "Positive behavioral support is not a new intervention package, nor a new theory of behavior. Instead, it is an application of a behaviorally-based systems approach to enhance the capacity of schools, families, and communities to design effective environments that improve the fit or link between research-validated practices and the environments in which teaching and learning occurs." "Attention is focused on creating and sustaining school environments that improve lifestyle results (personal, health, social, family, work, recreation, etc.) for all children and youth by making problem behavior less effective, efficient, and relevant, and desired behavior more functional. In addition, the use of culturally appropriate interventions is emphasized." Haring and De Vault (1996) indicate that PBS is comprised of: 1. "Interventions that consider the contexts within which the behavior occurs" 2. "Interventions that address the functionality of the problem behavior" 3. "Interventions that can be justified by the outcomes" 4. "Outcomes that are acceptable to the individual, the family, and the supportive community" (p. 116). It goes beyond one approach - reducing challenging or impeding behavior - to multiple approaches: changing systems, altering environments, teaching skills and focusing on positive behavior." The information above is designed to provide solely an overview of Positive Behavioral Support (PBS). Those interested should study the topic in much more detail, as the philosophy and practice can be quite complex.
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