Case Analysis – Integrating Theoretical Orientations Prior to beginning this assignment, read the PSY650 Week Two Treatment Plan , Case 16: Attention-Deficit/Hyperactivity Disorder in Gorenstein and

Theory Into Practice, 50:35–42, 2011 Copyright © The College of Education and Human Ecology, The O hio State University ISSN: 0040-5841 print/1543-0421 online DOI: 10.1080/00405841.2011.534935 George J. DuPaul Lisa L. Weyandt Grace M. Janusis ADHD in the Classroom:

Effective Intervention Strategies School-related dif culties are commonly associ- ated with attention de cit hyperactivity disorder (ADHD). This article describes effective school- based intervention strategies including behav- ioral interventions, modi cations to academic instruction, and home-school communication programs. One overlooked aspect of treatment of children with ADHD is the need to form partner- ships among school professionals who can work collaboratively on interventions for children with ADHD. Approaches to developing effective col- laboration between teachers and school psychol- George J. DuPaul is a professor in the College of Education at Lehigh University; Lisa L. Weyandt is a professor in the Department of Psychology at the University of Rhode Island; Grace M. Janusis is a doctoral student in the School Psychology Program at the University of Rhode Island.

Correspondence should be addressed to Professor George J. DuPaul, Department of Education and Hu- man Services, Lehigh University, 111 Research Drive, Bethlehem, PA 18015. E-mail: [email protected] ogists are presented. Multiple treatment strate- gies implemented in a consistent fashion across school years can optimize the school success of students with ADHD.

A T T E N T I O N D E FI C I T H Y PE R AC T I V I T Y disorder (ADHD) is characterized by pervasive and developmentally inappropriate dif culties with attention, impulsivity, and hyperactivity (American Psychiatric Association, 2000). ADHD symptoms cause signi cant impairments at home and in school and are associated with a number of behavior dif culties such as aggression and noncompliance (Barkley, 2006). Research also suggests that children with ADHD are more likely than typically developing classmates to be rejected socially and to have greater dif culties with their peers (Hinshaw, 2002). In addition, teachers are more 35 Current Perspectives on Learning Disabilities and ADHD likely to perceive a child with an ADHD label less favorably with respect to intelligence, personality, and behavior (Batzle, Weyandt, Janusis & Devietti, 2010).Academically, children with ADHD are more likely to have poorer grades, lower scores on standardized tests, greater likelihood of identi- cation for special education, and an increased use of school-based services, compared to peers without the disorder (Loe & Feldman, 2007).

Students with ADHD are also more likely to have a higher absenteeism rate, are three times more likely to be retained during elementary school, and are at a higher risk for dropping out of high school than their peers without ADHD (Barbaresi, Katusic, Colligan, Weaver, & Jacobsen, 2007). Students with ADHD who graduate from high school are less likely than their peers to pursue a post-secondary educa- tion (DuPaul & Weyandt, 2009). Interestingly, less research is available concerning methods to remediate academic problems associated with ADHD, compared to studies regarding ways to treat behavioral and social dif culties associated with the disorder (Jitendra, DuPaul, Someki, & Tresco, 2008). Given the less-than-favorable prognosis for children with ADHD, it is im- perative that empirically supported interventions are implemented early, particularly during the elementary school years. The most common interventions for students with ADHD include psychotropic medication and behavioral strategies implemented in home and school settings (Barkley, 2006). Although stimulant medication frequently is used to re- duce ADHD symptoms, pharmacological treat- ment rarely is suf cient in addressing the mul- tiple, chronic dif culties faced by students with ADHD (DuPaul & Stoner, 2003). The purpose of this article is to describe effective school- based intervention strategies for children with ADHD including behavioral interventions, mod- i cations to academic instruction, and home- school communication programs. Also discussed are approaches to developing partnerships among school professionals including methods to facili- tate collaborative relationships between teachers and school psychologist consultants. Behavioral Interventions Behavioral interventions for students with ADHD include both antecedent- and consequence-based strategies. Impaired delayed responding to the environment is the putative core de cit underlying ADHD (Barkley, 2006).

Behavioral interventions involve modi cations to the environment that directly address this impairment. A variety of antecedent- based interventions have been used to try to prevent inattentive and disruptive behaviors from occurring. Antecedents are events that precede and may trigger the occurrence of a speci c behavior. First, teachers can post and strategically review classroom rules (DuPaul & Weyandt, 2006). Rules should be few in number, phrased in a positive manner (i.e., tell students what to do, not just the behaviors to avoid), and posted in full view of all students. Rules should be clearly explained at the beginning and periodically throughout the year. Further, teachers should frequently praise students who are following the classroom rules. Children with ADHD may need to have rules posted in closer proximity (e.g., printed on an index card af xed to their desk) and should be provided with more frequent praise when following rules (P ffner, Barkley, & DuPaul, 2006). Another antecedent-based strategy frequently recommended for students with ADHD is to reduce task demands by modifying the length and/or content of assignments (DuPaul & Stoner, 2003). Reducing the length of an assignment to match students’ attention spans, may reduce off-task, disruptive behavior. This strategy of- ten is paired with teacher praise contingent on task completion. As students demonstrate success with shorter assignments, the length of assign- ments can be gradually increased thereby shaping task-related behavior to match classroom norms. A nal example of an antecedent-based strat- egy is to provide students with task choices when given classwork assignments. Choice-making in- terventions allow students to choose among two or more concurrently presented options (e.g., as- signments to complete, sequence of steps within an assignment, or partners for assigned activ- 36 DuPaul, Weyandt, JanusisADHD in the Classroom: Effective Intervention Strategies ities). The various options should all lead to similar outcomes; for example, students could choose an assignment from a menu of possible assignments all of which involve practice of the same speci c academic skill. Dunlap et al.

(1994) examined the effects of choice-making for several students with disruptive behavior disor- ders and ADHD. When students were provided with assignment choices, they showed higher rates of task engagement and lower frequency of disruptive behavior relative to class sessions when teachers chose the speci c assignments. Consequence-based strategies involve manip- ulating environmental events following a speci c behavior to alter the frequency of that behavior.

Several consequence-based strategies have been examined for students with ADHD including contingent positive reinforcement, response cost, and self-management interventions (DuPaul & Weyandt, 2006). The most common behavioral intervention for ADHD, at least in the research literature, is the use of contingent positive rein- forcement in the form of teacher praise or token reinforcement (DuPaul & Stoner, 2003). In such programs, students gain access to praise or token reinforcement when they exhibit speci c target behaviors (e.g., completion of assigned work).

Token reinforcers (e.g., poker chips, stickers, points) are exchanged later in the day or week for access to preferred activities (e.g., computer game, running errand for teacher) or other re- wards. Several guidelines should be followed in using reinforcement-based interventions with students with ADHD (DuPaul & Stoner, 2003; P ffner et al., 2006). First, reinforcement should be provided as frequently as possible, given that children with this disorder may experience dif- culties demonstrating consistent behavior under conditions of partial reward or intermittent rein- forcement schedules. Second, rather than assum- ing that a speci c reward will be motivating for a speci c child, rewards should be individual- ized based on student preferences and interests.

Further, speci c rewards should be rotated or varied over time so that children do not become bored or complacent with the same reinforcers.

Finally, reinforcement should be provided as close as possible in time to the occurrence of a target behavior (i.e., provided as immediately as possible following a desired behavior).

Response cost is an example of a consequence-based intervention in which token reinforcers are removed contingent on disruptive, off-task behavior. Response cost should be used in situations where positive reinforcement alone has not suf ciently ameliorated problem behavior. For example, a token reinforcement program may lead to increases in on-task behavior but there may still be situations when off-task, disruptive behavior is evident or the increases in on-task behavior may not be consistent across time. In most cases, response cost is implemented in conjunction with a token reinforcement program such that students are eligible to receive or lose tokens based on their behavior or work performance. Several studies (e.g., DuPaul, Guevremont, & Barkley, 1992) have demonstrated clinically signi cant improvements in task-related attention, as well as productivity and accuracy of classwork, when the combination of token reinforcement and response cost is used. Time-out from positive reinforcement is an- other strategy sometimes used to reduce problem behaviors (P ffner et al., 2006). This procedure involves brie y removing the student to a sepa- rate part of the classroom or outside the class- room following disruptive behavior. Of course, the ef cacy of time-out is solely dependent on whether the classroom is viewed as a positive environment by the student; otherwise time-out can actually reinforce (or increase the probability of) problematic behaviors. In addition, time-out should be used judiciously and only in combi- nation with a mostly positive behavior support program.

Self-Regulation Interventions Self-management (or self-regulation) inter- ventions encourage students with ADHD to mon- itor, evaluate, and/or reinforce their own be- haviors, often in conjunction with or following the successful application of teacher-mediated 37 Current Perspectives on Learning Disabilities and ADHD behavioral approaches. As is the case for be- havioral interventions, self-regulation strategies directly address the impaired delayed responding that theory has posited to be the core de cit underlying the disorder. As an example of self- regulation, students with ADHD may be taught to evaluate their classroom behavior and work performance at regular intervals using a Likert scale (ranging frompoortoexcellent ). Teachers use the same Likert scale to evaluate student per- formance. Students then receive reinforcement depending on their self-evaluated performance and the degree to which self-evaluation ratings match teacher ratings. As students demonstrate success in matching teacher ratings and improv- ing classroom behavior, the frequency of required matches to teacher ratings is gradually reduced, and eventually only self-ratings are used. A recent meta-analysis showed that self-evaluation and other self-regulation interventions lead to relatively large, positive effects on the on-task behavior and academic performance of students with ADHD (Reid, Trout, & Schartz, 2005). A particularly effective and feasible strategy is to teach students with ADHD to monitor their own behaviors. Sometimes the act of consistently monitoring behavior results in improvements. For example, Gureasko-Moore, DuPaul, and White (2007) found that training several middle school students with ADHD to monitor their homework and classroom preparedness led to quick and durable improvements in organizational skills.

Self-monitoring has been used successfully to promote other behaviors (e.g., on-task, classwork completion) and with a variety of age groups; this is a particularly effective strategy for students with milder levels of ADHD (for review, see Reid et al., 2005).

Academic Interventions Although stimulant medication and behav- ioral interventions typically lead to signi cant reductions in ADHD symptoms and improve- ments in classroom behavior, these treatments have minimal effect on academic achievement (DuPaul & Stoner, 2003). Thus, interventions that directly address academic skills are needed for many students with this disorder. One effec- tive academic intervention is to provide teacher- mediated direct instruction in relevant skills that require remediation. For example, Evans, Pel- ham, and Grudberg (1995) showed that middle school students with ADHD showed improved note-taking and test performance following direct instruction in taking notes during teacher instruc- tion. Academic interventions can also be deliv- ered through computer technology and classroom peers. Several studies have shown that computer- assisted instruction in math (Mautone, DuPaul, & Jitendra, 2005) and reading (Clar eld & Stoner, 2005) leads to signi cant improvements in on- task behavior and academic performance for students with ADHD relative to written seatwork conditions. Similarly, classwide peer tutoring in math, reading, or spelling can be used to enhance task engagement and test performance for all stu- dents, not just those with ADHD (e.g., DuPaul, Ervin, Hook, & McGoey, 1998). The combina- tion of academic intervention and self-regulation strategies may actually promote maintenance and generalization of academic skills gains beyond teacher-, computer-, or peer-mediated interven- tions, although this premise has yet to be demon- strated empirically.

Home–School Communication Programs Given that children with ADHD experience signi cant dif culties across settings, home– school communication programs are important components of a comprehensive treatment plan.

A daily report card system is an example of an effective home–school communication pro- gram. Daily report cards (DRCs) are one of the most frequently implemented interventions for children with ADHD, and several studies have documented their effectiveness when used as a component in a multimethod intervention (e.g., Owens et al., 2005). DRCs incorporate ongoing feedback to students and parents re- garding classroom performance and can target a variety of important behaviors (e.g., work 38 DuPaul, Weyandt, JanusisADHD in the Classroom: Effective Intervention Strategies completion, academic performance, participation in class, getting along with classmates). Typi- cally, a DRC contains a list of 3 to 5 goals (e.g., complete assigned classwork, get along with classmates) on which teachers indicate a student’s performance on a Likert scale (e.g., 1 represents superior performance and 5 represents unacceptable performance ). Teacher ratings are provided throughout the day (e.g., by academic class period) and parents then provide home- based reinforcement based on these ratings. As students make progress, goals are increased in complexity. DRC programs have been successful in enhancing classroom behavior and academic performance of students with ADHD, particularly those with milder levels of symptom severity (Murray, Rabiner, Schulte, & Newitt, 2008).

Interventions Addressing SocialRelationship Dif culties Children with ADHD often experience dif - culties with peer relationships, including mak- ing and keeping friends (DuPaul & Weyandt, 2006; Weyandt, 2007). Further, children with this disorder are more likely than their classmates to respond to interpersonal problems in an ag- gressive manner. Given the frequent association of ADHD with social relationship dif culties, interventions designed to address peer relations must be implemented for a suf cient duration to counteract the high risk for problematic outcome.

Unfortunately, interventions that target social knowledge and the acquisition of prosocial be- haviors in group therapy formats (i.e., traditional social skills training) have not been found to lead to durable changes in interpersonal functioning in real-world environments (Gresham, 2002). The lack of maintenance and generalization of tradi- tional social skills training has led to proposals for a more comprehensive approach to social relationship intervention for children with dis- ruptive behavior disorders (for a review of social skills strategies, see Gresham, 2002). Relatively few studies of social relationship interventions for children with ADHD have been conducted, especially in school settings. Most prior investigations of social skills training have been conducted in outpatient clinic settings with minimal school outcome data beyond teacher ratings. Results of these clinic-based studies are equivocal with respect to ef cacy (e.g., P ffner & McBurnett, 1997). Outcomes of these interven- tions are enhanced when speci c strategies are included to program for maintenance and gener- alization of effects. For example, peers without ADHD could be involved in all phases of a social relationship intervention to encourage generality of outcomes.

Collaborative Consultation Developing positive partnerships among school professionals through collaboration can also increase the likelihood of treatment success (DuPaul & Stoner, 2003). Collaborative consultation can improve school functioning outcomes and academic achievement (e.g., DuPaul et al., 2006). Collaborative consultation involves an equal partnership between two partners (e.g., school psychologist and classroom teacher) to de ne a problem and develop interventions. This model is in contrast to the traditional, expert model of consultation where a school psychologist prescribes interventions based on teacher input (Erchul & Martens, 2002).

An example of an effective partnership model is Project PASS (Promoting Academic Success in Students) that uses a collaborative consultation model between teachers and school psychologist consultants to design academic interventions for children with ADHD. DuPaul and colleagues (2006) found that consultation-based academic interventions may enhance reading and math skills for children with ADHD. Academic improvements were noted for students whose teachers received two different intensity levels of consultation. Collaborative consultation can vary in inten- sity with respect to the amount of data collected to design and evaluate interventions, as well as the degree to which consultants monitor teachers with respect to accuracy of treatment imple- mentation. All models include four core steps 39 Current Perspectives on Learning Disabilities and ADHD that involve school psychologists and teachers jointly de ning the academic problem(s), dis- cussing possible interventions (all of which are empirically supported), choosing an intervention plan that teachers believe to be feasible and effective, and evaluating the success of the plan so that modi cations can be made, if necessary.

Several studies have demonstrated that regardless of intensity, collaborative consultation leads to effective academic interventions for the majority of students with ADHD (e.g., DuPaul et al., 2006). The most effective outcomes are found when teachers take the lead during the problem identi cation stage of the collaborative relation- ship and when consultants lead when possible strategies to address problems are discussed and designed (Erchul et al., 2007; Erchul et al., 2009).

Stated differently, in most collaborative con- sultation relationships, teachers are the experts regarding their classroom, curriculum, and the target student’s dif culties, while the consultant typically is the expert regarding empirically- supported interventions to address student dif- culties. The most successful outcomes occur when there is reciprocal recognition of these complementary areas of expertise.Conclusions School-based interventions are a critical com- ponent to a comprehensive treatment plan for students with ADHD. These strategies are use- ful adjuncts to psychotropic medication and/or home-based behavioral interventions particularly in terms of directly addressing academic and behavioral functioning in classroom settings. In fact, the optimal treatment plan will include the combination of home- and school-based behav- ioral strategies, possibly in combination with psy- chotropic medication (Barkley, 2006; DuPaul & Stoner, 2003). There are three important princi- ples to consider when designing and implement- ing school-based interventions for this population (DuPaul & Weyandt, 2006). First, treatment plans should be balanced by including both proac- tive (i.e., antecedent-based) and reactive (i.e., consequence-based) behavioral interventions. It is unlikely that a singular focus on antecedent or consequent events will be suf cient in addressing the behavioral dif culties exhibited by students with this disorder. Further, many antecedent- based strategies have the additional advantage of directly addressing academic functioning. Sec- ond, assessment data should be used to design, evaluate, and modify interventions within and across school years. Assessment-based interven- tions presumably will be more effective and time-ef cient than using strategies on a trial- and-error basis. Finally, multiple mediators (e.g., peers, computer technology, and students with ADHD) should be used to deliver treatment so that classroom teachers are not asked to shoulder all of the responsibility for intervention. The use of collaborative consultation in choosing and developing classroom interventions can optimize the implementation of interventions across mul- tiple mediators. Although many effective school- based interventions are available to address the needs of students with ADHD, it is clear that more research is needed particularly with respect to the functioning of secondary school students with this disorder.

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