New CDC Report: Why Behavioral Interventions at Home and
School are Needed to “Add Value” Even When the Medication “is Working”
Dear Colleague,
According to the American Psychiatric
Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-V),
students with Attention Deficit Hyperactivity Disorder (ADHD) “show a
persistent pattern of inattention and/or hyperactivity-impulsivity that
interferes with functioning or development.”
There are three types of ADHD:
* Predominantly Inattentive Presentation
is identified when 6 (or more) out of 9 specific Inattention symptoms
are present (for children), or 5 (or more) out of the same 9 symptoms for
adolescents; and an insufficient number of Hyperactive-Impulsive
symptoms (see these symptoms below).
* Predominantly Hyperactive-Impulsive
Presentation is identified when 6 (or more) out of 9 specific Hyperactive-Impulsive
symptoms are present (for children), or 5 (or more) out of 9 of the same
symptoms for adolescents; and an insufficient number of Inattention
symptoms (see these symptoms below).
* Combined Presentation is identified
when enough Inattention and Hyperactive-Impulsive symptoms are both present.
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Critically: All of the symptoms must be present for at
least 6 months (some must be present before age 12); they must be
developmentally inappropriate for the child’s age; they must be present in two
or more different settings; they must interfere with (or reduce the quality) of
the student’s social, school, or home functioning; and they cannot be better
explained by another psychological disorder.
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The Inattention symptoms are:
* Often fails to give close attention to
details or makes careless mistakes in schoolwork, at work, or with other
activities.
* Often has trouble holding attention on
tasks or play activities.
* Often does not seem to listen when spoken
to directly.
* Often does not follow through on
instructions and fails to finish schoolwork, chores, or duties in the workplace
(e.g., loses focus, side-tracked).
* Often has trouble organizing tasks and
activities.
* Often avoids, dislikes, or is reluctant to
do tasks that require mental effort over a long period of time (such as
schoolwork or homework).
* Often loses things necessary for tasks and
activities (e.g. school materials, pencils, books, tools, wallets, keys,
paperwork, eyeglasses, mobile telephones).
* Is often easily distracted.
* Is often forgetful in daily activities.
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The Hyperactivity and Impulsivity
symptoms are:
* Often fidgets with or taps hands or feet,
or squirms in seat.
* Often leaves seat in situations when
remaining seated is expected.
* Often runs about or climbs in situations
where it is not appropriate (adolescents or adults may be limited to feeling
restless).
* Often unable to play or take part in
leisure activities quietly.
* Is often "on the go" acting as
if "driven by a motor.”
* Often talks excessively.
* Often blurts out an answer before a
question has been completed.
* Often has trouble waiting his/her turn.
* Often interrupts or intrudes on others
(e.g., butts into conversations or games).
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Spoiler Alert: All ADHD
Students are NOT Alike and Interventions should Focus on Changing
Behaviors, NOT “Treating” the Label
Given the information above, it is
critical to emphasize two major conclusions.
Conclusion 1: Not all ADHD Students are Alike. Knowing that students do not have to
exhibit all of the symptoms in the Inattention and Hyperactive-Impulsive
lists, it is essential to know exactly
which behaviors any specific ADHD student is having difficulties with.
Thus, if a teacher (God forbid) had five
ADHD students in her class, she would likely be interacting with five
different students with five different assortments of ADHD symptoms.
If this teacher did not know which
symptoms were associated with each student, she would not fully
understand how to approach each student.
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Conclusion 2: Any interventions being implemented with
any ADHD student must focus on the behaviors that- - for that
student- - are the underlying reasons for the diagnosis.
(Not to complicate matters further, but some
students with ADHD exhibit different concerning behaviors in different
settings- - and this must also be recognized.)
Thus, for our classroom (above) with five
different ADHD students, the behavioral interventions for each student
will be “targeted” to the specific symptoms exhibited separately by each
student. In all probability, then,
these five students may be receiving some similar, but some different
targeted interventions.
In summary: The ADHD label does not determine the
interventions. Instead, the symptoms and why they are functionally occurring
determine the interventions.
Parenthetically, many of the school-based
interventions require the expertise of your behavioral intervention/mental
health professionals (e.g., school psychologists, counselors, social workers,
special education teachers, OT/PTs, nurses).
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What Interventions Do Most ADHD Students
Receive? Preschool through High School
Last month (May 3, 2016), the Center for
Disease Control (CDC) published a Press Release, More Young Children with
ADHD Could Benefit from Behavior Therapy:
Behavior therapy recommended before medicine for young children with
ADHD.
[CLICK HERE for the Press Release]
The Release began by noting that
about 2 million of the more than 6 million children in this country with ADHD
are diagnosed before age 6.
The Release then reported the
following information based on the 2008 to 2011 Medicaid healthcare claims from
at least 5 million children from 2 to 5 years old, and another 1 million young
children insured from 2008 to 2014 through employer-sponsored insurance (ESI)
programs:
* In both groups, just over 75% of these
young children diagnosed with ADHD received ADHD medication.
* Only
54% of the children with Medicaid and 45% of the children with ESI programs
received any form of psychological services- - which might have included parent
training in behavior therapy.
* The percentage of parents receiving
psychological services did not increase over time (i.e., from 2008 to 2011, or
2008 to 2014, respectively).
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The Release noted that:
“Parents
do not cause their child’s ADHD, but parents can play a key role in the
treatment of ADHD. In behavior therapy, parents are trained by a
therapist during eight or more sessions, learning strategies to encourage
positive behavior, discourage negative behaviors, improve communication, and
strengthen their relationship with their child. When applied, these skills can help the child
at school, at home, and in relationships by improving behavior, self-control,
and self-esteem. Learning and practicing behavior therapy requires more time,
effort, and resources than treating ADHD with medicine, yet research shows that
there are lasting benefits making it worth the investment.”
Indeed, the American Academy of Pediatrics (AAP) and the American
Academy of Child and Adolescent Psychiatry (AACAP) have been on record
since 2011 and 2007, respectively, as recommending ADHD treatments that include
both behavior therapy and medication.
[CLICK HERE for the AAP Report]
[CLICK HERE for the AACAP Report]
In fact, the 2011 AAP Report recommends:
* For Preschool-aged Children- - “Evidence-based parent- and/or
teacher-administered behavior therapy as the first line of treatment, (and
medication) if the behavior interventions do not provide significant
improvement and there is moderate-to-severe continuing disturbance in the
child’s functioning.”
* For Elementary-aged Children- - “(A)pproved medications for
ADHD, and/or evidence-based parent- and/or teacher-administered behavior
therapy as treatment for ADHD, preferably both. . .”
* For Adolescents- - “(A)pproved medications for ADHD with the
assent of the adolescent, and may prescribe behavior therapy as treatment for
ADHD.”
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And yet, as in the CDC Press Release above, this is not
happening- - at least for preschoolers.
But it is not happening for school-aged students either.
Relative to elementary- and secondary-level students, a 2014 National Center for
Health Statistics
study reported that 4.2% of U.S. children between ages 6 and 17 were taking psychostimulant
medication in 2013, and that there was a five-fold increase in students
taking these medications from 1988-1994 to 2007–2010.
At the news conference last month highlighting the News Release, Dr.
Anne Schuchat, the Principal Deputy Director at the CDC stated:
“Behavior therapy has been shown to help improve symptoms in young
children with ADHD and can be as effective as medicine, but without the side
effects.”
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What Can Schools Do ?
At the very most, most students
with ADHD are not receiving the recommended treatment protocol that includes
(or leads with) behavior therapy.
Critically: With the right behavior therapy
interventions, some students with ADHD may actually not need medication. However, when medication is used and
“works,” it only opens the “window of learning”- - it does not do the
instruction.
That is, while medication may help a student
to slow down and improve attention, students still need to be taught the social,
emotional, and behavioral self-management skills needed to be successful in
different settings. Ultimately,
these self-management skills are the goals of the behavior therapy
program/interventions.
At the very least (continuing from
above), we may be over-medicating many young children and students with ADHD- -
or, at least, we may not be reaping or maximizing (in the absence of the
complementary behavior therapy) the positive potential of medication.
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So. . . What should/can schools do?
1. Schools need to know (within the boundaries
of HIPAA) which students have been diagnosed with ADHD; which students are
receiving medication, behavior therapy, or both; and what medications (if
relevant) are being taken (how and when).
This can be accomplished through parent self-reports,
enrollment documentation, cumulative record reviews, or by touching bases with
the school nurse, counselor, school psychologist, social worker, or building
principal.
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2. School personnel should not assume that
parents know what the recommended ADHD treatment protocols are.
Thus, parent newsletters or web-posts,
individual parent contacts (with written documentation and website links), or
information sessions by a local doctor at back-to-school or first parent/PTA
meetings should be considered.
Regardless of the information vehicle, this should occur at the
beginning of every new school year.
Parenthetically, an annual contact with
parents who have ADHD students (perhaps, by the school nurse) is strongly
recommended so that the school has the most updated behavioral, medical, and
other relevant information needed at the beginning of the school year.
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3.
Schools should know what school and district staff (especially mental
health staff) have assessment and/or intervention expertise with ADHD students.
They also should know what resources (e.g.,
agencies, professionals, advocacy groups) are available in the community,
region, state, and on-line.
When parents are not using
community-based professionals to guide the behavior therapy process, the
school should offer its school or district personnel to help develop and
implement school- and home-based services, supports, and interventions.
When parents are using community-based
professionals and give permission, school mental health staff need to
collaborate with those professionals. Indeed,
it is essential that the behavior therapy approaches being used by the
community-based professional for a specific student are consistent with
those being used in the school.
The worst case scenario is having a
student who is receiving competing, confusing, or inconsistent behavior therapy
interventions at home, in school, and/or out in the community.
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4. With
parent permission and release, school personnel also need to collaborate with
the attending physician or medical professional treating specific students.
Doctors need to know what behavioral
interventions are being used with a student (for documentation and, once again,
for consistency’s sake). But, at the
beginning of a (new) medication trial, doctors also need to receive
behavioral feedback from school staff.
Significantly, the choice of an ADHD
medication, the dosage, and the time when it is taken during the day involves
both science and art. While the doctor
is guided by science in determining these three factors, all three may be
adjusted as a function of how the student responds to the intervention.
Without
feedback- - from both home and the school- - the doctor can only assume
that his/her clinical decisions were correct.
But if the intended effects of the medication are not occurring in the
school- - and no behavioral feedback is provided to the doctor- - then no
adjustments will be made.
This situation does not help anyone- - the
student, the parents, or the school.
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5. Schools
need to make sure that their 504 assessment and intervention processes are
established and working well. Among the
available accommodations, schools need to have a range of assistive supports
that are tailored to specific student needs.
Indeed, many students with ADHD need
specific accommodations in order to “factor out” or “neutralize” the effects of
their ADHD. These accommodations often
are instrumental in helping these students with their learning, mastery, and
academic success.
However,
as emphasized earlier, the specific accommodations that a student with
ADHD receives should be matched to the specific
behaviors of concern.
In other words, different students
with ADHD should not be receiving the same “package” of
accommodations. ADHD is not a “one
size fits all” issue- - interventions must be linked to the behavioral concerns
and the reasons why they exist.
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6. Expanding
on #5: Functional assessments should
be completed as a part of the intervention process. This is because:
* Some ADHD behaviors are conditioned (think Pavlov). Many ADHD students’ impulsive behaviors
(e.g., blurting out answers) are classically conditioned. That is, they are involuntarily triggered in
the mid-parts of the brain- - without conscious or motivated intent. Interventions for these behaviors required clinical
reconditioning- - often done by psychologists or other mental health professionals
who have this training.
* Some ADHD behaviors involve skill deficits (that is, the
students have not learned and mastered these skills).
For example, students need to be taught the
specific steps and behaviors related to (for example) listening, following
directions, how to interrupt, and how to wait your turn (see the ADHD symptoms
above)- - just like they are taught math or reading skills.
Indeed, skill instruction and mastery
always needs to precede motivational strategies or interventions. Said another way, “You can’t motivate a student
out of a skill deficit.”
* Finally, some ADHD behaviors involve performance deficits (that is,
students can demonstrate the desired behaviors, they simply are
choosing not to).
For example, some students say that they
cannot “control” their ADHD behavior when they are not on medication. And yet- - if they have successfully received
behavioral training- - they sometimes can control certain
behaviors.
This is a motivational issue. Ultimately, it involves having the right mix
of both incentives and consequences (that are meaningful and powerful to an
individual student) that motivate the student “to make a good choice”- - along
with adults who consistently hold the student accountable for the demonstrating
appropriate behavior.
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7.
Next, schools need to train all of their teachers in the classroom-based
strategies, accommodations, and interventions that may be needed for different
students with ADHD.
Indeed, if there are 6 million students with
ADHD within the approximately 50 million students currently attending U.S. public
schools (about 3%), if 4.2% of U.S. children between ages 6 and 17 are taking psychostimulant
medication (as reported above in 2013), and if there are countless other
students in our classrooms who are demonstrating attention-related behaviors
(that do not rise to the level of an ADHD diagnosis), whole-staff teacher
training in these areas only makes sense.
This is especially the case when we also
know that most teachers have had precious little classroom management training
(even for “typical” students) in their teacher training programs.
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8.
Finally, schools (with their parents) need to educate students with ADHD
about their ADHD.
Very often, these students have never been
told about the biology, beliefs, behaviors, and behavioral interventions
related to ADHD. This “education” may go
a long way in helping these students to understand that we understand
what they are experiencing, and how we are trying to help.
This should not be a “one-time
discussion.” The discussions should be
ongoing. . . and they may be supplemented by an “ADHD Support Group” led by a
school counselor or social worker.
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Summary
In the end, schools- - with parents as full
partners- - need to take a systematic approach to supporting students with
ADHD. As emphasized here, the focus should
be on accommodating for and/or changing the ADHD behaviors - - not focusing on
or stereotyping the ADHD label. Moreover,
interventions should be based on student-specific discussions, student-centered
functional assessments, and student-supporting partnerships both within the
school, as well as with physicians and community-based practitioners.
I understand that many schools have many students with ADHD- - and that
these students can be frustrating and may take up a lot of time. But I also know that- - with the right
intervention protocols- - these students can be incredibly successful, and that
they can learn and behave like every other student in our diverse classrooms.
Together, we need to look at these students’ needs. We need to look at what we are doing, and
what is working and not working. . . as well as what we are not doing and need
to do. The upcoming beginning of the school
year gives us a great opportunity to “recalibrate the system.” I hope you will take advantage of this
opportunity.
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I
hope that today’s message motivates you to think about these students, and to take
a look at what your own school, district, or community is doing.
As always, I look forward to your thoughts
and comments. Feel free to contact me at
any time, and remember to look at my website (www.projectachieve.net) for the many free resources that are available there.
Let me know how I can help you further. Feel free to forward this Blog link to your
colleagues.
Best,
Howie
