0 - Cover - ADHD · 2015-01-13 · ADHD: What Every Parent Needs to Know (formerly entitled ADHD: A Complete and Authoritative Guide) is a balanced guide to help you and your child

ADHD

Proactive in your child’s care.

Empowering families for over 50 years.

Please take the time to read through this material. We provide this information because

we see value in educating our patients.

Mansfield Office454 Chauncy StreetMansfield, MA 02048

(508) 339-9944

Westwood Office541 High Street

Westwood, MA 02090(781) 326-7700

www.wmpeds.com

A Word about ADHD Medications and Your Child

Most parents, when bringing their children in to discuss ADHD, are against a trial of medication for their 5-7 year old.

However, if their child has been untreated, they often return when he or she is in 4th or 5th grade and are

experiencing school failure. At that point, parents want to trial medication and are often frustrated with the time it

takes to find the right dose of the right medication. The goal of all ADHD therapy is to improve school performance

and sustain a child's self-esteem. You and your spouse must be clear on what the goals are for your child and

how you want to reach them - be it with behavioral intervention or with medication.

When trialing medications, parents must realize that the process of finding which medication works best for their

child may take several months (either changing the brand or adjusting the dose). With these medications, we are

weighing the effects with the side effects and always looking for the maximal benefit for the child. For

example, almost all children started on Ritalin or other stimulant medications will lose weight the first few

months, but this may be acceptable if they are doing better in school. Addiction is rare.

Basically we use two types of medicines both in long--acting forms-- stimulants and non- stimulants.

Stimulants: Stimulants are amphetamine based medications

• Ritalin LA (capsule can be opened and put into food)

• AdderalXR (capsule can be opened and put into food)

• Concerta (pill)

• Vyvanse

• Daytrana (patch)

The most common side effects from this class of medications are weight loss, decreased appetite, and sleep issues.

You must trial the medication for a length of time to assess some side effects as many will resolve with time. Once off

the medication, side effects quickly resolve. Though addiction potential is low, abuse can occur, especially in high

school and college when someone wants to stay up all night to study. Because the effect of stimulants is

immediate and does not last longer than a day, we have the option of giving medications daily or just during

the school week.

Non-Stimulants:

• Strattera (pill form)

• Intuniv

The most common side effect is sleepiness. Often this medication is taken at night to offset this. Decreased appetite

may also occur, but less so than with the stimulants. The disadvantages to these medications are that they must

be taken every day and it takes about 2-4 weeks before they reach full effect.

ONCE YOUR CHILD IS ON THE PROPER DOSE WE EXPECT TO SEE YOU 3 TIMES PER SCHOOL YEAR AT WHICH TIME

WE NOT ONLY WRITE THE PRESCIPTION BUT DISCUSS YOUR CHILD'S SCHOOL AND SOCIAL PERFORMANCE

1/2012


(508) 339-9944


Westwood, MA 02090(781) 326-7700

www.wmpeds.com

Recommended Book & Suggested References

ADHD: What Every Parent Needs to Know

By: Michael Reiff, MD

ADHD: What Every Parent Needs to Know (formerly entitled ADHD: A Complete

and Authoritative Guide) is a balanced guide to help you and your child meet

the many challenges of the often misunderstood disorder. This invaluable

resource provides accurate, up-to-date information on

ADHD: A Complete and Authoritative GuideBy Michael Reiff, MD, Sherill Tippins

This comprehensive guide to attention deficit/hyperactivity disorder (ADHD)

offers parents balanced, reassuring, and authoritative information to help

them understand and manage this challenging and often misunderstood

condition. Based on the American Academy of Pediatrics' own clinical practice

guidelines for ADHD and written in clear, accessible language, this book

answers the common questions: How is ADHD diagnosed? What are today's

best treatment options? and Will my child outgrow ADHD? Accurate, up-to-date

findings on evaluation and diagnosis, coexisting conditions, and unproven

treatments are provided. Also addressed are behaviors associated with the

teenage years and what schools can do to support children with the condition.

ADHD management strategies that balance the roles of behavior therapy,

medications, and parenting techniques are suggested.

Suggested Reading & References

Parents:• All Kinds of Minds: A Young Student’s Book about Learning Abilities and Learning

Disorders, by Melvine Levine, M.D.

• A Mind at a Time, by Melvine Levine, M.D.

• A Call to Character: A Family Treasury of Stories, Poems, Plays, Proverbs, and Fables to

Guide the Development of Values for You and Your Children, by Colin Greer (Editor),

Hervert Kohl (Editor), a family reader

• ADD/ADHD Behavior-Change Resource Kit: Ready-To-Use strategies & Activities for

Helping Children With Attention Deficit Disorder, by Grad L. Flick, Ph. D.

• Drive to Distraction: Recognizing and Coping With Attention Deficit Disorder from

Childhood Through Adulthood, by Edward M. Hallowell and John J. Rate

•


(508) 339-9944


Westwood, MA 02090(781) 326-7700

www.wmpeds.com

• Girl in the Mirror: Mothers and Daughters in the Years of Adolescence, by Nancy L.

Snyderman and Peg Streep

• Hyperactivity: Why Won’t My Child Pay Attention?, By Sam Goldstein, Ph. D. and Michael

Goldstein, M.D., video and/or book

• Life on the Edge: Parenting a Child With ADD/ADHD, by David Spohn

• Raising Resilient Children : Fostering Strength, Hope, and Optimism in Your Child, by

Robert Brooks, and Sam Goldstein

• Taking Charge of ADHD, Revised Edition, by Russell A. Barkley

• Teenagers with ADD: A Parent’s Guide, by Chris Ziegler Denoy

GIVE YOUR TEENAGERS A CHANCE!

Children, Adolescents and College Students:• Adolescents and ADD, by Patricia O. Quinn, M.D.

• ADD and The College Student, by Patricia O. Quinn, M.D.

• I Would If I Could: A Teenagers’ Guide to ADHD/Hyperactivity, by Michael Gordon

• Eagle Eyes: A Child’s Guide to Paying Attention (ages 5-12), by Jeanne Gehret, M.A.

• Distant Drums, Different Drummers: A Guide for Young People with ADHD (ages 8-14), by

Barbara Ingersoll, Ph. D.

• Help 4 ADD at High School (ages 14-19), by Kathleen Nadeau Ph. D.

• Jumpin’ Johnny, Get Back to Work: A Child’s Guide to Hyperactivity (ages 6-10), by Michael

Gordon

• Learning to Slow Down and Pay Attention (ages 6-12), by Kathleen Nadeau and Ellen

Dixon

• Many Ways to Learn: Young Peoples Guide to Learning Disabilities (ages 8-13), by Judith

Stern, M.A. and Uzi Ben-Ami, Ph. D.

• My Brother’s a World Class Pain: A Sibling’s Guide to ADHD (ages 8-14), by Michael Gordon

• Otto Learns About His Medicine (ages 5 –10), by Matthew Galvin, M.D.

• Putting on the Brakes: Young People’s Guide to Understanding Attention Deficit

Hyperactivity Disorder (ages 8-13), by Patricia O. Quinn, Judith M. Stern, Neil Russell

(illustrator)

• “The Putting on the Brakes”, Activity Book for Yong People With ADHD (ages 8-13), by

Patricia O. Quinn, Judith M. Stern, Neil Russell (illustrator)

• Shelly the Hyperactive Turtle (ages 4-8), by Deborah Moss

• Succeeding in College with Attention Deficit Disorders: Issues and Strategies for Student,

Counselors and Educators, by Jennifer s. Bramer, Ph.D.

• Zipper, the Kid With ADHD (ages 8-13), by Caroline Janover

Many of the books listed above can be found on the website: www.quantumbooks.com

Another great resource for reading material on ADHD can be found at: www.ParentsMedGuide.org


(508) 339-9944


Westwood, MA 02090(781) 326-7700

www.wmpeds.com

Recommended Reading for Children:• Learning To Slow Down & Pay Attention: A Book for Kids About ADHD (2004), By Kathleen G.

Nadeau, Ellen B. Dixon, and Charles Bely

• Jumpin’ Johnny Get Back to Work! A Child’s Guide to ADHD/Hyperactivity (1991), By Michael

Gordon

• The Survival Guide for Kids with ADD or ADHD (2006), By John F. Taylor

• Joey Pigza Loses Control (2005), By Jack Gantos

• 50 Activities and Games for Kids with ADHD (2000), By Patricia O. Quinn

• The Girls’ Guide to AD/HD: Don’t Lose This Book! (2004), By Beth Walker

• Recommended Reading for Adults: Taking Charge of ADHD: The Complete, Authoritative

Guide for Parents (2000), By Russell Barkley

• Raising Resilient Children: Fostering Strength, Hope and Optimism in Your Child (2002), By

Robert Brooks and Sam Goldstein

• Attention Deficit Disorder: The Unfocused Mind in Children and Adults (2006), Tom Brown

• Teenager with ADD and ADHD: A Guide for Parents and Professionals (2006), Chris Dendy

• A Bird’s-Eye View of Life with ADD and ADHD: Advice from Young Survivors (2003), Chris Dendy

and Alex Dendy

• Making the System Work for Your Child with ADHD (2004), By Peter Jensen

• Practical Suggestions for ADHD (2003), By Clare Jones

• Kids in the Syndrome Mix of ADHD, LD, Asperger’s, Tourette’s, Bipolar, and More!, By Martin

Kutscher, Tony Attwood, and Robert Wolff

• Help4ADD@High School (1998), By Kathleen Nadeau

• Putting on the Brakes: Young People’s Guide to Understanding Attention Deficit Hyperactivity

Disorder (2001), By Patricia Quinn and Judith Stern

• The ADHD Book of Lists: A Practical Guide for Helping Children and Teens with Attention

Deficit Disorders (2003), By Sandra Rief

Another great book to help your child with organization:

• The Organized Student, Teaching Children the Skills for Success in School and Beyond, By

Donna Goldberg with Jennifer Zwieblel


(508) 339-9944


Westwood, MA 02090(781) 326-7700

www.wmpeds.com

ADHD Resources Available on the Internet

About Our Kids

www.aboutourkids.org

ADDitude Magazine for People with ADHD

www.additudemag.com

ADDvance Online Resource for Women and Girls

with ADHD www.addvance.com

American Academy of Family Physicians (AAFP)

www.aafp.org

American Academy of Pediatrics (AAP)

www.aap.org

American Medical Association (AMA)

www.ama-assn.org

Attention-Deficit Disorder Association (ADDA)

www.add.org

Attention Research Update Newsletter

http://helpforadd.com

Bright Futures

www.brightfutures.org

Children and Adults with Attention-

Deficit/Hyperactivity Disorder (CHADD)

www.chadd.org

Curry School of Education (University of Virginia)

ADD Resources

http://special.edschool.virginia.edu/categories/add.ht

ml

Intermountain Health Care

http://intermountainhealthcare.org/Pages/home.aspx

National Center for Complementary and Alternative

Medicine (NCCAM)

http://nccam.nih.gov

National Institute of Mental Health (NIMH)

www.nimh.nih.gov

Northern County Psychiatric Associates

www.ncpamd.com

One ADD Place

www.oneaddplace.com

Pediatric Development and Behavior

www.aap.org/sections/dbpeds/

Help4Kids with ADHD

https://research.tufts-nemc.org/help4kids/default.asp

Educational Resources

Consortium for Citizens with Disabilities

www.c-c-d.org

Council for Learning Disabilities

http://cldinternational.org

National Center for Learning Disabilities

http://ncld.org

Education Resources Information Center (ERIC)www.eric.ed.gov

Federal Resource Center for Special Education

www.rrcprogram.org/content/view/229/332/

Internet Resource for Special Children

www.irsc.org

Internet Special Education Resources

www.iser.com

Learning Disabilities Association of America

www.ldanatl.org

National Information Center for Children and Youth

with Disabilities (NICHCY)

http://nichcy.org

Parent Advocacy Coalition for Educational Rights(PACER) Center www.pacer.org

SAMSHSA

www.samhsa.gov

TeachingLD

http://teachingld.org

US Department of Education

http://www.ed.gov


(508) 339-9944


Westwood, MA 02090(781) 326-7700

www.wmpeds.com

Pediatric Neuropsychologist

Boston Neuropsychological Services

Dr. Kevin Domingos

Dr. David Wolff

Needham, MA

877-283-7863

Boston Floating Hospital for Children Center for

Children with Special NeedsBoston, MA

617-636-7242

Psychological Assessment Center (MGH)

Dr. Gretchen Felopolous

Boston, MA

617-726-2000

Behavioral Health & Social Service Providers

Clinical Neuropsychologist

Dr. Lisa Shaw, Ph. D

344 Harvard Street Suite #1

Brookline, MA

617-277-6286

Child & Family Psychological Services

Craig Malcom, Ph. D.Tim Martin, Ph. D.

89 Access Road, Unit 24

Norwood, MA781-551-0999

Children’s Evaluation CenterDr. Ann Helmus

Dr. Rafael Castro (pre-school)

Newton, MA 02464

617-641-0900

ICCD (Integrated Center for Child Development)

Canton Office

340 Turnpike Street, Suite 1-3A

Canton, MA

781-619-1500

Newton Office

193 Oak Street, Suite 1Newton, MA

617-658-5600

Intake Coordinator: 781-619-1580

Joseph Moldover, M.D.

555 Washington Street,

Wellesley, MA

781-237-1735

[email protected]

Maureen O’Brien Klautky, Psy, D.

Natick, MA

617-877-8862

Closer to Mansfield:

Dr. Patricia Wyckoff

Mansfield, MA

508-337-6127

Dr. Christine Trask

Rhode Island Hospital401-444-4500

Dr. Michael Weiler

617-968-6426

Rhode Island Office on Mondays

Rarely in Boston Office

Center for Children and Families http://ccf.buffalo.edu

Diefendorf Hall Rm. 106, 3435 Main St., Bldg. 20, Buffalo, NY 14214-3093 Tel: (716) 829-2244 Fax: (716) 829-3692

http://ccf.buffalo.edu

Evidence-based Psychosocial Treatment for ADHD Children and Adolescents

Comprehensive Treatment for ADHD should always include a strong psychosocial (that is, not medical) component. Most professionals believe that effective psychosocial treatment is the backbone of good treatment for ADHD. Medication is a very useful addition to psychosocial treatment in many cases, yielding a combination approach that may be even more effective than psychosocial treatments alone (see “ADHD Medication Information Sheet for Parents and Teachers”). Indeed, the scientific literature on treatment for ADHD, the National Institute of Mental Health, and many professional organizations say that there are two treatments that have a solid base of scientific evidence for short-term effectiveness: behavioral psychosocial treatments—also called behavior therapy or behavior modification—and stimulant medication. Behavior modification is the only nonmedical treatment for ADHD with a large scientific evidence base. Why Use Psychosocial Treatments? Why do professionals believe that behavioral treatment for ADHD is so important? There are several reasons. First, the problems faced by children with ADHD go well beyond their symptoms of inattentiveness, hyperactivity, and impulsivity. Most children with ADHD have problems in daily life functioning in many areas including academic performance and behavior at school, relationships with peers and siblings, noncompliance with adult requests, and relationships with their parents. These problems are extremely important because they predict long-term outcome of children with ADHD. How a child with ADHD will do in adulthood is best predicted by three things—(1) whether his or her parents use effective parenting skills, (2) how he or she gets along with other children, and (3) his or her success in school. Psychosocial treatments focus on these problems rather than the core symptoms of the disorder, so they are effective in treating these important domains. Second, in contrast to medication, behavioral treatments teach skills to parents, teachers, and children with ADHD, and these skills help overcome their impairments and are useful for a child’s lifetime. Because ADHD is a chronic condition, teaching skills that will be valuable across the lifetime is especially important. Finally, when medication is the only form of treatment, it has not been shown to improve long-term outcomes for children with ADHD. Many professionals believe that when medication is combined with behavioral approaches, both the core symptoms of ADHD and the associated problems in daily life functioning are best treated, and long-term positive outcomes will be greatest. Others believe that treatment should begin with psychosocial treatments, and medication should be added if and when it is necessary. Both are effective ways of treating ADHD and parents must decide, in consultation with their treating professionals, what is best for their child. Behavioral treatments for ADHD should be started when the child is as young as possible. There are behavioral interventions that work well for preschoolers, elementary-students, and adolescents with ADHD, but there is consensus that starting early is better than starting later. Parents, schools, and practitioners should not put off beginning effective behavioral treatments for children with ADHD. What exactly is behavior modification? Behavior modification is a form of therapy in which parents, teachers, and children are taught skills by a therapist. Parents and teachers then employ those skills in their daily interactions with their children with ADHD to improve the children’s functioning in the key areas noted above. In addition, the children with ADHD employ the skills they learn in their interactions with other children. Many parents think of behavior modification in terms of the ABCs—Antecedents (things that happen before behaviors that influence them), Behaviors (things the child does that parents and teachers want to change), and Consequences (things that happen after behaviors that influence them). In behavioral programs, adults are taught to modify antecedents (e.g., how they give commands to children) and consequences (e.g., how they follow-up if a child obeys or disobeys a command) to change the child’s behavior (that is, the child’s response to the command). By consistently changing the ways that they respond to children’s behaviors, adults teach the children to learn new ways of behaving. What is not behavior modification? It is important to note that many psychotherapeutic treatments are not behavior modification. Thus, traditional individual therapy, in which a child spends time weekly with a therapist or school counselor talking about his or her problems or playing with dolls or toys, is not behavior modification. Similarly, family therapy in which a family talks with a therapist about the dynamics of the interactions among the family is also not behavior modification. Such “talk” or “play” therapies do not have teaching skills as their primary goals, and they have not been shown to work for children with ADHD. Parents who want an



2

evidence-based psychosocial approach to working with their children with ADHD need to become informed about the characteristics of behavior modification that we discuss below so they can recognize effective behavioral treatment and be confident that what the therapist is offering will result in improved functioning for their child. What are typical forms of behavior modification? There are three parts of effective behavioral interventions for ADHD children—parenting training, school interventions, and child-focused treatments. Although working with teachers and the children themselves are critical in the vast majority of ADHD cases, teaching parents more effective ways of dealing with their children is the most important aspect of psychosocial treatment for ADHD. Ideally, parent, teacher, and child interventions must be integrated to yield the best outcome. Four points apply to all three parts: (1) always start with goals that the child can achieve and improve in small steps (e.g., “baby steps”); (2) always be consistent—across different times of the day, different settings, and different people; (3) ADHD is a chronic problem for the individual and treatments need to be implemented over the long haul—not just for a few months; and (4) teaching and learning new skills take time, and children’s improvement will be gradual with behavior modification. Characteristics of parent, teacher, and child interventions are listed below. (1) Parent Training

• Behavioral approach • Focus on parenting skills, child behavior in the home and neighborhood, and family relationships (e.g., getting along

with siblings, complying with parent requests) • Parents are taught skills by therapists and implement them at home • Typically group-based, weekly sessions with therapist initially (8 to 12 sessions); then faded to booster sessions

(monthly, quarterly) • Continually evaluate and modify what is being done to identify what works best and continue it as long as necessary • Plan for what will be done if parents or child backslides • Reestablish contact with therapist for major developmental transitions (e.g.,entry to middle school)

(2) School Intervention

• Behavioral approach • Focus on classroom behavior, academic performance, and peer relationships • Teachers are taught classroom management skills by a consultant (e.g., therapist, school psychologist or counselor)

and implement them with the ADHD child during school hours • Two to 10 hours of training are necessary depending on the teacher’s prior knowledge and skills, as well as the

child’s severity and responsiveness • Continually evaluate and modify what is being done to identify what works best and continue it as long as necessary • Plan for backsliding and spread; involve all relevant school staff; integrate with parenting classes so parent learns to

back up what the school is doing • Integrate with school-wide plans, and required, school-based programs (i.e., IEPs, 504 plans) • Reestablish contact with consultant for major developmental transitions (e.g., entry to middle school)

(3) Child Intervention

• Behavioral and developmental approach • Focus on teaching academic, recreational, and social/behavioral competencies, decreasing aggression, developing

close friendships, and building self-efficacy • Paraprofessional implemented, supervised by professionals • Settings such as clinic-based weekly group sessions, after-school or Saturday sessions, and summer camps • Typically more intensive rather than less intensive treatment is necessary (e.g., weekly clinic social skills groups are

typically not effective) • Monitor and modify as needed based on what works best; provide as long as necessary (e.g., multiple years or when

deterioration occurs) • Plan for what to do if backsliding occurs • Integrate with school and parent treatments • Reestablish contact with consultant for major developmental transitions (e.g., middle school entry)



3

How does a behavior modification program begin? The first step in starting a behavior modification program is a complete evaluation of the child's functional impairment in all relevant domains, including home, school (both behavioral and academic), and peer settings. Most of this information comes from parents and teachers, and that means that a professional will spend most of his or her time during the information gathering process with parents and teachers. Interaction with the child him or herself is needed for the therapist to get a sense of what the child is like. That assessment process should yield a list of target areas for treatment. Target areas—often called target behaviors--should be behaviors that differentiate the child being treated from other, nonproblematic children. They should be behaviors that, if changed, will contribute to an improvement in the child’s functioning/impairment and a positive long-term outcome. Target behaviors can be either negative behaviors that need to be eliminated or adaptive skills that need to be developed. That means that the areas targeted for treatment will typically not be the symptoms of ADHD—overactivity, inattention, and impulsivity—but instead the specific problems that those symptoms may cause in daily life. Thus, common classroom target behaviors would be “completes assigned work at 80% accuracy” and “followed classroom rules.” At home, “played well with siblings (that is, no fights)” and “complies with parent requests or commands” are common target behaviors (lists of common target behaviors in school, home, and peer settings that parents and teachers might find useful can be downloaded in Daily Report Card school and home packets at http://ccf.buffalo.edu). Target behaviors are things that can be easily observed and measured so that response to treatment can be monitored and treatment can be modified as necessary. After target behaviors are identified, behavioral interventions at home and at school follow similar formats. Parents and teachers identify the environmental conditions (the A’s) and consequences (the C’s) that are controlling those target behaviors (the B’s). Then behavioral treatment takes the form of parents and teachers learning and establishing programs in which the environmental antecedents and consequences are modified to change the child’s target behaviors. Treatment response is constantly monitored, and the interventions are modified when they fail to have a sufficient impact or are no longer needed. Parent Training Behavioral parent training programs have been around for a long time. Nearly 40 years ago the psychologists who developed behavioral parent training wrote the first books teaching others how to do what they had developed. Parenting sessions usually use a book and/or videotape that has been specially developed to teach parents how to use behavioral management procedures with their children; there are many good programs available (see list in appendix). The first session is often devoted to an overview of the diagnosis, causes, nature, and prognosis of ADHD. Thereafter, in group or individual sessions, parents learn a variety of techniques, some of which they may be already using at home but not as consistently or correctly as needed. Parents go home and implement what they learn in sessions during the week, and return to the parenting session the following week to discuss progress, problem solve, and learn a new technique. Although many of the ideas and techniques taught in behavioral parent training are common-sense parenting techniques (everyone knows to praise their children when they are doing something good!), most parents need careful teaching and support to learn and implement the parenting skills consistently. It is very difficult for parents to buy a book, learn behavior modification, and implement an effective program with their child on their own. Help from a professional who knows how to develop and implement behavioral programs is often essential. The topics covered in a typical series of parent training sessions include the following topics in sequence. 1. Establishing house rules and structure

• Posted chore lists • Posted morning and evening routines • Posted House Rules • Review until child has learned them

2. Learning to praise appropriate behaviors (praise good behavior at least five times as often as bad behavior is criticized)

and ignore mild inappropriate behaviors (choose your battles) 3. Using appropriate commands

• Obtain the child's attention: say the child's name first • Use command not question language (“Don’t you want to be good” is a bad command!) • Be specific, describing exactly what the child is supposed to do (at the grocery checkout line “be good” is not a good

command! “stand next to me and do not touch anything” is more specific!)



4

• Be brief and appropriate to the child's age • State consequences and always follow through (praise compliance and provide consequences for noncompliance) • Have a firm but neutral (not angry) tone of voice

4. Using when…then contingencies

• Give access to desired activities when the child has completed a less desired activity (e.g., ride bike when finished homework; watch TV when finished evening chores, going out with friends after completed yard work)

• For younger children, important to have rewarding activity occur immediately 5. Planning ahead and working with children in public places

• Explain situation to child before activity occurs • Establish ground rules, rewards, and consequences

6. Time out from positive reinforcement

• Assign short times away from preferred activities when the child has violated expectations or rules • Give time off for appropriate behavior during time out and lengthen time for noncompliance with time out • Base times on children's ages—shorter for younger children—e.g., one minute for each year of age

7. Daily Charts—Point/token systems with rewards and consequences

• Make charts with home rules/goals and post prominently in house • Establish system for rewards for following home rules and consequences for violations • Nickel jar for noncompliance or talking back (e.g., put a nickel in for each compliance, remove two for

noncompliance) • Home Daily Report Card (see target list and creating a Daily Report Card for the home at http://ccf.buffalo.edu)

8. School-home note system for rewarding behavior at school and tracking homework (see description below in School

Interventions) There are many other techniques that are part of a good behavioral parenting program. Those listed above are included in almost all of the good programs. Some families can learn these skills quickly in the course of 8 or 10 meetings, while other families—often those with the most severely impaired children—require more time and energy. The techniques listed above are those typically used in teaching parents of children with ADHD. When the presenting child is a teenager, parent training is modified somewhat. Parents are still taught behavioral techniques, but they are modified to be age-appropriate for adolescents. For example, time out is a consequence that is not effective with adolescents; instead loss of privileges (e.g., can’t take family car on date) or assignment of work chores would be more appropriate. After parents have been taught these techniques, the parents are typically involved in sessions that include the adolescent, with the therapist helping parents and adolescents in structured discussions in which they negotiate mutually agreeable solutions to their disagreements. Parents negotiate for improvements in the adolescents’ target behaviors (e.g., better grades in school) in exchange for rewards over which they have control (e.g., the teen’s being able to go out with friends). The give and take between parents and teen in these sessions is necessary to motivate the teenager to work with the parents to make changes in his or her behavior. Applying these skills with children and adolescents with ADHD takes a lot of hard work on the part of parents. However, the hard work pays off. Parents who master and consistently apply these skills will be rewarded with a child who behaves better and has a better relationship with his parents and siblings. School Interventions As is the case with parent training, the techniques used in classroom-based interventions for ADHD have been around for some time. Many teachers who have had training in classroom management are quite expert in developing and implementing classroom-based programs for their ADHD children. Others, however, are not intimately familiar with behavioral principles and need assistance to learn and implement the necessary programs. There are many widely-available handbooks, texts, and training programs that have been developed to teach classroom behavior management skills to teachers (see list in appendix). Most of these programs are designed to be implemented by regular or special education classroom teachers with training and guidance from school support staff or outside consultants. One of the most important things that the parent of an ADHD child can do is to work closely with the teacher to support his or her efforts implementing classroom programs for their ADHD child.



5

The following list includes typical classroom behavioral management procedures. They are arranged in order from mildest and least restrictive to more intensive and most restrictive procedures. Some of these programs may be included in 504 plans or Individualized Educational Programs that may apply to ADHD children (see http://www.ed.gov/parents/needs/speced/edpicks.jhtml?src=ln) or may need to be integrated with such plans. Typically an intervention is individualized and consists of several components based on the child’s needs, the classroom resources, and the teacher’s skills and preferences. 1. Classroom rules and structure

• Typical classroom rules: o Be respectful of others o Obey adults o Work quietly o Stay in assigned seat/area o Use materials appropriately o Raise hand to speak or ask for help o Stay on task/complete assignments

• Post rules and review before each class until learned • Make rules objective and measurable • Number of rules depends on developmental level • Establish a predictable environment • Enhance children’s organization (folders/charts for work) • Evaluate rule-following and give feedback/consequences consistently • Tailor frequency of feedback to child’s developmental level

2. Praise appropriate behaviors and ignore mild inappropriate behaviors that are not reinforced by peer attention

• Use at least five times as many praises as negative comments. • Use commands/reprimands to cue positive comments for children who are behaving appropriately—that is, find

children who can be praised each time a reprimand or command is given to a child who is misbehaving 3. Appropriate commands (clear, specific, manageable) and private reprimands (at child’s desk as much as possible)—same

characteristics as for good commands for parents described above 4. Accommodations and structure for individual child (e.g., desk placement, task sheet)

• Structure the classroom to maximize the child’s success • Sit by teacher to facilitate monitoring • Pair with peer to help copy assignments from board • Break assignments into small chunks • Give frequent and immediate feedback • Require corrections before new work

5. Increase academic performance

• Focus on increasing completion and accuracy on work • Provide task choices • Peer tutoring • Computer-assisted instruction

Such interventions have the advantage of being proactive (i.e., could prevent problematic behavior from occurring) and can be implemented by individuals other than the classroom teachers (e.g., peers, classroom aide). When disruptive behavior is not the primary difficulty, academic interventions sometimes lead to improvements in behavior that are equivalent to gains associated with more intensive classroom behavioral strategies. 6. When…then contingencies (e.g., recess time contingent upon completing work, staying after school to complete work

before dismissal, assigning less desirable work prior to more desirable assignments, require assignment completion in study hall before allowing free time) (same guidelines as for parents described above)

7. Daily School-Home Report Card (instruction packet available at http://ccf.buffalo.edu)

• Means of identifying, monitoring, and changing classroom problems



6

• Tool for parents and teacher to communicate regularly • Individualized target behaviors determined by teacher • Teachers evaluate targets at school and send DRC home with the child • Parents provide home-based rewards; more rewards for better performance and fewer for lesser performance • Continually monitor and make adjustments to targets and criteria as behavior improves or new problems

develop • Always used in the context of other behavioral components (commands, praise, rules, academic programs) • Cost little and take minimal teacher time

8. Behavior chart/reward and consequence program (point or token system) for the target child

• Establish target behaviors and ensure child knows behaviors and goals (e.g., list on index card taped to desk) • Establish rewards for meeting target behaviors • Monitor child and give feedback • Reward immediately for young children • Use points, tokens, stars that can later be exchanged for rewards

9. Classwide interventions and group contingencies • Establish goals for the class as well as the individual • Establish rewards for appropriate behavior that anyone in class can earn (e.g., class lottery, jelly bean jar, wacky

bucks) • Establish reward system in which whole class (or subset of class) earns rewards based on entire class functioning

(e.g, Good Behavior Game) or ADHD child’s functioning (e.g., class earns reward if ADHD child makes goals) • Encourages children to help one another because everyone can be rewarded • Easier for teacher than individual programs because improves whole class • Tailor frequency of rewards/consequences to children’s developmental level

Sample Daily Report Card

Child's Name: Date: Special Language

Arts Math Reading SS/Science

Follows class rules with no more than 3 rule violations per period.

Y N Y N Y N Y N Y N

Completes assignments within the designated time.

Y N Y N Y N Y N Y N

Completes assignments at 80% accuracy. Y N Y N Y N Y N Y N Complies with teacher requests.

(no more than 3 instances of noncompliance per period)

Y N Y N Y N Y N Y N

No more than 3 instances of teasing per period. Y N Y N Y N Y N Y N OTHER Follows lunch rules (No more than 3

violations). Y N

Follows recess rules (No more than 3 violations).

Y N

Total Number of Yeses

Teacher's Initials: Comments:

10. Time out (classroom, office); a program in which a child is removed from the ongoing activity for a few minutes (less for

younger children and more for older) when he or she misbehaves (same guidelines as for parents described above) 11. School-wide programs—e.g., discipline plans that are school-wide can be structured to minimize the problems

experienced by ADHD children at the same time as they help manage the behavior of all children in a school.



7

Beyond a listing of the techniques and procedures to be used, there are several important points to keep in mind when setting up behavioral interventions in school settings. Although the techniques taught to parents and teachers are similar, there may be different levels of motivation on the part of parents and teachers to help a child with ADHD. Because the majority of children with ADHD are not enrolled in special education services, their teachers will most often be regular education teachers who may know little about ADHD and little about behavior modification. They may not view treatment of the child with ADHD as their responsibility and behavioral treatments as too time consuming. However, as with parents, the effort that teachers put into implementing behavioral interventions in the classroom will involve less time and energy than they are currently spending in unsuccessful attempts to deal with the child. When working with adolescents with ADHD, modifications similar to those noted above for parents need to be done in school settings. Adolescents need to be more involved in goal planning and treatment implementation than do children. For example, teachers expect adolescents to be more responsible for belongings and assignments (e.g., have the student write assignments in weekly planners rather than the teacher’s sending home a daily report card), so organizational strategies and study skills need to be taught to the adolescent with ADHD. However, parent involvement with the school is as important in middle and high schools as it is in elementary school. Parents will often work with guidance counselors rather than individual teachers, so that the guidance counselor can coordinate intervention among the teachers. Child Interventions Nonspecific talk or play therapy in a therapist’s office is not a form of treatment with scientific support for children with ADHD. Instead, child-based treatments for ADHD with a scientific basis are those that focus on peer relationships and that typically occur in group settings outside of the therapist’s office. Very often, children with ADHD have serious disturbances in peer relationships, and those problems are very strong predictors of long-term outcomes. Children whose difficulties with peers are overcome will have considerably better long-term outcomes than those whose peer relationships remain problematic. Thus, intervention for peer relationships is a critical component of treatment for children with ADHD and it is the focus of child-based treatments. There are five forms of intervention for peer relationships, listed below. 1. Systematic teaching of social skills

• Cooperation • Communication • Being positive and friendly • Participation • Helping/sharing • Giving compliments • Coping with teasing

2. Social problem solving

• Identifying problem • Brainstorming solutions • Choosing best solution • Planning implementation • Evaluating outcome

3.Teaching other behavioral competencies that other children consider important

• Sports skills • Rules of sports • Board game rules • Good sportsmanship and good team membership

4. Decreasing undesirable and antisocial behaviors

• Target bossy, intrusive, aggressive, and other disruptive behaviors that children with ADHD exhibit with peers • Establish reward/consequence program to reduce these behaviors and to replace with prosocial behaviors taught in

social skills training 5. Developing a close friendship

• Develop program to help child with ADHD develop a close friendship with another child • Work with family and teacher to facilitate the relationship • May serve an important role in improving long-term outcomes



8

There are several ways of delivering these interventions to children, ranging from groups in clinic offices to summer camps. All of the programs utilize a core of procedures, including coaching, use of examples, modeling, role-playing, feedback, rewards and consequences, and practice. Programs differ in their location, format, and intensity. As noted earlier in this fact sheet, these child-directed treatments cannot be used alone—they are called for when a parent is participating in parent training and school personnel are conducting an appropriate school intervention. The child-based treatment needs to be integrated with the parent and school programs. Social skills training groups are the most common form of intervention, and they typically focus on the systematic teaching of social skills. They are typically conducted at a clinic or in school in a counselor’s office for an hour or two on a weekly basis for six to 12 weeks. Unfortunately, the scientific literature shows that social skills groups are not particularly effective with children with ADHD—especially if they are used in isolation of parent and school interventions and without rewards and consequences to reduce disruptive and negative behaviors. Some studies have shown that social skills groups employed with concurrent parent training are helpful. The same conclusion applies to social problem solving interventions. When used alone, the evidence is not strong, but with concurrent parent training and/or concurrent school interventions as described above, social problem solving programs are incrementally helpful. When parent and school interventions are integrated with child-focused treatments, the behaviors in the peer domain that are being targeted in the child treatments (e.g., being bossy, taking turns, sharing) are also included as target behaviors in the home and school programs (e.g., on the Home and School Daily Report Cards) so that the same behaviors are being monitored, prompted, and rewarded across intervention components. There are several models for working on peer relationships in school settings that integrate several forms of the interventions listed above. They combine skills training with a major focus on decreasing negative and disruptive behavior and are typically conducted by school staff. Some of these programs are used with individual children (e.g., token programs employed in the classroom or at recess) and some are employed school-wide (e.g., peer mediation programs). Generally, the more intensive the intervention in the peer domain, the more effective the intervention. Programs that are based in settings in which children with ADHD can work on their peer problems in child-relevant contexts (e.g., classroom or recreational settings) provide the most effective intervention. One model has involved establishing summer camps for children with ADHD in which child-based treatment of peer problems and academic difficulties are integrated with parent training. In these programs, all of the five forms of intervention noted above are incorporated in a 6 to 8 week program that runs for 6 to 9 hours on weekdays. Treatment is conducted in groups, with recreational activities (e.g., baseball, soccer) for the majority of the day, along with two hours of academics. One major focus is teaching competencies in and knowledge of sports to the children. This is integrated with intensive practice in social and problem-solving skills, good team membership, decreasing negative behaviors, and developing close friendships. Some approaches to child-based treatment for peer problems shoot for a compromise between clinic-based programs and intensive summer camps by conducting versions of the two that occur on Saturdays during the school year or in after-school settings. These involve two- or three-hour sessions in which children engage in recreational activities like those of summer camps in which many of the forms of social skills interventions are integrated. There have not yet been systematic studies of such approaches, but there are several programs that appear promising. Finally, psychologists have suggested that having a best friend may serve a protective effect on children with difficulties in peer relations as they develop through childhood and into adolescence. A few researchers are examining this approach and have developed programs to try to build at least one close friendship for a child with ADHD. These programs always begin with the other forms of intervention described above and then add having the families of the children with ADHD schedule monitored play-dates and other activities with their own child and with the child with whom they are attempting to foster a friendship (e.g., taking the friend along on a Saturday family outing). There has only been preliminary research in this approach. It is important to emphasize that simply inserting a child with ADHD in settings in which he or she may interact with other children—e.g., scouts, little league or soccer league, day care, or playing around the neighborhood without supervision—is not effective treatment for peer problems. As we have indicated, treatment for peer problems is quite complex and involves combining careful instruction in social and problem-solving skills with supervised practice in peer settings in which children receive rewards and consequences for appropriate peer interactions. It is very difficult to intervene in the peer domain; scout leaders, little league coaches, and day-care personnel are typically not trained in how to implement the peer interventions that are effective.



9

What About Combining Psychosocial Approaches with Medication? The question arises of whether behavior modification should be used alone as an intervention for ADHD or whether it should be combined with medication. Both treatments have short-term effectiveness, but there are differences between the two. Medication is less expensive and works more quickly, and arguably with larger immediate effects, but it is more invasive in the sense that it involves a drug that affects the child’s brain and it can produce side effects—both short and long-term. Behavior modification teaches skills to parents, teachers, and children, has no side effects, and is much preferred by families. A substantial portion of children with ADHD can avoid using medication if good behavioral treatments are employed. However, for children for whom behavioral interventions are not sufficient, the combination of the two modalities is generally more effective than either alone in the short-term, and enables the intensity (and therefore the expense) of behavioral treatments to be reduced and the dose of medication (and therefore side effects) to be reduced. These reductions in “dose” of the two treatments can be quite large for many children. Parents must decide the sequence in which they elect to try the two treatments. A parent who is concerned about medication and hopes to avoid it might consider starting with behavioral treatments and moving to medication only if behavioral treatments are insufficient. For example, after parents have attended a behavioral parent training class, after the teacher has worked for several months on classroom interventions, and after a good child-focused treatment, if there is still considerable room for improvement, parents might consider adding medication. Alternatively, parents whose child with ADHD is quite severe and needs more immediately effective treatment might elect for the more potent combined treatment from the very start. Parents should discuss these alternatives with their family physician (see “ADHD Medication Information Sheet for Parents and Teachers,” downloadable at http://ccf.buffalo.edu). An algorithm for this approach to treating ADHD is shown at the end of this document. What if there are Other Problems in Addition to ADHD? It has been often stated that even though individual therapy and play therapy are not effective in treating ADHD, they are called for when a child has a concurrent problem, called a comorbid problem, such as depression or anxiety or a “family” problem. It is important for parents and teachers to understand that this is not accurate. These forms of individual therapy do not have a scientific evidence base for any form of childhood mental health problem, including all of those that co-occur with ADHD. Each of those problems does have a form of behavioral treatment that does have evidence behind it, and it is those treatments—not generic talk or play therapy—that are indicated when there is a comorbid problem with ADHD. Several of these evidence-based treatments (e.g., for anxiety in children, depression, and substance use in adolescents) are listed in the list of evidence based manuals at the end of this sheet. In short, there are evidence-based approaches to every type of disorder that may occur at the same time as ADHD, and nonspecific talk therapies are not indicated for any of them. Summary

• Behavioral interventions as described herein are the only evidence-based nonmedical treatment for ADHD • Behavioral treatments focus on problems in daily life functioning in family relationships, peer relationships,

classroom functioning, and academic achievement • Behavioral treatments teach skills to parents, teachers, and children with ADHD to cope and improve in these

important areas of functioning • Because ADHD is a chronic disorder, behavioral treatments (just like medication) need to be maintained by parents

and teachers for as long as necessary for long term change • Behavioral and combined treatments are preferred by parents to medication alone. • Based on their own preferences about treatments, the child’s severity, parent and teacher resources and skill-

development, and the child’s response to behavioral treatments, parents must decide whether (1) to start with behavioral treatments first and add medication if necessary or (2) to start with behavioral/pharmacological treatments simultaneously

• If good behavioral treatments are started first and continued, many ADHD children will not require medication • For children who need them, combined behavioral and medication interventions often produce better short-term

effects with lower doses than either treatment alone • Families, schools, and service providers should stay in regular contact monitor and adjust interventions over the long • Start behavioral treatments early



10

Manuals for Evidence-Based Psychosocial Treatments for ADHD and Comorbid Disorders

Barkley, R. A. (1987). Defiant children: A clinician's manual for parent training. New York: Guilford. Barkley, R.A. (1987). Defiant children: Parent-teacher assignments. New York: Guilford Press. Center for Children and Families, University at Buffalo. How to Establish a Daily Report Card.

http://ccf.buffalo.edu Center for Children and Families, University at Buffalo. Creating a Daily Report Card for the Home.

http://ccf.buffalo.edu Clarke, G., et al. (1999). Adolescent coping with depression course. www.kpchr.org/public/acwd/acwd.html Cunningham, C. E., Bremner, R., & Secord-Gilbert, M. (1998). The community parent education (COPE)

program: A school based family systems oriented course for parents of children with disruptive behavior disorders. Unpublished manual. McMaster University and Chedoke-McMaster Hospitals.

Cunningham, C. E., Cunningham, L. J., & Martorelli, V. (1997). Coping with conflict at school: The collaborative student mediation project manual. Hamilton, Ontario: COPE Works.

DuPaul, G. J., & Stoner, G. (2003). ADHD in the schools: Assessment and intervention strategies (2nd ed.). New York: Guilford.

Forehand, R. & Long, N. (2002) Parenting and the strong-willed child. Chicago, IL: Contemporary Books. Forgatch, M., & Patterson, G. R. (1989). Parents and adolescents living together: Part 2: Family problem

solving. Eugene, OR: Castalia. Fuchs, D., Mathes, P. G., & Fuchs. L. S. (1993). Peabody Classwide Peer Tutoring Reading Methods. Unpublished

Teacher’s Manual. Hembree, T. L., & McNeil, C. B. (1995). Parent–child interaction therapy. New York: Plenum Press. Hops, H., & Walker, H. M. (1988). CLASS: Contingencies for Learning Academic and Social Skills Manual.

Seattle, WA: Educational Achievement Systems. Kendall, P.C. (2000). Cognitive-behavioral therapy for anxious children: Therapist manual (2nd ed.) Ardmore, PA:

Workbook Publishing. www.workbookpublishing.com Patterson, G.R., & Forgatch, M. (1987). Parents and adolescents living together: Part 1: The basics. Eugene,

OR: Castalia. Pelham, W. E., Greiner, A. R. & Gnagy, E. M. (1997). Children's summer treatment program manual. Buffalo, NY:

Comprehensive Treatment for Attention Deficit Disorders. www.summertreatmentprogram.com. Pfiffner, L. J. (1996). All about ADHD: The complete practical guide for classroom teachers. New York: Scholastic

Professional Books. Rief, S. F. (2002). How to reach and teach ADD/ADHD children: Practical techniques, strategies, and

interventions for helping children with attention problems and hyperactivity. Jossey-Bass. Sanders, M. R., Markie-Dadds, C., and Turner, K. M. T. (1998). Facilitator's kit for Enhanced Triple P. Brisbane,

Queensland, Australia: Familes International. http://www.pfsc.uq.edu.au/02_ppp/ppp.html Sanders, M. R., Markie-Dadds, C., and Turner, K. M. T. (1998). Practitioner's kit for Standard Triple P. Brisbane,

Queensland, Australia: Familes International. http://www.pfsc.uq.edu.au/02_ppp/ppp.html Walker, H. M. Hops, H., & Greenwood, C. R. (1992). RECESS manual. Seattle, WA; Educational Achievement

Systems. Walker, H.M., & Walker, J.E. (1991). Coping with noncompliance in the classroom: A positive approach for

teachers. Austin, TX: ProEd. Webster-Stratton, C. The Incredible Years. www.incredibleyears.com.

References

Angold, A., Costello, E. J., Farmer, E. M. Z., Burns, B.J., & Erkanli, A. (1999). Impaired but undiagnosed. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 129-137.

August, G.J., Realmuto, G.M., Hektner, J.M., & Bloomquist, M.L. (2001). An integrated components preventive intervention for aggressive elementary school children: The Early Risers Program. Journal of Consulting and Clinical Psychology, 69, 614-626.

Barkley, R. A., & Murphy, K. R. (1998). Attention-deficit hyperactivity disorder: A clinical workbook. (2nd ed.). New York: Guilford.

Barkley, R.A. (1995). Taking charge of ADHD: The complete, authoritative guide for parents. New York: Guilford.

Bierman, K. L., Miller, C. L., & Stabb, S. D. (1987). Improving the social behavior and peer acceptance of rejected boys: Effects of social skill training with instructions and prohibitions. Journal of Consulting and Clinical Psychology, 55, 194-200.

Brestan, E. V. & Eyberg, S.M. (1998) Effective psychosocial treatments of conduct-disordered children and adolescents: 29 years, 82 studies, and 5272 kids. Journal of Clinical Child Psychology, 27, 180-189.



11

Brown, R.T., Antonuccio, D.O., DuPaul, G.J., Fristad, M.A., King, C.A., Leslie, L.K., McCormick, G.S., Pelham, W.E., Piacentini, J.C., & Vitiello, B. (2007). Childhood mental health disorders. Evidence base and contextual factors for psychosocial, psychopharmacological, and combined interventions. Washington, DC: American Psychological Association.

Carlson, C. L., Pelham, W. E., Milich, R., & Dixon, M. J. (1992). Single and combined effects of methylphenidate and behavior therapy on the classroom performance of children with Attention Deficit-Hyperactivity Disorder. Journal of Abnormal Child Psychology, , 20, 213-232.

Chamberlain, P. & Patterson, G.R. (1995). Discipline and child compliance in parenting. In M. Bornstein (ed.), Handbook of Parenting: Vol. 4. Applied and Practical Parenting. (pp. 205-225). Mahwah, NJ: Lawrence Erlbaum Associates.

Chronis, A. M., Fabiano, G. A., Gnagy, E. M., Onyango, A. N., Pelham, W. E., Williams, A., et al. (in press). An evaluation of the summer treatment program for children with attention-deficit/hyperactivity disorder using a treatment withdrawal design. Behavior Therapy.

Chronis, A. M., Fabiano, G. A., Gnagy, E. M., Wymbs, B. T., Burrows-MacLean, L., & Pelham, W. E. (2001). Comprehensive, sustained behavioral and pharmacological treatment for attention deficit hyperactivity disorder: A case study. Cognitive and Behavioral Practice, 8, 346-359.

Clarke, G.N., Rhode, P., Lewinsohn, P.M., Hops, H., & Seeley, J.R. (1999). Cognitive-behavioral treatment of adolescent depression: efficacy of acute group treatment and booster sessions. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 272-279.

Coie, J. D. & Dodge, K. A. (1998). Aggression and antisocial behavior. In W. Damon (Series Ed.) & N. Eisenberg (Vol. Ed.), Handbook of Child Psychology: Vol. 3. Social, Emotional, and Personality Development. (5th ed., pp.779-862). New York: John Wiley & Sons, Inc.

Cooper, H., Charlton, K., Valentine, J. C., & Muhlenbruck, L. (2000). Making the most of summer school: A meta-analytic and narrative review. Monographs of the Society for Research in Child Development, 65 (1, Serial No. 260).

Cunningham, C. E., Cunningham, L. J., Martorelli, V., Tran, A., Young, J., & Zacharias, R. (1998). The effects of primary division, student-mediated conflict resolution programs on playground aggression. Journal of Child Psychology and Psychiatry and Allied Disciplines, 39, 653-662.

DuPaul, G. J. & Eckert, T. L. (1997). The effects of school-based interventions for attention deficit hyperactivity disorder: A meta-analysis. School Psychology Review, 26, 5-27.

Evans, S. W., Pelham, W. E., & Grudberg, M. V. (1995). The efficacy of notetaking to improve behavior and comprehension of adolescents attention deficit hyperactivity disorder. Exceptionality, 5, 1-17.

Fabiano, G. A., Pelham, W. E., Manos, M., Gnagy, E. M., Chronis, A. M., Onyango, A. N., et al. (in press). An evaluation of three time out procedures for children with attention-deficit/hyperactivity disorder. Behavior Therapy.

Hartman, R. R., Stage, S. A., Webster -Stratton ,C. (2003). A growth curve analysis of parent training outcomes: Examining the influence of child risk factors (inattention, impulsivity, and hyperactivity problems), parental and family risk factors. Journal of Child Psychology & Psychiatry & Allied Disciplines. 44, 388-398.

Hoza, B., Pelham, W. E., Sams, S. E., & Carlson, C. L. (1992). An examination of the "dosage" effects of both behavior therapy and methylphenidate on the classroom performance of two ADHD children. Behavior Modification, 16, 164-192.

Hupp, S. D. A. & Reitman, D. (1999). Improving sports skills and sportsmanship in children diagnosed with attention-deficit/hyperactivity disorder. Child and Family Behavior Therapy, 21, 35-51.

Kaplow, J. B., Curran, P. J., Dodge, K. A., Conduct Problems Prevention Research Group .(2002). Child, parent, and peer predictors of early-onset substance use: A multisite longitudinal study. Journal of Abnormal Child Psychology. 30, 199-216.

Kavale, K. A., Forness, S. R., & Walker, H. M. (1999). Interventions for oppositional defiant disorder and conduct disorder in the schools. In H. Quay & A. Hogan (Eds.), Handbook of Disruptive Behavior Disorders (pp. 441-454). New York: Kluwer.

Kavale, K. A., Mathur, S. R., Forness, S. R., Rutherford, R. G., & Quinn, M. M. (1997). The effectiveness of social skills training for students with emotional or behavioral disorders: A meta-analysis. In T. E. Scruggs & M. A. Mastropieri (Eds.), Advances in Learning and Behavioral Disabilities (Vol. 11; pp. 1-26). Greenwich, CT: JAI.

Kazdin, A. E. (2001). Behavior Modification in Applied Settings. (6th ed.). Belmont, CA: Wadsworth/Thomson Learning.

Kelley, M. L. (1990). School-home notes: Promoting children’s classroom success. New York: Guilford Press. Kendall, P.C., Flannery-Schroeder, E., Panichelli-Mindel, S.M., Southam-Gerow, M., Henin, A., & Warman, M.

(1997). Therapy for youths with anxiety disorders: A second randomized clinical trial. Journal of Consulting and Clinical Psychology, 65:3, 366-380.

Martin, G., & Pear, J. (1999). Behavior modification: What it is and how to do it. (6th ed.). Upper Saddle River, NJ: Prentice-Hall, Inc.

McFayden-Ketchum, S. A. & Dodge, K. A. (1998). Problems in social relationships. In E. J. Mash & R. A. Barkley



12

(Eds.). Treatment of childhood disorders. (2nd ed. pp 338-365). New York: The Guilford Press. Mrug, S., Hoza, B., Gerdes, A. C. (2001). Children with attention-deficit/ hyperactivity disorder: Peer relationships

and peer-oriented interventions. In D. W. Nangle & C. A. Erdley (Eds.). The role of friendship in psychological adjustment: new directions for child and adolescent development (pp. 51-77). San Francisco: Jossey-Bass, Inc., Publishers.

Northup, J., Fusilier, I., Swanson, V., Huete, J., Bruce, T., Freeland, J., et al. (1999). Further analysis of the separate and interactive effects of methylphenidate and common classroom contingencies. Journal of Applied Behavior Analysis, 32, 35-50.

Oden, S. & Asher, S. R. (1977). Coaching children in social skills for friendship making. Child Development, 48, 495-506.

Patterson, G. R., & Forgatch, M. S. (1987). Parents and adolescents living together Part 1: The basics. Eugene, OR: Castalia.

Pelham, W.E. (in press). Against the grain: A proposal for a psychosocial-first approach to treating ADHD – the Buffalo treatment algorithm. In, K. McBurnett, L.J. Pfiffner, R. Schacher, G. Elliott & J.T. Nigg (Eds.), Attention Deficit/Hyperactivity Disorder: A 21st Century Perspective. New York: Margel Dekker.

Pelham, W.E., & Fabiano, G.A. (in press). Evidence-based psychosocial treatment for attention deficit/hyperactivity disorder: An update. Journal of Clinical Child and Adolescent Psychology.

Pelham, W. E. & Fabiano, G. A. (2000). Behavior modification. Psychiatric Clinics of North America, 9, 671-688. Pelham, W.E., Fabiano, G.A, Gnagy, E.M., Greiner, A.R., & Hoza, B. (in press). Comprehensive psychosocial treatment for ADHD. In E. Hibbs & P. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice. New York: APA Press.

Pelham, W. E., Gnagy, E. M. Greiner, A. R., Hoza, B., Hinshaw, S. P., Swanson, J. M., et al. (2000). Behavioral vs. behavioral and pharmacological treatment in ADHD children attending a summer treatment program. Journal of Abnormal Child Psychology, 28, 507-526.

Pelham, W. E. & Hoza, B. (1996). Intensive treatment: A summer treatment program for children with ADHD. In E. Hibbs & P. Jensen (Eds.), Psychosocial Treatments for Child and Adolescent Disorders: Empirically Based Strategies for Clinical Practice. (pp. 311-340). New York: APA Press.

Pelham, W. E., Wheeler, T., & Chronis, A. (1998). Empirically supported psychosocial treatments for attention deficit hyperactivity disorder. Journal of Clinical Child Psychology, 27, 190-205.

Pfiffner ,L. J. & McBurnett, K. (1997). Social skills training with parent generalization: Treatment effects for children with attention deficit disorder. Journal of Consulting & Clinical Psychology, 65, 749-757.

Reitman D., Hupp, S.D.A., O’Callaghan P., Gulley, V., & Northup, J. (2001). The influence of a token economy and methylphenidate on attention during sports with children diagnosed with ADHD. Behavior Modification, 25, 305-323.

Robin, Arthur L. (1998). ADHD in adolescents: Diagnosis and treatment. New York, NY, USA: The Guilford Press.

Simmons, D.C., Fuchs, L.S., Fuchs, D., Mathes, P., & Hodge, J.P. (1995). Effects of explicit teaching and peer tutoring on the reading achievement of learning-disabled and low-performing students in regular classrooms. The Elementary School Journal, 387-408.

Waldron, H. B., Slesnick, N., Brody, Janet L; Turner, C. W. Peterson, T. R. (2001). Treatment outcomes for adolescent substance abuse at 4- and 7-month assessments. Journal of Consulting & Clinical Psychology. 65, 802-813.

Walker, H.M., Colvin, G., & Ramsey, E. (1995). Antisocial behavior in school: Strategies and best practices. Pacific Grove, CA: Brooks/Cole Publishing Company.

Wielkiewicz, R.M. (1995). Behavior management in the schools: Principles and procedures (2nd edition). Boston: Allyn and Bacon.

Buffalo Treatment Algorithm for ADHD • Conduct assessment using evidence-based measures

• Use brief P and T rating scales rather than structured interviews • Provide information about ADHD

• Focus assessment on functional impairment in key domains: • Family/parenting skills/parent-child relationship • Academic progress/school behavior • Relationships with peers

Impairment found?

• Explain risks and benefits of treatment and develop management plan with family • Begin evidence-based behavioral treatment focusing on areas identified as impaired:

• Family/Parenting: 8-week group-based behavioral parent training course • School: School-based Daily Report Card established by parent • Peer: 8-week group-based social skills training (concurrent with parent training)

Conduct ongoing, brief, idiographic assessments of functioning (e.g., IRS, ITBE) in home, school and peer domains throughout treatment

Continued impairment?

Add limited number of individual, problem-focused behavioral parent-training sessions and/or teacher consultations to establish additional evidence-based programs to deal with continued impairment in key

domains (family/parents, school, peers)

Discuss with family risk and benefits of additional treatments to develop management plan, taking into account parental preference, family resources (e.g., insurance coverage, teacher cooperativeness, socioeconomic

factors), and risk:benefit ratios


Parental Choice Add medication trial with methylphenidate or

amphetamine compounds; start with very low dose for school time only; if inadequate response,

increase dose and/or add doses for other times/settings; if inadequate response, assess the other

stimulant compounds; if inadequate response, assess Straterra

Increase intensity of behavioral interventions according to continued impairment; add parent

training sessions; add Summer Treatment Program; add teacher consultations or pursue

special education placement



Tackling the mess of organizational skills development

While time management and organization comes innately to some, for many children andadolescents effective study and organizational skills must be taught.

Cultural changes also add to the challenge. Technology: When most of us were growing up, we had just a handful of TV and radio channels.

Now kids can choose from hundreds of cable and satellite channels, computer gaming, portablemusic, and the Internet, as well as an array of communication options, from cell phones andtexting to social networking. Technology can be a time consuming distraction.

Increased academic challenge and extracurricular commitments: Schools and colleges requiremore from their applicants than in the past. Students feel pressure to not only excel inacademics, but also shine in leadership, sports, music and standardized testing. These activitiescan fragment a student’s schedule and make it harder to manage time.

How to recognize if my child might need to improve their organizational skills?1

Fails to bring home homework assignments Does not know the exact homework assignment Fails to return completed homework Does not know how the teacher typically informs students of the homework assignments Fails to bring home books or needed materials Does not know when assignments are due Does not have papers and study guides to study for test Does not know when tests are scheduled Does not have a regular study space Does not have needed supplies for homework Waits until the last minute to start homework/studying Runs out of time when studying for tests

1 Developed by AR State PIRC/Center for Effective Parenting, 2001

Tips to help kids improve time management and organization

In order to avoid the problems listed above, students need to do three things successfully: (1) Keeptrack of assignments, books and papers, (2) have a study place (3) and plan ahead.

Keep track of school assignments, books and papers1. Have your child talk with the teacher about when and how homework is assigned. Teachers

provide homework assignments at different times, e.g., weekly, daily; and in different ways,e.g., on-line, on the board, verbally, time and in a particular way. Knowing this informationwill help your child keep track of her assignments.

2. Provide your child with an assignment journal. Your child will need a pad or notebook towrite down daily assignments, test dates, project instructions, and other important schoolinformation, along with coaching in how to use it. This journal can be a simple pocket sizespiral pad or as fancy as a daily planning calendar.

3. Teach your child a system for remembering which books to bring home. Some tricks forremembering which books to bring home include having your child position books that needto go home in his locker or desk. For example, the student can put the books to go home on aparticular shelf in the locker. Other students turn the binding of the books to go hometoward the back of the locker/desk.

4. Provide your child with a subject folder. Your child will need a folder to keep all her papersorganized, ideally color coded for each subject.

5. Teach your child to have a nightly planning time. Teach children to spend a few minuteseach night organizing their papers. This should including placing all papers that need to goback to school in their proper pocket in the subject folder and placing the folder, books, andother needed materials into her backpack.

Create a study placeTasks are easiest to accomplish when tied to specific routines. This not only fosters a sense of order,but having a designated work space and common materials at hand, minimizes delays anddistraction.

1. Designate a dedicated homework spot. The right location will depend on your child and theculture of your family. For some, the quiet of a bedroom desk is best; for others, the whitenoise of a family room with ready access to parents for questions works well. Both you andyour child should discuss the pros and cons of different setting to arrive at a mutually agreedupon location.

2. Set up a homework center. Fix up the designated workspace as a home office/work center.Make sure there is workspace large enough to set out all necessary materials. Outfit thehomework center with the kinds of supplies your child is most likely to need, such as pencils,pens, colored markers, rulers, scissors, a dictionary and thesaurus, graph paper, constructionpaper, glue and tape, etc. Use a crate or bin to house these materials if the workspace needsto double as a dining table or other purpose.

Plan AheadMost children have important social and recreational activities going on throughout the week. Oneof the best ways of keeping track of time and all their activities is through a daily and weeklyschedule. A sample schedule is provided below.

1. Provide your child with a way to map out a daily and weekly schedule. A dry erase markerboard attached to the bedroom wall provides a good way for your child to see the activitiesof the week at a glance. Making a large paper schedule or using a week-at-a-glance calendarcan also work. Before school, these schedules can serve as a reminder of what your childneeds to bring home from school that day. After school, they can help your child decide whathe needs to work on that day.

2. At the beginning of the week, have your child list out all the activities for the coming week.This will help your child plan. For example, if your child has a Social Studies test onWednesday and he needs two days to study for it, he can plan on bringing his Social Studiesbook home Monday and Tuesday nights.

3. Each day, help your child decide what needs to be done that day and when to do it. Thisshould include a listing of all homework assignments and other activities andresponsibilities. It is often a good idea to decide ahead of time on the order of homeworkassignments, sandwiching the harder assignments in between the easier assignments.

Things To Do Today Mon. Tues. Wed. Thurs. Fri. Sat. Sun.

3:00-3:30 Snack and watch TV3:30-4:30 Homework:

1. Read2. Math worksheet3. Write out spelling

words

Baseballgame 7:30

SS Test!!!Guitarlesson5:00

Bookreportdue

Spellingtest

Poolparty4:00

4:30-5:00 Eat supper

Daily and weekly scheduleexample

5:00-6:30 Baseball practice

6:30-7:30 Play outside

7:30-8:00 Practice instrument

What parents can do….

Teach your child organizational skillsIt is important for parents to keep in mind that using the ideas described above requires disciplineand motivation. Your child will need to practice the skills until they become a regular part of hisroutine. You play an important role in helping your child develop these skills and keep motivated.There are a number of things to keep in mind as you work with your child.

Set and communicate high expectations: What you expect from your child plays an important role intheir motivation. Communicate the importance of staying organized by showing interest. Ask aboutand check that your child is using the skills every day. Your child may not want to practice theorganizational skills. Let them know you understand, but that this is part of what they areresponsible for and improvement here will make school/life easier.

Shape up your child’s skills over time. Start with where your child is at and set small incrementalgoals. Do not expect perfection right away. Reward small steps toward the ultimate end goal ofgood organization. As your child makes improvements, you can expect a bit more, graduallymoving toward the desired end goal of using the organizational skills regularly.

Some of the skills may require teacher assistance initially. Some behaviors need to take place atschool when you are not present to monitor them. For example, your child will need to write herassignments in her assignment journal at school. For some children, it is helpful to have the teachermonitor the behavior at school until the child is able to do it on her own. Parents will need to talkwith the teacher to enlist their cooperation.

Monitor your child’s organizational skills daily. In order to help your child establish a daily routineof staying organized, you will need to monitor several things.

Each day, help your child with the daily and weekly schedule. Remind him in the morning to checkhis schedule. Immediately after school, help him update his schedule.

Motivate your child through encouragement and rewards. Parents should make a special effort togive their children frequent praise for the effort that they put into keeping organized. A general rulefor using praise is to do it soon, strong, and often. A strong praise is one that is given in a warm toneof voice and includes a statement letting the child know what it is you are pleased with. Forexample, “I really like how you have been keeping track of your homework assignments! Greatjob!”

Tangible rewards may need to be used to help motivate children who are having some difficultywith using the organizational skills. A convenient method to manage tangible rewards is to use abehavior chart. With a behavior chart, you keep track of your child’s organizational behavior on achart or journal on a daily basis. You can provide your child with small, but meaningful rewards forusing the skills each day (e.g., stay up later, snack, play game with parent, money, etc.).

In addition, you can provide larger weekly rewards (e.g., trip to the ice cream store, rent a videogame/movie, have a friend sleep over, money, etc.) for meeting some prearranged goal (e.g., usingthe organizational skills at least 3 days this week).

Your general approach with your child around organization should be positive. Avoid usingcriticism or punishment to try to get your child to use the organizational skills, these strategies willwork against what you are trying to accomplish in the long run. You want your child to approachnew challenges with confidence in her abilities, to have a feeling that she has control over herlearning, and to be proud of her accomplishments. These goals are accomplished through beingsupportive and encouraging over time. When problems arise, your job should be to understand theproblem and come up with solutions.

Other ideas:1. Noisy or quiet? Observations and surveys of children and

adolescents have shown that they frequently choose to study whilelistening to a radio or watching television. Should this practice bediscouraged? Based on studies in this area, the answer appears tobe “it depends.” Audio and visual distractions will tend to interferemore with difficult assignments than with easy and routineassignments. As a general rule, try to control and limit meaningfuldistractions, such as telephone, TV, and interruptions from others during study time,particularly during difficult tasks. However, some children find music or other nonvocalbackground noise helpful during easy and routine assignments.

2. Write a homework contract: The contract should say exactly what the child agrees to do andexactly what the parents’ roles and responsibilities will be. Having a contract in place canreduce some of the tension parents and kids often experience around homework. Forinstance, if the contract states that the child will earn a point for not complaining abouthomework and the child does complain, the argument is de-personalized, i.e., no longer abattle of wills between parent and child. The child simply does not earn a point. Be sure topraise children for following the contract and establish terms that are realistic and that bothsides can live with/impose. Most incentive systems are iterative, to be refined over time.Parents should go into it with a willingness to “learn as they go.”

3. Adaptations and other support: The suggestions here will need to be adapted to the age andneeds of your child. Middle school is often the turning point and parents will need to makedecisions about how involved to be in homework based on the developmental level of theirchildren. If problems arise that seem intractable at any age, consult your child’s teacher,pediatrician or school psychologist.

A Parent’s Guide to Pediatric Neuropsychological Assessment

What is a Pediatric Neuropsychologist?A pediatric neuropsychologist is a doctoral level psychologist with specializedtraining in brain-behavior relationships. The pediatric neuropsychologist usesstandardized tests and observes behavior to define a child's pattern of cognitivedevelopment. The child's performance is compared to what is expected at thechild's age-level. The child's individual pattern of strengths and weaknessesis defined based on this comparison. The pediatric neuropsychologist usesknowledge of brain development, brain organization, and the effects of variousforms of brain pathology on development to guide this assessment and to interpret theresults.

How does neuropsychological assessment differ from the testing provided by aclinical psychologist or school psychologist?The pediatric neuropsychologist holds a doctoral degree in psychology withspecialized training in their area of practice, typically including two-year ofpost-doctoral work; while the school psychologist typically hold a master’sdegree and sometimes a doctoral degree. The pediatric neuropsychologist andschool psychologist may use some of the same tests; however, the schoolpsychologist is typically testing to determine eligibility for special education,while the pediatric neuropsychologist typically performs a more comprehensiveassessment and examines patterns of scores across different tests to come toconclusions about the child’s development, attempting to define a pattern ofstrengths and weaknesses to inform treatment. The pediatric neuropsychologistworks to understand where the child is having trouble and why. Unlike most schoolpsychologists, the pediatric neuropsychologist is able to render a diagnosis that the childmay require in order to receive the appropriate medical, educational, and developmentaltreatment and accommodations to reach their full potential.

The pediatric neuropsychologist may look at a broader range of skills, evaluatingskills not usually tested by the clinical or school psychologist, including:• General intellectual functioning• Academic achievement skills, such as reading, writing, and math skills• Executive functioning, such as organization, planning, inhibition, and flexibility• Attention• Learning and memory• Language• Visual–spatial skills• Motor coordination• Behavioral and emotional functioning• Social skills

When should I consider a neuropsychological evaluation?Referral is typically made by the child’s pediatrician, teacher, developmental specialist,or parents/caregivers to answer specific questions about a child’s developmental,

cognitive, and emotional status and to aid in differential diagnosis. A neuropsychologicalevaluation can be helpful if your child has:

Difficulty with learning, attention, behavior, problem-solving, socialization,acquisition of language, or emotional control.

A documented developmental condition, such as Attention-Deficit/HyperactivityDisorder (ADHD), autism spectrum disorder, learning disorder, or emotionaldisorder.

A neurological condition such as hydrocephalus, cerebral palsy, epilepsy(seizures), neurofibromatosis, tuberous sclerosis, or a brain tumor.

A brain injury as a result of an accident, a stroke, or an infection of the brain. Other medical problems that place him/her at an increased risk of brain

injury such as diabetes, chronic heart or respiratory problems, certain geneticdisorders, or treatment for childhood cancer.

Been exposed to toxins such as lead, street drugs, inhalants, mold, or wasexposed to these substances or to alcohol prior to birth.

Had an assessment by a clinical psychologist or the school multi-disciplinary team, but interventions resulting from that assessment failed tohelp your child.

How will neuropsychological assessment help my child and me?The neuropsychological assessment and report will provide you with:

An accurate diagnosis (if warranted) that can help guide effective interventionsandacquire educational and developmental services.

Documentation of the Department of Elementary and Secondary EducationDisability Category Qualification (if warranted).

Documentation of skills before and after interventions to evaluate treatmentefficacy.

Documentation of your child's cognitive developmental pattern over timeso that medical treatments, family expectations, and school programming canbe adjusted to your child's changing needs.

A description of your child's strengths and weaknesses. Recommendations for what you can do to help your child, including

recommendations for educational, medical, and/or developmentalprogramming.

Resources for community based interventions and supports. Help in knowing what is fair to expect from your child at this point in time. Help in knowing what your child's needs may be in the future, so that you can

plan for the future. Recommendations for improving your child's behavior and development. A

good pediatric neuropsychologist will provide ongoing follow-up over timeto monitor your child as he/she grows and make updated recommendations,as needed and help to coordinate care. In addition, the pediatricneuropsychologist may refer you to other specialists, such as a clinicalpsychologist, social worker, speech and language pathologist, occupationaltherapist, or behavioral therapist for ongoing help with your child's developmentand behavior.

The pediatric neuropsychologist should also be available to attend schoolmeetings with you or perform a school observation, if necessary.

What should I tell my child to prepare him/her for neuropsychological assessment?Children sometimes think that visits to a doctor will involve shots. It is importantto reassure your child that no shots or painful procedures will be involved in thevisit to the neuropsychologist. For school aged children, it is appropriate to describetesting as like school. You can tell your child that he/she will be doing manydifferent activities. Some activities involve listening and talking while otheractivities involving looking at things, building things and drawing. Parents are nottypically allowed to be present during testing unless the child is very young or hasdifficulties with separation. Let your child know that you will be close by whilehe/she works with the neuropsychologist. Reassure your child that she/he can havebreaks to use the bathroom and to eat lunch and that she/he may even earn specialrewards if they put forth their best effort!

For young children, you can describe neuropsychological assessment as playinggames involving listening, talking and remembering. Let the child know that theneuropsychologist will have toys like blocks and puzzles that he/she will get touse. Your preschool child may wish to bring a security object along to theappointment. Try to choose an object that will not be too distracting for the child(e.g. a security blanket or small stuffed animal as opposed to an action figure or toywith many small parts).

You can help your child get ready for assessment by making sure that he/she gets agood night sleep prior to testing. Make sure that you child has eaten so that he/shewill not be hungry during testing. Make the assessment day a special day for yourchild by leaving brothers and/or sisters at home.

1

1Adapted from The National Academy of Neuropsychology: Parent’s Guide to PediatricNeuropsychological Assessment. Retrieved October 15, 2012, fromhttp://psychiatry.unm.edu/centers/cns/common/docs/Parents%20Guide.pdf.1

What Can I Do When My Child Has Problems With Sleep?

Many children with ADHD have difficulty sleeping at night,whether or not they are on medication. This is partially related to the ADHD; parents often describe their children as being “onthe go” and collapsing late at night. It may also be due to the factthat stimulant medication has worn off, making it more difficultfor them to manage their behavior. Lastly, some children have difficulty falling asleep because the stimulants affect them thesame way caffeine affects adults.

Here are a few tips:

■ Develop bedtime rituals/routines.

� A bedtime ritual is a powerful sign that it is time to sleep.It needs to be simple so the child can “re-create” the ritual even if the parent is not present.

� Try writing out the bedtime ritual to make it consistent.

■ Pay attention to the sleep environment.

� Background noises, location, sleep partners, bedding,favorite toys, and lighting can all affect a child’s ability to fall asleep.

� A cool, dark, quiet room is best.

■ Letting children cry themselves to sleep is not recommended.

� Teach them to soothe themselves, such as giving the child a special blanket, a picture of the parent(s), or a stuffed animal to hold while falling asleep.

� Avoid activities that depend on a parent’s presence,including rocking or holding the child until he or she falls asleep.

■ Make the bedroom a sleep-only zone.

� Remove most toys, games, televisions, computers, and radios from your child’s bedroom if your child is having trouble falling asleep or is often up at night.

� One or two stuffed animals are acceptable.

■ Limit time in bed.

� Hours spent awake in bed interfere with good sleep patterns;the goal is to make the child’s bed a place for sleeping only.

� Be aware of how much sleep children need at different ages.Even though adults need about 8 hours of sleep, infants and toddlers often sleep more than 12 hours and children usuallysleep 10 hours. Teenagers also need lots of sleep, sometimes requiring 9 hours or more.

■ Establish consistent waking times.

� Bedtimes and waking times should be the same 7 days a week.

� It is easier to enforce a waking time than a bedtime.

■ Avoid drinks with caffeine.

� Caffeine is present in a wide range of beverages, such as tea, soda, cocoa, and coffee. Drinking these beverages past the afternoon may make it more difficult for your child to settle down to sleep.

■ Establish daytime routines.

� Regular mealtimes and activity times, including playtime with parents, also help set sleep times.

■ Chart your child’s progress.

� Praise your child for successful quiet nights.

� Consider marking successful nights on a star chart and providing rewards at the end of the week.

■ Waking up at night is a habit.

� Social contact with parents, feeding, and availability ofinteresting toys encourage the child to be up late, so set limits on attention-getting behaviors at night.

■ Consider medical problems.

� Allergy, asthma, or conditions that cause pain can disrupt sleep. If your child snores loudly and/or pauses in breathing,talk to your doctor.

■ Try medications to help your child sleep only under the care of your child’s doctor.

� Medications need to be used very carefully in young children. Many medications can have complications and make sleep worse.

� Some children with ADHD may actually be helped by a small dose of a stimulant medication at bedtime. Paradox-ically, this dose may help a child to get organized for sleep.

� Some children may ultimately need other bedtime medications—at least for a little while—to help improve sleep. Talk with your doctor before starting any over-the- counter or prescription medications.

Adapted from material developed by Laurel K. Leslie, MD, San Diego ADHD Project, and from material developed by Henry L. Shapiro, MD, FAAP, for the PediatricDevelopment and Behavior Web site (www.dbpeds.org).

The information contained in this publication should not be used as a substitute for themedical care and advice of your pediatrician. There may be variations in treatment thatyour pediatrician may recommend based on individual facts and circumstances.

Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’sHealthcare Quality

The information contained in this publication should not be used as a substitute for the

medical care and advice of your pediatrician. There may be variations in treatment that

your pediatrician may recommend based on individual facts and circumstances.

Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’s

Healthcare Quality

Revised - 1102

Educational Rights for Children With ADHD

There are 2 main laws protecting students with disabilities—including those with

ADHD: 1) the Individuals with Disabilities Education Act of 1997 (IDEA) and

2) Section 504 of the Rehabilitation Act of 1973. IDEA is special education law.

Section 504 is a civil rights statute. Both laws guarantee to qualified students a

free and appropriate public education (FAPE) and instruction in the least restric-

tive environment (LRE), which means with their peers who are not disabled and

to the maximum extent appropriate to their needs.

Because there are different criteria for eligibility, services/supports available, and

procedures and safeguards for implementing the laws, it is important for parents,

educators, clinicians, and advocates to be well aware of the variations between

IDEA and Section 504 and fully informed about the respective advantages and

disadvantages.

Additional Resources1. Advocacy Manual: A Parents’ How-to Guide for Special Education Services

Learning Disabilities Association of America, 1992. Contact the publisher at

4156 Library Rd, Pittsburgh, PA 15243 or 888/300-6710.

2. Better IEPs: How to Develop Legally Correct and Educationally Useful Programs

Barbara Bateman and Mary Anne Linden, 3rd edition, 1998. Contact the

publisher, Sopris West, at 303/651-2829 or http://www.sopriswest.com.

3. The Complete IEP Guide: How to Advocate for Your Special Ed Child

Lawrence Siegel, 2nd edition, 2000. Contact the publisher, Nolo, at 510/549-1976

or http://www.nolo.com.

4. Negotiating the Special Education Maze: A Guide for Parents and Teachers

Winifred Anderson, Stephen Chitwood, and Deidre Hayden; 3rd edition; 1997.

Contact the publisher, Woodbine House, at 6510 Bells Mill Rd, Bethesda, MD

20817 or 800/843-7323.

5. Children and Adults With Attention-Deficit/Hyperactivity Disorder

http://www.chadd.org

6. Education Resources Information Center

http://ericir.syr.edu

7. Internet Resource for Special Children

http://www.irsc.org

8. San Diego ADHD Web Page

http://www.sandiegoadhd.org

9. National Information Center for Children and Youth with Disabilities

http://www.nichcy.org

10. Parent Advocacy Coalition for Educational Rights Center

http://www.pacer.org

Glossary of Acronyms

ADHD

Attention-deficit/hyperactivity disorder

BIP

Behavioral Intervention Plan

ED

Emotional disturbance

FAPE

Free and appropriate public education

FBA

Functional Behavioral Assessment

IDEA

Individuals with Disabilities Education Act

IEP

Individualized Education Program

IST

Instructional Support Team

LRE

Least restrictive environment

MDR

Manifestation Determination Review

MDT

Multidisciplinary Team

OHI

Other health impaired

SLD

Specific learning disability

SST

Student Study Team





Healthcare Quality

Who Is Eligible?IDEA strongly emphasizes the provision of special education and

related services that enable students to access and progress in the

general education program. Sometimes students with ADHD

qualify for special education and related services under the dis-

ability categories of “specific learning disability” (SLD) or “emo-

tional disturbance” (ED). For example, a child who has ADHD

who also has coexisting learning disabilities may be eligible

under the SLD category. Students with ADHD most commonly

are eligible for special education and related services under the

IDEA category of “other health impaired” (OHI). Eligibility

criteria under this category require that the child has a chronic

or acute health problem (eg, ADHD) causing limited alertness

to the educational environment (due to heightened alertness to

environmental stimuli) that results in an adverse effect on the

child’s educational performance to the degree that special

education is needed.

Note: The adverse effect on educational performance is not limited

to academics, but can include impairments in other aspects of school

functioning, such as behavior, as well.

How Does a Parent Access Services Under IDEA?■ Parents or school personnel may refer a child by requesting

an evaluation to determine eligibility for special education and

related services. It is best to put this request in writing.

■ Within a limited time frame, the school’s multidisciplinary

evaluation team, addressing all areas of the child’s diffi-

culties, develops an assessment plan.

■ After parents or guardians consent to the assessment plan,

the child receives a comprehensive evaluation by the

multidisciplinary team of school professionals.

■ After the evaluation, an Individualized Education Program

(IEP) meeting is scheduled with the team, including parents,

teacher(s), special education providers, the school psychologist

and/or educational evaluator, a school system representative,

and the student (as appropriate).


IDEA

■ Based on the results of the evaluation, as well as other input

provided by parents and/or other team members, the team

decides whether the child meets eligibility criteria for special

education under one of the categories defined by IDEA.

■ An IEP is developed and written for qualifying students

through a collaborative team effort. It is tailored and designed

to address the educational needs of the student.

■ The IEP goes into effect once the parents sign it and agree to

the plan.

■ The IEP must address the following:

–Present levels of educational performance, including how

the child’s disability affects his or her involvement and progress

in the general curriculum

–Delineation of all special education and related services,

modifications (if any), and supports to be provided to the

child or on behalf of the child

–Annual goals and measurable, short-term objectives/

benchmarks

–The extent (if any) to which the child will not participate

with children in the regular class and other school activities

–Modifications (if any) in the administration of statewide and

district-wide tests the child will need to participate

in those assessments

–Dates and places specifying when, where, and how often

services will be provided, and by whom

What Happens After the IEP Is Written?1. Services are provided. These include all programs, supplemental

aids, program modifications, and accommodations that are

spelled out in the IEP.

2. Progress is measured and reported to parents. Parents are

informed of progress toward IEP goals during the year, and

an annual IEP review meeting is required.

3. Students are reevaluated every 3 years (triennial evaluation)

or sooner if deemed necessary by the team or on parent/

teacher request.

Adapted from Rief S. The ADD/ADHD Book of Lists. San Francisco, CA: Jossey-Bass Publishers; 2002, and from material developed by Laurel K. Leslie, MD, San Diego

ADHD Project.





Healthcare Quality


Who Is Eligible?Students with ADHD also may be protected under Section 504 of

the Rehabilitation Act of 1973 (even if they do not meet eligibility

criteria under IDEA for special education). To determine eligibility

under Section 504 (ie, the impact of the disability on learning), the

school is required to do an assessment. This typically is a much less

extensive evaluation than that conducted for the IEP process.

Section 504 is a federal civil rights statute that:

■ Protects the rights of people with disabilities from discrimina-

tion by any agencies receiving federal funding (including all

public schools)

■ Applies to students with a record of (or who are regarded as

having) a physical or mental impairment that substantially

limits one or more major life function (which includes learning)

■ Is intended to provide students with disabilities equal access to

education and commensurate opportunities to learn as their

peers who are not disabled

How Does a Parent Access Services Under Section 504?■ Parents or school personnel may refer a child by requesting

an evaluation to determine eligibility for special education and

related services. It is best to put this request in writing.

■ If the school determines that the child’s ADHD does signifi-

cantly limit his or her learning, the child would be eligible

for a 504 plan designating:

–Reasonable accommodations in the educational program

–Related aids and services, if deemed necessary (eg, counseling,

assistive technology)

What Happens After the 504 Plan Is Written?The implementation of a 504 plan typically falls under the responsi-

bility of general education, not special education. A few sample

classroom accommodations may include:

■ Tailoring homework assignments

■ Extended time for testing

■ Preferential seating

■ Supplementing verbal instructions with visual instructions

■ Organizational assistance

■ Using behavioral management techniques

■ Modifying test delivery

Section 504

What Do Section 504 and IDEA Have in Common?

Both:

■ Require school districts to provide free and appropriate public

education (FAPE) in the least restrictive environment (LRE)

■ Provide a variety of supports (adaptations/accommodations/

modifications) to enable the student to participate and learn

in the general education program

■ Provide an opportunity for the student to participate in

extracurricular and nonacademic activities

■ Require nondiscriminatory evaluation by the school district

■ Include due process procedures if a family is dissatisfied with a

school’s decision

Which One Is Right for My Child—a 504 Plan or an IEP?This is a decision that the team (parents and school personnel)

must make considering eligibility criteria and the specific needs

of the individual student. For students with ADHD who have

more significant school difficulties:

IDEA usually is preferable because:

■ It provides for a more extensive evaluation.

■ Specific goals and short-term objectives are a key component

of the plan and regularly monitored for progress.

■ There is a much wider range of program options, services, and

supports available.

■ It provides funding for programs/services (Section 504 is

non-funded).

■ It provides more protections (procedural safeguards, monitor-

ing, regulations) with regard to evaluation, frequency of review,

parent participation, disciplinary actions, and other factors.

A 504 plan would be preferable for:

■ Students who have milder impairments and don’t need special

education. A 504 plan is a faster, easier procedure for obtaining

accommodations and supports.

■ Students whose educational needs can be addressed through

adjustments, modifications, and accommodations in the general

curriculum/classroom.

Adapted from Rief S. The ADD/ADHD Book of Lists. San Francisco, CA: Jossey-Bass Publishers; 2002, and from material developed by Laurel K. Leslie, MD, San Diego

ADHD Project.





Healthcare Quality


(Date)

School Site Principal’s Name

School Name

Address

RE: (Student’s Name and Grade)

Dear (Principal’s Name)*:

I am the parent of (Student’s Name), who is in Mr/Ms (Teacher’s Name)’s class. (Student’s Name) has been

experiencing school problems for some time now. We have been working with the teacher(s) to modify (his/her)

regular education program but (we have not seen any improvement or the problems have been getting worse).

Therefore, I wish to request an assessment of my child for appropriate educational services and interventions

according to the provisions of Section 504 of the Rehabilitation Act.

I look forward to working with you as soon as possible to develop an assessment plan to begin the evaluation

process. I request copies of the assessment results 1 week prior to the meeting.

Thank you for your assistance. I can be reached by phone at (Area Code and Phone Number).

The best time to reach me is (times/days).

Sincerely,

(Sign Your Name)

(Print Your Name)

(Address)

(Telephone Number)

Adapted from San Diego Learning Disabilities Association.http://ldasandiego.org/

Sample Letter #1:Request for Assessment for Educational Services Under Section 504

Note: Remember to keep a copy for your files.

*If the principal does not respond, contact the district 504 coordinator. It is recommended that you either write a letter or document

your phone conversation. If you do not get a response, you have the right to file a compliance complaint.





Healthcare Quality


(Date)

School Site Principal’s Name:

School Name

Address

RE: (Student’s Name and Grade)

Dear (Principal’s Name)*:

I am the parent of (Student’s name) who is in Mr/Ms (Teacher’s Name)’s class. (Student’s Name) has been experiencing

school problems for some time now. These problems include:______________________________________________

______________________________________________________________________________________________

We have been working with the teacher(s) to modify (his/her) regular education program but (we have not seen any

improvement or the problems have been getting worse). Therefore, I wish to request an assessment of my child for

possible special education services according to the provisions of IDEA.

I look forward to working with you within the next 15 days to develop an assessment to begin the evaluation process.

Please ensure that I receive copies of the assessment results 1 week prior to the IEP meeting. Thank you for your

assistance. I can be reached by phone at (Area Code and Phone Number). The best time to reach me is (times/days).

Sincerely,

Sign your name Doctor’s Signature

Print your name License Number

Street Address Practice Address

City, State, ZIP City, State, ZIP

Adapted from San Diego Learning Disabilities Association.http://ldasandiego.org/

Sample Letter #2:Request for Assessment for Special Education

For Parents of Children With ADHD

General Tips1. Rules should be clear and brief. Your child should know exactly

what you expect from him or her.2. Give your child chores. This will give him or her a sense of

responsibility and boost self-esteem.3. Short lists of tasks are excellent to help a child remember.4. Routines are extremely important for children with ADHD.

Set up regular times for meals, homework, TV, getting up,and going to bed. Follow through on the schedule!

5. Identify what your child is good at doing (like art, math,computer skills) and build on it.

6. Tell your child that you love and support him or her unconditionally.

7. Catch your child being good and give immediate positive feedback.

Common Daily ProblemsIt is very hard to get my child ready for school in the morning.■ Create a consistent and predictable schedule for rising and

getting ready in the morning.■ Set up a routine so that your child can predict the order of

events. Put this routine in writing or in pictures on a poster for your child. Schedule example:

Alarm goes off ➔ Brush teeth ➔ Wash face ➔ Get dressed ➔ Eat breakfast ➔ Take medication ➔ Get on school bus

■ Reward and praise your child! This will motivate your child to succeed. Even if your child does not succeed in all parts of the “morning routine,” use praise to reward your child when he or she is successful. Progress is often made in a series of small steps!

■ If your child is on medication, try waking your child up 30 to 45 minutes before the usual wake time and give him or her the medication immediately. Then allow your child to “rest” in bed for the next 30 minutes. This rest period will allow the medica-tion to begin working and your child will be better able to participate in the morning routine.

My child is very irritable in the late afternoon/early evening.(Common side effect of stimulant medications)■ The late afternoon and evening is often a very stressful time for

all children in all families because parents and children have had to “hold it all together” at work and at school.

■ If your child is on medication, your child may also be exper-iencing “rebound”—the time when your child’s medication is wearing off and ADHD symptoms may reappear.

■ Adjust your child’s dosing schedule so that the medication is not wearing off during a time of “high demand” (for example,when homework or chores are usually being done).

■ Create a period of “downtime” when your child can do calm activities like listen to music, take a bath, read, etc.

■ Alternatively, let your child “blow off extra energy and tension”by doing some physical exercise.

■ Talk to you child’s doctor about giving your child a smaller dose of medication in the late afternoon. This is called a “stepped down” dose and helps a child transition off of medication in the evening.

My child is losing weight or not eating enough.(Common side effects of stimulant medication use)■ Encourage breakfast with calorie-dense foods.■ Give the morning dose of medication after your child has

already eaten breakfast. Afternoon doses should also be given after lunch.

■ Provide your child with nutritious after-school and bedtime snacks that are high in protein and in complex carbohydrates.Examples: Nutrition/protein bars, shakes/drinks made with protein powder, liquid meals.

■ Get eating started with any highly preferred food before giving other foods.

■ Consider shifting dinner to a time later in the evening when your child’s medication has worn off. Alternatively, allow your child to “graze” in the evening on healthy snacks, as he or she may be hungriest right before bed.

■ Follow your child’s height and weight with careful measure-ments at your child’s doctor’s office and talk to your child’s doctor.

Homework Tips■ Establish a routine and schedule for homework (a specific time

and place.) Don’t allow your child to wait until the evening to get started.

■ Limit distractions in the home during homework hours (reducing unnecessary noise, activity, and phone calls, and turning off the TV).

■ Praise and compliment your child when he or she puts forth good effort and completes tasks. In a supportive, noncritical manner, it is appropriate and helpful to assist in pointing out and making some corrections of errors on the homework.

■ It is not your responsibility to correct all of your child's errors on homework or make him or her complete and turn in a perfect paper.

■ Remind your child to do homework and offer incentives:“When you finish your homework, you can watch TV or play a game.”

■ If your child struggles with reading, help by reading the material together or reading it to your son or daughter.

■ Work a certain amount of time and then stop working on homework.

“Common Daily Problems” adapted from material developed by Laurel K. Leslie, MD, San Diego ADHD Project.



■ Many parents find it very difficult to help their own child with schoolwork. Find someone who can. Consider hiring a tutor! Often a junior or senior high school student is ideal, depending on the need and age of your child.

Discipline■ Be firm. Set rules and keep to them.■ Make sure your child understands the rules, so he or she does

not feel uninformed.■ Use positive reinforcement. Praise and reward your child for

good behavior.

■ Change or rotate rewards frequently to maintain a high interest level.

■ Punish behavior, not the child. If your child misbehaves, try alternatives like allowing natural consequences, withdrawing yourself from the conflict, or giving your child a choice.

Taking Care of Yourself■ Come to terms with your child’s challenges and strengths.■ Seek support from family and friends or professional help such

as counseling or support groups.■ Help other family members recognize and understand ADHD.

For Parents of Children With ADHD

“Common Daily Problems” adapted from material developed by Laurel K. Leslie, MD, San Diego ADHD Project.



Homework Tips for Parents

■ Establish a routine and schedule for homework (a specific time and place) and adhere to the schedule as closely as possible.Don’t allow your child to wait until the evening to get started.

■ Limit distractions in the home during homework hours (eg, reduce unnecessary noise, activity, and phone calls;turn off the TV).

■ Assist your child in dividing assignments into smaller parts or segments that are more manageable and less overwhelming.

■ Assist your child in getting started on assignments (eg, read the directions together, do the first items together, observe as your child does the next problem/item on his or her own).Then get up and leave.

■ Monitor and give feedback without doing all the work together. You want your child to attempt as much as possible independently.

■ Praise and compliment your child when he or she puts forth good effort and completes tasks. In a supportive, noncritical manner it is appropriate and helpful to assist in pointing out and making some corrections of errors on the homework.

■ It is not your responsibility to correct all of your child’s errors on homework or make him or her complete and turn in a perfect paper.

■ Remind your child to do homework and offer incentives:“When you finish your homework, you can…”

■ A contract for a larger incentive/reinforcer may be worked out as part of a plan to motivate your child to persist and followthrough with homework. (“If you have no missing or late home-work assignments this next week, you will earn. . .”).

■ Let the teacher know your child’s frustration and tolerance level in the evening. The teacher needs to be aware of the amountof time it takes your child to complete tasks and what efforts you are making to help at home.

■ Help your child study for tests. Study together. Quiz your child in a variety of formats.

■ If your child struggles with reading, help by reading the material together or reading it to your son or daughter.

■ Work a certain amount of time and then stop working on homework. Don’t force your child to spend an excessive and inappropriate amount of time on homework. If you feel your child worked enough for one night, write a note to the teacher attached to the homework.

■ It is very common for students with ADHD to fail to turn in their finished work. It is very frustrating to know your child struggled to do the work, but then never gets credit for having done it. Papers seem to mysteriously vanish off the face of the earth! Supervise to make sure that completed work leaves the home and is in the notebook/backpack. You may want to arrange with the teacher a system for collecting the work immediately on arrival at school.

■ Many parents find it very difficult to help their own child with schoolwork. Find someone who can. Consider hiring a tutor! Often a junior or senior high school student is ideal, depending on the needs and age of your child.

■ Make sure your child has the phone number of a study buddy—at least one responsible classmate to call for clarification of homework assignments.

■ Parents, the biggest struggle is keeping on top of those dreaded long-range homework assignments (eg, reports, projects). This is something you will need to be vigilant about. Ask for a copy of the project requirements. Post the list at home and go over it together with your child. Write the due date on a master calendar.Then plan how to break down the project into manageable parts,scheduling steps along the way. Get started AT ONCE with going to the library, gathering resources, beginning the reading, and so forth.

Adapted from Rief S. The ADD/ADHD Book of Lists. San Francisco, CA: Jossey-Bass Publishers; 2002



Working With Your Child’s School

Why Is My Child Having Trouble in School?It is very common for children with ADHD to have difficulties inschool. These problems can occur for several reasons:

■ Symptoms of ADHD like distractibility and hyperactivitymake it hard for children with ADHD to pay attention or stay focused on their work, even though they may be capable learners and bright enough to understand the material.

■ Many children with ADHD also have trouble organizingthemselves, breaking an assignment down into smaller steps,and staying on a schedule.

■ Some children with ADHD have difficulty with self-control and get into trouble with peers and/or teachers.

■ Many children with ADHD also have a learning disability.Schools usually define a learning disability as a discrepancy between a child’s IQ score and his or her performance on achievement tests. A child with a learning disability has diffi-culty understanding information he or she sees or hears OR trouble putting together information from different parts ofthe brain.

■ Children with ADHD often can learn material but it may take longer and require more repetition.

■ Children with ADHD often show inconsistency in their work because of their ADHD; one day they may know information and the next day they cannot seem to remember it.

Typical School Performance Difficulties Associated With ADHD■ Poor organization and study skills■ Weaknesses in written language/writing skills■ Minimal/inconsistent production and output (both in-class

assignments and homework)■ Behavior that interferes with learning and impacts on

interpersonal relationships■ Immature social skills

What Can I Personally Do to Help?There are many different ways that a parent’s participation canmake a difference in a child’s school experience, including:

■ Spending time in the classroom, if your work schedule allows,and observing your child’s behavior.

■ Talking with your child’s teacher to identify where your child is having the most problems.

■ Working with your child’s teacher to make a plan for how you will address these problems and what strategies at school and home will help your child be successful at learning and completing work.

■ Acknowledging the extra efforts your child’s teacher may have to make to help your child.

■ Reading all you can about ADHD and sharing it with your child’s teacher and other school officials.

■ Becoming an expert on ADHD and your child.■ Finding out about tutoring options through your child’s

school or local community groups. Children with ADHD may take longer to learn material compared with other children even though they are just as smart. Tutoring may help your child master new materials.

■ Making sure your child actually has mastered new material presented so that he or she does not get behind academically.

■ Acknowledging how much harder it is for your child to get organized, stay on task, complete assignments, and learn material compared with other children. Help your child to get organized,break tasks down into smaller pieces, and expend his or her ex- cess physical energy in ways that are “okay” at home and in the classroom.

■ Praising your child and rewarding him or her for a job well done immediately after completing tasks or homework.

■ Joining a support group for parents of children with ADHD or learning disabilities. Other parents may help you with ideas to help your child.

Another good way to get help from your school is to determine if your school has a regular education process that helps teacherswith students who are having learning or behavioral problems that the teacher has been unsuccessful in solving. The process differs in various school districts and even among different schoolsin the same district. Some of the names this process may go by in-clude Student Study Team (SST), Instructional Support Team (IST),Pupil Assistance Team (PAT), Student Intervention Team (SIT), orTeacher Assistance Team (TAT).

Parents are encouraged to request a meeting on their child to discuss concerns and create a plan of action to address their child’sneeds. In addition to the child’s teacher, members of the team mayinclude the child, the parents, a mentor teacher or other teachers,the principal, the school nurse, the resource specialist, a speech andlanguage specialist, or a counselor or psychologist. The team mem-bers meet to discuss the child’s strengths and weaknesses, the child’sprogress in his or her current placement, and the kinds of problemsthe child is having. The team members “brainstorm” to develop a plan of action that documents the kinds of interventions that will help the child, the timeline for the changes to take place, and the school staff responsible for the implementation of the team’s recommendations.

The team should also come up with a plan to monitor the child’sprogress. A follow-up meeting should be scheduled within a reason-able time frame (usually 4 to 6 weeks) to determine whether the team’s interventions are actually helping the child in the areas ofdifficulty.

Adapted from material developed by Laurel K. Leslie, MD, San Diego ADHD Project.

Documents

0 - Cover - ADHD · 2015-01-13 · ADHD: What Every Parent Needs to Know (formerly entitled ADHD: A Complete and Authoritative Guide) is a balanced guide to help you and your child