School- and classroom-based interventions to support children and adolescents with ADHD: Innovative

and promising approaches

Gary Stoner, Ph.D.Email: gstoner@uri.edu

University of Rhode IslandPresentation for the Coventry Public Schools

March 12, 2009

ADHD in School Contexts: Reasons for Concern

• School success is both critical and potentially elusive for students with ADHD

• Increasing numbers of children who are “difficult-to-teach” and “difficult-to-manage”

• Reactive support model (i.e., wait to fail) remains prevalent mode of practice in special education and school psychology

CHALLENGES TO INTERVENTION IN PUBLIC SCHOOLS

• Lack of knowledge about effective supports for students with ADHD

• Challenges in designing/implementing individual modifications

• Lack of knowledge or experience with behavioral techniques

• Support of administration/policies for intervention

• Class size• “Fairness” to other students?

CHALLENGES TO INTERVENTION AT SECONDARY LEVEL

• Multiple teachers/staff• Resistance of faculty• Defiance of student• Student reaction to peer pressure• Competing demands for student

time

TARGETS FOR TREATMENT

• Behavior Control• Staying on-task; Paying attention• Following classroom rules• Anger control

• Academic Performance• Class Participation• Homework Completion• Organizational Skills

• Note-taking• Studying for exams• Long-term projects

• Appropriate Social Behavior• Social Problem Solving

Some guiding principles for intervention with ADHD• Apply the group primary, secondary,

tertiary prevention/intervention model (RTI), but with individual students

• Combine proactive and reactive management strategies (e.g., teach rules and daily report)

• Intervention in place at point of performance of target behaviors

• Intervene early in the course of problems

Some guiding principles for intervention with

ADHD(cont.)

• Use multiple intervention agents• Link assessment data to

intervention• Individualize interventions• Again…deliver interventions at the

“point of performance”

Academic Systems Behavioral Systems

1-5% 1-5%

5-10% 5-10%

80-90% 80-90%

Intensive, Individual Interventions•Individual Students•Assessment-based•High Intensity

Intensive, Individual Interventions•Individual Students•Assessment-based•Intense, durable procedures

Targeted Group Interventions•Some students (at-risk)•High efficiency•Rapid response

Targeted Group Interventions•Some students (at-risk)•High efficiency•Rapid response

Universal Interventions•All students•Preventive, proactive

Universal Interventions•All settings, all students•Preventive, proactive

Designing School-Wide Systems for Student Success (see www.pbis.org)

Primary and Secondary Prevention Strategies: Preschool

• Home/school/community based support for:– Language development/early literacy/cognitive

development• (Read Together/Talk Together)

– Social development/socialization• The Incredible Years programs (U. Washington, Carolyn

Webster Stratton)• Oregon Resiliency Project: Strong Start Program, a

social and emotional development curriculum (Merrell, 2007; Brookes)

– School readiness

Elementary

• Academic– Skills for School Success (Curriculum Associates)– Basic Skills Instruction/Progress Monitoring

• Social/Emotional/Behavior– Positive Behavior Support; First Steps Program (Sopris

West)– Oregon Resiliency Project: Strong Start/Kids Programs, a

social and emotional development curriculum (Merrell, 2007; Brookes)

• Mental Health– Oregon Resiliency Project: Strong Kids (Online)

Middle

• Academic– Advanced Skills for School Success (Curriculum

Associates)– Assignment/Work Accommodations– Curriculum-based collaboration and Instructional

support (SPED)• Mental Health

– Oregon Resiliency Project: Strong Kids Program, a social and emotional development curriculum (Merrell, 2007; Brookes)

• Social/Emotional/Behavior– Positive Behavior Support; Teaching Self-Management

Strategies to Adolescents (Sopris West)

High School

• Academic– Advanced Skills for School Success– Assignment/Work Accommodations;– Curriculum-Based Collaboration and Instructional Support (SPED)

• Mental Health– Oregon Resiliency Project: Strong Teens Program, a social and

emotional development curriculum (Merrell, 2007; Brookes)• Social/Emotional/Behavior

– Positive Behavior Support– Teaching Self-Management Strategies to Adolescents (Sopris

West)• Dropout prevention

– Check and Connect Program, (Christenson, University of Minnesota)

Time/Grade/Age

Lo

Hi

The Effects of Computerized Reading Instruction on the Academic

Performance of Students Identified with ADHD

(School Psychology Review, 2005, 34, 246-254)Julie Clarfield and Gary Stoner

University of Massachusetts Amherst

Children with ADHD are at higher than average risk

for:• Behavioral and academic difficulties• Grade retention• Placement in special education

programs• School drop out• Lower high school GPA• Enrollment in college degree

programs

Children with ADHD and academics, continued:

• As many as 80% of students with ADHD exhibit academic difficulties, including lower than expected work completion rates

• Approximately 20-30% are identified with learning difficulties due to problems with acquisition of academic skills

• Recent studies show literacy/reading skill acquisition problems relative to matched peers as early as Kindergarten

• These risks and outcomes suggest need for effective educational interventions

Computers (CAI) are promising, as students

with ADHD perform better:• …when provided with immediate

(vs. delayed) feedback• …when stimulus conditions are

novel (vs. familiar)• …when provided with one-to-one

student-teacher ratio

Purpose of present study:

• evaluate the effectiveness of a recently developed computerized reading instruction program—Headsprout

• …with participants diagnosed with ADHD and experiencing reading problems

Research questions:

• Relative to teacher directed, small group instruction, what are the effects of the Headsprout reading program on students’ task engagement?

• Relative to teacher-directed, small group instruction, what are the effects of the Headsprout reading program on students’ oral reading fluency?

Participants:

• Tim. 6 yo, repeating Kindergarten. – inattentive subtype of ADHD; 2.5 mg of

methylphenidate once a day during the first 7 weeks; then an 18mg dose of Concerta once a day.

• Kevin. 7 yo, 1st grade student.– combined subtype of ADHD; receiving

Special Education services for math and writing

• Joe. 6 yo 1st grade student. – combined subtype of ADHD; 5mg of

methylphenidate once a day

Methods:

• Independent Variable: Headsprout reading program; 3 x week, 20-30 min. each

• http://www.headsprout.com• Dependent variables:

– Oral Reading Fluency– On- and off-task behavior

• Multiple Baseline Design, across participants

Features of Headsprout:

• internet-based reading program; no adult required

• explicit instruction in phonemic awareness and phonics

• introduces consistent letters and sounds, fluency building exercises and segmenting and blending strategies

• provides explicit instruction in building sight word vocabularies and recognizing and using punctuation cues

• student works sequentially through 40 animated lessons, each lasting approximately 20 minutes.

Headsprout features (cont.):

• highly interactive: students engage in over 180 active learner interactions per 20-minute lesson

• lessons are individualized and adapt to a child’s pace

• student success rate in each lesson is at least 90% • Completion of most Headsprout activities involve the

child moving a character to a desired destination• students keep track of own progress through the use

of a colorful progress map • positive feedback is provided after each correct

response, and the program rewards the student with brief (10-30 second) humorous movies in between activities

Figure 1. Percentage intervals of off task behavior as a function of typical reading instruction and computer assisted reading instruction.

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Baseline CAI

Off-task data

• Tim. Off-task 24% BL vs. 3% CAI

• Kevin. Off task 49% BL vs.6% CAI

• Joe. Off task 26% BL vs. 4% CAI

Figure 2. Words read correctly per minute as a function of typical reading instruction and computer-assisted reading instruction.

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Baseline CAI

Reading fluency data

• Tim. 6 WRC in baseline vs. 18 WRC during intervention; Weekly gain .55 before intervention to 1.65

• Kevin. 14 WRC in baseline vs. 33 WRC during intervention; Weekly gain .55 to 2.90

• Joe. 10 WRC in baseline vs. 24 WRC during intervention; Weekly gain .20 to .75

Discussion

• Positive effects of CAI on task engagement and academic performance, similar to Ota and DuPaul (2002)

• Different in that Ota and DuPaul study involved math, drill and practice, and upper elementary students

• High degree of social validity• URL: www.headsprout.com

Future work

• individual Headsprout effects (rather than additive)

• home based, parent guided intervention

• home/school combinations• group study with more effective

instructional comparison; control group?

Parent tutoring for students with

attention-deficit/hyperactivity disorder: effects on reading

performance at home and schoolChristine Hook and George J. DuPaul

School Psychology Review 1999, Vol.28, No. 1;  pg. 60-75.

Procedures

• Four children: three 2nd Graders, one 3rd Grader

• Parent tutoring in reading, 10 minute sessions

• Material from current school stories/reading

• Preview, reading aloud, error correction, praise, review of story

• Mean Sessions per week, 3• Mean weeks, 6

Peers as intervention agents

• Plumer, P. J., & Stoner, G. (2005). The relative effects of Classwide Peer Tutoring and peer coaching on the positive social behaviors of children with Attention Deficit Hyperactivity Disorder. Journal of Attention Disorders, 9 (1), 1-11

Table I

Results

Percent of intervals

observed containing

positive social Participants

interactions Heidi Colin Samantha

Academic Activity

Mean and range

Baseline 3%(2-3%) 5%(2-8%) 10%(0-25%)

CWPT 87%(80-99%) 93%(87-97%) 98%(95-100%)

CWPT and Peer 94%(80-100%) 99%(97-100%) 100%(No range)

Coaching

Recess and Lunch

Mean and Range

Baseline 45%(42-48%) 45%(12-63%) 68%(42-95%)

CWPT 32%(3-75%) 46%(0-77%) 69%(15-100%)

CWPT and Peer 62%(27-93%) 75%(63-87%) 90%(77-98%)

Coaching

The Effects of Self-Management in General Education Classrooms on

the Organizational Skills of Adolescents With ADHD

SAMMI GUREASKO-MOORE, GEORGE J. DUPAUL, GEORGE P. WHITE

BEHAVIOR MODIFICATION, Vol. 30 No. 2,

March 2006, 159-183.

Information

• Three 12-year old, 7th Grade boys• Focus on classroom organization,

including:– Arrive on time for class– Prepared to begin class (oriented to T_– Has paper/notebook– Has pen/pencil– Completes homework– Hands in homework on time

Procedure: Students provided

• Explanation and rationale for self-management

• A description of their current classroom functioning based on observation results

• An explanation of the importance of responsibility for one’s own behavior

• The specific responsibilities one must maintain to be considered prepared for class instruction

Monitoring

• Students established weekly goals• Initially, daily adult meeting and

monitoring and discussions• Daily meetings continued until student

met 100% of daily goals on 4 of 5 consecutive days

• Fading: every other day with monitor• Maintenance: One time per week

monitor

Support strategies for Middle and High School Students with

ADHD• Steve Evans and colleagues (James

Madison U., and now Miami of Ohio)

• Organization Checks• Social Problem Solving Skills• Homework Management Plan• EvansADHD.pdf

Some guiding principles for intervention with ADHD• Apply the group primary, secondary, tertiary

prevention/intervention model (RTI), but with individual students

• Combine proactive and reactive management strategies (e.g., teach rules and daily report)

• Intervention in place at point of performance of target behaviors

• Intervene as early as possible

Some guiding principles for intervention with

ADHD(cont.)

• Expand range of intervention agents beyond teachers, to:

• Peers• Computers• Self management• Parents

Effective support for students with ADHD: What

will it take?• Knowledge• Resources• General education--special education

collaboration• Communication• Effort • Persistence• Problem solving• REPEAT