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