Real-world interventions for students with attention deficit hyperactivity disorder (ADHD) are often done on the fly and may seem too limited and imperfect to produce results matching those from research studies.
But in a recent issue of School Psychology Review, several researchers provide reassuring evidence that low-intensity interventions may be as effective or almost as effective as high-intensity interventions for students with ADHD.
“This is good news for school psychologists like me who often worry that what we are doing may be far enough removed from ‘best practice’ that we question whether we should be doing anything at all,” writes Margaret Dawson of the Center for Learning and Attention Disorders in Portsmouth, NH in a commentary on the studies.
In one study in the journal’s special issue on ADHD, when researchers compared student responses to no behavior modification, low-intensive behavior modification or high-intensive behavior modification they found that low-intensive behavior modification was effective in the classroom, resulting in the completion of 15-21% more seatwork and better conduct compared with baseline.
A major finding of the study was that when behavior modification is combined with medication, lower doses of medication are effective in achieving the same outcomes. The study tested student response to three common approaches to treatment–medication, behavior modification or a combination of the two.
“Unlike other studies in which the dosages of behavior modification or stimulant medication were limited, not compared, or not combined, this study is one of the first to investigate in a classroom setting the effectiveness of varying intensities of both behavior modification and MPH (methylphenidate) alone,” writes the research team from the State University of New York (SUNY) at Buffalo.
Participants in the study were 44 boys and four girls between the ages of 5 and 12 who were enrolled in a summer program for children with ADHD conducted by SUNY at Buffalo.
“Parents are more willing to accept medication (a) when their child can be placed on a low dose, thus reducing the likelihood of side effects, and (b) when they feel their child’s teacher is also taking steps to address the problem in the classroom and not simply relying on medication to manage their child,” Dawson writes.
In her commentary, Dawson notes that effective school-based behavior modification should incorporate the following elements:
• posting and daily review of classroom rules;
• liberal use of praise and social reinforcement for children behaving appropriately;
• use of time-outs when children exhibit aggressive, destructive or defiant behaviors with length of time based on age; and
• daily report cards, linked to rewards provided by parents on at least a weekly basis.
Lower doses of medication
In another study (Jitendra and colleagues), researchers found that traditional consultations between school psychologists and teachers who collaborate on academic interventions for students were just as effective as the more sophisticated model of intensive data-based academic intervention (IDAI) that involves more formalized data utilization and feedback to teachers.
“Thus, the more intensive, on-going consultation support consultation support (i.e., IDAI) may be needed only for a select group of children with ADHD rather than all children with ADHD,” the authors write.
Dawson believes effective school-based consultations targeting children with ADHD should include the following:
• Education of teachers both about the nature of ADHD and about effective classroom interventions (e.g., reading materials).
• A collaborative process in which teachers and consultant together design academic interventions that teachers identify as appropriate to their classrooms and to the child in question. (An initial interview should identify academic concerns, performance and intervention goals; teachers should be given the opportunity to select preferred interventions during a second interview.)
• Detailed plans that outline the specific steps for teachers along with necessary materials for intervention.
• A choice of interventions that include teacher-mediated, peer-mediated, computer-assisted and self-mediated strategies.
• Weekly contact with teachers by phone or email to provide updates or address questions or concerns.
Simple practices such as educating teachers and parents about ADHD should not be underestimated, according to another study (Kern and colleagues) which looked at the effectiveness of a generic parent education program for children ages 3-5.
The researchers found that this less intensive intervention may be particularly effective at age 3-5 because the behavior patterns of both parents and children are less entrenched than when the child reaches elementary or middle school, Dawson writes.
Based on that study’s findings, she says, such parent education should, at minimum, incorporate the following:
• An intervention that lasts for at least a year. (In the Kern study parent education occurred in 20 two-hour sessions over an 18-month period.)
• Efforts to ensure parent attendance (e.g. transportation and child care)with follow-up to parents who miss sessions.
• Topics covered should include understanding child behavior, discipline, social emotional development and self-esteem. A well-developed curriculum and lesson plan (such as the Systematic Training for Effective Parenting program) ensure there is a well-thought-out sequence of lessons for the intervention.
“Although finding parent education programs targeted to children with ADHD may be difficult, more generic parent training for parents of young children with ADHD may be more accessible and would be a worthwhile alternative to no treatment at all.”
Dawson notes that the researchers caution against assuming that over the long term, children will continue to benefit from a low-level intervention such as parent education. Follow-up studies are also needed, she points out, because this study did not use a control group.
Middle school intervention
Finally, a classroom-based program for middle-school students with ADHD that used psychosocial interventions was disappointing in that it showed no clear academic benefits compared with a control group, Dawson reports in the special issue.
In this intervention, a certified school psychologist provided school-based consultations with teachers, who selected the interventions to use in their classrooms. Among the most frequently selected interventions were: establishing contingencies, a frequent monitoring system, and prompts for the student to independently and accurately record assignments in the assignment notebook. Interventions targeting organization were also frequently provided. A monthly monitoring system based on parent and teacher ratings was used to determine the need for additional treatment with medication or psychosocial interventions. Participants were 79 students ages 10-14 recruited from five middle schools in Virginia.
Over a three-year period, parent ratings showed a cumulative benefit on inattention, hyperactivity and social functioning, the researchers report. However, neither teacher nor parent ratings of academic functioning showed any cumulative academic benefits, they report. Student grades indicated there were within-year gains in the second semester of the 6th and 8th grades, they add. The finding of improved grades without improvements in teacher ratings is consistent with past findings on poor inter-rater reliability among secondary school teachers on these rating scales, they note.
“In my opinion, their results may tell as much about how hard it is to work with middle school students in general than it tells us about how challenging it is to design interventions for middle school students with ADHD,” Dawson writes. She notes that the interventions employed by Evans might be improved by incorporating clearer roles for parents and students, both in the intervention design and implementation.
“By making students an integral part of the intervention decision-making process, we increase their ownership in the process and their motivation to achieve positive outcomes,” Dawson writes.
“The Ideal Versus the Feasible When Designing Interventions for Students With Attention Deficit Hyperactivity Disorder,” by Margaret Dawson, School Psychology Review, 2007, Volume 36, Number 2, pp. 274-276.
“The Single and Combined Effects of Multiple Intensities of Behavior Modification and Methylphenidate for Children With Attention Deficit Hyperactivity Disorder,” by Gregory Fabiano et. al , School Psychology Review, 2007, Volume 36, Number 2, pp. 195-216.
“Cumulative Benefits of Secondary School-Based Treatment of Students With Attention Deficit Hyperactivity Disorder” by Steven Evans, et al., School Psychology Review, 2007, Volume 36, Number 2, pp. 256-273.
“Multisetting Assessment-Based Intervention for Young Children at Risk for Attention Deficit Hyperactivity Disorder: Initial Effects on Academic and Behavioral Functioning,” by Lee Kern et al., School Psychology Review, 2007, Volume 36, Number 2, pp. 237-255.
“Consultation-Based Academic Intervention for Children With Attention Deficit Hyperactivity Disorder: School Functioning Outcomes,” by Asha Jitendra and George DuPaul, et al., School Psychology Review, 2007, Volume 36, Number 2, pp. 217-236.
Published in ERN January 2008 Volume 21 Number 1