ADHD: Management Strategies &

Behavioral Interventions

CTA Good Teaching Conference South

March 19, 2011

Sandra Rief, Presenter

www.sandrarief.com

3 Types of AD/HD

1. The predominantly inattentive type

2. The predominantly hyperactive & impulsive
type
3. The combined type

Descriptions of AD/HD

AD/HD is characterized by developmentally

inappropriate degrees of: inattention,
impulsivity, and sometimes hyperactivity.

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AD/HD Descriptions
Neurobiological inefficiency (underactivity)
in the attention/inhibitory center of the
brain
A disorder involving delayed development
of executive functions/self-regulation.

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What are Executive Functions?

The management functions (overseers) of
the brain
The range of central control processes in
the brain
Cognitive processes and self-directed
actions we use to engage in goal-directed
behavior
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Executive Function Analogy

Dr. Thomas Brown

EF is the conductors role in orchestra.

EF impairment = a poor or absent conductor

EF Components

Inhibition
Working memory
Organizing, planning, and prioritizing
Time awareness & management
Arousal & Activation (initiation)
Sustaining focus, alertness, and effort
Self-regulation (emotional control, motivation)
Goal-directed persistence
Self-monitoring, metacognition
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Advances in Theory
Increasingly, AD/HD is being conceptualized
as a disorder of inhibition, self-regulation,
executive functioning.

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Common School Performance

Difficulties in Students with AD/HD
Poor planning, organization, time
management, study skills
Some academic weaknesses particularly
in written language
Minimal/inconsistent production & output
(both in-class assignments & homework)
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Common School Performance

Difficulties in Students with AD/HD
Forgetfulness/memory-related issues
Difficulty following rules
Behavioral & social difficulties affecting
interpersonal relationships
Unable to sustain effort for long-term
goals (need short term goals/rewards)
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Things to Keep in Mind

About AD/HD
Disorder in performance, output, and

production
Approximately 30% delay in self-control/
inhibition, and executive functions
High rate of coexisting conditions
(comorbidity)
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AD/HD & Coexisting Conditions

Learning disabilities (LD)

Oppositional Defiant Disorder
Anxiety Disorder
Conduct Disorder

Depression
Bipolar
Tourettes

30-60%
40-65%
25%-35%
10%-25%children;
25%-50% of teens
10%-47%
1%-20%
7% (but 60% of
those with Tourettes
also have ADHD)
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AD/HD Research Indicates

Heredity is number 1 cause of ADHD.
Multiple genes are involved in ADHD.

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AD/HD Research Indicates

Diminished activity & lower metabolism in
certain brain regions
Chemical imbalance/deficiency in
neurotransmitters

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AD/HD Research Indicates

Not enough neurotransmitters (dopamine
and norepinephrine) in all the brain
circuits.
These brain chemicals are not being
released and reloaded effectively.

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Research-Validated
Treatments for AD/HD
1. Medication therapy (stimulants)
2. Behavioral therapy

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An Optic View of ADHD

If corrective lenses did not exist
No well-meaning parent could hope to resist
A pill that enabled their child to see And increase that childs ability
For better sight and clear vision No, this would not be a tough decision.
Then why wouldnt the same analogy
Apply to the problem of ADHD?
For brains are a lot like eyes, I believe
They both need to focus in order to see!
Medication as treatment might be prevented
If ADHD lenses were someday invented.
K. Easter, 2005

Behavioral Treatment &

Management of AD/HD
Increased frequency and amount of
feedback and reinforcement
Behavior modification techniques
Individualized interventions (e.g., daily
report cards, contracts, self-monitoring
and self-regulation strategies)

Rief, S. (2008). The ADD/ADHD Checklist, 2nd edition. San Francisco: Jossey-Bass.

Treatment Components
Education re. ADHD

Medical

Psychosocial
(behavioral)

Academic Supports/Accommodations
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Getting Started & Staying OnOn-Task

Read directions together; get them started.

Accessible materials
Create a checklist.
Frequent check-in times
Divide assignment/task into parts.
Set mini-goals for what to accomplish with
rewards.

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Combat Attention-Busters
Distractions (environmental and
internal)
Boredom (add novelty)
Fatigue (movement breaks)

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Tertiary prevention
Individual student
System (~5%)
Secondary prevention
At Risk system (~15%)

Primary prevention
Universal interventions
School-wide/classroom
systems (~80%)

Chronic intense need students

At-risk students

Normative/without
serious problem behavior

SWPBS www.pbis.org & Behavioral RtI Model

Reverse the praise deficit.

It takes changing the interactions:

3:1
(minimally)
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Recognition, Acknowledgement,
and Specific Praise
I really appreciate how you ______.
I appreciate the self-control you are using.
I noticed how hard you were working on ____.
I see the effort you are showing.
Thank you for the good choice you just made.

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Group Positive
Reinforcement Systems
Social reinforcers
Earning minutes/time for choice activities
Marbles/Popcorn kernels, etc. in jar

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Group Positive
Reinforcement Systems
Team management table points
Token economy
(e.g., points, tickets, class currency)
Lottery grid
Chart moves
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Group Reinforcement
Contingencies
No problems reported at recess
No more than one name on board for
classroom rule violations during certain time
frame
X amount of time with no incidences of
(specific behavior)

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Universal Interventions

Effective academic support

Social skills teaching
Explicit teaching of school behavior
expectations
Active supervision and monitoring in
common areas
Positive reinforcement for all students
Firm, fair, and corrective discipline
Effective classroom management
Sprague, Bernstein, Munkres, et. al., (2003) Best Behavior

STARS

Safety first
Teamwork
Always Respectful
Ready to learn
Sharing and caring
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Best Behavior
3 School-wide Rules
Be Safe
Be Respectful
Be Responsible

J. Sprague, L. Bernstein, A. Munkres, A. Golly, R. March University of Oregon The Institute on Violence and Destructive Behavior

Inhibition Strategies
Have student repeat directions, restate in
own words before beginning tasks.
Praise for remembering to raise hand and
wait to be called on.
Role play and rehearse appropriate way to
stand and wait in line and other
problematic situations.
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Inhibition Strategies
Teach techniques to try to self-regulate
impulsive behavior such as: taking a deep
breath and counting silently to 10 before
responding.

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Inhibition Strategies
Create a voice volume scale (0 = silence;
2-3 = partner talk).
Use hand signals or other visual cue to
indicate wait and dont interrupt.
Teach problem-solving strategies and how
to weigh pros and cons before making a
decision or taking an action.

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Inhibition Strategies
Remind student prior to entering challenging
environments or situations about expected
behavior.
In cooperative groups give 3-5 tokens for each
student in the group, with rule that they can
only speak when using one of their tokens.

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Common Antecedents to
Misbehavior
Physically Based
Environmentally Based
Related to Specific Time
Performance/Skill Demand
Specific Person(s)

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Prevent Problems:
Alter the Antecedents
Provide closer monitoring and supervision.
Increase cueing & prompts.
Address skill deficits.
Provide accommodations & supports.
Prepare for transitions.
Adjust the environmental factors.
Rief, S. (2003). The ADHD Book of Lists. San Francisco: Jossey-Bass.

Environmental Accommodations
Preferential Seating (location & alternatives
to chair)
Standing work stations
Office area/study carrel, 2-desks
Adding structure and organization
Visual supports & prompts
Rief, S. (2003). The ADHD Book of Lists. San Francisco: Jossey-Bass.

Visual Cues
1. May talk with teacher permission only.
2. May leave seat with teacher permission only.

1. May use 12 whisper.

2. May leave seat when needed (e.g., to turn in work)

1. May talk quietly with other students.

2. May leave seat to work with other students.
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Non-Verbal Signals

Private signals (hand motions)

Reminder notes and messages

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Making Mistakes
John Kistler, contribution to The Original Social Story Book, Carol Gray, et. Al)

If I make a mistake on my work, it is all right.

Everyone makes mistakes.
After making a mistake, I can go back
and fix the mistake.
I will try to remember not to make the
same mistake twice.
If I do make the same mistake again, I can
go back until I get it right.
Thats how I learn.
Thats how others learn, too.

The Value of Mistakes

Einstein flunked grade-school
mathematics.
Edison tried over 9,000 kinds of filaments
before he found one that would work in a
lightbulb.
Walt Disney went bankrupt five times
before he built Disneyland.

www.whytry.org
for teaching social-emotional skills
Why Try Inc.

Menu of Creative + Reinforcers

Work on board/overhead
Choice of seat/special chair
Messenger/Mail carrier
Sharpen pencils, staple
papers, clean board
Library pass
Pet or plant caretaker
Decorating room/board
Listen to music
Reduced homework
Reading to someone
Time to read or be read to
No homework pass
Time on computer or use
of other technology

Special pens, paper,

materials, equipment
Pop bubble wrap
Tell a joke
Puzzles
Cartoons/Drawing
Talking periods
Dancing, Exercising
Arts & Crafts, Projects
Hoola hoops, jump ropes
Sports equipment
Board games/class games
Musical instrument
Activity/Learning Center
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Daily Report Card Information

12 page packet developed by Dr. William
Pelham, Jr., et al.

www.ccf.buffalo.edu/resources_downloads.php

Target Goals & Rewards

Goal: Working efficiently for a 20-minute period of
time.

Set timer in two 10-minute sessions (or four 5 min)

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Reaction to a Reaction

We are training children not to be reactive

without thinking.
Adults must show the same capability.

With Challenging Kids

Dont take it personally.
Dont threaten.
Dont provide an audience.
Dont engage in power struggles.

Rief, S. (2008). The ADD/ADHD Checklist, 2nd edition.

Emotional Control & Flexibility

Watch for warning signs of over-stimulation
or frustration & intervene :

diverting attention
redirecting
cues/signals
reminding about rewards/consequences
assigning a silent or calm activity ( journaling,
drawing)
providing opportunity to change environment

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Emotional Control
When student shows sign of losing control:
-

Lower and calm your voice.

Maintain a calm, patient tone.
Offer choices to student (going to
designated cool-down area, cue to use one
of the calming techniques taught).

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Emotional Control
Teach to use positive self-talk: I am calm
and in control. I can handle this situation.
Teach, model, and practice appropriate
strategies for anger management, stress
reduction, and conflict resolution.

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Emotional Control
Provide visual cue cards to remind student of
appropriate behaviors and steps to take when
feeling upset/angry/frustrated.
Teach awareness of emotions with scales (My
anger levelMy worry level).

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Emotional Control & Flexibility

Provide advance notice of upcoming changes
in activities, routines, schedules.
Anticipate frustrating/anxiety-provoking
situations and provide support (e.g., social
stories www.thegraycenter.org )

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To Aid Calming
Physical activities (brisk walk)
Take a break area (low stimulation area,
non-punitive)
Self-regulation techniques (counting
backwards, relaxation techniques like
stretching, deep breathing, visualization)

Rief, S. (2005). How to Reach & Teach Children with ADD/ADHD, 2nd edition.

Self-Regulation Strategies

Fidget toys

Self-monitoring

Rief, S. (2005). How to Reach & Teach Children with ADD/ADHD, 2nd edition.

Self-Monitor Your Behavior

On-task (Im focused on doing my work.)

Paying attention (I am listening and
following along)
In my seat
Remembering to raise hand
Being respectful to teacher (no arguing,
rude voice, or talking back)
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Organization & Homework Support

Require backpack and either 3-ring binder

or alternative of accordion file.

Use of simple pocket folder for younger
students

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Organization & Homework Support

Consistent use of planner/agenda,

calendar, or assignment sheet

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Organization & Homework Support

Walk through the recording of assignments.

Provide a second set of books for home.

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Organization & Homework Support

Be responsive to parent feedback and

frustration about homework difficulties.

Use a monitoring form to track and
communicate between home and school.

Rief, S. (2008). The ADD/ADHD Checklist: A Practical Reference for Parents & Teachers, 2nd ed.

LongLong-Term Projects: The EF

Nightmare

Planning
Organizing
Getting started
Estimating time
Self-monitoring
Meeting deadlines
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Time Awareness & SelfSelf-Monitoring

Write begin/end time on paper.

Student tracks length of time it takes to
complete assignments.

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Working Memory Strategies &

Accommodations
Provide written reminders and instructions.
Post assignments and other important
information in a consistent location.
Provide to-do lists, task cards, and visual
reminders of expectations.
Create checklists for procedures and routines.
Use technology to compensate (electronic
devices, email homework).
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Metacognition
Self-Awareness
Self-Monitoring
Self-Assessment

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Recommended Websites
Children & Adults with AttentionDeficit/Hyperactivity Disorder www.chadd.org
National Resource Center on AD/HD
www.help4adhd.org
Attention Deficit Disorder Association www.add.org
LD Online www.ldonline.org
Learning Disabilities Association of America
www.ldanatl.org
Great Schools www.greatschools.org formerly
Schwab Learning
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Recommended Websites
www.ccf.buffalo.edu/resources_downloads.php
(Dr. William Pelham, Jr. site lots of management tools)

www.russellbarkley.net

(Dr. Barkleys official website)

www.sandrarief.com (Sandras website)

www.helpforadd.com

(David Rabiners website)

S. Rief, 2011

The content of this session and slides come

from the following books & resources by Sandra:
BOOKS published by Jossey-Bass:
The ADD/ADHD Checklist: A Practical Reference for Parents & Teachers,
2nd edition (2008)
How to Reach & Teach Children with ADD/ADHD, 2nd edition (2005)
The ADHD Book of Lists: A Practical Guide for Helping Children & Teens
with Attention Deficit Disorders (2003)
DVDs produced by ERS (www.sandrarief.com )
ADHD & LD: Powerful Teaching Strategies & Accommodations (with RTI)
Successful Schools: How to Raise Achievement & Support At-Risk Students

LAMINATED CARDS published by National Professional Resources

Section 504: Classroom Accommodations (4-page laminated card)
ADHD & LD: Classroom Strategies At Your Fingertips (6-page laminated card, also
available in Spanish)
Executive Functions: Practical Applications in the Classroom (4-page card)