New England

Using Behavioral Strategies to Improve Skills in Students with ADHD Jessica R. Everett, Ph.D., BCBA-D Barbara O’Malley Cannon, Ph.D., BCBA

CHADD Annual International Conference November 14, 2015

Learning Objectives Learning Objective 1: Approach challenging behavior through functional assessment. Learning Objective 2: Discuss the importance of identifying replacement skills for interfering behavior.

Learning Objective 3:Apply behavioral strategies for skill acquisition and behavior reduction. Learning Objective 4:Identify strategies to improve on-task behavior within classroom settings. Learning Objective 5:Identify strategies to improve self-regulation.

ADHD in the Preschool Classroom

ADHD in the Elementary Classroom

ADHD in the Middle School Classroom

ADHD in the High School Classroom

Generally Speaking….. • Behavioral Intervention has been found to be efficacious in treating symptoms and improving skills in students with ADHD. – Pfiffner, L. J. (2014). Meta-analysis supports efficacy of behavioral interventions for attention-deficit/hyperactivity disorder–related problems. Journal Of The American Academy Of Child & Adolescent Psychiatry, 53(8), 830-832. – Daley, D., van der Oord, S., Ferrin, M., Danckaerts, M., Doepfner, M., Cortese, S., & Sonuga-Barke, E. S. (2014). Behavioral interventions in attention-deficit/hyperactivity disorder: A meta-analysis of randomized controlled trials across multiple outcome domains. Journal Of The American Academy Of Child & Adolescent Psychiatry, 53(8), 835-847. – Mulqueen, J. M., Bartley, C. A., & Bloch, M. H. (2015). Meta-analysis: Parental interventions for preschool ADHD. Journal Of Attention Disorders, 19(2), 118-124. – DuPaul, G. J., Eckert, T. L., & Vilardo, B. (2012). The effects of school-based interventions for attention deficit hyperactivity disorder: A meta-analysis 1996-2010. School Psychology Review, 41(4), 387-412.

Additionally….. • When function based assessments are used to inform behavioral interventions, the effectiveness of interventions is improved. – Miller, F. G., & Lee, D. L. (2013). Do functional behavioral assessments improve intervention effectiveness for students diagnosed with ADHD? A single-subject meta-analysis. Journal Of Behavioral Education, 22(3), 253-282. – Whitford, D. K., Liaupsin, C. J., Umbreit, J., & Ferro, J. B. (2013). Implementation of a single comprehensive function-based intervention across multiple classrooms for a high school student. Education & Treatment Of Children, 36(4), 147-167. – Hoff, K. E., Ervin, R. A., & Friman, P. C. (2005). Refining Functional Behavioral Assessment: Analyzing the Separate and Combined Effects of Hypothesized Controlling Variables During Ongoing Classroom Routines. School Psychology Review, 34(1), 45-57.

The ABC’s of Behavior Basic behavior paradigm

Antecedent

Behavior

Consequence

– Antecedent – what’s going on before the behavior occurs – Behavior – what the student does (both good and bad) – Consequence – what happens after the behavior occurs (either reinforces/increases or punishes/decreases)

Assessment of Behaviors • The “behavior” to be changed is not only the student’s, but ours as well… • Our changes may include: – Environment – Teaching/prompting – Materials – How we react – How we present materials, tasks and/or demands

Assessment of Behaviors • All behavior is functional • If a student continues to demonstrate problem behavior, then that behavior is working for him/her. • getting them something they want • getting out of something they don’t want • Our job is to make the behavior not work and to teach other ways to get what they want.

Challenging Behaviors • Some basic assumptions – Challenging behaviors are often related to a skill deficit (e.g., language, social) – All behaviors serve a function – A behavior that persists over time is working for the child – Need to look at changing your behavior and the environment, not just the child’s behavior(s)

Understanding Behavior • What could be the underlying function of the student’s challenging behavior? – Gain attention

– Escape – Access Tangible

– Sensory – Medical

Functional Behavior Assessment • A behavior that is maintained by attention will likely occur more frequently when: – You’re talking to someone else – You’re not attending to the student – People appear upset or annoyed when it happens – Student makes eye contact after demonstrating the behavior

Functional Behavior Assessment • A behavior that’s maintained by escape will probably occur more often when: – Demand is placed on student – A task is perceived as difficult – A task is overwhelming to a student – A more desirable option is available – There are few choices offered

Functional Behavior Assessment • A behavior that’s maintained by tangible-motivation will probably occur more often when: – A student wants something he can’t have – A student sees someone else with something she wants – Something is taken away from a student that he wants back

Functional Behavior Assessment • A behavior that’s maintained by selfstimulatory motivation will probably occur more often when: – The student is left alone – The student is overwhelmed or underwhelmed by a setting/activity – The behavior provides sensory feedback that is regulating

Function of Behavior • Remember – function does not imply negative intent • The student engages in the challenging behavior because it works • The goal is to teach a more appropriate skill that can replace the challenging behavior

Identifying the Function of Behavior • Conduct a Functional Behavior Assessment – Indirect Methods • Interview • Rating Scale – Direct Methods • Behavioral Observation • Data Collection

• Conduct a Functional Analysis – Systematic manipulation of variables

Developing a Behavior Support Plan • Prevention Strategies – How do we stop the behavior from happening in the first place?

• Teaching Adaptive Alternatives – What skills are we teaching to replace the inappropriate behavior?

• Reinforcement – How are we reinforcing use of the replacement behavior?

• Consequences – How are we all responding, in the same way if the behavior does occur?

Preventative Strategies • What can we do to prevent the behavior from occurring? – Increase the behavior supports so that consequences for inappropriate behavior are rarely needed (or not needed at all!)

• Preventative strategies come in many different forms – – – – – –

Visuals Offering Choice Changing Environment Minimizing Transitions Offering Breaks Modifying Work and Task Demands

Adaptive Alternatives • What replacement skills do we need to teach? – Functional Communication – Social Skills – Behavior Regulation Skills – Emotion Regulation Skills

Teach Replacement Skills • First identify function, then identify a more appropriate skill to teach that maintains the same function. • Attention – Seeking attention appropriately, social skills, peer relationships, waiting for attention • Escape – Escaping appropriately, asking for help, asking for a break, asking for a change, increasing skills • Tangible – Requesting, sharing, waiting, delaying • Sensory – Self-regulation, identification and communication

Teach Replacement Skills

• In order for the student to use the replacement skill it has to be easier to use and gain the same outcome as the challenging behavior in a more efficient manner • This means that you will have to change how the environment responds to the behavior

Alternative Appropriate Behavior • Functional Communication – An appropriate communicative behavior to compete with problem behaviors – It is an alternative to the inappropriate behavior – The alternative communicative response produces the same reinforcer that has maintained the problem behavior – The communicative response is functionally equivalent to the challenging behavior

Alternative Appropriate Behavior • Social Skills Instruction – – – – – –

Perspective taking Social awareness Emotion identification Pro-social skills (turn-taking, sharing) Behavioral flexibility Collaborative group skills

Alternative Appropriate Behavior • Instruction in Self-Regulation – – – – – –

Modulation of reactivity Inhibition of responses Emotional regulation Attention regulation Sensory regulation Self-monitoring

Reinforce Alternative Behaviors • Praise behaviors that are incompatible with the challenging behavior • Praise behaviors that are replacements for the challenging behavior • Identified alternative or replacement behaviors should be targets of individual and class-wide behavior management plans

Using Reinforcers • Activities – Use more-preferred activities to motivate lesspreferred ones • ‘first – then’

– Premack Principle - “Grandma’s Law” • “Eat your vegetables, then you can have dessert.” • “Clean your room, then you can play video game.”

Environmental Response • ‘Consequences’ – do not punish for lack of skills • ‘Consequence’ – should not reinforce the behavior you are trying to reduce • Have clear limits and expectations within all environments • Be clear about what the environmental response will be is the limits and expectations are not met • Discipline vs. Intervention

New England

Examples: Visual Supports and Intervention Strategies

New England

Teach Self-Monitoring to Improve On-Task Behavior Behavioral Intervention Checklists Token Boards Social Stories

Behavioral Interventions • Shaping – Gradually increase the amount of time that the student is expected to be on-task. – Gradually increase the complexity of the environment where the student is expected to be on-task • One on one instruction • Two on one instruction • Small group • Whole class

• Prompt Fading – Gradually reduce the amount of help that is given to the student to assist them in maintaining on-task behavior.

• Reinforcement

Social Story When I am On-Task When I am doing something I should be on-task. This means that I am doing my work. This means that I am keeping my body still. When I am ontask, I am looking at the teacher if the teacher is talking. If a teacher is not talking, I have my eyes on what I am doing. When I am on-task, I am following directions.

When I am on-task, I am paying attention and getting my work done. I am proud when I get my work done. It makes me happy and that makes everyone happy.

Recording Form I am Staying On-Task Yes

No

Yes

No

Yes

No

Yes

NO

Yes

My hands are still.

My hands are still.

My hands are still.

My hands are still

My hands are still

My body is still.

My body is still.

My body is still.

My body is still

My body is still

I am looking where I am supposed to

I am looking where I am supposed to

I am looking where I am supposed to

I am looking where I am supposed to

I am looking where I am supposed to

I am following directions.

I am following directions.

I am following directions.

I am following directions

I am following directions

I am working

I am working

I am working

I am working

I am working

TOTALS

No

New England

Date:

Enter Class

Period 1 Period 2 Period 3 Period 4 Period 5 Period 6 Period 7 Period 8 Total Points

Join Class Activity

Following Directions

Asking for a Break

Polite Voice and Tone

Emotional Regulation • Behavioral Interventions – Task Analysis – Shaping – Prompt Fading

• Visual Supports – 5 point checklists (Adapted from Kari Dunn Buron http://www.5pointscale.com)

– Cognitive behavior Mapping – Social Stories

• Social Skill Instruction – Perspective taking

Rating

Looks Like

Feels Like

I can try to

SOUNDS LIKE

WHERE OR WHEN

Emergency Only Screaming

Outside Voice

Classroom Voice

Whisper

No Talking

Recess/In Yard

In class/In house

In Library/At movies

Someone else is talking

Laughing too loud No one else is laughing

Laughing too loud, I can’t hear anyone I can’t stop laughing No one else is laughing

Laughing loud Other people are smiling and laughing

Giggling Other people are smiling and giggling

One laugh or giggle someone else laughed or giggled one time

Today at _______

My goal is a ______

I was a ______

Nowhere/Never

Nowhere/Never

With friends/playing

With friends/talking

With friends/ someone told a joke or said something funny

I reached my goal.

What am I thinking?

What are you thinking?

I did this:

I think

Now, I know that I should

You think

Summing It All Up • Understanding the function of the behavior informs behavioral intervention.

• Behavioral intervention should focus on reinforcing appropriate behaviors but also teaching skills to replace the behavior you are trying to decrease.

Thank You for Your Participation [email protected] [email protected]