ADHD in the classroom: Effective intervention strategies (2011) - DuPaul et. al. - Article

Teachers sometimes tend to perceive a child with ADHD as less favorably with respect to behavior, intelligence and personality. Children with ADHD more often attend schools for special education, they are more likely to have lower grades and have a higher risk of dropping out of school. Because of these impairments, it’s important that empirically supported interventions are implemented early in the development and starting the first years of school.

Types of strategies

Stimulant medication is often used as a treatment for the symptoms of ADHD, but this is rarely sufficient to solve all problems a student with ADHD faces. Therefore behavioral interventions have been developed for students with ADHD, including both antecedent- and consequence based strategies. Antecedent strategies try to prevent disruptive and/or inattentive behavior. An example of an antecedent strategy is for a teacher to review the classroom rules. There should be a few, short and positive phrased rules, posted in full view of all students and especially those with ADHD. When children with ADHD follow those rules, they should be praised frequently for their behavior. Another example is to reduce task demands by modifying the length and/or content of assignment in combination with a teachers praise. This matches the attention span of a child with ADHD, and therefore may reduce off-task, disruptive behavior. The length of assignments can be gradually increased thereby shaping task-related behavior to match classroom norms. The last example of an antecedent-based strategy is a choice-making intervention. Students have the possibility to choose from two or more presented options. When children with AHDH had the chance to choose between different assignments (which all have similar outcomes: they practice the same academic skills), they showed higher rates of task engagement and lower frequency of disruptive behavior. The advantage of antecedent-based strategies is that it addresses academic functioning directly.

Consequence based strategies are manipulations following specific (undesired) behavior to alter the frequency of that behavior. The most common intervention is praise or token reinforcement. When children show positive behavior they can be rewarded with tokens (positive reinforcement) which they can later on exchange for preferred activities such as gaming and watching television.

Given the fact that children with ADHD may have trouble with demonstrating consistent behavior under conditions of intermittent reinforcement, it’s important to provide reinforcement as often as possible. The rewards should be based on the interests and preferences of the specific child, and the rewards have to be changed over time so the child doesn’t get bored with it.

An example of a consequence-based intervention in which tokens are removed when the children show off-task, disruptive behavior is response cost. The combination of token reinforcement and response cost has shown to be significantly effective. Teachers can also use a time-out as negative reinforcement by placing the child out of the classroom for a little while following disruptive behavior. This is only useful when the child experiences the classroom as a positive environment, otherwise it isn’t a negative consequence.

Self-management or self-regulation interventions encourage students with ADHD to evaluate their own behavior. For example, they learn to evaluate their work performance and behavior using a Likert-scale (ranging from poor to excellent). Sometimes the act of consistently monitoring behavior results in improvements. This seems a particularly effective strategy for students with milder levels of ADHD.

For many students with ADHD, interventions that directly address academic skills are needed. A good is example is providing teacher-mediated direct instruction in relevant skills that require remediation. Furthermore, studies have shown that computer assisted instructions in math and reading also lead to academic improvements. This also accounts for peer tutoring.

Daily report cards (DRC) are an example of a home-school communication program. A DRC usually contains 3 to 5 goals on which teachers indicate the performance of a student on a Likert’s scale. By communicating these ratings with the parents, they can provide the child with fitting reinforcement at home. When the students show progress, the goals can be increased in complexity. This program yet again works best for students with milder levels of ADHD symptom severity.

Interventions that address problems with social difficulties, such as group therapy formats, haven not yet been found to lead to prolonged changes in interpersonal functioning. More comprehensive strategies to improve social relations for children with ADHD are therefore needed. Peers without ADHD could be involved in these engagements to encourage generality of outcomes.

What also seems to be necessary to effectively treat ADHD is collaborative consultation. This means that there should be an equal partnership between for example a teacher and a school psychologist, who together define the problem and come up with interventions. This results in the most effective outcomes when teachers take charge in defining the problem and consultants lead when possible interventions are discussed.

The best treatment plans involve a combination of home- and school based behavioral therapy and optionally stimulant medication. The treatment should be an effective combination of consequence-based (reactive) and antecedent-based (proactive) strategies. Multiple interventions should be used, such as computer technologies, so the teacher gets spared in some of the responsibility. More research is needed especially for students with ADHD who go to secondary school.

As a positive reinforcement strategy, the token economy is very common. Because social reinforcement like praise isn’t always working for students with ADHD, they can earn tokens by showing appropriate behavior that later on can be exchanged for rewards. A behavioral contract is a written document that states which positive behavior results in which specified rewards, such as a favorite activity not often available at school. These contracts can be very useful for increasing the quantity and quality of homework assignments students complete. A third positive reinforcement strategy are group-oriented contingencies, which can be divided into two subtypes. For a dependent group-oriented contingency, reinforcement relies on the behavior of an individual student. The hero procedure is an example of this strategy, where a student with ADHD has to answer three questions in order to receive a reward for the entire group. It’s hoped that peers provide encouragement or appreciation for the target child. For In an interdependent group-oriented contingency all the members of a group have to fulfill certain criteria in order to receive reinforcement. A good example is the Good Behavior Game, in which students get divided into two groups and the group that performs the best receives a reward. This way, cooperation among group members is stimulated and special attention towards the target child gets avoided. It is very important to monitor group-oriented strategies very carefully to avoid the occurrence of negative peer pressure.

Conclusion

A serious concern is whether it’s practical conducting functional assessment is school settings. This approach is very time intensive and expertise not normally available is required. Therefore it is necessary to train practitioners to perform functional assessment in everyday settings. This way functional assessment is both practical in terms of time and effort. The most important fact is that this strategy is effective.

Finally, adapting a functional perspective on ADHD means teachers no longer have an excuse for avoiding the issue by saying it is a medical problem beyond their purview. Currently, teachers see it as their major responsibility to promote the student’s academic skills. Students with ADHD will continue to cause problems in the classroom if teachers do not start to devote as much time developing accommodations and interventions as they do in planning academic lessons.

Because of the extensive amount of time functional assessment costs, it’s advisable to let teachers and exports work collaboratively. Furthermore, in contrast with the rather dichotomous traditional assessment, functional assessment is fluid. Therefore the information obtained should be seen as fluid and not as ‘set in stone’. The environment is also fluent and functional relationships are ongoing. Accommodations and interventions can be modified continuously until they meet the changing aspects of the environment. It’s important to keep a paper trail of all implemented accommodations and interventions to determine the effectiveness of environmental manipulations.