Victoria Brown
Ample research exists regarding effective interventions for students identified ADD/ADHD, but the question of how best to translate those carefully constructed research designs into daily practice in the real world has long nagged scientists and practitioners. Real world psychology is imperfect, and even with the best of intentions it is done on the fly. In a series of studies, high-intensity interventions or consultation models are compared with low-intensity models of treatment for children with ADD/ADHD, with the latter of the two models proving as effective, or almost as effective, as high-intensity interventions. This is a positive development in a field where diagnoses of the disorder have skyrocketed in recent years, leading to thousands of children on prescription drugs to “control” their “hyper-activity” and “inability to focus.”
There are certain elements of low-intensity interventions that have likely contributed to their success. Although the nature of the studies conducted do not allow us to unpack the interventions to determine which ones contributed most to the overall success, identifying the essential components of each intervention translates into a useful best practices guide for educators looking for effective interventions for students with ADD/ADHD.
Based on a study by Fabiano and colleagues (Fabiano et al., 2007), effective school-based behavior modification for children with ADD/ADHD should incorporate the following elements:
• Posting and daily review of classroom rules.
• Liberal use of praise and social reinforcement for children behaving appropriately.
• The use of some kind of time-out procedure (with length of time based on age) when children exhibit aggressive, destructive, or defiant behaviors.
• Daily report cards, linked to rewards provided by parents on at least a weekly basis.
Additionally, this study offers useful findings regarding the effectiveness of stimulant medications for students suffering from ADD/ADHD. Fabiano and colleagues (2007) found that when medication is combined with behavior modifications, lower doses are effective in achieving the same outcomes as higher dosages of any medication alone.
This is a discovery that must be embraced by all school psychologists and incorporated into their consultations with parents and teachers looking for answers to the challenges posed in educating a student with ADD/ADHD. Rarely do parents welcome the idea of medication without reservation, as most are concerned with the side effects the drugs cause in patients. Parents are far more likely to accept medication for their children when they can be put on a low dose, thereby reducing likely side effects, and when they feel their child’s teacher is also taking steps to address the challenges the student poses in the classroom, not merely relying on the medication to manage their child.
The second study by Jitendra et al. (2007) focused on models of consultation for ADD/ADHD students. Based on their findings, effective school-based consultation targeting children with ADD/ADHD should include the following:
• Educating teachers both about the nature of ADD/ADHD and about effective classroom interventions (e.g., through the dissemination of reading material).
• A collaborative process in which teachers and consultant together design academic interventions that teachers identify as appropriate to their classroom and the needs of the children in question. This should include an initial interview that identifies areas of academic concern, current performance, and intervention goals, followed by a second interview in which the teacher selects preferred interventions.
• Detailed plans that outline the specific instructional steps teachers need to use along with all the necessary materials they need to implement the intervention.
• Having a range of interventions to choose from, including teacher-mediated, peer-mediated, computer-assisted, and self-mediated strategies.
• Weekly contact with teacher by phone or e-mail to provide updates or address questions and concerns.
The third article by Kern et al. (2007) offers a description of useful intervention protocol for younger children, aged three to five years with ADD/ADHD. As the author states, both parents and physicians are frequently reluctant to place children in this young age range on medication, and there is evidence that children who are placed on medication at this age are more likely to experience negative side effects associated with medication trials (Wigal et al., 2006). Yet, parent consultation, even in the form of generic parent education, offers an attractive alternative to medication, as less intensive interventions may be particularly effective at young ages as the child’s behavior patterns, and the response of parents and teachers to these patterns, are less entrenched than when the child reaches elementary or middle school. According to the study, parent education should incorporate the following:
• An intervention that lasts for at least a year (in this study, parent education consisted of 20, two hour sessions spread out over 18 months).
• Efforts to ensure attendance (e.g., providing transportation and child care), with follow-up to those parents who missed sessions.
• Educating parents about ADD/ADHD as well as covering topics such as understanding child behavior, discipline, social-emotional development, and self-esteem. It may be that using a well-developed curriculum and lesson plan (such as the Systematic Training for Effective Parenting program) is a key ingredient because this ensures a well-thought out sequence of lessons that can serve as a framework for the intervention.
Additionally, this study discusses the limitations of care, cautioning against assuming that over the long-term children in low-level intervention will continue to do as well as those in high-level intervention. Regardless, the findings are encouraging. In general, school psychologists should look for community resources to supplement what they and other mental health professionals in the school are able to provide. Although seeking out parent education programs targeted to children with ADD/ADHD may be difficult, more generic parent training for those with young children diagnosed ADD/ADHD may be more accessible, ultimately offering a worthwhile alternative to no treatment at all.
This brings us to the article by Evans, Serpell, Schultz, and Pastor (2007) regarding middle school students with ADD/ADHD. Generally, middle school children are more likely to resist both medication and other types of intervention designed to reduce the symptoms associated with their attention disorder. Good reasons exist for this trend given the developmental tasks of this stage of child development, including the importance of conformity, the increasing dominance of the peer group in shaping the child’s opinions, values, and preferences, as well as a desire for increased independence associated with loosening ties with adults in positions of authority (both parents and teachers). Also, due to the way middle schools are structured, with each child assigned to classes with multiple teachers over the course of the school day, it is more challenging to design and implement interventions as the cooperation and sustained effort of multiple teachers, rather than just one, is required. All of these issues – some intrinsic to the child and some to the way middle schools are structured – present significant obstacles impeding the effectiveness of both traditional consultation models and of the kinds of behavior management strategies that have proven effective with younger children.
Consequently, it is imperative to look at different intervention models for this age group that will have a greater likelihood of success. Successful interventions must be a joint effort by parents, teachers, and students themselves, with clear roles for parents and students incorporated into the design, both in the intervention’s structure and implementation. By making students an integral part of the intervention decision-making process, their ownership in the process and their motivation to achieve positive outcomes increases tremendously. By involving parents, we can gain access to more powerful rewards and consequences than are typically available in the school setting. Also, by making home-school collaboration a key ingredient of success, we can work to close some of the loopholes that students this age are so skilled at exploiting (e.g., telling parents that they don’t have any homework because they know that parents have no way of verifying this report).
Ultimately, there is absolutely more work to be done regarding the design and assessment of the effectiveness of interventions for students with ADD/ADHD so that these strategies can be realistically incorporated in the classroom and daily practice of school psychology. Using authentic measures must lead to a careful analysis of what specific behaviors students engage in that lead to positive outcomes. Interventions can then target those behaviors and create a direct link between the intervention and the desired real-world outcome.
Margaret M Dawson. “The Ideal Versus the Feasible When Designing Interventions for Students With Attention Deficit Hyperactivity Disorder.” School Psychology Review. Bethesda: June 2007. Vol. 36, Iss. 2; pg. 274.