Treatments for ADHD
There is no cure for ADHD, but symptoms can be treated in several ways:
Classroom-based interventions have been widely used in treating problem symptoms of ADHD. These interventions include educational strategies, peer-directed strategies, and self-management strategies. Treatments have addressed both social and academic concerns associated with ADHD. Educational and instructional interventions manipulate classroom organization and instructional techniques that minimize the occurrence of ADHD symptoms (Waschbusch & Hill, 2001). Examples of this treatment strategy include the use of instructional materials to increase stimulation to students with ADHD during academic tasks to enhance attention and improve performance (Zentall, 1993).
Behavior management is one method of treatment for ADHD that has been most extensively research. Research in behavior management has focused on increasing on-task behaviors, task completion, compliance, impulse control, and social skills. Behavior management aims for a reduction in hyperactivity, off-task behavior, disruptive behavior, and aggression. Behavior therapy is a type of behavior management technique that refers to strategies that use reinforcement and punishment to increase or decrease specific behaviors. Behavior therapies are generally cost effective, easy and quick to implement, and adaptable to multiple settings. Positive reinforcement, punishment, and response cost techniques are the most widely used of the behavior therapies (Fiore, Becker, & Nero, 1993).
Cognitive-behavioral therapy has also been widely studied. Cognitive-behavioral therapy combines behavioral techniques with cognitive strategies to directly address problems of impulse control, problem solving, and self-regulation. Some evidence has also indicated that cognitive-behavioral techniques may produce desired changes in sustained attention, impulse control, hyperactivity, and self-concept (Fiore, Becker, & Nero, 1993).
Self-management strategies have been employed with children who have ADHD. This type of intervention focuses on teaching students to systematically rate their own behavior according to the rating of their teachers. Shapiro, DuPaul, and Bradley-Klug (1998) conceptualize self-management interventions as existing on a continuum. On one end, the teacher controls the intervention by providing feedback regarding whether the student’s behaviors have met the desired criteria and delivers appropriate consequences for the behaviors. On the other end, the student is able to self-evaluate his or her own behaviors against the criteria set for behavior and performance. The student also self-administers consequences. The goal of self-management interventions is to move the student toward the self-management side of the continuum. Once students are able to accurately measure their behavior against the standard set by their teacher, the frequency of teacher feedback on student judgments is gradually lessened until students are accurately judging the quality of their behavior without the help of eternal comparisons.
Several studies have examined the effectiveness of self-management techniques with ADHD children. Hoff and DuPaul (1998) examined the use of a self-management strategy in a general education classroom to decrease the disruptive behaviors of three elementary school students in the fourth grade. The self-management strategy was based on a system of rewards for appropriate behaviors. Behaviors were examined in both structured and unstructured settings. Results of the study indicated that the self-management intervention with the reinforcement led to decreases in disruptive behavior, which was maintained in the absence of the teacher. These data adds to the existing literature suggesting self-management as a viable alternative to traditional contingency management approaches.
Hinshaw and Melnick (1992) also examined reinforced self-management therapy. These researchers suggested that reinforcement and rehearsal-based behavioral interventions can be combined with self-management techniques to supplement and extend the gains induced by behavioral procedures alone. They argue that, when combined with pharmacologic and behavioral approaches, self-management procedures should be considered for addressing the social and behavioral problems of children with ADHD.
Fraser, Belzner, and Conte (1992) examined the use of a timing device in the development of self-monitoring with one ADHD child who had difficulty getting ready for class. After a failed attempt using a cognitive behavior modification alone, an alternative approach was attempted which rewarded the child with extra computer time if he successfully prepared himself for class within five minutes after lunch. The procedure was successful and the alternative approach was introduced in the morning and afternoon, with the reward being contingent on three successive days of meeting the five-minute criterion in the morning and afternoon. The resulted has lasting effects suggesting that the timing device had assisted the child in monitoring his behavior and in spontaneously generalizing the use of the timer across situations.
Response Cost Techniques & the Attention Training System
DuPaul, Guevremont, and Barkley (1992) examined the efficacy of response-cost contingencies alone and in combination with directed-rehearsal procedures for managing the classroom behavior and academic productivity of two boys with ADHD. This strategy involved positive reinforcement for appropriate behavior and a loss of a positive reinforcer or penalty for inappropriate behavior. Students’ behaviors and academic performance were examined. Results indicated that the response-cost contingencies led to marked improvements in each student’s task-related attention and reduction in other ADHD symptoms. Response-cost effects on academic productivity were also seen. These researchers suggested that response-cost procedures promote greater attention to independent seatwork and have the potential to affect other important areas of classroom functioning such as behavioral control during teacher lectures.
One specific contingency management procedure that has been used in the classroom to address ADHD is the Attention Training System (ATS; Gordon Systems, Inc., 1987). ATS is a behavioral intervention based on response-cost technology that uses a battery-operated, electronic apparatus to systematically deliver both positive and negative feedback to children. The ATS apparatus is placed on a child’s desk and displays cumulative pointes earned according to a fixed-interval schedule for on-task behavior. A point is added to the child’s module display for each minute he or she remains on-task during a given academic session. The teacher visually monitors the child’s behavior from anywhere in the classroom and activates a small remote control device by pressing a button whenever the child is off-task. When activated, a red light on top of the child’s module is illuminated for a 15-second interval, signaling that a point has been deducted from the accumulation total. The child’s accumulated point total at the end of the academic session or school day is cashed in for various rewards such as extra free-time activities or small toys.
In one study, ATS was used in combination with a token reinforcement program where points can be exchanged for rewards at the end of the school day to reduce off-task behavior in an 11 year-old boy diagnosed with ADHD (Evans, Ferre, Ford, & Green, 1995). Results indicated that the ATS plus token reinforcement was successful in reducing off-task behavior across reading, science, and social studies classes. Rate of off-task behaviors was also reduced, compared with baseline, when the ATS was removed. These results have implications for the use of ATS combined with a reinforcement program in the classroom setting to reduce problem symptoms associated with ADHD.
Gordon, Thomason, Cooper, and Ivers (1991) also examined the effectiveness of the ATS. Six students with ADHD were observed in their classrooms, and off-task behaviors were recorded during baseline and training phases. Results indicated that in five of the six cases, the children’s level of attention to tasks improved significantly from baseline to the training phases and then deteriorated during when the ATS was removed. Thus, the response cost program appeared to have a powerful and immediate effect on students’ level of sustained attention; however, because training effects deteriorated after removing the ATS, the researchers indicated that ATS should be implemented for a longer period than was used in their study. Gordon et al. (1991) suggested that a combination of positive rewards and negative consequences that are immediate and meaningful may be the most effective approach to managing inattention in the classroom.
Classroom-wide interventions have also been examined as a method of addressing problematic behaviors of students with ADHD. Classrwide interventions usually involve the entire classroom’s involvement in addressing problems associated with children in the classroom who have ADHD. DuPaul, Ervin, Hook, and McGoey (1998) studied the effects of classwide peer tutoring on the classroom behaviors and academic performance of students with ADHD. Regular instruction activities were compared with classwide peer tutoring for 18 children with ADHD and 10 comparison students (without ADHD) in first through fifth grades. Results indicated that classwide peer tutoring led to increased in academic engagement and reductions in off-task behavior for most participants. In addition, 50% of the students with ADHD exhibited improvements in math and spelling as a result of the classwide peer tutoring. Teachers and students both reported high levels of satisfaction with the intervention. Results suggest that peer tutoring appears to be an effective strategy for addressing the academic and behavioral difficulties associated with ADHD in general education classrooms.
Another specific classwide intervention, the ADHD Classroom Kit, an inclusive treatment package for children with ADHD was examined as a whole-classroom approach for managing disruptive behavior (Anhalt, McNeil, & Bahl, 1998). The Kit addresses three main areas of concern: consequences for appropriate behavior, consequences for inappropriate behavior, and peer-mediated interventions (involving cooperative learning with small groups of students). In a case study using the Kit, results indicated an increase in appropriate behavior of almost 17% above the baseline and an increase in on-task behavior approximately 11% above baseline measures. Anhalt et al. (1998) concluded that the ADHD Classroom Kit provides appropriate positive and negative consequences that have been useful in changing the behavior of children with ADHD. In addition, the Kit addresses aspects of inclusion and peer interventions.
Conclusion and Implications
It appears that the most effective interventions for decreasing symptoms of ADHD in the classroom include those with some component of reinforcement. The self-management techniques and the use of the ATS have surfaced in the literature as two interventions that have resulted in powerful effects of reducing off-task behaviors in children with ADHD. Findings from the studies examined in this paper seem to be consistent with the previously mentioned meta-analysis conducted by DuPaul and Eckert (1997) that indicated that behavior modification strategies as more effective than cognitive or cognitive-behavioral approaches to behavior management in children with ADHD.
There are however, several limitations that need to be considered in the research on classroom-based interventions for ADHD. In the literature that was reviewed for this paper, a majority of the studies included a very small sample size. More research needs to be conducted on larger samples to ensure that these interventions are consistently effective across individuals with ADHD. A second concern regarding literature on classroom-based interventions is that ADHD has known comorbid disorders such as Oppositional Defiant Disorder and Conduct Disorder. It is difficult to study the effects of these interventions on just ADHD when comorbidity exists.
Despite these limitations, the effects of classroom-based interventions for the treatment of ADHD should not be overlooked. The research clearly indicates that interventions such as self-management techniques, the ATS, and peer tutoring have resulted in dramatic decreases in problematic symptoms associated with ADHD and increases in more appropriate prosocial behaviors with children. These findings are promising for classroom teachers and school psychologists in enhancing the academic and social outcomes of children with ADHD.
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