Academic Intervention and ADHD

Best Practices in Academic Intervention for Children with ADHD APSY 658: Spring 2011 Shawna Sjoquist University of Calgary

Academic Intervention and ADHD 2 A variety of classroom difficulties may and often do present barriers to the optimal acquisition of education by the individual. Attentional difficulties have come to be one of the most common and pronounced obstacles to learning experienced within the classroom (DuPaul, Stoner and OReilly, 2002). DuPaul, Stoner and OReilly acknowledge that attention problems often are associated with behavioural difficulties, such as impulsivity, high activity level, and aggression (p. 1115, 2002). The American Psychiatric Association (2000) offers that ADHD is a neuropsychiatric disorder defined by an enduring pattern of inattention and/or hyperactivityimpulsivity that presents in excess of the norm prior to the age of seven (DSM-IV-TR). Given the prominent recognition of attentional difficulties experienced within the academic environment and symptomatic characterization of ADHD, it stands to reason that best practices in academic intervention would be a salient topic posed in recent research. In addition to attention, impulsivity and hyperactivity, symptoms pursuant to a diagnosis of ADHD may also be associated with a number of behavioural difficulties that can include aggression and noncompliance (Barkley, 2006). Taken together, it is evident that the academic success of children diagnosed with ADHD will be heavily influenced by the implementation of best practices with regard to academic intervention. Best practice in intervention has begun to accentuate an approach to intervention that emphasizes individual outcomes rather than individual deficits (Upah and Tilly, 2002). With this shift in practice comes the challenge and responsibility for school psychologists to ensure they are designing, implementing and evaluating quality interventions (Upah and Tilly, p. 483, 2002). In consideration of the salient concern for academic success of children diagnosed with ADHD, an approach toward best practice in designing, implementing and evaluating quality academic interventions will be used to insight the discussion that follows.

Academic Intervention and ADHD 3 In theory, ADHD is characterized by inhibitory and self-regulatory deficits (Wodka et al., 2007). As a result, treatment approaches that seek to increase motivation and inhibitory responses are now being considered by the research to be theoretically supported (Bradley et al., 2006). Research acknowledges that children with ADHD are developmentally diverse and characteristically heterologous group (Wodka et al., 2007) therefore efficacious treatment approaches must acknowledge the needs of the individual child and structure academic interventions accordingly. Additionally, treatment of children with ADHD can be complicated by factors pursuant to family dynamic, daily routine, presenting comorbidities and risk factors that require the application of intervention approaches to be individualized and often experimental in nature (Bradley et al., 2006). Reduced behavioural inhibition has been considered by Barkley (2003) to be the core deficit of ADHD impeding the effective action of executive functioning including working memory, self-regulation, the internalization of speech and reconstitution. It is this primary deficit that it theorized to establish the symptomatic difficulties noted with regard to inattention, behavioural disorganization, social rejection and difficulty with peers, aggression and noncompliance (Barkley, 2003) that come to impact academic success and necessitate the use of a best practice approach to academic intervention. As previously stated, appropriate support of the academic success of children diagnosed with ADHD begins with best practice in designing, implementing and evaluating quality academic interventions. Upah and Tilly (2002) suggest that best intervention practice begins with the identification and definition of the problem. DuPaul, Weyandt and Janusis offer that academically, children with ADHD are more likely to have poor grades, lower scores on standardized tests, greater likelihood of identification for special education, and an increased use of school-based services, when compared to peers without the disorder (p. 36, 2011). Through

Academic Intervention and ADHD 4 the research it becomes evident that problem identification will likely identify areas of difficulty that are deeply seeded within the academic domain. Barbaresi, Katusic, Colligan, Weaver and Jacobsen, (2007) indicate that, when compared with typically developing peers, children diagnosed with ADHD have higher rates of absenteeism, increased likelihood of retention during the elementary school years and demonstrate high risk for high school dropout. Moreover, DuPaul, Stoner and OReilly identify that for many children with attention problems associated with ADHD, the two primary classroom situations that prompt inattentive behaviour are teacherdirected instruction and the presentation of independent academic work (p. 1119, 2002). Problem identification of children diagnosed with ADHD may include the inability to demonstrate sustained attention, distractibility, restlessness, fidgeting and forgetfulness during teacher directed instruction or academic task (Brossard-Racine, Majnemer and Shevell, 2011). Upah and Tilly (2002) suggest that problem identification include an operational definition of the problem in question that is objective, clear and complete. Proper identification of the problem should include the concerned behaviour, the desired behaviour, the current level of performance and a representation of problem behaviour in comparison to peers (Upah and Tilly, 2002). Therefore, for the identified target population, identification of the behaviour of concern may include difficulty following academic directions, a tendency to miss important details and rush through tasks, experience problems focusing and maintaining attention and interrupting others (DuPaul and Stoner, 2003). Research indicates that in comparison to the larger peer group, children with ADHD may routinely finish academic tasks incompletely or inaccurately and state that they have finished tasks well before the majority of their peer group (Barbaresi, Katusic, Colligan, Weaver and Jacobsen, 2007). As an example, a childs current level of performance may include an inability to remain seated for periods longer than seven minutes, an inability to

Academic Intervention and ADHD 5 complete tasks involving three step directions, a minimally demonstrated ability to maintain engagement with written assignments and frequent presentation of work that is poorly constructed and/or illegible. An example of Upah and Tillys problem identification may present in the following format. Inability to demonstrate sustained attention means that child A has difficulty internalizing information germane to successful performance. Examples of an inability to sustain attention include difficulty completing tasks involving three step directions, difficulty sustaining adherence to classroom rules and difficulty maintaining activity engagement. Nonexamples of difficulties with sustained attention include reading words correctly in one context but not in another and an inability to comprehend what is read. Following proper problem identification, Upah and Tilly (2002) identify that the next step in best practice intervention includes the acquisition of baseline data. The baseline data component involves three steps: (a) establishing the relevant dimensions of the problem behaviour, (b) developing a method to systematically measure the behaviour, and (c) collecting data on the behaviour prior to implementation and intervention (Upah and Tilly, p. 487, 2002). Establishment of the appropriate dimensions of the problem behaviour include identifying frequency, latency, intensity, topography, accuracy and duration of the identified behaviour (Upah and Tilly, 2002). As an example baseline data may reveal that, child A demonstrates a difficulty attending three to four times during a ten minute teacher directed activity and 36 times daily across multiple teacher directed activities. Child A demonstrates the ability to sustain attention to a non-preferred task for a maximum of two minutes and intensely resists redirection toward non-preferred tasks. Intense reactions experienced during attempts to redirect often include shouting, verbal aggression toward adults and attempts to flee the task environment. Accuracy of completed tasks routinely fail to meet classroom standards, tasks regularly present

Academic Intervention and ADHD 6 with missing information, appear to be hurried and are often illegible in comparison to tasks completed on a preferred area of interest. To develop a systematic measurement strategy data collection approach, measurement materials, settings, designated collector, frequency and duration must be specifically identified during problem validation (Upah and Tilly, 2002). Data may be collected using a designated data collection tool such as a behavioural checklist, should be collected directly in the setting where the identified behaviour is perceived to be a challenge and be measured over several sessions, days and/or weeks (Upah and Tilly, 2002). A designated individual should be charged with the responsibility of collecting relevant data. The chosen individual will likely depend on the setting within which the data is being collected. For instance, a teacher or learning team coordinator may be in charge of collecting data germane to the school environment. Upah and Tilly (2002) identify that the measurement strategy used to collect appropriate data should reflect accurate and objective information pursuant to the identified behaviour itself, therefore a checklist may support the data collector in collecting the most appropriate information in the most appropriate manner possible. The measurement tool chosen to collect data will be used throughout the intervention process and ensuring accuracy in observation and evaluation of the child performance pre and post intervention (Upah and Tilly, 2002). As an example, best practice approach to intervention may include data collection of child A collected daily by the teacher within each of the childs classroom settings at nine am, eleven thirty am and two pm using DuPaul, Rapport and Perriellos Academic Performance Rating Scale (1991) for a period of two consecutive weeks. Following initial data collection Upah and Tilly (2002) suggest the next step in best practice intervention include, validation of the presented problem. During this process the

Academic Intervention and ADHD 7 magnitude of the problem is considered through conceptualization of the problem itself and an analysis of discrepancies between the childs current level of performance and the environmental expectations (Upah and Tilly, 2002). Discrepancies are identified through a comparison of current performance, as represented by the baseline data previously discussed, and what is considered to be typical or standard performance (Upah and Tilly, 2002). Common academic standards used to determine the presence and magnitude of present discrepancies may include academic peer performance, district norms, teacher or classroom expectations, school policy standards, developmental standards and/or medical standards (Upah and Tilly, 2002). DuPaul, Stoner and OReilly (2002) put forth that a primary concern relevant to the identification of performance discrepancies is a consideration of the degree to which the curriculum coordinates with child instructional levels. DuPaul, Stoner and OReilly posit that some students may demonstrate significant levels of inattention and off-task behaviour as a function of being exposed to curriculum material that is beyond their instructional level (p. 1119, 2002). Therefore should a discrepancy between child As performance and the performance standard be located and demonstrate a considerable magnitude that warrants the pursuit of intervention, further assessment will be required to inform intervention. Assessment must be used to further discern what is already known about the problem and to determine what knowledge is still required for an evaluation of the underlying causes instigating problem occurrence (Upah and Tilly, 2002). For children diagnosed with ADHD, known information may be collected with regard to instruction, current curriculum, environment as well as the individual learner themselves (Upah and Tilly, 2002). For example, known information provided by review of academic record, teacher/caregiver interview may include knowledge that Child A experiences substantial incidences of inattention when classroom

Academic Intervention and ADHD 8 instruction is presented in a multistep format and when child A is seated away from the teacher. However additional observations and tests may be necessary to discern with is not known about the problem behaviours. Common assessments that may be used to inform understanding and later intervention can and often do include Wechsler Intelligence Scale for Children (WISC-IV), Wechsler Individual Achievement Test (WIAT-III), Conners 3rd Edition and/or Developmental NeuroPsychological Assessment (NEPSY). Additionally, Upah and Tilly offer that problem analysis may also include use of Functional Behavioral Assessment (FBA) and CurriculumBased Evaluation (CBE) (2002). Once known and unknown information is collected a hypothesis can be generated (Upah and Tilly, 2002). A sample hypothesis for a child diagnosed with ADHD experiencing academic difficulty may present that a tendency to rush through activities or assignments with little or no regard for accuracy or quality occurs because child A also has a reading disability and becomes frustrated and disinterested when asked to complete tasks that are difficult for them. In support of this sample hypothesis, Palacios and Semrud-Clikeman (2005) present that ADHD related behavioural problems may precede and lead to a reading disability and/or reading difficulties may precede and lead to ADHD related behavioural problems resulting from the frustration incurred through the repeated failure experiences. Additionally, Ylvisaker and DeBonis (2000) identify that children with ADHD differ significantly from typically developing children with regard to executive function or metacognitive tasks necessary for proficient reading ability. Using this sample hypothesis we may then predict that if the academic tasks involving reading are modified, for example tasks and instructions are visually supported and broken down into smaller components, the tendency to rush through activities or assignments with little or no regard for accuracy or quality will either increase or decrease.

Academic Intervention and ADHD 9 Upah and Tilly offer that once hypotheses and predictions have been validated best practices in academic intervention would now include intervention design and plan implementation (2002). Plan implementation must identify the desired outcome of intervention through the use of a clearly defined goal statement that is written in observable, measurable terms and include four components: time frame, condition, behaviour and criteria (Upah and Tilly, p. 489, 2002). Therefore, a sample goal statement may offer that in eight weeks, when written directions are not read or followed child A will be supported in reading and reviewing the directions with a pre-determined peer partner. It is expected that child A will demonstrate use of this intervention strategy, with support three out of every five opportunities and independently one out of every five opportunities to negotiate instructions that have been provided in a written format. With the formation of a goal statement, practitioners may then proceed to develop a clearly stated intervention plan that will identify who, what, when, where and how the plan will be implemented (Upah and Tilly, 2002). DuPaul, Stoner and OReilly present that interventions that are simple by design and easily carried out are often well received intervention approaches as a well-designed intervention that a teacher finds difficult to implement and maintain is not likely to be put into action on a consistent basis (p. 1119, 2002). DuPaul, Stoner and OReilly also postulate that interventions included within the intervention plan that combine proactive and reactive strategy approaches generally provide the best results (2002). Research indicates that some of the most efficacious treatment approaches for academic achievement that can be included in intervention plans are direct instruction, use of computer technology as a teaching medium and class wide peer tutoring (DuPaul, Weyandt and Janusis, 2011). Although the strategy suggestions offered above posed for the purposes of this paper are generic in nature, it is

Academic Intervention and ADHD 10 paramount that the reader understand that best practice in intervention include specific descriptions of the chosen strategies. Therefore an intervention plan may dictate that the teaching team will support child A using direct instruction to read directions, ask questions about the directions and ultimately follow the directions during all instruction related classroom tasks. The intervention plan may also incorporate the use of computer technology to actively engage child A in direction following tasks and incorporate an element of peer tutoring that supports the rules for direction following as presented within the direct instruction. The intervention plan should also incorporate information discussed during the data collection phase of the best practice model as data will be collected as part of the intervention plan throughout intervention process as a means of evaluating the chosen treatment approach. While modifications may be made with regard to who, where and when the data will be collected the overarching method and materials should remain consistent with the previously used methods (Upah and Tilly, 2002). Lastly, the intervention plan should also present a decision making plan that discusses the frequency of data collection, strategies used for data summarization, data evaluation intervals and a decision rule (Upah and Tilly, 2002). Therefore, the sample intervention plan may dictate that while all measures of data collection will remain the same, the data will be summarized using a graphic data display and evaluated on a weekly basis. The part of the sample intervention plan that addresses a decision rule may dictate that should a pattern of data emerge that indicates a decrease in negative behaviour, the intervention is to be continued for the duration of the data collection period and an evaluation of the problem should be considered. Should a pattern of data emerge that suggests the current intervention approach is not producing positive outcomes practitioners and educators, as an example, may be instructed by the intervention plan to enter into problem evaluation including consideration of

Academic Intervention and ADHD 11 the effectiveness and current process of intervention implementation or treatment integrity. Regular appraisal of treatment integrity may also be integrated directly into the intervention plan through recurring observation and/or interview of educational staff relevant to implementation of the chosen intervention. Upah and Tilly identify a need for progress monitoring throughout intervention implementation [and] student performance should be assessed so continuous evaluation can occur and interventions may be modified as needed (p. 491, 2002). The sample intervention plan indicates use of a graphic data display which affords users of this intervention plan the ability to visually analyze data with regard to a change in mean, level, trend or latency of change. Completion of the best practice approach to intervention as presented by Upah and Tilly (2002) occurs with an overall summative evaluation. With best practice implementation it is hoped that the chosen intervention strategy will have proven successful thereby delivering positive academic outcomes for child diagnosed with ADHD.

Academic Intervention and ADHD 12 References American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Barbaresi, W. J., Katusic, S. K., Colligan, R. C., Weaver, A. L., & Jacobsen, S. J. (2007). Longterm school outcomes for children with attention-deficit/ hyperactivity disorder: A population-based perspective. Journal of Developmental and Behavioral Pediatrics, 28, 265-273. Barkley, R. A. (2006). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (3rd ed.). New York: Guilford. Barkley, R. A. (2003). Attention-deficit/hyperactivity disorder. In E. Mash, & R. Barkley (Eds.), Child psychopathology (2nd ed., pp. 75-143). New York: The Guilford Press. Bradley, H., Russell, A., Cheri, J., & Shapiro, J. (2006). Attention-Deficit/Hyperactivity Disorder. In Mash, J. E., & Barkley, R. A. (3rd Ed.), Treatment of Childhood Disorders (pp. 65-136). New York/ London: Guilford Press. Brossard-Racine, M., Majnemer, A., & Shevell, M. I. (2011). Exploring the neural mechanisms that underlie motor difficulties in children with Attention Deficit Hyperactivity Disorder; Developmental Neurorehabilitation, April 2011; 14(2): 101-111

Del'Homme, M., Tae, K., Loo, S., Yang, M., & Smalley, S. (2007). Familial Association and Frequency of Learning Disabilities in ADHD Sibling Pair Families. Journal of Abnormal Child Psychology, 35(1), 55-62. doi:10.1007/s10802-006-9080-5

Academic Intervention and ADHD 13 DuPaul G. J., Rapport, M. D., & Perriello, L. M. (1991). Teacher Ratings of Academic Skills: The Development of the Academic Performance Rating Scale, School Psychology Review, 20, 284-300. DuPaul, G. J., & Stoner, G. (2003). ADHD in the schools: Assessment and intervention strategies (2nd ed.). New York, NY: The Guilford Press. DuPaul, G. J., Stoner, G., & OReilly, M.J. (2002). Best practices in classroom interventions for attention problems. In Thomas, A. & Grimes, J. (Eds.), Best practices in school psychology (pp. 1115-1127). Bethesda, MD: NASP Publications. Hinshaw, S. P. (2002). Preadolescent girls with attention-deficit/hyperactivity disorder: Background characteristics, comorbidity, cognitive and social functioning, and parenting practices. Journal of Consulting and Clinical Psychology, 70, 1086-98.

Palacios, E., & Semrud-Clikeman, M. (2005). Delinquency, Hyperactivity, and Phonological Awareness: A Comparison of Adolescents With ODD and ADHD. Applied Neuropsychology, 12(2), 94-105. doi:10.1207/s15324826an1202_5

Upah, K. & Tilly, D.W. (2002). Best practices in designing, implementing, and evaluating quality interventions. In Thomas, A. & Grimes, J. (Eds.), Best practices in school psychology (pp. 483-501). Bethesda, MD: NASP Publications.

Wodka, E., Mahone, E., Blankner, J., Gidley Larson, J., Fotedar, S., Denckla, M., et al. Evidence that response inhibition is a primary deficit in ADHD. Journal

(2007).

of Clinical &

Experimental Neuropsychology, 29(4), 345-356. doi:10.1080/13803390600678046.

Academic Intervention and ADHD 14 Ylvisaker, M. & DeBonis, D. (2000). Executive function impairment in adolescence: TBI and ADHD. Topics in Language Disorders, 20(2), 29-57.