Do what works. Meta-analytic results on interventions in the classroom for ADHD

Transcription

1 Date Do what works Meta-analytic results on interventions in the classroom for ADHD Yvonne Groen Clinical and developmental neuropsychology University of Groningen The Netherlands y.groen@rug.nl

2 Date Classroom problems of ADHD Staying in seat Independent seatwork Following instructions Listening to teacher Often on the go Leaves seat Troubles waiting Easily distracted Trouble holding attention Deficits in sustained attention, planning, working memory Classroom demands ADHD symptoms Cognitive impairment Off-task and disruptive behavior

3 Date Off-task and disruptive behavior Off-task difficulties: Staying on task Following instructions Completing school work Disruptive behavior: Out-of-seat Interrupting classmates Calling out before turn

4 Date Consequences Academic difficulties (Barkley, 2006; Frazier, Youngstrom, Glutting, & Watkins, 2007; Loe & Feldman, 2007; Reid, Maag, Vasa, & Wright, 1994) Underachievement; being behind Retaining grade Special educational placement Suspension or drop-out from school Classroom dysfunction (DuPaul & Stoner, 2003; Wheeler & Carlson, 1994; Endman & Bernfeld, 1977) Lesson disruptions Maladaptive behavior in peers and teachers

5 Date Teacher problems with ADHD Children with ADHD are perceived as more stressful to teach (Greene et al., 2002; Hong, 2008) loss of satisfaction from teaching self-doubt need for support Often lack knowledge and skills to develop effective classroom managament strategies (Arcia et al., 2000; Mulligan, 2001; Murray, Rabiner, & Hardy, 2011) Might influence children s academic difficulties and classroom function -> negative spiral

6 Date Everyday problems are on the increase Time spent in school Increased number of ADHD diagnoses (5-7%) Less are included in special education One (+) in every regular classroom Regular schools obliged to povide adjusted education EVERYDAY behavior problems in the classroom affecting: ADHD children Peers teachers

7 Date Does medication suffice? Effective improvement of on-task behavior and academic achievement (meta-analysis by Prasad et al., 2013) HOWEVER, Improvement normalization (Gualtieri & Johnson, 2007; Tucha et al., 2006) Cognition needs lower doses than behavior (Hale et al., 2011; Berridge & Devillbiss, 2011) Limitations of medication (Langberg & Becker, 2012; Sonuga-Barke, Coghill, Wigal, DeBacker, & Swanson, 2009; Taylor et al., 2004) NO There is a need for non-pharmacological interventions

8 Date Do what works meta-analytic study Research questions: ADHD causes many classroom problems Detrimental consequences in all parties Everyday problems are increasing Medication is not sufficient 1. Which classroom interventions are effective? 2. Moderating variables?

9 Date Geraldina Gaastra

10 Date Inclusion criteria Study Published in academic journal English Participants Students with symptoms of ADHD Attending grade 1 through 12 (age 6 17 years) Intervention Regular teacher can apply, no excessive resources necessary Outcome measures Teacher ratings or direct observations On-task, off-task, or disruptive behavior

11 Date Intervention types Antecedent-based Prevention of off-task/disruptive behavior by altering the environment, instructions or task Consequence-based Rewarding on-task behavior, mildly punishing off-task/disruptive behavior Self-regulation Promoting development of self-control skills and problem-solving strategies Combined

12 Date Study designs: intervention baseline / control condition Group studies (k = 24, n = 471): Between subject variance 8 of 24 studies included control group Case studies (k = 76, n = 156) Within subject variance Separate meta-analyses, because different types of variance Case studies: only descriptive analyses

13 Date Outcomes M M L S Group studies Meta-analysis: - Large median SMD = 0.92, 95% CI [0.59, 1.25] - Moderator effect of intervention type, p <.001 Case studies Descriptive analysis: - Positive effects - Self-regulation most effective

14 Date Consequence-based interventions Rewarding on-task behavior, mildly punishing off-task/disruptive behavior Rewarding target behavior; k = 4; M/L effect Frequent Immediate Individualized/novel/reward menu Mildly punishing off-task/ disruptive behavior; k = 4; L effect Prudent negative consequences Calm corrections Reinforcement systems Daily report cards (k=2; L effect) Group contingencies, e.g. ADHD classroom kit (k=2; CS) Attention training system (k=2; CS)

15 Date Self-regulation interventions Promoting development of self-control skills and problem-solving strategies Self-monitoring Self-evaluation Observing target behavior/ performance/ attention Recording target behavior/ performance/ attention Rewarding OR Comparing to teacher record

16 Date Antecedent-based interventions Prevention of off-task/disruptive behavior by altering the environment, instructions or task Stability/therapy balls; k = 2; L effect (Classwide) peer tutoring; k = 3; L effect Adapt tasks/instructions Computer-assisted instruction (k=3, CS) Choice-making (k=1, CS) Adjusting instructions (notetaking, small group, stepwise)

17 Date Large variance of effect sizes Group studies Median 0.92 Case studies Median 2.63 Additional moderators: Educational setting - Special/ general Age - Children/ adolescents Gender - Most boys/ equally distributed/ most girls Medication - Most medicated/ equally distributed/ most medication free

18 Date Moderator effect of classroom setting Classroom setting Stronger effect in general education setting (p <.035) Explanation: Less severe samples? Less behavioral programs? More medication use?

19 Date Potential moderation of medication Descriptive analyses: Effect is reduced when medication-free Potential catalyzing effect of medication?

20 Date Conclusions meta-analysis Classroom interventions for ADHD effectively reduce off-task and disruptive behavior Consequence-based and self-regulation work best Most effective in general classroom Potential catalyzing effect of medication? Limitations Publication bias Diversity of outcome measures Generalizability: boys aged 6-11 years -> girls and adolescents? Focus on behavior -> cognition and performance?

21 Date Practical recommendation Antecedent-based interventions for all Optimal classroom management and structure Antecedent-based interventions for ADHD Consequent- based and Self-monitoring interventions for ADHD Defining target behavior (e.g. Reid & Maag, 1997) What behavior can replace the off-task/disruptive behavior? - Incompatible - Do-able Capability of teacher? Collaborative consultation model (DuPaul et al., 2011)

22 Date Implications fo practice Do what works? Many interventions available for effectively reducing offtask and disruptive behavior in students with ADHD Dissemination is necessary Development of a toolkit

23 Acknowledgements Funding by Geraldina Gaastra Nationaal Regieorgaan Onderwijsonderzoek Oliver Tucha Thank you for your attention! Lara Tucha 23