Developing coordinated, multimodal, school-based treatment for young adolescents with ADHD.

Developing coordinated, multimodal, school-based treatment for young adolescents with ADHD. Abstract Adolescents with ADHD Attention-Deficit/Hyperactivity Disorder (ADHD)DefinitionAttention-deficit/hyperactivity disorder (ADHD) is a developmental disorder characterized by distractibility, hyperactivity, impulsive behaviors, and the inability to remain focused on tasks or experience serious impairment that taxes oureducation, mental health, and healthcare systems as well as the childrenand families. The development and evaluation of effective treatments forthese youth have lagged far behind that of many other disorders and agegroups. This manuscript describes the treatment development process fora school-based comprehensive care model for treating middle-school agedyouth with ADHD. An overview of the development process is described aswell as future directions. Specific interventions that comprise theChallenging Horizons Program (CHP CHP ChapterCHP Combined Heat and PowerCHP California Highway PatrolCHP Cumhuriyet Halk Partisi (Turkish: Republican People's Party)CHP Chemical Hygiene Plan (OSHA)CHP Community Health Plan ) are explained as well as theirfeasibility in public middle schools. ********** According to according toprep.1. As stated or indicated by; on the authority of: according to historians.2. In keeping with: according to instructions.3. the Centers for Disease Control and Prevention Centers for Disease Control and Prevention(CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. (CDC See Control Data, century date change and Back Orifice. CDC - Control Data Corporation ,2005), the rate of ADHD in the general population of children in theU.S. is approximately 7.8%. In child clinical settings, however, therate often exceeds 50% (Barkley, 1998); making ADHD one of the mostcommonly diagnosed psychiatric disorders for children. Longitudinalstudies longitudinal studies,n.pl the epidemiologic studies that record data from a respresentative sample at repeated intervals over an extended span of time rather than at a single or limited number over a short period. indicate that these children continue to suffer ADHD relatedimpairment into adulthood and the majority of the children diagnosedwith ADHD continue to meet age-adjusted diagnostic criteria inadolescence (Barkley, Fischer, Smallish, & Fletcher, 2002). Childrenwith ADHD typically present at clinics with problems including academicdifficulties, discipline problems at school and at home, and conflictwith peers. Adolescents with ADHD have many of these same problems, butoften with more serious consequences such as school drop out and legalproblems. School dropout (1) On magnetic media, a bit that has lost its strength due to a surface defect or recording malfunction. If the bit is in an audio or video file, it might be detected by the error correction circuitry and either corrected or not, but if not, it is often not noticed by the human , family conflict, serious social impairment,failing grades, and problems obtaining and holding a job are commonoutcomes for these adolescents (Barkley, Anastopoulos, Guevremont, &Fletcher, 1991, 1992). Moreover, due to physical and social maturation,adolescents encounter new sets of problems such as automobile accidents,traffic tickets, difficulty in romantic relationships, vocationalproblems, and substance use or abuse (Barkley, Murphy, & Kwasnik,1996; Molina & Pelham Noun 1. Pelham - a bit with a bar mouthpiece that is designed to combine a curb and snafflebit - piece of metal held in horse's mouth by reins and used to control the horse while riding; "the horse was not accustomed to a bit" , 2001). While some of these new problems donot fully materialize until high school, the path towards these negativeoutcomes frequently begins in middle school. Outcomes are often much worse when an adolescent meets diagnosticcriteria for a comorbid disorder, especially Oppositional DefiantDisorder Oppositional Defiant DisorderDefinitionOppositional defiant disorder (ODD) is defined by the Diagnostic and Statistical Manual of Mental Disorders (ODD) or Conduct Disorder Conduct DisorderDefinitionConduct disorder (CD) is a behavioral and emotional disorder of childhood and adolescence. Children with conduct disorder act inappropriately, infringe on the rights of others, and violate the behavioral expectations of (CD). Between 25% and 75% ofadolescents with ADHD are reported to meet diagnostic criteria for ODDor CD (Fischer, Barkley, Smallish & Fletcher, 2002). Thesecomorbidities increase the difficulty of working with adolescents withADHD; hence, treatments for this subset of the population will need toaddress a wide range of potential impairments. Although comorbidconditions contribute to impairment, many serious problems are directlylinked to ADHD. For example, research suggests that the persistence ofADHD contributes more to peer rejection than a diagnosis of CD (Bagwell,Molina, Pelham, & Hoza, 2001). In addition, severity of inattention in��at��ten��tion?n.Lack of attention, notice, or regard.Noun 1. inattention - lack of attentionbasic cognitive process - cognitive processes involved in obtaining and storing knowledge in childhood ADHD predicts substance use and abuse in adolescence(Molina & Pelham, 2003). Thus, ADHD in and of itself is expected tolead to serious impairments that warrant treatment for adolescents, evenamong those who received intensive multimodal treatments in childhood(Bagwell et al.). Impact on Society Although schools have been required to meet the needs of studentswith ADHD since 1991, there has been very little research on effectiveinterventions for secondary school students to guide this effort. Theneed to do something has rapidly outpaced the knowledge of what to do.Currently, children and adolescents with ADHD constitute the largestportion of students in special education under the category of"Other Health Impaired". Since 1993, adolescents (ages 12 to17) classified as OHI OHI Other Health InsuranceOHI Other Health ImpairedOHI Oral Hygiene IndexOHI oral hygiene instructionOHI Organizational Health Inventory (USA)OHI Oil Heat InstituteOHI Ocala Heart InstituteOHI Obsolete Hardware Interface comprise the special education category and agegroup that has grown more than any other (574%). Elementary school elementary school:see school. agedchildren gaining this classification over the same time period increased204%. These large increases occurred during the same period of time thatthe number of elementary school children classified with specificlearning disabilities and mental retardation mental retardation,below average level of intellectual functioning, usually defined by an IQ of below 70 to 75, combined with limitations in the skills necessary for daily living. decreased. In addition tothe rapidly growing number of students, the costs associated witheducating and caring for these children are quite large. Per pupilspecial education expenditures for each student (above and beyondregular education costs) were $6,510 for the 1999-2000 school year(Chambers, Shkolnik, & Perez, 2003). The majority of these dollarsgo to support a resource specialist and provide special educationclasses (63% of special education expenses) needed to remove a studentfrom the mainstream. These numbers are likely to continue to increasesince reports indicate that only 24% of children and adolescents withADHD receive school services http://commons.wikimedia.org/wiki/Image:Schools_Collection_May_2007_2.JPGSchool Services are a business unit of the National Library of New Zealand (Te Puna Mātauranga o Aotearoa). They provide curriculum and advisory services to support New Zealand schools. (Jensen et al., 1999). Youth with ADHD alsocost the health care system more than twice what it costs to providecare for children without ADHD (Guevara, Lozano, Wickizer, Mell, &Gephart, 2001; Swensen et al., 2003) with average annual costs of $1,465per child. This difference is largely attributable to increased costsassociated with primary care, outpatient mental health, and pharmacy. Inaddition, others have reported that costs associated with youth withADHD escalate as a result of increased use of emergency services emergency servicesEmergency care '…services …necessary to prevent death or serious impairment of health and, because of the danger to life or health, require the use of the most accessible hospital available and equipped to furnish those services' andtreatment of injuries (DiScala, Lescohier, Barthel, & Li, 1998;Szatmari, Offord, & Boyle, 1989). Given the extensive resourcesallocated to care for children and adolescents with ADHD and the lack oftreatment development and research with adolescents (Smith, Waschbusch,Willoughby & Evans, 2000), there is a need to identify effectivetreatments for this population so society's resources may beallocated in an efficient and effective manner. Addressing treatment issues with adolescents is particularlychallenging. Treatment utilization data for adolescents with any type ofclinically significant dysfunction indicate that only 23% of those whocould benefit from mental health care actually receive it (Kataoka,Zhang, & Wells, 2002). One possible explanation for this obstacle tocare is that the treatment that parents desire for their adolescentswith ADHD is not readily available. For example, in a survey of parents,most said that although they preferred psychosocial intervention psychosocial interventionPsychology A nonpharmacologic maneuver intended to alter a Pt's environment or reaction to lessen the impact of a mental disorder. See Attention-deficit-hyperactivity syndrome. tomedication for treating their adolescent's ADHD, they were morelikely to have access to medication than psychosocial psychosocial/psy��cho��so��cial/ (si?ko-so��shul) pertaining to or involving both psychic and social aspects. psy��cho��so��cialadj.Involving aspects of both social and psychological behavior. treatments (Jensenet al., 1999). Also of note are the results of a major randomized ran��dom��ize?tr.v. ran��dom��ized, ran��dom��iz��ing, ran��dom��iz��esTo make random in arrangement, especially in order to control the variables in an experiment. trialin which parent satisfaction ratings were higher when their childrenreceived psychosocial treatment than when they received medication alone(The MTA (1) (Message Transfer Agent or Mail Transfer Agent) The store and forward part of a messaging system. See messaging system.(2) See M Technology Association. 1. (messaging) MTA - Message Transfer Agent. Cooperative Group, 2004). The reasons underlying thispreference for psychosocial over pharmacological treatment are notcompletely understood, but the implication is clear: parents are wary ordissatisfied with medication as the sole option of treatment for theirchildren. One way to potentially increase access to treatment for adolescentswith ADHD is to provide school-based services (e.g., Dishion &Kavanagh, 1999). Studies by Adelman, Barker, and Nelson (1993) and Evans(1999) have reported that youth and their parents experience fewertreatment barriers when choosing school-based services as opposed toclinic-based care. For example, many transportation and fiscal obstaclesexperienced in clinic-based care are removed by a school-based approach.Thus, to the extent that barriers to traditional care account forunder-treatment among youth with ADHD, school-based treatment mayincrease treatment utilization. Preliminary reports have suggested thatschool based services for adolescents with ADHD have the potential to bean effective and accessible treatment modality treatment modalityMedtalk The method used to treat a Pt for a particular condition for these youth (Evans,Axelrod, & Langberg, 2004; Evans, Langberg, Raggi, Allen &Buvinger, 2005). Given the broad range of impairment impacting schools,families, peers, as well as cost to society; there is a grat need todevelop effective and accessible services for adolescents with ADHD. Current Status of the Treatment Research for Adolescents with ADHD Stimulant stimulant,any substance that causes an increase in activity in various parts of the nervous system or directly increases muscle activity. Cerebral, or psychic, stimulants act on the central nervous system and provide a temporary sense of alertness and well-being as Medication Methylphenidate methylphenidate/meth��yl��phen��i��date/ (meth?il-fen��i-dat) a central stimulant, used in the form of the hydrochloride salt in the treatment of attention-deficit in children and narcolepsy. (MPH) is the most commonly researched treatment forADHD. A comprehensive review completed in the mid-1990s found more than127 published research studies on MPH treatment for ADHD (Spencer etal., 1996). Another review found over 8,000 separate source articleslisted in over 300 review articles (Swanson, McBurnett, Christian, &Wigal, 1995). The number of citations on MPH has grown in the past fewyears, with many noteworthy additions from the MTA study (e.g., MTACooperative Group 1999; 2004). However, our search for controlledmedication studies with data specific to adolescents with ADHD uncoveredonly 20 published studies (Evans et al., 2001; Smith et al, 2000;Findling, Short, & Manos, 2001). Overall the state of the literatureon stimulant treatment suggests that (a) stimulants are efficacious ef��fi��ca��cious?adj.Producing or capable of producing a desired effect. See Synonyms at effective.[From Latin effic , butproduce improvement rather than normalization In relational database management, a process that breaks down data into record groups for efficient processing. There are six stages. By the third stage (third normal form), data are identified only by the key field in their record. of functioning, (b) dataspecific to adolescents are often not examined separately, even incontrolled studies that cover a broad age span (e.g., Wilens et al.,2003), and (c) more studies need to be conducted that examine theinteraction between psychosocial interventions and stimulant medication. While studies of stimulant medications demonstrate groupdifferences between treatment and control groups, the data suggest thatthere are many important behaviors for which medication is aninsufficient treatment. For example, Bagwell et al. (2001) reported thathistory of medication usage by adolescents with ADHD was not associatedwith current social functioning social functioning,n the ability of the individual to interact in the normal or usual way in society; can be used as a measure of quality of care. as measured by parent-reported peerrejection or number of close friends. In addition, Meichenbaum, Pelham,Gnagy, Smith, and Bukstein (1999) reported that stimulant medicationappears insufficient for treating the common problem of parent-teenconflict. Findings from MTA studies indicate that psychosocial treatmentin addition to medication optimizes gain on measures of impairment(Conners et al., 2001). In their 24-month outcome study they reportedthat those participants in the medication only condition were takingsignificantly higher dosages of stimulant medication than those in thecombined (medication and psychosocial) group (The MTA Cooperative Group,2004). These data highlight the potential importance of psychosocialtreatment even when participants are receiving medication treatment. Family-Based Interventions Psychosocial intervention with families is frequently recommendedfor adolescents with ADHD (Robin, 1998). Two studies have examined thistype of intervention with adolescents with ADHD (Barkley, Guevremont,Anastopoulos & Fletcher, 1992; Barkley, Edwards, Laneri, Fletcher,& Metevia, 2001). In the first (1992), three types of family-basedtreatments were compared: (a) parent training in behavior management behavior managementPsychology Any nonpharmacologic maneuver–eg contingency reinforcement–that is intended to correct behavioral problems in a child with a mental disorder–eg, ADHD. See Attention-deficit-hyperactivity syndrome. skills, (b) structural family therapy, and (c) behavioral-family systemstreatments. The three treatments performed about equally and producedstatistically significant improvements on a variety of rating scalescompleted by parents and their adolescents with ADHD. However, fewsubjects exhibited clinically significant improvement and the authorsconcluded that more potent treatments are needed than eight to ten1-hour family sessions. Subsequently, Barkley and colleagues (Barkley etal., 2001) reported that increasing the intensity (doubling the numberof sessions to two per week), and combining behavioral parent trainingfollowed by behaviorally-oriented family therapy led to lower rates ofdropout than family therapy alone, as well as significant improvement inparent and teen ratings of conflict. Similar to the findings from thefirst study, only 23% of families showed reliable change, andobservations of family interactions did not reveal changes in adolescentor father use of positive and negative behavior. The authors suggestedthat other treatment modalities may prove more effective than familytreatment for these adolescents. Other family treatments targeting youth with similar problems haveyielded encouraging results (e.g., Dishion & Kavanagh, 2003;Waldron, Slesnick, Brody, Turner, & Peterson, 2001). In particularthe 3-session Family-Check-up (a family treatment within the AdolescentTransitions Program; Dishion & Kavanagh, 2003) is an efficient andpotentially effective technique for reducing substance use andincreasing parental monitoring for teens in the 7th, 8th and 9th grade(Dishion, Nelson et al., 2003). The Family Check-up procedures are basedon motivational interviewing techniques (Miller & Rollnick, 2002)and address issues related to engagement and motivation for change. TheFamily-Check-up is a three-session intervention that includesassessment, feedback, and treatment planning In radiotherapy, Treatment Planning is the process in which a team consisting of radiation oncologists, medical radiation physicists and dosimetrists plan the appropriate external beam radiotherapy treatment technique for a patient with cancer. Typically, medical imaging (i.e. . Engagement and motivationare problems associated with teens with ADHD entering treatment, as theyfrequently deny that they have any problems and believe they do not needany help. Although Family-Check-up alone is unlikely to be a sufficienttreatment for young adolescents with ADHD, it holds promise as componentof a comprehensive psychosocial treatment. Academic Skills Training Another set of promising interventions is academic skills training,which may take the form of organizational skills, study skills, andnote-taking training. In one study, adolescents with ADHD were taught totake structured notes while they listened to a lecture-format Americanhistory class (Evans, Pelham, & Grudberg, 1995). Compared to whenthey simply listened to the lectures, after receiving this training theadolescents showed improved comprehension and on-task behavior, anddemonstrated lower levels of disruptive behavior. The effect size forthe note-taking intervention was in the moderate range. Other academicinterventions target organization skills, study skills, and homeworkmanagement (see descriptions below). Preliminary data existsdemonstrating gains from organizational interventions (Evans, White,& Torre, 2005), but much more research and development in this areais needed. As with family therapy, while academic interventions alonemay not deal with the full range of problems exhibited by adolescentswith ADHD, they are likely to be a useful component in a multi-modaltreatment. Classroom Interventions A third promising treatment for adolescents with ADHD involves theuse of classroom based behavioral interventions. For example, Ervin,DuPaul, Kern, and Friman (1998) completed a functional assessment of thetarget behaviors of two middle school-aged youth with problematic ratesof off-task behavior. Following the assessment, functional hypotheseswere developed and recommendations were offered to the teachers. Theteachers selected the strategies to be used based on practicality andperceived effectiveness. Implementation of these interventions yieldedlarge improvements in the on-task behavior of both boys in the targetedclassrooms. For both boys, the average percentage of on-task intervalsat baseline averaged between 54% and 78% whereas post-treatmentclassroom averages ranged from 88% to 95%. In a separate case study, anintervention to teach self-monitoring skills was effective for a studentreceiving social and tangible reinforcement for on-task behavior(Stewart & McLaughlin, 1992). Behavioral interventions ranging fromresponse cost, time outs, daily report cards, and methods foradministering verbal praise and reprimands are described in theliterature (e.g., DuPaul & Stoner ston��er?n.1. One that stones.2. Slanga. One who is habitually intoxicated by alcohol or drugs.b. One who is a delinquent or failure. , 2003) and additional work on thevalue of these interventions in middle and high school settings issorely needed. Modifications are likely to be needed due todevelopmental changes associated with adolescence and dramatic changesin context as youth move from elementary school to secondary school. Theaforementioned case studies can provide useful guidance for making theseadjustments. Treatment Development Process During the past six years we have been developing and evaluatingschool-based psychosocial and educational interventions for youngadolescents with ADHD. The process for developing empirically supportedtreatments has received a great deal of attention recently with twotreatment development models proposed. Weisz and colleagues haveproposed the Deployment Focused Model (Weisz, Jensen, & McLeod,2005) and a series of NIDA NIDA National Institute on Drug AbuseNIDA National Institute of Dramatic Arts (Australia)NIDA Northern Ireland Development Agency (UK)NIDA Northern Ireland Dairy Association workshops produced a Stage Model(Rounsaville, Carroll, & Onken, 2001). The major advantage of thesetwo models is that they incorporate "real-world" factors (e.g.no-shows, parent pathology, etc.) into the development and evaluationprocess earlier than other methods. Similarly, guidelines for thedevelopment of treatment manuals have been described by Hibbs et al.(1997) and a detailed stage model of manual development was presented byCarroll and Nuro (2002). These authors describe many important aspectsof manual development including the competencies of the clinicians,training, rationale, troubleshooting, definition of target population,and differences between the treatment in the manual and othertreatments. Our development of school-based treatments has been guidedby these models with modifications for the school context instead of thetraditional clinic-based services. Development and Evaluation of the Challenging Horizons Program The Challenging Horizons Program (CHP) was developed as anafter-school treatment program for middle school students with ADHD. TheCHP started as an after-school program at least partly due to ahesitation to interrupt the school day on the part of the schooladministrators who agreed to support this project. Working with theprincipal and staff of Montevideo Middle School in the Rockingham CountySchools in Virginia in the fall of 1999, a small treatment manual wasdeveloped along with procedures for involving middle school students.The treatment procedures were designed to target social and academicimpairment associated with middle school aged children with ADHD. Theinterventions were based on interventions used in the adolescent versionof the Summer Treatment Program (Evans & Pelham, 1991) and theBridges for Education Program (school based treatment program developedby first author at Western Psychiatric Institute and Clinic) in additionto the few articles on intervention for middle school youth with ADHDthat were available at that time (Ervin et al., 1998; Evans, Pelham,& Grudberg, 1995; Shapiro, DuPaul, Bradley, & Bailey, 1999;Stewart & McLaughlin, 1992). During the first year of the programseven children participated and most of them demonstrated moderate gainsin both academic and social functioning (Evans et al., 2004). The CHP operated two hours after school three days per week. It wasstaffed by several undergraduate counselors and graduate students. Eachcounselor worked individually with one student to individualize in��di��vid��u��al��ize?tr.v. in��di��vid��u��al��ized, in��di��vid��u��al��iz��ing, in��di��vid��u��al��iz��es1. To give individuality to.2. To consider or treat individually; particularize.3. ,implement, and monitor a set of interventions in the treatment manual.In addition students participated in two group interventions (socialskills & education skills). Students spent at least 20 minutes eachday one-on-one with the counselor to review progress, practice specificskills, and maintain an individual therapeutic relationship andconnection to the program. Counselors were also responsible forcoordinating contact with the students' teachers and parents toidentify specific areas for improvement and facilitate generalization ofgains to other settings. CHP -- Academic Interventions The academic impairment associated with middle-school students withADHD is characterized by disorganization disorganization/dis��or��gan��iza��tion/ (-or?gan-i-za��shun) the process of destruction of any organic tissue; any profound change in the tissues of an organ or structure which causes the loss of most or all of its proper characters. , failure to complete tasks, andpoor writing and study skills. One of the core academic interventions inthe CHP targeted organization. Program staff helped students establish asystem to organize and maintain their binders, bookbags, and lockers.The system included frequent monitoring and behavioral contingencies tohelp students advance towards independently maintaining theorganizational system. A list of criteria for determining appropriateorganization for bookbags, lockers, and notebooks was used each day ofthe program to evaluate these three main storage units for students.Counselors taught the students how to check their own materials againstthe organization criteria and correct inconsistencies. The CHP met threetimes per week and improvement frequently took many weeks. Sample datafrom three participants are displayed in Figure 1. These data reveal theneed for patience and persistence with these interventions with middleschool youth. There are organization scores after three weeks of theintervention that are nearly equivalent to the scores at the beginning.Nevertheless, the trend is towards improvement and after two months thestudents were achieving organization scores near a mastery level. Whenimplementing interventions with this population, it is important toremember to persist past the low points that characterize the greatvariability in the behavior of youth with ADHD. All students in the CHP were also required to use an assignmentnotebook provided by the school. Students were required to recordhomework assignments for each class, or write "none" ifhomework was not assigned. Teacher signatures in the assignment notebookwere required in the early phases of this intervention to insureaccurate recording. If a participant in the CHP came to the programafter school without assignments correctly recorded in the notebook, thestudent's counselor took them to find the teacher of the class withthe missing assignments while the rest of the students in the programenjoyed casual conversation and snacks as the opening activity. Therequirement for teachers' signatures was tapered as studentsprogressed towards independent mastery of this skill. Figure 2 showsdata from three sample students receiving this assignment notebookintervention. As can be seen from these data, the value of persistenceand patience is evident with this intervention as it was with theorganization intervention. Early setbacks can sometimes lead people todiscontinue interventions that may eventually prove to be very effectivewith these children. Other interventions that assisted with academic problems wereprovided during education group and targeted note taking and studyskills. During education group, students were taught how to make and useflash cards, acronyms, and other tools for studying. Students learnedmethods for taking notes from classroom presentations and text (Evans,Dowling & Brown, in press), how to prepare written summaries oftext, and how to create and use outlines to help them write coherentpapers. After demonstrating mastery within the CHP, students wererequired to show their counselor examples of having used the studyskills and notes at home and in their classes. Complete mastery of askill was not achieved until competency was demonstrated within the CHP,at home and in their classrooms. CHP -- Disruptive Behavior Interventions The CHP also included interventions to target disruptive, defiant,and annoying behaviors frequently displayed by young adolescents withADHD. When a student exhibited a targeted behavior defined in thetreatment manual, a counselor announced the behavior aloud to the childand recorded it on a behavior-tracking card. These behaviors includedboth positive behaviors, such as contributing and complimenting, andnegative behaviors such as teasing, complaining, blurting, and repeatednon-compliance. The system of behavior calls was a modified version ofthe point system used in the Summer Treatment Program (Pelham, Fabiano,Gnagy, Greiner, & Hoza, 2005). The calls served as prompts as wellas praises or reprimands. Many behaviors were successfully modifiedwithout explicit contingencies beyond the consistent use of behaviorcalls. When the rate or intensity of a behavior needed to be modifiedand was not sufficiently responding to the behavior calls,individualized contingencies were applied. Following successful behaviorchange Behavior change refers to any transformation or modification of human behavior. Such changes can occur intentionally, through behavior modification, without intention, or change rapidly in situations of mental illness. at the CHP, interventions shifted focus to modifying thesebehaviors in other settings. One frequently used technique to achievethis generalization involved the use of daily or weekly report cards(DuPaul & Stoner, 2003; Evans, Vallano, & Pelham, 1995). Parentsor teachers would rate the target behavior on a daily or weekly basisand contingencies for desirable ratings were implemented in the CHPand/or at home. [FIGURE 1 OMITTED] [FIGURE 2 OMITTED] CHP -- Social Functioning Interventions To address problems with social impairment, students alsoparticipated in an Interpersonal Skills "Interpersonal skills" refers to mental and communicative algorithms applied during social communications and interactions in order to reach certain effects or results. The term "interpersonal skills" is used often in business contexts to refer to the measure of a person's ability Group (ISG ISG Iraq Study GroupISG Iraq Survey GroupISG International Steel GroupISG Integrated Security GatewayISG Information Systems GroupISG Information Systems Group (IBM)ISG Integrated Starter/Generator ), which providedinterventions targeting the types of social impairment frequentlyassociated with youth with ADHD. ISG had three major components: socialproblem solving problem solvingProcess involved in finding a solution to a problem. Many animals routinely solve problems of locomotion, food finding, and shelter through trial and error. , social cues, and skill development. The problem-solvingcomponent involved teaching students to systematically think through andsolve problems using steps similar to other problem-solvinginterventions. Social cues were taught using critiques of videotapedclips of student behavior during the CHP. Segments containing targetbehaviors were played back during group sessions and students identifiedthese behaviors and the subtle social contingencies related to thebehavior. For example, when viewing a segment demonstrating teasing,students discussed the changed impressions of others viewing the teasingand the potential implications for future interactions between theperson who teased and those who observed it. These peer reactions weredescribed as forms of social reinforcement or social punishment. Thevideo segments were selected to demonstrate positive and negativeexamples of core social skills such as good sportsmanship, acceptingconsequences, and recognizing and dealing with feelings (Pfiffner,Calzada, & McBurnett, 2000). The final portion of ISG involved skillbuilding and provided students with instruction and practice withspecific social skills. These included conversation skills, facialcommunication A person's face, especially their eyes, creates the most obvious and immediate cues that lead to the formation of impressions. This article discusses eyes and facial expressions and the effect they have on interpersonal communication. , assertive responding, and ignoring provocation anddistraction. Students worked in small groups or pairs to learn andpractice the targeted skills. The CHP also included a 30-minute recreation time that targetedgeneralization of interpersonal skills and the development of sportsskills. Adolescents spent time playing sports such as soccer,basketball, and football and counselors modeled, prompted, and rewardedappropriate social interactions. These activities challenged theadolescents' social skills because it is much more difficult toimplement an appropriate social behavior In biology, psychology and sociology social behavior is behavior directed towards, or taking place between, members of the same species. Behavior such as predation which involves members of different species is not social. in the "heat of agame," when one may perceive that a child has fouled him/her, thanit is to describe an appropriate response in an ISG session. It alsoprovided a context to practice positive skills such as complimenting andteamwork. In addition, students were provided instruction and practiceon the sports skills associated with each game as many of them haddiscontinued playing sports at a young age and lacked prerequisiteskills and knowledge of game rules. This lack of knowledge served as abarrier to playing recreational sports in their neighborhoods and duringphysical education classes, which in turn reduced social opportunitiesand increased social awkwardness. The goal for this portion of the CHPwas to help them become sufficiently skilled to play and enjoy the gamesin recreational and social situations. In addition to the direct instruction, practice, and counselingthat took place in the CHP, the counselors and supervisors also workedclosely with participants' parents and teachers. Initialcommunication with these adults helped shape the treatment priorities,and subsequent interactions focused on monitoring progress, identifyingobstacles to improvement, and focusing on generalization (Evans,Langberg, & Williams, 2003). Counselors attended meetings at theschool and met with parents to achieve these goals. In addition, monthlyparent meetings took place at the school after the program. Dinner wasprovided and child care was available for the students in the CHP aswell as for their siblings. These meetings were used to presentpsychoeducational information about ADHD including treatment andimpairment in the adolescent years, advice for facilitatinggeneralization of the techniques taught in the CHP, and support forparents struggling with the stress of raising a teenager with ADHD.Brief interactions with parents when they picked their child up fromschool helped facilitate the continuity of these efforts whileindividual meetings and phone calls were used to make changes oradditions to the treatment plans. Similar communication strategies wereused with teachers and school counselors. CHP -- Integrated and After-School Model Continued measurement of outcomes indicated moderate to largeeffect sizes and led to revisions in some of the interventions used inthe CHP (Evans, Langberg, Raggi, Allen, & Buvinger, 2005). Althoughthe outcome data were encouraging, the labor intensive Labor IntensiveA process or industry that requires large amounts of human effort to produce goods.Notes:A good example is the hospitality industry (hotels, restaurants, etc), they are considered to be very people-oriented.See also: Capital Intensive, Trading Dollars nature of theprogram led to concerns about the potential for future dissemination. Itbecame evident that many of the interventions emerging as central to theCHP were activities that some combination of regular education teachers,special education teachers, and school counselors could potentiallyprovide to students during the school day. In order to evaluate thefeasibility of developing a model of CHP that could be integrated intothe school day, we recruited a group of middle school teachers, parentsof middle school aged children with ADHD, mental health providers, andphysicians to work with us to evaluate and create a model of the CHPthat was integrated into the school day (Evans, Green, & Serpell,2005). The resulting manual and training procedures were implemented intwo middle schools for three years. A school psychologist trained andexperienced in the CHP procedures worked closely with the faculty in thetwo schools to support their efforts to use these techniques. Heconducted training prior to the beginning of each school year andprovided consultation and support two to three times per week at each ofthe schools. The degree of overlap between the integrated and after schoolmodels of the CHP is vast; however, some key differences exist. In theintegrated model, the role of the counselor has been changed to that ofa mentor, who is often one of the child's teachers. In addition,the behavior rating scales completed every month by each child'sfour core class teachers (math, English, social studies and science) inthe integrated model were used to check whether a child has met specificcriteria referred to as a "trigger." This "trigger"system provided constant monitoring for children, as a trigger indicatedthat the child may benefit from additional treatment. If the child met atrigger, the parent was called and asked if they wished to add/modifypsychosocial interventions that were being implemented at school orbegin the medication component of the program. If the parent opted forthe medication component, the process was coordinated with thechild's physician and teachers. The physician prescribed amedication, while the teachers completed behavior ratings for each ofthe four weeks that the child was on the medication trial to provide thephysician and parent data to guide a subsequent prescribing decision. Ifthe parent opted to add/modify psychosocial interventions the researchstaff school psychologist was informed and communicated with thechild's mentor and teachers to help determine the most appropriatecourse of action given the child's problems. Although the data on the integrated model of the CHP is still beingcollected and analyzed, experience indicates that there are some CHPinterventions that many teachers adopted and effectively implementedwith identified students. Other CHP interventions were rarely if everimplemented, suggesting they may not be practical for an integratedmodel of the program. There were also large differences betweenteachers' use of interventions independent of characteristics ofthe students. For example, the quantity and quality of interventionsprovided to participants varied as a function of student needs, but alsoas a function of teacher motivation, beliefs about their role in helpingstudents, and their willingness to make an effort for a particularstudent. The data resulting from this trial will be used to shape futuredesigns of the CHP as well as guide training strategies and methods forassessing treatment adherence and outcomes. Future Directions Combining the CHP with family services and psychopharmacological psy��cho��phar��ma��col��o��gy?n.The branch of pharmacology that deals with the study of the actions, effects, and development of psychoactive drugs.psy treatment may allow for the comprehensive, coordinated, and multimodaltreatment frequently recommended for youth with ADHD. Clinic-basedfamily treatment may be an effective adjunct to the CHP treatment model.We are currently evaluating the combination of the CHP after-schoolmodel with the Family Check-Up (Dishion & Kavanaugh, 2003) and otherfamily treatments. We are also experimenting with the use of manualizedmedication algorithms that are integrated into the school-day model ofthe CHP using a web based Coming from a Web server. See Web application. care coordination system. This system isdesigned to facilitate communication among physicians, educators, andclinicians and thereby improve efforts to coordinate care. The systemincludes a series of web pages assigned to each participant thatincludes a list of current and previously provided medication andpsychosocial treatments. Monthly ratings (that can be submitted onlineor paper and pencil) from teachers and parents are posted along withgrades, class schedule, and diagnostic information. Progress andassociated outcome data are also presented in graphs and tables. Thechild's parents, physician, and teachers have access to this site. The extension of the CHP to include family treatment and medicationservices are very important and help the CHP progress towards acomprehensive system of care for these young adolescents. Our clinicalexperience with the CHP suggests that the most efficient and effectivemodel of the CHP may be a combination of the after-school model and theintegrated model. In this combined model of the CHP, teachers may betrained and supported in their use of some of the interventions mostpractical for them to provide. Other treatment components of the CHPsuch as the ISG and some of the academic interventions may be offered inan after-school program. This dovetailing of after-school and integratedmodels will allow for a flexible application of the program to schoolsthat may be more or less equipped to provide integrated services In computer networking, IntServ or integrated services is an architecture that specifies the elements to guarantee quality of service (QoS) on networks. IntServ can for example be used to allow video and sound to reach the receiver without interruption. .Coupled with the medication and family treatment, the CHP may provide avariety of treatment options as well as the option of an intensivecomprehensive multimodal treatment integrated into the environment whereyoung adolescents with ADHD exhibit some of their greatest impairment. References Adelman, H.S., Barker, L.A., & Nelson, P. (1993). A study of aschool-based clinic: Who uses it and who doesn't? 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This work was supported by grants to the first author from theMosier Fellowship, Virginia Tobacco Settlement Foundation, NIMH (R34MH073968), and the Alvin V. Baird Attention and Learning DisabilitiesCenter. The authors wish to thank all of the parents and professionalswho helped with this line of development and research.