ADHD Behavior Management, Children with ADHD, Behavioral Consultant McLean, VA, Behavior Management, Tufts Medical Center, Karen J. Miller, Mental Health Care, Resource Toolkit, Developmental-Behavioral Pediatrics, Sharon K. Weiss, Floating Hospital for Children, Children with Special Needs, Commercial Products Commercial products, private practice, Medical Practices, Pediatrics Center, 2nd Edition, Sharon K. Weiss Financial disclosure, Behavioral consultant, Elk Grove Village, Community School System Social Network, Vanderbilt scales School, Realistic expectations, mental health professionals, ADHD child, Understanding ADHD, ADHD, American Academy of Pediatrics, ADHD Behavior Management AAP Resources, Effective Discipline for Children, ADHD Behavior, Guilford Press, Family-Focused Pediatrics, Child Management, Caring for Children with ADHD
Miller/Weiss ADHD Behavior Management 1
Behavior Management: Coaching Parents in medical practice
Karen J. Miller, MD, FAAP Developmental-Behavioral Pediatrics Center for Children with Special Needs The Floating Hospital for Children Tufts Medical Center, Boston [email protected]
Sharon K. Weiss, M.Ed. Behavioral Consultant McLean, VA [email protected][email protected]
Karen J. Miller No conflicts of interest commercial products
Commercial products will be discussed; options offered Medications-Off-label medications will not discussed Gratitude-On the shoulders of giants-Other people's ideas may be mentioned but I don't know who said them first;
Sharon K. Weiss Financial disclosure Author of books on behavior Commercial Products Commercial products will be discussed; options offered Medications: N/A
Why we are here - Karen's story
Child development/DBP fellowship primary care
practice DBP private practice DBP academic practice Work with primary care docs on ADHD, behavior and DBP issues Clinical Professor of Pediatrics Center for Children with Special Needs, The Floating Hospital for Children, Tufts Medical Center, Boston, MA
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Why we are here - Sharon's story S
Behavioral consultant in private practice in McLean, VA Work with families Work with individuals Work with schools Work with physicians Work with CHADD, National organization supporting scientific approach to ADHD for parents, adults and professionals;
What it is like having ADHD by Mitch (17)
Why YOU are here - YOUR story
11% to 20% of children in the United States have a behavioral or emotional disorder at any given time Percentage of children with an ADHD diagnosis continues to increase (CDC) 7.8% in 2003 9.5% in 2007 11.0% in 2011 <50% receiving behavioral treatments Realities of practice
Mitch - Maby we could try medication for a little while K
After attending this session participants will be able to:
Assess your "practice readiness" strategies to address behavioral health needs of children with ADHD in your community provide "bumper sticker" behavioral recommendations for common behavior issues associated with ADHD but work for everyone Collaborate with mental health
professionals to improve behavioral health in primary care settings
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Overview of the session
Basic principles and examples ADHD as prototype KJM-Pediatrician's response SKW-Behavior therapist consult Q&A Resources in handout Additional case vignettes in breakout Different ages Different co-morbidities
Audience Participation Questions "What I do" cards- "what I find useful in my office is..." Your email so you can receive follow-up email survey
-what did you try and how did it work? When survey is completed you can see what others suggested and some additional resources Project email: [email protected]
Who are YOU? Behavioral expectation Raise hand when your group is called Or don't if you don't want to S
SK Member of a family? General pediatrician family practice
Pediatric sub-specialist Mental health professionals
Nurses, NP, Phys. Assistant Other professionals Collaborative care setting Parents K
Behavior Bumper Stickers
o Compact Key Concepts - short and sticky o Use with parents, kids, trainees and yourself o 3x5 cards or paper notes o Sticky notes to remind yourself K
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Practice makes better AUTOMATIC S
Take out 3x5 cards Write:
Demonstrated: Bumper Sticker Demonstrated: Positive Practice
Sharon K. Weiss
"You don't practice batting in the ball game" K
Philip's 6 year old well-child visit
Routine visit until... You ask about school Litany of complaints You ask about home Litany of complaints Now what?
Where do you start?
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Primary Care Preparedness
Office Work Flow Routine behavioral screening Scheduling options ADHD rating scales School packets ADHD champion Local Resource list
Resources Weitzman C, Wegner L- article on behavioral/emotional screening AAP Mental Health Toolkit AAP ADHD Toolkit, 2nd Edition New screening tool - Survey of Well Being of young children
www.theSWYC.org Strengths and Difficulties Questionnaire www.sdqinfo.com; Multiple languages S
Build a Team - Collaborating with
· Collaboration with mental health professionals · In your community · In your office (co-location) · Know your community · Cultures and languages · Outreach to local schools · Private specialists Resource lists save time
Community Resource List Array of professionals Psychiatrists Psychologists Social Worker
Mental health counselors Educational specialists Behavioral consultant Advocates
Phillip - Second visit - Now what? K Diagnosis ADHD "simplex" Meets DSM 5 criteria Performance impaired 2+ settings No significant comorbidities Importance of beginning of the journey Developmental disability perspective K
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ADHD - Framing the Treatment Plan
BEAM Framework Behavior Emotional Academic Medical / Medication
Resources for parents AAP's Healthychildren.org AAP ADHD toolkit handout AACAP ADHD resource center www.Help4ADHD.org
S Understanding ADHD - behavioral perspective DSM checklist understanding ADHD BEHAVIORAL PERSPECTIVE OF ADHD: 1. An inability to organize time and space 2. A disorder of performance, not skill - an inability to do what you know (Barkley) 3. An inability to delay responding 4. Driven by what's on their radar at the moment S
· Parenting that is responsive and planful, not reactive or punitive · Children with ADHD benefit from structure and predictability, who wouldn't? If you treat a non-ADHD child as if he has ADHD, it can only be beneficial. If you treat an ADHD child as if he is not, it can be a disaster. Sharon K. Weiss K
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Office ADHD Behavior Basics
Help parents learn about ADHD Recognize ADHD is highly familial Key principle: Warm and Firm Warm: Increase positive connections o Time-in before Time-out Firm: Positive and clear structures
Resources for parents AAP ADHD toolkit or booklet Refer to reliable websites o www.HealthyChildren.org o www.CHADD.org o www.Understood.org
Unhelpful Parent Directives "Behave" "Be careful" "Don't _____"
Positive Procedure: Giving Directions K 1. Get on their radar 2. Use child's name PAUSE 3. EMPATHY e.g. "I understand it may be hard to stop what you are doing" 4. State simply and clearly what you want them TO DO INSTEAD of what they are doing (If it is not a choice, don't phrase as a question) 5. Check for understanding 6. Reinforce movement in the right direction K
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Model positive directives and clear choices
Don't you want to clean up your toys now? Do you want to see how much you weigh? Can I look in your ear?
Toys in the backpack. Take off your shoes. On the scale please. Time to look at your ears. Which one first?
Improving: a step in the right direction S
Narrow the focus TARGET outcome Progress is made in steps
What skills does child have NOW?
What might be next step towards improvement?
How can we set CHILD up to GET IT RIGHT?
How can we set it up so PARENT notices?
Behavior Map: 3 steps in the right
1. What do you want the child TO DO INSTEAD of what she's doing. 2. How can I make it VISUAL? 3. How can I REINFORCE the behavior I want?
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VISUAL reminders -- other than your face Tools depersonalize the expectations, specify guidelines and clarify limits so you don't have to. Timers + Checklists + Schedules = Predictability = Fewer Meltdowns
S TimerTimer S
VISUALS to consider
Timers Clocks on walls Sticky notes Checklists Schedules Calendars Before/After pictures Baskets by the door Red paper stop signs Phone alerts (child's or parent's)
Reinforcing Better Behaviors
What will make it worth his while? ADHD brains require more More social reinforcement (praise) More external reinforcers (rewards)
Cognitive Test Composite z-score
Fosco et al, Greater
reinforcement effects among
children with ADHD
(2015) Behavioral and Brain
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S Keeping it up--Make it into a ROUTINE
What are your expectations? Morning, Evenings, Mealtime Positively framed Collaborate with child Post it Practice it Praise progress
Write down what is essential What can be done ahead of time?
The power of modeling
Become a LISTmaking family K
Carmen - age 6 - problem-focused visit K Parent requested consult for "bad behavior" Staff had sent packets before appointment History Always been a "difficult child" Active, impulsive, loud, easily bored Happy when things are going her way "drama queen", "demanding" "sassy" "Taken everything away and still does it" Older sister had "no problems" K
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Carmen - review of packet data
Review of parent and school packet; Vanderbilt scales School - average skills but variable report cards School - reporting issues with compliance and selfcontrol; Conclusion: ADHD, combined, "oppositional" behaviors impacting multiple domains
Vanderbilt Mother Father ADHD
Inattention: 7/9 *
Directions Directions, Problems
K Behavior Counseling what can I say?
What to say to the PARENT Empathy: "That sounds very tough" MAGIC WORDS
"What I hear you saying is..."
What do I do when she says she hates
Don't argue or reassure; validate feeling
Matter of fact or sad tone
Repeat brief "stock phrases"
Try "Thanks for letting me know how you
are feeling right now" Try "How sad"
ASK: How do people in YOUR family handle behavior like that?
Shift focus to system-based view
Biopsychosocial perspective Family-focus (Coleman, 2011) Triple P programs Community, provider, primary care, parent www.triplep.net To change behavior, change the system
Community School System Social Network Parents Siblings CHILD
Miller/Weiss ADHD Behavior Management 12Focus on the Family
Who are we as a family? What is important to us? "In our family, we treat each other with respect". "In our family, we are problem-solvers". Useful when talking with fragmented families
Okay we have a vision, NOW what?
S Notice the pattern of behaviors Don't take behavior personally Don't assume negative motive Observe for patterns What happens JUST BEFORE? What EXACTLY do they DO? What happens NEXT? ALSO When do we get it RIGHT? Have expectations * ADHD is not excuse for bad behavior S
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ABC chart- the pattern of behaviors S
Date/ time Before (Antecedent)
What happened Afterwards
Sunday, 6 pm
Told him to do homework
Screaming hateful words
Took away X-Box for 2 days
Wed, 4 pm
Reminded to check his list
Did spelling with Had time for extra book only one prompt at bedtime
Punishment and Consequences Problem with punishment Doesn't teach a better behavior Just interrupts (may be good thing) May be preferred to task demanded Consequences to consider Problem with natural consequences in ADHD Logical consequences link the action/effect "When-Then" Alternatives to time-outs o Positive Practice - Over-correction
Realistic expectations is that negative behavior occurs: Less often Lower intensity Shorter duration
Progress is Success K
Miller/Weiss ADHD Behavior Management 14 K What if she has a meltdown?
The Frustration Continuum - Fuss
The Fuss · Upset/angry · Not always goaloriented; cranky · Still has language · Limited perspective · Lost higher order prefrontal skills
Management: · Empathy · Calm voice · Real choices · Silly choices K
The Frustration Continuum Tantrum K
The Tantrum · Upset/angry · Goal-oriented · Has some control · Often without tears · "Verbal debris" language · Goal-focus but lost higher order reasoning and higher language skills · Ends quickly
Management: · Empathy · Don't argue or try to reason · Don't discuss choices · Change scene if you can K
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The Frustration Continuum - Meltdown K
The Meltdown · Overwhelmed with distress · Minimal language · Loss of control · Often with tears · Lost reasoning and language skills · Primitive, can be rageful · Longer and slower recovery
Management · Low voice · Slow movements · May need space · Safety is the priority · Defer "teaching" S
Manage upsets before they happen S Upsets happen Notice the pattern What signals/situations precede Manage their expectations Teach to taking a break What "secret signal" can use? If they've "lost it"--Stop talking S
Managing Power Struggles
Power Struggles-If you think you are in one, you are Make the child part of the solution Discussion-in advance and LISTEN HARD Choices and collaboration Agree to disagree Model staying calm and taking a break DISENGAGE Let them be upset if they need to be Stick with game plan for two weeks
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Carmen - Relationships Repair
Celebrate small victories Schedule connections -- short SPECIAL TIME 10 minutes with timer Involve her in planning Family FUN Guide thinking about other family members
' preferences Gossip to others about her kindness and cooperativeness
K So what can you try in your office next week?
Which Bumper Sticker will you try? K
Start with empathy, finish with hope Begin with the end (Long-term vision) Warm and firm What TO DO INSTEAD Real choices ROUTINES-Set `em up to get it right Practice behavior BEFORE you need it OVER-Practice the BETTER behavior VISUALS-Prompts at the Point of Performance
Don't take behavior personally People can't listen until they feel heard What I hear you saying is... Don't talk to brainstems Teams work together Progress is Success What is our next GAME PLAN?
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Practice Changes to consider
Meet with office team to update "practice readiness" strategies to meet behavioral health needs of children with ADHD Look up community mental health providers and local parent support group to start building your resource list Model starting with empathy statement, giving a clear direction and nurturing a "sprout" of the better behavior.
Questions and comments
Useful Websites about ADHD for Parents CHADD (Children and Adults with Attention Deficit Disorders. http://chadd.org . Scientifically based information for parents and adults, parent support and resource for professionals. magazine published quarterly. National conference, local chapters and web-based training "Parent to Parent: Family Training on ADHD"; (English and Spanish) www.help4adhd.org The National Resource Center
on AD/HD (NRC); clearinghouse for the latest evidence-based information on ADHD; funded by the Centers for Disease Control
and Prevention (CDC), National Center on Birth Defects and Developmental Disabilities www.cdc.gov/parents/essentials/Free online resource developed by the Centers for Disease Control and Prevention (CDC). Guidance for Parenting Toddlers
and preschoolers. Include video clips. www.UNDERSTOOD.org - new website combined effort of 15 non-profits. information on learning, attention, executive function and special education
issues. Very user-friendly; in English and Spanish and will read text to you;
Miller/Weiss ADHD Behavior Management 18 AAP Electronic resources · Healthychildren.org AAP website and mobile app has good basic resources on ADHD and behavior management. English and Spanish · DBPeds.org (www2.aap.org/sections/dbpeds/) AAP Section on Developmental and Behavioral Pediatrics; handouts to download · www.medicalhomeinfo.org information on collaboration between professionals including mental health · ADHDtracker 1.0 - free app enables completing and submitting a behavioral assessment using the Vanderbilt Scales; published by the American Academy of Pediatrics
Interested in ADHD? Organizations to join AAP Section on Developmental and Behavioral Pediatrics (SODBP) DBPeds.org (www2.aap.org/sections/dbpeds/); also affiliate memberships for non-AAP members such as nurses. www.sdbp.org Society for Developmental and Behavioral Pediatrics; for pediatricians and other professionals (e.g. psychologists) CHADD (Children and Adults with Attention Deficit Disorders. http://chadd.org; professional membership available; National conference presents cutting edge research American Academy of Child and Adolescent Psychiatry (AACAP)affiliate membership www.aacap.org/aacap/Member_Resources/Membership_Informati on/ Available to physicians who have not completed child and adolescent psychiatry training but are making contributions to the field of child and adolescent psychiatry. Behavioral Resources · Triple P Positive Parenting Program - evidence-based parenting programs; programs at community, provider, primary care and parent level; global as well as USA; www.triplep.net · American Academy of Child and Adolescent Psychiatry ADHD Resource Center www.aacap.org/aacap/Families_and_Youth/Resource_Centers/ADHD _Resource_Center · locator.apa.org-Psychologist Locator, a service of the American Psychological Association
Practice Organization. find practicing psychologists in your area. · www.findcbt.org- Association for Cognitive and behavioral therapies
· www.addwarehouse.com; ADDWarehouse has wide variety of materials relating to ADD for parents and professionals. · www.addrc.org/ ADD Resource Center website. Information for and about people with ADHD and the people who live or work with them.
Miller/Weiss ADHD Behavior Management AAP Resources · Caring for Children with ADHD: A Resource Toolkit for Clinicians, 2nd edition (2011) American Academy of Pediatrics · Addressing Mental Health Concerns in Primary Care: A Clinician's Toolkit; (2010) American Academy of Pediatrics; · ADHD: What every parent needs to know (2011) Edited by Reiff MI, Elk Grove Village, Ill: American Academy of Pediatrics · Coleman, WL; Family-Focused Pediatrics: Interviewing Techniques and Other Strategies to Help Families Resolve Their Interactive and Emotional Problems; A clinical and teaching manual for all pediatric care professionals; American Academy of Pediatrics; 2nd Edition (June 15, 2011) · Connected Kids: Safe, Strong, Secure series (2004) for 0-21 years; behavior brochures series · Other AAP brochures on behavior, mental health and discipline (e.g. tantrums) Books · ADHD: What every parent needs to know (2011) Edited by Reiff MI, Elk Grove Village, Ill: American Academy of Pediatrics · 1-2-3 Magic: Effective Discipline for Children 2-12, Fifth Edition (2014). Phelan TW; Child Management; (English and Spanish) http://www.123magic.com/ also YouTube clips to watch · Taking Charge of ADHD: The Complete, Authoritative Guide for Parents, Third Edition (2013) Barkley RA; Guilford Press www.guilford.com · Angry Children, Worried Parents: Seven Steps to Help Families Manage Anger (Seven Steps Family Guides) Goldstein S, Brooks R, Weiss S (2004) Specialty Press. · From Chaos to Calm: Effective Parenting of Challenging Children with ADHD and Other Behavioral Problems. Heininger JE, Weiss SK (2001) Perigee Press · Prescriptions for Parenting, Meeks, CA; 1990, Time Warner. Out of print but used copies available on Amazon. By a pediatrician, concise advice to write on prescription pad. References · AAP Subcommittee on ADHD. ADHD: clinical practice guideline
for the diagnosis, evaluation, and treatment of ADHD in children and adolescents. Pediatrics. 2011;128(5):1007-1022. · AAP, Committee on Psychosocial Aspects of Child and Family Health. Guidelines for effective discipline. Pediatrics.1998;101(4 pt 1):723728 [being updated] · Foy, J et al. Enhancing Pediatric Mental health care
: Strategies for Preparing a Primary Care Practice. Pediatrics. 2010;125:S87-S108. · Williford AP, Shelton TL; Management for preschool-aged children; Child and Adolescent Psychiatric Clinics of North America
, 2014; 23:717-730 · Pfiffner LJ, Lauren M. Haack LM; Behavior management for schoolaged children with ADHD; Child and Adolescent Psychiatric Clinics of North America. 2014;23:1-746
Miller/Weiss ADHD Behavior Management 20 Want additional resources? · email: [email protected]
(project's email) · Complete short survey · Indicate whether attended session or reviewed handout · Provide feedback · Provide outcome · Did you try any of the suggestions? · Receive list of suggestions from other pediatric providers · Receive additional resources such as · Behavior chart templates · Helping parents cope with media and technology · Other resources