Case Illustration

How To Conquer Add / Adhd

Improve Listening Skills in ADHD Children

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To describe the elements of behavioral consultation, we will consider the hypothetical, somewhat ideal case of "Jimmy." Jimmy is a third grade student. His teacher, Ms. Thompson, has reported that Jimmy often "acts out" in class and that his behavior is disruptive to other students. Jimmy often spends so much time acting out that he completes very little of his work. She believes that Jimmy has attention deficit hyperactivity disorder (ADHD), and has asked the school psychologist what can be done about Jimmy's behavior.

To successfully initiate the consulting relationship, it is important for the school psychologist to begin by listening to Ms. Thompson's concerns about Jimmy. One of the first steps that the psychologist needs to take after hearing Ms. Thompson's account of the situation is to discuss the nature of the consultative process, the stages of consultation, and the roles and responsibilities of each participant at each stage. Ms. Thompson appears to believe that the psychologist will either work directly with Jimmy to "cure" his disorder or will provide her with a "quick fix" solution that will promptly eliminate the behavior problem. Such beliefs can be common among consultees who have not participated in the consultation process before and do not understand the indirect nature of service delivery. The consultant must make clear that he and Ms. Thompson will collaborate on developing a treatment to improve Jimmy's behavior, which Ms. Thompson will implement in the classroom. Contrary to traditional, direct service models, that consultant probably will not conduct individual therapy with Jimmy, nor will he simply give a one-step solution to Ms. Thompson. The consultant needs to describe the stages of the consultation process (e.g., problem identification, problem analysis, plan implementation, and plan evaluation) so that Ms. Thompson is aware that she and the consultant will work together, and that a certain amount of time and effort will be required before Jimmy's behavior can be effectively treated. The consultant also needs to emphasize that he brings professional training in behavior principles to the relationship, while Ms. Thompson contributes her knowledge of Jimmy, her classroom expertise, and her knowledge of effective instructional techniques. Thus, the consultant can work with Ms. Thompson to identify behaviors for treatment, develop a treatment plan, and monitor treatment effectiveness. Ms. Thompson, however, will implement the plan in the classroom setting and will act as the primary agent of change.

Once Ms. Thompson understands the nature and stages of consultation, problem identification may be started. Ms. Thompson's early statements that Jimmy "acts out" give some indication of the type of behavior problem but do not describe the behavior in a clear way. The consultant begins by asking Ms. Thompson to describe exactly what Jimmy does when he "acts out." Ms. Thompson reports that Jimmy will rock in his chair, fidget, play with items from his desk, get out of his seat, and wander around the room.

The consultant pursues further description of the behavior by asking how often Jimmy displays these behaviors, how long they go on for, and how severe they are. Ms. Thompson replies that the behaviors seem to occur in streaks of 15 to 30 minutes, occurring two or three times per day. The behaviors are sufficiently severe that Jimmy only gets about one-quarter of his work done, and other students have complained to Ms. Thompson that they cannot concentrate when Jimmy is acting up.

The consultant now has a reasonably clear picture of Jimmy's problem behaviors. In the consultant's professional knowledge, Ms. Thompson's concerns about Jimmy fall into the category of "academic-engaged" behavior. At this point, however, there is no information that might indicate what triggers Jimmy's "nonen-gaged" behavior or what reinforces its occurrence. The consultant proceeds to ask important "W" questions: when the behaviors occur, in what setting they occur, who is present when they occur, and what happens after Jimmy performs the behaviors.

Ms. Thompson reports that Jimmy's challenging behaviors seem to occur when the class begins new seat-

work assignments. Knowing that there are different types of seatwork, the consultant asks for additional clarification about what types of seatwork assignments Jimmy is doing when the behavior occurs. Also, there are typically more than two or three periods of seat-work per day in most third grade classes, so it seems that something else must be triggering Jimmy's behavior in certain situations. Ms. Thompson indicates, however, that she is not aware of any particular work types associated with the behavior at the moment. Moreover, the setting (Ms. Thompson's classroom) and the people present are consistently the same.

The consultant now turns to what happens once Jimmy begins to display the nonengaged behaviors. Ms. Thompson reports that she attempts to direct Jimmy to sit still and do his work. She indicates that she gives verbal directions, or verbal reprimands, or stands next to him until he settles down and starts working. The consultant asks how Jimmy responds to these attempts to make him work. Ms. Thompson indicates that Jimmy may start his work but soon begins some other nonengaged behavior. The consultant asks if any other treatments have been tried with Jimmy, and Ms. Thompson indicates not.

The consultant now has a fairly clear understanding of the antecedents, behavior, and consequences regarding Jimmy's behavior problem, as far as Ms. Thompson can describe them during this interview. The antecedent appears to be starting seatwork assignments. The behavior includes a variety of nonengaged activities, such as rocking in the chair, rummaging through his desk, fidgeting, and getting out of his seat. The consequences seem to be that Jimmy receives a fair amount of attention from Ms. Thompson and does not do much of his work.

The consultant and Ms. Thompson discuss goals for Jimmy. Ms. Thompson at first indicates that she wants Jimmy to work like the other children in her class. The consultant pursues further clarification of her statement in order to obtain a specific description (e.g., an operational definition) of the desired behavior. In operational terms, Ms. Thompson wishes to increase Jimmy's on-task behavior to the same level as that of the other students, and to increase his work completion to the same level as other students, although she cannot describe more specifically what levels of on-task behavior and work completion she desires at the moment.

Finally, the consultant requests that Ms. Thompson record data on Jimmy's behavior for a two-week period. Ms. Thompson is understandably impatient to begin treatment, so the consultant explains the importance of obtaining baseline data for treatment evaluation. With this understanding of the significance of behavior observation, Ms. Thompson agrees.

The consultant knows that in most circumstances, the most informative type of data to have on academic behavior is the amount of time spent working on academic tasks, relative to the amount of time spent off-task. The consultant suggests that Ms. Thompson observe Jimmy during representative seatwork assignments and record the amount of time he is engaged in academic work. Ms. Thompson indicates, however, that she does not think she has time to make such detailed observations. The consultant, aware that Ms. Thompson is unlikely to carry out any procedure that requires too much time, discusses with her alternative strategies for data collection. They agree that she will go over Jimmy's seatwork assignments, and they note the amount of work completed. Although this technique does not directly address the problem of engaged behavior, it certainly addresses the problem of work completion. Moreover, work completion is likely correlated with Jimmy's on-task behavior, so this technique represents a reasonable compromise for data collection.

The consultant also realizes that the current understanding of antecedents for Jimmy's behavior is incomplete, as is the current understanding of the desired behavior level. The consultant asks Ms. Thompson to make further notes of when Jimmy's behavior occurs (including time of day and specific seatwork tasks), as well as to note the level of work completion by other children in the class, so that a specific goal for Jimmy may be formulated. Ms. Thompson agrees.

The problem identification interview is now concluded. Ms. Thompson's willingness to collect behavior observations indicates that good rapport has been established between the consultant and consultee. A generally clear description of the ABCs of the behavior has been obtained; where vagaries remain, the consultant has arranged for Ms. Thompson to collect additional relevant information. The availability of baseline data will ensure accurate assessment of treatment effectiveness, at least with respect to work completion. Because only two specific behavior problems have been identified, problem-centered consultation appears to represent a more appropriate treatment modality for Jimmy than developmental consultation at the present time.

The consultant and Ms. Thompson meet two weeks later for the problem analysis interview, after Ms. Thompson has collected the baseline data. The interview begins with a review of the data collected. Com plete data for the entire consultation period are displayed in Figure 2; at the time of the problem analysis interview, only the data in the "baseline" region of the graph actually would be available. The data generally confirm Ms. Thompson's initial reports that Jimmy completes only about one-fourth of his work. With respect to the times of occurrence, Ms. Thompson reports that Jimmy's behavior occurs at various times of the day. Hence, time does not appear to be an important factor in determining Jimmy's behavior. Ms. Thompson notes, however, that Jimmy's behavior occurs whenever the seatwork assignments involve writing. The consultant realizes that this is an important additional specification to the antecedent conditions for Jimmy's problem behavior.

Ms. Thompson also reports the level of work completion among other children in her class whom she regards as good students. These children completed approximately 90% of their seatwork.

The consultant and consultee now conduct a functional assessment of the conditions that trigger and maintain Jimmy's behavior. Considering what has been learned about the ABCs of Jimmy's behavior, they hypothesize that Jimmy's behavior is related to working on writing assignments. They hypothesize further that his off-task behavior is both positively and negatively reinforced. It is negatively reinforced in that he is able to avoid doing writing assignments, which he dislikes. It is positively reinforced in that he receives considerable attention from Ms. Thompson when he engages in these behaviors.

Using this information, the consultant and consultee now work to formulate a treatment plan. They decide on a plan that involves several components. Ms.Thompson will no longer pay attention to Jimmy when he displays off-task behavior. Instead, she will provide praise to Jimmy when he is appropriately engaged in his seatwork. In addition, Jimmy will earn rewards for work completion involving writing. He will be awarded stickers for completing a specified amount of his work. When he earns five stickers, he also will receive a prize from Ms. Thompson's selection of rewards that she uses with her class on special occasions. Jimmy will be allowed to pick the reward he wants to work for in advance. Ms. Thompson indicates that the treatment plan is very acceptable to her, and she does not anticipate significant difficulties with implementation—indicating that treatment integrity is likely to be high.

This treatment plan has a number of desirable features. It is a "positive" plan, in the sense that Jimmy has

FIGURE 2 Jimmy's work completion.

the opportunity to earn rewards rather than working to avoid punishment. It is also positive in that desirable, positive behaviors (staying engaged and achieving work completion), which are alternatives to Jimmy's problem behaviors, are specified. It is easily implemented because the rewards are easy to give; providing verbal praise as the desired behavior is occurring requires little effort and can be very motivating. In fact, the use of verbal praise seems especially promising in this case, since there is already evidence that Jimmy is motivated by teacher attention. It is also easy for Ms. Thompson to check Jimmy's work completion; indeed, this task is one she performs on an informal basis for all students. Giving stickers is an easy, commonly utilized procedure, and using rewards that are already available and in use in Ms. Thompson's classroom is a straightforward matter. Allowing Jimmy to pick rewards in advance helps to ensure that he will find something motivating to work for and will have a clear awareness of what he can gain by behaving appropriately. Also, allowing Jimmy to pick from a selection of rewards helps to ensure that he will not burn out or "satiate" on one particular reward. All of these factors contribute to the high degree of acceptability, and anticipated integrity, of the treatment.

The final step in problem analysis is to determine goals for Jimmy. Ms. Thompson has decided that she wants Jimmy to attain 90% work completion on writing seatwork, like other good students do. She believes that Jimmy's off-task behavior will decrease as his work production increases; therefore, she wants to focus on increasing his work completion. The consultant agrees that this approach is a reasonable one and is supported by research. Now the consultant and Ms. Thompson must determine an attainable initial goal. Because Jimmy is completing only about one-fourth of his writing seatwork at the present, it is too much to expect that he will achieve full work completion immediately. Instead, the consultant and Ms. Thompson agree that an initial goal of one-third of the work is reasonable. Jimmy will receive a sticker every day when he completes one-third of his work. Once this goal has been consistently attained, it will be raised to half his work, then two thirds, three quarters, and finally 90% of his work. In addition, Ms. Thompson will praise Jimmy when she notices him on task.

At the conclusion of the interview, Ms. Thompson agrees to start the treatment at the beginning of the following week. She will continue to collect data on work completion as during baseline, so that baseline and treatment stages may be compared. The consultant and Ms. Thompson agree to meet briefly twice per week to review Jimmy's progress and to determine whether changes are needed in the treatment plan.

Ms. Thompson proceeds to implement the treatment. She explains the new reward system to Jimmy, and she allows him to pick a reward to work for during the first week.

Data from the first two days, as depicted in Figure 2, show an immediate decrease in Jimmy's work completion. Ms. Thompson also reports that Jimmy's nonen-gaged behavior increased considerably during this time. This increase in problematic behavior, and the corresponding decrease in work production, is probably an extinction burst, which the psychologist anticipates. Although Ms. Thompson is initially discouraged by this worsening in Jimmy's behavior, the psychologist explains the phenomenon to her and encourages her to continue the treatment.

On the third day there is a sudden improvement in Jimmy's behavior, and he earns his first sticker for completing one-third of his work. He is learning that he will no longer receive attention for his inappropriate behavior and that positive consequences are now associated with engaged behavior and work completion. As a result, his on-task behavior and work completion increase significantly. Ms. Thompson and the consultant, however, decide to maintain the same goal until Jimmy has earned stickers for three days in row, to ensure that he has firmly associated his new behavior with success. After earning three stickers in a row, the goal is raised to completing one-half of his seat-work.

Over the next few weeks, Jimmy attains higher and higher behavior goals. Goals are raised after Jimmy earns stickers for three days in a row. As the goals are slowly raised, his behavior improves to meet them. Full data on Jimmy's work completion are displayed in Figure 2. Occasionally, Jimmy has off days when he does not earn stickers (such as Days 17 and 24), but the treatment program is continued as planned because he is able to achieve his goals fairly regularly. If some point had been reached where Jimmy consistently failed to achieve his goal, the consultant and Ms. Thompson would have met to discuss possible causes for the difficulty and develop appropriate modifications to the treatment plan.

After the fourth week, the consultant and Ms. Thompson meet for the plan evaluation interview. They review the data collected through treatment, and they conclude that Jimmy has attained the desired behavior level determined during the problem identification interview. Ms. Thompson, however, wonders whether suddenly discontinuing the treatment program will bring a return of the problem behavior. The consultant applauds Ms. Thompson's awareness of the potential danger of abruptly terminating the treatment procedure. He indicates that it is usually best to use some sort of fading procedure in which the frequency of rewards is gradually decreased while Jimmy continues the appropriate behavior. In this way, Jimmy's appropriate behavior becomes less dependent on special reward contingencies. The consultant and Ms. Thompson decide to require two days of 90% work completion to earn stickers, then three days, and finally up to one week. If he maintains appropriate behavior at that point, it seems likely that Jimmy will no longer require special rewards for the behavior, and the treatment program will be ended.

In the plan evaluation interview, the consultant also asks Ms. Thompson whether she believes similar treatments might work with other children. Ms. Thompson indicates that she believes so and is able to name other situations where she would use similar methods. The consultant also asks if Ms. Thompson believes she could use the problem-solving steps they have used in consultation to address other challenging behaviors displayed by other children. Ms. Thompson expresses confidence in her ability to do so. The consultant and Ms. Thompson agree that Ms. Thompson is capable of finishing the fading portion of the treatment without additional consultant input. At this point, the consultative relationship may be ended, because it appears that both client and consultee have achieved maximum benefit.

It is important to note what has not been addressed through the consultation process. Ms. Thompson's initial impression, that Jimmy suffers from ADHD, was not addressed because a short list of only two specific related behavior problems (nonengaged behavior and failure to complete work) was generated. These behaviors were adequately treated through the problem-centered consultation process, and Ms. Thompson reports no other concerns about Jimmy. Thus, there seems to be no need to pursue developmental consultation to address wide-ranging ADHD issues at this time. If Ms. Thompson's list of concerns about Jimmy had included a wider variety of problems which appeared, in the consultant's professional knowledge, to be related to ADHD, a developmental consultation approach might have been used to address issues of broad psychological dysfunction.

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