Don’t Pay Attention to: Attention Deficit Disorder (ADD)/ Attention Deficit Hyperactive Disorder (ADHD)

As a Pre-School Consultant, I design school wide systems to ensure systemic behavioral intervention plans (BIP), consistent with behavioral interventions known as applied behavior analysis (ABA)for children. The design of the interventions is consistent with New York State, State Education guidelines. It is important that all Teachers regularly assigned to the classroom are trained in any child’s BIP. This includes all related service providers as well as substitutes and floaters. This is no easy task as it requires a commitment from the whole team including administration. Too often neglected are the parents. Working in the classroom with parents helps but at home it is even better.

Only working with the school staff, is not adequate. The primary teacher is the parent. (The emotional world has not been touched here, but that will be another paper.) Teaching the parent how to watch and listen to their child is extremely important. Catching them when they are demonstrating the desired behaviors on both a macroscopic and a microscopic level may not only make ABA theory richer but we might find it blending into our conscious and “unconscious”* learning process’. This might provide sight into what the emotional communication of the behavior is about, or in ABA lingo; understanding the communicative function of the behavior.

Attention Deficit Hyperactive DisorderTo this end, I became particularly involved with a 3-year-old boy who I will name Jimmy. He demonstrates significant language delays as well as poor impulse regulation. Based on data from Functional Analysis of Behavior (FBA) we found sensory and attention seeking to be primary motivators. The BIP for Jimmy was developed accordingly. While he was not diagnosed, he was and is clearly hyperactive and demonstrates difficulty attending/sitting at age level. When he is excited he is clearly “wired” you can almost see his body vibrate. In his class the Tier 2* intervention called for the reinforcement of competing behaviors, i.e., remaining in his chair, attending to task and/or participating in the activity. The behaviors we are working to reduce were categorized as; Non-compliance – defined as running around, getting out of his chair, grabbing objects, running away from others, throwing objects and yelling loudly. Jimmy is an extremely bright boy, who despite his non-compliance and over all high energy, demonstrated the ability to respond to the Teachers’ questions during circle time, while he was on the other side of the classroom, “vibrating”.

The clinical team agreed there was impulse regulation difficulties, sensory integration difficulties, gross and fine motor delays in addition to the speech delays as well. In school the high intensity of Jimmy’s affect and rapid motor responses were omnipresent. The parents are very concerned about Jimmy. The parents and I have established a good working relationship while working on Jimmy’s behavior over the school year. Both parents made themselves available for parent training workshops and in classroom training. Despite their efforts, the non-compliance while significantly decreased, continued at home at high levels of frequency and duration. So, knowing without actually seeing what was happening at the home, I knew Jimmy’s progress was going to be limited, if someone did not go to the home and see what was actually going on. As such I arranged to go for the home visit and view Jimmy and his family in action.

True to their word, the parents had established a nice routine for Jimmy. He was clearly aware of consequences if he did not comply. However, when not engaged, he would continue to run from one toy to another, run to one parent or the other and seek their attention. The attention seeking component became more clear as any time we tried to speak, his voice volume would escalate, he would throw puzzle pieces, crumple up papers throw them around the living room, at times in our direction and/or get too close to the new born infant and as a last resort ask for food.

In school when I would see Jimmy attending, participating, playing independently I would go to him, give him “high five” or a big “bear hug”. (He loves those hugs.) He sees me, and looks at me waiting expectantly for me to ask him if he wants a hug? He always nods his head in the affirmative and comes for it. At home I demonstrated this as well as the reinforcement for on task, compliant and verbal behaviors. When Jimmy was being disruptive, throwing puzzle pieces, crumpling papers we all ignored him and then he would start talking/signing loudly and we in response, continued to ignore. But while still running at a high-energy level so long as he was “good” we resumed positive verbal and social reinforcement. All the above is standard ABA intervention/practice. However, I am going to title these ABA interventions, Interventions Addressing “Macro Behaviors”. These Macro Behaviors or visible behaviors are operationally defined as non-compliance as stated above. These Macro Behaviors are what we typically identify as coinciding with the diagnosis of ADD/ADHD. Too often we do not address/pay attention to, the moments of calm/still behavior (If there is the opportunity).

Then there was this moment, a “Micro Analysis”** he made eye contact when asking for something, but in a loud voice. I did not respond to the request until he asked at an appropriate volume and incidentally when he was making eye contact and incidentally he was still for a moment, and waited a moment before I answered. I began this ABA intervention, waiting till he was “Still” and then responding, reinforcing him for being still. Within 20 minutes, Jimmy began to calm down, his verbalizations became more frequent, articulation improved, statements were more related the whole home seemed more calm. We were all stunned. So much of Jimmy’s high energy, vibrating behavior was attention seeking. In effect, we paid attention to the clam moments, when he was still and making eye contact and speaking at a “normal” volume.

By not giving Jimmy the negative attention (still attention and better than none) for all the hyperactive high energy behaviors and waiting for the eye contact, and making himself “still” he started self-calming. In this manner, we began to shape down his hyperactive, non-compliant behaviors. In 20 minutes he was calmer than I have ever seen him in the 7 months I have been working with him. Moreover, when I left he said loud, clear and independently; “Bye Adam.”

This is not to say all of Jimmy’s behaviors were attention seeking, they are not. There is a biological basis but out of biology comes “psychology” or learned behaviors. In the most difficult ADD/ADHD cases, medications are required to address the biology. Best practice dictates both medical and behavioral intervention to help the child obtain his or her highest potential. Part of understanding a child, is learning what they can and cannot do. How much of their behavior is, biological, emotional or learned?

I am available to schools as a consultant to provide workshops, establish policy and procedures to implement ABA systems to address Tier 1, 2 and 3 interventions** from informal to BIPs. Feel free to write and ask questions or make suggestions for future blogs. Please note I also work with parents and their child’s schools to ensure continuity between home and school to optimize each child’s potential.

*I highly recommend a review of the of Dr. Beatrice Beebe, Ph.D. who analyzes non-verbal interaction, eye contact between mother and infant. She calls micro analysis a “Social microscope.” There are many more books she has written all of which continue to outline the profound social/emotional learning process which begins at birth.

**Tier 2 interventions are informal behavioral interventions designed for a specific child. The goal of Tier 2 interventions is to try and maintain a child in the classroom setting they are already in, verses going to a BIP Tier 3 intervention where a more restrictive setting or a 1:1 is required. These interventions are designed to work with existing teacher to child ratios. Tier 1 interventions are universal interventions that are there to support all the children.

P.S. So much is communicated non-verbally, and the genesis is the first interaction between mother and infant. A large part of that communication is not only evolutionary but also reflects the current social culture. Another book discusses pragmatics is called the; “Hidden Curriculum” by S. Myles, Ph.D., M. Trauman, Ed. And R. Schelvan, Ed. This book discusses the need to teach children with Autism Spectrum Disorders, ASD, all the unspoken rules as this is a primary challenge, i.e., social skill development. Many children with ADD/ADHD also struggle processing and understanding social rules and/or pragmatics with respect to non-verbal communication.

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