11-11-02 - Social Skills Intervention for Teens with ADHD
Featured Article
Social Skills Intervention for Teens with ADHD
Ashlyn Cunningham
Summary
Although occupational therapy practitioners employed by a school system provide services through IDEA or Section 504, this author provides intervention through a pilot program development project funded by a small grant, allowing her to address adolescent students 'ability to engage in occupation across many performance areas and contexts.
Although the teenage years typically are a time of turmoil, disorganization, and impulsivity, these behaviors are amplified in a teen who has attention deficit hyperactivity disorder (ADHD). ADHD describes a person who has difficulty with attention, impulsivity, and possible hyperactivity.1 ADHD is not just a disorder of childhood: 50% to 80% of children diagnosed will continue to display symptoms into adolescence.2 It is estimated that 2% to 4% of the adult population has ADHD.3
ADHD is categorized by the predominant behavior presented.1 In ADHD, Predominantly Inattentive Type (ADHD-I), the person primarily has difficulty with inattention. Teens with this disorder often do not attend to detail, cannot sustain attention, are disorganized and forgetful, and are easily distracted. These behaviors are particularly apparent in school situations, where students generally are required to sit quietly for long periods and to learn primarily through a lecture format. The inability of students with ADHD to function well in this type of environment often results in poor academic performance.
In ADHD, Predominantly Hyperactive-Impulsive Type (ADHD-HI), the person is more motorically involved: He or she fidgets; excessively runs, climbs, and talks; and often interrupts and is inpatient. Peers and adults frequently ostracize teens who display this behavior, which affects their social participation. In ADHD Combined Type (ADHD-C) the person displays both ADHD-I and ADHD-HI behaviors. Although many teens sometimes show inattentiveness, it is the inability to perform occupations that require attention that differentiates teens with ADHD from typically developing adolescents.
A common misunderstanding of children with ADHD is that they will outgrow the disorder in adolescence. This is inaccurate. Hyperactivity and impulsivity may decrease during the teen years to the level of one's peers, but the inability to attend to tasks remains. Teens who demonstrate a decline in hyperactivity during adolescence are described as being in partial remission.1 These teens often are misjudged as being more attentive because they appear calmer.
As an occupational therapy faculty member supervising Level I fieldwork, my most recent clinical involvement (as both a clinician and a fieldwork supervisor) has been with middle school and high school pupils in an alternative school setting. In addition to those behaviors seen in typical adolescent development (e.g., moodiness, argumentativeness), these students also consistently displayed negative social behavior in their regular school environment. Incidents such as fighting, disregard for authority and school rules, and overall disruptive behavior resulted in their placement in an alternative education environment. In addition, many of the pupils I work with are inattentive, disorganized, impulsive, forgetful, and hyperactive. Although adolescents with attention problems can be frustrating at times, they are also in great need of intervention to help them become independent in their daily occupations.
The majority of the students with whom I work are not identified as requiring special education services--I primarily provide intervention for social competence and social skills as part of a pilot program development project funded by a small grant. However, many of the students I see have these social difficulties as a result of their attention problems. Because I am not employed by the school district, the scope of my approach differs from that of other school-based practitioners. Although the interventions presented here are applicable to many students, occupational therapy practitioners employed by the schools need to select service delivery options through collaboration with other members of each student's individualized education program team with a focus on educational performance.
IMPACT ON OCCUPATIONAL PERFORMANCE
The Occupational Therapy Practice Framework: Domain and Process4 outlines the process of occupational therapy evaluation and intervention, linked to the profession's focus on and use of occupation. This process is a useful guide for teens who display attention problems and who are having difficulty engaging in the occupational performance areas of education, leisure, and social participation.
The Framework describes maintaining attention to a task as a process performance skill. Attention is essential for most occupational endeavors. It includes the ability to initially attend to tasks and activities, maintain attention over time, shift attention from one thing to another, and sometimes attend to more than one thing at a time.5 Teens who have difficulty with this competency are at a greater risk for mistakes, accidents, and otherwise unsafe behavior. If an adolescent is unable to fully use attention skills, he or she will miss critical elements in the home, school, and work environments.
For example, reflect for a moment on typical high school students' task of taking notes in class. They must first enter the classroom and have their materials organized. They must then attend to the lecture while alternating among writing notes, copying items from the board, and listening to the teacher's instructions. The students also must be able to ignore extraneous noises and stimuli, such as peer whispering, hallway commotion, or a rainstorm outside while remaining focused on taking notes and listening. For teens with ADHD, this struggle occurs for 1-hour periods six to eight times per day.
Adolescents with ADHD often have a 2- to 4-year delay in social, emotional, and sometimes cognitive and academic development.6 These teens are immature and have difficulty relating to others in a socially acceptable manner. As a result, they are excluded from peer groups, are not selected for collaborative projects or teams, and are the target of teasing and bullying. The resulting impact on their communication/interaction skills is most evident in the performance areas of education, leisure, and work, because relating to others is an essential component of these occupations.
EVALUATION
Evaluating and assessing adolescents with ADHD to identify the impact that their attention problem has on their occupational performance can be challenging. Many of these teens are described as untestable because they frequently sabotage the assessment or refuse to be assessed altogether. The evaluation process is threatening, especially for teens with a history of difficulty paying attention and who have repeatedly failed in academic endeavors.
Traditional evaluative methods of observation and interview can provide critical information about a teen's history and current performance in daily occupations as well as identify the type and scope of attention problems. It is helpful to interview the student, family, teacher, and school personnel to get a complete picture of the impact the attention deficit is having on the teen's occupational performance.
If the teen is willing, in addition to observation the occupational therapy practitioner may administer such standardized assessments as the Canadian Occupational Performance Measure7 and the Adolescent Role Assessment,8 which focus on occupational performance and role performance. These instruments are useful not only for identifying what the teen sees as important regarding occupational performance, but also for identifying areas where the teen is having difficulty in occupations and roles due to attention problems.
PHYSICAL CONTEXTS
Interventions for teens with ADHD are specific to their various contexts. The primary physical contexts encountered by adolescents are home and school. When working with adolescents, the focus shifts from a developmental approach to promoting independent living skills; however, interventions with teens should provide as much structure as possible without limiting the teen's interactions or drive for independence.
School Environment
The domain of occupational therapy is engagement in occupation to support participation in daily activities.4 Therefore, my intervention for adolescents with ADHD generally not only addresses task-specific skills that improve attention, but also includes strategies for teachers to compensate for these students' inability to attend, such as behavior management strategies. (Because not all of the students I see are enrolled in special education, and because I am not employed by the school district, my interventions are outside the scope of the requirements of Individuals With Disabilities Education Act9 and Section 504.10 School-based practitioners employed by the district need to ensure that their interventions are selected with other members of the student's individualized education program.) Additional goals may include improved social skills (when dealing with authority and peers) as well as improved self-monitoring strategies for decreasing hyperactivity and off-task behaviors to enable the student to focus on the occupation performance area of education.
Another common goal for teens with ADHD is to improve personal organization, particularly for school tasks, to help focus attention. Strategies for teens may include the following:
- Use a planner system or personal data assistant to organize each day. Include reminders of what is coming up.
- Keep an assignment list and review it daily to keep up with homework and school projects.
- Use a color-code system for each class to help keep papers and projects organized.
- Organize your backpack every day to reduce unnecessary clutter.
The occupational therapist can recommend to school personnel that the teen's schedule be developed so that distances between classes (and thus transition times) are shorter and logically sequenced to reduce the amount of time (and opportunity for distraction) the teen has while changing classes. In each classroom the teen should sit where he or she can best focus: usually near the front and center. Although posters, signs, mobiles, and other additions can be educational and cheerful, these distractions make it very hard for teens with ADHD to remain focused. The occupational therapist can assist in determining the optimum environment for the student with ADHD while maintaining a classroom that fosters learning for all of the students.
Teachers should be selected on the basis of who will best support the student's goals, particularly when there are multiple sections of a particular course. Teachers who are energized and engaging have a greater likelihood of sustaining the teen's attention. In addition, teachers who are flexible yet systematic will further help the teen with ADHD by providing organization and structure. The teacher's use of multiple forms of instruction and feedback will help ensure that the student understands the information.
Occupational therapists may also consult with teachers regarding classroom modifications. Some suggestions include establishing a quiet study space in the class for the student when "seat work" is required, allowing for movement breaks during class, and providing "white noise" (e.g., a fan or headphones with preapproved music or sounds) to block extraneous noise that the teen might find distracting.
Home Environment
The home environment should follow the same physical space guidelines as the classrooms. Structure and orderliness will help the teen locate and gather needed items (e.g., to complete the morning hygiene routine), to organize objects to complete a task (e.g., prepare simple meals while a parent is away), and to restore objects to their previous location for future use (e.g., return cleaning items to the cabinet in preparation for the following week's chores). Alarm clocks and timers, along with prominently displayed calendars and "to do" lists, will help teens with ADHD to complete home tasks and chores in a timely fashion. Parents initially will be the primary implementers of these adaptations, but they may find that they can gradually increase the teen's responsibilities.
SOCIAL CONTEXT
The social context is the area most often significantly impaired for teens with ADHD, particularly with their peers. In my practice, teens with attention problems struggle to fit in with the rest of their classmates due to the fact that they have difficulty staying focused and frequently get into trouble because of off-task behaviors. In addition to modeling appropriate social behaviors, I use cooperative activities that pair students who have attention problems with students who do not so they have to depend on each other to achieve a common goal. This strategy not only allows the teen with the attention problem to socialize and work with a peer, but it also encourages the teen who does not have the attention problem to be a role model and offer feedback.
An example of a cooperative activity I recently used was making "no-bake" cookies. The teens were placed in small groups to make two types of cookies. One group included a student who was easily distracted and impulsive. While I was assisting the other group, this student poured all of the ingredients into the bowl without following the recipe's instructions. I intervened by asking, "What can we do to save the cookies?" The peers in the group (along with the student) decided to try to remove the various ingredients from the bowl and start over. They were able to "rescue" most of the ingredients and restart the mixing process without ruining the product. The student who initially poured in all the ingredients was given the job of stirring at the end of the process, and the cookies turned out okay.
In addition to providing occupation-based activities, I also incorporate a simple behavior management system that provides consequences for on-task and off-task behaviors, where the reward is highly motivating for the student (in this environment the reward usually is being able to go outside). Overall, I find that addressing the students' attention difficulties leads to improvement in their social skills and competence.
For any intervention strategies to be successful when working with teens with ADHD, the teens must be involved. The more the teen is included in decision making and implementation, the higher the likelihood that he or she will use and follow through with occupational therapy recommendations. The occupational therapist can carefully guide the process while still allowing for input and control by the teen. For example, I ask my students to identify what reward they would like to work toward (e.g., going outside, cooking, playing a game) then I structure the process by stating what needs to be done to get there (i.e., what task needs to be completed, how much time there is to do it, etc.).
Independent decision making also needs to take place in the home environment. Parents typically struggle with the thought of allowing their teen to make independent decisions, particularly when the teen displays attention problems. It is often difficult for a parent to "let go" and allow the child to potentially fail. The occupational therapist can help with this stressor by reminding parents of the typical stages of teen development and helping them identify areas in which they can allow their adolescent to be autonomous and independent without compromising safety.
In addition, most teens do not like being seen as different from any of their peers. All interventions need to be as unobtrusive as possible so as not to embarrass them or draw attention to the fact that they are receiving services. Meeting with teens after school instead of talking with them in class or pulling them from class in front of others is one way to eliminate some embarrassment. The occupational therapist also could incorporate some of the school strategies before the beginning of classes so the structure is in place when school starts.
CONCLUSION
The acronym FOCUS summarizes the main points occupational therapy practitioners should remember when working with adolescents with ADHD:
- Feedback: Use multiple forms of feedback, such as visual, oral, and kinesthetic, to ensure that the teen understands what needs to be accomplished.
- Organization: Organize materials in the classroom and at home to help the teen focus.
- Choice: Use a client-centered approach to facilitate intervention compliance.
- Understanding: Remember that these teens are not "lazy"; they have attention problems.
- Structure: Provide consistency in your approach, which is the key to the teen being able to follow through.
By using these concepts, occupational therapy practitioners can help teens with ADHD learn the skills they need to navigate through adolescence and prepare for adulthood.
References
1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., rev.). Washington, DC: Author.
2. Brown, M. B. (2000). Diagnosis and treatment of children and adolescents with attention deficit/hyperactivity disorder. Journal of Counseling and Development, 78, 195203.
3. Murphy, K. R., & Barkley, R. A. (1996). The prevalence of DSM-IV symptoms of AD/HD in adult licensed drivers: Implications for clinical diagnosis. Comprehensive Psychiatry, 37, 393401.
4. American Occupational Therapy Association. (2002). Occupational Therapy Practice Framework: Domain and Process. American Journal of Occupational Therapy, 56, 609639.
5. Radomski, M. (2002). Assessing abilities and capacities: Cognition. In C. Trombly & M. Radomski (Eds.), Occupational therapy for physical dysfunction (pp. 197211). Philadelphia: Lippincott Williams & Wilkins.
6. Dumas, M. C. (1998). The risk of social interaction problems among adolescents with ADHD. Education and Treatment of Children, 21, 447460.
7. Law, M., Baptiste, S., McColl, M., Opzoomer, A., Polatajko, H., & Pollack, N. (1990). The Canadian Occupational Performance Measure: An outcome measure for occupational therapy. Canadian Journal of Occupational Therapy, 57, 8287.
8. Black, M. M. (1976). Adolescent Role Assessment. American Journal of Occupational Therapy, 30, 7379.
9. Individuals With Disabilities Education Act Amendments of 1997. Pub. L. 105Ð117.
10. Rehabilitation Act of 1973. Pub. L. 93112, 29 U.S.C. paragraph 701 et seq.
For More Information
Association on Higher Education and Disability (AHEAD)
University of Massachusetts of Boston
100 Morrissey Blvd.
Boston, MA 02125-3393
http://www.ahead.org
Attention-Deficit/Hyperactivity Disorders (Practice Guidelines Series)
By B. E. Hanft & D. Lieberman. (2001). Bethesda, MD: American Occupational Therapy Association. ($17 for members, $25 for nonmembers. To order, call toll free 877-404-AOTA or shop online.)
Children and Adults with Attention Deficit Disorder (C.H.A.D.D.)
8181 Professional Place, Suite 201
Landover, MD 20785
800-233-4050
http://chadd.org
Making Assessment Accommodations: A Toolkit for Educators
By IDEA Partnerships--The Council for Exceptional Children. ($50 for members, $60 for nonmembers. To order, call toll free 877-404-AOTA or shop online.)
School System Interview
By Model of Human Occupation Products. Chicago: University of Illinois at Chicago. ($30 for members and nonmembers. To order, call toll free 877-404-AOTA or shop online.)
The Tool Chest: For Teachers, Parents and Students
By D. Henry, 2001. Youngtown, AZ: Henry OT Services. ($20 for members, $30 for nonmembers. To order, call toll free 877-404-AOTA or shop online.)
Tools for Parents: Bringing Sensory Integration Into the Home
By D. Henry, 2001. Youngtown, AZ: Henry OT Services. ($20 for members, $30 for nonmembers. To order, call toll free 877-404-AOTA or shop online.)
Tools for Teachers: Making Sense of Sensory Integration (17-minute Video)
By D. Henry, 1996. Youngtown, AZ: Henry OT Services. ($60 for members, $70 for nonmembers. To order, call toll free 877-404-AOTA or shop online.)
Ashlyn Cunningham, MA, OTR/L, is an assistant professor in the Department of Occupational Therapy at Eastern Kentucky University (EKU) in Richmond. In addition to her teaching and Level I A fieldwork coordination duties, she has also been granted a Professional Education Fellowship through EKU that allows her to integrate occupational therapy services in a rural alternative school program. She can be reached at 859-622-3300 or at ashlyn.cunningham@eku.edu.