[music] Hey everybody! Welcome to Abia Inside Track, the podcast that's like reading in your car, but safer. I'm your host Robert Perry Cruise, and with me as always are my fabulous co-hosts. Hey Rob, it's Jackie. And it's me Diana. Hello. Ah, so long-time listeners might say your microphones sound different, everybody. And well, there's a reason for that, folks. Oh, nobody said that, Rob. Nobody said, you know, I get so many emails. I delete them, so you guys don't have to see them. People say, "Your audio is different today. I'm so mad. They don't like it." They don't say that. Well, somebody's thinking it out there. And if you're thinking it, then please email to say, "You were thinking it," and I was right. Please, I'd appreciate that. Thank you so much. While you listen to our podcast about behavior analysis and behavior and analytic research, wherever week we pick a topic related to the field and discuss relevant research articles. Anyway, back to mic sounding a little weird. A couple things. One more one. This is our live recording episode. If you are joined us on Patreon, you're able to get a recording of this video or join us while we're recording it, or you can just watch the video afterwards. So if you want to see how the magic gets made, that's patreon.com/abiainsidetrack. Second reason is it's summer while we're recording. There's actually happy Juneteenth to all of you out there who are not listening to it unless you were here and you're not listening to this on Juneteenth. You're listening to it in the future. But for anyone who's here, it's Juneteenth. Hooray. So, very nice. It's Juneteenth observed. Oh, Juneteenth observed. Yes, yes, you're right. It's the observed date. So hopefully the past two days have been, you know, great celebration, some time off. Maybe you got some time off from work. That'd be nice. Well, maybe you also did some work on yourself and, you know, donated to you know, great black black communities, organizations, or you went and shopped at black owned businesses. You went to the Boba conference perhaps. You know, lots of great, lots of great things you could be doing. Or you did them. You did them already. If you didn't, you know, you got next year too. But we're in the future now. So we're going to be doing this live episode. Also, we are all in different places. So Diana and I, you know, you're here. Diana's here with me. Jackie is in a different place than where we are and we're in a place we've never recorded before. So I don't actually know how this will sound. If you're, if we're watching the video, we got some tall ceilings. So we may sound like we are in an echo chamber. Sounds great, actually. Because I can hear you and it sounds fine. Oh, good. Okay. Great. In any case, I'm sorry. I have on a hard time staying focused, which is great because the topic today is attention, deficit, hyperactivity disorder treatments. So we're going to be talking all about research related to behavioral treatments for ADHD. Now, long time listeners might say, I think you did one of these episodes. And we did an episode on the on task component of individuals with ADHD. So how to increase on task behavior. So we did some review of what ADHD is and some treatment options. But this was an episode. What was that? It's episode 16. So it's super duper long ago. Yes. But I noticed it that is an episode that a lot of people download and listen to in order for CE. So I thought that likely would be of interest to people to hear some updated research on that. And then because this is our live episode, people can vote on what the topic is. And this was the topic that won. It was the unanimous choice. My hypothesis. That it was a popular topic. Yes. Excellent. So that is what we will be talking about on today's episode. So now that we've got all of our recording mumbo jumbo out of the way and the brief intro out of the way, let's get into it, shall we? I don't know what articles will we be discussing. I hope I know because I would be unprepared otherwise. All right. So we have four articles. We're going to review for everyone today. And they are as follows. Behavior management for school age children with ADHD by Fifner and Hack. That was published in child and adolescent psychiatric clinics of North America journal in 2014. Then we will discuss a flow chart of behavior management strategies for families of children with co-occurring attention deficit hyperactivity disorder and conduct problem behavior by Danforth behavior analysis and practice 2016. We also have effectiveness of specific techniques and behavioral teacher training for childhood ADHD, a randomized controlled micro trial. And a lot of people helped on this one. Staff, Vander Hoefdiker, Vander Ord, Hornstra, Hokstra, Twisk, Ustrelon, and Lumen. And that was in the Journal of Clinical Child and Adolescent Psychology 2021. And finally, using fidget spinners to improve on task classroom behavior for students with ADHD by Esperanti and Huluck. That was in behavior analysis and practice 2022. fidget spinners only like six years too late to hit the wave of popularity. So let's get into our discussion of these articles. And let's do a brief review of what ADHD is. So ADHD, like we said at the top, stands for attention deficit hyperactivity disorder to DSM description of various symptomologies usually seen in young children, but also would stay with an individual through the lifespan probably that diagnosis. And it usually results in inattentive or hyperactive behavior, impulsive behavior of the individual. If any of you have children out there, you probably filled out the form of your doctor's office. This your child move like their motor is always running kind of questions. So there's a sense of inattentiveness to usually consider to be an executive functioning disorder in which one has trouble making plans, sticking to plans, timing things out. And when you know severe or even when not mild can lead to academic or social impairments across a variety of settings and then can last through the lifespan of the individual. Like I said, it's about it's about a 5% prevalence in children worldwide with like the full criteria. So they have all the attention and inattentiveness and executive functioning symptomology. But if you just look at individuals who have impaired levels of those symptoms, the number goes up to about 10 to 15% is sort of the best estimate right now. Now, while some of those, you know, again, oh well this child has a little trouble paying attention. That in itself doesn't sound unsafe. It can lead to patterns of behavior where you see children who begin to engage in more non-compliance or at least seeming non-compliance where they have troubles being independent with things like chores or routines. And this can lead to problems with things like homework. And because of the stress that can put on a family unit or a teacher student relationship, you can see an increase in aggression and defiance leading to other disorders like oppositional defiant disorder and conduct disorder. This is something that has been, you know, in the DSM for quite some time. And while there is usually, you know, for many of you probably have heard of ADHD, oh, you take medication for that, there's pretty robust research supporting the use of behavioral treatments. Now, that's not to say that one could not also use medication. We'll talk about that too. But overall behavioral treatments have been shown to be very, very effective. One of the main treatments that you're going to see are things that are considered, you know, behavior management trainings with families. So behavior parent training or behavior teacher training. And this has been in the research before. So we're going to describe sort of what that looks like in the home. And then we're going to give a nice example from that flow chart of sort of what that practice might look like in real life. And then we're going to come back after a break and talk about, well, what could this look like in school? They look pretty similar, which is nice. So if you can run along with the parents, then you can run along with the teachers in terms of at least the, you know, following the behavioral principles that are relevant to the use of this treatment. One of the reasons that you might want to start with working with a family or the family might want you to start working with them on these skills is because one of the challenges with parenting a child of ADHD is that you will often see parents, whether they were engaging in these patterns before or after diagnosis or all at the same time, you'll often see patterns in which parents find themselves engaged in negative or ineffective strategies. They do a lot of punitive practices with their child or they're inconsistent. Possibly because a lot of parents who have children with ADHD may have a diagnosis of ADHD themselves, one parent or both parents, which is going to lead to trouble with consistency, routines themselves, right. And you'll probably see more argumentary argumentativeness between the child and the parent, which could lead to more aggression and destruction. So in the short term with ADHD, you're often going to see sort of things like poor report card. Your child's not doing as well in school. They might have poor relationships or few friendships. They get neglected or rejected by other students. But long term, once this pattern begins, you're going to see these problems get worse and worse. Most children who have ADHD that is not treated may end up receiving special education services, which again, in itself is not a problem, but if there were other treatments that could have been done ahead of time, this may not be the best use of resources for the child or may make them feel stigmatized. You could see retention, and a lot of these are sort of precursors to behaviors that are going to lead to dropout, delinquency. And then in girls with ADHD over the long term, you have a much more chance of seeing self-harm or suicidality. So ADHD is not something that's like, I wish the kids pay more attention, but what are you going to do? It is something that over the lifespan can really impact a lot of social and academic development skills that will impair emotional health or mental health over time. So when we focus on behavioral parent training, we're starting that as early as the parent is interested, and we're really just focusing on how do we teach new interaction skills for the parent to work with the child. Now, we're going to talk general principles, and as, you know, kind of the first, the fifth-ner-and-hack article we'll go into, there are lots of modifications that you can make. And so, again, I think this is a treatment that is great for behavior analysts, because what do we know how to do? Why take general principles and individualize them based on our analysis of, you know, the setting of ads and seedings and consequences? So we're sort of going to tell some general practices or general principles, and then a couple add-ons, you know, that you can put into the overall treatment. So the first step that they recommend is doing an FBA. Now one thing I will say is if you're like, I've never done an FBA before, that sounds hard. I hope these articles give me a detailed description. They will not. It usually seems like it's mostly descriptive assessment or interview assessment, but they don't get into a lot of details as to what this process is. So again, if you were, say, a special educator or school psychologist without a lot of training in this area, some of the literature might not give you the information you need to appropriately figure out what are the relevant antecedents and consequences. But for the most part, it seems like it's a lot of interview. What are the parents interested in? Billy won't get ready in the morning. I don't know if he just can't or won't. Okay, well, that's where you're going to do your observation. So it's a lot of descriptive assessment informed by your interview is what it seems like in the literature. That's out there. But really, the goal is looking at where is the child impaired in terms of their relationship with the family in terms of their sense of being able to function. Rather than just assuming, well, they have ADHD, here are all the treatment options I need to do for them because you may not need all of those treatment options. Yeah, I think that's a really good point to bring up. Sorry to interrupt. No, no, no. But you know, when we're talking about ADHD, like this is falling underneath the larger umbrella of looking at sort of neurodibrogen presentations in the same way that AST might. So if you're used to working with AST, then a lot of the same, you know, principles of how we might approach your problem are going to be the same in that this is only an issue if it's coming up to us as an issue for that individual and or their, you know, care team. I guess you could say their parents or their teachers. So we don't automatically have to go in and say, oh, no, you have the diagnosis. And so this, this, this, this are now things that we need to address, just as with any other person we need to look individually. So a lot of those same types of interview questions that we might ask if we have a client who's autistic, the same types of approach may be appropriate here. And just the other thing I'm glad that you brought up to Rob is that you might see a different presentation just as with AST between girls and boys. So with boys, you may tend to see more of that hyperactivity piece with girls, AST is more likely to go on, like, no, for a long time. And then in retrospect, when, you know, maybe students start to have issues with executive functioning down the road, they look back and say, oh, I'd spent a lot of my time daydreaming. And so I just was more of that into an attentive type versus a hyperactivity piece. So it's, you know, of course, there could be overlap as far as gender, but that is often what people tend to report. And then the daydreaming also with girls will also coincide with being very chatty. So I've looked into a lot of this. So if they're just non-stop talking, don't understand how they need to wait, right? This is non-talk talking. And then they'll talk about their daydreams that also is one of the symptoms for girls that not necessarily may be there for boys. Yeah, I think the mental health piece that you brought up is super important regardless of gender as well for kids. So there's a lot of reports of lowered self-esteem over time due to, you know, like you said, hearing from parents, why aren't you doing this? Why can't you do this? Why did you forget this or that thing? You know, you hear that over time and that really can start to weigh on you and give you a bad impression of yourself. So that is also really important and tied up into what we should be doing for behavioral parent training is teaching parents how they can reinforce those positive interactions with their child. And also using a multi-disciplinary approach and getting help from the mental aspects that we don't necessarily do as behavioral analysts, but, you know, help them find a counselor, a therapist to help work through those as well. Yeah. And again, when we talk about kind of behavioral parent training, you may not need to do all of these components. You know, certainly if you're working with the family with, say, a kindergarten or diagnosed with ADHD, which, and you might not get a diagnosis that young, because young children tend to be a little hyperactive already, then you are probably focusing on some of the preventative measures that, you know, if anyone listened to kind of our preview or to our full, you know, you hear you listen to the hopefully list of the full nurture effect book club. Anytime you can do preventative care, that is ideal because, you know, the earlier parents are using a lot of these positive interactions. They know where do I provide reinforcement? Ask me contingent on the behavior I want to see more of. Punishment is not always going to be effective. Where might my child need additional training and support for underdeveloped skills. And I have to recognize that kids with ADHD tend to respond poorly to delayed or weak or inconsistent patterns of reinforcement. So, especially if you have two children, well, my first child without ADHD, I'd pray as sometimes, I wouldn't other time. Sometimes they get a pony, sometimes they wouldn't, you know, I'd deliver whenever I felt like it, rather than when they did any, you know, whether I than contingent on some behavior. And there are, they were the valedictorian. 20 ponies. Where, you know, this is a great family with all the ponies. Whereas my second child with ADHD, I did exactly the same thing and they're a mess. They're failing school. They don't have friends because some of those, you know, the shortcuts we might take as parents, because there's only so much time in the day or some of those inconsistent patterns that we engaged in won't work. And when we're told, as parents, hey, you got to do more of something. That can be hard to hear as a parent. You know, like, well, I did it already. It worked. So, why do I have to do it differently this time? So, that can be, that can be a challenge or one of the barriers you might find with treatment. And I'm not saying that two parents I've worked with. I'm saying that as a parent myself, so I can make fun of my own parenting. All I like, thanks you very much. So, when we get into the treatment, it's really those key principles, how to reinforce, where to reinforce, and are there other skills that need to be supported. So, when you look at the package of behavioral parent training, you're usually talking about some number of training sessions, which is nice, because there's a limit to it. However, it's also not nice in that if you miss most of the training sessions, you're probably not going to see the benefits of treatments. About eight to 12 treatment sessions, they can be done in a group, they can be individual, and the goals are really number one. Psycho education about what is ADHD, possibly with the child, but definitely with the parents. Number two, what are the effective parenting skills that you should be using to improve desired behaviors and decrease problem behaviors, and then number three, a chance to practice, and a chance to troubleshoot. So, what is it that doesn't work in this package for your home, for your family, and how can we help you fix that? There are going to be didactic components of this training, there's going to be interactive apportions, as well as homework assignments. So, here are the strategies we practice. I know you can do them because you did them with me in the practice session, try them for the week, and when we'll come back together, we'll talk about what worked, what didn't work. So, the pieces of psycho education are going to really be all around how can you attend to the positive behaviors that your child does, especially parents who have a child with ADHD, and they've had that diagnosis for a long time. They might find themselves the only time I talk to my child is to tell them how very, very badly they're doing it. All of these various things that they totally should be able to do, and I don't know what else to do, because when you're parenting, it's not quite the same as when you're observing from a far. So, paying attention to the positive behaviors. Talking about contingent positive consequences, like we said, what are your initial reward system? This could be a token economy, this could just be more praise in the day for those contingent activities. You might get additional training, and how do you give clear and specific commands? Not don't do what Donnie don't does, so much as Donnie do this, and it needs to be short. It's Simpson's reference. Donnie Darko. Not Donnie Darko, no. It's about setting up consistent routines and expectations using when then contingencies, so as my example, when you take out the trash, you can tick talk all about, as the children are wants to do, you know, they tick talk Jackie, you know what that is. I do. They tick talk it, right? Is that what they say? You tick talk, yes. Tick talk, you don't stop. And- They'll say that to us, and he said never say that again. No, they just like it. He doesn't think it's funny. He doesn't even think it's like, oh, my parents are doing a bit. It's like they just, no, don't go. So don't try. Don't try. Is the message? When you take out the trash, you can have screen time. Is that better? That sounds- that sounds more foggy to me. And then finally, what are the responses to those rule violations? With younger children, you might use timeout, the older children you might use response costs, or you may just use to use plan ignoring, you know, type kind of extinction procedures instead. But you know when to use them, and you're using them very sparingly, it's not your go-to strategy. Right. Your go-to here is that you're setting up clear routines with clear contingencies, right? And you're sticking to that plan while you're maybe adding in some additional anesthetics supports and strategies for students, such as visual supports, you know, maybe additional timers or systems like that, and explaining to students as well, or your kids as well, how these systems are going to operate. And I feel like for me, and this is true for any client that we work with, but I think that it's applicable here is the phrase kids do well when they can, right? Have you guys heard that before? Just because someone has an ADD diagnosis, or they're hearing from, you know, this end of the other place that they're not doing a good job, right? Then that doesn't mean that they don't want to do a good job, or that they are not trying. To do a good job, it's that we haven't established systems, they're going to work for them to allow them to do a good job. So as much setup and organization that the parent or the teacher can provide is going to ultimately be really helpful in a situation. And your child, if they're not doing a good job, they know they're not doing, you know, quote unquote, a good job. They know they're not the same, they know they're not doing it as well as some of their peers. So you're reiterating the fact, you're not telling them something new. It's not like, oh my, you're right, mom and dad, I totally am, you know, I didn't realize I wasn't completing any of my homework. I was doing badly in school. Thank you for telling me. I'll get right on that. That's not the interaction that you're looking for. You're just repeating a message. They've probably heard 50 times already. And just telling someone do better, at least it's a do command, but it's not really the one you're looking for. A little too vague. It may be more specific. So, you know, that probably to most of us out there are saying, okay, those all sound like pretty easy, pretty basic, like good parenting techniques. And yes, if you, you know, as a parent, if you want to start these right off the bat, if you can, you may not need as robust a reinforcement system. Your rules may be allowed to be a little more fluid or loose egoosey and you still sort of get the same results. But it's the right, it's the same idea. Now, we're behavior parent training. And as we'll talk about behavior teaching training, you're going to come into play. You can add on to this because that, that kind of baseline treatment is not necessarily going to teach your child everything they need. You can combine this with other treatment options like daily report cards from school. You know, your child is rated on how they perform a couple of skills at school. And then that comes home and it's continued in their their performance at school is also going to lead to rewards at home. And as someone who works in schools, if I ever had a parent email me out of the blue to say, I'd really love your help as a behavior analyst to help set up this daily report card at school, I would drive to the house, give him a big old hug. Just like, wow, that's so proactive. It's amazing. Thank you so much. Parents do a lot, but just like go that extra step where like I have a great idea. I want to add this. Oh, so great. You could do pure intervention. So you might need, you know, if a child's really just struggling with their social interactions, all right, perhaps they just need social interaction skill training. And again, that's going to look a lot like many of the other trainings we talked about on the show. The example they give here is called the child life and attention skills program or class. And it really doesn't change much from the same idea of identifying the skills, do some didactic instruction paired with modeling, child chance to rehearse the new period or social skills, give them corrective feedback, make sure to do some in vivo practice. The real change here is with children ADHD, you might also tie that into a reward system. So their good peer relationships are also rewarded with some sort of tangible or activity reward, whereas a lot of the social skill instruction might just say you do the instruction this way and the skills appear might be a little different for kids with ADHD. They may need additional reinforcers to see that same increase in the pro social behaviors. You can also talk about well, what might the parent need? Because again, one of the challenges is you're working with a family, not just the individual child with ADHD. So behavior parent training might need to be modified for specific challenges that those parents are having. Those challenges could be, you know, single mothers, but they don't have a lot of a support system, depressed mothers who are also suffering from their own mental health challenges. And then one of the worst parenting challenges, being a dad, I mean, that got its own call out in the article, you know, it's really, you know, it's a special group. Oh man, how are we going to treat the dads? Wow, really, we're struggling. We need a special modification. So some examples would be with the single mothers, work on your intake procedures or add more intake procedure to focus on treatment adherence and maybe group problem solving so that you can start helping build their support network. For depressed mothers, you might add mood monitoring or scheduling and pleasurable activities. For dads, it's really tough. Got to add sports. Is there a recommendation there? Wow. No, yeah, without sports dads, just they that they don't adhere to treatments. I think that's stereotyped. Yeah, it's from the article. I don't make it. That's you wouldn't do sports. You would do games. I know. Or I would like, let's go watch a Marvel movie or something. Yeah, and then talk through the whole thing. That's what you know, that's why you do your FBA Jackie because you come to me with you're like, we're adding all these sports. It's like in treatment adherence. It's out the window, bud. Sorry. Get the bricks. I'm not following your treatment. So yeah, but all of these kind of carry a similar component, right? Which is the parents need to be in a good place in order to do this. And I think the other piece of that is the kids need to be in a good place to do this too. So any of these types of interventions that you're layering on and you're not adding in, you know, consequences or additional rewards. Like that should be like a small layer of frosting on top of a large cake of unconditional love that you're providing to your child, right? So you're starting from a place where I love you. I love who you are. Separate from that, there are some things that we could do together to kind of improve our family dynamics and relationship and make things easier for you in this that or the other way. But that is a smaller piece of this overall acceptance of who your child is. And that I think is important starter position. Yeah, it's it's the Mr. Roger principle. Mr. Rogers principle, you you need to you should love your child for who they are. And that's not, you know, I think people usually take that as a sense of like, but yeah, but everyone's still my kids all of all these kids are so snowflakes like they should get unconditional love. That's not a that's not a sense of your kid can't improve or learn your skills. It's just you will get nowhere if your starting position is here's how my kid is broken and someone needs to come fix them for me the adult and then then I will love them because that is starting you off with the wrong attitude for a lot of this treatment to be effective. You could also add treatments related to organizational problems, you know, more specific rules and targeted reinforcement systems like token economies. You can add that if you want to add on other skill acquisition components that based on your FBA, based on the needs of the family, you know, you might just want to provide additional training. And this isn't necessarily explicit to kids with ADHD. Everyone could use some executive functioning training, you know, now and again, but again, you might want to make that a part of your training package. Now, the key limitations to this treatment really have to do with unfortunately, the treatment tends to be somewhat setting specific. So if parents are using a very effective behavioral parent training, they're adhering to the track treatment. Awesome. You're going to see good result. You should see good results. You know, maybe after a few months, you'll need some boosters for the family, but overall, the treatment does tend to be sort of robust and last for many, many months without additional support. However, you're not necessarily going to see that generalization to the school setting, if many of the same principles aren't being carried over. You also might not see what in the article, they refer to as normalization of your child. They have a disability. They have ADHD. So while many of their skills will improve, they may not do everything exactly the same as other peers, which is okay, which is okay. But if your goal is, I don't want my kid to have ADHD anymore, that's not really a goal of treatment. It's to treat the symptoms of having ADHD that are going to impact their development down the road. Also, this is a treatment that requires some amount of follow-through. So if your, you know, a family is saying, I could really only meet once every couple months, this might not be the most effective treatment and you're going to need to work with the family to figure out are there smaller goals we want to set to start to just increase the regularity to start building your own rapport or targeting some really needful areas to begin with. And if the parents have their own challenges, that's going to be harder. So again, that's where things like your FBA, even if it's just the interview, will come into play. Now, over time, I think some people always say, "Well, can I just medicate my kid?" Yeah, I mean, there's plenty of research. We go back to the multimodal treatment of ADHD study. The MTA study from 1999 does highly, highly cited as an ADHD treatment study. And medication can be effective for symptom reduction of ADHD. However, it isn't effective for improving areas of functional impairment. So if your goal is I want my child to be less hyperactive, to potentially be more attentive, then you will probably see a lessening with medication, at least that's what our research tells us. But that's not going to lead to now my child is better at completing their homework. As a parent, I'm better at reinforcing what they're doing correctly because the medication, you're not taking the medication if you're a parent. So there's really kind of a give-and-take as to which one you want. And ideally, you would be using a behavioral intervention first, looking at the results with your clinician and then determining whether the results are significant enough that you do or do not need medication. Even in the nights you do whatever's right for your family. Well, yes, but there are some caveats even to what's right for your family. In that, if you are using a high dose of medication, it does seem like you will see improvements and you may not need as much behavioral behavioral treatment. However, if you're using a lot of behavioral treatment, you may not need as much medication. About 75% of the kids in the MTA study were in behavioral intervention groups alone. They didn't need medication to reach their treatment goals. And it remained that way for two-thirds of those participants for about a year or two years and follow up. Also, for many children who then end up needing medication, the dosage they need is much lower when they've already had behavioral intervention. So really, it does seem like behavioral intervention should be implemented before medication. It doesn't have to be. But, you know, from our perspective, the recommendation would be let's do behavioral intervention and then keep looking at data to determine if and when, if or when medication would be needed. And if it is, hopefully it's not needed at such a high dose for the child. So that's kind of a summary of behavioral parent training. But Jackie, why don't we get into the flow chart and kind of paint the word picture for our listeners of what this would look like or what this treatment might look like in practice? I really love this article and you know, originally Diana was going to do it because she loves herself some flow charts. But I was like, no, I want to do it because flow chart. And so the rationale for this study was that we all know that what you said behavioral parent training is effective, but it is hard to do. Right. In the real world because life, no matter what the variable is, they gave a ton in the article. I don't think we need to go over what they are. It's just life, right? That's from your FDA, Jackie. When you're in the moment, when you're in the community, when you're in your home, there's also many other things that are occurring at the same time as the time that you're engaging in some treatment implementation that it may not work in your favor, right? So life happens. And so what they thought is that if I make this flow chart, it's not just a flow chart. I can't just be like flow chart. Here you go, parent. This flow chart paired with behavioral skills training in this parent training will serve as a visual SD on what I need to do next, right? So they made this recommendation. They didn't talk about it a ton, but they said, you know, like we trained using behavioral skills training with instructions, modeling, role play and feedback throughout each of the steps, right? Steps one through nine, where the first part or one through 10 with the first steps, and then they made the parents go home and practice. If they still were seeing some challenges, then they came back and learned about step 11 through 30, right? So they weren't saying again that this is a one size fits all. And this is one specific problem, right? That you might see. And so their their recommendation is to encourage behavior analysts to make these types of visual cues for parents, right? So they said, yes, it was on a piece of paper during the training, but once they had acquired or mastered the parent training training, then they printed out a little wallet size of the flow chart. If they didn't have a phone or send it to their phones or that in the moment, when everything is hitting the fan, you're like, okay, what do I need to do? You have something as a reference. And I knew you'd like that. I knew you'd like to read that. I was like, I actually love this. Tiny, tiny take home charts and lists, right? And I was like, oh, I would want it in both places, right? Because I don't always have my phone on me. But, and I also don't always have pockets, sadly. But anyway, so it's important to note that they said this was specifically for following directions for individuals that have ADHD and potentially some CP, right? So they call that, you know, like, oh, my God, I'm losing it. Conduct problem, right? So if there's more argumentative, there's maybe some aggression, whatever. And they say, again, this isn't going to be a one-size-fits-all model, like you still need to do an F-based or do. But here's one way that we did it. So the thing they had two parts. Part one was that parent training. They said it was a didactive analysis. And just so the listeners know, I had to look that up because I had no idea what it meant. I think didactive means two people, but then they announced parts. I looked it up and it says educational activity, which is teacher led. So the same as didactic instruction. Yeah, yeah. It's not dynamic is the two people. Yeah, oh, yes, right. So I was like, I don't know. And it's okay not to know. Right, I have a lot of years in behavior now. I was like, I don't know what that word is. So I googled it. Just trying to model that it's okay. That was one of the first words that I read. And I was like, so I had to look it up. And it was okay. And I got through it, right? So the first thing that they do in the first session is they do exactly what Rob recommended from the previous articles. They presented the ADHD characteristics, etiology, their review general behavior and principles. And why so many kids with ADHD may have conduct problems, right? Then they stress the importance of these trainings to talk about the relation between ADHD and learn conduct problems. They talked about how to teach each of the behavior management procedures in the flow chart and that in order for it to be successful, the parent needs to know being a good place, right? They need to know what's going on in order to be successful, right? And then they did say that in the beginning, we need to be mindful as parents that there may be coercive child parent relationships. We may be using more punishment. We may be not delivering enough reinforcement right from our past history. And just be mindful of that and work to change that. Before we go on, I don't think we talked, we started to talk generally about the idea that some of these relationships may exist. But we didn't talk about why. I mean, I think many relationships probably can figure out sort of like what's the pattern, what's the behavioral pattern, where's the reinforcement in terms of where these coercive parenting strategies came from. But it's probably worth it just to just to make sure we get it out there in terms of why these relationships occur. Yeah, what the what the author said is that parents may have a expectation that is unrealistic for their their children, right? And so if they set a demand and the child doesn't necessarily start doing it, then they get angry. And then they start maybe pre-presenting the demand multiple times, right? Then the child may be become defensive and argumentative, which then may increase the bidirectionality arguing, which is then aversive for both parties, right? And so then apparent when when parents are on balance, they're frustrated, right? They're more likely to use punishment procedures because they're effective immediately, right? So you may see more punishment, less reinforcement, that's in the whole context, right? And these authors note, which is it's so small in the article, but I think it's are really like key nugget that I would like to pull out that it's complete, it's starting the demand, not completing the demand, right? So they said it's hard to start demands. So if you can reinforce just starting the demand, you're you're already in a better place than if you only provide reinforcement upon completion at demand, right? Because we know the characteristics are it's really hard to start an activity. If the activity gets like lost in the way said, then you just start over with the full chart, right? And maybe it is on you to make the instruction that you gave smaller and more manageable. So they said in start of set instead of saying go get ready for school and being annoyed that when you go into the room, nothing's happening, right? They're like playing with toys. You say it's time to get ready for school. Get your pants, right? So that's one very clear directive. Get your pants once that's saying, wow, you got your pants. Let's move on to the next task, right? So I think that was I think that was like a real like for me, I think which can help increase that reinforcement, relative reinforcement of that relationship and decrease that that opportunity for punishment, right? Because we don't obviously as parents, we don't want to read, we don't want to punish our kids all the time, right? But sometimes, right, the context, what we've set up, right? In our past, it's been more reinforcing to use punishment than it has to use reinforcement. Sure. And that's one of the challenges of coercive behavior, right? Is that it's immediately met with reinforcement and it looks like it's working until you look at the long-term effects, which can have detrimental consequences that aren't immediately apparent according to Simon. Yeah. And so yeah, so this flow chart is enough, the nice thing about the flow chart too is that when parents are engaging in the behavior, if they notice, oh, I didn't provide reinforcement for the start, they can highlight it and then they can go back and that's where the trainer can start focusing on, right? Because it's delivered in these small steps. So I really like that. Yeah, I also like that before they kind of get into the flow chart, they also say, now this is just an example, but you should still do some type of functional assessment for the individual child because the way that this is set up is could actually be somewhat reinforcing if the behavior has an escape component to it, right? And you maybe you're going to bring that up and I don't mean to steal the thunder. Okay, I'm sorry. But so that's always an important step. You know, just, you can't just blanketly apply this in all situations. No, but you can apply the idea of the flow chart because remember the flow chart is just an example. Exactly. So I'm going to go through the flow chart with you, not all of 30 steps, right? But I'm just going to give you the highlight of the steps. One thing I do love is that they're like, okay, before we begin, here are the different types of shapes you might see. And I was like, oh, you prepared. It looks like a socket diagram, like physics class. Like, how do I like the light bulb? Like, what am I going to do? It's too much. So parent options are parent, like what you think we yourself are rectangles, diamonds are yes, no options. Circles mean the interaction is complete that you're out of it, right? It's just called out out. So the first thing you have to do is let's say you've given a direction to your child. Then I love this one. The first steps is do they actually have to do it? Right, right. Sometimes they don't. And if they're just not doing it, then you make the decision before this, like, okay, if they don't have to do it, that's okay. We hope that we'll provide some options, some some different options, right? That they could then engage in. I think that that's really important to note is that the goal here is not just blind compliance, right? But there are some things you kind of do need to do to get through your day. And if this is one of those things, then that is when you need to kind of go through this whole process. But, you know, especially as kids age, I also think it's important that they learn to discuss with you and do some level of negotiation on whether this task needs to be completed at this time in this way, etc. And so if you have wiggle room, then you can, you know, modify where you're doing in order to help them build those skills, which are actually good life skills. Yeah, and another thing I know that they're, they like kind of pushed in, they're like, and if you have less things that you're asking them to, the correlation is that they're more likely to do them. So just think that what you need to do. Yeah, I know that as a parent, I've said, hey, can you do this? Like, do this thing? And it's not happening. And I'm like, does she actually have to do that thing? Or can I just get up and do it because I'm being lazy, right? Like, I think you need to be thinking about that. So they said, you know, you can give them options. But then what I love here is that if the child still doesn't follow the instructions, it's okay. You're out of it because you've determined, even if they don't do these options, you've already determined that it's not important that they follow the instructions. So it doesn't matter, right? It's a new point. Love that. I think sometimes parents would be like, but I've given them options. They have to pick one. Not if you've already determined that it's not important for them to do it. Right? They can just out and you have to move on with your life, right? If they do start choosing one of the options, you do some very specific praise for just starting the task, not doing the whole task, right? That's the important part. And then you're out of the scenario. Right? So here, that's the easiest. You're like, whoa, done. If you determine that you do have to follow the instruction, right? So one of the examples they gave, it's 15 degrees outside. You do have to wear coat while you walk to school, right? So here, you've decided, okay, they do have to follow this rule for this instruction for whatever reason. It's important for the parent to stay present in what's happening right now and not what's happening in the future, right? So instead of saying, when you finish your breakfast, do this, right? What they say is you're going to do this when you finish your breakfast. And that's just the preview of the command. That's not your actual instruction. I like that, right? But in the moment, you'll provide the instruction when you need to engage in the instruction and not say like, in 10 hours, right? You're going to do this or even in like two minutes, you're going to do that. So you have to do that, stay in the moment, provide a reason for the demand. That's not like I told you so or because it's important to me, but an actual reason, like, if you don't put the milk away, it'll go bad, right? If you don't wear your coat while you're walking to school, you make it frostbite. And then make sure that you are near the child when you present the demand and make sure it's an actual statement and not a question, right? Because it's a question, you moved it up into it. It doesn't really matter if you need to follow through. Then you want to make sure that you prevented the instruction with as few steps as possible to ensure compliance. And after you've done that, while you're waiting, they said, wait silently. I like that part. Wait silently for five seconds. You decided you've done a good job in these above steps. Did you get close to the child? Were they oriented? Were they listening? Were they in a place that they could do the instruction? Was it with the instruction clear? Was it small that they could do, right? You're all thinking about this. If not, you go back to the beginning and restart. No big deal. If yes, right, then you're waiting again. And they make a point that this is where arguments may start. This is where you might see some emotional responding. They say, okay, it's okay if emotional responding occurs, but don't engage in bi-directional arguments, right? You've stated your command now. You're just waiting for them to either do it or not do it. If they start to do it, even if it's at the start, you provide that praise. If they don't finish the step, if you don't finish the task, they go back to step one and start, okay, and that's okay. If no, you're going to provide a concise reprimand. So this is the first part of the training here. You're going to say, you did not follow your instructions. You know, like we need to follow our instructions. So you just try that and see what happens. That's the first part. Parents go home. Practice just doing that. If they see improvement, then they stop. If they don't, they come back and this is where part two begins, where they provide the instructions in a warning for what they recommend is a timeout, right? But doesn't have to be a timeout. You're going to specify what it must. Like sit on the chair, sit on the stairs, go sit on the couch. You don't necessarily have to call the timeout. And again, here, this is where an FBA is important, right? As Diana said, you don't necessarily want to be providing timeout for escape or avoidant behavior. Then you're going to wait silently. Again, all of those silent options are places for arguments to start. You're not engaging. You're just waiting. If the student or the child, and starts engaging in the response, great, provide reinforcement just for starting it. If not, you will then, you know, implement the timeout procedure. Before you do that during the training, the parents have already decided what will constitute timeout, right? Where timeout will be held. And they'll talk about where it'll be in for what behaviors. And then they'll also have talk to their child about what that means. Just like you said, it's important, right? You'll come home and say, if you do this in this, usually they're the, the worst of the worst, right? Here's what's going to happen. You might have to go to timeout. Then if you're using timeout, you're going to see if this effect is a child staying in timeout, is there disrupting your timeout? Are they trying to threaten or leave timeout? If that is the case, don't use timeout. They're like, okay, you need to think with your clinician for other backup reinforcers or backup consequences, right? Yeah. And that's okay. And then they have the last part is like, okay, if timeout doesn't work, did you implement a backup consequence? Did that work? Yes. Great. No. Do you have another backup consequence? Did that work? Yes. If no, the final is that you're just going to separate yourself from the child, give them a safe place to engage in emotional responding and wait until they calm down. So the author does state that sometimes there's not a place for learning. We've all been there, right? We've all been to a place where someone's like, if you could just calm down, we could chat about it, right? Okay. At this point, you're just going to have to separate people to make sure everyone is safe, let the child calm down and then you can go back in and try again. Yeah, right. And they do suggest that sometimes you might have, you want the child to complete the task and sometimes you may not. And that's okay, but you're going to have that decision and you're just going to go back to that step one and then just keep going through the flow chart. I love it. And at the end, they give you tiny examples of smaller flow charts that, you know, a parent says, I have a, my kid has a hard time not interrupting me. Here's your flow chart. Well, here's what you're going to do. My kid throws his clothes on the floor. Here's a flow chart. So they give you kind of examples of what that flow chart is. So I love that. I think it's a great kind of encapsulation. If you're, if you're just learning about ADHD treatments and you're saying like, I get the principles, but what does it look like? I can't think of another article that sort of like, it looks, it looks like this, not all the time, but this is an example of exactly what the parent child relationship that you've trained will look like. Here are the decision points. Here are the responses. It's really neat that way. I don't, I can't think of too too many other articles that kind of capture that practice to visualization component quite, quite so succinctly. Great. All right. Well, we've covered the parent portion of things. What about the schools? Let's take a break. And when we come back, we will discuss just that. We'll be right back. [Music] Do you want to be a BCBA? Sure. We all do. Now you can come to Regis College in Western Mass to get your graduate degree. Choose from any one of these courses. Master's of Science in Applied Behavior Analysis. Master's of Science in Special Education. Dual degree in Special Ed and ABA. Or be eligible for your postmaster certificate. You can complete your degree and be ready to sit for the exam in two years and our 2017 grads had a hundred percent pass rate on the BACB exam. Come enjoy practical placement support, ethics mini handbooks, PhD level professors, small class sizes and a service trip to Iceland. If interested, don't delay. Supplies are limited. Learn more at regiscollege.edu. Again, that's www.regiscollege.edu. Regiscollege.edu. One more time, www.regiscollege.edu. See you there. [Music] And we are back talking about ADHD treatments. But before we get back into the conversation, I want to remind listeners that ABA Inside Track is ace approved by listening to our show. You're able to earn one learning credit. All you need to do is finish listening to the episode. Then go to our website, ABAinsideTrack.com/getCEU. That's G-E-T hyphen, C-E-U-S, or click the link down at the bottom of the show notes in your podcast player. Take your right to it and enter in some information, including two-seeker code words. I'm going to give you the first one now. It is Robin R-O-B-I-N. It's a bird. It's Batman's sidekick. Whichever one you want to remember, just remember the code word is Robin. All right. So before the break, we were talking about treatment at home. Let's talk a little bit about treatment in school. So I'm very briefly going to discuss a staff at all's 2021 review with using micro trials. I'm not going to go too far into this article though, because again, micro trials might sound really fancy. It's kind of just an ABA design paired with like a randomized control trial. It's not really special about it in that regard. And really, the question here was does behavioral teacher training for ADHD work as a treatment and so much as can we figure out the relevant components? Is it the antecedent components? Is it the consequent components? So I'm not going to get too much into the details and really just get to the results. But basically, what happened is we had a number of schools in the Netherlands and the teachers sort of were nominating a couple of their students. I think you get two maximum across all these different schools. And they said these trial is ADHD. Here are the symptoms. These are the symptoms that are most relevant to me of the list, kind of the DSM list of symptoms of ADHD. And then they were randomly placed into either the antecedent only package, the consequent only package or the wait list control non-package. Right. And then they were given some amount of training. Now, we talk about what did they learn? Well, if you're in the antecedent condition only you only learn the antecedent components of the training protocol. So teachers were taught how very stimuli will evoke problem behaviors. They were taught about how executive functioning can impact students with ADHD, what that looks like, how the problems develop over time, children might have trouble responding to certain stimuli as you might expect. And then identifying, all right, what are the relevant antecedents for the students that you're working with? And using what it sounds like an interview-based FBA though, I don't believe they called it anything like that. And then they talked about, well, here's how you could change some of those antecedents effectively. You could set clear rules. You could make clear instructions. You could discuss challenging situations in a response to the child in advance of this stimuli being presented. And you can add more structure to your classroom. Then they tell the teacher, "Why don't you pick one or two of these you want to use?" They practice. And then they'd send the teacher on their way. They come back in a couple weeks and say, "Hey, how's it going? Make any modifications?" And then they would, and that was the treatment. For consequent, same idea, it just was the consequent components of the behavioral treatment. So that was talking about how kids with ADHD had trouble with delayed rewards. What behavior might be shaped by the environment when they have trouble with these delayed rewards? How do you pick the relevant consequences for the child? And then how do you use praise? How do you use rewards, plan, ignoring, potentially negative consequences? I think more in the sense of kind of like when this rule gets broken, here's how you do some sort of restitution in the classroom, right? And then how could you do some amount of maybe shaping of some of those behaviors? So that's really it. Now you'll note that things like time out, we're not mentioned, or token economy, something more complex. We're not mentioned because the researchers did not want to do any component of treatment that had an antecedent and a consequent piece to it. So it really was a little bit like the light version of both of these treatment packages. And then only half of that light version to begin with. Same idea for treatment, two hour training, come back in a couple weeks, we talk about how things have been going. In the meantime, every week they get a phone call from the researchers who would say, hey, teachers, how is your child doing on blank, blank, blank measures? And the teacher would use a lighter scale to say, one to five, really great, not so great, whatever their score was. So once they were in a package, or once they were in a condition, that was their condition for the couple weeks in which they did this treatment. That's the microtrial there. And then a lot of statistics were done to determine what were the effect sizes seen. Now, previous research had shown effect sizes in schools were pretty moderate, but still positive in terms of overall outcome. And what was being looked at here was A, did they see better effect sizes when one versus another treatment was being used? And then B, were there differences in terms of the demographics of the student or demographics of the teacher that would go into whether the treatment was more or less effective? So the good news, both interventions improved symptomology of ADHD. They were both effective. And there really wasn't a statistical difference in how the training went and the results of the training. There was a large effect size for both antecedent and consequent groups, and they were significantly improved over the control group. So yes, what we already knew, these treatments are effective. What we might not have known is that just using antecedent interventions or just using consequent interventions can also be effective, which is great to know because telling teachers here's the giant package is going to have the same challenges as you might have with parents in terms of this training. So if you could only pick a few that makes the most sense based on your FBA to teach the teacher how to use, here are some antecedent techniques. Here are some consequent techniques. You might still see pretty good results and success for the child. These effects persisted up to three months from the start of intervention too, which is great. That's what you're seeing with the big package intervention. The majority of the teachers liked the interventions and they said, "I still use the things I learned in this study." Again, you see large effect sizes specifically for inattentive behavior, for oppositional behaviors, and a medium effect size for the hyperactivity and impulsiveness symptoms. But again, effect sizes none the left. Now where you did see some interesting patterns were when you were using consequent interventions for younger children, you saw significantly better results for those children. Though again, the antecedent interventions were effective, but they were significantly more effective for younger children. With older children, you get the opposite effect. The antecedent interventions seems to be more effective, though it didn't sound like it was significantly more effective, just had a larger effect than the consequent only interventions. And also, this is not too surprising. The smaller the number of students, the larger the effect size with the antecedent interventions, but not really that much of a difference for the consequent intervention. So, class size really only matters if you only want to use antecedent intervention, at least in this case. Some of the reasons the effect sizes were better in this study than in previous studies, might have been that some of the studies didn't really effectively use some of the antecedent interventions. They used like more general rules, so they weren't as specific, was one thing that was noted. It was surprising that there weren't any other moderating factors, but hey, that's great. You know, the less moderating factors, the better chance for generalization or, you know, the generalization of your treatment to lots of different populations, potentially, or settings. A big limitation, though, was the model of the treatment was pretty light. They never really talked to the teacher about what they were doing in the classroom. There's no guarantee that the teachers didn't actually use a whole bunch of other interventions. They just didn't talk about with the researcher. Maybe they started using consequent interventions, even though they were in the antecedent condition. So, while we do kind of see some of these patterns of both are effective, they're slightly more effective, slightly less effective, depending on the class size, depending on the population, the age of the student. There's no real, there's no real control for other components of classroom management having been used at the same time. So, I think this is kind of a light recommend. The big take home is these treatments can be very effective in schools. You may be able to get away with supporting teachers only in using portions of the overall package and still see benefits. Again, why that is is not clear. Maybe the antecedent, you know, the authors hypothesize maybe antecedent interventions work better with older students because what to older students with ADHD have less of? Structure, because their older, it's expected they already know how to do all the executive functioning skills. They already know how to navigate the classroom, but it's possible that they never got taught those skills and they are falling behind, so maybe the antecedent interventions are better in that population. Hard to say, that wasn't tested, but I think that's an interesting hypothesis. So, we know that we can make change in schools. We know that similar to parents. You may not need every component of the behavior package. So, now let's talk about one really interesting idea of taking some of the basic principles we've been talking about and tweaking it to use last decade's hottest tool. All right, that's your segue over to me to talk about this. Digest spinner study. So, you know, there was a body research that's looked at both allowing access to gross motor movement and then smaller fidget type toys either before or during academic tests to either improve academic performance or decrease disruptive behavior, potentially disruptive behavior. But it's a little bit of a mixed bag as far as what all that research looks like. And this study is one of the more promising ones in that arena and it just was just published. So, we were excited to see this and wanted to review it. I think if you are, you know, potentially consulting to a student and they're very likely these suggestions has been made or is currently being made that they are offered some type of fidget toy in the classroom. And this isn't to say that's automatically a bad idea, right? It very well could be a good idea, but we don't always know based on the research that we have published thus far. So, the idea behind this is that if we typically see higher levels of maybe hyperactive behavior or impulsive behavior from students, we could surmise that access to high motor activity would be reinforcing for these students. And from that, we could surmise that there is likely a high EO in place for engaging in some type of movement, right? So, that having a high EO for that would mean that movement is more likely to function as a reinforcer and behavior that produces access to additional movement is more likely to occur. Now, this, if you are a teacher attempting to have students sit down and learn in your classroom, then this may be difficult to accommodate and get the behavior that you're ideally looking for from your students. So, while there's some research that said increased movement has produced increased correct responding on academic tasks, the one that they quote is Hartanto and college 2016, while that may be true, figuring out how that's going to work inside a classroom setting, maybe a little bit more complicated. So, it's definitely been suggested and it's 100% out there and like the regular world, right? That maybe a small fidget toy could help and there is a lot of social validity for this idea. You hear a lot of people saying that they do use fidgets or fidgets might be helpful for them, might be helpful for their students. And from a behavioral perspective, this is working in the same way as the gross motor movement. And our authors here, I have a quote from them, this is from a behavioral perspective, fidgets may function as an abolishing operation that decreases the reinforcing power of more over disruptive movements. And quote. And again, it seems like a good idea. There's limited research in this area, but a few have looked at this with, again, kind of varying results. One of them that looked at disruptive movements in the classroom was led for it in college 2020. They found access to fidget toys with effective there. Others have looked at improving academic performance. Stalvie and Brassel 2006 used stress balls and found that they produced increased scores and lower distraction. And then other studies have looked at on task behavior. So for this one is Kirkoud and colleagues 20 sorry 2007. They had a small fidget and they saw higher on task behavior, but they did not see changes in performance, academic performance. So it's a little bit of a mixed bag for these. As far as like Rob said, the toy did sure maybe of the 2010s was fidget spinners. And so you know how long it takes you to study published, right? So now we're getting the research on the fidget spinners from 10 years ago probably. This recent one related to this fidget spinners specifically was Graziano and colleagues 2020. They gave ADHD students fidget spinners and they saw some improvements on on task behavior and being in whatever area they were supposed to be in. But it really worked the best where they were first given the spinners. So they thought there might be a novelty effect for that because it was kind of an exciting and different thing. But the results really did not persist over time. So with all of that background, the current study wanted to look at the effective fidget spinner use on on task behavior with elementary students who were diagnosed with ADHD in a general ed classroom. So that combination of factors had not yet been looked at. There were three participants here. They were all in second grade. They either had a diagnosis or were getting a diagnosis of ADHD. And they were referred by their teachers because they were seeing that they were not paying attention in class. And that was kind of defined as talking to friends, throwing objects around the classroom. And for one participant Carl, he was doing a lot of sleeping during the time. Poor guy. I know. I didn't mention it. I think he had seven troubles at home, I think, was an article too. Yeah. It seemed like he had a lot going on. So it was a concurrent multiple baseline across participants. And the DV that they picked was on task behavior. Now, like I just mentioned, right? There were like a bevy of choices of DV when you're looking at this research, which is partially why it's hard to get a full clear takeaway picture when you try to look at the conglomerate of research here, because you could do on task, you could do academic performance, you could do other disruptive behavior that maybe is not exclusive of being on task. So the one they picked was on task and they defined that as the student's eyes oriented toward work materials or the person speaking or another student who was following the teacher's directions. If the teacher said like, Joey, go pick up all the, you know, pencils. They watched Joey do it. That would be on task. They did the they clicked a data during centers. And if anyone wasn't there, they didn't collect data. So it was really was concurrent, which I thought was nice. They told us about that. And during the time period, each of the three students was always doing the same activity as well to kind of help control for it, but they were different activities. So one of them was in a reading reading group. One of them was doing guided reading and one of them was doing independent work. It was a 22nd MTS interval across 20 minutes. The IOA and the PI load's great. In baseline, no one had a fidget spinner. Teachers were told do business as usual. This lasted for four to 10 days, depending on the student. And then the intervention, they were given a fidget spinner. That was the intervention. They were all they were also told some rules to follow. And so they said you need to keep two fingers on the spinner at all time. Only use the spinner when doing work or listening to the teacher. Keep your eyes on the teacher or the work when you're using the spinner. You may use the spinner, but don't distract others with it. And finally, only you can use the fidget spinner, right? Like Smokey the Bear said, it's only you can use the video. Exactly. So once they knew the rules, understood the rules, then they got the spinner. And this treatment lasted for four to 10 days. All right. So this whole study was done in 20 days, about a being about a boom. The results overall looked pretty good. Everyone had variable, but low, low to mid scores for on task behavior in baseline. They were, you know, decreasing for the most part. And then when we move to treatment, everyone, once they received the fidget spinner, we saw an immediate increase in their on task behavior up to about 80, 80% on average of intervals, which was better. The, I'm sorry, the baseline scores it didn't tell you were probably averaging about 40, 30 to 40%. Our first participant Allison saw an immediate increase in stable rates of responding up near 80%. Our other two participants Ben and Carl, again, saw an immediate increase, but their daily percentages of on task behavior were more variable with a few points that were a little bit lower. Carl had one day where it was actually zero. You fell asleep. Yes. Hold on. So overall, it looked pretty good. What's why you get a zero sleeping? You're not using, you're finishing it fearlessly. So overall, those results looked pretty good, but they did have one more dependent variable that they were looking at here, which was validity, social validity. So they asked the students three questions. Did they like the fidget spinner? Did it help you stay on task and did it help you do more work? Allison and Ben both agreed with all the statements, but Carl disagreed with all three statements. Did they ask him all in as a sleep? I do not know. They didn't say. Okay, so that's like they're, you know, they probably got those results back and they're like, huh, okay, well, that's interesting. But then they added in another thing too, and they asked the teacher how they felt about the study. So they asked them, was this a good intervention? Did the students work completion increase? Did the students have more on task behavior? Are they going to use this in the future? Would they recommend it to other people? Teacher, and remember, there's only one teacher in the study, gave all of the questions to the lowest score possible. They said no to everything, strongly disagree for everything. I know. How heartbreaking as a researcher. It was hard not to read it as the teacher being like, yeah, but what have you done for me recently, researcher? Yeah, and that's the thing is they said, you know, when we started the study, the teacher identified the mangle for these students, and her mind was that the students don't disrupt other students, and they focus on their work. But at the end of the study, when they did the social validity, the reason, and they asked her why, did you score as a one, and she said the reason was because at the end of the study, she said, well, they are still not completing their assignments accurately. So what her expectation was for the students changed over the course of the study, and the dependent measure that they had chosen was just on task behavior. They weren't measuring any type of academic performance. So that was not reflected, and it was based on those initial goals. So they said, it kind of makes sense if they started to see the students more on task, then they would have higher expectations for them, and they'd say, well, now that they're on task, I want them to be on, you know, working more versus just maybe quote unquote, looking like they're working. So this, again, I think speaks to the challenges in trying to pick the right, even a variable for these studies, because they did see behavior change, which was great, but it wasn't everything that the teacher wanted at the end of the study. And that's not to say that the students couldn't get there or that the fidget spinners may not have been helpful in getting them there, but we don't have the full picture of what else might have happened at the conclusion of the study. I don't even know if they had data as to whether the teacher's report on the children are not doing more work or doing better on their work. I don't even know whether that was collected at the same, at the same time. Like did the teacher say, yeah, but on this day, when you had 100% or 90% on task, they failed the entire assignment. So we don't even know, like the teacher's memory of the events may not even be accurate. It may just be a sense of their grades aren't improving. Even though it was a short-term intervention, there are a lot of reasons grades can't improve. If you're ever consulting to a teacher and you're doing an intervention like this and get these results and you like to not be consulting to that teacher, you might recommend, well, this is where your teaching should come in. Like that's a great way to end that relationship, but real fast. Yeah. Your goal is to not have a job. So again, these are some of the more promising results that I've seen in this in this arena of studies related to fidget stress balls, etc. But there's definitely still more work to be done here given the social-lady results and then considering the population you're working with, the types of gross motor or fine motor fidgets you have access to and then the deepening variables that you're ultimately your goal. Well, I think we've covered all, covered all the bases, well not all the bases, but a lot of bases. So why don't we move into dissemination station? It's still really quiet. It's just not coming through. I don't know. That's all right. If you're watching the video, you got to see Jackie make great faces. If you're just listening, you may not know what section of the show we're in. So I'll tell you, we're now in the dissemination station section of the show where we do kind of a quick summary and talk about some recommendations for practitioners. Do you want to mind if I go first? Nope. Go ahead. Thank you. Thank you. So I think in terms of overall treatment packages, hey, here are kind of what we would be looking at as sort of the main components of ADHD treatment, whether you're working with families or whether you're working with teachers. So I don't think there's anything in any of these procedures that on their own sound confusing or hard for anyone who's been practicing behavior analysis for a while in the relevant settings. I think two of the pieces that were most interesting to me are really the utility of an FBA as a part of your component. Now I know we always, you should always be doing in a behavior assessment before you implement any treatment. However, I know for me, some of these practices feel like they could have been done preventatively to begin with, which hey, you know what, if you're working with a young enough parent child or teacher or student diet, maybe you do want to use some of these treatment practices preventatively. They're good practice to begin with. But when you are called upon to do a treatment plan, I think even if you're just doing an interview informed assessment or a very light descriptive assessment, you're still going to benefit from that because it's going to let you know what of these components are relevant and not just relevant for the student, but which are relevant for the stakeholder who have to implement these treatment options. I think sometimes we focus so hard on we've got to get the behavior under control and then generalization will happen at some point. We'll figure that out then. But with this treatment, it really is a matter of if you are using it only if you are using it with a family that is unable to follow through with all of the recommendations, you're just not going to see the same kind of significant reduction in symptomology of ADHD, which means you might have family saying this treatment is ineffective, your service is ineffective. So you really do have to take that into account from the jump of what are the barriers, what are the individual skill deficits of the child, what are some other kind of antecedents or what are some other factors or setting events that are going to make implementation of this treatment very, very difficult because this isn't the sort of treatment that I can work with this child and show reduction in symptomology and then I'll figure out how to transfer it to the family. You really want to be starting that off right from the beginning. So that's one kind of one takeaway ahead. And another was really unrelated to the articles, but a trend I know I've been seeing in schools, which is a lot more families are looking at the executive functioning component of supporting their child with ADHD and they're even, you know, executive functioning schools and ejected a functioning coaches popping up everywhere. And I realize I always sort of just assume, well, of course, that's going to be an important skill. We all need to work on our executive functioning skills, right, using calendars, using to-do lists. But one thing I don't think I've done and you know, as I was prepping for the episode, even just this morning, kind of reviewing my notes, I thought I kind of want to look into what these services are because when we look at sort of what the best research on, you know, treatment, behavioral treatments tells us executive functioning individual skills aren't actually a key component of these packages. They can be used and they may need to be a key component of these packages for decreasing the ADHD symptomology, but they themselves are not listed as they have to be included. That's going to be very specific to the family, to the teacher, and to the child or student that you are working with. So I'm kind of wondering, uh-oh, are a lot of families just assuming because executive functioning that if they have to have their child work on these ejection of functioning skills, that all ADHD symptomology is going to be decreased, and is that the result that they would expect to get? I don't know, I don't actually think we have a lot of research supporting just executive functioning skill acquisition as being a treatment for all of the symptoms that can lead to poorer outcomes for students with ADHD. So something to think about, you know, something to think about, is it just an ADHD not just being a skill acquisition deficit disorder, but being something that impacts a lot more areas of functioning for the individual, where we just focus on one or the other, may not see those same positive results. So again, I'm not saying anything wrong, there's anything wrong with executive functioning, training, or coaches, I just, it just made me think about how is that a component that needs to be a part of a package, or is it an optional component? I don't know. So something I'd like to see in future research myself. Well, I think what I would like to see is the use of those slow charts more, right? The use of these visual reminders for parents. In a simplified format, I like the smaller ones, rather than a larger one, right? That's kind of a lot to go through when you're just looking at it. But I like providing thinking of different ways, more creative ways to encourage the probability that that parents are going to implement treatments in a way that is going to be meaningful for them. I was just going to build on what you said, Robin, if people are interested in hearing more about executive functioning, we did do an episode with Dr. Andel and the Jalski, and talking about her research in that area, and that's episode 107. Yes, and her book Flexible and Focus, which I know I have used with a lot of students. I really like that book. It's nice, it's simple, it lays out kind of some of these executive functioning skills. So yes, yes, let's check that one out. Yeah. And check out the book. That's all. That's all I'm going to say, I think. I think I said my stuff in the middle. And buy stock and fidget spinners. All right. Well, so that I had a lot of fun going over our kind of review of ADHD treatment research. We hope you did as well. If you are joining us to watch, thank you so much for coming. Thank you for supporting us on Patreon. If you are watching this video after the fact, also, same thank yous go out. 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We just recorded our episode on the nurture effect, which was a great guide for preventative behavioral treatment at the parent, family, school, and societal level. And we'll be just preparing. When this comes out, we've got a couple weeks. We'll be doing another poll for patrons to choose a book about social justice topics will be our summer, our summer book library. We don't know a book yet, though. You'll have to check out the page again. That's patreon.com/ABA inside track. If you just want to get access to our podcast with subtitle feature, head on over to our YouTube page where that is available. You can check us out on social media where everywhere is ABA inside track. And if you want to email us with any questions or thoughts on this topic, please either message us through any of those social means or email at ABA inside
[email protected]. Let's make sure that everyone gets the second secret code word. It is chipmunk, CHIP, MUNK, what lives in my grill and digs holes all around our house to the point that I worried we're going to fall into a single. Why that would be chipmunks. Chipmunks. They also live under the basketball goal. And they live under a basketball goal. Yeah. Chipmunk. All right. If you were here with us again, big, big thank you for supporting us. Big, big thanks for joining us. If you're watching the video, thank you from the past. That video will be up in a couple days after we record that. Patrons, please check the little blurb under the post that only you can access for your third bonus, not a code word, but your bonus code. If you want to get a CE for watching and listening to this for no additional charge. If you're listening to this and you are just listening to the free feed, you can access that post. So it's all a mood point and you've probably done the skit button to the end of the show. So why don't we wrap up with some final big thanks, big thanks to Dr. Jim Carr for recording our intro and outro music to Kyle Sturry for making our interstitial song and for Dan Thabby to the podcast doctors for his fabulous fabulous editing work. We'll be back next week with another full length episode, but until then, keep responding. Bye. Bye. (gentle music)
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