Learning Strategies and Social Skills Training for Students with AD/HD

Steven R. Forness, Dwight P. Sweeney, and Steven R. Wagner

Although there is no "typical" educational program for AD/HD, learning strategies and social skills training are likely to be important for most students with AD/HD, both in regular and special education classrooms.

As all parents and educators know, each child is first and foremost an individual with his or her own particular pattern of strengths and needs for improvement. While this is clearly true of all children, it is particularly important to remember when designing interventions for children who have AD/HD. Studies of students with this condition indicate that a significant percentage may have problems in only two of the three core symptoms areas (i.e., inattention, impulsivity, and hyperactivity) (Lahey & Carlson, 1991). Research also shows that although children with AD/HD generally score in the normal range on IQ tests, some are intellectually gifted whereas others have IQs that fall in the range of mental retardation (Forness et al., 1992). Similarly, their academic achievement scores also vary considerably. Studies of psychiatric diagnoses indicate that perhaps as many as half of all children with AD/HD have significant conduct problems, in addition to attention deficits, and that others have depression, mania, or anxiety disorders (Biederman et al., 1997; Bussing, Zima, Belin, & Forness, in press; Carlson & Rapport, 1989; Szatmari et al., 1989).

Clearly, there is no "typical" educational program for AD/HD because the difficulties of any individual child with this diagnosis will vary considerably depending on age, presence or absence of associated problems, level of academic functioning, and a variety of other factors. Nevertheless, there are some components of educational programming that are likely to be important in most cases of AD/HD, and they are routinely used with a wide variety of children with learning and behavioral difficulties, both in special education settings as well as in the regular classroom (Forness, Kavale, Blum, & Lloyd, 1997). Two of these components are learning strategies and social skills training.

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Children with AD/HD frequently have difficulty monitoring and regulating their behavior to fit the changing demands of both school and social situations. Whereas most children may talk themselves silently through new tasks, they quickly move beyond these subvocal means of regulating their behavior as their responses become more automatic. Children with AD/HD, however, often do not seem able to automatically generate these strategies on their own because their inattention and impulsiveness interfere.

Teachers have discovered that such strategies, which seem natural or automatic in most children, have to be taught systematically to children with AD/HD (Ellis et al., 1991). These approaches are generally termed "cognitive behavior modification" and have been shown to be quite effective in managing hyperactive, inattentive, or impulsive behaviors that interfere with learning (Robinson, Brownell, Smith, & Miller, in press). The overall approach is to:

1. Isolate techniques or strategies that are necessary for certain tasks
2. Demonstrate or model them for the child
3. Have the child rehearse their use
4. Give the child feedback on how well he or she seems to have mastered the strategy
5. Encourage and monitor the child the first few times he or she uses the strategy in actual practice

It may be further necessary to cue the child as to when he or she needs to use the strategy or which strategies need to be used with which tasks. The overall goal is to diminish the child’s reliance on these external prompts and eventually make strategies become as automatic as possible.

An example of such an approach involves the issue of impulsiveness. When given a task such as a worksheet with multiple choice answers, many children with AD/HD will read the question hurriedly and pick the first answer that comes to mind. The goal of this intervention technique is to interrupt this rush from stimulus (question) to response (answer) and interject a more reflective and systematic approach between the two events. With very young children, a teacher might operationalize the process described above in this way.

1. Isolate techniques or strategies. Place four little cardboard cutouts upright on the child’s desk. The first is a stop sign (stop); the second is a happy face with the eyes enlarged or enhanced (look); the third is a happy face with the ears highlighted (listen); and the fourth is a happy face with little exclamation points above the head (think). (Involving children in making the cutouts can often ensure that they incorporate the strategy as their own.) Ask the child what each cutout means and guide him or her toward the correct interpretation.

2. Demonstrate or model on a similar task how the child should read the question carefully, then stop, look at all the possible answers, listen or review the directions or alternatives, think about the correct possibilities, and then choose the most appropriate answer.

3. Rehearse. Ask the child to follow the sequence, thinking aloud so the teacher can monitor his or her approach.

4. Give feedback. As the child practices the correct strategy with the teacher, coach the child on his or her application.

5. Encourage and monitor. Leave the cutouts on the child’s desk, and guide and prompt the child as necessary when he or she begins to apply it to new tasks (e.g., reading aloud, answering questions in a class discussion, doing a math problem).

The ultimate goal is to have the child incorporate the strategy so completely that he or she no longer needs the cutouts as a reminder. The strategy can be adapted for slightly older children by using a more discreet strip of paper with the four figures on it as the initial visual display or by focusing only on the verbal sequence of the four steps.

Other approaches in this general area of learning strategies involve self-monitoring or self-recording, in which children are taught to keep a running tally or record of their own behaviors. For example, students can keep track of and record the number of minutes on-task during a specified period. (See article by Scott, this issue, for more information.) Self-organizational skills are another form of strategy training. This could involve study skills in which children are taught to scan the text to be read prior to beginning, note the main points or concepts that will be discussed, underline or note key phrases as they read, outline the main points and subpoints that were learned, and then synthesize and evaluate what they have learned in their own words. Many different types of learning strategies can thus be devised over a wide range of academic skills or subjects. These strategies can often be developed in cooperation with the child in order to enlist his or her support for using the strategy (Graham et al., 1992).

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Many children with AD/HD have difficulty with social relationships because of impulsiveness, lack of attention to social feedback, or behaviors that are perceived by others as immature, aggressive, or defiant. Although most children develop social skills by observing and interacting with others, the child with AD/HD may not as readily profit from these interactions or may have diminished opportunity to learn because of social rejection. A number of social skills training programs are now becoming available for use by teachers (Walker & Fabre, 1991; Walker et al., 1983), which address a variety of social skill deficits that occur in school settings.

Some of these social skills curricula are designed to systematically cover a variety of topics such as basic manners, asking for help and permission to do things, beginning and carrying on a conversation, initiating a play activity, sharing belongings, recognizing and expressing feelings, dealing with aggression, developing friendships, responding to group pressure, demonstrating sportsmanship, and a variety of other essential social skills. The lessons included in such curricula typically involve describing or modeling the behavior to be learned, which is sometimes done using prepared videotapes of these behaviors. Role playing follows, in which the child gets a chance to demonstrate and practice the behavior while receiving feedback, encouragement, and helpful criticism. Finally, the child demonstrates the social skill (generalization) in another setting or a new situation. Some programs include homework assignments to practice the approach with a parent or a friend.

Other opportunities to develop social skills occur daily as a way of resolving conflict or dealing with social skills issues. For example, a child with AD/HD may impulsively snatch items, such as a box of crayons, from another child. In this situation, the teacher can immediately choose to use a brief period of time out, in which the child must temporarily leave the group, stand off to one side for a minute or two, and not be allowed to participate during that time. Upon rejoining the group, he or she can then be shown the correct way to ask permission to use the crayons (modeling), be given a chance to do so with the teacher or even with the same child (practice), and then be praised or encouraged for doing so correctly (feedback). However, it is important to note that time out should not be used with children when their behavior seems to be escape motivated (Sweeney & Toy, 1996). Using such "teachable" moments may in fact be more effective than the use of purchased social skill training programs in some situations with children with AD/HD (Forness & Kavale, 1996).

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Even for children who are not eligible for special education (which guarantees special assistance), there are many other ways for the school to provide help for a child with AD/HD. Furthermore, the effectiveness of combining these treatments is very important. It has generally been established that in some cases, coordinated educational, family, and psychopharmacological interventions are required for successful outcomes (American Academy of Child and Adolescent Psychiatry, 1997; Pelham, 1989; Satterfield et al., 1987). Whether in general or special education, knowing about the many components of a good comprehensive program for children with AD/HD—such as learning strategies and social skills training—should assist teachers and parents when designing opportunities for the children’s school success (Forness & Walker, 1994).

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