The Effects of Nonverbal Cues on Behavior in ADHD-Diagnosed Adolescent Males

I. INTRODUCTION

Purpose

This study investigates whether a relationship exists between nonverbal cues and positive social interaction among two ADHD-diagnosed adolescent boys, one medicated and one non-medicated, in a small-group setting. Two boys, both 12 years in age, and in 7^th grade at a rural Illinois middle school, serve as the subjects of this study. Both boys have been clinically diagnosed with ADHD. One boy is clinically recognized as medicated, as he takes prescription Adderall, and the other is regarded as non-medicated, as his parents insist on solely homeopathic treatments.

The baseline measure for this study was collected over the course of two small- group social work meetings. The groups were held during the school day. The two boys and their fellow group members were pulled from their usual classrooms and placed in a separate room within the school for the 46-minute sessions. Direct behavioral observation was utilized during baseline measurement to gauge the current level of the boys’ active, positive participation in group proceedings. Instances of positive contribution to group discussion were noted with tick marks beside the boys name on a sheet of paper. Participation during the baseline measurements was limited, with the medicated boy offering minimal input, and the non-medicated boy offering no input whatsoever.

Research Question

Through the course of this study, it is likely that a relationship between nonverbal cues and positive group behavior in these boys will be recognized. It is probable that relative to the frequency of empathic nonverbal cues implemented by the social worker, the incidences of positive behavior within the group setting will increase among both the medicated and non-medicated, ADHD-diagnosed adolescent boys. For the purposes of this study the research question is, “Will utilization of nonverbal cues by a group leader impact positive behavior in ADHD-diagnosed adolescent boys?” The hypothesized outcome of this study is that there is a direct relationship between the frequency of nonverbal cues implemented by the social worker, and output of positive behavior displayed by both the medicated and non-medicated adolescent boy in the small group setting.

Relevance to Social Work

This study is pertinent to social work. Diagnoses of ADHD among school children have increased dramatically over the last ten years, which has raised questions among social workers and members of related social service and mental health fields as to the validity of these diagnoses, as well as the intervention methods, which rely heavily on the use of psychotropic prescription drugs. Social workers, particularly school social workers, must be aware of alternative methods of managing ADHD symptoms in children, as well as the simple need for understanding strategic interventions that can be utilized to control problem behavior in the classroom. This study intends to investigate one strategy (the use of nonverbal cues) intended to incite positive behavior among medicated and non-medicated ADHD adolescent boys, both belonging to groups relevant to the social worker.

Definitions of Variables in the Study

The independent variable in this study is the nonverbal cue, or wordless communication, implemented by the social worker, utilizing body language as a means of expression. For the purpose of this study, the nonverbal cue is defined as any of the following: head nodding, eye contact, head tilting, smiling, leaning in, head shaking, eyebrow furrowing, hand gestures, and winking.

The dependent variable in this study is positive behavior in the small-group setting. For the purpose of this study, positive behavior is defined by any of the following: hand raising, active participation in discussion, empathic expression, offering of advice, and refraining from side conversation.

These variables were measured using direct behavioral observation. For each instance of a nonverbal cue directed toward one of the boys by the social worker, a tick mark was recorded by the social worker. For each instance of positive behavior during group time, a tick mark was recorded by the social worker.

Summary

Through direct behavioral observation, this study will measure the frequency of positive behavior displayed by one medicated and one non-medicated ADHD 7^th grade boy in a small group setting, as a function of the frequency of nonverbal cues initiated by the social worker.

II. Relevant Literature

“ADHD” (Attention Deficit Hyperactivity Disorder) refers to one of a cluster of related neurobiological behavioral disorders, characterized by chronic, inappropriate levels of impulsivity, general inattention and often, hyperactivity (CHADD, 2001c.). ADHD is a brain-based condition resulting from differences in neurochemical and structural aspects of the central nervous system (Rief, 2005).

Approximately 15 million American children and adults, regardless of socioeconomic or intellectual status, suffer from ADHD. In fact, virtually every human being exhibits symptoms of ADHD, to a certain degree, at some time in his/her life. However, individuals suffering from ADHD display these traits to a developmentally maladaptive degree, as compared with others of their age (Rief, 2005).

ADHD is a “developmental disorder of self-control,” whose characteristic impulsivity, increased activity, and reduced attention span interfere with one’s ability to self-regulate in and out of the classroom (Barkley 2001b.). It is often incorrectly identified as a learning disorder, as behavioral symptoms associated with ADHD create “inconsistencies in performance, output, and production,” which are particularly damaging in the classroom (Rief, 2005). The most common neurobehavioral disorder of early childhood, ADHD is also highly prevalent in middle-childhood, making it one of the most common chronic health conditions affecting school-aged children (American Academy of Pediatrics, 2000). At one time, medical consensus seemed to suggest that ADHD was a disorder restricted to childhood, although it is now apparent that only about 33% of ADHD-sufferers “grow out” of the condition, while the other 67% continue struggling with it throughout adulthood (Hallowell & Ratey, 1994). For all suffering from ADHD, symptoms are pervasive and developmentally inappropriate, causing difficulty in daily life (Goldstein, 1999).

ADHD, although prevalent across age-groups, socioeconomic statuses, and intellectual levels, is most common during early childhood and school-age years. Therefore, addressing behavior modification in the classroom is an essential tool for educators and other school personnel. Among the many approaches to ADHD intervention, one tactic with only limited research literature is the use of nonverbal cues in the classroom or other group setting.

Because ADHD is accepted as a disorder of self-control, it is logical to presume that redirection and intensive, consistent reinforcement of social norms and cues would likely be helpful in regulating self-control in ADHD patients, particularly in the classroom or other group setting (Johnston, 1991). Using nonverbal cues to reinforce such norms would be helpful, as they would mirror of broader social situations, in which such cues are often subtle, silent, and frequent. Also, maintaining active nonverbal contact with an ADHD student would engage the student in the lesson or discussion by providing increased direct visual stimulation, and creating a sense that the student is essential to the lesson at hand. This combination of a sense of involvement and increased visual stimulation would, theoretically, blunt the symptoms of ADHD, creating a more conducive learning environment for the student. It should also be noted that the student is being actively watched during the class or other group setting, which may also influence his/her behavior during this time. Whether affecting the student through intimidation of being watched, or engagement in conversation through obvious nonverbal attention from the instructor, nonverbal cues present a logical, subtle theoretical method of obtaining attention and participation from the ADHD student.

III. Methodology

Introduction

This study examines whether positive behavior in ADHD-diagnosed adolescent boys will be affected by nonverbal cues. This SSD will help provide data reflecting the efficiency of a behavior intervention on target (positive) behavior. A consistent measurement approach is utilized throughout the report. These measurements are based on direct observations by the researcher. Data was recorded during two baseline sessions, four follow-up sessions, and two new baseline sessions. This study investigates whether simple nonverbal cues will increase the positive participation of two ADHD-diagnosed adolescent boys in a social work group setting.

Type of Study

This is an exploratory, quantitative study. It intends to search for a relationship between an intervention and a target behavior, and is measured with numerical data (which will be interpreted statistically later in the report).

Study Design

This study uses single subject, A-B-A methodology. This design is most appropriate for the study because it allows for repeated measurements, which reduce false conclusions, and a total of four baseline measurements (two initial, and two follow-up). Adequate baseline measurements provide a solid control against which to measure repeated observational data., resulting in as accurate inferences as possible.

Intervention

In a middle school setting, students with academic, emotional, or other identified social or developmental problems are referred to social work groups for support and social skill development. The two boys in this study participate in a group co-led by the researcher. Within these groups, there are often students displaying difficulty participating appropriately in group discussion. In particular, students diagnosed with ADHD present difficulty focusing on group tasks, and offering relevant input when appropriate. This study examines whether the social researcher’s use of seven specific nonverbal cues (nodding, smiling, eye contact, hand gestures, head shaking, head tilting, and smiling) increase prevalence of positive student participation (as indicated by hand raising, relevant input, sharing stories when called upon, refraining from side conversation) in the group setting. The researcher actively utilized each of these nonverbal cues within the four non-baseline measurements, and document the number of times the students observed exhibit positive participation during that group meeting. Data was compared against two initial baseline measurements, in which no nonverbal cues were used, and again in two “new” baseline measurements at the conclusion of the study.

Population and Sample

The participants in this study are two 7^th grade boys, both 12 years of age. One of the boys is medicated for his ADHD, and one is not. The boys were chosen through convenience sampling, as the researcher is time-limited at the middle school group sessions, and both boys met the criteria of being ADHD-diagnosed, and being involved in social work groups co-led by the researcher. The school is set in a rural town approximately 75 miles west of Chicago, IL. The majority of the students in the school are Caucasian, and socio-economically lower-middle class. Both boys involved in this study are white males, also belonging to the lower-middle class. They come from intact nuclear families, living in single-family homes.

Investigative Techniques

Direct behavioral observation was the primary technique used in collecting data for this study. This was the most appropriate technique for this study, largely because it allowed for a relaxed setting with minimally-disruptive research methods. Students were able to act naturally and openly, while the researcher was able to directly observe the situation where problem behavior was frequently noted.

Instrumentation

To record data, the researcher simply initiated the aforementioned seven nonverbal cues, and recorded instances of positive participation by the two boys during group time. No standardized instrument was used in data collection. The use of direct behavioral observation in this study was not adversely affected by the lack of a standardized instrument, as the researcher herself observed all the data, and did not require any feedback or further written recordings from any outside source. Frequency of positive group behavior was recorded via tick marks on a sheet of paper, over a total of eight weeks. For statistical purposes, the researcher will identify each student’s total tick marks per day as his “positive behavioral score.”

Collecting Data

Direct behavioral observations were recorded during social work group time. The group met for 46 minutes, each Monday morning, from September 19^th, 2005, to November 14^th, 2005. Observations were recorded each meeting for a total of eight meetings (see Appendix A).

Data Analysis Plan

Statistics will likely be interpreted as descriptive/univariate. There was only one variable being tested and controlled for (univariate), and the major aspect being measured was frequency of a target behavior. Also to be measured is whether there is a central tendency of both boys toward a similar behavioral result.

Human Subjects Protection

The researcher gained permission from the school social worker to conduct this study with the boys during group time. During all data recording, pseudonyms were assigned to the boys to ensure confidentiality. During a conference, the school social worker and the researcher concluded that subtle nonverbal cues, and candid behavioral observation were neither physically nor emotionally risky for human subjects.

Ethics

The power differential between the researcher and subjects was existent, though not monumental. The subjects were aware of the researcher’s status as a student intern, and frequently acknowledged the researcher as being “young.” They clearly felt a connection and significant level of comfort with the researcher, though they were aware of her role as a staff member. Also, the students were informed before the study began that the researcher “may act a little differently” during group time, but it was just because she was trying to understand people’s feelings better.

Bias

The major differences between the researcher and the subjects of this study were educational level, gender, and developmental level. The subjects are both early adolescent, 7^th grade males, while the researcher is a 24-year old female graduate student. Both the subjects and the researcher have significantly varied outlooks on life, friendships, and the world in general, which may affect the way they interacted, communicated, and understood one another.

IV. Findings

Introduction

This study investigated the hypothesis that use of nonverbal cues by a social work group co-leader (the researcher in this study) would increase output of positive behavior in ADHD-diagnosed adolescent boys. Within a small group of eight seventh-grade boys, aged eleven to twelve years, two ADHD-diagnosed boys were singled out for this study.

One of the boys was medicated, taking a daily regimen of prescription Aderrall, while the other boy was non-medicated. The researcher interacted with these two boys exclusively through nonverbal interaction for four consecutive group meetings, and recorded instances of positive participation by each boy as the behavior occurred.

Results

The independent variable in this study was the use of nonverbal cues as reinforcement by the researcher. The dependent variable in this study was the output of positive behavior by the boys during group meetings. The researcher utilized an equal number of nonverbal cues in communicating with each boy throughout the course of the group meetings. No nonverbal cues were explicitly used during the four baseline measurements.

Over the course of the eight week study, the instances of positive behavior displayed by each of the boys increased at a rate paralleling the use of nonverbal cues. The medicated boy offered slightly more positive participation than the non-medicated boy overall, but proportionally, both boys increased their positive behavior noticeably from their baseline levels (see Appendix B).

Instances of positive behavior, as well as incidences of nonverbal cue use, were recorded via tick marks by the researcher. These recordings, derived from direct behavioral observation, clearly signify an increase in positive behavior output as a function of nonverbal communication from the researcher.

Summary

As graphically visualized, each boy’s behavior increase from the baseline was steady and noticeable. Over a period of two weeks, positive behavior in each of the boy’s cases had nearly doubled from the initial baseline measurements. Also, although the recorded positive behavior fell slightly for each boy during the follow-up baseline measurements, it remained considerably higher than in the initial baseline measurements. This suggests that the effects of nonverbal cues were long-lasting, and may have built a rapport between the students and the researcher that enhanced behavior quality, even when the researcher ceased using nonverbal communication as methodically.

V. Discussion

This study attempted to explore the potential relationship between nonverbal cues and positive behavioral output in two ADHD-diagnosed adolescent boys. In doing so, the study covertly attempted to examine discreet, effective behavior management of ADHD symptoms.

Conclusions

Analysis of data collected revealed that the initial hypothesis was correct: the results indicated a clear, positive relationship between the researcher’s use of nonverbal cues and positive behavior output. As hypothesized, use of nonverbal cues by the researcher incited increased positive participation in group discussion on behalf of the two ADHD-diagnosed adolescent males. Within the first non-baseline measurement, the subjects’ recorded positive behavior increased slightly. Over the next two meetings, it peaked, and leveled off for the remaining meetings. The final two “new” baseline measurements revealed a slight drop in positive participation (relative to the measurements taken during the intervention process) which may be attributed to the halt in nonverbal cue usage during this time. However, the final baseline data demonstrated notably higher instances of positive behavior output than was recorded during the first baseline measurements. This trend not only suggests that the researcher’s use of nonverbal communication during the intervention phase impacted the participants’ behavior, but also indicates that these behavioral influences were lasting. Although further research is necessary to determine causality, the data suggest that an intervention utilizing nonverbal cues yielded an increase in positive group behavior in the ADHD-diagnosed seventh-grade boys in this study.

Limitations

An obvious limitation of this study was the medication status of the participants. One boy was medicated, and one non-medicated, which may have affected their processing of and responses to the nonverbal cues. Another limitation was the consistency of the participants; on three occasions, one or both of the boys arrived to group more than five minutes late, which offered less time for the nonverbal communication to unfold naturally. Finally, the time constraints involved in the study allowed for limited data collection. This study was part of a requirement, due midway through a sixteen-week graduate research course. The restricted number of group meetings allowed for few measurements, whereas the most reliable results would be gathered from several more meetings and measurements, taken over a longer period of time.

Implications

The data collected in this study suggests a speculative relationship between nonverbal cues and positive behavioral output. Because the subjects of this study were two ADHD-diagnosed adolescent boys, any implications therein cannot be generalized to a larger population. However, the information gathered from the data could be beneficial to social workers dealing with ADHD-diagnosed adolescents. The study outlined a clear behavioral intervention, which proved successful with a small sample of the target population (ADHD-diagnosed youth). Through further studies, these implications may be cemented, or expounded upon, and used in the development of innovative new interventions for adolescents (and perhaps other populations) diagnosed with ADHD. Information gleaned from this study may provide a stepping-stone for social workers, educators, researchers, and theorists in their approaches to understanding, accommodating, providing treatment for, and controlling symptoms of students diagnosed with ADHD.

VI. Cited Literature

Barkley, R. A. (2001b). Genetics of childhood disorders: XVII. ADHD, Part I: The executive functions and ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1064-1068.

Children and Adults with Attention Deficit Disorders (CHADD). (2001). The disorder named AD/HD – CHADD fact sheet #1. Retrieved October 15, 2005, from http://www.chadd.org.

Goldstein, S. (1999). The facts about AD/HD: An overview of attention-deficit hyperactivity disorder. CHADD 1999 Conference Book. Landover, MD: CHADD.

Hallowell, E.M. Ratey, J. (1994). Driven to distraction : Recognizing and coping with Attention Deficit Disorder from childhood through adulthood. New York, NY: Touchstone.

Johnston, R.B. (1991). Attention deficits, learning disabilities, and Ritalin: A practical guide (2^nd ed.). San Diego, CA: Singular Publishing Group, Inc.

Rief, S. F. (2005). How to reach and teach children with ADD/ADHD : Practical techniques, strategies, and interventions. San Francisco, CA: Jossey-Bass.