Transcript Evidence-Based Psychosocial Treatment of ADHD

Evidence-Based Psychosocial
Treatment of ADHD
Developed by the Center for School Mental Health with support provided
in part from grant 1R01MH71015-01A1 from the National Institute of
Mental Health and Project # U45 MC00174 from the Office of Adolescent
Health, Maternal, and Child Health Bureau, Health Resources and Services
Administration, Department of Health and Human Services
What works for ADHD?
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All of the evidence-based practice
elements for use in ADHD have their basis
in Clinical Behavior Therapy.
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We will first cover the basic premises behind
behavior therapy, then cover the specifics of
effective interventions for ADHD
What doesn’t work for ADHD?
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Treatments with little or no evidence of
effectiveness include
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Special elimination diets
Vitamins or other health food remedies
Psychotherapy or psychoanalysis
Biofeedback
Play therapy
Chiropractic treatment
Sensory integration training
Social skills training
Self-control training
Clinical Behavior Therapy:
Theory
Proposed Mechanism: Individuals with
ADHD have difficulty understanding the
consequences of their actions.
Approach: Application of the principles of
social learning theory to modify children’s
behavior by training parents and teachers
to manipulate environmental antecedents,
consequences and contingencies.
The ABC Model
Antecedents
Behavior
Contingencies
Consequences
An example: The ABC Model
Antecedent
9:30 bell signals
beginning
of math period
Behavior
Student ignores
bell while rest of
class takes out math
books
Consequences
Teacher yells at
student
The ABC Model
Antecedent
9:30 bell signals
beginning
of math period
Behavior
Student takes out
math book
Contingencies
Teacher makes
eye contact
with student,
says, “Take
out your math
books.”
Consequence
Teacher smiles
at student
Specific interventions to help the
student with ADHD
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Psycho-education with parent
Parent praise
Commands/limit setting
Tangible rewards
Response cost
Parent monitoring
Time out
Ignoring or DRO
Parent Psychoeducation
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Engage and empower parents by teaching
them about ADHD
Establish relationship with parents as
partner in treatment process
Look at how ADHD influences parent-child
interaction (bi-directional)
Parent Psychoeducation
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Review information about ADHD
Symptoms
 Causes
 Diagnostic criteria (3 sub-types)
 Treatment modalities
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Parent Psychoeducation
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Emphasize caretaker role in development
and treatment of ADHD
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Problems in parenting and parenting styles
may make ADHD worse
Establishing behavioral interventions at home
or at school require caretaker involvement
Knowledge enables parents to more
effectively advocate for better services
Parent Psychoeducation
 More effective if therapist devotes more
than one session to psychoeducation
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More effective if therapist educates
parents about ADHD across multiple
settings (home, school, playground, etc)
Resources for Parent
Psychoeducation
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Center for Children and Families
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“What Parents and Teachers Should Know
about ADHD”
Children and Adults with AttentionDeficit/Hyperactivity Disorder (CHADD)
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Fact sheets for parents
Resources for Parent
Psychoeducation
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National Initiative for Children’s Healthcare
Quality
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“How to Establish a School-Home Daily Report
Card”
Vanderbilt Assessment Scales (parent and
teacher version)
ADHD Resources Available on the Internet
“Working with Your Child’s School”
Parent praise
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Training parents to praise correctly
increases compliance in youth with
ADHD
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Praise can include
 Verbal
praise, Encouragement
 Attention
 Affection
 Physical proximity
Giving effective praise
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Be honest, not overly flattering
Be specific
No “back-handed compliments” (i.e., “I
like the way you are playing quietly, why
can’t you do this while I’m on the
phone?”)
Give praise immediately
Training parents to praise children
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Barkley manual, Step 2 (Defiant Children)
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Teach parents to set up “special time” to pay
attention to their child during play
Teach parents to narrate their child’s play
Teach parents not to ask many questions nor give any
commands
Teach parents to ignore misbehavior during this
playtime
Teach parents how to praise and praise lavishly
during this time
Training parents to praise teens
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Barkley manual, Step 3 (Defiant Teens)
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Encourage parents to set aside 15 minutes a few
times a week to pay attention to their adolescent
Teach parents to pay attention to what their teen
is doing, and show interest in a relaxed way
Teach parents not to ask questions nor give any
instructions
Teach parents to ignore if the teenager reacts
with sarcasm, coolness or suspicion
Teach parents to praise well and often
Improving commands/limit setting
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Training for parents and teachers to give
commands in the most effective way
Effective command increase compliance in
children and adolescents with ADHD (and
in others, too!)
Improving commands/limit setting
with children
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Barkley Step 3 (Defiant Children)
Teach parents and teachers:
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To only give commands that they intend to
back up with consequences (positive and
negative)
Not to present commands as questions or
favors
Not give too many commands at once
Improving commands/limit setting
with children
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Teach parents and teachers:
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To make eye contact with the child before giving
command
To reduce other distractions while giving commands
To ask the child to repeat the command
To watch the child for one minute after giving the
command to ensure compliance
To immediately praise child when s/he starts to
comply
Improving commands/limit setting
with adolescents
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Barkley, Defiant Teens, Step 4
Teach parents and teachers:
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To consider the intent of their command
Do they have the time/energy to follow through?
 Do they have consequences for noncompliance?
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To avoid ambiguity when issuing commands
To not respond to compliance with gratitude
Improving commands/limit setting
with adolescents
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Teach parents and teachers:
 To praise teens for appropriate behavior
 To tell teen what to do, rather than what not
to do
 To eliminate other distractions while giving
commands
 To break down multi-step commands
 To use aids for commands that involve time
Tangible rewards
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Children and adolescents with ADHD do
not respond to natural (intrinsic) rewards
as well as typical youth
The training of parents and teachers in the
use of tangible rewards is effective in
increasing desired behaviors
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Can use token systems, behavior charts, or
immediate rewards
Setting up a reward system for
children at home
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Barkley, Defiant Children, Step 4
Determine family’s readiness to implement
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Tailor the program to family’s ability-simplify it
for overwhelmed or stressed families
Use poker chip system with younger
children (4-7), point system with older
children (8 and up)
Setting up a reward system for
children at home
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Set a positive tone for the program
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“We are going to make sure that you get rewarded for all of
the good stuff you do at home”
Parent(s) buys chips and makes a bank, or sets up a
chart or notebook for tracking points
The parent(s) and child together (with your help)
make up a list of 10-15 rewards
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There should be everyday rewards, like TV or computer time,
and longer term rewards, like going to a movie or earning a
new video game)
Setting up a reward system for
children at home
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Help the parent(s) and child make a list of
jobs or problem areas
Determine how much each is worth
Add up how much the child might earn in a day
 Harder jobs should earn more
 Bigger rewards should cost more
 Make sure the child has some success in the
beginning
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Setting up a reward system for
children at home
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Discuss the concept of bonus chips to reward
helpful or other positive behaviors, even if
they aren’t on the list
Chips and points are only given if the child
complies after the first command
Don’t take away chips or points (response
cost)
All caregivers should use the same system
Remind parents to praise while giving the
points
Setting up a reward system for
children at school
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Barkley, Defiant Children, Step 8, Daily School
Report Card
The teacher tracks the child’s behavior and
reports it to the parent daily, who rewards the
child
This is particularly effective because both the
parent and teacher are involved
If the parent can’t be involved, the rewards may
be given at school
Setting up a reward system for
children at school
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Choose a few target behaviors at school
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Choose one that the child will be successful
with most of the time
Set up a system for school report card or
school/home note system
See samples on page 244-246
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Pick from the targets given, or create your own
with the blank samples
Setting up a reward system for
adolescents at home
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Barkley, Defiant Teens, Step 5
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Use a point system (see previous slides) for
13/14 and under
Set up basically the same way as with children
 Warn parents to expect resistance, their teen is
used to getting all of their privileges for free!
Make sure parents don’t give in.
 Make sure parents only choose privileges they can
control
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Setting up a reward system for
adolescents at home
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Barkley, Defiant Teens, Step 5
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Use a behavior contract for teens 14/15 and
older
See sample contract on page 208
 Begin with only “do” behaviors (clean up room, set
table, get ready for school on time)
 “Don’t” behaviors are dealt with under response
cost in next section
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Setting up a reward system for
adolescents at school
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Barkley, Defiant Teens, Step 9
Establish a homework contract (see sample on
page 121)
This can be adapted for other behavioral goals
Can also set up guidance counselor, tutor or
peer as “coach” for organizational skills or other
targets
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Rewards for teen’s participation can be made part of
the home contract, or part of a school reward system
Response Cost
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Using a point or token system in which
negative behaviors result in the loss of
points or tokens.
Training parents and teachers to use
response cost is effective in reducing
undesired behavior and noncompliance
Response Cost with Children
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Barkley, Defiant Children Step 4 & 8
Train parents and teachers:
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To develop list of undesirable behavior to be
fined by reward system
To deduct points/chips for undesirable
behavior
Parent and child have chosen to reduce whining
 If child whines, parent deducts three points
 Penalties increase based on severity of behavior
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Response Cost with Children
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Train parents and teachers:
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To avoid “punishment spiral”
When parent fines child for misbehavior, the child
may respond with more misbehavior
 Child continues to lose points, then loses
motivation for the point system
 Rule: Parent fines child once through point
system, then sends child to time out if undesirable
behavior continues
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Response Cost with Adolescents
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Barkley, Defiant Teens Step 6
To train parents and teachers:
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To now use behavioral contract with the teen
for “fines”
Teen agrees to not swear
 If teen swears, teen loses Internet privilege
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Response Cost with Adolescents
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Train parents and teachers:
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To begin with 1 week “training period,” during which
parent labels misbehavior every time it happens and
warns of new fines
To avoid “punishment spiral”
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When parent fines teen for misbehavior, the teen responds
with more misbehavior
Teen continues to lose privileges, then loses motivation
Rule: Parent fines teen no more than twice, then directs
teen to “cool off” away from the situation
Response Cost with Adolescents
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Encourage parents to act as “judge and
jury” when teen lies
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The teen should remain above suspicion
Response cost allows parents to
discipline/educate instead of just punish
Emphasis of response cost is on
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“Warm” – positive, loving
“Firm” – specific, immediate, and consistent
Parent Monitoring
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Give parents a structured way to monitor
their child’s behavior
Measurement of the target behavior
should be repeated
Can use either informal or formal
measures
Parent Monitoring
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Informal measures
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Daily homework log
Behavior chart as part of a reward system
Home Situations Checklist (Barkley, Defiant
Children)
Parent Monitoring
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Formal measures
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Vanderbilt Scales (from your Resource Toolkit
or on the web)
Disruptive Behavior Disorders Scale (in
Barkley or on the web)
Time Out
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Time out is the removal of a child or
adolescent from all reinforcement for a
specified period of time after a targeted
misbehavior
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It is an effective intervention, but only if it is
used correctly and is not used too often
Using Time Out with Children at
Home
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Barkley, Defiant Children, Step 5
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Teach parents to give an effective command
(Step 3)
Teach parents to count out loud (initially)
from 5 to 1
Teach parents to give a time out warning if
the child has not complied
After warning, count from 5 to 1 again
Using Time Out with Children at
Home
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Teach parents to guide child to time out chair
IMMEDIATELY
Teach parents to place the child in the chair
“Stay there until I tell you to get up”
Teach parents not to argue or interact with
the child in any way
Teach parents to not come back until the child
is calm. Once the child is calm and the time
is served, the child must correct the
misbehavior
Using Time Out with Children at
Home
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Teach the parents that the child should now
go and comply with the previous command,
or correct the misbehavior
Teach the parent to now praise compliance,
and to praise the next behavior that the child
does well
Time Out Tips with Children
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The first time out may be difficult
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Prepare parents for a worst case scenario of a
complete struggle.
Reassure parents that this is how the child learns time
out and correcting misbehavior.
Make sure the time out area is away from
anything interesting or fun
Remind parents not to “make up for” the time
out (i.e., saving dessert for them)
Using Time Out with Adolescents
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Barkley, Defiant Teens, Step 8
“Grounding” = “house arrest”
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NO access to privileges (phone, TV, etc)
Parent must be home to enforce
Most effective with younger teens
May include “work detail” (cleaning out
basement, scrubbing bathroom floor)
Ignoring and Differential
Reinforcement
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Train parents and teachers to
selectively
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Ignore mild unwanted behaviors
AND
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Attend to alternative positive behaviors
Teaching parents and teachers to
ignore
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Teaching parents and teachers how
and when to ignore undesirable
behavior
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Ignoring can include
 Visual
cues
 Postural cues
 Vocal cues
 Social cues
How to ignore
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Visual cues
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Look away once child engages in undesirable
behavior
Do not look at the child until behavior stops
Postural cues
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Turn the front of your body away from the location of
child’s undesirable behavior
Do not appear frustrated (e.g., hands on hip)
Do not vary the frequency or intensity of your current
activity (e.g., chopping faster, hammering harder)
How to ignore
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Vocal cues
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Maintain a calm voice even after your child begins
undesirable behavior
Do not vary the frequency or intensity of your voice
(e.g., don’t talk faster or shout over the child)
Social cues
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Continue your intended activity even after your child
begins undesirable behavior
Do not panic once child’s begins inappropriate
behavior (i.e., do not draw more attention to child)
When to ignore
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When to ignore undesirable behavior
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Child
Child
Child
Child
interrupts conversation or class
blurts out answers before question completed
continuously talks during dinner
tantrums while at the grocery store
Do not ignore undesirable behavior that could
potentially harm the child or someone else
Differential reinforcement
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Teach parents and teachers how and
when to differentially reinforce desirable
behavior
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Step One: Ignore (stop reinforcing) the
child’s undesirable behavior
Step Two: Reinforce the child’s desirable
behavior in a systematic manner
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The desirable behavior should be a behavior that is
incompatible with the undesirable behavior
Differential reinforcement
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Define the behavior of concern (target)
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Determine how often the target behavior
occurs
Determine how often to reward the child for
alternative behavior
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Fixed interval – reward every X minutes
Determine how to reward the child for
alternative behavior
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Praise, attention, points or chips
Reinforcement of target behavior
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Target behavior: Interrupting
Alternative behavior: Playing by himself
Reward schedule: 5 minutes
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If child goes 5 minutes without interrupting,
the child receives reinforcement
If child interrupts before 5 minutes is up, the
child does not receive reinforcement
Re-set schedule once child interrupts
Differential reinforcement
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Parent or teacher systematically delays
reinforcement once child responds to
initial schedule
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Target behavior: Interrupting
1st reinforcement schedule: 5 minutes
2nd reinforcement schedule: 6 minutes
3rd reinforcement schedule: 7.5 minutes
Problems with ignoring and
differential reinforcement
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Extinction burst
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Warn parents and teachers that the behavior
will get worse before it gets better (child will
work harder to gain their attention)
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If you put your money in a vending machine, and
the soda doesn’t come out, what do you do? You
probably press the button a few more times,
maybe you even try pressing harder
Indiscriminant reinforcement
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Train parents to reward the alternative
(desirable) behavior, so they don’t reward
other unwanted behaviors by mistake