Transcript Medicatie en Gezin - GGS Jeugdgezondheidszorg

ADHD
Parent Training and
Classroom interventions
Prof. M. Danckaerts
UZ-KULeuven
1
Drive for behavioural
interventions

Children with ADHD have
negative interactions:
1 / min with parents
 2 / min with teachers/peers in
school
 0.7 /min with peers outside
school
= enormous potential learning
history of negative behaviour

2
Danforth ea 2006, Abikoff ea 1993, Pelham & Bender 1982
Parent training and classroom
interventions
What is the evidence ?
II. In practice
I.
3
History

Behavioural interventions



since > 40 years for children with “disruptive
disorders”
Since > 30 years for children with ADHD
3 types: directed to



Parents
School
Child / adolescent
4
Family-based interventions
Pelham e.a. 1998

Behavioural parent training barely meets criteria for
well-established treatment





Outpatient based, 8-20 sessions
Manualized training protocols teaching standard
behavioural techniques (contingency management, timeout)
Studies heterogeneous in design
Various combinations with other interventions
Average effect inferior to medication
5
School-based interventions



Classroom behaviour management
Academic interventions (= manipulation of
instructions or materials)
DRC (Daily Report Card)

Nearly all single case studies and intensive
contingency management

Effect sizes in the range of 1.4 on child behaviour
(= targeted behaviour)
6
DuPaul and Eckert, 1997, Pelham et al. 1998
History - 2

Review Pelham et al. 1998:


Behavioural parent training & classroom
intervention are empirically supported treatments
for ADHD
Cognitive treatment of child : not efficacious


Enhancement of self-control
Enhancement of problem-solving
7
ADHD Psychosocial treatments

Recent landmark
comparative
treatment studies
played down the
importance of
psychosocial
treatments in the
management of
ADHD
8
MTA-study
Month
0
14
14-m Treatment Stage
10-m Followup After
Treatment
24
22-m Followup After
Treatment
36
Medication Only
144 Subjects
Random
Assignment
579 ADHD
Subjects
Psychosocial (Behavioral)
Treatment Only
144 Subjects
Combined Medication &
Behavioral Treatment
145 Subjects
Community Controls
No Treatment from Study
146 Subjects
Early
Treatment
(3 m)
Jensen et al 1999
MidEnd
treatment Treatment
(9 m)
(14 m)
Follow-up
(24 m)
Recruitment of
LNCG Cohort
36 m
FU
9
MTA-psychosocial treatment




30 parent sessions
20 school visits and teacher
training sessions
2-month individual summer
treatment program
Part-time classroom aid
10
MTA-outcome 14-month
Teacher SNAP inattention
3
Time x Tx: F=10.6, p<.0001
Site x Tx: F=0.9, ns
Site: F=2.7, p<.02
Average Score
2.5
CC
Beh
MedMgt
2
Comb
1.5
1
Comb, MedMgt > Beh, CC
0.5
0
0
Jensen et al 1999
100
200
300
Assessment Point (Days)
400
11
MTA-outcome
Teacher SNAP Hyp-Imp
3
Time x Tx: F=10.6, p<.0001
Site x Tx: F=0.9, ns
Site: F=2.7, p<.02
Average Score
2.5
CC
Beh
MedMgt
2
Comb
1.5
1
Comb, MedMgt > Beh, CC
0.5
0
0
Jensen et al 1999
100
200
300
400
Assessment Point (Days)
12
MTA-outcome: Normalization
100
88%
80
68%
56%
60
34%
25%
40
20
Class Cntrls
Comb
MedMgt
Beh
ComCare
0
Baseline
Endpoint
MTA N = 579
Classroom Cntrls N = 288
Swanson et al. for the MTA Cooperative Group
13
Montreal-study
2 year comparison of methylphenidate only and
methylphenidate + multimodal treatment (in
MPH-responders)


Significant short-term benefits on behaviour,
academic achievement and social behaviour
maintained over 2 years
No support for adding psychosocial
interventions, academic support or social
skills training for medication responsive
children
14
Abikoff et al. 2004
The Netherlands
Randomized: 50
10 weeks


MPH mgt
Parent training: 10 sessions (Barkley)
MPH mgt +
brief multimodal
treatment
Teacher training: 1 session (Pelham)
Child cognitive-behaviour therapy: 10
sessions
Both treatments yielded significant improvement on
all domains (ADHD, ODD/CD, social skills, parenting
stress, anxiety, self-worth
NO significant differences
15
Vanden Oord ea 2007
History - 3
Conclusion after these results:


If a child responds well to medication: not
much extra gain to be expected from
behavioural treatment
If a child does not respond well to
behavioural treatment: still a lot of gain to be
expected from adding medication
16
Is there a need for
psychosocial treatments ?








Some children are effectively treated with psychosocial
interventions only
For certain comorbid subgroups they have the largest
effects
Medication is not effective in every child
Medication is not always effective every hour of the day
Improvement on medication does not always mean
normalization
There may be intolerable side effects
Medication may be unacceptable or ethically objected
against (e.g. very young children)
Compliance to medication is far from optimal
17
Is there a need for
psychosocial treatments ? - 2





Medication results in positive effects in structured
situations, but families with ADHD are often highly
unstructured
Medication effects on academic, social and family
functioning are smaller in effect size
Uncertainty about long-term effects and side-effects of
medication
Comparison of effects on Quality of Life is still lacking
Developmentally important opportunities for enduring
change may be missed
18
Is there a need for
psychosocial treatments ?
YES
Important questions:





Are they efficacious ? Are they effective ?
On which domains / aspects do they exert their
effect ?
Which factors moderate / mediate the effect ?
Which ingredient is most important ?
Further issues
19
History - 4

Recent revival of interest in psychosocial
therapies: reviews:



Chronis et al. 2004: Enhancements to the
behavioural parent training paradigm for families
of children with ADHD: review & future directions
Chronis et al. 2006: Evidence-based psychosocial
treatments for children and adolescents with
ADHD
Daly et al. 2007: Psychosocial treatments for
children with ADHD
20
History - 5

Pelham & Fabiano 2008: Evidence-based
psychosocial treatments for ADHD
 Parent training: 22 new studies
 Behavioral Classroom Management: 23 new
studies
Both are now well-established
 Behavioural Peer Interventions:


Traditional group-based, weekly: minimal effects
Summer-treatment programs (5-8 weeks; 200400 hours): effective , but costly and difficult to
implement
21
Effect sizes
Pelham & Fabiano 2008
Groupdesign
Parent Mgt.
Training
.47 - .70
Classroom
Beh.
Management
Beh. Peer
Intervention
-.03 - 0.44
Beh. Interv.
(all)
Withinsubject
Single-case
6.08
.29 - .63
2.46
0.47
0.64
3.64
22
Is there a need for
psychosocial treatments ?
YES
Important questions:





Are they efficacious ?
On which domains / aspects do they exert their
effect ?
Which factors moderate / mediate the effect ?
Which ingredient is most important ?
Further issues
23
MTA-outcome
DOMAIN
ADHD Symptoms
Oppos./Aggress.
Anxiety
Social Skills
Academics
P-C Relations
C vs Cc? M vs Cc? B vs Cc?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
24
MTA Cooperative Group, 1999
MTA-outcome
Parent-child arguing
3
Time x Tx: F=5.6, p<.0008
Site x Tx: F=1.0, ns
Site: F=2.8, p<.02
2.9
Average Score
2.8
CC
Beh
2.7
MedMgt
2.6
Comb
2.5
2.4
2.3
2.2
Comb, Beh > CC
2.1
2
0
100
200
300
Assessment Point (Days)
400
25
MTA-outcome
Negative-ineffective discipline
1
0.5
Average Score
CC
Group Comparisons: All treatment
groups sig. different from CC
Treatment groups not sig. different
from each other
0
Beh
MedMgt
Comb
-0.5
-1
-1.5
-2
0
100
200
300
400
Assessment Point (Days)
26
Wells et al., for the MTA Cooperative Group
Parent training effects
Routine
Clinical Care
=
Family
support +
pharmacotherapy if
appropriate
4-12y
+ parent
training
Behavioural symptoms:
RCC + PT > RCC
N=42
Internalizing symptoms:
RCC + PT > RCC
RCC
continued
N=47
6 months
ADHD, parental stress
RCC + PT= RCC
Regardless of medication
status
27
Van den Hoofdakker ea 2007
Parenting training effects

Larger effects on





Compliance with parental
requests
Rule-following
Defiant-aggressive behaviour
Parenting skills (<
negative/ineffective parenting
practices)
Than on

Specific ADHD behaviours
28
Which outcomes should we
address ?



Symptom reduction
Compliance, less disruptive behaviour
Modify behaviour to



Conflict reduction





Parent-child
Teacher-child
Peer-child
Self-esteem, contentment, happiness, QoL
Functional improvement



Classroom rules, classroom norm
Individualized norm
Completion of classroom assignments
School results
Parent, teacher satisfaction
29
Is there a need for
psychosocial treatments ?
YES
Important questions:





Are they efficacious ?
On which domains / aspects do they exert their
effect ?
Which factors moderate / mediate the effect ?
Which ingredient is most important ?
Further issues
30
Moderators of success ? - 1



Age: mixed results

Less effective on ADHD with age

Equally effective on negative behaviour (Lundahl ea 2006)
Sex: 1 study: no effect
Comorbidity:
Comorbid aggression in ADHD: no difference
 Comorbid ADHD in CD predicts better response in ½ studies
 Comorbid anxiety in ADHD predicts better response (MTA)
Summary: comorbidity has NO negative effect !

31
Sensitive period foreffects
altering the on
Parent-training
progression of the developmental course
ADHD behaviours
?
PRESCHOOL
PRIMARY SCHOOL
ADOLESCENTS
Inconsistent
results on ADHD
behaviour +
possible rater bias
Barkley 1992
Statist but not
clinically sign.
Incredible years
Jones ea 2007
New Forest PT
Sonuga-Barke
Ea 2001
Triple P
Bor ea 2002
50-80 %
Clinically sign effect
Barkley 2001
double number
sessions: idem
32
Moderators of success ? - 4

Comorbidity
1,4
1,2
ADHD-only
w/DBD
w/Anxiety
w/Both
1
0,8
0,6
0,4
0,2
0
CC
MTA, Jensen ea 2001
Beh
MedMgt
Comb
33
Moderators of success ? - 2

Parental mental health



Negative parental cognitions


Maternal ADHD associated with poorer outcome in parent
training (Sonuga-Barke ea 2002)
Maternal depressive symptoms associated with poorer outcome
for MedMgt & Comb MTA groups (Owens ea 2003)
about themselves, their children and their parenting associated
with poorer response to all MTA-treatments (Hoza ea 2000)
Who is attending


Only 4/32 report on fathers (Fabiano 2007)
No information on independent effect of father
involvement
34
Should fathers participate


Fathers report impairment in their relationship with
the ADHD child AND the mother
Fathers contribute to many developmental aspects
of the child:





Emotion regulation
Social cognition
Focused attention
Peer relationships
Specific contribution to


Participation in organized sports
Academic achievement
BUT: they are less likely to attend PMT programs and
do not view their parenting as in need for
intervention
35
Fabiano 2007
Moderators of success ? - 3

Setting


Possibly more pos. effects in academic than in recreational settting
at school (Kolko ea 1999)
SES

Poorer treatment compliance to parent training
(McMahon ea 1981)



MTA: white collar families incremental benefit of Beh
over Med on ADHD symptoms
MTA: blue collar families incremental benefit of Beh
over Med on ODD symptoms (Rieppi ea 2002)
Ethnic minorities

Less likely to seek help
Equal effects once in training (Reid ea. 2002)

In MTA: minority: pos. effect on outcome

36
Mediators of success ? - 4

Format:



Individual/clinic based versus group/community based:
lower threshold in the latter (Cunningham ea 1995)
Didactic versus collaborative or using videotaping: latter
more effective in behaviour problems, but not
demonstrated in ADHD.
 Incredible Years (Webster-Stratton 1996)
 Community Parent Education Program –COPE
(Cunningham ea 1995)
 NFPT (Thompson ea 2001)
Motivation & Skills of provider
37
Mediators of success ? - 4

Intensity of treatment


Contingency mgt > low intensity behav. intervention (eg.
DRC) in single case studies (Pelham ea 1998)
Fabiano ea 2007:







low intensity closer to high intensity than to no behavioural
intervention (Fabiano ea 2007)
High intensity some additional, but non-significant effect over
low-intensity
Low dose Med + BI = High dose medication
Duration ?
Delay interval ?
Nature of antecedent control ?
Treatment setting

Each component seems necessary to bring about change
in the targeted domain (i.e. lack of generalizability)
38
Intensity of treatment

Comparison of low/high intensity and
low/high doses of medication
39
Intensity of treatment

Comparison of low/high intensity and low/high
doses of medication
40
Fabiano ea 2007
Moderators / Mediators of effect

MTA:


In the Comb group: enhanced outcome for
positive social skills at school was mediated by
reduced Negative/Ineffective Discipline at home
Comb treatment moderated the way in which
Negative/Ineffective Discipline was associated
with reductions in school-based disruptive
behaviour
Thus: the effects of pharmacological treatment
were at least partially explained by
psychological processes
41
Is there a need for
psychosocial treatments ?
YES
Important questions:





Are they efficacious ?
On which domains / aspects do they exert their
effect ?
Which factors moderate / mediate the effect ?
Which ingredient is most important ?
Further issues
42
Which ingredient is most
important ?
Active ingredients ?
 Modification of antecedents


Commands, rules, expectations
Modification of consequences


Prudent negative consequences
(verbal reprimands, backed up with
time-out ?
Positive consequences ?
43
Which ingredient is most
important ?



Prudent negative consequences superior to
contingent praise alone
Response cost programs more effective than reward
programs in controlled classroom settings
MTA: Changes in Positive parental involvement did
not mediate outcome whereas changes in
Negative/Ineffective Parenting did.
44
Abramowitz ea 1987, Fabiano ea 2004, pfiffner & O’Leary 1987
Is there a need for
psychosocial treatments ?
YES
Important questions:





Are they efficacious ?
On which domains / aspects do they exert their
effect ?
Which factors moderate / mediate the effect ?
Which ingredient is most important ?
Further issues
45
Further Issues - 1




Few studies have shown maintenance effects
beyond a few months after the active treatment:
long term management plans ?
Substantial proportion of children fail to improve and
improvement is not always complete
Efficacy depends on motivation and capabilities of
the significant adults
Efficacy versus effectiveness in real world ? Eg.
Most consumers favor behavioural interventions
46
Further issues - 2



Cost-effectiveness relative to medication
treatment ?
Dismantle separate effect of BPT, BCM,
BPI
Sequence of interventions
47
Current Clinical Guidelines

European:


APA:


BI first choice unless severe and pervasively
impairing ADHD
Treatment recommendation for medication
(strong) and for behaviour therapy (fair)
AACAP:

If no robust response to either of 3 FDA-approved
medications: try behaviour therapy or nonapproved medication
48
Parent training and classroom
interventions
What is the evidence ?
II. In practice
I.
49
Available Manuals
Disruptive Behaviour
 Patterson (1976)
 Forehand & Mc Mahon
(1981)
 Triple P (2001)
www.health.nsw.gov.au

The incredible years
www.incredibleyears.com
ADHD
 Barkley (1987)
 Pelham and Hoza (1996)
 COPE (Cunningham)
(1997)
 New Forest PT (Thompson
2001)
School
 Challenging Horizons
Program TM (Evans 1999)
Combined http://ccf.buffalo.edu
 STP: Summer Treatment
Program (Pelham ea)
50
Behavioural interventions
= manipulating environmental factors
that are antecedents to (e.g.
setting, structure) or
consequences of (e.g. adult
attention) the maladaptive
behaviour
= largely based on social learning
principles
51
Chronis et al, 2006
General principles of BI




Identify and manipulate antecedents and
consequences of child behaviour
Target and monitor problematic behaviour
Reward prosocial behaviour through praise,
positive attention and tangible rewards
Decrease unwanted behaviours through
planned ignoring, time-out and non-physical
discipline techniques (e.g. removal of
privileges)
52
Behavioral Interventions
(Bear, Cavalier, & Manning, 2005)

Behavioral Interventions – general tips:







Consequences should occur soon after behavior
Consequences should be ‘salient’
Don’t give tangible reinforcers for intrinsically motivated
behavior (e.g., $ for playing baseball)
Move from contrived reinforcers to natural reinforcers over
time (generalizability)
Move from dense reinforcement schedules to thin
reinforcement schedules over time
Do not over-rely on punishment!!!
Punishment should fit the crime and be limited in scope
53
Leuven Teacher-Parent Training
Build up Model
Level of
expectation
frustration
motivation
Level of the
child
Starting Point
Adaptation
54
School Based Interventions
BEHAVIOURAL
INTERVENTIONS



Targeting on-task and
disruptive behaviour in the
classroom
Through praise, ignoring,
effective commands, timeout
Daily Report Card
Adaptation of the child
ACADEMIC
INTERVENTIONS


Manipulating academic
instruction and materials
Structuring of homework time,
goal setting in shorter
periods, note-taking training,
reducing task length, dividing
into subunits, peer tutoring,
increased task stimulation
Adaptation of demands
55
What Interventions Are Used?

General & SPED teachers differ in their emphasis, but the
interventions are surprisingly similar…
Intervention
General Education
Special Education
Changing seats
1
5
Behavior modification
2
1
Time-Out
3
4
Shortened Assignments
4
7
One-to-one instruction
5
3
Special Consultation
6
2
Peer tutoring
7
9
Frequent breaks
8
8
Assignment format
9
6
56
General principles






Most teachers already use BI, yet ADHD still
poses enormous problem for schools
Need for intensity and consistency
Child should be actively involved in the
planning phase
Time investment on return
Tailored to ADHD: frequent, immediate and
consistent feedback and reward
Teacher-parent communication &
collaboration
57
Leuven Toolkit for Teachers




Aim: develop a practical toolkit for teachers to
put on their desk
ADHD-symptoms translated into schoolrelated problems
4-step procedure
Based on the Build-up principle
59
Leuven Toolkit for Teachers
Proces
Aanmoedigen
Dagelijks oefenen
Hulpmiddelen gebruiken
Door de vingers zien
Applaud, stimulate
Daily Practice
Help, use props
Dispensate, disregard
60
Leuven Toolkit: step I: defining
the goals

Meaningful: leading to







Impairment
Stressful for the child
Stressful for others: peers, teacher
Classrules should be clear
Goals defined as TARGET BEHAVIOURS
Observable and countable
Goals within reach: > 75% succes
61
TARGET BEHAVIOURS

Examples




Compliance: no more than 3 violations per period
Following directions: no more than 2 reminders
Able to ignore negative behaviour of others: no
more than 3 x observable response to negative
behaviour of others
School diary: no more than 1 correction needed
62
Leuven Toolkit: step II:
Monitoring

Level A: Applaud, praise


Level D: Daily exercise-times are defined


Child gets specific reminders during set time-periods
Level H: Help is provided



Child tries to reach goals with praise only
Child gets tangible aids, reminders
Teachers helps to reach the goal
Level D’: Dispensation


The goal is too difficult for this child at this stage
Teacher will give constant help
Constant monitoring + modification along the way
63
ADHD-TOOLKIT
for
TEACHERS
64
Danckaerts & Dewitte, in preparation
65
Daily Report Card




Daily monitoring of the target behaviours
Communication with the parents
Home-based reward program attached to the
DRC
Teacher can also use classroom-based
rewards at level 3
66
Daily Report Cards - 2
68
Reward menu at home
http://ccf.buffalo.edu
69
Classroom rewards
http://ccf.buffalo.edu
70
Caveats

Teacher does not get started



Target behaviours are





First time takes more time
Defining the targets needs some practice
Unclear or vague
Not salient
Too difficult
No consistency in monitoring
Home reward system fails
71
DAGELIJKS GERICHT OEFENEN
AANMOEDIGEN
ADHD toolkit
M. Danckaerts
Ilse Dewitte
HULPMIDDELEN GEBRUIKEN
DOOR DE VINGERS ZIEN
72
Leuven Parent Training
Based on Barkley’s PT
6 sessions of 2 hours, 6-7 pairs of parents
HOMEWORK

Session 1: Psychoeducation: in depth

What fits your child / you
and your partner

Session 2: Principles of
BT + Build up model Lost ideal

15’ non-interventional
observation / play , seek
for base level, mourning,
seek for charm

Session 3: Pos/Neg
balance: compliments,
praise, giving adequate
commands

Positive interactions, 7
compliments/day,
compliance to commands
73
Leuven Parent Training - 2
Based on Barkley’s PT
6 sessions of 2 hours, 6-7 pairs of parents

Session 4: positive
reinforcement, token
techniques

Design a reinforcement
(reward) plan for specific
behaviours

Session 5: negative
consequences / timeout

Apply time-out and
negative consequences to
unwanted behaviours

Session 6: Pos/Neg
balance, review, sibling
conflicts

Continue until booster 6
months later
74
Conclusions



There is a need
There are manuals
Hope you are motivated !
75