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  Center for Children and Families http://ccf.buffalo.edu Diefendorf Hall Rm. 106, 3435 Main St., Bldg. 20, Buffalo, NY 14214-3093 Tel: (716) 829-2244 Fax: (716) 829-3692 http://ccf.buffalo.edu Evidence-based Psychosocial Treatment for ADHD Children and Adolescents Comprehensive Treatment for ADHD should always include a strong psychosocial (that is, not medical ) component. Most  professionals believe that effective psychosocial treatment is the backbone of good treatment for ADHD. Medication is a very useful addition to psychosocial treatment in many cases, yielding a combination approach that may be even more effective than psychosocial treatments alone (see “ADHD Medication Information Sheet for Parents and Teachers”). Indeed, the scientific literature on treatment for ADHD, the National Institute of Mental Health, and many professional organizations say that there are two treatments that have a solid base of scientific evidence for short-term effectiveness: behavioral  psychosocial treatments—also called behavior therapy or behavior modification—and stimulant medication. Behavior modification is the only  nonmedical treatment for ADHD with a large scientific evidence base. Why Use Psychosocial Treatments? Why do professionals believe that behavioral treatment for ADHD is so important? There are several reasons. First, the  problems faced by children with ADHD go well beyond their symptoms of inattentiveness, hyperactivity, and impulsivity. Most children with ADHD have problems in daily life functioning in many areas including academic performance and  behavior at school, relationships with peers and siblings, noncompliance with adult requests, and relationships with their  parents. These problems are extremely important because they predict long-term outcome of children with ADHD. How a child with ADHD will do in adulthood is best predicted by three things—(1) whether his or her parents use effective  parenting skills, (2) how he or she gets along with other children, and (3) his or her success in school. Psychosocial treatments focus on these problems rather than the core symptoms of the disorder, so they are effective in treating these important domains. Second, in contrast to medication, behavioral treatments teach skills to parents, teachers, and children with ADHD, and these skills help overcome their impairments and are useful for a child’s lifetime. Because ADHD is a chronic condition, teaching skills that will be valuable across the lifetime is especially important. Finally, when medication is the only form of treatment, it has not been shown to improve long-term outcomes for children with ADHD. Many  professionals believe that when medication is combined with behavioral approaches, both the core symptoms of ADHD and the associated problems in daily life functioning are best treated, and long-term positive outcomes will be greatest. Others  believe that treatment should begin with psychosocial treatments, and medication should be added if and when it is necessary. Both are effective ways of treating ADHD and parents must decide, in consultation with their treating professionals, what is  best for their child. Behavioral treatments for ADHD should be started when the child is as young as possible. There are behavioral interventions that work well for preschoolers, elementary-students, and adolescents with ADHD, but there is consensus that starting early is better than starting later. Parents, schools, and practitioners should not put off beginning effective behavioral treatments for children with ADHD. What exactly is behavior modification? Behavior modification is a form of therapy in which parents, teachers, and children are taught skills by a therapist. Parents and teachers then employ those skills in their daily interactions with their children with ADHD to improve the children’s functioning in the key areas noted above. In addition, the children with ADHD employ the skills they learn in their interactions with other children. Many parents think of behavior modification in terms of the ABCs—  A ntecedents (things that happen before behaviors that influence them), B ehaviors (things the child does that parents and teachers want to change), and C onsequences (things that happen after behaviors that influence them). In behavioral programs, adults are taught to modify antecedents (e.g., how they give commands to children) and consequences (e.g., how they follow-up if a child obeys or disobeys a command) to change the child’s behavior (that is, the child’s response to the command). By consistently changing the ways that they respond to children’s behaviors, adults teach the children to learn new ways of behaving. What is  not   behavior modification?  It is important to note that many psychotherapeutic treatments are not   behavior modification. Thus, traditional individual therapy, in which a child spends time weekly with a therapist or school counselor talking about his or her problems or playing with dolls or toys, is not behavior modification. Similarly, family therapy in which a family talks with a therapist about the dynamics of the interactions among the family is also not behavior modification. Such “talk” or “play” therapies do not have teaching skills as their primary goals, and they have not been shown to work for children with ADHD. Parents who want an    Diefendorf Hall Rm. 106, 3435 Main St., Bldg. 20, Buffalo, NY 14214-3093 Tel: (716) 829-2244 Fax: (716) 829-3692 http://ccf.buffalo.edu 2evidence-based psychosocial approach to working with their children with ADHD need to become informed about the characteristics of behavior modification that we discuss below so they can recognize effective behavioral treatment and be confident that what the therapist is offering will result in improved functioning for their child. What are typical forms of behavior modification? There are three parts of effective behavioral interventions for ADHD children—parenting training, school interventions, and child-focused treatments. Although working with teachers and the children themselves are critical in the vast majority of ADHD cases, teaching parents more effective ways of dealing with their children is the most important aspect of  psychosocial treatment for ADHD . Ideally, parent, teacher, and child interventions must be integrated to yield the best outcome. Four points apply to all three parts: (1) always start with goals that the child can achieve and improve in small steps (e.g., “baby steps”); (2) always be consistent—across different times of the day, different settings, and different people; (3) ADHD is a chronic problem for the individual and treatments need to be implemented over the long haul—not just for a few months; and (4) teaching and learning new skills take time, and children’s improvement will be gradual with behavior modification. Characteristics of parent, teacher, and child interventions are listed below. (1)   Parent Training ã   Behavioral approach ã   Focus on parenting skills, child behavior in the home and neighborhood, and family relationships (e.g., getting along with siblings, complying with parent requests) ã   Parents are taught skills by therapists and implement them at home ã   Typically group-based, weekly sessions with therapist initially (8 to 12 sessions); then faded to booster sessions (monthly, quarterly) ã   Continually evaluate and modify what is being done to identify what works best and continue it as long as necessary ã   Plan for what will be done if parents or child backslides ã   Reestablish contact with therapist for major developmental transitions (e.g.,entry to middle school) (2)   School Intervention ã   Behavioral approach ã   Focus on classroom behavior, academic performance, and peer relationships ã   Teachers are taught classroom management skills by a consultant (e.g., therapist, school psychologist or counselor) and implement them with the ADHD child during school hours ã   Two to 10 hours of training are necessary depending on the teacher’s prior knowledge and skills, as well as the child’s severity and responsiveness ã   Continually evaluate and modify what is being done to identify what works best and continue it as long as necessary ã   Plan for backsliding and spread; involve all relevant school staff; integrate with parenting classes so parent learns to  back up what the school is doing ã   Integrate with school-wide plans, and required, school-based programs (i.e., IEPs, 504 plans) ã   Reestablish contact with consultant for major developmental transitions (e.g., entry to middle school) (3 ) Child Intervention   ã   Behavioral and developmental approach ã   Focus on teaching academic, recreational, and social/behavioral competencies, decreasing aggression, developing close friendships, and building self-efficacy ã   Paraprofessional implemented, supervised by professionals ã   Settings such as clinic-based weekly group sessions, after-school or Saturday sessions, and summer camps ã   Typically more intensive rather than less intensive treatment is necessary (e.g., weekly clinic social skills groups are typically not effective) ã   Monitor and modify as needed based on what works best; provide as long as necessary (e.g., multiple years or when deterioration occurs) ã   Plan for what to do if backsliding occurs ã   Integrate with school and parent treatments ã   Reestablish contact with consultant for major developmental transitions (e.g., middle school entry)    Diefendorf Hall Rm. 106, 3435 Main St., Bldg. 20, Buffalo, NY 14214-3093 Tel: (716) 829-2244 Fax: (716) 829-3692 http://ccf.buffalo.edu 3 How does a behavior modification program begin? The first step in starting a behavior modification program is a complete evaluation of the child's functional impairment in all relevant domains, including home, school (both behavioral and academic), and peer settings. Most of this information comes from parents and teachers, and that means that a professional will spend most of his or her time during the information gathering process with parents and teachers. Interaction with the child him or herself is needed for the therapist to get a sense of what the child is like. That assessment process should yield a list of target areas for treatment. Target areas—often called target behaviors--should be behaviors that differentiate the child being treated from other, nonproblematic children. They should be behaviors that, if changed, will contribute to an improvement in the child’s functioning/impairment and a positive long-term outcome . Target behaviors can be either negative behaviors that need to be eliminated or adaptive skills that need to be developed. That means that the areas targeted for treatment will typically not be the symptoms of ADHD— overactivity, inattention, and impulsivity—but instead the specific problems that those symptoms may cause in daily life. Thus, common classroom target behaviors would be “completes assigned work at 80% accuracy” and “followed classroom rules.” At home, “played well with siblings (that is, no fights)” and “complies with parent requests or commands” are common target behaviors (lists of common target behaviors in school, home, and peer settings that parents and teachers might find useful can be downloaded in Daily Report Card school and home packets at http://ccf.buffalo.edu). Target behaviors are things that can be easily observed and measured so that response to treatment can be monitored and treatment can be modified as necessary. After target behaviors are identified, behavioral interventions at home and at school follow similar formats. Parents and teachers identify the environmental conditions (the A ’s) and consequences (the C ’s) that are controlling those target  behaviors (the B ’s). Then behavioral treatment takes the form of parents and teachers learning and establishing programs in which the environmental antecedents and consequences are modified to change the child’s target behaviors. Treatment response is constantly monitored, and the interventions are modified when they fail to have a sufficient impact or are no longer needed. Parent Training Behavioral parent training programs have been around for a long time. Nearly 40 years ago the psychologists who developed  behavioral parent training wrote the first books teaching others how to do what they had developed. Parenting sessions usually use a book and/or videotape that has been specially developed to teach parents how to use behavioral management  procedures with their children; there are many good programs available (see list in appendix). The first session is often devoted to an overview of the diagnosis, causes, nature, and prognosis of ADHD. Thereafter, in group or individual sessions,  parents learn a variety of techniques, some of which they may be already using at home but not as consistently or correctly as needed. Parents go home and implement what they learn in sessions during the week, and return to the parenting session the following week to discuss progress, problem solve, and learn a new technique. Although many of the ideas and techniques taught in behavioral parent training are common-sense parenting techniques (everyone knows to praise their children when they are doing something good!), most parents need careful teaching and support to learn and implement the parenting skills consistently. It is very difficult for parents to buy a book, learn behavior modification, and implement an effective program with their child on their own. Help from a professional who knows how to develop and implement behavioral programs is often essential. The topics covered in a typical series of parent training sessions include the following topics in sequence. 1. Establishing house rules and structure ã   Posted chore lists ã   Posted morning and evening routines ã   Posted House Rules ã   Review until child has learned them 2. Learning to praise appropriate behaviors (praise good behavior at least five times as often as bad behavior is criticized) and ignore mild inappropriate behaviors (choose your battles) 3. Using appropriate commands ã   Obtain the child's attention: say the child's name first ã   Use command not question language (“Don’t you want to be good” is a bad command!) ã   Be specific, describing exactly what the child is supposed to do (at the grocery checkout line “be good” is not a good command! “stand next to me and do not touch anything” is more specific!)    Diefendorf Hall Rm. 106, 3435 Main St., Bldg. 20, Buffalo, NY 14214-3093 Tel: (716) 829-2244 Fax: (716) 829-3692 http://ccf.buffalo.edu 4 ã   Be brief and appropriate to the child's age ã   State consequences and always follow through (praise compliance and provide consequences for noncompliance) ã   Have a firm but neutral (not angry) tone of voice 4. Using when…then contingencies ã   Give access to desired activities when the child has completed a less desired activity (e.g., ride bike when finished homework; watch TV when finished evening chores, going out with friends after completed yard work) ã   For younger children, important to have rewarding activity occur immediately 5. Planning ahead and working with children in public places ã   Explain situation to child before  activity occurs ã   Establish ground rules, rewards, and consequences 6. Time out from positive reinforcement ã   Assign short times away from preferred activities when the child has violated expectations or rules ã   Give time off for appropriate behavior during time out and lengthen time for noncompliance with time out ã   Base times on children's ages—shorter for younger children—e.g., one minute for each year of age 7. Daily Charts—Point/token systems with rewards and consequences ã   Make charts with home rules/goals and post prominently in house ã   Establish system for rewards for following home rules and consequences for violations ã    Nickel jar for noncompliance or talking back (e.g., put a nickel in for each compliance, remove two for noncompliance) ã   Home Daily Report Card (see target list and creating a Daily Report Card for the home at http://ccf.buffalo.edu) 8. School-home note system for rewarding behavior at school and tracking homework (see description below in School Interventions) There are many other techniques that are part of a good behavioral parenting program. Those listed above are included in almost all of the good programs. Some families can learn these skills quickly in the course of 8 or 10 meetings, while other families—often those with the most severely impaired children—require more time and energy. The techniques listed above are those typically used in teaching parents of children  with ADHD. When the presenting child is a teenager  , parent training is modified somewhat. Parents are still taught behavioral techniques, but they are modified to  be age-appropriate for adolescents. For example, time out is a consequence that is not effective with adolescents; instead loss of privileges (e.g., can’t take family car on date) or assignment of work chores would be more appropriate. After parents have been taught these techniques, the parents are typically involved in sessions that include the adolescent, with the therapist helping parents and adolescents in structured discussions in which they negotiate mutually agreeable solutions to their disagreements. Parents negotiate for improvements in the adolescents’ target behaviors (e.g., better grades in school) in exchange for rewards over which they have control (e.g., the teen’s being able to go out with friends). The give and take  between parents and teen in these sessions is necessary to motivate the teenager to work with the parents to make changes in his or her behavior. Applying these skills with children and adolescents with ADHD takes a lot of hard work on the part of parents. However, the hard work pays off. Parents who master and consistently apply these skills will be rewarded with a child who behaves better and has a better relationship with his parents and siblings. School Interventions As is the case with parent training, the techniques used in classroom-based interventions for ADHD have been around for some time. Many teachers who have had training in classroom management are quite expert in developing and implementing classroom-based programs for their ADHD children. Others, however, are not intimately familiar with behavioral principles and need assistance to learn and implement the necessary programs. There are many widely-available handbooks, texts, and training programs that have been developed to teach classroom behavior management skills to teachers (see list in appendix). Most of these programs are designed to be implemented by regular or special education classroom teachers with training and guidance from school support staff or outside consultants. One of the most important things that the parent of an ADHD child can do is to work closely with the teacher to support his or her efforts implementing classroom programs for their ADHD child.
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