Therapy for Youth with ADHD
Point of Performance or Bust!
Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) exhibit frequent and severe inattentive (e.g., difficulty sustaining attention to and completing tasks) and/or hyperactive-impulsive (e.g., interrupting others, difficulty remaining seated) behaviors that lead to significant impairment in academic and/or social functioning (American Psychiatric Association, 2013). ADHD symptoms and associated impairment typically are chronic and thus require ongoing treatment (i.e., there is no cure). Although psychotropic medications (e.g., central nervous system stimulants like methylphenidate) are effective in reducing ADHD symptoms, pharmacotherapy is rarely sufficient in addressing the myriad of functional impairments experienced by youth with this disorder (Brown et al., 2008). Psychosocial and education interventions are necessary adjuncts to medication and lead to improvements in behavioral, academic, and social functioning (Evans, Owens, & Bunford, 2014). The purpose of this article is to discuss a key concept underlying psychosocial intervention for ADHD and briefly describe empirically-supported treatment strategies that incorporate this concept.
Intervene at the Point of Performance
By far, the most important concept for ADHD psychosocial treatment is to intervene at the point of performance (i.e., at the point in time and setting where symptomatic behaviors are leading to impairment) (Goldstein & Goldstein, 1998). If, for example, a child’s inattentive, disruptive behavior is most evident during math instruction each weekday morning, then the most effective interventions will be those that are implemented during math instruction each weekday morning. Alternatively, treatment that is removed in time and setting from the symptomatic behavior (e.g., weekly psychotherapy in a community-based psychologist’s office) typically is ineffective. This is because the putative deficit underlying ADHD symptoms is an inability to delay responding to the environment (Barkley, 2015). Thus, youth with ADHD require intervention that is delivered as close in time as possible to the target behavior, i.e., delayed treatment will be delivered too late.
Teachers and Parents as “Therapists”
One of the major implications of the need to intervene at the point of performance is that teachers and parents will serve as the primary therapists in that they will deliver intervention to address symptomatic behavior in real time. Specifically, the most effective methods for reducing ADHD symptoms and enhancing academic and social functioning are strategies based on operant behavioral principles. Multiple research investigations and meta-analyses have documented medium to large effects on child behavior and small to medium effects on child academic and social functioning as a function of behavioral intervention (DuPaul, Eckert, & Vilardo, 2012; Fabiano et al., 2009). Effective strategies include adult praise contingent on appropriate child behavior (i.e., catch them being good), token reinforcement or point systems, home-based reinforcement for school behavior (e.g., daily report card), and limited use of mild punishment strategies (e.g., response cost, time out from positive reinforcement) when necessary. Thus, clinicians must educate parents and teachers in use of effective strategies across situations and over time.
Behavioral Parent Training
Several programs for providing behavioral parent training (BPT) have been developed (e.g., Barkley, 1997; Eyberg et al., 2001; Sonuga-Barke, Daley, Thompson, Laver-Bradbury, & Weeks, 2001; Webster-Stratton & Reid, 2014) and can be delivered to individual parents or in a group format. Usually the child does not participate in the education program, except in cases where the therapist wants the parent to practice management skills in vivo. BPT sessions typically last 1–1.5 hours for an individual family and 1.5–2 hours for groups of parents. BPT programs follow a similar sequence of activities, including a review of the information covered the previous week, a brief assessment of whether any critical events occurred since the previous meeting, and a discussion of homework activities that were assigned at the end of the last session. The therapist then provides instruction with respect to particular behavior management methods that the parents are to practice during the subsequent week. Training can include didactic instruction, video vignettes, and therapist modeling of the specific strategy. Parents rehearse strategies and receive feedback and further guidance from the therapist. At the end of the session, additional practice of prescribed strategies is assigned as homework for the coming week. Handouts detailing specific strategies and procedures are distributed for review or made available online.
BPT is usually provided over the course of 8 to 12 weekly sessions. Typical session topics include background information about ADHD, discussion of why children engage in disruptive behavior (i.e., with an emphasis on environmental events at the point of performance), strategies for positively attending to desired child behavior, methods to increase compliance and independent play, development of a token reinforcement program, use of response cost and time-out from positive reinforcement, strategies to manage child behavior in public places, use of a home–school communication program (e.g., daily report card), and how to handle future behavior problems. At the conclusion of the initial course of BPT, periodic booster sessions can be provided to support maintenance and generalization of acquired parenting skills.
Participatory BPT may enhance family engagement with and adherence to prescribed strategies. In fact, parent attendance and engagement with treatment can be challenging particularly for parents with their own mental health issues or for families from economically disadvantaged and/or ethnic/linguistic minority backgrounds (Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004). Thus, investigators have developed ways to increase parent engagement and make BPT as acceptable and feasible as possible. For example, Chacko et al. (2008) developed the Strategies To Enhance Positive Parenting (STEPP) program that involves specific components (e.g., pre-intervention motivational interviewing) to improve parent engagement. STEPP has been found to promote consistent parent session attendance and associated child behavior improvements (Chacko et al., 2012).
As summarized in comprehensive reviews of the literature (e.g., Evans et al., 2014 and meta-analyses (e.g., Fabiano et al., 2009), multiple studies have established the efficacy of BPT for enhancing outcomes for children with ADHD especially regarding compliance with household rules and parent directives, completion of assigned responsibilities, and positive parent-child interactions. Thus, BPT is a critical component of a multimodal treatment approach for ADHD as is noted in recommended treatment guidelines (American Academy of Pediatrics, 2011).
Behavioral Consultation with Teachers
Clinicians can also work directly with general and special education teachers to facilitate implementation of empirically-supported academic and behavioral intervention strategies in the classroom (DuPaul & Stoner, 2014). Specifically, a behavioral consultation approach can be used to facilitate teacher use of data-based problem-solving in developing and implementing interventions. Behavioral consultation is comprised of four stages including problem identification, problem analysis, plan development/implementation, and plan evaluation (Sheridan & Kratochwill, 2008). Problem identification focuses on developing a clear, operational definition of the target student behavior(s) as well as identifying aspects of the classroom environment that may elicit or reinforce student behavior (i.e., antecedent and consequent events). Teachers are asked to collect data about these events over a week or two to facilitate problem analysis. In the problem analysis stage, decisions are made as to those events that appear to trigger or reward student behavior. The clinician and teacher develop a hypothesis as to the function of the target behavior. For example, a student could be demonstrating off-task behavior (e.g., looking away from task, bothering other students) when given a written assignment in order to avoid working on the assignment. In the next stage, the clinician and teacher collaborate to design an intervention that directly addresses the putative function. For example, the assignment could be modified to be less aversive (e.g., shortened in length or include content of high interest to the student) such that the student is less likely to engage in avoidant behavior. The final stage of the consultation process involves the teacher collecting data once the plan is in place to evaluate whether the intervention is successful
As was the case for BPT, numerous studies have demonstrated the effectiveness of behavioral consultation with teachers in terms of improved teacher knowledge of behavioral principles and enhanced child academic and behavior outcomes (Sheridan & Kratochwill, 2008). In particular, teacher implementation of praise, token reinforcement, daily report card, and response cost interventions helps students with ADHD to be less disruptive, follow classroom rules, complete more assignments, and get along better with adults and peers (DuPaul et al., 2012). Studies have demonstrated that gains obtained through classroom behavior intervention are equivalent to those found for stimulant medication (Rapport, Murphy, & Bailey, 1982).
Because youth with ADHD live “in the now” and exhibit significant difficulties delaying responding to environmental events, therapeutic interventions must be delivered as close as possible to the point of performance. Treatment that is delayed in time and delivered outside of home and school settings is typically ineffective. Fortunately, clinicians can educate parents and teachers to act as therapists in delivering ameliorative strategies in situations and at times when symptomatic behavior is most impairing. Thus, a multimodal treatment approach should always include BPT and teacher consultation either as an adjunct to or in lieu of pharmacotherapy.
Cite This Article
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