Clinical Case Studies

10(1) 23 36
The Author(s) 2011
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DOI: 10.1177/1534650110391653
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The Use of Homework
Success for a Child With
Attention-Deficit/
Hyperactivity Disorder,
Predominantly
Inattentive Type
Alexis Resnick
1
and David Reitman
1
Abstract
This case study describes use of the Homework Success Program (HSP) for a child with
attention-deficit/hyperactivity disorder (ADHD), predominantly inattentive type. Larry, an
8-year-old boy, presented with homework-related difficulties, including difficulty focusing and
sustaining attention, becoming easily distracted, spending 3 to 4 hr per night on homework,
forgetting to bring home books, and inconsistently writing down assignments in his planner.
Treatment with the HSP included a seven-session intervention with a 1- and 7-month follow-up,
which resulted in parent-reported improvements in Larrys homework performance, homework
completion time, and the percentage of homework completed. Parental satisfaction with the
program was noted. Results of treatment revealed minimal change in teacher-reported academic
performance. Recommendations for successful implementation of the HSP are provided.
Keywords
homework, ADHD, intervention
1 Theoretical and Research Basis
A diagnosis of attention-deficit/hyperactivity disorder (ADHD) is made when individuals dis-
play developmentally inappropriate levels of inattention and/or hyperactivity-impulsivity, which
results in functional impairment in at least two settings. In addition, at least six symptoms of
inattention and/or hyperactivity-impulsivity must appear before the age of 7 and persist for at
least 6 months (Diagnostic and Statistical Manual of Mental Disorders [4th edition, text revision];
DSM-IV-TR; American Psychiatric Association [APA], 2000). Prevalence rates for ADHD range
from 3% to 7% (APA, 2000). Boys are at an increased risk for the disorder and received an
ADHD diagnosis about 2 to 3 times more often than girls in the general population (Silverman,
Iseman, & Jeweler, 2009).
1
Nova Southeastern University, Fort Lauderdale, FL
Corresponding Author:
David Reitman, Nova Southeastern University, Center for Psychological Studies,
3301 College Avenue, Fort Lauderdale, FL 33314
Email: reitmand@nova.edu
24 Clinical Case Studies 10(1)
Numerous reviews have chronicled the functional impairments experienced by children diag-
nosed with ADHD, and several of these have concentrated on academics issues (DuPaul, 2007;
Loe & Feldman, 2007; Raggi & Chronis, 2006; Rogers, Wiener, Marton, & Tannock, 2009).
Indeed, up to 80% of those diagnosed with ADHD struggle in the academic arena (DuPaul &
Eckert, 1998; Trout, Lienemann, Reid, & Epstein, 2007; Weyandt, 2007). Moreover, about one
fourth of children with ADHD have learning disabilities (DuPaul, 2007; Power, Karustis, &
Habboushe, 2001), and there is a strong relationship between ADHD and academic underachieve-
ment (DuPaul & Power, 2009; DuPaul & Stoner, 1994; Power et al., 2001; Raggi & Chronis,
2006; Rogers et al., 2009; Silverman et al., 2009). Children diagnosed with ADHD also have a
greater likelihood of repeating a grade, being in a special class, and being tutored (DuPaul, 2007;
Faraone et al., 1993; Raggi & Chronis, 2006; Silverman et al., 2009). Finally, ADHD-diagnosed
children followed into adolescence receive lower grades on their report cards and perform worse
than controls on standardized tests of achievement (DuPaul, 2007; Loe & Feldman, 2007).
The various symptoms characteristic of the diagnosis of ADHD are associated with particular
difficulties in academic functioning. For instance, classroom inattention may be manifested as
off-task behavior or failure to follow directions. Classroom displays of hyperactivity may be
equated with problems remaining seated, fidgetiness, and difficulty playing or engaging in a task
quietly. In addition, the impulsivity characteristic of ADHD may be reflected in a tendency to
make careless errors (Raggi & Chronis, 2006). With respect to homework in particular, children
diagnosed with ADHD tend to show more frequent and intense homework problems than their
peers and, specifically, fail to write down or bring home assignments, fail to begin working on
time, become easily distracted, engage in conflict with their parents, and work in a careless man-
ner (Power et al., 2001). Furthermore, children diagnosed with ADHD often show low home-
work engagement, along with poor time management and organization (Rogers et al., 2009). As
a diagnosis of ADHD requires functional impairment, academic difficulties and, specifically,
homework problems are almost always a key aspect of making such assertions.
Despite the important role that homework problems are likely to play in the lives of children
diagnosed with ADHD, treatments for the homework problems of ADHD-diagnosed children
have been limited. Indeed, although a multitude of homework interventions exist, only two have
been specifically designed to address the homework difficulties of children with ADHD (Raggi,
Chronis-Tuscano, Fishbein, & Groomes, 2009). The first, the Homework Success Program
(HSP), is a seven-session familyschool intervention for children with ADHD enrolled in Grades
1 through 6 and includes parent training with an emphasis on collaborative parentteacher con-
sultation (Power et al., 2001). The second, the Child Life and Attention Skills (CLAS) Program,
is designed for children with ADHD, predominantly inattentive type and involves teacher con-
sultation, parent training, and child skills training over a 12-week period (Pfiffner et al., 2007).
In the latter intervention, Pfiffner et al. conducted a randomized, controlled study of 69 children
aged between 7 and 11 years. Participants were assigned either to the CLAS Program or a non-
intervention control group. Results indicated that in comparison to the control group, children in
the CLAS Program showed clinically significant reductions in attention problems and increases
in organizational and social skills. The HSP, however, has yet to be empirically evaluated (Raggi
et al., 2009; Rogers et al., 2009).
Although the CLAS intervention was considered in the present case, a number of consider-
ations related to implementation resulted in the authors selection of the HSP. As the intervention
occurred late in the school year, there was insufficient time to have completed the 12-week
CLAS intervention. Also, modifying the CLAS Program for use with single families would have
been a greater challenge than modifying the HSP. For instance, in the CLAS Program, multiple
therapists would have had to be recruited, as according to the protocol, the primary therapist
provides teacher consultation and parent training, whereas additional therapists provide life skills
training to the children. Even if the intervention were modified such that the primary therapist
Resnick and Reitman 25
provided life-skills training to the children after providing teacher consultation and parent train-
ing, there still would have been insufficient time to conduct the CLAS intervention. In general,
the HSP appeared to be a more practical choice because of the aforementioned issues. As the
HSP is a group intervention of untested effectiveness when applied to individual families, the
present study sought to evaluate its effectiveness with an 8-year-old boy diagnosed with ADHD,
predominantly inattentive type.
2 Case Presentation
Larry (a pseudonym) presented to treatment as an 8-year-old White boy living with his sister
(11 years old), mother (46 years old), and father (62 years old). Larry attended a Catholic school
and enrolled in regular third-grade classes. Larry was diagnosed with ADHD, predominantly
inattentive type at a university clinic and shortly thereafter was referred to our clinic for home-
work-related difficulties.
3 Presenting Complaints
On entering treatment, Larry reportedly had difficulty sustaining attention during academic
tasks. Larrys parents reported spending 3 to 4 hr a night with him on homework, along with
seatwork that was not completed at school. According to his parents, Larry typically attended to
homework for one or two questions and then required redirection to the task, as he would begin
walking around or playing with his pencil. Larrys parents stated that they frequently had to
repeat instructions to gain compliance. Furthermore, Larry often forgot to bring home books
necessary for homework and did not consistently write assignments in a planner. Despite his
reportedly poor study habits, Larrys most recent report card indicated that he obtained three As
(in spelling/vocabulary, social studies, and science), three Bs (in reading, grammar/composition,
and mathematics), two Cs (in religion and foreign language), good in art, satisfactory in
music and physical education, and improvement needed in technology. Finally, though Larry
earned reasonably good grades, his parents reported that homework time was stressful and that
they hoped to reduce the amount of time and effort needed to complete his homework assign-
ments. Larrys homework-related difficulties were observed across all school subjects.
4 History
Larrys parents reported that his first-grade teacher commented that he could go off-task for
minutes to hours at a time without redirection. Larrys previous teachers also reported that he
had difficulties paying attention, being responsible for personal belongings, following directions,
and initiating and completing academic tasks. Reportedly, on at least one occasion, Larry was
sent to the principals office as a result of failure to complete seatwork. Larry had not repeated
or skipped any grades.
At home, Larrys mother reported that she recently (about a year ago) accepted a lower
level position at her job because of the additional attention Larry seemed to require to complete
homework and unfinished seatwork at night. At the time of treatment, Larry was not taking any
medication.
5 Assessment
A previous clinician assessed Larry using a clinical interview, direct observation, and a broad
range of academic, achievement, behavior, and projective measures.
1
From these assessments,
the previous clinician diagnosed Larry with ADHD, predominantly inattentive type. Larrys overall
26 Clinical Case Studies 10(1)
cognitive ability and achievement level fell within the average range of functioning. Although
the ADHD diagnosis was conferred by a previous therapist, our clinic independently evaluated
Larry using a multimethod and multisource approach that included both structural and functional
assessment. Specifically, the present ADHD diagnosis was confirmed through parent, child, and
teacher interviews; parent and teacher rating scales;
2
and direct school observation. Information
from this assessment, as well as a previous psychoeducational evaluation, was used to rule out
other problems that might have warranted additional attention (i.e., learning, emotional, and/or
behavioral problems involving misconduct and aggression).
To assess Larrys eligibility for the HSP, the psychology trainee (first author) used the
following selection criteria (answers required for eligibility):
1. Is the child experiencing significant homework problems? [Yes]
2. Does the child have ADHD or problems related to ADHD that are contributing to home-
work impairments? [Yes]
3. Are additional learning, emotional, and/or behavioral problems present that may require
more individualized and intensive interventions in addition to or in lieu of Homework
Success? [No, or if Yes, additional strategies may be needed]
4. Are the parents prepared and able to commit to full participation in the program? [Yes].
(Power et al., 2001, p. 21)
Larry met eligibility criteria to begin the treatment program; he clearly had homework
problems that were related to his ADHD symptoms, and his parents seemed willing to commit
to the treatment program. Importantly, as noted above, Larry did not seem to evidence other
problems that would have complicated the intervention.
Throughout treatment, Larrys mother completed the Homework Performance Questionnaire
(HPQ; Power et al., 2001), a measure designed to provide information about the nature and
severity of homework problems. The HPQ describes 12 homework-related problem behaviors
rated from 0 (never) to 3 (very often) and asks parents for information about the amount of time
spent on homework, the percentage of homework completed, and the quality of homework for
each subject over the past 2 weeks. Sample items include Leaves necessary homework materi-
als at school and Rushes through assignments, making careless errors. Larrys mother also
completed daily homework logs, which required her to record the subject, number of problems
assigned, number of problems completed, and the total amount of time spent on each subject. In
addition, Larrys teacher completed the Academic Performance Rating Scale (APRS; DuPaul,
Rapport, & Perriello, 1991), a 19-item questionnaire that measures academic performance. On
the APRS, teachers report on the students rate of work completion and accuracy for math and
language arts as well as how well the student pays attention, follows instructions, and learns in
the classroom. The APRS yields scores on three factors: (a) academic productivity (i.e., How
frequently does this child take more time to complete work than his or her classmates?),
(b) academic success (i.e., How consistent has the quality of this childs academic work been
over the past week?), and (c) impulse control (i.e., How often does the child complete written
work in a hasty fashion?).
Two social validity measures were employed. The first, the Homework Success Program
Evaluation Scale (HSPES; Power et al., 2001), is a 16-item measure of parental satisfaction with
the HSP. The Likert-type rating scale ranges from 1 (not helpful) to 5 (extremely helpful), with
two open-ended questions for providing unstructured feedback on the program. On the HSPES,
Section A asks parents to rate the helpfulness of each topic of the program (i.e., Managing time
and goal setting), Section B asks parents to rate each aspect of the programs helpfulness (i.e.,
The parent homework assignments), and Section C requests user-specific feedback on the
Resnick and Reitman 27
program (i.e., What aspects of the program have been the most helpful to you?). The second,
Homework Success Evaluation Inventory (HSEI; Power et al., 2001), is a 7-item measure of
parents views about the usefulness, fairness, and appropriateness of the HSP. The Likert-type
scale ranges from 1 (strongly disagree) to 6 (strongly agree). Sample items on the HSEI included
The strategies of Homework Success make sense to me and I think that most families would
find the Homework Success strategies to be practical and useful.
6 Case Conceptualization
A modified functional assessment framework was used to conceptualize the case (Reitman &
Hupp, 2003). According to this model, both traditional diagnostic or structural assessment and
functional assessment approaches can be combined to improve treatment outcome. Structural
approaches provide the what of assessment (i.e., whether the childs behavior meets DSM-IV
criteria), whereas the functional assessment provides answers to the what for or why ques-
tions. Taking traditional antecedent-behavior-consequence (A-B-C) analysis as the starting
point, functional assessments help clinicians identify environmental factors that may influence
or maintain problem behavior at home and in the classroom, and thus links assessment more
directly to treatment (Noell, 2003).
An important conceptual element derived from this model is the heuristic of cant do or
wont do problems (Witt & Beck, 1999). Indeed, because Larrys grades and cognitive abilities
were deemed average to above average, our assumption was that most homework problems could
be considered wont do as opposed to cant do problems. As a result, it seemed reasonable to
assume that our efforts to influence Larrys behavior would need to be more heavily weighted
toward antecedent interventions and contingency management approaches designed for individu-
als who have the ability to complete work but nevertheless find it challenging to do so.
Indirect (e.g., parent, child, and teacher interviews) and direct (e.g., observation of classroom
behavior) functional assessments suggested that Larrys inattentive behavior (see walking
around and playing with his pencil below) likely served two functions. First, inattentive behav-
iors seemed to produce attention from his parents. For instance, Larrys parents reportedly spent
3 to 4 hr a night with Larry on homework and unfinished seatwork. Larrys parents also tended
to repeat instructions and frequently redirect him when he was off-task. In sum, Larry appeared
to receive a great deal of social attention during homework that may have contributed to mainte-
nance of some inattentive behaviors. Results also suggested that Larrys inattentive behavior
produced temporary escape from unpleasant or difficult tasksin two ways. For instance, during
homework time, Larry would attend to his work for one or two questions and then take breaks
to walk around or play with his pencil. Breaks were thus rewarded immediately through termina-
tion of the effort needed to successfully answer the homework item. Moreover, after redirection,
Larrys parents also supplied appreciable assistance with homework, which further reduced the
effort requirement. Combined with the fact that he had already successfully escaped from teacher
demands to complete seatwork during the school day, it became apparent that escape/avoidance
of academic demands could be an important function of his inattentive behavior. Collectively,
Larrys difficulty focusing, becoming easily distracted, and failure to remain on task
seemed very efficient at producing attention from his parents and producing escape from task
demands.
Fortunately, many intervention elements from the HSP were theoretically compatible with
our formulation. For instance, in the HSP, parents complete A-B-C worksheets weekly to learn
what is triggering and maintaining the targeted problematic behaviors. The HSP also requires
parents and clinicians to work together to restructure the antecedents and consequences of home-
work behavior. After conducting an A-B-C analysis with assistance from the psychology trainee,
28 Clinical Case Studies 10(1)
Larrys mother was instructed to refocus parental attention on more adaptive responses and
discontinue practices that seemed to reward inefficient or unproductive behavior with parental
attention or escape from task demands. Moreover, the HSP requires that time limits are placed
on homework to make homework more manageable, reduce opportunities for parental repri-
mands, reduce the amount of time and energy that parents must devote to helping their child with
homework, and improve the overall parentchild relationship (Power et al., 2001). Furthermore,
the family establishes a regular time and place for homework that enhances homework routines
and minimizes distractions. In addition, parents learn how to give effective instructions (i.e., in
Larrys case, his mother learned to give a command once, followed by a warning if necessary,
instead of repeating herself). Parents also learn how to praise and provide rewards for the home-
work behaviors they want to increase, in addition to providing consequences for behaviors they
wish to decrease, which is intended to increase overall productivity during homework sessions.
7 Course of Treatment and Assessment of Progress
Treatment with the HSP involved seven weekly 60-min sessions. Treatment elements included
introducing the program, establishing a homework ritual and giving instructions, providing posi-
tive reinforcement, managing time and setting goals, using punishment successfully, and inte-
grating skills and anticipating future problems. Treatment was delivered by a psychology trainee
(the first author) under the supervision of a licensed clinical psychologist (the second author).
Supervision was provided weekly.
During the initial treatment session, the psychology trainee gathered baseline data about
homework performance through the administration of the HPQ. The trainee and Larrys mother
discussed homework concerns, program goals, how ADHD is related to homework problems,
and the importance of limiting time spent on homework and using a homework assignment book.
At the end of each session, the trainee asked Larrys mother to complete daily homework logs,
which were then reviewed at the beginning of the following session. Larrys mother was encour-
aged to set up a parentteacher meeting to inform Larrys teacher about the program.
During the second session, Larrys mother reported that his teacher agreed to sign Larrys
planner and prompt him to bring his books home. The trainee and Larrys mother also discussed
the homework time limit. First, Larrys teacher had recommended that he spend about 1 hr per
night on homework (her estimate of the time each child in her classroom should spend on home-
work). Second, it was agreed that Larry would work under his mothers supervision for 1 hr.
After 1 hr, Larry could, if he wished, continue to work, though his mother would no longer pro-
vide assistance. Third, Larrys teacher agreed to grade any and all work turned in but not to
penalize Larry for incomplete homework. The amount of homework assigned remained
unchanged. Later in the session, the daily homework logs and antecedents and consequences of
Larrys homework behavior were reviewed. Finally, Larrys mother received assistance in
implementing a homework ritual and giving effective instructions. At the end of the session,
Larrys mother was asked to obtain the teachers input on the APRS.
After the session, the trainee called Larrys teacher to discuss his progress and problems that
needed to be addressed. Larrys teacher said that she had been checking his planner and occa-
sionally had to ask him 4 times to get a book out. Her biggest concerns with Larrys behavior
had to do with not listening to her and ignoring her on purpose.
During the third session, the trainee administered the HPQ, collected the APRS, and collected
samples of Larrys work. The trainee and Larrys mother also reviewed the daily homework logs.
After reviewing previously assigned tasks, the trainee discussed the principles, rationale, and
types of positive reinforcement and helped Larrys mother develop a token system for Larry,
which was to be implemented before the next session.
Resnick and Reitman 29
Unfortunately, because the token system had yet to be successfully implemented, the fourth
session was devoted to a review of obstacles to implementation (i.e., busy schedules and techni-
cal problems associated with assigning point values). After troubleshooting issues related to the
token system, the trainee briefly introduced the concept of time management and setting goals
for homework, and reviewed daily homework logs. Again, Larrys mother was asked to imple-
ment the token system, speak to Larrys teacher about progress and obstacles, and obtain another
APRS by the next session. Following the session, the trainee called Larrys teacher to discuss his
progress, other problems that needed to be addressed, and the procedures being used in
treatment.
During the fifth session, Larrys mother was administered the HPQ, and the trainee collected
the APRS and reviewed daily homework logs. The session was devoted to a review of token
system implementation, time management and goal setting strategies, and the introduction of the
goal-setting tool (GST), which facilitates setting goals for homework completion, accuracy, and
time. Specifically, children set goals for the number of items completed, the number of items
correct, and the amount of time it will take to complete those items. The GST also allows the
children and parents to evaluate the childs accomplishments and to incorporate results into the
existing token system. At the end of the session, punishment procedures were introduced, but
these were covered in more depth during the following session. Larrys mother was asked to use
the GST each day for the next week.
At the beginning of the sixth session, the trainee reviewed the HPQ and daily homework log
data with Larrys mother. Progress on the GST was discussed, and a summary worksheet was
introduced that allowed Larrys mother to record goal-setting tasks across several subjects or
several assignments within the same subject. Response cost and correction (i.e., instructing the
child on what to do) procedures were also taught and role-played. Finally, Larrys mother was
asked to use the summary worksheet of the GST and implement response cost as part of the token
system.
During the seventh session, Larrys mother completed the HPQ and the previous weeks tasks,
including daily homework logs, were reviewed. Importantly, Larry had been sick during the
week and had missed a few days of school. As a result, he had more homework than usual and
had to catch up. As therapy was drawing to a close, the therapeutic techniques that had been
introduced were reviewed, and the trainee and Larrys mother anticipated future problems and
brainstormed solutions. Larrys mother reported noticing that her overall level of stress had
decreased and that she felt her relationship with Larry had improved since the beginning of treat-
ment. At the end of the session, Larrys mother agreed to allow the trainee to obtain outcome data
from Larrys teacher, and she was informed that the next session would be in 1 month.
After the seventh session, the trainee called Larrys teacher to assess his progress and areas of
weakness. Larrys teacher stated that Larry was making progress but that she still monitored him
closely. She also reported that positive reinforcement worked and kept Larry motivated. Larrys
teacher reported that he occasionally still forgot to bring home books and hand in work from his
folder. Nevertheless, Larrys teacher reported an improvement in Larrys use of a planner and
rate of homework completion. Furthermore, Larrys teacher stated, socially, he has friends and
is happymore so than before. The trainee mailed a self-addressed, stamped envelope to Larrys
teacher to obtain APRS outcome data.
Figure 1 presents Larrys mothers ratings of his homework performance (HPQ Items 1-12)
and the quality of his homework on the HPQ throughout treatment and at follow-up. For graph-
ing purposes, quality was converted to a 4-point scale (see Figure 1). Larrys homework perfor-
mance appeared to improve (from 50% of the HPQ Items 1-12 endorsed as occurring often or
very often at the beginning of treatment to none of the items at the end of treatment, at 1-month
follow-up and at 7-months follow-up), though the quality of the homework appeared stable.
30 Clinical Case Studies 10(1)
Figure 2 presents Larrys mothers estimates of homework time and completion data on the
HPQ throughout treatment and at follow-up. Results show that the amount of time Larry spent
on homework decreased (consistent with the goals of the HSP), with the exception of Session 7,
when Larry had been sick and had to make up the previous weeks homework (in addition to his
regular homework). Furthermore, as treatment progressed, Larry generally completed more
homework (from 42.5% at the beginning of treatment to 90% at the end of treatment, 95% at
1-month follow-up, and 90% at 7 months follow-up), with the exception of Session 5, when he
forgot to bring home some books during the week.
Figure 1. Maternal ratings of HPQ items 1-12 and Larrys homework quality
Note: HPQ = Homework Performance Questionnaire.
Figure 2. Maternal ratings of Larrys homework efficiency and task completion on the HPQ
Note: HPQ = Homework Performance Questionnaire.
Resnick and Reitman 31
Figure 3 displays Larrys mothers report of time spent on homework and the percentage of
all work completed on daily homework logs throughout treatment. Importantly, although the
increase in homework productivity from Sessions 1 to 3 was accompanied by a corresponding
increase in time spent on homework, the trend lines from Sessions 3 through 7 indicate an increase in
efficiency (i.e., a greater percentage of homework completed accompanied by less time spent on
homework). The amount of homework assigned during treatment did not change over the course
of treatment.
Figure 4 presents Larrys teachers responses on the APRS. The data reveal that Larrys aca-
demic performance was generally within the normative range (i.e., within 1.5 standard devia-
tions) for boys of his age, though his level of impulsivity at Session 2 (baseline) and academic
success at Session 4 was significantly below the normative sample. Scores on the Impulse Con-
trol subscale appeared to indicate an upward trend throughout treatment, whereas scores on the
other subscales seemed to be more stable from Session 2 to Session 7 (Larrys teacher-rated
academic success, though below the normative sample at Session 4, fell within the normative
range and yielded the same scores at Sessions 2 and 7). Thus, for teacher-rated change, only a
slight improvement (reduction) in impulsivity seemed to be associated with intervention.
8 Complicating Factors
Although Larry and his mother appeared motivated for treatment, and Larrys teacher was coop-
erative, several factors complicated treatment implementation and delivery for Larry. As might
be expected, disruptions in school attendance are serious threats to successful implementation of
the HSP. Specifically, Larrys illness between Sessions 6 and 7 resulted in additional homework
for that week. Soon thereafter, Larry and his family left town to attend a funeral. Missing school
was harmful in multiple ways. For example, students not only miss the opportunity to learn the
material taught in class but also face the additional challenge of mastering the new content while
new material is being introduced. Although such disruptions are to be expected, they neverthe-
less affect continuity of care and could negatively influence the integrity of treatment implemen-
tation. After treatment, Larrys teacher provided the trainee with the APRS and feedback that
Larry has been absent a week and now has been out of town for a death in the family.
Figure 3. Larrys homework efficiency and task completion on the parent-reported daily homework logs
32 Clinical Case Studies 10(1)
Fortunately, these events occurred after all HSP strategies had been introduced (Session 7 was a
review of all the techniques learned throughout the program). Nevertheless, the disruption may
have affected Larrys teachers final rating of his academic performance, as she completed the
measure following Larrys absences from school.
Another complicating factor involved measurement of homework performance. For instance,
normative data on the HPQ have yet to be made available. There is an updated version of the
HPQ for parents and teachers (refer to Power, Dombrowski, Watkins, Mautone, & Eagle, 2007);
however, it too requires a critical review of its psychometric properties. Still, the HPQ seemed to
provide useful information about Larrys homework-related problem behaviors as well as a rea-
sonable estimate of parent-perceived progress in therapy (i.e., face validity). Undoubtedly, more
direct measures of homework performance and related outcomes, such as homework completion
and accuracy data derived from the teachers grade book, would have improved our ability to
establish the success or failure of the intervention.
9 Managed Care Considerations
As treatment occurred in a training clinic that used a sliding scale to determine session fees and
did not accept insurance, third-party payment was not an issue in the present case. That being
said, it is clear that many elements of the HSP, and empirically based assessments and treatments
in general, could face billing challenges. For example, all third-party payers may not support
billing insurance companies for ancillary services such as phone contacts with teachers and par-
ents that are needed to ensure adequate treatment integrity.
10 Follow-Up
Assessment at 1- and 7-months follow-up revealed maintenance of treatment gains in terms of
parental report of homework performance, homework completion time, and the percentage of
homework completed (refer to Figures 1 and 2).
At the 1-month follow-up, Larrys mother completed the HPQ (refer to Figures 1 and 2), the
HSPES, and the HSEI. On the HSPES, Larrys mother reported that the program had generally
been very helpful for her and her family (M = 4.33). On the HSEI, Larrys mother tended to
Figure 4. Teacher ratings of Larrys academic performance over time
Resnick and Reitman 33
strongly agree that the HSP was helpful and that the techniques were reasonable, fair, practi-
cal, and useful (M = 5.57). In regards to Larrys teachers ratings, she provided the final rating
on the APRS just after the seventh session (refer to Figure 4). However, as school was out-of-
session by the time of the 1-month follow-up, no additional data were available from this source.
Interestingly, although Larry no longer received homework from his teacher at follow-up, he was
still being assigned homework, as his mother had placed him in classes over the summer. As a
result, Larry was able to maintain a homework routine despite the summer recess.
At 7-month follow-up, Larrys mother completed the HPQ (refer to Figures 1 and 2). It is
important to note that data were not collected from Larrys teacher at 7-month follow-up, as
Larry had successfully moved on to the fourth grade and had been assigned new teachers.
11 Treatment Implications of the Case
The purpose of this case study was to evaluate the effectiveness of the HSP for an 8-year-old boy
diagnosed with ADHD, predominantly inattentive type. Results indicated that the HSP was asso-
ciated with improvements in parental report of homework performance and homework comple-
tion time as well as the percentage of homework completed. The quality of homework appeared
to be stable throughout treatment. A reduction in Larrys teachers estimates of his impulsivity
was noted. Otherwise, teacher-rated changes in Larrys behavior were minimal.
There are several possible explanations for the divergence of teacher and parent report. For
example, Larrys mother monitored his homework performance daily; so, she may have been
more sensitive to improvements than Larrys teacher, who was otherwise preoccupied with man-
aging the rest of the classroom. Previous research has suggested that teachers ratings may not be
especially sensitive to changes in child behavior in the classroom (see Reitman, Murphy, Hupp,
& OCallaghan, 2004). Furthermore, it is possible that Larrys teachers awareness of his ADHD
status could have intersected with assumptions about the nature of the disorder (i.e., this is a
biological disorder that is invariant) to mask treatment effects. In addition, the teachers final
rating on the APRS followed Larrys absences from school due to an illness and a death in the
family, which may have affected her rating. Finally, Larrys grades (i.e., three As, three Bs, and
two Cs) and classroom performance were not initially problematic, thus making it more difficult
for the teacher to observe change. As Larrys mother reportedly reviewed his homework with
him, it is possible that teacher ratings of homework problems may have been attenuated. How-
ever, despite the limited change in the teachers formal ratings, her subjective report revealed
improvements in organization (i.e., using a planner) and homework completion.
It is essential to note that Larry had high-functioning parents who were proactive in address-
ing his academic issues. Indeed, although Larry showed functional impairments in homework
performance (i.e., difficulty focusing and sustaining attention, becoming easily distracted,
spending 3 to 4 hr per night on homework, completing around half of his assigned homework,
forgetting to bring home books, and inconsistently writing down assignments in his planner), his
classroom performance and grades had yet to be negatively impacted. Parents may be wise to
seek such treatment before problems become evident to teachers and school administrators, as a
recent study involving children with ADHD symptoms suggests that early intervention may
improve academic and behavioral functioning (Kern et al., 2007). As such, parents should be
encouraged to pursue treatment as early as is feasible and before problems escalate. Neverthe-
less, it should also be noted that the positive effects of the HSP may not generalize to children
with more severe or longstanding impairments.
Of course, interventions made available to parents should be deemed acceptable and reason-
ably straightforward to implement. As such, it was gratifying that Larrys mother rated the HSP
favorably and reported that it had been helpful. Overall, the techniques used in the intervention
34 Clinical Case Studies 10(1)
may be able to help clinicians, student trainees, teachers, staff, and parents create a more optimal
environment for students with ADHD who struggle with homework.
12 Recommendations to Clinicians and Students
In implementing the HSP, it is recommended that the referred student be encountering substan-
tial homework problems. However, if comorbid developmental, learning, externalizing, or inter-
nalizing problems are present, then they may require more specialized attention prior to initiation
of the HSP. The presence of a comorbid condition, though, should not uniformly be used to
exclude anyone from using the HSP, as adaptation, modification, and even simplification of the
HSP may render it suitable as an adjunctive treatment (Power et al., 2001). As was evident in the
present case, parents must be willing to commit the necessary time and energy to facilitate suc-
cessful implementation of the HSP. Clinicians who stress the nature of this commitment and its
potential rewards upfront are likely to be more successful than those who take such things for
granted (see Kanfer & Schefft, 1988). For instance, the HSP requires parents to complete daily
homework logs and discuss them during each session. If parents miss sessions or fail to complete
assignments, then the HSP is unlikely to be helpful to them.
Clinicians and student trainees must attend carefully to the childs academic calendar when
implementing the HSP. Thus, one should avoid implementing the HSP during school breaks or
holidays, as the intervention requires that students have homework to complete between each
session. Furthermore, as the HSP was created for use with groups, clinicians and trainees may
have to tailor the program for use with individual families. Fortunately, the present authors
found the HSP to be easily modifiable, as the main changes involved introducing treatment as
an individualized process, rather than a group process; shortening the duration of the sessions
(i.e., from 90-60 min), and, in our case, including the child in the sessions for the full duration
of each session, as it has been suggested that including both parents and children in treatment
is more effective than working with either in isolation (Power, Soffer, Clarke, & Mautone,
2006). Finally, supervisors of student trainees who use the HSP should be familiar with it,
along with the needs of students with ADHD. A more general understanding of behavior ther-
apy principles is also useful to ground the intervention and facilitate the professional growth
of the trainee. In summary, the HSP appears to be a potentially helpful treatment option for
clinicians and students who work with ADHD-diagnosed children presenting with significant
homework problems.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication
of this article.
Funding
The author(s) received no financial support for the research and/or authorship of this article.
Notes
1. Wechsler Intelligence Scale for ChildrenFourth Edition (WISC-IV); WoodcockJohnson III, Tests of
Achievement (WJ-III ACH); WoodcockJohnson III, Tests of Cognitive Abilities (WJ-III COG);
Bender Visual-Motor Gestalt Test, Second Edition (Bender-Gestalt II); Conners Continuous Perfor-
mance Test, Second Edition (CPT II); the Behavior Assessment System for Children, Second Edition
(BASC-2), including the parent, child, and teacher versions; Conners Third Edition (Conners 3),
including the parent, child, and teacher versions; projective drawings and stories; and a sentence com-
pletion test.
Resnick and Reitman 35
2. Conners Parent Rating ScaleRevised, Conners Teacher Rating ScaleRevised, Home Situations
Questionnaire, School Situations Questionnaire, and the Eyberg Child Behavior Inventory.
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Bios
Alexis Resnick, MS, is a graduate student in clinical psychology at Nova Southeastern University with
special interests in child and adolescent psychology.
David Reitman, PhD, is an associate professor of psychology at Nova Southeastern Universitys Center for
Psychological Studies and the director of the ADHD Assessment Consultation and Treatment (AACT)
Program. His research interests include child behavioral problems, behavior management, and parenting
practices.