Child and Adolescent

Interventions
EVIDENCE-BASED TREATMENTS FOR
ADHD
WEISZ, 2004
CH. 6 & 7
Using Behavioral Parent
Training to Treat ADHD

WEISZ, CHAPTER 6
 ADHD

DSM-IV Criteria for ADHD

I. Either A or B:

Six or more symptoms of inattention have been present for at least 6 months
to a point that is disruptive and inappropriate for developmental
level, for example: difficulty keeping attention on tasks or play activities, does
not seem to listen when spoken to directly, does not follow instructions and fails
to finish schoolwork, loses things, is easily distracted

Six or more symptoms of hyperactivity-impulsivity have been present for at

least 6 months to an extent that is disruptive and inappropriate for
developmental level, for example: (hyperactivity) fidgets with hands or
feet or squirms in seat, gets up from seat when remaining in seat is expected,
runs about or climbs when not appropriate, trouble playing or enjoying leisure
activities quietly, "on the go" or often acts as if "driven by a motor“, talks
excessively; and (impulsivity) blurts out answers before questions have been
finished, has trouble waiting one's turn, interrupts
 ADHD

 Present before age 7 years.

 Some impairment from the symptoms is present in two or more

settings (e.g. at school/work and at home).

 There must be clear evidence of significant impairment in social,

school, or work functioning.

 Three types of ADHD are identified:

 ADHD, Combined Type: if both criteria 1A and 1B are met for the
past 6 months
 ADHD, Predominantly Inattentive Type: if criterion 1A is met but
criterion 1B is not met for the past six months 
 ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion
1B is met but Criterion 1A is not met for the past six months.
 Barkley’s Points of Performance
Conceptual Model

Barkley (1998) describes ADHD as “...a developmental

disorder of probable neurogenetic origins in which some
unique environmental factors play a role in expression of
the disorder, though a far smaller role than genetic ones
do” (p. 69).

ADHD is viewed NOT as a skills deficit, but as a disorder of

performance. That is, children know what to do, but
cannot make themselves do it.
 Barkley’s Points of Performance
Conceptual Model
It follows, then, that ADHD is not very responsive to
interventions emphasizing the transfer of knowledge or
skills, or requiring generalization from the clinician’s office
to homes or schools or peer groups.

As a result, Barkley advocates for interventions that are

implemented at points of performance, that is, at those
times and in those situations where the child must perform
specific behaviors:
 at home—behavioral parent training
 at school—classroom management skills
 with peers—school or camp settings
 The Role of Parents & Teachers in
ADHD Treatment

Parents are viewed as an important part of the solution to

child problems, but in the case of ADHD, parenting is not
a causal factor.

Parent training (and classroom strategies, for that

matter) are best seen as contextual interventions that
help children cope with self-regulation deficits that are
genetically influenced, neurologically based, and
enduring (see Barkley, 1997).

Note: Parent “training” is a bit grandiose, no?

 Evidence Against Parent Blaming

Poor behavior management is more closely

associated with ODD
Negative and controlling parent behavior appears to
be a “reaction” to ADHD behaviors rather than a
cause of ADHD behaviors
Generalization of behavioral parent training
interventions is limited
Parent-focused ADHD interventions are seen as
behavioral support, largely thru greater structure
and consistency
 Barkley’s Defiant Children: In brief

ADHD/Defiant Children: Ages 2-12

Sessions=9, plus boosters, follow-up; 1-2 hours each
Session 1: ADHD Education; Session 2: “Attending”
Session 3: Effective Commands; Session 4: Token E
Session 5: Response Cost/TO; Session 6: More TO
Session 7: Public Bx Problems; Session 8: School Bx
Session 9: Generalization; Session 10: Booster(1 mo.)
KEYS: Immediate, specific consequences, promote good bx,
prevent bad bx, bidirectional causality (aka “response-
ability, not responsibility”)
Interventions for Disruptive Behaviors: Hanf-Model Programs

 Defiant Children Program (DCP)

 Russell Barkley (1997)
 Helping the Noncompliant Child Program (HNCP)
 Forehand & McMahon (2003)

 Parent-Child Interaction Training (PCIT)

 Eyberg & Calzada (1998)

 Other Approaches
 Living with Children
 Patterson (1976)
 Hanf-model Parent Training Commonalities

 Education: Nature of disorder (change motivation, “framing”)

 Structuring the environment for success (prevention)

 Prompts, routines, eliminating skill/resource deficits
 e.g., “think aloud-think ahead,” tutoring, task prompts (put up pictures that are
reminders)

 Part I: Training in Increasing attention, praise & rewards for appropriate,

compliant behavior, instituted via “special time” with child [WARMTH]
 Part II: Training in Effective Commands, “Active” Ignoring, & Effective
consequences for inappropriate, noncompliant behavior (e.g., response-
cost, time out) [CONTROL]

 Coordination w/ schools via home-school daily report cards

 Research on BPT for ADHD

Improved school performance (O’Leary et al., 1976)

Parent satisfaction, academic and behavioral
(noncompliance), but NOT attention (Pisterman et al.,
1989, 1992)
Limited evidence of effect for self-control tx (Horn and
colleagues, 1987)
Test of DC look good, but limited impact for adolescents
Summary: Core problems seem relatively unchanged, no
“ADHD-specific” treatment impact (but don’t really
target these problems)
 Troubleshooting BPT for ADHD

Parents who miss sessions

 Take seriously, monitor attendance, address problems
 Motivational Interviewing?
Parents who don’t do “homework” (aka “practice)
 Problem solve around the “issue”
 Breakage fee?
Parents who don’t practice properly
 Parents may not executes skills as needed, require feedback
until mastery is achieved
 Role plays help to limit problems with this
 Scientific and Clinical Issues in ADHD
Scientific
Small Ns, control groups,
varied PTs evaluated
No change in “Core”
symptoms (so what?)
Moderators
 Age, gender, & ses,
Mediators
 Parent management skills
Outcome Assessment
 Functional (grades), direct obs
(not self-report), maintenance?
Clinical
Good manual, nice blend
of research and clinical
wisdom (flexibility)
Training needs?
Costs (group vs.
individ.), 1o sessions
Barkley has also
authored “Defiant Teens”
 Interesting that not all
ADHD-dx’ed are Defiant!
Behavioral Programs in the
Classroom & Camp Settings

WEISZ, CHAPTER 7
 Goals of School-based and Camp Intervention for ADHD

Improving Attention (compliance) to tasks

Reducing Overactive and Impulsive behavior
Reducing Disobedience (non-compliance)

KEY: Placing the intervention in the place where the

problems associated with ADHD arise (re: the
“points of performance” model)
 Use reminders (structured environment)
 Use rewards (enhanced differential reinforcement)
 Setting specific (classroom, social settings, etc)
 Pelham’s STP: In brief

ADHD kids, 5-15 yrs, 360 hrs, 8 wks (8-5pm daily)

Elements: SST, Academics (1 hr), Arts, Sports (3 hr),
Computers
KEY: Staff Training! 5 to 12 ratio (staff:child)
Instructions w/ differential R+ for compliance
Elaborate Token System w/ Time Out
Parent involvement (in token system, via home notes,
especially)
Medication evaluation
Follow-up and booster sessions (STP is an “intensive
beginning to ….what needs to be long-term tx..”)
 Details about Daily Report Cards

Individualized, 4-6 target behaviors (see also table 7.2 for

general “Dos’ and “Don’ts” for STP)
Functions of the Report Cards
 Daily feedback to child
 Daily feedback to parent
 Systematically alerts adults (e.g., staff and parents) about when and how
much to reward children for good behavior
Payday Fridays (cashout)
Variation on “leveled system”- Level I & II- (field trip) , Level
III & IV (same), Level V & VI (chores)
Honor Roll (Star; earning yourself off the system!)
 Emphasis on self-management and rating
 Importance of Social Skills Training (SST)

Peer relations among the most predictive of long-term

success
Four Core SSTs
 Communication- talking about interesting things, listening
 Cooperation- sharing, being a good sport
 Validation (of others)- offering help, being friendly
 Participation- getting involved, not quitting!
Children/Staff Role play skills each week
 Staff and kids LOOK for skills during the day
 Staff prompt self-evaluation of SS
Group problem solving &s Sports extensions of SST
 ADHD & Sports

3 Core Clinical Problems in Sports Settings

 Poor motor skills
 Poor Understanding of Rules
 Poor Rule Following
Focus is on development of “life values” such as good
sportsmanship, self-confidence, discipline,
cooperation, and skill-building thru practice
Medication evals can also be done, and not just for
sports bx (see Northup, Reitman, & deBack, 2009)
 Our data show that for younger children, SS did not improve
consistent w/ meds but did for token systems
 STAR LSU/NSU: An Operant STP for Young Children w/
ADHD (Northup, Reitman, & deBack, 2009)

What we learned from our work:

 Medication evaluations are idea for summer
 Programs are ideal for training students
ADHD specific findings:
 For younger children, SS did not improve consistently w/ meds
but did for token systems
 Response to treatment with medication and to a lesser extent
contingency management was idiosyncratic for both social and
academic behaviors
 High rates of parent satisfaction and changes in parent attitudes
about discipline, like Pelham- very high parent attendance
 What Seems to Work in the “Classroom”

Contingency management for academic performance

Response cost (added to a token system)
 Confounded with feedback re: performance
Verbal reprimands (better than nothing)
 Better w/ eye contact and proximity, consistency/immediacy
Social Skill Training
 Limited generalization though
School-Home Notes/Self-evaluation
In general, programs combining the above elements,
change but don’t normalize all behaviors (but the most
significant problems are normalized)