Case Analysis – Integrating Theoretical Orientations

Case Analysis – Integrating Theoretical Orientations

Prior to beginning this assignment, read the PSY650 Week Two Treatment Plan , Case 16: Attention-Deficit/Hyperactivity Disorder in Gorenstein and Comer (2014), and Attention-Deficit/Hyperactivity Disorders in Hamblin and Gross (2012).

Assess the evidence-based practices implemented in this case study by addressing the following issues:

· Explain the connection between each theoretical orientation used by Dr. Remoc and the four interventions utilized in the case.

· Consider Dr. Remoc’s utilization of two theoretical frameworks to guide her treatment plan. Assess the efficacy of integrating two orientations based on the information presented in the case study. Describe some potential problems with prescribing medication as the only treatment option for children with ADHD.

· Identify tasks and positive reinforcements that might be included in Billy’s token economy chart given the behavior issues described in the case. (There are articles in the recommended resources that may assist you in this portion of the assignment.)

· Evaluate the effectiveness of the four treatment interventions implemented by Dr. Remoc and support your statements with information from the case and two to three peer-reviewed articles from the Ashford University Library.

· Recommend three additional treatment interventions that would be appropriate in this case. Use information from the Hamblin and Gross “Attention-Deficit/Hyperactivity Disorders” chapter to help support your recommendations. Justify your selections with information from the case.

The Case Analysis

· Must be 4 to 5 double-spaced pages in length (not including title and references pages) and formatted according to APA style as outlined in the Ashford Writing Center (Links to an external site.)Links to an external site..

· Must include a separate title page with the following:

o Title of paper

o Student’s name

o Course name and number

o Instructor’s name

o Date submitted

· Must use at least two peer-reviewed sources from the Ashford University Library.

· Must document all sources in APA style as outlined in the Ashford Writing Center. (Links to an external site.)Links to an external site.

· Must include a separate references page that is formatted according to APA style as outlined in the Ashford Writing Center.

Attention-Deficit/

Hyperactivity Disorders

REBECCA J. HAMBLIN AND ALAN M. GROSS

OVERVIEW

Attention-deficit/hyperactivity disorder (ADHD)

is one of the most well-studied child psychopathologies,

and a tremendous amount of

research has been published related to its

etiology, primary problems and impact,

demographic and contextual variability, and

treatment methods. The label has also received

heavy criticism as being an artificial U.S.

construct for labeling normally exuberant

children; however, early clinical descriptions

of attention impairments date to 1798 (Barkley,

2006; Palmer & Finger, 2001). Attentiondeficit/hyperactivity

disorder symptoms are

reported to occur in all countries in which

ADHD has been studied (Polanczyk, de Lima,

Horta, Biederman, & Rohde, 2007). Despite

early conceptualization of the disorder as

resulting from poor character or wayward

parenting, ADHD is now seen as a neurologically

based disorder (Barkley, 2006).

ADHD is one of the most common disorders

of childhood, affecting an estimated

3% to 5% of children in the United States,

and is the most common reason for clinical

referral of children to psychiatric clinics

(American Psychiatric Association, 2000).

Children with ADHD display symptoms of

inattention, impulsivity, and hyperactivity

across multiple situations beginning at an

early age. The frequency of these behaviors

is out of bounds with respect to normal

development, and symptoms cause significant

impairments in family and peer relationships,

academic functioning, and emotional wellbeing

(Barkley, 2006).

This chapter will provide an overview of the

core symptoms and current diagnostic features

of the disorder, describe its prevalence and

epidemiology, impairments to daily life,

comorbid disorders, and long-term outcomes.

The next sections will describe various

psychosocial treatments that have been

empirically explored, and will review the most

current research on treatment efficacy. The

chapter concludes with a summary and list of

evidence-based treatments for ADHD.

CORE SYMPTOMS

Inattention

Relative to children without ADHD, those

with the disorder have difficulty maintaining

attention or vigilance in responding to environmental

demands. That is, they have trouble

sustaining effort in tasks, particularly for

activities that are tedious, difficult, or with

little intrinsic appeal (Barkley, 2006). In the

classroom setting, impairment in attention and

task vigilance may be evident in inability to

c10 21 April 2012; 9:57:7

243 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders, John Wiley &

Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=817355.<br>Created from ashford-ebooks on 2017-11-28 18:25:28. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved.

complete independent assignments or listen

to class instruction. In unstructured settings,

inattention may be apparent in frequent shifts

between play activities. Parents and teachers

report that these children have difficulty

focusing, are often forgetful, lose things, frequently

daydream, fail to complete chores and

schoolwork, and require more redirection

and supervision than others the same age.

Children with high levels of inattentive

symptoms in the absence of hyperactive or

impulsive symptoms may also have a different

kind of attention problem marked by sluggish

cognitive processing and deficiency in selective

attention (Barkley, 2003).

Hyperactivity and Impulsivity

Hyperactivity and impulsivity almost always

co-occur and are therefore considered a single

dimension of ADHD. The hyperactiveimpulsive

dimension of the disorder is often

conceptualized as behavioral disinhibition.

Hyperactivity is displayed in fidgeting, restlessness,

loud and excessive talking, and

excessive levels of motor activity. Impulsive

behaviors include interrupting or intruding on

others, difficulty waiting and taking turns, and

blurting out without thinking. Children

and adolescents with hyperactive-impulsive

features are described by caregivers as reckless,

irresponsible, rude, immature, squirmy,

and on the go (APA, 2000; Barkley, 2006).

Diagnostic Criteria and Subtypes

Diagnostic criteria for ADHD are defined by

the Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition, Text Revision (DSMIV-TR)

as presence of several symptoms in

inattention, hyperactivity-impulsivity, or both,

as seen in Table 10.1 (APA, 2000). Individuals

with symptoms in both domains are classified as

having ADHD, combined type (ADHD-C).

Those who manifest multiple symptoms of

inattention but no or few hyperactive-impulsive

characteristics are diagnosed with ADHD,

predominately inattentive type (ADHD-PI).

The ADHD, predominately hyperactiveimpulsive

type (ADHD-PHI) describes individuals

with behavioral disinhibition without

significant symptoms of inattention. Table 10.1

contains the complete diagnostic contained in

the DSM-IV-TR.

PREVALENCE AND DEMOGRAPHIC

VARIABLES

Nearly 5 million children in the United States

are diagnosed with ADHD (Centers for Disease

Control and Prevention [CDC], 2005).

Prevalence rates of ADHD translate, on average,

to one to two children in every classroom

in America (APA, 2000). The most commonly

diagnosed subtype is ADHD-C, representing

about 50% to 75% of children diagnosed.

Another 20% to 30% are classified with

ADHD-PI, while fewer than 15% are diagnosed

with ADHD-PHI. It is thought that

ADHD-PHI may be a developmental precursor

to the combined type, seen in preschool-age

children who have not yet manifested symptoms

of inattention.

Boys are 2 to 9 times more likely than girls to

be diagnosed with ADHD (APA, 2000). The

gender discrepancy is more pronounced in

clinic referred than in community samples.

Higher rates among males may be at least

partially attributable to a stronger tendency for

males to present ADHD-C and comorbid disruptive

behavior disorders, which are more

likely to rise to the level of clinical attention.

Girls are more likely to have ADHD-PI and

comorbid disorders are more likely to be

internalizing disorders. Because symptoms of

ADHD-PI and emotional disorders are more

likely to go unnoticed, girls with ADHD

may be underindentified and undertreated

(Biederman, 2005).

ADHD is present among all socioeconomic

levels and ethnic groups within the United

States, though prevalence and symptoms vary

by gender, age, and ethnicity (Barkley, 2003;

244 Specific Disorders

c10 21 April 2012; 9:57:7

Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders, John Wiley &

TABLE 10.1 DSM-IV-TR Criteria for Attention-Deficit/Hyperactivity Disorder

I. Either A or B:

A. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is

inappropriate for developmental level:

Inattention

1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other

activities.

2. Often has trouble keeping attention on tasks or play activities.

3. Often does not seem to listen when spoken to directly.

4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace

(not due to oppositional behavior or failure to understand instructions).

5. Often has trouble organizing activities.

6. Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time

(such as schoolwork or homework).

7. Often loses things needed for tasks and activities (e.g., toys, school assignments, pencils, books, or tools).

8. Is often easily distracted.

9. Is often forgetful in daily activities.

B. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an

extent that is disruptive and inappropriate for developmental level:

Hyperactivity

1. Often fidgets with hands or feet or squirms in seat when sitting still is expected.

2. Often gets up from seat when remaining in seat is expected.

3. Often excessively runs about or climbs when and where it is not appropriate (adolescents or adults may feel

very restless).

4. Often has trouble playing or doing leisure activities quietly.

5. Is often “on the go” or often acts as if “driven by a motor.”

6. Often talks excessively.

Impulsivity

7. Often blurts out answers before questions have been finished.

8. Often has trouble waiting one’s turn.

9. Often interrupts or intrudes on others (e.g., butts into conversations or games).

II. Some symptoms that cause impairment were present before age 7 years.

III. Some impairment from the symptoms is present in two or more settings (e.g., at school/work and at home).

IV. There must be clear evidence of clinically significant impairment in social, school, or work functioning.

V. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other

Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g., Mood Disorder,

Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Based on these criteria, three types of ADHD are identified:

IA. ADHD, Combined Type: If both criteria IA and IB are met for the past 6 months.

IB. ADHD, Predominantly Inattentive Type: If criterion IA is met but criterion IB is not met for the past six months.

IC. ADHD, Predominantly Hyperactive-Impulsive Type: If criterion IB is met but criterion IA is not met for the past

6 months.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text

Revision (Copyright r 2000). American Psychiatric Association.

Attention-Deficit/Hyperactivity Disorders 245

c10 21 April 2012; 9:57:8

Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders, John Wiley &

Cuffe, Moore, & McKeown, 2005). Worldwide

prevalence estimates typically range

from 3% to 8% of the world population.

Estimates vary by geographic region, but

this is thought to be primarily due to differences

in diagnostic criteria and study

methodologies (Biederman, 2005; Polanczyk

et al., 2007).

Studies of current and lifetime prevalence

rates in the United States indicate that Hispanics

and Latinos have lower risk for ADHD

than either African Americans or Caucasians.

Some studies show a higher rate of ADHD

diagnosed among African Americans than in

Caucasians, but these differences are not

always statistically significant (Breslau et al.,

2006; Cuffe et al., 2005). Lower socioeconomic

status is related to higher incidence

of ADHD. This difference may be attributable

to lower socioeconomic status being a risk

factor for development of the disorder; additionally,

parents of children with ADHD are

likely to also have ADHD, and therefore may

have low educational obtainment and occupational

difficulties (Barkley, 2003; Cuffe et al.,

2005). Results of the 2003 National Survey of

Children’s Health (CDC, 2005) showed that

ADHD was more commonly diagnosed among

children whose parents had obtained a high

school education than those whose parents had

achieved more or less education. Children in

ethnic minority populations and uninsured

children were less likely than others to receive

medication treatment. Finally, prevalence of

reported ADHD increased with age and

was greater for children 9 years and up than

for younger children (CDC, 2005; Visser,

Lesesne, & Perou, 2007).

IMPACT OF ADHD

Social

Children with ADHD experience a great deal

of difficulty in their family and peer relationships.

They tend have more conflict with their

parents over issues like chores and homework.

Parents are more likely to be harsh and

inconsistent in their discipline, and children

respond with greater hostility and avoidance of

their parents than their non-ADHD peers. This

pattern of negative interaction results in

strained and distant parent-child relationships

(Anastopolous, Sommer, & Schatz, 2009;

Wehmeier, Schacht, & Barkley, 2010).

Children and teens with ADHD also engage

in more conflict with their siblings than do

other children of the same age. Externalizing

behavior problems seem to be one of the major

sources of this conflict; when comorbid disruptive

behavior disorders are present, conflict

increases substantially. While children with

ADHD generally do not rate their sibling

relationships as less close than do other children,

the presence of comorbid internalizing or

externalizing disorders has been shown to

relate to less warmth and closeness in these

interactions (Mikami & Pfiffner, 2008).

Social skills deficits and conflictual interactions

extend to peer relations as well. A

majority (70%) of these children have been

found to have serious problems in peer and

friend relationships. Younger children with

ADHD can be difficult playmates as they have

a harder time waiting and taking turns, and

paying attention to and following rules of

games. Those with ADHD-C in particular tend

to interact in an impulsive, intrusive manner,

and are disruptive (Wehmeier et al., 2010). In

contrast, children with ADHD-PI are often

characterized as being socially passive, shy,

and withdrawn (Barkley, 2006). As a result of

these skill deficits, they tend to be less wellliked,

experience more frequent rejection, and

have fewer reciprocal friendships than their

peers. Those with oppositional defiant disorder

(ODD) or conduct disorder (CD) display the

most serious social problems; for these youth,

most do not develop any close friendships by

the third grade, and in adolescence are more

likely to become bullies or victims of bullies

(Wehmeier et al., 2010). Treatment with

psychostimulant medication frequently does

246 Specific Disorders

c10 21 April 2012; 9:57:8

Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders, John Wiley &

not improve social problems even when it

decreases aggression and other negative

behaviors (Pelham & Fabiano, 2008).

Academic

The academic environment may be the most

challenging context that students with ADHD

have to navigate. Symptoms appear dramatically

in the school setting, where children are

required to remain vigilant to instruction and

tasks at longer intervals than at home or in

social settings (Barkley, 2003). Nearly

all children with ADHD experience significant

impairment in academic achievement

throughout their school years, and on average

score a full standard deviation below classmates

on achievement tests (G. J. DuPaul &

Stoner, 2003; Loe & Feldman, 2007). Problems

with inattention manifest in increased

off-task behavior, and increased time to return

to an activity after being distracted, resulting in

decreased productivity. Children with ADHD

have difficulty completing homework and

assignments, organizing materials and tasks,

and planning completion for long-term projects.

Hyperactivity and impulsivity appear in

such behaviors as getting up without permission,

disturbing others, talking noisily, and

rule-breaking, which lead to punishments

and negative interactions with teachers. They

may spend less time in the classroom as a result

of frequent disciplinary action, and thus miss

out on instruction. It is not surprising that

children with ADHD are at higher risk

than their peers for grade retention, suspension,

expulsion, and school drop out (Barkley,

2006; G. J. DuPaul et al., 2006).

Emotional

Adolescents and children with ADHD experience

rejection, failure, frustration, and conflict

on a day-to-day basis. The ADHD-related

impairments often take an emotional toll on

these children as they navigate a variety of

social and performance situations, often facing

criticism from all sides. They may learn to

anticipate failure instead of success, developing

a sense of learned helplessness and dejection

(Wehmeier et al., 2010). They also tend to

have poorer self-perception than their peers

and rate themselves more negatively on social

and communication skills (Klimkeit et al.,

2006). Related to the impairment in behavioral

inhibition, children with ADHD are less able

to moderate or regulate their emotions and to

suppress their external emotional reactions.

Consequently, they may experience extreme

emotional reactions to stressful situations

(Barkley, 2006).

COMORBID DISORDERS

Children with ADHD frequently have one or

more comorbid psychiatric disorders. Recent

studies suggest that around 80% of children

and adolescents with ADHD have at least

one comorbid disorder, and over half have

two or more (Biederman, Petty, Evans,

Small, & Faracone, 2010; Cuffe et al., 2005).

The most common pattern of comorbidity

seen in children with ADHD is that of

ADHD-C with other externalizing behavior

disorders. About half of youth diagnosed

with ADHD also meet diagnostic criteria for

ODD or CD. ODD is characterized by a

pattern of defiant behavior and rule-breaking,

including noncompliance with direct commands,

denying responsibility for actions,

and arguing. CD is more severe, defined by

a pattern of aggression, destruction, lying,

stealing, or truancy (APA, 2000).

Internalizing disorders also commonly

co-occur with ADHD. About 30% of youth with

ADHD have a comorbid anxiety disorder, and

about 25% have a mood disorder (Biederman,

2005). Rates of anxiety disorders may be

slightly higher in individuals with ADHD-PI.

Anxiety disorders are found to reduce the risk of

impulsiveness compared to ADHD without

anxiety. As noted before, children with ADHD

experience considerable rejection and failure;

Attention-Deficit/Hyperactivity Disorders 247

c10 21 April 2012; 9:57:8

Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders, John Wiley &

it may be that high rates of comorbidity are

related to such a negative learning history

(Barkley, 2003; Wehmeier et al., 2010).

ADHD and mood disorders may share a

common genetic factor predisposing an individual

to both disorders, but no genetic link or

familial pattern has been found for comorbidity

of anxiety disorders (Barkley, 2003;

Biederman, 2005). Learning disabilities, tic

disorders, and sleep disorders and disturbances

are other problems frequently seen in children

with ADHD (Barkley, 2003).

DEVELOPMENTAL COURSE

Although usually diagnosed in childhood,

ADHD is increasingly conceptualized as a

chronic disorder, often persisting through

adulthood. Hyperactivity and impulsivity tend

to present in the preschool years, at around age

3 to 4 years, and symptoms of inattention

typically appear slightly later at 5 or 6 years.

Some evidence suggests that ADHD-PI has a

slightly later onset than ADHD-C, and symptoms

may not occur until age 8 or later. Almost

all cases of ADHD have an onset prior to age

16 years (Barkley, 2003, 2006).

Hyperactivity symptoms begin to decline in

adolescence, and at this time take on a more

internalized subjective sense of restlessness

rather than external motor activity. For this

reason, ADHD was previously thought to be a

remitting disorder in which most children

outgrew their symptoms; however, while

hyperactivity tends to decline, symptoms of

inattention typically do not, and most children

with ADHD continue to have impairments as

adolescents and as adults. Symptoms of

ADHD decline in a similar manner for males

and females (Monuteaux, Mick, Faraone, &

Biederman, 2010). A longitudinal study that

followed boys with ADHD showed that 78%

of participants continued to experience clinically

significant symptoms as young adults

(Beiderman et al., 2010). Adults with ADHD

also continue to display high rates of

psychiatric comorbidity relative to comparisons,

with higher lifetime prevalence for mood

and anxiety disorders, substance use disorders,

externalizing disorders, bulimia nervosa,

Tourette’s, and language disorders (Beiderman

et al., 2010; Kessler et al., 2006). For adults,

anxiety disorders are the most common

comorbid diagnoses; estimates suggest that

around 50% of adults with ADHD also have an

anxiety disorder (Biederman, 2005).

TREATMENT APPROACHES

Treatments for ADHD proliferate and include

such various approaches as behavioral parent

training, academic interventions, classroom

management, summer treatment programs,

neurofeedback, psychostimulant medication,

and cognitive behavior therapy, among

others. The two most empirically tested interventions

for ADHD are psychostimulants

and behavior contingency management, which

is usually delivered as parent or teacher

training.

Administration of psychotropic medication,

generally in the form of central nervous system

stimulants, is the most commonly employed

treatment method for ADHD. Evidence for the

effectiveness of psychostimulant medication

for ADHD is extensive; it is considered the

gold standard of treatment as it results in large

improvements in the short term for ADHD

symptoms of inattention, hyperactivity, and

impulsivity and in some related impairments,

such as aggression, compliance, and productivity

at school. About 80% of individuals

treated with psychostimulants show some

improvement in symptoms, but the remaining

portion are considered nonresponders to

medication. Among those who show a positive

response, most do not achieve normalized

functioning with medication alone. Still others

experience significant adverse effects, such as

dry mouth, loss of appetite, nausea, and

insomnia and prefer not to take medications

for those reasons. Parents commonly prefer

248 Specific Disorders

c10 21 April 2012; 9:57:8

Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders, John Wiley &

alternative treatment options. Additionally,

psychostimulants may not be adequate in

addressing all significant life impairments, such

as parent–child relationships, social skills and

peer relations, long-term academic achievement,

and comorbid disorders. Because of these

limitations, a number of psychosocial interventions

for ADHD have been developed

and investigated both as stand-alone therapies

and as adjunctive treatments to psychostimulant

medication (Biederman, 2005;

Pelham & Fabiano, 2008).

The second most commonly implemented

treatment is behavior modification, also

known as contingency management, usually

delivered as training in behavior techniques

to parents and teachers. For this treatment,

parents and teachers are instructed by a

professional in methods to systematically

administer consequences to reduce unwanted

behavior and increase desired behavior. By

contrast, direct contingency management is

delivered directly to children by clinicians,

and also involves shaping consequences to

promote desired behavior. For children with

ADHD, direct contingency management is

delivered in summer treatment programs. A

combination of these behavioral strategies is

frequently used to maximize effectiveness

and generalize gains.

BEHAVIOR MODIFICATION

Behavior contingency management/behavior

modification was initially used for children

with hyperactive and inattentive symptoms

because they had successfully been implemented

with children with intellectual disabilities.

Their use was originally driven by the

idea that faulty learning or social contingencies

were the cause of the disorder, and that

correcting the contingencies by training the

parents would produce lasting changes.

Although social learning is not to blame for the

symptoms and impairments that arise from

ADHD, training parents and teachers to

manipulate antecedents and consequences is a

technique that may serve to cue and motivate

appropriate behavior (Antshel & Barkley,

2008). Antecedent modification involves using

cues to prompt desired behavior (e.g., effective

commands, visual reminders). Reinforcement

contingencies are created to increase desired

behaviors, such as compliance with commands,

completion of schoolwork, and so

forth, and are often implemented in the form of

point systems or token economies. Punishments

are applied to reduce inappropriate

behaviors such as arguing and aggression; a

common punishment for young children is

time-out. Parents and teachers are trained in

the use of operant conditioning techniques

in the child’s natural environment. Behavior

management strategies are not likely to completely

eliminate symptoms and impairments

of such a strongly neurologically based disorder;

however, if delivered consistently and

appropriately, behavior management strategies

that are focused on immediate and

significant relationships and environmental

settings often reduce some of the more devastating

psychosocial consequences of ADHD

through improving parent-child relationships,

social functioning, academic achievement, and

reducing or eliminating comorbid psychiatric

problems. No one treatment approach is likely

to be adequate in addressing every area of

difficulty for a child with ADHD.

Behavioral parent training (BPT) is the most

frequently implemented behavioral intervention

for ADHD. Several manualized BPT

programs have been effective in the treatment

of ODD and have been used in children with

ADHD and with comorbid ADHD and ODD.

Barkley’s (1987) Defiant Children program

has been adapted for use with ADHD and is

described here as a representation of a typical

program; similar programs include Community

Parent Education Program, and the Incredible

Years Series (IYS) (Cunningham, Bremner, &

Secord, 1997; Webster-Stratton, 1992).

Barkley’s (1987) BPT program consists of

8–12 weekly training sessions taught by a

Attention-Deficit/Hyperactivity Disorders 249

c10 21 April 2012; 9:57:8

Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders, John Wiley &

mental health professional either to groups or

individual parents. Each session focuses on a

different behavioral technique that parents

then apply at home. Treatment begins with

psychoeducation on ADHD, behavior problems,

and basic learning/behavior principles.

Parents are taught to increase positive attention

by spending daily one-on-one special time

with the child. Attention is used to reinforce

compliance and independent play. Increasing

compliance is one of the more important targets

for children with ADHD (even those

without ODD) because parents so often have to

cue appropriate behavior (e.g., “stop at the

curb,” “look at your homework”). The program

incorporates the use of a token economy

for increasing individualized target behaviors

and teaches use of appropriate time-out as a

mild punisher for misbehavior. A daily report

card system between parents and teachers is

implemented to generalize behavioral gains to

the school environment. Table 10.2 provides

an example sequence of steps in a BPT

program.

Consensus Panel Recommendations

Expert panels created among medical and

psychiatric associations and government health

organizations periodically review existing

empirical research and develop guidelines to

aid practitioners in choosing the most wellestablished,

scientifically supported treatments

for ADHD. Published guidelines include

recommendations of best practice for assessment,

treatment, and treatment maintenance

of ADHD. The American Academy of Child

and Adolescent Psychiatry (2007) practice

parameters for the assessment and treatment

of ADHD recommend psychopharmalogical

treatment with an FDA-approved psychostimulant

as the first line of treatment for most

individuals with ADHD. Behavior therapy,

including BPT and behavioral classroom management,

is suggested as the first-line treatment

option for cases in which ADHD symptoms are

mild or in which parents reject treatment with

psychostimulants. Behavior therapy is recommended

as the second intervention alternative

when an individual does not respond to an

FDA-approved drug. A combination of treatment

with medication and behavioral intervention

is recommended for children with less

than optimal response to medication and for

those with comorbid psychiatric disorders or

significant impairments in daily functioning.

These recommendations include behavior

therapy as treatment consideration for a considerable

portion of children and adolescents

with ADHD.

The National Institute for Health and Clinical

Excellence (NICE) of the United Kingdom

guidelines for assessment and treatment of

ADHD (NICE, 2009) endorse behavioral

treatments for all children and adolescents

diagnosed with ADHD. Group parent training

TABLE 10.2 Sequence of Sessions for Behavioral Parent Training

1. Overview of ADHD and ODD and behavior management principles

2. Establishing special time, increasing positive attention

3. Attending to appropriate behavior (e.g., compliance) and ignoring minor, inappropriate behaviors (e.g., whining)

4. Giving effective commands and reprimands

5. Establishing and enforcing rules and contingencies

6. Teaching effective time-out procedures

7. Home token economy system for rewards and sometimes response costs

8. Enforcing contingencies in public places; planning ahead for misbehavior outside the home

9. Implementing a daily school behavior report card

10. Troubleshooting techniques, managing future misconduct

11. One month booster session

250 Specific Disorders

c10 21 April 2012; 9:57:9

Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders, John Wiley &

programs are recommended as the first-line

treatment for all preschool-age children. For

school-age children and adolescents with

moderate levels of symptoms and psychosocial

impairments, the NICE guidelines recommend

a combination of a parent training program and

behavioral interventions implemented in the

classroom. Medication is recommended as an

adjunctive therapy when school-age children

and adolescents do not show adequate

response to behavioral and psychological

interventions. In instances in which symptoms

and impairments are severe, the guidelines

recommend a combination of psychostimulant

medication, parent training, and classroom

behavior management. The NICE guidelines

state that pharmacological ADHD treatments

should always be accompanied by a

comprehensive treatment plan that includes

behavioral, psychological, educational, and

interventions.

Randomized Controlled Trials

Development of clinical practice guidelines is

based upon a review of empirical studies of

various treatment methods and comparison

of cumulative support of each therapy.

Particular weight is given to randomized

controlled trials (RCTs), which compare a

particular treatment method with control

groups and alternative treatments. A number of

early RCTs that compared BPT to wait-list

controls established a base of empirical support

for BPT in the treatment of children

with ADHD (Gittelman-Klein et al., 1980;

Horn, Ialongo, Greenberg, Packard, & SmithWinberry,

1990; Horn et al., 1991; Pisterman

et al., 1989). These studies generally showed

BPT to reduce problem behaviors in children as

rated by parents, improve parent-child interactions,

and decrease parental stress (Chronis,

Chacko, Fabiano, Wymbs, & Pelham, 2004).

For example, one early study examined the

effectiveness of BPT for ADHD symptoms

and parental stress among families of schoolaged

children randomly assigned to either a

BPT group or wait-list control. The BPT group

received nine sessions of BPT training. Preand

postmeasures of parent and child functioning

were taken. The BPT participants

showed significant gains in comparison to the

control group on measures of parent-reported

child ADHD symptoms, parenting stress, and

parenting self-esteem. These gains were

shown to be maintained in a 2-month follow-up

measure (Anastopoulos, Shelton, DuPaul, &

Guevremont, 1993).

A more recent study compared the effectiveness

of BPT as adjunct to routine care with

routine care alone (treatment as usual). Children

ages 4 through 12 years receiving care in

an outpatient clinic for treatment of ADHD

were randomly assigned to either 5 months of

BPT in conjunction with routine clinical care

(N ¼ 47) or to routine care alone, which consisted

of family support and medication treatment

as indicated (BPT consisted of 12 group

training sessions). Parent-reported ADHD

symptoms, conduct problems, internalizing

symptoms, and parenting stress were assessed

for both groups pre- and posttreatment, and a

follow-up assessment of the BPT group was

conducted 25 weeks after treatment. Both

treatment groups improved on all measures.

The BPT group showed larger improvements

for conduct problems and internalizing symptoms

than the routine care group, but no group

differences were found for either parenting

stress or ADHD symptoms. Results were

equivalent for children receiving medication

and not receiving medication, although those in

the BPT treatment received less medication

treatment. The researchers suggested that BPT

enhances the effectiveness of routine clinical

treatment for children with ADHD for behavioral

and internalizing problems, but not for

ADHD symptoms or parenting stress. They

also suggest that BPT may limit the need for

medication treatment (Van den Hoofdakker

et al., 2007).

As a result of consistent positive findings

regarding the effectiveness of BPT for enhancing

parent behavior management skills and

Attention-Deficit/Hyperactivity Disorders 251

c10 21 April 2012; 9:57:9

Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders, John Wiley &

reducing child externalizing behavior, attention

has increasingly focused on enhancing

BPT programs to increase effectiveness for

core ADHD symptoms and to address correlates

associated with poor treatment response,

such as low socioeconomic status, parental

psychopathology, and single-parenting. For

example, single mothers of children with

ADHD face special challenges and barriers to

receiving treatment, and tend to show

decreased treatment response to BPT. In

response to this special need, an enhanced

version of BPT was created, including additional

treatment components addressing

treatment influences identified in this population

(e.g., low-intensity, didactic format). In

order to evaluate the efficacy of the program,

120 single mothers of 5- to 12-year-old children

with ADHD were randomly assigned to a

wait-list control group, a traditional behavioral

parent training program, or an enhanced

behavioral parent training program—the

Strategies to Enhance Positive Parenting

(STEPP) program. Both traditional BPT and

STEPP resulted in significant improvements

in several areas of functioning, including

oppositional behavior, and parent-child relations.

While both treatments were superior to

the control group, the STEPP group demonstrated

superior outcomes to the standard

BPT group for these domains (overall mean

effect sizes were 0.36 and 0.44 across all

outcomes). Participants in the STEPP program

attended more frequently, were more

engaged, and were more satisfied with treatment

compared to single mothers in the

traditional BPT program. Similar to other

studies of BPT, the BPT and STEPP programs

in this study did not significantly

improve core ADHD symptoms and improvements

were not maintained at 3-month

follow-up (Chacko et al., 2009).

A similar BPT program was designed to

increase fathers’ engagement in BPT. Fathers

of 6- to 12-year-old children with DSM diagnoses

of ADHD were randomly assigned to

attend either a standard BPT program or the

Coaching Our Acting-Out Children: Heightening

Essential Skills (COACHES) program.

The COACHES program included BPT plus

sports skills training for the children and parent-child

interactions in which the fathers

practiced parenting techniques in the context

of a soccer game. Children’s ADHD and ODD

symptoms were similarly improved across

groups, but fathers who participated in the

COACHES program were significantly more

engaged in the treatment process, as demonstrated

by more frequent punctuality and

attendance of sessions, increased compliance

with homework assignments, and greater

consumer satisfaction on posttreatment measures

(Fabiano et al., 2009). The studies demonstrating

benefits of enhanced BPT programs

indicates the possibility that tailoring psychosocial

treatments to meet individual client

needs may be an effective means of increasing

treatment compliance and may result in

larger treatment gains for children targeted

in the interventions.

A number of studies have shown BPT to

result in greater improvement for conduct

problems and internalizing problems than

for core ADHD symptoms (inattention,

hyperactivity) among school-aged children

(Barkley et al., 2000; Chacko et al., 2009;

Corcoran and Dattalo, 2006; MTA, 1999; Van

den Hoofdakker et al., 2007). A handful of

enhanced BPT programs have shown more

favorable results on both ADHD symptoms

and related impairments for preschool-aged

children. The New Forest Parenting Package

(NFPP) (Weeks, Thompson, & Laver-Bradbury,

1999) is a BPT intervention that was evaluated

in a community sample of 78 three-year-olds

diagnosed with ADHD. Participants were

randomized to NFPP, parent counseling and

support, or a waiting-list control group. The

NFPP group received directive coaching in

child management techniques while the

counseling group received only nondirective

support and counseling. The management

techniques were not geared only toward

oppositional behavior, but also trained parents

252 Specific Disorders

c10 21 April 2012; 9:57:9

Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders, John Wiley &

to help children self-regulate through a variety

of activities. Pre-, post-, and follow-up measures

of child ADHD symptoms and mother’s

sense of well-being were obtained. The BPT

group proved superior to the counseling and

wait-list groups for both ADHD symptom

reduction and increased maternal well-being.

The ADHD symptom improvement was clinically

significant for 53% of children in the

BPT group, and treatment effects were maintained

at the 15-week posttreatment follow-up.

Authors concluded that BPT is a valuable

treatment option for preschoolers with

ADHD, and that constructive training in parenting

strategies is an essential component of

BPT over and above therapist contact and

support (Sonuga-Barke, Daley, Thompson,

Laver-Bradbury, & Weeks, 2001).

A more recent study of the NFPP program

showed similarly positive outcomes. Forty-one

preschoolers were randomly assigned to either

NFPP or treatment as usual conditions. Measures

of ADHD and ODD symptoms, mothers’

mental health, and the quality of mother–child

interactions were taken pre- and posttreatment,

and at a 9-week follow-up. The ADHD

symptoms were significantly lower for the

treatment groups versus control group (effect

size . 1) and were maintained at a 9-week

follow-up measure. Improvement in ODD

symptoms was more moderate but favored the

treatment group. No improvements were seen

in maternal mental health or parenting behavior

during mother–child interactions, although

mothers spoke more positively of their children

in a speech sample following treatment.

The authors concluded that results support

efficacy of the NFPP program, though replication

with a larger sample size is needed

(Thompson et al., 2009).

Similar evaluations of the IYS and the Triple

P Positive Parenting Program with preschool

children have shown reductions in ADHD and

disruptive behavior problems for families

randomized to BPT compared to waitlist

conditions (Jones, Daley, Hutchings,

Bywater, & Eames, 2007; Bor, Sanders, &

Markie-Dadds, 2002). The IYS participants

showed maintenance in treatment gains at

18-month follow-up (Jones, Daley, Hutchings,

Bywater, & Eames, 2008). Other RCTs evaluating

the Triple P program have shown clinically

significant reductions in conduct problems

in preschoolers, though these studies were not

specific to children with ADHD (Sanders,

Markie-Dadds, Tully, & Bor, 2000). Such

positive findings from BPT with preschoolers

are especially encouraging considering the

potential long-term outcomes associated with

the disorder.

Parent training for adolescents with ADHD

has been studied far less than for younger

children. The BPT programs that were

developed for younger children are modified

for use with a teenage population. Behavior

targets for adolescents are decided on by

child and parent, and privilege loss (grounding)

is used in place of time-out. Positive

reinforcement and token economies are

adjusted to be appropriate with teenagers

(Antshel & Barkley, 2008; Young & Myanthi

Amarasinghe, 2010). A few uncontrolled studies

have shown BPT to be modestly beneficial

for this age group, but no controlled studies

have been conducted to date demonstrating

superiority of BPT to other treatment options

(Young & Myanthi Amarasinghe, 2010).

Barkley, Edwards, Laneri, Fletcher, and

Metevia (2001) compared two family-based

psychosocial therapies for adolescents with

ADHD. Families (N ¼ 97) were assigned to

either 18 sessions of problem-solving communication

training or behavior management

training for nine sessions followed by PSCT for

nine sessions. Posttreatment, both groups were

equally improved on ratings and observations

of parent–teen conflicts, although significantly

more families dropped out of PSCT alone than

out of BMT/PSCT. For both treatment groups,

only about one fourth demonstrated reliable,

clinically significant improvement, and some

families worsened in their degree of conflict.

Thus the verdict is out regarding parent training

with adolescent ADHD.

Attention-Deficit/Hyperactivity Disorders 253

c10 21 April 2012; 9:57:9

Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders, John Wiley &

Improvements at home resulting from BPT

are not likely to generalize to the school

environment because the structure and contingencies

created by the parent are not

immediately present for the child at school. In

order to improve behavior and performance at

school, antecedent modification and contingency

management need to be implemented

there as well (Abramowitz & O’Leary, 1991).

Some school-based behavioral programs have

focused on school-wide training of teachers

and programs that are inclusive of many children

in the school with ADHD (e.g., Pfiffner

et al., 2007). More commonly, mental health

professionals are contacted as consultants for

individual children when ADHD symptoms

create behavioral disruptions in the classroom

and interfere with academic progress

(Abramowitz & O’Leary, 1991; G. J. DuPaul

et al., 2006; Fabiano & Pelham, 2003).

Behavioral training procedures used with parents

are generally very similar to those used to

help teachers manage ADHD in the classroom.

Behavioral classroom management is a parallel

form of behavior modification treatment in

which the child’s classroom teacher is trained

in the use of effective commands, time-out,

token systems, immediate feedback, and

increased positive reinforcement (Antshel &

Barkley, 2008).

As with BPT, a frequent behavioral target in

classroom management is increasing compliance

with commands. A recent study focused

on the effectiveness of Barkley’s method of

reducing repetition of commands to increase

compliance within the school setting. Elementary

school teachers were randomly assigned

to either a treatment group (which received

instruction on reducing repetition and increasing

effectiveness of commands) or to a

nontreatment control group. Students whose

teachers received the training significantly

reduced noncompliance while students in the

control group did not. The author concluded

that this method is effective in the classroom

setting and should be implemented for students

with ADHD (Kapalka, 2005).

One study examined the effects of an intensive

classroom treatment in 158 kindergartners

identified as having high levels of hyperactive,

inattentive, impulsive, and aggressive behaviors.

Participants were randomly assigned to

one of four treatment groups: no treatment,

Case Analysis – Integrating Theoretical Orientations

U.S Elite Tutors

Writing Services

/

Contact Info