Case Analysis – Integrating Theoretical Orientations

Case Analysis – Integrating Theoretical Orientations

Sample Answer for Case Analysis – Integrating Theoretical Orientations Included After Question

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.). 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 Dx Checklist Attention-Deficit/Hyperactivity Disorder 1. Individual presents 1 or both of the following patterns: (a) For 6 months or more, individual frequently displays at least 6 of the following symptoms of inattention, to a degree that is maladaptive and beyond that shown by most similarly aged persons: • Unable to properly attend to details, or frequently makes careless errors • Finds it hard to maintain attention • Fails to listen when spoken to by others • Fails to carry out instructions and finish work • Disorganized • Dislikes or avoids mentally effortful work • Loses items that are needed for successful work • Easily distracted by irrelevant stimuli • Forgets to do many everyday activities. (b) For 6 months or more, individual frequently displays at least 6 of the following symptoms of hyperactivity and impulsivity, to a degree that is maladaptive and beyond that shown by most similarly aged persons: • Fidgets, taps hands or feet, or squirms • Inappropriately wanders from seat • Inappropriately runs or climbs • Unable to play quietly • In constant motion • Talks excessively • Interrupts questioners during discussions • Unable to wait for turn • Barges in on others’ activities or conversations 2. Individual displayed some of the symptoms before 12 years of age. 3. Individual shows symptoms in more than 1 setting. 4. Individual experiences impaired functioning. (Based on APA, 2013.) Billy was his parents’ first child. He was born after a normal, uncomplicated pregnancy, an especially healthy baby who grew rapidly and reached the standard developmental milestones— sitting, crawling, standing, walking, and so forth—either at or before the expected ages. His parents marveled at his exuberance and his drive to be independent at an early age. He was sitting by the age of 5 months and walking at 11 months. Once mobile, he was a veritable dynamo (in fact, they called him “the Dynamo”) who raced around the house, filled with a curiosity that led him to grab, examine, and frequently destroy almost anything that wasn’t nailed down. Although very low birth weight (less than 1,500 grams) presents a twofold to threefold risk for developing ADHD, most children with low birth weight do not develop the disorder (APA, 2013). Billy From “Dynamo” to “Dynamite” During his toddler period, Billy’s parents had no inkling that his activity level was at all unusual and, in truth, in many ways it was just an exaggeration of tendencies that most toddlers exhibit. Still, his parents found it exhausting to cope with his behavior. Just watching over him was a full-time job. Billy’s mother, Marie, had contemplated doing some freelance accounting at home to earn extra money. However, with her very first project she realized that this was completely unrealistic. Marie had hoped that she could contain Billy by keeping him in a playpen while she worked, but she found that he wouldn’t tolerate such confinement for more than 2 minutes before he was yelling to get out. Once out, he was a roving accident scene. Within minutes, Marie would hear a crash or some other noise that demanded investigation. When Billy’s mother became pregnant with his sister, Billy was well into the “terrible twos” and his mother and his father, Stan, were beginning to doubt their suitability as parents. Of 0000000000000000000001885751 (Ingrid Brooks) – Case Studies in Abnormal Table 16-1 Half the children with ADHD also have learning or communication problems, many perform poorly in school, a number have social difficulties, and about 80 percent misbehave (Goldstein, 2011; Mash & Wolfe, 2010). Billy at Home A Parent’s Perspective By age 8, Billy rarely carried out his parents’ requests or instructions, or he carried them out only partially before becoming caught up in some other activity. One evening in November was illustrative: Billy’s mother had just finished preparing dinner when she went to her son’s room and asked him to stop playing his video game, wash his hands, and take his place at the dining room table. “Okay, Mom,” Billy answered. “Thank you, Billy,” Marie said as she went back down to the kitchen to do some final preparations. However, 5 minutes later she realized she still had not seen Billy. She went back up to his room and found he had never turned off the video game. “Billy, I mean it. Stop playing now!” she told him. “Oh, all right.” he said, and turned the game off. Although this was Marie’s second effort, for once Billy was coming without too much of a struggle, so his mother was relieved. “Go wash your hands,” she reminded him. “Okay,” Billy replied. He headed down the hall toward the bathroom, but caught a glimpse of his 5-year-old sister already seated at the dining room table, holding a new doll. Jennifer was pulling a string that made the doll talk. “Hey, neat!” Billy exclaimed. “Let me try.” He ran over, grabbed the doll from Jennifer’s hands and pulled the string. The doll spoke in a squeaky voice, while Billy’s sister complained that she wanted her toy back. “Does the doll say anything else?” Billy asked, ignoring Jennifer’s protests. He began to pull the string over and over in rapid succession until, finally, it broke off. Twice as many boys as girls have ADHD. This ratio decreases to 1.6:1 when examining ADHD in adults. Females are more likely to present primarily with inattentive features (APA, 2013). “Uh, oh,” Billy observed. 0000000000000000000001885751 (Ingrid Brooks) – Case Studies in Abnormal course, other new parents often remarked on how demanding children were, but Marie and Stan could tell that the other parents felt nowhere near the same sense of desperation. With the arrival of Billy’s sister, Jennifer, Marie and Stan developed a budding awareness that their problems in handling their son might not be due entirely to their inadequacy. As an infant Jennifer—unlike Billy—did not try to squirm and break free every time she was held. Later, there were other differences. As a toddler, she was content to sit quietly for long periods just playing with her toys, and she listened until the end of the entire story when Marie read to her, whereas Billy would get restless and run off within a couple of minutes. When Billy reached school age, and Marie and Stan received more objective feedback about his situation, their sense of his difficulties became more defined. After his first day of school, his kindergarten teacher described him as “quite a handful”; then, at the parent-teacher conference, the teacher informed Billy’s parents that his activity level was well above that of the other children. In the first and second grades, as the academic component of the curriculum increased and the demands on the children for behavioral control increased correspondingly, Marie and Stan started to get yet stronger complaints from his teachers. In addition, Billy’s academic progress was slowed because of his problems with attention. Although he eventually learned to read, he didn’t really begin to master the skill until the second grade. Now 8 years old and in the third grade, Billy was falling behind the other children in a wide range of academic tasks. With encouragement—actually, insistence—from his teacher, Mrs. Pease, his parents decided to seek help for him at the Child Development Center. Billy at School A Teacher’s Perspective Billy’s third-grade teacher, Mrs. Pease, found his behavior intolerably disruptive in school. She was also concerned that Billy’s behavior problems were interfering with his ability to learn. She believed he was a bright child, but his attention and behavior problems were causing him to fail to complete his lessons and hampering the other children’s ability to complete theirs. Approximately 5 percent of children and 2.5 percent of adults have ADHD (APA, 2013). One day at school in mid-April Mrs. Pease had called the class to attention to begin an oral exercise: reciting a multiplication table on the blackboard. The first child had just begun her recitation when, suddenly, Billy exclaimed, “Look!” The class turned to see Billy running to the window. “Look,” he exclaimed again, “an airplane!” A couple of children ran to the window with Billy to see the airplane, but Mrs. Pease called them back, and they returned to their seats. Billy, however, remained at the window, pointing at the sky. Mrs. Pease called him back, too. “Billy, please return to your desk,” Mrs. Pease said firmly. But Billy acted as though he hadn’t heard her. “Look, Mrs. Pease,” he exclaimed, “the airplane is blowing smoke!” A couple of other children started from their desks. “Billy,” Mrs. Pease tried once more, “if you don’t return to your desk this instant, I’m going to send you to Miss Warren’s office.” Billy seemed oblivious to her threats and remained at the window, staring excitedly up at the sky. Mrs. Pease, her patience wearing thin, addressed Billy through gritted teeth. “Billy, come with me back to your seat.” She took him by the hand and led him there. She also considered making good on her threat to send him to Miss Warren, the principal, but she glanced at the clock and 0000000000000000000001885751 (Ingrid Brooks) – Case Studies in Abnormal “Mommy, he broke my doll!” Jennifer cried. Billy’s mother emerged from the kitchen to find him holding the broken doll while his sister wailed. What had begun as a simple attempt to get Billy to wash his hands and seat himself at the dinner table had ended in a tumultuous scene. And so it would go. Unless Billy was escorted through every task of the day, he’d get sidetracked, and it usually ended with an argument or something getting broken. Consequently, his parents often found it easier just to do things for Billy—wash his hands, clean his room, get him dressed—because getting him to do the tasks himself was the greater effort. When left to his own devices, Billy’s behavior was disruptive in other ways. He jumped on the beds, ran through the house, or played shrill games of hide-and-seek under the dinner table with his unwilling parents or sister. If his mother was on the phone, he would think nothing of yelling out demands for a drink, a snack, or help in finding some lost toy, despite Marie’s numerous warnings not to interrupt her. Even playing out in the yard was not a solution, because if Billy wasn’t watched closely, in a flash he might run out into the street after a ball, without any regard for traffic. When playing indoors with neighborhood children, Billy was bossy, continually grabbing their toys or refusing to share his own. Thus, his play dates had to be closely supervised by his parents to avoid squabbles. Because of these problems, Billy had few friends. Instead, most of his leisure time was spent watching television or playing video games, activities that Marie and Stan were reluctant to encourage, but which they felt forced to accept since the 8-year-old could do little else without supervision. The number of children ever given a diagnosis of ADHD increased from 7 percent in 2000 to 9 percent in 2009 (Akinbami, Liu, Pastor, & Reuben, 2011). Mrs. Pease tried again. “Who knows 3 times 7?” This time Billy raised his hand, but he still couldn’t resist creating a disruption. “I know, I know!” Billy pleaded, jumping up and down in his seat with his hand raised high. “That will do, Billy,” Mrs. Pease admonished him. She deliberately called on another child. The child responded with the correct answer. “I knew that!” Billy exclaimed. “Billy,” Mrs. Pease told him, “I don’t want you to say one more word for the rest of this class period.” Billy looked down at his desk sulkily, ignoring the rest of the lesson. He began to fiddle with a couple of rubber bands, trying to see how far they would stretch before they broke. He looped the rubber bands around his index fingers and pulled his hands farther and farther apart. This kept him quiet for a while; by this point, Mrs. Pease didn’t care what he did, as long as he was quiet. She continued conducting the multiplication lesson while Billy stretched the rubber bands until finally they snapped, flying off and hitting two children, one on each side of him. All three children let out yelps of surprise, and the class turned toward them. “That’s it, Billy,” Mrs. Pease told him, “You’re going to sit outside the classroom until the period is over.” “No!” Billy protested. “I’m not going. I didn’t do anything!” “You shot those rubber bands at Bonnie and Julian,” Mrs. Pease said. “But it was an accident.” “I don’t care. Out you go!” Billy stalked out of the classroom to sit on a chair in the hall. Before exiting, however, he turned to Mrs. Pease. ‘’I’ll sue you for this,” he yelled, not really knowing what it meant. Soon, the school bell rang, signaling the end of the period and the beginning of recess. Mrs. Pease was thankful to get some relief from the obligation of controlling Billy, but was frustrated that almost the entire math period had been wasted due to his disruptions. Symptoms of ADHD, particularly the hyperactive symptoms, are typically most pronounced during the elementary school years. They become less conspicuous by late childhood and early adolescence (APA, 2013). Out in the schoolyard during recess, Billy’s difficulties continued. As the children lined up for turns on the slide, Billy pushed to the head of the line, almost knocking one child off the ladder as he elbowed his way up. After going down the slide, Billy barged into a dodgeball game that some younger children were playing; he grabbed the ball away from one child and began dribbling it like a basketball, while the other child cried in frustration. The supervising teacher told Billy to give the ball back, but Billy kept dribbling, oblivious to her demands. Finally, she took the ball away from him, and Billy wailed in protest. 0000000000000000000001885751 (Ingrid Brooks) – Case Studies in Abnormal realized Miss Warren would not be in her office now. Finding someone else to supervise Billy would probably be more disruptive than disciplining him within the class, so she settled for getting him back in his seat, then took her place once more in front of the class. By now she was almost I0 minutes into the lesson period and still had not finished a single multiplication table. Mrs. Pease tried to resume the lesson. “Who can tell me the answer to 3 times 6?” she asked. Fifteen children raised their hands, but before she could call on anyone, Billy blurted out the correct answer. “Thank you, Billy,” she said, barely able to contain her exasperation, “but please raise your hand like the others.” Billy in Treatment The Therapist in Action After repeatedly observing a child’s tornadoes of activity, inattention, and recklessness, teachers or parents often conclude that he or she suffers from attention-deficit/hyperactivity disorder (ADHD). However, 25 years of practice had taught child psychiatrist Dr. Sharon Remoc that such a conclusion is often premature and inaccurate, leading to incorrect and even harmful interventions. Thus, when Billy’s parents brought him to the Child Development Center, Dr. Remoc was careful to conduct lengthy interviews with the child, his parents, and his teacher; to arrange for Billy to be observed at home and at school by an intern; to set up a physical examination by a pediatrician to detect any medical conditions (for example, lead poisoning) that might be causing the child’s symptoms; and to administer a battery of psychological tests. In addition to obtaining a description of Billy’s current problems and his history from his parents, Dr. Remoc had Billy’s mother respond to questions from 2 different assessment instruments: the Swanson, Nolan, and Pelham Checklist, which contains questions pertaining specifically to disruptive behavior problems, and the Conners Parent Rating Scale, which contains questions specifically for assessing ADHD. Similarly, Dr. Remoc sent the teacher’s versions of the Swanson, Nolan, and Pelham Checklist and the Conners scale to Mrs. Pease. Only approximately one-third of children who receive a diagnosis of ADHD from pediatricians actually undergo psychological or educational testing to support the diagnosis (Hoagwood, Kelleher, Feil, & Comer, 2000; Millichap, 2010). In a 2007 national study of children with and without ADHD, parents reported that 46 percent of children with ADHD had a learning disability compared with 5 percent of children without ADHD who had a learning disability. In addition, 27 percent of children with ADHD versus 2 percent of those children without ADHD were reported to have conduct disorder (Larson, Russ, Kahn & Halfon, 2011). Billy’s battery of tests included the Wechsler Intelligence Scale for Children and the Wechsler Individual Achievement Tests (to provide scores in reading, mathematics, language, and written 0000000000000000000001885751 (Ingrid Brooks) – Case Studies in Abnormal “Hey, give that back!” he insisted. “You took this ball from someone else,” the teacher explained. “But you took it from me. That’s not fair!” Billy argued. The teacher sent Billy to sit on a bench, where he remained sulking and feeling mistreated for the rest of the recess period. This was an average day for Billy at school. On some of his better days, he was less physically disruptive, but he still had his problems, particularly in attending to and completing his schoolwork. In a typical case, Mrs. Pease would give the class an assignment to work on, such as completing a couple of pages of arithmetic problems. While most of the children worked without supervision until the assignment was completed, Billy was easily distracted. When he got to the end of the first page, he would lose his momentum and, rather than continuing, would begin fiddling with some object on his desk. Other times, if another child asked the teacher a question, Billy would stop his own work to investigate the situation, getting up to view the other child’s work and failing to complete his own. Finally, at a parent-teacher conference, Mrs. Pease told Billy’s parents that she thought Billy’s problems might be attributable to an attention-deficit disorder. Concerned about Billy’s growing academic and social problems—not to mention feeling exhausted from continually having to remind, encourage, and threaten their son to get him to do the most elemental things—Marie and Stan decided to seek professional assistance. They arranged for a consultation at the Child Development Center. An estimated 3.5 percent of U.S. children received stimulant medication in 2008 compared with 2.4 percent in 1996 (Zuvekas & Vitiello, 2012). Stimulant drugs, which include amphetamine/dextroamphetamine mixed salts (Adderall), methylphenidate (Ritalin), methylphenidate extended-release (Concerta), dextroamphetamine (Dexedrine), and pemoline (Cylert), were first used to treat ADHD decades ago, when clinicians noted that the drugs seemed to have a “paradoxical” tranquilizing, quieting effect on these children. Subsequent research has shown that all children—both those with and those without ADHD—experience an increase in attentional capacity when taking stimulant drugs, resulting in behavior that is more focused and controlled. This may create the appearance of sedation, but the children are actually not sedated at all. Unfortunately, the drugs are not effective for all children, and only partially effective for others. And even when a drug is optimally effective, other areas of behavioral adjustment may still need to be addressed, because the ADHD child may have little practice in the more appropriate behaviors that he or she now is theoretically capable of producing. This is where behavioral programs may come into play. In the ideal case, both parents and teachers are involved in implementing a behavior modification program, which is based on the ABC model of behavior. The A in the model denotes antecedents, the conditions that provide the occasion for a particular behavior; the B denotes the behavior itself; and the C denotes the consequences of the behavior. Thus, a given behavior is seen as prompted by certain antecedents, and maintained by its consequences. For example, Billy’s sprint to the window was prompted by the antecedent condition of a boring classroom exercise and the appearance of an exciting stimulus (the airplane). It was maintained, according to the model, by the rewarding effect of viewing the airplane, which was much greater than the punishing effect of Mrs. Pease’s warnings or even of being sent out of the room. In a behavior modification program, the usual strategy is to increase the rewards for engaging in alternative behaviors under the same antecedent conditions. Thus, if the reward for remaining seated can be made to exceed the reward for viewing the airplane, then, theoretically, the child will be more inclined to remain seated. 0000000000000000000001885751 (Ingrid Brooks) – Case Studies in Abnormal achievement). The results of these tests confirmed the impression already supplied by Billy’s parents and Mrs. Pease: Billy’s intelligence was above average, and his academic achievement was lower than his intelligence scores would predict. These findings established that Billy’s academic problems were not due to intellectual limitations. After completing this comprehensive assessment, Dr. Remoc was confident that Billy’s difficulties met the criteria in DSM-5 for a diagnosis of attention-deficit/hyperactivity disorder, combined type. He exhibited a majority of the symptoms listed both for inattention (for example, difficulty sustaining attention, failure to follow instructions, oblivious to verbal commands, easily distracted) and for hyperactivity-impulsivity (for example, difficulty remaining seated, excessive motor activity in inappropriate situations, difficulty waiting his turn). The symptoms were apparent before the age of 12, occurred both at home and school, and caused significant impairments in both the social and academic spheres. Over the years, research has indicated that many children with ADHD respond well to either stimulant drugs or systematic behavioral treatment. Although some therapists prefer one of these approaches over the other, Dr. Remoc had come to believe that a combination of the interventions increases a child’s chances of recovery. By helping the child to focus better and slow down, the medications may help him or her to profit from the procedures and rewards used in the behavioral program. Research suggests that a combination of drug therapy and behavioral therapy is often helpful to children with ADHD (Parker, Wales, Chalhoub, & Harpin, 2013). Dr. Remoc explained that stimulant medication was important for increasing Billy’s attention and impulse control; this, in turn, would enhance his capacity to do what was expected of him, both in general and in response to the behavior modification plan. The parental training, she explained, would acquaint Marie and Stan with principles of behavior modification, allowing them to deal optimally with any remaining behavior problems, as well as with Billy’s behavior during periods when he might not be taking medication (so-called drug holidays). Social skills training seemed necessary, Dr. Remoc said, in light of Billy’s problems in getting along with other children and in cooperating at home. Finally, she explained that, since a large portion of Billy’s difficulties occurred in the classroom, it would be helpful for both Billy and Mrs. Pease to have a behavioral program operating in that environment. Dr. Remoc spoke to Mrs. Pease about the matter, and the teacher was agreeable to instituting a program provided it wasn’t too burdensome; but given Billy’s problems up to now, Mrs. Pease said that almost anything seemed less burdensome than simply doing nothing. Stimulant medication After ruling out any physical problems (e.g., motor tics) that might preclude the use of stimulant medication, Dr. Remoc discussed the basic rationale for use of the medication with Billy’s parents. She explained that the medication had been used for years to treat children with symptoms of inattention, impulsivity, and hyperactivity. She also explained that the medication is not a tranquilizer. On the contrary, the medication stimulates the central nervous system for 3 to 4 hours after it is ingested. This stimulant effect, she explained, seems to increase the capacity of children with ADHD to maintain their attention and to control their impulses. As a result, they are better equipped to meet the requirements of school, home, and a social life. According to the United Nations, the United States produces and consumes approximately 85 percent of the world’s methylphenidate. (Medicating Kids. Statistics on Stimulant Use. Retrieved March 24, 2014 from http://www.pbs.org/wgbh/pages/frontline/shows/medicating/drugs/stats.html. In addition, she informed Billy’s parents that certain side effects can develop, including weight loss, slowed growth, dizziness, insomnia, and tics. Dr. Remoc noted, however, that these 0000000000000000000001885751 (Ingrid Brooks) – Case Studies in Abnormal Learning alternative behaviors may involve more than just adjusting incentives or antecedents. Some skills may have to be taught directly. A child who has never practiced asking politely for a toy, as opposed to grabbing it, will need to learn this skill before he or she can respond to incentives to implement it. Direct behavioral skills training usually follows a standard sequence. First, the child receives an explanation of the skill; next, he observes a model demonstrating the skill; then, he practices performing the skill, first through role-playing in the training session and then through real-life behavioral practice. After the skill is learned, both parents and teachers can prompt the child to employ it in a given situation. For example, after the skill of sharing is well learned, the parent can prompt the child to “share” in a situation calling for cooperation with another child, and then praise the child appropriately for so doing. Theoretically, the more the skill is employed and reinforced in a variety of appropriate circumstances, the more the child will use the skill spontaneously, receiving naturalistic positive reinforcement from the environment in the form of friendly or gratified reactions from others. Thus, Dr. Remoc outlined for Billy’s parents four treatment components: (a) stimulant medication, (b) parental training in the use of behavioral modification principles, (c) social skills training for Billy, and (d) token economy in the school environment. The use of stimulant drugs to treat children with ADHD has increased by 57 percent since 2000 (Carlson, Maupin, & Brinkman, 2010). Out in the schoolyard, Billy was now less inclined to barge into other children’s games or push others aside. But, he still did not have a good social sense. Either he drifted off by himself or, if he did join a game, he failed to abide by the rules consistently, which ended up provoking arguments. For example, in joining a game of catch with four other children, Billy was inclined to hog the ball after he received it; he would then hold it and giggle, in spite of the other children’s yells that he was supposed to throw the ball to the next receiver. At home, Billy seemed less driven physically. He sat at the dinner table for the entire meal, without constant requests to be excused and without getting up repeatedly to grab things or to play under the table. Also, his passion for jumping on the beds was gone, and he became more dependable in carrying out instructions. For example, if his parents sent him to wash up and sit at the table, they now could count on his following through 75 percent of the time (as opposed to 25 percent, as before). Tendencies such as stubbornness and defiance remained a problem, however; it remained a struggle to get him to do chores, to get started on his homework, or to follow household rules in general. He continued to barge in on his mother when she was on the phone, shouting his insistent requests for snacks, toys, and videos. Overall, however, the medication seemed to have many advantages. Parental training To gain some knowledge of behavioral management techniques, Billy’s parents enrolled in a training group for parents of children with ADHD (at about the same time that Billy began taking medication). The group, led by psychologist Dr. James Grendon, was designed to educate parents about both ADHD and the principles of behavior modification for managing it. Group sessions were held three times a month, and once a month Dr. Grendon met alone with Billy’s parents to discuss the child’s individual situation. Although family conflict is often present in families with a child with ADHD, negative family interaction patterns are unlikely to cause the development of ADHD (APA, 2013). At the very first group session, Billy’s parents found comfort in learning that other parents’ experiences closely paralleled their own. All the parents were able to share their experiences and found that they were all dealing with very similar concerns. Many parents saw humor in some of the situations, and this helped to soften the impact of what they had all been going through. It also helped Marie and Stan to know that some of their marital disputes were shared by the other parents. Like the others in the group, Billy’s parents often argued over how to deal with 0000000000000000000001885751 (Ingrid Brooks) – Case Studies in Abnormal effects usually are not severe and often disappear after the body becomes accustomed to the drug or whenever a drug holiday is scheduled. The clinician noted that since most children with ADHD respond well to Concerta without prohibitive side effects, she was inclined to try Concerta first. Dr. Remoc pointed out that the decision to take medication was not carved in stone. Indeed, the parents should consider the initial medication regimen as a trial period; if, during this time, they concluded that the medication was not worthwhile, then it should be discontinued. They could try a different medication or they could rely on the behavioral methods alone. Once Billy began taking the medication, it was apparent that his behavior improved substantially, although not completely. In class, for example, Billy still blurted out some answers and turned around to talk to his neighbors during silent reading period, but he did these things only about one fourth as often as before. Most noticeable from Mrs. Pease’s standpoint was that simply saying his name was often enough to get him to cease what he was doing. Children whose parents or other close relatives had ADHD are more likely than others to develop the disorder (APA, 2013). This was the first behavioral plan that Billy’s parents put into effect, and after ironing out a few wrinkles, Billy was able to follow the procedure, even to the point of fetching the message pad himself whenever the phone rang. Eventually, he resisted interrupting almost entirely. Other behavioral plans were then put into effect for other matters, such as household chores and homework completion. In both cases, Billy’s parents found an effective formula by reversing antecedent conditions and behavioral consequences. For example, they saw to it that television viewing would always follow the completion of homework, rather than vice versa. Social skills training Marie and Stan also enrolled their son in a class where he could learn skills for getting along better with other children. The class was composed of other children receiving treatment at the center for ADHD. About half of children with ADHD, combined type, also have oppositional defiant disorder. Conduct disorder is present in about 25 percent of children and adolescents with ADHD, combined type (APA, 2013). 0000000000000000000001885751 (Ingrid Brooks) – Case Studies in Abnormal their child. Although it didn’t solve the problem, it helped them to know that even their arguments were “normal,” given the circumstances. In additional group sessions, Marie and Stan were progressively introduced to the ABC principles of behavior management. Among the points they found helpful was the idea that parents can become unduly focused on discouraging problem behaviors through criticism or punishments; the punishments, in turn, are often ineffective and just fuel resentment. A different approach, Dr. Grendon explained, was to think in terms of the alternative behaviors (B) that parents would like their children to perform under the same circumstances (A), and to provide praise and rewards (C) accordingly. Billy’s parents explored this principle in greater detail in individual sessions with the group leader, as they felt it applied particularly to the way they were handling (or mishandling) many situations with their son. For example, a regular problem with Billy was that he interrupted his mother when she was on the phone. She had to lock herself in the bedroom in order to have a coherent conversation with a pediatrician, repairman, friend, or relative. Often, even locking herself in was not enough to insure peace and quiet, as Billy might start pounding on the door in order to convey his demands, in spite of repeated scolding. To address the problem, the psychologist asked Billy’s parents to think of specific, alternative actions they would like Billy to carry out under these conditions. At first, all Marie and Stan could think of was “not interrupt,” but Dr. Grendon reminded them of the stipulation that they think of a tangible alternative behavior for Billy to carry out under the same circumstances. After some discussion, they came up with the idea of having Billy write down his requests whenever his mother was on the phone. They noted that their son loved to write notes, so this might be a tangible thing he could do to satisfy his demands temporarily, and allow him to resist interrupting. With further discussion, Billy’s parents and the psychologist worked out the following procedure: Before Marie made a call or answered the phone, she would hand Billy a special message pad, reminding him to write down any questions or problems that he had while she was talking; Marie would then give prompt attention to Billy’s messages as soon as she was off the phone; finally, if Billy succeeded in using the pad, instead of interrupting, for the majority of calls in a given week (his mother would keep a checklist to tabulate Billy’s compliance), he would be given a special reward on the weekend (such as eating out at his favorite restaurant). Token economy The token economy is an element of the ABC behavior modification system; it uses tokens, rather than immediate, tangible rewards, to reinforce desired behavior. The tokens are exchanged for an actual reward at a later time. Token reinforcement is particularly advantageous for ADHD children, who can get so wrapped up in the attractiveness of the actual reward that they find it difficult to remain mindful of the behaviors that the reward is designed to encourage. Mrs. Pease thought that some form of behavior modification might assist her in regulating several of Billy’s behaviors. Accordingly, she and the therapist decided to focus on encouraging three specific school behaviors in Billy: raising his hand to answer questions (instead of blurting out answers), staying in line, and finishing in-class assignments. As token reinforcers, Mrs. Pease would use dinosaur stickers affixed to a piece of paper, with the number of stickers in each of three columns reflecting Billy’s compliance with the three behavioral objectives. According to the plan (explained to Billy in a meeting with his parents and Mrs. Pease), Mrs. Pease would keep track of Billy’s compliance separately for the morning period and the afternoon period, and award him one sticker if he achieved full compliance with a given behavioral objective in a given period. He would receive his morning stickers at lunchtime, and his afternoon stickers upon dismissal. The stickers could then be redeemed at home for special privileges (going out to eat, going out to a movie, an extra half hour of television or a video game, and so forth). Billy liked the idea of getting stickers so he agreed to the plan. On the first morning of the program, he received only one sticker: for finishing his assignment within the allotted time (he had blurted out a couple of answers and had wandered off the line going to art class). In the afternoon, however, he received two stickers: for staying in line and for finishing assignments. After a few more days on the program, Billy was averaging five stickers per day, a level that he was able to maintain, and which reflected a substantial improvement in all three areas. Within 2 months of the combined treatment program, Billy had improved considerably. He was conforming to classroom rules by staying in his seat, not talking, and finishing his assignments most of the time. When he deviated, he required only gentle reminders from Mrs. Pease to get back on track. Similarly, at home, he was less frenetic. He could carry out instructions more dependably, and he usually accepted his household responsibilities without too 0000000000000000000001885751 (Ingrid Brooks) – Case Studies in Abnormal During each class the focus was on learning one particular social skill, such as sharing. First, the group leader explained the concept of sharing, and then asked the children their own opinions of what it meant. Next, she demonstrated the implementation of the skill with several children in different, contrived, situations: sharing toys, sharing food, or sharing a seat. Then each child came up, one by one, and practiced sharing in each of these hypothetical circumstances. The group leader and the other children then gave the child corrective feedback on how well he or she had shared. Similar classes were devoted to other social skills, such as cooperating, speaking calmly, making polite requests, and following rules. Billy’s parents and Mrs. Pease received written guidelines for discussing the social skills training sessions at home and in school and for guiding Billy to use the skills in everyday situations. Many of the opportunities to prompt him arose at home in his interactions with his 5year-old sister. With continued prompting, Billy started to share things with his sister spontaneously on many occasions, which increased the harmony in the household. Because of these successes, and Billy’s additional successes using the social skill of cooperation, Marie and Stan finally felt confident enough to invite one of Billy’s schoolmates over for a play date. The last time a child had come to their house, it had been a disaster, as Billy had refused to relinquish any of his toys to his guest. Needless to say no child was likely to return after such treatment. Although this play date was far from perfect and needed Marie’s constant attention, it turned out to be reasonably pleasant. In the DSM-II (1968), ADHD was known officially as hyperkinetic reaction of childhood, and it was commonly referred to simply as hyperactivity or hyperkinesis (the latter term from the Greek for over and motion). Unfortunately, after about 4 months of this improved functioning, Billy began to slip into some of his old patterns both at home and at school. His parents felt that the problems had to be addressed, as he seemed to be losing ground. The recurrence of problems seemed to coincide with the birth of his new baby brother. In a discussion with Dr. Remoc, Billy’s parents wondered whether their total preoccupation with the birth of the baby, and their consequent inability to implement many features of the behavioral program (including not following through on redeeming Billy’s dinosaur stickers), was responsible for the slippage in his progress. A renewed effort by the parents to apply the behavioral program, and an adjustment in the dosage of Billy’s medication, helped him to regain his previous achievements within a few weeks. Epilogue After 18 sessions of group parental training (over a 6-month period), 6 sessions of individual parent training, 6 sessions of social skills training for Billy, and 4 meetings at school with Billy’s teacher, his ADHD symptoms stabilized at an improved level. In addition to being viewed negatively by peers and parents, children with ADHD often view themselves negatively and have significantly lower self-esteem than children without ADHD (Mazzone et al., 2013; McCormick, 2000). Billy reported that he was happier at school and enjoying time at home with his family. He still took medication and saw Dr. Remoc for a checkup every 4 months. Billy’s parents planned to give Billy a drug holiday in the summer and felt confident of their ability to manage his behavior during that time with just the behavioral techniques. They were a family again— sometimes laughing, sometimes crying—but, overall, enjoying their lives and activities together. Assessment Questions 1. When did Billy’s parents begin to suspect that Billy’s “dynamo” personality might be a behavioral disorder? 2. Describe at least 3 behaviors that suggest that Billy’s activity level is beyond what’s normal for a child his age. 3. When did Billy’s family finally receive more objective feedback about Billy’s behavior? 4. How long did it take for Billy’s teachers to suggest professional consultation regarding Billy’s disruptive behavior? 5. Why did Dr. Remoc, the therapist at the Child Development Center, feel it was important to conduct a thorough assessment of Billy before diagnosing ADHD? 6. Describe at least 4 different assessment techniques used by Dr. Remoc to test for ADHD. 7. What were the assessment results that led Dr. Remoc to diagnose ADHD in Billy? 8. Why did Dr. Remoc decide to use both medication and behavioral therapy to treat Billy? 0000000000000000000001885751 (Ingrid Brooks) – Case Studies in Abnormal much argument. In peer relations, Billy was still learning the culture of give and take, but with periodic guidance and further experience he was becoming increasingly effective. As a result, he was getting along well with his sister, and he now had a couple of friends who would come over regularly to play, and who invited him to their homes as well. 0000000000000000000001885751 (Ingrid Brooks) – Case Studies in Abnormal 9. What are some potential problems with prescribing medication as the only treatment option for children with ADHD? What are some side effects of stimulant medications? 10. Describe the ABC model of behavioral therapy and give examples. 11. What were the four treatment components outlined for Billy’s treatment? 12. Why is it important for Billy’s parents to be a part of the treatment plan? 13. Describe the ABC plan that Billy’s parents developed to control his “interrupting” behaviors. 14. What other childhood behavioral diagnoses are often comorbid with ADHD? 15. Describe the concept of a token economy. 16. What event disrupted Billy’s progress? 17. What was the ultimate outcome after 18 sessions of group parental training? 10 Attention-Deficit/ Hyperactivity Disorders REBECCA J. HAMBLIN AND ALAN M. GROSS Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. 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 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders, John 243 Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=817355. Created from ashford-ebooks on 2019-09-26 17:16:27. c10 21 April 2012; 9:57:7 244 Specific Disorders 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). Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. 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; 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. Created from ashford-ebooks on 2019-09-26 17:16:27. c10 21 April 2012; 9:57:7 Attention-Deficit/Hyperactivity Disorders 245 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. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. 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. 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. Created from ashford-ebooks on 2019-09-26 17:16:27. c10 21 April 2012; 9:57:8 Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. 246 Specific Disorders 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 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. Created from ashford-ebooks on 2019-09-26 17:16:27. c10 21 April 2012; 9:57:8 Attention-Deficit/Hyperactivity Disorders not improve social problems even when it decreases aggression and other negative behaviors (Pelham & Fabiano, 2008). Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. 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; 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. Created from ashford-ebooks on 2019-09-26 17:16:27. c10 247 21 April 2012; 9:57:8 248 Specific Disorders 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). 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 Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. 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 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 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. Created from ashford-ebooks on 2019-09-26 17:16:27. c10 21 April 2012; 9:57:8 Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Attention-Deficit/Hyperactivity Disorders 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 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. Created from ashford-ebooks on 2019-09-26 17:16:27. c10 249 21 April 2012; 9:57:8 250 Specific Disorders 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 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. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. 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 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 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. Created from ashford-ebooks on 2019-09-26 17:16:27. c10 21 April 2012; 9:57:9 Attention-Deficit/Hyperactivity Disorders 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. Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. 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 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. Created from ashford-ebooks on 2019-09-26 17:16:27. c10 251 21 April 2012; 9:57:9 Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. 252 Specific Disorders 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 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. Created from ashford-ebooks on 2019-09-26 17:16:27. c10 21 April 2012; 9:57:9 Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Attention-Deficit/Hyperactivity Disorders 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. 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. Created from ashford-ebooks on 2019-09-26 17:16:27. c10 253 21 April 2012; 9:57:9 Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. 254 Specific Disorders 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, parent training, classroom behavioral treatment, or a combination of classroom and parent training treatments. Unfortunately, parents assigned to the BPT-only group showed very poor attendance and this group did not demonstrate treatment gains; however, the classroom management treatment condition resulted in improvements in objective observations of externalizing behavior in the classroom, teacher ratings of attention, social skills, self-control, and aggression, as well as parent ratings of adaptive behavior. Behavior improvements in the classroom did not generalize to the home environment per parent ratings. Additionally, while externalizing behaviors improved, no gains were seen in academic achievement or laboratory-based measures of attention (i.e., Continuous Performance Test). The intervention was conducted for one school year only (Barkley et al., 2000). A 2-year follow-up of the intervention indicated no difference between those treated in the classroom condition and those not treated, and the children continued to display high levels of ADHD and ODD symptoms compared to peers (Shelton et al., 2000). These results again demonstrate that behavioral gains resulting from contingency management in one setting are not likely to generalize to other settings or to persist once the contingencies have been removed; therefore, it is important that contingency management be implemented across settings. Several other investigation teams have found beneficial results in both home and school settings, as indicated by parent and teacher ratings when incorporating parent training and classroom management into the same treatment package. Corkum, McKinnon, and Mullane (2005) demonstrated superior results when adding a behavioral training intervention 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. Created from ashford-ebooks on 2019-09-26 17:16:27. c10 21 April 2012; 9:57:9 Attention-Deficit/Hyperactivity Disorders with children’s teachers to the behavior training provided to parents alone. Similarly, Owens et al. (2005) reported treatment gains across contexts from a small-scale RCT of a behavioral package that included parent and teacher behavior contingency management strategies. A study that compared a behavioral package to medication found superior results for the medication group, although the behavioral group showed gains at home and at school (Van der Oord, Prins, Oosterlaan, & Emmelkamp, 2008). Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. Meta-Analyses of Group Designs Corcoran and Dattalo (2006) examined a small set of studies examining BPT published between 1980 and 2003. Studies that compared BPT to control or comparison groups were included. The overall effect size (Cohen’s d ) of BPT on ADHD symptoms was relatively low (0.40), as was the effect size (0.36) on externalizing symptoms. A moderate effect was observed for family functioning (0.67) and internalizing symptoms (0.64). This finding is also consistent with those of individual RCTs; however, an effect size of 8.2 was reported for academic performance. This finding is not consistent with data from RCTs, which failed to show generalization of treatment gains to the school environment. This discrepancy may be at least partially attributable to inclusion of only two studies that reported this outcome. Consistent with a number of studies the effects of BPT on social functioning were near zero. Similar to individual RCTs described earlier, the findings indicate that BPT produces some change in ADHD symptoms of inattention and hyperactivity, and results in more substantial improvements in family relationships and internalizing symptoms. A meta-analytic review of BPT studies to identify effective components of BPT programs examined 77 published evaluations of BPT outcomes for children up to age 7 years. Component analysis was conducted by using content and delivery methods of training programs to predict effect sizes on measures of children’s externalizing behavior and parenting behaviors, controlling for differences among research designs. Components of BPT programs consistently associated with larger effect sizes were teaching parents the use of time-out and the value of consistency, increasing positive parent–child interactions, enhancing emotional communication skills, and incorporating practice of new skills with their children during training sessions. Program components consistently associated with smaller effects included teaching parents problem solving; teaching parents to promote children’s cognitive, academic, or social skills; and providing various additional services (Kaminski, Valle, Filenne, & Boyle, 2008). G. DuPaul and Eckert (1997) conducted a meta-analysis examining the effects of schoolbased interventions for children and teenagers with ADHD. Studies included were those based on either contingency management, academic interventions that use antecedent modification (such as adding structure to a task), or cognitive behavior therapy (which includes teaching of strategies such as reflective problem solving). Behavior effect sizes (weighted least squares) for within-subject and between-subject designs were computed for all three types of interventions. For withinsubjects design studies, behavior effect sizes were greater for contingency management (0.94) and academic interventions (0.69) than for cognitive behavioral interventions (0.19). Behavior effect sizes for between-subjects designs were not different among the three types of interventions. Academic outcome effect sizes for within-subjects designs were small among all three interventions types; the effect size for contingency management was 0.11. Academic effect sizes were not available for between-subjects designs. The authors concluded that behavior modification techniques are more effective than cognitive techniques in improving behavioral outcomes for children with ADHD. 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. Created from ashford-ebooks on 2019-09-26 17:16:27. c10 255 21 April 2012; 9:57:9 256 Specific Disorders Single-Subject Experimental Analyses Copyright © 2012. John Wiley & Sons, Incorporated. All rights reserved. An 8-year-old boy attending the third grade was the subject of a consultant directed Between-group design studies evaluating behavior modification program. John was in a behavior modification techniques are based on general education classroom and received positive findings from earlier work using sinremediation in math and reading in a small gle-case designs. Results of single-subject group special education setting. John…

A Sample Answer For the Assignment: Case Analysis – Integrating Theoretical Orientations

Title: Case Analysis – Integrating Theoretical Orientations