Approach
Description
Results
Multimodal approach
Any combination of parent and teacher interventions/training including pharmacological treatment
Interventions are most successful when combined with stimulant medication, especially for school-aged children with severe impairments. Multimodal treatment has the greatest effect on social outcomes and as good an effect on behavioral outcomes as pharmacological treatment. In addition, parent and teacher acceptance is enhanced and necessary drug dose may be lowered. Multimodal treatment has little or no effect on academic functioning.
Contingency management/behavioral interventions
Includes contingency management (reinforcement and punishment/antecedent and consequence based), clinical behavior therapy, self-management approaches, and intensive behavioral interventions
There is strong and consistent evidence that behavioral treatments are effective for reducing ADHD symptoms, including disruptive and off-task behaviors. Empirical studies have supported the efficacy of behavioral interventions. Behavioral interventions tend not to be as effective as medical treatment.
Academic interventions
School-based interventions including behavioral classroom management, psychoeducation, organizational skills intervention, strategy training, teacher-based behavioral training, task and instructional modification, and computer-assisted instruction
Findings indicate that academic interventions may be weaker than behavioral interventions but are potentially effective. Behavioral classroom management is a well-established, evidence-based treatment for ADHD. A variety of school-based interventions were associated with moderate to large improvements in academic and behavioral functioning. Behavioral effect sizes were similar and academic effect sizes were superior to those found for pharmacotherapy. The effects on educational and cognitive outcomes were greatest for educational interventions. Strategies that directly address the academic difficulties experienced by students with ADHD (e.g., task and instructional modification, strategy training) should be incorporated into a multimodal treatment approach to achieve educational success. For school-aged children with moderate impairments, there is some evidence to suggest that classroom behavioral interventions and group parent training may suffice as first-line treatment.
Academic interventions may incorporate other types of approaches if school-based (e.g., behavioral, self-regulation)
Parent training
Includes parent-based behavioral intervention training, behavioral management strategies, contingency training, and parent tutoring
Parent training is the most appropriate intervention for preschoolers. For school-aged children with moderate impairments, there is some evidence that group parent training and classroom behavioral interventions may suffice as first-line treatment. Behavioral parent training is supported as a well-established, evidence-based treatment for children with ADHD.
Parent training may incorporate other types of approaches that parents were trained to provide (e.g., behavioral)
Peer interventions
Includes peer-focused behavioral interventions, social skills building, peer mediation, peer tutoring, assistance, instruction, and feedback
Behavioral peer interventions are supported as evidence-based treatments for children with ADHD. Intensive, peer-focused behavioral interventions implemented within recreational settings are well established. Some promising interventions for addressing social relationship difficulties among students have been developed. Peer tutoring is effective in enhancing academic engagement and scholastic performance, especially in combination with other treatments.
Peer interventions may incorporate other types of approaches, but the main focus is on utilizing peers to create improvements
Self-regulation interventions
The regulation of cognitions or behaviors through strategies such as self-monitoring and self-management
Effect sizes for on-task behavior, inappropriate behavior, and academic accuracy and productivity were large, with similar results across different types of self-regulation interventions. Self-regulation interventions are effective for children with ADHD.
These results are examined independently of other approaches that may incorporate self-regulation components (e.g., contingency management, CBT)
Cognitive-behavioral techniques
Includes cognitive-behavioral techniques such as self-reinforcement and cognitive rehearsal to develop self-control, problem solving skills, social skills, and metacognitive thinking
School-based cognitive-behavioral therapy was associated with improvements in the academic and behavioral functioning of students with ADHD. It is more effective to utilize cognitive-behavioral treatment along with medicine. Moderate mean weighted effect sizes were shown to improve social and behavioral outcomes, but multimodal and pharmacological treatment was more effective. Significant effects have been reported and some promise is shown for cognitive-behavioral treatment of ADHD.
Working memory training
The use of computerized programs to train working memory skills
Memory training programs appear to produce reliable short-term improvements in working memory skills that are not generalizable. For verbal working memory, limited evidence suggests that these effects might be maintained. In the absence of more general effects on cognitive performance or measures of scholastic attainment, working memory procedures should not be recommended as suitable for treating ADHD, although they may show promise in the future.
Cognitive training
Direct skills training of cognitive skills and remediation of deficiencies in thinking or cognitive processes
Studies have demonstrated significant effects for the cognitive treatment of ADHD, and some promise is shown across a larger age range.
Neural-based training
Including neurofeedback and maintaining effort and focus through metacognitive strategies
Studies have demonstrated significant effects, and promise is shown across a larger age range.
Based on the extensive literature, a multimodal cognitive-behavioral intervention framework is warranted that addresses the varied and individualized needs of children with ADHD in school and home. Our intervention approach is broadly conceptualized in six areas: assessment, behavior modification, parent training, teacher assessment and training, skill building, and accommodations. A case example is provided to illustrate the implementation of these methods in schools.
Assessment Implications
A comprehensive assessment will provide a wealth of information that can inform diagnostic decisions and intervention plans tailored to the child’s specific needs. Once an ADHD diagnosis is confirmed, an assessment can help practitioners identify specific behavioral targets for intervention within and across settings (e.g., following directions, hyperactivity, tasks engagement, academic skills). Behavioral targets should be assessed for intensity (frequency), severity, and delivery process. Attention to specific contextual factors such as setting (morning routine, structure class time, mealtime), task (cognitive) demands required of the child, adult behaviors, peer behaviors, and temporal influences are warranted. Assessment information can inform the need for psychiatric consultation in addition to cognitive-behavioral interventions. Second, the neuropsychological assessment will provide information about the breadth and severity of related neurocognitive dysfunctions. This information is often helpful in informing skill building strategies and necessary accommodations. Comorbid disorders and conditions may require additional targets (e.g., reading or writing fluency, oral language skills) and interventions (e.g., academic, medical, occupational therapy, speech/language therapy). Additionally, youth with more severe cognitive impairment may limit the choice for interventions.
Behavior Modification
Although specific implementation of behavior modification strategies differs across settings, the basic principles are the same. Adaptive and prosocial behaviors are reinforced, and maladaptive behaviors are ignored, redirected, or, in limited circumstances, punished. Clear commands and cues are given to the child in order to form explicit expectations for appropriate behavior so she/he has an alternative option to the current behaviors that are deemed inappropriate. Research has indicated that children with ADHD should be given no more than one- or two-step clear directives (Reddy, Fabiano, Barbarasch, & Dudek, 2012; Reddy & Dudek, 2014). Contingencies are also managed in such a way that the child has many opportunities for success.
Several approaches are commonly used to accomplish the goals of behavior modification. One common strategy is to use praise (i.e., specific labeled immediate statements) as reinforcement for positive behaviors. Since teachers and parents often heavily rely on behavioral corrective feedback (pointing out what the child is doing wrong), it is imperative they are taught to (1) structure the environment to allow for frequent observation of the child and (2) “catch the child being good” followed by providing specific (labeled) praise immediately after appropriate behavior is observed. It is typically recommended that the child be praised 3–5 times for every one corrective command that is given in order to mitigate the adult and child frustration that occurs from constant corrective feedback. Reinforcement is also commonly given externally. Token economies are frequently used in which children earn points, stars, or stickers for meeting goals related to the performance of clearly specified target behaviors (e.g., homework completion, remaining quietly in seat for a specified period of time, doing specific chores). Children are typically given a menu of privileges that are associated with different point values and time periods, and they are allowed to choose a reward for which they earned enough points.
Reinforcement for positive behaviors is the primary approach that is recommended for behavior modification for ADHD. Punishment is generally not recommended because it does not usually produce long-lasting results, and may result in unintended consequences. However, there are situations in which punishment is warranted (e.g., child is actively engaged in inappropriate behavior, and it is necessary to stop it immediately). In these cases, time-out (focus on regaining positive self-control) may be needed. This strategy generally consists of the child spending a minimum specified amount of time in an isolated area where she/he is unable to interact with desired stimuli such as other people or objects (i.e., toys) until she/he has regained self-control.
The strategies outlined above are useful in many situations, but as noted, their implementation may look different across and within settings. For example, each parent may deal with different challenges during morning routines, homework, and bedtime routines. Similarly, different teachers may deal with varying challenges. Therefore, behavior modifications must be tailored to specific targets, contexts, and time periods. Furthermore, collaboration between key stakeholders (parents, teachers) within and between settings is urged for the child to fully benefit from a multimodal intervention.
Parent Training
A number of training programs have been developed over the past few decades for parents of children with ADHD. One such program is a cognitive-behavioral approach detailed by Anastopoulos and Farley (2003). In this approach, parent training typically begins with psychoeducation. This includes teaching parents about ADHD symptoms and associated behaviors, as well as a discussion about the implications of the diagnosis and the expectations that parents should have of their children. It can also include a discussion of child characteristics (e.g., demographics, temperament), parent characteristics (e.g., personality, parenting styles), fit between child and parent characteristics, and the impact of stress on the child and family. Psychoeducation is then followed by teaching of parent skills. Parents are taught how to give unambiguous 1- and 2-step directives and to avoid directives that invite compliance issues. They are also taught how to attend to and reinforce adaptive behaviors and to ignore maladaptive behaviors. Training is provided in the proper use of time-out when necessary.
Training may also focus on parents identifying their thoughts and behaviors during times when their child behavior is difficult or escalating. Anger and stress strategies can be identified and discussed for use in specific contexts. Finally, parents are taught how to engage their child in explicit problem-solving strategies.
Behavioral progress in the home is often assessed through the use of daily behavioral charts which require specific parent training on design, implementation, and monitoring. Parents of children with ADHD are often overwhelmed by a number of different behaviors that they consider problematic. However, they are encouraged to choose only a few (i.e., 2 to 3) targets for behavior modification. Behaviors should be as specific and concrete as possible so the child knows exactly what she/he needs to do to earn a point (e.g., brushed teeth by 7:15 am). A menu of rewards should also be constructed that involves a combination of short-term and longer-term goals. For example, daily rewards should consist of basic privileges that the child enjoys (e.g., 1 h of TV time after homework; 15 min of parent positive attention). Daily rewards can be further bridged with weekly rewards (relatively inexpensive bonus rewards) for obtaining a predetermined number of points for the week. Longer-term rewards can include special toys or trips to special places (e.g., Chuck E. Cheese, amusement park); however, it is strongly recommended that daily rewards be maintained to help the child to sustain efforts. Review of daily and weekly goal attainment through the use of behavior charts helps monitor progress, reevaluate targets, and revise reinforcements to sustain behavioral goals.
Teacher Assessment and Training
Teacher classroom instructional and behavioral management practices influence student learning and behavior. Students with ADHD often require changes in teacher’s classroom-wide and student-specific practices/approaches. Teacher training with teacher formative assessment (visual performance feedback) can significantly improve educators’ classroom practices related to student outcomes (Reddy, Fabiano, Barbarasch, & Dudek, 2012; Reddy & Dudek, 2014). The Classroom Strategies Scale (CSS) is a multisource, multi-method approach for identifying and monitoring teachers’ usage of empirically supported instructional and behavioral management strategies (Reddy, Fabiano, Dudek, & Hsu, 2013a). The CSS was developed based on the effective teaching literature and principles from the response-to-intervention framework. The CSS generates scores that assess use of evidence-based practices, identify practice goals, and monitor progress toward practice goals following teacher training. The CSS Observer Form includes three parts centered on classroom observation: Part 1 Strategy Counts, Part 2 Instructional and Behavioral Management Strategies Scales, and Part 3 Classroom Checklist. The CSS Teacher Form includes two parts: Part 1 Instructional and Behavioral Management Strategies Scales and Part 2 Classroom Checklist. The Observer and Teacher Forms generate scores that can be used to enhance collaboration and communication among consultants (observers) and teacher to improve teacher practices and student learning and behavior (Reddy & Dudek, 2014).
The CSS Strategy Counts include eight teacher strategies: (1) concept summaries, (2) academic response opportunities, (3) clear 1- to 2-step directives, (4) vague directives, (5) praise statements for academic performance, (6) praise for appropriate behavior, (7) academic corrective feedback, and (8) behavioral corrective feedback. The observer is to tally the number of times each behavior is observed in a specific lesson. For the Strategy Rating Scales, Instructional Scales (28 items) and Behavioral Management Scales (26 items), observers and teachers are asked to rate strategies/items on a 7-point Likert scale on how often the teacher used each strategy (Frequency Rating Scale) and how often the teacher should have used each strategy (Recommended Frequency Rating Scale) in the lesson observed. The Classroom Checklist assesses the presence of specific classroom structures and resources and is completed by the observer and teacher after the completion of the Strategy Rating Scales. The CSS has evidence of content, construct, reliability, and validity (e.g., Reddy, Fabiano, Dudek, & Hsu, 2013a, 2013b, 2013c).
Using behavioral consultation, the CSS can be used to inform teacher practice targets and monitor progress toward targets and refine approaches for specific classroom-wide and ADHD student-specific needs. Likewise, teacher formative assessment and training guided by the CSS can be further enhanced with the use of a Daily Report Card (DRC) system employed by teachers and parents (Volpe & Fabiano, 2013; http://casgroup.fiu.edu/CCF/pages.php?id=1401. For a detailed case example using the CSS and DRC systems for students with ADHD, see Reddy, Fabiano, Barbarasch, & Dudek, 2012; Reddy & Dudek, 2014.)
Skill Building
While making clear and concise commands is an important way for children to understand what behaviors are expected of them, it is not sufficient in cases where the desired behaviors are skills that have not been developed as part of the child’s repertoire. In these instances, skill building (self-regulated learning) strategies are an important component of intervention for ADHD (Reddy, Newman, & Verdesco, in press). Metacognitive skills can be taught and practiced in order to help the child “self-talk” his/her way through the steps to achieving a goal or solving a problem (see section “Stress-Inoculation Training (SIT) per Meichenbaum” in Chap. 12). This can help children with ADHD to slow down and think through a strategy before acting. Social skills may also be an important part of treatment for certain children with ADHD. Similar to other skill building exercises, social skills training groups help children to learn and practice effective steps toward getting along with others and forming and maintaining friendships. Peer and adult modeling during group training allow for repeated exposures to desired behaviors and are potentially effective ways of teaching these skills (Reddy, 2012). A specific type of peer modeling noted above that has shown some success is peer tutoring (see Table 8.1). Children with ADHD may be paired with other children of the same or slightly older age who have recently mastered academic skills with which the child is currently struggling. This provides the ADHD child with the opportunity for successful peer interactions as well as the opportunity to have problem-solving and learning strategies modeled by peers.
Accommodations
The flip side of skill building is that the child with ADHD may demonstrate certain limitations and/or delays that make it more difficult for him/her to learn skills than the typical child. Schools offer a variety of accommodations that have been shown to improve opportunities for success. Examples may include extra time (specified) on tests, fewer homework problems on page (specified), and/or modified test/homework instructions (e.g., simplified directives) or settings (e.g., a separate classroom to reduce distractions by other children). Next, a de-identified case study is presented using the proposed intervention framework.
Case Example
John is a 7-year-old Caucasian male in a 2nd grade general education classroom. His teacher is concerned because he is often disruptive in class. He frequently is out of his seat, talks to his peers, inconsistently completes his assignments, and appears to have difficulties understanding lessons. John’s parents have observed that he is easily frustrated with his homework, distracted and inattentive when getting ready for school in the morning, struggling following directions, and tantruming on occasion when limits are set. His parents sought a comprehensive evaluation from a licensed psychologist. Based on the evaluation results, John was diagnosed with ADHD combined type exhibiting moderate deficits in attention, working memory, and executive functioning. It was recommended that John receive behavior therapy and be considered for an accommodation plan in school. A medication consult was noted if initial steps did not result in improvements.
John’s parents sought behavior therapy from a licensed psychologist in the community. They reported that John is a sweet and loving boy, but that it is difficult to keep him on task and following directions. They often became frustrated and avoided dealing with his misbehavior because it became “too tiring to keep trying,” eventually tending yell at him and saying things they regret. After reading John’s assessment report and gathering information from his parents, it was determined that behavior modification through parent training would be appropriate. The goals were to help John’s parents to understand their son’s strengths and limitations, to clarify their expectations for themselves as parents and for John, and to implement a consistent behavior plan emphasizing particular target behaviors, reinforcement for performing those behaviors, and consequences for noncompliance and inappropriate behaviors.
Related posts:
Introduction: The Future Is Now—Challenges in the New Age of Psychological Practice
Trauma, PTSD, and Secondary Trauma in Children and Adolescents
Depression
Using CBT to Assist Children with Autism Spectrum Disorders/Pervasive Developmental Disorders in the School Setting
Cognitive Interventions
Externalizing Disorders: Assessment, Treatment, and School-Based Interventions
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