Download Child and Adolescent Psychopathology

Chapter 12:
Evidence-Based Treatment of
Attention-Deficit/Hyperactivity
Disorder in Children and
Adolescents
Heather A. Jones
Annie E. Rabinovitch
Overview
 ADHD: neurodevelopmental disorder marked by age-
inappropriate levels of inattention and/or hyperactivity and
impulsivity
 One of the most common psychological disorders in
childhood (Salmeron, 2009)
 8.7% of children aged 8–15 in United States meet DSM-IV
diagnostic criteria for ADHD
 Boys:girls = 3:1 ratio
 Presentations: predominately hyperactive/impulse,
combined, or predominately inattentive
Impairment in ADHD
 Home
 High levels of family stress
 Conflicted parent-child relationships
 Managing behaviors of children with ADHD can be challenging
and stressful
 School
 Difficult for children to remain seated or still
 Distractibility and difficultly following instructions can interfere
with a child’s ability to complete schoolwork successfully
 Peers
 Hyperactivity and intrusiveness considered aversive by peers
 Can be isolated from peers due to symptoms
Diagnostic Criteria
 Three presentations: distinguish clusters of
symptoms
 Inattentive type
 Hyperactive/impulsive type
 Combined type
 To receive diagnosis of ADHD
 At least six symptoms of inattention
 At least six symptoms of hyperactivity/impulsivity
 At least six symptoms of inattention and
hyperactivity/impulsivity
 Symptoms present for at least 6 months
 Coincide with functional impairment in at least two settings
(e.g., home, school)
Developmental Perspective
 ADHD-associated impairment changes across
development (Seidman, 2006)
 E.g., toddlers demonstrate some core symptoms typically
associated with ADHD (e.g., high energy) but symptoms
are not generally accompanied by impairment
 Longitudinal research
 By age 3–4, hyperactive/impulsive symptoms can be
distinguished from normative disinhibition by virtue of
symptom severity and corresponding impairment
(Barkley, 2003)
Middle-Childhood ADHD
 Home
 Parent-child relationships characterized by greater
negative emotionality, conflict, coerciveness
 Family function also disrupted: greater family discord
(Wells et al., 2000), higher rates of divorce (Wymbs et al.,
2008)
 School
 Academic underachievement
 Repeating academic grades
 School-related disciplinary action (e.g., suspensions)
 Social impairment
Adolescent ADHD
 50–80% of clinically referred children will continue
to experience ADHD-related impairment (Parke et
al., 2002)
 May engage in greater risk behaviors
 E.g., dangerous driving habits (Cantwell, 1996)
 School
 Failing more classes
 Greater number of years to graduate from high school
 Lower rates of college attendance and graduation
Chronic Disorder
 Once conceptualized as a childhood disorder
 ADHD is chronic
 Symptoms continue into adulthood (Pary et al.,
2002)
 Adults with ADHD
 Poorer health outcomes
 Fewer intimate relationships
Comorbidity
 Externalizing disorders – most common:
 Oppositional Defiant Disorder (ODD)
 Conduct Disorder (CD)
 20–50% go on to develop CD by middle childhood
 Internalizing disorder—most common:
 Anxiety
 Depression
 10–40% diagnosed with ADHD also diagnosed with an anxiety
disorder
 Learning disorder (LD)
 19–26% of children with ADHD also have LD
Evidence-Based
Approaches to Treatment
 Evolutionary biology perspective
 ADHD conceptualized as a mismatch between a child’s
interrelated characteristics (e.g., genetics, temperament) and
his or her environmental demands
 Multimodal Treatment Study of Children with ADHD
 First large-scale, multi site study
 Safety and relative effectiveness of stimulant medication and
behavior therapy alone and in combination
 14-month clinical trial
 Medication management superior to behavioral treatment and
community care at completion of study
 In 8-year follow-up, all children enrolled reported maintenance
of improvement in functioning relative to pretreatment levels
• Still functioning less well than comparison controls
Behavioral Interventions
 Behavioral Parent Training (BPT)
 Most well-studied intervention for children with ADHD
 Foci of change: child’s unwanted and wanted behaviors
 Parent is agent of change
 Therapist’s role is to teach parent how to use effective
behavior management strategies, monitor change, and
troubleshoot difficulties
 Classroom Behavior Management
 Teachers implement rewards system for children with
ADHD in the classroom
 Principles of reinforcement and punishment
Behavioral Treatments
 Intensive Treatment Programs
 E.g., Summer Treatment Program: 2 month, all day
program; combines behavioral point system, daily report
cards, academic skills training, social skills training,
problem-solving training, and sports training
 Peer Interventions
 Other interventions (e.g., medication, behavioral
management) do not improve peer relations
 E.g., Making Socially Accepting Inclusive Classroom
• Provides instructions to teachers and peers regarding specific
behavioral changes (e.g., teachers taught to diffuse their
frustrations by providing positive comments)
Behavioral Treatments
 Neurofeedback Training
 Computer programs that present puzzles/tasks designed
to enhance set shifting, inhibitory control, working
memory, or attention
 Have not been subjected to rigorous empirical testing
 Recent meta-analysis suggests that these programs are
not efficacious (Rapport et al., 2013)
Parental Psychopathology
 Maternal depression: Mothers of children with ADHD
are more likely to experience depressive symptoms, as
well as major depression episodes
 Depressed mothers found to be less consistent and more
negative in their parenting, and to have more negative
expectations of their children
 Maternal ADHD: Parents of children with ADHD are
more likely than parents of nonaffected children to
suffer from the disorder (e.g., Albert-Corush et al.,
1986)
 Maternal ADHD may interfere with treatment of the child with
ADHD
Adaptations for
Specific Populations
 Fathers: have experienced particular difficulty
engaging in BPT (Fabiano et al., 2009)
 Typically excluded from research
 Often report greater impairment in their relationships with
their child and child’s mother
 Include more in BPT to underscore role of fathers
fostering emotion regulation, social competence, and
sustained attention in children
 Father involvement linked to more positive outcomes
Single-Parent Households
 Family adversity often compromises benefits of
BPT
 Single mothers at higher risk for negative
consequences (e.g., depression, stress)
 Barrier to BPT, less likely to enroll
 Strategies to Enhance Positive Parenting
(STEPP) Program
 Focused on identifying and tackling barrier to treatment
for single mothers
Measuring ADHD
Symptom Outcomes
 Treatment outcomes often utilize ADHD symptom severity
as an index
 SNAP-IV
 ADHD Rating Scale
 Vanderbilt ADHD Rating Scale
 Treatment approaches operate under the assumption that
core symptoms of ADHD are directly and causally linked to
functional impairment
 I.e., decreases in ADHD symptom severity should result in similar
reductions in associated impairment
 Empirical data indicate that reduction in ADHD symptoms
does not necessarily translate into improvements in
functional deficits (e.g., Epstein et al., 2010)
Measuring Functional
Impairment Outcomes
 Changes in functional impairment appear more robust
relative to those assessing outcomes at the symptom level
 Home and family
 Parent-child relationships, family functioning, parenting practices,
parental well-being
 Self-report (e.g., PCRQ), behavioral observation (e.g., ITBE)
 Academics
 Grades, note-taking ability, completion of homework assignments
 Peer relationships
 Self-report (e.g., Self-Perception Profile for Children)
Clinical Case: Benjamin
 8 years old, African American
 Diagnosis: ADHD, Combined Type
 Treatment Plan: Parents initiated behavioral parent
training
 Psychoeducation
 Treatment expectations
 Positive reinforcement
 Issuing specific, direct, short commands/instructions
 Daily Report Card for school
 Parents initiate child playdates
Treatment Outcome
 Parents reported improvement in son’s behavior
within the home
 E.g., follows instructions within the household
 Improvement in school behavior
 Remains seated ~65% of independent classwork time
 Parents continue to encourage positive peer
interactions by guiding Benjamin to use
appropriate social skills during play dates