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