5/26/2016

Behavioral Interventions for ADHD: Important Resources for Parents Jennifer Simon-Thomas, Ph.D. Pediatric Clinical Psychologist Children’s Developmental Health Services Albertina Kerr

Disclosure  Nothing to disclose

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Overview     

The Development of Executive Functioning Executive Functioning Difficulties Behavioral Therapies Case Studies Resources

Basics of ADHD – Executive Functioning Skills      

Attention Impulse Control Monitoring Planning Working Memory Emotional Regulation (bully in the brain)

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Development of Executive Functioning

Assessment of Executive Functioning  Attention and Freedom from Distractibility  Vigilance tests  Selective/sustained attention  Attentional switching

 Initiation and Maintenance of Set  Go/no go  Word fluency

 Mental Flexibility and Abstract Reasoning  Inhibition  Sorting tests

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Assessment of Executive Functioning  Executive functioning deficits can be components of many diagnoses:        

Traumatic Brain Injury Attention Deficit-Hyperactivity Disorder Pervasive Developmental Disorders Mood Disorders Attachment Disorders Learning Disabilities Auditory Processing Disorder Medical issues

Executive Functioning Difficulties      

Increased impulsivity Decreased sustained attention Decreased goal-persistence Decreased planning and organizational abilities Decreased self-monitoring and self-regulation Decreased flexibility

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Different Presentations In Boys and Girls  Boys:      

Squirming in seat In trouble Shouting out/interrupting Messy work and desk area Disorganized Can’t concentrate on schoolwork, but can play video games for hours

Different Presentations In Boys and Girls  Girls:      

Daydreaming Doodling Playing with hair Staring out window Forgetful Poor organization

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It’s not all bad…

It’s not all bad…  Weaknesses can also be strengths:    

Impulsivity = willingness to take chances Questioning of authority = ability to think “outside the box” Restlessness = discontent with the “status quo” Distractibility = able to notice small details

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Behavioral Therapies  Behavior Modification

 Increase rewards and consequences  Classical Conditioning  Operant Conditioning

 Cognitive-Behavioral Therapy

Behavioral Therapies  Medication and behavioral therapy together have the best long-term benefit.  Medication works best to decrease impulsivity and distractibility, but it does not change behavior.  Less effective over time.  There is agreement that Behavioral Therapy should be the first line of treatment in children under 5 years of age.

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Behavioral Therapies  It is recommended that children 6-17 receive both medication and behavioral therapy.  The earlier the intervention the better the outcome.

Multimodal Treatment Study of Children with ADHD (MTA)

Goal of Behavioral Interventions for ADHD       

Increase understanding of ADHD Increase realistic expectations Increase organizational skills Increase activity Increase support Decrease demands Lifestyle changes

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Early Childhood Trevor is a 4 year old boy whose parents are concerned because he is very emotional, and quick to anger. He was late to speak and receives EI services. Trevor is reported to be very active and “on the go.” He cannot sit through a book or an arts and craft project. Trevor struggles to go to sleep and bedtime is the hardest part of the day. He attends day-care, and his teachers report that Trevor is careless with his body and “doesn’t pay attention.” The teachers have recommended that Trevor’s parents talk to his pediatrician about medication. Parents shared that they fear Trevor will be asked to leave day-care if they don’t put him on medication.

Immediate Interventions  Recommend that parents enlist the help of EI services to educate day-care about Trevor’s needs.  Have parents and teachers complete the Vanderbilt.  Educate parents about ADHD:  Create a plan and “act don’t yack.”  Increase immediate rewards and consequences.  Increase physical activity (nightly walk after dinner).

 Create a bedtime routine.  Recommend Behavioral Therapy.

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Elementary School Sarah is a 11 year old girl who is described as shy and “in her own world.” She has a history of academic struggles despite average intelligence. Sarah completes her homework, but “can never seem to turn it in.” She does not seem motivated by consequences or rewards. Sarah has struggled to make friends at school, and recently was the only girl in her class to not be invited to a peer’s birthday party. Parents have tried enrolling Sarah in many activities, but she has not shown interest. Parents feel Sarah is becoming more withdrawn and are at a loss for what to do.

Immediate Interventions  Encourage the family to enlist the help of the school:    

Immediate rewards: invisible ink. Organizational tools: In and out folder Special jobs Social skills/friendship group

 Recommend school conduct assessment to rule-out LDs.  Have parents and school staff complete the Vanderbilt, but also SCARED.

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Immediate Interventions  Assess anxiety versus ADHD or both.  Recommend Cognitive-Behavioral Therapy.  Consider medication if therapy alone is not effective.

Middle and High School Kevin is a 14 year old boy with a history of Dyslexia and Oppositional Defiant Disorder. He is a gifted athlete, but parents feel his performance is hampered by not being able to remember the plays. As he gets older, this is having more and more of a negative impact. Parents shared that Kevin was always an active child and sports have been his outlet. When he is not involved in sports, he is extremely sedentary and will play video games “all day.” Kevin is unwilling to complete chores at home, and parents have given up on making him clean his room. Parents report “consequences only make his behavior worse.” They feel Kevin is bright, but so far behind his peers academically, and in terms of maturity, that they wonder if he will be able to be a “functional adult.” Parents present as very frustrated and report little enjoyment in parenting Kevin.

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Immediate Interventions  Get the school involved. Does he have the right accommodations for Dyslexia? Does he have other learning differences?  Have parents and teachers complete Vanderbilt and SCARED.  Assess for depression.  Consider medication.  Recommend Cognitive-Behavioral Therapy.

Immediate Interventions  In your office:

 Education about ADHD and comorbid depression.  Encourage both parents to plan one activity a week with Kevin that is not contingent on his behavior.  Encourage parents to talk to Kevin’s coach about his learning style and brainstorm ways to improve his retention of plays (i.e. drawing pictures he can study).  Have parents pick two behaviors and identify a behavioral plan.  Encourage parents to highlight Kevin’s strengths.  Encourage Kevin to “See His Future.”

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General Resources for ADHD  Taking Charge of ADHD, by Russell Barkley, Ph.D.  Smart but Scatter by Peg Dawson, Ed.D. and Richard Guare, Ph.D.  Executive Skills in Children and Adolescents: A Practical Guide to Assessment and Intervention by Peg Dawson and Richard Guare.  50 Activities and Games for Kids with ADHD by Patricia Quinn & Judith Stern.  Seeing My Time (www.ExecutiveFunctioningSuccess.com).

General Resources for ADHD  Children and Adults with ADHD (www.chadd.org).  ADDitude: Strategies and Support for ADHD and LD (http://www.additudemag.com/).

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How to Find a Behavioral Therapist  How to find therapists:    

www.locator.apa.org www.therapistlocator.net/iMIS15/therapistlocator www.findcbt.org/xFAT www.mentalhealth.gov/get-help/immediate-help/index.html

CME Topic for the next Project ECHO tele-clinic:

Trauma and ADHD Sara Kemper, LCSW Licensed Clinical Social Worker Children’s Developmental Health Services Albertina Kerr

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