Hyperactivity Disorder in Children and Adolescents

33 Attention-Deficit/Hyperactivity Disorder in Children and Adolescents Miguel T. Villodas University of California, San Francisco, United States St...
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Attention-Deficit/Hyperactivity Disorder in Children and Adolescents Miguel T. Villodas University of California, San Francisco, United States

Stephen P. Hinshaw University of California, Berkeley, United States

Linda J. Pfiffner University of California, San Francisco, United States

Attention-deficit/hyperactivity disorder (ADHD) is one of the most frequently diagnosed psychiatric disorders among children and adolescents, characterized by pervasive symptoms of inattention (e.g., difficulty completing tasks) and/or hyperactivity (e.g., difficulty sitting still) and impulsivity (e.g., difficulty waiting one’s turn; American Psychiatric Association, 2000). These problems typically develop during early to middle childhood, although detection in some cases may not be until middle school, and manifest in profound impairments in multiple contexts. Multiple etiologies may lead to ADHD, but evidence supports neurological and genetic factors as leading causes (Barkley, 2006). Nevertheless, it is clear that social-environmental variables can impact symptom severity, extent and type of impairment, and the development of comorbid disorders. At school, children with ADHD often have significant impairments in their academic performance and are frequently cited for behavioral problems (DuPaul & Stoner, 2003). At home, relationships with their parents are often strained and they have difficulty managing and organizing responsibilities (Johnston & Jassy, 2007; Langberg et al., 2011). Moreover, children’s ADHD symptoms interfere with peer relations, as they are often perceived as uninterested and spaced out, or aggressive and overbearing (McQuade & Hoza, 2008; Nijmeijer et al., 2008). In consideration of the pervasive nature of this disorder, behavioral interventions have been developed that provide parents and teachers with strategies to improve The Wiley Handbook of Cognitive Behavioral Therapy, First Edition. Edited by Stefan G. Hofmann. Volume II edited by Winfried Rief. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd. DOI: 10.1002/9781118528563.wbcbt33


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symptoms and functioning of children with ADHD across settings. Despite the neurological and genetic underpinnings of ADHD, evidence indicates that changing the social environment through behavioral interventions can dramatically impact outcomes for youth with ADHD. A substantial literature supports these approaches. Indeed, a meta-analysis reported large average effect sizes (Cohen’s ds ranging from 0.70 to 3.78 depending on study design) that were stable across demographic factors (e.g., age, IQ, and race of children, family structure, etc.; Fabiano, Pelham, et al., 2009). In contrast to these approaches, early cognitive approaches attempted to address ADHD deficits and impairments by directly teaching children to use self-instruction and self-reinforcement in order to improve self-regulation and behavioral responses (Baer & Nietzel, 1991; DuPaul & Eckert, 1997; Dush, Hirt, & Schroeder, 1989). The hope was that these approaches would provide a more portable and sustainable method for promoting behavior change than strictly behavioral approaches, which rely on parents and teachers. Unfortunately, such strategies were not supported in empirical studies. A combination of factors may have limited the success of selfinstruction, including the need for sufficient verbal-executive control for children to generalize their use of the strategies outside of the therapy setting, inadequate methods within the procedures for addressing the impulsivity and affective instability characteristics of ADHD, and a failure to address potential skill deficits (Pfiffner, Calzada, & McBurnett, 2000). Despite the shortcomings of stand-alone cognitive interventions, a growing evidence base supports psychosocial intervention strategies that include cognitive and behavioral approaches. For the purposes of this chapter, we will define cognitive behavioral interventions broadly, with a focus on psychosocial interventions, including those with cognitive behavioral elements, which have been empirically demonstrated to improve symptom and functioning deficits in children and adolescents with ADHD. ADHD symptoms are frequently comorbid with many other psychiatric disorders, most notably disruptive behavior problems; a number of interventions have been developed to address both sets of problems (Barkley, 2006). Although this chapter will primarily focus on interventions with evidence for treating ADHD-related problems, many of the outcomes will also apply to the comorbid externalizing problems. Frequently comorbid internalizing problems (e.g., anxiety, depression) may require additional strategies (MTA Cooperative Group, 1999b).

Behavioral Interventions Behavioral interventions are the most consistently researched and implemented psychosocial interventions for ADHD (Pelham & Fabiano, 2008). Rooted in social learning theory (Bandura, 1977), behavioral interventions for this population are supported by empirical evidence of efficacy across multiple implementation settings. Although effect sizes vary depending on the outcome of interest and the method of assessment, results of a key meta-analysis (Fabiano, Pelham, et al., 2009) indicated medium to large average effect sizes for improvements in parent-reported parenting practices, direct observations of parenting practices and children’s behaviors, and

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parent and teacher reports of children’s ADHD symptoms, externalizing behaviors, and impaired functioning. Average effect sizes for academic outcomes were more variable, generally small to medium for measures of academic achievement. Behavioral interventions typically begin with a functional behavioral analysis, in which treatment targets are identified (Pfiffner & Kaiser, 2010). Specifically, positive and negative behaviors are chosen as targets to increase or decrease, respectively, the antecedents and consequences of the identified behaviors. Based on this analysis, a structured system of contingencies (i.e., immediate incentives and consequences) is developed and is directly linked to the target behaviors. The utility of these approaches for ADHD is underscored by studies showing that children with ADHD lack responsivity to partial reinforcement (Parry & Douglas, 1983), delayed reinforcement (Sonuga-Barke, 2005), and signs of punishments or loss of rewards (Quay, 1997). They may also have elevated reward thresholds (Haenlein & Caul, 1987). Such reward-related deficits may relate, at a neural level, to an inherent lack of crucial receptors for dopamine in key brain tracts (Volkow et al., 2009). Based on these findings, it would appear that children with ADHD are ideal candidates for behavioral interventions, which stress immediate, expectable, and salient rewards, appropriate consequences, consistent routines, and clearly structured rules and expectations. Behavioral programs have been adapted to target children and adolescents of all ages in either the home or school setting using behavioral parent training (BPT), behavioral classroom management (BCM), or a combination of the two. Although for younger children the primary focus is on training parents and teachers, as children get older and become more autonomous it becomes increasingly important to involve them directly in treatment (Pfiffner & Kaiser, 2010). This is often accomplished by including child skills training components for elementary school-aged children, as discussed below, or directly including adolescents in the problem-solving process used to identify target behaviors and contingencies. Adolescents and their parents may also benefit from interventions that include components of communication skills training.

Behavioral Parent Training BPT, also referred to as parent training, parent management training, or behavioral family therapy, focuses on reshaping the “coercive” parent–child interaction process, as described by Patterson (1982), among families with children characterized by behavior problems. In this process, parents and their children struggle to control one another’s behaviors through negative reinforcement (Pfiffner & Kaiser, 2010). For example, a child may learn to avert parental demands (e.g., chores) by engaging in increasingly undesirable behavior (e.g., argumentativeness, aggression) until his or her parents withdraw their demands. Conversely, parents may learn that they can achieve compliance from their children by engaging in extremely aversive or punitive behaviors (e.g., yelling, slapping). Among children with ADHD in particular, the early emergence of behaviors related to core ADHD symptoms has been found to increase the use of negative parenting practices, which in turn increases the problematic behaviors in a transactional manner (Johnston & Jassy, 2007). Thus, teaching parents of children with ADHD to implement effective behavior management techniques is particularly appropriate.


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Versions of BPT have been designed for children and adolescents of all ages with ADHD (Pfiffner & Kaiser, 2010). BPT is often included in multicomponent treatments but has also been shown to be effective as a stand-alone treatment for symptoms and impairments related to ADHD (Fabiano, Pelham, et al., 2009). When implemented alone, BPT is typically 8–16 sessions and can be administered in a parent group format or to individual parents/families (Pelham & Fabiano, 2008), or as a mixture of group and individual sessions (Wells et al., 2000). Most BPT programs for ADHD include education about ADHD symptoms and impairments plus common social-learning-theory derived elements that teach parents the following: • • • • • • • • •

to give short, clear, and effective instructions; to develop a structured routine with consistent rules and expectations; to reward appropriate behaviors with praise, attention, and incentives; to develop a token-economy system to reinforce appropriate home behaviors; to extend this system to manage school behaviors (e.g., using daily report cards); to actively ignore negative behaviors; to effectively use time-out when the child is noncompliant and/or aggressive; to effectively manage noncompliant and/or aggressive behaviors in public places; to apply the skills to future challenging situations.

Furthermore, many BPT programs are combined with specific skills training for children, discussed in further detail below. A variant of BPT is parent–child interaction therapy (PCIT; Zisser & Eyberg, 2010). Although not designed specifically for ADHD, PCIT is an evidence-based intervention that has been shown to be effective with young children (aged 2–7) with ADHD. PCIT focuses on restructuring dyadic interactions between parents and their children in the context of structured play in order to create a context in which behavior can be managed effectively. In the first phase, child-directed interaction, children lead play while parents learn to praise enthusiastically, reflect, imitate, and describe the child’s actions. During the second phase, parent-directed interaction, parents direct the child to complete tasks using behavioral strategies like those taught in BPT, such as effectively giving commands and implementing time-out when the child is noncompliant. Parents learn and practice skills in session with live coaching from a therapist. Mediators and moderators of behavioral parent training. Despite the success of BPT, researchers have identified important factors related to implementation that influence the impact of this intervention on children with ADHD (Pelham & Fabiano, 2008). For example, researchers have found that the match between parental treatment preferences, such as program times, locations, activities, and advertised benefits of the treatment in which parents participated, influenced their utilization of BPT programs (Cunningham et al., 2008). Moreover, positive parental expectations prior to and throughout treatment have been found to predict better treatment engagement in BPT and better child outcomes (Kaiser, Hinshaw, & Pfiffner, 2010). Similarly, based on a review of the relevant literature, Mah and Johnston (2008) recommended that parental social cognitions, such as attributions and parenting efficacy, may be crucial

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targets for increasing acceptability of and engagement in BPT, particularly during the early stages of the treatment. Researchers have found that factors related to family socioeconomic status may influence the impact of BPT for children with ADHD and their families because of barriers to treatment engagement (Lundahl, Risser, & Lovejoy, 2006), such as attrition, low income, parent education level, single motherhood, and a lack of father involvement (Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004; Pelham & Fabiano, 2008). In response to concerns about the barriers faced by single mothers, Chacko et al. (2009) developed the Strategies to Enhance Positive Parenting (STEPP) program. This program enhances BPT by integrating it with a group-based supportive problem-solving format that follows a manualized approach to common burdens of single motherhood. In order to increase engagement in treatment among fathers, Fabiano, Chacko, et al. (2009) developed the Coaching Our Acting-out Children: Heightened Essential Skills (COACHES) program. This program facilitated the acquisition of behavioral management techniques among fathers in the context of sports activities, and found that it increased father involvement in treatment. Atkins et al. (2006) recruited respected parents from the African American community to serve as community consultants in a partnership with providers and school personnel as part of the Positive Attitudes for Learning in Schools (PALS) program in order to increase engagement in BPT among low-income African American families. Based on input from these community consultants, the program improved engagement in BPT by framing sessions as “parent parties” rather than training sessions, emphasizing social support and community building, and having a community consultant co-lead groups with a therapist. Given the strong heritability of ADHD and the risk for a variety of psychopathology among parents of youth with ADHD, researchers have begun developing BPT protocols that include cognitive behavioral therapy (CBT) elements for parents. For example, in response to the finding that maternal depression may limit the impact of BPT on child outcomes (Owens et al., 2003), an integrated treatment protocol that combines BPT and an adjunctive CBT treatment for maternal depression, the Coping with Depression Course for mothers of children with ADHD, is being developed and evaluated (e.g., Chronis-Tuscano & Clarke, 2008). Similarly, researchers have identified that maternal ADHD symptoms attenuate the impact of BPT on child outcomes because mothers with ADHD often have difficulty adopting and implementing the new parenting practices (Chronis-Tuscano et al., 2011; Sonuga-Barke, Daley, & Thompson, 2002). However, a combined treatment for parents and children who each have ADHD has not yet been developed.

Behavioral Classroom Management BCM is analogous to BPT and aims to train teachers in behavioral principles that can be implemented in the classroom setting (DuPaul & Eckert, 1997; Pelham & Fabiano, 2008). In this intervention model, mental health professionals train teachers in empirically supported behavior management techniques and provide regular consultation (e.g., DuPaul et al., 2006). Strategies include the use of token-economies (Pfiffner, Barkley, & DuPaul, 2006) and a mix of positive reinforcement (e.g.,


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praise) and prudent negative consequences (e.g., response cost; Pfiffner, O’Leary, Rosen, & Sanderson, 1985; Pfiffner, Rosen, & O’Leary, 1987) for managing the behavior problems of children with ADHD. These approaches have been found to improve academic achievement and behaviors that facilitate academic productivity (e.g., motivation, engagement, etc.; DuPaul et al., 2006). A variant of a token economy is the use of a daily report card, on which the child is rated each day on his or her performance in a number of prespecified domains of behavior that require improvement—and rewarded for performance (Fabiano et al., 2010). Daily report cards have been found to improve observed classroom functioning, attainment of individualized education plan goals, and teacher-rated academic productivity and disruptive behaviors (Fabiano et al., 2010). Daily report cards also facilitate communication between teachers and parents and allow for the coordination of school and home behavioral targets. Mediators and moderators of behavioral classroom management. Few studies have examined specific mediators and moderators of BCM, but as with BPT, it is likely that implementation factors such as engagement, fidelity, and intervention intensity/dosage are important considerations (Pelham & Fabiano, 2008). For example, although evidence supports the utility of specific interventions, such as daily report cards, recent studies have demonstrated that these strategies are more likely to be implemented adequately if conjoint parent–teacher consultation meetings are held at the child’s school (Murray, Rabiner, Schulte, & Newitt, 2008) and if existing school personnel substitute for teachers so that they can attend consultation meetings (Owens, Murphy, Richerson, Girio, & Himawan, 2008). Pfiffner et al. (2011) trained existing school mental health personnel, learning support professionals, to schedule conjoint sessions at school with teachers, parents, and their children in order to develop and manage home and school daily report cards as part of a multicomponent intervention. In these examples, the use of existing school infrastructure may result in sustainable implementation of interventions. In another example, Atkins et al. (2008) recruited influential teachers, referred to as key opinion leaders, and trained them to implement evidence-based intervention techniques in their classrooms. This strategy resulted in an increase in the acquisition of these techniques by other teachers in the same school, as a result of social diffusion. These studies have demonstrated the utility of these innovative implementation methods for children in low-income, ethnically diverse, rural and urban communities.

Child Skills Training Interventions Whereas the above interventions target parents and teachers in order to improve symptoms and functioning in children with ADHD, skills training interventions that directly address the skill deficits of these children have also been developed. These generally include cognitive components but are differentiated from purely cognitive interventions through their focus on specific skills for day-to-day functioning rather than global self-instruction.

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Social Skills Training As mentioned above, ADHD in children and adolescents is often associated with profound and enduring social impairments, many of which are the direct result of ADHD symptoms (e.g., social unawareness; McQuade & Hoza, 2008; Nijmeijer et al., 2008). Researchers have identified that youth with ADHD are often more insensitive and self-centered than their peers (Normand et al., 2011) and more likely to interrupt others, talk excessively, and behave aggressively and impulsively (Nijmeijer et al., 2008). Symptoms of inattention may also contribute to difficulty interpreting emotional and nonverbal cues from peers, often resulting in social performance deficits (Semrud-Clikeman, 2010). As a result of such impairments in social functioning, youth with ADHD are more frequently rejected by peers and have fewer friends (Mikami, 2010; Murray-Close et al., 2010; Nijmeijer et al., 2008). Social skills training programs have been developed for ADHD to teach a variety of skills such as good sportsmanship, conversation and communication skills, and handling teasing and disagreements. A challenge has been generalizing the newly acquired skills from the treatment setting to everyday encounters at home and school (e.g., Antshel & Remer, 2003). Programs that have focused on training children at the point of performance, among similar-age peers, are prone to reinforce the acquisition of skills and increase the likelihood that they will generalize beyond the treatment context (Frankel, Myatt, Cantwell, & Feinberg, 1997; Pfiffner et al., 2000; Pfiffner & McBurnett, 1997; Pfiffner et al., 2007). An exception to this recommendation is for interventions targeting deviant and delinquent behaviors, in which group treatments have been found to foster peer training in undesirable behaviors (e.g., Dishion & Dodge, 2006). Studies have found that training parents to reinforce or coach the skills taught in social skills training groups facilitates the acquisition of social skills and the improvement of social outcomes, such as children’s knowledge of social skills and parents’ and teachers’ ratings of social skill use and social functioning (Frankel et al., 1997; Pfiffner & McBurnett, 1997; Pfiffner et al., 2007). Despite the more promising results yielded by studies using these implementation strategies, impact on peer acceptance and rejection is not especially strong (Mikami, 2010). In addition, it is not apparent that improvements in social skills translate to improvements in the quality or quantity of children’s friendships. In an attempt to better target friendship development, Mikami et al. (2010) developed an eight-session intervention for parents of children with ADHD in which parents were trained to coach their children in appropriate social skills as well as structure and facilitate appropriate social interactions or play dates. The results of a pilot study revealed that children improved on parent-reported social skills and friendship quality and teacher-reported peer acceptance/rejection (Mikami, Lerner, et al., 2010).

Training Skills for Academic Success Children and adolescents with ADHD are often characterized by academic problems that result directly and indirectly from their symptoms (DuPaul & Stoner, 2003). Specifically, they often have severe difficulties performing executive functions such as organizing tasks, managing their time, and planning effectively (Barkley, 2006;


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Langberg et al., 2011; Langberg, Epstein, Urbanowicz, Simon, & Graham, 2008; Willcutt, Doyle, Nigg, Faraone, & Pennington, 2005). These functions are particularly impairing in the academic setting, in which children’s academic success (i.e., organizing and completing class work, homework, tests, and projects) is often dependent on these skills. Poor organizational and study skills often translate into lower scores on academic achievement tests, poorer class work and homework completion, lower report card grades, and overall deficits in academic performance (Barkley, 2006; Power, Werba, Watkins, Angelucci, & Eiraldi, 2006; Schultz, Evans, & Serpell, 2009). Interventions have been developed to target the following specific skills, which promote academic success: • organizational skills (Abikoff et al., 2013; Evans, Langberg, Raggi, Allen, & Buvinger, 2005; Langberg, Epstein, Urbanowicz, et al., 2008); • self-management (Gureasko-Moore, DuPaul, & White, 2006, 2007); • note-taking (Evans, Pelham, & Grudberg, 1995); • homework skills (Raggi, Chronis-Tuscano, Fishbein, & Groomes, 2009). Comprehensive programs that teach many of these skills, such as the Challenging Horizons Program (CHP; Evans et al., 2005; Evans, Schultz, DeMars, & Davis, 2011; Langberg, Epstein, Urbanowicz, et al., 2008), have recently demonstrated their utility for the improvement of children’s academic outcomes as well as their organization and homework skills. CHP combines various treatment components, which have been evaluated individually and in varying doses, into a comprehensive after-school program involving intensive intervention 2 to 4 days each week. The intervention can be implemented in different forms, but in general the sessions last approximately 2 hours each and can continue for 10 weeks up to an academic year, and can be implemented by mental health professionals or school personnel. The most comprehensive implementations of CHP include three Family Check-Up (FCU; Dishion, Nelson, & Kavanagh, 2003) sessions during the fall semester prior to the start of the intervention (Evans et al., 2011). The Family Check-Up was designed as an enhancement to more intensive interventions, in which parents are motivated and engaged in better monitoring of their children and management of their families. The three sessions consist of an initial interview, an assessment session, and a feedback session, in which feedback about the assessment results is delivered using motivational interviewing techniques.

Mediators and Moderators of Child Skills Training Interventions As noted above, most social skills training programs are targeted for child training, and the effects are a function of the extent to which generalization is achieved. Recent studies have found that negative parenting practices (Kaiser, McBurnett, & Pfiffner, 2011; Mikami, Jack, Emeh, & Stephens, 2010) and maternal ADHD (Griggs & Mikami, 2011b; Mikami, Jack, et al., 2010) were not only related to poor social functioning and poor peer relations among children with ADHD, but also moderated parents’ abilities to facilitate their children’s development and maintenance of friendships (Griggs & Mikami, 2011a). These findings highlight the importance

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of combining social skills training with parent training, such as BPT. They also underscore the importance of including parents in a complementary role in these interventions. It is likely that social skills training will be most beneficial with ongoing monitoring and incentives from parents and that didactic learning will be insufficient. With regard to training skills for academic success, some important factors should also be considered. For example, it has been estimated that approximately 30% of children and adolescents with ADHD have a comorbid specific learning disorder (DuPaul & Stoner, 2003). Teaching study and organizational skills may be necessary but not sufficient for those with a specific learning disorder, which will in all probability require educational interventions in the areas of disability. Another potential consideration for the development of academic skills interventions is the age range of the youth who are targeted. Langberg and colleagues (Langberg, Epstein, Altaye, et al., 2008; Langberg et al., 2011) have identified that ADHD symptoms and impairments generally decrease as children develop, but this trend can be disrupted by contextual shifts (e.g., the transition to more demanding academic environments). These findings suggest that it is appropriate to tailor these interventions to meet the needs of key transition periods. Moreover, teaching these skills in the context in which they will be used (e.g., the school setting) may facilitate their acquisition and application.

Cognitive Skills Training Researchers have recently begun to investigate interventions to directly treat the neurocognitive deficits thought to underlie many of the core symptoms and impairments of children with ADHD, such as deficits in the executive functioning domains involved with attention, planning, inhibition, and working memory (Barkley, 2006; Willcutt et al., 2005). In response to preliminary successes in improving these executive functions among individuals who have sustained brain injuries (e.g., Sohlberg, McLaughlin, Pavese, Heidrich, & Posner, 2000), researchers began to develop programs to target children with similar cognitive deficits that result from ADHD. For example, investigators have developed computer-mediated programs that require children to complete increasingly difficult working memory tasks for approximately 25 to 45 minutes daily for 4 to 6 weeks (Holmes et al., 2010; Klingberg et al., 2005; Klingberg, Forssberg, & Westerberg, 2002; Mezzacappa & Buckner, 2010). Although some clinical evaluations have shown promising preliminary results for improvements on tests of verbal and visuo-spatial working memory and other executive functions (e.g., response inhibition), effects on ADHD symptoms and day-to-day impairments have been less consistently investigated. Specifically, although one study reported improvements in teacher ratings of ADHD symptoms (Mezzacappa & Buckner, 2010), only one study used blinded ratings of such symptoms, finding significant improvements in parent but not teacher reports (Klingberg et al., 2005). Other similar neurocognitive training programs aim to improve the attention deficits that are central to ADHD (Hagen, Moore, Wickman, & Maples, 2008; Kerns, Eso, & Thomson, 1999; Semrud-Clikeman et al., 1999; Shalev, Tsal, & Mevorach, 2007). These programs have followed a similar format, requiring varying


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doses (ranging from 50 minutes to 2 hours weekly for 4 to 8 weeks) of attention exercises of increasing difficulty, using either computer-mediated tasks (e.g., Hagen et al., 2008; Shalev et al., 2007) or neurocognitive training administered in person (e.g., Kerns et al., 1999; Semrud-Clikeman et al., 1999). Children received auditory feedback based on their accuracy and reaction time, converted into points upon the completion of each task. Evidence of improvement in attention problems has been documented, and a randomized clinical trial reported evidence of improvements in academic outcomes (i.e., reading comprehension and writing fluency) as well (Shalev et al., 2007). However, significant improvements in ADHD symptoms were reported only in this study (a randomized clinical trial) and were restricted to parent reports of inattention symptoms (Shalev et al., 2007). Neurofeedback, a specific type of biofeedback, which involves the use of electrodes to measure the electrical activity of the brain in different functional states, has also been proposed as a potential treatment for children with ADHD (Lofthouse, McBurnett, Arnold, & Hurt, 2011; Sherlin, Arns, Lubar, & Sokhadze, 2010). Neurofeedback uses auditory and visual feedback about changes in the brain’s electrical activity, which allows individuals to learn to control their physiological states. Children with ADHD in particular have been found to have low levels of arousal in frontal areas of the brain as a result of excessive theta (slow) waves and a deficit of beta (fast) waves. Through intensive neurofeedback training (approximately 30 to 40 hours over 2 to 3 months), the goal is to teach children through operant and classical conditioning to increase beta and decrease theta brain wave patterns in frontal areas. Researchers have called for improved methodological rigor in the evaluation of these treatments, pointing to the dearth of randomized clinical trials and studies comparing neurofeedback to semi-active control groups and placebo treatments, such as sham neurofeedback and cognitive skills trainings, that simulate the nonspecific effects of neurofeedback (e.g., therapist–client interaction, time-intensive training, etc.; Loo & Barkley, 2005). However, recent studies have addressed these concerns and have begun to establish evidence of the efficacy of this treatment for improving beta-theta activity as well as symptoms of ADHD, particularly inattention, in children (Bakhshayesh, H¨ansch, Wyschkon, Rezai, & Esser, 2011; Gevensleben et al., 2009; Gevensleben et al., 2010). Although these treatments have demonstrated some preliminary evidence for positive effects on core neurocognitive impairments associated with ADHD, it is unclear whether these treatments ameliorate symptoms or functional impairments. Although it is possible that these programs could develop into important adjunctive or complementary components to other skill remediation and behavioral interventions, more research is needed to identify their potential efficacy, particularly given the relative time and financial costs with which they are associated.

Multicomponent Interventions The preponderance of contemporary intervention programs consists of combinations of the aforementioned interventions, often including some form of BPT, BCM, and child skills training. Although each component has been supported, in part, by empirical evidence, the multicomponent interventions described below have

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evidenced the most comprehensive impacts on the symptoms and functioning of children with ADHD.

Child Life and Attention Skills/Collaborative Life Skills programs The majority of interventions for children with ADHD have focused on improving hyperactivity and impulsivity, with little emphasis on improving inattention. To address this gap, Pfiffner et al. (2007) developed the Child Life and Attention Skills program (CLAS), which was designed to directly address the symptoms and impairments of elementary school-aged children with the predominantly inattentive type of ADHD (ADHD-I). The intervention was adapted from previous evidencebased treatments and consists of 10 sessions of concurrent BPT and child skills training groups that are delivered in a clinic setting, as well as up to five teacher consultation sessions in which teachers learn to implement classroom accommodations and develop a daily report card. In the skill groups, children learn social, emotion regulation, organizational, problem-solving, and independent living skills. Parents learn the general principles of behavior management and develop a home daily report card that complements the school daily report card. Delivery is coordinated so that parents, children, and teachers are simultaneously trained, with identical terminology, via group and individualized methods. Reinforcement contingencies are implemented within and across settings in order to maximize the impact of the intervention across impairment domains in an active partnership of parents, teachers, and learning support professionals. The results of a randomized clinical trial indicate that children who received CLAS had significant improvements in aggregate parent and teacher ratings of ADHD symptoms and severity, as well as social and organizational skills, at posttreatment, which were sustained at 3- to 5-month follow-up (Pfiffner et al., 2007). A large-scale, two-site randomized clinical trial of CLAS is currently being conducted. Based on the success of CLAS, Pfiffner et al. (2011) extended this program in order to target the more general ADHD population, including all types, with the objective of establishing a sustainable implementation method in a public school setting. The adapted intervention, the Collaborative Life Skills (CLS) program, is targeted for elementary school-aged children, but is designed to be implemented at the child’s school by existing school mental health personnel, learning support professionals. Implementation in the school setting also allows for intervention delivery at the point of performance, that is, in the setting in which many of the children’s problems are occurring. Learning support professionals are trained in the intervention by universitybased clinicians. As part of the program, learning support professionals conduct 10 weekly BPT and child skills training groups at the children’s schools, lead a 30to 60-minute orientation meeting for participating teachers, and coordinate two or three meetings with teachers, parents, and their children to develop a school daily report card to complement the home daily report card developed by the parents. Initial pre-post results reveal that children significantly improved in parent ratings of problem behavior, homework problems, and social skills; teacher ratings of behaviors that enable academic success; parent and teacher ratings of ADHD symptoms and organizational skills; and academic achievement scores, observations of classroom behavior, and report card grades (Pfiffner et al., 2011; Pfiffner et al., 2013).


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Summer Treatment Programs Some of the most comprehensive and intensive multicomponent intervention programs are summer treatment programs, which are generally targeted for children in grades 1–11 (e.g., Pelham, Fabiano, Gnagy, Greiner, & Hoza, 2005; Pelham et al., 2010; Pelham & Hoza, 1996). Summer treatment programs combine BPT, child skills training, and analogous BCM interventions in a summer-camp-like setting that children attend for approximately 9 hours per day for 8 weeks. Trained behavioral counselors maintain a behavior management system analogous to BCM as the children engage in sports, art, and academic classes. Included in the regular curriculum are child social and academic skill interventions, with individual daily report cards developed for each child. In addition, group BPT sessions and medication evaluation and management are provided. Studies evaluating summer treatment programs have generally indicated that these programs improve symptoms and functional impairments across a variety of domains as rated by parents, teachers, and counselors. Although summer treatment programs provide a convenient treatment setting for families in which children are supervised daily, these programs are labor-intensive and costly, which may limit their feasibility. Researchers are currently exploring adaptations to the intervention protocol that would facilitate their implementation as after-school programs (Frazier, Cappella, & Atkins, 2007). Furthermore, there is no evidence that summer treatment programs provide gains that fundamentally alter the trajectories of youth with ADHD across the long term. It seems likely that ongoing, albeit less intensive, behavioral interventions will be needed.

Programs with Partial Support for Attention-Deficit/Hyperactivity Disorder First steps to success. Although not specifically designed for children with ADHD, the First Steps to Success program is another intervention in which school personnel implement BPT and BCM in the school context in order to ameliorate children’s externalizing behavior problems (Walker et al., 2009). The program is targeted for children in Kindergarten to third grade and consists of 30 “program days” on which the intervention is implemented at school, plus six home sessions in which parents learn to implement BPT strategies. Seeley et al. (2009) conducted a randomized clinical trial for children with ADHD and found that children assigned to the intervention condition had significantly greater improvements in ADHD behaviors, social skills, and academic problems at school. However, they did not find significantly greater improvements in ADHD behaviors and social skills at home among this group, which may indicate that the parent component of this intervention needs further adaptation to adequately address the impairments of children with ADHD. Incredible years. Initially designed for disruptive behavior problems in preschool children, the Incredible Years program (Webster-Stratton & Reid, 2010) has shown some evidence of utility for children with both comorbid and primary ADHD problems. Incredible Years is a comprehensive, multisetting program for young children (ages 3–7) that integrates BPT, BCM, and child skills training interventions. Each

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component of the program can be implemented separately, but the program is more potent when the components are combined. The only evaluation of Incredible Years for ADHD is a recent 20-week randomized clinical trial with just the BPT and child skills training components. Results showed improvements in a variety of child externalizing behavior problems, including inattention and hyperactivity, by mother and father reports, but not teacher reports (Webster-Stratton, Reid, & Beauchaine, 2011). Additional studies that include the BCM component are needed to evaluate the effects of the intervention for key areas of ADHD impairment.

Multimodal Treatments The focus of this chapter has been on psychosocial interventions for ADHD, but it is also important to consider the impact of these interventions in the context of pharmacological approaches to treatment, given their status as an evidence-based treatment for ADHD (Hinshaw, Klein, & Abikoff, 2007). Stimulant medication in particular has a strong evidence base supporting its efficacy for ADHD and is widely used by pediatricians and psychiatrists for managing ADHD symptoms in children and adolescents. Additionally, medication and behavioral interventions in combination appear to form an especially potent treatment. The largest and most renowned study of medication and behavioral treatments was the Multimodal Treatment Study of ADHD (MTA), a six-site collaborative effort designed to rigorously evaluate the effects of pharmacological, behavioral, and combined intervention approaches for the treatment of ADHD (MTA Cooperative Group, 1999a; Pelham et al., 2000; Swanson et al., 2008a, 2008b). The behavioral treatment included 35 BPT sessions for parents, both group and individual; therapist-facilitated consultation and coordination with the children’s teachers; an 8-week summer treatment program; and paraprofessional aide involvement in the classroom for 3 months following the summer treatment program. These treatments were faded toward the end of the 14-month intervention period. Although initial results supported the superiority of the medication and combined treatments over behavioral treatment alone for ADHD symptom reduction, (a) combination treatment was superior with regard to academic, social, and parenting-related impairments (e.g., Connors et al., 2001); and (b) after the active intervention period, medication benefits fell off more sharply than those from behavioral intervention (e.g., Molina et al., 2009). Furthermore, during the summer treatment program, a comparison of differences between the behavioral and combined treatment groups across three sites revealed few differences between them while both treatments were active (Pelham et al., 2000). Moreover, subsequent analyses have revealed important and positive impacts of the behavioral treatment on parent–child interactions (Wells et al., 2006) and homework success (Langberg et al., 2010). Finally, combination treatment, when associated with improved parenting, was prone to yield not just improvement in behavior, but normalization of such behavior (Hinshaw et al., 2000). Overall, the MTA study has demonstrated the substantial benefit of combined pharmacological and behavioral interventions as the most potent treatment approach for


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the most impaired children with ADHD. Further evidence for this treatment approach comes from studies showing that when behavioral interventions are in place, optimal medication dosages may be lower, with more durable and broader effects (Fabiano et al., 2007).

Conclusions The evidence base for behavioral interventions is longstanding, with BPT, BCM, and intensive peer-based treatments meeting rigorous criteria for categorization as evidence-based treatments (Pelham & Fabiano, 2008). Although initial evaluations of cognitive interventions focused on self-instruction for children with ADHD were discouraging, more recent psychosocial interventions that incorporate both cognitive and behavioral strategies targeting specific skill development show significant and clinically important effects on ADHD symptoms and functional impairments. Moreover, despite evidence for individual intervention strategies such as BPT, BCM, and child skills training, combined/multicomponent/multimodal treatment packages have demonstrated the most consistent impact on a broader range of symptoms and impairments among these children and adolescents. This latter finding is likely to be the result of direct training of skills in the real-world contexts to which they apply (e.g., school, home, etc.) and the generalization of the structured behavioral contingencies across these contexts. Given the potential for moderators and mediators to influence the impact of interventions, emerging research on adaptive implementation strategies should improve the sustainability and dissemination of interventions to populations who were previously unable to access them. In addition, the personalization of intervention packages to match the preferences and needs of specific populations should facilitate increased treatment engagement. Also, in light of support for the incremental impact of combined pharmacological and behavioral interventions, it is possible that personalizing this combined treatment approach through sequencing of interventions could provide the most potent effects. Although evidence for working memory and attention training is still preliminary, additional research is warranted to determine the potential benefits of these approaches for the full range of ADHD symptoms and impairments. Finally, researchers should continue to explore and develop innovative methods of intervention dissemination that are both sustainable and cost-effective.

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