Psychosocial Treatment

Psychosocial Treatment for Children and Adolescents with AD/HD*
Psychosocial treatment is a critical part of treatment for attention-deficit/hyperactivity disorder (AD/HD) in children and adolescents. The scientific literature, the National Institute of Mental Health, and many professional organizations agree that behaviorally oriented psychosocial treatments—also called behavior therapy or behavior modification—and stimulant medication have a solid base of scientific evidence demonstrating their effectiveness. Behavior modification is the only nonmedical treatment for AD/HD with a large scientific evidence base.
Treating AD/HD in children often involves medical, educational and behavioral interventions. This comprehensive approach to treatment is called “multimodal” and consists of parent and child education about diagnosis and treatment, behavior management techniques, medication, and school programming and supports. The severity and type of AD/HD may be factors in deciding which components are necessary. Treatment should be tailored to the unique needs of each child and family.

This fact sheet will:
• define behavior modification
• describe effective parent training, school interventions and child interventions
• discuss the relationship between behavior modification and stimulant medication in treating children and adolescents with AD/HD

Why use psychosocia Treatments?
Behavioral treatment for AD/HD is important for several reasons. First, children with AD/HD face problems in daily life that go well beyond their symptoms of inattentiveness, hyperactivity and impulsivity, including poor academic performance and behavior at school, poor relationships with peers and siblings, failure to obey adult requests, and poor relationships with their parents. These problems are extremely important because they predict how children with AD/HD will do in the long run.
How a child with AD/HD will do in adulthood is best predicted by three things—
(1) whether his or her parents use effective parenting skills,
(2) how he or she gets along with other children,
(3) his or her success in school

1. Psychosocial treatments are effective in treating these important domains. Second, behavioral treatments teach skills to parents and teachers that help them deal with children with AD/HD. They also teach skills to children with AD/HD that will help them overcome their impairments. Learning these skills is especially important because AD/HD is a chronic condition and these skills will be useful throughout the children’s lives
2.Behavioral treatments for AD/HD should be started as soon as the child receives a diagnosis. There are behavioral interventions that work well for preschoolers, elementary-age students, and teenagers with AD/HD, and there is consensus that starting early is better than starting later. Parents, schools, and practitioners should not put off beginning effective behavioral treatments for children with AD/HD .

What is behavior modification?
With behavior modification, parents, teachers and children learn specific techniques and skills from a therapist, or an educator experienced in the approach, that will help improve children’s behavior. Parents and teachers then use the skills in their daily interactions with their children with AD/HD, resulting in improvement in the children’s functioning in the key areas noted above. In addition, the children with AD/HD use the skills they learn in their interactions with other children.
Behavior modification is often put in terms of ABCs:
Antecedents (things that set off or happen before behaviors),
Behaviors (things the child does that parents and teachers want to change),
Consequences (things that happen after behaviors).
In behavioral programs, adults learn to change antecedents (for example, how they give commands to children) and consequences (for example, how they react when a child obeys or disobeys a command) in order to change the child’s behavior (that is, the child’s response to the command). By consistently changing the ways that they respond to children’s behaviors, adults teach the children new ways of behaving.
Parent, teacher and child interventions should be carried out at the same time to get the best results The following four points should be incorporated into all three components of behavior modification:

1. Start with goals that the child can achieve in small steps.
2. Be consistent—across different times of the day, different settings, and different people.
3. Implement behavioral interventions over the long haul—not just for a few months.
4. Teaching and learning new skills take time, and children’s improvement will be gradual.

Parents who want to try a behavioral approach with their children should learn what distinguishes behavior modification from other approaches so they can recognize effective behavioral treatment and be confident that what the therapist is offering will improve their child’s functioning. Many psychotherapeutic treatments have not been proven to work for children with AD/HD. Traditional individual therapy, in which a child spends time with a therapist or school counselor talking about his or her problems or playing with dolls or toys, is not behavior modification. Such “talk” or “play” therapies do not teach skills and have not been shown to work for children with AD/HD

How does a behavior modification program begin?
The first step is identifying a mental health professional who can provide behavioral therapy. Finding the right professional may be difficult for some families, especially for those that are economically disadvantaged or socially or geographically isolated. Families should ask their primary care physicians for a referral or contact their insurance company for a list of providers who participate in the insurance plan, though health insurance may not cover the costs of the kind of intensive treatment that is most helpful. Other sources of referrals include professional associations and hospital and university AD/HD centers (visit www.help4adhd.org for a list).
The mental health professional begins with a complete evaluation of the child’s problems in daily life, including home, school (both behavioral and academic), and social settings. Most of this information comes from parents and teachers. The therapist also meets with the child to get a sense of what the child is like. The evaluation should result in a list of target areas for treatment. Target areas—often called target behaviors—are behaviors in which change is desired, and if changed, will help improve the child’s functioning/impairment and long-term outcome.
Target behaviors can be either negative behaviors that need to stop or new skills that need to be developed. That means that the areas targeted for treatment will typically not be the symptoms of AD/HD—overactivity, inattention and impulsivity—but rather the specific problems that those symptoms may cause in daily life. Common classroom target behaviors include “completes assigned work with 80 percent accuracy” and “follows classroom rules.” At home, “plays well with siblings (that is, no fights)” and “obeys parent requests or commands” are common target behaviors. (Lists of common target behaviors in school, home and peer settings can be downloaded in Daily Report Card packets at http://wings.buffalo.edu/adhd.)
After target behaviors are identified, similar behavioral interventions are implemented at home and at school. Parents and teachers learn and establish programs in which the environmental antecedents (the A’s) and consequences (the C’s) are modified to change the child’s target behaviors (the B’s). Treatment response is constantly monitored, through observation and measurement, and the interventions are modified when they fail to be helpful or are no longer needed.

Parent Training
Behavioral parent training programs have been used for many years and have been found to be very effective
Although many of the ideas and techniques taught in behavioral parent training are common sense parenting techniques, most parents need careful teaching and support to learn parenting skills and use them consistently. It is very difficult for parents to buy a book, learn behavior modification, and implement an effective program on their own. Help from a professional is often necessary. The topics covered in a typical series of parent training sessions include the following:
• Establishing house rules and structure
• Learning to praise appropriate behaviors (praising good behavior at least five times as often as bad behavior is criticized) and ignoring mild inappropriate behaviors (choosing your battles)
• Using appropriate commands
• Using “when…then” contingencies (withdrawing rewards or privileges in response to inappropriate behavior)
• Planning ahead and working with children in public places
• Time out from positive reinforcement (using time outs as a consequence for inappropriate behavior)
• Daily charts and point/token systems with rewards and consequences
• School-home note system for rewarding behavior at school and tracking homework
Some families can learn these skills quickly in the course of 8-10 meetings, while other families—often those with the most severely affected children—require more time and energy.
Parenting sessions usually involve an instructional book or videotape on how to use behavioral management procedures with children. The first session is often devoted to an overview of the diagnosis, causes, nature, and prognosis of AD/HD. Next, parents learn a variety of techniques, which they may already be using at home but not as consistently or correctly as needed. Parents then go home and implement what they have learned in sessions during the week, and return to the parenting session the following week to discuss progress, solve problems, and learn a new technique.

Parent training can be conducted in groups or with individual families. Individual sessions often are implemented when a group is not available or when the family would benefit from a tailored approach that includes the child in sessions. This kind of treatment is called behavioral family therapy. The number of family therapy sessions varies depending on the severity of the problems.. CHADD offers a unique educational program to help parents and individuals navigate the challenges of AD/HD across the lifespan. Information about CHADD’s “Parent to Parent” program can be found by visiting CHADD’s Web site at www.chadd.org. Click on “Conferences and Training” and then “Parent to Parent Program.”

When the child involved is a teenager, parent training is slightly different. Parents are taught behavioral techniques that are modified to be age-appropriate for adolescents. For example, time out is a consequence that is not effective with teenagers; instead, loss of privileges (such as having the car keys taken away) or assignment of work chores would be more appropriate. After parents have learned these techniques, the parents and teenager typically meet with the therapist together to learn how to come up with solutions to problems on which they all agree. Parents negotiate for improvements in the teenagers’ target behaviors (such as better grades in school) in exchange for rewards that they can control (such as allowing the teenager to go out with friends). The give and take between parents and teenager in these sessions is necessary to motivate the teenager to work with the parents in making changes in his or her behavior.
Applying these skills with children and teens with AD/HD takes a lot of hard work on the part of parents. However, the hard work pays off. Parents who master and consistently apply these skills will be rewarded with a child who behaves better and has a better relationship with parents and siblings.

School Interventions
As is the case with parent training, the techniques used to manage AD/HD in the classroom have been used for some time and are considered effective Many teachers who have had training in classroom management are quite expert in developing and implementing programs for students with AD/HD. However, because the majority of children with AD/HD are not enrolled in special education services, their teachers will most often be regular education teachers who may know little about AD/HD or behavior modification and will need assistance in learning and implementing the necessary programs. There are many widely available handbooks, texts and training programs that teach classroom behavior management skills to teachers. Most of these programs are designed for regular or special education classroom teachers who also receive training and guidance from school support staff or outside consultants. Parents of children with AD/HD should work closely with the teacher to support efforts in implementing classroom programs.
Managing teenagers with AD/HD in school is different from managing children with AD/HD. Teenagers need to be more involved in goal planning and implementation of interventions than do children. For example, teachers expect teenagers to be more responsible for belongings and assignments. They may expect students to write assignments in weekly planners rather than receive a daily report card. Organizational strategies and study skills therefore need to be taught to the adolescent with AD/HD. Parent involvement with the school, however, is as important at the middle and high school levels as it is in elementary school. Parents will often work with guidance counselors rather than individual teachers, so that the guidance counselor can coordinate intervention among the teachers.

Child Interventions
Interventions for peer relationships (how the child gets along with other children) are a critical component of treatment for children with AD/HD. Very often, children with AD/HD have serious problems in peer relationships Children who overcome these problems do better in the long run than those who continue to have problems with peers There is scientific basis for child-based treatments for AD/HD that focus on peer relationships. These treatments usually occur in group settings outside of the therapist’s office.

There are five effective forms of intervention for peer relationships:
1. systematic teaching of social skills
2. social problem solving
3. teaching other behavioral skills often considered important by children, such as sports skills and board game rules
4. decreasing undesirable and antisocial behaviors
5. developing a close friendship
There are several settings for providing these interventions to children, including groups in office clinics, classrooms, small groups at school, and summer camps. All of the programs use methods that include coaching, use of examples, modeling, role-playing, feedback, rewards and consequences, and practice. It is best if these child-directed treatments are used when a parent is participating in parent training and school personnel are conducting an appropriate school intervention When parent and school interventions are integrated with child-focused treatments, problems getting along with other children (such as being bossy, not taking turns, and not sharing) that are being targeted in the child treatments are also included as target behaviors in the home and school programs so that the same behaviors are being monitored, prompted and rewarded in all three settings.
Social skills training groups are the most common form of treatment, and they typically focus on the systematic teaching of social skills. They are typically conducted at a clinic or in school in a counselor’s office for 1-2 hours on a weekly basis for 6-12 weeks. Social skills groups with children with AD/HD are only effective when they are used with parent and school interventions and rewards and consequences to reduce disruptive and negative behaviors
There are several models for working on peer relationships in the school setting that integrate several of the interventions listed above. They combine skills training with a major focus on decreasing negative and disruptive behavior and are typically conducted by school staff. Some of these programs are used with individual children (for instance, token programs in the classroom or at recess) and some are schoolwide (such as peer mediation programs)

Generally, the most effective treatments involve helping children get along better with other children. Programs in which children with AD/HD can work on peer problems in classroom or recreational settings are the most effective One model involves establishing a summer camp for children with AD/HD in which child-based management of peer problems and academic difficulties are integrated with parent training All five forms of peer intervention are incorporated in a 6-8 week program that runs for 6-9 hours on weekdays. Treatment is conducted in groups, with recreational activities (e.g., baseball, soccer) for the majority of the day, along with two hours of academics. One major focus is teaching skills in and knowledge of sports to the children. This is combined with intensive practice in social and problem-solving skills, good team work, decreasing negative behaviors, and developing close friendships.
Some approaches to child-based treatment for peer problems fall somewhere between clinic-based programs and intensive summer camps. Versions of both are conducted on Saturdays during the school year or after school. These involve 2-3 hour sessions in which children engage in recreational activities that integrate many of the forms of social skills intervention.
Finally, preliminary research suggests that having a best friend may have a protective effect on children with difficulties in peer relations as they develop through childhood and into adolescence . Researchers have developed programs that help children with AD/HD build at least one close friendship. These programs always begin with the other forms of intervention described above and then add having the families schedule monitored play dates and other activities for their child and another child with whom they are attempting to foster a friendship.
It is important to emphasize that simply inserting a child with AD/HD in a setting where there is interaction with other children—such as Scouts, Little League or other sports, day care, or playing in the neighborhood without supervision—is not effective treatment for peer problems. Treatment for peer problems is quite complex and involves combining careful instruction in social and problem-solving skills with supervised practice in peer settings in which children receive rewards and consequences for appropriate peer interactions. It is very difficult to intervene in the peer domain, and Scout leaders, Little League coaches, and day-care personnel are typically not trained to implement effective peer interventions.

What about combining Psychosocial approaches with medication?
Numerous studies over the last 30 years show that both medication and behavioral treatment are effective in improving AD/HD symptoms. Short-term treatment studies that compared medication to behavioral treatment have found that medication alone is more effective in treating AD/HD symptoms than behavioral treatment alone. In some cases, combining the two approaches resulted in slightly better results.
The best-designed long-term treatment study—the Multimodal Treatment Study of Children with AD/HD (MTA)—was conducted by the National Institute of Mental Health. The MTA studied 579 children with AD/HD-combined type over a 14-month period. Each child received one of four possible treatments: medication management, behavioral treatment, a combination of the two, or the usual community care. The results of this landmark study were that children who were treated with medication alone, which was carefully managed and individually tailored, and children who received both medication and behavioral treatment experienced the greatest improvements in their AD/HD symptoms
Combination treatment provided the best results in improving AD/HD and oppositional symptoms and in other areas of functioning, such as parenting and academic outcomes . Overall, those who received closely monitored medication management had greater improvement in their AD/HD symptoms than children who received either intensive behavioral treatment without medication or community care with less carefully monitored medication. It is unclear whether children with the inattentive type will show the same pattern of response to behavioral interventions and medication as have children with combined type.
Some families may choose to try stimulant medication first, while others may be more comfortable beginning with behavioral therapy. Another option is to incorporate both approaches into the initial treatment plan. The combination of the two modalities may enable the intensity (and expense) of behavioral treatments and the dose of medication to be reduced

A growing number of physicians believe that stimulant medication should not be used as the only intervention and should be combined with parent training and classroom behavioral interventions . In the end, each family has to make treatment decisions based on the available resources and what makes the best sense for the particular child. No one treatment plan is appropriate for everyone.

What if there are other problems as well as AD/HD?
There are evidence-based behavioral treatments for problems that can co-exist with AD/HD, such as anxiety and depression . Just as play therapy and other non-behaviorally based therapies are not effective for AD/HD, they have not been documented to be effective for the conditions that often occur with AD/HD.

Suggested Reading for Professionals
Barkley, R.A. (1987). Defiant children: A clinician’s manual for parent training. New York: Guilford.
Barkley, R.A., & Murphy, K.R. (1998). Attention-deficit hyperactivity disorder: A clinical workbook. (2nd ed.). New York: Guilford.
Chamberlain, P. & Patterson, G.R. (1995). Discipline and child compliance in parenting. In M. Bornstein (Ed.), Handbook of parenting: Vol. 4. Applied and practical parenting. (pp. 205–225). Mahwah, NJ: Lawrence Erlbaum Associates.
Coie, J.D., & Dodge, K.A. (1998). Aggression and antisocial behavior. In W. Damon (Series Ed.) & N. Eisenberg (Vol. Ed.), Handbook of child psychology: Vol. 3. Social, emotional, and personality development. (5th ed., pp.779–862). New York: John Wiley & Sons, Inc.
Dendy, C. (2000). Teaching teens with ADD and ADHD: A quick reference guide for teachers and parents. Bethesda, MD: Woodbine House.
DuPaul, G.J., & Stoner, G. (2003). AD/HD in the schools: Assessment and intervention strategies (2nd ed.). New York: Guilford.
Forehand, R., & Long, N. (2002). Parenting and the strong-willed child. Chicago, IL: Contemporary Books.
Hembree-Kigin, T.L., & McNeil, C.B. (1995). Parent-child interaction therapy: A step-by-step guide for clinicians. New York: Plenum Press.
Kazdin, A.E. (2001). Behavior modification in applied settings. (6th ed.). Belmont, CA: Wadsworth/Thomson Learning.Kendall, P.C. (2000). Cognitive-behavioral therapy for anxious children: Therapist manual (2nd ed.). Ardmore, PA: Workbook PublishingMartin, G., & Pear, J. (2002). Behavior modification: What it is and how to do it. (7th ed.). Upper Saddle River, NJ: Prentice-Hall, IncMcFayden-Ketchum, S.A. & Dodge, K.A. (1998). Problems in social relationships. In E.J. Mash & R.A. Barkley (Eds.). Treatment of childhood disorders. (2nd ed., pp 338–365). New York: Guilford Press.
Mrug, S., Hoza, B., & Gerdes, A.C. (2001). Children with attention-deficit/hyperactivity disorder: Peer relationships and peer-oriented interventions. In D.W. Nangle & C.A. Erdley (Eds.). The role of friendship in psychological adjustment: New directions for child and adolescent development (pp. 51–77). San Francisco: Jossey-Bass.
Pelham, W.E., & Fabiano, G.A. (2000). Behavior modification. Psychiatric Clinics of North America, 9, 671–688.
Pelham, W.E., Fabiano, G.A, Gnagy, E.M., Greiner, A.R., & Hoza, B. (in press). Comprehensive psychosocial treatment for AD/HD. In E. Hibbs & P. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice. New York: APA Press.
Pelham, W.E., Greiner, A.R., & Gnagy, E.M. (1997). Children’s summer treatment program manual. Buffalo, NY: Comprehensive Treatment for Attention Deficit Disorders.
Pelham, W. E., Wheeler, T., & Chronis, A. (1998). Empirically supported psychosocial treatments for attention deficit hyperactivity disorder. Journal of Clinical Child Psychology, 27, 190-205.
Pfiffner, L.J. (1996). All about AD/HD: The complete practical guide for classroom teachers. New York: Scholastic Professional Books.
Rief, S.F., & Heimburge, J.A. (2002). How to reach and teach ADD/AD/HD children: Practical techniques, strategies, and interventions for helping children with attention problems and hyperactivity. San Francisco: Jossey-Bass.
Robin, A.L. (1998). AD/HD in adolescents: Diagnosis and treatment. New York: Guilford Press.
Walker, H.M., Colvin, G., & Ramsey, E. (1995). Antisocial behavior in school: Strategies and best practices. Pacific Grove, CA: Brooks/Cole Publishing Company.
Walker, H.M., & Walker, J.E. (1991). Coping with noncompliance in the classroom: A positive approach for teachers. Austin, TX: ProEd.
Wielkiewicz, R.M. (1995). Behavior management in the schools: Principles and procedures (2nd ed.). Boston: Allyn and Bacon.

Suggested Reading for Parents/Caregivers
Barkley, R.A. (1987). Defiant children: Parent-teacher assignments. New York: Guilford Press.
Barkley, R.A. (1995). Taking charge of AD/HD: The complete, authoritative guide for parents. New York: Guilford.
Dendy, C. (1995). Teenagers with ADD: A parents’ guide. Bethesda, MD: Woodbine House
Forehand, R. & Long, N. (2002) Parenting and the strong-willed child. Chicago, IL: Contemporary Books.
Greene, R. (2001). The explosive child: A new approach for understanding and parenting easily frustrated, chronically inflexible children. New York: Harper Collins.
Forgatch, M., & Patterson, G. R. (1989). Parents and adolescents living together: Part 2: Family problem solving. Eugene, OR: Castalia.
Kelley, M. L. (1990). School-home notes: Promoting children’s classroom success. New York: Guilford Press.
Patterson, G.R., & Forgatch, M. (1987). Parents and adolescents living together: Part 1: The basics. Eugene, OR: Castalia.
Phelan, T. (1991). Surviving your adolescents. Glen Ellyn, IL: Child Management.

Internet Resources
Center for Children and Families, University at Buffalo, http://wings.buffalo.edu/adhd
Comprehensive Treatment for Attention Deficit Disorder, http://ctadd.net

Model Programs
The Incredible Years
www.incredibleyears.com
Triple P: Positive Parenting Program
www.triplep.net
The Early Risers Program
August, G.J., Realmuto, G.M., Hektner, J.M., & Bloomquist, M.L. (2001). An integrated components preventive intervention for aggressive elementary school children: The Early Risers Program. Journal of Consulting and Clinical Psychology, 69, 614–626.
CLASS (Contingencies for Learning Academic and
Social Skills)
Hops, H., & Walker, H.M. (1988). CLASS: Contingencies for Learning Academic and Social Skills manual. Seattle, WA: Educational Achievement Systems.
RECESS (Reprogramming Environmental Contingencies for Effective Social Skills)
Walker, H.M., Hops, H., & Greenwood, C.R. (1992). RECESS manual. Seattle, WA; Educational Achievement Systems.
Peabody Classwide Peer Tutoring Reading Methods
Mathes, P. G., Fuchs, D., Fuchs, L.S., Henley, A.M., & Sanders, A. (1994). Increasing strategic reading practice with Peabody Classwide Peer Tutoring. Learning Disabilities Research and Practice, 9, 44–48.

Mathes, P.G., Fuchs, D., & Fuchs, L.S. (1995). Accommodating diversity through Peabody Classwide Peer Tutoring. Intervention in School and Clinic, 31, 46–50.
COPE (Community Parent Education Program)
Cunningham, C. E., Cunningham, L. J., & Martorelli, V. (1997). Coping with conflict at school: The collaborative student mediation project manual. Hamilton, Ontario: COPE Works.