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ADHD Parent Training and Classroom interventions. Prof. M. Danckaerts UZ-KULeuven. Drive for behavioural interventions. Children with ADHD have negative interactions: 1 / min with parents 2 / min with teachers/peers in school 0.7 /min with peers outside school

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Adhd parent training and classroom interventions

ADHD Parent Training and Classroom interventions

Prof. M. Danckaerts

UZ-KULeuven


Drive for behavioural interventions
Drive for behavioural interventions

  • Children with ADHD have negative interactions:

    • 1 / min with parents

    • 2 / min with teachers/peers in school

    • 0.7 /min with peers outside school

      = enormous potential learning history of negative behaviour

Danforth ea 2006, Abikoff ea 1993, Pelham & Bender 1982


Parent training and classroom interventions
Parent training and classroom interventions

  • What is the evidence ?

  • In practice


History
History

  • Behavioural interventions

    • since > 40 years for children with “disruptive disorders”

    • Since > 30 years for children with ADHD

  • 3 types: directed to

    • Parents

    • School

    • Child / adolescent


Family based interventions
Family-based interventions

Pelham e.a. 1998

  • Behavioural parent training barely meets criteria for well-established treatment

    • Outpatient based, 8-20 sessions

    • Manualized training protocols teaching standard behavioural techniques (contingency management, time-out)

    • Studies heterogeneous in design

    • Various combinations with other interventions

  • Average effect inferior to medication


School based interventions
School-based interventions

  • Classroom behaviour management

  • Academic interventions (= manipulation of instructions or materials)

  • DRC (Daily Report Card)

  • Nearly all single case studies and intensive contingency management

  • Effect sizes in the range of 1.4 on child behaviour

    (= targeted behaviour)

DuPaul and Eckert, 1997, Pelham et al. 1998


History 2
History - 2

  • Review Pelham et al. 1998:

    • Behavioural parent training & classroom intervention are empirically supported treatments for ADHD

  • Cognitive treatment of child : not efficacious

    • Enhancement of self-control

    • Enhancement of problem-solving


Adhd psychosocial treatments
ADHD Psychosocial treatments

  • Recent landmark comparative treatment studies played down the importance of psychosocial treatments in the management of ADHD


Mta study
MTA-study

Month

0

14

24

36

22-m Follow-

up After

Treatment

10-m Follow-

up After

Treatment

14-m Treatment Stage

Medication Only

144 Subjects

Random

Assignment

Psychosocial (Behavioral)

Treatment Only

144 Subjects

Combined Medication &

Behavioral Treatment

145 Subjects

579 ADHD

Subjects

Community Controls

No Treatment from Study

146 Subjects

Follow-up

(24 m)

Mid-

treatment

(9 m)

End

Treatment

(14 m)

36 m FU

Early

Treatment

(3 m)

Recruitment of

LNCG Cohort

Jensen et al 1999


Mta psychosocial treatment
MTA-psychosocial treatment

  • 30 parent sessions

  • 20 school visits and teacher training sessions

  • 2-month individual summer treatment program

  • Part-time classroom aid


Mta outcome 14 month teacher snap inattention
MTA-outcome 14-monthTeacher SNAP inattention

Average Score

Assessment Point (Days)

Jensen et al 1999


Mta outcome teacher snap hyp imp
MTA-outcomeTeacher SNAP Hyp-Imp

Average Score

Assessment Point (Days)

Jensen et al 1999


Mta outcome normalization
MTA-outcome: Normalization

88%

68%

56%

34%

25%

MTA N = 579

Classroom Cntrls N = 288

Swanson et al. for the MTA Cooperative Group


Montreal-study

2 year comparison of methylphenidate only and methylphenidate + multimodal treatment (in MPH-responders)

  • Significant short-term benefits on behaviour, academic achievement and social behaviour maintained over 2 years

  • No support for adding psychosocial interventions, academic support or social skills training for medication responsive children

Abikoff et al. 2004


The netherlands
The Netherlands

10 weeks

  • Both treatments yielded significant improvement on all domains (ADHD, ODD/CD, social skills, parenting stress, anxiety, self-worth

  • NO significant differences

MPH mgt

Randomized: 50

Parent training: 10 sessions (Barkley)

Teacher training: 1 session (Pelham)

Child cognitive-behaviour therapy: 10 sessions

MPH mgt + brief multimodal treatment

Vanden Oord ea 2007


History 3
History - 3

Conclusion after these results:

  • If a child responds well to medication: not much extra gain to be expected from behavioural treatment

  • If a child does not respond well to behavioural treatment: still a lot of gain to be expected from adding medication


Is there a need for psychosocial treatments
Is there a need for psychosocial treatments ?

  • Some children are effectively treated with psychosocial interventions only

  • For certain comorbid subgroups they have the largest effects

  • Medication is not effective in every child

  • Medication is not always effective every hour of the day

  • Improvement on medication does not always mean normalization

  • There may be intolerable side effects

  • Medication may be unacceptable or ethically objected against (e.g. very young children)

  • Compliance to medication is far from optimal


Is there a need for psychosocial treatments 2
Is there a need for psychosocial treatments ? - 2

  • Medication results in positive effects in structured situations, but families with ADHD are often highly unstructured

  • Medication effects on academic, social and family functioning are smaller in effect size

  • Uncertainty about long-term effects and side-effects of medication

  • Comparison of effects on Quality of Life is still lacking

  • Developmentally important opportunities for enduring change may be missed


Is there a need for psychosocial treatments1
Is there a need for psychosocial treatments ?

YES

Important questions:

  • Are they efficacious ? Are they effective ?

  • On which domains / aspects do they exert their effect ?

  • Which factors moderate / mediate the effect ?

  • Which ingredient is most important ?

  • Further issues


History 4
History - 4

  • Recent revival of interest in psychosocial therapies: reviews:

    • Chronis et al. 2004: Enhancements to the behavioural parent training paradigm for families of children with ADHD: review & future directions

    • Chronis et al. 2006: Evidence-based psychosocial treatments for children and adolescents with ADHD

    • Daly et al. 2007: Psychosocial treatments for children with ADHD


History 5
History - 5

  • Pelham & Fabiano 2008: Evidence-based psychosocial treatments for ADHD

  • Parent training: 22 new studies

  • Behavioral Classroom Management: 23 new studies

    Both are now well-established

  • Behavioural Peer Interventions:

    • Traditional group-based, weekly: minimal effects

    • Summer-treatment programs (5-8 weeks; 200-400 hours): effective , but costly and difficult to implement


Effect sizes
Effect sizes

Pelham & Fabiano 2008


Is there a need for psychosocial treatments2
Is there a need for psychosocial treatments ?

YES

Important questions:

  • Are they efficacious ?

  • On which domains / aspects do they exert their effect ?

  • Which factors moderate / mediate the effect ?

  • Which ingredient is most important ?

  • Further issues


Mta outcome
MTA-outcome

DOMAIN C vs Cc? M vs Cc? B vs Cc?

ADHD Symptoms Yes Yes

Oppos./Aggress. Yes Yes

Anxiety Yes

Social Skills Yes Yes

Academics Yes

P-C Relations Yes Yes

MTA Cooperative Group, 1999


Mta outcome parent child arguing
MTA-outcomeParent-child arguing

Average Score

Assessment Point (Days)


Mta outcome negative ineffective discipline
MTA-outcomeNegative-ineffective discipline

Average Score

Assessment Point (Days)

Wells et al., for the MTA Cooperative Group


Parent training effects
Parent training effects

Routine Clinical Care =

Family support + pharmaco-therapy if appropriate

4-12y

Behavioural symptoms:

RCC + PT > RCC

Internalizing symptoms:

RCC + PT > RCC

ADHD, parental stress

RCC + PT= RCC

+ parent training N=42

RCC continued N=47

Regardless of medication status

6 months

Van den Hoofdakker ea 2007


Parenting training effects
Parenting training effects

  • Larger effects on

    • Compliance with parental requests

    • Rule-following

    • Defiant-aggressive behaviour

    • Parenting skills (< negative/ineffective parenting practices)

  • Than on

    • Specific ADHD behaviours


Which outcomes should we address
Which outcomes should we address ?

  • Symptom reduction

  • Compliance, less disruptive behaviour

  • Modify behaviour to

    • Classroom rules, classroom norm

    • Individualized norm

  • Conflict reduction

    • Parent-child

    • Teacher-child

    • Peer-child

  • Self-esteem, contentment, happiness, QoL

  • Functional improvement

    • Completion of classroom assignments

    • School results

  • Parent, teacher satisfaction


Is there a need for psychosocial treatments3
Is there a need for psychosocial treatments ?

YES

Important questions:

  • Are they efficacious ?

  • On which domains / aspects do they exert their effect ?

  • Which factors moderate / mediate the effect ?

  • Which ingredient is most important ?

  • Further issues


Moderators of success 1
Moderators of success ? - 1

  • Age: mixed results

    • Less effective on ADHD with age

    • Equally effective on negative behaviour(Lundahl ea 2006)

  • Sex: 1 study: no effect

  • Comorbidity:

    • Comorbid aggression in ADHD: no difference

    • Comorbid ADHD in CD predicts better response in ½ studies

    • Comorbid anxiety in ADHD predicts better response (MTA)

      Summary: comorbidity has NO negative effect !


Parent training effects on adhd behaviours
Parent-training effects on ADHD behaviours

Sensitive period for altering the progression of the developmental course ?

PRESCHOOL

PRIMARY SCHOOL

ADOLESCENTS

Incredible years

Jones ea 2007

New Forest PT

Sonuga-Barke

Ea 2001

Inconsistent results on ADHD behaviour + possible rater bias

Barkley 1992 Statist but not clinically sign.

Triple P

Bor ea 2002

Barkley 2001 double number sessions: idem

50-80 %

Clinically sign effect


Moderators of success 4
Moderators of success ? - 4

  • Comorbidity

MTA, Jensen ea 2001


Moderators of success 2
Moderators of success ? - 2

  • Parental mental health

    • Maternal ADHD associated with poorer outcome in parent training (Sonuga-Barke ea 2002)

    • Maternal depressive symptoms associated with poorer outcome for MedMgt & Comb MTA groups (Owens ea 2003)

  • Negative parental cognitions

    • about themselves, their children and their parenting associated with poorer response to all MTA-treatments (Hoza ea 2000)

  • Who is attending

    • Only 4/32 report on fathers (Fabiano 2007)

    • No information on independent effect of father involvement


Should fathers participate
Should fathers participate

  • Fathers report impairment in their relationship with the ADHD child AND the mother

  • Fathers contribute to many developmental aspects of the child:

    • Emotion regulation

    • Social cognition

    • Focused attention

    • Peer relationships

  • Specific contribution to

    • Participation in organized sports

    • Academic achievement

      BUT: they are less likely to attend PMT programs and do not view their parenting as in need for intervention

Fabiano 2007


Moderators of success 3
Moderators of success ? - 3

  • Setting

    • Possibly more pos. effects in academic than in recreational settting at school (Kolko ea 1999)

  • SES

    • Poorer treatment compliance to parent training (McMahon ea 1981)

    • MTA: white collar families incremental benefit of Beh over Med on ADHD symptoms

    • MTA: blue collar families incremental benefit of Beh over Med on ODD symptoms (Rieppi ea 2002)

  • Ethnic minorities

    • Less likely to seek help

    • Equal effects once in training (Reid ea. 2002)

    • In MTA: minority: pos. effect on outcome


Mediators of success 4
Mediators of success ? - 4

  • Format:

    • Individual/clinic based versus group/community based: lower threshold in the latter (Cunningham ea 1995)

    • Didactic versus collaborative or using videotaping: latter more effective in behaviour problems, but not demonstrated in ADHD.

      • Incredible Years (Webster-Stratton 1996)

      • Community Parent Education Program –COPE (Cunningham ea 1995)

      • NFPT (Thompson ea 2001)

    • Motivation & Skills of provider


Mediators of success 41
Mediators of success ? - 4

  • Intensity of treatment

    • Contingency mgt > low intensity behav. intervention (eg. DRC) in single case studies (Pelham ea 1998)

    • Fabiano ea 2007:

      • low intensity closer to high intensity than to no behavioural intervention (Fabiano ea 2007)

      • High intensity some additional, but non-significant effect over low-intensity

      • Low dose Med + BI = High dose medication

    • Duration ?

    • Delay interval ?

    • Nature of antecedent control ?

  • Treatment setting

    • Each component seems necessary to bring about change in the targeted domain (i.e. lack of generalizability)


Intensity of treatment
Intensity of treatment

  • Comparison of low/high intensity and low/high doses of medication

Fabiano ea 2007


Intensity of treatment1
Intensity of treatment

  • Comparison of low/high intensity and low/high doses of medication

Fabiano ea 2007


Moderators mediators of effect
Moderators / Mediators of effect

  • MTA:

    • In the Comb group: enhanced outcome for positive social skills at school was mediated by reduced Negative/Ineffective Discipline at home

    • Comb treatment moderated the way in which Negative/Ineffective Discipline was associated with reductions in school-based disruptive behaviour

      Thus: the effects of pharmacological treatment were at least partially explained by psychological processes


Is there a need for psychosocial treatments4
Is there a need for psychosocial treatments ?

YES

Important questions:

  • Are they efficacious ?

  • On which domains / aspects do they exert their effect ?

  • Which factors moderate / mediate the effect ?

  • Which ingredient is most important ?

  • Further issues


Which ingredient is most important
Which ingredient is most important ?

Active ingredients ?

  • Modification of antecedents

    • Commands, rules, expectations

  • Modification of consequences

    • Prudent negative consequences (verbal reprimands, backed up with time-out ?

    • Positive consequences ?


Which ingredient is most important1
Which ingredient is most important ?

  • Prudent negative consequences superior to contingent praise alone

  • Response cost programs more effective than reward programs in controlled classroom settings

  • MTA: Changes in Positive parental involvement did not mediate outcome whereas changes in Negative/Ineffective Parenting did.

Abramowitz ea 1987, Fabiano ea 2004, pfiffner & O’Leary 1987


Is there a need for psychosocial treatments5
Is there a need for psychosocial treatments ?

YES

Important questions:

  • Are they efficacious ?

  • On which domains / aspects do they exert their effect ?

  • Which factors moderate / mediate the effect ?

  • Which ingredient is most important ?

  • Further issues


Further issues 1
Further Issues - 1

  • Few studies have shown maintenance effects beyond a few months after the active treatment: long term management plans ?

  • Substantial proportion of children fail to improve and improvement is not always complete

  • Efficacy depends on motivation and capabilities of the significant adults

  • Efficacy versus effectiveness in real world ? Eg. Most consumers favor behavioural interventions


Further issues 2
Further issues - 2

  • Cost-effectiveness relative to medication treatment ?

  • Dismantle separate effect of BPT, BCM, BPI

  • Sequence of interventions


Current clinical guidelines
Current Clinical Guidelines

  • European:

    • BI first choice unless severe and pervasively impairing ADHD

  • APA:

    • Treatment recommendation for medication (strong) and for behaviour therapy (fair)

  • AACAP:

    • If no robust response to either of 3 FDA-approved medications: try behaviour therapy or non-approved medication


Parent training and classroom interventions1
Parent training and classroom interventions

  • What is the evidence ?

  • In practice


Available manuals

Disruptive Behaviour

Patterson (1976)

Forehand & Mc Mahon (1981)

Triple P (2001) www.health.nsw.gov.au

The incredible years www.incredibleyears.com

ADHD

Barkley (1987)

Pelham and Hoza (1996)

COPE (Cunningham) (1997)

New Forest PT (Thompson 2001)

School

Challenging Horizons Program TM (Evans 1999)

Combined

STP: Summer Treatment Program (Pelham ea)

Available Manuals

http://ccf.buffalo.edu


Behavioural interventions
Behavioural interventions

= manipulating environmental factors that are antecedents to (e.g. setting, structure) or consequences of (e.g. adult attention) the maladaptive behaviour

= largely based on social learning principles

Chronis et al, 2006


General principles of bi
General principles of BI

  • Identify and manipulate antecedents and consequences of child behaviour

  • Target and monitor problematic behaviour

  • Reward prosocial behaviour through praise, positive attention and tangible rewards

  • Decrease unwanted behaviours through planned ignoring, time-out and non-physical discipline techniques (e.g. removal of privileges)


Behavioral interventions bear cavalier manning 2005
Behavioral Interventions(Bear, Cavalier, & Manning, 2005)

  • Behavioral Interventions – general tips:

    • Consequences should occur soon after behavior

    • Consequences should be ‘salient’

    • Don’t give tangible reinforcers for intrinsically motivated behavior (e.g., $ for playing baseball)

    • Move from contrived reinforcers to natural reinforcers over time (generalizability)

    • Move from dense reinforcement schedules to thin reinforcement schedules over time

    • Do not over-rely on punishment!!!

    • Punishment should fit the crime and be limited in scope


Leuven teacher parent training build up model
Leuven Teacher-Parent Training Build up Model

Level of expectation

frustration

motivation

Level of the child

Adaptation

Starting Point


School based interventions1

Targeting on-task and disruptive behaviour in the classroom

Through praise, ignoring, effective commands, time-out

Daily Report Card

Manipulating academic instruction and materials

Structuring of homework time, goal setting in shorter periods, note-taking training, reducing task length, dividing into subunits, peer tutoring, increased task stimulation

School Based Interventions

BEHAVIOURAL INTERVENTIONS

ACADEMIC INTERVENTIONS

Adaptation of the child

Adaptation of demands


What interventions are used
What Interventions Are Used?

  • General & SPED teachers differ in their emphasis, but the interventions are surprisingly similar…


General principles
General principles

  • Most teachers already use BI, yet ADHD still poses enormous problem for schools

  • Need for intensity and consistency

  • Child should be actively involved in the planning phase

  • Time investment on return

  • Tailored to ADHD: frequent, immediate and consistent feedback and reward

  • Teacher-parent communication & collaboration


Leuven toolkit for teachers
Leuven Toolkit for Teachers

  • Aim: develop a practical toolkit for teachers to put on their desk

  • ADHD-symptoms translated into school-related problems

  • 4-step procedure

  • Based on the Build-up principle


Leuven toolkit for teachers1
Leuven Toolkit for Teachers

Proces

Aanmoedigen

Dagelijks oefenen

Hulpmiddelen gebruiken

Door de vingers zien

Applaud, stimulate

Daily Practice

Help, use props

Dispensate, disregard


Leuven toolkit step i defining the goals
Leuven Toolkit: step I: defining the goals

  • Meaningful: leading to

    • Impairment

    • Stressful for the child

    • Stressful for others: peers, teacher

  • Classrules should be clear

  • Goals defined as TARGET BEHAVIOURS

  • Observable and countable

  • Goals within reach: > 75% succes


Target behaviours
TARGET BEHAVIOURS

  • Examples

    • Compliance: no more than 3 violations per period

    • Following directions: no more than 2 reminders

    • Able to ignore negative behaviour of others: no more than 3 x observable response to negative behaviour of others

    • School diary: no more than 1 correction needed


Leuven toolkit step ii monitoring
Leuven Toolkit: step II: Monitoring

  • Level A: Applaud, praise

    • Child tries to reach goals with praise only

  • Level D: Daily exercise-times are defined

    • Child gets specific reminders during set time-periods

  • Level H: Help is provided

    • Child gets tangible aids, reminders

    • Teachers helps to reach the goal

  • Level D’: Dispensation

    • The goal is too difficult for this child at this stage

    • Teacher will give constant help

      Constant monitoring + modification along the way


ADHD-TOOLKIT

for

TEACHERS

Danckaerts & Dewitte, in preparation


Daily report card
Daily Report Card

  • Daily monitoring of the target behaviours

  • Communication with the parents

  • Home-based reward program attached to the DRC

  • Teacher can also use classroom-based rewards at level 3



Reward menu at home
Reward menu at home

http://ccf.buffalo.edu


Classroom rewards
Classroom rewards

http://ccf.buffalo.edu


Caveats
Caveats

  • Teacher does not get started

    • First time takes more time

    • Defining the targets needs some practice

  • Target behaviours are

    • Unclear or vague

    • Not salient

    • Too difficult

  • No consistency in monitoring

  • Home reward system fails


DAGELIJKS GERICHT OEFENEN

AANMOEDIGEN

ADHDtoolkit

M. Danckaerts

Ilse Dewitte

HULPMIDDELEN GEBRUIKEN

DOOR DE VINGERS ZIEN


Leuven parent training

Session 1: Psycho-education: in depth

Session 2: Principles of BT + Build up model - Lost ideal

Session 3: Pos/Neg balance: compliments, praise, giving adequate commands

What fits your child / you and your partner

15’ non-interventional observation / play , seek for base level, mourning, seek for charm

Positive interactions, 7 compliments/day, compliance to commands

Leuven Parent Training

Based on Barkley’s PT

6 sessions of 2 hours, 6-7 pairs of parents

HOMEWORK


Leuven parent training 2

Session 4: positive reinforcement, token techniques

Session 5: negative consequences / time-out

Session 6: Pos/Neg balance, review, sibling conflicts

Design a reinforcement (reward) plan for specific behaviours

Apply time-out and negative consequences to unwanted behaviours

Continue until booster 6 months later

Leuven Parent Training - 2

Based on Barkley’s PT

6 sessions of 2 hours, 6-7 pairs of parents


Conclusions
Conclusions

  • There is a need

  • There are manuals

  • Hope you are motivated !


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