Evidence-Based Psychosocial Treatment of ADHD Developed by the Center for School Mental Health with...

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Evidence-Based Evidence-Based Psychosocial Treatment Psychosocial Treatment of ADHD of ADHD Developed by the Center for School Mental Health with Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1 support provided in part from grant 1R01MH71015-01A1 from the National Institute of Mental Health and from the National Institute of Mental Health and Project # U45 MC00174 from the Office of Adolescent Project # U45 MC00174 from the Office of Adolescent Health, Maternal, and Child Health Bureau, Health Health, Maternal, and Child Health Bureau, Health Resources and Services Administration, Department of Resources and Services Administration, Department of Health and Human Services Health and Human Services

Transcript of Evidence-Based Psychosocial Treatment of ADHD Developed by the Center for School Mental Health with...

Page 1: Evidence-Based Psychosocial Treatment of ADHD Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1.

Evidence-Based Psychosocial Evidence-Based Psychosocial Treatment of ADHDTreatment of ADHD

Developed by the Center for School Mental Health with support Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1 from the provided in part from grant 1R01MH71015-01A1 from the

National Institute of Mental Health and Project # U45 MC00174 National Institute of Mental Health and Project # U45 MC00174 from the Office of Adolescent Health, Maternal, and Child Health from the Office of Adolescent Health, Maternal, and Child Health

Bureau, Health Resources and Services Administration, Bureau, Health Resources and Services Administration, Department of Health and Human ServicesDepartment of Health and Human Services

Page 2: Evidence-Based Psychosocial Treatment of ADHD Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1.

What works for ADHD?What works for ADHD?

All of the evidence-based practice All of the evidence-based practice elements for use in ADHD have their elements for use in ADHD have their basis in Clinical Behavior Therapy. basis in Clinical Behavior Therapy. We will first cover the basic premises We will first cover the basic premises

behind behavior therapy, then cover the behind behavior therapy, then cover the specifics of effective interventions for specifics of effective interventions for ADHDADHD

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What doesn’t work for What doesn’t work for ADHD?ADHD?

Treatments with little or no evidence of Treatments with little or no evidence of effectiveness includeeffectiveness include Special elimination dietsSpecial elimination diets Vitamins or other health food remediesVitamins or other health food remedies Psychotherapy or psychoanalysisPsychotherapy or psychoanalysis BiofeedbackBiofeedback Play therapyPlay therapy Chiropractic treatmentChiropractic treatment Sensory integration trainingSensory integration training Social skills trainingSocial skills training Self-control trainingSelf-control training

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Clinical Behavior Therapy: Clinical Behavior Therapy: TheoryTheory

Proposed Mechanism:Proposed Mechanism: Individuals with Individuals with ADHD have difficulty understanding ADHD have difficulty understanding the consequences of their actions.the consequences of their actions.

Approach:Approach: Application of the principles Application of the principles of of social learning theorysocial learning theory to modify to modify children’s behavior by training parents children’s behavior by training parents and teachers to manipulate and teachers to manipulate environmental antecedents, environmental antecedents, consequences and contingencies. consequences and contingencies.

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The ABC ModelThe ABC Model

Behavior

Consequences

Antecedents

Contingencies

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An example: The ABC ModelAn example: The ABC Model

BehaviorStudent ignoresbell while rest of

class takes out mathbooks

ConsequencesTeacher yells at

student

Antecedent9:30 bell signals

beginningof math period

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The ABC ModelThe ABC Model

BehaviorStudent takes out

math book

ConsequenceTeacher smiles

at student

Antecedent9:30 bell signals

beginningof math period

Contingencies

Teacher makes eye contact with student, says, “Take out your math books.”

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Specific interventions to help Specific interventions to help the student with ADHDthe student with ADHD

Psycho-education with parentPsycho-education with parent Parent praiseParent praise Commands/limit settingCommands/limit setting Tangible rewardsTangible rewards Response costResponse cost Parent monitoringParent monitoring Time outTime out Ignoring or DROIgnoring or DRO

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Parent PsychoeducationParent Psychoeducation

Engage and empower parents by Engage and empower parents by teaching them about ADHDteaching them about ADHD

Establish relationship with parents as Establish relationship with parents as partner in treatment processpartner in treatment process

Look at how ADHD influences parent-Look at how ADHD influences parent-child interaction (bi-directional)child interaction (bi-directional)

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Parent PsychoeducationParent Psychoeducation

Review information about ADHDReview information about ADHD SymptomsSymptoms CausesCauses Diagnostic criteria (3 sub-types)Diagnostic criteria (3 sub-types) Treatment modalitiesTreatment modalities

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Emphasize caretaker role in Emphasize caretaker role in development and treatment of ADHDdevelopment and treatment of ADHD Problems in parenting and parenting Problems in parenting and parenting

styles may make ADHD worsestyles may make ADHD worse Establishing behavioral interventions at Establishing behavioral interventions at

home or at school require caretaker home or at school require caretaker involvementinvolvement

Knowledge enables parents to more Knowledge enables parents to more effectively advocate for better serviceseffectively advocate for better services

Parent PsychoeducationParent Psychoeducation

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Parent PsychoeducationParent Psychoeducation

More effective if therapist devotes More effective if therapist devotes more than one session to more than one session to psychoeducationpsychoeducation

More effective if therapist educates More effective if therapist educates parents about ADHD across multiple parents about ADHD across multiple settings (home, school, playground, settings (home, school, playground, etc)etc)

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Resources for Parent Resources for Parent PsychoeducationPsychoeducation

Center for Children and FamiliesCenter for Children and Families ““What Parents and Teachers Should What Parents and Teachers Should

Know about ADHD”Know about ADHD”

Children and Adults with Attention-Children and Adults with Attention-Deficit/Hyperactivity Disorder Deficit/Hyperactivity Disorder (CHADD)(CHADD) Fact sheets for parentsFact sheets for parents

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Resources for Parent Resources for Parent PsychoeducationPsychoeducation

National Initiative for Children’s National Initiative for Children’s Healthcare QualityHealthcare Quality ““How to Establish a School-Home Daily How to Establish a School-Home Daily

Report Card”Report Card” Vanderbilt Assessment Scales (parent and Vanderbilt Assessment Scales (parent and

teacher version)teacher version) ADHD Resources Available on the InternetADHD Resources Available on the Internet ““Working with Your Child’s School”Working with Your Child’s School”

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Parent praiseParent praise

Training parents to praise Training parents to praise correctly increases compliance in correctly increases compliance in youth with ADHDyouth with ADHD Praise can include Praise can include

Verbal praise, EncouragementVerbal praise, Encouragement AttentionAttention AffectionAffection Physical proximityPhysical proximity

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Giving effective praiseGiving effective praise

Be honest, not overly flatteringBe honest, not overly flattering Be specificBe specific No “back-handed compliments” (i.e., No “back-handed compliments” (i.e.,

“I like the way you are playing “I like the way you are playing quietly, why can’t you do this while quietly, why can’t you do this while I’m on the phone?”)I’m on the phone?”)

Give praise immediatelyGive praise immediately

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Training parents to praise Training parents to praise childrenchildren

Barkley manual, Step 2 (Defiant Children)Barkley manual, Step 2 (Defiant Children) Teach parents to set up “special time” to pay Teach parents to set up “special time” to pay

attention to their child during playattention to their child during play Teach parents to narrate their child’s playTeach parents to narrate their child’s play Teach parents not to ask many questions nor Teach parents not to ask many questions nor

give any commandsgive any commands Teach parents to ignore misbehavior during Teach parents to ignore misbehavior during

this playtimethis playtime Teach parents how to praise and praise Teach parents how to praise and praise

lavishly during this timelavishly during this time

Page 18: Evidence-Based Psychosocial Treatment of ADHD Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1.

Training parents to praise Training parents to praise teensteens

Barkley manual, Step 3 (Defiant Teens)Barkley manual, Step 3 (Defiant Teens) Encourage parents to set aside 15 minutes a few Encourage parents to set aside 15 minutes a few

times a week to pay attention to their adolescenttimes a week to pay attention to their adolescent Teach parents to pay attention to what their teen Teach parents to pay attention to what their teen

is doing, and show interest in a relaxed wayis doing, and show interest in a relaxed way Teach parents not to ask questions nor give any Teach parents not to ask questions nor give any

instructionsinstructions Teach parents to ignore if the teenager reacts Teach parents to ignore if the teenager reacts

with sarcasm, coolness or suspicionwith sarcasm, coolness or suspicion Teach parents to praise well and oftenTeach parents to praise well and often

Page 19: Evidence-Based Psychosocial Treatment of ADHD Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1.

Improving commands/limit Improving commands/limit settingsetting

Training for parents and teachers to Training for parents and teachers to give commands in the most effective give commands in the most effective wayway

Effective command increase Effective command increase compliance in children and compliance in children and adolescents with ADHD (and in adolescents with ADHD (and in others, too!)others, too!)

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Improving commands/limit Improving commands/limit setting with childrensetting with children

Barkley Step 3 (Defiant Children)Barkley Step 3 (Defiant Children) Teach parents and teachers:Teach parents and teachers:

To only give commands that they intend To only give commands that they intend to back up with consequences (positive to back up with consequences (positive and negative)and negative)

Not to present commands as questions Not to present commands as questions or favorsor favors

Not give too many commands at onceNot give too many commands at once

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Improving commands/limit Improving commands/limit setting with childrensetting with children

Teach parents and teachers:Teach parents and teachers: To make eye contact with the child before To make eye contact with the child before

giving commandgiving command To reduce other distractions while giving To reduce other distractions while giving

commandscommands To ask the child to repeat the commandTo ask the child to repeat the command To watch the child for one minute after giving To watch the child for one minute after giving

the command to ensure compliancethe command to ensure compliance To immediately praise child when s/he starts to To immediately praise child when s/he starts to

complycomply

Page 22: Evidence-Based Psychosocial Treatment of ADHD Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1.

Improving commands/limit Improving commands/limit setting with adolescentssetting with adolescents

Barkley, Defiant Teens, Step 4Barkley, Defiant Teens, Step 4 Teach parents and teachers:Teach parents and teachers:

To consider the intent of their commandTo consider the intent of their command Do they have the time/energy to follow through?Do they have the time/energy to follow through? Do they have consequences for noncompliance?Do they have consequences for noncompliance?

To avoid ambiguity when issuing commandsTo avoid ambiguity when issuing commands To not respond to compliance with gratitudeTo not respond to compliance with gratitude

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Improving commands/limit Improving commands/limit setting with adolescentssetting with adolescents

Teach parents and teachers:Teach parents and teachers: To praise teens for appropriate behaviorTo praise teens for appropriate behavior To tell teen what To tell teen what toto do, rather than what do, rather than what

notnot to do to do To eliminate other distractions while To eliminate other distractions while

giving commandsgiving commands To break down multi-step commandsTo break down multi-step commands To use aids for commands that involve To use aids for commands that involve

timetime

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Tangible rewardsTangible rewards

Children and adolescents with ADHD do Children and adolescents with ADHD do not respond to natural (intrinsic) not respond to natural (intrinsic) rewards as well as typical youthrewards as well as typical youth

The training of parents and teachers in The training of parents and teachers in the use of tangible rewards is effective the use of tangible rewards is effective in increasing desired behaviorsin increasing desired behaviors Can use token systems, behavior charts, or Can use token systems, behavior charts, or

immediate rewardsimmediate rewards

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Setting up a reward system for Setting up a reward system for children at homechildren at home

Barkley, Defiant Children, Step 4Barkley, Defiant Children, Step 4 Determine family’s readiness to Determine family’s readiness to

implementimplement Tailor the program to family’s ability-Tailor the program to family’s ability-

simplify it for overwhelmed or stressed simplify it for overwhelmed or stressed familiesfamilies

Use poker chip system with younger Use poker chip system with younger children (4-7), point system with older children (4-7), point system with older children (8 and up)children (8 and up)

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Setting up a reward system for Setting up a reward system for children at homechildren at home

Set a positive tone for the programSet a positive tone for the program ““We are going to make sure that you get rewarded We are going to make sure that you get rewarded

for all of the good stuff you do at home”for all of the good stuff you do at home” Parent(s) buys chips and makes a bank, or sets Parent(s) buys chips and makes a bank, or sets

up a chart or notebook for tracking pointsup a chart or notebook for tracking points The parent(s) and child together (with your The parent(s) and child together (with your

help) make up a list of 10-15 rewardshelp) make up a list of 10-15 rewards There should be everyday rewards, like TV or There should be everyday rewards, like TV or

computer time, and longer term rewards, like going computer time, and longer term rewards, like going to a movie or earning a new video game)to a movie or earning a new video game)

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Setting up a reward system for Setting up a reward system for children at homechildren at home

Help the parent(s) and child make a list Help the parent(s) and child make a list of jobs or problem areasof jobs or problem areas

Determine how much each is worthDetermine how much each is worth Add up how much the child might earn in a Add up how much the child might earn in a

dayday Harder jobs should earn moreHarder jobs should earn more Bigger rewards should cost moreBigger rewards should cost more Make sure the child has some success in the Make sure the child has some success in the

beginningbeginning

Page 28: Evidence-Based Psychosocial Treatment of ADHD Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1.

Setting up a reward system for Setting up a reward system for children at homechildren at home

Discuss the concept of bonus chips to Discuss the concept of bonus chips to reward helpful or other positive behaviors, reward helpful or other positive behaviors, even if they aren’t on the listeven if they aren’t on the list

Chips and points are only given if the child Chips and points are only given if the child complies after the complies after the firstfirst command command

Don’t take away chips or points (response Don’t take away chips or points (response cost)cost)

All caregivers should use the same systemAll caregivers should use the same system Remind parents to praise while giving the Remind parents to praise while giving the

pointspoints

Page 29: Evidence-Based Psychosocial Treatment of ADHD Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1.

Setting up a reward system for Setting up a reward system for children at schoolchildren at school

Barkley, Defiant Children, Step 8, Daily Barkley, Defiant Children, Step 8, Daily School Report CardSchool Report Card

The teacher tracks the child’s behavior The teacher tracks the child’s behavior and reports it to the parent daily, who and reports it to the parent daily, who rewards the childrewards the child

This is particularly effective because both This is particularly effective because both the parent and teacher are involvedthe parent and teacher are involved

If the parent can’t be involved, the If the parent can’t be involved, the rewards may be given at schoolrewards may be given at school

Page 30: Evidence-Based Psychosocial Treatment of ADHD Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1.

Setting up a reward system for Setting up a reward system for children at schoolchildren at school

Choose a few target behaviors at Choose a few target behaviors at schoolschool Choose one that the child will be Choose one that the child will be

successful with most of the timesuccessful with most of the time Set up a system for school report card or Set up a system for school report card or

school/home note systemschool/home note system See samples on page 244-246See samples on page 244-246

Pick from the targets given, or create your Pick from the targets given, or create your own with the blank samplesown with the blank samples

Page 31: Evidence-Based Psychosocial Treatment of ADHD Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1.

Setting up a reward system for Setting up a reward system for adolescents at homeadolescents at home

Barkley, Defiant Teens, Step 5Barkley, Defiant Teens, Step 5 Use a point system (see previous slides) Use a point system (see previous slides)

for 13/14 and underfor 13/14 and under Set up basically the same way as with Set up basically the same way as with

childrenchildren Warn parents to expect resistance, their teen Warn parents to expect resistance, their teen

is used to getting all of their privileges for is used to getting all of their privileges for free! Make sure parents don’t give in.free! Make sure parents don’t give in.

Make sure parents only choose privileges they Make sure parents only choose privileges they can controlcan control

Page 32: Evidence-Based Psychosocial Treatment of ADHD Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1.

Setting up a reward system for Setting up a reward system for adolescents at homeadolescents at home

Barkley, Defiant Teens, Step 5Barkley, Defiant Teens, Step 5 Use a behavior contract for teens 14/15 Use a behavior contract for teens 14/15

and olderand older See sample contract on page 208See sample contract on page 208 Begin with only “do” behaviors (clean up Begin with only “do” behaviors (clean up

room, set table, get ready for school on room, set table, get ready for school on time)time)

““Don’t” behaviors are dealt with under Don’t” behaviors are dealt with under response cost in next sectionresponse cost in next section

Page 33: Evidence-Based Psychosocial Treatment of ADHD Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1.

Setting up a reward system for Setting up a reward system for adolescents at schooladolescents at school

Barkley, Defiant Teens, Step 9Barkley, Defiant Teens, Step 9 Establish a homework contract (see sample Establish a homework contract (see sample

on page 121)on page 121) This can be adapted for other behavioral This can be adapted for other behavioral

goalsgoals Can also set up guidance counselor, tutor or Can also set up guidance counselor, tutor or

peer as “coach” for organizational skills or peer as “coach” for organizational skills or other targetsother targets Rewards for teen’s participation can be made part Rewards for teen’s participation can be made part

of the home contract, or part of a school reward of the home contract, or part of a school reward systemsystem

Page 34: Evidence-Based Psychosocial Treatment of ADHD Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1.

Response CostResponse Cost

Using a point or token system in Using a point or token system in which negative behaviors result in which negative behaviors result in the loss of points or tokens.the loss of points or tokens.

Training parents and teachers to use Training parents and teachers to use response cost is effective in reducing response cost is effective in reducing undesired behavior and undesired behavior and noncompliancenoncompliance

Page 35: Evidence-Based Psychosocial Treatment of ADHD Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1.

Response Cost with ChildrenResponse Cost with Children

Barkley, Defiant Children Step 4 & 8Barkley, Defiant Children Step 4 & 8 Train parents and teachers:Train parents and teachers:

To develop list of undesirable behavior to To develop list of undesirable behavior to be fined by reward systembe fined by reward system

To deduct points/chips for undesirable To deduct points/chips for undesirable behaviorbehavior

Parent and child have chosen to reduce whiningParent and child have chosen to reduce whining If child whines, parent deducts three pointsIf child whines, parent deducts three points Penalties increase based on severity of behaviorPenalties increase based on severity of behavior

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Response Cost with ChildrenResponse Cost with Children

Train parents and teachers:Train parents and teachers: To avoid “punishment spiral”To avoid “punishment spiral”

When parent fines child for misbehavior, the When parent fines child for misbehavior, the child may respond with more misbehaviorchild may respond with more misbehavior

Child continues to lose points, then loses Child continues to lose points, then loses motivation for the point systemmotivation for the point system

Rule: Parent fines child Rule: Parent fines child once once through point through point system, then sends child to time out if system, then sends child to time out if undesirable behavior continuesundesirable behavior continues

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Response Cost with Response Cost with AdolescentsAdolescents

Barkley, Defiant Teens Step 6Barkley, Defiant Teens Step 6 To train parents and teachers:To train parents and teachers:

To now use behavioral contract with the To now use behavioral contract with the teen for “fines”teen for “fines”

Teen agrees to not swearTeen agrees to not swear If teen swears, teen loses Internet privilegeIf teen swears, teen loses Internet privilege

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Response Cost with Response Cost with AdolescentsAdolescents

Train parents and teachers:Train parents and teachers: To begin with 1 week “training period,” during To begin with 1 week “training period,” during

which parent labels misbehavior every time it which parent labels misbehavior every time it happens and warns of new fineshappens and warns of new fines

To avoid “punishment spiral”To avoid “punishment spiral” When parent fines teen for misbehavior, the teen When parent fines teen for misbehavior, the teen

responds with more misbehaviorresponds with more misbehavior Teen continues to lose privileges, then loses Teen continues to lose privileges, then loses

motivation motivation Rule: Parent fines teen Rule: Parent fines teen no more than twiceno more than twice, then , then

directs teen to “cool off” away from the situationdirects teen to “cool off” away from the situation

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Response Cost with Response Cost with AdolescentsAdolescents

Encourage parents to act as “judge and Encourage parents to act as “judge and jury” when teen liesjury” when teen lies The teen should remain above suspicionThe teen should remain above suspicion

Response cost allows parents to Response cost allows parents to discipline/educate instead of discipline/educate instead of justjust punish punish

Emphasis of response cost is onEmphasis of response cost is on ““Warm” – positive, lovingWarm” – positive, loving ““Firm” – specific, immediate, and consistentFirm” – specific, immediate, and consistent

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Parent MonitoringParent Monitoring

Give parents a structured way to Give parents a structured way to monitor their child’s behaviormonitor their child’s behavior

Measurement of the target behavior Measurement of the target behavior should be repeatedshould be repeated

Can use either informal or formal Can use either informal or formal measuresmeasures

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Parent MonitoringParent Monitoring

Informal measuresInformal measures Daily homework logDaily homework log Behavior chart as part of a reward Behavior chart as part of a reward

systemsystem Home Situations Checklist (Barkley, Home Situations Checklist (Barkley,

Defiant Children)Defiant Children)

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Parent MonitoringParent Monitoring

Formal measuresFormal measures Vanderbilt Scales (from your Resource Vanderbilt Scales (from your Resource

Toolkit or on the web)Toolkit or on the web) Disruptive Behavior Disorders Scale (in Disruptive Behavior Disorders Scale (in

Barkley or on the web)Barkley or on the web)

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Time OutTime Out

Time out is the removal of a child or Time out is the removal of a child or adolescent from all reinforcement for adolescent from all reinforcement for a specified period of time after a a specified period of time after a targeted misbehaviortargeted misbehavior It is an effective intervention, but only if It is an effective intervention, but only if

it is used correctly and is not used too it is used correctly and is not used too oftenoften

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Using Time Out with Children Using Time Out with Children at Homeat Home

Barkley, Defiant Children, Step 5Barkley, Defiant Children, Step 5 Teach parents to give an effective Teach parents to give an effective

command (Step 3)command (Step 3) Teach parents to count out loud Teach parents to count out loud

(initially) from 5 to 1(initially) from 5 to 1 Teach parents to give a time out Teach parents to give a time out

warning if the child has not compliedwarning if the child has not complied After warning, count from 5 to 1 againAfter warning, count from 5 to 1 again

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Using Time Out with Children Using Time Out with Children at Homeat Home

Teach parents to guide child to time out chair Teach parents to guide child to time out chair IMMEDIATELYIMMEDIATELY

Teach parents to place the child in the chair Teach parents to place the child in the chair “Stay there until I tell you to get up”“Stay there until I tell you to get up”

Teach parents not to argue or interact with Teach parents not to argue or interact with the child in any waythe child in any way

Teach parents to not come back until the Teach parents to not come back until the child is calm. Once the child is calm and the child is calm. Once the child is calm and the time is served, the child must correct the time is served, the child must correct the misbehaviormisbehavior

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Using Time Out with Children Using Time Out with Children at Homeat Home

Teach the parents that the child should Teach the parents that the child should now go and comply with the previous now go and comply with the previous command, or correct the misbehaviorcommand, or correct the misbehavior

Teach the parent to now praise Teach the parent to now praise compliance, and to praise the next compliance, and to praise the next behavior that the child does wellbehavior that the child does well

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Time Out Tips with ChildrenTime Out Tips with Children

The first time out may be difficultThe first time out may be difficult Prepare parents for a worst case scenario of a Prepare parents for a worst case scenario of a

complete struggle.complete struggle. Reassure parents that this is how the child Reassure parents that this is how the child

learns time out and correcting misbehavior.learns time out and correcting misbehavior. Make sure the time out area is away from Make sure the time out area is away from

anything interesting or funanything interesting or fun Remind parents not to “make up for” the Remind parents not to “make up for” the

time out (i.e., saving dessert for them)time out (i.e., saving dessert for them)

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Using Time Out with Using Time Out with AdolescentsAdolescents

Barkley, Defiant Teens, Step 8Barkley, Defiant Teens, Step 8 ““Grounding” = “house arrest”Grounding” = “house arrest”

NO access to privileges (phone, TV, etc)NO access to privileges (phone, TV, etc) Parent must be home to enforceParent must be home to enforce Most effective with younger teensMost effective with younger teens May include “work detail” (cleaning out May include “work detail” (cleaning out

basement, scrubbing bathroom floor)basement, scrubbing bathroom floor)

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Ignoring and Differential Ignoring and Differential ReinforcementReinforcement

Train parents and teachers to Train parents and teachers to selectivelyselectively Ignore mild unwanted behaviorsIgnore mild unwanted behaviors

ANDAND

Attend to alternative positive Attend to alternative positive behaviorsbehaviors

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Teaching parents and teachers Teaching parents and teachers to ignoreto ignore

Teaching parents and teachers Teaching parents and teachers how and when to ignore how and when to ignore undesirable behaviorundesirable behavior Ignoring can includeIgnoring can include

Visual cuesVisual cues Postural cuesPostural cues Vocal cues Vocal cues Social cuesSocial cues

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How to ignoreHow to ignore

Visual cuesVisual cues Look away once child engages in undesirable Look away once child engages in undesirable

behaviorbehavior Do not look at the child until behavior stopsDo not look at the child until behavior stops

Postural cuesPostural cues Turn the front of your body away from the Turn the front of your body away from the

location of child’s undesirable behaviorlocation of child’s undesirable behavior Do not appear frustrated (e.g., hands on hip)Do not appear frustrated (e.g., hands on hip) Do not vary the frequency or intensity of your Do not vary the frequency or intensity of your

current activity (e.g., chopping faster, current activity (e.g., chopping faster, hammering harder)hammering harder)

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How to ignoreHow to ignore

Vocal cuesVocal cues Maintain a calm voice even after your child begins Maintain a calm voice even after your child begins

undesirable behaviorundesirable behavior Do not vary the frequency or intensity of your Do not vary the frequency or intensity of your

voice (e.g., don’t talk faster or shout over the voice (e.g., don’t talk faster or shout over the child)child)

Social cuesSocial cues Continue your intended activity even after your Continue your intended activity even after your

child begins undesirable behaviorchild begins undesirable behavior Do not panic once child’s begins inappropriate Do not panic once child’s begins inappropriate

behavior (i.e., do not draw more attention to child)behavior (i.e., do not draw more attention to child)

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When to ignoreWhen to ignore

When to ignore undesirable behavior When to ignore undesirable behavior Child interrupts conversation or classChild interrupts conversation or class Child blurts out answers before question Child blurts out answers before question

completedcompleted Child continuously talks during dinnerChild continuously talks during dinner Child tantrums while at the grocery storeChild tantrums while at the grocery store

Do Do notnot ignore undesirable behavior that ignore undesirable behavior that could potentially harm the child or could potentially harm the child or someone elsesomeone else

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Differential reinforcementDifferential reinforcement

Teach parents and teachers how and Teach parents and teachers how and when to differentially reinforce when to differentially reinforce desirable behaviordesirable behavior Step One: Ignore (stop reinforcing) the Step One: Ignore (stop reinforcing) the

child’s undesirable behaviorchild’s undesirable behavior Step Two: Reinforce the child’s desirable Step Two: Reinforce the child’s desirable

behavior in a systematic mannerbehavior in a systematic manner The desirable behavior should be a behavior The desirable behavior should be a behavior

that is incompatible with the undesirable that is incompatible with the undesirable behaviorbehavior

Page 55: Evidence-Based Psychosocial Treatment of ADHD Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1.

Differential reinforcementDifferential reinforcement

Define the behavior of concern Define the behavior of concern (target)(target) Determine how often the target behavior Determine how often the target behavior

occursoccurs Determine how often to reward the child Determine how often to reward the child

for alternative behaviorfor alternative behavior Fixed interval – reward every X minutesFixed interval – reward every X minutes

Determine how to reward the child for Determine how to reward the child for alternative behavioralternative behavior

Praise, attention, points or chipsPraise, attention, points or chips

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Reinforcement of target Reinforcement of target behaviorbehavior

Target behavior: InterruptingTarget behavior: Interrupting Alternative behavior: Playing by himselfAlternative behavior: Playing by himself Reward schedule: 5 minutesReward schedule: 5 minutes

If child goes 5 minutes without interrupting, If child goes 5 minutes without interrupting, the child receives reinforcementthe child receives reinforcement

If child interrupts before 5 minutes is up, the If child interrupts before 5 minutes is up, the child does not receive reinforcementchild does not receive reinforcement

Re-set schedule once child interruptsRe-set schedule once child interrupts

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Differential reinforcementDifferential reinforcement

Parent or teacher systematically Parent or teacher systematically delays reinforcement once child delays reinforcement once child responds to initial scheduleresponds to initial schedule Target behavior: InterruptingTarget behavior: Interrupting 11stst reinforcement schedule: 5 minutes reinforcement schedule: 5 minutes 22ndnd reinforcement schedule: 6 minutes reinforcement schedule: 6 minutes 33rdrd reinforcement schedule: 7.5 minutes reinforcement schedule: 7.5 minutes

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Problems with ignoring and Problems with ignoring and differential reinforcementdifferential reinforcement

Extinction burstExtinction burst Warn parents and teachers that the behavior Warn parents and teachers that the behavior

will get worse before it gets better (child will will get worse before it gets better (child will work harder to gain their attention)work harder to gain their attention)

If you put your money in a vending machine, and If you put your money in a vending machine, and the soda doesn’t come out, what do you do? You the soda doesn’t come out, what do you do? You probably press the button a few more times, probably press the button a few more times, maybe you even try pressing hardermaybe you even try pressing harder

Indiscriminant reinforcementIndiscriminant reinforcement Train parents to reward the alternative Train parents to reward the alternative

(desirable) behavior, so they don’t reward (desirable) behavior, so they don’t reward other unwanted behaviors by mistakeother unwanted behaviors by mistake