The Use of Behavior Therapy to Treat ADHD. Robin Elizabeth Kuebler. Texas State University

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1 Running Title: THE USE OF BEHAVIOR THERAPY TO TREAT ADHD 1 The Use of Behavior Therapy to Treat ADHD Robin Elizabeth Kuebler Texas State University

2 THE USE OF BEHAVIOR THERAPY TO TREAT ADHD 2 Abstract ADHD is the most common neurobehavioral disorder of childhood. It is characterized by difficulties with inattention, hyperactivity, impulsivity, or a combination of these issues. It is a growing public health issue; the incidence of diagnosis is growing quickly. ADHD can cause issues personally, academically, and professionally. The front line defense against ADHD is primarily pharmaceutical; however, evidence suggests that behavioral therapy can help augment and sustain gains made against the condition. Behavioral therapy can be used successfully in both home and academic settings to help treat what can be a debilitating, chronic medical condition.

3 THE USE OF BEHAVIOR THERAPY TO TREAT ADHD 3 Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood. It can have profound effects on the academic achievement, well-being, and social interactions of affected children (American Academy of Pediatrics [AAP], 2011). It is a chronic medical condition characterized by difficulties with inattention, hyperactivity, impulsivity, or a combination of these issues. ADHD affects a person's ability to regulate behavior and attention. Students with ADHD have problems sustaining attention, controlling hyperactivity, and managing impulses. The executive functions of the brain - activating, organizing, integrating, and managing other functions - appear to be affected by ADHD. Research indicates that the frontal lobe, basal ganglia, caudate nucleus, cerebellum, as well as other areas of the brain play a significant role in ADHD because they are involved with the executive functions (MyADHD.com, n.d.). Per the American Psychiatric Association's Diagnostic and Statistical Manual, Fifth edition (DSM-5), ADHD is characterized by the presence of up to eighteen symptoms. Symptoms of the inattention component of ADHD include: A failure to give close attention to details or the commission of careless mistakes in schoolwork, work, or other activities; A difficulty sustaining attention in tasks or play activities; A deficit in listening when directly addressed; A failure to follow instructions and finish schoolwork, chores, or workplace duties; A difficulty organizing tasks and activities; An avoidance, dislike, or reluctance to engage in tasks that require sustained mental effort; A pattern of losing things necessary for tasks or activities; A susceptibility to distraction by extraneous stimuli; A forgetfulness in daily activities. Symptoms of the hyperactivity component of ADHD include: Fidgeting with hands or feet or squirming in seat;

4 THE USE OF BEHAVIOR THERAPY TO TREAT ADHD 4 Leaving one s seat in the classroom or in other situations in which there is an expectation of remaining seated; Excessive running or climbing in inappropriate situations; An inability to play or take part in leisure activities quietly; A tendency to be on the go or to act as if driven by a motor; A pattern of talking excessively. Finally, symptoms of the impulsivity component of ADHD include: Blurting out answers before questions have been completed; A difficulty awaiting one s turn; A tendency to interrupt or intrude on others; to butt in. Of course, it can be difficult to diagnose ADHD in a younger child, as many of these symptoms can be attributed to age-related immaturity. Prior to the age of 4, many preschoolers are highly active and prone to being easily distracted and overly impulsive. As the young child gets older, problems with hyperactivity, inattention, or impulsivity tend to stand out, gaps in school performance become clearer, and problems with behavior or learning become more of a concern to parents and teachers. If a child has had problems in school, at home, or in social activities for at least six months, and if these problems appear to correlate with the defined symptoms of ADHD, an evaluation should be considered (MyADHD.com, n.d.). The exact causes of ADHD are not yet known. Heredity is the most commonly cited risk factor in the development of ADHD. Other risk factors include in utero exposure to toxic substances such as tobacco and alcohol and acquired brain injuries. Contrary to myth, ADHD is not the result of laziness, poor motivation, low intelligence, disobedience, poor upbringing, or selfishness. It is a chronic medical condition (MyADHD.com, n.d.). The impact on the affected individuals, their families, their schools, and the nation as a whole is massive. ADHD can have a profound effect on a person s quality of life. Children and

5 THE USE OF BEHAVIOR THERAPY TO TREAT ADHD 5 adolescents with the disorder often have difficulty with socialization, school performance, and behavior. Failure to perform as well as others can lead to problems with self-esteem, anxiety, and depression. Sufferers have higher rates of other psychiatric and behavior disorders and are at greater risk for problems in academic performance and accidental injury. Socially, children with ADHD are frequently rejected by their peers as early as the first day of contact, likely as a result of their tendency toward disruptive and aggressive behavior. ADHD also has long-term negative outcomes for children, including decreased educational attainment, work performance, and occupational stability. Children with ADHD are more than twice as likely to have been arrested (Matza et al., 2005). Those who suffer from ADHD are also at increased risk for substance abuse (Fabiano et al., 2009). Families and schools are strained as well. The behavior of a child with ADHD can be very disruptive to a family; the hereditary nature of the condition means that parents are frequently coping not only with their own symptoms, but with those of their child/children as well (MyADHD.com, n.d.). The growing rate of diagnosis of this condition indicates that virtually no classroom will be untouched by ADHD. ADHD is one of the most common problems encountered in mental health, primary care, and educational settings. Due to its associated impairments, serious outcomes, and prevalence, it is a costly problem for society. Its estimated annual cost in the US approximates the societal cost of major depression and stroke (Pellham et al., 2007). It is a rapidly growing problem. In 2003, approximately 7.8% of children had an ADHD diagnosis. The prevalence rate rose to 9.5% in 2007 and 11.0% in 2014 (boys were more than twice as likely as girls to have an ADHD diagnosis). The rate of diagnosis increased an average of 3% per year from , and an average of 5% per year from 2003 to 2011 (Centers for Disease Control and Prevention [CDC],

6 THE USE OF BEHAVIOR THERAPY TO TREAT ADHD 6 n.d.). The expansion of diagnosis of ADHD at a growing rate is a trend worthy of emergency research and action. The first line of defense against ADHD is pharmacological. A discussion of specific drug therapy is beyond the scope of this paper; however, evidence does suggest that there are limitations to a primarily pharmacological treatment approach. Widespread use and evidence for the efficacy of stimulant medication are overwhelming on the surface. It is estimated that at least 85% of children diagnosed with ADHD are medicated with stimulants. Stimulant medication has had large, beneficial effects on many outcome measures, particularly measures of ADHD symptoms for the majority of children for whom they are prescribed. In the classroom, stimulants have been found to reduce classroom disruption and increase on-task behavior, compliance, and academic productivity. In addition, stimulants have been shown to decrease negative social behaviors, such as aggression, inappropriate peer interactions, and negative parent-child interactions (Chronis et al., 2006). Medication is linked to reductions in anger, improved participation in organized sports, and reduced bossy, defiant, and oppositional behavior. Over 150 double-blind studies of stimulant use in children with ADHD have indicated that these drugs improve attention, self-control, behavior, fine motor control, and social functioning. Medication has improved motor activity and coordination and has improved handwriting. Cognitively, ADHD drugs have resulted in reduced distractibility, decreased impulsivity, increased work production, and increased accuracy (MyADHD.com, n.d.). There are limitations, however. First, as many as 30% of children do not show a clear beneficial response (Chronis et al., 2006). Second, although academic productivity has shown to benefit from stimulant therapy, overall academic performance has not been conclusively shown to improve. Socially, ADHD drugs can reduce inappropriate and disruptive behaviors, but they

7 THE USE OF BEHAVIOR THERAPY TO TREAT ADHD 7 do not normalize children socially; a 1992 study showed that children who are actively medicated displayed muted social behavior, decreased social engagement, and an increased likelihood of unhappiness (Daly et al., 2007). There are side effects associated with stimulant therapy; commonly reported problems include headaches, stomachaches, insomnia, decreased appetite, weight loss, and irritability. 4-10% of users have side effects that are so severe that the drugs must be discontinued (Daly et al., 2007). Another issue is the duration of the drugs. The duration of action of most stimulants is eight hours; parents and caregivers struggle with the behavior of the ADHD child after the drugs lose efficacy, in afternoons, evenings, weekends, and summers (Daly et al., 2007). Finally, the long term effects of stimulants used to treat ADHD are largely unknown (Chronis et al., 2006). There is much evidence to support the inclusion of a behavior therapy component as part of the treatment protocol of the ADHD patient. Results of the Multimodal Treatment Study of Children with ADHD suggested that although medication was effective in reducing ADHD symptoms, only combined behavioral-pharmacological treatment resulted in improved social skills and improved parental relationships. Children who received combined treatments were more likely to be normalized; parents also overwhelmingly endorse treatment plans that include a behavioral focus (Chronis et al., 2006). The proven success of a behavioral therapy component in the treatment of ADHD highlights the need for a continuation of this approach (Chronis et al., 2006). A 2008 meta-analysis of behavioral treatment plans indicated that behavioral treatments are highly effective. It showed strong and consistent evidence that behavioral treatments are effective for treating ADHD. Unlike a pharmacological approach that arguably mask the symptoms of the disorder, behavior therapy targets the underlying behavior and focuses on changing this behavior until a desired outcome can be reached. Behavioral approaches focus on an objective analysis of student

8 THE USE OF BEHAVIOR THERAPY TO TREAT ADHD 8 behavior, which may include behaviors to be reduced, eliminated, acquired, or increased (Plotts & Lasser, 2013). According to Pellham and Fabiano (2008), behavioral therapies have the most supporting evidence for treatment of ADHD in children and adolescents. According to the website for the Association for Behavioral and Cognitive Therapies, the research literature on ADHD treatment has shown that behavior therapy is the one psychosocial treatment that is effective for those with ADHD. Effective behavior therapy can be described with the use of two acronyms. The basic processes can be summarized as ABC: antecedents precede behavior, behavior results in consequences (Plotts & Lasser, 2013). An antecedent is a circumstance that precedes an observed behavior. An instructor s teaching style, parental conflicts, and a fear of failure are all examples of antecedents that influence the subsequent behavior of the child. Consequences are defined as anything that follows a behavior and has the effect of either increasing or decreasing the probability that the behavior will happen again in the future. There are two types of consequences: reinforcement, which increases the likelihood that a behavior will recur, and punishment, which decreases the likelihood of a recurrence. Examples of consequences include report cards, improved/diminished social relationships, rewards and restrictions. Behavior therapy, then, is the manipulation of the antecedents and consequences to produce more effective behavior (Tresco, 2010). The components of a successful behavior therapy plan can be defined with a second acronym: CISS-4. The letters represent consistency, immediacy, specificity, and salience; the 4 refers to a performance ratio. Consistency refers to the adherence to a specified behavioral plan. Immediacy means that consequences should be administered immediately after the target behavior so that the source of the consequence is clear. Specificity refers to a parent or teacher

9 THE USE OF BEHAVIOR THERAPY TO TREAT ADHD 9 being explicit about which behavior is being targeted and what the consequence is for that behavior. A salient program creates consequences that are meaningful to the child. Finally, a ratio of 4:1, positive reinforcement to punishment, is critical to establish and maintain a strong relationship with the child (Tresco, 2010). Consequences can be designed to increase, decrease, generalize, and establish behavior. Positive reinforcement rewards a desired behavior: a boy manages to raise his hand before speaking, and is rewarded with access to a favorite toy. Theoretically, this should increase the likelihood of the desired hand-raising in the future. Or, the reinforcement can be negative: an unpleasant consequence can be removed. The boy raises his hand before speaking and avoids removal from the group, thus encouraging future repetitions of the behavior. Consequences can also be designed to reduce undesired behavior. With overcorrection, the acceptable behavior is practiced immediately after the inappropriate behavior is displayed; the boy who speaks out of turn must practice raising his hand, reducing the likelihood of future disruptions. Punishment can be used to decrease behavior: the boy is sent to the principal s office if he speaks out of turn, prompting him to avoid future recurrences. Extinction is the removal of reinforcement for the inappropriate behavior. If the boy speaks out of turn, the teacher does not acknowledge his response, therefore removing any incentive for the boy to interrupt the classroom discussion. A final consequence designed to reduce behavior is satiation, the repeated practice of a behavior until the behavior becomes aversive. The boy might actually be encouraged to repeatedly interrupt the teacher until he realizes that his behavior is not constructive to a classroom discussion. Consequences can also be used to help generalize a positive behavior; the boy, having learned to wait until an appropriate moment to express his thoughts in the classroom, is granted a few minutes of extra play at home when he does not interrupt family conversations.

10 THE USE OF BEHAVIOR THERAPY TO TREAT ADHD 10 Fading can establish a behavior by providing rewards until the behavior becomes more innate: the boy is given a gold star when he waits his turn to speak, but the use of the stars is decreased as the positive behavior becomes more standard. Or the behavior can be established by shaping reinforcing increasingly positive behavior. The boy has to demonstrate increasing patience in waiting his turn in order to keep receiving a star. The use of consequences can help reverse some of the inappropriate behaviors of an ADHD child (Plotts & Lasser, 2008). By DSM-5 definition, a child must display symptoms of ADHD in two settings to qualify for the diagnosis. For school aged children, these settings are most notably school and home. Treatments must be utilized in each setting to bring about the maximum benefit (Pellham et al., 1998). Many of the difficulties that characterize ADHD may interfere with a child s classroom behavior and their ability to learn, resulting in lower academic achievement and impaired school functioning (Chronis et al., 2006). A number of school-based interventions have been found to improve behavior in children with ADHD. Many antecedents have been identified as part of a school-based behavior therapy. The first crucial antecedent is an emphasis on clear rules and expectations. Rules and expectations should be concise, clear, and posted for reference. Similarly, antecedent commands and instructions should be clear and precise; behavioral compliance improves with clarity and brevity. Appropriate expectations are another important antecedent; inappropriate expectations can cause poor behavior due to academic frustration. The use of interesting tasks can help keep an ADHD child more readily engaged; the use of computers to engage the ADHD students allows for the use of motor skills as well as cognitive skills. Peer tutoring has been demonstrated to improve attention and academic performance; it allows for frequent, immediate feedback beyond the teacher s capacity, and allows for more increased opportunities in academic engagement (Tresco, 2010). Task and instructional

11 THE USE OF BEHAVIOR THERAPY TO TREAT ADHD 11 modifications and strategy training can be tailored to the individual learning style of the ADHD student (Chronis et al., 2006). Many behavioral therapy techniques in the school setting focus on consequences as well. Antecedent strategies should be reinforced with the liberal use of positive reinforcement. The use of attention and praise can both increase the frequency of positive behavior and provide motivation for changing inappropriate behavior. As defined in the CISS-4 strategy, praise should be used 1) consistently, 2) immediately following the targeted behavior, 3) with a clear statement of the specific behavior that is being rewarded, and 4) in a way that is salient to the child. Rewards can also take the form of more concrete reinforcers, such as privileges, small toys, or tokens that can be exchanged for rewards (Tresco, 2010). The use of a daily report card (DRC) measures the progress of a student against clearly defined goals. Goals are ramped up as the child progresses, pushing the child toward developmentally normal levels. It also provides frequent and meaningful feedback for the child, particularly when coupled with a reward program offered by the child s parents at home. Punishment strategies can also be used in a school-based behavior therapy program. The most basic form of punishment strategy is verbal correction (Tresco, 2010). A time-out can be used to curb a specific, pre-defined behavior for a short period of time; however, the use of a time-out as a vague relief period is not considered to be productive. Generally speaking, Plotts and Lasser (2013) find that punishment techniques are less effective than positive reinforcers for the following reasons: Punishment extinguishes behavior only on a short term basis, and only when the punisher is present. Punishment does not define positive behavior it only highlights inappropriate behavior.

12 THE USE OF BEHAVIOR THERAPY TO TREAT ADHD 12 Punishment may suppress, not eliminate, the targeted behavior. Students may imitate punishment strategies in their peer interactions. If a punishment strategy must be used, it should similarly adhere to the CISS-4 protocol, so that all corrective actions are consistent, immediate, specific, and salient to the child. Reinforcement strategies should be used with at least four times the frequency of punishment strategies (Tresco, 2010). Most studies suggest that behavioral-based strategies typically result in very large improvements. Behaviorally based classroom interventions appear to be an effective means of managing the behavior of children with ADHD in schools. However, the efficacy of all such programs relies largely on the cooperation of school professionals and the consistent use of behavior therapy techniques by classroom teachers (Chronis et al., 2006). The challenges of ADHD extend beyond the schools and into the homes of the children. Per Baldwin, et al. (1995), symptoms of ADHD, such as inattention, hyperactivity, and impulsivity not only affect a child's daily functioning but also may influence the parent-child relationship, as well as increase stress in caregivers and of children with the disorder. Home based interventions can be vital in reversing maladaptive or counterproductive parental practices that have developed in response to the ADHD-exacerbated stress (Chronis et al., 2006). Familybased interventions that focus on modifying antecedents and consequences of ADHD behavior are called behavioral parent training (Daly et al., 2007). Parents are taught to target and monitor problematic behaviors, reward appropriate behavior with praise, attention, and rewards, and decrease unwanted behavior through extinction and non-physical punishment techniques (Chronis et al., 2006). The parents also focus on reducing consequences that positively reinforce inappropriate behavior. Parents are trained in the use of CISS-4 compliant techniques for

13 THE USE OF BEHAVIOR THERAPY TO TREAT ADHD 13 maximum effect (Daly et al., 2007). An example of a key parental behavior is the establishment of an optimal time and environment for homework completion. The coupling of this antecedent with a positive consequence has shown to be effective (Dupaul & Stoner, 2003). In a meta-analysis of parent training programs to modify disruptive child behaviors and parental behaviors and perceptions, Ludahl, et al. found that parent training designed to modify disruptive child behavior is a robust intervention producing moderate effects immediately following treatment. Although smaller in magnitude, parent training effects remained apparent after one year. In summary, a large evidence base exists for the use of parent behavioral interventions to improve parenting skills and their sense of competence, and to diminish family distress. Given this compelling body of literature attesting to its effectiveness, behavioral parent training should be considered as a first line treatment for ADHD. As Tresco (2010) summarizes, a wide range of behavioral interventions are available for the treatment of ADHD. These interventions can be differentiated into those that attempt to modify antecedents to modified behaviors, those that focus on the consequences of behavior, and those that include antecedent-based and consequence-based components. Hallmarks of effective interventions are consistency, immediacy, specificity, and saliency. Effective approaches emphasize positive reinforcement strategies. Punishment has a role in behavioral therapy, but it is essential that reinforcement be used four times more frequently. The schools and families serve critical roles in this process: family involvement through the use of homework interventions, behavior training, and problem-solving partnerships with teachers can add substantially to the effectiveness of a behavior management approach to overcoming ADHD.

PRACTICE PARAMETERS FOR THE ASSESSMENT AND TREATMENT OF CHILDREN WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER

PRACTICE PARAMETERS FOR THE ASSESSMENT AND TREATMENT OF CHILDREN WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER Attention-Deficit / Hyperactivity Disorder (ADHD). (2017, August 31). Retrieved April 06,