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ADHD Parent and Teacher Training

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School-based interventions. Classroom behaviour management ... 15' non-interventional observation / play , seek for base level, mourning, seek for charm ... – PowerPoint PPT presentation

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Title: ADHD Parent and Teacher Training


1
ADHD Parent and Teacher Training
  • Prof. M. Danckaerts
  • UZ-KULeuven

2
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
3
History
  • Behavioural interventions
  • since gt 40 years for children with disruptive
    disorders
  • Since gt 30 years for children with ADHD
  • 3 types directed to
  • Parents
  • School
  • Child / adolescent

4
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

5
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
6
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

7
ADHD Psychosocial treatments
  • Recent landmark comparative treatment studies
    played down the importance of psychosocial
    treatments in the management of ADHD

8
MTA-study
Month
0
36
24
14
10-m Follow- up After Treatment
22-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
9
MTA-psychosocial treatment
  • 30 parent sessions
  • 20 school visits and teacher training sessions
  • 2-month individual summer treatment program
  • Part-time classroom aid

10
MTA-outcome 14-monthTeacher SNAP inattention

Average Score
Assessment Point (Days)
Jensen et al 1999
11
MTA-outcomeTeacher SNAP Hyp-Imp

Average Score
Assessment Point (Days)
Jensen et al 1999
12
MTA-outcome Normalization

88
68
56
34
25
MTA N 579 Classroom Cntrls N 288
Swanson et al. for the MTA Cooperative Group
13
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
14
The Netherlands
10 weeks
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
  • Both treatments yielded significant improvement
    on all domains (ADHD, ODD/CD, social skills,
    parenting stress, anxiety, self-worth
  • NO significant differences

Vanden Oord ea 2007
15
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

16
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

17
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

18
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 ?
  • Do they have long-term effects ?

19
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

20
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

21
Effect sizes
Pelham Fabiano 2008
Group-design Within-subject Single-case
Parent Mgt. Training .47 - .70
Classroom Beh. Management -.03 - 0.44 6.08 6.08
Beh. Peer Intervention .29 - .63 2.46
Beh. Interv. (all) 0.47 0.64 3.64
22
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 ?
  • Do they have long-term effects ?

23
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
24
MTA-outcomeParent-child arguing

Average Score
Assessment Point (Days)
25
MTA-outcomeNegative-ineffective discipline

Average Score
Assessment Point (Days)
Wells et al., for the MTA Cooperative Group
26
Parent training effects
Routine Clinical Care Family support
pharmaco-therapy if appropriate 4-12y
Behavioural symptoms RCC PT gt
RCC Internalizing symptoms RCC PT gt
RCC ADHD, parental stress RCC PT RCC
parent training N42
RCC continued N47
Regardless of medication status
6 months
Van den Hoofdakker ea 2007
27
Parenting training effects
  • Larger effects on
  • Compliance with parental requests
  • Rule-following
  • Defiant-aggressive behaviour
  • Parenting skills (lt negative/ineffective
    parenting practices)
  • Than on
  • Specific ADHD behaviours

28
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 ?
  • Do they have long-term effects ?

29
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 !

30
Parent-training effects on ADHD behaviours
Sensitive period for altering the progression 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
31
Moderators of success ? - 4
  • Comorbidity

MTA, Jensen ea 2001
32
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)
  • Setting
  • Possibly more pos. effects in academic than in
    recreational settting at school (Kolko ea 1999)

33
Moderators of success ? - 3
  • 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

34
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

35
Mediators of success ? - 4
  • Intensity of treatment
  • Contingency mgt gt low intensity behav.
    intervention (eg. DRC) (Pelham ea 1998)
  • New trial low intensity closer to high intensity
    than to no behavioural intervention
  • 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)

36
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

37
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

38
Further issues - 2
  • Cost-effectiveness relative to medication
    treatment ?
  • Dismantle separate effect of BPT, BCM, BPI
  • Sequence of interventions
  • How do programs lead to improvement ? Active
    ingredients of success

39
How does parent training work ?
  • Active ingredients ?
  • Prudent negative consequences (verbal reprimands,
    backed up with time-out ?
  • Positive consequences ?

40
How does parent training work?
  • 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 dit
    not mediate outcome whereas changes in
    Negative/Ineffective Parenting did.

Abramowitz ea 1987, Fabiano ea 2004, pfiffner
OLeary 1987
41
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

42
IN PRACTICE 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)

43
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
44
Family-based interventions
  • 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)

45
Behavioral Interventions(Bear, Cavalier,
Manning, 2005)
  • Behavioral Interventions general tips
  • Consequences should occur soon after behavior
  • Consequences should be salient
  • Dont 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

46
Leuven Parent Training
Based on Barkleys PT 6 sessions of 2 hours, 6-7
pairs of parents
HOMEWORK
  • 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

47
Leuven Parent training Build up Model
Level of expectation
frustration
motivation
Level of the child
Adaptation
Starting Point
48
Leuven Parent Training - 2
Based on Barkleys PT 6 sessions of 2 hours, 6-7
pairs of parents
  • 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

49
School Based Interventions
BEHAVIOURAL INTERVENTIONS
ACADEMIC INTERVENTIONS
  • 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

50
Daily Behavior Report Cards(Challenging Horizons
Treatment Manual, 2005)
  • Goal The student will demonstrate improvement in
    the targeted behavioral and/or academic problem
    areas.

              1 The mentor and student identify target (desired) behaviors (e.g., remaining on task in class) that the student needs to improve.
              2 The mentor and/or classroom teacher(s) documents ratings of the student's performance on the target behaviors on a regular basis (at least weekly).
              3 The mentor/teacher ratings are communicated in writing to the parents/guardians of the student (at least weekly).
              4 Behavioral contingencies are provided at home.  Progress is also discussed between the mentor and student in one-to-one meetings at school.
51
Daily Report Cards - 2
52
Daily Behavior Report Cards - 3
Monday Behavior 1 Monday Behavior 1 Monday Behavior 1 Monday Behavior 1 Tuesday Tuesday Tuesday Tuesday Wednesday Wednesday Wednesday Wednesday
1 2 3 4 1 2 3 4 1 2 3 4
Behavior 2 Behavior 2 Behavior 2 Behavior 2
1 2 3 4 1 2 3 4 1 2 3 4
Behavior 3 Behavior 3 Behavior 3 Behavior 3
1 2 3 4 1 2 3 4 1 2 3 4
Turns in work on time
BKS
BKS
Produces high quality work
BKS
BKS
Brings materials necessary for class/subject area
BKS
BKS
1 Needs Much Improvement, 2 Some Difficulty,
3 Good Job, 4 Great Job!
Challenging Horizons Program, Evens ea 2005
53
What Interventions Are Used?
  • General SPED teachers differ in their emphasis,
    but the interventions are surprisingly similar

Intervention General Education Special Education
Changing seats 1 5
Behavior modification 2 1
Time-Out 3 4
Shortened Assignments 4 7
One-to-one instruction 5 3
Special Consultation 6 2
Peer tutoring 7 9
Frequent breaks 8 8
Assignment format 9 6
54
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

55
Leuven Toolkit for Teachers
Proces
  • Aanmoedigen
  • Dagelijks oefenen
  • Hulpmiddelen gebruiken
  • Door de vingers zien

Applaud, stimulate
Daily Practice
Help, use props
Dispensate, disregard
56
ADHD-TOOLKIT for TEACHERS
Danckaerts Dewitte, in preparation
57
(No Transcript)
58
DAGELIJKS GERICHT OEFENEN
AANMOEDIGEN
ADHD toolkit M. Danckaerts Ilse
Dewitte


HULPMIDDELEN GEBRUIKEN
DOOR DE VINGERS ZIEN
59
Conclusions
  • There is a need
  • There are manuals
  • Hope you are motivated !
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