Used to Treat Children with ADHD Safety and Efficacy

Psychosocial Interventions Used to Treat Children with ADHD Safety and Efficacy Steven W. Evans, PhD; Brandon K. Schultz, EdD; and Joanna M. Sadler, BS Although stimulant therapy is the most common treatment for attention-deficit/ hyperactivity disorder (ADHD) in children, it is not always effective in reducing behavioral symptoms. As a result, research on psychosocial interventions has progressed in recent years. This article provides a synopsis of psychosocial interventions for childhood ADHD, with an emphasis on basic behavior management principles, evidence-based interventions, and safety issues. Developmental issues that distinguish psychosocial interventions for children and adolescents are highlighted, and practical recommendations for collaborating with mental health professionals are provided. Earn 4.0 Contact Hours Journal of Psychosocial nursing • Vol. 46, no. 8, 2008 49 © 2 00 8 Ju pi te rIm ag es C or po ra tio n C hildren and adolescents with attention-deficit/ hyperactivity disorder (ADHD) experience impairments that can result in poor long-term outcomes in academic achievement and relationships with peers and family members. The most frequently used treatment for ADHD is stimulant therapy; however, this treatment does not relieve some ADHDrelated impairments (Hoza et al., 2005), appears ineffective in reducing behavioral symptoms in up to 30% of cases (Spencer et al., 1996), and is rejected or abandoned by a significant proportion of youth and caregivers. As a result, research on psychosocial treatments has progressed, as detailed in several recent reviews (Pelham & Fabiano, 2008; Raggi & Chronis, 2006). This article provides a synopsis of psychosocial interventions for childhood ADHD, with an emphasis on basic behavior management principles, evidence-based interventions, and safety issues. We also highlight developmental issues that distinguish psychosocial interventions for children and adolescents, as well as provide practical recommendations for collaborating with mental health professionals. PrinciPles of behAviorAl intervention Children with ADHD appear to respond best to clear and consistent behavioral expectations monitored by the adults at home and school. In contrast, psychosocial strategies that emphasize insight-driven change, such as individual counseling, are generally less effective. Behavioral techniques rely on the use of rewards and consequences to shape target behaviors. One of the challenges of using behavioral techniques involves identifying rewards and consequences that are salient enough to result in behavioral change while safely avoiding behavioral side effects. In addition, the schedule that contingencies follow may be based on the frequency, intensity, or duration of a behavior. In this article, contingencies refers to the relationship between a child’s behavior and adult responses to that behavior. Adult responses may be consistent (i.e., fixed) or may fluctuate randomly (i.e., variable) on the basis of the behavior, the environment, and the desired outcomes. Contingencies may involve the application or presentation of a consequence for behavior. For example, to reduce unwanted behavior, the adult may present something undesirable to the child (e.g., additional chores), which is referred to as positive punishment. To increase desired behavior, the adult may provide something desirable to the child (e.g., permission to borrow the car), which is referred to as positive reinforcement. Alternatively, contingencies can involve the removal of something as a consequence for behavior. For example, to decrease unwanted behavior, the adult may keep something desirable from the child (e.g., restrict access to video games), which is referred to as negative punishment. To increase desired behavior, an adult may remove or reduce an aversive condition (e.g., allow the child to skip chores), which is referred to as negative reinforcement. Because these labels are often confused, it is important to keep them distinct when communicating with patients and other professionals. Both positive and negative reinforcement increase the rate, intensity, or duration of a behavior, and both positive and negative punishment decrease the rate, intensity, or duration of a behavior. Almost all evidence-based psychosocial interventions for youth with ADHD rely on these concepts. For example, common techniques used with preadolescent children include behavioral systems such as token economies, whereby desired behaviors (e.g., getting ready for school on time) are rewarded with tangible tokens, such as stars, stickers, or poker chips. Undesirable behaviors result in the withholding or removal of tokens or other desirable items or privileges in a process referred to as response cost. Serious behavioral infractions often are addressed successfully with time-out procedures used in conjunction with a token economy. Behavior therapists recommend that adults teach children the criteria for earning rewards, response cost, and time-out procedures prior to implementation. Once a token economy is started, progress is visually charted and, at prearranged times, children are encouraged to redeem tokens for rewards, such as toys, candy, or special activities. As children mature or their behavior improves, the criteria for rewards gradually become more challenging, and token trade-ins occur less frequently. In addition, behavior therapists recommend that rewards move from tangible items, such as candy and toys, to special activities and privileges, which are often less costly and more important for older children, as well as easier to provide than tangible items (Bear, 2004). For high-functioning children and adolescents, token economies may be replaced with behavior contracts. Behavior contracts are written documents that clearly define behavioral expectations and contingencies (Downing, 2002). This process typically begins with negotiations between the adult and the adolescent in an attempt to achieve a consensus regarding behavioral expectations and con-