# Evidence based psycho-social behavioral intervention for ADHD

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## Psycho-social Behavioral Interventions for Adolescents

Attention Deficit Hyperactivity Disorder during adolescence can often be debilitating if untreated; however, there are treatments available that focus on the intersection between societal influences and the thoughts and feelings of the individual known as psychosocial treatments. These treatments are evidence-based and focus on behavioral management, as well as parent training, in order to promote self-efficacy in adolescents, healthy parent-teen interaction, and improve social skills and academic functioning.

## About

Attention-deficit/hyperactivity disorder is a chronic and limiting neurodevelopmental disorder that usually develops during childhood and persists into adolescence and adulthood. Acronyms that exist for psychosocial treatments include BT (e.g., behavioral therapy) and it’s subsections which are the following: BPT (e.g., behavioral parental training). Usually behavioral interventions are conducted through multiple sessions over a long period, in addition to training the mediators of the treatment (e.g., teacher, parent, peer) and the adolescent.
Psychosocial treatments are evidence based treatments that are scientifically known to improve the outcomes of youth with attention-deficit/hyperactivity disorder (e.g., ADHD). It is important to note that psychosocial treatments is an umbrella term for various treatments including behavioral management (e.g., characterized by changing behavioral tendencies of the target environment) which is one of the latest well established treatments for adolescents with ADHD. Furthermore, treatment for adolescents with ADHD is highly important since approximately 50% of children will still meet the diagnostic criteria for ADHD as an adolescent.
Behavioral therapy is intended for children and adolescents, however behavioral therapies are usually modified since adolescents experience an increased amount of parent and teen conflict. Behavioral interventions involving parents are beneficial for the teen’s treatment as well. It allows parents to better understand the disorder and increase engagement with their teenager’s treatment. As a result, adolescents need to be an integral part of the treatment process since this age group has the cognitive capacity to guide their treatment. Next, this age group is most likely to be less cooperative, deny the treatments, or underestimate their limited functionality. Lastly, according to, approximately 90% of adolescents refuse and are unmotivated to take ADHD medication which highlights the importance of psychosocial treatments.

## Versions

Overall, behavioral therapies for adolescents usually are implemented in the following versions: behavioral parent training, teacher behavioral interventions, and intensive peer interventions.

##### I. Behavioral Parenting Training

According to review of behavioral therapies, behavioral parent training is one of the types of well established treatments for adolescents. Specific types of programs include Community Oriented Parenting program and Defiant Children program. In sum, this type of therapy focuses on applying contingencies, incentives, and lowering emotional reactivity. In addition, the main objective of this intervention is to improve parenting techniques which in turn improves adolescent behavior. As a result, behavioral parent training has been shown to improve parenting reports on the adolescent's symptoms’ severity and impairment as well as the relationship between the parent and adolescent by enhancing parental behaviors and the child’s compliance.
For example, programs such as Strategies to Enhance Positive Parenting changed traditional parental sessions to longer sessions that lasted 2.5 hours and provided opportunities for single mothers to watch the process of behavior management and promoting incentives. Also, programs such as Coaching Our Acting-Out Children was created to provide special training for fathers to improve their behavior management skills.

#### II. Behavioral Classroom Management

The next type of version is the behavioral classroom management that has been very effective in treating ADHD. Specifically, this intervention includes a Daily Report Card (DRC) and a teacher consultation throughout the entire school year. This type of intervention resulted in lower reports of classroom violations and ratings of ADHD symptoms. Also, this intervention resulted in higher academic productivity and classroom behavior.
According to, classroom management consists of both antecedent and consequence based strategies. Specifically, antecedent based interventions prevent disruptive behaviors from occuring in the first place. Examples of antecedent based strategies include modifying the length of work assignments or providing options of work assignments to students. Based on previous research, emphasizing choice making for students with ADHD is associated with longer periods of engagement and lower levels of negative behavior in the classroom. On the other hand, consequence based strategies consist of changing the individual’s environment after the negative behavior. Examples of consequence based interventions include contingent positive reinforcement such as praise or rewards when the adolescent engages in a positive behavior (e.g., completion of homework). highlight that students receive positive reinforcement for target behaviors (e.g., raises hand to participate) or token reinforcement which can be used for exchange for desired activities such as computer time for play time.
In more depth, special education teacher preparation is a main component that can help adolescents with behavioral disorders. Teachers who are efficiently prepared are more likely to implement the use of individualized plans, reinforcement strategies, and document student progress to evaluate changes. Specific changes to trained teachers is that they are more likely to have clear expectations about behavior, explicitly taught classroom and rules, acknowledged appropriate behavior, responded quickly to inadequate behavior consistently reacted to appropriate and inappropriate behavior.

##### Classroom Interventions Table

* Common Behavior Interventions
* Reduce Assignment Length
* Emphasize Quantity or Quality
* Immediate Feedback on Assignments
* Start with simple tasks and slowly progress
* Increase novelty (e.g., using different notations during class instructions, colored paper, films, models, skits, etc.)
* Provide choice of activities
* Teacher-directed seatwork
* Critical Instruction in the morning
* Non-academic activities during the afternoon
* Incorporate physical activities (e.g., trip to the office, sharpen pencil, take note to teacher, watering plants, standing at desk)
* Encourage active responses
* Place student in close proximity to the teacher and away from distractions (e.g., windows, doorways, etc.)

##### Classroom Reinforcement Table

* Common External Reinforcement
* 1. Self-monitoring- - involves student and teacher to evaluate whether the student is on-task at predetermined intervals throughout the day.
* 2. Token Economy System - involves student tokens that can be exchanged for desired rewards or privileges.
* 3. Response-Cost Programs - involves allocating a fixed set of points at the start of each day and when a rule is broken points are subtracted.
* 4. Time Out - involves removing the student from activities or from peers. Time-out area should be a neutral environment and should not be used if a child wants to avoid schoolwork. A discussion must occur to discuss a student's poor behavior.
* 5. Daily Report Card - involves parents and teachers to identify 3 to 5 disruptive behaviors. The adolescent will take the report card home to earn a reward for meeting a specific goal.

#### III. Behavioral Peer Interventions

The third type of version is the behavioral peer interventions to enhance adolescent's social skills across various contexts. These interventions manipulate contingencies in various settings to improve social functioning. One of the programs called Parent Friendship Coaching (PFC) utilized this framework and resulted in significant improvements in parental reports of social skills and teaching rating of peer liking and acceptance. Other programs including the Summer Treatment Program Adolescent were modified to be delivered in peer settings and are more practical than outpatient care.
However, this type of treatment has very limited research and few studies have tested for the effectiveness of such treatments. One way of implementing this type of intervention is through assigning a student with an adult who coaches the student in a school setting. Specifically, both the student and coach work together in order to create objectives to work on through goal-setting, monitoring behavior, feedback, and contingency Based on the manual, Coaching the ADHD Student emphasizes the importance of facilitating a coaching relationship with a student that struggles with ADHD In addition, it emphasizes that focusing on short term goals with the coach instead of long term goals, allows the student to cognitively maintain their goals This also allows the individual to cope with any obstacles that prevent them from achieving their goals. The manual also emphasizes that this type of intervention works best for older individuals with ADHD, such as adolescents., conducted a study in order to examine the effects of classwide peer tutoring (CWPT) with and with peer tutoring on the social behaviors of three children diagnosed with ADHD during school activities. The results revealed that using both CWPT and peer coaching contributed to the most improvement of social behaviors compared to without peer coaching.

##### Advantages/Disadvantages of Versions Table

| Behavioral Parenting Training | Behavioral Classroom Management | Behavioral Peer Training |
| Pros: Parents learn strategies to encourage positive behavior and discourage negative behaviors, while improving communication, and strengthening their relationship with their child Helps in decreasing behavioral and internalizing problems Effective for parents of young children who are not mature enough to change their own behavior | Pros: Prevents poor behavior and decrease frequency of poor behavior Preventive strategy to decrease likelihood of disruptive behaviors from occurring Consequence based strategy decreases disruptive behavior Implemented in school setting where adolescent which heavily impacts by ADHD Desired outcomes: Longer attention and engagement | Pros: Enhances adolescents’ social skills across multiple contexts Focuses on short-term goals which allows the student to cognitively focus on and maintain their goals Has demonstrated success in producing immediate positive treatment effects |
| Cons: May be ineffective at reducing core symptoms of ADHD Ongoing training may lead to increased costs to parents who are economically disadvantaged | Cons: Training of teacher required to implement intervention Required communication between teachers, psychologist, and parents More attention to specific child’s behavior required | Cons: Has very little research behind the effectiveness of the treatment Has very little research behind the maintenance of the effects of successful treatment |

## Outcomes

Behavioral therapy promotes self-efficacy in adolescents as well as an increase in autonomy due to an emphasis on the relationship between parent and teen through joint therapy sessions.
In addition, BT reduces the levels of negative parenting (e.g. reduction in parent’s negative comments) and increases the quality of parent-teen relationship. The parents’ perception of the teenager’s behavior changes, as well as an increase in the parents’ sense of self worth. The quality of the relationship is strengthened with an increase in positive feelings and attitudes toward one another.
Furthermore, also found that BT may have beneficial effects on social skills and academic function of the adolescent if specialized modules that target social and academic skills are incorporated in the treatment.

## History of the Treatment

Often times, behavioral interventions such as parent interaction have been developed from children to be used with adolescents that have ADHD. However, previous studies have shown that implementing rigid cognitive and behavioral treatments for adolescents have been deemed ineffective since adolescents spend less time with their parents and are highly influenced by their peers and teachers. Also, treatments consider the fundamental developmental changes that occur as a child transitions into adolescence. Specifically, behavioral interventions include various strategies such as classical contingency management, behavioral therapy, and cognitive behavioral therapy (e.g., verbal self-instruction, problem-solving, and social skills training).
In more depth, specific developmental changes that are implicated to behavioral interventions for adolescents can be based off six developmental changes, which include the following: greater cognitive capacity, increased self-awareness, emphasis on identity, increased independence, and greater reliance on peers for information.
In general, behavioral interventions are defined as treatments directed to increase healthy behaviors and decrease unhealthy behaviors through the use of reinforcement such as positive or negative reinforcement and other social learning principles such as modeling.

## Limitations

Furthermore, behavioral interventions as a whole have certain limitations that need to be addressed. Most psychosocial treatments have been mainly studied and implemented among children. Also, most studies focus on treatments on children with ADHD instead of adolescents with ADHD. Consequently, few studies have been published researching the impact of psychosocial treatments among adolescents with ADHD.
In terms of internal and external validity, many of the studies conducted to examine ADHD behavioral treatments focused on white samples. As a result, the multicultural component is not addressed in ADHD experiments, therefore it is not known if different racial or ethnic groups respond similarly or differently to behavioral treatments. Furthermore, there is limited research on the effectiveness of behavioral therapies, specifically parent behavioral interventions, for fathers and single mothers. As a result, little research has been conducted to determine how to adapt the intervention for this population because they are the least likely to attend therapy sessions. Next, behavioral interventions do not focus in reducing ADHD symptoms, but rather in learning how to cope with these symptoms. Lastly, these treatments are not as effective for individuals who experience comorbidity with conduct disorder since these individuals are prone to refuse the treatment procedures.

## Resources

Society of Clinical Child & Adolescent Psychology- ADHD Therapy
American Academy of Child & Adolescent Psychiatry- ADHD Resource Center
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)
ADHD Support Groups
Parent Guide to ADHD
How to Establish a Daily-Home Report Card
What Parents and Teachers Should Know about ADHD

## See Also

General Information on ADHD Evidence Based Assessment for ADHD Evidence Based Assessment Questionnaire ADHD Rating Scale