Treating ADHD, Predominantly Inattentive Type with Integrated Psychosocial Treatment

1
Treating ADHD, Predominantly Inattentive Type
with Integrated Psychosocial Treatment
Linda Pfiffner, Ph.D. Childrens Center at
Langley Porter University of California, San
Francisco
2
What is ADHD-I?

• Case Description Kayla
• 8 y/o girl, 3rd grade, private school
• Referred due to concerns about attention mind
  floats, lives in fantasy world, organizational
  problems, needs to be redirected. Also concerns
  about social interaction problems.
• Family background lives with her biological
  mother and sister parents are divorced. History
  of ADHD, behavior problems, depression in family.
  Mother works full-time.
• Birth, medical and developmental history
  normal, but slightly late in some fine and
  gross motor skills.

3

• School History
• Problems with attention, focus and completing
  tasks began during first grade and have worsened
  each year.
• Teacher comments
• Capable, but works slowly
• Doesnt use class time well, mostly in her own
  world
• Concentration problems worse as day progresses or
  if activity is lengthy
• Lack of attention leads to missing directions
• Needs 11 or small group to stay on task and
  achieve
• Work is often sloppy, messy, incomplete, not
  turned in
• Academic ability on grade level
• Very imaginative, artistic
• Few behavior problems

4

• Peer Relations
• Immature, fits in better with younger children
• Has a few friends but does not seek new friends
• Makes up stories
• Can be bossy
• Some teasing by peers
• Teacher describes as eccentric
• Home Behavior
• Daily routine activities and homework are an
  ordeal.
• Takes forever to get things done
• Lots of frustration and conflict over need for
  reminders and not completing tasks
• Needs constant supervision
• Affects getting ready in am, homework, chores,
  bedtime
• High levels of mother-daughter conflict, but
  evidence of loving relationship

5
Teacher Ratings

• Teacher CSI ADHD IA 8/9 often or very often,
  H/I 0/9
• SCT 11/15 often or very often
• APRS 50 work completed, often completes work
  in careless fashion, often requires assistance
  to complete work, quality of work is more
  successful than poor
• Peer Relations Scale often chosen late, never
  sought after by peers, none would like for a best
  friend, none would wish she was not in class
• School Situations Q moderate-severe in 4/8
  areas
• SSRS SS Scale 79, AC88, PB130

6
Parent Interview and Ratings

• Parent KSADS and CSI IA 9/9, H/I2/9, past sep
  anx disorder.
• Home Sit. Q. moderate in 10/13 areas
• HPC very often 17/20 items
• SSRS SS Scale 67, PB Scale134
• PSI P-C Dys Interaction 99, Difficult Child
  97, Total Stress 97
• ABAS Gen Adaptive Composite 72

7
Test Results

• Behavioral Observations cheerful, rapport each
  to establish, somewhat slow to respond, compliant
  and friendly
• WASI FSIQ108, Verb114, Perf102
• WIAT II WR93, MR106, S96
• MASC T65, elevated
• CDI T47, normal range
• DSM-IV Diagnosis ADHD-I

8
Life in families with ADHD-I

• Homework vacillates between a struggle and a
  crisis
• Routine activities and chores are forgotten
• Getting ready in the morning is a formidable
  challenge
• Dawdling and procrastination means things are
  done at the last minute
• Bedrooms and play areas usually messy and
  disorganizedclothes laying in the same spot they
  were dropped toys, papers, books, and magazines
  in disarray.
• Lots of time spent looking for lost things
• Off in own world," not listening and not
  following through

9
School (cont.)

• Academic underachievement, learning disabilities
  (McBurnett et al., 1999 Carlson Mann, 2000)
• These problems may be less extreme in early
  elementary years, but as demands for independence
  increase with each grade, these problems can be
  quite severe by middle and high school.

10
Peer Relations in ADHD-ICarlson Mann, 2000
Maedgen Carlson, 2000 Blachman Hinshaw, 2002

• Tend to be passive and withdrawn
• Often play by themselves play with others for
  only short periods of time.
• Often shy, not tuned in to group conversation.
• Poor tracking and processing of social cues,
• Not well-accepted by peers teased, unpopular,
  neglected rather than openly rejected.
• Deficits in knowing what to do when interacting
  with others, not just a performance problem.

11
DSM-IV ADHD-I Must occur OFTEN, cause
IMPAIRMENT, X 2 settings

• Inattentive (6)
• Fails to give attention to details/makes careless
  mistakes
• Difficulty sustaining attention
• Seems not to listen
• Fails to finish tasks
• Difficulty organizing
• Avoids tasks requiring sustained attention
• Loses things
• Easily distracted
• Forgetful

• Hyper/Impulsive (5-)
• Fidgets or squirms in seat
• Difficulty remaining seated when asked to
• Runs about or climbs on things when asked not to
• Difficulty playing quietly
• Acts on the go or driven by a motor
• Talks excessively
• Blurts out answers
• Difficulty awaiting turn in group activities
• Interrupts people, butts into others activities

12
Sluggish Cognitive Tempo(McBurnett et al., 2001
Carlson et al., 2002

• Daydreams
• Sluggish or drowsy
• Confused or in a fog
• Absent-minded
• Apathetic or unmotivated
• Stares blankly
• Underactive or unmotivated
• Forgetful

13
Attention Problems in ADHD-I vs. ADHD-C

• ADHD-I more severe alertness/orientation problems
  than ADHD-C (McBurnett et al., 2001).
• ADHD-I more problems in focused or selective
  attention ADHD-C more problems with persistence,
  working memory and behavioral inhibition
  (Barkley, 1997).
• Both types share deficits on tests of frontal
  lobe functions, but additional problems in
  perceptual-motor speed and slow processing
  specific to ADHD-I (e.g., Barkley et al., 1992)

14
Work Style in ADHD-I vs. ADHD-C (Booth et al.,
2001 Carlson et al., 2002)

• ADHD-I and ADHD-C-
• lower motivation for learning
• less interest in challenging tasks
• less persistent and more easily discouraged
• ADHD-I prefer cooperative work setting ADHD-C
  prefer more competitive environment.
• ADHD-I motivated to please teacher, make good
  grades more so than for own curiosity, interest
  or internal drive.
• ADHD-C more likely to value being perceived as
  high performing and successful than those with
  ADHD-I.

15
Comorbid DisordersCarlson Mann, 2000

• Oppositional Defiant Disorder and Conduct
  Disorder less in ADHD-I than ADHD-C
• Anxiety and Depression comparable or more in
  ADHD-I than ADHD-C
• Learning Disorders comparable or more in ADHD-I
  than ADHD-C (esp. math achievement)

16
Tailoring psychosocial treatment to ADHD-I

• Academic impairment -- necessitates close
  involvement with school direct intervention for
  homework.
• Work style issues use non-competitive external
  rewards for specific goals accommodations to
  tasks and assignments to address slow processing
  speed
• Social difficulties-- teach and practice specific
  skills provide opportunities and reinforcement
  for approaching and interacting with peers.

17
Tailoring Tx (cont.)

• Lack of independence in daily living tasks-- most
  efficiently increased with routines, parent
  monitoring and reinforcement.
• Fewer disruptive behavior problems-- Limit
  setting strategies (time-out) less useful.
  Instead, positive reinforcement targeting
  specific goals and routines indicated.

18
Why psychosocial treatment?

• Medication may be less helpful for ADHD-I than
  ADHD-C. (Barkley et al, 1991 Greenhill et al,
  2000)
• Social impairment in ADHD-I (social
  passivity/withdrawal, lack of social knowledge)
  likely to be more amenable to PST than ST
  (Pfiffner et al, 2000)
• ST side effects of social withdrawal (Granger et
  al., 1996) may be less acceptable in children who
  already have social withdrawal problems
• ST often does not normalize functioning the
  inclusion of PST may be necessary to produce
  excellent treatment response
• Parents show a significant preference for
  behavioral treatments over pharmacological
  treatment alone (Pelham, 1999)
• These factors suggest that psychosocial
  interventions may be even more important for this
  subtype.

19
Life Skills Training for ADHD-Inattentive Type

• Exploratory/Developmental 3 year grant funded by
  NIMH (2002-2005)
• Treatment incorporates rehabilitation approaches
  based on similarities between ADHD-I and mild
  brain injuries (e.g., sluggish cognitive tempo,
  forgetfulness)
• Emphasizes adaptive skills, functional
  competence, compensatory strategies
• Uses cues, prompts, routines
• Involves teachers and parents to provide
  necessary environmental supports at school and at
  home

20
Child Life Skills Program

• Study Screening and Assessment Process
• Telephone screenings (parent, teacher)
• Agreement from school to participate
• Standardized rating scales completed by parent
  and teacher (symptoms, impairment)
• Clinic visit for family
• Clinical Interview
• KSADS Diagnostic Interview
• WASI and WIAT II screener
• Child self-report MASC, CDI
• Parent-completed PSI, APQ

21
Child Life Skills Program

• Study design
• 28 children (age 7-11) randomly assigned to
• Life Skills Training program, or
• Assessment only group (Treatment as usual)
• DSM-IV Diagnoses
• ADHD-I only 61
• Comorbid ODD 32
• Comorbid anxiety disorder 21
• Comorbid depressive disorder 4
• Parent and teacher ratings gathered at
  pre-treatment, post-treatment and follow-up

22
Participant Characteristics

Standard deviation (SD) in parentheses.
23
Child Life Skills Program

• Treatment Components
• Child
• Weekly Child Group meetings (90 min.) for eight
  weeks, concurrent with Parent Group meetings.
• Four family meetings with study therapists
• Parent
• Weekly Parent Group meetings (90 min.) for eight
  weeks, concurrent with Child Group meetings
• Four family meetings with study therapists
• Teacher
• Five consultations with study therapists,
  families attend part of meetings

24
Child Component Skills Taught

• Independence Modules
• Homework/study skills
• Self-care skills
• Getting chores done
• Routines, organization and time tools
• Public Situations

• Social Skills Modules
• Friendship-making
• Handling teasing
• Assertion
• Accepting
• Being a good sport
• Problem-solving

25
Structure of each Child Group

• Review homework, previous skills taught, stars
  earned at home and school
• Present skill of the week
• Skill game
• Role Plays
• Independence Stations and/or free play to
  practice new skills
• Reinforcement
• Review and meet with parents

26
Parent Component Skills Taught

• Positive communication (attending, praising,
  quality time)
• Use of more powerful reinforcement programs to
  support daily living skills (e.g., star systems,
  home challenge)
• Use of effective instructions and commands
• Prudent discipline (planned ignoring, response
  cost)

27
Parent Component (cont.)

• Using routines and plans to promote success
• Morning and evening routines
• Homework
• Playdate plan
• Chores
• Child skill of the week also reviewed with
  parents to promote generalization
• Social skills
• Independence Modules

28
Outline of session content

• Week 1
• Child Group Session 1
• Friendship-making Skills
• Good Sportsmanship
• Parent Group Session 1
• Overview of ADHD, Child Life Skills Program
• Behavioral Model of Child Behavior
• Attending and Quality Time
• Positive Attention and Verbal Praise
• Teacher Component (Orientation)
• Overview of Child Life Skills Program, behavioral
  intervention, classroom accommodations
• Classroom Challenge overview

29

• Week 2
• Child Group Session 2
• Whats my job? Intro to routines
• Morning routine planning
• Accepting
• Parent Group Session 2
• Rewarding behavior with praise, activities and
  privileges
• Token Economy
• Effective use of Positive Reinforcement (novelty,
  consistency, specificity)
• Effective Communication with school and teacher
  (Classroom challenge)

30

• Week 3
• Individual Family Session 1
• Review of home programs
• Individualized feedback and assistance
• Review classroom challenge
• Parent/Teacher/Child Meeting 1
• Discuss and develop classroom challenge
• Review homework routine, modify as needed

31

• Week 4
• Child Group Session 3
• Homework and study skills
• Remembering important things
• Parent Group Session 3
• Strategies for Handling Homework Problems
• Review Teacher Homework Expectations
• Discuss a Script for Parent-Teacher Meetings
• Plan Homework Program

32

• Week 5
• Child Group Session 4
• Homework and study skills practice
• Assertive Behavior
• Parent Group Session 4
• Effective vs. Ineffective Commands
• How to Structure Antecedents to Improve Peer
  Relations
• Practice Homework Routine

33

• Week 6
• Individual Family Session 2
• Review and Troubleshoot Home Programs
• Individualized Feedback and Assistance
• Practice Using Script for Parent-Teacher Meetings
• Review classroom challenge
• Parent/Teacher/Child Meeting 2
• Review classroom challenge, modify as needed
• Review homework routine, modify as needed
• Review accommodations

34

• Week 7
• Child Group Session 5
• Dealing with Teasing
• Lets Make a Plan!
• Parent Group Session 5
• Reducing Problem Behavior by Planned Ignoring
• Effective Strategies for Changing Antecedents
• Applying Antecedents to Evening Routine or Other
  Activity
• Parent/Teacher/Child Meeting 3
• Review classroom challenge, modify as needed
• Review homework routine, modify as needed
• Review accommodations, modify as needed

35

• Week 8
• Individual Family Session 3
• Troubleshoot and Individualize Other Home
  Programs
• Review Parent-Teacher Meetings
• Review classroom challenge
• AND
• Child Group Session 6
• Study Skills and Homework Practice
• Problem Solving and Organization
• Parent Group Session 6
• Response Cost (and Fines)
• Using Punishment Effectively
• Approaches to Problem Solving and Organization
  with my Child

36

• Week 9
• Child Group Session 7
• Time Management Tools
• Do it Now! Overcoming Procrastination
• Parent Group Session 7
• Improving My Childs Organization and Time
  Management Skills
• Planning Activities in Advance
• Promoting Independence in Public Places
• Parent/Teacher/Child Meeting 4
• Review classroom challenge, modify as needed
• Review homework routine, modify as needed
• Review accommodations, modify as needed
• Individual Family Session 4 (if needed)

37
Week 10

• Child Group Session 8
• Review all skills taught
• Select personal challenge
• Parent Group Session 8
• Review all skills taught
• Discuss strategies for maintaining gains working
  with new teachers
• Being prepared for future problems
• Plus monthly family meetings until follow-up

38
Sample Home Challenge
Name Date
39
Sample home target behaviors

• Complete morning routine (e.g., get up w/o
  complaining, get dressed-all items, put backpack
  by front door)
• Complete H/W assignment independently (e.g.,
  start with one page, increase with success
  strategies for going on when stuck)
• Complete chores
• Complete evening routine independently (e.g.,
  bathe, dressed, clothes in hamper, brush teeth in
  x mins).

40
Name DateHome Challenge
41
Teacher Component

• Orientation meeting with teacher and therapist
• Overview of ADHD-I and the Child Life Skills
  Program
• Overview of behavioral interventions and
  classroom-based accommodations for ADHD-I
• Overview of Daily Report Card (Classroom
  Challenge)
• Four meetings between teacher, therapist and
  family focus on
• Homework Plan
• Classroom Challenge
• Classroom-based accommodations

42
Homework Expectations

• When, what and how is homework assigned?
• Should parent help child with homework or correct
  homework?
• How important is neatness?
• How long should it take?
• Is homework meant for practicing skills or is
  there some other purpose?

43
Homework plan

• Own desk
• Organize space with paper sorter, etc.
• Lighting
• Prioritize, break down h/w
• H/W sheet checked each day
• Built in breaks
• Closely supervised H/W, incidental teaching, not
  just giving answers

44
Sample Classroom Challenge
Name Date
45
Steps to set up Classroom Challenge

• Select target behaviors
• List target behaviors on the CC Card
• Discuss logistics during school day
• Discuss logistics when at home

46
Sample target behaviors

• Academics/ Study habits
• completes assigned work accurately
• has materials necessary for task
• completes and returns homework
• keeps desk area organized/neat
• starts work with X or fewer reminders
• Peers
• plays with other children
• shows good sportsmanship
• Rules/behavior
• accepts consequences
• follows rules/directions

47
Steps (cont.)

• Identify reinforcers for the child to earn at
  home
• Discuss baseline ratings Match Game
• Review plan do a walk-through of procedure
  with child
• Schedule Follow-up meeting for 1-2 weeks after CC
  begins

48
Communication styles for working with attention
problems

• Giving directions
• Praise
• Corrective feedback

49
Give clear directions
50
Effective and Ineffective Praise You should
always keep your desk that clean!! Your desk is
spotless!! Finally you remembered your
homework. I like the way you remembered your
homework today. I hope you can put your things
away like this all the time. Its so helpful when
you have your things away on time. You ignored
Sallys teasing right now. I just hope you dont
get back at her when I leave. You made a super
effort at ignoring Sallys teasing. Why cant
your desk look like this all of the time? Your
desk looks very organized.
51
Prudent and Imprudent Feedback
52
Classroom Accommodations for Attentional Problems

• For problems following instructions and
  directions
• Keep instructions brief (one or two parts),
  specific, and step-by-step.
• For problems completing assignments and tasks
• Reduce length of assignment (break into smaller
  parts).
• Allot extra time for work completion.
• Give assignments one at a time, rather than all
  at once.
• Set time limits or challenges for completion of
  tasks.
• Include some method of checking work.

53
Classroom Accommodations (cont.)

• For problems with organization, planning, or
  beginning assignments or tasks
• Encourage child to make to do lists and use
  organizer notebooks or folders. Monitor these
  regularly.
• Teach child to organize assignments by
  completion notes according to chronological
  order, etc.
• Teach outlining and note-taking skills (e.g., by
  providing outlines for child to complete).
• Praise child for getting started on a task.

54
Classroom Accommodations (cont.)

• For problems staying focused and on task
• Seat child away from doors, windows, areas of
  frequent activity or noise, and disruptive
  students.
• Place child near teachers desk to help teacher
  monitor more closely whether child is paying
  attention to oral instructions and completing
  work.
• Provide quiet zone (e.g., desk with study
  carrel located in a corner) in which child can
  sit while taking tests, or at times when
  distracted or having trouble concentrating.

55
Classroom Accommodations (cont.)

• Cue child when it is important to pay attention
  by putting important information on chalkboard or
  introducing it with verbal prompts (for example,
  This is important).
• Cue child in advance about times or tasks where
  independence is needed, and encourage
  non-disruptive activities while waiting (for
  example, reading, journal writing, doodling, note
  taking).
• Instruct child to move on to another task when
  work finished early or to continue on easier
  parts of an assignment or task while waiting for
  assistance.

56
Classroom Accommodations (cont.)

• For problems working independently
• Reward child for finishing small portions of an
  assignment on his/her own gradually increase the
  requirement as s/he is successful.
• Set time limits or challenges for completion of
  tasks.

57
Kayla Home program

• H/W moved work station into bedroom too noisy
  in kitchen area due to remodeling. Made sure
  desk area stocked and clean/organized
• To remember assignments and bring back, CC and
  prompting most helpful
• AM routine added checklists and daily rewards
  get up earlier- reward with shower in am.
• Commandsdistant commands decreased

58

• Playdates
• during playdates would withdraw into own activity
  and engage in parallel play. Parent monitored
  more often and found alternatives for interactive
  play
• Selected specific girls for playdates
• Planned activities in advance

59
Kayla School program

• Listening target implies social behavior of
  less chatting, more eye contact. Teacher took
  the time to define and troubleshoot. Used
  praise.
• H/W target implies remembering to get it home.
  Needed reminders/cues. Tried
• Visual sticker in cubby
• Hawaiian dress key chain on backpack
  (laminated)jingly noise helped the most
• Self-monitoring whats the first thing I need
  to do when I get to the classroom
• Teacher posted homework sign for all

60
 
61
Dennis, 9 years, 3rd grade

• Getting started target due to spacing out,
  forgetting instructions. Teacher agrees to
  accommodate cross checking that he understood
  instructions
• Organization target mastered in 2 weeks
• Completing work half of problems assigned to
  the rest of classskill development still
  accomplished with half the problems.
• Child identified problems to work on, he helped
  set the goal which increased motivation

62
 
63
Tips for making a DRC work

• Define target behaviors very specifically
• Organized desk give examples of criteria
• Vague targets (paying attention) hard to track
• Include easy target behavior
• Change target behaviors or requirements if not
  working take flexible approach

64
Tips (cont.)

• Be encouraging and positive use praise
• Integrate self-monitoring, Match Game
• Make homework expectations clear
• Maintain close communication between home and
  school

65
Troubleshooting a program

• Are target behaviors clear to the child (and
  teacher) and appropriate?
• Does child understand the program?
• Does child remember the target behaviors during
  the day?
• Are the criteria realistic?
• Is the child getting sufficient feedback during
  day about his/her progress?
• Is child interested in the rewards? Are more
  immediate rewards at school needed?

66
Progress during Teacher/Family meetings, Sample
Case ADHD-ILD

• Meeting 1
• Pxs distractibility and not completing work
• When distracted go to secret spot
• Complete all in-class assignment during class
  time
• Meeting 2
• Modify in-class assignments to writing only
• Decrease doodling on h/w (parent reluctant to set
  higher expectations)
• Meeting 3
• Good progress, mostly 2s on CC
• Secret spot not used, add ignoring to CC
• Add completion of h/w problem in homework clinic

67

• Meeting 4
• Mostly 2s on CC for writing assignments
• Ignoring a px, modify to before lunch, using sign
  (could use response cost)
• Not doing h/w problem in h/w clinic teacher had
  not communicated with homework clinic staff

68
Progress during family meetingsSample case
ADHD-ILD

• Meeting 1
• Px with am routine, hard to get out of bed
• Dad doing h/w for her pessimistic
• Set up HC targeting h/w and am program, use
  stickers for daily reward and weekly video
• Meeting 2
• Not much improvement in h/w
• Modify after school routine dad picks up 30 min
  early, small snack, start h/w earlier, make sure
  rewards given (parent did not believe in
  incentives)

69

• Meeting 3
• Program is working Dad goes through h/w
  instructions, but she does it without Dads help.
  
• Earning daily and weekly rewards
• Dad says still distractible. Get a desk and put
  in her room.
• Meeting 4
• Desk has greatly helped decrease distractions
• Routine and rewards working, earning free time
• Using incidental teaching (not giving the
  answers)
• For am, using alarm clock and stars
• Parents did not think much could change, but
  small modification made a big difference. She is
  happy on playground, increased confidence, doing
  better with social entry, less snippy with peers,
  and has playdates for first time.

70
Mean scores for Child Life Skills and Assessment
Only groups at baseline and post-treatment,
Parent Report
71
Mean scores for Child Life Skills and
Assessment-Only groups at baseline and
post-treatment, Parent Report
72
Mean scores for Child Life Skills and Assessment
Only groups at baseline and post-treatment,
Teacher Report
73
Parent Consumer Satisfaction Ratings

• Attention Difficulties 90 improved or much
  improved
• Change in Target Behaviors
• 88 improved or much improved
• Morning routine
• Social Skills
• Homework
• Classroom
• Home and School Challenge 100 helpful or very
  helpful
• Usefulness of Skills Taught 95 useful or
  extremely useful
• Satisfaction With Treatment 100 satisfied or
  very satisfied

74
Teacher Consumer Satisfaction Ratings

• Classroom Challenge 100 helpful or
  very helpful
• Effort required to participate 88 not too much
  
• Continued use of Classroom Challenge
• 80 likely or very likely
• Recommendation of the program to other parents
  and teachers
• 93 recommend or strongly recommend
  
• Use of program to treat attentional/academic/socia
  l skills problems
  100 appropriate or very appropriate

75
Child Consumer Satisfaction Ratings

• (Ratings on 5- point scale not at all, a little,
  somewhat, pretty much, a lot)
• How much did you like the group? 90 pretty much
  or a lot
• How much did you learn in group? 90 pretty much
  or a lot
• How much did the Home Challenge help you do
  better at home?
• 85 pretty much or a lot
• How much did the School Challenge help you do
  better at school?
• 80 pretty much or a lot
• How much would you like to continue in the group?
• 80 pretty much or a lot
• Note for all questions, one child rated
  sometimes

76
Common Issues

• Family fails to do homework
• Does not understand
• Too angry
• Disagrees with need
• Too much effort
• No time (and didnt get needed supplies)
• Forgot
• Kitchen-sinking, hard to stay on topic
• Child tests the system
• Siblings
• Teacher/school not supportive or parents and
  teacher fail to communicate

77
Common Issues (cont.)

• Resistance to using rewards re-name, hear about
  success from other parents, use small, practical
  rewards
• Managing parent affect and emotion increase
  awareness, coping strategies
• Anxiety and perfectionism in implementing
  program lower the threshold for success, step
  back, be more supportive and catch them being
  good

78
What was most helpful?

• Using consequences rather than repeating
  directions over and over.
• Attending and praising
• Setting time limits, using a timer
• Ignoring outbursts
• Using varying levels of rewards cuddle time,
  computer time, having friend over, dessert
  choice, movie, lunch date with mom, bike to park
• Using job jar for infractions (home tasks)
• Applying the program consistently

79

• Giving immediate commands (e.g., do xyz, rather
  than when this is over can you do this?)
• Playdates
• Plans importantactivity, length, practice
  setting up, use telephone, coaching before child
  came, rewarding afterwards
• Using a chart
• Having a defined program allowed for more
  couples time without constant discussion of
  parenting/child.

80
What did parents like about the program?

• Groups
• Children in own peer group made it fun
• Relating to other parents
• Feeling supported, individualized advice,
  sharing info
• Group size great
• Therapists addressed concerns well, responsive
  to feedback
• Educating parents (informative), increased
  awareness of parenting
• Program
• Separate family and teacher components, holistic
  approach
• Positive reinforcement and praise for target
  behs, home and classroom challenges
• Rewards program for children
• Organized (structured), common sense approach
  that values the child
• Parenting Help
• Parenting tips, ABC, social skills for children
• Immediate change in childs beh
• Learning that children need limits

81
What did teachers like about the program?

• Effort
• Quick and efficient, meetings were short and
  productive
• Easy target behaviors to work on
• Minimal effort
• Teacher-Child Relationship
• Daily feedback, classroom challenge helped
  student and teacher focus on behaviors
• One-on-one work
• Hands-on nature
• Seeing child pleased with ratings
• Made teacher pay close attention to child
• Gets student involved in own decision-making
• School/Family Relations
• Educating, involving both teachers and parents

82
Barriers to treatment

• Parent psychopathology
• Low SES (transportation, childcare px, no job/
  neighborhood factors)
• No coverage for mental health services
• Marital conflict (and inconsistent parenting)
• School not willing or able to participate
• Insular family, lack of social support
• Language and/or learning px in parent

83
Methods for tailoring behavioral intervention

• Parenting skills Group vs. family format
• Child skills Group vs. individual, need to
  teach basics to parents/teachers
• School List accommodations, request 504 or IEP
  (if comorbidities present) to formalize. Daily
  report card almost always helpful during
  school-age years.

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Reference for Child Life Skills Program

• Pfiffner, L.J. (2003). Psychosocial treatment
  for ADHD-Inattentive Type. The ADHD Report, 11,
  1-8.