ADHD Family Therapy Options

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ADHD Family Therapy Options

• By Patti Higgins

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ADHD symptoms diagnosis

• ADHD occurs in 3 to 5 of school-aged children
  and is associated with both concurrent and
  long-term impairments in academic and social
  functioning.
• Three subtypes have been identified by the
  DSM-IV. The first refers to the hyperactive type,
  described as displaying over activity,
  impulsivity, excessive talking, fidgeting and
  disruptive behaviors (Rizzo, et al., 2000).
• The second type is called the inattentive type,
  commonly referred to as attention deficit
  disorder (ADD), which is characterized by
  difficulty in organizing tasks, difficulties with
  focused attention, forgetfulness,
  distractibility, trouble listening to or
  following directions, without symptoms of
  hyperactivity.
• The third type, the combined type, demonstrates
  symptoms of both the inattentive and hyperactive
  types (Rizzo et al., 2000).

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Family Therapy

• Family psychology is based on a systems theory
  approach. Goldenberg and Goldenberg (2000),
  define systems theory as a generic term in
  common use, encompassing general systems theory
  and cybernetics, referring to the view of
  interacting units or elements making up the
  organized whole (p. 446).
• Current empirically validated treatment options
  include family therapy. Specifically, parent
  training, behavioral modification and
  communication skills training have proven
  effectiveness.

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Alternative therapies

• The profusion of problems called ADHD mandates
  multimodal approaches not only to optimize
  therapeutic impact, but also to inform theories
  of developmental psychopathology and therapeutic
  change (Whalen Henker, 1991).
• Such multimodal approaches may combine family and
  pharmacological therapy with alternative
  treatments such as hippotherapy, virtual reality
  and dolphin-assisted therapies.

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ADHD family systems

• As a lifestyle rather than an acute disorder,
  ADHD has a salient impact on key members of the
  child's social network, a network that, in turn,
  plays a pivotal role in shaping all future
  outcomes.
• The nonpharmacologic treatments considered here
  teach problem-solving and coping skills not only
  to ADHD children but also to those who interact
  with the children on a regular basis.
• Psychosocial approaches treat ADHD in its
  interpersonal context, recruiting the child's
  family and caretakers as partners and equipping
  the team with resources for managing a
  challenging and persistent disorder (Whalen
  Henker, 1991).

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PSCT BMT

• Barkley, Edwards, Laneri, Fletcher and Metevia
  (2001) compared two family therapies,
  problem-solving communication training (PSCT) and
  behavior management training (BMT) with teens
  with attention-deficit/hyperactivity disorder.
  Results indicated that both family therapies were
  effective in normalizing family interactions.
  Families reported decreased conflicts and
  increased communication and problem-solving
  skills in both treatments.

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BMT, PSCT Structural therapy

• According to Barkley, Guevremont, Anastopoulos
  and Fletcher (1992), three family therapy
  programs were successful in reducing conflicts in
  ADHD families
• Child behavioral management training (BMT)
  emphasizes the enforcing consequences for
  oppositional or noncompliant behavior and the
  reward of compliant behavior. It successfully
  reduces parentchild conflicts and child
  noncompliance.
• Problem solving and communication training (PSCT)
  programs for parentadolescent conflicts have
  demonstrated effectiveness in decreasing
  noncompliance behaviors.
• Structural family therapy has demonstrated its
  effectiveness in reducing child noncompliance by
  reestablishing parental authority and hierarchy.

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Parent Training

• Reid Webster-Stratton (2001) described the
  successful treatment of a 6-year-old boy with ODD
  and ADHD using the Incredible Years Parent,
  Teacher, and Child Training programs. The boy
  decreases his incidences of misconduct and
  increased compliance after therapy. "Children who
  present for treatment with oppositional-defiant
  disorder (ODD) and conduct disorder (CO)
  frequently exhibit these symptoms across settings
  and often show comorbid symptoms of ADHD and/or
  internalizing symptoms such as anxiety or
  depression" (p. 378).

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PCIT

• The Parent-Child Interaction Therapy (PCIT T. L.
  Hembree-Kigin and C. B. McNeil, 1995) does
  involve learning and practicing specific
  techniques during sessions. PCIT was used to
  successfully in family counseling with a
  7-year-old boy with ADHD. In this case study,
  specific PCIT techniques for enhancing
  communication and understanding, demonstrated
  improved parent-child interactions.

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Homework Success Program

• ADHD families who used a Homework Success Program
  demonstrated significant improvements in both
  home and school behaviors. This brief therapy
  program involves increasing parent understanding
  of their child's behavior and training in
  behavioral techniques to improve academic
  productivity and behavioral functioning.
  (Habboushe, Daniel-Crotty, Karustis, Leff,
  Costigan, Goldstein, Eiraldi. Power, 2001, p.
  123)

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Culturally sensitive multimodal

• Eiraldi and Power (2001) successfully used a
  multimodal treatment approach with an 8-year-old
  ADHD girl which included interventions for
  specific situations, as well as
  culturally-sensitive school and family
  interventions.

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Bonney (2000)

• evaluated a therapy that blended theories of
  cognitive psychological, communicative and
  systemic processes for the treatment of children
  with ADHD. Study of 46 elementary school children
  about 8-years-old resulted in 52.6 showing
  significant behavioral and academic improvements.
  Bonney (2001) reiterated the need for inclusion
  of "family constellations in the treatment of a
  hyperactive child" (p. 285).

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Psychoeducation parent training

• Parent training uses a psychoeducational approach
  to instruct parents in cognitive-behavioral
  management techniques for addressing children's
  behavior problems (Smith Barrett, 2000). In a
  study, three girls, aged 10 - 11 years-old, with
  ADHD were examined before, during and after a
  parent training intervention. Results from parent
  ratings of behavior and emotional status,
  observations of parent and child home behaviors
  showed that child compliance improved in 2 out of
  3 families.

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Behavioral Mngmt. Flow Chart

• A 35-year-old mother of 4-year-old twin boys with
  ADHD and ODD received parent training and used
  the Behavior Management Flow Chart. Results of
  the training and her unique interactions with the
  twins demonstrated remarkable success.
• Data revealed how the twin boys individually
  responded to the parent training program and how
  the mother interacted with her sons differently.
  (Danforth, 1999, p. 59)

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Storybook Family Therapy

• Hanney and Kozlowska (2002) demonstrated the
  effectiveness of the creating and discussing
  illustrated storybooks in family therapy. One of
  their three vignettes for use of storybook
  therapy includes an 11-yr-old boy with ADHD who
  successfully increased compliance and decreased
  symptoms of behavioral disorders.

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Milan family therapy

• The Milan model of family therapy involves three
  main intervention techniques hypothesizing,
  circularity and neutrality (Goldenberg
  Goldenberg, 2000).
• By guessing the family games, asking circular
  questions of family members and maintaining
  neutrality, Milan therapists encourage clients to
  come to their own conclusions about new options
  and necessary changes in the family system
  (Goldenberg Goldenberg, 2000).

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More family approaches

• Narrative therapists engage in externalizing
  conversations to demonstrate that the family or
  client is not the problem the problem is the
  problem (Goldenberg Goldenberg, 2000, p. 316).
  
• McDaniel, Hepworth and Doherty (1992) proposed
  medical family therapy, which refers to the
  biopsychosocial treatment of individuals and
  families who are dealing with medical problems
  (p. 2) (Goldenberg Goldenberg, 2000, p. 330).
  In medical family therapy, clinicians try to
  treat ADHD from a multisystemic approach.
• Satir proposed 5 stages of change for ADHD 1)
  the status quo, 2) the foreign element, 3) chaos,
  4) new integration and 5) practice Within these
  stages, Satirs methods incorporated therapeutic
  phases including skills such as 1) making
  contact, 2) validating, 3) facilitating
  awareness, 4) promoting acceptance, 5) making
  changes, and 6) reinforcing changes (Loeschen,
  1991).

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Child Behavioral Checklist

• The Child Behavioral Checklist (CBCL) is
  completed by parents, teachers or clinicians to
  measure childrens behavior and emotional
  problems (Murphy, Conoley Impara, 1993). The
  CBCL is highly valid and widely used to
  distinguish between children with and without
  behavioral disturbances. It is considered the
  preferred behavioral rating scale for most
  research purposes and certain clinical purposes.
  The CBCL has high internal consistency and
  reliability problems (Murphy, Conoley Impara,
  1993).

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Parenting Stress Index

• The Parenting Stress Index is a 120-item
  self-report measure to identify stress levels in
  parent-child systems (Murphy, Conoley Impara,
  1993). Although originally developed to identify
  potentially dysfunctional parenting, the test can
  also be used to assess specific parenting
  vulnerabilities, to recommend appropriate parent
  education and to develop prevention strategies
  (Murphy, Conoley Impara, 1993 Cohen
  Swerdlik, 1999).

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Pharmaceutical approaches

• More than 9, 000 studies evaluating the efficacy
  of stimulant drugs in ADHD have been published
  (Pelham, Hoza, Kipp, Gnagy Trane, 1997, p. 3).
  Approximately 8090 of all children diagnosed
  with ADHD received treated psychostimulants,
  central nervous system stimulants at some time.
  The most popular psychostimulant, Ritalin, has
  demonstrated efficacy in improving attention,
  decreasing noncompliant behaviors and enhancing
  prosocial attitudes towards family members and
  school peers.

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Rice (1992) suggested

• (a) that clinicians incorporate a systems view of
  the family in their model of consultation when
  assessing for ADHD, thus ensuring consideration
  of wider family effects when interventions are
  planned
• (b) that medication be presented to parents as a
  means of reducing family stress so that maximum
  benefit may be derived from adjunctive therapies
  such as family counseling
• (c) that early concerns over a child's behavior
  be addressed. (p. 130)

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Dolphin Assisted Therapy

• Dolphin Assisted Therapy (DAT) at Dolphins Plus,
  through Island Dolphin Care, Inc., incorporates a
  behavioral modification approach, whereby
  swimming with dolphins serves as the reward for
  improved behavior.
• When children display the requested desirable
  cognitive, physical or affective responses,
  they receive the reinforcement and
  reward of playing and
  swimming with the
  dolphins(Island Dolphin Care,
  Inc., 2001).

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Virtual Reality Therapy

• The Virtual Environments Laboratory at the
  University of Southern California developed
  virtual reality technology to study, assess and
  rehabilitate cognitive functional processes such
  as attention deficits. Virtual Environment
  technology appears to provide specific assets for
  addressing the impairments of attention deficit
  disorder, and related impairments, because it
  allows control of distracting auditory and visual
  stimuli (Rizzo, Buckwalter, Bowerly, Van Der
  Zaag, Humphrey, Neumann, Chua,
  Kyriakakis, Van Rooyen, Sisemore,
  2000).

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Hippotherapy

• The Therapeutic Horseback Riding Program at the
  Helen Woodward Animal Center in Rancho Santa Fe
  offers services to people with physical,
  emotional and development disabilities. The horse
  is perceived as a non-judgmental, patience and
  loving teacher for emotionally or developmentally
  challenged children.

• In general, children express increased motivation
  and display focused attention when learning to
  care for and ride the horses. Such progress
  builds their self-esteem and confidence. People
  not only learn how to ride a horse, but they also
  learn acceptance, trust, respect and love (THRP,
  2001).

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Conclusion

• Current empirically validated treatment options
  include family therapy and pharmacological
  treatments. Specifically, parent training,
  behavioral modification and communication skills
  training have proven effectiveness.
• Multimodal approaches may combine family and
  pharmacological therapy with alternative
  treatments such as hippotherapy, virtual reality
  and dolphin-assisted therapies. However, those
  treatments have yet to be empirically validated.