Topic 5: Treatment of Behavioral-Externalizing Disorders {by 7/10}

There are three readings due this week for ADHD & Conduct Problems: Mash and Barkley Chapters 2 and 3 (see specific page numbers) and Friedberg & McClure Chapter 13.  Address the following two discussion points:  (1) In many ways, relative to the other disorders covered in this course, the effectiveness (and “practicality”) of psychosocial-psychological treatments for ADHD seems to be minimal.  (For example, the brief comments for CBT [Mash & Barkley, pp. 106-107] are not encouraging.)  Knowing this, what treatment approach appears to have the most promise in producing significant behavioral improvements for youth with ADHD (excluding psychopharmacological only approaches). Of course, explain and support your position. (2) Skills training approaches for treating conduct problems has received increasing attention in research and clinical practice.  Multiple approaches are discussed.  Identify at least a couple of themes that tend to generalize across these skills training approaches (i.e., what do these approaches have in common?).  Your original post should be posted by the beginning of class 7/10.  Have your two replies no later than 7/12.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

45 Comments (+add yours?)

  1. Jane Jenkins
    Jul 06, 2014 @ 18:38:58

    1) The treatment approach that seems to have the most promise producing significant behavioral improvements for youth with ADHD are those that provide experiential, in-the-moment practice of applications, along with continued management. Barkley’s theory attributes ADHD to deficits in executive functioning that, in-turn, result in problems with self-regulation and behavioral inhibition. I think a common assumption is that youth with ADHD are just hyper or act impulsively. The way Barkley explains it, it is more like the impairment in executive functioning causes problems with delay discounting and an under-developed ability to deal with concentration interference. CBT may not address it because as the authors noted, it is more about the child not doing what he or she knows to do versus not knowing what to do. Executing a behavior at the point of performance (Smith, Barkley & Shapiro) is the most effective way to practice and retain strategies that can assist with the challenges of ADHD. Regarding the strategies as prostheses that the child will always need reminds us that ADHD does not go away and needs to be managed long term. Social Skills Training (SST) seems to give children both social skills knowledge and practice that they lack, and point of performance practice to learn when to apply the correct skills. This also serves to address distorted perceptions about other kids and teaches them about social interactions.
    2) A couple of themes that generalize across skills training approaches for conduct problems in youth are that they work best when modeled and practiced, and that parent training is a necessary component for improvement. Improving social skills seems to generalize across all of the interventions as well. Children seem to internalize more effectively when they get to practice the skills they are being taught about. Dysfunctional parent/child interactions also feed the cycle of conduct problems, so parent training is also a common theme across approaches. This makes sense because the relationship that perpetuates the behavior needs to be modified in order for long lasting changes to occur.

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    • Rebecca Boisvert
      Jul 12, 2014 @ 09:17:16

      Hi Jane, I really agree with your thoughts about point of performance when it comes to behavior modification in ADHD treatment. As we talked about during the presentation, an immediate response at the time of the behavior allows the child to recognize what are desired/not about his/her actions so that they may be able to recognize similar situations as they occur. I think that while this may seem overly simple, and should be something that is carried out with all children, the difference with a child with ADHD is that the reinforcement must be consistent and the same every time, otherwise the child is not provided a reliable behavior modification plan, and it most likely not going to work well in the long run.

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    • Robin Horsefield
      Jul 12, 2014 @ 19:13:45

      Jane, I agree with your assessment that in-the-moment practice holds the most promise. I also like your description of why CBT may not be as effective with ADHD children. They have no problems processing information or situations, it is a problem with interruptions in concentration. The change in approach also supports the research showing that these treatment approaches cannot be maintained without continued direct application. The children would seemingly have to rewire their brains in order to make any change permanent. Without this understanding of ADHD, I can see how therapists might become discouraged and frustrated with the lack of effectiveness of the current treatments.

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  2. Taylor Tagg
    Jul 07, 2014 @ 21:54:40

    1) Based on the information provided by Mash and Barkley in regards to the treatment of ADHD in children, it appears that the interventions that are most effective are those that focus on accommodating to and coping with the child’s developmental deficiencies that accompany the disorder. This will essentially facilitate in reducing further impairments in functioning that arise in the home, school, and other important settings. The text emphasized the perception that ADHD is not a disorder of knowledge or skill, rather it is a disorder of performance. Therefore, direct behavioral interventions that aim to elicit a child’s ability to show what they already know would be most effective. Of course, such tactics can be implemented by both parents and teachers, in addition to the implementation of reward systems, which also have been proven to be effective in children with ADHD.
    2) Based on the presumption that disruptive behavior disorders are characterized by multiple behavior problems, it is important to consider certain themes that transpire when considering treatment approaches. One theme when working with externalizing disorders that I always take into consideration is the importance of positive reinforcement. All too often, such children are consistently being called upon to their negative behaviors and this can have serious implications to their self-esteem and how they view themselves in this world. With that being said, parent education is also something I believe to be crucial in skills training for treating conduct problems. Parents have to become more aware of attending more to positive behaviors and validation, as opposed to the negative behaviors. A final theme that I consider to generalize across skills training approaches is that of performance-based accomplishments. Therapy must promote the active practice of what we as therapists teach in order to further facilitate the child in showing what he or she knows (i.e. jigsaw- putting the child in a position of leadership and power). The more we give such children the opportunity to be in the positive spotlight, the more likely we are to see positive changes.

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    • Julianna Aguilar
      Jul 10, 2014 @ 14:46:54

      Taylor, I like how you mentioned the importance of positive reinforcement as a theme when treating conduct problems. Like you said, these children and adolescents are often viewed as having only negative qualities. I image it can be difficult for parents, teachers, and other adults to highlight the child’s positive characteristics when they consistently observe the child’s disruptive, and sometimes dangerous, negative behaviors. Their frustration, among other factors, may cloud their ability to identify and praise their child’s positive attributes. Though it is important to recognize and validate the parents’ frustration, it is even more important, as you pointed out, to provide parent education and training to help them recognize their child’s positive qualities. Highlighting these positive qualities will not only help the child feel a sense of pride and accomplishment, but will be important for the overall case conceptualization being that understanding the client’s strengths can be an important part of treatment planning.

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      • Taylor Tagg
        Jul 10, 2014 @ 19:34:30

        Julianna, I appreciate your response. As was presented earlier today in class, it is proposed that for every negative corrective feedback we give a child who presents with ADHD, we should give five positive corrections or responses to their behaviors. I think that this declaration shows in and of itself just how important positive reinforcement is for such children and how they perceive their worlds.

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    • Jane Jenkins
      Jul 11, 2014 @ 09:38:32

      Taylor,
      I like your focus on the disorder of performance rather than skill as the take-away from Barkley’s literature. Sure puts a different spin on it to look at it from that perspective. Many parents that I have spoken with focus on the medical model of just “giving the kid a pill” as though that fixes lack of attention and stops hyperactivity. Though I understand medication helps, focusing on performance of the task in the moment rather than assuming they don’t possess mastery of the task is probably alien to a multitude of parents. I hope we see a culture shift soon if Barkley is correct.

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    • nafi
      Jul 13, 2014 @ 22:04:27

      Taylor,

      I completely agree with your comment on positive reinforcement. Often times it is so easy to point out the problems or to give attention to things that may be annoying in the moment. Children struggling with externalizing disorders do not receive nearly as much positive reinforcement. In some instances this may be discouraging to the child when they do something “good” and it is not recognized. Some parents may not even know how to effectively do this, hence the importance of parent training. Sometimes acknowledging the good can promote more of a change than reprimanding the bad.

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  3. Robert
    Jul 09, 2014 @ 11:24:13

    1) Treatments that emphasize quick applications, experiential learning and continued case management appear to be more effective than other treatment approaches to children with ADHD. Since ADHD may be the result of an impairment of executive functioning, it is often not the amount of knowledge or social skills that is the main concern in children, but their knowledge of how to use these resources at the proper time that is the issue. This discrepancy between knowledge and performance needs to be dealt with over the long-term so the effects of any short-term intervention are likely to diminish without continuous reinforcement. Social skills training (SST) may be useful for children with ADHD to develop their social skills, and more importantly, know how to successfully execute these skills. However, these skills that children develop in SST may diminish without their parents and teachers reinforcing these skills after the program concludes. While incorporating parents and teachers on paper appears to be a good idea, in reality, it represents SST’s biggest hurdle.
    2) The multiple approaches tend to emphasize a systemic approach for treating conduct problems. They tend to focus on addressing the child, the child’s family, school system, interpersonal relations with teachers and peers. If the youth is involved with the legal system, the therapeutic intervention may involve their probation officer for example. Since children with conduct problems tend to exhibit these behaviors across a wide-range of settings, it is important to treat such behaviors in as many settings as possible to ensure lasting effects of therapy. If a child is receiving therapy and interventions at home and from his teachers, the positive effects of these interventions may be quickly subverted if his peers engage in similar conduct problematic behaviors, highlighting the need for therapy to be all-inclusive.

    Reply

    • Taylor Tagg
      Jul 10, 2014 @ 19:49:26

      Robert, I really liked how you pointed out the importance of social skills training (SST) and the discrepancy between knowledge and performance of those children suffering from ADHD. This was a point that Dr. V emphasized in class and how it is not that children with ADHD do not have social skills, but they do not know how to use them effectively, due to their impairment in executive functioning skills. Therefore, we as therapists aim to motivate children to essentially execute these skills through social skills training. I like this point of view because we as therapists are giving such children the opportunity to be in the spotlight and strive to perform at their best. This gives us the perfect opportunity to validate such children and call attention to their strengths.

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  4. nafi
    Jul 09, 2014 @ 20:08:31

    This week’s text reading focused on treating externalizing disorders in children such as ADHD. Treatment for these disorders can be difficult for not just the child but also for his/her system. The text suggest that the treatment approach that appears to produce behavioral improvements for youth with ADHD are behavioral modification programs. The text describes that ADHD is a disorder of performance rather than knowledge or skill. Therefore, interventions that are more action oriented, and overt may be more beneficial in modifying problematic behavioral patterns. Moreover, interventions such as Social Skills Training appear to be effective in teaching children appropriate social skills. Simply teaching a skills is not enough with these disorders, being able to practice these techniques is just as important. We can all sit and listen on how to do something but in most cases, applying what we have been taught can be more difficult.

    Improving social skills with peers is important but social skills with parents are also important. Parent training appeared to be a common theme across approaches as well. As children we tend to pick up varying behaviors from our parents, good and/or bad and at a young age, we look to our parents for social cues. Parent/child interactions can sometimes reinforce or contribute the development and maintenance of conduct behaviors. Parent training is beneficial for teaching parents how to manage their child’s symptoms and respond in a more appropriate way. Some parents may be resistant and think their parenting style is great but change has to come from all areas. If the child is expected to change, the environment and the people that make up different environments for that child must be willing to promote some change themselves.

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    • Rebecca Boisvert
      Jul 12, 2014 @ 09:57:40

      Nafi, I think that your emphasis on the systems aspect of ADHD is a very important consideration when it comes to the impact of the disorder. It is not just the child who is affected and certainly not just the child who takes part in any interventions that are developed. In reality the child’s system takes on the largest amount of the responsibility, at least until they become old enough to take on the responsibility themselves. However, until that time, the bulk of the needs are placed on others, and without their persistent hard work, the child’s behavior plan most likely won’t succeed. This path is not easy for anyone, and I think was good of you to emphasize that ADHD is not a disorder that impacts one person more than others; rather it can have an impact on any number of the child’s surrounding family, friends, teachers, school, neighborhood, social groups, church, etc. Of course the child is impacted the most, because they must carry the burden of the symptoms, but so many others are directly affected by the symptoms as well, that they must also be considered in treatment as well.

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  5. Sara Grzejszczak
    Jul 09, 2014 @ 20:24:04

    1)The treatment approach that seems to be most promising for producing significant behavioral improvements for youth with ADHD are programs that will help the child with his or her self-regulation and the self-motivation that will be needed to complete the task. Since ADHD is a disorder of performance, many times the child knows what he or she should do to get a desired outcome but chooses not to worry about later consequences for the action being taken in the immediate future. Our book, Friedberg & McClure, I feel have an example that could fit. The authors mention a client who sells drugs because he gets a lot more money immediately instead of working weeks at a fast food restaurant to get a similar amount. By implementing programs that are behavioral in nature that can help the child with self-regulation in different settings, the child’s ability to plan on how to interact with others in different situations or follow directions can be generalized easier. Behavioral techniques also use immediate types of reinforcement to keep children interested in the demand that was placed on them as well as give them immediate feedback on how they are doing. Since a child with ADHD cannot and does not always have the capabilities to stay motivated having feedback will help to keep him or her on target.
    2)Multiple approaches for treating conduct disorder have in vivo practice and/or practicing the skills that the children have learned by using role-play. Many times these types of interventions were done in group settings. These themes seem to come up over again in the different approaches because while doing different types of exercises to help with anger can be effective with just the child and the clinician, many times the child may not be able to use the same exercise techniques in the heat of the moment. By having the child in a group with peers, natural occurrences will happen that will give the therapist an opportunity to help the child through a difficult time where they want to get angry and instead practice the exercises that they will be expected to use in the real world.

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    • Taylor Tagg
      Jul 10, 2014 @ 20:08:30

      Sara, I like your standpoint on the importance of improving behavioral responses for youth with ADHD that will facilitate self-regulation and self-motivation. It is important to remember that children with ADHD have difficulty in considering later consequences for the action that is being taken in the immediate future. Self-regulation, by definition, is any self-directed action used to change one’s behaviors so as to alter the probability of a delayed future consequence. Children with ADHD are unable to think about the long-term consequences of certain actions and behaviors. Therefore, it is important to assist such children in considering alternative responses that they can do in the future, when they are able to consider them.

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    • Jane Jenkins
      Jul 11, 2014 @ 09:45:55

      Sara,
      Your reminder that in vivo experiences for kids is especially helpful was a good point. It’s one thing to talk to them about what was wrong AFTER the fact, but quite another to be with them IN the situation, helping to guide them, and helping them identify what’s going on with their body and feelings at the time. In a way, it reminds me of gradual exposure. They repeat each task until they are more comfortable performing it.

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    • Rebekah Kiely
      Jul 12, 2014 @ 18:17:19

      Sara,
      I really agree with your statement about understanding ADHD as a disorder of performance and the relevance of self-regulation and self-motivation. As a disorder of performance, it is also easy to see how in school settings a child with ADHD may develop significant learned helplessness. If a child with ADHD is unable to perform well in math because of attention issues, he/she may adopt the belief that there is not point to even try doing the math homework and the teacher takes away his/her recess time as a result. Although this may lead the child to try on the homework, I can’t help but wonder if this would have any long-term benefit: Would this actually help to increase his/her self-efficacy in math? I think for situations such as this relative to children with ADHD, a reward system that includes praise and acknowledging successes to support self-efficacy is extremely important to successful treatment.

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  6. Juliana Eells
    Jul 09, 2014 @ 21:58:59

    1) Barkley’s conceptualization of ADHD describes the disorder as a developmental delay in behavioral inhibition and self-regulation, and a deficit in executive functions. As Mash & Barkley describe, psychosocial interventions appear to be focused on skills training, but based on this conceptualization it may be the case that children with ADHD have the skills already, and they simply do not know how or when to use them appropriately. Therefore, it seems the most promising psychosocial-psychological treatments would not only involve skills training, but also training the child in how and when to use those skills and giving the child opportunities to practice the skills with guidance.

    2) One theme that seemed to generalize across many of the skills training approaches including involving both the parent and the child in treatment. Parents must be involved so they can learn skills for dealing with conduct problems, develop a more functional relationship with the child, and provide plenty of positive reinforcement. It is also important to engage the child in therapy as most children with conduct problems are resistant to treatment. It is important to engage the child and get them to participate in treatment. Another theme I noticed throughout these approaches is the importance of opportunities for the child to practice the new skills that they are trying to learn. The child must have an opportunity to learn how to apply and practice the new skills through exposure situations, role plays, modeling, metaphors/examples, etc.

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    • Paige Hartmann
      Jul 11, 2014 @ 10:13:07

      Juliana,

      I liked how you discussed the use of skills training with children with ADHD and how these children already have the skills, but do not know how to use them in natural settings. We discussed this point in class yesterday, and it is really important for the therapist to work with the child to know how to use these skills that they already have in an appropriate manner.

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    • Robin Horsefield
      Jul 12, 2014 @ 19:20:58

      Julianna, I agree 100% that parents are an essential component in the treatment of ADHD. I think it is important for the parents to be not only involved but also on board with any treatment they choose to undertake with their child. Especially for very young clients, the parents are the ones who will make sure that homework is completed between sessions and will be an ally with the therapist to enforce the techniques covered in sessions.

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    • nafi
      Jul 13, 2014 @ 22:08:51

      Juliana, I like how you discussed skills training for parents and children. This is important to not that parents may lack the appropriate skills for interacting with their children. As seen through the readings, parent-child interactions can enhance or hinder the process of therapy. Parent’s will need to put just as much effort into treatment as expected of the child. Consistency from parents is also important as some days parent’s may be tired and not want to follow through with treatment. This is hard to control for in treatment nonetheless parents will need to learn that they are just as much a part of their child’s treatment.

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  7. Melissa Symolon
    Jul 09, 2014 @ 23:33:58

    1. I feel rather torn answering the first question because I believe multiple techniques can be beneficial depending on the child’s age and development. For instance, I think behavior parent training is most effective for younger children because these children in particular need their parents to set limits and boundaries for them. Young children, about preschool to seven or eight I’d say, are still developing social skills, regulation skills, etc. I believe that younger children are not mature enough to monitor their behavior, so I think parent reinforcement and punishment to learn what behaviors are acceptable and unacceptable works best with youngsters. As children get older, mature, and can understand how their behaviors impact consequences, I think interventions that focus on the child learning to self-regulate and understanding the consequences of their behaviors are most effective.
    2. There are many themes that generalize in treatments for conduct problems. One theme is that teaching parents parenting skills and that parents are the agent of the child’s behavior changes. Another theme is working with children to develop prosocial behavior/moral reasoning rather than the aggressive/inappropriate behavior they revert to. Another theme in regard to the way these skills are taught is that children and parents are both active during treatment. Treatment often involves the therapist modeling parenting skills, problem solving skills, etc to both the child and parents. I think this can be effective because the child knows what his/her parents will expect of him/her and the parent knows the child understands these new expectations.

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    • Ashley
      Jul 10, 2014 @ 10:01:44

      Melissa, I enjoyed your answer regarding the treatment of ADHD. I think age is a big consideration in the treatment of many disorders and ADHD should not be an exception to that. However, I wonder if some reinforcement would have to be used regardless of age. For instance, what if a child has presented with ADHD for years but is only now getting treated as a high schooler. Some of those behaviors might be in-grained within the adolescent by now. Would self monitoring be enough to elicit change?

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      • Melissa Symolon
        Jul 10, 2014 @ 18:39:41

        I agree with you, and that is my fault that I did not convey my thought clear enough. I think that when children are younger, the primary intervention should be PBT. When they get older and are capable of identifying problems, thoughts, etc., I think reinforcers and punishments should still be used, but other interventions, like self-monitoring, etc., should be integrated into treatment along with PBT.

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    • Rebekah Kiely
      Jul 12, 2014 @ 18:20:27

      Melissa,
      I agree completely that naming one treatment as most beneficial to treating ADHD among all ages is difficult. I also believe that this may be the case depending on the specific presentation of the disorder as well. For instance, if a child is presenting with significant inattention but no significant hyperactivity or impulsivity, parent management in the form of punishment especially may not be as beneficial an intervention as it would for a hyperactive or impulsive child.

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  8. Robin Horsefield
    Jul 10, 2014 @ 09:10:10

    The treatment of ADHD has shifted focus from retaining “whatever works” to a more structured developmental approach. Barkley conceptualizes the disorder as inhibition or delay in executive functioning. His treatment includes contingency management as a method of increasing motivation. Parents and teachers are recruited and trained to put into place a system of reinforcements and punishments for desirable and undesirable behavior respectively. Barkley’s approach also recognizes that children generally know what is expected of them, they just have trouble motivating or controlling their behavior, therefore his approach is meant to reinforce their motivation to perform as expected. As most treatments recognize the behavioral inhibitions inherent in ADHD, Barkley’s approach attempts to empower the children to motivate themselves.

    The sections covering skills training approaches seemed to converge on a number of themes. The first theme was the focus on repairing or improving peer relationships. Children with ADHD tend to struggle significantly with their social interactions. This is not limited to acquaintances but includes parents, siblings and other intimate relationships. Many of the approaches try to address these skill deficits to improve the daily functioning and happiness of the child. Another theme is the need for skills to apply across environments. Researchers recognize that while skills in the lab can become stable, these skills are often lost once the environment changes. The same can be said for when the training structure is no longer in place. Contingency management is meant to slowly transition to allow desired behaviors to become intrinsically motivated. Unfortunately for ADHD, once the reward system is no longer in place, these children find it difficult to find the motivation to uphold the expected behaviors and often revert back to pre-training behaviors.

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    • Melysa Faria
      Jul 12, 2014 @ 11:52:59

      Robin,
      I like your point regarding contingency management, specifically your statement that one children with ADHD lose their reinforcements they may lose their motivation to continue the skills they have learned. Although this could potentially be a problem, it’s also important to remember that once the child is following through with new behaviors for a while they become habit and may also develop natural reinforcers. For example, if the child had trouble completing homework and he was earning tangible rewards at the end of each week, he grades are likely to improve which can work as a natural reinforcement.

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  9. Sarah Chelio
    Jul 10, 2014 @ 09:37:28

    1) Chapter 2 of Mash and Barkley discusses the lack of long term effectiveness for treating ADHD. I think that the treatment approach that seems to have the most promise are ones that reshape the child’s environment. This means that parents should be just as, if not more, involved in therapy as their children. This way, results will not be as short-term because the parents can apply the education and skills they received at home.

    2) I noticed a couple of themes in the skills training being used to treat conduct problems. First, they seem to stress the importance of positive reinforcement. Things like praise and rewards work as incentives for children to want to do the desired task again. If they are acknowledged for successfully following directions, they will be more likely to want to do that again because that positive acknowledgement feels good. A second theme I picked up on was the need to educate, both kids and parents, on the skills. This involves a thorough explanation of the training and the rationale behind it. I think this is very important because if the parent does not understand why the training is beneficial, they will not enforce it at home. As we have learned, these skills must be practiced at home in order to effectively change behaviors.

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    • Ashley
      Jul 10, 2014 @ 10:09:34

      Sarah, when conducting skills training with parents, what happens when the parent is not on board with treatment? (lets say the child is court mandated to attend treatment). What would you do to treat the child in this circumstance? The conduct problems could be exacerbated by what is seen at home– if you cant remove the child from the home, how do you help promote healthy behaviors?

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    • Larrisa Palmer
      Jul 11, 2014 @ 04:11:54

      Sarah, I do agree with you that treatment approaches that reshape the child’s environment can be very effective. Young children are dependent on their environment and when parents are not involved in therapy it makes it difficult for change to occur. It’s almost a waste of time to teach children skills when they will return to their untreated environment which will only maintain their problem behaviors. So, it’s always great to get parents and teachers on board.

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  10. Ashley
    Jul 10, 2014 @ 09:56:14

    1) In this weeks reading, behavioral interventions/modifications appeared to be the most effective treatment for children with ADHD. Children with ADHD are not limited in knowledge just in performance. Thus positive reinforcements and structure are good behavioral modifications since the prognosis (aka increased attention) are gained through more action orientated interventions. Teaching a child with ADHD social skills would also be an important tool as well. Behavioral modification is best used in the child’s natural environment where the behaviors are more pronounced. Reinforcing or correcting a behavior in the natural setting is critical to get the appropriate outcome.
    2) Skills training approach has gained increasing attention for the treatment of conduct disorders. There are several themes throughout the skills training approach. One being in vivo and/or practicing skills in role-plays. This theme seems to appear in most of the multiple approaches for conduct disorders because it gives the clinician to work through an emotional aggravating situation in the moment. Obviously, this would be more easily done in group there where tensions are more likely to arise than in individual therapy. By catching the behavior in the moment the clinician can help the individual to reduce the anger and find a new way to deal with the situation. This can lead to positive change when similar situations arise outside the clinical setting.

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    • Sara Grzejszczak
      Jul 10, 2014 @ 20:03:34

      Ashley, I agree with you that behavioral interventions and modifications appear to be the most effective in treating ADHD. Since ADHD seems to be a disorder of performance rather than a deficit of some kind, behavioral therapy would be the best option because it will help reinforce children immediately rather than having to have them wait until later. Behavioral modifications and interventions also have to be done across settings so that way the child can learn how to generalize in each setting to be successful.

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  11. Julianna Aguilar
    Jul 10, 2014 @ 10:15:30

    There appears to be very little promising research about effective treatments for ADHD. Based on this literature, I am hesitant to say that any one technique or combined techniques show promise for significant long-term behavioral improvements in children with ADHD. However, Mash and Barkley (2006) argue that psychopharmacology and behavioral interventions appear to be more effective on their own then when combined (i.e., assigning each method an “A” separately but a “B” or lower when combined into a multimodal treatment). Therefore, aside from psychopharmacology, it appears that behavioral modifications alone appear to show the most promise for treating children with ADHD. More specifically, CBT interventions which included a variety of self-instruction, self-statements, and self-reinforcement were thought to beneficial for children with ADHD. In addition, more recent research has examined the effectiveness of different approaches including social skills training. Though these different approaches have revealed some short-term positive effects for these children, there seem to be two key issues with these and other similar interventions. First, skills that children and parents learn in clinical settings may be not be generalizable to home or school settings. Second, it appears that many of the existing interventions were constructed from a conceptualization of of ADHD that may not be accurate. That is, it has recently been posited that children with ADHD may not have skill deficits, but rather lack the knowledge about when and how to use those skills appropriately. Therefore, interventions may be more beneficial if they focus on teaching these children how to use their skills effectively and motivating them to use those skills as opposed to simply teaching them the skills as if they are simply unaware.

    Mash and Barkley (2006) and Friedberg and McClure (2002) highlighted numerous skills training programs for treating children with conduct problems that seem to share several common themes. The themes that I found to be most interesting and prominent are information processing, coping, and multiple levels of involvements. First, training related to information processing (e.g., problem-solving, cognitive appraisals, moral reasoning, etc.) seemed to be a central theme as it is posited that children and adolescents with conduct problems may engage in maladaptive behavior as a result of misinterpreting certain situations and interactions with others. Second, coping appears to be an important skill for these children and adolescents. For example, anger and aggression can be a common response to stressful situations in this population. Therefore, learning more appropriate coping skills would help them engage in more prosocial behavior. Finally, many of these interventions included multiple levels of involvement. For example, families may be taught certain skills to help their children at home and programs may be implemented in schools or in the community (e.g., residential programs) depending on the severity and nature of the child or adolescent’s specific problems.

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  12. Paige Hartmann
    Jul 10, 2014 @ 11:02:07

    Since youth with ADHD are not limited in knowledge, but just performance, treatment involving behavior modification appears to produce the most improvement. Action oriented interventions involving positive reinforcement promotes increased attention in youth with ADHD. The use of social skills training has also been found to be beneficial for youth with ADHD. However, it is important that the child is not only taught the skills, but is able to understand how to put them into practice within real world situations.

    Parenting training seemed to be a common theme across skills training approaches. This is an important intervention tool, since many children’s behaviors are developed and maintained due to the style of parenting. It is important to utilize parent training within the treatment of a child’s ADHD because it will help the parents understand the child’s symptoms and how to effectively work with the child to improve symptoms. Parents can understand what aspects of their parenting skills have been ineffective while learning more adaptive skills.

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  13. Rebekah Kiely
    Jul 10, 2014 @ 12:01:34

    Currently, I believe that an integrated approach employing multimodal treatment interventions has the most promise in producing significant behavioral improvement for youth with ADHD. Effective treatment of ADHD requires focusing on multiple aspects of the child’s life, and as such interventions focusing on all of those aspects are immensely important. The variety of ways in which ADHD may present further promotes my perspective on multimodal approaches being the most optimal treatment method. Some interventions may be more or less important/beneficial to the treatment process depending on the ADHD presentation (i.e. inattentive vs. combined vs. hyperactive-impulsive type). However, defining one method that has the most promise will also vary on the developmental level/age and gender of the youth. To put this in further perspective, employing relaxation training as an intervention with preschool aged children would not likely be effective (rather, likely developmentally inappropriate) but emphasizing parent training offers great benefit. Multimodal approaches will likely be most effective with older children, but certain interventions such as parent training may remain quite effective among multiple age groups.
    Among the many skills training approaches available for treating conduct problems, the importance of parent involvement. Supportive family members who are active and willing to learn parenting skills to adaptively manage their child’s behavior can make all the difference when it comes to effective interventions. Another point that is emphasized among these approaches is the significance of the group format: This may not be effective in some cases, and may lead to an unintentional negative impact. All of these approaches emphasize the importance of consistent observation and assessment of the child on the basis that alternatives to group treatment may be necessary.

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    • Julianna Aguilar
      Jul 10, 2014 @ 14:31:26

      Rebekah, I like how you mentioned both the advantages and disadvantages of using a group format for addressing conduct problems which shows up often as a common theme in social skills training for externalizing behaviors. As others mentioned, the group format can be very effective for observing behaviors as they occur in the moment and subsequently helping the child or adolescent cope with the situation in a more positive or prosocial way. However, group formats that address these types of behaviors also run the risk of the group members learning negative behaviors from each other or becoming more motivated to engage in negative behaviors, among other issues.

      Reply

  14. Anthon Rofino
    Jul 10, 2014 @ 12:10:07

    1) While the chapter describes mixed results of social skills training for the treatment of ADHD, as someone in the field who works with many children with ADHD, I have found that social skills training is a very useful approach for those with ADHD. This type of training can help a child with ADHD approach social situations more appropriately, and when combined with mindfulness techniques and breathing exercises, can be very effective at treatment. Even acquiring friends with similar interests can calm a child down surprisingly well if the child senses their friend is concerned about their hyperactivity.
    2) The key components for treating conduct disorders is parent training, as well as modeling. It is important that parents are aware of how to properly parent their children, especially those that have conduct issues, as lax parenting can be detrimental for the overall development of the disorder. It is also important that therapeutic work models appropriate behaviors for the child to engage in so that they know what is appropriate and what is not. Through parenting training, skills can be learned that are ineffective as well as to correct any future issues.

    Reply

    • Larrisa Palmer
      Jul 10, 2014 @ 16:39:36

      Anthon, I like the incorporation of mindfulness techniques and breathing exercises with ADHD children and parents. ADHD children can be inattentive, hyperactive and impulsive, with mindfulness they are able to settle down and focus on a particular activity instead of being all over the place. Mindfulness techniques can be very useful for parents, it can help them to reduce their stress, make better decisions and respond to their child’s behavior rather than reacting to it.

      Reply

    • Melissa Symolon
      Jul 10, 2014 @ 18:45:37

      Anthony, after class today I am wondering what your thoughts are on Dr. V’s standpoint that social skills are not always necessary when treating ADHD because that premise assumes that the child lacks the skills rather than that the child has the skills but is not using them? Do you disagree with Barkley that ADHD is a problem with performance?

      Reply

  15. Angela Vizzo
    Jul 10, 2014 @ 12:56:47

    As the text discusses ADHD is not a disorder of knowledge or skill but rather a deficit in performing these skills. Therefore, training should focus on teaching social skills but also including role play and other opportunities to practice these skills so they can be utilized outside of therapy as well. Also, behavioral interventions such as positive reinforcement has been show to work with ADHD clients as well, and as such this involves parental training and consistency at home and school as well.

    Major themes involved in the treatment of conduct disorder include parent training to stop the cycle of bad behavior. Through this parents can model correct behavior and the children will learn and practice this beahvior at home. In addition, positive reinforcement and validation is necessary when correct or appropriate behavior is displayed to reinforce that behavior and therefore increase that type of behavior.

    Reply

  16. Larrisa Palmer
    Jul 10, 2014 @ 13:35:16

    1) In Barkley’s model, ADHD is viewed as a disorder of performance wherein the child knows how to act but does not act that way when placed in a particular social setting. Therefore, the treatment approaches that will be most helpful in producing significant behavioral improvements are those that assist with the execution of a particular behavior at the point of performance and self-regulatory skills. These approaches can help the child with ADHD to learn to link his or her actions to the consequences and eventually gain control over his or her behaviors. Psychosocial treatment of ADHD optimal involves parents and teachers to manage disruptive and impulsive behaviors in the home and at school.

    2) One major theme that tends to generalize across the different skills training approaches in regards to the treatment of CP is parenting management training. These programs train parents to manage their child’s behavioral problems at home and school by teaching them how to use techniques such as positive reinforcement and punishment effectively. Parenting training is important because it provides the opportunity for the parents to learn about what their child is going through and the ways in which they can effect change. It is also more effective when parents and child are on the same page in terms of what is going on in therapy.

    Reply

    • Sara Grzejszczak
      Jul 10, 2014 @ 20:21:48

      Larrisa, I also agree that the approach to help children with ADHD are ones that improves their behaviors. Treatment should also be able to be generalized to different environments and help the child increase self-regulatory skills. I wonder what you think the best way to do that is?

      Reply

  17. Becca Boisvert
    Jul 10, 2014 @ 14:31:23

    Mash & Barkley’s review of treatments for ADHD emphasizes that although there are numerous methods available, none have been given the “gold standard” so to speak. According to M&B, the challenge with ADHD is that it is not a disorder that prevents the individual from acquiring the necessary knowledge (how to behave, methods of attention maintenance, social skills, etc); instead ADHD is a disorder prevents the individual from conveying the acquired knowledge at the appropriate time, because there seems to be an unknown disassociation between the knowledge and the action. Because of this, treatments which address the undesired behavior and reinforce the desired behavior at the time that it occurs have been found to be the most effective. These methods may include several types of behavioral techniques including reward and punishment systems such as ABCs, token economy, and time outs, and also social skills training. However, in order for these interventions to be effective, all parties involved must be willing to consistently reinforce behavior at the time that it occurs. Parent and teacher training provides necessary education/skills for such responsibilities. The overarching emphasis is consistent reinforcement so the child becomes self-aware of the times/places where the necessary behavior should/shouldn’t take place.
    Interventions for conduct problems seem to provide an overarching method of treatment. This involves treatment for the child, family, child and family, parent training, social skills, school based treatment, and home based interventions, etc. Although these may not be used simultaneously, the use of a multi-method approach may yield best treatment practices for children with conduct problems due to the fact that it is a disorder that presents with multi-dimensional symptoms/challenges.

    Reply

    • Melysa Faria
      Jul 12, 2014 @ 18:12:56

      Becca,
      I agree with what you said about consistency being one of the key features in making behavioral interventions effective when you are working with children who have ADHD and other externalizing disorders. Consistency of positive reinforcements like token economies and consistency in consequences such as time outs are most effective when used in multiple settings. I like that you mentioned involving the school in using interventions in order to teach the child self-awareness and what behaviors are appropriate in particular settings and situations.

      Reply

  18. Melysa Faria
    Jul 10, 2014 @ 14:47:54

    1) It seems that the most effective treatment for improvement of behavior in youth with ADHD is likely to be a multimodal treatment which would involve a combination of social skills training and behavior modifications and possibly the use of medication as well. Barkley states that ADHD is more of a delay in executive functioning than a psychosocial problem, so coupling skills training with behavior modifications can help to learn and practice skills to incorporate them into daily life. This combination with the addition of medication (in some cases) can help in regulation of executive functioning. Parent-training is also an important part of working with any child population, but particularly necessary when working with kids who have ADHD in order to teach parents skills of how to accommodate and work with their child in using the skills they are learning in therapy.
    2) Some of the characteristics each of the skills training approaches have in common are generalization of skills in multiple settings, collaboration with families and other providers, and the importance of positive reinforcement. Learning new skills in therapy would be pointless if they were not generalizable to other settings to improve the child’s general functioning. In order to help with generalization across settings, as well as after treatment ends, is collaboration with families. It is important for families, schools and other providers to be on board and helping the child practice the skills they are learning in order for the skills training to be maintained after treatment and improve functioning. Encouraging collaterals like parents and schools to use frequent positive reinforcement such as praise and reward contingencies can motivate the child to continue their use of skills being learned in therapy.

    Reply

  19. Paige Hartmann
    Jul 11, 2014 @ 10:19:50

    Melysa,

    You discuss a valid point about the importance of the generalization of skills within multiple settings for children with ADHD. If a child is not able to use these skills across a variety of settings, it would not promote improvement in the child’s overall level of functioning. For treatment to be effective for the child, involvement from the parents as well as the teachers would be necessary.

    Reply

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Adam M. Volungis, PhD, LMHC

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