Effective Approaches for Promoting Prosocial Behavior and Reducing Disruptive and

Aggressive Behaviors in Youth with ADHD: Recent Innovations

in TreatmentGregory A. Fabiano, Ph.D.

University at BuffaloDepartment of Counseling, School, and Educational Psychology

Attention-deficit hyperactivity disorder (ADHD)

• ADHD is characterized by developmentally inappropriate levels of:– Inattention – Hyperactivity– Impulsivity

• ADHD behaviors are developmentally inappropriate, pervasive, chronic, and result in considerable impairment in social and academic functioning.

History of ADHD

• Heinrich Hoffman, a German psychiatrist, authored a widely-published children’s book of short stories in 1844.– “Fidgety Phillip”– “Johnny Look-in-the-Air”

• “The Story of Cruel Frederick”• The Story of Little Suck a Thumb”• The Dreadful Story of Pauline and the Matches”

Thome & Jacobs, 2004

Prevalence

• Prevalence estimates vary depending on method used, geographic region, age targeted, and rater.

• Prevalence of ADHD estimated at 8.7% (Froehlich et al., 2007)

• More common in boys than girls• Symptom presentation may reduce as

individual becomes older

Fabiano et al., 2013

Impact of ADHD - Impairment

Domains of Impairment

• Peer relationships• Adult relationships• Sibling relationships• Academic Progress• Self-esteem• Group functioning• Associated problems

Parent IRS scores 6-12 year olds

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Fabiano et al., 2006; available for free at www.ccf.buffalo.edu

Teacher IRS Scores 6-12 Year Olds

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Fabiano et al., 2006; available for free at www.ccf.buffalo.edu

Educational Costs (Robb et al, 2013)

Costs of • Special education*

$3230• Disciplinary referrals** $

740• Retention $ 110• Special schools $ 780

• Total: $4900*Does not include Section 504 Accommodation Plans/OHI classifications not used pre-1992**Likely under-estimated

Costs in the Aggregate(assuming prevalence of 5% and 60 million school aged children--2000

census--2005 dollars)

• Health and Mental Health $11.6 billion

• Education $14.7 billion

• Crime and Delinquency $11.4 billion• Parental work loss $ 2.3 billion

• Total $40 billion

• Range $34.1--$53.7

Pelham, Foster, & Robb, 2007; Robb et al., under review

Annual Cost of Other Disorders in U.S.

Depression: $44 billionStroke: $53.6 billionADHD (child, $80 billion

adolescent, adult) Alzheimer’s $100 billionAlcohol abuse/dep $180Drug abuse/dep $180

Why is it so critical to intervene early and in a sustained way for

children with ADHD?

Effective Treatments for ADHD

Evidence-Based ADHD Treatments

• Behavior Modification– Classroom Contingency Management– Behavioral Parent Training– Contingency Management Strategies

implemented in Recreational Settings (i.e., STP)• Stimulant Medication

DuPaul & Eckert, 1997; Fabiano, et al., 2009; Greenhill & Ford, 2002; Hinshaw et al., 2002; Pelham & Fabiano, 2008; Pelham, Wheeler, & Chronis, 1998

Fabiano, et al., 2015

• Behavior Modification is based on social learning theory

• It teaches parents and teachers how to change environmental contingencies to improve behavior.

• Settings where behavior modification is used include:– Home– School– Peer/recreational settings

• Antecedents

– Structuring situations– Clarifying expectations and contingencies– Establishing rules– Issuing clear commands

“Fights among the prisoners have decreased 62% since we got the Slip-and-Slide”

• Consequences

– Praising and attending– Planned ignoring– Rewards– Punishments

Peer-based interventions

Negative Behavior During Board Games

0123456789

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7:45 AM 9:55 AM 1:25 PM 4:35 PM

Concerta™TID MPHPlaceboControl

Pelham et al., 2001

Summer Treatment Program Overview

• Eight-week program, 9 hours daily• Children grouped by age into groups of 12• Groups stay together throughout the day• 5 counselors work with each group all day

outside of the classroom• One teacher and an aide staff the classroom for

each group• Treatment implemented in context of

recreational and academic activities

Typical STP Schedule Time Activity7:30-8:00 Arrivals8:00-8:15 Social Skills Training8:15-9:00 Soccer Skills Training9:15-10:15 Soccer Game10:30-11:30 Art Class11:45-12:00 Lunch12:00-12:15 Recess12:15-2:15 Academic/computer class2:30-3:30 Softball Game3:30-4:30 Swimming4:45-5:00 Recess5:00-5:30 Departures

Summer Treatment Program Overview• Treatment Components:

• Point System• Social Skills Training, Cooperative Tasks, • Team Membership, and Close Friendships• Group Problem Solving• Time out• Daily Report Cards• Sports Skills Training and Recreation

Summer Treatment Program Overview• Treatment Components:

• Positive Reinforcement & Appropriate Commands

• Classrooms--Regular, Peer Tutoring, Computer, and Art

• Individualized Programs• Parent Training• Medication Assessments• Adolescent Program

Comparison of STP with multiple STP withdrawals

Pelham et al., 2005

Daily Report Cards in Schools

Gregory A. Fabiano, Ph.D.University at Buffalo, SUNY

ADHD Treatment Effects in Classrooms

Fabiano, Pelham, et al., (2007)

Frequency of Classroom Rule Violations

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No BMOD

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Frequency of Classroom Rule Violations

Fabiano, Pelham, et al., (2007)

Fabiano, Pelham, et al., (2007)

Frequency of Classroom Rule Violations

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Daily Report Card

What is a Daily Report Card (DRC)?

• The DRC is an operationalized list of a child’s target behaviors– Specific criteria– Immediate feedback– Communication tool– Home-based privileges contingent on

meeting DRC goals

Creating the DRC

Enhancing the Effectiveness of Special Education Services for Children with ADHD Using a Daily Report Card Program

Fabiano et al., 2010; Institute of Education Sciences Grant # R324J06024

Participants

Child with ADHD referred for study

Random assignment

Diagnosis confirmed and intake completed

IEPIEP + DRC

Endpoint Assessment

Results

Primary Outcomes Measures

• Blinded observations of classroom behavior• Academic Achievement Testing• Teacher Rating of IEP goal attainment

Blinded Observations of Classroom Behavior – Change Score

p < .05

Academic Achievement Testing

• Broad Math scores were significantly improved over time (p < .001), whereas Basic Reading scores were not (p > .05).

• There was no time x group interaction.

Teacher Ratings of IEP Goal Attainment

• Each teacher was asked to rate whether the child had attained idiographic IEP goals and objectives.

Monitoring Behavioral Consultation1

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For these analyses, there was a significant difference between groups, t (55, one-tailed) = -1.98, p = .027.

Secondary Outcome Measures

ADHD, ODD, CD Symptoms

DBD-ADD DBD-ODD DBD-CD0

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Getting Dads Off the Sidelines: Practices for Promoting Child Social Skills Development in Peer Settings

What do fathers do?

• Economic Provision (“Bread-winning”)• Involvement

– Engagement– Availability

• Responsibility• Parenting• Co-Parenting• Spouse/Partner• All these parameters are on a continuum,

thus fathering is multi-dimensional.

Pleck, 1997

Father Influence on Child Development

• The development of:– emotion regulation– social cognition– focused attention– likely because of these factors, appropriate

peer relationships (Parke, et al., 2002). • Positive father involvement results in

fewer mother-reported behavior problems (Amato & Rivera, 1999).

• Fathers contribute uniquely to the child’s academic achievement and academic sense of competence (Forehand, et al., 1986; McBride, et al., 2005; Nord, 1997).

• For children with mental health disorders, it may be critical to involve fathers in interventions. – Fathers contribute to parenting

• Positive parenting and discipline– Helps promote consistency between parents– Provides an additional point of view– May support other parent– May promote maintenance of treatment over

time or as children progress through development (Bagner & Eyberg, 2003; Webster-Stratton, 1980).

Why are fathers not involved in BPT studies?

• Approach to/Engagement of fathers during initial clinical contact:– Clinicians may implicitly exclude fathers by

addressing correspondence to only mothers or require only mothers for interviews.

– Because most rating forms are normed on mothers, fathers are often not asked for their input.

– Standard clinical hours (i.e., 9 to 5 weekdays) are not convenient for employed mothers or fathers

• Parents of children with ADHD have an increased likelihood to have ADHD themselves (Biederman, Faraone, Monuteaux, 2002)

• ADHD impedes parenting and BPT progress (Arnold, O’Leary, & Edwards, 1997; Evans, Vallano, & Pelham, 1994; Sonuga-Barke et al., 1999)

• Most BPT classes are classroom-based, and use didactic lectures to introduce parenting skills.

• The format may act to discourage fathers from participating

“Research has yet to identify any child-care task for which fathers have primary responsibility.” (Pleck, 1997)

• Fathers’ participation in recreational activities and unstructured play times is more typical relative to mothers’ activities (Russell & Russell, 1987).

• The content of BPT classes may therefore fail to address the needs of many fathers.

• Men generally do not seek out or ask for help for health/mental health services (Addis & Mihalik, 2003).

• Fathers report few problems in parenting, even in the face of self-reported dysfunctional discipline techniques (Hoza et al., 2000)

Why is increased father participation needed?

• As mentioned, fathers are primarily responsible for children during recreational and sports activities and unstructured times independent of other roles they fill (Marsiglio, 1991), and they are a critical agent for helping their child establish appropriate peer relationships (Parke, 2002).

• Children with ADHD exhibit poor sportsmanship behaviors that result in poor peer relationships and are likely to struggle with behavior during such activities (Hupp & Reitman, 1999; Pelham et al., 1990).

• Fathers may also need skills to help them appropriately parent/coach during unstructured activities and sports.

Thomas Junta, whose case was considered one of the worst examples of the national problem of "sideline rage," faces 20 years in prison.

Jury convicts hockey dad of manslaughter

Courttv.com

So What Can We Do to Increase Father Participation?

FREE BEER!!!???

BAD IDEA (Pelham et al., 1997, 1998)

• To involve and engage fathers in ADHD treatment the Coaching Our Acting-out Children: Heightening Essential Skills (COACHES) program was developed.

• COACHES is a two-hour, weekly, eight-session parent training program.

A BPT PROGRAM DESIGNED SPECIFICALLY FOR FATHERS

• The COACHES program combines and synergizes two manualized treatments commonly used for children with ADHD:– Summer Treatment Program (Pelham, Greiner,

& Gnagy, 1998)– Community Parent Education Program

(Cunningham, Secord, & Bremner, 1998)• Treatment components from these programs

are adapted for use in the father-based parenting class, the child-based skill drills, and the father-child interactions.

COACHES format

• During the first hour, fathers review how to implement effective parenting strategies in a group class (e.g., using praise, using time out).

• Concurrently, children practice soccer skill drills with para-professional counselors, to increase competencies in the sports domain (Pelham et al., in press; Pelham, Greiner, & Gnagy, 1997; Pelham & Hoza, 1996).

Content of COACHES BPT Sessions

• During the second hour, the fathers and children join together for a soccer game.

• Fathers “coach” the soccer game by employing the strategies discussed during the first half of the program.

• During frequent breaks, fathers receive on-line feedback from trained staff, work together to trouble-shoot problems that occur, and reinforce each other for the successful implementation of parenting strategies.

• How is the COACHES program different from other parenting programs?– Does not approach fathers as “deficient” in parenting

strategies. Frames treatment as a way to build competencies in an area where many may already have skills (e.g., coaching).

– Framing treatment in this way may reduce stigma associated with initiating and participating in mental health services.

– Includes a sports competency-building component for the children, known to be effective and well-liked by parents and children (Pelham, et al., in press; Pelham, Greiner, & Gnagy, 1997).

– Soccer game provides a naturally reinforcing activity as part of treatment (as opposed to a two-hour class).

– Research suggests fathers benefit from practicing parenting strategies (Adesso & Lipson, 1981).

Clinical Trial of COACHES Efficacy

Fabiano et al., 2012

Measures• Measures of parenting

– DPICS• Praise• Criticism• Commands

• Measures of problem behaviors– Eyberg Child Behavior Inventory (ECBI)

• Frequency Rating• Intensity Rating

• Measures of Satisfaction with treatment– Therapy Attitude Inventory

• Process factor• Outcome factor

DPICS - Praise

ES=.54

DPICS-Negative Talk

ECBI – Intensity Rating

Treatment Satisfaction

• 100% of fathers reported they were Satisfied with Outcomes.

• 89% of fathers reported they were Satisfied with Treatment Process.

Clinical Trial of COACHES Effectiveness

Fabiano et al., 2009

Method

• Fathers who gave informed consent and completed intake procedures were randomly assigned to one of two parent training groups:– COACHES

• Fathers watch videotapes of exaggerated parenting errors, identify errors, generate solutions, and then role-play suggested solutions.

• Children practice soccer skills.• Parents and children join for soccer game; fathers practice

skills– Traditional Behavioral Parent Training

• Fathers watch videotapes of exaggerated parenting errors, identify errors, generate solutions, and then role-play suggested solutions (Cunningham et al., 1997).

• Children participate in group board game activities during the parenting group (Pelham et al., 2001)

• The major difference between BPT groups is the parent-child interactions in COACHES.

Measures• Fathers rated child improvement at post-treatment

across domain-specific targeted behaviors (Pelham et al., 2001)

• Measures of engagement included– Father Attendance/Drop-out– Father on-time arrival for meetings– Child Attendance/Drop-out– Father homework completion

• Father satisfaction with treatment (TAI; Brestan et al.)

Results

Average Improvement Rating

F = 22.28, p < .001

COACHES vs. Traditional: Father Attendance

Attendance0

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COAC...

p <.04

COACHES vs. Traditional: On-time for Session Attended

On-time0

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p < .03

COACHES vs. Traditional: Child Attendance

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COACHES vs. Traditional: Homework Compliance

Homework Completion0

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p < .003

COACHES vs. Traditional: Father Drop-Out(Defined as Attendance at Fewer than Half of Sessions)

Father Drop-out0

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COACHESTraditional

p < .03

COACHES vs. Traditional: Child Drop-Out(Defined as Attendance at Fewer than Half of Sessions)

p < .001

COACHES vs. Traditional: Consumer Satisfaction

Clinical Implications• BPT is an effective approach for improving father-

related parenting behavior.• Programs for fathers should include recreational

based activities that promote skill development for children.

• Fathers should be given the opportunity to interact with their children and practice parenting skills during the session.

• Future studies need to address interventions to facilitate effective co-parenting and inter-parental consistency

Thank you!

• Greg Fabianofabiano@buffalo.edu