ADHD Family Therapy Options

By Patti Higgins

ADHD symptoms & diagnosisADHD 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).

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.

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.

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).

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.

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 parent—child conflicts and child noncompliance.

Problem solving and communication training (PSCT) programs for parent—adolescent 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.

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).

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.

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)

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.

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).

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.

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)

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.

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).

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, Satir’s 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).

Child Behavioral Checklist

The Child Behavioral Checklist (CBCL) is completed by parents, teachers or clinicians to measure children’s 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).

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).

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 80%—90% 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.

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)

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).

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).

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).

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.