In February and March of 2016, I presented two workshops for the Eastern Area Health Education Center (AHEC), first at the Marine Base in Cherry Point, NC and then at the Edwin W. Monroe AHEC Conference Center in Greenville, NC. Although the content of these presentations varied based on the needs of the audiences, below is a brief summary of the information presented at both workshops (additional materials are available in the Resources section.)
The prevalence rate of attention-deficit hyperactivity disorder (ADHD) among children in North Carolina is one of the highest in the country (12.8%), and the proportion of cases treated with medications (74.4%) exceeds the national average (66.3%). Although the reasons for the high rate of diagnosis and medication usage are unclear, it seems likely that the problem is exacerbated in areas that lack behavioral health resources, such as eastern North Carolina. In a study conducted by Visser and colleagues (2014), it appears that parents generally report higher rates of ADHD medication usage in states where behavioral treatments are rarely accessed. It seems safe to conclude from these data that, when available, behavioral treatments offer an alternative to medications. Medications are often needed, but when alternatives are unavailable, medications are used at much higher rates than in areas with alternatives. Part of this problem may be related to families who seek help first from primary care physicians who might resort to medications as a first-line treatment for ADHD.
ADHD diagnosis, however, requires a comprehensive evaluation using data from several sources. Currently, the DSM-5 (American Psychiatric Association, 2013) diagnostic criteria for ADHD require practitioners to gather information on an extensive set of behavioral symptoms, the age of onset, the duration, evidence for impairment (e.g., academic, social), pervasiveness across settings, and the rule-out of other conditions that might provide a better explanation of the problems. Although the DSM-5 clearly gets many things wrong about the disorder (e.g, ignores emotion dysregulation), it is imperative that practitioners carefully conduct diagnosis based on the DSM criteria. To gather this information, practitioners typically must conduct a diagnostic interview with caregivers, collect rating scales from parents and other adults familiar with the child (e.g., teachers), conduct independent observation(s), and consider academic and medical records. Unfortunately, many practitioners fail to complete all necessary steps, and others add unnecessary components that are unhelpful and potentially misleading (e.g., IQ scores, continuous performance tasks).
In addition to diagnostic difficulties, treatment planning for ADHD is often hindered by persistent myths perpetuated by parents and teachers. For example, children are unlikely to "outgrow" the disorder, as was once popularly believed. In fact most (roughly 80%) continue to exhibit significant impairment into adolescence and beyond. Similarly, ADHD is not simply the creation of pharmaceutical companies, nor is it the product of over-stimulation by modern technology. On this latter point, children with ADHD do tend to use computers and social media more than their normally developing peers (Nikkelen et al., 2014), but it seems likely that poor social skills leads to solitary play (e.g., video games) rather than the other way around. Similarly, parents and teachers appear to over-rely on media to babysit the difficult child. (For an interesting example of how technology is wrongly blamed for ADHD, click the image below and watch the section starting at 3:37.)
Once we discard the myths, it is clear that ADHD is a serious condition that, by definition, causes functional impairments in academic, social, and/or vocational performance. In fact, the cost of these impairments have been estimated to exceed an additional $5000 per student each year in K-12 schools (Robb et al., 2013).
What is Evidence-Based Practice for ADHD?
Only three treatments have been well-established in the empirical research literature: (1) Stimulant medications (in 70-80% cases); (2) Behavioral modification; and (3) Combinations of 1 and 2. Each option has been shown effective in the short-term, but none have been shown to consistently improve long-term academic outcomes or adolescent and adult outcomes. Other options have been researched, but most continue to be inconclusive, particularly in terms of long-term impact or "far transfer" beyond the treatment setting (e.g., neurofeedback, cognitive training).
In recent years, researchers have examined a specific set of behavior modification techniques referred to as training interventions (Evans et al., 2013). Training interventions are similar to "ADHD coaching" for adults, where trained paraprofessionals help individuals organize activities of daily living in an effort to strengthen coping skills for the disorder. Note that the goal is not to cure ADHD, but rather to reduce the most impairing aspects. Thus, interventions are targeted specifically to the impairments created by the disorder, rather than its symptoms or presumed causes. Often these coping skills are reinforced through extensive practice and behavioral contingencies (i.e., rewards, punishments). Training interventions are a downward extension of these efforts for adolescents and younger children.
The Challenging Horizons Program (CHP; Schultz & Evans, 2015) is an example of a psychosocial program that utilizes a set of training interventions to address the needs of young adolescents with ADHD. Training begins with teaching the participants definitions for specific behaviors--both desirable and undesirable--that interventionists (as well as parents and teachers) track over time. As an example of a well-defined behavior, consider the following:
Compliments - A child exhibits a verbal or non-verbal behavior directed at a peer or adult that would typically lead to another person feeling good about himself or his behavior.
The definition above is defined to be both observable and measurable, meaning that another adult could conceivably learn this definition and come to identical conclusions if asked to monitor the child's behavior. Once a child is taught a behavioral definition, adults can then offer immediate praise whenever a desirable behavior is observed (e.g., "Billy, that's complimenting!"). Here is another example:
Property Destruction - A child exhibits a behavior that would typically result in a reduction in the value, function, or aesthetic appeal of an object.
Obviously this latter behavior is undesirable; in fact, our goal may be extinguish it altogether. Again, however, once the child knows this definition and can recite it back to adults, the adult interventionist needs only to say, "Billy, that's property destruction" before a planned consequence is imposed. In the workshops, we explored other behavioral definitions and discussed how these definitions form the basis of psychosocial interventions. In effect, the behavior calls that interventionists make serve as a "surrogate prefrontal cortex" for the child with ADHD, while preparing adults to enact effective (and proactive) responses to challenging behaviors.
Effective Psychosocial Interventions
It is easy to see how interventions then flow naturally from observable and measurable behavioral definitions. One such example is the Daily Report Card (instructions from Cincinnati Children's Hospital Center), which involves ratings of the behavioral definitions at school, and then sending those rating to parents who enact behavioral consequences at home. Multiple variations of the Daily Report Card have been proposed (e.g., Direct Behavior Ratings, Check-In, Check-Out), but the basic concept is identical to interventions described forty years ago (cf. Dougherty & Dougherty, 1977).
In the CHP, we move beyond strictly behavioral interventions to help children and adolescents develop good habits (coping skills), including organization, assignment tracking, social problem solving, and homework compliance. The cardinal feature of training interventions is repeated practice over time ("patience and persistence"), with performance feedback, in real-world situations. For example, the organization intervention of the CHP is based on checklists that interventionists and adolescents construct together to define organization for binder, bookbags, and lockers. Once the checklist is constructed, the interventionist checks the system periodically and scores organization based on the number of items met. Note that, as above, each item on the checklist is defined in observable and measurable terms. An example of such a checklist is provided below.
Note that each item is rated in an all-or-nothing fashion (yes/no), and the resulting score is the number of items correct divided by the total number of checklist items, multiplied by 100. We doubt that the specific items on the checklist matter as much as the consistency with which adolescents adhere to these criteria over time. To that end, these data are tracked and graphed for adolescents to consider. In cases where trends stay flat or decline, a reward menu might be tied to checklist performance to ensure motivation. We also encourage interventionists to slowly taper the support they offer during organization checks, while increasing the expectation for adolescents to manage the checks independently.
Research in the CHP suggests that psychosocial intervention require long-term investment because typical responses involve frequent "ups and downs" (Evans et al., 2009). Parents and teachers often give up on such interventions because the occasional backslides can give the impression that the intervention has failed. In truth, children and adolescents with ADHD are inconsistent over time, even after they learn important new skills (i.e., performance deficits).
Even when evidence-based practices are selected, there are still many challenges that confront interventionists during implementation. Chief among these concerns is the degree to which teachers and parents are motivated to participate. To be effective, interventions must occur at the point of performance (e.g., home, school), which typically requires consultation with parents and teachers. Unfortunately, many parents and teachers have a history of failed or abandoned intervention attempts, so new ideas are often approached skeptically. Research on psychotherapy is instructive in these instances. For example, we find that clients enter psychotherapy with varying degrees of motivation for change. Therapists might hope that their clients are actively engaged in the intervention process, but many clients fail to acknowledge their role in the problem (i.e., "If the teacher would just do her job, I wouldn't have this issue!") or, if they do, feel ambivalent toward making a meaningful change. If the therapist moves too quickly to intervention in these cases, she runs the risk of losing her client to "resistance" or premature dropout.
For these reasons, researchers are increasingly using Motivational Interviewing strategies to increase client motivation (e.g., Herman, Reinke, Frey, & Shepard, 2014). In the workshops, we discussed how these concepts apply in several real-world scenarios involving the parents and teachers of children with ADHD. Modifications to our interventions are warranted when it is clear that treatment elements are overly burdensome or unacceptable in the targeted settings. In short, even the most well-researched intervention can fail when our consultees are unable or unprepared to implement as intended.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author.
Dougherty, E.H., & Dougherty, A. (1977). The daily report card: A simplified and flexible package for classroom behavior management. Psychology in the Schools, 14, 191-195.
Evans, S.W., Owens, J.S., & Bunford, N. (2013). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology, 42, 1-25.
Evans, S.W., Schultz, B.K., White, L.C., Brady, C., Sibley, M.H., & Van Eck, K. (2009). A school-based organization intervention for young adolescents with Attention-Deficit Hyperactivity Disorder. School Mental Health, 1, 78-88.
Herman, K.C., Reinke, W.M., Frey, A.J., & Shepard, S.A. (2014). Motivational interviewing in schools: Strategies for engaging parents, teachers, and students. New York: Springer.
Nikkelen, S.W., Valkenburg, P.M., Huizinga, M., & Bushman, B.J. (2014). Media use and ADHD-related behaviors in children and adolescents: A meta-analysis. Developmental Psychology, 50, 2228-2241.
Robb, J.A., Sibley, M.H., Pelham, W. E., Foster, E.M., Molina, B.S.G., Gnagy, E.M., & Kuriyan, A.B. (2011). The estimated annual cost of ADHD to the US education system. School Mental Health, 3, 169–177.
Schultz, B.K., & Evans, S.W. (2015). A practical guide to implementing school-based interventions for adolescents with ADHD. New York: Springer.
Visser, S.N., Danielson, M.L., Bitsko, R., Holbrook, J.R., Kogan, M.D., Ghandour, R.M., Perou, R., & Blumberg, S.J. (2014). Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011. Journal of the American Academy of Child & Adolescent Psychiatry, 53, 34-46.e2. doi: 10.1016/j.jaac.2013.09.001