This Month's Feature Article:
Teens with ADHD Overestimate their Driving Skills.
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For many parents, the day their teenager begins driving introduces a host of new worries and concerns. When that teen has ADHD, however, these concerns are often amplified as multiple studies have documented that adolescents with ADHD have more accidents and engage in more risky driving behavior than other teens.
One possible explanation for these findings are the core ADHD symptoms of inattention and impulsivity, or perhaps the oppositional behavior that often accompanies ADHD, contibutes to poorer driving outcomes. It is reasonable to hypothesize that being inattentive and easily distracted would contribute to driving accidents and that impulsive decisions, e.g., cutting across lanes quickly to avoid missing an exit, could lead to accidents. Or, high levels of oppositionality may lead to a greater disregard for traffic rules/regulations.
A less obvious factor that may contribute to poor driving outcomes for teens with ADHD would be a tendency to overestimate their driving competence. Overestimating one's driving ability could lead to teens taking greater risks because they believe they are 'good' drivers and can afford to take risks. They may also learn less from driving mistakes if they believe that because they are such good drivers, they don't need to worry about a similar mistake happening again.
Multiple studies of children with ADHD indicate that they tend to overestimate their competence in different domains relative to ratings made by those who know them. There is also some research documenting this tendency among teens with ADHD, including one study suggesting that the relationship between ADHD symptoms and risky driving outcomes is explained by the tendency of teens with ADHD to overestimate their behavioral competence. In related work, young adults with ADHD rated their driving skills similarly to other adults, even though their objective performance in a driving simulator as well as their driving record was significantly worse.
A study published online recently in the Journal of Attention Disorders took a closer look at the tendency of teens with ADHD to overestimate their driving skills and whether this may contribute to poorer driving outcomes [Fabiano et al., (2015). Positive bias in teenage drivers with ADHD within a simulated driving task. Journal of Attention Disorders, doi: 10.1177/108705471616186].
Participants were 172 16 to 18 year old youth diagnosed with ADHD (72% male); approximately 70% were receiving stimulant medication. As part of a larger study examining driving interventions for teens with ADHD, all youth participated in a driving simulator exercise that lasted 20 minutes. The simulator consisted of a front-seat real vehicle passenger cabin, an actual steering wheel, and regular floor pedals. The virtual simulation driving environment - which was presented on a computer screen - was modeled after actual roads from local neighborhoods. Youth were instructed to drive through the 'neighborhood' as they typically would; as they negotiated the simulated environment, the simulator continually monitored their speed, whether complete stops were made at stop signs, and how they reacted to roadway obstacles and hazards that appeared.
ADHD Symptoms - Each teen and his/her parents rated ADHD symptoms using a standardized rating scale called the Disruptive Behavior Scale.
Driving Behavior - Teens’ driving in the simulator was rated by teens and by an adult observer. This 17-item measure inquired about specific negative driving behaviors during the simulated driving task, e.g., speeding, crossing into the wrong lane, failing to stop fully at stop signs, etc.
Overall driving performance ratings - In addition to rating specific driving behaviors, teens and observers provided an overall rating of the quality of the teen’s driving.
Simulator behavior composite - The number of instances of 5 specific driving outcomes was calculated for each driver. These included the number of deer hit when animals ‘ran’ into the roadway unexpectedly, the number of traffic cones hit in construction zones, how often the car deviated from the correct lane, instances of speeding, and rolling through stop signs. This composite store provided an 'objective' indicator of negative driving behavior.
Ratings of ADHD and oppositional symptoms - Teens reported significantly less severe ADHD symptoms than parents. The magnitude of this difference was large and particularly large for ratings of inattentive symptoms. Teens also reported lower levels of oppositional. This replicates findings that have consistently been reported in younger children.
Ratings of driving behavior - Teens rated their driving behavior more favorably than observers, both for specific negative driving behaviors and for overall driving quality. This reflects a 'positive bias' in that teens themselves as better drivers than adults who observed them. Teens' bias was greater for the overall performance rating than for ratings of specific driving behaviors.
Relationship between positive bias and risky driving - In a final analysis, the researchers examined the prediction of the cumulative number of dangerous driving behaviors recorded in the simulated driving task. Predictors were parents’ rating of oppositional behavior, gender, medication status, and how positively biased teens were in rating their overall driving quality. The only significant predictor of negative driving was the size of this positive bias; specifically, the more biased the rating the higher the rate of negative driving behavior in the simulator.
Summary and implications
Results from this study indicate that teens with ADHD underestimate their behavioral symptoms relative to parents and overestimate their driving competence relative to adult observers. The positive bias for driving performance was greater for the overall driving rating than for ratings of specific behaviors, but was statistically significant in both instances.
These findings have important implications because teens who overestimate their driving ability may take more risks while driving and learn less from their mistakes. It was noteworthy that the size of teens positive driving bias was the only significant predictor of their actual negative driving during the simulation task.
Based on these findings, the authors highlight suggest that clinicians working with teens diagnosed with ADHD should provide precise driving recommendations and monitoring strategies to families. Additionally, they caution against relying on teens’ self-report of their driving and suggest that parents consider the use of objective indicators of driving performance such as on-board engine performance monitors and/or in-vehicle video recorders. Such measures are not likely to be well-accepted by many teens, however, and may engender conflicts that that become another source of difficulty. Certainly, this is an area where working with a professional experienced in helping families negotiate these issues could be helpful.
There are limitations to this study that are important to note. The most significant is the absence of a non-ADHD comparison group. It would not be surprising if adolescents without ADHD also overestimated their driving competence and this study provides no information on whether the bias displayed by teens with ADHD is larger than for other teens. This would be an important issue to examine in subsequent research. It would also be interesting to know how the driving performance compared for teens who were and were not being treated with medication; medication status did not emerge as a significant predictor of negative driving performance but it was not clear whether teens were on medication at the time of the driving test.
Finally, although a particularly interesting finding was that teens’ positive bias, and not their level of oppositional behavior, predicted negative driving in the simulator, it is not clear why parent ratings of ADHD symptoms were not included in this analysis. Perhaps ratings of core ADHD symptoms would have emerged as more important. Given that this is a study of youth with ADHD, it is a perplexing omission.
In summary, results from this interesting study highlight that teens with ADHD are likely to overestimate their driving competence and this may be an important factor contributing to negative driving outcomes, perhaps even more important than their behavioral symptoms. This suggests that efforts to engage teens in realistic discussions about their driving skills, and working with them to develop accurate appraisals of their competence, would be useful for parents and clinicians to pursue.
Additional recent articles below:
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Helping teens with ADHD develop friends.
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A consistent finding in studies examining the prediction of negative developmental outcomes for children is that peer relationship difficulties are an important predictor of multiple problems.
Unfortunately, many children with ADHD struggle to develop positive peer relationships and to establish and maintain supportive friendships. For example, one study reported that over 80% of children with ADHD experience negative peer relationships and that many have no mutual friendships. This is problematic because close friendships have mulitiple important functions for children including providing companionship, enabling feelings of self-validation, contributing to emotional security, creating a context for self-disclosure, offering guidance and support, and serving as a reliable ally. Children who lack friends miss out on these important supports, and may experience more adjustment difficulties as a result.
Because children with ADHD frequently experience social difficulties, interventions to help them make and keep friends have been developed and have shown promise. In one such program called Children's Friendship Training (CFT), parents and children participate in 12 90-minute sessions where children learn a variety of socialization skills, including conversational skills, sportsmanship, how to cope with teasing, and conflict resolution skills. Parents learn to support children's efforts to make friends and are encouraged to arrange get-togethers where their child can practice newly learned social skills. Results indicate that this program helps many children with ADHD attain more positive social outcomes, although the impact on long-term social outcomes needs further study.
Although supportive peer relationships are equally important for adolescents, research on improving peer relations in adolescents with ADHD is strikingly limited. In fact, I am not aware of a single study that has specifically examined this issue. I was thus pleased to come across a study of this topic that was published recently online in the Journal of Attention Disorders [Gardner et al., (2015). Examination of a parent-assisted, friendship-building program for adolescents with ADHD. Journal of Attention Disorders. DOI: 10.1177/1087054715588188].
Participants were 20 youth with ADHD between the ages of 11-16 and their parents. (Given that some participants were 11 and 12, it is more accurate to describe the sample as including older children and adolescents.) All youth were reported by their parents to have significant difficulties with peer relations; they also all volunteered to participate in the study, suggesting that they were motivated to improve their peer relations.
The intervention tested was called PEERS - Program for the Evaluation and Enrichment of Relational Skills. It consisted of 14 weekly, 90-minute group sessions - one group for youth and one for parents. Participating youth learned a variety of social skills including initiating and maintaining conversations, appropriate use of electronic communication, using humor appropriately, dealing with peer teasing, and how to join groups. The program began by introducing foundational skills, e.g., initiating conversations) and progressed to more advanced skills such as hosting get-togethers and dealing with a negative reputation. Youth were given homework assignments each week that required them to practice the skills they were taught in the group. Parent sessions focused on educating parents about the skills their child was learning and discussing how they could support the development of those skills. Parents were encouraged to discuss homework assignments with their child and to assist them as needed in arranging get-togethers with peers. Essentially, parents were taught to function as 'friendship coaches' for their child.
To assess the impact of the program, multiple measures of participants' social functioning and experience were collected before and after the intervention. This included information on whether youth had initiated a new friendship during the program, their knowledge of appropriate social skills, the perceived quality of their closest friendship, how accepted they felt by peers, and how frequently they initiated get- togethers. Parents were also asked how frequently their child had initiated get-togethers.
Comparisons of ratings provided before and after the intervention indicated positive intervention effects in some areas. These included the following:
- Nearly 80% of parents and 70% of youth reported the initiation of a mutual friendship post-treatment. Thus, the majority of participants seem to have attained this primary intervention goal.
- There was a significant increase in the number of hosted get-togethers that parents and youth reported. At the end of treatment, nearly 95% of parents and 90% of youth reported that the youth had hosted at least one get-together in the past month.
- There was a large increase in participants' social knowledge and knowledge of appropriate social skills.
Change in adolescents' report of the quality of their closest friendship was in the predicted direction, but did not reach statistical significance. They also reported higher levels of social acceptance following the intervention, but this increase was not statistically significant.
Summary and Implications
This is the first study to specifically examine whether peer relationships in older children/young adolescents with ADHD can be improved by a parent-assisted friendship-building program. Because positive peer relations play an important role in children's healthy development - particularly having at least one supportive friendship - and many youth with ADHD struggle in this domain, this is an important and understudied issue.
Results of this initial study suggest that interventions that provide structured practice in friendship making skills, and that help parents become 'friendship coaches' for their teen, are potentially helpful. This was evident in the number of participants who initiated new friendships during the program, an increase in hosted get-togethers, and an increase in social knowledge. These are changes in the right direction and highlight the value of additional work to develop and refine the program.
While these initial findings are positive, it is important to recognize that this is only a first step in establishing the benefits of the intervention. As a pilot study, the sample size was small and there was no control group. As noted above, although the authors describe their program as an intervention for adolescents, many participants were not yet teenagers. There was also no information provided on other treatments participants were receiving, e.g., medication. And, a longer-term follow-up to determine whether benefits reported immediately following the intervention persisted for a reasonable time period was not conducted. There is thus considerable work to be done to learn whether this approach will be helpful for older adolescents and whether it can promote improvements in social relationships that are enduring.
While it is important to recognize these limitations, this should not take away from a thoughtful attempt to develop a much needed treatment approach for older children and adolescents. One of the most difficult aspects for youth with ADHD, as well as for their parents, are the peer relationship difficulties that many experience. Efforts to develop effective interventions for these difficulties are important, and hopefully this initial effort will lead to more such studies.
Note - For an informative summary of peer relationship challenges in youth with ADHD, visit http://jpepsy.oxfordjournals.
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* Does treatment for ADHD improve long-term outcomes?
The core symptoms of ADHD frequently cause significant impairment in academic, social and behavioral functioning that adversely impact individuals' quality of life. These symptoms often persist into adulthood, potentially compromising an individual's functioning over many years. Understanding how ADHD impacts long-term functioning, and whether adverse long-term effects are diminished with treatment, is thus extremely important. However, despite ample evidence that treatments such as medication and behavior therapy yield substantial short-term benefits for most individuals, the impact of treatment on longer-term outcomes remains less well-established. This is an important gap in the research literature.
In last month's issue of Attention Research Update - see http://www.helpforadd.com/
2015/january.htm- I reviewed a paper that synthesized research on long-term academic outcomes for youth with ADHD. Key findings were that academic outcomes were generally better for treated vs. untreated youth, but generally remained significantly below outcomes attained by youth without ADHD.
What about the impact of ADHD and ADHD treatment on long-term outcomes in other important domains such as social and occupational functioning, antisocial behavior and substance use, driving, and self-esteem? Is there evidence that treatment helps? Does it help enough to normalize outcomes relative to those without ADHD? These important issues were addressed in a paper titled 'A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: Effects of treatment and non-treatment'. The paper was published in 2012 in BMC Medicine - you can find the full text of the article at http://www.biomedcentral.com/
The authors began by searching for relevant studies published between 1980 and 2010. All studies compared outcomes in participants with and without ADHD or between treated and untreated participants with ADHD. A total of 351 studies were identified; these included longitudinal studies where individuals were followed for at least 2 years and cross-sectional studies where outcomes were measured in groups of participants at different ages. Only studies where outcomes were assessed in individuals at least 10-years old were included. The ages of participants in these studies extended from children to older adults.
It is important to note that the studies included were quite varied and have different methodological strengths and weaknesses. And, many were not 'long-term' in the sense of following individuals diagnosed in childhood to learn how they were doing as young adults; instead, the authors chose to define 'long-term' as 2 years or more. These issues are problematic, but being more restrictive on the studies included would have introduce different challenges, e.g., too few studies to analyze. Thus, limitations in what can be concluded from the authors work are inevitable and reflect limitations in the studies they had to draw on.
As noted above, 351 studies were included for analysis. Many of these studies included more than one outcome, so the number of outcomes compared exceeded this total. Nine different types of outcomes were examined. These outcomes, and the number of studies in which each was examined, are as follows:
1. Drug use/addictive behavior - 160 studies
2. Academic outcomes - 119 studies
3. Antisocial behavior - 104 studies
4. Social functioning - 98 studies
5. Occupational functioning - 45 studies
6. Self-esteem - 44 studies
7. Driving outcomes - 30 studies
8. Service use (emergency health care, financial assistance) - 26 studies
9. Obesity - 10 studies
Across all studies, the average length of time for which researchers collected data on participants was 9 years; the range of time for which data was collected was 2 years to 40 years. As noted above, the studies included participants across a wide age-range.
Comparing results across such disparate studies is complicated, particularly given the variety of outcomes examined and the measures used to examine them. This makes it challenging to combine results across studies into a single analysis, as is frequently done in meta-analytic work. As an alternative, the authors counted how often outcomes were significantly different between the groups compared in each study, e.g., youth with and without ADHD or treated vs. untreated youth with ADHD. They then counted the number of times that outcomes were found to be significantly different.
For example, if driving outcomes were compared between treated vs. untreated individuals with ADHD in 22 studies, they counted how many times the outcome was significantly better for treated individuals and how many times there was no significant difference.
Outcomes comparing individuals with untreated ADHD to peers
A total of 333 studies compared outcomes between untreated participants with ADHD and controls; in many of these studies, multiple outcomes were compared. Overall, outcomes for individuals with untreated ADHD were significantly worse than for comparison subjects approximately 75% of the time. Information on whether this varied significantly across different outcomes, and how much worse outcomes for untreated participants tended to be, was not provided. Thus, one can't conclude much from this summary beyond the fact that individuals with untreated ADHD tend to fare worse over the long-term in multiple domains relative to those without ADHD.
Outcomes with ADHD treatment
Treated vs. untreated ADHD was compared in 48 studies involving 76 outcomes. For 72% of the outcomes, treated individuals were doing significantly better. For the remaining 28% of outcomes, treated and untreated individuals generally did not differ although in rare instances treated individuals were doing worse.
The likelihood that treatment was linked was linked to better outcome varied considerably across the different outcomes examined. Treated individuals did better than untreated individuals for 100% of driving and obesity outcomes, 90% of self-esteem outcomes, 83% of social functioning outcomes, 71% of academic outcomes, 67% of drug use outcomes, 50% of antisocial behavior outcomes, 50% of service use outcomes, and 33% of occupational outcomes.
Thus, for all outcomes except for antisocial behavior, service use, and occupational functioning, treated individuals were likely to be doing better. For the latter 3 outcomes, however, treated individuals were doing better between one-third and one-half of the time, and about the same the rest of the time.
It is important to note that treatment varied across studies and determining the quality of treatment received was not possible. In most studies, participants received medication treatment; however, non-medical treatment and treatment that combined medication with other treatments were also common. Treatment type did not seem to be associated with the likelihood of better outcomes but details on this were not provided.
Does treatment normalize outcomes?
The results above suggest that ADHD treatment is generally associated with better outcomes. However, is treatment likely to normalize outcomes relative to individuals without ADHD?
This was examined in 42 studies that included 76 different outcomes. In most cases, outcomes were not normalized with treatment, meaning that individuals with ADHD were doing significantly worse than comparison subjects. This was found for 58 of the 76 outcomes examined. Thus, equivalent outcomes between treated participants and controls were found only 18 times.
An important caution
The above results suggest that treatment generally provides long-term benefits to individuals with ADHD but that it does not typically 'normalize'their outcomes. Because the studies considered by the authors included ones from both North America (US + Canada) and Europe, the authors also examined whether treatment outcomes varied geographically. It appears that they did.
Specifically, 86% of outcomes for studies conducted in Europe were consistent with treatment benefits compared to only 50% of outcomes for North American studies. This may be because North American studies tended to use prospective designs in which individuals with ADHD who did vs. did not receive treatment were followed over time while European studies were typically retrospective studies of adults. The former would generally be considered a stronger design so one possible interpretation is that more rigorous studies were less likely to document long-term benefits of ADHD treatment.
Summary and implications
The authors' ambitious goal in this paper was to summary existing research on long-term outcomes associated with ADHD to address 3 fundamental questions:
1. Without treatment, how often do individduals with ADHD experience significantly worse outcomes than those without the disorder?
2. Is there evidence that ADHD treatment improves long-term outcomes? And,
3. Is there evidence that ADHD treatment generally normalizes outcomes?
To address these questions, they identified over 350 studies conducted in North America and Europe in which diverse outcomes were examined over at least a 2-year period. A wide mix of studies and ages were included, and detailed information on the type, duration, and quality of ADHD treatment was not provided (although this may be examined in subsequent work). While this makes it difficult if not impossible to draw firm conclusions, the patter of results obtained converge on the following:
1. Without treatment, the majority of individuals with ADHD attain significantly poorer outcomes in multiple domains relative to peers.
2. Treatment generally results in more positive outcomes relative to no treatment, particularly for driving, obesity, self-esteem, and social functioning. The consistently positive results found for obesity may reflect the appetite suppressing effects of stimulant medication. Antisocial behavior and occupational outcomes were less likely to show benefits with treatment.
3. Although ADHD treatment generally results in better long-term outcomes relative to no treatment, even with treatment outcomes are typically not normalized. Thus, most individuals with ADHD continue to be doing less well in multiple domains than their peers.
As noted above, limitations in the research base that the authors had to drawn on limits any conclusions that can be made about the long-term impact of ADHD treatment. In addition, the authors did not consider how different types of treatment or duration of treatment effected treatment outcomes, although they indicate plans to do this in subsequent work. They also did not discuss the magnitude of treatment effects, which makes it difficult to know how often statistically significant differences between treated and untreated individuals were likely to be clinically meaningful.
Thus, despite the significant effort represented by this paper, important questions remain about the long-term impact of ADHD treatment. In fact, the authors conclude their paper by stating that the "...question remains as to whether the short-term benefits demonstrated by short-term drug or non-pharmacological treatment studies translate into long-term outcomes."
Hopefully, subsequent work by these authors and others in the field will soon provide a more definitive answer to this basic and important question.
* Study: To help children with ADHD improve academic performance, combine medication AND behavioral treatment*************************************************************************************************************
Academic problems are extremely common in children with ADHD and often the issue that leads to referral for an ADHD evaluation. Unfortunately, the significant academic struggles that many children with ADHD experience can undermine their long-term success in areas that extend far beyond formal schooling.
Given these facts, an important question is whether long-term academic functioning in youth with ADHD improves with treatment? Because this is such a fundamentally important question, and ADHD is the most well-researched mental health condition in children, one might think that the answer is clearly established. For a variety of reasons — perhaps the most important of which is the inherent difficulty of conducting long-term treatment studies — this is not the case.
Prior studies have looked at academic outcomes in 2 different ways — academic achievement and academic performance. Achievement refers to the information and skills that children acquire and is typically measured by standardized academic achievement tests. Academic performance focuses on direct measures of success at school such as grades, grade retention, high school graduation, and college enrollment. Thus, achievement measures focus on what children demonstrate they have learned on a one-time test. Performance measures, in contrast, reflect how children actually perform in school over an extended period. Both types of outcomes are compromised in children with ADHD.
The impact of ADHD treatment on achievement and performance outcomes remains controversial. Some studies have found that while ADHD treatment clearly improves classroom behavior, the impact on academic functioning is less evident. In other studies, there is evidence that treatment improves some aspects of academic performance but not achievement. Other researchers have questioned whether medication or behavioral treatment has positive long-term effects on either type of academic outcome.
A new study published recently online in the Journal of Attention Disorders [Long-term outcomes of ADHD: Academic achievement and performance] represents a valuable effort to organize relevant studies on this issue so that broad conclusions about how ADHD treatment affects long-term academic outcomes can be made.
The authors began by conducting a systematic literature search to identify all potentially relevant studies. Specifically, they looked for all studies published in peer reviewed journals between 1980 and 2012 that examined academic outcomes associated with treatment over at least a 2-year period. Some of these studies compared academic outcomes in treated and non-treated children, others had no comparison group but looked at achievement and/or performance measures before and after treatment, while others compared outcomes between treated youth and youth without ADHD.
Ultimately, the authors identified 14 studies that looked at academic achievement outcomes and 12 that assessed performance outcomes were compared — there was some overlap in these studies. To create a common outcome metric across multiple studies that used varying methods, studies were grouped into those that showed treatment benefits and those that did not. They then simply counted the number of studies where evidence of treatment benefits were found.
For studies that compared treated vs. untreated youth, or academic functioning before and after treatment, benefit was defined as a statistically significant gain associated with treatment. Where treated youth were compared to youth without ADHD, benefit was assumed when academic outcomes for youth with ADHD were not significantly worse than for non-ADHD controls.
For achievement test scores, treatment yielded improvement in 7 of 9 studies (78%) when the comparison was with pre-treatment baseline and in 4 of 5 studies (80%) when treated and untreated youth were compared.
For academic performance outcomes, improvement was found in 1 of 2 studies that used pre– vs. post-treatment comparisons and in 4 of 10 studies comparing treated and non-treated youth.
Overall, therefore, there was greater evidence of treatment benefits on achievement outcomes than on performance outcomes.
The authors also examined how treatment outcomes varied for medical, non-medical, and treatments that combined both approaches, i.e., multimodal treatment. Although the number of studies on which these comparisons were based is small, available evidence supported the value of multimodal treatment. Such treatment yielded benefits in 100% of studies examining achievement outcomes and 67% of those examining performance outcomes. For medication treatment only the percentages were 75% and 33% respectively; for non-medical treatments, the figures were 75% and 50%.
Finally, there were 5 studies where achievement and performance outcomes were compared between children treated for ADHD and youth without ADHD. Even with treatment, outcomes were significantly worse for ADHD youth 4 of 5 studies that looked at achievement outcomes and 3 of 5 that looked at performance outcomes.
Summary and Implications
The overall message from this summary of research examining how treatment affects long-term academic outcomes in youth with ADHD is positive. Many studies found improvement with ADHD treatment for both achievement and performance outcomes, with evidence suggesting that treatment has more consistently positive impacts on achievement than on performance. As the study notes, “More achievement test and academic performance outcomes improved with multimodal (100% and 67%, respectively) than pharmacological (75% and 33%) or non-pharmacological (75% and 50%) treatment alone.”
One interesting finding — although based on a limited number of studies — was the indication that better academic outcomes were more likely when medical and non-medical approaches were combined. This is consistent with the generally held view that most youth for ADHD should receive multi-modal treatment as opposed to medical or non-medical approaches alone. However, as I recently noted (Study finds large gaps between research and practice in ADHD diagnosis and treatment) a study that examined treatment practices in a large number of pediatricians found that while medication treatment was recommended for over 90% of youth diagnosed with ADHD, behavioral treatment was recommended fewer than 15% of the time. Thus, many children may not be receiving multimodal treatment in community care.
While the overall message from this study is basically positive, results from studies that compare youth treated for ADHD with non-ADHD controls indicate that treatment generally does not ‘normalize’ academic outcomes in ADHD youth. Thus, while treated youth may generally be doing better than they would have without treatment, treatment often does not bring them up to the level of their peers.
It is important to place these findings in the context of the limited data base on which they were drawn. First, despite systematically searching the relevant research over a 32-year period, the authors identified only 5 studies that specifically compared long-term academic outcomes in treated vs. non-treated youth. And, these studies were not necessarily randomized-controlled trials which makes it impossible to conclude that positive outcomes associated with treatment can be attributed specifically to treatment itself. This will be an ongoing limitation in the research base as conducting long-term randomized-controlled trials in which treatment is denied to a group of ADHD youth for a sustained period is not something that could be ethically done.
It is also the case that the authors’ analysis only indicates that treated youth generally have better long-term academic outcomes. However, the magnitude of treatment benefits was not discussed. There is an important difference between statistical significance and clinical significance, and whether treatment tended to produce gains that parents and educators would consider educationally meaningful is not known. It is unclear to me why the authors did not incorporate such analysis into their paper and this issue was not addressed in their discussion.
Thus, while this study makes a nice contribution by summarizing the relevant literature in a way that enables at least broad conclusions about the impact of ADHD treatment on long-term academic outcomes, it also highlights that a number of significant questions on this important issue remain. The authors conclude by noting that despite the number of studies that have been conducted, there remains a lack of data to guide “…(a) educators as to how to best manage individual children, (b) management at the school system level, and, © the formation of policy at the national level. To this I would add that data-based decisions about the course of action most likely to improve long-term academic outcomes for individual children are also difficult to make based on the available research base.
In the years ahead, one hopes that the research needed to better address these important issues will become more available.
* Pediatric care for children with ADHD - Discouraging new findings*************************************************************************************************************
Most children with ADHD receive their care from community-based pediatricians. Given the large number of school-age children who require evaluation and treatment services for ADHD, and the adverse impact that poor quality care can have on children's development, it is important for children to routinely receive care in the community that is consistent with best-practice guidelines.***********************************************************************************************************************
The American Academy of Pediatrics has clearly recognized this and published guidelines for the evaluation of ADHD back in 2000; this was followed by a set of treatment guidelines in 2001. You can find the complete paper in which these guidelines are presented at http://pediatrics.aappublications.org/content/108/4/1033.full.pdf+html
Based on data collected since then, these guidelines were modified in 2011. The complete text of the revised guidelines can be found at .http://pediatrics.aappublications.org/content/128/5/1007.ful
Below is a brief summary of the key elements from these guidelines.
Evaluation Recommendations for school-age children
- Youth ages 4 through 18 years who present to their primary care clinician with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity should be evaluated for ADHD.
- Diagnosing ADHD requires determining that DSM criteria for the disorder have been met. Making this determination requires information to be obtained from parents or guardians, teachers, and others. Clinicians should rule out any alternative cause of the child's ADHD symptoms. You can find a review of DSM diagnostic criteria - these recently changed with the publication of DSM-V - at www.helpforadd.com/2013/june.htm
- ADHD evaluations should include assessment for other conditions that may co-occur with ADHD, including emotional or behavioral (eg, anxiety, depressive, oppositional defiant, and conduct disorders), developmental (eg, learning and language disorders or other neurodevelopmental disorders), and physical (eg, tics, sleep apnea) conditions.
Treatment recommendations for school-age children
- Treatment and management of ADHD should reflect that it is a chronic condition and may impact children's development and functioning over many years. Parents need to be supported in consistently implementing treatments for their child over an extended period.
Specific treatment recommendations vary by the age of the child.
- For children ages 4-5, evidence-based parent- and/or teacher-administered behavior therapy should be the first line of treatment. Stimulant medication may be prescribed if improvement is not significant and there remain moderate-to-severe disturbances in the child's function.
- For 6-11 year old children, FDA-approved medications for ADHD and/or evidence-based parent- and/or teacher-administered behavior therapy are the front line treatments for ADHD; ideally, these treatments would be combined. The school setting is an essential context for any treatment plan.
- For adolescents, FDA-approved medications should be prescribed with the adolescent's assent. Behavior therapy may also be prescribed and will ideally be combined with medication.
Note that for all ages, family preference is an essential element in determining the treatment plan. For older children and adolescents, their preference should also be taken into account.
- When prescribing medication, clinicians should titrate doses of ADHD medication to achieve the maximum benefit with minimum side effects. Clinicians should inform parents and children that changing medication dose and/or medication may be necessary to determine the optimal medication/dose and that this can require several months. - It is important for medication efficacy to systematically monitored at regular intervals so that adjustments can be made when indicated.
How well are these recommendations being followed?
The best data on this question comes from a study published online recently in Pediatrics [Epstein, et al. (2014). Variability in ADHD care in community-based pediatric practices. Pediatrics; originally published online November 3, 2014; DOI: 10.1542/peds.2014-1500.] The authors recruited 184 pediatricians across 50 pediatric practices in Central and Northern Ohio for a study focused on improving community-based care for children with ADHD. For each pediatrician, 10 charts for patients with an ADHD diagnosis code were randomly selected so that the assessment and treatment procedures received by those patients could be reviewed.
For each chart reviewed, the researchers documented the following:
1. Presence of parent and teacher ratings of ADHD symptoms during the assessment.
2. Documentation that the child met DSM criteria for ADHD.
3. Documentation of whether ADHD medication was prescribed.
4. Documentation that behavior therapy was suggested.
5. Date of initial ADHD medication prescription.
6. Dates of ADHD-related treatment visits or other contacts, e.g., phone, email.
7. Dates of collection for parent and teacher ADHD rating scales.
- Evidence that DSM criteria for ADHD were met was documented in approximately 70% of patients' charts. Thus, for nearly one-third of children diagnosed with ADHD, evidence that DSM criteria were met was missing.
- ADHD rating scales were collected from parents and teachers for roughly 56% of youth with an ADHD diagnosis. Presumably, pediatricians would have obtained information about ADHD symptoms from parents via other means, i.e., clinical interview. For teachers, however, the absence of rating scales in over 40% of the cases suggests obtaining information directly from teachers is frequently not done, as speaking with teachers on the phone is unlikely to have occurred.
- Pediatricians prescribed ADHD medication to roughly 93% of youth diagnosed with ADHD. Documentation that behavioral treatment was recommended, however, was present in only 13% of the charts.
- Follow-up contact (visit, phone call, or email) within 30 days of prescribing medication was documented in fewer than 50% of charts. Thus, for over half of youth prescribed medication, there is no indication that any information on the child's response to medication was obtained during the 1st month.
- For youth on medication for at least one year, an average of 5.7 contacts occurred during the year; the majority of these were office visits, some were phone calls, and email was virtually never used. Contacts declined during the 2nd and 3rd year of treatment.
- With respect to monitoring treatment response with standardized ratings, this rarely occurred. Only 11% of charts had any evidence of parent ratings to monitor treatment response and less than 8% had teacher ratings within the 1st year of treatment. In addition, the average time between initiating medication treatment and collecting parent or teacher ratings was quite long - 396 days for parents and 362 days for teachers.
Summary and Implications
Results from this study are unfortunately clear and discouraging in that guidelines from the American Academy of Pediatrics on the evaluation and treatment of ADHD are frequently not followed. The data indicate that many children are diagnosed with ADHD in the absence of clearly meeting DSM diagnostic criteria and that behavioral treatment is rarely recommended.
Although pediatricians are frequently initiating medication treatment - which has a strong evidence base - gathering data early in treatment to determine the child's response is often neglected and systematically monitoring treatment response over time hardly ever occurs. As a result, many children are likely to be deriving significantly less benefit from such treatment than they would if the guidelines were routinely followed. This is because careful monitoring often reveals the need to adjust a child's dose, and sometimes medication, to maintain optimal benefits. You can review an article on this issue at www.helpforadd.com/2001/march.htm
Although I don't like to be pessimistic, it is worth noting that these findings may underestimate the degree to which AAP evaluation and treatment guidelines are failing to be followed. Thus, this study provided no data on whether pediatricians' evaluations included the assessment of other conditions that often co-occur with ADHD so that a comprehensive treatment plan could be developed. Given that such co-occurring problems are unlikely to be addressed by ADHD medication alone, and that behavioral or other psychosocial treatments were so infrequently recommended, it seems likely that co-occurring problems were often not addressed. In the relatively small percentage of children for whom referrals for such treatment was made, no information on the quality of such treatment was available.
I think it is important not to interpret these findings as an opportunity to blame pediatricians for providing poor quality care to many children with ADHD. Certainly, the data indicate that there is ample room for improvement in terms of pediatricians following the AAP guidelines more consistently. However, pediatricians often have dozens (or in some cases, hundreds) of youth with ADHD in their practice and providing systematic follow up care and treatment monitoring in the context of a busy community-based practice can be extraordinarily difficult. Even when rating scales are provided to parents and teachers so that a child's treatment can be monitored, they are often not returned in a timely manner. Thus, the behavior of parents and teachers can undermine a physician's efforts to provide care consistent with AAP guidelines despite his or her best efforts.
One thing that can and should facilitate physicians obtaining the information they need for both initial assessments and ongoing treatment monitoring is use of the internet. There are now several sites that enable parent and teacher behavior rating forms to be completed online and transmitted securely to physicians involved in a child's care. I have been consulting with one such company that offers this service for the past year - www.attentionpoint.com - and am perplexed that more professionals are not taking advantage of this type of service.
There are limits, of course, in what can be concluded from this study. In particular, all pediatricians were recruited from a specific geographic area, and generalizations to the care provided in other regions can't be made with certainty.
The authors conclude by noting that "Although guidelines are an important first step, additional efforts, likely initiated or incentivized outside the practice, are required to improve the quality of care delivered in pediatric settings. Such efforts may take the form of quality improvement, clinical decision support tools, using pay-for-performance incentives,and/or partnering with mental health professionals."
The authors themselves are involved in efforts to help pediatricians deliver higher quality ADHD care which you can learn about at www.myadhdportal.com/default.aspx?r=1
You can read the full text of the article summarized above at http://pediatrics.aappublications.org/content/134/6/1136.full.pdf+html
* A New Treatment for Inattentive ADHD*************************************************************************************************************
Children with the inattentive type of ADHD (ADHD-I) show high rates of attention difficulties without the hyperactive and impulsive behavior shown by children with ADHD Combined Type (ADHD-C). The inattentive type of ADHD is quite common and is associated with significant impairment with school work, planning and organizational skills, processing speed, and peer relations. Even so, children with ADHD-I tend to be identified later than those with ADHD-C, perhaps because they do not typically display the disruptive behavior problems that command parents' attention early on. They are also less disruptive in the classroom and teachers may be less aware that they are struggling academically.***********************************************************************************************************************
Most treatment research on ADHD has been focused on children with ADHD-C. For example, the MTA Study - the largest ADHD treatment study ever conducted - included only children with ADHD-C. The role of medication treatment for ADHD-I is less well documented than for ADHD-C. Medication benefits may be less obvious in children with ADHD-I because they exhibit less disruptive and impulsive behavior. Parents may be less willing to medicate their children with ADHD-I because their behavior problems are less overt. And, medication alone may be less effective for the academic struggles that are especially important in children with ADHD-I.
Behavioral treatments for ADHD have also been developed primarily to meet the needs of children with ADHD-C, as many behavioral interventions focus on reducing disruptive and impulsive behavior and typically devote less attention to promoting alertness, organization and planning skills. Because traditional behavioral treatments are not tailored to the specific needs of children with ADHD-I they may be less effective for these children.
The lack of interventions specifically matched to the impairments experienced by most children with ADHD-I was addressed in a study published recently in the Journal of Consulting and Clinical Psychology [Pfiffner et al., (2014). A two-site randomized clinical trial of integrated psychosocial treatment for ADHD-Inattentive Type. Journal of Consulting and Clinical Psychology. Online first publication,
May 26, 2014. http://dx.doi.org/10.1037/ a0036887].
Participants were 199 7-11 year-old children (58% boys) diagnosed with ADHD-I. These children were recruited from via mailings to principles, school mental health providers, pediatricians, and child mental health professionals. Following an initial phone screening for ADHD-I conducted with parents and teachers, structured interviews were conducted in person to confirm that all participants met full DSM-IV criteria for ADHD-I.
These participants were randomly assigned to 1 of 3 treatment conditions: Child Life and Attention Skills (CLAS), a newly developed treatment designed specifically for children with ADHD-I; Parent-focus treatment (PFT), a behavioral parent training program, and Treatment as Usual (TAU), in which parents pursued whatever treatment they chose to. These treatments are described below.
Child Life and Attention Skills (CLAS) - The CLAS intervention included parent, teacher, and child components.
Parent component - The parent component included 10 90-minute parent group meetings and up to 6 30-minute family meetings. During group meetings, parents were educated about ADHD-I and how it impacted children's functioning. They learned strategies that included effectively using rewards and positive consequences, establishing daily routines, giving effective directions, avoiding power struggles, stress management, how to organize and structure their home to promote their child's adaptive functioning, and how to use negative consequences.
Relative to traditional ADHD parenting programs, greater attention was paid to teaching parents how to address executive functioning deficits that characterize many children with ADHD-I, e.g., planning, organizing, working memory, prioritizing). For example, they were taught how to set up specific routines for getting homework done and for helping children to organize the various tasks they needed to complete. Each week they were given homework that involved practicing and implementing specific skills at home; these assignments and troubleshooting problems parents had implementing new strategies were discuss at each session before new content was introduced. Parents were also taught skills for interacting effectively with teachers and how to help develop, evaluate, and reinforce classroom interventions developed in conjunction with their child's teacher.
Child component - The child component included 10 90-minute child group meetings focused on teaching children skills for independence, e.g., academic, study, and organizational skills, and social skills, e.g., conversational skills, dealing with teasing, friendship making, etc. Children were also taught strategies to promote attention, time management skills, and task completion. Specific plans were developed for morning, after school and evening routines with tasks and activities specified clearly. Role plays were used frequently in teaching and practicing the skills and rewards were provided to improve the use of skills taught. The latter was done through having children bring in records from their parents and teacher indicating how well they had done in meeting specific home and school challenges that required the use of newly developing skills.
Teacher component - The teacher component included an initial 30-minute orientation meeting with the teacher, child, parent(s) and therapist followed by up to 5 subsequent meetings. Teachers were given an overview of ADHD-I, how it affects children in the classroom, and taught strategies for promoting children's attention and organizational skills. They also set up a daily report card system called the Classroom Challenge in which they rated children 3 times per day on up to 4 specific goal behaviors. These included such behaviors as 'getting started right away', 'finishing work on time', and 'turning in homework'. Specific social behaviors, e.g., 'playing with a peer at recess', were also included. These ratings were taken home daily so that parents were informed about their child's progress on important school goals. Teachers were instructed on the skills children were working on in the child group and how to support and reinforce those skills.
Parent focused training (PFT) - PFT included only the parent training component from CLAS. The skills taught were identical to those described above but did not include training parents to work effectively with teachers. There was no child skills group,direct consultation with teachers, or home-school daily report card.
Treatment as usual (TAU) - When children were assigned to this condition, parents received a list of community treatment providers but were not given specific treatment recommendations - what they pursued was up to them. Fourteen percent of these children went on to receive medication treatment, one-third received some form of psychotherapy (child therapy or parenting group), 51% received educational intervention at school, and 53% received some type of classroom accommodation.
Measures - Data was collected from both parents and teachers before treatment began, immediately following treatment, and 5 to 7 months after treatment ended. The latter assessment occurred during the following school year when children were with a new teacher. At each time point,ratings were collected to measure the presence of DSM-IV inattentive symptoms, organizational skills relevant to academic success, and social skills. Parents and teachers rated children's overall improvement from baseline immediately after treatment; parents completed a similar rating at the long-term follow up.
Post-treatment - Immediately following treatment, parent and teacher ratings indicated that compared to childre in TAU children in CLAS showed fewer inattentive symptoms, better organizational skills, better social skills, and greater overall improvement. The magnitude of the group differences were in the moderate to large range. According to parents, nearly 55% of CLAS participants now showed 'normalized' levels of inattentive symptoms compared to only 30% TAU children. For teachers, the corresponding figures 58% vs. 33%
Differences between CLAS and PFT were more modest but still evident on teacher ratings of inattentive symptoms, parent and teacher ratings of organizational skills, teacher ratings of social skills, and teacher ratings of overall improvement. Effect sizes were small to moderate. Normalized inattentive symptoms for PFT children were reported by 43% of parents (vs. 55% for CLAS) and 44% of teachers (vs. 58% for CLAS). These differences were not significant.
Follow-up - At the 5-7 month follow-up CLAS remained superior to TAU based on parent ratings of inattentive symptoms, organizational skills, and overall improvement. Differences between CLAS and PFT were only evident for organizational skills and the effect size was modest. For teacher ratings (as noted above, these were ratings provided by a new teacher as children had advanced to the next grade) CLAS was not superior to TAU or PFT on any measure.
Consumer satisfaction - Parents and teachers reported a high level of satisfaction with CLAS. Over 95% felt the child and parent skills taught were very useful and 96% would recommend the program to others. Ninety-four percent of teachers in CLAS felt the intervention was helpful and 83% said they would be likely to continue to program. In addition, approximately 80% of parents in the PFT would have preferred to have had the child and teacher components to supplement the parent training they received.
Summary and Implications
The authors of this study made a laudable effort to design a psychosocial intervention specifically tailored to meet the needs of children with ADHD-I. The intervention they designed was thorough and comprehensive, and carefully integrated work with parents, teachers and children. Teaching parents how to work effectively with teachers to support their child - something that often proves challenging for parents - was an especially nice feature of the intervention.
In many ways, results from the study are highly encouraging. Immediately following treatment, both parents and teachers reported superior gains across multiple areas for children who received CLAS compared to either PFT or TAU. In several instances, differences between CLAS and the other groups were of substantial magnitude. And, it was clear that parents and teacher were highly satisfied with the program and believed that it had real value.
Against this positive backdrop, there are several concerns to keep in mind. The first concerns the feasibility of providing this intervention outside of a grant funded research project. CLAS involved 10 1.5 hour meetings with parents and children, and up to 6 30-minute meetings with teachers. Delivering this in a regular community setting could be challenging and the extend to which this could happen remains unknown.
Second, an important study limitation is that outcome measures were restricted to the parents and teachers who participated in the intervention. One could argue that they had a vested interest in the treatment's success, given the time and effort they had devoted to it. Although parents in PFT had also devoted significant time, the effort required by CLAS was still greater. As a result, the ratings provided by parents - and especially by teachers - may have been influenced by this factor in favor of CLAS relative to the other interventions.
This is especially concerning given that teacher ratings at follow-up showed no beneficial effects of CLAS compared to PFT or TAU. Recall that these ratings were completed by a new teacher who may have been unaware of treatments children and parents had received. In a sense, these were the only 'blind' ratings in the study, and the fact that no effects were found on any of the measures raises some questions about the validity of the other ratings. This is an important study limitation that the authors appropriately acknowledge, and they note that including objective measures of outcome such as 'blind' observations of "...parent-child interactions, classroom behavior and/or peer interactions, homework products, or tests of academic achievement would avoid these rater biases and are important to include in future studies."
These limitations not withstanding, the valuable contribution of this study is in developing a psychosocial intervention that is specifically tailored to the needs of children with ADHD-I, something that is long overdue. I particularly appreciated the efforts to help parents develop the skills and knowledge to work effectively with their child's teacher to promote his/her success at school. This is an important effort and provides a strong foundation on which other researchers can build.
* Effective Neurofeedback Treatment in Only 12 Sessions? -- July 2014*************************************************************************************************************
Neurofeedback - also known as EEG Biofeedback - is treatment for ADHD in which individuals learn to produce and maintain a pattern of EEG activity that is consistent with a focused, attentive state. This is done by collecting EEG data from individuals as they focus on stimuli presented on a computer screen. Their ability to control the stimuli, for example, keeping the smile on a smiley face or keeping a video playing, is contingent on maintaining an EEG state consistent with focused attention. Overtime, individuals learn to do this during the training; neurofeedback proponents argue that this generalizes to real world situations and results in better attention during academic and related tasks.
I have reviewed multiple neurofeedback studies in prior issues of Attention Research Update and recently reviewed 2 studies that yielded exceptionally positive findings. Results from these suggested that neurofeedback may yield comparable benefits for children with ADHD as those provided by medication treatment. You can find my review of these studies at www.helpforadd.com/2014/april.htm
Despite growing evidence that neurofeedback provides meaningful benefits to many individuals with ADHD, an important concern remains the time and expense of the treatment. A typical course of neurofeedback treatment often involves 30-40 sessions; this was the case in the studies noted above. This is a time consuming an expensive proposition, particularly since neurofeedback is rarely covered by health insurance.
Thus, developing a neurofeedback treatment protocol that yielded clinical benefits in fewer sessions would be an important development for the field. A study recently published in the journal Clinical EEG and Neuroscience suggests that this may be possible [Hillard et al., (2013). Neurofeedback training aimed to improved focused attention and alertness in children with ADHD: A study of relative power of EEG rhythms using custome-made software application. Clinical EEG and Neuroscience, 44, 193-202].
Participants were 18 children and adolescents with ADHD - average age 13.6 years; 6 females. Diagnoses were made using a structured psychiatric interview along with parent and teacher rating scales. Participants completed 12 weekly neurofeedback sessions of 25 minutes per session. The training protocol and equipment was developed by Peak Achievement; the goal was to enhance Focus throughout the session will maintaining an adequate level of Alertness. (Note - The Peak Achievement system is described at http://peakachievement.com. Peak Achievement was a sponsor of Attention Research Update approximately 7 years ago but I have no current relationship with the company.)
Sessions were completed using different segments of documentary films. Feedback that an individual's EEG state deviated from the desired parameters was conveyed by changing the screen brightness and size of the video and/or slowing down/stopping the video. Thus, participants were continually informed about whether they were maintaining EEG activity consistent with a Focused and Alert state. EEG data was collected throughout each session so that changes within and across sessions could be determined.
Measures - Behavioral ratings from parents were collected before and after treatment using the Aberrant Behavior Checklist which assessed hyperactivity, lethargy (indicative of a day-dreamy, unfocused state), and hyperactivity. Objective assessments of attention were collected pre- and post- treatment using a computerized test of attention called the IVA+Plus. As noted above, EEG data was also collected throughout training so that changes associated with training could be computed.
Behavior ratings - A comparison of parents' pre- vs. post-behavior ratings indicated significant reductions in irritability, lethargy, and hyperactivity.
Computerized attention measure - The IVA+Plus showed significant gains in measures of visual attention that were of large magnitude. Gains in auditory attention approached, but did not quite reach, statistical significance.
EEG changes - Significant changes were found in a range of different EEG parameters. Particularly noteworthy was a significant decrease in participants theta/beta ratio; as noted in a prior issue of Attention Research Update, the theta/beta ratio has been found to be a reliable indicator of ADHD, with higher ratios more likely to be found in diagnosed individuals (see www.helpforadd.com/2013/september.htm). A steady decline was observed in this ratio over the course of the 12 training sessions. Parallel changes from minute to minute within each individual session were also observed.
Summary and Implications
The most encouraging implication of this study is that neurofeedback treatment for ADHD can yield significant benefits in far fewer sessions than has typically been required. In this study, behavior improvements, gains in a computerized measure of attention, and corresponding EEG changes were all observed after only 12 25 minute training sessions, i.e., only about 5 total hours of training. Whether this is because of the specific training protocol used in this study, i.e., the Peak Achievement training system, or could be attained with other training protocols, is unclear. (Note - You can find additional information on this protocol at http://peakachievement.com/professional/BrainwaveBasicsforPeakAchievementTraining.htm
It is important to emphasize that this was not a randomized controlled trial - in fact, there was not even a control group. Thus, reliable conclusions about the clinical efficacy of this approach cannot be made from this study alone. For instance, parent rating may have improved because of expectations about treatment benefits rather than actual changes in children's behavior. However, the computerized measure of attention would not be subject to such expectancy effects. And, documenting that EEG parameters changed in ways that are consistent with improved focus and attention also strengthens the study.
In addition to the absence of a control group, there are several other limitations to this study that should be noted. First, the rating scale used in this study is not a widely used measure in the assessment of ADHD and does not include all ADHD symptoms. Thus, including a more conventional rating scale for ADHD, e.g., the Conners, the ADHD Rating Scale, the Vanderbilit Assessment Scale, would have been helpful. Second, no data was collected from children's teachers; finding improvements in teacher ratings of participants' attention would also have strengthened the results. Thus, we do not learn whether the treatment was associated with functional improvements at school, an essential target for ADHD treatment.
Third, it would have been a nice addition if the authors reported on the strength of the association between EEG changes and changes in behavior ratings and computerized attention results. If a significant relationship were found, it would more clearly link EEG changes that occurred during training to the improvements in the behavior ratings and computerized assessment of attention that was observed.
Finally, although the documentation of EEG changes was a strong feature of the study, all EEG data was collected during training itself. If similar changes in the theta/beta ratio were documented outside of the specific training context, it would indicate that neurofeedback induced EEG changes are not confined to when participants are actively engaged in training. This would provide a basis for explaining why improvements in focus and attention in real world contexts, e.g., while doing school work, may occur. Of course, documenting that such changes and benefits persist over time would be another critical factor in evaluating the real-world utility of neurofeedback, particularly because the benefits associated with current evidence-based treatments - medication and behavior therapy - are not typically associated with lasting gains.
These limitations aside, it is encouraging to see initial evidence that neurofeedback may yield significant benefits to youth with ADHD in fewer sessions than has previously been documented. If supported by subsequent work, it would clearly make neurofeedback a more affordable and viable treatment option for many families.
* ** STRONG Results for a Dietary Treatment for ADHD ***************************************************************************************************************
The idea that some children's ADHD symptoms are caused by dietary factors has been around for many years. In fact, the possibility that diet exerts a significant influence on ADHD symptoms was proposed over 3 decades ago by Dr. Ben Feingold, a pediatrician who suggested that eliminating a variety of artificial food colors (AFCs), naturally occurring salicylates (salicylates are chemicals that occur naturally in many fruits and vegetables), artificial flavors, and particular preservatives could substantially reduce ADHD symptoms in many children.
Controlled trials of the Feingold Diet first appeared in the literature during the 1970s, and a meta-analysis of relevant research published in 2004 - see www.helpforadd.com/2005/april.htm - concluded that children's behavior showed a statistically significant improvement when AFCs were eliminated from their diet. The size of the improvement was relatively modest - about a third to a half as large as the improvement typically associated with medication treatment for ADHD. (If you would like to learn more about the this, you can do so at Feingold Diet).
Results from a more recent meta-analysis on the association between ADHD and diet concluded that roughly one-third of children diagnosed with ADHD may respond to diets that restrict access to certain foods.[Nigg et al., (2012). Meta-Analysis of Attention-Deficit/Hyperactivity Disorder or Attention-Deficit/Hyperactivity Disorder Symptoms, Restriction Diet, and Synthetic Food Color Additives. Journal of the American Academy of Child & Adolescent Psychiatry, 51, 86-97] The authors noted, however, that the impact of diet on ADHD symptoms is likely to be substantially smaller than that produced by medication.
Results from a study published in 2011, however, suggests that dietary interventions for ADHD may be more powerful than previously thought [Pelsser et al., (2011). Effects of a restricted elimination diet on the behaviour of children with attention-deficit hyperactivity disorder (INCA study): a randomised controlled trial. Lancet, 377, 494-503. I missed this study when it was published and only recently became aware of the findings. Because this is potentially an extremely important investigation I am pleased to summarize it for you below.
The Impact of Nutrition on Children with ADHD (INCA) Study
The INCA study was conducted in the Netherlands and Belgium and involved 100 4- to 8-year old children (86 boys) diagnosed with any subtype of ADHD; 47 also had a diagnosis of Oppositional Defiant Disorder (ODD). Diagnoses were established via a structured psychiatric interview administered by an experienced pediatrician. One hundred eighty-nine children were initially screened for the study. Fifty-five were excluded because they did not meet criteria for ADHD and another 27 were excluded because families were either insufficiently motivated to enroll or experiencing circumstances that were likely to interfere with completing the study. Six children taking medication were also excluded.
Children were randomly assigned to a 5-week Restricted Elimination Diet(RED)or to a 'healthy diet'. The former was a highly restricted diet and included only a few hypo-allergenic foods - rice, turkey, a range of vegetables (lettuce, carrots, cauliflower, cabbage, beets), pears and water; this is referred to as the 'few foods' diet.
During the first week, children were permitted some additional foods so that the diet was not more limited than it needed to be. However, if significant behavior changes were not observed by parents after one week, these additional foods were gradually removed and children were limited to the 'few foods' diet. Calcium was supplemented via adding it to a daily non-dairy rice drink so that children were not at risk for nutritional deficiencies.
Parents of children assigned to the 'healthy diet' group were given information on healthy eating for children, but were not required to restrict the foods their child ate. Both groups kept careful records of children's food intake during the trial.
After 5 weeks, children in RED who responded positively - defined as a 40% reduction in ADHD symptoms - proceeded with a 4-week double-blind food challenge phase. During the challenge phase, two groups of additional foods were introduced for successive 2-week periods. These foods differed in their propensity to induce an allergic response and parents did not know when children were receiving hyper- or hypo-allergenic foods. The food challenge was implemented to see whether introducing new foods led to a return of ADHD symptoms in children who responded to RED, and, whether this depended on the types of foods introduced.
Measures - The main outcomes collected were ratings of ADHD symptoms completed by parents and teachers using the ADHD Rating Scale; ratings of oppositional behavior were also obtained. These ratings were collected at baseline, 5 weeks after the diet began, and then again after each 2-week food challenge.
Keeping parents and teachers 'blind' to whether children were in the RED or Healthy Diet group was not possible as parents prepare food for their children and teachers see what children bring for lunch. However, the pediatrician completing ratings was blind to children's condition. Other than having 'blind' observers in the classroom to rate children's behavior, which unfortunately was not part of the study, this as good as one can do.
Forty-one of 50 children assigned to RED completed the 5-week diet. Thirty-two (78%) were considered 'responders' in that parent ratings showed at least a 40% reduction in ADHD symptoms. This is a clinically meaningful reduction.
On average, parent ratings of inattentive symptoms declined by 53% for children in the RED group; ratings of hyperactive impulsive symptoms declined by an average of 54%. These average reductions are based on all 41 children assigned to RED, not just the 32 considered 'responders'. Results based on teacher and pediatrician ratings were highly similar. And, comparable results were obtained for ratings of oppositional behavior.
In contrast to the substantial symptom declines seen in the majority of children on RED, symptom ratings for children in the Healthy Diet group remained essentially the same for all 3 raters.
What happened when children who responded to RED had new foods added to their diet? Approximately 60% showed a significant increase in ADHD symptoms and this did not depend on whether the foods introduced were more or less likely to trigger an allergic response. On average, symptoms did not return all the way to baseline levels but there was a statistically significant and clinically meaningful increase.
This is an important study. What is especially noteworthy is that the majority of children with ADHD who were placed on the few foods diet showed a 40% reduction in ADHD symptom ratings; their oppositional behavior improved as well. In fact, the magnitude of the benefits obtained were larger, on average, than what is commonly found with medication. These results suggest that a restricted elimination diet can have substantial benefits for many children with ADHD, and not just for a small minority of diagnosed children. Although results from this study indicate a potentially larger effect of a restricted elimination diet on ADHD symptoms than has been reported in previous work, the results are largely consistent with other studies that have examined this issue in a similar way.
Based on this finding, the authors recommend that all children should be considered for dietary intervention for ADHD, provided that parents can to follow a restricted elimination diet for at least 5 weeks so that its value can be determined and that close supervision is available.
Because these results are so striking, it is important to place them in an appropriate context. First, the study included only children between 4 and 8. This age range was chosen because the authors felt it would be easier for parents of younger children to maintain their child on the diet. Whether the diet would be equally effective with older children/adolscents is unknown. And, it would likely be more difficult to keep older children on such a restricted diet for an extended period.
Second, even with younger children, it is unclear how long such a diet could be maintained and how long the benefits would persist. A majority of children 'relapsed' when new foods were added to their diet and trying to keep children on the 'few foods' diet over a truly extended period could be extremely difficult. Even if this were done, it is possible that the benefits reported here would not last.
Third, parent and teachers could not be kept blind to children's condition, i.e., RED vs. Healthy Diet. Thus, expectancy effects may have contributed to the findings. Although the pediatrician was blind, her ratings were based on observations of the child and on information provided by parents. Thus, ratings of the 'blind' pediatrician were at least partially influenced by 'unblinded' parents.
It would have been ideal to have 'blind' raters observe children at school and to collect objective measures of attention - perhaps with a computerized test - but this was not done. I think this is an important limitation as if similar findings had been obtained from a truly 'blind' observer, or from an objective assessment that would not be affected by 'expectancy effects', the findings would be very difficult to dispute.
Fourth, the mechanism by which the elimination diet 'worked' in children who responded remains unclear. As noted above, not all children relapsed during the food challenge phase and relapse did not depend on whether the foods added were more or less likely to trigger an allergic response. Thus, the underlying mechanism of food sensitivity in ADHD is suggested to be non-allergic, although what that mechanism is remains unknown.
Although these are important limitations, the results of this study are striking and suggest that there may be a much larger role for dietary interventions than has been previously assumed. Certainly, the findings highlight the value of additional research on dietary interventions that begin to address the limitations noted above..
* ** ADHD Study: Reducing the Need for High Medication Doses with Behavior Therapy ***************************************************************************************************************
Medication treatment and behavior therapy are both considered effective treatments for ADHD; the combination of these treatments is generally regarded as an ideal approach for many children. However, in the Multimodal Treatment Study of ADHD (MTA Study), the largest ADHD treatment study ever conducted, the benefit of combined treatment relative to medication treatment alone — while significant for some outcome measures — was not especially robust. This has led some professionals to question whether behavior therapy is necessary when a child is being effectively treated with medication, i.e., will behavior therapy make a sufficient different to be worthwhile? (For a review of the initial set of findings from the MTA study.
One limitation of most prior studies examining combined treatment — MTA included — is that the incremental benefits of behavior therapy have been examined in the context of an optimized medication dose. For example, each child in the MTA Study began medication treatment with an intensive placebo-controlled trial to determine his or her most effective dose. Thus, the benefits of adding behavioral treatment to medication was evaluated in the context of an optimized medication regime. Generally speaking, the incremental benefits of behavior treatment when evaluated in this context are modest at best.
However, medication treatment in community settings is rarely delivered in ways to optimize benefits. And, an entirely different but important question is whether combining behavior therapy and medication can significantly reduce the dose of medication required to attain effective symptom management. This would be an important result because sustained stimulant medication treatment may be associated with growth suppression. Lower doses may reduce growth suppression effects, be associated with reduced side effects overall, and be more palatable to families concerned about medicating their child.
A study recently published online in the Journal of Abnormal Child Psychology [Pelham et al., (2014). A dose-ranging study of behavioral and pharmacological treatment in social settings for children with ADHD, DOI 10,1007/s10802-013‑9843-8 ] takes a careful look at this important issue. Participants were 48 5–12 year-old children with ADHD who were participating in an intensive summer treatment program (STP). The STP ran for 9 hours/day and lasted 9 weeks. Children spent 2 hours each day in academic activities and the rest of each day in group recreational activities similar to a regular summer day camp.
Medication — During the STP, children received 3 different dose of stimulant medication, i.e., low, medium and high, along with a placebo. The medication was a short-acting methylphenidate (the generic form of ritalin) and was administered 3 times each day. Medication dose was switched daily and STP staff were blind to what the child received each day.
Behavior Therapy — Behavior therapy was provided in low intensity and high intensity variants. In both cases, treatment included a point system to promote desired behavior, clearly stated rules and expectations, social skills and social problem solving training, social praise and reinforcement, athletic skills training, and the use of daily and weekly rewards.
The main difference was that in the low intensity condition, each element was modified so that it required less effort to provide. For example, in the high intensity condition, children earned and lost points throughout the day based on their behavior. In the low intensity condition, children received feedback on their behavior but did not gain or lose points. Similarly, although the content of social skills lessons was similar, in the low intensity condition, social skills feedback was not incorporated into daily activities and social problem solving training was not provided. Rewards for good behavior were provided on a weekly rather than daily basis.
The basic design of the study varied medication dose — placebo, low, medium, high — with behavioral treatment — none, low intensity, high intensity — so that children’s behavior in each treatment combination could be assessed. Thus, each child was evaluated during all possible combinations of medication dose and behavior therapy. This enabled the researchers to determine, for example, how a low dose of medication combined with low intensity behavior therapy compared to a high dose of medication alone.
Assessments of children’s behavior during each combination of medication and behavior therapy was provided by counselors. Counselors were blind to medication status but, because they delivered the behavioral treatment, were aware of which behavioral condition the child was in, i.e., no, low intensity, high intensity.
The main outcome rating was derived from the daily point system employed in the STP. Through this system, daily measures were derived for each child’s level of rule violations, noncompliance, interrupting, serious conduct problems, and negative verbalizations. In addition, counselors completed a daily rating of ADHD symptoms, overall degree of impairment, and medication side effects.
As expected, medication treatment in the absence of behavior modification was associated with significant improvements in children’s behavior. And, as dose increased, so did the benefits — on average — to children’s behavior.
Behavior therapy in the absence of medication treatment was also associated with significant behavioral improvement across a wise range of measures. In general, high intensity behavior management was associated with greater behavioral improvements and ADHD symptom reductions than low intensity behavior management.
The really interesting findings from this study concern the combination of medication and behavioral treatment. On virtually all measures, adding high intensity behavior management to the lowest medication dose of medication yielded comparable improvements to those produced by the high dose medication alone. For a number of measures, even low intensity behavior management combined with the lowest medication dose was as effective as high dose medication.
To be concrete, results suggested that a typical child with ADHD could be treated with the equivalent of 5 mg of methylphenidate 2X/day if he/she concurrenlty received moderate to high intensity behavior therapy. Without behavior therapy, the same child would require a 20 mg dose 2X/day to attain comparable benefits. Thus, the daily reduction in methylphenidate would be 30 mg/day. One reason this may be important is that the appetite suppression effects observed in the current study increased substantially with increasing dose — the percentage of their lunch that children ate was 81%, 73%, 59%, and 45% on placebo, low, medium, and high medication doses respectively.
It is also important to note that for several of the outcomes, adding either low or high intensity behavior therapy yielded incremental improvements at every dose of medication; the effect size for these incremental gains were frequently large. Similarly, adding medication to either variant of behavior therapy was associated with significant incremental gains at each dose.
Summary and Implications
Results from this study provide a compelling demonstration that adding behavior therapy to medication treatment could enable most children to be maintained on significantly lower doses of medication than would otherwise be the case. This could potentially reduce the appetite reduction and perhaps growth suppression that can be associated with prolonged stimulant treatment; it could also be more comfortable for many parents who have concerns about medication treatment for their child.
While this study highlights the viability of this approach, it is worth noting that current practice is generally not oriented in this way. Typically, when children begin medication treatment for ADHD, the clinician’s goal is to find a dose that yields the greatest benefits. The question of whether similar benefits could be attained through a combination of less medication and behavior therapy is not typically addressed.
There are limitations to this study that should be noted. First, even the ‘low intensity’ behavior treatment provided had multiple components and could be challenging for families to sustain over time. Second, the study occurred in the context of an intensive summer treatment program, a very different context from where children spend their daily lives. And, treatment results were evaluated over only a 9-week period, with the different combination of medication dose and behavioral treatment intensity lasting for much shorter times. Thus, the sustainability of the effects, and the generalization to more typical environments remains to be demonstrated.
These limitations not withstanding, a basic point demonstrated by this study is clear and straight forward — medication doses can be decreased when such treatment is combined with well executed behavior therapy. This may be particularly valuable when children are unable to tolerate higher medication doses and where there are concerns related to appetite reduction and growth suppression. By the same token, lower doses of medication can reduce the intensity of behavioral treatment required to obtain good effects. Such complementary findings speak to the value of combined treatment for many children with ADHD.
* ** An Innovative Approach for Helping 'Explosive & Inflexible Children' ***************************************************************************************************************
One of the most challenging problems for parents to deal with are explosive outbursts in their child. Such outbursts occur with distressing regularity in some children - regardless of whether the child also has ADHD - and can contribute to an extremely difficult home environment.
A number of years ago I cam across a book called 'The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, "Chronically Inflexible" Children' that I found to provide some very useful ideas for addressing these issues. The book is authored by Dr. Ross Greene, a clinical psychologist from Harvard Medical School. Dr. Greene's approach impressed me as a thoughtful and respectful way to deal with the behavioral volatility and emotional outbursts that often add to the challenges faced my many parents of children with ADHD.
** WHAT ARE THE COMMON CHARACTERISTICS OF INFLEXIBLE-EXPLOSIVE CHILDREN? **
The label "inflexible-explosive" child is not a diagnostic term recognized in DSM-IV, the official diagnostic guide for psychiatric disorders. Instead, it is used by Dr. Greene to capture the key features of children who are extremely difficult for parents to manage. According to Dr. Greene, the key features of such children are the following:
1. A very limited capacity for flexibility and adaptability and a tendency to become "incoherent" in the midst of severe frustration.
These children are much less flexible and adaptable than their peers, become easily overwhelmed by frustration, and are often unable to behave in a logical and rational manner when frustrated. During periods of incoherence, they are not responsive to efforts to reason with them, which may actually make things worse. Dr. Greene refers to these episodes as "meltdowns" and argues that the child has little or no control over his/her behavior during these episodes.
2. An extremely low frustration tolerance threshold.
These children often become overwhelmingly frustrated by what seem like relatively trivial events. Because their capacity to tolerate frustration develop more slowly than their peers, they often experiences the world as a frustrating place filled with people who do not understand what they are experiencing.
3. The tendency to think in a concrete, rigid, black- and-white manner.
These children fail to develop the flexibility in their thinking at the same rate as peers, and tend to regard many situations in an either-or, all-or-none, manner. This greatly impairs their ability to negotiate and compromise.
4. The persistence of inflexibility and poor response to frustration despite a high level of intrinsic or extrinsic motivation.
Even very salient and important consequences do not necessarily diminish the child's frequent, intense, and lengthy "meltdowns". As a result, typical approaches of rewarding a child for desired behavior and punishing negative behavior do not diminish the child's tendency to "fall apart". According to Dr. Greene, traditional behavioral therapy approaches for such children often don't work at all and can make things worse.
In addition to these key features, Dr. Greene notes that a child's meltdowns often have an "out-of-the-blue" quality, occurring in response to an apparently trivial frustration even when the child has been in a good mood. As a result, parents never know what to expect and things can seem to fall apart at any moment.
** WHAT CAUSES A CHILD TO BE THIS WAY? **
According to Dr. Greene, most children who become extremely inflexible and explosive do so because of biologically-based vulnerabilities and not because of "poor parenting". The list of biological vulnerabilities that may predispose children to develop these characteristics include the following:
- Difficult Temperament -
By nature, some infants come in to the world being more finicky, emotionally reactive, and more difficult to soothe than others. These "innate" aspects of personality are what psychologists refer to as temperament. (Note: It is important to recognize that even very difficult temperaments can be modified over time and this in no way "dooms" a child to a life of ongoing difficulty and struggle.)
- ADHD and Executive Function Deficits -
Many children with difficult temperaments are eventually diagnosed with ADHD. As discussed in prior issues of Attention Research Update, current theorizing about the core deficits associated with ADHD focus on problems in a crucial set of thinking skills referred to as "executive functions".
Although there is not universal agreement on the specific skills that constitute executive functions, most lists would include such things as: organization and planning skills, establishing goals and being able to use these goals to guide one's behavior, working memory, being able to keep emotions from overpowering one's ability to think rationally, and being able to shift efficiently from one cognitive activity to the next.
Deficiencies in these skills are believed to help explain not only the core symptoms of ADHD (i.e. inattention and hyperactivity/impulsivity), but also the poor frustration tolerance, inflexibility, and explosive outbursts that are seen in the "inflexible-explosive" children described by Dr. Greene.
For example, if a child has difficulty shifting readily from one activity to the next because of an inherent cognitive inflexibility, this child may feel overwhelmingly frustrated when parents say it is time to stop playing and come in for dinner. The child may not intend to be disobedient, but may have trouble complying with parents' demands because of trouble shifting flexibly and efficiently from one mind-set to another. In fact, Dr. Greene argues that most "explosive children" want to behave better and feel badly about their outbursts. He believes they are motivated to change their behavior but lack the skills to do it.
- Language processing problems -
Language skills set the stage for many critical forms of thinking including problem solving, goal setting, and regulating/managing emotions. Thus, it is not surprising that children with poorly developed language abilities, as is often true in children with ADHD, would have greater difficulty managing frustration.
- Mood difficulties -
Some children are born predisposed to perpetually sunny and cheerful moods. Others, unfortunately, tend to experience sustained periods of irritability and crankiness for reasons that are rooted largely in biology. This is not just true for children who experience full-blown mood disorders such as depression or bipolar disorder, but can apply to "sub-clinical" mood difficulties as well.
Imagine for a moment how you tend to handle things when feeling cranky and irritable. If you're like most people, you probably become frustrated more easily and lose your temper more readily. For children who are prone to these negative mood states, more chronic difficulties with frustration and temper are thus likely to be evident.
** WHAT CAN PARENTS DO? **
How can a parent help their "explosive" child become less explosive, develop greater self-control, and thereby create a better quality of life for everyone in the family?
According to Dr. Greene, the first step is to develop a clear understanding of the reasons for the child's explosiveness. To the extent that parents - and others - regard a child's explosiveness as reflecting deliberate and willful attempts to "get what they want", the overwhelming tendency will be to respond in punitive ways. Dr. Greene argues convincingly, however, that punishments will not work for a child who lacks the skills to handle frustration more adaptively. That is because when these children are frustrated they are not able to use the anticipation of punishment to alter their behavior.
When one's mindset changes from "my child is acting like a spoiled brat" to "my child needs help in learning to deal with frustration in a more flexible and adaptive manner", it becomes easier to move from a punishment-oriented approach to a skills-building approach. At the heart of this effort is what Dr. Greene refers to as the "Basket Approach".
** THE "BASKET" APPROACH **
Because "meltdowns" can be so difficult for everyone in the family to endure, the primary objective in working with "explosive children" is to first reduce the frequency of such episodes. Reducing the number of meltdowns from several per day to one per day, and eventually to just a handful per week, can make an enormous difference in the quality of family life and to children developing a sense of being able to control their behavior. Initially, this is accomplished largely by reducing the demands to tolerate frustration that are made on the child by sorting the types of behaviors the create problems into 3 baskets according to how critical it is to change the behaviors or to curtail them when they occur.
- Basket A -
Some behaviors are so problematic that they must remain off-limits even if enforcing the rule against them will result in a meltdown. Initially, Dr. Greene suggests that the only behaviors to be placed in Basket A are those that are clear safety issues (e.g. wearing a seat belt in the car; not engaging in dangerous or harmful behaviors such as hitting others). This is where parents must continue to stand firm and insist on compliance. Dr. Greene's specific criteria for what goes in Basket A are as follows:
1. The behavior must be so important that it is worth enduring a meltdown to enforce:
2. The child must be capable of behaving in the way that is expected.
For example, Dr. Greene would argue that there is no point insisting that completing assigned homework be placed in Basket A when the child lacks the skills and frustration tolerance to do this consistently.
By reducing the number of behaviors for which compliance is non-negotiable to those that are really and truly essential and that the child is capable of performing, the number of exchanges that are likely to set off explosive episodes can be drastically reduced.
- Basket B -
Basket B - the most important basket according to Dr. Greene - contains behaviors that really are high priorities but are ones that you are not willing to endure a meltdown over. These can include such items as completing schoolwork, talking to parents with respect, complying with reasonable expectations, etc.
It is around Basket B behaviors that Dr. Greene believes that critical compromise and negotiation skills can be taught to your child. For example, suppose your child is watching TV and you know it is time to stop and get started on homework. You tell your child to turn off the TV and get started, and he refuses.
The temptation here would be to insist on immediate compliance and to threaten punishment (e.g. no TV for the rest of the week) if your child does not comply. But, in Dr. Greene's framework, this is not a safety issue, and thus should not be placed in Basket A. He would ask what is likely to happen if you make such a response? One likely consequence is that your child's frustration will increase, he or she will lose control, and a full-fledged meltdown will ensue.
Is this worth it? If standing firm and tolerating this meltdown made it more likely that your child would comply the next time you made such a demand, the answer would be yes. If, however, standing firm and triggering the meltdown does not increase the likelihood of compliance in the future, or reduce the probability of future meltdowns, Dr. Greene would suggest it was definitely not worth it.
What to do instead? Dr. Greene argues that these Basket B behaviors provide wonderful opportunities to try and engage your child in a compromise and negotiation process. In the scenario above, the parent could say something like, "I know that it is important to you to keep watching TV. I would like for you to be able to do this, but I also know that you have homework that needs to get done. Let's try to come up with a compromise where you'll get some of what you want, and I'll get some of what I want."
The goal here is not only to get the child to give in and do what you want, but to begin teaching your child the compromise and negotiation skills that will contribute to his or her becoming more flexible over time. Dr. Greene points out how this process can be extremely difficult for inflexible-explosive children, and that it is not unusual for them to become increasingly agitated when trying to negotiate a solution.
As a parent, if you observe this starting to occur, and sense your child is getting closer to a meltdown, the goal becomes trying to diffuse the tension so that a meltdown does not take place. This can mean offering compromise solutions for the child in an effort to help things calm down. When this does not work, Dr. Greene suggests just letting things go so that the meltdown is avoided. In the example above, should the efforts to negotiate fail and lead the child to the verge of a meltdown the parent might say, "Well, I can see you are getting really upset about this. I appreciate that you tried to work out a compromise with me but we have not been able to come up with a good one yet. So, why don't you just watch a bit more TV for now and we can try again in a little while to work out a good compromise."
This can be very difficult to do and many parents along with mental health professionals would be concerned that such actions would result in teaching the child that he or she can get what she wants by refusing to give in and becoming upset. This is what a traditional behavioral therapist would argue. From Dr. Greene's perspective, however, insisting that the child turn off the TV when a compromise was not reached would accomplish little more than triggering a meltdown that would also prevent homework from getting started on and be much more upsetting for everyone. Because of this, he advocates doing your best to help your child develop some much needed negotiation skills, but dropping things when it is clear that an explosion is imminent. Later, when the child has settled back down, you can resume your efforts to negotiate.
Developing skills to compromise and tolerate frustration does not happen right away. Dr. Greene points out that progress in these areas can be painstakingly slow, but that over time, the approach he recommends can lead to substantial gains for explosive children.
- Basket C -
Basket C contains those behaviors that are simply not worth enduring a meltdown over, even though they may have previously seemed like a high priority. By placing a number of previously important behaviors in Basket C, the opportunity for conflict producing meltdowns between parents and their child is greatly diminished.
What kinds of things belong in Basket C? This depends on the specifics of each situation but may include such things as what a child will and will not eat, what clothes they wear, how they keep their room, etc. Dr. Greene suggests that the question to ask in determining whether a particular behavior falls into Basket C is "Is this so important that it is really worth risking a meltdown over?" If not, and you've already identified a number of behaviors that seem more important and worth negotiating over (i.e. those in Basket B), then into Basket C it goes.
- How does this compare to traditional parenting approaches? -
Dr. Greene's approach to dealing with explosive children runs counter to what many parents and professionals believe, i.e., that if a child is not punished, for behaving inappropriately they will never develop the necessary self-control nor be deterred from continuing to misbehave. Thus, Dr. Greene's thesis here is a controversial one and is at odds with traditional behavior therapy approaches that have substantial research support. Dr. Greene suggests, however, that for children whose explosiveness stems from a basic and biologically based inability to manage frustration, Dr. Greene suggests that behavioral interventions may not be effective can actually make things worse by increasing, rather than decreasing, the frequency with which a child loses control.
- Isn't this just giving in to a misbehaving child? -
Not necessarily. Dr. Greene points out that there is an important difference between giving in and deciding what behaviors are important enough to stand firm on. It remains the responsibility and prerogative of parents to be clear about what is non-negotiable, when compromise is a reasonable way to go, and what things to let slide for the time being. As the child becomes better able to tolerate frustration and learn much-needed compromise and negotiation skills, more and more behaviors can be moved from Basket C into Basket B, thus providing your child with increasing opportunities to practice learning to compromise.
- DOES THIS APPROACH WORK? RESULTS FROM A RECENT STUDY -
Dr. Greene's approach will resonate with some people and be sharply criticized by others. However, the hallmark of a scientist is a willingness and desire to test one's theories through empirical research and I was thus quite pleased to recently come across a study published several years ago by Dr. Greene in which he tested the approach described above against more traditional behavioral parent training therapy with a sample of oppositional defiant children who also had symptoms of a mood disorder (Greene et al. . Effectiveness of collaborative problem solving in affectively dysregulated children with oppositional-defiant disorder: Initial findings. Journal of Consulting and Clinical Psychology, 2004, 72, 1157-1164).
Participants in this study were parents of 50 children with ODD - for a description of diagnostic criteria for ODD see www.helpforadd.com/oddcd.htm - who also had at least sub threshold features of either childhood bipolar disorder or major depression. In addition, about two-thirds of the children were diagnosed with ADHD and many were being treated with medication.
The parents of these children were randomly assigned to 1 of 2 interventions designed to help them bring their child's behavior under better control: the collaborative problem solving model developed by Dr. Greene or a more traditional behavioral parent training program developed by Dr. Russell Barkley, one of the world's leading authorities on ADHD.
Dr. Barkley's parent training program is a highly structured behavior management program that lasted for 10-weeks. The focus is on teaching parents more effective discipline and behavior management strategies and sessions were attended primarily by parents, although children participated occasionally as well.
Families assigned to the Collaborative Problem Solving (CPS) treatment were educated about the biological factors contributing to their child's aggressive outbursts, the "baskets" framework described above, and about the use of collaborative problem solving as a means for resolving disagreements and defusing potentially conflictual situations so as to reduce the likelihood of aggressive outbursts. As with Barkley's parent training program, sessions were attended primarily by parents. The number of sessions attended by parents ranged from 7-16 and the average length of treatment was 11 weeks.
- RESULTS -
At the conclusion of treatment, parents in both groups reported a significant decline in their child's level of oppositional behavior. At 4-months post-treatment, however, the gains reported by families who received traditional parent training were beginning to erode while those who received Greene's Collaborative Problem Solving therapy reported that gains were fully sustained. Specifically, 80% of children in the CPS condition were reported to be either very much improved or much improved by their parents compared to only 44% in the traditional parent training program.
Parents in the CPS condition also reported that they were experiencing significantly less stress, that their children were more adaptable, and that hyperactive-impulsive symptoms were reduced. They also felt more effective at setting limits for their children and that communication with their child had improved. Significant improvements on these dimensions were not evident.
- SUMMARY and IMPLICATIONS -
The approach developed by Dr. Greene for developing self-control in children prone to emotional outbursts and melt-downs represents an important shift from traditional behavioral treatment methods. It is based on the premise that when this behavior has a strong biological underpinning, as he feels is true for many children, the use of punishments and rewards are not likely to be effective. Instead, he advocates that parents work to remove sources of frustration from their child's life, become clear about what behaviors they truly need to take a stand on, and focus on helping their child develop the ability to negotiate, compromise, and manage their affect. Because melt-downs can be so painful for everyone to endure, parents are taught to avoid making demands on their child that would be likely to trigger a melt-down unless it is absolutely necessary.
This will be regarded by many as a controversial approach, but results from a preliminary test suggest that these ideas may have real value for children and families. Because this is only an initial study, however, it is clear that more work needs to be done, and there is currently a larger trial underway. When these results become available, I will make sure to report them in Attention Research Update.
For those of you who would like to learn more about these interesting ideas, there is an excellent web site at www.livesinthebalance.org/ where you can find a wide range of additional information on this approach. Another excellent site to visit developed by Dr. Greene is at http://cpsconnection.com/ I believe you will find these sites to be worth visiting.
***** I hope you enjoyed the above review. Please remember that information presented in Attention Research Update is for educational purposes only, and is not intended to provide specific treatment recommendations for any child.
David Rabiner, Ph.D.
Senior Research Scientist
Source: David Rabiner, PhD
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