Case Analysis – Integrating Theoretical Orientations

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Attention-Deficit/

Hyperactivity Disorders

REBECCA J. HAMBLIN AND ALAN M. GROSS

OVERVIEW

Attention-deficit/hyperactivitydisorder (ADHD)

is one of the most well-studied child psycho-

pathologies, and a tremendous amount of

research has been published related to its

etiology, primary problems and impact,

demographic and contextual variability, and

treatment methods. The label has also received

heavy criticism as being an artificial U.S.

construct for labeling normally exuberant

children; however, early clinical descriptions

of attention impairments date to 1798 (Barkley,

2006; Palmer & Finger, 2001). Attention-

deficit/hyperactivity disorder symptoms are

reported to occur in all countries in which

ADHD has been studied (Polanczyk, de Lima,

Horta, Biederman, & Rohde, 2007). Despite

early conceptualization of the disorder as

resulting from poor character or wayward

parenting, ADHD is now seen as a neuro-

logically based disorder (Barkley, 2006).

ADHD is one of the most common dis-

orders of childhood, affecting an estimated

3% to 5% of children in the United States,

and is the most common reason for clinical

referral of children to psychiatric clinics

(American Psychiatric Association, 2000).

Children with ADHD display symptoms of

inattention, impulsivity, and hyperactivity

across multiple situations beginning at an

early age. The frequency of these behaviors

is out of bounds with respect to normal

development, and symptoms cause significant

impairments in family and peer relationships,

academic functioning, and emotional well-

being (Barkley, 2006).

This chapter will provide an overview of the

core symptoms and current diagnostic features

of the disorder, describe its prevalence and

epidemiology, impairments to daily life,

comorbid disorders, and long-term outcomes.

The next sections will describe various

psychosocial treatments that have been

empirically explored, and will review the most

current research on treatment efficacy. The

chapter concludes with a summary and list of

evidence-based treatments for ADHD.

CORE SYMPTOMS

Inattention

Relative to children without ADHD, those

with the disorder have difficulty maintaining

attention or vigilance in responding to envir-

onmental demands. That is, they have trouble

sustaining effort in tasks, particularly for

activities that are tedious, difficult, or with

little intrinsic appeal (Barkley, 2006). In the

classroom setting, impairment in attention and

task vigilance may be evident in inability to

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complete independent assignments or listen

to class instruction. In unstructured settings,

inattention may be apparent in frequent shifts

between play activities. Parents and teachers

report that these children have difficulty

focusing, are often forgetful, lose things, fre-

quently daydream, fail to complete chores and

schoolwork, and require more redirection

and supervision than others the same age.

Children with high levels of inattentive

symptoms in the absence of hyperactive or

impulsive symptoms may also have a different

kind of attention problem marked by sluggish

cognitive processing and deficiency in select-

ive attention (Barkley, 2003).

Hyperactivity and Impulsivity

Hyperactivity and impulsivity almost always

co-occur and are therefore considered a single

dimension of ADHD. The hyperactive-

impulsive dimension of the disorder is often

conceptualized as behavioral disinhibition.

Hyperactivity is displayed in fidgeting, rest-

lessness, loud and excessive talking, and

excessive levels of motor activity. Impulsive

behaviors include interrupting or intruding on

others, difficulty waiting and taking turns, and

blurting out without thinking. Children

and adolescents with hyperactive-impulsive

features are described by caregivers as reck-

less, irresponsible, rude, immature, squirmy,

and on the go (APA, 2000; Barkley, 2006).

Diagnostic Criteria and Subtypes

Diagnostic criteria for ADHD are defined by

the Diagnostic and Statistical Manual of Mental

Disorders,Fourth Edition,TextRevision (DSM-

IV-TR) as presence of several symptoms in

inattention, hyperactivity-impulsivity, or both,

as seen in Table 10.1 (APA, 2000). Individuals

with symptoms in both domains are classified as

having ADHD, combined type (ADHD-C).

Those who manifest multiple symptoms of

inattention but no or few hyperactive-impulsive

characteristics are diagnosed with ADHD,

predominately inattentive type (ADHD-PI).

The ADHD, predominately hyperactive-

impulsive type (ADHD-PHI) describes indi-

viduals with behavioral disinhibition without

significant symptoms of inattention. Table 10.1

contains the complete diagnostic contained in

the DSM-IV-TR.

PREVALENCE AND DEMOGRAPHIC

VARIABLES

Nearly 5 million children in the United States

are diagnosed with ADHD (Centers for Dis-

ease Control and Prevention [CDC], 2005).

Prevalence rates of ADHD translate, on aver-

age, to one to two children in every classroom

in America (APA, 2000). The most commonly

diagnosed subtype is ADHD-C, representing

about 50% to 75% of children diagnosed.

Another 20% to 30% are classified with

ADHD-PI, while fewer than 15% are diag-

nosed with ADHD-PHI. It is thought that

ADHD-PHI may be a developmental precursor

to the combined type, seen in preschool-age

children who have not yet manifested symp-

toms of inattention.

Boys are 2 to 9 times more likely than girls to

be diagnosed with ADHD (APA, 2000). The

gender discrepancy is more pronounced in

clinic referred than in community samples.

Higher rates among males may be at least

partially attributable to a stronger tendency for

males to present ADHD-C and comorbid dis-

ruptive behavior disorders, which are more

likely to rise to the level of clinical attention.

Girls are more likely to have ADHD-PI and

comorbid disorders are more likely to be

internalizing disorders. Because symptoms of

ADHD-PI and emotional disorders are more

likely to go unnoticed, girls with ADHD

may be underindentified and undertreated

(Biederman, 2005).

ADHD is present among all socioeconomic

levels and ethnic groups within the United

States, though prevalence and symptoms vary

by gender, age, and ethnicity (Barkley, 2003;

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TABLE 10.1 DSM-IV-TR Criteria for Attention-Deficit/Hyperactivity Disorder

I. Either A or B:

A. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is

inappropriate for developmental level:

Inattention

1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other

activities.

2. Often has trouble keeping attention on tasks or play activities.

3. Often does not seem to listen when spoken to directly.

4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the work-

place (not due to oppositional behavior or failure to understand instructions).

5. Often has trouble organizing activities.

6. Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time

(such as schoolwork or homework).

7. Often loses things needed for tasks and activities (e.g., toys, school assignments, pencils, books, or tools).

8. Is often easily distracted.

9. Is often forgetful in daily activities.

B. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an

extent that is disruptive and inappropriate for developmental level:

Hyperactivity

1. Often fidgets with hands or feet or squirms in seat when sitting still is expected.

2. Often gets up from seat when remaining in seat is expected.

3. Often excessively runs about or climbs when and where it is not appropriate (adolescents or adults may feel

very restless).

4. Often has trouble playing or doing leisure activities quietly.

5. Is often “on the go” or often acts as if “driven by a motor.”

6. Often talks excessively.

Impulsivity

7. Often blurts out answers before questions have been finished.

8. Often has trouble waiting one’s turn.

9. Often interrupts or intrudes on others (e.g., butts into conversations or games).

II. Some symptoms that cause impairment were present before age 7 years.

III. Some impairment from the symptoms is present in two or more settings (e.g., at school/work and at home).

IV. There must be clear evidence of clinically significant impairment in social, school, or work functioning.

V. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other

Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g., Mood Disorder,

Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Based on these criteria, three types of ADHD are identified:

IA. ADHD, Combined Type: If both criteria IA and IB are met for the past 6 months.

IB. ADHD, Predominantly Inattentive Type: If criterion IA is met but criterion IB is not met for the past six months.

IC. ADHD, Predominantly Hyperactive-Impulsive Type: If criterion IB is met but criterion IA is not met for the past

6 months.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text

Revision (Copyright r 2000). American Psychiatric Association.

Attention-Deficit/Hyperactivity Disorders 245

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Cuffe, Moore, & McKeown, 2005). World-

wide prevalence estimates typically range

from 3% to 8% of the world population.

Estimates vary by geographic region, but

this is thought to be primarily due to differ-

ences in diagnostic criteria and study

methodologies (Biederman, 2005; Polanczyk

et al., 2007).

Studies of current and lifetime prevalence

rates in the United States indicate that His-

panics and Latinos have lower risk for ADHD

than either African Americans or Caucasians.

Some studies show a higher rate of ADHD

diagnosed among African Americans than in

Caucasians, but these differences are not

always statistically significant (Breslau et al.,

2006; Cuffe et al., 2005). Lower socio-

economic status is related to higher incidence

of ADHD. This difference may be attributable

to lower socioeconomic status being a risk

factor for development of the disorder; add-

itionally, parents of children with ADHD are

likely to also have ADHD, and therefore may

have low educational obtainment and occupa-

tional difficulties (Barkley, 2003; Cuffe et al.,

2005). Results of the 2003 National Survey of

Children’s Health (CDC, 2005) showed that

ADHD was more commonly diagnosed among

children whose parents had obtained a high

school education than those whose parents had

achieved more or less education. Children in

ethnic minority populations and uninsured

children were less likely than others to receive

medication treatment. Finally, prevalence of

reported ADHD increased with age and

was greater for children 9 years and up than

for younger children (CDC, 2005; Visser,

Lesesne, & Perou, 2007).

IMPACT OF ADHD

Social

Children with ADHD experience a great deal

of difficulty in their family and peer relation-

ships. They tend have more conflict with their

parents over issues like chores and homework.

Parents are more likely to be harsh and

inconsistent in their discipline, and children

respond with greater hostility and avoidance of

their parents than their non-ADHD peers. This

pattern of negative interaction results in

strained and distant parent-child relationships

(Anastopolous, Sommer, & Schatz, 2009;

Wehmeier, Schacht, & Barkley, 2010).

Children and teens with ADHD also engage

in more conflict with their siblings than do

other children of the same age. Externalizing

behavior problems seem to be one of the major

sources of this conflict; when comorbid dis-

ruptive behavior disorders are present, conflict

increases substantially. While children with

ADHD generally do not rate their sibling

relationships as less close than do other chil-

dren, the presence of comorbid internalizing or

externalizing disorders has been shown to

relate to less warmth and closeness in these

interactions (Mikami & Pfiffner, 2008).

Social skills deficits and conflictual inter-

actions extend to peer relations as well. A

majority (70%) of these children have been

found to have serious problems in peer and

friend relationships. Younger children with

ADHD can be difficult playmates as they have

a harder time waiting and taking turns, and

paying attention to and following rules of

games. Those with ADHD-C in particular tend

to interact in an impulsive, intrusive manner,

and are disruptive (Wehmeier et al., 2010). In

contrast, children with ADHD-PI are often

characterized as being socially passive, shy,

and withdrawn (Barkley, 2006). As a result of

these skill deficits, they tend to be less well-

liked, experience more frequent rejection, and

have fewer reciprocal friendships than their

peers. Those with oppositional defiant disorder

(ODD) or conduct disorder (CD) display the

most serious social problems; for these youth,

most do not develop any close friendships by

the third grade, and in adolescence are more

likely to become bullies or victims of bullies

(Wehmeier et al., 2010). Treatment with

psychostimulant medication frequently does

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not improve social problems even when it

decreases aggression and other negative

behaviors (Pelham & Fabiano, 2008).

Academic

The academic environment may be the most

challenging context that students with ADHD

have to navigate. Symptoms appear dramatic-

ally in the school setting, where children are

required to remain vigilant to instruction and

tasks at longer intervals than at home or in

social settings (Barkley, 2003). Nearly

all children with ADHD experience sig-

nificant impairment in academic achievement

throughout their school years, and on average

score a full standard deviation below class-

mates on achievement tests (G. J. DuPaul &

Stoner, 2003; Loe & Feldman, 2007). Prob-

lems with inattention manifest in increased

off-task behavior, and increased time to return

to an activity after being distracted, resulting in

decreased productivity. Children with ADHD

have difficulty completing homework and

assignments, organizing materials and tasks,

and planning completion for long-term pro-

jects. Hyperactivity and impulsivity appear in

such behaviors as getting up without permis-

sion, disturbing others, talking noisily, and

rule-breaking, which lead to punishments

and negative interactions with teachers. They

may spend less time in the classroom as a result

of frequent disciplinary action, and thus miss

out on instruction. It is not surprising that

children with ADHD are at higher risk

than their peers for grade retention, suspen-

sion, expulsion, and school drop out (Barkley,

2006; G. J. DuPaul et al., 2006).

Emotional

Adolescents and children with ADHD experi-

ence rejection, failure, frustration, and conflict

on a day-to-day basis. The ADHD-related

impairments often take an emotional toll on

these children as they navigate a variety of

social and performance situations, often facing

criticism from all sides. They may learn to

anticipate failure instead of success, develop-

ing a sense of learned helplessness and dejec-

tion (Wehmeier et al., 2010). They also tend to

have poorer self-perception than their peers

and rate themselves more negatively on social

and communication skills (Klimkeit et al.,

2006). Related to the impairment in behavioral

inhibition, children with ADHD are less able

to moderate or regulate their emotions and to

suppress their external emotional reactions.

Consequently, they may experience extreme

emotional reactions to stressful situations

(Barkley, 2006).

COMORBID DISORDERS

Children with ADHD frequently have one or

more comorbid psychiatric disorders. Recent

studies suggest that around 80% of children

and adolescents with ADHD have at least

one comorbid disorder, and over half have

two or more (Biederman, Petty, Evans,

Small, & Faracone, 2010; Cuffe et al., 2005).

The most common pattern of comorbidity

seen in children with ADHD is that of

ADHD-C with other externalizing behavior

disorders. About half of youth diagnosed

with ADHD also meet diagnostic criteria for

ODD or CD. ODD is characterized by a

pattern of defiant behavior and rule-breaking,

including noncompliance with direct com-

mands, denying responsibility for actions,

and arguing. CD is more severe, defined by

a pattern of aggression, destruction, lying,

stealing, or truancy (APA, 2000).

Internalizing disorders also commonly

co-occur with ADHD. About 30% of youth with

ADHD have a comorbid anxiety disorder, and

about 25% have a mood disorder (Biederman,

2005). Rates of anxiety disorders may be

slightly higher in individuals with ADHD-PI.

Anxiety disorders are found to reduce the risk of

impulsiveness compared to ADHD without

anxiety. As noted before, children with ADHD

experience considerable rejection and failure;

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it may be that high rates of comorbidity are

related to such a negative learning history

(Barkley, 2003; Wehmeier et al., 2010).

ADHD and mood disorders may share a

common genetic factor predisposing an indi-

vidual to both disorders, but no genetic link or

familial pattern has been found for comor-

bidity of anxiety disorders (Barkley, 2003;

Biederman, 2005). Learning disabilities, tic

disorders, and sleep disorders and disturbances

are other problems frequently seen in children

with ADHD (Barkley, 2003).

DEVELOPMENTAL COURSE

Although usually diagnosed in childhood,

ADHD is increasingly conceptualized as a

chronic disorder, often persisting through

adulthood. Hyperactivity and impulsivity tend

to present in the preschool years, at around age

3 to 4 years, and symptoms of inattention

typically appear slightly later at 5 or 6 years.

Some evidence suggests that ADHD-PI has a

slightly later onset than ADHD-C, and symp-

toms may not occur until age 8 or later. Almost

all cases of ADHD have an onset prior to age

16 years (Barkley, 2003, 2006).

Hyperactivity symptoms begin to decline in

adolescence, and at this time take on a more

internalized subjective sense of restlessness

rather than external motor activity. For this

reason, ADHD was previously thought to be a

remitting disorder in which most children

outgrew their symptoms; however, while

hyperactivity tends to decline, symptoms of

inattention typically do not, and most children

with ADHD continue to have impairments as

adolescents and as adults. Symptoms of

ADHD decline in a similar manner for males

and females (Monuteaux, Mick, Faraone, &

Biederman, 2010). A longitudinal study that

followed boys with ADHD showed that 78%

of participants continued to experience clini-

cally significant symptoms as young adults

(Beiderman et al., 2010). Adults with ADHD

also continue to display high rates of

psychiatric comorbidity relative to compari-

sons, with higher lifetime prevalence for mood

and anxiety disorders, substance use disorders,

externalizing disorders, bulimia nervosa,

Tourette’s, and language disorders (Beiderman

et al., 2010; Kessler et al., 2006). For adults,

anxiety disorders are the most common

comorbid diagnoses; estimates suggest that

around 50% of adults with ADHD also have an

anxiety disorder (Biederman, 2005).

TREATMENT APPROACHES

Treatments for ADHD proliferate and include

such various approaches as behavioral parent

training, academic interventions, classroom

management, summer treatment programs,

neurofeedback, psychostimulant medication,

and cognitive behavior therapy, among

others. The two most empirically tested inter-

ventions for ADHD are psychostimulants

and behavior contingency management, which

is usually delivered as parent or teacher

training.

Administration of psychotropic medication,

generally in the form of central nervous system

stimulants, is the most commonly employed

treatment method for ADHD. Evidence for the

effectiveness of psychostimulant medication

for ADHD is extensive; it is considered the

gold standard of treatment as it results in large

improvements in the short term for ADHD

symptoms of inattention, hyperactivity, and

impulsivity and in some related impairments,

such as aggression, compliance, and product-

ivity at school. About 80% of individuals

treated with psychostimulants show some

improvement in symptoms, but the remaining

portion are considered nonresponders to

medication. Among those who show a positive

response, most do not achieve normalized

functioning with medication alone. Still others

experience significant adverse effects, such as

dry mouth, loss of appetite, nausea, and

insomnia and prefer not to take medications

for those reasons. Parents commonly prefer

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alternative treatment options. Additionally,

psychostimulants may not be adequate in

addressing all significant life impairments, such

as parent–child relationships, social skills and

peer relations, long-term academic achieve-

ment, and comorbid disorders. Because of these

limitations, a number of psychosocial inter-

ventions for ADHD have been developed

and investigated both as stand-alone therapies

and as adjunctive treatments to psycho-

stimulant medication (Biederman, 2005;

Pelham & Fabiano, 2008).

The second most commonly implemented

treatment is behavior modification, also

known as contingency management, usually

delivered as training in behavior techniques

to parents and teachers. For this treatment,

parents and teachers are instructed by a

professional in methods to systematically

administer consequences to reduce unwanted

behavior and increase desired behavior. By

contrast, direct contingency management is

delivered directly to children by clinicians,

and also involves shaping consequences to

promote desired behavior. For children with

ADHD, direct contingency management is

delivered in summer treatment programs. A

combination of these behavioral strategies is

frequently used to maximize effectiveness

and generalize gains.

BEHAVIOR MODIFICATION

Behavior contingency management/behavior

modification was initially used for children

with hyperactive and inattentive symptoms

because they had successfully been imple-

mented with children with intellectual dis-

abilities. Their use was originally driven by the

idea that faulty learning or social contingen-

cies were the cause of the disorder, and that

correcting the contingencies by training the

parents would produce lasting changes.

Although social learning is not to blame for the

symptoms and impairments that arise from

ADHD, training parents and teachers to

manipulate antecedents and consequences is a

technique that may serve to cue and motivate

appropriate behavior (Antshel & Barkley,

2008). Antecedent modification involves using

cues to prompt desired behavior (e.g., effective

commands, visual reminders). Reinforcement

contingencies are created to increase desired

behaviors, such as compliance with com-

mands, completion of schoolwork, and so

forth, and are often implemented in the form of

point systems or token economies. Punish-

ments are applied to reduce inappropriate

behaviors such as arguing and aggression; a

common punishment for young children is

time-out. Parents and teachers are trained in

the use of operant conditioning techniques

in the child’s natural environment. Behavior

management strategies are not likely to com-

pletely eliminate symptoms and impairments

of such a strongly neurologically based dis-

order; however, if delivered consistently and

appropriately, behavior management strat-

egies that are focused on immediate and

significant relationships and environmental

settings often reduce some of the more dev-

astating psychosocial consequences of ADHD

through improving parent-child relationships,

social functioning, academic achievement, and

reducing or eliminating comorbid psychiatric

problems. No one treatment approach is likely

to be adequate in addressing every area of

difficulty for a child with ADHD.

Behavioral parent training (BPT) is the most

frequently implemented behavioral interven-

tion for ADHD. Several manualized BPT

programs have been effective in the treatment

of ODD and have been used in children with

ADHD and with comorbid ADHD and ODD.

Barkley’s (1987) Defiant Children program

has been adapted for use with ADHD and is

described here as a representation of a typical

program; similar programs include Community

Parent Education Program, and the Incredible

Years Series (IYS) (Cunningham, Bremner, &

Secord, 1997; Webster-Stratton, 1992).

Barkley’s (1987) BPT program consists of

8–12 weekly training sessions taught by a

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mental health professional either to groups or

individual parents. Each session focuses on a

different behavioral technique that parents

then apply at home. Treatment begins with

psychoeducation on ADHD, behavior prob-

lems, and basic learning/behavior principles.

Parents are taught to increase positive attention

by spending daily one-on-one special time

with the child. Attention is used to reinforce

compliance and independent play. Increasing

compliance is one of the more important tar-

gets for children with ADHD (even those

without ODD) because parents so often have to

cue appropriate behavior (e.g., “stop at the

curb,” “look at your homework”). The pro-

gram incorporates the use of a token economy

for increasing individualized target behaviors

and teaches use of appropriate time-out as a

mild punisher for misbehavior. A daily report

card system between parents and teachers is

implemented to generalize behavioral gains to

the school environment. Table 10.2 provides

an example sequence of steps in a BPT

program.

Consensus Panel Recommendations

Expert panels created among medical and

psychiatric associations and government health

organizations periodically review existing

empirical research and develop guidelines to

aid practitioners in choosing the most well-

established, scientifically supported treatments

for ADHD. Published guidelines include

recommendations of best practice for assess-

ment, treatment, and treatment maintenance

of ADHD. The American Academy of Child

and Adolescent Psychiatry (2007) practice

parameters for the assessment and treatment

of ADHD recommend psychopharmalogical

treatment with an FDA-approved psychosti-

mulant as the first line of treatment for most

individuals with ADHD. Behavior therapy,

including BPT and behavioral classroom man-

agement, is suggested as the first-line treatment

option for cases in which ADHD symptoms are

mild or in which parents reject treatment with

psychostimulants. Behavior therapy is recom-

mended as the second intervention alternative

when an individual does not respond to an

FDA-approved drug. A combination of treat-

ment with medication and behavioral inter-

vention is recommended for children with less

than optimal response to medication and for

those with comorbid psychiatric disorders or

significant impairments in daily functioning.

These recommendations include behavior

therapy as treatment consideration for a con-

siderable portion of children and adolescents

with ADHD.

The National Institute for Health and Clin-

ical Excellence (NICE) of the United Kingdom

guidelines for assessment and treatment of

ADHD (NICE, 2009) endorse behavioral

treatments for all children and adolescents

diagnosed with ADHD. Group parent training

TABLE 10.2 Sequence of Sessions for Behavioral Parent Training

1. Overview of ADHD and ODD and behavior management principles

2. Establishing special time, increasing positive attention

3. Attending to appropriate behavior (e.g., compliance) and ignoring minor, inappropriate behaviors (e.g., whining)

4. Giving effective commands and reprimands

5. Establishing and enforcing rules and contingencies

6. Teaching effective time-out procedures

7. Home token economy system for rewards and sometimes response costs

8. Enforcing contingencies in public places; planning ahead for misbehavior outside the home

9. Implementing a daily school behavior report card

10. Troubleshooting techniques, managing future misconduct

11. One month booster session

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programs are recommended as the first-line

treatment for all preschool-age children. For

school-age children and adolescents with

moderate levels of symptoms and psychosocial

impairments, the NICE guidelines recommend

a combination of a parent training program and

behavioral interventions implemented in the

classroom. Medication is recommended as an

adjunctive therapy when school-age children

and adolescents do not show adequate

response to behavioral and psychological

interventions. In instances in which symptoms

and impairments are severe, the guidelines

recommend a combination of psychostimulant

medication, parent training, and classroom

behavior management. The NICE guidelines

state that pharmacological ADHD treat-

ments should always be accompanied by a

comprehensive treatment plan that includes

behavioral, psychological, educational, and

interventions.

Randomized Controlled Trials

Development of clinical practice guidelines is

based upon a review of empirical studies of

various treatment methods and comparison

of cumulative support of each therapy.

Particular weight is given to randomized

controlled trials (RCTs), which compare a

particular treatment method with control

groups and alternative treatments. A number of

early RCTs that compared BPT to wait-list

controls established a base of empirical sup-

port for BPT in the treatment of children

with ADHD (Gittelman-Klein et al., 1980;

Horn, Ialongo, Greenberg, Packard, & Smith-

Winberry, 1990; Horn et al., 1991; Pisterman

et al., 1989). These studies generally showed

BPT to reduce problem behaviors in children as

rated by parents, improve parent-child inter-

actions, and decrease parental stress (Chronis,

Chacko, Fabiano, Wymbs, & Pelham, 2004).

For example, one early study examined the

effectiveness of BPT for ADHD symptoms

and parental stress among families of school-

aged children randomly assigned to either a

BPT group or wait-list control. The BPT group

received nine sessions of BPT training. Pre-

and postmeasures of parent and child func-

tioning were taken. The BPT participants

showed significant gains in comparison to the

control group on measures of parent-reported

child ADHD symptoms, parenting stress, and

parenting self-esteem. These gains were

shown to be maintained in a 2-month follow-up

measure (Anastopoulos, Shelton, DuPaul, &

Guevremont, 1993).

A more recent study compared the effect-

iveness of BPT as adjunct to routine care with

routine care alone (treatment as usual). Chil-

dren ages 4 through 12 years receiving care in

an outpatient clinic for treatment of ADHD

were randomly assigned to either 5 months of

BPT in conjunction with routine clinical care

(N ¼ 47) or to routine care alone, which con- sisted of family support and medication treat-

ment as indicated (BPT consisted of 12 group

training sessions). Parent-reported ADHD

symptoms, conduct problems, internalizing

symptoms, and parenting stress were assessed

for both groups pre- and posttreatment, and a

follow-up assessment of the BPT group was

conducted 25 weeks after treatment. Both

treatment groups improved on all measures.

The BPT group showed larger improvements

for conduct problems and internalizing symp-

toms than the routine care group, but no group

differences were found for either parenting

stress or ADHD symptoms. Results were

equivalent for children receiving medication

and not receiving medication, although those in

the BPT treatment received less medication

treatment. The researchers suggested that BPT

enhances the effectiveness of routine clinical

treatment for children with ADHD for behav-

ioral and internalizing problems, but not for

ADHD symptoms or parenting stress. They

also suggest that BPT may limit the need for

medication treatment (Van den Hoofdakker

et al., 2007).

As a result of consistent positive findings

regarding the effectiveness of BPT for enhan-

cing parent behavior management skills and

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reducing child externalizing behavior, atten-

tion has increasingly focused on enhancing

BPT programs to increase effectiveness for

core ADHD symptoms and to address correl-

ates associated with poor treatment response,

such as low socioeconomic status, parental

psychopathology, and single-parenting. For

example, single mothers of children with

ADHD face special challenges and barriers to

receiving treatment, and tend to show

decreased treatment response to BPT. In

response to this special need, an enhanced

version of BPT was created, including add-

itional treatment components addressing

treatment influences identified in this popula-

tion (e.g., low-intensity, didactic format). In

order to evaluate the efficacy of the program,

120 single mothers of 5- to 12-year-old chil-

dren with ADHD were randomly assigned to a

wait-list control group, a traditional behavioral

parent training program, or an enhanced

behavioral parent training program—the

Strategies to Enhance Positive Parenting

(STEPP) program. Both traditional BPT and

STEPP resulted in significant improvements

in several areas of functioning, including

oppositional behavior, and parent-child rela-

tions. While both treatments were superior to

the control group, the STEPP group demon-

strated superior outcomes to the standard

BPT group for these domains (overall mean

effect sizes were 0.36 and 0.44 across all

outcomes). Participants in the STEPP pro-

gram attended more frequently, were more

engaged, and were more satisfied with treat-

ment compared to single mothers in the

traditional BPT program. Similar to other

studies of BPT, the BPT and STEPP pro-

grams in this study did not significantly

improve core ADHD symptoms and impro-

vements were not maintained at 3-month

follow-up (Chacko et al., 2009).

A similar BPT program was designed to

increase fathers’ engagement in BPT. Fathers

of 6- to 12-year-old children with DSM diag-

noses of ADHD were randomly assigned to

attend either a standard BPT program or the

Coaching Our Acting-Out Children: Height-

ening Essential Skills (COACHES) program.

The COACHES program included BPT plus

sports skills training for the children and par-

ent-child interactions in which the fathers

practiced parenting techniques in the context

of a soccer game. Children’s ADHD and ODD

symptoms were similarly improved across

groups, but fathers who participated in the

COACHES program were significantly more

engaged in the treatment process, as demon-

strated by more frequent punctuality and

attendance of sessions, increased compliance

with homework assignments, and greater

consumer satisfaction on posttreatment meas-

ures (Fabiano et al., 2009). The studies dem-

onstrating benefits of enhanced BPT programs

indicates the possibility that tailoring psycho-

social treatments to meet individual client

needs may be an effective means of increasing

treatment compliance and may result in

larger treatment gains for children targeted

in the interventions.

A number of studies have shown BPT to

result in greater improvement for conduct

problems and internalizing problems than

for core ADHD symptoms (inattention,

hyperactivity) among school-aged children

(Barkley et al., 2000; Chacko et al., 2009;

Corcoran and Dattalo, 2006; MTA, 1999; Van

den Hoofdakker et al., 2007). A handful of

enhanced BPT programs have shown more

favorable results on both ADHD symptoms

and related impairments for preschool-aged

children. The New Forest Parenting Package

(NFPP) (Weeks, Thompson, & Laver-Bradbury,

1999) is a BPT intervention that was evaluated

in a community sample of 78 three-year-olds

diagnosed with ADHD. Participants were

randomized to NFPP, parent counseling and

support, or a waiting-list control group. The

NFPP group received directive coaching in

child management techniques while the

counseling group received only nondirective

support and counseling. The management

techniques were not geared only toward

oppositional behavior, but also trained parents

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to help children self-regulate through a variety

of activities. Pre-, post-, and follow-up meas-

ures of child ADHD symptoms and mother’s

sense of well-being were obtained. The BPT

group proved superior to the counseling and

wait-list groups for both ADHD symptom

reduction and increased maternal well-being.

The ADHD symptom improvement was clin-

ically significant for 53% of children in the

BPT group, and treatment effects were main-

tained at the 15-week posttreatment follow-up.

Authors concluded that BPT is a valuable

treatment option for preschoolers with

ADHD, and that constructive training in par-

enting strategies is an essential component of

BPT over and above therapist contact and

support (Sonuga-Barke, Daley, Thompson,

Laver-Bradbury, & Weeks, 2001).

A more recent study of the NFPP program

showed similarly positive outcomes. Forty-one

preschoolers were randomly assigned to either

NFPP or treatment as usual conditions. Meas-

ures of ADHD and ODD symptoms, mothers’

mental health, and the quality of mother–child

interactions were taken pre- and posttreatment,

and at a 9-week follow-up. The ADHD

symptoms were significantly lower for the

treatment groups versus control group (effect

size . 1) and were maintained at a 9-week

follow-up measure. Improvement in ODD

symptoms was more moderate but favored the

treatment group. No improvements were seen

in maternal mental health or parenting behav-

ior during mother–child interactions, although

mothers spoke more positively of their chil-

dren in a speech sample following treatment.

The authors concluded that results support

efficacy of the NFPP program, though repli-

cation with a larger sample size is needed

(Thompson et al., 2009).

Similar evaluations of the IYS and the Triple

P Positive Parenting Program with preschool

children have shown reductions in ADHD and

disruptive behavior problems for families

randomized to BPT compared to wait-

list conditions (Jones, Daley, Hutchings,

Bywater, & Eames, 2007; Bor, Sanders, &

Markie-Dadds, 2002). The IYS participants

showed maintenance in treatment gains at

18-month follow-up (Jones, Daley, Hutchings,

Bywater, & Eames, 2008). Other RCTs evalu-

ating the Triple P program have shown clinic-

ally significant reductions in conduct problems

in preschoolers, though these studies were not

specific to children with ADHD (Sanders,

Markie-Dadds, Tully, & Bor, 2000). Such

positive findings from BPT with preschoolers

are especially encouraging considering the

potential long-term outcomes associated with

the disorder.

Parent training for adolescents with ADHD

has been studied far less than for younger

children. The BPT programs that were

developed for younger children are modified

for use with a teenage population. Behavior

targets for adolescents are decided on by

child and parent, and privilege loss (ground-

ing) is used in place of time-out. Positive

reinforcement and token economies are

adjusted to be appropriate with teenagers

(Antshel & Barkley, 2008; Young & Myanthi

Amarasinghe, 2010). A few uncontrolled stud-

ies have shown BPT to be modestly beneficial

for this age group, but no controlled studies

have been conducted to date demonstrating

superiority of BPT to other treatment options

(Young & Myanthi Amarasinghe, 2010).

Barkley, Edwards, Laneri, Fletcher, and

Metevia (2001) compared two family-based

psychosocial therapies for adolescents with

ADHD. Families (N ¼ 97) were assigned to either 18 sessions of problem-solving com-

munication training or behavior management

training for nine sessions followed by PSCT for

nine sessions. Posttreatment, both groups were

equally improved on ratings and observations

of parent–teen conflicts, although significantly

more families dropped out of PSCT alone than

out of BMT/PSCT. For both treatment groups,

only about one fourth demonstrated reliable,

clinically significant improvement, and some

families worsened in their degree of conflict.

Thus the verdict is out regarding parent train-

ing with adolescent ADHD.

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Improvements at home resulting from BPT

are not likely to generalize to the school

environment because the structure and con-

tingencies created by the parent are not

immediately present for the child at school. In

order to improve behavior and performance at

school, antecedent modification and contin-

gency management need to be implemented

there as well (Abramowitz & O’Leary, 1991).

Some school-based behavioral programs have

focused on school-wide training of teachers

and programs that are inclusive of many chil-

dren in the school with ADHD (e.g., Pfiffner

et al., 2007). More commonly, mental health

professionals are contacted as consultants for

individual children when ADHD symptoms

create behavioral disruptions in the class-

room and interfere with academic progress

(Abramowitz & O’Leary, 1991; G. J. DuPaul

et al., 2006; Fabiano & Pelham, 2003).

Behavioral training procedures used with par-

ents are generally very similar to those used to

help teachers manage ADHD in the classroom.

Behavioral classroom management is a paral-

lel form of behavior modification treatment in

which the child’s classroom teacher is trained

in the use of effective commands, time-out,

token systems, immediate feedback, and

increased positive reinforcement (Antshel &

Barkley, 2008).

As with BPT, a frequent behavioral target in

classroom management is increasing compli-

ance with commands. A recent study focused

on the effectiveness of Barkley’s method of

reducing repetition of commands to increase

compliance within the school setting. Elem-

entary school teachers were randomly assigned

to either a treatment group (which received

instruction on reducing repetition and increas-

ing effectiveness of commands) or to a

nontreatment control group. Students whose

teachers received the training significantly

reduced noncompliance while students in the

control group did not. The author concluded

that this method is effective in the classroom

setting and should be implemented for students

with ADHD (Kapalka, 2005).

One study examined the effects of an inten-

sive classroom treatment in 158 kindergartners

identified as having high levels of hyperactive,

inattentive, impulsive, and aggressive behav-

iors. Participants were randomly assigned to

one of four treatment groups: no treatment,

parent training, classroom behavioral treat-

ment, or a combination of classroom and par-

ent training treatments. Unfortunately, parents

assigned to the BPT-only group showed very

poor attendance and this group did not

demonstrate treatment gains; however, the

classroom management treatment condition

resulted in improvements in objective obser-

vations of externalizing behavior in the class-

room, teacher ratings of attention, social

skills, self-control, and aggression, as well as

parent ratings of adaptive behavior. Behavior

improvements in the classroom did not

generalize to the home environment per

parent ratings. Additionally, while external-

izing behaviors improved, no gains were seen

in academic achievement or laboratory-based

measures of attention (i.e., Continuous

Performance Test). The intervention was

conducted for one school year only (Barkley

et al., 2000). A 2-year follow-up of the

intervention indicated no difference between

those treated in the classroom condition

and those not treated, and the children con-

tinued to display high levels of ADHD and

ODD symptoms compared to peers (Shelton

et al., 2000). These results again demonstrate

that behavioral gains resulting from contin-

gency management in one setting are not likely

to generalize to other settings or to persist

once the contingencies have been removed;

therefore, it is important that contingency

management be implemented across settings.

Several other investigation teams have found

beneficial results in both home and school

settings, as indicated by parent and teacher

ratings when incorporating parent training

and classroom management into the same

treatment package. Corkum, McKinnon, and

Mullane (2005) demonstrated superior results

when adding a behavioral training intervention

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with children’s teachers to the behavior train-

ing provided to parents alone. Similarly,

Owens et al. (2005) reported treatment gains

across contexts from a small-scale RCT of a

behavioral package that included parent and

teacher behavior contingency management

strategies. A study that compared a behavioral

package to medication found superior results

for the medication group, although the

behavioral group showed gains at home and at

school (Van der Oord, Prins, Oosterlaan, &

Emmelkamp, 2008).

Meta-Analyses of Group Designs

Corcoran and Dattalo (2006) examined a small

set of studies examining BPT published

between 1980 and 2003. Studies that compared

BPT to control or comparison groups were

included. The overall effect size (Cohen’s d)

of BPT on ADHD symptoms was relatively

low (0.40), as was the effect size (0.36) on

externalizing symptoms. A moderate effect

was observed for family functioning (0.67) and

internalizing symptoms (0.64). This finding is

also consistent with those of individual RCTs;

however, an effect size of 8.2 was reported for

academic performance. This finding is not

consistent with data from RCTs, which failed

to show generalization of treatment gains to

the school environment. This discrepancy may

be at least partially attributable to inclusion of

only two studies that reported this outcome.

Consistent with a number of studies the effects

of BPT on social functioning were near zero.

Similar to individual RCTs described earlier,

the findings indicate that BPT produces some

change in ADHD symptoms of inattention and

hyperactivity, and results in more substantial

improvements in family relationships and

internalizing symptoms.

A meta-analytic review of BPT studies to

identify effective components of BPT pro-

grams examined 77 published evaluations of

BPT outcomes for children up to age 7 years.

Component analysis was conducted by using

content and delivery methods of training

programs to predict effect sizes on measures

of children’s externalizing behavior and

parenting behaviors, controlling for differ-

ences among research designs. Components

of BPT programs consistently associated

with larger effect sizes were teaching par-

ents the use of time-out and the value of con-

sistency, increasing positive parent–child

interactions, enhancing emotional communi-

cation skills, and incorporating practice of

new skills with their children during training

sessions. Program components consistently

associated with smaller effects included

teaching parents problem solving; teaching

parents to promote children’s cognitive, aca-

demic, or social skills; and providing various

additional services (Kaminski, Valle, Filenne, &

Boyle, 2008).

G. DuPaul and Eckert (1997) conducted a

meta-analysis examining the effects of school-

based interventions for children and teenagers

with ADHD. Studies included were those

based on either contingency management,

academic interventions that use antecedent

modification (such as adding structure to a

task), or cognitive behavior therapy (which

includes teaching of strategies such as reflect-

ive problem solving). Behavior effect sizes

(weighted least squares) for within-subject and

between-subject designs were computed for

all three types of interventions. For within-

subjects design studies, behavior effect sizes

were greater for contingency management

(0.94) and academic interventions (0.69) than

for cognitive behavioral interventions (0.19).

Behavior effect sizes for between-subjects

designs were not different among the three

types of interventions. Academic outcome

effect sizes for within-subjects designs were

small among all three interventions types; the

effect size for contingency management was

0.11. Academic effect sizes were not available

for between-subjects designs. The authors

concluded that behavior modification tech-

niques are more effective than cognitive

techniques in improving behavioral outcomes

for children with ADHD.

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Single-Subject Experimental Analyses

Between-group design studies evaluating

behavior modification techniques are based on

positive findings from earlier work using sin-

gle-case designs. Results of single-subject

studies demonstrate effectiveness of behav-

ioral principles in managing ADHD. For

example, in a study of a 6-year-old girl with

ADHD, a system of positive reinforcement and

response costs was implemented in the class-

room. The teacher was trained to implement

the class-wide management system. An ABA

reversal design was used in order to determine

effectiveness of the behavioral interventions

used in combination. Direct behavioral obser-

vations were made to determine baseline levels

of appropriate versus oppositional and on-task

versus off-task behaviors. Preintervention, the

child displayed appropriate behavior for 61%

of observed intervals. During the intervention

phase, her appropriate behavior increased to

79%, and when the treatment was withdrawn,

appropriate behavior decreased, though not to

baseline level (71%). On-task behavior

increased from 76% at baseline to 88% during

the treatment interval, and dropped to 82%

when the treatment was withdrawn (Anhalt,

McNeil, & Bahl, 1998).

Similarly, McGoey and DuPaul (2000) used a

single-subject withdrawal design to compare

the effects of a token reinforcement and a

response cost intervention in improving class-

room behavior for four preschool-age children

with ADHD. A reversal design was used to

compare behavior at baseline (A), with imple-

mentation of a token economy system (B), and

with a response cost intervention (C). Two

participants received the ABACABAC inter-

vention, and the other two received treatments

in the opposite order. The results of behavior

observations and teacher rating scales showed

that both interventions were effective in

improving behavior for all four children. Three

of the children improved to levels equal to their

peers. The teachers found the response cost

procedures to be easier to administer in a large

group setting.

An 8-year-old boy attending the third grade

was the subject of a consultant directed

behavior modification program. John was in a

general education classroom and received

remediation in math and reading in a small

group special education setting. John received

special education services because ADHD

significantly impaired his academic progress.

His disruptive behaviors at the start of treat-

ment included interrupting others, poor aca-

demic work, being out of his seat without

permission, talking back when corrected,

teasing peers, and noncompliance. John’s

teachers expressed frustration with his behav-

ior and his peers did not want to be seated next

to him. In addition to small group instruction,

John also received a behavioral intervention

that involved a behavior tracking sheet through

which John could earn biweekly rewards. Five

behavior goals were identified for John, and he

met with his teacher at the end of each aca-

demic period to determine whether he had

achieved his goals. With this intervention in

place for several weeks, John had not earned a

reinforcer. The behavioral consultant observed

John and his classmates in the morning and

afternoon for a few weeks in order to gather

baseline data on the frequency of John’s dis-

ruptive and off-task behavior in relation to that

of his classmates. In order to make his

behavioral targets more objective and clear for

John, and to provide him with immediate

feedback when he was violating a rule, John’s

teacher was instructed to issue a reprimand

when he was violating a rule (i.e., off-task or

disruptive). In order to receive reinforcement,

John had to have fewer than three violations of

each objective. Instead of receiving a delayed

reinforcer, John earned the opportunity to play

a video game for a few minutes after each

academic period in which he met his behav-

ioral targets (fewer than three violations).

John’s off-task behavior declined immediately

with the implementation of the new plan. Over

a few weeks, both off-task behavior and

classroom disruptions were brought to the

level of the average for his class. Unfortu-

nately, the authors did not report on academic

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achievement or work productivity gains

as a result of the intervention. It was not

possible to follow-up with John’s progress

because the school year ended (Fabiano &

Pelham, 2003).

Meta-Analyses of Single-Subject

Experiments

Although behavioral interventions were

developed based on findings and methods of

small N experiment, few meta-analytic reviews

have been devoted to single-subject designs.

Thirty-eight single-case designs were included

within a larger meta-analysis (G. DuPaul &

Eckert, 1997) of school-based interventions

for ADHD. Both published and unpublished

studies that used behavioral (contingency

management or antecedent modification)

or cognitive behavioral interventions were

included. The overall weighted least squares

effect size for behavioral outcomes was 1.16

with a median of 0.80. Interventions using

contingency management (ES ¼ 1.44) and antecedent modification (academic interven-

tion) (ES ¼ 1.61) were significantly more effective than cognitive behavioral treatments

(ES ¼ 0.80). Interestingly, interventions based in public school settings were significantly

more effective than those implemented in pri-

vate schools. Effect sizes from cases in special

education settings (ES ¼ 1.52) were signifi- cantly greater than those obtained in general

education or combined general education/

special education programs (0.96; 1.30). The

mean effect size for academic outcomes was

0.82 with a median of 0.30 for all treatment

interventions. No differences were found

among types of treatment on academic out-

comes. For both behavioral and academic

outcomes, effect sizes from published studies

were significantly greater than those from

unpublished studies.

Conclusions

Results of RCTs, single-subject studies, and

meta-analyses show that stand-alone behavior

modification interventions are effective treat-

ments for ADHD. They are not as effective as

psychostimulant medication for core symp-

toms of ADHD (inattention and hyperactivity),

but are especially helpful in targeting specific

impairments including oppositional behavior,

parent–child relationships, externalizing behav-

ior, and internalizing disorders. Many pro-

grams are based on treatments originally

developed for ODD and tend to focus on

conduct or externalizing problems more so

than attention impairments; this is a major

limitation on the part of behavior management.

Many studies do not address academic per-

formance, inattention symptoms, or organiza-

tion and time management, but more recently

developed programs are beginning to include

strategies targeting these areas (Pfiffner et al.,

2007). Parents tend to prefer behavioral

interventions over stimulant medication as a

first line of treatment, which is important

to consider when deciding how beneficial

contingency management strategies are in

comparison to medication. These treatments

tend to be time consuming in comparison to

stimulant medication, but if offered in com-

munity mental health settings or in public

schools, they may be provided in a more

cost-effective manner. A major limitation of

behavioral modification strategies is that

treatment gains are usually not maintained

postintervention and do not generalize

across settings in which contingencies are

not implemented (Antshel & Barkley, 2008;

Barkley et al., 2000; Kaiser, Hoza, & Hurt,

2008; MTA, 1999). Psychostimulants also do

not result in lasting gains and are not effective

on days when the child does not take them

(Biederman, 2005). Common impediments to

both treatments include single-parent house-

hold, low socioeconomic status, and ethnic

minority status (Chronis et al., 2004). While

behavior modification improves areas of

functioning not affected by medication, neither

intervention has consistently shown enhance-

ment of academic achievement, although some

of the more recent school-based treatments

have begun to focus more intensely on this

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area (Evans, Serpell, Schultz, & Pastor, 2007).

Overall, behavior contingency management

would likely be beneficial for nearly all chil-

dren who have ADHD, as they result in some

gains in ADHD symptoms and larger gains in

family functioning, academic productivity,

and symptom improvement for internaliz-

ing and externalizing disorders. In order for

lasting effects to occur, treatment boosters

should be delivered and contingencies main-

tained across settings.

SUMMER TREATMENT PROGRAM

Summer treatment programs (STPs) were

developed in order to provide a comprehensive

treatment model for children and teenagers

with ADHD in a camp-like recreational set-

ting. The STPs do not focus directly on ADHD

symptoms as listed in the DSM-IV-TR, but

instead focuses on social, academic, and par-

enting functional impairments that are theor-

ized to moderate long-term outcomes for

children with ADHD. Goals of treatment are

to improve peer relationships, interactions

with adults, academic performance, and self-

efficacy, each of which is related to long-term

functioning (Pelham et al., 2010).

The STPs are held in the summer months

during school breaks. Programs generally are

conducted for 7 to 8 weeks, 5 days per week, 8

or 9 hours per day. The STPs are designed for

children between the ages of 5 and 15 years.

Small groups of 12 to 16 youth matched by age

are created at the beginning of the program

and are led by trained interns. Treatment

components include social reinforcement for

appropriate behavior, teaching the use of

effective commands, a reward/response cost

point system, social skills training, daily report

cards to parents, sports training, time-out, and

academic instruction. Camp participants spend

3 hours per day in a classroom setting that

employs a point system for managing behavior

and encouraging work completion. Much of

the remainder of each day is devoted to

recreational activities (Pelham et al., 2010;

Pelham, Greiner, & Gnagy, 1997).

Social skills training is delivered in

10-minute group sessions, and appropriate

social behavior is prompted and reinforced

throughout the day. While clinic-based social

skills training has not been shown to be

effective, developers of the STP system argue

that social skills can be targeted more directly

in STP. Sports skills training is also included in

order to promote social interaction and to

enhance motor skills, which are typically poor

in children with ADHD. Parents attend weekly

BPT sessions in order to acquire management

skills for facilitating generalization and main-

tenance of treatment gains. Many children

involved in STPs also take stimulant medica-

tion; optional placebo-controlled evaluations

are provided in order to find the most effective

dose or to determine whether medication pro-

vides benefits beyond those produced by

the program (Pelham et al., 2010; Pelham,

Greiner, & Gnagy, 1997).

This intensive, multicomponent treatment is

based on conceptualization of ADHD as a

chronic disorder with long-lasting psycho-

social consequences. Developers argue that in

order to be effective in improving quality of

life and produce meaningful changes, intensive

long-term psychosocial interventions need to

be implemented across settings. The STP also

includes intensive monitoring through the

daily point system, academic work, and daily

ratings by adults (Pelham et al., 2010).

Consensus Panel Recommendations

The APA Task Force (Brown et al., 2007)

review of behavioral, pharmacological, and

combined treatments recommended behav-

ioral treatments as the first-line intervention

and medication as an adjunct treatment for

those who need it. The panel concluded that

behavioral, pharmacological, and combined

treatments are each effective interventions.

Considering side effects of medication

and consumer preference for psychosocial

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treatment, a cost-benefit analysis favored

behavioral treatment.

The American Academy of Pediatrics (AAP)

guidelines are less clear concerning which

treatments to try first but recommend stimulant

medication and/or behavior therapy as appro-

priate treatments. Further, the guidelines sug-

gest establishing a treatment program that

recognizes ADHD as a chronic condition,

collaboration among the clinician, parents,

child, and school to specify target outcomes,

and continued monitoring of progress with

information from parents, teachers, and the

child. Evaluation of the treatment plan, ori-

ginal diagnosis, and possibility of comorbid

disorders is recommended when target out-

comes are not reached (American Academy of

Pediatrics [AAP], 2001).

Although not specifically endorsed, STPs are

consistent with AAP practice guidelines. The

STP allows for easy identification of target

outcomes, collaboration with parents, clin-

ician, school, and child, and systematic moni-

toring of treatment outcomes. Maintenance of

parent and school contingency strategies

through the school year addresses the chronic

nature of the disorder. In the clinical setting,

such intensive management is impractical if

not impossible. Inclusion of the placebo-

controlled medication trials and communi-

cation with parents and teachers helps to meet

individual treatment needs and maximize

positive outcomes.

Randomized Controlled Trials

No between-group RCTs have been published

for STPs as a stand-alone treatment; however,

RCTs have been published that demonstrate

the efficacy of individual components of STPs.

Additionally, the Multimodal Treatment Study

of Children with ADHD (MTA) included STP

as part of a multicomponent behavioral treat-

ment package along with BPT and classroom

contingency management. While the MTA did

not evaluate the effectiveness of STP as a

stand-alone treatment, examining the results of

the study is beneficial in determining the

potential for STPs.

The MTA is the largest, multisite RCT

to date. Based on research supporting psy-

chostimulants and behavior therapy as effica-

cious treatments, the MTA study compared

the two treatments, their combination, and

treatment as usual regarding efficacy, gen-

eralizeability, and sustained improvement.

Participants were 579 children ages 7–9.9

years in grades one to four who met DSM-IV

criteria for ADHD-C. Children with comorbid

disorders were included in the study. All were

randomly assigned to one of four treatment

strategies: (1) medication management care-

fully monitored and titrated by the research

group; (2) behavioral treatment package

including behavioral parent training based on

Barkley’s and Forehand and McMahon’s

procedures, the summer treatment program

developed by Pelham, and school-based

contingency management; (3) combined medi-

cation and behavioral interventions; or

(4) treatment as usual (community care). Most

of the participants (67.4%) in the treatment as

usual group were on medication but did not

receive treatment from the study group. Par-

ticipants were assessed and monitored before,

during, and after 14 months of treatment on

outcomes including core ADHD symptoms

and impairment domains related to ADHD. All

treatment groups showed clinically meaning-

ful symptom reduction. Medication manage-

ment and combined treatment were superior

to community care and behavioral treatments

for core ADHD symptom reduction and did

not differ from one another. Those in the

combined group required significantly lower

doses of medication than those in the medi-

cation management group. Combined treat-

ment was superior to treatment as usual

and behavioral treatments for internalizing

symptoms, opposition/aggression, teacher-

rated social skills, parent–child relations, and

reading achievement score, while medication

management was not. Behavior treatment

outperformed treatment as usual in improving

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parent–child relations. Parents of children in

the behavioral and combined treatment groups

rated treatments with greater satisfaction than

the medication management group; the study

group suggested that behavioral treatment

components likely benefitted family function-

ing. Using success rates, a significantly higher

success rate is reported for the combined

treatment condition (67%) compared to the

methylphenidate treatment condition (55%)

(Swanson et al., 2001).

Overall, results suggest that medication

management and combination treatment are

efficacious treatments for reducing ADHD

symptoms, and that a combination of intensive

behavioral treatments and medication are most

effective in improving secondary impairments.

Thus for pure ADHD-C, medication alone may

be adequate to treat symptoms, but for those

with comorbid disorders or significant family

disruption, combination treatment provides

incremental improvement in functioning. The

authors note that these findings cannot be

generalized to other subtypes (ADHD-PI) or

age groups. Additionally, the authors caution

that results do not suggest that behavioral

treatment was ineffective, as those in the treat-

ment condition showed significant improve-

ments in the course of treatment (MTA

Cooperative Group, 1999).

The lack of greater impact of the intensive

behavioral intervention in the absence of

medication and on ADHD/ODD symptoms

generally was unexpected. A limitation of

the study is that posttreatment measures were

gathered after the behavioral interventions

were discontinued and were no longer imple-

mented at their highest intensity, while medi-

cation was still being used at its most effective

dose. The absence of maintenance of treatment

gains following the cessation of behavioral

interventions has been a significant problem. As

noted before, return to baseline levels of prob-

lem behavior is also reported when individuals

with ADHD discontinue taking medication.

Secondary analyses for the MTA study

derived a composite score of treatment

outcome across measures and showed that the

combination treatment was significantly better

than the other treatments on the composite. For

children with a comorbid anxiety disorder,

behavioral treatment was as effective as the

medication management, and the combination

condition proved superior to other conditions,

particularly when a disruptive behavior dis-

order was also present. This finding is par-

ticularly noteworthy when considering that

nearly 40% of the sample had a comorbid

anxiety disorder, and nearly one fourth had

both an anxiety and disruptive behavior dis-

order (Jensen et al., 2001). Also noteworthy is

the finding that 8 years after completion of the

study, the MTA treatment groups did not differ

significantly from one another on repeated

measures or newly analyzed variables includ-

ing hospitalizations and academic achieve-

ment. Despite having received intensive

intervention, the adolescents fared more

poorly than their non-ADHD peers on 91% of

measures. Neither the type nor intensity

of treatment delivered in the 14-month trial

predicted functioning for the teenagers

(Molina et al., 2009).

Meta-Analyses of Group Designs

In order to provide an updated quantitative

account of the magnitude of the effectiveness

of behavioral interventions for ADHD, a

comprehensive meta-analysis of behavioral

treatment reports was conducted using 174

studies indentified in the literature (Fabiano

et al., 2009). Authors aimed to incorporate all

behavioral treatment studies conducted to date,

across type of intervention (BPT, Summer

Treatment Program, Classroom Contingency

Management) and study design. Effect sizes

varied by study design. Effect sizes in pre-post

studies (0.70), between-group studies (0.83),

and within-group studies (2.64) demonstrate

effectiveness. Authors concluded that results

add to an existing body of strong evidence that

behavioral treatments are effective for treating

ADHD.

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Van der Oord et al. (2008) conducted a

meta-analysis of group design studies com-

paring medication, behavioral, and combination

medication and behavioral interventions for

ADHD in order to evaluate the relative

effectiveness of each. Analyses were con-

ducted using RCTs published from 1985–2006

with children ages 6–12 years. Medication and

combined treatments yielded large effect sizes

for ADHD symptoms, ODD, and conduct

problems. By contrast, behavioral treatments

had moderate effect sizes for these outcomes.

All treatment modalities had a moderate effect

size for social behavior and small effect size for

academic functioning. Efficacy rates of com-

bined conditions were larger than medication

on all outcome domains, but these differences

were not statistically significant. Based on

these results, researchers concluded that

behavioral treatments are less effective than

medication and do not appear to have additive

treatment effects when used in combination

with medication. The researchers also noted

that children who are nonresponders to medi-

cation or who take low doses would likely

benefit from behavioral interventions.

Single-Subject Experimental Analyses

In order to evaluate individual response to

behavior modification within the STP, four

children aged 11–12 years participated in a

treatment withdrawal study. The compre-

hensive behavioral treatment package was

delivered and withdrawn in a BABAB reversal

design over the course of the 8-week program.

Measures were frequency of negative behav-

iors, counts of rule violations in recreational

and classroom settings, and accuracy and

completion in academic work. Behavioral

intervention was effective for each of the

children, as demonstrated by rapid increase in

rule violations and negative behavior, and

decrease in accuracy and completion of

academic work when the treatment was

withdrawn. Behavior worsened increasingly

over the course of the withdrawal weeks.

Following the second withdrawal, behaviors

took longer to return to levels seen in

the initial treatment condition. In general,

behavior worsened progressively during the

withdrawal period (Coles et al., 2005).

Meta-Analyses of Single-Subject

Experiments

Fabiano et. al (2009) recently reported on

single-case experiments within a larger meta-

analysis of behavioral interventions of ADHD

that included group designs (described earlier).

A total of 100 single-case studies for ADHD

published from 1968–2006 were included

in the analysis. Outcomes were based on

parent observations of ADHD symptoms,

direct observations of child behavior, and

academic productivity. Effect sizes were large

across these domains. The unweighted effect

size for behavioral treatments averaged 3.78.

Conclusions

STPs offer numerous advantages compared

to other behavioral interventions, including

the direct administration of intensive behav-

ior therapy, combination of multiple well-

established treatment components, and

collaboration among treatment providers,

teachers, and parents. STPs also demonstrate

high attendance and low dropout rate com-

pared to other psychosocial interventions.

Parents and children rate STPs very favorably.

The recreational setting seems to make STPs

a particularly palatable treatment option.

Additionally, children who attend STPs have

shown decreased need for stimulants, an

important outcome considering incremental

adverse effects with increased doses of psy-

chostimulants (Pelham et al., 2010).

Research support for the efficacy of STP

comes primarily from the laboratory of the

original developers. Chambless and Hollon

(1998) require independent replication of

treatment effects in a randomized controlled

design by more than one investigation team in

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order for a treatment to be considered effica-

cious and specific. No published studies have

yet compared STP as a stand-alone treatment

with a nontreatment control group in a ran-

domized trial, although several crossover

designs have shown efficacy. Existing research

including multiple single-case studies and

within-group designs have shown promising

results. Additionally, while the MTA study

incorporated multiple behavior treatments into

the behavior treatment condition, two out of

those three treatments are delivered in STPs:

STP and BPT.

As with other treatment for ADHD, much

of the treatment gains made during the STP

disappear almost immediately upon removal

of treatment (Coles et al., 2005). While

direct contingency management demonstrates

results, it is not feasible for clinicians and STP

staff to follow children through their daily

routines year-round. Therefore, following

direct contingency management as delivered

in STP with parent and teacher training in

contingency management is critical to main-

tain improvements gained during the summer

weeks.

EVIDENCE-BASED PRACTICES

BPT is the most widely implemented and

thoroughly researched behavioral treatment

for ADHD. BPT, classroom management,

and STPs have strong support. None of

these psychosocial treatments is as effective

as psychostimulant medication for ADHD

symptoms (inattention, hyperactivity), but

each is more efficacious in reducing secondary

functional impairments, though only while

treatment is in place (MTA, 1999; Molina

et al., 2009). Multimodal treatment includes a

combination of behavior contingency modifi-

cation at home and at school, STP, and

psychostimulant medication, and is the most

effective mode of addressing ADHD and its

secondary impairments.

BPT and classroom management are rela-

tively costly and time-consuming compared to

stimulant medication, and STP is the most

expensive and time-intensive intervention

available. Evaluation of the long-term cost-

effectiveness of STPs when delivered across

multiple consecutive summers could provide

crucial information in selecting the best treat-

ments; if STPs result in long-term benefits to

psychosocial functioning, it may be that they

serve as an investment preventing significant

future costs. Some evidence supports the

notion that BPT programs developed specif-

ically for preschoolers with ADHD may be

effective in curtailing ADHD symptoms and

result in lasting gains, though longitudinal

analyses of such programs are needed. More

research is needed in areas of dissemination

and implementation of evidence-based prac-

tices in general and specifically in ADHD.

Also of concern is how to tailor treatments

to meet the individual needs of the child and

family, and how to gain generalization and

maintenance of treatment effects.

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