1. BEHAVIOR THERAPY FOR ADHD CJ Powers, PhD Psychologist University Neuropsychiatric Institute (UNI)

2. WHAT IS BEHAVIOR THERAPY?

3. YOU’VE ALL EXPERIENCED BEHAVIOR THERAPY

4. ABC’S OF BEHAVIOR THERAPY Behavior: the problematic behavior AND a desired replacement behavior  Use the active forms (avoid “dead person goals”)  Be specific and measurable

5. ABC’S OF BEHAVIOR THERAPY Antecedent: ANYTHING that occurs before a behavior that influences behavior choice. Change these by proactively structuring the setting. Ex.  Schedules and routines  Clearly specified rules and consequences  Eating well, sleeping well  Removing “attractive nuisances.”  Physical layouts  Relationship building

6. ABC’S OF BEHAVIOR THERAPY Consequences: Anything that happens after the behavior that makes a behavior more or less likely to occur. PositiveNegative ReinforcementGive something desirableRemove something undesirable PunishmentGive something undesirableRemove something desirable

7. THERAPIES THAT WORK 1. Behavioral Parent Training (BPT) 2. Behavioral Classroom Management (BCM) 3. Behavioral Peer Interventions (BPI) “Well-established treatment for ADHD” per APA Div53 Taskforce guidelines for evidence-based treatments Therapies align with three core domains of impairment due to ADHD

8. BEHAVIOR PARENT TRAINING Typically 8-16 sessions long Goal: Teach parents behavior modification -Comparable in effectiveness to medication (Wells et al, 2000) -Greater parent satisfaction with treatment and parent-perceived improvement in referring problem(compared with medication) (Pelham et al, 2008) -Increase in observed parenting skills (Wells et al, 2006)

9. EXAMPLE BEHAVIOR PLAN Ready for school on time Followed directions the first or second time asked In bed (and stayed there) by bedtime Monday Tuesday Wednesday Thursday Friday Saturday Sunday

10. “BUT I TRIED THAT, AND IT DIDN’T WORK…” Kids with ADHD are:  more sensitive to reward  less sensitive to punishments Need more frequent rewards Need rewards immediately Parents need to be consistent and can’t stop

11. BEHAVIORAL CLASSROOM MANAGEMENT Teacher implemented reward program Point systems Time-out Daily Report Card

12. EXAMPLE DAILY REPORT CARD

13. BEHAVIORAL PEER INTERVENTIONS Typically day-long programs conducted multiple times per week (E.g. Summer treatment programs) Hard to find… Expensive! Office-based social-skills training is not effective (Taylor, Eddy, Biglan, 1999) We don’t really have good interventions to improve peer relationships.

14. WHAT BEHAVIOR THERAPY CAN’T DO… Behavioral interventions cannot cure ADHD. Interventions must be maintained in order to maintain effectiveness.

15. THERAPYTHAT IS INEFFECTIVE FOR ADHD ANY child-focused individual therapy  Cognitive-behavioral therapy  Play therapy  Psychodynamic Social-skills training

16. BEHAVIOR THERAPY AND CO-MORBIDITY No findings to date that comorbidity has a negative moderating impact on effect of behavioral interventions Generally children with comorbid problems benefit the MOST! (though likely due to more severe impairment at baseline).

17. BEHAVIOR THERAPY & MEDICATION Which works better?  Effect sizes are comparable (depends on the study)  Consider both: with behavioral intervention, children are 6 (on medication) to 19 (w/ placebo) more likely to meet daily behavioral goals than without BI. (Pelham et al., 2002; MacLean el al, 2005) What to do first?  Medication is less expensive (Jensen et al. 2005)  If start with medication: 82% of kids need additional behavior therapy  If start with behavior therapy: 33% of kids need additional medication (Dopfner et al. 2004)

18. WHAT TO ASK THERAPISTS… Do you do behavioral therapy with parents? Do you work with schools/teachers? If they primarily work with the child, that is a red flag!

19. SETTING UP EXPECTATIONS… 8-16 sessions Therapist will train the parent to be the “therapist” Therapy will not “cure” ADHD, but will help parents be more effective at managing it

20. HOW TO DO THIS IN 10 MINUTES… Quickly assess for symptoms of inattention/hyperactivity Assess for functioning at home AND in school: need cross-setting consistency  “What do teacher say about Johnny?”  ask them to bring in report cards (if you know ahead of time that ADHD is a question) Assess sleep  “Do you have an established bedtime?”  “If X is bedtime, what time does Juan actually fall asleep?”  “Does Maria sleep through the night?” Assess other behavior problems and parenting efficacy Assess anxiety/depression/mood Assess for substance-use disorders

21. HOW TO DO THIS IN 10 MINUTES. (CONT) Discuss medication and behavior therapy Assess the acceptability and manageability of each Tx modality *If you are uncertain about a Dx of ADHD, recommend a behavioral specialist (therapist) who has the time to do a more thorough assessment.