1. Psychological Treatment of ADHD
Rachael Berg-Martinez, Ph.D.
Licensed Clinical Psychologist, PSY 26730
Center for Individual and Family Therapy (CIFT)
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About Me
Questions

2. Introductions
Licensed Clinical Psychologist (not the one that prescribes medications)
Long history in community mental health studying evidenced-based practices (EBPs) and supervising/training other psychologists and therapists
Internship at USC/Children’s Hospital Los Angeles, Project HEAL (child trauma specialty)
Postdoctoral fellowship at UCLA TIES for Families (foster care/adoption specialty)
Clinical supervisor at Vanguard University Counseling Center
Work at The Center for Individual and Family Therapy (CIFT)
Therapy
Psychological Testing
Extensive experience doing psychological testing with ADHD, therapy with children with ADHD, and parent training, and several family members with ADHD.

3. What questions do you have about treatment of ADHD that you are hoping are answered today?

4. What is ADHD? Individuals with ADHD typically have difficulties with:
Neurodevelopmental disorder – a quantitative delay of self- regulation/inhibition
Characterized by developmentally inappropriate levels of inattention, impulsivity, and hyperactivity
Affects 11% of school-aged children
Symptoms continue into adulthood in more than three-quarters of cases and more than 75% of children with ADHD continue to experience significant symptoms in adulthood.
Individuals with ADHD typically have difficulties with:
Maintaining attention
Working memory
Executive functioning skills
Challenges with emotions start in the brain itself

5. What causes ADHD?
Research has yet to determine the exact causes of ADHD
Have found a strong genetic link in research as ADHD can run in families
More than 20 genetic studies have shown evidence that ADHD is strongly inherited. Yet ADHD is a complex disorder, which is the result of multiple interacting genes.
1/3 for males (less for females) is acquired (during pregnancy or early development) vs. 2/3 genetic
Causes interact and are compound
Other factors in the environment may increase the likelihood of having ADHD:
Exposure to lead, toxic substances, or pesticides in early childhood or en utero
Premature birth or low birthweight
Brain injury
Scientists continue to study the exact relationship of ADHD to environmental factors, but point out that there is no single cause that explains all cases of ADHD and that many factors may play a part.

6. Executive Functioning Skills
Executive skills involving thinking (cognition):
Executive skills involving doing (behavior):
Working Memory
Planning/Prioritization
Organization
Time Management
Metacognition
Response Inhibition
Emotional Control
Sustained Attention
Task Initiation
Goal-Directed Persistence
Flexibility

7. Executive Skill Definition Child Example Teen Example Working Memory
The ability to hold information in memory while performing complex tasks. It incorporates the ability to draw on past learning or experience to apply to the situation at hand or to project into the future.
A young child can hold in mind and follow one- or two- step directions. The middle school child can remember the expectations of multiple teachers.
Some kids keep track of their belongings, like coats, keys, or sports equipment, or are really good at remembering what they have to do. Other kids forget where they have left stuff and misplace things a lot or say, “I’ll do it later,” but then forget about it. Some kids seem to learn from experience; others don’t.
Planning/ Prioritization
The ability to create a roadmap to reach a goal or to complete a task. It also involves being able to make decisions about what’s important to focus on and what’s not important.
A young child, with coaching, can think of options to settle a peer conflict.
A teenager can formulate a plan to get a job.
Organization
The ability to create an maintain systems to keep track of information or materials.
A young child can, with a reminder, put toys in a designated place.
A teenager can organize and locate sports equipment.
Taken from Smart but Scattered by Dawson and Guare

8. Executive Skill Definition Child Example Teen Example
Time Management “time blindness”
The capacity to estimate how much time one has, how to allocate it, and how to stay within time limits and deadlines. It also involves a sense that time is important.
A teenager can establish a schedule to meet task deadlines.
Metacognition
The ability to stand back and take a bird’s-eye view of yourself in a situation, to observe how you problem solve. It also includes self-monitoring and self- evaluative skills (e.g., asking yourself, “How am I doing?” or “How did I do?”).
A young child can change behavior in response to feedback from an adult.
A teenager can monitor and critique their performance and improve it by observing others who are more skilled.

9. Executive Skill Definition Child Example Teen Example
Response Inhibition
The capacity to think before you act- this ability to resist the urge to say or do something allows a child time to evaluate a situation and how their behavior might impact it.
A young child can wait for a short period of time without being disruptive. An adolescent can accept a referee’s call without an argument.
Some teenagers thing about the consequences before they do something. Other kids just act- they don’t waste time thinking about consequences.
Emotional Control
The ability to manage emotions to achieve goals, complete tasks, or control and direct behavior.
A young child with this skill can recover from disappointment in a short time.
A teenager can manage the anxiety of a game or test and still perform. Some teenagers have a short fuse and get easily frustrated by little things or get stressed out if something doesn’t go right. Other teenagers can stay cool despite irritation and take unexpected events in stride.
Sustained Attention
The capacity to keep paying attention to a situation or task in spite of distractibility, fatigue, or boredom.
Completing a 5-minute chore with occasional supervision is an example of sustained attention in the younger child.
A teenager can pay attention to homework, with short breaks, for 1 to 2 hours.

10. Executive Skill Definition Child Example Teen Example Task Initiation
The ability to begin projects without undue procrastination, in an efficient or timely fashion.
A young child is able to start a chore or assignment right after instructions are given.
A teenager does not wait until the last minute to begin a project.
Goal-Directed Persistence
The capacity to have a goal, follow through to the completion of the goal, and not be put off by or distracted by competing interests.
A first grader can complete a job to get to recess.
A teenager can earn and save money over time to buy something of importance.
Flexibility
The ability to revise plans in the face of obstacles, setbacks, new information, or mistakes. It relates to an adaptability to changing conditions.
A young child can adjust to a change in plans without major distress.
A teenager can accept an alternative such as a different job when the first choice is not available.

11. What are the risks of undiagnosed and untreated ADHD?
Early identification and proper treatment is very important
If left undiagnosed and treated ADHD can have significant consequences including:
School failure
Difficulty making and keeping close friendships
Family stress and disruption
Depression
Problems with relationships
Substance abuse
Delinquency
Accidental injuries (including increased risk for car accidents)
Job failure
Obesity

12. Co-morbid diagnoses (having additional conditions)
2/3 or more of children with ADHD have at least one other co-existing condition
Most common co-occurring diagnoses:
Oppositional Defiant Disorder
Conduct Disorder
Anxiety
Depression/mood disorders
Tics and Tourette Syndrome
Substance abuse*
Sleep disorders
Learning disabilities

13. Psychological Conditions Mimicking ADHD
Trauma and PTSD
Anxiety
Depression
Learning Disabilities
Oppositional Defiant Disorder
Sleep Disorders

14. Components of Effective Treatment
1. Evaluation
2. Family education/training
Psychoeducation
The impact of ADHD on executive functioning skills and self-regulation
Reducing blame and shame
Parent Training
Positive behavior management
Creating an external working memory system
Learning to advocate for your child
Child Skill Training
3. Environmental Accommodations
This may include educational supports:
School Consultation and Advocacy
Teacher Training in positive behavior management
4. Medication

15. Parent Training: Positive Behavior Management
Parent-Child Interaction Therapy (PCIT)
Triple P (Positive Parenting Program)
Incredible Years parenting program (Webster-Stratton)
New Forest Parenting Programme
All have similar elements:
Help parents develop effective discipline strategies using rewards and non-punitive consequences
Parent who attend more training sessions see greater improvements in the child’s behavior (Give yourself credit! You’re here right now!)
These benefits can be maintained long-term
Parents who have untreated ADHD themselves are less likely to benefit (25-25% of parents of a child with ADHD have ADHD themselves)

16. Parent Training: Principles for Improving a Child’s Executive Skills
Teach deficient skills rather than expecting the child to acquire them through observation or osmosis
Consider your child’s developmental level
Move from the external to the internal
The external includes changes you can make in the environment, the task, or the way you interact with your child
Use, rather than fight, the child’s innate drive for mastery and control
Modify tasks to match your child’s capacity to exert effort
Use incentives to augment instruction
Provide just enough support for the child to be successful
Keep supports and supervision in place until the child achieves mastery or success
When you do stop the supports, supervision, and incentives, fade them gradually, never abruptly

17. Effective Consequences and Rewards
Child needs increased accountability
Consistency
Act don’t yack
Must be immediate
Keep the E-R-O’s close:
Event – Response – Outcome/Consequence
Give effective commands/directions
Touch more, talk less
Check in on child more often
Help to motivate the child in order to develop executive functioning skills and reinforce the positive effects to aid in continued motivation
Reinforcing executive skills with praise
Something fun at the finish line
Wording incentives instead of negatives
Using more formal incentive systems
Points, tokens, stickers, privileges
Expect and plan for set backs.
This is a part of learning. Focus on overall progress. Revisit previously successful strategies. Revise as needed. Not all strategies will work for all kids or work all the time.

18. Transition Planning Stop Pre-teaching: Review 2-3 rules ahead of time
Explain the incentive or punishment
Distribute the reward or consequence throughout the task
Review with them

19. Parent and Child Partnership
Change the physical or social environment to reduce problems
Change the nature of the tasks your child is expected to perform (Creating an External Working Memory System)
Change the way caregivers (or other adults) interact with the child
Reducing distractions
Organize the house
Breaking tasks down into components (“chunking”)
Using checklists and charts
Daily and/or visual schedules
Timers
Signs, symbols, cues, reminders, sticky notes
Movement breaks
Positive reinforcement
Problem-Solving as a team
Develop a homework plan with your child
Limit choices
Set small, reachable goals
Educate other caregivers to increase consistency across settings

20. Child Training Informally teaching executive skills:
Verbal scaffolding
Visual scaffolding
Teach child to write down things immediately
Use timers
Teach child to break things down into steps and do one at a time (i.e., a book report is due in a week: Read 4 pages today. Write 4 sentences today. You earn 4 tokens right now.)
Teaching executive skills in the course of family activities – making the skills more explicit
Meal planning and prep
Grocery shopping
Allowance money
Make it fun!

21. Child Training Formally teaching executive skills
Identify the problem behaviors you want to work on
Set a goal
Involve the child in goal setting
Set interim goals and pair with rewards
Outline the steps the child needs to follow to reach the goal
Turn the steps into a list, a checklist, or a short list of rules to be followed
Supervise the child following the procedure
Fade the supervision
Expect and plan for set backs to combat discouragement.

22. Social Skills and Self-Esteem
Many children with ADHD have poor social skills and peer relations
Social skills training is most effective when the child is given immediate feedback – in the natural environment (a group with peers or at school)
Role-playing in session is unlikely to produce significant and lasting change
Try to use real-life situations
Help parents to recognize and be able to encourage positive social skills
Children with ADHD end up being punished more frequently for normal child conflicts rather than taught how to respond
Leads to decreased self-esteem and anger problems
Help children develop close friendships

23. School Involvement
Teacher using positive behavior management strategies
Teacher-Child Interaction Training (TCIT)
Consistency and communication between home and school
Monitoring card – rate the target behavior(s) and use a token economy system at home
Frequent evaluation that comes back to you
Increases accountability
Advocating for appropriate modifications
504 plan
Individualized Education Plan (IEP)
School-based interventions alone can also be effective for young children (6 and below), but gains may diminish with time
Medication and academic achievement:
First productivity
Then (after 2 years), improvements in academic achievement

24. What Does NOT Work for ADHD
Non-directive play therapy
Insight-oriented therapy (such as psychanalysis)
High doses of vitamins and minerals*
Dietary changes*
Pet therapy
Chiropractic care
Limited support for long-term effects of biofeedback (but some growing research)
Sensory integration training
Dietary interventions
Self-control training for young children
Yelling
Bribing
Lecturing
Threatening punishment
Grounding
Blaming yourself as a parent
Taking away recess
*low probability, works for few people, very small effects

25. One of the most important things a parent of a child with a disability can do is…
Forgive yourself
Forgive your child
Forgive other people/the public

26. References and Resources
Children and Adults with ADHD (CHADD)
Barkley, R. A. (2013). Taking Charge of ADHD, Third Edition: The Complete, Authoritative Guide for Parents.
ADHD Essential Ideas for Parents: rkIfo
Dawson, P., Guare, R. (2009) Smart but Scattered: The Revolutionary “Executive Skills” Approach to Helping Kids Reach Their Potential. New York: Guildford Press.
Reiff, Michael (2011) ADHD: What Every Parent Needs to Know. American Academy of Pediatrics.
Salisbury-Afshar, E. (2013). ADHD Interventions in Children Younger Than Six Years.