Behavioral Treatments for ADHD

Behavioral Treatments for ADHD


– Thanks for having me. I’m gonna try and talk a little bit about the non-pharmacological, or also known as the
behavioral treatments for ADHD. And I was talking to a former
colleague from Nebraska and yes, there are effective
behavioral treatments out there for ADHD. I’m gonna try and review the
current affairs with ADHD, where it stands now and how we got there, review some of these behavioral approaches and try and give you a sense
of what they look like, and then actually provide,
you know, some evidence to support the use of
behavioral treatments. So ADHD is probably the
most commonly presenting behavioral disorder
that we see in children. About 20% of all children
will meet diagnostic criteria for a DSM-4 or DSM-5 diagnosis. And I work in primary
care and it’s probably the most common issue
that we see referrals for. So about a quarter of the referrals to us as a psychologist in the primary
care setting are for ADHD. And you see that, you know, about 11% of children are diagnosed and about one in five boys. So it’s a very commonly
presenting behavioral disorder. So there are some, there’s a long history of the treatment of ADHD. And a lot of it stems
back to the MTA study conducted in 1999. It was a large,
multi-treatment assessment, randomized clinical trial, looking at the behavioral
treatment of ADHD versus the pharmacological treatment. And there are some problems
with that study in 1999. Mainly, just to touch on a couple of them, the intensity of the behavioral treatments was never really allowed
to be varied within that and pharmacological treatment was varied, even outside of recommended doses ranges. When they assessed the outcomes, they only looked at the
behavioral treatments a month or so, several months, actually, after the behavioral
treatment was discontinued, whereas they evaluated
the pharmacological side at the peak of the pharmacological dosage. And maybe most importantly, when they introduced the sequencing, when they looked at behavioral and pharmacological treatments combined, they only introduced medication first and then the behavioral treatment. They never did behavioral treatments first and then introduced medication. And I think that’s a
really important piece. And I’ll come back to that a
couple times during the talk. So there’s been, after
that time, from that study, and when it was released
in right around 2000, a lot of individuals,
clinicians, interpreted that as medication was the primary and only necessary treatment for ADHD. And this really influenced
the number of stimulants being prescribed. You can see here, from 2002 to 2012, sales in stimulants quadrupled. And at that time, at around 2012, there was data that suggests
that one in five children before the age of 18 would
go on a stimulant medication. Which, a prevalence rate of
11%, which is very high as well, that is, I think everyone
was getting the sense that we’re using too many
stimulant medications, maybe over-prescribing. And the American Academy of
Pediatrics responded to this in 2011 by putting out guidelines
essentially saying that we should be using both behavioral and pharmacological
treatments simultaneously and that’s probably the best
strategy for treating ADHD. And that was done in 2011,
after about 10 years of, primarily the pharmacological
treatments being used. But there were a lot of
people working diligently on trying to demonstrate
that behavioral treatments were effective during those 10 years. And eventually got those guidelines out. Currently, the state of affairs
are not that encouraging, in terms of access to
behavioral treatment. Only about 13% who are diagnosed with ADHD are receiving effective
behavioral therapy. 93% of children with ADHD
are on stimulant medications. It is the most expensive
disorder in child healthcare, next to the birth of the child. So because of the
prevalence and the expense associated with the medications, it is the most expensive
childhood disorder at 20.6 billion dollars
a year and increasing. And there are some
really concerning things that are happening, such
as, in 2013, CDC saw that about 10,000 children
that were two years old were on stimulant medications. Why is this? Why are these things happening? Because I don’t think people are aware of the efficacy of behavioral treatments, the fact that they’re out there, and that they can be effective. So of children who need
behavioral health services, only about 20% of those
kids actually ever get any. And of them, maybe 10 to 15% are getting high-quality services. So very few, very little access. And that’s what we try
and do in primary care as a psychologist is to
increase that access. And I think that when we do
that, it’s kind of interesting, what is it that we’re actually doing? And so I want to give you
a little bit of a taste of, what do these behavioral
treatments look like when we provide them in primary care? And I think that it would
be very generalizable to, you know, the cardiac clinics
that you all work in, as well. So this is a Buffalo Model. And it’s essentially kind of like, it’s also referred to
as a safety-first model because of some of the side-effects associated with stimulant medications. I think Stewart, you know,
sort of highlighted that for us all. I’m not sure that I’m clear
on whether it’s good or bad, but I think that, necessarily, you would want to be conservative. And that goes regardless
of if there’s cardiac issue in the equation for that child or not. There are side effects with sleep, there are side effects with eating, and it can exacerbate other problems like anxiety or tics and
things of that nature. So a safety-first model, a Buffalo Model, essentially was developed
by this individual, William Pelham, who’s been
quite active in this area. And the idea is to do a
very thorough assessment of the ADHD, up front. The American Academy of Pediatrics says we want at least a Vanderbilt
at home and school. The NIH, the American
Psychological Association, and the Michigan
Psychological Association, all would recommend a
little bit more than that, maybe some multiple measures
from multiple individuals in multiple settings. So something maybe a couple
measures beyond the Vanderbilt. The Vanderbilt is nice, but
it’s essentially a checklist and it’s really not norm-based, so that we don’t have a sense of, is this child varying
outside of normal limits on any of these dimensions of ADHD. So it just kind of gives you a sense of, is the child experiencing symptoms. It doesn’t give you a sense of how far those symptoms are
varying outside of the norm. So it’s a good start. And then treatment, and then
putting behavioral treatment in place after the assessment. And the assessment is nice
because it gives you a sense of, are there other things going on, such as anxiety and depression, which can really make
a child look distracted or look inattentive. It also might be helpful in pointing out a specific learning issue. If a child doesn’t understand how to read, then a stimulant medication
is not gonna be effective in treating that issue. You will need to pull that child out and go back and work
on some reading skills that they didn’t learn through
the regular ed curriculum. Through the mainstream curriculum. And then the treatment
that Pelham would recommend through the Buffalo Model
would be first, you know, sort of a parent training model. And generally speaking, he would recommend about four to eight
sessions of parent training and then usually what’s
called a daily report card. A school behavior program, a behavior program for
the school, as well. And see how that works, and
if that is not getting you sort of traction over the
course of four to six weeks, then introduce medication. So these are some of the
measures that we use. This is kind of a checklist that we use that’s similar to the Vanderbilt, just to give you kind of a sense of some of the things that we use. This is a DSM-5 ADHD checklist. This is an Eyberg behavior inventory. This is norm-referenced, so it’s nice, it gives you a sense of,
does a child, you know, just have kind of externalizing
behavioral problems or are the issues more ADHD-related. It helps provide a little
bit of differential diagnosis between behavioral and ADHD. This is a broad-band
measure called the BASC. This is an older version, but behavior assessment
scale for children, some people might be familiar with this. But it’s basically giving you sort of what I would call like a 20,000-foot view of a child’s psychological functioning, their overall functioning. And it’s helpful in
identifying things like anxiety or depression or externalizing
behavioral problems, maybe even some social problems at home, that might be influencing a
child’s ADHD or inattention. And it helps you separate
those things out from ADHD. And then this is a Conners’, which is a nice sort of narrow band. It looks very closely at ADHD,
but it gives you a sense of maybe are there some academic issues and things of that nature. So we’ll use a variety of those measures, so usually two or three of those measures, to try and get a sense of, is it ADHD or are there other psychological issues that might be explaining the inattention. And another thing that
we’ll do is actually go in and directly observe the child. Because all of those measures
are filled out by the parents and the teachers, there’s always gonna be a little bit of
subjectivity to their views, even though they are
norm-referenced tests. So going into the classroom
and getting a direct view, laying your eyes actually on the child and getting a direct assessment. This is, the way we do this,
the direct observation is we’ll take 10, 15 minutes and we’ll just watch the target child. And every 20 seconds
or so, we’ll mark down whether or not they’re on task or not for that period of time. And then we’ll take two randomly-selected same-gendered peers within the classroom and do the same thing. And we get a sense of the on-task behavior versus the other kids in that classroom. And it’s a nice way to
get a sense of, okay, each class has sort of its own equilibrium or level of activity and attention. Like, you know, some classes
are very active and loud, other classes are, you know, quiet and everyone’s seated in their chairs, and it gives you a sense of, you know, where the target child is relative to the norm within that classroom. And it’s a nice way to look at everything through the lens of a direct observation, to make a differential diagnosis. So when we score these
all up, what we’ll do is we’ll put them in a measure
of a spreadsheet like this. And we’ll put all the
home ratings over here and we’ll put little asterisks in the areas where they’ve elevated. And then these are the school ratings and we’ll put them side by side like this. And by doing this, it
gives us a good sense of what else might be going on here. And though there are some attention issues that are consistent
between home and school, there’s also a lot of concerns
about academic problems. And those might be even more of a concern. So if nothing else, you’re
gonna want to make sure that, you know, we initiate an
academic evaluation at the school and work on, you know, reading
and specific academic issues as a first line approach
and maybe in addition to the ADHD treatment. And this is just another example of that, where you can see kinda how this child, maybe more of a behavioral flavor. This is the inattention stuff in here. And it’s really super consistent, but the behavioral stuff
is pretty consistent across the different
home and school settings. So maybe more of a behavior problem than it is an ADHD
focus, inattention issue. So what do the behavior
treatments actually look like? So I wanna try and give you
a little bit of a sense of what these programs look like, what the parent training looks like. It’s usually referred to as
behavior parent training. It’s delivered in four to six sessions, or four to eight sessions. Usually what we’re trying
to do is teach parents like the role of attention. And one recommendation that you’ll see in almost all of these is that they take, you
know, 10, 15 minutes of one-on-one time with their
child every single night and really shower them with attention, pull away from trying
to control that period with questions or demands. We don’t want it to look
like an academic situation. We’re not trying to teach
during this situation. We’re trying to teach the
child through showing them that if you do pro-social behavior, you’ll get a lot of reinforcement
from parental attention for doing that. And we really try and
teach them strategies to do that, to use their
attention as a tool. And we also try and teach them reinforcement and
motivation-based strategies, which are kind of hard to learn because they’re
consequence-based strategies. So you have to be very good at finding the behaviors that you’re trying to shape and then reinforcing them consistently. And that’s not something that
you can just do one time. And it’s also something
where you can’t sort of dangle a reward at the end of the month and say, well, you know, they
didn’t change their behavior, therefore reinforcement didn’t work. Reinforcement will only
work if they actually engage in that, actually
experience that reward consistently in the short term. And we’ll also shape up some consequences, refine their time-out abilities, their time-out strategies
for the home, as well. So we’ll do that on the home levels, try and give parents some
basic parenting skills, evidence-based, proven
methods for managing behavior, getting homework done,
things of that nature that are very associated with ADHD. So this is probably
the hallmark feature of an ADHD behavior program. It’s called the daily
behavior report card. And so what we try and do is
target a couple behaviors. So for this child, we
targeted on-task behavior and following directions. And we’ll have the teacher
just rate the child every day on a scale of one to 10. This is just for example. This is kind of the elementary version and this is the high school
version, middle school version. It’s a little bit different. But for the elementary school
kids, which are most of them, we wanna get what we call like a baseline. And so at first we’ll
say, just have the teacher send this note home for a couple weeks. And reinforce the child, we’ll talk about the reinforcement that we use in a second. Deliver the incentives at home, as soon as they walk in the door for just bringing the note home. And then get a sense
of where the child’s at on these targeted behaviors. And each child can have different targets. Some kids, you’re gonna
target in-seat behavior, other kids, you’re gonna be
targeting completing work, following directions, hands to
self, things of this nature. Each kid’s operationalizing their ADHD, you wanna do that, you know, individually and each kid’s is a little bit different. So after, let’s, this is a
scale of one to 40, total. So after, let’s say a couple weeks, the kid’s average score was 23.5. We would actually set a goal of, okay, Johnny, your goal now is to get a 24. So you wanna set the goal right at where they’re coming in at, basically. And then at home, you’d
have something like this, where immediately when
they walk in the door, you’re gonna have usually kinda like all those things that
I remember as a child that were sort of the
right after school routine, which was kind of like watching
a little bit of screen time, having like a special snack, and some one-on-one
attention from parents. And so we usually kind of
do a combination of those to make it really look
salient and impactful. So all of that is
delivered contingent upon meeting your goal,
bringing your note home. And then as a consequence,
to start out with, and this is what I would call kind of a light behavioral intervention, somewhere where you wanna start, as a consequence for
not meeting your goal, all we would do is withdraw that. There wouldn’t be any sort
of punishment procedure. It would just be like, you
don’t get it on those days. And the idea is that
you’re showing these kids, you’re teaching them by showing them when you behave in a particular way and receive a certain
score for that behavior, that translates to home. It’s not like Las Vegas. What you do at school
does not stay at school. It comes home, and there’s a consequence. Things will look different for you on the days that you meet your goal verus days that you don’t. And if you’re consistent with that, over time, usually you’ll see the child gravitate towards meeting this goal. As they meet the goal,
you can raise the bar. And you can connect it to
weekly incentives, as well, for consistently meeting your daily goals. And you’re trying to teach
them through showing them, teach them through these consequences. And about 70% of kids will
respond favorably, with ADHD. You can manage, according
to Pelham’s data, you can manage ADHD symptoms effectively with about 70% of kids using
a strategy similar to this, which is light, and then an
intense behavioral intervention would be to do something like
this, but also in the school, where you’re actually delivering feedback at like an hour interval or a
half-hour interval at school and then delivering actual incentives, privilege-based incentives,
being the line leader or the special helper,
taking a note to the office, things like that, contingent upon meeting those goals in school. That would be a more
intensive intervention. So, let’s look at the data. So we looked at, here at U of
M in our primary care clinics, we looked at two clinics: one
clinic with a psychologist who was providing what we call integrated behavioral health strategies, and we had standard medical care, which was Vanderbilt and medication. Integrated behavioral health
was that thorough assessment, a behavior treatment package, a little bit of parent training, and then introduce medication if needed. So we can see that
these are ADHD symptoms, so we want these to reduce. We measured it over
the course of 12 weeks. The dark line is the integrated
behavioral health group, the dash line is medication only. We had 68 kids, 35 in the
standard medical care group and 33 in the integrated
behavioral health group. So you can see, reduction was
a little big more significant, these were statistically
significantly different at 12 weeks. More reduction and with ADHD,
only treatment was medication, you see the kind of reduction
and then maybe kind of tailing off over the course of 12 weeks. This is according to the parents. And teachers agreed, maybe
a little bit more dramatic. The kids in the integrated
behavioral health group started out a little bit more severe, but ended up having better outcomes, whereas the medication only
group, standard medical care, did not have quite the impact. Maybe, by the end of it,
we’re almost back to baseline. So one of the things that we
looked at when we did this, one of the things I was
always concerned about this is that parents wouldn’t want to do this, that they would not want to do the parent training aspect of it, they would just kind of
want to use medication to treat it quickly and
efficiently, from their perspective. But when we assessed their acceptability, they actually found the
behavioral treatments to be more acceptable. This was on a scale of one
to six, and you can see, a lot of fives for the
behavioral treatments from both parents and teachers. And standard medical care,
kind of more in the four range in terms of finding the
treatment to be acceptable. So this was not randomized,
and that’s kind of one of the main flaws of the study. But one of the most
interesting aspects was standard medical care,
about 66% of the kids went on the medication, and integrated behavioral
health group, about 22% went on. So that was one of the big findings, even though we had sort of
maybe better clinical outcomes in the behavioral side. Some more sort of refined
studies looking at this. This is a dose-range crossover
study conducted by Pelham. He had 44 kids and they all received every level of behavioral treatment, no behavioral treatment,
low behavioral treatment, and high behavioral treatment. And they received a placebo,
.15, different dosages on the X axis, down here. So this is the dosage. So every kid went through
the different dosage, all 44 kids, age six to 12 went through the different dosages and
the different intensities in terms of the behavioral treatment. They vary the dosages
about three to four days and they varied the behavioral treatments every about three weeks. And the main thing you
can see here is that there’s a big gap in
terms of the reduction, which is what we want,
reduction of ADHD symptoms, on the Y axis here. The big gap when there’s no
behavioral treatment in place, that you don’t get as big of an effect. And that you do kind of still
get a pretty big effect, even without the medication in place. But sequencing is really important. And in the most recent release of, this is a randomized
control trial with 150 kids, 75 into a behavior treatment,
75 into medication treatment. And after that, after they were randomized into behavioral or medication,
they randomized them again to see, they wanted every kid to be on both of those treatments, to be behavioral and medication. They randomized again to put
them into a group after that. So what we found in this,
when he sequenced it, was that, and this is, on the X here, we’ve got medication first,
it’s a little bit hard to read, versus behavior first. And these are, on the Y
axis you basically have behavioral symptoms in class. You can see a greater reduction in the behavioral only
groups on both of these. These are both in-class
behavioral problems and behavioral problems
that are significant enough to get you kicked out of class. So you had a, more reduction
with the behavior first versus med only first,
but the key was that if you went from med first to behavior, the outcome was very poor. Med first to behavior
is a very poor outcome. Behavior first to med
is still pretty good. But med first to behave,
that’s the main finding that he found is that behavior
alone does a pretty good job, especially compared to medication, but if you go, if you wanna
have them both involved, if you go medication
first to behavior second, the outcome is the worst
outcome in the study. And he also found that it
had a really big impact on parental involvement. And I talked a little bit previously about how parents were, they
found it quite acceptable to do behavior therapy. But they don’t show up if
you do the behavior second. So when you do behavior first, your attendance rate for one session versus the whole parent training
of six to eight sessions, you see, you know, 70%
follow-through, roughly, if you do behavior first. If you do behavior second,
follow-through is 20% or so, or lower, for the whole thing. And then more people show
up for booster sessions, follow-up behavioral booster
sessions, when, you know, when they need a sort of a
ADHD sick visit, if you will, more people show up for those as well, if you do the behavior first. So I would recommend, the
treatment of choice would be good thorough evaluation, a few
measures at home and school, introduce some parent
training, in particular, get the daily report card in place, and if that is not effective,
then introduce the medication. The daily report card
becomes a really nice way to evaluation medication efficacy. You can blind school to
the medication manipulation and use that as a fairly objective report of how effective that medication is in addressing the ADHD symptoms. And that’s a very nice way to use it. I think this has proven, we see
this to be fairly effective. I don’t think it’s
overly challenging to do. I think you can do this. I don’t think it’s overly involved. And I’m happy to take
any questions anyone has, although I think we’re
gonna save that for the end. I really appreciate you having me. And thank you. (audience applauding)


26 thoughts on “Behavioral Treatments for ADHD

  1. The best way to treat ADHD is by yelling and violently screaming at the children it'll with them the shape by making them subordinate

  2. As you said this is felt everwhere. I was diagnosed in my 30s and medication was my only 'therapy'. I asked for CBT and was told there isn't any & the lists and planners I was already doing were the only suggestions. There are 0 adhd psycs in my area and I live in a large city. Even online there are plenty of symptom checks but little to no tools.

  3. A child to be made to sit at a table for hours on end, at a school room desk , is not a healthy environment , should not be expected or encouraged. Exercise a couple of minutes per hour is natural , healthy and elevates 90% of the behavioral problems. This exercise period is an
    obvious proper care of the health of a child. The exercise inducing the proper chemical makeup of the brain ; (Endorphins ,chemical balance of receptor / transmitters etc .) and of the whole body.

    Although ADHD may be seen as physiological disorders ; A large percentage of ADHD are disorders of the Brain not the Mind and so the health and regulation of the Physical Brain is at the root of the problem. Rather than this being a common physiological disorder 20%; It is commonly a behavioral disorder "Perpetrated upon the child."…. (Much more common than the "Testing " determines.)

    Parents should also be aware of the foods that contribute to Hyperactivity.
    Fruity loops with Milk and sugar, given to a normal healthy child ,as breakfast; will result in behavior mimicking that of classic ADHD.

  4. Finally I am still waiting for my 8 year old son to recieve behavorial therapy and to see a Neuropsychological team for assessment and it's has been two years. How is still on a waiting list and no answers for me.

  5. This video is not made for ADHD viewers. This guy is slow, never gets to the point, I skipped the video like 50 times trying to see what behavioral changes he recommends and I still can't find it. Why be so long winded when your target audience has an attention deficit disorder?

  6. I don't believe in all these ridiculous pharmaceutical approaches that hospitals/doctors are touting. Yes the pharmaceutical industry is one of the biggest industries worldwide but it would be better if doctor's took a more psychological approach regardless of whether they think that is their job or not. As someone with severe ADHD, I have refused any sort of medication as having previously tried them those medicines side effects are very unhealthy and unforgiving (loss of appetite, suppressed emotions or 'zombie' like feeling). If anyone can share any more behavioural tips on dealing with this as someone who cares about their health and well-being. Thanks and have a good day.

  7. Behavioral treatment is not treatment, it is bringing up a child, and if such treatment is required, it means parents simply have not been doing their lot.

  8. I have ADD, and my son does as well….but I need my husband to watch this and explain it to me. 😜

  9. Wtf 2 yr old on medicine???? Hell no. That's most likely just a kid being a kid and a useless parent. In my opinion meds should NEVER be the first choice. That's what they did with me at 19 when I was diagnosed. Heres pills now go away. A lot of times adhd is caused by shitty nutrition (which was my case), not enough excercise, or just shitty people who dont realize you cant expect kids to act like adults. First and foremost check their diet/nutrient levels and make sure they're running around playing enough, and/or add therapy at the same time. If that doesnt help after a few months then try pills.

  10. Skimmed and suffered through some on 2x speed these are generally "motivate and give positive reinforcement" nothing to assist the child/person in the actual situation.
    Just trying to motivate and be a good parent.
    Wasn't what I was looking form; I wanted a more of tricks and tips not a "This is how you raise a kid who can't focus because we don't want to give them meds."

Leave a Reply

Your email address will not be published. Required fields are marked *