Comprehensive Interventions

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A number of cognitive-behavioral researchers have developed comprehensive interventions for children and adolescents with ADHD, which include individual skills training, family therapy, and school interventions. To our knowledge, none of these comprehensive intervention packages have been compared in their totality vis-à-vis stimulant medications, contingency management, or as an adjunct intervention to the established treatments. Building on the successes and failures of the first generation of CBI for ADHD, Lauren Braswell and Michael Bloomquist (1991) developed one of the most comprehensive treatment packages for children and adolescents with ADHD. This treatment package, Cognitive-Behavioral Therapy with ADHD Children: Child, Family and School Interventions, was developed based on an ecological- developmental model of cognitive-behavioral therapy to improve children's self-control. In contrast to previous treatment packages where most of the interventions focused on the child, Braswell and Bloomquist emphasized the role of parents and teachers in teaching, modeling, and monitoring strategies for enhancing self-control. According to Braswell and Bloomquist, just as children have cognitive and behavioral deficits that need to be addressed through skills training, so do parents and families. The primary aim of the treatment is to teach children self-control strategies using problem-solving and self-instruction training. These training strategies are employed in dealing with impersonal problems (e.g., academic work or poor effort) and/or interpersonal problems (e.g., interaction difficulties with peers and family members). Children and adolescents also receive social skills training, anger management training, and strategies for improving academic work. To modify parents' thoughts and attitudes, educational and cognitive restructuring are employed. Parents are taught effective behavior management skills and strategies for reinforcing what the children learn in individual and group sessions.

Families receive communication skills training, and anger and conflict management training. Finally, Braswell and Bloomquist (1991) offer a model for cognitive-behavioral school consultation and instructions for school-based interventions. The treatment manual is intended for children who have ADHD with and without conduct disorder. The manual contains separate child, parent-family, and school components. Cognitive-Behavioral Therapy with ADHD Children: Child, Family, and School Interventions (Braswell & Bloomquist, 1991) probably represents the most ambitious effort thus far to apply cognitive-behavioral methods and strategies to children with ADHD and their families. Even though many of the treatment components in this package have been found to be effective in treating a number of behavioral and emotional disorders in children, their effectiveness has not yet been assessed in children with ADHD.

Recent large, long-term, multisite studies indicate that a significant proportion of children with ADHD must be treated using a combination of several treatment modalities including medication and behavioral (contingent management) strategies. Despite the success of stimulant medication and contingency management for treating symptoms of ADHD and mild forms of the most common comorbidities, studies have shown that children with ADHD typically do not generalize skills learned across situations and that treatment gains decrease rapidly after treatment is terminated. Further, the chronic nature of this disorder makes it very difficult for patients and those involved in managing the interventions to coordinate the various treatments and maintain treatment fidelity. Although CBI has proven ineffective for treating clinical levels of inattention, hyperactivity, or impulsivity, it may be effective for treating common comor-bidities such as internalizing disorders and thus serve as an effective adjunct treatment. Because CBI places great emphasis on enabling the child to develop self-control and problem-solving skills, it may prove to be effective in supporting generalization and maintenance of treatment gains. The next generation of multimodal treatment studies for ADHD should test the effectiveness of CBI as facilitators and boosters for proven effective treatments. For example, parents could be taught problem-solving steps that they can use to modify contingency management strategies between office visits or after treatment has been terminated. Cognitive restructuring and the scientific method of systematic evidence gathering and hypothesis testing can be taught to parents who hold negative biases or irrational beliefs about medication as a treatment for ADHD. Goal setting and self-management strategies could be used with adolescents who have difficulty managing their medication.

For the past three decades, CBI for ADHD has seen an initial period of theory development, application, and empirical effort, a longer period of critical evaluation followed by strong skepticism, and a more recent period of renewed interest. There is some indication that CBI for ADHD could serve an important role as an adjunct treatment to psychostimulant medication and behavioral contingency management. Future research should investigate what specific components of CBI should be used with specific children to supplement their established treatments.

See also: Attention-deficit/hyperactivity disorder (ADHD)—adult, Parents of children with ADHD

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