Evidence-based psychotherapies for children and adolescents by Weisz and Kazdin (third edition) – Chapter 13 summary

Interventions for ADHD need to be constructed in a way which allows them to be conducted for years and it needs to be implemented across settings since ADHD is a chronic disorder. The most common treatment is medication with central nervous system stimulants. This leads to short-term improvements. However, there are several limitations to medication:

• It is not preferred by parents.
• Medication is not sufficient to normalize functioning.
• Medication has a limited impact on key domains of functioning.
• Long-term compliance is poor.
• Mediation alone does not lead to good long-term outcomes.
• The long-term safety of stimulant medications has not been established.

Behaviour modification is another common treatment for ADHD. This teaches skills to parents, teachers and children to overcome some of the key functional impairments associated with ADHD. However, outpatient behavioural interventions alone may not be sufficient to improve acute functioning.

Effective treatments need to focus on peer relationships (1), parenting (2) and academic functioning (3) as impairments in these domains lead to negative long-term outcomes in children with psychopathology.

Social skills training is not efficacious for improving peer relationships although this can be targeted in the recreational settings (e.g. sports). ADHD is often comorbid with learning disabilities. Combining recreational activities with educational activities increases children’s attendance. This may lead to greater benefit from summer schools. The summer can also be used to teach parent skills while working intensively with children with ADHD during the day to help these skills generalize. It is important to maintain treatment over the summer as treatment gains may otherwise be lost.

The Summer Treatment Programme (STP) is a summer treatment for children with ADHD which aims to improve children’s peer relationships (1), interactions with adults (2) and self-efficacy (3) while training their parents in behavioural management. It focuses on functional impairments rather than symptoms.

It is a weekday programme for children and adolescents from 3-16 years. The programme typically runs for 7-8 weeks for 8-9 hours per day. The children are placed in a group and these groups stay together over the summer to make sure that they receive intensive experience in group functioning (1), making friends (2) an interacting appropriately with adults (3). For 2-3 hours per day, there are classroom activities and the remainder of the day is used for recreationally-based group activities. Parent training is weekly. The treatment consists of several components:

1. Point system
   Children earn points for appropriate behaviour (i.e. behaviour targeted for development) and lose points for inappropriate behaviour (e.g. teasing). The points can be exchanged for prizes, privileges, social honours, camp-based reward and parent-administered rewards.
2. Social reinforcement and appropriate commands
   Children receive praise and public recognition for appropriate behaviour. This makes sure that there is modelling of appropriate social behaviour.
3. Daily report cards and parent involvement
   There are daily report cards which include individualized target behaviours across all settings. The target behaviours and criteria for meeting goals are set and revised in an ongoing manner. Parents provide rewards for reaching daily report card goals.
4. Time-out
   This includes disciplining (e.g. privilege loss; time-out) for certain behaviours.
5. Medication assessment
   There is elaborate evaluation on medication use to assess whether this is helpful beyond the effects of the behavioural interventions.

The intervention also includes skills building in several ways:

1. Sports skills training
   Involvement in sports may enhance self-efficacy which may promote behaviour change. A lot of time is spent on playing sports.
2. Peer interventions
   There are daily 10-minute group sessions which include instruction (1), modelling (2), role playing (3) and review (4) and there are group tasks. This is believed to contribute to cohesive peer relationships. Children’s implementation of the skills is continually prompted and reinforced using the point system. This is believed to promote positive peer skills.
3. Academic setting
   Children engage in a variety of structured academic activities and complete assignments in major academic areas individualized according to each child’s needs and abilities. There are both individual and cooperative group projects. One hour a day is spent in a less-structured art class to facilitate building skills to transfer to the regular skills settings.

The training can be modified for pre-schoolers to include less intensive feedback delivery systems and age-appropriate modifications to daily activities.

Evidence shows that STR produces large, clinically meaningful changes in child behaviour. There are also incremental contributions of individual treatment components (e.g. time-out is useful to reduce aggressive and non-compliant behaviour). Treatment gains are comparable to those produced by medication. The drop-out rate of STP is extremely low. The effect of medication is maximized at very low doses when STP is in place.