Erika K. Coles

A meta-analysis of behavioral treatments for attention-deficit/hyperactivity disorder

There is currently controversy regarding the need for and the effectiveness of behavior modification for children with attention-deficit hyperactivity disorder (ADHD) despite years of study and multiple investigations reporting beneficial effects of the intervention. A meta-analysis was conducted by identifying relevant behavioral treatment studies in the literature. One-hundred seventy-four studies of behavioral treatment were identified from 114 individual papers that were appropriate for the meta-analysis. Effect sizes varied by study design but not generally by other study characteristics, such as the demographic variables of the participants in the studies. Overall unweighted effect sizes in between group studies (.83), pre-post studies (.70), within group studies (2.64), and single subject studies (3.78) indicated that behavioral treatments are highly effective. Based on these results, there is strong and consistent evidence that behavioral treatments are effective for treating ADHD.

Transdermal methylphenidate, behavioral, and combined treatment for children with ADHD

Stimulant medication and behavioral treatments are evidence-based for children with attention-deficit/hyperactivity disorder, but the combination of the 2 treatments has been understudied. In this investigation, methylphenidate (MPH) was crossed with 2 levels of behavior modification (BMOD) in a summer treatment program. Twenty-seven children with attention-deficit/hyperactivity disorder, aged 6-12, participated. Children received placebo and 3 doses of transdermal MPH (12.5 cm(2), 25.0 cm(2), and 37.5 cm(2)). BMOD was implemented on alternating weeks. Both treatments produced large and significant effects. Combined treatment was superior to either treatment alone. The effects of transdermal MPH were comparable to those found in this setting in previous studies with multiple stimulant medications and formulations. Consistent with other research, low doses of MPH--even lower than in previous studies--yielded enhanced effects in combination with behavior modification.

An evaluation of three time-out procedures for children with attention-deficit/hyperactivity disorder * **

Behavior modification is an evidence-based treatment for children with attentiondeficit/hyperactivity disorder (ADHD). Time-out from positive reinforcement is one behavior-modification procedure commonly recommended to manage disruptive or noncompliant behavior. This investigation examined the effects of time-out on childrens behavior within the context of an intensive summer treatment program at two sites. Short (5-minute), long (15-minute), and escalating/de-escalating time-out conditions were compared to no time-out for 71 children. Results indicated that the time-out conditions were superior to no time-out in reducing the occurrence of intentional aggression, intentional destruction of property, and repeated noncompliance in the recreational and classroom settings regardless of child age or parent reported oppositional or conduct problems. There were no effects of time-out on staff member ratings of time-out effectiveness or the pleasantness of staff-child interactions. All three time-out conditions were equally effective in the group analyses, though analyses of normalization of functioning indicated there were individual differences in response to the time-out conditions. The results indicated that time-out is an effective means of reducing negative behavior in children with ADHD.

A Controlled Evaluation of Behavioral Treatment With Children With ADHD Attending a Summer Treatment Program

Individual treatment response to behavior modification was examined in the context of a summer treatment program. Four children ages 11 to 12 and diagnosed with attention-deficit/hyperactivity disorder were examined in a BABAB design in which a comprehensive behavioral program was utilized and withdrawn across an 8-week period. Dependent measures included frequency counts of negative behaviors, rule violations in recreational and classroom settings, and academic seatwork completion and accuracy. Results documented the effectiveness of the behavioral intervention with all 4 children. Some children showed consistent responses regardless of setting,while others showed differential responses in classroom and recreational settings. In general, behavior worsened progressively over days during the withdrawal weeks.The second withdrawal of treatment produced deleterious effects for several children that persisted for a time even when behavior modification was reinstated.The individual response patterns of each of the 4 children are discussed.

Exploring the Gender Gap in Referrals for Children With ADHD and Other Disruptive Behavior Disorders

Objective: The current study examined the impact of the gender of children with ADHD on teachers’ perceptions toward inattentive, hyperactive, or oppositional behaviors, and how these perceptions relate to teachers’ ratings of children’s impairment and referral recommendations. Method: Teachers read eight vignettes depicting boys and girls with different subtypes of ADHD, as well as one depicting comorbidity (ADHD + ODD). Teachers then completed measures of impairment, and responded to questions about what services they would likely refer for the child and why. Results: Teachers rated girls as being significantly more impaired and more in need of services than boys. Regardless of gender, teachers overwhelmingly reported preferring the use of behavior modification for the described child. Also, children who were described with symptoms of ADHD-predominately inattentive subtype were rated as being the least impaired, while girls described as hyperactive and impulsive were rated by teachers as being the most impaired. Conclusion: The current study adds to previous literature on gender bias in ADHD referrals by providing evidence for the differential referral of ADHD boys and girls to treatment based on presentation of symptoms.

Behavior Therapy and Callous-Unemotional Traits: Effects of a Pilot Study Examining Modified Behavioral Contingencies on Child Behavior

The conduct problems of children with callous-unemotional (CU) traits (i.e., lack of empathy, lack of guilt/lack of caring behaviors) are particularly resistant to current behavioral interventions, and it is possible that differential sensitivities to punishment and reward may underlie this resistance. Children with conduct problems and CU (CPCU) are less responsive to behavioral punishment techniques (e.g., time-out), whereas reward techniques (e.g., earning points for prizes or activities) are effective for reducing conduct problems. This study examined the efficacy of modified behavioral interventions, which de-emphasized punishment (Condition B) and emphasized reward techniques (Condition C), compared with a standard behavioral intervention (Condition A). Interventions were delivered through a summer treatment program over 7 weeks with an A-B-A-C-A-BC-A design to a group of 11 children (7-11 years; 91% male). All children were diagnosed with either oppositional defiant disorder or conduct disorder, in addition to attention-deficit hyperactivity disorder. Results revealed the best treatment response occurred during the low-punishment condition, with rates of negative behavior (e.g., aggression, teasing, stealing) increasing over the 7 weeks. However, there was substantial individual variability in treatment response, and several children demonstrated improvement during the modified intervention conditions. Future research is necessary to disentangle treatment effects from order effects, and implications of group treatment of CPCU children (i.e., deviancy training) are discussed.

Efficacy of a Methylphenidate Transdermal System Versus t.i.d. Methylphenidate in a Laboratory Setting

Objective: To test the efficacy and tolerability of the methylphenidate transdermal formulation (MTS) against immediate-release methylphenidate (IR MPH) and placebo in a 12-hr analog classroom setting. Method: A total of nine boys ages 6 to 9 years, medicated with MPH for ADHD, complete a within-subject, double-blind study. For the purpose of the study, the boys are administered a dose of 20 cm2 MTS, a matched dose of IR MPH 10 mg TID, and placebo. ADHD symptoms and frequency counts of classroom rule violations and the number of math problems completed are assessed hourly, during three consecutive analog classroom sessions. Results: Findings show that, across measures and throughout the day, both treatments significantly differentiated from placebo (p < .05) but not from each other. It is also observed that the MTS produced more consistent results across the day but had a delayed onset versus IR MPH. Both medications are well tolerated with only mild reductions in sleep onset. Conclusion: The MTS demonstrates comparable efficacy and tolerability to TID IR MPH.

Rates of Common Classroom Behavior Management Strategies and Their Associations With Challenging Student Behavior in Elementary School

In this study, we (a) describe patterns of challenging student behaviors (classwide and for a target student with attention deficit hyperactivity disorder [ADHD]) and teacher behaviors (i.e., praise, commands, and responses to challenging behavior) in kindergarten through Grade 5 classrooms, (b) examine the relations between these behaviors, and (c) describe a threshold of teacher behaviors most associated with low levels of challenging student behavior. Participants were 55 teachers observed using a modified version of the Student Behavior Teacher Response (SBTR) system. Across grades, there was variability in rates of classwide challenging behavior per hour (M = 35.81 to 102.62) and rates of praise per hour (M = 10.90 to 37.70). The percentage of challenging behaviors to which teachers responded appropriately was generally low (M = 27% to 47%) and stable across grades. For classwide challenging behavior, higher percentages of appropriate teacher response were significantly associated with lower rates of challenging behavior (b = −.43; p < .01), but effective commands and labeled praise were not. Classwide challenging behaviors dropped to 30 per hour once teachers reach a threshold of 51% appropriate response, with little incremental benefit at higher levels. Implications for professional development and future study of behavior management practices are discussed.

Parental Attributions for Success in Managing the Behavior of Children With ADHD

Objective: The current study evaluated the effects of differing intensities of behavior modification and medication on parents’ self-reported success in managing their child’s misbehavior and the attributions parents gave for success or failure. Method: Children were randomized to receive in counterbalanced orders different levels of behavior modification, each for 3-week cycles. In addition, medication was manipulated using a medication assessment procedure. Parents reported daily how successful they were in managing their child’s misbehavior and the attributions for either their success or failure. Results: Parents of children with ADHD generally felt successful in managing their child’s behavior, regardless of treatment condition. In the high behavior modification condition, they were more likely to endorse items that attributed their success to their own effort. Conclusion: In conditions in which parents were given more intensive tools to manage misbehavior they were more likely to attribute their success to their own effort.

Effects of behavioral and pharmacological therapies on peer reinforcement of deviancy in children with ADHD-only, ADHD and conduct problems, and controls.

OBJECTIVE This study compared the unique and combined effects of evidence-based treatments for ADHD-stimulant medication and behavior modification-on childrens rates of reinforcement for deviant peer behavior (RDPB). METHOD Using a within-subjects design, 222 elementary school-age children attending a summer treatment program, including 151 children with ADHD (127 male), with and without comorbid conduct problems, and 71 control children (57 male), received varying combinations of behavior modification (no, low-intensity, and high-intensity) and methylphenidate (placebo, 0.15 mg/kg, 0.30 mg/kg, and 0.60 mg/kg). RDPB was measured through direct observation and compared across all behavior modification and medication conditions. RESULTS Children with ADHD reinforced the deviant behavior of their peers at a significantly higher rate than control children in the absence of either intervention. However, that difference largely disappeared in the presence of both behavior modification and medication. Both low and high-intensity behavior modification, as well as medium (0.30 mg/kg) and high (0.60 mg/kg) doses of methylphenidate, significantly reduced the rate of ADHD childrens RDPB to levels similar to the control group. CONCLUSIONS Results indicate that although untreated children with ADHD do engage in RDPB at a greater rate than their non-ADHD peers, existing evidence-based interventions can substantially decrease the presence of RDPB, thereby limiting potential iatrogenic effects in group-based treatment settings.