Effective Approaches for
Promoting Prosocial Behavior
and Reducing Disruptive and
Aggressive Behaviors in Youth
with ADHD: Recent Innovations
in Treatment
Gregory A. Fabiano, Ph.D.
University at Buffalo
Department of Counseling, School, and Educational Psychology
Attention-deficit hyperactivity disorder
(ADHD)
• ADHD is characterized by developmentally
inappropriate levels of:
– Inattention
– Hyperactivity
– Impulsivity
• ADHD behaviors are developmentally
inappropriate, pervasive, chronic, and
result in considerable impairment in social
and academic functioning.
History of ADHD
• Heinrich Hoffman, a German psychiatrist,
authored a widely-published children’s
book of short stories in 1844.
– “Fidgety Phillip”
– “Johnny Look-in-the-Air”
• “The Story of Cruel Frederick”
• The Story of Little Suck a Thumb”
• The Dreadful Story of Pauline and the Matches”
Thome & Jacobs, 2004
Prevalence
• Prevalence estimates vary depending on
method used, geographic region, age
targeted, and rater.
• Prevalence of ADHD estimated at 8.7%
(Froehlich et al., 2007)
• More common in boys than girls
• Symptom presentation may reduce as
individual becomes older
Fabiano et al., 2013
Impact of ADHD - Impairment
Domains of Impairment
•
•
•
•
•
•
•
Peer relationships
Adult relationships
Sibling relationships
Academic Progress
Self-esteem
Group functioning
Associated problems
P arent IRS scores 6-12 year olds
6
5
Score
4
3
2
1
Peers
Siblings
Parents
Academics
Self-esteem
Family
Fabiano et al., 2006; available for free at www.ccf.buffalo.edu
Comparison
ADHD
Comparison
ADHD
Comparison
ADHD
Comparison
ADHD
Comparison
ADHD
Comparison
ADHD
Comparison
ADHD
0
Overall
Teacher IRS Scores 6-12 Y ear Olds
6
5
Score
4
3
2
1
Peers
Teacher
Academics
Classroom
Self-esteem
Fabiano et al., 2006; available for free at www.ccf.buffalo.edu
Comparison
ADHD
Comparison
ADHD
Comparison
ADHD
Comparison
ADHD
Comparison
ADHD
Comparison
ADHD
0
Overall
Educational Costs
(Robb et al, 2013)
Costs of
• Special education*
• Disciplinary referrals**
• Retention
• Special schools
$3230
$ 740
$ 110
$ 780
• Total:
$4900
*Does not include Section 504 Accommodation Plans/OHI classifications not used
pre-1992
**Likely under-estimated
Costs in the Aggregate
(assuming prevalence of 5% and 60 million school aged children--2000
census--2005 dollars)
•
•
•
•
Health and Mental Health
Education
Crime and Delinquency
Parental work loss
$11.6 billion
$14.7 billion
$11.4 billion
$ 2.3 billion
• Total
$40 billion
• Range
$34.1--$53.7
Pelham, Foster, & Robb, 2007; Robb et al., under review
Annual Cost of Other Disorders in U.S.
Depression:
Stroke:
ADHD (child,
adolescent, adult)
Alzheimer’s
Alcohol abuse/dep
Drug abuse/dep
$44 billion
$53.6 billion
$80 billion
$100 billion
$180
$180
Why is it so critical to intervene
early and in a sustained way for
children with ADHD?
Effective Treatments for ADHD
Evidence-Based ADHD
Treatments
• Behavior Modification
– Classroom Contingency Management
– Behavioral Parent Training
– Contingency Management Strategies
implemented in Recreational Settings (i.e., STP)
• Stimulant Medication
DuPaul & Eckert, 1997; Fabiano, et al., 2009; Greenhill & Ford,
2002; Hinshaw et al., 2002; Pelham & Fabiano, 2008; Pelham,
Wheeler, & Chronis, 1998
Fabiano, et al., 2015
• Behavior Modification is based on social
learning theory
• It teaches parents and teachers how to
change environmental contingencies to
improve behavior.
• Settings where behavior modification is used
include:
– Home
– School
– Peer/recreational settings
• Antecedents
–
–
–
–
Structuring situations
Clarifying expectations and contingencies
Establishing rules
Issuing clear commands
“Fights among the prisoners have decreased
62% since we got the Slip-and-Slide”
• Consequences
–
–
–
–
Praising and attending
Planned ignoring
Rewards
Punishments
Peer-based interventions
Negative Behavior During Board
Games
10
9
8
7
6
5
4
3
2
1
0
Concerta™
TID MPH
Placebo
Control
7:45 AM
Pelham et al., 2001
9:55 AM
1:25 PM
4:35 PM
Summer Treatment Program
Overview
•
•
•
•
Eight-week program, 9 hours daily
Children grouped by age into groups of 12
Groups stay together throughout the day
5 counselors work with each group all day
outside of the classroom
• One teacher and an aide staff the classroom for
each group
• Treatment implemented in context of
recreational and academic activities
Typical STP Schedule
Time
7:30-8:00
8:00-8:15
8:15-9:00
9:15-10:15
10:30-11:30
11:45-12:00
12:00-12:15
12:15-2:15
2:30-3:30
3:30-4:30
4:45-5:00
5:00-5:30
Activity
Arrivals
Social Skills Training
Soccer Skills Training
Soccer Game
Art Class
Lunch
Recess
Academic/computer class
Softball Game
Swimming
Recess
Departures
Summer Treatment Program Overview
•
Treatment Components:
• Point System
• Social Skills Training, Cooperative Tasks,
• Team Membership, and Close Friendships
• Group Problem Solving
• Time out
• Daily Report Cards
• Sports Skills Training and Recreation
Summer Treatment Program Overview
• Treatment Components:
• Positive Reinforcement & Appropriate
Commands
• Classrooms--Regular, Peer Tutoring, Computer,
and Art
• Individualized Programs
• Parent Training
• Medication Assessments
• Adolescent Program
Comparison of STP with multiple
STP withdrawals
120
100
80
60
No Behavior Mod
Behavior Mod
40
20
0
Class rule violations Noncompliance
Pelham et al., 2005
Negative
Verbalization
Daily Report Cards in Schools
Gregory A. Fabiano, Ph.D.
University at Buffalo, SUNY
ADHD Treatment Effects in
Classrooms
Frequency of Classroom Rule Violations
50
45
40
35
30
No BMOD
25
20
15
10
Low BMOD
High BMOD
5
0
Placebo
.15 mg/kg
Fabiano, Pelham, et al., (2007)
.30 mg/kg
.60 mg/kg
Frequency of Classroom Rule Violations
Frequency
50
45
No BMOD
40
Low BMOD
35
High BMOD
30
25
20
15
10
5
0
Placebo
.15 mg/kg
.30 mg/kg
Medication
Fabiano, Pelham, et al., (2007)
.60 mg/kg
Frequency of Classroom Rule Violations
50
45
40
35
30
No BMOD
25
20
15
10
Low BMOD
High BMOD
5
0
Placebo
.15 mg/kg
Fabiano, Pelham, et al., (2007)
.30 mg/kg
.60 mg/kg
Daily Report Card
What is a Daily Report Card (DRC)?
• The DRC is an operationalized list of a child’s
target behaviors
– Specific criteria
– Immediate feedback
– Communication tool
– Home-based privileges contingent on
meeting DRC goals
Creating the DRC
Enhancing the Effectiveness of Special Education
Services for Children with ADHD Using a Daily
Report Card Program
Fabiano et al., 2010; Institute of Education Sciences Grant # R324J06024
Participants
Child with ADHD
referred for study
Random
assignment
Diagnosis confirmed
and intake completed
IEP +
DRC
IEP
Endpoint Assessment
Results
Primary Outcomes Measures
• Blinded observations of classroom behavior
• Academic Achievement Testing
• Teacher Rating of IEP goal attainment
Blinded Observations of Classroom
Behavior – Change Score
p < .05
Academic Achievement Testing
• Broad Math scores were significantly
improved over time (p < .001), whereas
Basic Reading scores were not (p > .05).
• There was no time x group interaction.
Teacher Ratings of IEP Goal
Attainment
• Each teacher was asked to rate whether
the child had attained idiographic IEP goals
and objectives.
Teacher IEP Rating
7
6
5
4
3
2
1
Monitoring
Behavioral Consultation
For these analyses, there was a significant difference between
groups, t (55, one-tailed) = -1.98, p = .027.
Secondary Outcome Measures
ADHD, ODD, CD Symptoms
2
1.8
*p< .05
*p < .05
1.6
1.4
1.2
1
Monitoring
Behavioral Consultation
0.8
0.6
0.4
0.2
0
DBD-ADD
DBD-ODD
DBD-CD
Getting Dads Off the Sidelines:
Practices for Promoting Child Social
Skills Development in Peer Settings
What do fathers do?
• Economic Provision (“Bread-winning”)
• Involvement
– Engagement
– Availability
•
•
•
•
•
Responsibility
Parenting
Co-Parenting
Spouse/Partner
All these parameters are on a continuum,
thus fathering is multi-dimensional.
Pleck, 1997
Father Influence on Child
Development
• The development of:
– emotion regulation
– social cognition
– focused attention
– likely because of these factors, appropriate peer
relationships (Parke, et al., 2002).
• Positive father involvement results in fewer
mother-reported behavior problems (Amato
& Rivera, 1999).
• Fathers contribute uniquely to the child’s
academic achievement and academic sense of
competence (Forehand, et al., 1986; McBride,
et al., 2005; Nord, 1997).
• For children with mental health disorders, it
may be critical to involve fathers in
interventions.
– Fathers contribute to parenting
• Positive parenting and discipline
–
–
–
–
Helps promote consistency between parents
Provides an additional point of view
May support other parent
May promote maintenance of treatment over
time or as children progress through
development (Bagner & Eyberg, 2003;
Webster-Stratton, 1980).
Why are fathers not involved in
BPT studies?
• Approach to/Engagement of fathers during
initial clinical contact:
– Clinicians may implicitly exclude fathers by
addressing correspondence to only mothers or
require only mothers for interviews.
– Because most rating forms are normed on
mothers, fathers are often not asked for their
input.
– Standard clinical hours (i.e., 9 to 5 weekdays)
are not convenient for employed mothers or
fathers
• Parents of children with ADHD have an increased
likelihood to have ADHD themselves (Biederman,
Faraone, Monuteaux, 2002)
• ADHD impedes parenting and BPT progress
(Arnold, O’Leary, & Edwards, 1997; Evans,
Vallano, & Pelham, 1994; Sonuga-Barke et al.,
1999)
• Most BPT classes are classroom-based, and use
didactic lectures to introduce parenting skills.
• The format may act to discourage fathers from
participating
“Research has yet to identify any child-care task for
which fathers have primary responsibility.” (Pleck,
1997)
• Fathers’ participation in recreational activities and
unstructured play times is more typical relative to
mothers’ activities (Russell & Russell, 1987).
• The content of BPT classes may therefore fail to
address the needs of many fathers.
• Men generally do not seek out or ask for
help for health/mental health services
(Addis & Mihalik, 2003).
• Fathers report few problems in parenting,
even in the face of self-reported
dysfunctional discipline techniques (Hoza et
al., 2000)
Why is increased father
participation needed?
• As mentioned, fathers are primarily responsible for
children during recreational and sports activities and
unstructured times independent of other roles they fill
(Marsiglio, 1991), and they are a critical agent for helping
their child establish appropriate peer relationships (Parke,
2002).
• Children with ADHD exhibit poor sportsmanship
behaviors that result in poor peer relationships and are
likely to struggle with behavior during such activities
(Hupp & Reitman, 1999; Pelham et al., 1990).
• Fathers may also need skills to help them appropriately
parent/coach during unstructured activities and sports.
Jury convicts hockey dad of manslaughter
Thomas Junta, whose case was considered one of the
worst examples of the national problem of "sideline
rage," faces 20 years in prison.
Courttv.com
So What Can We Do to Increase
Father Participation?
FREE BEER!!!???
BAD IDEA (Pelham et al., 1997, 1998)
A BPT PROGRAM DESIGNED SPECIFICALLY
FOR FATHERS
• To involve and engage fathers in ADHD
treatment the Coaching Our Acting-out
Children: Heightening Essential Skills
(COACHES) program was developed.
• COACHES is a two-hour, weekly, eightsession parent training program.
• The COACHES program combines and
synergizes two manualized treatments
commonly used for children with ADHD:
– Summer Treatment Program (Pelham, Greiner,
& Gnagy, 1998)
– Community Parent Education Program
(Cunningham, Secord, & Bremner, 1998)
• Treatment components from these programs
are adapted for use in the father-based
parenting class, the child-based skill drills,
and the father-child interactions.
COACHES format
• During the first hour, fathers review how to
implement effective parenting strategies in a group
class (e.g., using praise, using time out).
• Concurrently, children practice soccer skill drills
with para-professional counselors, to increase
competencies in the sports domain (Pelham et al.,
in press; Pelham, Greiner, & Gnagy, 1997; Pelham
& Hoza, 1996).
Content of COACHES BPT Sessions
Session Session content
number
1
Introduction to social learning theory
and constructing a home behavior
management plan
2
Appropriate rewards and praise
3
Ignoring mild, inappropriate
behaviors
4
Delivering effective commands and
instructions
5
Using Premack contingencies and
transitional warnings
6
Using time out
7
Problem-solving
8
Closing Session; Programming for
maintenance
• During the second hour, the fathers and children
join together for a soccer game.
• Fathers “coach” the soccer game by employing
the strategies discussed during the first half of the
program.
• During frequent breaks, fathers receive on-line
feedback from trained staff, work together to
trouble-shoot problems that occur, and reinforce
each other for the successful implementation of
parenting strategies.
• How is the COACHES program different from
other parenting programs?
– Does not approach fathers as “deficient” in parenting
strategies. Frames treatment as a way to build
competencies in an area where many may already have
skills (e.g., coaching).
– Framing treatment in this way may reduce stigma
associated with initiating and participating in mental
health services.
– Includes a sports competency-building component for
the children, known to be effective and well-liked by
parents and children (Pelham, et al., in press; Pelham,
Greiner, & Gnagy, 1997).
– Soccer game provides a naturally reinforcing activity as
part of treatment (as opposed to a two-hour class).
– Research suggests fathers benefit from practicing
parenting strategies (Adesso & Lipson, 1981).
Clinical Trial of COACHES
Efficacy
Fabiano et al., 2012
Schedule
10
minutes
50
minutes
5
minutes
50
minutes
5
minutes
COACHES
Homework Review
Small and large group discussions of weekly
parenting program topic. Discussions include
direct instruction, group discussions, and role
plays.
Break
Fathers participate with child in soccer game.
Explain homework procedures for the week.
Measures
• Measures of parenting
– DPICS
• Praise
• Criticism
• Commands
• Measures of problem behaviors
– Eyberg Child Behavior Inventory (ECBI)
• Frequency Rating
• Intensity Rating
• Measures of Satisfaction with treatment
– Therapy Attitude Inventory
• Process factor
• Outcome factor
DPICS - Praise
ES=.54
DPICS-Negative Talk
ECBI – Intensity Rating
Treatment Satisfaction
• 100% of fathers reported they were
Satisfied with Outcomes.
• 89% of fathers reported they were Satisfied
with Treatment Process.
Clinical Trial of COACHES
Effectiveness
Fabiano et al., 2009
Method
• Fathers who gave informed consent and completed
intake procedures were randomly assigned to one
of two parent training groups:
– COACHES
• Fathers watch videotapes of exaggerated parenting errors,
identify errors, generate solutions, and then role-play suggested
solutions.
• Children practice soccer skills.
• Parents and children join for soccer game; fathers practice
skills
– Traditional Behavioral Parent Training
• Fathers watch videotapes of exaggerated parenting errors,
identify errors, generate solutions, and then role-play suggested
solutions (Cunningham et al., 1997).
• Children participate in group board game activities during the
parenting group (Pelham et al., 2001)
Schedule
10
minutes
50
minutes
5
minutes
50
minutes
5
minutes
COACHES
Homework Review
Traditional program
Homework Review
Small and large group
discussions of weekly
parenting program topic.
Discussions include
direct instruction, group
discussions, and role
plays.
Break
Small and large group
discussions of weekly
parenting program topic.
Discussions include
direct instruction, group
discussions, and role
plays.
Break
Fathers participate with Leader models use of
strategies and fathers
child in soccer game.
role play use of the
strategies with each
other.
Explain homework
Explain homework
procedures for the week. procedures for the week.
• The major difference between BPT groups
is the parent-child interactions in
COACHES.
Measures
• Fathers rated child improvement at post-treatment
across domain-specific targeted behaviors (Pelham
et al., 2001)
• Measures of engagement included
– Father Attendance/Drop-out
– Father on-time arrival for meetings
– Child Attendance/Drop-out
– Father homework completion
• Father satisfaction with treatment (TAI; Brestan et
al.)
Results
Average Improvement Rating
7
6
5
BPT
Comparison
4
3
2
1
Rating
F = 22.28, p < .001
COACHES vs. Traditional: Father Attendance
100
p <.04
80
60
COAC…
Traditi…
40
20
0
Attendance
COACHES vs. Traditional: On-time for Session Attended
100
80
p < .03
60
COAC…
Traditi…
40
20
0
On-time
COACHES vs. Traditional: Child Attendance
100
p < .001
80
60
COAC…
Traditi…
40
20
0
Attendance
COACHES vs. Traditional: Homework Compliance
100
80
p < .003
60
COAC…
Traditi…
40
20
0
Homework Completion
COACHES vs. Traditional: Father Drop-Out
(Defined as Attendance at Fewer than Half of Sessions)
100
80
p < .03
60
COACHES
Traditional
40
20
0
Father Drop-out
COACHES vs. Traditional: Child Drop-Out
(Defined as Attendance at Fewer than Half of Sessions)
100
80
p < .001
60
COACHES
Traditional
40
20
0
Child Drop-out
COACHES vs. Traditional: Consumer Satisfaction
p < .08
p < .04
20
COACHES
Traditional
0
Outcome
Process
Clinical Implications
• BPT is an effective approach for improving fatherrelated parenting behavior.
• Programs for fathers should include recreational
based activities that promote skill development for
children.
• Fathers should be given the opportunity to interact
with their children and practice parenting skills
during the session.
• Future studies need to address interventions to
facilitate effective co-parenting and inter-parental
consistency
Thank you!
• Greg Fabiano
fabiano@buffalo.edu