This summer I was afforded the outstanding opportunity to complete an internship with the
Cleveland Clinic Children’s Hospital Summer Treatment Program (STP) through the School of
Health Sciences and Human Performance Emerson Scholarship. Before fulfilling the role as an
undergraduate counselor for seven weeks I went through a two week intensive training process
that fully immersed me in the STP protocol and culture. During our first day of “contact
orientation” we were promised that we would gain much more from the program than we were
going to put in. Considering I had spent the first two weeks of my summer studying and
memorizing 22 operational definitions for specific behaviors, the notes to accompany them and a
whole host of rules for implementing the program point system, verbatim, from a 370 page
manual, in preparation for a test on the first day of training, I was wondering just how that would
be possible. For example, here is a sample of just one of the operational definitions that I had to
memorize:
Name Calling/Teasing- The child directs a negative communication toward one or more peers
who are identifiable as intended recipients who can see or hear the negative communication. A
negative communication consists of either (1) a derogatory name, or (2) any other behavior,
verbal or nonverbal, that would typically elicit a clear behavioral indication of annoyance or
distress from the intended recipient.
Notes: (1) Societal norms regarding peer interactions should be used to determine if a behavior
would typically elicit annoyance or distress and should therefore be classified as Name
Calling/Teasing, or if a behavior is only mildly annoying and should therefore be classified as
Complaining/Whining. (2) Name Calling/Teasing takes precedence over Cursing/Swearing,
Interruption, and Complaining/Whining. (3) If a child directs a behavior that meets the criteria for
Cursing/Swearing at a peer, the lead counselor should inform parents of the behavior at the end of
the day. If the child repeats the behavior on subsequent days, counselors should have the child
inform the parents immediately by telephone.
Looking back on my experience I am pleasantly overwhelmed with just how profound of an
effect my participation in the STP has had on me. I can whole-heartedly say that I have gained
much more from the STP then I put in and I put everything I had into the program, the STP was
the definition of my summer.
The Summer Treatment Program (STP) is directed by Michael J. Manos, Ph.D., at the Cleveland
Clinic Foundation. Cleveland Clinic's STP is one of 10 sites in the country. It is based on an
award-winning program developed over the past 20 years by William E. Pelham, Ph.D., a
nationally recognized expert in ADHD. It is the only program selected for the national
Multimodal Treatment of ADHD (MTA) study funded by the National Institutes of Health and
the U.S. Office of Education. To date, more than 2,500 children and their parents have taken
advantage of this unique resource. Cleveland Clinic's treatment program has earned a high rate of
parent satisfaction (95 percent) and produces demonstrable results in most children with ADHD.
The Cleveland Clinic Children’s Hospital Summer Treatment Program for children with
Attention-Deficit/Hyperactivity Disorder (ADHD) and provides families with individually
designed treatment plans that address their children's behavioral, emotional and learning
difficulties. The overall goal of the seven-week daytime treatment program is to help children and
families manage ADHD symptoms throughout the year.
Program Goals
A social learning approach is used that focuses on achieving the following goals, which are to:
develop the child's social skills and social awareness; improve the child's learning skills and
academic performance; develop the child's ability to follow through with instructions, complete
tasks and comply with adults' requests; improve the child's self-efficacy by developing
competencies in interpersonal, recreational, academic and other task-related areas necessary in
daily life; teach parents how to develop, strengthen and maintain these positive changes through
weekly parent training sessions; and evaluate the effects of medication (when appropriate) on the
child's academic and social functioning in a natural setting. Treatment includes individually
adapted reward and cost programs, training in group problem-solving skills, behavioral
contracting, social skills training, instruction in learning deficits, strategies for improving
concentration and completing tasks, strategies for improving self-concept, use of time-outs, and a
daily feedback system. As part of the program, children can participate in weekly field trips to
educational and recreational sites in and around the Cleveland area. Treatment plans and
strategies are continuously monitored and modified as necessary. A final report, which includes a
summary of the child's progress and recommendations for future treatment, is sent to parents and
referring professionals at the end of the program.
Point System
The point system is a major component of the STP intervention. This system is a token economy
in which children earn and lose points contingent upon their behavior. The specific problematic
behaviors that the point system targets are commonly exhibited by children with ADHD, ODD,
Asperger’s Disorder, and other disorders of childhood. Children exchange points for a variety of
rewards, including privileges, field trips, and special honors. This type of treatment program
provides for the efficient use of incentives because it uses tokens or points as mediators that let
individuals know immediately the consequences of their behaviors without having to provide an
immediate reward. The point system serves two primary functions in the STP. First, it is one of
the main procedures used to increase the frequency of appropriate behaviors and to decrease the
frequency of undesirable behaviors exhibited by the children in treatment. Second, it is the
primary data system for the STP. An accurate record of positive and negative behaviors provides
information that details the nature of a child's problems. The daily data collected from the point
system is compiled and evaluated for use in determining treatment recommendations for the child
at the culmination of the program.
A Typical Day at the STP
Honestly the typical day at the STP was anything but. Everyday brought new challenges,
triumphs and situations with the kiddos that always left me saying “You couldn’t write this
stuff!” Managing the chaos is the tagline for the STP counselors, our primary responsibility and
that is just what we did day in and day out handling each off the wall situation with the kids as it
came. Children and adolescents with ADHD and other behavioral disorders of similar ages were
placed in groups of 10 to 12 kids. There are four different groups for specific age groups and I
worked with Group one (ages 6-8 years old) and the kids nicknamed our group, with a little
swaying of the votes by the counselors, “The Bombers” and our group cheer was “Tick, Tick,
Tick BOOM!” The cheer was used to signal an interval change during recreational activities. The
group was supervised by five clinical staff members, one lead graduate counselor and 4
undergraduate counselors. The groups stayed together throughout the day so children received
intensive experience in functioning as a group and in making friends.
The kiddos spent three hours each day in a classroom context to learn to manage their behavior in
the school environment. Developmental specialists conduct these group sessions. They received
individual, computer-assisted and art instruction. The remainder of each day involved agespecific, recreational group activities, including swimming, soccer, baseball, basketball and other
games. During these recreation periods, children participate in group problem-solving
discussions, social-skills training, the behavioral point system and other treatment strategies.
Undergraduate Counselor Duties
Counselors of the STP are the front line of the treatment; we define the program and completed
all the tasks necessary to keep the program functioning from day to day. We were expected to,
after training, to know verbatim all of the operational definitions for the specific point system
behaviors, the hierarchy of negative verbal behaviors, rules for implementing the point system,
and activity rules for every activity from bathroom breaks to vehicular transitions (bus rides)
verbatim in preparation for implementing the behavioral point system. Studying, training and role
playing made it possible for me to “call points” on the children during the day as behaviors were
occurring. For example, during a walking transition from the soccer field inside to the classroom I
would hear one of my kiddos, lets call him Johnny, call Suzy a “stinky head” and Suzy turn away
and continue walking in line. My role as a counselor was to witness the behavior and then say,
“Johnny, you lose 20 points for teasing and Suzy, you earn 25 big points for ignoring that tease!”
Then I would give quick feedback to Johnny about why that behavior was inappropriate and then
give a lot of validation to Suzy for ignoring a negative stimulus. After this quick exchange I
would then call in the points to the counselor that was marking the point sheet at the time, all the
while we were walking in line monitoring 10 other children. Calling in points to the point sheet
counselor was a bit like speaking in code and sounded like this, “Johnny: tease, Suzy: ignore,”
upon hearing this the point sheet counselor would mark tallies in the appropriate box on the sheet.
Each counselor acted as a point sheet counselor at some point during the day and there were point
sheets designated for each specific activity.
Each undergraduate counselor was responsible for leading a recreational activity and skill drill a
few times during the week. I was the soccer sport lead and this required me to design fun and
engaging drills for the kids to do. Sport leads also facilitated group discussions before and after
every game or skill drill. The other sports were basketball and softball, those were led by my
fellow group one counselors. Each sport game was divided into four different intervals and the
sport lead was required to ask “standard attention questions” to each child during each interval to
track the child’s attentiveness to the ongoing game. There were varying levels of questions that
could be asked, for example “what would have been a better play?” is a basic level standard
attention question. The other counselors could ask children “nonstandard attention questions”
throughout the game as well; these questions could be about anything about the game and were
often used as a means of bringing a child’s attention back to the activity at hand.
There was a tremendous amount of paperwork that we completed as counselors because of the
data collection that we were doing. Each counselor had 3-4 kids from the group that were their
“primary” children. These were the children that I tracked for the entire summer, the children
whose parents I would give feedback to every single day after the program, and the ones who I
wrote their final clinical summary reports about. This process of tracking the child throughout the
summer was my favorite part. I loved seeing the progress that they made, it was unbelievable.
Counselors were also responsible for data entry everyday after the kids were gone and also for
correcting data errors that were found when it was checked by the data management team.
This was the graphic that was put on t-shirts for all the counselors, it’s a compilation of all of the
crazy and funny phrases that we used at the STP, a lot of inside jokes here!
I loved this experience so much because I had a hand in everything. I got to be apart of every
aspect of the program and I knew full well that the program functioned because of the counselors,
we were the program. We were with the children 8 hours a day, we were responsible for their
progress through the day and the program, we spent two extra hours with kids during child care
on Wednesdays during parent training sessions, we tracked their data, we talked with their
parents, we “got real” with kids that were just getting to out of hand, we sat for hours with them
in time out and even physical management when it was necessary, we felt the disappointment
when they didn’t earn their recess or field trip, and we felt the unbelievable excitement when they
met their daily report cards or ear when they got “academic all-star” in the academic learning
center. One of the principles of the program is that our language is our world and how we use it is
very important and not something we give much thought to on a daily basis. The training portion
of the program taught me how to use language to effectively modify the actions of the children.
“Speaking with intention” was discussed and it was understood that this was the foundation of the
program. So we focused a lot on effective versus ineffective commands, effective problem
solving discussions using “the four what’s” and other ways to speak with intention when dealing
with the kiddos. The way we talk to children was important; our language has the ability to
influence the child’s behavior.
This program required every bit of energy we had 5 days a week for 10 weeks. I never knew what
true exhaustion was until the STP. This internship evolved much further beyond just a career
development opportunity. I forged relationships with my fellow staff members that will last a
lifetime, I was able to be a significant part of the life of a child, I was able to help parents create
new strategies to maintain behavior change, I was given a complete new skill set to use when
working with children, I got to see limits of the program and help brainstorm ways to move
beyond them and I got to work for an world renowned health care organization in a program that
is only one of ten in the entire country. This program, the experiences I’ve had and the lessons
I’ve learned have completely shaped my career path, it has given me a better scope of the type of
work I want to go into and it determined what I already knew to be true, I adore children and I
want to work with them in my profession. I have been asked back to the program to fulfill a lead
position next summer and it’s almost needless to say that I am already filling out my application.
This experience was in every way, shape, and form, unlike anything else I have ever been apart of
and I can barely wait for a whole new year of managing the
chaos!
More info:
http://my.clevelandclinic.org/Documents/Childrens_Hospital/STP_staff_description.pdf