Lecture 6: Interventions for school-aged children with ADHD Flashcards
(24 cards)
Dutch ADHD guideline in children <12: stepped care
eerst psycho-educatie en adviezen aan ouders en/of school. daarna ouder/leerkrachttraining. als het echt severe is ook medicatie training er bij.
-> alle interventies zijn gericht op de ouders of de school, behalve medicatie (maar dat alleen als het heel severe is)
benefits of starting with behavioral treatment
Initiating treatment with behavioral intervention:
- better outcomes than starting with meds
- more cost-effective
- behavioral interventions reduce the need for meds with 40%
why do we want to reduce the need for meds?
- parents prefer non-pharmacological interventions
- no improvement on all domains
- long-term compliance is low
- no improved long-term outcomes
- long-term safety is unclear
- side effects
mediation therapy=
you only work with the parents and teachers. you teach them strategies to make the environment suitable for the child. interventions directly involving the child often have little effect.
dual pathway model & ABC model
- lower executive functioning: influence with Antecedents, making the environment better for the child (e.g. give one instruction at a time)
- different reinforcement strategies: influence with the Consequents (e.g. praise them, give positive feedback on behavior you want to see)
antecedent interveentions
something in the environment that increases the probability that the child shows certain behaviors:
- rules
- expectations
- structure
- support
examples:
1. clear instructions before start: what is expected from them?
- visual support
- repeat
- divide task
- clear rules for undesired behavior
- remove/minimalize other stimuli
- take children apart
- positioning in class - visualize time frame of the activity
setting events
events that intensify problems, or increase the probability of problematic behaviors:
- hungry
- tired
- argument with a friend
- too hot/cold
- different teacher
in order to select an intervention, you need to….
determine the function of behavior
functions of behavior
- escape or avoid (person or activity/setting)
- gain attention
- gain activity or object
- sensory input (gain sensory stimulation, or escape from too much stimulation)
consequent interventions
- reward desired behavior:
- focused attention
- compliments for desired behavior
- reward system - ignore/punish undesired behavior
- planned ignoring mild undesired behavior
- time-out after undesired behavior
- remove a priviledge
- add annoying task
ignoring works, but…
first you are going to experience an extinction burst (where it gets really worse before it gets better)
what was wrong about the video they showed
- tired/hungry (setting events)
- task not matched to the level of the child
- messy, many distractors, too many cue cards
- no clear instruction, what is the desired behavior? any rules?
- position children and teacher
common elements of parent/teacher training (van ander artikel)
Psychoeducatie:
- describe treatment, describe core symptoms and supported treatment
- review the parent-child interaction cycle (hwo negative behaviors from both are perpetuated
- explain ABC model
Quality time:
- children with adhd, asd and sld often receive more corrective feedback and have more negative interactions: therefore increased quality time is needed
- child directs the activities, parents are nondirective and dont interrupt, attent to positive behavior, ignore minor negative behaviors
Labeled praise:
- positive behaviors are often ignored as negative behaviors tend to be more salient
- reinforce positive behaviors by providing effective praise
- specific! -> i like the way you started right away with your homework ipv. good job.
- immediate
- consistent
- unspoiled: “You did a great job staying on task while finishing your book report. I wish you did that with all of your homework” (= niet goed)
Positive reinforcement/token economy
- reward menu, daily and weekly rewards
- observable behaviors rather than their qualities
- behaviors should only be slightly challenging so they obtain rewards
Effective instructions:
- get the childs attention
- be specific, brief, and state what the child should do instead of what they should not do
- command statements ipv. asking a question -> ‘lets start on…’
- pause for 10 seconds to allow child to process instructions
When-then/premacks principle
- desirable behaviors as reinforcers to increase compliance with less desirable behaviors
- when you finish homework, you can play on the playstation for 10 min
Planned ignoring:
- negative behaviors often serve as a way to get attention from adults
- minor misbehaviors such as whining, negotiating, arguing are ignored
- give the child a warning, after that do not talk, give physical attention and attent to the child as soon as the behavior stops
Time out
- after misbehavior
- issue a warning: “I have asked you to put away the tablet. If you do not put it away now, you will earn a 5-min time out”
- time out area
- be time limited
Parent stress management
- coping strategies (mindfullness, deep breathing, preferred activities) when stressed
- recognize antecedents that cause stress
- replace unhelpful thoughts (e.g., I shouldn’t have to monitor homework so closely!) with helpful thoughts (e.g., Math is particularly challenging for my child. It makes sense that he would need extra help following through and organizing himself. I’m glad that I am available to help him)
main effects found
- positive parenting increased
- negative parenting decreased
- parent child relation increased
- parenting competence
- parental stress/mental health increased
medium-sized effects on all
- Manipulating antecedents (e.g., anticipate for misbehavior):
Positive effect on parenting competence and parenting stress/parent mental health - Providing positive consequences (e.g., offering social reward):
Positive effect on negative parenting - Psycho-education:
Negative effect on positive parenting and parent-child relation
uitleg voor psychoeducatie negatieve relatie op positive parenting and parent-child relationship
hopeless, when you tell them it is lifelong and all the risks. they want something very concrete.
furthermore, it takes away time from learning techniques
microtrial =
see which techniques are the most effects
wat liet de microtrial zien
beiden antecedents & consequences are important:
A:
- rules
- clear instructions
- anticipate for problems
- structure in time and space
C:
- praise
- reward
- ignore
- mild punishment
what was the primary outcome in these micro trials
Primary outcome in these microtrialswas not ADHD or ODD characteristics, but target behaviors selected by parents/teachers
-> Why is that more personalized than measuring DSM criteria? Measured with ecological momentary assessment (EMA): “EMA involves repeated assessmentof the participant’s behavior in real time and in its natural environment(Bentley et al., 2019), therefore minimizing bias and maximizing ecological validity”.
interventions that have not recommended guidelines
- cognitive training: dont really transfer to real life (academic tasks, behavior, cognitive tasks), task relevant task only. seems to be mostly placebo effects (significant illusory rater effects are evident following cognitive training.
- neurofeedback: no evidence for stand alone.
- dietary interventions: artificial food studies show it is wise to minimize the food intake, but true for all kids.
sugar is unclear.
omega 3: small effects but consistenly positive, could be added as addition. unclear if only for children with adhd and low omega 3 levels
micronutriets: niet echt goede studies
elimination diet (eliminating everything and slowly adding things: but very stressful. healthy diet is better) - mindfulness: methodological limitations, no first line interventions. but yoga, mindfullness and meditation may be beneficial, although research is needed
do clinicians adhere to the guidelines?
no, they dont really do. although there are positive attitutes towards behavioral interventions: but long waiting lists, and hard to deliver school interventions. parents drop out (25%) or never start (25%) or dont attent all sessions, lack of skilled staff.
-> brief interventions, self-help interventions, explicitly addressing barriers with families, and include fathers, tailor interventions towards specific subgroups.
Findings:
1. Low guideline use
2. Attitudes do not translate to policy
Barriers to parent training:
1. Waiting lists
2. Lack of skilled staff
- Teacher trainings are hardly ever used (or they use non evidence based trainings)
brief parenting training results
- 2 sessions
- antecedent vs. consequent vs. waitlist
- effects are similar to longer programmes!
other programme:
- 3 sessions pilot
- antecedent and consequence combined
- lower drop out, higher satisfaction rates, high treatment fidelity
- significant reductions in impairment and behavioral problems (not inattention, hyper activity and parenting competence)
what is the major issue in adhd research and practice
dominance of the biological paradigm. adhd is still seen as a brain disorder/genetics. secondary is the environment (parenting, complications during brith, trauma, poverty, nutrition, screentime), but this leads to decontextualisation:
- lower expectations of psychotherapy
- higher expectations of meds
- more pessimissm towards the future
- more desired distance towards person with problems
- less empathy in clinicians
one study: biological explanation is linked to
1. More pessimism about treatability
2. More faith in medication, less in psychotherapy
3. But…less blame, less desire for distance
dus de uitleg van de clinician is heel belangrijk! proberen om….
minder brein-gericht, meer psychosociaal.
want dan minder:
- pessimism about future
- stigma
- overreliance on meds
