Week 6 Flashcards
(22 cards)
Noem de stappen in ADHD therapie
- ADHD diagnose
- Psycho-educatie en adviezen aan ouders/ school
- Zijn er gedragsproblemen?
- Nee:
— Lichte ADHD: ouder- en/of leerkrachttraining
— Matig/ernstige ADHD: bespreek behandelopties > medicatie of ouder- en/of leerkrachttraining of combinatie - JA:
— Ernstig: bespreek behandelopties > medicatie of ouder- en/of leerkrachttraining of combinatie
— matig: ouder- en/of leerkrachttraining
— Licht: ouder- en/of leerkrachttraining
NR = geen of onvoldoende response: overweeg alternatieve medicatie of een combinatie van therapieen
Why do you want to reduce the need of medication?
- 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
- Frequent side-effects
How to start treatment when there are multiple evidence-based options?
> Start with behavioural interventions when treating ADHD.
BEWIJS:
- Better Overall Outcomes
— Pelham et al., 2016:
Starting with behavioral therapy led to better overall treatment outcomes than starting with medication.
- More Cost-Effective
— Page et al., 2016:
Behavioral first approaches were more cost-effective than starting with medication.
- Reduced Need for Medication
— Coles et al., 2020:
Behavioral interventions led to a 40% reduction in the need for medication.
How does parent/teacher training work?
Parent/Teacher Training for children with ADHD refers to structured behavioral programs where parents and/or teachers are taught specific skills to manage the child’s behavior more effectively. These programs are evidence-based first-line treatments, especially for young children.
- the therapist doesn’t work directly with the child, he/she trains the parent or teacher. And these people apply the behavioral strategies to the child’s daily invironment. This indirect approach—via parents and teachers—is referred to as “mediation therapy”.
Therapist → Parent/Teacher → Child
- This process recognizes that:
- Parents and teachers are the ones consistently present in the child’s life.
- They can reinforce behavior strategies more consistently and in real-life contexts (e.g., home, school).
Interventions directly involving the child, showed little effect.
This emphasizes that±
- Direct therapy with the child alone (e.g., one-on-one sessions) is less effective for ADHD.
- Changing the environment and responses of adults around the child yields more impactful and lasting results.
INVOLVES:
1. Understanding ADHD
- Educates adults on what ADHD is, how it affects behavior, learning, and relationships.
- Helps reduce blame and frustration.
- Behavior Management Techniques
- Parents/teachers learn how to:
— Use positive reinforcement (e.g., praise, rewards).
— Set clear expectations and consistent consequences.
— Use structured routines and visual schedules.
— Apply time-outs or loss of privileges for inappropriate behavior. - Consistency Across Settings
- Training aims to align home and school strategies to provide consistent support.
- Coordination between parents and teachers improves outcomes. - Skill-Building
- Adults learn how to help the child build skills in:
— Attention and focus
— Task completion
— Social behavior and emotional regulation
GOALS:
- Reduce disruptive or impulsive behavior.
- Improve parent–child and teacher–student relationships.
- Support academic and social success.
- Often reduce or delay the need for medication.
PROGRAMS:
- Triple P (Positive Parenting Program)
- Incredible Years
- Parent–Child Interaction Therapy (PCIT)
- Behavioral Classroom Management Programs
Why do they use the ABC-model for the interventions
Describe the dual pathway for ADHD
- Executive dysfunction
- Motivational- reward system dysregulation
Explain the antecedent interventions for ADHD
WHAT?
- Antecedent interventions are changes made to the environment or context before a behavior happens, to increase the likelihood of desired behaviors
- Examples of antecedent factors:
— Rules: Clear and consistent behavioral expectations.
— Expectations: What children are supposed to do.
— Structure: Predictability in time, space, and activities.
— Support: Assistance such as cues or tools.
PRACTICAL CLASSROOM OR HOME STRATEGIES FOR IMPLEMENTING ANTECEDENT INTERVENTIONS
✅ Before a task/activity:
- Give clear instructions:
— Use visual aids (e.g., icons showing sit, listen, clean up).
— Repeat instructions to reinforce understanding.
— Break tasks into smaller steps (reduce overwhelm).
🚫 For undesired behavior:
- Set clear rules so children know what is not acceptable.
— Shown in the photo: rules like “Stay in your seat” or “Raise your hand.”
🔇 Reduce distractions:
- Modify the environment to minimize competing stimuli:
— Separate easily distracted children.
— Strategically seat them in class (e.g., front row, away from windows).
⏱️ Use time visuals:
- Visualize how long an activity lasts using timers or countdown visuals to improve understanding and attention.
🧠 Why this matters for ADHD:
Children with ADHD struggle with:
- Processing verbal instructions
- Shifting attention
- Organizing behavior in time
Antecedent interventions leverage structure and predictability to help them stay on track and reduce problem behaviors before they arise.
What are setting events?
Setting events are background factors or conditions that don’t directly cause a behavior, but they increase the likelihood or intensity of problematic behavior when a triggering event (antecedent) occurs. They act as “amplifiers” of behavior problems.
EXAMPLES:
- Hungry – Low blood sugar reduces self-regulation.
- Tired – Fatigue impairs focus and increases irritability.
- Argument with a friend – Emotional distress can make children more reactive.
- Too hot/cold – Physical discomfort reduces patience and attention.
- Different teacher – Unexpected changes disrupt routine and increase anxiety
Identifying and accounting for setting events helps caregivers and teachers:
- Understand context behind sudden behavioral shifts.
- Adjust expectations and supports on difficult days.
- Prevent escalation by offering more structure, support, or flexibility.
Explain consequence interventions
Strategies used to manage behavior after it occurs, by modifying its consequences.
- Understand the function of the behavior : why is the child acting out?
4 common functions of challenging behavior:
- Escape or Avoidance
— E.g., avoiding a task, person, or setting.
- Gain Attention
— Seeking interaction from adults or peers.
- Gain Activity or Object
— Trying to access a preferred item or activity.
- Sensory Input
— Getting stimulation (e.g., repetitive movement), or avoiding overstimulation.
The same behavior can have different meanings for different children, so consequences should match the function.
- Techniques for consequent interventions
- Reward Desired Behavior:
— Reinforce what you want to see more of.
Use focused praise, reward systems, or positive attention.
- Ignore or Punish Undesired Behavior:
— Planned ignoring: Withhold attention from minor misbehavior.
— Time-out: Short break from reinforcement after undesirable acts.
— Remove a privilege: Take away access to something valued.
— Add an annoying task: Like extra chores (used cautiously and constructively).
In which ways can you determine what the effective elements are from parent/teacher training?
Meta-Analysis:
- What was done?
Researchers collected manuals from BPT programs and used a taxonomy to code the “dosage” (intensity/frequency) of 39 behavioral techniques included.
- Research question:
Does dosage of specific techniques relate to parenting outcomes?
- Method:
Multilevel meta-regression across 29 RCTs (Randomized Controlled Trials), totaling 138 effect sizes.
- Results:
— medium-sized effects across all key parenting outcomes:
1. Positive parenting
2. Negative parenting
3. Parent/child relationship
4. Parenting Competence
5. Parental stress/ mental health
Which types of techniques drove the positive effects?
1. ✅ Manipulating Antecedents
- E.g., planning for misbehavior, adding structure
→ Boosted parenting competence and reduced stress
🔑 Shows value of proactive planning and environmental structure
2. ✅ Providing Positive Consequences
- E.g., social rewards, praise
→ Improved negative parenting (reduced harsh responses)
🔑 Reinforces importance of rewarding desired behaviors
3. ⚠️ Psycho-education (Alone)
- Surprisingly had a negative effect on:
— Positive parenting
— Parent-child relationship
🔑 Suggests that information without active training may not be sufficient—or may even backfire.
SUMMARY:
This meta-analysis provides evidence-based guidance on what actually drives change in BPT:
- Active behavioral techniques (like antecedent manipulation and positive reinforcement) are effective.
- Psychoeducation alone is not enough—real change happens when parents are trained in practical, structured skills.
Explain the method: micro-trial to determine which elements are most effective in parent-teacher training.
A micro-trial study: a small-scale, targeted experimental design that tests specific components of an intervention. In this case, researchers tested short versions of parent training techniques to see how effective they are individually.
THE STUDY:
- Goal: Test whether brief, focused interventions targeting antecedents or consequences can reduce children’s problem behavior.
- Design: Parents received only 2 sessions of training.
Training targeted either:
- Antecedents: Stimulus control (e.g., clear rules, structure, anticipating problems)
- Consequences: Contingency management (e.g., praise, rewards, ignoring, mild punishment)
🧠 This approach breaks down the classic ABC model (Antecedent → Behavior → Consequence) into distinct parts to isolate what works.
RESULTS:
- 3 groups:
1. Control group
2. Antecedent training group
3. Consequent training group
- Both intervention groups showed greater reductions in behavior problems than control.
- Antecedent training had a slightly stronger effect than consequent training.
KEY TAKEAWAYS:
- Even very brief training (2 sessions) in targeted behavioral techniques can significantly reduce child behavior problems.
- Antecedent interventions (structure, rules, anticipation) may be slightly more effective than consequence-focused strategies.
- This supports the idea of stepped or modular parent training, where effective techniques can be delivered efficiently.
This type of microtrial is useful for identifying which specific parts of a broader intervention (like BPT) are most powerful and scalable.
Why are personalized interventions important and how can you do this?
- The target behaviors in the microtrials were chosen by parents or teachers, based on what actually was challenging or important for that specific child. This is personalized because: DSM-based criteria are broad and diagnostic, but may not capture:
- Everyday struggles that matter most to families
- Context-specific behaviors (e.g., homework refusal, interrupting in class)
Personal targets allow for individualized goals that are more relevant and actionable.
Personalizing interventions by focusing on real-world behaviors chosen by caregivers makes treatment more relevant and effective.
Using EMA improves data quality and ensures the effects of interventions are measured in contexts that matter, not just in clinical checklists.
- EMA = repeated, real-time assessments in the child’s natural environment (e.g., home, school).
According to the quote:
- “EMA involves repeated assessment of the participant’s behavior in real time and in its natural environment… minimizing bias and maximizing ecological validity.”
✅ Benefits of EMA:
- Reduces recall bias (no reliance on memory).
- Captures behavior as it happens, not weeks later.
- More accurate and representative of everyday functioning.
Which 4 interventions are not recommended by guidelines?
- Cognitive training
- Neurofeedback
- Dietary interventions
- Mindfulness
Why is cognitive training not recommended?
Cognitive training programs aim to improve executive functioning (e.g., working memory, attention control) through repetitive, game-like tasks—like those shown in the image (e.g., Brain Training or working memory games).
KEY PROBLEM: poor transfer to real life
- The main issue with cognitive training is that improvements don’t generalize:
Children might get better at the trained task, but not at other important areas like:
✅ Academic skills
✅ ADHD-related behavior
✅ Other cognitive functions
These effects are task-specific, with no meaningful impact on daily functioning or symptoms.
SUPPORTING EVIDENCE:
- Research shows no or minimal effects on:
— Academic tasks
— Behavioral symptoms of ADHD
— Untrained cognitive tasks
- The slide also notes placebo effects, citing:
“Significant illusory rater effects are evident following cognitive training.”
This means raters (parents or teachers) might believe the child improved due to high expectations, even when there’s no objective change.
WHY IT IS NOT RECOMMENDED:
- Lack of clinical effectiveness:
Doesn’t improve real-world ADHD symptoms or functioning.
- Limited generalizability:
Gains don’t transfer outside of the trained context.
- Misleading expectations:
Can lead to wasted time, money, and hope due to placebo-like illusions of improvement.
- Inferior to behavioral interventions:
Unlike cognitive training, behavioral parent/teacher training consistently shows measurable, functional improvement.
Why is neurofeedback not recommended
Neurofeedback (or EEG biofeedback) is a method where individuals learn to regulate their brain activity by receiving real-time feedback from brainwave monitoring.
The goal is to “train the brain” to improve attention and self-regulation—functions often impaired in ADHD.
2 systematic reviews and meta-analyses:
🔎 Main Conclusion:
“RCTs using probably blinded outcomes do not support the use of neurofeedback as a stand-alone ADHD treatment.”
This means that in well-designed trials (especially those that control for expectation/placebo effects), neurofeedback does not reliably outperform placebo or other controls.
WHY NEUROFEEDBACK IS NOT RECOMMENDED AS A STAND-ALONE INTERVENTION:
- Limited Evidence of Effectiveness:
— Benefits are often seen only in non-blinded studies (where raters knew about the treatment).
— Blinded ratings (less biased) show little to no benefit.
- Lack of Real-World Impact:
— Like cognitive training, neurofeedback improvements don’t consistently transfer to daily functioning, such as school behavior or attention.
- Time and Cost Intensive:
— Requires multiple sessions over weeks or months.
— High cost, often not covered by insurance.
— No consistent evidence of cost-effectiveness.
- Not superior to behavioral treatments:
— Unlike parent/teacher training or medication, neurofeedback has weaker and less consistent outcomes.
📌 Summary:
Despite being theoretically appealing, neurofeedback lacks strong evidence from high-quality trials. It is not supported as a stand-alone treatment for ADHD in current clinical guidelines. Evidence-based approaches like behavioral parent training and medication remain more effective and reliable.
Why are dietary interventions not recommended?
🔶 Why Consider Diet?
There is interest in how nutrition affects brain function and behavior, particularly in children with ADHD. However, scientific support remains limited or inconsistent, and most effects are small or uncertain.
COMMON DIETARY INTERVENTIONS
1. Artificial Food Colors:
- Research (e.g., Nigg et al., 2012) shows small effects, not large enough to justify as a sole treatment.
- Still, it’s reasonable to minimize intake as a general health guideline.
2. Sugar:
- Commonly blamed, but evidence is unclear and weak.
- Few well-designed studies, and most don’t show a significant link.
3. Omega-3 Fatty Acids:
- Most promising of the dietary options.
- Small but consistently positive effects (Hawkey & Nigg, 2014).
- Might help as an add-on to standard treatments.
- Still unclear if benefits apply only to children with low Omega-3 levels.
4. Micronutrient Supplementation:
- Includes vitamins and minerals (e.g., zinc, iron, magnesium).
- Very limited evidence; few high-quality trials.
5. Elimination Diets:
- Remove potential food triggers (e.g., gluten, dairy).
- Heavily criticized:
— Difficult to follow
— Not practical for most families
— High dropout rates
- New studies are ongoing, but current evidence is insufficient.
❌ Why Not Recommended for ADHD Treatment:
- Weak or inconsistent scientific support
- Small effect sizes, not clinically meaningful
- Not generalizable (some may benefit, but unclear who)
- Hard to implement and maintain
- Better alternatives exist, like behavioral parent training and medication, which have stronger evidence
Why is mindfulness not recommended as first-line treatment?
The quote is from a systematic review and meta-analysis, which evaluated the effectiveness of these interventions for youth with ADHD. The authors concluded:
“Positive effect sizes found in studies should be interpreted with caution due to significant methodological limitations.”
- These limitations include:
— Small sample sizes
— Poor study design (e.g., lack of randomization or blinding)
— Subjective outcomes
— Lack of replication
❌ Why Mindfulness Is Not Recommended as a Core ADHD Treatment:
1. Limited and Low-Quality Evidence:
- Most studies suffer from weak methodology, making it hard to trust the results.
- Results may be inflated due to placebo effects or reporting bias.
2. Lack of Functional Impact:
- Even if some studies show reduced stress or improved awareness, there is little evidence of lasting improvement in ADHD symptoms or functioning (e.g., attention, impulsivity, school behavior).
3. Not Suitable for All Children:
- Children with ADHD may struggle with sustained focus, making long or still mindfulness sessions impractical.
- Younger children or those with severe symptoms may not benefit.
4. Preliminary and Inconsistent:
- Although some early results are promising, they are not strong or consistent enough to support use as a stand-alone intervention.
🧠 Bottom Line:
While mindfulness, yoga, and meditation may be helpful as complementary strategies, especially for older or highly motivated children, they:
- Should not replace evidence-based treatments like parent training or medication.
- Require more high-quality research to confirm whether they truly help with ADHD symptoms.
Explain the implementation issues: do clinicians follow the guidelines?
1 study: Survey among Dutch clinicians (N=219). Topics explored:
- Whether clinicians follow ADHD treatment guidelines.
- Their attitudes toward parent training vs medication.
- Practical barriers to implementation of parent training.
Results:
- Low guideline adherence:
Only ~16% of clinicians reported “often” using guidelines.
- Mismatch between beliefs and practice:
Many clinicians support parent training in theory, but don’t apply it in practice.
- Barriers to parent training:
— Waiting lists
— Lack of skilled staff
1 study a survey at schools N=102:
- Teacher training is rarely used.
- Only 18.6% reported using only evidence-based interventions.
- 38.2% used both evidence-based and non-evidence-based methods.
- Evidence quality was poor:
— 0/22 commonly used school programs met the highest standard (Level 1).
— 12/22 were rated as “questionable.”
Name some explanations why interventions are not implemented
- “Usual suspects”: Practical problems
- High dropout: 25% don’t start; 26% don’t finish.
- Long waiting lists
- Lack of trained staff - ADHD is not purely biological. It results from interacting factors, but clinical practice often focuses too narrowly on brain and genes (biological paradigm), ignoring the broader context.
- Different explanations of mental disorders shape attitudes—including for ADHD
- Biological explanations are linked to:
— Lower expectations for psychotherapy
— Greater reliance on medication
— More pessimism about improvement (prognostic pessimism)
— More social distance from people with the disorder
— Lower clinician empathy
A study specific to ADHD found that biological explanations:
- Increased pessimism about treatability
- Decreased belief in behavioral treatments
- Reduced blame, but also reduced hope for change
🧠 Key implication: Framing ADHD primarily as a brain disorder may unintentionally reduce support for psychosocial interventions, like parent training.
Solutions:
- Use brief, digital, or self-help formats
- Tailor interventions to family needs
- Explicitly address barriers
Explain the solution: brief parent training:
Microtrial + pilot study:
- Tested 2- to 3-session programs using antecedent and consequent strategies.
- Found effects similar to full-length programs (effect sizes d = .53–.77).
- High satisfaction, low dropout (14%).
📈 Outcomes:
- Large improvements in daily behavior (primary outcome).
- Moderate improvements in impairment and hyperactivity at follow-up.
Explain the implementation issue: decontextualization
The final slides argue that suboptimal uptake of behavioral interventions may be due not just to logistics, but also cultural and conceptual issues:
- The dominance of a biological model of ADHD (brain-based, medical framing).
- Parents, clinicians, and the public often think of ADHD as a “brain disorder” needing medical treatment—making behavioral approaches feel secondary or irrelevant.
- This “decontextualizes” ADHD—ignoring environmental, relational, and educational factors.
ADHD diagnosis + biological framing by clinicians →
Leads to decontextualization: ignoring environment, relationships, and life circumstances
This triggers three major negative consequences:
- Pessimism about the future
- Stigmatization of the child
- Overreliance on medication
🧠 This shows that how we explain ADHD (e.g., as a brain-based problem vs a contextualized behavioral difficulty) shapes how we treat it, support the child, and invest in interventions.
Geef samenvatting over implementation issue
Parent training works, but is underused.
This is due to:
- Practical/logistical barriers (“usual suspects”): waiting lists, staff shortage, dropout.
- A deeper issue: dominance of a medical/biological model that devalues behavioral solutions.
Decontextualization of ADHD contributes to poor uptake of psychosocial interventions.
Solutions include:
- Brief, accessible parent training formats
- Reframing ADHD in clinical conversations to include context (family, environment)
- Challenging the biological paradigm to create room for psychosocial approaches.
