ADHD Framework for Treatment Planning James H Johnson

ADHD: Framework for Treatment Planning James H. Johnson, Ph. D. , ABPP University of Florida

Focusing on Treatment Planning • The topic for the day has to do with ADHD treatment planning. – important in managed care systems, – Important in guiding therapy, and – role in treatment evaluation. • The focus will be on developing comprehensive treatment plans that will meet the accountability requirements of modern day clinical practice.

Assessment as the Foundation for Treatment Planning • Proper assessment of the child is essential for ADHD treatment planning. • Indeed, adequate assessment information is the foundation on which the treatment plan is built. • For a treatment plan to be useful the assessment must be well conceived and comprehensive in nature.

ADHD Assessment: Overview • While issues related to the assessment of ADHD have been touched on in discussing practice parameters, it should again be noted that assessment involves several basic elements. – Assessing the presence/severity of core symptoms across situations. – Assessing age of onset and duration of symptoms – Assessing the nature and severity of existing impairment – Assessing factors that can mimic symptoms of ADHD. – Assessing conditions that may co-occur with ADHD. – Assessing the impact of ADHD on family functioning.

Assessing Core Symptoms • Focused Interviewing –Behavioral observations – School; Clinic • Parent and teacher questionnaires assessing core symptoms (e. g. , Conners). • Comprehensive measures of Inattention (Tea. Ch) • Continuous Performance Test (CPT) • Parent and Teacher ratings of impairment Assessment of Impairment Should Include Social, Academic, Family, & Adaptive Functioning

Assessment of Factors that Might Mimic Symptoms of ADHD. • Will most likely get this type of information from parent and child interviews, medical records, and/or formal psychological testing (e. g. BASC, CBCL). – – – Seizure disorders Medication effects Anxiety disorders Depressive disorders Bipolar disorder PTSD

Assessment of Comorbid Conditions • Considered here are comorbid disorders that can be seen in children with ADHD. • Learning Disabilities • ODD/CD • Anxiety Disorders • Depressive Disorder • Bipolar Disorder • Tic Disorders • Others

Approaches to the Assessment of Comorbidity • Informal or structured interviews with parent and/or child. • Parent questionnaires that can be used to assess for comorbid conditions (e. g. , PIC, CBCL, BASC) • Child questionnaires to assess for convergence with parent report data (e. g. , CDI, R-CMAS). • Child questionnaires to tap other specific possibilities (e. g. , Child Trauma Symptom Checklist) • Direct testing of the child (IQ, Achievement, personality assessment measures [e. g. , MMPI – A]).

Assessing The Impact of ADHD on The Family • It is clear that it is important to assess the impact of ADHD related stress on the family. • High levels of stress may impact on the ability to carry out complex treatment programs. • It can impact on parent mental health. • High levels of parent stress can also impact negatively on parent child interactions. • It may also increased probability of unintentional injuries in the home.

Assessing The Impact of ADHD on The Family • Assessing family stress resulting from ADHD and its effects can be accomplished through the use of parental interviews and various questionnaire measures • Parenting Stress Index • Disruptive Behavior Stress Inventory • Etc.

Role of the Clinician in the Assessment Process • While information can be obtained through the use of measures like those described here, assessment involves more than simply obtaining scores from test measures. • Central to the assessment process is the ability of the clinician to integrate data from assessment methods in such a way as to obtain an accurate picture of the child and his/her difficulties that has implications for treatment planning. • Especially relevant to treatment planning is information regarding important areas of impairment.

From Assessment to Intervention • ADHD assessment should have direct implications for treatment planning. • The focus of treatment should be on the full range of difficulties displayed by the child, as these problems are displayed in various settings (with consideration being given to assumed causal factors). • The extensiveness of the treatment approach is likely to vary with the complexity of the case.

Issues in ADHD Treatment • While “pure” cases of ADHD may involve only one approach to treatment , via a single modality, many children with ADHD will require treatments that are multimodal in nature (as these may relate to different problems). • Here, specific consideration should be given to matching effective treatments to the specific needs of the child.

Issues in ADHD Treatment Planning • Commonly used treatment approaches may involve – Various forms of pharmacological treatment – Behavioral approaches to intervention in the home, the school, and/or the clinic. – Various types of classroom accommodations – Special educational assistance in the case of learning disabilities – As well as other approaches

ADHD Treatment Planning • Given the uniqueness of each child, a wide range of treatment activities may go into treatment planning. • In the sections to follow, we will highlight possible interventions strategies that may be useful for children with ADHD. • Not all of the examples presented here would necessarily be useful for all children with ADHD. • Likewise, interventions other than the one’s considered here may be required for some children with ADHD – especially those with comorbid disorders.

The Importance of Treatment Plans • It is desirable that a formal plan be developed to guide the treatment of children with ADHD. • Again, most managed care providers require it! • Treatment plans are also important in guiding the direction of therapy. • As treatment plans require well defined (measurable) objectives, they make it easier for the effects of treatment to be evaluated in an objective manner. • Finally, objective treatment plans fit nicely within a scientist-practitioner approach to clinical work, where accountability is considered important.

Developing Treatment Plans: Essential Elements • Treatment plans are based on data derived from a comprehensive assessment which serves as a foundation for the plan. • Essential elements of a formal treatment plan include the following: – Problem Selection – Problem Definition – Goal Development – Developing Treatment Objectives – Selecting Interventions The following draws heavily on Jongsma, et al (2003). The Child Psychotherapy Treatment Planner, New York: John Wiley and Sons.

Sample Treatment Plan: Basic Structure Problem Behavioral Definition (Operationally Define Problem Goals Treatment Objectives/Interventions Objective 1 – Intervention One - Intervention Two Objective 2 – Intervention One - Intervention Two Objective 3 – Intervention One - Intervention Two Diagnosis

Problem Selection • What is the nature of the child’s presenting problem(s)? • Determine the Primary Problem, those problems that are Secondary, as well as those that are less urgent (which could be deferred until later in treatment). • Solicit parent/child input to insure that problems are appropriately prioritized and relate to issues seen as being most relevant to the reasons for seeking help.

Problem Definition • Problem behaviors are expressed in different ways by different children. • For this reason it is important that each problem selected for treatment be behaviorally defined in terms of how it is reflected in the behavior of the specific child being treated. • The selection of problem behaviors should be associated with the DSM IV diagnosis. • Problem definition must be sufficiently objective that it is possible to determine changes in these problems behaviors resulting from treatment (the issue of accountability).

Goal Development • Step three of the treatment plan involves developing broad goals for the resolution of problem behaviors. • These treatment goals do not have to be stated in measurable terms. • Rather, they can take the form of more global long-term goals that are relevant to a desired positive treatment outcome.

Developing Treatment Objectives • Treatment objectives must be stated in behaviorally measurable language. • It must be clear when the patient has achieved the established objectives. • Vague subjective statements of objectives are not acceptable. • Here it can be noted that HMO’s and other managed care organizations require that psychosocial treatment outcomes be measurable.

Developing Treatment Objectives (cont. ) • Each objective should be presented as a step toward attaining a broad treatment goal. • Here, objectives can be thought of as a series of steps that will result in achieving longer term therapeutic goals. • There should be at least two objectives for each presenting problem on the problem list (and at least one problem), but the clinician may construct as many as is necessary for goal achievement.

Developing Treatment Objectives (cont. ) • New objectives may be added to the plan if additional problems are delineated as treatment progresses. • When all the objectives have been achieved the target problems should have been resolved successfully. • If this is not the case, then new objectives may be added to address these unresolved issues.

Selecting Interventions • Interventions are those things therapist does that are designed to meet therapy objectives. • If the patient does not accomplish the objectives after initial interventions, then new interventions should be added to the treatment plan. • Intervention should be selected based on the specific needs of the patient and therapist’s full therapeutic repertoire.

Selecting Interventions (cont. ) • Ideally, interventions should be Evidence. Based. • In the absence of these, interventions should represent those consistent with accepted clinical practice. • Intervention may be provided by a single provider or by multiple professionals with skills in specific areas, working in different settings. • There should be as many interventions as necessary to meet the specific treatment objective.

Relationship of Treatment Planning to Diagnosis • While the development of a treatment plan usually focuses more on specific “problems”, rather than specifically on the child’s diagnosis, a diagnosis is required for third-party reimbursement. • The problems, goals, objectives, and interventions defined in the final treatment plan should bear a significant relationship to problems associated with the child’s diagnosis.

Evaluating Success • As treatment objectives, linked to presenting problems, treatment goals, and interventions are objectively defined (and measurable) it should be possible to determine the degree to which treatment has been effective. • Such outcome data can be extremely useful in assessing improvement – When possible termination is being considered – When requesting additional therapy sessions from a managed care program, and – When the treatment summary is being prepared.

Sample Treatment Plan: Problems and Definition Problem: ADHD Definitions: Displays short attention span; Consistently shows difficulty sustaining attention. Distracted by environmental stimuli and internal thoughts - shows high levels of off-task behavior. Repeatedly fails to follow instructions and complete in-class assignments on time. Fails to complete homework and perform household chores.

Sample Treatment Plan: Goals • Sustain attention and concentration for consistently longer periods of time and reduce impulsive behavior. • Take stimulant medication as prescribed to decrease inattention and impulsivity. • Teacher implement classroom accommodations to reduce distractions and increase on-task behavior. • Parents and/or teachers successfully use behavior management strategies to increase desirable behaviors and reduce undesirable behaviors.

Sample Treatment Plan: Objectives and Interventions • Objective 1: Take medication as prescribed by pediatrician. – Arrange for medication evaluation by primary care physician. – Monitor patient for medication usage; Assess compliance, effectiveness, side effects. – Consult with prescribing physician regularly.

Sample Treatment Plan: Objectives and Interventions • Objective 2: Delay instant gratification in favor of achieving meaningful longterm goals. • Teach the child mediational and self control strategies (e. g. , “Stop, Look, Listen, and Think”) to inhibit impulsive behavior and achieve long term goals. • Assist parents in increasing structure in the home to help patient learn to delay gratification (e. g. , completing chores before playing).

Sample Treatment Plan: Objectives and Interventions • Objective 3: Parent and teachers identify and use a variety of effective reinforcers to increase positive and reduce negative behaviors. – Identify a variety of positive reinforcers or rewards to maintain the patient’s interest and motivation in achieving desired goals/changes in behavior. – Teach parents and teachers basic behavior management principles to insure correct use of behavioral principles.

Sample Treatment Plan: Objectives and Interventions • Objective 4: Patient and parents comply with the implementation of behavior management strategies to reduce the frequency of inattentive, impulsive, and non-compliant behaviors. – Design a reward and/or contingency contract system to reinforce the patient’s desired behavior and reduce inappropriate behaviors.

Sample Treatment Plan: Objectives and Interventions • Objective 5: Teachers implement classroom accommodations to reduce distractions and increase attention. – Provide seating arrangement to minimize distractions; close to teacher; away from door, windows, and distracting classmates. – Provide advance cues when patient is about to transition from one task to another. – Provide reinforcement for complying with seat work and other academic activities requiring on-task behavior.

Sample Treatment Plan: Objectives and Interventions • Objective 7: Parent and teacher implement system to enhance homework completion. – Design a “Day Planner” system to insure that parents are aware of all assignments and teacher is aware that homework has been completed. – Parent works with child to break homework assignments into smaller units with breaks between units. – Parents use rewards to increase homework completion at appropriate level of accuracy.

Quantifying the Treatment Plan • In addition to including the type of information just presented, clinicians should attempt to introduce measurable/quantifiable aspects of the child, parent and teacher behavior into the treatment plan. – – Competes homework 90% of the time. Does chores 90% of the time. Takes medication 100% of the time. By 03/15/2009 scores on Conner’s ADHD Index within the normal range.

Other Examples of Objectives & Interventions for ADHD Children • Items in the previous treatment plan illustrate Definitions, Goals, Objectives & Interventions for a relatively straight forward case of ADHD. • Other children with ADHD may require very different types of interventions, depending on the nature of their specific problems. • In the slides to follow we will look at some frequently used Behavioral Definitions, Common Long-Term Goals, and a range of (Objectives and Interventions) that might be possible additions to ADHD treatment plans. The following draws heavily on Jongsma, et al (2003). The Child Psychotherapy Treatment Planner, New York: John Wiley and Sons.

Commonly Used Behavioral Definitions • Short attention span; difficult sustaining attention on a consistent basis. • Susceptibility to distraction by extraneous stimuli and internal thoughts. • Gives impression that he/she is not listening. • Repeated failure to follow through on instructions or complete school assignments or chores in a timely manner. • Poor organizational skills as demonstrated by forgetfulness, inattention to details, and losing things necessary for tasks.

Commonly Used Behavioral Definitions • Hyperactivity as evidenced by a high energy level, restlessness, difficulty setting still, or loud excessive talking. • Impulsivity as evidenced by difficulty awaiting turn in group situations, blurting out answers to questions before the questions have been completed, and frequent intrusions into others’ personal business.

Commonly Used Behavioral Definitions • Frequent disruptive, aggressive, or negative attention-seeking behaviors. • Tendency to engage in careless or potentially dangerous activities. • Difficulty accepting responsibility for actions, projecting blame for problems onto others, and failing to learn from experience. • Low self-esteem and poor social skills.

Common Long-Term Goals • Sustain attention and concentration for consistently longer periods of time. • Increase the frequency of on-task behaviors. • Demonstrate marked improvement in impulse control. • Regularly take medication as prescribed to decrease impulsivity, hyperactivity, and distractibility

Common Long-Term Goals • Parents and/or teachers successfully use a reward system, contingency contract, or token economy to reinforce positive behaviors and deter negative behaviors. • Parents set firm, consistent limits and maintain appropriate parent-child boundaries. • Improve self-esteem. • Develop positive social skills to help maintain lasting peer friendships.

ADHD Objectives/Interventions: A Treatment Sampler • Complete psychological assessment to confirm the diagnosis of ADHD and/or rule out other factors. – Arrange for psychological testing to confirm the diagnosis of ADHD and/or rule out emotional factors that may be contributing to the child’s inattentiveness, impulsivity and hyperactivity. – Give feedback to the client and his/her parents

ADHD Objectives/Interventions: A Treatment Sampler • Take prescribed medication as directed by the physician. – Arrange for a medication evaluation for the child. – Monitor patient for medication prescription compliance, side effects and effectiveness. – Consult with prescribing physician at regular intervals.

ADHD Objectives/Interventions: A Treatment Sampler • Delay instant gratification in favor of achieving meaningful long-term goals. – Teach the child mediational and self control strategies (e. g. , “Stop, Look, Listen, and Think”) to inhibit impulsive behavior and achieve long term goals. – Assist parents in increasing structure to help patient learn to delay gratification (e. g. , completing chores before playing).

ADHD Objectives/Interventions: A Treatment Sampler • Parents and child increase knowledge about ADHD. – Educate parents and siblings about symptoms of ADHD and how to manage them. – Assign the parents readings to increase their knowledge about ADHD – Assign the child reading to increase his/her knowledge about ADHD and ways to manage symptoms

ADHD Objectives/Interventions: A Treatment Sampler • Parents develop and use an organized system to keep track of child’s school assignments, courses and household responsibilities. – Assist the parents in developing and implementing a system to increase the child’s on-task behaviors and completion of school assignments, chores and household responsibilities (using calendars, charts, notebooks, day planners, and class syllabi. ) – Assist the parents in developing a routine schedule to increase the child’s compliance with school, chores, or household responsibilities.

ADHD Objectives/Interventions: A Treatment Sampler • The parent’s maintain regular communication with the school to monitor the child’s academic, behavioral, emotional, and social progress. – Encourage parents and teachers to maintain regular communication about the child’s academic, behavioral, emotional, and social progress.

ADHD Objectives/Interventions: A Treatment Sampler • Use effective study skills on a regular basis to improve academic performance. – Teach the child more effective skills (e. g. , reducing distractions, studying in quiet places, scheduling breaks in studying) – Assign parents to read The ADD Hyperactivity Handbook for Schools (Parker) to improve the child’s school performance and behavior; process the reading with therapist. – Assign the child 13 Steps to Better Grades (Silverman) to improve organizational and study skills.

ADHD Objectives/Interventions: A Treatment Sampler • Increase the frequency of completion of school assignments, chores and household responsibilities. – Assist parents in developing a routine schedule to increase compliance with school, chores, or household responsibilities (charts; other prompts). – Consult with the child’s teachers to implement strategies to improve school performance (e. g. setting in front row of class, using prearranged signals to redirect child back to a task, providing frequent feedback, calling on the child often, arranging for a listening buddy). – Encourage parents/teachers to use a school contract and reward system to reward completion of work.

ADHD Objectives/Interventions: A Treatment Sampler • Implement effective test-taking strategies on a consistent basis to improve academic performance. – Teach the child more efficient test-taking strategies (e. g. , reviewing material regularly, reading directions twice, rechecking work)

ADHD Objectives/Interventions: A Treatment Sampler • Parents reduce extraneous stimuli as much as possible when giving directions to the child. – Instruct the parent on how to give the child proper directions (e. g. , get the child’s attention; make one request at a time; clear away distractions; repeat instructions; obtain frequent feedback from child to insure understanding.

ADHD Objectives/Interventions: A Treatment Sampler • Parents set firm limits and use natural logical consequences to deter the child’s impulsive behaviors. – Establish clear rules for the child at home and at school; ask him/her to repeat the rules to demonstrate an understanding of the expectations – Encourage parents to use natural, logical consequences for the child’s disruptive and negative attention seeking behavior.

ADHD Objectives/Interventions: A Treatment Sampler • Express feelings through controlled, respectful verbalizations and healthy physical outlets. – Teach child effective communication and assertiveness skills to express feelings in a controlled fashion and meet his/her needs through more constructive actions. – Use therapeutic game “Stop, Relax, Think” (Bridges) to assist the child in developing self control.

ADHD Objectives/Interventions: A Treatment Sampler • Identify and implement effective problem-solving strategies. – Teach the child effective problem solving skills (e. g. , identifying problems, brainstorming alternative solutions, selecting an option, implementing a course of action and evaluating) – Use Let’s Work it Out: A conflict Resolution Tool Kit (Shapiro) in sessions to teach the child effective problem-solving skills.

ADHD Objectives/Interventions: A Treatment Sampler • Identify stressors or emotions that trigger and increase in hyperactivity and impulsivity – Explore and identify stressful events or emotional factors that contribute to an increase in impulsivity, hyperactivity and distractibility. Help the child and parent develop positive coping strategies (e. g. , : Stop, look, listen and Think”; relaxation techniques; positive self-talk) to manage stress more effectively.

ADHD Objectives/Interventions: A Treatment Sampler • Increase verbalizations of acceptance of responsibility for misbehavior. – Firmly confront the child’s impulsive behaviors, pointing out consequences for himself/herself or others. – Confront statements where the child blames others for his/her annoying or impulsive behavior and fails to accept responsibility for his/her actions.

ADHD Objectives/Interventions: A Treatment Sampler • Increase the frequency of positive interactions with parents. – Assess periods of time when child demonstrates good impulse control and engages in fewer disruptive behaviors; process his/her responses and reinforce positive coping approaches that were used to deter impulsive or disruptive behavior. – Encourage parent to record three to five positive child behaviors displayed between sessions – reward these behaviors. – Encourage parents to spend 15 – 20 minutes daily of one-on-one time with child to create a closer parentchild bond. Allow child to take lead in selecting activity or task.

ADHD Objectives/Interventions: A Treatment Sampler • Increase the frequency of socially appropriate behavior with siblings/peers. – Identify and reinforce positive social behaviors to help child establish and maintaining friendships. – Use therapeutic game, the Helping, Sharing and Caring Game (Gardner), to help child develop positive social skills. – Assign the child the task of showing empathy, kindness, or sensitivity to others (e. g. , allowing sibling or peer to take first turn in a video game, helping with a school fund raiser). – Have child identify 5 – 10 strengths or interests; review the list; encourage him/her to use strengths or interests to establish friendships.

ADHD Objectives/Interventions: A Treatment Sampler • Identify and list constructive ways to use energy. – Instruct the child to create drawings reflecting the positive and negative aspects of his/her high energy level; process the content of these drawings with therapist. – Use puppets, dolls, or stuffed animals to create a story that models positive ways to use energy and gain attention from peers; then ask the child to create a story with similar characters and themes.

ADHD Objectives/Interventions: A Treatment Sampler • Implement a process of monitoring and assessing own behavior. – Encourage the child to use selfmonitoring checklists to improve his/her attention and social skills. – Assign the “Social Skills Exercise” in the Brief Child Therapy Homework Planner (Jongsma, Peterson and Mc. Innis)

ADHD Objectives/Interventions: A Treatment Sampler • Parents and the child regularly attend actively participate in group therapy. – Arrange for the child to attend group therapy to build social skills. – Encourage the child’s parents to participate in an ADHD support group.

ADHD Objectives/Interventions: A Treatment Sampler • The Child and parents comply with the implementation of behavior management strategies to reduce the frequency of impulsive, disruptive, and negative attention-seeking behaviors. – Identify a variety of positive reinforcers to maintain the child’s interest and motivation in achieving desired goals or changes in behavior. – Design a reward and/or contingency contract system to reinforce the child’s positive behavior and deter impulsive behaviors. – Design and implement a token economy to improve the child’s academic performance, social skills, and impulse control.

Final Comments • It is important to note that, while the objectives and examples of interventions listed here may be applicable to developing treatment plans for many children with ADHD, they my not be sufficient for many cases. • Here it can be noted that a range of other interventions may be required in cases where children display comorbid conditions. • Interventions that relate specifically to problems resulting from comorbid conditions may need to be included in these treatment plans.

That’s It!