Evidenced Based Behavioral Treatment (EBT) of AD/HD in Children

1. Evidenced Based Behavioral Treatment (EBT) of AD/HD in Children Kimberly Sirl, PhD October 12, 2013

2. Current EBT’s for AD/HD • Behavior Therapy • Behavioral parent training • Behavioral Classroom management • Intensive Behavioral Treatment

3. Parent-training • Contingency management strategies • Immediate Feedback • Frequent Feedback • Consistent Feedback • Positive / Novel Reinforcement

4. School interventions • Daily Behavior Report Card • Russell Barkley, PhD. • Classroom accommodations • 504 Plan • Individual Education Plan (IEP) under educational dx of Other Health Impairment (OHI)

5. Summer Treatment Program William Pelham, PhD 8 weeks 9 hours /day • Explicit behavioral instruction 2 hrs Recreational group activities 2 hrs Behavior modification Parent training & involvement in B-mod

6. Behavior Therapy Obstacles • Recent longitudinal research indicates that When kids start stimulant meds first, families are less likely to try behavior therapy (Pelham)

7. Behavior Therapy Obstacles • Lack of consumer education about EBTs • Efforts to inform consumers about EBTs http://effectivechildtherapy.com http://helpyourkeiki.com

8. Behavior Therapy Obstacles Difficulties accessing EBT • Demand outweighs the supply • Insurance issues • Competing demands on family

9. Neuropsychological Perspective on AD/HD Neuropsycholgoical tests can measure and describe deficits in specific neurocognitive processes Executive Functioning skills are often less well-developed in children with AD/HD compared to same-aged peers

10. What Are Executive Functions? Higher order cognitive skills that allow for controlled, intentional, goal directed behavior Processes that guide, direct and manage cognitive, emotional and behavioral functions, especially during novel problem solving Organization – Cognitive flexibility Working Memory – Self-monitoring Task Initiation – Inhibition Task Persistence – Emotion Modulation Planning – Fluency

11. Will my child outgrow ADHD? Neuroanatomical structures and executive functioning skills continue to develop until young adulthood

12. Specific Executive Functions • Organization – Cognitive flexibility • Working Memory – Self-monitoring • Task Initiation – Inhibition • Task Persistence – Planning • Emotion Modulation – Fluency

13. Working Memory The ability to mentally manipulate information held in immediate attention • Online” processing • Flexible problem solving • Rehearsal Children with AD/HD have moderate to marked Working Memory Deficits

14. Promising Interventions to Improve Specific Executive Functioning Skills

15. Working Memory Training • Cogmed • Computer based daily training • 25 training sessions, 30-40 min. each for 5 weeks • separate programs for preschoolers, children/adolescents, and adults • Progress monitored by a qualified coach weekly • Not covered by insurance

16. Working Memory Training • Cogmed: Promising empirical evidence • Improvements in parent & teacher ratings of attention, inhibition, academic performance, & daily functioning • Metanalysis 769 kids, 82% improved inattention sx • Baseline to post tx improvement average of 36% • Improvement generalizes to other measures of WM • Improvement in visual spatial & verbal WM • Improvements maintained at 3-6 mos. f/u Green el al (2012)

17. Working Memory Training Discriminant validity does not improve IQ, LTM, reading decoding Impacts symptoms of inattention primarily Not clearly better than current EBTs

18. Neurofeedback Treatments Uses EEG to modify cortical arousal Theta/Beta Protocols (US) • Initial QEEG mapping • 20-40 30-60 min. sessions, initially 2-3x/wk • Uses operant conditioning to maintain EEG within target range (i.e., video dims /brightens)

19. Neurofeedback Treatments • Research methodology improving • Improved attention compared to WLC • Not clearly better than placebo/sham tx • Current EBT’s much easier & cheaper (Loo & Makeig, 2012)

20. Pediatric Cognitive Remediation Programs • Focused on systematic training of attention and executive functioning skills • Uses aspects of cognitive-behavior therapy (e.g., self-talk, reinforcement) • Butler & Copeland (2002) 20 2 hour sessions

21. Pediatric Cognitive Remediation Programs • Promising evidence from clinical trials • Multicenter study of pediatric cancer survivors sign. improvements post-intervention in parent ratings of attention & academic functioning (Butler et al 2008) Pilot fMRI Study differences in brain activation between survivors & controls at baseline, but survivors showed increased activation post remediation and at 6 month follow-up (Zou et al 2012)

22. Abbreviated Ped. Cognitive Remediation Program - 6 1-hour individual sessions - included variety of neurological dx (e.g, ADHD, TS, NF epilepsy) - improved on 4 types of attentionselective, sustained, shifting & divided attention using auditory & visual measures (O’Toole et al @ CHOA)

23. Brain Balance System • Limited empirical evidence • Uses sensory integration, nutrition and cognitive exercises to improve balance between left and right brain functioning

24. Acknowledgements Special thanks for assistance in the preparation of this presentation goes to : • Stephanie Powell, Ph.D. • Shera Kafka & Lisa Hadley of 454-TEEN • SLCH Family Resource Center