Organizational, Time Management, and Planning Treatment for Children with ADHD (OTMP Study)

1. Organizational, Time Management, and Planning Treatment for Children with ADHD (OTMP Study) NIMH-funded R01 New York University – Howard Abikoff, PI Duke University Medical Center – Karen Wells, PI

2. Rationale for the Study • Children with ADHD often evidence significant difficulties with organization • Planning and completing assignments • Managing materials for school and activities • Remembering tasks and materials • Creating a schedule to complete tasks • Keeping track of time • This negatively impacts academic performance and creates parent-child conflict, particularly around homework

3. Rationale for Study, con’t. • Despite the large ADHD treatment literature, no research has addressed OTMP behaviors specifically • Contingency management approaches show some benefit for end-point goals such as homework completion and academic productivity but has not been evaluated for effects on organizational skills • OTMP skills training differs from cognitive training and social skills training which have not been shown to be effective for ADHD children • A skills-based approach is based on extensive clinical observations and experience that a skill deficit exists and that direct instruction may be beneficial

4. Preliminary Work (Abikoff & Gallagher) • Development of the Children’s Organizational Skills Scale (COSS), Parent, Teacher, and Child versions • Organized Actions • Memory and Materials Management • Task Planning • Small medication study (n=19) showed stimulants improved OTMP behaviors but the majority remained impaired • R21 treatment development grant (n=20) created OST skills-based intervention and showed that it resulted in significant improvements in parent and teacher COSS ratings and on a laboratory assessment of organizational skills.

5. Specific Aims • Compare a skills-based intervention to a contingency management intervention for organizational deficits in ADHD children • Outcomes also assessed on academic performance, homework behaviors, attitude towards school, and parent-child relations • Evaluate both treatments to a wait-list control group • Evaluate the long-term impact of treatment • One month post-treatment follow up; one and four months into the next school year • Explore impact of parent ADHD on parents’ treatment compliance and children’s outcomes

6. Study Design • Randomized clinical trial with wait-list control • All children receive treatment • Organizational Skills Training (OST) OR • Parents and Teachers Helping Kids Organize (PATHKO) • Both involve teachers and parents • Both address materials management, time management, and planning • Both have 20 treatment sessions over 10 weeks • 20% will wait 14 school weeks to start (wait list control)

7. Diagram of the Study DOES NOT MEET CRITERIA FOR STUDY FAMILY GIVEN REFERRALS Screen Baseline MEETS CRITERIA FOR STUDY Assigned to OST Assigned to PATHKO Assigned to 10 wk Waitlist and then choice of OST or PATHKO Follow-Up Assessments: - Immediate post treatment - 1 month post treatment - 1 month next year - 4 month next year Follow-Up Assessment: - Immediate post treatment - 1-Month post treatment

8. Subjects • 180 3rd-5th graders meeting criteria for ADHD, any subtype • Diagnostic evaluation performed by study staff and confirmed by wash-out of medication if indicated • Evidence of OTMP difficulties at home OR school • No significant psychiatric comorbidities • No plans to change medication or initiate similar behavioral interventions • One primary teacher (3/5 core classes) • Teacher agreement to participate

9. Description of OST Components • Psycho-education regarding ADHD and organizational deficits • Parents taught to prompt-monitor-praise • Child-friendly model of OTMP difficulties (“glitches”) • Skills-building through modeling, shaping, guided practice, labeled praise • In-session reinforcement system (points for a prize box) • Contingency management by parents and teachers through simple point/reward system

10. Rationale for PATHKO • Long history of the use of contingency management approaches, esp. parent training (PT) with ADHD children • PT improves primary symptoms, co-morbid conditions and functional impairments in ADHD • PT improves parent-child conflict in children with disruptive and oppositional behavior

11. Primary Assumptions of PATHKO • Enhancing motivation through parent/teacher training will result in improvements in problems related to organizational skills. • Focus will be on end-point target behaviors; not on skills training • Focus on problems related to organization, management and planning; not on skills per se

12. Description of PATHKO Components • Orientation to Social-Learning Theory • Daily Report Card at school • Parent taught to work with teacher to maintain • Homework structure and rules • Token economy targeting OTMP behaviors • Management of oppositional behaviors around OTMP behaviors with time-out • Use of response cost for OTMP behaviors • Anticipating future problems and encouraging maintenance

13. Treatment Fidelity and Integrity • Study therapists treat training cases and must be “certified” by each treatment developer • Weekly individual supervision and cross-site group clinical conferences • Therapists complete fidelity and integrity checklists after each session • Fidelity = content covered • Integrity = treatment components kept distinct within each of the two treatments • IE’s listen to 15% of session audio-recordings and agreement with therapists is calculated • Assessments of parent, teacher, and child compliance (e.g., homework) also collected

14. Current Progress • Entering 4th of 5 year grant • Approximately 130 of 180 children randomized and treated across 2 sites • 22 DPS students • Large percentage Inattentive type; diverse gender and ethnicity • Over 95% of all parent/child assessment data collected • 80-85% teacher data collected (next year follow up challenging) • Satisfaction ratings high • Attendance at treatment sessions is good • >95% completed content of all 20 sessions