Attention-Deficit Hyperactivity Disorder

Case 16

Attention-Deficit Hyperactivity Disorder

table 16-1 Dx 1. 2. 3. 4. Checklist Attention-Deficit/Hyperactivity Disorder Individual presents 1 or both of the following patterns: (a) For 6 months or more, individual frequently displays at least 6 of the following symptoms of inattention, to a degree that is maladaptive and beyond that shown by most similarly aged persons: • Unable to properly attend to details, or frequently makes careless errors • Finds it hard to maintain attention • Fails to listen when spoken to by others • Fails to carry out instructions and finish work • Disorganized • Dislikes or avoids mentally effortful work • Loses items that are needed for successful work • Easily distracted by irrelevant stimuli • Forgets to do many everyday activities. (b) For 6 months or more, individual frequently displays at least 6 of the following symptoms of hyperactivity and impulsivity, to a degree that is maladaptive and beyond that shown by most similarly aged persons: • Fidgets, taps hands or feet, or squirms • Inappropriately wanders from seat • Inappropriately runs or climbs • Unable to play quietly • In constant motion • Talks excessively • Interrupts questioners during discussions • Unable to wait for turn • Barges in on others’ activities or conversations Individual displayed some of the symptoms before 12 years of age. Individual shows symptoms in more than 1 setting. Individual experiences impaired functioning.

Although very low birth weight (less than 1,500 grams) presents

a twofold to three- fold risk for developing ADHD, most children with low birth weight do not develop the disorder (APA, 2013).

Billy was his parents’ first child. He was born after a normal, uncomplicated preg- nancy, an especially healthy baby who grew rapidly and reached the standard de- velopmental milestones—sitting, crawling, standing, walking, and so forth—either at or before the expected ages. His parents marveled at his exuberance and his drive to be independent at an early age. He was sitting by the age of 5 months and walking at 11 months. Once mobile, he was a veritable dynamo (in fact, they called him “the Dynamo”) who raced around the house, filled with a curiosity that led him to grab, examine, and frequently destroy almost anything that wasn’t nailed down.

Billy From “dynamo” to “dynamite” During his toddler period, Billy’s parents had no inkling that his activity level was at all unusual and, in truth, in many ways it was just an exaggeration of tenden- cies that most toddlers exhibit. Still, his parents found it exhausting to cope with his behavior. Just watching over him was a full-time job. Billy’s mother, Marie, had contemplated doing some freelance accounting at home to earn extra money. However, with her very first project she realized that this was completely unre- alistic. Marie had hoped that she could contain Billy by keeping him in a playpen while she worked, but she found that he wouldn’t tolerate such confinement for more than 2 minutes before he was yelling to get out. Once out, he was a roving accident scene. Within minutes, Marie would hear a crash or some other noise that demanded investigation. When Billy’s mother became pregnant with his sister, Billy was well into the “terrible twos” and his mother and his father, Stan, were beginning to doubt their suitability as parents. Of course, other new parents often remarked on how de- manding children were, but Marie and Stan could tell that the other parents felt nowhere near the same sense of desperation. With the arrival of Billy’s sister, Jennifer, Marie and Stan developed a bud- ding awareness that their problems in handling their son might not be due entirely to their inadequacy. As an infant Jennifer—unlike Billy—did not try to squirm and break free every time she was held. Later, there were other differences. As a toddler, she was content to sit quietly for long periods just playing with her toys, and she listened until the end of the entire story when Marie read to her, whereas Billy would get restless and run off within a couple of minutes. When Billy reached school age, and Marie and Stan received more objec- tive feedback about his situation, their sense of his difficulties became more defined. After his first day of school, his kindergarten teacher described him as “quite a handful”; then, at the parent-teacher conference, the teacher informed Billy’s parents that his activity level was well above that of the other children. In the first and second grades, as the academic component of the curriculum increased and the demands on the children for behavioral control increased correspondingly, Marie and Stan started to get yet stronger complaints from his teachers. In addition, Billy’s academic progress was slowed because of his problems with attention. Although he eventually learned to read, he didn’t re- ally begin to master the skill until the second grade. Now 8 years old and in the third grade, Billy was falling behind the other children in a wide range of academic tasks. With encouragement—actually, insistence—from his teacher, Mrs. Pease, his parents decided to seek help for him at the Child Develop- ment Center.

Half the children with ADHD also have learn- ing or communication problems, many per- form poorly in school, a number have social difficulties, and about 80 percent misbehave (Goldstein, 2011; Mash & Wolfe

Billy at Home A Parent’s Perspective

By age 8, Billy rarely carried out his parents’ requests or instructions, or he carried them out only partially before becoming caught up in some other activity. One evening in November was illustrative: Billy’s mother had just finished preparing dinner when she went to her son’s room and asked him to stop playing his video game, wash his hands, and take his place at the dining room table. “Okay, Mom,” Billy answered. “Thank you, Billy,” Marie said as she went back down to the kitchen to do some final preparations. However, 5 minutes later she realized she still had not seen Billy. She went back up to his room and found he had never turned off the video game. “Billy, I mean it. Stop playing now!” she told him. “Oh, all right.” he said, and turned the game off. Although this was Marie’s second effort, for once Billy was coming without too much of a struggle, so his mother was relieved. “Go wash your hands,” she reminded him. “Okay,” Billy replied. He headed down the hall toward the bathroom, but caught a glimpse of his 5-year-old sister already seated at the dining room table, holding a new doll. Jennifer was pulling a string that made the doll talk. “Hey, neat!” Billy exclaimed. “Let me try.” He ran over, grabbed the doll from Jennifer’s hands and pulled the string. The doll spoke in a squeaky voice, while Billy’s sister complained that she wanted her toy back. “Does the doll say anything else?” Billy asked, ignoring Jennifer’s protests. He began to pull the string over and over in rapid succession until, finally, it broke off. “Uh, oh,” Billy observed. “Mommy, he broke my doll!” Jennifer cried!

“Mommy, he broke my doll!” Jennifer cried. Billy’s mother emerged from the kitchen to find him holding the broken doll

while his sister wailed. What had begun as a simple attempt to get Billy to wash his hands and seat himself at the dinner table had ended in a tumultuous scene.

And so it would go. Unless Billy was escorted through every task of the day, he’d get sidetracked, and it usually ended with an argument or something get- ting broken. Consequently, his parents often found it easier just to do things for Billy—wash his hands, clean his room, get him dressed—because getting him to do the tasks himself was the greater effort.

When left to his own devices, Billy’s behavior was disruptive in other ways. He jumped on the beds, ran through the house, or played shrill games of hide- and-seek under the dinner table with his unwilling parents or sister. If his mother was on the phone, he would think nothing of yelling out demands for a drink, a snack, or help in finding some lost toy, despite Marie’s numerous warnings not to interrupt her.

Twice as many boys as

girls have ADHD. This ratio decreases to 1.6:1 when examining ADHD in adults. Females are more likely to present primarily with inattentive features (APA, 2013).

Even playing out in the yard was not a solution, because if Billy wasn’t watched closely, in a flash he might run out into the street after a ball, without any regard for traffic. When playing indoors with neighborhood children, Billy was bossy, continually grabbing their toys or refusing to share his own. Thus, his play dates had to be closely supervised by his parents to avoid squabbles. Because of these problems, Billy had few friends. Instead, most of his leisure time was spent watch- ing television or playing video games, activities that Marie and Stan were reluctant to encourage, but which they felt forced to accept since the 8-year-old could do little else without supervision. Billy at School

A teacher’s Perspective Billy’s third-grade teacher, Mrs. Pease, found his behavior intolerably disruptive in school. She was also concerned that Billy’s behavior problems were interfering with his ability to learn. She believed he was a bright child, but his attention and behavior problems were causing him to fail to complete his lessons and hamper- ing the other children’s ability to complete theirs. One day at school in mid-April Mrs. Pease had called the class to attention to begin an oral exercise: reciting a multiplication table on the blackboard. The first child had just begun her recitation when, suddenly, Billy exclaimed, “Look!” The class turned to see Billy running to the window. “Look,” he exclaimed again, “an airplane!’’ A couple of children ran to the window with Billy to see the airplane, but Mrs. Pease called them back, and they returned to their seats. Billy, however, remained at the window, pointing at the sky. Mrs. Pease called him back, too.

“Billy, please return to your desk,” Mrs. Pease said firmly. But Billy acted as though he hadn’t heard her.

“Look, Mrs. Pease,” he exclaimed, “the airplane is blowing smoke!” A couple of other children started from their desks.

“Billy,” Mrs. Pease tried once more, “if you don’t return to your desk this in- stant, I’m going to send you to Miss Warren’s office.” Billy seemed oblivious to her threats and remained at the window, staring excitedly up at the sky.

Mrs. Pease, her patience wearing thin, addressed Billy through gritted teeth. “Billy, come with me back to your seat.” She took him by the hand and led him there. She also considered making good on her threat to send him to Miss Warren, the princi- pal, but she glanced at the clock and realized Miss Warren would not be in her office now. Finding someone else to supervise Billy would probably be more disruptive than disciplining him within the class, so she settled for getting him back in his seat, then took her place once more in front of the class. By now she was almost I0 min- utes into the lesson period and still had not finished a single multiplication table.

Approximately 5 per- cent of children and 2.5 percent of adults have ADHD (APA, 2013).

Mrs. Pease tried to resume the lesson. “Who can tell me the answer to 3 times 6?” she asked. Fifteen children raised their hands, but before she could call on anyone, Billy blurted out the correct answer. “Thank you, Billy,” she said, barely able to contain her exasperation, “but please raise your hand like the others.” Mrs. Pease tried again. “Who knows 3 times 7?” This time Billy raised his hand, but he still couldn’t resist creating a disruption. “I know, I know!” Billy pleaded, jumping up and down in his seat with his hand raised high. “That will do, Billy,” Mrs. Pease admonished him. She deliberately called on an- other child. The child responded with the correct answer. “I knew that!” Billy exclaimed. “Billy,” Mrs. Pease told him, “I don’t want you to say one more word for the rest of this class period.” Billy looked down at his desk sulkily, ignoring the rest of the lesson. He began to fiddle with a couple of rubber bands, trying to see how far they would stretch before they broke. He looped the rubber bands around his index fin- gers and pulled his hands farther and farther apart. This kept him quiet for a while; by this point, Mrs. Pease didn’t care what he did, as long as he was quiet. She continued conducting the multiplication lesson while Billy stretched the rubber bands until finally they snapped, flying off and hitting two children, one on each side of him. All three children let out yelps of surprise, and the class turned toward them. “That’s it, Billy,” Mrs. Pease told him, “You’re going to sit outside the classroom until the period is over.”

The number of children ever given a diagno- sis of ADHD increased from 7 percent in 2000 to 9 percent in 2009 (Akinbami, Liu, Pastor, & Reuben, 2011).

“You shot those rubber bands at Bonnie and Julian,” Mrs. Pease said. “But it was an accident.” “I don’t care. Out you go!” Billy stalked out of the classroom to sit on a chair in the hall. Before exiting, however, he turned to Mrs. Pease. ‘’I’ll sue you for this,” he yelled, not really know- ing what it meant. Soon, the school bell rang, signaling the end of the period and the beginning of recess. Mrs. Pease was thankful to get some relief from the obligation of control- ling Billy, but was frustrated that almost the entire math period had been wasted due to his disruptions. Out in the schoolyard during recess, Billy’s difficulties continued. As the chil- dren lined up for turns on the slide, Billy pushed to the head of the line, almost knocking one child off the ladder as he elbowed his way up. After going down the slide, Billy barged into a dodgeball game that some younger children were playing; he grabbed the ball away from one child and began dribbling it like a basketball, while the other child cried in frustration. The supervising teacher told Billy to give.

Symptoms of ADHD, par- ticularly the hyperactive symptoms, are typically most pronounced dur- ing the elementary school years. They become less conspicuous by late child- hood and early adoles- cence (APA, 2013).

the ball back, but Billy kept dribbling, oblivious to her demands. Finally, she took the ball away from him, and Billy wailed in protest. “Hey, give that back!” he insisted. “You took this ball from someone else,” the teacher explained. “But you took it from me. That’s not fair!” Billy argued. The teacher sent Billy to sit on a bench, where he remained sulking and feeling mistreated for the rest of the recess period. This was an average day for Billy at school. On some of his better days, he was less physically disruptive, but he still had his problems, particularly in attending to and completing his schoolwork. In a typical case, Mrs. Pease would give the class an assignment to work on, such as completing a couple of pages of arithmetic problems. While most of the children worked without supervision until the as- signment was completed, Billy was easily distracted. When he got to the end of the first page, he would lose his momentum and, rather than continuing, would begin fiddling with some object on his desk. Other times, if another child asked the teacher a question, Billy would stop his own work to investigate the situation, getting up to view the other child’s work and failing to complete his own. Finally, at a parent-teacher conference, Mrs. Pease told Billy’s parents that she thought Billy’s problems might be attributable to an attention-deficit disorder. Concerned about Billy’s growing academic and social problems—not to mention feeling exhausted from continually having to remind, encourage, and threaten their son to get him to do the most elemental things—Marie and Stan decided to seek professional assistance. They arranged for a consultation at the Child Development Center.

Billy in Treatment the therapist in Action

After repeatedly observing a child’s tornadoes of activity, inattention, and reck- lessness, teachers or parents often conclude that he or she suffers from attention- deficit/hyperactivity disorder (ADHD). However, 25 years of practice had taught child psychiatrist Dr. Sharon Remoc that such a conclusion is often premature and inaccurate, leading to incorrect and even harmful interventions. Thus, when Billy’s parents brought him to the Child Development Center, Dr. Remoc was careful to conduct lengthy interviews with the child, his parents, and his teacher; to arrange for Billy to be observed at home and at school by an intern; to set up a physical examination by a pediatrician to detect any medical conditions (for example, lead poisoning) that might be causing the child’s symptoms; and to administer a bat- tery of psychological tests. In addition to obtaining a description of Billy’s current problems and his history from his parents, Dr. Remoc had Billy’s mother respond to questions from 2 different assessment instruments: the Swanson, Nolan, and Pelham Checklist, which contains questions pertaining specifically to disruptive

Only approximately one- third of children who receive a diagnosis of ADHD from pediatri- cians actually undergo psychological or educa- tional testing to support the diagnosis (Hoagwood, Kelleher, Feil, & Comer, 2000; Milli

In a 2007 national study of children with and without ADHD, parents reported that 46 percent of children with ADHD had a learning disability compared with 5 per- cent of children without ADHD who had a learn- ing disability. In addition, 27 percent of children with ADHD versus 2 per- cent of those children without ADHD were reported to have conduct disorder (Larson, Russ, Kahn & Halfon, 2011).

behavior problems, and the Conners Parent Rating Scale, which contains ques- tions specifically for assessing ADHD. Similarly, Dr. Remoc sent the teacher’s versions of the Swanson, Nolan, and Pelham Checklist and the Conners scale to Mrs. Pease. Billy’s battery of tests included the Wechsler Intelligence Scale for Children and the Wechsler Individual Achievement Tests (to provide scores in reading, mathematics, language, and written achievement). The results of these tests con- firmed the impression already supplied by Billy’s parents and Mrs. Pease: Billy’s intelligence was above average, and his academic achievement was lower than his intelligence scores would predict. These findings established that Billy’s academic problems were not due to intellectual limitations. After completing this comprehensive assessment, Dr. Remoc was confident that Billy’s difficulties met the criteria in DSM-5 for a diagnosis of attention-deficit/ hyperactivity disorder, combined type. He exhibited a majority of the symptoms listed both for inattention (for example, difficulty sustaining attention, failure to follow instructions, oblivious to verbal commands, easily distracted) and for hy- peractivity-impulsivity (for example, difficulty remaining seated, excessive motor activity in inappropriate situations, difficulty waiting his turn). The symptoms were apparent before the age of 12, occurred both at home and school, and caused significant impairments in both the social and academic spheres. Over the years, research has indicated that many children with ADHD re- spond well to either stimulant drugs or systematic behavioral treatment. Although some therapists prefer one of these approaches over the other, Dr. Remoc had come to believe that a combination of the interventions increases a child’s chances of recovery. By helping the child to focus better and slow down, the medications may help him or her to profit from the procedures and rewards used in the be- havioral program.

An estimated 3.5 per- cent of U.S. children received stimulant medi- cation in 2008 com- pared with 2.4 percent in 1996 (Zuvekas & Vitiello, 2012)

Stimulant drugs, which include amphetamine/dextroamphetamine mixed salts (Adderall), methylphenidate (Ritalin), methylphenidate extended-release (Concerta), dextroamphetamine (Dexedrine), and pemoline (Cylert), were first used to treat ADHD decades ago, when clinicians noted that the drugs seemed to have a “paradoxical” tranquilizing, quieting effect on these children. Subse- quent research has shown that all children—both those with and those without ADHD—experience an increase in attentional capacity when taking stimulant drugs, resulting in behavior that is more focused and controlled. This may create the appearance of sedation, but the children are actually not sedated at all. Unfortunately, the drugs are not effective for all children, and only partially effec- tive for others. And even when a drug is optimally effective, other areas of behav- ioral adjustment may still need to be addressed, because the ADHD child may have little practice in the more appropriate behaviors that he or she now is theoretically capable of producing. This is where behavioral programs may come into play.

In the ideal case, both parents and teachers are involved in implementing a behavior modification program, which is based on the ABC model of behavior. The A in the model denotes antecedents, the conditions that provide the occa- sion for a particular behavior; the B denotes the behavior itself; and the C denotes the consequences of the behavior. Thus, a given behavior is seen as prompted by certain antecedents, and maintained by its consequences. For example, Billy’s sprint to the window was prompted by the antecedent condition of a boring classroom exercise and the appearance of an exciting stimulus (the airplane). It was maintained, according to the model, by the rewarding effect of viewing the airplane, which was much greater than the punishing effect of Mrs. Pease’s warn- ings or even of being sent out of the room. In a behavior modification program, the usual strategy is to increase the rewards for engaging in alternative behaviors under the same antecedent conditions. Thus, if the reward for remaining seated can be made to exceed the reward for viewing the airplane, then, theoretically, the child will be more inclined to remain seated. Learning alternative behaviors may involve more than just adjusting incentives or antecedents. Some skills may have to be taught directly. A child who has never practiced asking politely for a toy, as opposed to grabbing it, will need to learn this skill before he or she can respond to incentives to implement it. Direct behavioral skills training usually follows a standard sequence. First, the child receives an ex- planation of the skill; next, he observes a model demonstrating the skill; then, he practices performing the skill, first through role-playing in the training session and then through real-life behavioral practice. After the skill is learned, both parents and teachers can prompt the child to employ it in a given situation. For example, after the skill of sharing is well learned, the parent can prompt the child to “share” in a situation calling for cooperation with another child, and then praise the child appropriately for so doing. Theoretically, the more the skill is employed and rein- forced in a variety of appropriate circumstances, the more the child will use the skill spontaneously, receiving naturalistic positive reinforcement from the environ- ment in the form of friendly or gratified reactions from others.

Research suggests that a combination of drug therapy and behavioral therapy is often helpful to children with ADHD (Parker, Wales, Chal- houb, & Harpin, 2013).

Thus, Dr. Remoc outlined for Billy’s parents four treatment components: (a) stimulant medication, (b) parental training in the use of behavioral modifi- cation principles, (c) social skills training for Billy, and (d) token economy in the school environment.

Dr. Remoc explained that stimulant medication was important for increasing Billy’s attention and impulse control; this, in turn, would enhance his capacity to do what was expected of him, both in general and in response to the behavior modification plan. The parental training, she explained, would acquaint Marie and Stan with principles of behavior modification, allowing them to deal optimally with any remaining behavior problems, as well as with Billy’s behavior during pe- riods when he might not be taking medication (so-called drug holidays). Social skills training seemed necessary, Dr. Remoc said, in light of Billy’s problems in get- ting along with other children and in cooperating at home. Finally, she explained that, since a large portion of Billy’s difficulties occurred in the classroom, it would be helpful for both Billy and Mrs. Pease to have a behavioral program operating in that environment. Dr. Remoc spoke to Mrs. Pease about the matter, and the teacher was agreeable to instituting a program provided it wasn’t too burden- some; but given Billy’s problems up to now, Mrs. Pease said that almost anything seemed less burdensome than simply doing nothing.

According to the United Nations, the United States produces and con- sumes approximately 85 percent of the world’s methylphenidate. (Medi- cating Kids. Statistics on Stimulant Use. Retrieved March 24, 2014 from wgbh/pages/frontline/ shows/medicating/drugs/ stats.htm

Stimulant medication After ruling out any physical problems (e.g., motor tics) that might preclude the use of stimulant medication, Dr. Remoc discussed the basic rationale for use of the medication with Billy’s parents. She explained that the medication had been used for years to treat children with symptoms of inat- tention, impulsivity, and hyperactivity. She also explained that the medication is not a tranquilizer. On the contrary, the medication stimulates the central nervous system for 3 to 4 hours after it is ingested. This stimulant effect, she explained, seems to increase the capacity of children with ADHD to maintain their attention and to control their impulses. As a result, they are better equipped to meet the requirements of school, home, and a social life.

In addition, she informed Billy’s parents that certain side effects can develop, including weight loss, slowed growth, dizziness, insomnia, and tics. Dr. Remoc noted, however, that these effects usually are not severe and often disappear after the body becomes accustomed to the drug or whenever a drug holiday is sched- uled. The clinician noted that since most children with ADHD respond well to Concerta without prohibitive side effects, she was inclined to try Concerta first.

Dr. Remoc pointed out that the decision to take medication was not carved in stone. Indeed, the parents should consider the initial medication regimen as a trial period; if, during this time, they concluded that the medication was not worth- while, then it should be discontinued. They could try a different medication or they could rely on the behavioral methods alone.

The use of stimulant drugs to treat children with ADHD has increased by 57 percent since 2000 (Carlson, Maupin, & Brinkman, 2010).

Once Billy began taking the medication, it was apparent that his behavior improved substantially, although not completely. In class, for example, Billy still blurted out some answers and turned around to talk to his neighbors during silent reading period, but he did these things only about one fourth as often as before. Most noticeable from Mrs. Pease’s standpoint was that simply saying his name was often enough to get him to cease what he was doing.

Out in the schoolyard, Billy was now less inclined to barge into other children’s games or push others aside. But, he still did not have a good social sense. Either he drifted off by himself or, if he did join a game, he failed to abide by the rules con- sistently, which ended up provoking arguments. For example, in joining a game of catch with four other children, Billy was inclined to hog the ball after he received it; he would then hold it and giggle, in spite of the other children’s yells that he was supposed to throw the ball to the next receiver. At home, Billy seemed less driven physically. He sat at the dinner table for the entire meal, without constant requests to be excused and without getting up re- peatedly to grab things or to play under the table. Also, his passion for jumping on the beds was gone, and he became more dependable in carrying out instructions. For example, if his parents sent him to wash up and sit at the table, they now could count on his following through 75 percent of the time (as opposed to 25 percent, as before). Tendencies such as stubbornness and defiance remained a problem, however; it remained a struggle to get him to do chores, to get started on his homework, or to follow household rules in general. He continued to barge in on his mother when she was on the phone, shouting his insistent requests for snacks, toys, and videos. Overall, however, the medication seemed to have many advantages.

Although family conflict is often present in families with a child with ADHD, negative family interac- tion patterns are unlikely to cause the development of ADHD (APA, 2013)

Parental training To gain some knowledge of behavioral management tech- niques, Billy’s parents enrolled in a training group for parents of children with ADHD (at about the same time that Billy began taking medication). The group, led by psychologist Dr. James Grendon, was designed to educate parents about both ADHD and the principles of behavior modification for managing it. Group sessions were held three times a month, and once a month Dr. Grendon met alone with Billy’s parents to discuss the child’s individual situation. At the very first group session, Billy’s parents found comfort in learning that other parents’ experiences closely paralleled their own. All the parents were able to share their experiences and found that they were all dealing with very similar concerns. Many parents saw humor in some of the situations, and this helped to soften the impact of what they had all been going through. It also helped Marie and Stan to know that some of their marital disputes were shared by the other parents. Like the others in the group, Billy’s parents often argued over how to deal with their child. Although it didn’t solve the prob- lem, it helped them to know that even their arguments were “normal,” given the circumstances. In additional group sessions, Marie and Stan were progressively introduced to the ABC principles of behavior management. Among the points they found helpful was the idea that parents can become unduly focused on discouraging problem behaviors through criticism or punishments; the punishments, in turn, are often ineffective and just fuel resentment. A different approach, Dr. Grendon explained, was to think in terms of the alternative behaviors (B) that parents would like their children to perform under the same circumstances (A), and to provide praise and rewards (C) accordingly.

Billy’s parents explored this principle in greater detail in individual sessions with the group leader, as they felt it applied particularly to the way they were handling (or mishandling) many situations with their son. For example, a regular problem with Billy was that he interrupted his mother when she was on the phone. She had to lock herself in the bedroom in order to have a coherent conversation with a pediatrician, repairman, friend, or relative. Often, even locking herself in was not enough to insure peace and quiet, as Billy might start pounding on the door in order to convey his demands, in spite of repeated scolding. To address the problem, the psychologist asked Billy’s parents to think of spe- cific, alternative actions they would like Billy to carry out under these conditions. At first, all Marie and Stan could think of was “not interrupt,” but Dr. Grendon reminded them of the stipulation that they think of a tangible alternative behav- ior for Billy to carry out under the same circumstances. After some discussion, they came up with the idea of having Billy write down his requests whenever his mother was on the phone. They noted that their son loved to write notes, so this might be a tangible thing he could do to satisfy his demands temporarily, and allow him to resist interrupting. With further discussion, Billy’s parents and the psychologist worked out the following procedure: Before Marie made a call or answered the phone, she would hand Billy a special message pad, reminding him to write down any questions or problems that he had while she was talking; Marie would then give prompt attention to Billy’s messages as soon as she was off the phone; finally, if Billy succeeded in using the pad, instead of interrupting, for the majority of calls in a given week (his mother would keep a checklist to tabulate Billy’s compliance), he would be given a special reward on the weekend (such as eating out at his favorite restaurant). This was the first behavioral plan that Billy’s parents put into effect, and after ironing out a few wrinkles, Billy was able to follow the procedure, even to the point of fetching the message pad himself whenever the phone rang. Eventually, he resisted interrupting almost entirely. Other behavioral plans were then put into effect for other matters, such as household chores and homework completion. In both cases, Billy’s parents found an effective formula by reversing antecedent conditions and behavioral conse- quences. For example, they saw to it that television viewing would always follow the completion of homework, rather than vice versa.

Children whose par- ents or other close rela- tives had ADHD are more likely than others to develop the disorder (APA, 2013)

About half of children with ADHD, combined type, also have opposi- tional defiant disorder. Conduct disorder is pres- ent in about 25 percent of children and adolescents with ADHD, combined type (APA, 2013)

Social skills training Marie and Stan also enrolled their son in a class where he could learn skills for getting along better with other children. The class was composed of other children receiving treatment at the center for ADHD.

During each class the focus was on learning one particular social skill, such as sharing. First, the group leader explained the concept of sharing, and then asked the children their own opinions of what it meant. Next, she demonstrated the implementation of the skill with several children in different, contrived, situa- tions: sharing toys, sharing food, or sharing a seat. Then each child came up, one by one, and practiced sharing in each of these hypothetical circumstances. The group leader and the other children then gave the child corrective feed- back on how well he or she had shared. Similar classes were devoted to other social skills, such as cooperating, speaking calmly, making polite requests, and following rules. Billy’s parents and Mrs. Pease received written guidelines for discussing the so- cial skills training sessions at home and in school and for guiding Billy to use the skills in everyday situations. Many of the opportunities to prompt him arose at home in his interactions with his 5-year-old sister. With continued prompting, Billy started to share things with his sister spontaneously on many occasions, which increased the harmony in the household. Because of these successes, and Billy’s additional successes using the social skill of cooperation, Marie and Stan finally felt confident enough to invite one of Billy’s schoolmates over for a play date. The last time a child had come to their house, it had been a disaster, as Billy had refused to relinquish any of his toys to his guest. Needless to say no child was likely to return after such treatment. Although this play date was far from perfect and needed Marie’s constant attention, it turned out to be reasonably pleasant. Token economy The token economy is an element of the ABC behavior modification system; it uses tokens, rather than immediate, tangible rewards, to reinforce desired behavior. The tokens are exchanged for an actual reward at a later time. Token reinforcement is particularly advantageous for ADHD children, who can get so wrapped up in the attractiveness of the actual reward that they find it difficult to remain mindful of the behaviors that the reward is designed to encourage. Mrs. Pease thought that some form of behavior modification might assist her in regulating several of Billy’s behaviors. Accordingly, she and the therapist decided to focus on encouraging three specific school behaviors in Billy: raising his hand to answer questions (instead of blurting out answers), staying in line, and finishing in-class assignments. As token reinforcers, Mrs. Pease would use dinosaur stickers affixed to a piece of paper, with the number of stickers in each of three columns reflecting Billy’s compliance with the three behavioral objec- tives. According to the plan (explained to Billy in a meeting with his parents and Mrs. Pease), Mrs. Pease would keep track of Billy’s compliance separately for the morning period and the afternoon period, and award him one sticker if he achieved full compliance with a given behavioral objective in a given period. He would receive his morning stickers at lunchtime, and his afternoon stickers upon dismissal. The stickers could then be redeemed at home for special privi- leges (going out to eat, going out to a movie, an extra half hour of television or a video game, and so forth).

In the DSM-II (1968), ADHD was known offi- cially as hyperkinetic reaction of childhood, and it was commonly referred to simply as hyperactivity or hyperkinesis (the lat- ter term from the Greek for over and motion)

Billy liked the idea of getting stickers so he agreed to the plan. On the first morning of the program, he received only one sticker: for finishing his assignment within the allotted time (he had blurted out a couple of answers and had wan- dered off the line going to art class). In the afternoon, however, he received two stickers: for staying in line and for finishing assignments. After a few more days on the program, Billy was averaging five stickers per day, a level that he was able to maintain, and which reflected a substantial improvement in all three areas. Within 2 months of the combined treatment program, Billy had improved considerably. He was conforming to classroom rules by staying in his seat, not talking, and finishing his assignments most of the time. When he deviated, he required only gentle reminders from Mrs. Pease to get back on track. Similarly, at home, he was less frenetic. He could carry out instructions more dependably, and he usually accepted his household responsibilities without too much argu- ment. In peer relations, Billy was still learning the culture of give and take, but with periodic guidance and further experience he was becoming increasingly ef- fective. As a result, he was getting along well with his sister, and he now had a couple of friends who would come over regularly to play, and who invited him to their homes as well.

Unfortunately, after about 4 months of this improved functioning, Billy began to slip into some of his old patterns both at home and at school. His parents felt that the problems had to be addressed, as he seemed to be losing ground. The recur- rence of problems seemed to coincide with the birth of his new baby brother. In a discussion with Dr. Remoc, Billy’s parents wondered whether their total preoc- cupation with the birth of the baby, and their consequent inability to implement many features of the behavioral program (including not following through on redeeming Billy’s dinosaur stickers), was responsible for the slippage in his prog- ress. A renewed effort by the parents to apply the behavioral program, and an adjustment in the dosage of Billy’s medication, helped him to regain his previous achievements within a few weeks.

In addition to being viewed negatively by peers and parents, chil- dren with ADHD often view themselves nega- tively and have signifi- cantly lower self-esteem than children without ADHD (Mazzone et al., 2013; McCormick, 2000)


After 18 sessions of group parental training (over a 6-month period), 6 sessions of individual parent training, 6 sessions of social skills training for Billy, and 4 meetings at school with Billy’s teacher, his ADHD symptoms stabilized at an improved level.

Billy reported that he was happier at school and enjoying time at home with his family. He still took medication and saw Dr. Remoc for a checkup every 4 months. Billy’s parents planned to give Billy a drug holiday in the summer and felt confident of their ability to manage his behavior during that time with just the behavioral techniques. They were a family again—sometimes laughing, sometimes crying— but, overall, enjoying their lives and activities together.

Assessment Questions

1. When did Billy’s parents begin to suspect that Billy’s “dynamo” personality might be a behav- ioral disorder? 2. Describe at least 3 behaviors that suggest that Billy’s activity level is beyond what’s normal for a child his age. 3. When did Billy’s family finally receive more ob- jective feedback about Billy’s behavior? 4. How long did it take for Billy’s teachers to sug- gest professional consultation regarding Billy’s disruptive behavior? 5. Why did Dr. Remoc, the therapist at the Child Development Center, feel it was important to conduct a thorough assessment of Billy before diagnosing ADHD? 6. Describe at least 4 different assessment tech- niques used by Dr. Remoc to test for ADHD. 7.What were the assessment results that led Dr. Remoc to diagnose ADHD in Billy? 8. Why did Dr. Remoc decide to use both medica- tion and behavioral therapy to treat Billy? 9. What are some potential problems with pre- scribing medication as the only treatment option for children with ADHD? What are some side effects of stimulant medications? 10. Describe the ABC model of behavioral therapy and give examples. 11. What were the four treatment components out- lined for Billy’s treatment? 12. Why is it important for Billy’s parents to be a part of the treatment plan? 13. Describe the ABC plan that Billy’s parents devel- oped to control his “interrupting” behaviors. 14. What other childhood behavioral diagnoses are often comorbid with ADHD? 15. Describe the concept of a token economy. 16. What event disrupted Billy’s progress? 17. What was the ultimate outcome after 18 ses- sions of group parental