ADHD: Framework for Treatment Planning

1
ADHD Framework for Treatment Planning

• James H. Johnson, Ph.D., ABPP
• University of Florida

2
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.

3
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.

4
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.

5
Assessing Core Symptoms

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

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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

7
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

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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).
  

9
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.

10
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.

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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.

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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.

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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 multi-modal 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.

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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

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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 ones
  considered here may be required for some children
  with ADHD especially those with comorbid
  disorders.

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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.

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Developing Treatment PlansEssential 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.

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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

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Problem Selection

• What is the nature of the childs 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.

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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).

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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.

22
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 HMOs and other managed
  care organizations require that psychosocial
  treatment outcomes be measurable.

23
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.

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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.

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Selecting Interventions

• Interventions are those things the 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 the
  therapists full therapeutic repertoire.

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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.

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Relationship of Treatment Planning to Diagnosis

• While the development of a treatment plan usually
  focuses more on specific problems, rather than
  specifically on the childs 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 childs diagnosis.

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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.

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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.

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Sample Treatment PlanGoals

• 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.

31
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.

32
Sample Treatment Plan Objectives and
Interventions

• Objective 2 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 in the
  home to help patient learn to delay gratification
  (e.g., completing chores before playing).

33
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 patients 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.

34
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 patients desired
  behavior and reduce inappropriate behaviors.

35
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.

36
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.

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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 Conners ADHD Index
  within the normal range.

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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.

39
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.

40
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.

41
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.

42
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

43
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.

44
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 childs
  inattentiveness, impulsivity and hyperactivity.
• Give feedback to the client and his/her parents

45
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.

46
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).

47
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

48
ADHD Objectives/Interventions A Treatment Sampler

• Parents develop and use an organized system to
  keep track of childs school assignments, courses
  and household responsibilities.
• Assist the parents in developing and implementing
  a system to increase the childs 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 childs compliance with
  school, chores, or household responsibilities.

49
ADHD Objectives/Interventions A Treatment Sampler

• The parents maintain regular communication with
  the school to monitor the childs academic,
  behavioral, emotional, and social progress.
• Encourage parents and teachers to maintain
  regular communication about the childs academic,
  behavioral, emotional, and social progress.

50
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
  childs school performance and behavior process
  the reading with the therapist.
• Assign the child 13 Steps to Better Grades
  (Silverman) to improve organizational and study
  skills.

51
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 childs 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.

52
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)

53
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 childs
  attention make one request at a time clear away
  distractions repeat instructions obtain
  frequent feedback from child to insure
  understanding.

54
ADHD Objectives/Interventions A Treatment Sampler

• Parents set firm limits and use natural logical
  consequences to deter the childs 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 childs disruptive and
  negative attention seeking behavior.

55
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 the therapeutic game Stop, Relax, Think
  (Bridges) to assist the child in developing self
  control.

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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 Lets Work it Out A conflict Resolution Tool
  Kit (Shapiro) in sessions to teach the child
  effective problem-solving skills.

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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.

58
ADHD Objectives/Interventions A Treatment Sampler

• Increase verbalizations of acceptance of
  responsibility for misbehavior.
• Firmly confront the childs 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.

59
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
  parent-child bond. Allow child to take lead in
  selecting activity or task.

60
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 the 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.

61
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 the 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.

62
ADHD Objectives/Interventions A Treatment Sampler

• Implement a process of monitoring and assessing
  own behavior.
• Encourage the child to use self-monitoring
  checklists to improve his/her attention and
  social skills.
• Assign the Social Skills Exercise in the Brief
  Child Therapy Homework Planner (Jongsma, Peterson
  and McInnis)

63
ADHD Objectives/Interventions A Treatment Sampler

• Parents and the child regularly attend and
  actively participate in group therapy.
• Arrange for the child to attend group therapy to
  build social skills.
• Encourage the childs parents to participate in
  an ADHD support group.

64
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 childs interest and motivation in
  achieving desired goals or changes in behavior.
• Design a reward and/or contingency contract
  system to reinforce the childs positive behavior
  and deter impulsive behaviors.
• Design and implement a token economy to improve
  the childs academic performance, social skills,
  and impulse control.

65
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.

66
Thats It!