Abstract
Attention deficit hyperactivity disorder [ADHD] is one of the most common psychiatric disorders of childhood with poor prognosis if not treated effectively. Recommended psychosocial evidence-based treatment for preschool and school-aged children is behavioral parent and teacher training [BPT]. The core elements of BPT are instrumental learning principles, i.e., reinforcement of adaptive and the ignoring or punishment of non-adaptive behaviors together with stimulus control techniques. BPT is moderately effective in reducing oppositional behavior and improving parenting practices; however, it does not reduce blinded ratings of ADHD symptoms. Also after training effects dissipate. This practitioner review proposes steps that can be taken to improve BPT outcomes for ADHD, based on purported causal processes underlying ADHD. The focus is on altered motivational processes (reward and punishment sensitivity), as they closely link to the instrumental processes used in BPT. Following a critical analysis of current behavioral treatments for ADHD, we selectively review motivational reinforcement-based theories of ADHD, including the empirical evidence for the behavioral predictions arising from these theories. This includes consideration of children’s emotional reactions to expected and unexpected outcomes. Next we translate this evidence into potential ADHD-specific adjustments designed to enhance the immediate and long-term effectiveness of BPT programs in addressing the needs of children with ADHD. This includes the use of remediation strategies for proposed deficits in learning not commonly used in BPT programs and cautions regarding the use of punishment. Finally, we address how these recommendations can be effectively transferred to clinical practice.
Highlights
Attention deficit/hyperactivity disorder [ADHD] (American Psychiatric Association 2013) is one of the most common psychiatric disorders of childhood with poor prognosis if not treated effectively (Tarver et al 2014)
The exception being that children with ADHD show a negative emotional reaction to delay, behavioral evidence for this prediction is to date limited
There is very strong evidence for Douglas’s proposal that children with ADHD have an abnormally strong inclination to seek immediate reward. The evidence for her predictions that children with ADHD are more vulnerable to the distracting effects of reward and to increased frustration in face of non-reward is limited
Summary
Attention deficit/hyperactivity disorder [ADHD] (American Psychiatric Association 2013) is one of the most common psychiatric disorders of childhood with poor prognosis if not treated effectively (Tarver et al 2014). The primary evidence-based, and most common, nonpharmacological treatment for preschool and elementary school-aged children with ADHD is Behavioral Parent and Teacher Training [BPT] An extensive meta-analysis of the effects of psychosocial treatments over time (including mostly behavioral treatments) shows that in the last 50 years effect sizes for treatments of ADHD have not improved, but rather show a non-significant decline in effectiveness (Weisz et al 2018). All in all, this calls for exploring how our current BPTs for ADHD may be improved. One potential way is the integration of research on causal processes in ADHD into behavioral treatment
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