Abstract
Medication has proved highly efficacious as a means of alleviating general symptoms of attention-deficit hyperactivity disorder (ADHD). However, many patients remain functionally impaired by inappropriate behavior. The present study analyzed the use of cognitive behavioral therapy (CBT) with the Token-Economy (TE) technique to alleviate problem behavior for 25 participants with ADHD, all children (19 boys, mean age 10.11) on long-term methylphenidate medication, who were given 20 CBT sessions with 10 weeks of TE introduced as of session 5. Their ten most acute problem behaviors were selected and written records kept. On weekdays, parents recorded each inappropriate behavior and provided a suitable model for their actions. At weekly sessions, problem behaviors were counted and incident-free participants rewarded with a token. To analyze improvement (less frequent problem behavior), a list of 11 behavioral categories was rated: inattention, impulsivity, hyperactivity, disorganization, disobeying rules and routines, poor self-care, verbal/physical aggression, low frustration tolerance, compulsive behavior, antisocial behavior, lacking in initiative and distraction. Two CBT specialists categorized behaviors and an ADHD specialist ruled on discrepancies. Statistical analyses used were Generalized Estimating Equations with Poisson distribution and autoregressive order correlation structure. In the course of the sessions, problematic behaviors decreased significantly in seven categories: impulsiveness, hyperactivity, disorganization, disobeying rules and routine, poor self-care, low frustration tolerance, compulsive behaviors, and antisocial behaviors. Caregiver attitudes to children’s inappropriate behavior were discussed and reshaped. As functional improvement was observed on applying TE for 10 weeks, this type of intervention may be useful as an auxiliary strategy combined with medication.
Highlights
Attention Deficit and Hyperactivity Disorder (ADHD) has become one of the most extensively researched neurodevelopmental disorders over the last 30 years
Children with attention-deficit hyperactivity disorder (ADHD) were recruited from an outpatient clinic, associated with the Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil, that specialized in the diagnostic of children and adolescents with neurodevelopmental disorders
The sample consisted of 25 children with ADHD, 19 boys, mean age 10.11 (SD 1.79), average IQ 108.20 (SD 12.27), 13 inattentive subtype and 12 combined subtype
Summary
Attention Deficit and Hyperactivity Disorder (ADHD) has become one of the most extensively researched neurodevelopmental disorders over the last 30 years. Studies have noted that ADHD in the course of its development is associated with increased risk of poor school performance, exam failure, school transfers, conflictive relationships with family and colleagues, development of internalizing symptoms (anxiety, depression, low self-esteem) and externalizing symptoms (conduct problems, delinquency, early experimenting with and abuse of substances) [3]. Given all these impairments, in addition to unfavorable prognosis in the absence of treatment, revised ADHD treatment guidelines have ranged from medication to behavioral treatments such as psychoeducation, behavioral therapy, and interventions in school or other settings [4]. Numerous clinical trials have found core symptoms of hyperactivity, impulsivity, and inattention showing statistically significant improvement as well as better academic performance, relations with family and peers and behavioral problems, and medication may even diminish the risk of subsequent psychiatric comorbidities [5, 6]
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