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Cognitive-Behavioral Therapies for ADHD in Children

Aude Henin, Ph.D.

Co-Director, Child CBT Program

Massachusetts General Hospital

www.mghcme.org

Disclosures

My spouse/partner and I have the following relevant financial relationship with a commercial

interest to disclose:

Otsuka – Consultant

Alkermes – Consultant

Clintara – Consultant

Oxford University Press – Royalties (book authorship)

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CBT Model

Psychiatric Disorder

Affective Reactions

Physiological Sx.

Cognitions

Behaviors

Family Factors

Extrafamilial Factors

Individual Predisposition

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Common Aspects of BT/CBT Approaches

• Therapy is usually time-limited

• Emphasis on manualized, empirically-supported treatments

• Sessions are structured

• Therapist is active

• Therapist as “coach”, teacher

• Collaborative enterprise with patient

• Active practice of skills between sessions

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Developmental Perspective on CBT Interventions

Parent Training

Multimodal Interventions

Preschool Age

School Age

Adolescent

Adult

Parent Training

Classroom-Based Interventions

Intensive Summer Programs

Multimodal Interventions

CBT for Comorbid Disorders

Organizational Skills Training

CBT

Organizational Skills Training

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Parent Management Training Approaches

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Behavioral Management Techniques

• Based on operant behavioral principles

– Positive/negative reinforcement – Punishment – Contingent reinforcement – Extinction – Identifying antecedents to behaviors – Modeling

Antecedent Behavior Consequence

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Rationale

• Children with ADHD have deficits in rule-governed behaviors – Parents may need to use more explicit,

systematic ways of presenting and enforcing rules to address these deficits

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Rationale

• Symptoms of ADHD contribute to impairment in the parent-child relationship – Parents may develop maladaptive parenting

strategies to deal with behavioral difficulties

– Modifying poor parenting

practices may increase

positive outcomes in

children

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Examples of PMT Approaches

• Defiant Children (Barkley, 1997)

• The Incredible Years (Webster-Stratton, 1992)

• Parent-Child Interaction Therapy (PCIT; Eyberg & Robinson, 1982)

• Triple P-Positive Parenting Program (Sanders et al., 2000)

• New Forest Parenting Package (NFPP: Sonuga-Barke et al., 2006)

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PMT Strategies

• Review of information on ADHD and causes of non-compliant behaviors

• Rewarding pro-social behaviors (Catching your child being good)

– Attending to positive behaviors

– Praising positive behaviors

– Child-centered play (PCIT)

– Token Economy System (points; stickers)

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PMT Strategies (cont’d)

• Decreasing Unwanted Behaviors

– Selecting Ignoring

– Time-out for noncompliance

– Giving effective commands

• School Daily Report Card

• Managing future misconduct/relapse prevention

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PMT for Preschool Children (Sonuga-Barke et al., 2001)

• 78 3 year old children with ADHD randomized to: – Parent Training (n=30)

– Parent Counseling and Support (n=28)

– Waitlist Control (n=20)

• Assessed at post-treatment (8 weeks) and 23 week follow-up with the PACS and observational measure

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Efficacy of PMT in Preschool Children: Changes in ADHD Symptoms

-1.2

-1

-0.8

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

Sta

nd

ard

ize

d A

DH

D I

nd

ex

Parent Training

Parent Support

Waitlist Control

Baseline Week 8 Week 23

a,b

a,b

Sonuga-Barke et al., 2001; J Am Acad Child Adolesc Psychiatry; 40: 402-408

a: vs PS

b: vs WLC

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Follow-up Study of Efficacy of PMT (Jones et al., 2008)

• 79 Families with children 3-5 years with signs of ADHD and conduct problems

• Randomized to Incredible Years PMT (n=50) or Waitlist (n=29)

• Followed up to 12 months post-treatment (n=50)

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Post-Treatment Gains

0 20 40 60

Percentage Clinically Improved

Waitlist

Treatment

Jones et al., 2008, Child: Care, Health, & Development, 33, 749-756.

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12 Month Follow-up Data

53

4746

20.6

13.514.6

13.4

37

42

47

52

57

Baseline Post-Trmt 6 mo FU 12 mo FU

0

5

10

15

20

25

% Recovered

Conners Scores

Jones et al., 2008, Child: Care, Health, & Development, 33, 749-756.

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Meta-analysis of Behavioral Treatments (Daley et al., 2014, JAACAP: 53(8) 835-847)

• Meta-analysis of 32 randomized, controlled trials of behavioral interventions for children with ADHD

• Examined both un-blinded proximal outcomes, and ratings blind to treatment allocation

• Examined 3 questions: – Changes in behavior of responsible adults? – Improvements in adult efficacy/competency and

decreases in adult mental health problems in caregivers?

– Changes in child symptoms and associated impairments?

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Results of Meta-Analysis: Parenting Outcomes

(Daley et al., 2014, JAACAP: 53(8) 835-847)

0.68 0.63

0.57

0.43 0.37

0.09

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

PositiveParenting(proximal)

PositiveParenting

(blind)

NegativeParenting(proximal)

NegativeParenting

(blind)

ParentalSelf-Concept

ParentalMentalHealth

Stan

dar

diz

ed

Me

an D

iffe

ren

ce

sig sig

sig

sig

sig

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Results: Child Outcomes

0.35

0.02

0.26

0.31

0.47

0.28

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

0.5

ADHD(proximal)

ADHD (blind) ConductProbs

(proximal)

ConductProbs (blind)

Social Skills(proximal)

AcademicAchievement

(proximal)

Stan

dar

diz

ed

Me

an D

iffe

ren

ce

sig

sig

sig

sig

sig

(Daley et al., 2014, JAACAP: 53(8) 835-847)

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Integrated Psychosocial Treatment for ADHD-Inattentive Subtype

(Pfiffner et al., 2014; JCCP; 82(6): 1115-1127)

• Child Life and Attention Skills (CLAS) • 3 components: • 1) group-based parent training • 2) group-based child training (including organizational

and social components) • 3) teacher consultation including daily report card • Adaptations of well-established interventions,

including positive reinforcement, social assertion, distraction management, parent training, use of common terminology

• Decreased emphasis on reducing impulsivity

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Evaluation of CLAS

• 199 children (ages 7-11 years) from 2 sites randomized to 10-13 weeks of: – CLAS – Parent-training – TAU

• Evaluated at baseline, posttreatment, and 5-7 mo fu • Child Characteristics:

– primary dx of DSM-IV ADHD-I – Mean child age 8.6 years – >50% in 2nd or 3rd grade – 54% caucasian, 17% Latino, 5% African-American, 8% Asian-American,

17% mixed race – 58% Boys – 4.5% taking medication at time of randomization

Pfiffner et al., 2014; JCCP; 82(6): 1115-1127

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Study Results: Effect Sizes Across Conditions

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

Inattentive sx-PInattentive sx-TOrg. Skills-P Org skills-T Social skills-PSocial skills-T

CLAS-PFT

CLAS-TAU

PFT-TAU

Pfiffner et al., 2014; JCCP; 82(6): 1115-1127

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Cognitive Training for ADHD

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Rationale

• Based on evidence of brain plasticity (rehabilitation and neuroscience research)

• Brain networks implicated in ADHD can be strengthened via information processing tasks

• Target a range of deficits associated with ADHD – Attentional control

– Working memory

– Inhibitory control

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Intervention

• Presented using computer tasks (e.g., CogMed) that increase in difficulty based on child’s competence

• Delivered in 30-45 mins over 5 days/week for 5 weeks (25 days total)

• Several small, randomized clinical trials(Cog-Med vs. placebo) suggest effects on

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Example of CogMed training

• https://www.youtube.com/watch?v=JHqsyXgoJis?t=1m08s

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Meta-analysis of Efficacy of Cognitive Retraining

• 15 trials of 759 children with ADHD that targeted:

– Working memory (6 trials)

– Attention (4 trials)

– Combined attention & Working memory (2 trials)

– Inhibition & Working memory (2 trials)

– General executive functioning (1 trial)

Cortese et al. (2015). JAACAP, 54(3): 164-74

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Results of Meta-analysis

0.01

0.09

0.14

0.07

0.52*

0.35*

0.11

0.2*

0.37*

0.35

0.32

0.47*

0.14

0 0.1 0.2 0.3 0.4 0.5 0.6

Arithmetic

Reading

Attention

Inhibition

Working Mem

EF

ADHD med

ADHD total blind

ADHD total

Inattention Med

Inattention blind

Inattention

Hyper/Imp

Effect Size (SMD)

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Conclusions

• Behavioral approaches are well-established, evidence-based treatments for preschool- and school-aged children with ADHD

• Behavioral treatments are less efficacious than medications for core ADHD symptoms

• However, they promote other positive outcomes (e.g., improved parent-child relationships, decreased noncompliance)

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• The combination of medication and behavioral treatment is the most efficacious, powerful intervention (and may decrease the dosing of each)

• Parent interventions may be enhanced by school-based interventions to enhance generalization

• More work is needed to extend behavioral treatment to primary care and community settings

• More work needed to individualize treatments given known mediators/moderators of change (e.g., parental ADHD).

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Conclusions

• Cognitive retraining approaches appear to have some benefits for specific deficits (e.g., working memory)

• Impact on ADHD sx and academic performance not demonstrated

• More research needed before recommending this as an intervention for youth with ADHD

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Finding a CBT Therapist

• Look for graduate training in a CBT program and/or CBT internship

• Association for Behavioral and Cognitive Therapies

• www.abct.org

• European Association of Behaviour and Cognitive Therapies

• www.eabct.com