Psychosocial Interventions - Attention-deficit and Disruptive Behavior Disorders

Psychosocial Interventions

Among the systematically studied psychosocial interventions found to be useful are home-based interventions/parent training, classroom-based behavior modifications, social skills training and intensive summer treatment programs. Since family, peer and school interactions are important in the morbidity and main-tenance of these disorders, it is important to utilize psychosocial treatments to target each of these areas. In contrast to these more structured techniques, individual play therapy with children is generally ineffective in decreasing problem behaviors of the AD-DBDs.

Behavior therapy (BT) relies primarily on training par-ents and/or teachers to be the agents of change. The focus is on decreasing the frequency of problematic behaviors and/or increasing the rate of desirable behaviors. Parent management training is one of the most common techniques and consists of group and individual sessions with parents in order to of-fer psychoeducational intervention and to teach the principles and implementation of behavioral programs. Consultation with classroom teachers to set up parallel behavioral programs in the school is also an important adjunct to this treatment. When ef-fective, some parent-based interventions have resulted in ben-efits that have generalized for periods of over a year. Among the limitations of this technique are the labor-intensive nature of the interventions, nongeneralizability to nontargeted behaviors, and the fact that effectiveness depends upon the competence and willingness of parents and teachers to carry out the behavioral programs.

Another aspect of BT is contingency management (CM), which is implemented directly with the child in the setting in which the problem behaviors occur. CM programs use both re-ward procedures and negative consequences, such as time-out and response cost or “punishments”. In some situations, main-tenance of appropriate behavior following withdrawal of contin-gencies is better for a negative consequence than for a reward. Similarly to BT, CM approaches are extremely labor-intensive and questions regarding their generalizability remain.

Cognitive–behavioral approaches (CBT) are based on the premise that the difficulties experienced by children with AD-DBDs are a result of deficient self-control and problem-solving skills, or that changes in these domains of function can override other deficits. Examples of CBT include training in self-monitoring, anger control and self-reinforcement. Study results have been mixed, although some CBT procedures, such as anger control, have shown more consistent success.

Short-term gains from psychosocial interventions are of-ten limited to the period during which the programs are actually in effect. Additional problems in implementation include the un-willingness of many teachers to use behavioral programs and the fact that as many as half the parents discontinue parent training due to their labor-intensive nature. However, it is important to note that in the MTA study, the presence of anxiety (as reported by parents on the DISC interview) moderated the outcome of treatment, such that psychosocial interventions were more effica-cious than medication alone in children with ADHD who also had symptoms of anxiety (March et al., 2000).