ADHD: Framework for Treatment

Planning

James H. Johnson, Ph.D., ABPP

University of Florida
 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.
 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.
 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.
 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
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
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
 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]).
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.
 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.
 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.
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.
 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.
 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
 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
one’s considered here may be required for
some children with ADHD – especially those
with comorbid disorders.
 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.
 Developing Treatment Plans:
Essential 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.
 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
 Problem Selection
• What is the nature of the child’s
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.
 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).
 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.
 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 HMO’s and other
managed care organizations require that
psychosocial treatment outcomes be
measurable.
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.
 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.
 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
therapist’s full therapeutic repertoire.
 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.
Relationship of Treatment Planning
to Diagnosis
• While the development of a treatment
plan usually focuses more on specific
“problems”, rather than specifically on
the child’s 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 child’s diagnosis.
 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.
 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.
 Sample Treatment Plan:
Goals
• 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.
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.
 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).
 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 patient’s 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.
 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 patient’s desired
behavior and reduce inappropriate behaviors.
 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.
 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.
 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 Conner’s ADHD Index
within the normal range.
 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.
 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.
 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.
 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.
 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
 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.
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 child’s
inattentiveness, impulsivity and hyperactivity.
– Give feedback to the client and his/her parents
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.
 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).
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
 ADHD Objectives/Interventions: A
Treatment Sampler
• Parents develop and use an organized
system to keep track of child’s school
assignments, courses and household
responsibilities.
– Assist the parents in developing and implementing a
system to increase the child’s 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 child’s compliance with school,
chores, or household responsibilities.
 ADHD Objectives/Interventions: A
Treatment Sampler
• The parent’s maintain regular
communication with the school to
monitor the child’s academic, behavioral,
emotional, and social progress.
– Encourage parents and teachers to maintain
regular communication about the child’s
academic, behavioral, emotional, and social
progress.
 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
child’s 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.
 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 child’s 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.
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)
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 child’s
attention; make one request at a time;
clear away distractions; repeat
instructions; obtain frequent feedback
from child to insure understanding.
ADHD Objectives/Interventions: A
Treatment Sampler
• Parents set firm limits and use natural
logical consequences to deter the
child’s 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 child’s disruptive and
negative attention seeking behavior.
 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.
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 Let’s Work it Out: A conflict Resolution
Tool Kit (Shapiro) in sessions to teach the
child effective problem-solving skills.
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.
ADHD Objectives/Interventions: A
Treatment Sampler
• Increase verbalizations of acceptance
of responsibility for misbehavior.
– Firmly confront the child’s 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.
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.
 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.
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.
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)
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 child’s parents to
participate in an ADHD support group.
 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 child’s interest and motivation in achieving
desired goals or changes in behavior.
– Design a reward and/or contingency contract system
to reinforce the child’s positive behavior and deter
impulsive behaviors.
– Design and implement a token economy to improve
the child’s academic performance, social skills, and
impulse control.
 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.
That’s It!