Self-Management and ADHD: A Literature Review

Transcription

1 Self-Management and ADHD: A Literature Review Leasha M. Barry and Dana L. Haraway University of West Florida Literature on self- as it is applied to children with Attention Deficit Hyperactivity Disorder (ADHD) is reviewed in the context of Barkley s (1997) theoretical model of ADHD and best practices in overall treatment intervention. Searchers for articles in which self- was applied to a sample with ADHD were conducted in medical, psychological, and educational databases. A total of fourteen articles and dissertations were located and reviewed. The authors interpretations are discussed in light of Barkley s theoretical model and best practice in treatment. Future research directions and implications for practice are included. Keywords: Self-, Attention Deficit Hyperactivity Disorder (ADHD), Behavioral Intervention. Attention deficit hyperactivity disorder (ADHD) is the most prevalent neurobehavioral disorder diagnosed in children today with nearly 3.8 million diagnosed in the United States (Frazier & Merrell, 1997; Root & Resnick, 2003; Treat ADHD, 2002). Given the prevalence of ADHD, considerable research has explored treatment options for this population. Literature reviews and meta-analyses of treatment options including medical, psychosocial interventions, and educational treatments are available in their respective fields (see Conners; 2002; DuPaul & Eckert, 1997; Purdie, Hattie, & Carroll, 2002). This literature review briefly summarizes a theoretical model of ADHD and empirically supported best practices in treatment of ADHD as a means of establishing the context for a review of literature on self-. The literature on self- applied specifically to ADHD is limited in scope and contains discrepant findings. Variations in treatment methods and effects are considered. Future research directions and implications for professionals in the field of behavior analysis are discussed. Theoretical Model of ADHD and Support for Self-Management Teaching appropriate behavioral skills is a common intervention when an appropriate replacement behavior is warranted or a skill deficit is observed. Prior to teaching skills, it is always important to discriminate between actual behavioral deficits and behavioral performance. Barkley (2000) noted much of the research in the area of psychosocial and educational treatments for ADHD has been conducted based on the assumption that individuals with ADHD have skill deficits due to a lack of learning. He further postulated that these efforts have been misguided because a lack of learning is not the problem for this population. When considering treatment options, it is important to understand the nature of the disorder and the observed behavioral deficits. Barkley s (1997) theoretical model provides a useful context in which to evaluate possible treatment interventions and observed outcomes. Barkley (1997) proposed a theory of behavioral inhibition, sustained attention, and executive function in which he ascribed the fundamental problem of ADHD to a deficit in inhibitory control caused by a neurological difference in the prefrontal cortex. This lack of inhibitory control in individuals with ADHD impairs the executive functions that control organization and planning identified as nonverbal working memory, internalization of speech, self-regulation of affect/motivation/arousal, and behavioral analysis and synthesis. These impaired executive functions directly affect an individual s ability to self-manage behavior by 48

2 limiting their capacity to a) consider their own behavior in the context of past events or possible future consequences, b) internalize self-directing statements [which is the crux of cognitivebehavioral self-, Michenbaum, (1977)], c) self-regulate emotional reactions, motivation or effort towards a goal, and arousal, and d) coordinate evaluation of behavior through analysis of events or synthesis of ideas. Empirical research supports this theoretical model and specifically the assumption that children with ADHD present a deficit in self-regulation (Douglas 1989; Miranda, Presentacion, & Soriano 2002; Pennington & Ozonoff, 1996; Sergeant & van der Meere, 1990; Tannock, 1998). Based on this model and drawing from the literature that documents a generalized deficit in selfregulation, researchers have proposed self- as a possible intervention for individuals with ADHD. Self- skills have been identified as a core deficit exhibited in individuals with ADHD with evidence to suggest that remediation and coping strategies can be effectively implemented through behavioral self- interventions (Hinshaw & Melnick, 1992; Shapiro, DuPaul, & Bradley-Klug, 1998). Best Practices in Treatment of ADHD The American Academy of Pediatrics released recommendations for treating children diagnosed with ADHD recommending the use of both psycho-stimulants and behavioral interventions to help control symptoms ( Treat ADHD, 2002). These recommendations for the use of both psycho-stimulants and behavioral interventions are consistent with the majority of literature available on the treatment of ADHD (MTA Cooperative Group, 2004; Brown & La Rosa, 2002). Although best practice indicates a combination is best, in applied practice treatment for symptoms of ADHD typically consists of psycho-stimulants alone (DuPaul, Eckert, & McGoey, 1997; Pelham & Gnagy, 1999; Root & Resnick, 2003). It is a commonly held misconception by parents and educational professionals that psycho-stimulants are the only effective treatment for ADHD (DuPaul et al., 1997; Mathes & Bender, 1997). This is disconcerting when empirical evidence suggests that behavioral interventions are warranted not only in combination with medical, but as the first line of intervention in very young children diagnosed with ADHD and those with mild cases of the disorder (Conners, March, Frances, Wells, & Ross, 2001 as cited in Root and Resnick, 2003). Further, parents indicate that they would prefer other options to medication for treatment of ADHD (Wilson & Jennings, 1996) and express greater satisfaction with treatment when behavioral-psychosocial components are included (MTA Cooperative Group, 2004). Research supporting best practice in treatment for ADHD can be understood in light of Barkley s (1997) theoretical model in which a deficit in inhibition is identified as the fundamental problem. The combination of psycho-stimulants and behavioral-psychosocial interventions is thought to be most beneficial because psycho-stimulants address the deficit in inhibition directly by altering the chemistry of the brain while behavioral-psychosocial interventions can provide strategies for improving deficit areas and can address family system issues (Miranda et al., 2002; Pelham & Gnagy, 1999; Root & Resnick, 2003). Best practice in treatment as it relates to self specifically suggests that self- strategies would be most beneficial when applied in combination with psycho-stimulants. Self-Management as a Potential Treatment for ADHD Before reviewing the relevant literature on ADHD and self-, it should be made clear that by the term self- it is our intent to also include treatments referred to 49

3 in the literature as self-monitoring, self-regulation, self-control, self-talk, and reinforced selfevaluation. There is a division in the literature regarding what self- is and what it is not. Much of the earlier literature on self- and ADHD focuses on a cognitivebehavioral view of self-, where more recent work focuses on a strictly behavioral definition (Roberts & Dick, 1982; Shapiro et al, 1998). The earlier cognitive-behavioral self- literature was reviewed by Abikoff (1985, 1987, 1991). The present review references this earlier work, highlights findings, and reviews recent publications in the area of cognitive-behavioral self- and behavioral self- interventions. Our review includes both perspectives so that comparisons can be drawn between the construction of the interventions used and the treatment effects found. Searches for relevant literature were conducted in medical, psychological, and educational databases. Articles and dissertations were included if the were children or adolescents diagnosed with ADHD and reported using self- (or synonymous label) as an intervention. A total of fourteen publications are included in this review and are summarized in Table 1. Table 1. Summary of articles and dissertations addressing both ADHD and self- Author Design Population & Setting Intervention Outcome variables & Results Austin (2003) Unpublished dissertation design 4 children School setting Barry & Messer (2003) Bradley-Klug (1997) Unpublished dissertation Davies & Witte (2000) Edwards, Salant, Howard, Brougher, & McLaughlin ABABAB design multiple baseline across settings and across ABAB design design 5 male children 3 adolescents 2 male children 2 female children 3 children School setting 3 of the 4 children were using medical is unknown Peer monitoring Token economy Off-task behavior Fidgeting On-task behavior Academic accuracy Academic completion Decrease in Classroom behavior Effects were differential across Inappropriate verbalizations Attention to task 50

4 (1995) is unknown Froelich, Nonexperimental 17 male children Cognitive- Doepfner, & 1 female child behavioral self- Lehmkuhl single group Home and school (2002) AB design settings Parent training Eight were using medical Gureasko- Moore (2004) Unpublished dissertation Hinshaw & Melnick (1992) Hoff & DuPaul (1998) Mathes & Bender (1997) Miranda & Presentacion (2000) multiple baseline across Case Study Multiple probe design across three settings multiple baseline across Four group comparison between two treatment conditions and two sample populations 6 male children 2 male children Summer research program 2 male children 1 female child 3 male children 32 children 16 with aggression 16 without aggression Home and school settings is unknown Anger Management One received medical Token reinforcement w/ verbal feedback No medical Cognitivebehavioral self Combined Cognitivebehavioral self and Anger No medical Reading comprehension ADHD core symptoms Conduct problems Homework problems Class preparation Work completion Anger Non-compliance Aggression Self-control Parent and teacher self-reports were inconclusive Disruptive behaviors Teacher rating scale On-task behavior Parent and teacher self-reports of behavior and academic performance 51

5 Miranda, Presentacion, & Soriano (2002) Shaprio, DuPaul, Bradley-Klug (1998) Shimabukuro, Prater & Jenkins (1999) Quasiexperimental two group comparison Case study multiple baseline across three settings and three 71 children Home and school settings 2 male children 3 male children with ADHD and LD Multi-component teacher education program Cognitivebehavioral self No medical One child was using medical Self-graphing is unknown Parent and teacher self-reports of behavior and academic performance Academic skill Decrease in Behavior problems Academic accuracy Academic productivity On-task behavior Cognitive-behavioral self-. Cognitive-behavioral self- focuses on internal thought dialog, awareness of thoughts, relationships between thoughts, behaviors, and consequences, covert self-statements, and recognizing antecedents of behavior. Examples of cognitive-behavioral self- strategies include self-talk, self-instruction, and problemsolving interventions. For instance, Kendall, Padever, and Zupan (1980) proposed a method for encouraging children to stop and think prior to acting. Cognitive-behavioral self- extends from Meichenbaum's (1977) work on self-statement modification (SSM), and developed from the strictly behavioral perspective by adding the concept that covert thoughts are behaviors that are simply not observable. Michenbaum also proposed a developmental model in which self-statements are gradually internalized through typical development. The internalization of language is thought of as a precursor to the development of self-control and regulation of behavior (Dush, Hirt, & Schroeder, 1989). Abikoff (1991) conducted a thorough review of studies using cognitive-behavioral strategies, many of which used cognitive-behavioral self- specifically. Based on the literature he reviewed, Abikoff contended that in the majority of studies using cognitivebehavioral strategies, little improvement in impulsivity, attention, planning, academic skill, or problem behavior was evident. Minimal gains were found in few studies and most demonstrated no generalization or maintenance of effects. For example, no differences were found between students receiving psycho-stimulants alone and those receiving a combination of psychostimulants and cognitive-behavioral intervention on teacher ratings of student achievement post intervention and outside treatment settings (Abikoff, 1991; Barkley, Copeland, & Sivage, 1980; Hinshaw, Henker, & Whalen, 1984). Drawing from this review, it has been concluded that support for cognitive-behavioral self- with individuals diagnosed with ADHD is limited by a lack of evidence to support generalization and maintenance of gains (Shapiro et al., 52

6 1998). It should be noted, however, that Abikoff indicated the specific diagnoses of samples used in the research he reviewed were inconsistent which presents a problem when attempting to draw inferences about the application of interventions to children with ADHD specifically. Contemporary literature employing cognitive-behavioral self- is very limited. Three articles were identified that used a cognitive-behavioral approach applied to children diagnosed with ADHD. Each used non-experimental designs to address their research questions and assessed outcomes using parent and teacher self-report rating scales. All three applied cognitive-behavioral self- to a sample of children diagnosed with ADHD in a school setting. Miranda and Presentacion (2000) compared the combination of cognitive-behavioral self with anger training to cognitive-behavioral self- alone between children diagnosed with ADHD and those diagnosed with ADHD with aggressiveness. The cognitive-behavioral self- program used was derived from Kendall et al. s (1980) stop and think intervention and included behavioral contingency reinforcement. Outcomes were assessed using seven teacher and parent self-report. Inherent problems of this study are the limited sample size (only eight in each comparison group) and use of interventions at one time. Since all received cognitive-behavioral self- with or without anger, it is difficult to derive any support for cognitive-behavioral self- alone. A second similar study was conducted by Miranda et al. (2002) to assess the effectiveness of a multi-component treatment for ADHD children within a natural school environment. Seventy-one were divided into treatment and control groups dependent on whether the classroom teachers received training in behavior modification, cognitive behavior interventions, and instructional strategies. Outcomes were assessed using neuropsychological tasks, teacher and parent rating scales, and a review of academic records. Results comparing treatment and control groups on neuropsychological measures were inconclusive. Significant decreases in hyperactivity, inattention, and related behavior problems were reported on parent and teacher rating scales. Academic improvement was noted in science, language arts and mathematics. As with the previous article, the use of a multi-component approach makes it difficult to assign support for cognitive-behavioral self- specifically. Froelich, Doepfner, & Lehmkuhl (2002) used a non-experimental AB design to assess the effectiveness of cognitive-behavioral self- on academic skills and conduct problems in home and school settings. In addition to cognitive-behavioral self-, parents also participated in six hours of parent education about ADHD symptoms, treatments, and basic behavioral training in reinforcement, token economies, and the use of response costs. To assess outcomes, parents and teachers completed self-report questionnaires. The authors reported significant findings in reduction of teacher and parent reported symptoms of ADHD, conduct problems, and homework problems. No follow-up measures were included to assess efficacy of these gains. The use of self-report rating scales from parents and teachers as the sole outcome measure is weak in comparison to the literature available employing behavioral self- that typically includes operational definitions of behaviors, data recording, and reliability. In addition, the use of multiple interventions at one time and non-experimental designs make interpretation difficult. Considering the extremely limited current literature available and given Abikoff s (1985, 1987, 1991) reviews of previous literature, there is little to no support available 53

7 for the use of cognitive-behavioral self- for children with ADHD. Drawing this conclusion, however, may be problematic due to the lack of experimental methodology used in the literature and confounding differences in terminology. Therefore, we are inclined to say that support for the use of cognitive-behavioral self- is inconclusive based on the literature reviewed here due to a lack of evidence. It seems intuitive that cognitive-behavioral strategies would work with the ADHD population given the success these same strategies have had in populations with behavior disorders, impulsivity, and self-control [see Robinson, Smith, Miller, & Brownell, (1999)] for a review). However, other researchers reached similar conclusions that cognitive-based strategies are not as successful for individuals diagnosed with ADHD as behavior-based strategies (Abikoff & Gittelman, 1985; DuPaul & Eckert, 1997; DuPaul et al., 1997; Shapiro et al., 1998). In light of Barkley s (1997) theoretical model, it is not surprising that these individuals do not benefit from cognitive based strategies as these approaches rely on executive functioning such as goal setting, reflection, and internalization of skills and verbalizations that are thought to be impaired in ADHD populations. Behavioral self-. After Abikoff s (1991) review of cognitive-behavioral strategies, the literature reflects a shift in focus to behavioral based strategies for children with ADHD in general. Developments in the understanding of the disorder, including Barkley s (1994, 1997) theory of inhibition also likely contributed to the move away from cognitive-behavioral interventions for the population. Research supporting the effects of behavioral based strategies for children with ADHD includes Slusarek, Velling, Bunk, & Eggers (2001), who demonstrated the ability of children with ADHD to overcome their deficit of inhibitory control in highly reinforced situations. Others have demonstrated the effects of strong external reinforcement and response costs on the behavior of children diagnosed with ADHD (Brown & La Rosa, 2002; Carlson & Tamm, 2000). The literature reflects a shift to interventions in which the elements of self become, data based, and include reinforcement and reliability measures of observable behavior change as opposed to internal thought processes and cognitive awareness (Hinshaw & Melnick, 1992). Behavioral self- includes reinforcement, response costs, contingency of behavior with specific prompts for self-monitoring, behavioral goals, operational definitions of behaviors, data based self-assessment, and data recording with reliability measures (Koegel, Koegel, & Parks, 1995). Behavioral self- varies in the amount of control ascribed to the target individual. Shapiro et al. (1998) described the behavioral self- intervention as being based on the work of Rhode, Morgan, and Young (1983). In this procedure, self- exists on a continuum in which more or less control is given to a behavior analyst, teacher, or parent who also monitors the behavior of the target individual to check for accuracy in recording and apply or withhold consequences. As students learn to accurately selfmanage their own behavior, external feedback and reinforcement can be faded depending on need. Of the literature reviewed, eleven studies employed behavioral self- with a sample of children with ADHD and three of these were unpublished dissertations. All studies used a single case design or a case study method with two to six. Each study employed a behavioral self- intervention in an applied school setting. At first glance, the literature in behavioral self-, although extremely limited, shows consistent behavioral changes on individually targeted outcome variables. However, there are significant limitations in the literature that is available. 54

8 Two studies included more than one intervention at a given time (Davies & Witte, 2000; Hinshaw & Melnick, 1992). While this approach is more likely to produce significant results, it makes it impossible to discern which aspects of the intervention actually influenced the findings. For instance, Davies & Witte used a combination of behavioral self- and peer monitoring in a single case ABAB design to assess changes in inappropriate verbalizations in a classroom setting. The intervention was applied class wide to all students and data was collected on the four targeted children with ADHD. While the authors found reductions in the target behavior, it is difficult to say that this literature supports the use of self- specifically. Two studies parceled out aspects of behavioral self- as additional intervention strategies. These authors discussed token economy (Hoff & DuPaul, 1998) and selfgraphing (Shimabukuro, Prater, Jenkins, & Amelia, 1999) separately from their discussion of self-, as if they were an additional intervention. Applying reinforcement through a token economy and self-monitoring through self-graphing of performance data, however, are included in the larger conceptual frame of appropriate self- by most authors. Therefore, these studies are considered in this literature review as examples of behavioral self that include token economy and self-graphing. Findings from these studies are included with those that employed behavioral self- as the only intervention in addition to possible medical. Nine studies, including the three dissertations, used behavioral self- as the only intervention beyond possible medical. These studies consistently found immediate effects on most variables as well as most teacher and parent selfreports where used. For instance, Austin (2003) conducted a study on behavioral self with children with ADHD in a classroom setting. Austin s dissertation provided an extension of the literature by examining multiple reinforcement choices and increasing the involvement of the target child in the development of behavioral goal setting. Each dissertation reported finding immediate behavioral changes in target behaviors; however, self-report measures from parents and teachers did not indicate behavior change as a whole. When considered with the published literature available, these dissertations provide additional support for the use of behavioral self- with children diagnosed with ADHD. As another example, Mathes & Bender (1997) used a single case multiple baseline design to assess effects of behavioral self- on the on task behavior of three male in a school setting. The intervention included timed auditory and written prompts for selfassessment, verbal reinforcement, daily practice and instruction, operational definitions of behaviors and goals, and reliability of data collection by comparing teacher and student data sheets. These authors reported significant increases in on-task behavior for all three that maintained to some degree through a three-day maintenance phase. The authors discussed the lack of measuring long-term maintenance as a weakness of the study and attributed the documented short term success of this intervention to intense daily student involvement in the procedure. Barry & Messer (2003) used behavioral self- in a regular education context targeting five children diagnosed with ADHD. The authors employed a single case ABABAB design with a one-month follow-up to address their research questions. The intervention included timed and written prompts for self-recording data, individually based contingency reinforcement, child choice of reinforcement, daily practice and instruction, operational definitions of behaviors and goals, and reliability of data collection by comparing teacher and student data sheets. The 55

9 researchers reported increases in behaviors of on task behavior, class work accuracy, and class work completion. The authors noted, however, that in each A phase, the student s behavior returned to baseline levels. Further, at follow-up in which data seemed to maintain from the final B phase, the teacher still employed the self- intervention, although it had been faded to some extent. Issues with generalization and maintenance of initial treatment effects, as identified in Barry & Messer (2003) above, were also noted by other authors (Hinshaw & Melnick, 1992; Hoff & DuPaul, 1998; Shapiro et al., 1998). For instance, Shapiro et al. reported that the children in their case studies never achieved complete self- because they ran out of time in the school year. Hoff & DuPaul and Barry & Messer found that they could fade treatment and effects would maintain to some extent over baseline, but fading was limited. Further, generalization across settings did not occur without specific skill instruction in new settings (Hoff & DuPaul). In general, the initial effects documented did not generalize to novel environments and did not maintain over time without additional support. Taken in light of Barkley s (1997) theory, it is likely that behavioral support strategies will have limited generalization and maintenance for this population. These children will likely need continued behavioral support throughout their lifespan to assist them in behavior change because these children exhibit a deficit in their ability to apply what they have learned previously to new situations or contexts. Further, these children lack the ability to self-regulate their motivation or effort to continue self- of their behavior in the absence of external contingency reinforcement. The use of medical in the samples is unknown in four of the sources reviewed. Only one, Hoff & DuPaul (1998) specifically indicated that they selected who were not using medical interventions of any kind. Hoff & DuPaul reported decreases in disruptive behavior using a multiple probe design across behaviors with three students. Others did not report the participant s use of medical or we did not have access to that information. Several articles report that changes were made to the medical plan of a given participant that was out of their control. This lack of information and inconsistency in treatment further limits our ability to interpret findings. Based on the wealth of literature available on ADHD in general and the resulting best practices for treatment interventions, it seems likely that results of behavioral self- would be improved when combined with medical. The success of behavioral self- over cognitive-behavioral self- supports Barkley s (1997) logic. Because these children have a deficit in several aspects of executive functioning, they lack the ability to participate in cognitive-behavioral self without behavioral support and ongoing intervention. The deficit in inhibitory control may preclude individuals with ADHD from performing the cognitive processes necessary to apply more cognitive based strategies. The use of reinforcement to increase accuracy in data recording within self- may assist children diagnosed with ADHD to overcome the lack of inhibitory control associated with the disorder (Barry & Messer, 2003; Slusarek et al., 2001). Future Research Directions Due to the limited sources available for review in the area of self- as it is applied specifically to children with ADHD, a primary area for future research should focus on investigations of the application of behavioral self- to this population in general. More specifically, investigations that employ true experimental designs with appropriate sample sizes and controls that limit threats to internal validity should be pursued. In addition, all future 56

10 research in this area should include clear information regarding the diagnoses of and the medical interventions already in place including any changes in medical during an investigation. Beyond this general call for research, there are specific research questions that warrant further investigation. There is a clear need for a component analysis of behavioral self- as it is applied to children with ADHD. The various component parts that, as a whole, create behavioral self- need to be and analyzed using component analysis to find which parts of the intervention contribute to documented effects found for this population. Further parceling out of reinforcement and self-recording strategies such as individual versus group contingencies and self-graphing versus self-charting of behavioral data could also be investigated. Most of the research reviewed here applied self- in a school environment. While the classroom setting is an excellent context for the application of self-, certainly the deficits in executive functioning experienced by these children affects their abilities in other contexts beyond school. Other research has demonstrated benefits of self- in home settings with children with other disabilities including autism (Barry & Singer, 2001) and mental retardation (Barry & Santarelli, 2000). Further research should include application of self in home and community settings with children diagnosed with ADHD based on individual need. Several future research directions were articulated in the literature reviewed. For instance, Hoff & DuPaul (1998) called for future research on the reactive effects of self on additional variables. These authors also discussed the need for future research on fading procedures, ease of implementation, and the level of student involvement in the procedure. Hinshaw & Melnick (1992) discussed the need for research on the effects of various combinations of strategies and the effects of treatment length. Related to treatment length, most authors of the literature we reviewed articulated the need for further investigation of generalization and maintenance issues. Implications for Practice As professionals in the field of behavior analysis, it is important to keep the cause and function of behavior in mind when implementing treatment. In the case of individuals diagnosed with ADHD, deficits in inhibitory control and the concomitant deficits in executive functions must be considered. Professionals can use tools such as motivation assessments to detect true behavioral deficits as compared to performance deficits. Observed skill deficits do not necessarily mean that the individual has not learned those skills. More likely, professionals will need to address deficits in inhibitory control by applying behaviorally based interventions, such as self, in combination with psycho-stimulants. Based on the literature reviewed, components of behavioral self- that may influence the beneficial effects found include a) timed auditory and/or written prompts for selfrecording of behavioral data, b) individually or group based contingency reinforcement, c) child choice of reinforcement, d) daily practice and instruction, e) operational definitions of behaviors and goals, f) reliability of data collection by comparing teacher and student data sheets or graphs g) specific skill instruction in empirically and theoretically supported areas of deficit, h) monitored acquisition of skill, and i) the possible combination of the intervention with medical. In practice, until a worthy component analysis is complete; the application of behavioral-self may work best if each of these components is used in some capacity. 57

11 Generalization of treatment effects was a consistent problem identified in the literature of both cognitive-behavioral and behavioral self-. In practice, interventions should be implemented across multiple settings as it is quite clear generalization will not automatically occur in this population. Specific skill instruction in self-, or any other behavioral support, is likely to be needed in each new setting. Additionally, problems with maintenance of behavioral change were reported in the literature. Maintenance of effects should be addressed using caution with careful fading procedures developed based on individual needs. Professionals in field of behavior analysis should be aware that, for the ADHD population, total fading of behavioral supports may not be warranted. The deficit in inhibitory control and associated executive functions experienced by children with ADHD may require that behavioral supports be long term support strategies. Finally, in light of best practices in treatment of ADHD and given the large numbers of children with ADHD who are prescribed medication, it would likely be useful for parents and professionals, including the prescribing physician working with a given child, to collaborate with each other to coordinate and monitor interventions. In the literature reviewed, changes in medication during the course of a given study were a recurring limitation. Clearly, collaboration between treatment providers is missing in these instances. Behavior specialists can be valuable liaisons between physicians, schools, and parents while providing consultation and assistance in planning, implementing, and monitoring effective behavioral self- strategies across settings. Since ADHD is a chronic disorder impacting the individual across the life-span, and given limitations in generalization and maintenance of interventions, behavior specialists have the unique opportunity of providing flexible, research based treatment plans, with consistency across time and settings, and coordination of those involved to promote positive prognoses for this population. Author Design Population & Setting Austin (2003) 4 children School Unpublished design setting dissertation Barry & Messer (2003) Bradley-Klug (1997) Unpublished dissertation ABABAB design multiple baseline across settings and across 5 male children 3 adolescents Intervention 3 of the 4 children were using medical is unknown Outcome variables & Results Off-task behavior Fidgeting On-task behavior Academic accuracy Academic completion Decrease in Classroom behavior Effects were differential across 58

12 Davies & Witte (2000) Edwards, Salant, Howard, Brougher, & McLaughlin (1995) Froelich, Doepfner, & Lehmkuhl (2002) Gureasko- Moore (2004) Unpublished dissertation Hinshaw & Melnick (1992) Hoff & DuPaul (1998) ABAB design design Nonexperimental single group AB design multiple baseline across Case Study Multiple probe design across three settings 2 male children 2 female children 3 children School setting 17 male children 1 female child Home and school settings 6 male children 2 male children Summer research program 2 male children 1 female child Peer monitoring Token economy is unknown Cognitivebehavioral self Parent training Eight were using medical is unknown Anger Management One received medical Token reinforcement w/ verbal feedback No medical Inappropriate verbalizations Attention to task Reading comprehension ADHD core symptoms Conduct problems Homework problems Class preparation Work completion Anger Non-compliance Aggression Self-control Parent and teacher self-reports were inconclusive Disruptive behaviors Teacher rating scale Mathes & Bender (1997) multiple baseline across 3 male children On-task behavior Miranda & Four group 32 children Cognitive- 59

13 Presentacion (2000) Miranda, Presentacion, & Soriano (2002) Shaprio, DuPaul, Bradley-Klug (1998) Shimabukuro, Prater & Jenkins (1999) comparison between two treatment conditions and two sample populations Quasiexperimental two group comparison Case study multiple baseline across three settings and three 16 with aggression 16 without aggression Home and school settings 71 children Home and school settings 2 male children 3 male children with ADHD and LD References behavioral self Combined Cognitivebehavioral self and Anger No medical Multi-component teacher education program Cognitivebehavioral self No medical One child was using medical Self-graphing is unknown Parent and teacher self-reports of behavior and academic performance Parent and teacher self-reports of behavior and academic performance Academic skill Decrease in Behavior problems Academic accuracy Academic productivity On-task behavior Abikoff, H. (1985). Efficacy of cognitive training interventions in hyperactive children: A critical review. Clinical Psychology Review, 5, Abikoff, H. (1987). An evaluation of cognitive-behavior therapy for hyperactive children. In B.B. Lahey & A.E. Kazdin (Eds.), Advances in clinical child psychiatry, (Vol. 10, pp ). New York: Plenum Press. Abikoff, H. (1991). Cognitive training in ADHD children: Less to it than meets the eye. Journal of Learning Disabilities, 24(4), Abikoff, H., & Gittelman, R. (1985). Hyperactive children treated with stimulants: Is cognitive training a useful adjunct? Archives of general Psychiatry, 42, Austin, H. M. (2003). Use of self- techniques for the treatment of students diagnosed with ADHD: An empirical investigation of the self-regulation of behavior. Dissertation Abstracts International, 64(06), (AAT ) 60

14 Barkley, R. A. (1994). Impaired delayed responding: A unified theory of attention deficit hyperactivity disorder. In D. K. Routh (Ed.), Disruptive behavior disorders: Essays in honor of Herbert Quay (pp.11-57). New York: Plenum. Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin, 121(1), Barkley, R. A. (2000). Commentary on the multimodal treatment study of children with ADHD. Journal of Abnormal Child Psychology, 28(4), Barkley, R. A., Copeland, A., & Sivage, C. (1980). A self-control classroom for hyperactive children. Journal of Autism and Developmental Disorders, 1, Barry, L. M., & Messer, J. J. (2003). A practical application of self- for students diagnosed with attention deficit/hyperactivity disorder. Journal of Positive Behavior Interventions, 5(4), Bradley-Klug, K. L. (1997). The effects of a self- intervention on the classroom behavior of young adolescents with attention deficit hyperactivity disorder. Lehigh University. Dissertation Abstracts International, 58(05), (AAT ) Brown, R. T., & La Rosa, A. (2002). Recent developments in the pharmacotherapy of attentiondeficit/hyperactivity disorder (ADHD). Professional Psychology: Research and Practice, 33(6), Carlson, C. L., & Tamm, L. (2000). Responsiveness of children with attention deficithyperactivity disorder to reward and response cost: Differential impact on performance and motivation. Journal of Consulting and Clinical Psychology, 68(1), Conners, C. K. (2002). Forty years of methylphenidate treatment in attention-deficit/hyperactivity disorder. Journal of Attention Disorders, 6(1), S Davies, S., & Witte, R. (2000). Self- and peer-monitoring within a group contingency to decrease uncontrolled verbalizations of children with attentiondeficit/hyperactivity disorder. Psychology in the Schools, 37(2), Douglas, V. I. (1989). Can Skinnerian therapy explain attention deficit disorder? A reply to Barkley. In L. M. Bloomingdale & J. Swanson (Eds.), Attention deficit disorder: Current concepts and emerging trends in attentional and behavioural disorders of childhood (pp ). Oxford, England: Pergamon Press. DuPaul, G. J., & Eckert, T. L. (1997). The effects of school-based interventions for attention deficit hyperactivity disorder: A meta-analysis. The School Psychology Review, 26(1), DuPaul, G. J., Eckert, T. L., & McGoey, K. E. (1997). Interventions for students with attentiondeficit/hyperactivity disorder: One size does not fit all. School Psychology Review, 26(3), Dush, D. M., Hirt, M. L., & Schroeder, H. E. (1989). Self-statement modification in the treatment of child behavior disorders: A meta-analysis. Psychological Bulletin, 61

15 106, Edwards, L., Salant, V., Howard, V. F., Brougher, J., & McLaughlin, T. F. (1995). Effectiveness of self- on attentional behavior and reading comprehension for children with attention deficit disorder. Child and Family Behavior Therapy, 17(2), Frazier, M. R., & Merrell, K. W. (1997). Issues in behavioral treatment of attention deficit/hyperactivity disorder. Education and Treatment of Children, 20, Froelich, J., Doepfner, M., & Lehmkuhl, G. (2002). Effects of combined cognitive behavioural treatment with parent training in ADHD. Behavioural and Cognitive Psychotherapy, 30, Gureasko-Moore, S. P. (2004). The effects of self- on organizational skills of adolescents with ADHD. Dissertation Abstracts International, 65(03), (AAT ) Hinshaw, S. P., & Erhardt, D. (1991). Attention deficit-hyperactivity disorder. In P. C. Kendall (Ed.), Child and adolescent therapy: Cognitive-behavioral procedures (pp ). New York: Guilford. Hinshaw, S. P., Henker, B., & Whalen, C. K. (1984). Cognitive-behavioral and pharmacologic interventions for hyperactive boys: Comparative and combined effects. Journal of Consulting and Clinical Psychology, 52, Hinshaw, S. P., & Melnick, S. (1992). Self- therapies and attention-deficit hyperactivity disorder. Behavior Modification, 16, Hoff, K. E., & DuPaul, G. J. (1998). Reducing disruptive behavior in general education classrooms: The use of self- strategies. The School Psychology Review, 27(2), Kendall, P. C., Padever, W., & Zupan, B. (1980). Developing self-control in children: A manual of cognitive-behavioral strategies. Minneapolis: University of Minnesota. Koegel, R. L., Koegel, L. K., & Parks, D. R. (1995). A Guide to self-: A training manual. University of California, Santa Barbara. Mathes, M. Y., & Bender, W. N. (1997). The effects of self-monitoring on children with attention-deficit/hyperactivity disorder who are receiving pharmacological interventions. Remedial and Special Education, 18, Michenbaum, D. H. (1977). Cognitive behavior modification: An integrative approach. New York: Plenum. Miranda, A., & Presentacion, M. J. (2000). Efficacy of cognitive-behavioral therapy in the treatment of children with ADHD, with and without aggressiveness. Psychology in the Schools, 37(2), Miranda, A., Presentacion, M. J., & Soriano, M. (2002). Effectiveness of a school-based multicomponent program for the treatment of children with ADHD. Journal of Learning Disabilities, 35(6),

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17 Treat ADHD with behavior techniques and meds, pediatricians say. (2002, January). Curriculum Review, 41, S3. Wilson, L. J., & Jennings, J. N. (1996). Parents acceptability of alternative treatments for attention-deficit hyperactivity disorder. Journal of Attention Disorders, 1(2), Author Contact Information Leasha M. Barry, PhD University of West Florida College of Professional Studies Special, Primary, & Vocational Education University Pkwy, 85/189 Pensacola, FL (850) Dana L. Haraway, PhD University of West Florida College of Professional Studies Special, Primary, & Vocational Education University Pkwy, 85/164 Pensacola, FL (850) Advertising in The Behavior Analyst Today Advertising is available in BAT. All advertising must be paid for in advance. Make your check payable to Joseph Cautilli. The copy should be in our hands 3 weeks prior to publication. Copy should be in MS Word or Word Perfect format and advertiser should include graphics or logos with ad copy. The prices for advertising in one issue are as follows: 1/4 page: $ /2 page: $ vertical or horizontal Full Page: $ If you wish to run the same ad in all four issues for the year, you are eligible for the following discount: 1/4 Pg.: $40 - per issue 1/2 Pg.: $75 - per issue -vertical or horizontal Full Page: $ per issue For more information, or place an ad, contact: Joe Cautilli via at jcautilli@cctckids.com or by phone at (215)