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Section 18
A Multimethod Intervention with Children with ADHD and their Parents

Question 18 | Test | Table of Contents

Cognitive (e.g., self-instruction and self-monitoring), behavioral (e.g., behavioral rehearsal and contingent reinforcement), and medication procedures are appealing because when used in combination, they appear to focus on the remediation of primary deficiencies of children with ADHD, including poor problem-solving capabilities, impulsivity, and difficulties with rules and instructions (Barldey; Weiss & Hechtman). Unfortunately, although these techniques appear to be effective, significant others in the child’s life generally are not included in social skills treatment. Likewise, skills learned in an artificial treatment setting typically do not generalize to naturalistic settings such as the home and playground (DuPaul & Eckert). There is a need to incorporate specific generalization components into social skills programs, and parents can be instrumental in this process. Parents play essential roles in a child’s socialization experiences and should be involved in the intervention process (Budd). It has been empirically demonstrated that parents can be trained to effectively manage overt behavioral problems and noncompliance in children with ADHD (Barkley); however, their role in enhancing prosocial skills is not clearly understood. It may be unrealistic to expect parents to provide direct and primary social skills training to their children (Budd). For example, the task of social skills training may be challenging when a child is noncompliant or demonstrates extremely socially deficient behaviors. Further, the construct of "social competence" may be elusive, complex, and contextually determined. These characteristics will likely cause many parents difficulties with important concepts and strategies. However, we believe that parents are in an ideal position to provide supplemental (i.e., adjunct) training in natural settings; help children’s problem-solving efforts directly within the social environment; and prompt, monitor, and reinforce skill use immediately The majority of general social skills training programs, however, give little attention to the manner in which parents can facilitate children’s social development and experiences in naturalistic situations. This study sought to investigate the efficacy of a combined medication/social skills training program for children diagnosed as Attention Deficit-Hyperactivity Disorder (ADHD) and their parents. Specific objectives included (a) teaching children with ADHD skills in social entry, maintaining interactions, and problem solving through cognitive-behavioral procedures; (b) encouraging child subjects to generalize these skills to nontreatment settings through relevant rehearsal and behavioral contracts; (c) training parents of children with ADHD in the skills of debriefing, problem solving, and goal setting to help their children with their social difficulties; and (d) encouraging parent subjects to generalize skills to nontreatment settings. Consumer satisfaction with the procedures also was assessed. Child subjects included 5 boys who met the diagnostic criteria for ADHD as outlined in the American Psychiatric Association’s DSM. Subjects ranged in age from 8 to 10 (M age = 9.0), and were enrolled in grades 2 through 5 (M 4). All subjects were Caucasian. Four subjects lived with both biological parents; I lived with his mother and stepfather. Subjects attended separate public schools, with only I receiving pull-out resource services.

Child Training
Children’s social skills training groups were conducted by two graduate students in school psychology. The leaders were provided with a detailed manual which outlined the (a) rationale for social skills training for students with ADHD; (b) general procedures for facilitating groups; and (c) specific steps for conducting group sessions (Sheridan). Ongoing (i.e., weekly) supervision was provided by the senior investigator. All sessions were video taped through a one-way mirror. The objective of the child group included teaching child subjects the skills of social entry (SE), maintaining interactions (Ml), and solving problems (SP). These behaviors were chosen prior to subject selection to allow for systematic and direct assessment of a predetermined set of skills, to control behavioral targets, and to solicit a relatively homogeneous sample. The skills were routinely identified by parents of these and previous clients to be problematic for their children with ADHD (Sheridan). Further, these skills have been identified by previous authors as problematic for children with ADHD (Guevremont). However, careful functional analyses of subjects’ skills were not conducted and may be considered a limitation of the present study. Within each general social skills area, at least two observable, measurable target behaviors were taught. Each child group included a review of homework and home programs with parents, identification of personal goals, introduction and discussion of a new skill, modeling, behavioral rehearsal, performance feedback by leaders and peers, reinforcement for appropriate within-group behavior and for returning homework, and establishment of a weekly home contract. Some of the salient aspects of the group are described below.
Modeling. Modeling was introduced to the group in two phases. First, the two group leaders demonstrated the skill using inappropriate procedures and requested that subjects identify problems with the role play. This procedure proved helpful in maintaining subjects’ interest as it injected humor into the group. Second, the leaders performed the skill again, corrected initial mistakes as pointed out by the subjects, and asked for additional feedback.
Behavioral rehearsal. Behavioral rehearsal (role play) procedures required subjects to perform the weekly skill with each other. Each subject had an opportunity to role play at least once in each group session. To the greatest extent possible, actual situations relevant to individual subjects were used as role play scenarios. Role plays were followed with performance feedback by peers and leaders, and subjects were required to continue rehearsing the skill until they performed it effectively (i,e., by following all of the required steps).
Homework/Contracts. Weekly homework sheets were distributed, requiring subjects to (a) self-monitor each occasion they used the weekly skill, (b) identify strengths and weaknesses in their behavior, (c) discuss their skill usage with their parents, and (d) obtain their own and their parent’s signatures prior to returning to the group. On the reverse side of the homework sheet was a "home program form" on which parents and their children established a contract for behavioral performance and home-based reinforcement. Specifically, parent and child subjects identified behavioral goals for performing the target skill and reinforcement contingencies for meeting the goals (i.e., the reinforcer to be earned, time frame for earning it, and number of behavioral occasions required for reinforcement). Compliance with the homework component was reinforced in the groups via a "mystery motivator system" (Rhode, Jenson, & Reavis).

Parent Training
The objectives of parent training were to teach parents to (a) interact and converse with their child in a supportive and nonthreatening manner (Debriefing); (b) guide and support their child’s efforts to resolve their social difficulties (Problem Solving); (c) assist their child in establishing social goals for themselves (Goal Setting); and (d) help their child generalize skills learned in the children’s group to actual social situations (Transferring). The components of parent training included the 10-week group, a written manual, video taped modeling, role play, and in vivo performance feedback via an unobtrusive transmitter (i.e., Bug-in-the-Ear). The parents’ group was conducted by two graduate students in school psychology supervised by the senior author. The skills taught to parents in the group are in Table I. Within each group session, the group leader facilitated discussion of the weekly skill with input and interaction elicited from parent subjects. Specifically, after presenting basic information, relevant examples and situations were generated by parents as they applied to their own children. Key components of the parents’ group are described below.
Manual. A written manual (Sheridan & Dee) was given to parents at the beginning of parent training. Parents were asked to read only the chapter assigned each week in the parent group. The contents of the parent manual included (a) the importance of social skills; (b) positive reinforcement; (c) debriefing; (d) problem solving; (e) goal setting; (f) transferring; and (g) putting it all together. The parents’ manual served as a forum for instruction and discussion within the parent groups.
Video tape models. Video tape models of each parent skill (i.e., reinforcement, debriefing, problem solving, goal setting, transferring) were developed by the first two authors using various child actors. The video tape models (n = 5) ranged in length from 4-10 minutes. Specific steps of each parent skill were demonstrated in each tape. Three independent observers viewed the tapes as training for observations of parent skills (see below), and agreed that all components of each skill were present. The video tapes were shown to parent subjects approximately every 2 weeks, when new target skills were first presented (i.e., Weeks 2, 3, 5, 7, and 8).

In vivo performance feedback. The Bug-in-the Ear (Farrall Instruments), an unobtrusive transmitter similar in appearance to a standard hearing aid, was used by one of the group leader (second author) to provide live feedback and prompts to parents as they interacted with their child in the social skills clinic. Specifically, after each group session, the parent and child sat at a table in a room equipped with a one-way mirror, a microphone attached to the ceiling, and wiring to support the transmitter system. The observer sat on the opposite side of the mirror next to a speaker through which she could hear the parent and child talking. The parent and child were instructed to engage in a conversation about a social situation in which the child participated. The parent was asked to perform the skills learned to date in the parent training group (i.e., debriefing, problem solving, and/or goal setting). As the leader observed the parent and child, she provided verbal feedback and prompts to the parent via a microphone that transmitted her voice through the Bug-in­-the-Ear. Feedback statements included comments such as "Nice job using eye contact with your child"; prompts included statements such as "Tell him you understand how he would feel frustrated."

Discussion
All child-subjects demonstrated mean increases in each target behavior with the onset of treatment. Treatment gains were most stable for social entry behaviors, and appeared to maintain over time for most subjects. On the other hand, treatment effects for maintaining interactions and solving problems skills were more variable across subjects. Although mean increases were evident across baseline and treatment conditions, replicated treatment effects across behaviors and subjects was not evident. Little observed effect was noted in child subjects’ performance of target skills in the naturalistic setting of the school playground, particularly in regard to social entry and solving problems skills. Some changes were noted in Ml skills, however a great deal of variability within and overlap between conditions was evident. While unequivocal conclusions regarding these data patterns are difficult to make, it should be noted that the social difficulties of children with ADHD are quite intractable. The intervention was only 10 weeks long and was probably ineffective in producing long-range effects. Variability in performance and the need for ongoing intervention are central in understanding the behaviors of children with ADHD (Weiss & Hechtman). All child-subjects reported increases of at least one standard deviation on self-reports of social skills. Three parents and two teachers reported similar increases. However, inconsistencies were noted in child-subjects’ responsiveness to various measures. On analogue observation assessments, Subjects 4 and 5 demonstrated relatively good treatment effects, with changes in level and low to moderate overlap across social entry and maintaining interactions behaviors. Subjects I and 3 demonstrated the most consistent improvements on the SSRS. Subjects 3 and 4 parent ratings on 5 of the 6 Conners’ factors improved by at least one standard deviation. Regarding parent skills, Subjects 3 and 5 demonstrated the best general response to treatment. All parent-subjects demonstrated mean increases in their use of problem solving skills with the onset of treatment, but only 4 of 5 subjects exhibited increases in debriefing and goal setting. Parents’ use of skills appeared variable during treatment phases, however, percentages of overlapping data points were low for at least 2 subjects across all skills. Children and parents generally reported the interventions to be acceptable.
- Sheridan, Susan M and Candace C Dee; A multimethod intervention for social skills deficits in children with ADHD and their parents; School Psychology Review; 1996, Vol. 25 Issue 1, p57

Personal Reflection Exercise #4
The preceding section contained information about a multimethod intervention with children with ADHD and their parents.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
The management of ADHD in children and adolescents:
bringing evidence to the clinic: perspective from the
European ADHD Guidelines Group (EAGG)

- Coghill, D., Banaschewski, T., Cortese, S., Asherson, P., Brandeis, D., Buitelaar, J., Daley, D., Danckaerts, M., Dittmann, R. W., Doepfner, M., Ferrin, M., Hollis, C., Holtmann, M., Paramala, S., Sonuga-Barke, E., Soutullo, C., Steinhausen, H. C., Van der Oord, S., Wong, I. C. K., Zuddas, A., … Simonoff, E. (2023). The management of ADHD in children and adolescents: bringing evidence to the clinic: perspective from the European ADHD Guidelines Group (EAGG). European child & adolescent psychiatry, 32(8), 1337–1361. https://doi.org/10.1007/s00787-021-01871-x

Peer-Reviewed Journal Article References:
Granziera, H., Collie, R. J., Martin, A. J., & Nassar, N. (2021). Behavioral self-regulation among children with hyperactivity and inattention in the first year of school: A population-based latent profile analysis and links with later ADHD diagnosis. Journal of Educational Psychology.

QUESTION 18
In Sheridan’s multimethod intervention, what are the four objectives of parent training? To select and enter your answer go to Test.

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