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Section 20
Conjoint Behavioral Consultation for Children with ADHD

Question 20 | Test | Table of Contents

CBC (conjoint behavioral consultation) is defined as a structured model of service delivery that joins parents and teachers in collaborative problem solving with the assistance of a consultant—psychologist. It is carried out in four stages: problem identifica­tion, problem analysis, treatment implementation, and treatment evalu­ation (Sheridan et al.). In this model, the relation between home and school is viewed as a cooperative and interactive partnership with shared ownership of a problem. Among the assumptions of CBC are that parents and teachers will share information, learn from each other, value each other’s input, and incorporate each other’s insights into intervention plans. As such, collaborative problem solving between the home and school systems is believed to afford the greatest benefits (Sheridan & Kratochwill; Sheridan et al.). The utility of CBC as a process by which to structure and support behavioral interventions has been evaluated in previous research. The first study investigated the treatment of socially withdrawn elementary school children, and CBC resulted in a substantial increase in social initiations for clients in both home and school settings (Sheridan, Kratochwffl, & Elliott). Another investigation was conducted with children experiencing academic underachievement. Participants were elementary schoolchildren who frequently failed to complete math assignments or completed the math assignments with low levels of accuracy. For 3 participants, a home note and self-instruction manual was used to address the performance deficit. For 3 additional participants, CBC was added to the procedures. Results indicated that although all children demonstrated improvements in math completion arid accuracy, achievement gains were greater and more stable in the CBC condition than in the home-note/instruction-manual condition. Further, treatment integrity and acceptability as well as maintenance of treatment gains were greater when CBC was an active intervention compo­nent (Galloway & Sheridan,; additional case studies are reported in Sheridan et al). This study extends previous research by investigating its efficacy with 3 boys diagnosed with attention deficit hyperactivity disorder (ADHD) who were experiencing deficits in specific social behav­iors.

ADHD And Social Skills
As many as 50% to 60% of children with ADHD experience social problems (Barkley). Further, social problems and peer rejection prob­lems tend to be maintained over time and are quickly reestablished even when moving into a new peer group. Children with ADHD seem unable to modulate their behavior in response to situational demands (Abikoff), and may not benefit from past experiences because they have diffi­culty taking the time to consider consequences before speaking or acting (Silver). Weiss and Hechtman discussed several long-term follow-up stud­ies of children with ADHD. In their extensive review, they reported that children who experience ADHD with antisocial behavior patterns are at risk for developing problems later in life. These problems include occupa­tional difficulties, relationship and marital difficulties, alcoholism, antiso­cial and criminal behavior, and psychiatric disorders. Children with ADHD experience a wide variety of problems related to their disorder. However, most intervention research has focused on behav­ioral and academic concerns. The social problems of children with ADHD are less frequently prioritized in research. The purpose of this study was to evaluate the efficacy of an intervention package comprised of CBC and social skills training (SST) in improving the cooperative play behaviors of 3 boys with ADHD. Although one goal of consultation services is to individualize services for children based on unique case needs, the experimental design required continuity of pro­grams across participants. Therefore, a behavioral social skills interven­tion with four general strategies (coaching, self-monitoring, home-school communication, positive reinforcement) was employed across participants. Individualization occurred as parents and teachers jointly identified primary social problems and coconstructed specific intervention tactics. Direct measures of social behaviors in analogue settings and behavioral checklists served as the dependent variable. Measures of treatment acceptability, treatment integrity, and social va­lidity were also included.

Consultation Stages And Treatment Components
Based on the information obtained during screening, the focus of consult­ation across all cases was identified as increasing positive cooperative play behaviors (i.e., positive interactive social behaviors such as praising, con­versing, smiling, and sharing; and positive noninteractive behaviors or game-related behaviors if the child was clearly engaged in play with another child, such as waiting for a turn). CBC was carried out in four stages (problem identification, problem analysis, treatment implementation, and treatment evaluation) and involved three structured interviews (problem identification, problem analysis, and treatment evaluation). Standardized CBC interview forms were used in this study (see Sheridan et al.). Denise L. Colton (a doctoral student in school psychology with extensive training in behavioral consultation, assessment, and interventions) served as the consultant in each case.

Problem Identification: A problem identification interview (P11) was conducted by the consultant with each of the mother-teacher consultee dyads. Pus were conducted in teachers’ classrooms after school. Total time commitment for completing PITs averaged approximately 60 mm. The purposes of this interview were to discuss behaviors relevant to social skills that were problematic for each client and to develop procedures by which parents and teachers could collect anecdotal data across all experimental phases. Specifically, con­sultees used narrative recording procedures to record observational infor­mation regarding the types of difficulties the child encountered with peers (e.g., teasing) as well as outcomes of these encounters (e.g., hitting, crying, running away).

Problem Analysis: The problem analysis stage of CBC was initiated via the problem analysis interview (PAl). PAls were conducted between 5 and 14 days after PITs for each participant (lengthier periods were required for 2 participants due to scheduled school breaks). PAls averaged approximately 40 minutes and were conducted in teachers’ classrooms. Problem analysis and PATs involved two phases. In the analysis phase, the consultant and consultees discussed the narrative information collected by consultees and conditions surrounding clients’ problem behavior(s). For example, it was noted that Child 3’s social difficulties were often related to isolative behaviors. Antecedents included not being asked to play and failing to initiate interactions on his own. When he did ask others to play, it was reported that he was often teased and rejected, thereby reinforcing his isolative play. The narrative information collected by parents and teachers was used to select target subskills that would be the focus of training. This was accom­plished in two phases. First, a list of cooperative behaviors based on McGinnis and Goldstein (1984) was presented to parent-teacher pairs. Then the parent, teacher, and consultant together identified seven cooperative behaviors that were believed to be priority subskills. These seven priority subskills became the content of SST. Table 1 lists the priority subskills taught to each participant.

In the plan phase of the PAL a 15-day behavioral SST program was discussed among the consultant and consultees. This program served as an overarching structure within which individualization occurred per child. In other words, similarbehavioral strategies were used across children (i.e., social skills coaching and role play, self-monitoring of recess behaviors, a home—school communication system, and positive reinforcement). How­ever, details of individual programs (i.e., program tactics) were cocon­structed by parents and teachers with the assistance of the consultant. For example, each parent—teacher pair determined (a) the specific subskills to be included on "friendship recipe cards," (b) when and where coaching would occur, (c) the person responsible for coaching, (d) reinforcement schedules, and (e) the specific reinforcers to be earned by individual chil­dren and their mode of delivery (e.g., reinforcement menu). We discuss general strategies in the following section.

Coaching and role play. Coaching and role-play procedures were im­plemented as primary skill-training mechanisms. Specifically, steps for each cooperative play subskill were written on note cards termed "friend­ship recipe cards," which served as a medium for coaching. Steps were adapted from the skillstreaming curriculum (McGinnis & Goldstein, 1984). The back side of each card contained general recess rules, including "what to do" (e.g., play nicely with others; practice your recipe goal during at least one recess today) and "what not to do" (e.g., no hitting or fighting, no teasing or name calling). Coaching instruction cards were included with each friendship recipe card, instructing the coach (the teacher or parent) to (a) review recess rules, (b) explain the steps in the chosen skill, (c) discuss examples and nonexamples of the skill, and (d) role play a scenario with the child. On alternate days, each child drew a recipe card to practice for 2 school days. On Day 15 of the intervention, each child was allowed to choose a favorite card from those already practiced and repeat that skill. For Child 1 and Child 3, teachers provided coaching of each target skill in their classrooms before the first recess each day. During the PAT, the teacher of Child 2 indicated that she did not have adequate time to provide the coaching, so it was agreed that the procedure would be carried out by this child’s mother at home before school each day. The daily coaching sessions lasted approximately 5 to 7 min each.

Self-monitoring. As part of the behavioral intervention, participants self-monitored their behaviors during three recess periods per day. After the child was coached in the skill identified on the friendship recipe card, he was responsible for practicing the skill on the playground and monitor­ing his performance. A home—school note provided a place for the child to rate performance of his target skill (whether he used the skill, when and with whom he used the skill, and how it went). Each child also rated how well he followed the recess rules during each recess period on a scale of I (poor) to 4 (excellent). The teacher completed this section with the child by discussing his play behaviors each day. Unknown to the child, teachers made random casual observations during recess to confirm that the child’s self-ratings were reasonably honest. Due to logistical and practical con­straints, these observations were informal and thus did not generate objec­tive behavioral data.

Home—school communication system. An important component of the treatment package involved systematic home--school communication. This was accomplished through a daily two-page home-school note that included (a) recess rules, (b) the skill being practiced, (c) the self-monitoring component as described previously, and (d) questions for the child’s parent to review his daily behaviors (e.g., "Did I discuss my friendship recipe card with mom or dad and tell them about when I practiced it today?"; "How many points did I earn?"; "Was the home note signed and returned to school yesterday?"). Points were awarded for successful completion of each part of the home note. Teachers and parents were responsible for filling out the information on the home—school note and had five and eight questions to complete, respectively. Information included on the note was obtained via direct questions to the child, whose input was necessary for completing the note. An outline of all components of the home note/self-monitoring form appears in Table 2.

Positive reinforcement. In addition to teacher and parent praise for engaging in cooperative interactions with peers, the participants also re­ceived points for practicing their skill recipes (worth 15 points), following the recess rules (assessed by self-report and worth up to 15 points), discuss­ing their performance with their parents (5 points), and returning the home note to school each day (5 points). Thus, up to 40 points were possible daily. A daily reward was provided by parents if 35 points were attained each day. Reinforcers varied across children and included money, visits with friends, kite flying, ice-cream cones, etc.

Treatment Implementation and Evaluation
During the treatment implementation stage, intervention plans were im­plemented and behavioral data were collected. All programs were begun on the most immediate school day following PATs. Interventions lasted for 15 consecutive school days. Treatment evaluation interviews (TEIs) were conducted at the end of the 15-day period to aid in determining the success of the treatment plan. Children were present at these interviews to elicit their perceptions of the treatment program. Because parents, teachers, and students were generally pleased with the children’s progress, fading procedures were instituted. Specifically, all participants agreed to continue to review and practice their friendship recipe cards informally for the remainder of the school year (ranging between 2 and 5 weeks). Formal self-monitoring was discontinued on the playground. The parents of Child 1 and Child 3 decided to continue to communicate with a simplified home note; however, these notes did not carry any point values. These parents agreed to provide weekly rewards based on satisfactory performance. With one exception, TEIs were con­ducted after school. They required an average of 20 minutes to complete.

Discussion
One strength of this exploratory study is that it contributes to the small but growing body of research in a relatively new area of investigation. The treatment package composed of CBC and SST outlined in this study seems promising for use by professionals working with parents and teachers of young boys with ADHD who are experiencing problems related to their cooperative interactions with peers. Further, it demonstrates the role of parents and teachers as partners and coconstructors in the development of intervention tactics for children. For example, after closely observing the students’ interactions with peers for 1 week, teachers and parents jointly chose the social subskills (e.g., using self-control) they considered most important. Similarly, when the teacher of Child 2 expressed concern about being able to spend time coaching the student, the student’s mother readily volunteered to assume this role. Anecdotal information collected during the study revealed that parents viewed their participation in CBC very favorably. Parents commented that they had never worked with teachers to jointly solve problems and that they liked the CBC format. Rather, their past experiences had consisted of teachers simply reporting problems to them. One parent commented that prior to CBC, she had begun dreading calls from the school. She stated that she appreciated working on ideas for problem solutions with the teacher and consultant and having her opinions valued. This study is also the first to include CBC with children with ADHD, aimed at increasing their positive interactions with peers. This research adds support to the handful of other studies that have demonstrated the effectiveness of CBC as a means of behavioral treatment delivery for schoolchildren (Galloway & Sheridan; Sheridan & Colton; Sheri­dan et al). The inclusion of behavioral rating scales and ancillary outcome measures investigating treatment acceptability, treatment integ­rity, and social validity are desirable features of the study. These measures are critical for practitioners to use in determining the acceptability and importance of their intervention procedures and in promoting socially valid and relevant changes in client behavior.
- Colton, Denise L and Susan M Sheridan; Conjoint Behavioral Consultation And Social Skills Training: Enhancing The Play Behaviors Of Boys With Attention Deficit Hyperactivity Disorder; Journal of Educational & Psychological Consultation; 1998, Vol. 9 Issue 1, p3

Personal Reflection Exercise #6
The preceding section contained information about conjoint behavioral consultation for children with ADHD.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Remote assessment of ADHD in children and adolescents:
recommendations from the European ADHD Guidelines Group
following the clinical experience during the COVID-19 pandemic

- Santosh, P., Cortese, S., Hollis, C., Bölte, S., Daley, D., Coghill, D., Holtmann, M., Sonuga-Barke, E. J. S., Buitelaar, J., Banaschewski, T., Stringaris, A., Döpfner, M., Van der Oord, S., Carucci, S., Brandeis, D., Nagy, P., Ferrin, M., Baeyens, D., van den Hoofdakker, B. J., Purper-Ouakil, D., … Simonoff, E. (2023). Remote assessment of ADHD in children and adolescents: recommendations from the European ADHD Guidelines Group following the clinical experience during the COVID-19 pandemic. European child & adolescent psychiatry, 32(6), 921–935. https://doi.org/10.1007/s00787-023-02148-1


Peer-Reviewed Journal Article References:
Courrégé, S. C., Skeel, R. L., Feder, A. H., & Boress, K. S. (2019). The ADHD Symptom Infrequency Scale (ASIS): A novel measure designed to detect adult ADHD simulators. Psychological Assessment, 31(7), 851–860.

Karalunas, S. L., Gustafsson, H. C., Fair, D., Musser, E. D., & Nigg, J. T. (2019). Do we need an irritable subtype of ADHD? Replication and extension of a promising temperament profile approach to ADHD subtyping. Psychological Assessment, 31(2), 236–247.

Pelham, W. E. III, Page, T. F., Altszuler, A. R., Gnagy, E. M., Molina, B. S. G., & Pelham, W. E., Jr. (2020). The long-term financial outcome of children diagnosed with ADHD. Journal of Consulting and Clinical Psychology, 88(2), 160–171.

QUESTION 20
In Colton’s example of conjoint behavioral consultation, how was home-school communication accomplished? To select and enter your answer go to Test.

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