Adhd Medication Agreement - PowerPoint

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					Organizational, Time Management,
and Planning Treatment for Children
with ADHD (OTMP Study)


                   NIMH-funded R01
       New York University – Howard Abikoff, PI
    Duke University Medical Center – Karen Wells, PI




                                                       1
Rationale for the Study

   Children with ADHD often evidence
    significant difficulties with organization
        Planning and completing assignments
        Managing materials for school and activities
        Remembering tasks and materials
        Creating a schedule to complete tasks
        Keeping track of time
   This negatively impacts academic
    performance and creates parent-child
    conflict, particularly around homework



                                                    2
    Rationale for Study, con’t.

   Despite the large ADHD treatment literature, no
    research has addressed OTMP behaviors specifically
   Contingency management approaches show some
    benefit for end-point goals such as homework
    completion and academic productivity but has not
    been evaluated for effects on organizational skills
   OTMP skills training differs from cognitive training
    and social skills training which have not been shown
    to be effective for ADHD children
   A skills-based approach is based on extensive clinical
    observations and experience that a skill deficit exists
    and that direct instruction may be beneficial


                                                           3
Preliminary Work (Abikoff & Gallagher)

     Development of the Children’s Organizational Skills
      Scale (COSS), Parent, Teacher, and Child versions
         Organized Actions
         Memory and Materials Management
         Task Planning
     Small medication study (n=19) showed stimulants
      improved OTMP behaviors but the majority
      remained impaired
     R21 treatment development grant (n=20) created
      OST skills-based intervention and showed that it
      resulted in significant improvements in parent and
      teacher COSS ratings and on a laboratory
      assessment of organizational skills.



                                                            4
    Specific Aims

   Compare a skills-based intervention to a contingency
    management intervention for organizational deficits
    in ADHD children
       Outcomes also assessed on academic performance,
        homework behaviors, attitude towards school, and
        parent-child relations
   Evaluate both treatments to a wait-list control group
   Evaluate the long-term impact of treatment
       One month post-treatment follow up; one and four
        months into the next school year
   Explore impact of parent ADHD on parents’ treatment
    compliance and children’s outcomes



                                                            5
Study Design
     Randomized clinical trial with wait-list
      control
     All children receive treatment
         Organizational Skills Training (OST) OR
         Parents and Teachers Helping Kids Organize
          (PATHKO)
            Both involve teachers and parents
            Both address materials management, time
             management, and planning
            Both have 20 treatment sessions over 10
             weeks
     20% will wait 14 school weeks to start
      (wait list control)


                                                       6
                             DOES NOT MEET                  FAMILY GIVEN
                            CRITERIA FOR STUDY               REFERRALS
Screen   Baseline
                                MEETS CRITERIA
                                  FOR STUDY




                                                  Assigned to 10 wk Waitlist
  Assigned to OST            Assigned to PATHKO      and then choice of
                                                      OST or PATHKO



                  Follow-Up Assessments:
                                                     Follow-Up Assessment:
              -   Immediate post treatment
              -   1 month post treatment
                                                   - Immediate post treatment
              -   1 month next year
                                                   - 1-Month post treatment
              -   4 month next year
                                                                                7
Subjects

   180 3rd-5th graders meeting criteria for
    ADHD, any subtype
       Diagnostic evaluation performed by study staff
        and confirmed by wash-out of medication if
        indicated
   Evidence of OTMP difficulties at home OR
    school
   No significant psychiatric comorbidities
   No plans to change medication or initiate
    similar behavioral interventions
   One primary teacher (3/5 core classes)
   Teacher agreement to participate
                                                         8
Description of OST Components

   Psycho-education regarding ADHD and
    organizational deficits
   Parents taught to prompt-monitor-praise
   Child-friendly model of OTMP difficulties
    (“glitches”)
   Skills-building through modeling, shaping, guided
    practice, labeled praise
   In-session reinforcement system (points for a
    prize box)
   Contingency management by parents and
    teachers through simple point/reward system


                                                        9
    Rationale for PATHKO

•   Long history of the use of contingency
    management approaches, esp. parent
    training (PT) with ADHD children
•   PT improves primary symptoms, co-
    morbid conditions and functional
    impairments in ADHD
•   PT improves parent-child conflict in
    children with disruptive and oppositional
    behavior


                                                10
Primary Assumptions of PATHKO

•   Enhancing motivation through
    parent/teacher training will result in
    improvements in problems related to
    organizational skills.
•   Focus will be on end-point target
    behaviors; not on skills training
•   Focus on problems related to
    organization, management and planning;
    not on skills per se


                                        11
    Description of PATHKO Components

•    Orientation to Social-Learning Theory
•    Daily Report Card at school
•    Parent taught to work with teacher to
     maintain
•    Homework structure and rules
•    Token economy targeting OTMP behaviors
•    Management of oppositional behaviors
     around OTMP behaviors with time-out
•    Use of response cost for OTMP behaviors
•    Anticipating future problems and
     encouraging maintenance

                                               12
    Treatment Fidelity and Integrity

   Study therapists treat training cases and must be
    “certified” by each treatment developer
   Weekly individual supervision and cross-site group
    clinical conferences
   Therapists complete fidelity and integrity checklists
    after each session
        Fidelity = content covered
        Integrity = treatment components kept distinct within
         each of the two treatments
   IE’s listen to 15% of session audio-recordings and
    agreement with therapists is calculated
   Assessments of parent, teacher, and child
    compliance (e.g., homework) also collected


                                                            13
Current Progress

   Entering 4th of 5 year grant
   Approximately 130 of 180 children randomized
    and treated across 2 sites
       22 DPS students
       Large percentage Inattentive type; diverse gender
        and ethnicity
   Over 95% of all parent/child assessment data
    collected
   80-85% teacher data collected (next year follow
    up challenging)
   Satisfaction ratings high
   Attendance at treatment sessions is good
       >95% completed content of all 20 sessions

                                                            14

				
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