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The Impact of Family Therapy on Adolescents with ADHD and Oppositional Defiant Disorder
Although it was previously believed that the vast majority of children with ADHD would simply "outgrow" the disorder during adolescence, this is now known to be incorrect. Most children with ADHD continue to struggle with the condition during the adolescent years, and, even when they no longer meet full diagnostic criteria for the condition, often experience symptoms that contribute to difficulty in such diverse areas as school, peer relations, family relations, and self-esteem.
Unfortunately, relative to the amount of treatment research conducted with children, the available treatment studies of adolescents with ADHD are limited. Stimulant medication treatment has been shown to be effective for adolescents. And, longer-acting medications such as Concerta and AdderallXR, which eliminate the need for in-school dosing, may help reduce compliance problems common to this age group.
As with children, however, medication treatment alone may not be adequate, particularly in those instances where co-occurring behavior difficulties such as those associated with Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD) are also present. In such instances, the level of parent-teen conflict that is present may require direct work with families to reduce conflict and improve family functioning. (For a discussion of ODD and CD click here.)
Recently, an extremely well-conducted study comparing two family-therapy approaches for adolescents with ADHD and ODD was published in the Journal of Consulting and Clinical Psychology (Barkley, RA., et al., (2001). The efficacy of problem-solving communication training alone, behavioral management training alone, and their combination for parent-adolescent conflict in teenagers with ADHD and ODD. JCCP, 69, 926-941).
Participants in this study included 97 adolescents diagnosed with ADHD and ODD, as well as their parents. Families were randomly assigned to receive one of two family-therapy treatments; 1) 18 sessions of Problem-Solving Communication Training (PSCT), or 2) 9 sessions of Behavior Management Training (BMT) followed by 9 sessions of PSCT. A brief description of these 2 treatment options is provided below.
Problem Solving Communication Training
The PSCT treatment included three primary components for changing parent-adolescent conflict. In the problem solving component of the treatment, parents and teens were trained in a five-step problem-solving approach: 1) problem definition; 2) brainstorming for possible solutions; 3) negotiation around these solutions; 4) decision-making processes surrounding a solution; and 5 and implementation of the solution. This training was intended to help parents and adolescents develop new skills for resolving disagreements with less conflict. Adolescents were required to attend all 18 sessions of this treatment.
The communication-training component focused on helping parents and teens develop more effective communication skills when discussing family conflicts. For example, parents and teens were taught to maintain an even tone of voice, to demonstrate an understanding of the others' concerns before voicing one's own concerns, to avoid insults and put-downs, and to provide approval for positive communication. These skills were intended to reduce the use of aversive communication strategies that can make parents and teens angrier, and thereby intensify the conflict.
The final component of PSCT was training in cognitive restructuring. This involved helping families learn to detect, confront, and modify irrational, extreme, or rigid belief systems held by parents or teens about their own or the others' conduct. This aspect of the treatment was intended to combat the overly rigid and biased views of one another that may develop in families marked by conflict, and which can make resolving conflicts more difficult.
Behavioral Management Training/psct
In this treatment, the first nine sessions were attended by parents only and were devoted to teaching parents more effective behavior-management skills. Session topics included: the use of positive attention to promote desirable behavior; developing a point system for reinforcing the accomplishment of responsibilities; using age-appropriate punishments and loss of privileges for undesirable behavior; and teaching parents how to anticipate problem situations and develop plans in advance for dealing with them. Following this nine-week instruction in behavior management, the teens joined parents for the final nine sessions and the PSCT approach described above was implemented.
Results
The researchers collected a variety of measures from mothers, fathers, and teens to evaluate the impact of each treatment. This included participant ratings of the quality of parent-teen interactions, the frequency and intensity of conflicts, and the strategies used to resolve conflicts when they occurred. In addition, families were videotaped while discussing a recent situation that had generated conflict, so that their actual behavior during conflicts could be observed and analyzed. Results are summarized below.
How Many Families Completed The Treatment?
Halfway through treatment, 26% of families in the PSCT group had already dropped out, compared to only 8% of families in the BMT/PSCT condition. By the end of treatment, these numbers had risen to 38% for the former and 18% for the latter.
The researchers suggest this may have occurred because, in the PSCT approach, teens attended all sessions and families were immediately required to deal with difficult issues. In the BMT/PSCT condition, in contrast, parents initially attended by themselves and worked on developing more effective behavior management skills rather than immediately discussing issues of conflict with their teen. As a result, parents may have developed a greater comfort level with the therapist and more effective strategies for dealing with their child's oppositional behavior before beginning the direct and difficult interaction with their teenager. The researchers suggest this may be the reason why fewer of these parents chose to end treatment prematurely.
How Effective Was Each Treatment Approach?
The answer to this question depends on how one chooses to examine the results. On virtually all outcome measures collected directly from participants, significant improvements were evident. This was true for mothers, fathers, and teens themselves. Thus, participants reported that fewer parent-teen conflicts were occurring, that the anger experienced during conflicts had declined, and that more effective strategies for resolving conflicts were being used. This was true for families in both treatment conditions, and no significant differences between the treatments were found. Furthermore, these apparent gains were still evident -- for the most part -- in follow-up data collected two months after treatment had ended, as parents and teens reported high levels of overall satisfaction with the treatment. These findings are certainly encouraging.
A somewhat less optimistic picture emerges, however, when other aspects of the results are considered. First, given the significant improvements participants reported in multiple areas of parent-teen interaction, one would expect substantial changes in the way parents and teens behaved during the videotaped interactions. However, this was the case.
Immediately following treatment, observer ratings indicated that mothers were engaging in significantly more positive behavior and significantly less negative behavior than before treatment began. For teens and fathers, however, no differences were observed.
At the two-month post-test, the positive effects that had been evident for mothers no longer were apparent. In addition, there was an indication that fathers in the BMT/PSCT group were now less positive and more negative than they were immediately following treatment. Overall, therefore, the positive reports that participants provided were not matched by changes in their actual behavior -- at least in the samples of behavior that could be collected during these brief videotaped interactions. This calls into question the validity of the benefits reported by the participants.
What Proportion Of Families Changed As A Result Of Treatment?
The results discussed above describe the average level of change for all families in each treatment. A different, and perhaps more instructive, way to understand treatment impact is to determine the degree of change that occurred within each family. The researchers considered this issue in 2 different ways.
First, they looked at the percentage of families in each treatment group who demonstrated reliable change. By reliable change, the researchers are referring to change that is greater than what could reasonably be attributed to chance. It is based on the concept that all families would be expected to show some change in functioning during the time period over which treatment occurred -- or at least in how they respond to the questionnaires -- and that the changes reported must be greater than what may have otherwise occurred to represent a true treatment benefit.
From this perspective, the results are less encouraging. For these analyses, the researchers focused on those measures that were the primary targets of each treatment. Across three different measures of parent-teen relationship functioning -- parents' perception of the quality of the relationship with their teen, the number of different topics that elicit conflict, and the intensity of anger experienced during conflicts -- reliable change was evident in fewer than 25% of families, based on maternal and paternal reports. For example, in regards to parents' overall rating of relationship quality with their teen, only about 20% of fathers and 15% of mothers reported improvement that was substantial enough to be considered a reliable change.
As a final way of considering the data, the researchers also determined the percentage of families whose scores on the different measures moved from the abnormal range into the normal range during treatment. These results provide a somewhat more optimistic picture. At the beginning of treatment, between 3% and 40% of mothers provided ratings of overall relationship quality with their teen, number of issues that generate conflict, and anger intensity during conflict that fell within a non-deviant range. After treatment, the researchers obtained non-deviant ratings on these measures from between 34% and 78% of mothers. For fathers, a comparable increase occurred.
Summary And Implications
The authors should be commended for presenting their results in such a careful and rigorous fashion. The overall summary they provide of their results is that "...the findings raise serious questions about the effectiveness of using parents as the major focus of achieving change in adolescents with ADHD/ODD when there is significant interpersonal conflict with parents." They base this conclusion on the fact that, although significant benefits were found when averaged across families, the percentage of parents for whom "reliable" change was found -- a more conservative approach for estimating the benefits of treatment -- placed them in a distinct minority. In addition, the observational data were notable for the relative absence of significant improvements in parent-teen interaction during actual conflict.
The family-treatment approaches used in this study are well-developed interventions that were delivered for what seems to be an adequate time period. In fact, the duration of treatment in this study was twice as long as what has been delivered in earlier studies of family treatment for adolescents with ADHD.
Why were more positive results -- as indicated by reliable improvement occurring for a greater number of families -- not obtained?
The authors suggest several possibilities. First, they speculate the entire model of having such treatments delivered in a clinical setting, rather than working directly with families in their homes, may have undermined treatment effectiveness. Working with families at home where their problems actually occur may enhance the impact of the treatments provided. In fact, there is evidence to suggest that intensive in-home treatment for families where a teen has serious behavior problems can produce positive results. One exemplar of this treatment approach is called multi-systemic therapy (Learn more about this treatment method at http://www.mstservices.com.)
The researchers also suggest, however, that the family may be less important for reducing conflict in families where there is a teen with ADHD/ODD than is commonly believed. They point to recent evidence suggesting the influence of genetic factors on such aspects of family functioning as parent-child conflict and family cohesion may actually increase in strength as children move into the adolescent years. They note that, although such findings do not preclude the possibility of inducing changes in parent-teen conflict through efforts to alter communication patterns and parent-management skills, they do imply that parent management of the teen may not be the major source of such conflicts, as many family therapists assume. If this is correct, the authors suggest that medication treatment may actually be a more helpful approach to reducing parent-adolescent conflict in teens with ADHD/ODD.
This rich and complex data set lends itself to a variety of interpretations, of course, and the ideas put forth by the authors are not the only reasonable way of interpreting their data. In my own view, they seem to be too pessimistic in their interpretation of the results. Even using the most conservative definition of improvement -- i.e. reliable change -- treatment was associated with gains in up to 25% of families on some of the measures. In addition, because they did not employ a control group, the extent to which families would have changed in the absence of any treatment cannot be determined. Finally, the families themselves clearly felt as though treatment had been helpful to them - a fact which is important to consider.
Therefore, interpreting these findings as evidence that family treatment for teens with ADHD/ODD is unlikely to be helpful is not the only way this data can be interpreted. One can also interpret these results as suggesting these treatments can be of value, and that families who participate in this treatment will find it helpful. Even this more optimistic interpretation of the findings, however, does not negate the fact that promoting reliable and significant improvements in parent-teen relations when the teen has ADHD and ODD is a difficult task.
As discussed above, this was difficult to do, even when high-quality family treatment was provided and when many of the teens that participated also were receiving medication treatment. Developing effective methods for preventing the development of ODD in children with ADHD, and the conflict patterns of parent-child interactions that generally accompany this, is thus an even more important objective for researchers and clinicians to pursue.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.