Presenter: Gregory Fabiano, Ph.D. From: UB Alberti Center for Bullying Abuse Prevention, Colloquium Series (April 9, 2015) More: gse.buffalo.edu/alberticenter ........ Attention-deficit/hyperactivity disorder (ADHD) is a chronic, pervasive childhood mental health disorder with a typical onset during early childhood, and it results in considerable impairments in social, academic, and family functioning. Evidence-based treatments for ADHD include pharmacological interventions and behavioral interventions. Behavioral interventions typically include teaching parents and teachers how to manipulate and control the antecedents and consequences of behavior to promote increased adaptive functioning and reduce problematic behaviors. Recent innovations in behavioral interventions include using social, recreational activities to engage fathers in treatment programs, combining pharmacological and behavioral interventions to promote appropriate behaviors in schools, and enhancing special education services for youth with ADHD. Emphasis within the talk will include a discussion of how youth with ADHD and their families can be effectively treated to reduce their roles as both perpetrators and recipients of aggressive, bullying, and other negative social behaviors.

1. Effective Approaches for
Promoting Prosocial Behavior
and Reducing Disruptive and
Aggressive Behaviors in Youth
with ADHD: Recent Innovations
in Treatment
Gregory A. Fabiano, Ph.D.
University at Buffalo
Department of Counseling, School, and Educational Psychology

2. Attention-deficit hyperactivity disorder
(ADHD)
• ADHD is characterized by developmentally
inappropriate levels of:
– Inattention
– Hyperactivity
– Impulsivity
• ADHD behaviors are developmentally
inappropriate, pervasive, chronic, and
result in considerable impairment in social
and academic functioning.

3. History of ADHD
• Heinrich Hoffman, a German psychiatrist,
authored a widely-published children’s
book of short stories in 1844.
– “Fidgety Phillip”
– “Johnny Look-in-the-Air”
• “The Story of Cruel Frederick”
• The Story of Little Suck a Thumb”
• The Dreadful Story of Pauline and the Matches”
Thome & Jacobs, 2004

4. Prevalence

5. • Prevalence estimates vary depending on
method used, geographic region, age
targeted, and rater.
• Prevalence of ADHD estimated at 8.7%
(Froehlich et al., 2007)
• More common in boys than girls
• Symptom presentation may reduce as
individual becomes older

6. Fabiano et al., 2013

7. Impact of ADHD - Impairment

8. Domains of Impairment
• Peer relationships
• Adult relationships
• Sibling relationships
• Academic Progress
• Self-esteem
• Group functioning
• Associated problems

9. Parent IRS scores 6-12 year olds
0
1
2
3
4
5
6
ADHD
Comparison
ADHD
Comparison
ADHD
Comparison
ADHD
Comparison
ADHD
Comparison
ADHD
Comparison
ADHD
Comparison
Peers Siblings Parents Academics Self-esteem Family Overall
Score
Fabiano et al., 2006; available for free at www.ccf.buffalo.edu

10. Teacher IRS Scores 6-12 Year Olds
0
1
2
3
4
5
6
ADHD
Comparison
ADHD
Comparison
ADHD
Comparison
ADHD
Comparison
ADHD
Comparison
ADHD
Comparison
Peers Teacher Academics Classroom Self-esteem Overall
Score
Fabiano et al., 2006; available for free at www.ccf.buffalo.edu

11. Educational Costs
(Robb et al, 2013)
Costs of
• Special education* $3230
• Disciplinary referrals** $ 740
• Retention $ 110
• Special schools $ 780
• Total: $4900
*Does not include Section 504 Accommodation Plans/OHI classifications not used
pre-1992
**Likely under-estimated

12. Costs in the Aggregate
(assuming prevalence of 5% and 60 million school aged children--2000
census--2005 dollars)
• Health and Mental Health $11.6 billion
• Education $14.7 billion
• Crime and Delinquency $11.4 billion
• Parental work loss $ 2.3 billion
• Total $40 billion
• Range $34.1--$53.7
Pelham, Foster, & Robb, 2007; Robb et al., under review

13. Annual Cost of Other Disorders in U.S.
Depression: $44 billion
Stroke: $53.6 billion
ADHD (child, $80 billion
adolescent, adult)
Alzheimer’s $100 billion
Alcohol abuse/dep $180
Drug abuse/dep $180

14. Why is it so critical to intervene
early and in a sustained way for
children with ADHD?

15. Effective Treatments for ADHD

16. Evidence-Based ADHD
Treatments
• Behavior Modification
– Classroom Contingency Management
– Behavioral Parent Training
– Contingency Management Strategies
implemented in Recreational Settings (i.e., STP)
• Stimulant Medication
DuPaul & Eckert, 1997; Fabiano, et al., 2009; Greenhill & Ford,
2002; Hinshaw et al., 2002; Pelham & Fabiano, 2008; Pelham,
Wheeler, & Chronis, 1998

17. Fabiano, et al., 2015

18. • Behavior Modification is based on social
learning theory
• It teaches parents and teachers how to
change environmental contingencies to
improve behavior.
• Settings where behavior modification is used
include:
– Home
– School
– Peer/recreational settings

19. • Antecedents
– Structuring situations
– Clarifying expectations and contingencies
– Establishing rules
– Issuing clear commands

20. “Fights among the prisoners have decreased
62% since we got the Slip-and-Slide”

21. • Consequences
– Praising and attending
– Planned ignoring
– Rewards
– Punishments

23. Peer-based interventions

24. Negative Behavior During Board
Games
0
1
2
3
4
5
6
7
8
9
10
7:45 AM 9:55 AM 1:25 PM 4:35 PM
Concerta™
TID MPH
Placebo
Control
Pelham et al., 2001

25. Summer Treatment Program
Overview
• Eight-week program, 9 hours daily
• Children grouped by age into groups of 12
• Groups stay together throughout the day
• 5 counselors work with each group all day
outside of the classroom
• One teacher and an aide staff the classroom for
each group
• Treatment implemented in context of
recreational and academic activities

26. Typical STP Schedule
Time Activity
7:30-8:00 Arrivals
8:00-8:15 Social Skills Training
8:15-9:00 Soccer Skills Training
9:15-10:15 Soccer Game
10:30-11:30 Art Class
11:45-12:00 Lunch
12:00-12:15 Recess
12:15-2:15 Academic/computer class
2:30-3:30 Softball Game
3:30-4:30 Swimming
4:45-5:00 Recess
5:00-5:30 Departures

27. Summer Treatment Program Overview
• Treatment Components:
• Point System
• Social Skills Training, Cooperative Tasks,
• Team Membership, and Close Friendships
• Group Problem Solving
• Time out
• Daily Report Cards
• Sports Skills Training and Recreation

28. Summer Treatment Program Overview
• Treatment Components:
• Positive Reinforcement & Appropriate
Commands
• Classrooms--Regular, Peer Tutoring, Computer,
and Art
• Individualized Programs
• Parent Training
• Medication Assessments
• Adolescent Program

29. Comparison of STP with multiple
STP withdrawals
0
20
40
60
80
100
120
Class rule violations Noncompliance Negative
Verbalization
No Behavior Mod
Behavior Mod
Pelham et al., 2005

30. Daily Report Cards in Schools
Gregory A. Fabiano, Ph.D.
University at Buffalo, SUNY

31. ADHD Treatment Effects in
Classrooms

32. Fabiano, Pelham, et al., (2007)
Frequency of Classroom Rule Violations
0
5
10
15
20
25
30
35
40
45
50
Placebo .15 mg/kg .30 mg/kg .60 mg/kg
No BMOD
Low BMOD
High BMOD

33. 0
5
10
15
20
25
30
35
40
45
50
Placebo .15 mg/kg .30 mg/kg .60 mg/kg
Medication
Frequency
No BMOD
Low BMOD
High BMOD
Frequency of Classroom Rule Violations
Fabiano, Pelham, et al., (2007)

34. Fabiano, Pelham, et al., (2007)
Frequency of Classroom Rule Violations
0
5
10
15
20
25
30
35
40
45
50
Placebo .15 mg/kg .30 mg/kg .60 mg/kg
No BMOD
Low BMOD
High BMOD

35. Daily Report Card

36. What is a Daily Report Card (DRC)?
• The DRC is an operationalized list of a child’s
target behaviors
– Specific criteria
– Immediate feedback
– Communication tool
– Home-based privileges contingent on
meeting DRC goals

37. Creating the DRC

39. Enhancing the Effectiveness of Special Education
Services for Children with ADHD Using a Daily
Report Card Program
Fabiano et al., 2010; Institute of Education Sciences Grant # R324J06024

40. Participants

42. Child with ADHD
referred for study
Random
assignment
Diagnosis confirmed
and intake completed
IEP
IEP +
DRC
Endpoint Assessment

43. Results

44. Primary Outcomes Measures
• Blinded observations of classroom behavior
• Academic Achievement Testing
• Teacher Rating of IEP goal attainment

45. Blinded Observations of Classroom
Behavior – Change Score
p < .05

46. Academic Achievement Testing
• Broad Math scores were significantly
improved over time (p < .001), whereas
Basic Reading scores were not (p > .05).
• There was no time x group interaction.

47. Teacher Ratings of IEP Goal
Attainment
• Each teacher was asked to rate whether
the child had attained idiographic IEP goals
and objectives.

48. 1
2
3
4
5
6
7
Monitoring Behavioral Consultation
Teacher IEP Rating
For these analyses, there was a significant difference between
groups, t (55, one-tailed) = -1.98, p = .027.

49. Secondary Outcome Measures

50. ADHD, ODD, CD Symptoms
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
DBD-ADD DBD-ODD DBD-CD
Monitoring
Behavioral Consultation
*p< .05 *p < .05

51. Getting Dads Off the Sidelines:
Practices for Promoting Child Social
Skills Development in Peer Settings

58. What do fathers do?

59. • Economic Provision (“Bread-winning”)
• Involvement
– Engagement
– Availability
• Responsibility
• Parenting
• Co-Parenting
• Spouse/Partner
• All these parameters are on a continuum,
thus fathering is multi-dimensional.
Pleck, 1997

61. Father Influence on Child
Development
• The development of:
– emotion regulation
– social cognition
– focused attention
– likely because of these factors, appropriate peer
relationships (Parke, et al., 2002).
• Positive father involvement results in fewer
mother-reported behavior problems (Amato
& Rivera, 1999).
• Fathers contribute uniquely to the child’s
academic achievement and academic sense of
competence (Forehand, et al., 1986; McBride,
et al., 2005; Nord, 1997).

62. • For children with mental health disorders, it
may be critical to involve fathers in
interventions.
– Fathers contribute to parenting
• Positive parenting and discipline
– Helps promote consistency between parents
– Provides an additional point of view
– May support other parent
– May promote maintenance of treatment over
time or as children progress through
development (Bagner & Eyberg, 2003;
Webster-Stratton, 1980).

63. Why are fathers not involved in
BPT studies?

64. • Approach to/Engagement of fathers during
initial clinical contact:
– Clinicians may implicitly exclude fathers by
addressing correspondence to only mothers or
require only mothers for interviews.
– Because most rating forms are normed on
mothers, fathers are often not asked for their
input.
– Standard clinical hours (i.e., 9 to 5 weekdays)
are not convenient for employed mothers or
fathers

65. • Parents of children with ADHD have an increased
likelihood to have ADHD themselves (Biederman,
Faraone, Monuteaux, 2002)
• ADHD impedes parenting and BPT progress
(Arnold, O’Leary, & Edwards, 1997; Evans,
Vallano, & Pelham, 1994; Sonuga-Barke et al.,
1999)
• Most BPT classes are classroom-based, and use
didactic lectures to introduce parenting skills.
• The format may act to discourage fathers from
participating

66. “Research has yet to identify any child-care task for
which fathers have primary responsibility.” (Pleck,
1997)
• Fathers’ participation in recreational activities and
unstructured play times is more typical relative to
mothers’ activities (Russell & Russell, 1987).
• The content of BPT classes may therefore fail to
address the needs of many fathers.

68. • Men generally do not seek out or ask for
help for health/mental health services
(Addis & Mihalik, 2003).
• Fathers report few problems in parenting,
even in the face of self-reported
dysfunctional discipline techniques (Hoza et
al., 2000)

69. Why is increased father
participation needed?

70. • As mentioned, fathers are primarily responsible for
children during recreational and sports activities and
unstructured times independent of other roles they fill
(Marsiglio, 1991), and they are a critical agent for helping
their child establish appropriate peer relationships (Parke,
2002).
• Children with ADHD exhibit poor sportsmanship
behaviors that result in poor peer relationships and are
likely to struggle with behavior during such activities
(Hupp & Reitman, 1999; Pelham et al., 1990).
• Fathers may also need skills to help them appropriately
parent/coach during unstructured activities and sports.

72. Thomas Junta, whose case was considered one of the
worst examples of the national problem of "sideline
rage," faces 20 years in prison.
Jury convicts hockey dad of manslaughter
Courttv.com

73. So What Can We Do to Increase
Father Participation?

74. FREE BEER!!!???

75. BAD IDEA (Pelham et al., 1997, 1998)

76. • To involve and engage fathers in ADHD
treatment the Coaching Our Acting-out
Children: Heightening Essential Skills
(COACHES) program was developed.
• COACHES is a two-hour, weekly, eight-
session parent training program.
A BPT PROGRAM DESIGNED SPECIFICALLY
FOR FATHERS

77. • The COACHES program combines and
synergizes two manualized treatments
commonly used for children with ADHD:
– Summer Treatment Program (Pelham, Greiner,
& Gnagy, 1998)
– Community Parent Education Program
(Cunningham, Secord, & Bremner, 1998)
• Treatment components from these programs
are adapted for use in the father-based
parenting class, the child-based skill drills,
and the father-child interactions.

78. COACHES format
• During the first hour, fathers review how to
implement effective parenting strategies in a group
class (e.g., using praise, using time out).
• Concurrently, children practice soccer skill drills
with para-professional counselors, to increase
competencies in the sports domain (Pelham et al.,
in press; Pelham, Greiner, & Gnagy, 1997; Pelham
& Hoza, 1996).

79. Session
number
Session content
1 Introduction to social learning theory
and constructing a home behavior
management plan
2 Appropriate rewards and praise
3 Ignoring mild, inappropriate
behaviors
4 Delivering effective commands and
instructions
5 Using Premack contingencies and
transitional warnings
6 Using time out
7 Problem-solving
8 Closing Session; Programming for
maintenance
Content of COACHES BPT Sessions

80. • During the second hour, the fathers and children
join together for a soccer game.
• Fathers “coach” the soccer game by employing
the strategies discussed during the first half of the
program.
• During frequent breaks, fathers receive on-line
feedback from trained staff, work together to
trouble-shoot problems that occur, and reinforce
each other for the successful implementation of
parenting strategies.

81. • How is the COACHES program different from
other parenting programs?
– Does not approach fathers as “deficient” in parenting
strategies. Frames treatment as a way to build
competencies in an area where many may already have
skills (e.g., coaching).
– Framing treatment in this way may reduce stigma
associated with initiating and participating in mental
health services.
– Includes a sports competency-building component for
the children, known to be effective and well-liked by
parents and children (Pelham, et al., in press; Pelham,
Greiner, & Gnagy, 1997).
– Soccer game provides a naturally reinforcing activity as
part of treatment (as opposed to a two-hour class).
– Research suggests fathers benefit from practicing
parenting strategies (Adesso & Lipson, 1981).

82. Clinical Trial of COACHES
Efficacy
Fabiano et al., 2012

83. Schedule COACHES
10
minutes
Homework Review
50
minutes
Small and large group discussions of weekly
parenting program topic. Discussions include
direct instruction, group discussions, and role
plays.
5
minutes
Break
50
minutes
Fathers participate with child in soccer game.
5
minutes
Explain homework procedures for the week.

84. Measures
• Measures of parenting
– DPICS
• Praise
• Criticism
• Commands
• Measures of problem behaviors
– Eyberg Child Behavior Inventory (ECBI)
• Frequency Rating
• Intensity Rating
• Measures of Satisfaction with treatment
– Therapy Attitude Inventory
• Process factor
• Outcome factor

85. DPICS - Praise
ES=.54

86. DPICS-Negative Talk

87. ECBI – Intensity Rating

88. Treatment Satisfaction
• 100% of fathers reported they were
Satisfied with Outcomes.
• 89% of fathers reported they were Satisfied
with Treatment Process.

89. Clinical Trial of COACHES
Effectiveness
Fabiano et al., 2009

90. Method

91. • Fathers who gave informed consent and completed
intake procedures were randomly assigned to one
of two parent training groups:
– COACHES
• Fathers watch videotapes of exaggerated parenting errors,
identify errors, generate solutions, and then role-play suggested
solutions.
• Children practice soccer skills.
• Parents and children join for soccer game; fathers practice
skills
– Traditional Behavioral Parent Training
• Fathers watch videotapes of exaggerated parenting errors,
identify errors, generate solutions, and then role-play suggested
solutions (Cunningham et al., 1997).
• Children participate in group board game activities during the
parenting group (Pelham et al., 2001)

92. Schedule COACHES Traditional program
10
minutes
Homework Review Homework Review
50
minutes
Small and large group
discussions of weekly
parenting program topic.
Discussions include
direct instruction, group
discussions, and role
plays.
Small and large group
discussions of weekly
parenting program topic.
Discussions include
direct instruction, group
discussions, and role
plays.
5
minutes
Break Break
50
minutes
Fathers participate with
child in soccer game.
Leader models use of
strategies and fathers
role play use of the
strategies with each
other.
5
minutes
Explain homework
procedures for the week.
Explain homework
procedures for the week.

93. • The major difference between BPT groups
is the parent-child interactions in
COACHES.

94. Measures
• Fathers rated child improvement at post-treatment
across domain-specific targeted behaviors (Pelham
et al., 2001)
• Measures of engagement included
– Father Attendance/Drop-out
– Father on-time arrival for meetings
– Child Attendance/Drop-out
– Father homework completion
• Father satisfaction with treatment (TAI; Brestan et
al.)

95. Results

96. 1
2
3
4
5
6
7
Rating
BPT
Comparison
Average Improvement Rating
F = 22.28, p < .001

97. COACHES vs. Traditional: Father Attendance
0
20
40
60
80
100
Attendance
COAC…
Traditi…
p <.04

98. COACHES vs. Traditional: On-time for Session Attended
0
20
40
60
80
100
On-time
COAC…
Traditi…
p < .03

99. COACHES vs. Traditional: Child Attendance
0
20
40
60
80
100
Attendance
COAC…
Traditi…
p < .001

100. COACHES vs. Traditional: Homework Compliance
0
20
40
60
80
100
Homework Completion
COAC…
Traditi…
p < .003

101. COACHES vs. Traditional: Father Drop-Out
(Defined as Attendance at Fewer than Half of Sessions)
0
20
40
60
80
100
Father Drop-out
COACHES
Traditional
p < .03

102. COACHES vs. Traditional: Child Drop-Out
(Defined as Attendance at Fewer than Half of Sessions)
0
20
40
60
80
100
Child Drop-out
COACHES
Traditional
p < .001

103. COACHES vs. Traditional: Consumer Satisfaction
0
20
Outcome Process
COACHES
Traditional
p < .08
p < .04

104. Clinical Implications
• BPT is an effective approach for improving father-
related parenting behavior.
• Programs for fathers should include recreational
based activities that promote skill development for
children.
• Fathers should be given the opportunity to interact
with their children and practice parenting skills
during the session.
• Future studies need to address interventions to
facilitate effective co-parenting and inter-parental
consistency

106. Thank you!
• Greg Fabiano
fabiano@buffalo.edu