Psychotherapy 2014, Vol. 51, No. 1, 110 –116
© 2013 American Psychological Association 0033-3204/14/$12.00 DOI: 10.1037/a0033984
Structured Dyadic Behavior Therapy Processes for ADHD Intervention David F. Curtis
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Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas Children with Attention-Deficit/Hyperactivity Disorder (ADHD) present significant problems with behavioral disinhibition that often negatively affect their peer relationships. Although behavior therapies for ADHD have traditionally aimed to help parents and teachers better manage children’s ADHD-related behaviors, therapy processes seldom use peer relationships to implement evidence-based behavioral principles. This article introduces Structured Dyadic Behavior Therapy as a milieu for introducing effective behavioral techniques within a socially meaningful context. Establishing collaborative behavioral goals, benchmarking, and redirection strategies are discussed to highlight how in-session dyadic processes can be used to promote more meaningful reinforcement and change for children with ADHD. Implications for improving patient care, access to care, and therapist training are also discussed. Keywords: disruptive behavior, behavioral therapy, pair therapy, pair counseling
therapy to add relational meaning to the behavioral contingencies established to promote child and family change. In doing so, families may share examples of common difficulties they experience at home to practice behavioral strategies introduced within the session. For instance, parents may discuss the difficulty they encounter in trying to get their child to follow instructions every night associated with the bedtime routine. The therapist may then use this example to bring to life strategies for gaining the child’s attention, delivering effective commands, and administering verbal rewards both when the child initiates and completes the activity. Although the behavioral strategies clearly serve as the primary objective in this instance, rehearsing them within the family context allows for all family members to clarify their understanding and expectations for this daily experience within the process of interacting with one another in the therapy session. Similar to family processes in therapy, behavior therapies that incorporate interactions with peers also offer opportunities to add more meaning to the methods introduced. Children with ADHD often display outgoing socially motivated behaviors, and even positive social skills. However, as Barkley (1997) describes ADHD as a disorder of performance and not ability, these children often encounter secondary social problems. Behaviors such as poor turn-taking, nonadherence to rules of games being played, interrupting others, and rough play resulting from poor downregulation of emotional/behavioral responses may deter peers from seeking interaction with children with ADHD (Hoza, 2007). Further, peers may wish to avoid these affiliations to escape the disciplinary scrutiny often placed on children with ADHD by teachers and other caregivers (DuPaul & Power, 2008). Because many children with ADHD struggle with peer interactions, intervention that involves social processes may add greater validity and generalizability to therapy activities. Emerging evidence has supported the benefits of social skills training for ADHD within intensive summer treatment programs (STP; Sibley, Smith, Evans, Pelham, & Gnagy, 2012). STP has demonstrated remarkable effectiveness for improving behavioral and social functioning for children with ADHD. Unfortunately, access to this treatment is limited by restricted regional and seasonal offerings. A potential
As the sophistication of clinical intervention manuals continues to increase, therapists are faced with the increasing challenge to prove the benefits of how our techniques ultimately serve to go beyond mere symptom reduction to “illuminate aspects of the patient’s relationship to other people” (Yalom, 1995, p. 131). Behavior therapy is an evidence-based practice for treating children with a wide variety of disruptive behavior problems (Eyberg, Nelson, & Boggs, 2008). Behavioral therapies have historically been considered to be divorced from interpersonal therapy processes, relying strictly on the environmental contingencies surrounding rewards and punishments (Skinner, 1969). However, the social processes involved in managing these contingencies may certainly provide the establishing operations for maximizing the potency of reinforcement principles to be used within modern behavior therapies. Applied to children with Attention-Deficit/Hyperactivity Disorder (ADHD), behavioral interventions have been exclusively identified as the only psychosocial interventions to be effective for amelioration of core symptoms (Fabiano et al., 2009). Contingency management techniques typically serve as primary processes for interventions; however, these strategies are most commonly provided to parents and teachers charged with the daily care of children with ADHD (Pelham & Fabiano, 2008). The most effective behavior therapies for ADHD are family-based approaches delivered either within family therapy or via parent management training (PMT) (Diamond & Josephson, 2005; Fabiano et al., 2009). Such family-based approaches call on family processes in
This article was published Online First December 30, 2013. David F. Curtis, Section of Psychology, Department of Pediatrics, Baylor College of Medicine, and Psychology Service, Department of Pediatrics, Texas Children’s Hospital, Houston, Texas. Completion of this article was supported by a grant from the Texas Children’s Hospital Pediatric Pilot Research Fund. Correspondence concerning this article should be addressed to David F. Curtis, Texas Children’s Hospital, Psychology Service, 6701 Fannin Street, CCC 1630.31, Houston, TX 77030-2399. E-mail: [email protected] 110
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extension of these therapeutic processes to usual care settings is worthy of consideration using a dyadic therapy milieu (Karcher & Lewis, 2002). The primary aim of this article is to illustrate how processes known to be effective in behavior therapy may be accentuated within a dyadic modality. The use of Structured Dyadic Behavior Therapy (SDBT) is introduced as a novel behavioral approach for treating ADHD, with examples of three behavioral techniques used to highlight key clinical processes. Specific SDBT techniques discussed are behavioral goal setting, benchmarking, and redirection strategies. Although the efficacy of a child clinical intervention manual for ADHD (Curtis, 2012) has not yet been evaluated, the process of implementing SDBT strategies is of greater importance than its content. Presenting for therapy with a disorder of performance rather than ability (Barkley, 1997), children with ADHD may already know how to perform the skills or content introduced within a behavior therapy session. However, they continue to show significant behavioral and social impairments despite having knowledge or ability for these skills. Consequently, the process of SDBT emphasizes intensive instruction, modeling, repeated rehearsal, and feedback to improve more consistent performance of these behaviors that are often required by everyday demands. Thus, a brief overview of a typical SDBT session is provided, followed by more descriptive narratives to depict key process elements for some of the core behavioral methods used. To ensure patient privacy and confidentiality, narrative exchanges are based on themes frequently observed by the author within SDBT sessions rather than verbatim transcripts abstracted from specific comments.
Defining SDBT SDBT is a novel behavior therapy approach for children ages 7 to 12 with ADHD that combines self-regulation techniques and social learning strategies within a pair milieu. Provided the aim to promote greater self-regulation and social learning, SDBT is intended for children ages 7 to 12 who are (1) likely to possess the necessary abstract reasoning and comprehension skills to participate and (2) more likely to encounter these challenges within their everyday settings. Reflective of its name, SDBT is a highly structured and model-driven approach to behavior therapy. This is intended to maximize the benefits of therapy processes by establishing clear, consistent, and predictable parameters that compensate for common ADHD-related problems. Similar to the pioneering work contributed by Barkley (2006), McMahon and Forehand (2005), Sanders (1999), and other developers of successful PMT
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programs, the primary aim of SDBT is to use intensive contingency management methods to address the A, B, C’s (antecedents, behaviors, and consequences) commonly associated with ADHDrelated problems. Thus, SDBT is truly a behavior therapy based on foundations of operant and classical conditioning. In addition, SDBT calls on social learning principles in its secondary aim to use modeling, interactive rehearsal, and peer feedback as parts of the therapy process. An outline of SDBT processes relevant to treating ADHD symptoms is provided in Table 1. Rather than attempting to suppress children’s ADHD-related tendencies to be active in social situations, act on impulse, and display socially interfering behaviors, SDBT aims to engage children in more effective self-regulation and social management of their behavior by providing model-driven protocols and scripts to rehearse to improve their performance in these situations. Thus, children are provided with clear behavioral expectations for highfrequency behaviors and are given numerous opportunities to practice these models over multiple sessions. Frequent opportunities to practice these behaviors promote overlearning of skills to increase automaticity, or more adaptive reflex-like responses, when these behaviors are needed or prompted by everyday situations. Unlike insight-oriented therapies, the goal is not necessarily to achieve greater awareness. Instead SDBT adopts a “solutionfocused” approach by providing children with adaptive skills that can promote their success regardless of the inherent reason for the difficulty (Bliss & Bray, 2009). SDBT can be implemented as an independent therapy or as a complement to PMT. If provided as a stand alone treatment, brief parent consultations with parenting handouts can accompany each child session to facilitate better home implementation and rehearsal of new strategies. If conducted as a complement to PMT, a portion of each session can be dedicated to in vivo family rehearsal of behavioral strategies to be implemented at home. SDBT establishes a consistent routine sequence of behavioral expectations for each therapy session. As asserted by eminent psychiatrist and group clinical process expert, Irvin Yalom (1995), “One of the most potent ways of providing structure is to build into each session a consistent, explicit sequence” (p. 471). This promotes efficiency of therapy activities, lowers confusion regarding behavioral expectations, and increases predictability to lower the anxiety associated with participation. Toward this goal, the basic routine for SDBT sessions consists of the activities outlined in Table 2. The routine sequence of SDBT activities is intended to support clinical processes within the therapy with clear and predictable parameters for participation, allowing the clinician to take
Table 1 SDBT Processes Relevant to Treating ADHD Symptoms Behavioral relevance
Social relevance
• Over-learning of target behaviors for high frequency demands (e.g. orienting/actively attending to others) • Proactive goal-driven behaviors vs. reactive inhibition-focused skills
• Increased awareness of social impact of ADHD symptoms on others
• Normalizes problem-solving and repair processes to compensate for impulsive errors • High rate of reinforcement for performance of target behaviors to harness child’s motivation to rehearse mundane tasks
• Social modeling and rehearsal with immediate peer feedback for target behaviors • Emphasis placed on collaboration and social problem-solving • External/token rewards contingent on successful social interactions
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Table 2 Sequence of Session Routines for SDBT Welcome participants and prompt review of posted target behaviors for the session, including a frequency benchmark for performing the target behaviors, Warm-up by writing down session themes on a “home note” to prime in-session discussion and post-session discussion with parents, Conduct sharing time and a brief reflection of weekly individual and dyadic performance, Review previous therapy assignments and award token (treasure chest ticket) for return of home rehearsal worksheet, Introduce a new experiential, skills-focused in-session activity, Collaboratively facilitate multiple ongoing behavioral rehearsals of newly introduced skills, Review procedures for the new home assignment using the worksheet for the session, Administer second token reward for achievement of behavioral benchmark, Facilitate treasure-chest trade-ins and provide free play period if time permits, Provide parent consultation regarding current child session objectives, skills, and activities.
a more active role in facilitating meaningful peer exchanges and therapist– child interactions. The following sections illustrate how SDBT processes are facilitated using specific behavioral techniques.
eligibility to receive a token reward at the end of the session. As a sample, the following target behavior is posted and introduced with the dyad:
Today’s Behavior Goal is “Showing That You are Paying Attention”
Establishing Collaborative Behavioral Goals Behavior therapy applies operant and classical conditioning principles to promote the performance of desired behaviors and to ameliorate the performance of undesired behaviors (Miltenberger, 2011). In order for this to be successful, behavioral expectations must be clearly defined and understood by the patient and reinforcement efforts must be perceived as rewarding. A dyadic modality not only allows these assumptions to be met, but enables the therapist to facilitate active participant rehearsal with social modeling, multiple repetitions, and peer feedback throughout the course of a typical session. Owing to the altered reinforcement sensitivity needs of children with ADHD, it is especially important to limit target behaviors to a single goal for each session (Luman, Tripp, & Scheres, 2010). Focusing on one goal at a time provides a single clear performance target for child participants who are intrinsically prone to distraction. In addition, the single target behavior allows the therapist to effectively deliver specific verbal reinforcement at a high rate without having to attend to multiple positive behaviors displayed by two very active children within a given session. Introducing the target behavior at the beginning of each SDBT session, the behavior therapist aims to (1) enlist the dyad to read aloud the operational definitions of the posted behavioral target, (2) model each of the behaviors described, (3) prompt child modeling/rehearsal of the target behaviors, (4) administer specific labeled praise for each child’s performance, (5) elicit peer observations and support, and (6) facilitate opportunities for child partners to reciprocate with observations and supportive feedback. This collaborative process is similar to the techniques presented within Ross Greene’s collaborative problem-solving model (Greene, 2010). However, SDBT aims to facilitate proactive, model-driven collaboration to direct the pair’s work toward a predefined common goal; whereas, Greene’s collaborative approach emphasizes using scripts for effective action-driven, reactive methods for problem-solving (Greene, 2010). The therapist also explains to the dyad that the frequency of their combined performance will be monitored to determine their
1) Look at the person speaking, face to face and make eye contact 2) Move close to the person talking 3) Nod my head to show that I am listening 4) Stand/sit with my hands at my side (stop doing other things) Therapist. You will be able to earn prizes for your hard work each week. The first way is by performing the behavior goals we read on the poster. Not only do you need to try really hard to perform the behaviors posted, you will need to work together as a team to meet your goal. If your team (i.e., the dyad) is able to beat your record from the last week’s session, then you will each be given a ticket to purchase something from the treasure chest. Today’s behavior goal is “showing you are paying attention.” Tell me. How do you know if someone is listening and paying attention to you? What are they doing? What do they look like?
Blake. They would be looking at you.
Therapist. Yes! They would be making face to face, eye contact. What else would you notice? What are they not doing?
Sam. and they wouldn’t be talking
Therapist. Right! They would stop what they are doing. So, how do you show that you are listening?. . .Notice my eyes. Where are they looking when we are talking?
Blake and Sam. at us. . . we would make eye contact
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Therapist. Now, what do you notice about my chin when you are talking to me?. . . .Where is my body; close to you or far away? Now it’s your turn. Blake and Sam, show me what it looks like when you are giving face-to-face eye contact. Excellent eye contact! Now Sam, tell Blake about your soccer game last week. Blake, I want you to show us what you do with your chin when he is talking . . . Great nodding!
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Now Sam, when you were practicing, what did Blake do best to show that he was paying attention to you?. . .Blake, tell Sam what you noticed about what he was doing? While facilitating this process, the clinician will acknowledge and provide verbal reinforcement and simultaneously associate this praise with clicks on a tally counter used to monitor the frequency of the dyad’s target behaviors in the session.
Behavioral Benchmarking The concept of behavioral benchmarking is an important use of evidence for monitoring target behaviors and challenging participants to progress in their behavioral performance. This use of evidence of behavioral mastery to earn rewards is consistent with recent studies showing improved child motivation and behavioral performance resulting from performance-based praise (Corpus & Lepper, 2007; Corpus, Ogle, & Love-Geiger, 2006). This is especially important for ADHD intervention, where patients may initially respond to the novelty of the goal but then display “vigilance decrements” as the novelty fades (Nigg, 2006). Children with ADHD generally struggle to exert the sustained mental effort to carry out mundane tasks (Weinberg & Harper, 1993). Vigilance decrements are therefore observed as slower, more inconsistent responses, with more errors, which are signs of faltering sustained attention (Nigg, 2006). To address this tendency to display vigilance decrements, the therapist will monitor the pair’s performance of the identified behavioral goal throughout the session. The therapist strives to provide specific labeled praise and a demonstrative “click” of the tally counter when target behaviors are observed. When a new target behavior is introduced, the clinician aims to provide continuous reinforcement whenever possible to promote more rapid adoption of the target behavior (Miltenberger, 2011). As the current target behavior is repeated in subsequent sessions, the clinician may provide intermittent reinforcement to maintain the frequency of these behaviors (Miltenberger, 2011) by providing clicks on a variable schedule (e.g., one click for every two to three times the behavior is observed). The therapist will explain that clicks are based on both children’s participation and, thus, a combined effort. Results will be tallied at the end of each weekly session and used as a “benchmark” for the next week’s performance. Dyads are told that they can earn a token reward each week by “beating their record” from their previous session’s performance. At the end of the session, a ticket will be awarded to each child if the pair collaboratively exceeds their benchmark from the previous week. The ticket may then be used as currency for purchasing rewards from the treasure chest. A three-tiered treasure chest (i.e., one ticket, three tickets, or five tickets) is used to offer tangible rewards for either immediate or delayed reinforcement of in-session behaviors.
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It is important to note that weekly benchmarking is preferred to “personal bests.” The dyad’s all-time best may appear too daunting after an initial week’s failure and inadvertently discourage future efforts. Thus, the therapist can use this failure as a learning opportunity within the process of the next session using reflective practice and solution-focused techniques. Therapist. Sam and Blake, tell me what it was like to miss your goal last week.
Sam. I was so mad because I saved my last 2 tickets and I really wanted to get that hot wheel out of the 3-ticket drawer of the treasure chest!
Blake. Me too! It didn’t seem fair because we got 44 clicks the week before. There is no way that we are going to be able to beat that record!
Therapist. You guys seem really disappointed after trying so hard. I know it’s tough to come so close and not get what you wanted. But you guys earned 39 clicks last week and I know you can beat that. What will you guys do together today to make sure you get at least 40 clicks?
Blake. I guess we could remind each other to keep making eye contact and to nod when people are talking.
Sam. Yeah, and we can stop each other from doing stuff we are not supposed to do so we’ll pay attention better.
Therapist. Great ideas! Now let’s talk about some ways that I can help you meet your goal. One thing I can do is say out loud what I see when you are showing our target behaviors. So I might say something like “Sam, I like the way that you are looking at me when I’m talking to you” or “Blake, I noticed that you put your marker down when Sam started sharing something.” Linking the dyad’s behavioral performance to these weekly therapy benchmarks allows the therapist to appropriately push participants to maximize their contributions while enlisting them to engage in collaboration and social problem-solving. The example above shows ways in which the therapist may join with the dyad to promote this goal. In addition, the therapist may strategically use orienting and redirection during the session to promote better goal adherence.
Orienting Attention and Redirecting Using Effective Commands Off-task behaviors, especially those occurring for children with ADHD in a social context, may be challenging to correct without a more directive role from the behavior therapist. The attention and social stimulation of the session may also exacerbate the selfregulation challenges associated with ADHD. Schachar and colleagues (2007) describe inhibition to be akin to the brakes in a car,
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noting that children with ADHD may have a much harder time suppressing their impulsive responses or down-regulating their escalating behavioral responses. Thus, orienting child participants’ with an external prompt in SDBT may be needed to assist them in down-regulating undesired behaviors in session. Attention orienting prompts can be provided in several ways. Nonverbal orienting prompts may include physical touch (e.g., hand on the child’s shoulder) or simply the active withdrawal of the therapist’s attention by disengaging and directing attention to another activity (e.g., attending to the on-task partner or viewing the screen of one’s mobile phone until both children return to task). Other nonverbal prompts may involve the delivery of a predetermined cue or gesture such as clapping one’s hands or tapping the top of one’s head to initiate a preestablished behavioral response from child participants. Verbal orienting prompts can also be effective by using key words. For example, the therapist may invoke a “freeze” rule whereby all are required to remain still and quiet until prompted to “melt.” Other orienting key words may involve using stilted language to gain children’s attention before delivering a command (e.g., “I’m giving you an instruction . . .”). To maximize child performance while preserving a positive therapeutic alliance, the therapist facilitates redirection with the immediate goal to create an opportunity to deliver verbal rewards. Off-task behaviors may themselves present immediate reinforcement value that is greater than the reward of desired participation. If one or both members of the dyad continue to contribute off-task verbal or nonverbal behaviors, the clinician may use a quick three-step “V.I.P.” redirection technique—validate, instruct, praise. The VIP technique is a simplified strategy that is consistent with effective behavioral methods portrayed within the response interruption and redirection (RIRD) literature (Dickman, Bright, Montgomery, & Miguel, 2012). Validation involves the therapist reflecting on the child’s comments to acknowledge the child’s interest and invite collaboration before issuing the redirection. Instruction is simply the effective delivery of a command. Effective commands are typically described as simple single-step operations with clearly defined expectations (Barkley, 2006). Praise provides a verbal reward for the child’s compliant behavior. In some cases, differential ignoring of negative attitudes during redirection is necessary while praising compliance to facilitate completion of the redirection. For example: Sam. Hey Blake, check it out. I just drew a killer picture of the inside of my nose.
Therapist. (Validate) Boy Sam, your drawings sure are important to you. (Instruct) I’m giving you an instruction. I need you to sit down right now with your bottom on the floor, your legs crossed, and your arms by your side.
Sam. OK, but look at this (showing the drawing as he complies with the command).
Therapist. (Praise) (ignoring Sam’s display of the drawing) Look at you! You followed my instruction right away, just like I asked! (accompanied by a click of the tally counter). The primary role of the SDBT therapist is to promote, reinforce, and facilitate multiple rehearsals for children to overlearn positive behavioral responses in therapy. Calling upon the therapy process within SDBT, the therapist should attempt to use dyadic interactions to preempt the need for redirection. However, redirection is often necessary when peer feedback and the therapist’s less directive methods of promoting positive behaviors are not successful. In these instances, the therapist may not only draw particular attention to the child’s ultimate compliance, but also prompt the peer to reflect and provide feedback about his or her partner’s cooperation.
Implications of SDBT Processes for Psychotherapy Therapists are currently driven more and more to demonstrate both the effectiveness and the efficiency of their work (Chorpita et al., 2011). This has consequently led to the proliferation of clinical intervention manual development for many specific clinical conditions, raising concerns that techniques are too often prioritized over process-oriented therapy skills (Marshall, 2009). Although studies have dismantled some of the most effective techniques used within behavior therapy (Chorpita et al., 2011), others have called for more theoretically grounded process-oriented practices to be studied to expand the evidence-based treatment literature (David, 2011). SDBT presents an approach to child intervention that enables therapists to use behavior therapy techniques and principles that are proven to be effective, while creating a context for meaningful process-focused interactions and reflections. Therapists using SDBT may therefore adhere to sound theoretically grounded and evidence-based techniques while paying attention to the “how” and the “why” of the content shared by each member of the dyad in relation to one another. In behavioral terms, this social relationship potentially contributes to the “establishing operations” present in the therapy session for increasing the reinforcement value of the contingency management technique put into action (Miltenberger, 2011). By increasing children’s motivation to attend therapy with this social capital, it is likely that greater therapeutic adherence and ultimately greater magnitude of treatment outcomes can be achieved. Keeping in mind the primary purpose of SDBT is to improve behavioral self-regulation, many of the dyadic interactions emulate those within contexts such as school and home settings were children must work within a social milieu to meet their everyday behavioral demands. Consequently, much of the therapy process involves peer collaboration directed toward following the therapist’s directives and session objectives rather than focusing on primary social outcomes. In addition to improving the quality of child therapy participation through SDBT, this dyadic modality offers versatility for increasing access to care. PMT for ADHD is often delivered within a multifamily group modality (Cunningham, 2005). Multifamily PMT interventions present great opportunities for implementing SDBT as a complementary service. This not only addresses child care needs often associated with parents’ therapy attendance, but harnesses child strengths to collaborate with parents’ efforts during home implementation. Parents who would otherwise be disinclined to attend PMT due to childcare issues and/or due to the distraction
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of child interruptions within family sessions can instead consider a productive alternative. Previous studies that have included SDBT an adjunct to PMT have demonstrated its feasibility and show a high magnitude of main effects (Curtis, 2010). Finally, SDBT may prove to be beneficial for reaching children in alternative settings when parent participation is not possible. Although SDBT is a novel intervention currently being examined with regard to its treatment efficacy, even modest positive research outcomes could prove beneficial to support its use in places like school settings. Sadly, the majority of children with behavioral and mental health needs do not receive any form of treatment (Cooper, 2008). Increasing access to care by providing SDBT in school settings would circumvent barriers to treatment for families whose parents can’t participate in therapy owing to logistical barriers. School-based SDBT may also provide skills and methods for children with less severe symptoms who are at risk to experience more clinically significant problems as academic demands and behavioral expectations. Although children with ADHD present symptoms throughout their childhood, referrals for intervention tend to occur once symptom severity has reached a level of impairment— often in concert with progressively increasing gradelevel expectations. Thus, SDBT may serve a preventative or protective function for children with emerging symptoms, who would not otherwise seek therapy for less severe concerns. Although the burden of proof currently exists to demonstrate the benefits of SDBT as a stand alone intervention for ADHD, it certainly offers an innovative approach for addressing clinical process within child therapy. It has demonstrated feasibility and strong treatment outcomes for when used as a complement to PMT (Curtis, 2010; Curtis, Chapman, Dempsey, & Mire, 2013). SDBT was specifically developed to address self-regulation difficulties associated with ADHD. However, noting that these symptoms can be viewed as extremes of normal behaviors (Barkley, 2006), it is possible that this therapy approach may be like PMT in that it may also prove beneficial for children presenting other externalizing behavior problems. For instance, children presenting oppositionality, social difficulties, behavioral adjustment problems, or just subclinical symptoms of ADHD may also benefit from SDBT. In addition to these therapeutic implications for children and their families, the format of SDBT processes offers a framework for training future therapists to become more process oriented in their work.
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Miltenberger, R. A. (2011). Behavior modification: Principles & procedures (4th ed.). Belmont, CA: Wadworth. Nigg, J. T. (2006). What causes ADHD? Understanding what goes wrong and why? New York: Guilford Press. Pelham, W. E., & Fabiano, G. (2008). Evidence-based psychosocial treatments for attention-deficit/ hyperactivity disorder. Journal of Clinical Child and Adolescent Psychology, 37, 184 –214. doi:10.1080/ 15374410701818681 Sanders, M. R. (1999). The Triple P-Positive parenting program: Towards an empirically validated multilevel parenting and family support strategy for the prevention of behavior and emotional problems in children. Clinical Child and Family Psychology Review, 2, 71–90. doi:10.1023/ A:1021843613840 Schachar, R., Logan, G. D., Robaey, P., Chen, S., Ickowicz, A., & Barr, C. (2007). Restraint and cancellation: Multiple inhibition deficits in attention deficit hyperactivity disorder. Journal of Abnormal Child Psychology, 35, 229 –238. doi:10.1007/s10802-006-9075-2 Sibley, M. H., Smith, B. H., Evans, S. W., Pelham, W. E., & Gnagy, E. M. (2012). Treatment response to an intensive summer treatment program
for adolescents with ADHD. Journal of Attention Disorders, 16, 443– 448. doi:10.1177/1087054711433424 Skinner, B. F. (1969). Contingencies of reinforcement: A theoretical analysis. New York: Meredith Corporation. Verbruggen, F., & Logan, G. D. (2009). Automaticity of cognitive control: Goal priming in response-inhibition paradigms. Journal of Experimental Psychology: Learning, Memory, and Cognition, 35, 1381–1388. doi: 10.1037/a0016645 Weinberg, W. A., & Harper, C. R. (1993). Vigilance and its disorders. Neurologic Clinics, 11, 59 –78. Yalom, I. D. (1995). Theory and practice of group psychotherapy (4th ed.). New York: Basic Books.
Received January 15, 2013 Revision received May 8, 2013 Accepted July 2, 2013 䡲
© 2013 American Psychological Association 0033-3204/14/$12.00 DOI: 10.1037/a0033984
Structured Dyadic Behavior Therapy Processes for ADHD Intervention David F. Curtis
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Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas Children with Attention-Deficit/Hyperactivity Disorder (ADHD) present significant problems with behavioral disinhibition that often negatively affect their peer relationships. Although behavior therapies for ADHD have traditionally aimed to help parents and teachers better manage children’s ADHD-related behaviors, therapy processes seldom use peer relationships to implement evidence-based behavioral principles. This article introduces Structured Dyadic Behavior Therapy as a milieu for introducing effective behavioral techniques within a socially meaningful context. Establishing collaborative behavioral goals, benchmarking, and redirection strategies are discussed to highlight how in-session dyadic processes can be used to promote more meaningful reinforcement and change for children with ADHD. Implications for improving patient care, access to care, and therapist training are also discussed. Keywords: disruptive behavior, behavioral therapy, pair therapy, pair counseling
therapy to add relational meaning to the behavioral contingencies established to promote child and family change. In doing so, families may share examples of common difficulties they experience at home to practice behavioral strategies introduced within the session. For instance, parents may discuss the difficulty they encounter in trying to get their child to follow instructions every night associated with the bedtime routine. The therapist may then use this example to bring to life strategies for gaining the child’s attention, delivering effective commands, and administering verbal rewards both when the child initiates and completes the activity. Although the behavioral strategies clearly serve as the primary objective in this instance, rehearsing them within the family context allows for all family members to clarify their understanding and expectations for this daily experience within the process of interacting with one another in the therapy session. Similar to family processes in therapy, behavior therapies that incorporate interactions with peers also offer opportunities to add more meaning to the methods introduced. Children with ADHD often display outgoing socially motivated behaviors, and even positive social skills. However, as Barkley (1997) describes ADHD as a disorder of performance and not ability, these children often encounter secondary social problems. Behaviors such as poor turn-taking, nonadherence to rules of games being played, interrupting others, and rough play resulting from poor downregulation of emotional/behavioral responses may deter peers from seeking interaction with children with ADHD (Hoza, 2007). Further, peers may wish to avoid these affiliations to escape the disciplinary scrutiny often placed on children with ADHD by teachers and other caregivers (DuPaul & Power, 2008). Because many children with ADHD struggle with peer interactions, intervention that involves social processes may add greater validity and generalizability to therapy activities. Emerging evidence has supported the benefits of social skills training for ADHD within intensive summer treatment programs (STP; Sibley, Smith, Evans, Pelham, & Gnagy, 2012). STP has demonstrated remarkable effectiveness for improving behavioral and social functioning for children with ADHD. Unfortunately, access to this treatment is limited by restricted regional and seasonal offerings. A potential
As the sophistication of clinical intervention manuals continues to increase, therapists are faced with the increasing challenge to prove the benefits of how our techniques ultimately serve to go beyond mere symptom reduction to “illuminate aspects of the patient’s relationship to other people” (Yalom, 1995, p. 131). Behavior therapy is an evidence-based practice for treating children with a wide variety of disruptive behavior problems (Eyberg, Nelson, & Boggs, 2008). Behavioral therapies have historically been considered to be divorced from interpersonal therapy processes, relying strictly on the environmental contingencies surrounding rewards and punishments (Skinner, 1969). However, the social processes involved in managing these contingencies may certainly provide the establishing operations for maximizing the potency of reinforcement principles to be used within modern behavior therapies. Applied to children with Attention-Deficit/Hyperactivity Disorder (ADHD), behavioral interventions have been exclusively identified as the only psychosocial interventions to be effective for amelioration of core symptoms (Fabiano et al., 2009). Contingency management techniques typically serve as primary processes for interventions; however, these strategies are most commonly provided to parents and teachers charged with the daily care of children with ADHD (Pelham & Fabiano, 2008). The most effective behavior therapies for ADHD are family-based approaches delivered either within family therapy or via parent management training (PMT) (Diamond & Josephson, 2005; Fabiano et al., 2009). Such family-based approaches call on family processes in
This article was published Online First December 30, 2013. David F. Curtis, Section of Psychology, Department of Pediatrics, Baylor College of Medicine, and Psychology Service, Department of Pediatrics, Texas Children’s Hospital, Houston, Texas. Completion of this article was supported by a grant from the Texas Children’s Hospital Pediatric Pilot Research Fund. Correspondence concerning this article should be addressed to David F. Curtis, Texas Children’s Hospital, Psychology Service, 6701 Fannin Street, CCC 1630.31, Houston, TX 77030-2399. E-mail: [email protected] 110
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extension of these therapeutic processes to usual care settings is worthy of consideration using a dyadic therapy milieu (Karcher & Lewis, 2002). The primary aim of this article is to illustrate how processes known to be effective in behavior therapy may be accentuated within a dyadic modality. The use of Structured Dyadic Behavior Therapy (SDBT) is introduced as a novel behavioral approach for treating ADHD, with examples of three behavioral techniques used to highlight key clinical processes. Specific SDBT techniques discussed are behavioral goal setting, benchmarking, and redirection strategies. Although the efficacy of a child clinical intervention manual for ADHD (Curtis, 2012) has not yet been evaluated, the process of implementing SDBT strategies is of greater importance than its content. Presenting for therapy with a disorder of performance rather than ability (Barkley, 1997), children with ADHD may already know how to perform the skills or content introduced within a behavior therapy session. However, they continue to show significant behavioral and social impairments despite having knowledge or ability for these skills. Consequently, the process of SDBT emphasizes intensive instruction, modeling, repeated rehearsal, and feedback to improve more consistent performance of these behaviors that are often required by everyday demands. Thus, a brief overview of a typical SDBT session is provided, followed by more descriptive narratives to depict key process elements for some of the core behavioral methods used. To ensure patient privacy and confidentiality, narrative exchanges are based on themes frequently observed by the author within SDBT sessions rather than verbatim transcripts abstracted from specific comments.
Defining SDBT SDBT is a novel behavior therapy approach for children ages 7 to 12 with ADHD that combines self-regulation techniques and social learning strategies within a pair milieu. Provided the aim to promote greater self-regulation and social learning, SDBT is intended for children ages 7 to 12 who are (1) likely to possess the necessary abstract reasoning and comprehension skills to participate and (2) more likely to encounter these challenges within their everyday settings. Reflective of its name, SDBT is a highly structured and model-driven approach to behavior therapy. This is intended to maximize the benefits of therapy processes by establishing clear, consistent, and predictable parameters that compensate for common ADHD-related problems. Similar to the pioneering work contributed by Barkley (2006), McMahon and Forehand (2005), Sanders (1999), and other developers of successful PMT
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programs, the primary aim of SDBT is to use intensive contingency management methods to address the A, B, C’s (antecedents, behaviors, and consequences) commonly associated with ADHDrelated problems. Thus, SDBT is truly a behavior therapy based on foundations of operant and classical conditioning. In addition, SDBT calls on social learning principles in its secondary aim to use modeling, interactive rehearsal, and peer feedback as parts of the therapy process. An outline of SDBT processes relevant to treating ADHD symptoms is provided in Table 1. Rather than attempting to suppress children’s ADHD-related tendencies to be active in social situations, act on impulse, and display socially interfering behaviors, SDBT aims to engage children in more effective self-regulation and social management of their behavior by providing model-driven protocols and scripts to rehearse to improve their performance in these situations. Thus, children are provided with clear behavioral expectations for highfrequency behaviors and are given numerous opportunities to practice these models over multiple sessions. Frequent opportunities to practice these behaviors promote overlearning of skills to increase automaticity, or more adaptive reflex-like responses, when these behaviors are needed or prompted by everyday situations. Unlike insight-oriented therapies, the goal is not necessarily to achieve greater awareness. Instead SDBT adopts a “solutionfocused” approach by providing children with adaptive skills that can promote their success regardless of the inherent reason for the difficulty (Bliss & Bray, 2009). SDBT can be implemented as an independent therapy or as a complement to PMT. If provided as a stand alone treatment, brief parent consultations with parenting handouts can accompany each child session to facilitate better home implementation and rehearsal of new strategies. If conducted as a complement to PMT, a portion of each session can be dedicated to in vivo family rehearsal of behavioral strategies to be implemented at home. SDBT establishes a consistent routine sequence of behavioral expectations for each therapy session. As asserted by eminent psychiatrist and group clinical process expert, Irvin Yalom (1995), “One of the most potent ways of providing structure is to build into each session a consistent, explicit sequence” (p. 471). This promotes efficiency of therapy activities, lowers confusion regarding behavioral expectations, and increases predictability to lower the anxiety associated with participation. Toward this goal, the basic routine for SDBT sessions consists of the activities outlined in Table 2. The routine sequence of SDBT activities is intended to support clinical processes within the therapy with clear and predictable parameters for participation, allowing the clinician to take
Table 1 SDBT Processes Relevant to Treating ADHD Symptoms Behavioral relevance
Social relevance
• Over-learning of target behaviors for high frequency demands (e.g. orienting/actively attending to others) • Proactive goal-driven behaviors vs. reactive inhibition-focused skills
• Increased awareness of social impact of ADHD symptoms on others
• Normalizes problem-solving and repair processes to compensate for impulsive errors • High rate of reinforcement for performance of target behaviors to harness child’s motivation to rehearse mundane tasks
• Social modeling and rehearsal with immediate peer feedback for target behaviors • Emphasis placed on collaboration and social problem-solving • External/token rewards contingent on successful social interactions
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Table 2 Sequence of Session Routines for SDBT Welcome participants and prompt review of posted target behaviors for the session, including a frequency benchmark for performing the target behaviors, Warm-up by writing down session themes on a “home note” to prime in-session discussion and post-session discussion with parents, Conduct sharing time and a brief reflection of weekly individual and dyadic performance, Review previous therapy assignments and award token (treasure chest ticket) for return of home rehearsal worksheet, Introduce a new experiential, skills-focused in-session activity, Collaboratively facilitate multiple ongoing behavioral rehearsals of newly introduced skills, Review procedures for the new home assignment using the worksheet for the session, Administer second token reward for achievement of behavioral benchmark, Facilitate treasure-chest trade-ins and provide free play period if time permits, Provide parent consultation regarding current child session objectives, skills, and activities.
a more active role in facilitating meaningful peer exchanges and therapist– child interactions. The following sections illustrate how SDBT processes are facilitated using specific behavioral techniques.
eligibility to receive a token reward at the end of the session. As a sample, the following target behavior is posted and introduced with the dyad:
Today’s Behavior Goal is “Showing That You are Paying Attention”
Establishing Collaborative Behavioral Goals Behavior therapy applies operant and classical conditioning principles to promote the performance of desired behaviors and to ameliorate the performance of undesired behaviors (Miltenberger, 2011). In order for this to be successful, behavioral expectations must be clearly defined and understood by the patient and reinforcement efforts must be perceived as rewarding. A dyadic modality not only allows these assumptions to be met, but enables the therapist to facilitate active participant rehearsal with social modeling, multiple repetitions, and peer feedback throughout the course of a typical session. Owing to the altered reinforcement sensitivity needs of children with ADHD, it is especially important to limit target behaviors to a single goal for each session (Luman, Tripp, & Scheres, 2010). Focusing on one goal at a time provides a single clear performance target for child participants who are intrinsically prone to distraction. In addition, the single target behavior allows the therapist to effectively deliver specific verbal reinforcement at a high rate without having to attend to multiple positive behaviors displayed by two very active children within a given session. Introducing the target behavior at the beginning of each SDBT session, the behavior therapist aims to (1) enlist the dyad to read aloud the operational definitions of the posted behavioral target, (2) model each of the behaviors described, (3) prompt child modeling/rehearsal of the target behaviors, (4) administer specific labeled praise for each child’s performance, (5) elicit peer observations and support, and (6) facilitate opportunities for child partners to reciprocate with observations and supportive feedback. This collaborative process is similar to the techniques presented within Ross Greene’s collaborative problem-solving model (Greene, 2010). However, SDBT aims to facilitate proactive, model-driven collaboration to direct the pair’s work toward a predefined common goal; whereas, Greene’s collaborative approach emphasizes using scripts for effective action-driven, reactive methods for problem-solving (Greene, 2010). The therapist also explains to the dyad that the frequency of their combined performance will be monitored to determine their
1) Look at the person speaking, face to face and make eye contact 2) Move close to the person talking 3) Nod my head to show that I am listening 4) Stand/sit with my hands at my side (stop doing other things) Therapist. You will be able to earn prizes for your hard work each week. The first way is by performing the behavior goals we read on the poster. Not only do you need to try really hard to perform the behaviors posted, you will need to work together as a team to meet your goal. If your team (i.e., the dyad) is able to beat your record from the last week’s session, then you will each be given a ticket to purchase something from the treasure chest. Today’s behavior goal is “showing you are paying attention.” Tell me. How do you know if someone is listening and paying attention to you? What are they doing? What do they look like?
Blake. They would be looking at you.
Therapist. Yes! They would be making face to face, eye contact. What else would you notice? What are they not doing?
Sam. and they wouldn’t be talking
Therapist. Right! They would stop what they are doing. So, how do you show that you are listening?. . .Notice my eyes. Where are they looking when we are talking?
Blake and Sam. at us. . . we would make eye contact
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Therapist. Now, what do you notice about my chin when you are talking to me?. . . .Where is my body; close to you or far away? Now it’s your turn. Blake and Sam, show me what it looks like when you are giving face-to-face eye contact. Excellent eye contact! Now Sam, tell Blake about your soccer game last week. Blake, I want you to show us what you do with your chin when he is talking . . . Great nodding!
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Now Sam, when you were practicing, what did Blake do best to show that he was paying attention to you?. . .Blake, tell Sam what you noticed about what he was doing? While facilitating this process, the clinician will acknowledge and provide verbal reinforcement and simultaneously associate this praise with clicks on a tally counter used to monitor the frequency of the dyad’s target behaviors in the session.
Behavioral Benchmarking The concept of behavioral benchmarking is an important use of evidence for monitoring target behaviors and challenging participants to progress in their behavioral performance. This use of evidence of behavioral mastery to earn rewards is consistent with recent studies showing improved child motivation and behavioral performance resulting from performance-based praise (Corpus & Lepper, 2007; Corpus, Ogle, & Love-Geiger, 2006). This is especially important for ADHD intervention, where patients may initially respond to the novelty of the goal but then display “vigilance decrements” as the novelty fades (Nigg, 2006). Children with ADHD generally struggle to exert the sustained mental effort to carry out mundane tasks (Weinberg & Harper, 1993). Vigilance decrements are therefore observed as slower, more inconsistent responses, with more errors, which are signs of faltering sustained attention (Nigg, 2006). To address this tendency to display vigilance decrements, the therapist will monitor the pair’s performance of the identified behavioral goal throughout the session. The therapist strives to provide specific labeled praise and a demonstrative “click” of the tally counter when target behaviors are observed. When a new target behavior is introduced, the clinician aims to provide continuous reinforcement whenever possible to promote more rapid adoption of the target behavior (Miltenberger, 2011). As the current target behavior is repeated in subsequent sessions, the clinician may provide intermittent reinforcement to maintain the frequency of these behaviors (Miltenberger, 2011) by providing clicks on a variable schedule (e.g., one click for every two to three times the behavior is observed). The therapist will explain that clicks are based on both children’s participation and, thus, a combined effort. Results will be tallied at the end of each weekly session and used as a “benchmark” for the next week’s performance. Dyads are told that they can earn a token reward each week by “beating their record” from their previous session’s performance. At the end of the session, a ticket will be awarded to each child if the pair collaboratively exceeds their benchmark from the previous week. The ticket may then be used as currency for purchasing rewards from the treasure chest. A three-tiered treasure chest (i.e., one ticket, three tickets, or five tickets) is used to offer tangible rewards for either immediate or delayed reinforcement of in-session behaviors.
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It is important to note that weekly benchmarking is preferred to “personal bests.” The dyad’s all-time best may appear too daunting after an initial week’s failure and inadvertently discourage future efforts. Thus, the therapist can use this failure as a learning opportunity within the process of the next session using reflective practice and solution-focused techniques. Therapist. Sam and Blake, tell me what it was like to miss your goal last week.
Sam. I was so mad because I saved my last 2 tickets and I really wanted to get that hot wheel out of the 3-ticket drawer of the treasure chest!
Blake. Me too! It didn’t seem fair because we got 44 clicks the week before. There is no way that we are going to be able to beat that record!
Therapist. You guys seem really disappointed after trying so hard. I know it’s tough to come so close and not get what you wanted. But you guys earned 39 clicks last week and I know you can beat that. What will you guys do together today to make sure you get at least 40 clicks?
Blake. I guess we could remind each other to keep making eye contact and to nod when people are talking.
Sam. Yeah, and we can stop each other from doing stuff we are not supposed to do so we’ll pay attention better.
Therapist. Great ideas! Now let’s talk about some ways that I can help you meet your goal. One thing I can do is say out loud what I see when you are showing our target behaviors. So I might say something like “Sam, I like the way that you are looking at me when I’m talking to you” or “Blake, I noticed that you put your marker down when Sam started sharing something.” Linking the dyad’s behavioral performance to these weekly therapy benchmarks allows the therapist to appropriately push participants to maximize their contributions while enlisting them to engage in collaboration and social problem-solving. The example above shows ways in which the therapist may join with the dyad to promote this goal. In addition, the therapist may strategically use orienting and redirection during the session to promote better goal adherence.
Orienting Attention and Redirecting Using Effective Commands Off-task behaviors, especially those occurring for children with ADHD in a social context, may be challenging to correct without a more directive role from the behavior therapist. The attention and social stimulation of the session may also exacerbate the selfregulation challenges associated with ADHD. Schachar and colleagues (2007) describe inhibition to be akin to the brakes in a car,
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noting that children with ADHD may have a much harder time suppressing their impulsive responses or down-regulating their escalating behavioral responses. Thus, orienting child participants’ with an external prompt in SDBT may be needed to assist them in down-regulating undesired behaviors in session. Attention orienting prompts can be provided in several ways. Nonverbal orienting prompts may include physical touch (e.g., hand on the child’s shoulder) or simply the active withdrawal of the therapist’s attention by disengaging and directing attention to another activity (e.g., attending to the on-task partner or viewing the screen of one’s mobile phone until both children return to task). Other nonverbal prompts may involve the delivery of a predetermined cue or gesture such as clapping one’s hands or tapping the top of one’s head to initiate a preestablished behavioral response from child participants. Verbal orienting prompts can also be effective by using key words. For example, the therapist may invoke a “freeze” rule whereby all are required to remain still and quiet until prompted to “melt.” Other orienting key words may involve using stilted language to gain children’s attention before delivering a command (e.g., “I’m giving you an instruction . . .”). To maximize child performance while preserving a positive therapeutic alliance, the therapist facilitates redirection with the immediate goal to create an opportunity to deliver verbal rewards. Off-task behaviors may themselves present immediate reinforcement value that is greater than the reward of desired participation. If one or both members of the dyad continue to contribute off-task verbal or nonverbal behaviors, the clinician may use a quick three-step “V.I.P.” redirection technique—validate, instruct, praise. The VIP technique is a simplified strategy that is consistent with effective behavioral methods portrayed within the response interruption and redirection (RIRD) literature (Dickman, Bright, Montgomery, & Miguel, 2012). Validation involves the therapist reflecting on the child’s comments to acknowledge the child’s interest and invite collaboration before issuing the redirection. Instruction is simply the effective delivery of a command. Effective commands are typically described as simple single-step operations with clearly defined expectations (Barkley, 2006). Praise provides a verbal reward for the child’s compliant behavior. In some cases, differential ignoring of negative attitudes during redirection is necessary while praising compliance to facilitate completion of the redirection. For example: Sam. Hey Blake, check it out. I just drew a killer picture of the inside of my nose.
Therapist. (Validate) Boy Sam, your drawings sure are important to you. (Instruct) I’m giving you an instruction. I need you to sit down right now with your bottom on the floor, your legs crossed, and your arms by your side.
Sam. OK, but look at this (showing the drawing as he complies with the command).
Therapist. (Praise) (ignoring Sam’s display of the drawing) Look at you! You followed my instruction right away, just like I asked! (accompanied by a click of the tally counter). The primary role of the SDBT therapist is to promote, reinforce, and facilitate multiple rehearsals for children to overlearn positive behavioral responses in therapy. Calling upon the therapy process within SDBT, the therapist should attempt to use dyadic interactions to preempt the need for redirection. However, redirection is often necessary when peer feedback and the therapist’s less directive methods of promoting positive behaviors are not successful. In these instances, the therapist may not only draw particular attention to the child’s ultimate compliance, but also prompt the peer to reflect and provide feedback about his or her partner’s cooperation.
Implications of SDBT Processes for Psychotherapy Therapists are currently driven more and more to demonstrate both the effectiveness and the efficiency of their work (Chorpita et al., 2011). This has consequently led to the proliferation of clinical intervention manual development for many specific clinical conditions, raising concerns that techniques are too often prioritized over process-oriented therapy skills (Marshall, 2009). Although studies have dismantled some of the most effective techniques used within behavior therapy (Chorpita et al., 2011), others have called for more theoretically grounded process-oriented practices to be studied to expand the evidence-based treatment literature (David, 2011). SDBT presents an approach to child intervention that enables therapists to use behavior therapy techniques and principles that are proven to be effective, while creating a context for meaningful process-focused interactions and reflections. Therapists using SDBT may therefore adhere to sound theoretically grounded and evidence-based techniques while paying attention to the “how” and the “why” of the content shared by each member of the dyad in relation to one another. In behavioral terms, this social relationship potentially contributes to the “establishing operations” present in the therapy session for increasing the reinforcement value of the contingency management technique put into action (Miltenberger, 2011). By increasing children’s motivation to attend therapy with this social capital, it is likely that greater therapeutic adherence and ultimately greater magnitude of treatment outcomes can be achieved. Keeping in mind the primary purpose of SDBT is to improve behavioral self-regulation, many of the dyadic interactions emulate those within contexts such as school and home settings were children must work within a social milieu to meet their everyday behavioral demands. Consequently, much of the therapy process involves peer collaboration directed toward following the therapist’s directives and session objectives rather than focusing on primary social outcomes. In addition to improving the quality of child therapy participation through SDBT, this dyadic modality offers versatility for increasing access to care. PMT for ADHD is often delivered within a multifamily group modality (Cunningham, 2005). Multifamily PMT interventions present great opportunities for implementing SDBT as a complementary service. This not only addresses child care needs often associated with parents’ therapy attendance, but harnesses child strengths to collaborate with parents’ efforts during home implementation. Parents who would otherwise be disinclined to attend PMT due to childcare issues and/or due to the distraction
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of child interruptions within family sessions can instead consider a productive alternative. Previous studies that have included SDBT an adjunct to PMT have demonstrated its feasibility and show a high magnitude of main effects (Curtis, 2010). Finally, SDBT may prove to be beneficial for reaching children in alternative settings when parent participation is not possible. Although SDBT is a novel intervention currently being examined with regard to its treatment efficacy, even modest positive research outcomes could prove beneficial to support its use in places like school settings. Sadly, the majority of children with behavioral and mental health needs do not receive any form of treatment (Cooper, 2008). Increasing access to care by providing SDBT in school settings would circumvent barriers to treatment for families whose parents can’t participate in therapy owing to logistical barriers. School-based SDBT may also provide skills and methods for children with less severe symptoms who are at risk to experience more clinically significant problems as academic demands and behavioral expectations. Although children with ADHD present symptoms throughout their childhood, referrals for intervention tend to occur once symptom severity has reached a level of impairment— often in concert with progressively increasing gradelevel expectations. Thus, SDBT may serve a preventative or protective function for children with emerging symptoms, who would not otherwise seek therapy for less severe concerns. Although the burden of proof currently exists to demonstrate the benefits of SDBT as a stand alone intervention for ADHD, it certainly offers an innovative approach for addressing clinical process within child therapy. It has demonstrated feasibility and strong treatment outcomes for when used as a complement to PMT (Curtis, 2010; Curtis, Chapman, Dempsey, & Mire, 2013). SDBT was specifically developed to address self-regulation difficulties associated with ADHD. However, noting that these symptoms can be viewed as extremes of normal behaviors (Barkley, 2006), it is possible that this therapy approach may be like PMT in that it may also prove beneficial for children presenting other externalizing behavior problems. For instance, children presenting oppositionality, social difficulties, behavioral adjustment problems, or just subclinical symptoms of ADHD may also benefit from SDBT. In addition to these therapeutic implications for children and their families, the format of SDBT processes offers a framework for training future therapists to become more process oriented in their work.
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Received January 15, 2013 Revision received May 8, 2013 Accepted July 2, 2013 䡲
