Managing Inattentive ADHD with Psychosocial Treatments
Linda Pfiffner PhD
INATTENTIVE ADHD is the most common form of ADHD. It is less well recognized than other forms of ADHD, however, because overactivity and disruptive behaviors are usually not a concern. Instead, regulating attention and executive dysfunction (difficulty planning and organizing goal-directed behavior) are the primary reasons children with this form of ADHD struggle at school and at home. Treatment professionals and researchers refer to it as ADHD-Predominantly Inattentive Presentation or ADHD-I.
At school, children with ADHD-I usually have difficulty completing their work. They often have trouble keeping track of assignments and belongings and they work slowly with drifting attention. They may appear to lack internal motivation and may underperform relative to their academic ability. At home, children with ADHD-I often have difficulty independently and efficiently completing routine activities like getting ready in the morning and completing chores. Homework is often challenging due to slowness and confusion about assignments. Socially, they may be somewhat passive and withdrawn. Some may not always know what to say or do during social interactions.
Extensive research supports the use of psychosocial (nonmedical, behaviorally oriented) treatments for ADHD. However, this research has been conducted almost exclusively with youth having hyperactivity/impulsivity along with inattention. In response to this gap, we developed the Child Life and Attention Skills (CLAS) program specifically for ADHD-I.
CLAS includes integrated, parent, child, and teacher components. Parents and children attend eight ninety-minute concurrent group sessions (one for the parents and one for the children) and four individual family sessions. Up to five meetings are held between the teacher, parent, and child. The components work together to target common goals across home and school using a supportive reward-based programs, skills training, and organizational structures.
The CLAS approach is similar to the approaches used in a number of parent training programs but adapted to more fully address concerns including homework routines, independence, compliance with parent requests, organizational and time-management skills, and peer interactions. Parenting strategies covered include:
● giving quality attention
● using effective "labeled" praise and other positive consequences (desired activities and privileges, for example)
● developing clearly laid-out routines for the morning, homework time, and bedtime
● giving brief and specific directions
● using prudent negative consequences when needed
● using a variety of tools to promote attention and adaptive functioning (such as to-do lists and plans, organized homework areas, and structured playdates)
● parent stress management.
To maximize motivation and buy-in, children help to design their own routines and choose their rewards. At first, parents closely monitor the child's behavior using strategic reminders and positive feedback to reinforce success. Independence is gradually developed, for example, by increasing time between parent check-ins and by using labeled praise, such as "I really like how you started your homework with only one reminder!"
An individualized plan is designed for each child and includes specific positive behaviors ("bring your planner home" instead of "don't lose your planner"), a system for monitoring progress (often a visual chart), and tokens or points for meeting goals which are exchanged for rewards. Parents are also taught strategies for checking and reinforcing a daily report card and methods to promote and reinforce social skills taught during the child group. For example, parents are encouraged to prompt their child to use friendship-making skills (such as friendly words with good eye contact) when joining a group or asking a child to play. Parents also learn to facilitate successful playdates.
The child program targets independence at school and home (in homework and study skills, organization and time management skills, and self-care skills such as getting ready for school), and social competence (being a good sport, assertion, dealing with teasing, friendship-making skills, playdate skills). Children practice these skills during group sessions via role-plays of common problem scenarios (such as joining a game or being teased, staying on-task during homework) and during activities and relay races with high doses of positive feedback (such as backpack organization challenges).
Self-management of alertness is supported by "attention checks," during which time children are prompted to repeat back what's been said. Each week, children bring in points earned at home and school in exchange for group-based rewards (cheers from group members, for example, or a pizza party). Parents and children meet together at the end of each group to go over the "skill of the week" and plan home activities (such as developing a morning routine checklist or planning a playdate) to practice new skills.
Teachers are taught strategies to support success in the classroom, with a focus on using an individualized report card that goes home with the child each day. Teachers rate students three times a day on up to four target behaviors. Target behaviors are based on the needs of the child and typically include academic work ("get started right away," "finish work on time," or "turn in your homework") and social interactions ("play with a peer at recess," "stay calm when frustrated").
Rewards are provided at home when the child meets daily and weekly goals. Skills taught in the child group are shared with teachers so that the child's use of these skills can be reinforced at school. Additional accommodations (such as preferential seating, teacher monitoring of a planner to track homework) also may be implemented to improve classroom functioning.
What the research shows
Two studies with over 260 children show that CLAS, compared to usual care, improves inattention symptoms, increases organizational and social skills, reduces daily parenting stress, and increases positive parenting. Over half the participants improved such that their behavior was similar to most typical children. Parents, teachers, and children were very satisfied with the program. Including all components (parent, teacher, child) resulted in the greatest benefit at home and at school. However, we also found that the parent component alone was similarly helpful for improving child behavior at home.
Two findings are also important to note:
● The more consistently the parents implemented the recommended strategies, the greater the improvement observed in the child.
● The amount of child behavioral improvement was predicted by the degree to which the parent reduced their inconsistent discipline and increased their positive parenting.
We also note a couple of caveats:
● Findings are based on reports from parents and teachers who may have been biased by their participation in the program, and
● Ongoing treatments are likely needed to sustain positive outcomes into subsequent school years.
Nevertheless, these results show that psychosocial treatments can lead to considerable improvement in children with ADHD-I. They also demonstrate the necessary role of parenting in creating these positive outcomes. Coordinating treatment among parents, teachers, and children through common behavioral strategies appears well indicated for children with ADHD-I.
Linda Pfiffner, PhD, is a professor in residence, licensed clinical psychologist and director of the Hyperactivity, Attention, and Learning Problems Program in the department of psychiatry at the University of California, San Francisco. She is a former member of the CHADD professional advisory board and a recipient of the CHADD Hall of Fame Award. Elizabeth Owens, PhD, is a licensed psychologist and an assistant professor of clinical psychology at the University of California, Berkeley.
Pfiffner, L. J., Hinshaw, S. P., Owens, E. B., Zalecki, C., Kaiser, N., Villodas, M., & McBurnett, K, (2014). A two-site randomized clinical trial of integrated psychosocial treatment for ADHD-inattentive type. Journal of Consulting and Clinical Psychology, 82, 1115-1127.
Pfiffner, L. J., Mikami, A. Y., Huang-Pollock, C., Easterlin, B., Zalecki, C., & McBurnett, K. (2007). A randomized controlled trial of integrated home–school behavioral treatment for ADHD, predominantly inattentive type. Journal of the American Academy of Child & Adolescent Psychiatry, 46, 1041–1050.
Pfiffner, L.J. (2011). All About ADHD: The Complete Practical Guide for Classroom Teachers, 2nd edition. Scholastic, Inc. New York, NY.