Attention Magazine Fall 2017

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MENTAL HEALTH PROFESSIONALS who work with teens with ADHD and their parents know that effective treatment often goes beyond simply teaching teens how to be more organized and focused. It’s also about helping to reduce homework battles, improve parent-teen communication, and reduce family stress. Treatment must also help teens to feel more invested in learning new strategies–and help them remain motivated so they continue to practice these strategies over the long term. An innovative treatment model known as STAND (Supporting Teens’ Autonomy Daily) is designed to address these as well as other important real-life issues. Initial research findings suggest that the program is achieving its intended outcomes.

The brainchild of Margaret Sibley, PhD, associate professor of psychiatry and behavioral health at Florida International University and recipient of CHADD’s 2014 Young Scientist Award, STAND incorporates elements of family therapy, behavioral parent training, organizational skills training, and perhaps most importantly, motivational interviewing (MI). Says Dr. Sibley, “MI is the glue that holds the model together.”

Motivational interviewing is a counseling approach that inspires people to make changes in their lives at a time when they might feel ambivalent about doing so. Here’s an example, one commonly addressed by STAND practitioners: You’re a mom of a teen with ADHD, and you feel you’re spending far too much time organizing your child’s school day. You know you need to take some of this responsibility off your plate and put it on your child’s plate. But you’re ambivalent, and for good reason. Your instincts tell you that it if you do so, your child might start to fail. And previous experiences may have only further convinced you of this.

A modular approach

STAND is based on a modular approach toward treatment that draws upon evidence- based practices to target specific treatment goals and desired outcomes. Four engagement models are followed by seven skilled-based modules, which are then followed by four mobilization modules. Engagement modules help set the tone. Parents and teens learn that treatment is not about an expert telling them what to do, but rather a partnership where one’s personal voice and goals help guide the process.

Within the course of engagement sessions, parents and teens also learn strategies for staying calm during stressful discussions, ways to listen effectively, ways to communicate honestly and respectfully, and how to create a balance between responsibilities and enjoyable activities at home. Next, parents and teens select from a menu of seven skill-based modules:

1 Writing down homework

2 Making a homework plan

3 Organization checks

4 Time-management strategies

5 Study skills

6 Note taking

7 Problem solving

For each module, the therapist helps the parent and teen devise a mutually agreed-upon plan for applying the skill. Discussions include ways to integrate the skill into daily use and what changes can be made at home to maximize its long term use. Four STAND mobilizing modules, which follow successful mastery of skill modules, are intended to generate lasting change. Modules focus on ways to engage the school in the parent-teen treatment plan, how a teen can turn newly learned skills into daily habits, how the teen will continue to practice skills over the long term, and how the parent can arrange for a home structure that reinforces skills use.

STAND modules are supported by parent and teen activity worksheets and other handouts. Two assessment tools are also provided:

● the Adolescent Academic Problems Checklist (AAPC), which parents, teachers, and/or teens can complete to help identify the extent to which the teen uses compensatory organizational skills to manage daily school responsibilities; and

● the Parent Academic Management Scale (PAMS) which parents complete to help identify the degree to which they rely on either of two common coping strategies in response to the stresses associated with their child’s persisting attentional and executive function challenges, one being over-involvement in helping their child succeed in school, the other being under-involvement.

These assessment tools help therapists guide discussions, improve parent-teen collaborative problem solving, and reduce tensions at home.

The spirit of motivational interviewing

STAND’S first two engagement modules and the final mobilizing module are largely MI-focused, intended to plant seeds for personal change and to motivate parents and teens to continue to use newly learned skills and tools. MI strategies are also used during the skill-based module to reinforce reflection and personal choice regarding the benefits of change.

While STAND treatment service providers can suggest which skill areas can benefit the family the most, in the spirit of MI, families are viewed as the ones who know best where problems lie and what skill modules are likely to work best. Parents and teens are thereby empowered to choose their own treatment goals, decide on their own modular treatment components, and openly communicate ways to try new and different things at home.

STAND has been used effectively with middle- and high-school students ranging in age from eleven to eighteen. The modules are sufficiently flexible so that service providers can tailor the program to varying ages and varying needs. Sessions are typically an hour in length, once a week. While modules are arranged in a sequential order, treatment providers will remain focused on one module rather than moving on to another when mastery of the module has not been achieved.

Sibley recommends that the provider use clinical judgement to determine whether certain comorbidities might impact successful completion of the program. The model has been helpful to teens experiencing coexisting anxiety, depression and oppositional tendencies, but any of these or other conditions could also interfere with the successful completion of the program depending upon the degree to which symptoms impair functioning.

Promising outcomes

In a recent study comparing STAND to a community treatment group, teens improved significantly in their use of organizational and other strategies and showed a significant reduction in ADHD severity. Parents also reported lower levels of parenting stress following completion of treatment as well as six months later. Dr. Sibley and her team also explored how to deliver STAND via teleconferencing in order to reach families in more rural settings. Additional studies are under way, one of which compares STAND outcomes when delivered to parents and teens in a group setting, and another exploring STAND outcomes with low-income families.

STAND not only weaves together important elements from other treatment approaches, but does so in ways that appreciate day-today realities of life. Parents, for example, often have to work late. Teens are involved in afterschool activities that are important to their health and wellbeing, and many spend a lot of time distracted by technology. STAND helps parents and teens with ADHD establish a healthy balance, and in the process also achieve specific outcomes; among these, STAND helps teens with ADHD learn to be more independent and responsible, thus helping their parents feel less stressed and more in control.

Treatment providers who are interested in learning more about STAND are encouraged to read Sibley’s Parent-Teen Therapy for Executive Function Deficits and ADHD: Building Skills and Motivation (Guilford, 2016). The book, which serves as a treatment manual, describes each module in detail, including how to effectively integrate each module into a comprehensive treatment plan. Purchasers are also provided access to a website where they can download the program’s many reproducible tools and activities.

According to Dr. Sibley, the spirit of MI in STAND distinguishes it from other skill-based treatment models. As such, STAND providers should be trained in the approach. Sibley recommends that untrained providers read Motivational Interviewing: Helping People Change by William R. Miller and Stephen Rollnick (Guilford, 2013), and attend an MI training to develop skills in the approach.

A clinical and consulting psychologist, Mark Katz, PhD, is the director of Learning Development Services, an educational, psychological, and neuropsychological center in San Diego, California. As a contributing editor to Attention magazine, he writes the Promising Practices column and serves on the editorial advisory board. He is also a former member of CHADD’s professional advisory board and a recipient of the CHADD Hall of Fame Award.

LEARN MORE

Learn more at http://www.margaretsibley.com/about-stand. Dr. Sibley also provides a video training series for professionals that explores ten key components of STAND at http://www.margaretsibley.com/videos/. The series follows a real-life case from the first to final treatment session.

The Motivational Interviewing Network of Trainers (MINT) provides a list of upcoming MI trainings (www.motivationalinterviewing.org).

FURTHER READING

Miller, W.R., & Rollnick, S. (2013). Motivational Interviewing: Helping People Change, 3rd Edition (Applications of Motivational Interviewing. New York: Guilford Press.

Sibley, M. H. (2016). Parent-Teen Therapy for Executive Function Deficits and ADHD: Building Skills and Motivation. New York: Guilford Press.