Podcast Transcript

Psychosocial Treatments for ADHD in Children and Adolescents

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Summary:
This podcast discusses psychosocial treatments for ADHD in children and adolescents. Psychosocial treatments typically involve working on emotional functioning, performance in different environments (school, home, social), and understanding how ADHD is perceived by others. Common approaches to treating ADHD include behavior therapy, behavior management training, and cognitive-behavioral therapy. Psychosocial treatments often involve multiple components, including behavioral strategies, parent training, and teaching skills directly to youth. The specific interventions and their effectiveness can vary depending on the age group and treatment model. Key considerations include engaging parents and teachers, addressing logistical barriers to implementation, and tailoring treatments to the individual needs and developmental stage of the child or adolescent. Virtual delivery of psychosocial treatments has also shown promise. Overall, psychosocial treatments can be effective at improving organization, time management, and parenting skills, with more variable effects on core ADHD symptoms. A lifespan approach that monitors and addresses ADHD-related needs at different developmental stages is recommended.

Margaret H. Sibley, PhD
Margaret H. Sibley, PhD, is an associate professor of psychiatry and behavioral sciences at the University of Washington School of Medicine and Seattle Children's Research Institute. Her work focuses on the diagnosis and treatment of ADHD in adolescents and young adults. She developed a parent-teen therapy for ADHD, Supporting Teens’ Autonomy Daily (STAND), that combines motivational interviewing and skills training for parents and teens. She has authored or coauthored more than eighty scientific papers on ADHD and published a book, Parent-Teen Therapy for Executive Function Deficits and ADHD: Building Skills and Motivation (Guilford Press, 2016). She is a member of CHADD’s professional advisory board and the editorial advisory board for CHADD’s Attention magazine.

Richard Gallagher, PhD
Richard Gallagher, PhD, is associate professor of child and adolescent psychiatry at the Child Study Center, NYU School of Medicine. He specializes in anxiety disorders, ADHD, and learning disorders. He has been a co-principal investigator on NIMH grants investigating executive function deficits in children with ADHD and how to overcome those deficits. Dr. Gallagher is coauthor on numerous papers, first author of Organizational Skills Training for Children with ADHD: An Empirically-Supported Treatment (Guilford Press, 2014) and The Organized Child: An Effective Program to Maximize Your Kid’s Potential—in School and in Life (Guilford Press, 2018; for parents), and coauthor of the Children’s Organizational Skills Scale.

Learning Objectives

  1. Identify the components of psychosocial treatments.
  2. Describe the different psychosocial models of treatment for ADHD.
  3. Identify what skills are targeted through this type of intervention.
  4. Explain who should be involved and how they can support a child with ADHD.

 

The following transcript has been edited for clarity.

Announcer (00:00): You are listening to Pocket MD training on ADHD in children and adults.

Dr. Maggie Sibley (00:07): Hi, I am Maggie Sibley. I'm a clinical psychologist at Seattle Children's Hospital and a professor at the University of Washington School of Medicine. I am the host of our podcast. Today we will be talking about psychosocial treatments for ADHD in childhood and adolescence, and I am joined by Dr. Richard Gallagher. Dr. Gallagher, do you want to introduce yourself?

Dr. Richard Gallagher (00:30): Yes. Thank you, Maggie. I'm Richard Gallagher. I'm a clinical psychologist at New York University Grossman School of Medicine, and I'm on the faculty also at the New York University Grossman School of Medicine and happy to be here.

Dr. Maggie Sibley (00:43): I wanted to start out today by talking a little bit about what do we mean by psychosocial treatment and what do we consider are the components of those interventions? How are they usually delivered? Can you tell us a little bit about that?

Dr. Richard Gallagher (00:58): Well, my impression of psychosocial treatments means that we're working with ADHD by looking at their psychological characteristics and their social environment and working on helping people with ADHD manage those aspects of the disorder as well as possible. I think what it usually means is that it does deal with emotional functioning and then also how people perform in their environment with kids and adolescents. It's often school and home and social situations. And then the social aspect of it is to understand how this condition is perceived by other people and how persons with this condition are often reacted to when people don't completely understand the nature of the disorder. I think that the components are often investigating and looking at kids' emotional experiences—the way that ADHD affects the way that they respond to their demands in a number of different environments. It's also something that does usually involve aspects of the people around them, so involving parents and teachers and sometimes other people that have a lot of interaction with these kids. It's usually delivered by psychologists, social workers, or other mental health counselors, and oftentimes is an adjunct to work with medication.

Dr. Maggie Sibley (02:18): We often hear people call the psychosocial treatments behavior therapy behavior management training, or, especially as the youth get older, cognitive behavioral therapy. So, for our listeners, all of these are sort of under the same umbrella, and the B in CBT or the behavior therapy aspect is a pretty constant piece of these approaches. And you see the C, which starts out small when you're working with children, the cognitive aspect really working on reframing the way they think about and experience the world, you see that part grow and get a little bit bigger as people get older. I think by adulthood most of the psychosocial approaches are full-on CBT with the C and B probably being pretty equal to each other, But in childhood, I think in one review that my research team did a couple years ago, we found that almost all of the psychosocial approaches that had evidence really relied on operant behavioral principles as sort of their backbone, and then they also had a range of other components built onto that backbone depending on if it was a parent only approach or a parent-teacher approach or a student approach. I was wondering, Dr. Gallagher, could you tell us a little bit about those different intervention models that seem to be prominent in that psychosocial world for children?

Dr. Richard Gallagher (03:36): One of the things I'm concerned about, Maggie, and I'm sure that you would support this idea as well, is that I think we need to be expanding people's understanding of the psychosocial treatments. There's been an awful lot of development in the last twenty years, or even within the last ten years, for advancing the psychosocial methods. I think a lot of people do think, and I'm not sure if you have this impression in your area, but that it's a medication and behavioral parent training, teaching parents how to use this operant conditioning idea, learning how to praise kids and reward kids for positive behaviors and learning how to be able to use these mild forms of punishment for behaviors that are often present in kids with ADHD getting off task, being oppositional, being sometimes a bit cranky. But the field has really changed a lot, and I think we need to make a good strong effort to let people know that there's other things available that do have empirical support.

Dr. Maggie Sibley (04:33): And I'm specifically really interested in hearing a little bit about the work that you've been involved with teaching skills directly to elementary school-aged kids, because I think for a long time people thought that was something that you only did with maybe adolescents or adults, and we're now seeing some pretty interesting results when you bring the kid into the therapy room and try to help them learn to manage their ADHD a little bit on their own, I guess.

Dr. Richard Gallagher (04:58): Right, and again, I think it's with supports from others that the kids do need prompting from other people and they do need some praise and rewards from other people to keep on track, because they're basically struggling with this inherent condition that makes them less likely to pay attention and less likely to calmly respond to situations. Our work has been that we have decided that one of the issues that is really important is how kids handle schoolwork. This a situation where kids get involved with lots of conflict with their parents, lots of problems with teachers, and lots of worries because they don't do simple things that are necessary, such as writing down their assignments and bringing home the right materials. This is elementary-school kids; they're mostly doing things with papers and books and they have a really hard time managing their time and understanding how long it takes to do things so they don't get involved with the process of waiting until the last minute and having their parents really getting quite frustrated with them because they're not staying on task. They're doing things really at the last moment, staying up late, and it's just really a major issue.

I know that in your work you find that the parents of the adolescents have these same kinds of issues, but after many years of this problem with the adolescents, I know that you've written about the situation saying that the parents are oftentimes quite burned out or at the other extreme, often putting themselves in a position of doing just about everything for their kid. In elementary school we want to be able to give the kids some work where they learn to do more of this on their own, and they gradually learn these basic behaviors of responding to schoolwork. And we found, fortunately, very good success with this effort by having the kids there and teaching them these skills and having their parents and their teachers prompt them to use the skills and praise them for when they do it for these specific situations.

Dr. Maggie Sibley (06:50): Yeah, it makes me think about one myth going around out there that for children in elementary school, you mostly work with the parents and really there's no role for the youth. And then there's another myth, I think, that for adolescents there's no longer a role for the parents and that you just work with the youth. And one research study that my team did, where we got audio recorded work samples from community therapists who are working with adolescents with ADHD and community mental health clinics, we found that most people were working just directly with the teen with very minimal parent involvement. But like you mentioned, there is still this piece for parents of teenagers with ADHD of learning to navigate how to give more independence and how to age appropriately, create structure and plan for the future when the kids are no longer in your house. So, really thinking about that teenage time, is that it’s a time to slowly taper off parent supports but really keep the parents actively involved. I would say that for me, as a specialist who mostly works with teens and then young adults after they've transitioned out of high school, I can't emphasize enough how important it is to keep the parents involved.

Dr. Richard Gallagher (08:00): And I think that's a really important aspect of your work, because clinically not doing research work with adolescents we certainly hear that a lot, and the parents are interested in dropping the kids off and let's work on having you convince them to overcome their ADHD without some supports, but it's a really very difficult thing. So, I think that the elements of what has been included in your research and your clinical work are really very useful. Again, even when we do work clinically, we also find that in some cases we even have to see what we can do about it incorporating the parent's assistance with the appropriate amount of independence with college kids, and because even there, there's some situations where some outside supports are really helpful.

Dr. Maggie Sibley (08:46): So, we have different models of treatment that fit under this umbrella of psychosocial. I think we've talked about how what they have in common is that they're usually delivered by someone in a mental health therapy setting. We haven't touched too much yet on how some interventions seem to be situated more in the school setting versus in a community clinic versus in primary care, too. There are people who are doing behavioral approaches in primary care. I think one thing that I want to hit on is just how much heterogeneity there is underneath this umbrella of psychosocial. I think one thing they have in common is they're all multi-component approaches. There's not too much strict sort of behavioral work where you only work on rewards and consequences but don't also integrate other things. And again, this review that my team did a couple years ago found that almost all psychosocial treatments for youth had a behavioral aspect, had some parent training aspect, but there was a huge mix of different skills that might have also been taught to the youth; a huge mix of different levels of school involvement, some interventions that were actually just happening in the school setting with only a small amount of parent involvement. And so I think when we start transitioning this conversation into what does the research say about the effectiveness, I think it's really important for listeners to remember that the effectiveness probably depends a little bit on which model you choose to implement, because they're all different and they all highlight and try to help with different things.

Dr. Richard Gallagher (10:18): I would agree. I think that's a major component, and it's this involvement of schools and parents that does in fact get to be really challenging in both settings, so that some of the work I'm familiar with in regard to the school-based efforts, including a school-based effort of our program at the elementary school level, is the consistent challenge of, how do you effectively engage parents when there's a school-based delivery? And what I mean by school-based delivery is that the kids are seen in school and by some school counselors, some school special education persons. It depends upon the different programs that are working with the students in school and try to incorporate parents. And they do incorporate parents, but then we have this kind of conflict of when the kids are at school and when the school personnel are at school, the parents are often at work, and when the parents are available, it's often after school hours.

And the practical aspects of getting school personnel to be able to interact with the parents is one challenge. On the other end, sometimes the clinical efforts have the challenge of how to get teachers involved and how to be able to have that be a major element. And as you stated, there are differences. The programs that have some challenges getting parents involved have some limited outcomes, and the programs that have limited contact with teachers also have limited outcomes. So, if we can get everybody involved, that's probably the best effort and the best outcome overall, but it is really a practical challenge in doing so. I don't know what your experience has been with teenagers. When you're trying to be in your clinical program trying to incorporate the involvement of teachers, you actually have a challenge because you're dealing with four or five teachers and trying to get them invested in this process. They only see the kids for 45 minutes a day. They don't see them all day long. I know that must be something that you see as being a challenge in working with the older kids.

Dr. Maggie Sibley (12:16): Yeah, it is. And we've really moved to a parent empowerment model, where instead of putting the burden on the clinician to do all of this logistical work to get everyone on the same page, really thinking, how sustainable is that? If everyone's willing one time to sit down with this clinician because they know the family's working with them, really, if we can teach the parent the skills they need to be able to be the one who gets everyone organized and on the same page, then we're creating something much more sustainable. So, a lot of what we do is that.

Dr. Richard Gallagher (12:47): That's a great idea. And, as you say, there are these multiple component efforts and some of that process of teaching parents how to be an advocate. Teaching parents how to be able to interact with teachers and schools effectively is really important. One of the programs that I think has shown some good success with elementary school aged kids that was developed by people at the Children's Hospital Philadelphia, the Family School Success Program, this is what they do. They have the parents learn about the process of interacting with schools and they work on helping the parents get coached on how to do this effectively. And it has been found to be effective as a result with changing the kids' behavior and also changing the kids' productivity at school.

Dr. Maggie Sibley (13:26): Can you share with folks what that program is called in case they're interested in looking it up?

Dr. Richard Gallagher (13:30): It is specifically called the Family School Success Program. There's available information, in fact, I do believe that they've come up with a second edition that's actually getting published and available. Again, it's a description of how clinicians can actually use this program and how to be able to get parents invested in it.

Dr. Maggie Sibley (13:49): I will share a couple things that came out of some recent systematic review work that I was a part of, and I want to get your feedback on the extent to which this matches what you see in real life.

Dr. Richard Gallagher (14:03): Okay, sure.

Dr. Maggie Sibley (14:03): This is a fun little activity.

Dr. Richard Gallagher (14:06): And I get to learn about what you found.

Dr. Maggie Sibley (14:08): Exactly. Yeah. So, in the large Lancet review that I did with 20 coauthors two years ago, it covered child and adolescent interventions for ADHD and we looked at randomized control trials. We didn't just look at psychosocial, we also looked at other non-medication treatments. So if anyone's interested in that, you can look that up. But we found that some of the largest effects across these psychosocial trials, if you're looking for what variable we're finding the biggest effects sizes on, it was actually organization skills, and second to that was parenting skills. That's where we got the largest effect sizes. The effects on ADHD symptoms were inconsistent. Some trials had good effects on ADHD symptoms. Some trials didn't. We didn't do a deep dive into which ones did and which ones didn't and why, but I wonder if what you're hearing me summarize there is consistency with what you see or you think that there might be something more to the story?

Dr. Richard Gallagher (15:07): I think there might be slightly more to the story, but I also think that it doesn't surprise me, partly from our research as well as partly from clinical experience in supervising students that are working with kids with ADHD. I think that it's really very hard to change the core symptoms. I think we have to recognize that the attention issues, the hyperactivity, and the impulsivity are all things that are really being driven by a slightly different—and we want to be careful—a slightly different neurological system. I do think that in effect when we do talk about trying to change the core symptoms, we're really asking people to fight themselves. That their brain, because of areas that are not helping with management of these basic characteristics, their brain is often looking for lots of different information from the environment that is new and interesting and rewarding or being careful about doing things that are harmful. So that their brains are in basic research are often really oscillating and changing attention all the time.

I think it's very hard to be able to alter that. I think that people with ADHD also say, I have a really hard time sitting still. It feels uncomfortable to try to sit still. My body wants to move. Again I do think that this is a pattern that you're fighting yourself. If we do things like organization—and this, we found in our own work—we actually did not pinpoint core symptoms as a target symptoms, we decided to focus on organization and the impact of that on school productivity, on family interactions and on school performance, and we did find that happened. Incidentally ,we did find reports of core symptoms going down, but again, our main focus was on changing organization. I'm not surprised that other people are finding that's what happens, because it's something you can do. You can manage your papers better, you can get better at understanding how long it takes to do things. You can develop a plan as opposed to changing how well you pay attention and changing what your brain focuses on. That's really hard to do. Parent involvement, yeah, we can change parents' ideas, we can change their impressions, and we often need to do that. We have to do it. They need to understand ADHD, and they need to understand what their kids are struggling with, and we want to be able to have them become more patient by recognizing that their kids are not just doing this on purpose.

Dr. Maggie Sibley (17:35): Something I say a lot to patients and to clinicians that I train is that we're not very good at teaching people to be less forgetful, for example, if they're very forgetful. But we can teach people that if they're the kind of person that forgets a lot, they can learn how to write things down so that forgetfulness doesn't cause them problems. They always have their lists and their schedules and can go to those to lean on them. And I think that's exactly right. It's interesting that some studies of psychosocial treatments do find effects on ADHD symptoms. I often wonder if there's this kind of indirect loop where things get less chaotic, people are able to feel calmer about their life and then when they do that, their symptoms just feel more at bay, even if it's subjectively.

Dr. Richard Gallagher (18:18): When we get into the weeds of this, we might be talking about these two relatively simple models. Some of the work is designed to be top-down models where we're trying to say, let's change the brain. And I think that some of the mostly ineffective work on general executive function training using computers and other things like that in games, they're trying to be able to change the brain and then that would result in behavior change. I wonder if there's a way and a system that works where you can get a bottom-up change? That you change the behavior on the outside, you change what the people are doing, and does that have this kind of feedback process of changing what's going on in the brain? I can't really talk about it very strongly because it's not been peer reviewed yet, but in our most recent work, we have looked at brain scans before and after our treatment, and I can say at least with pilot data that has been reported and has been out there that we did find changes in the brain. But in our most recent study we're getting ready to publish, it's again information that does say that the brain activity does change in the kids that got our treatment compared to the control group, and so that we may have this bottom-up effect that does occur.

Dr. Maggie Sibley (19:33): Let me go with that for a little bit. I've known about that data that you've had for a while, and I'm really excited and everyone else should be, too, for seeing that hit prime time and get published. One of the things we're finding on the teen side, and my group has found this at least twice, possibly three times, if I'm allowed to talk about things that haven't been published yet, is that there is a long-term effect on some outcomes of the teen psychosocial treatments that are delivered during the adolescent years. And I've always wondered if there's better brain plasticity in those years. There's a lot changing in those years. If we can make a difference, can that difference sustain? And we have effects three years after treatment, published effects, three years after treatment ended, for a couple interventions mostly on the executive function skills areas. So, kind of related to the organization and time management skills, that kids are still looking better in those areas several years later, and to some extent smaller, but still there, effects on ADHD symptoms also. I do think that if you put what you're finding in the brain imaging research together with what we're finding in the long-term effect research, there is something to that that—people can learn things in psychosocial treatment that last longer than when you take a medication and then it's out of your system 24 hours later.

Dr. Richard Gallagher (20:56): And I think that's why I really want to be in this process of having people within the field, and physicians especially as well as others, to know that there are things available that may be having these effects and that the science is really investigating that process. I think with regard to other aspects of skills training in terms of, even if you think about things like learning a sport, let's say tennis, if you keep practicing some of those behaviors, it is likely that your brain's motor system will become a bit more efficient in handling the movements for doing a forehand and a backhand. So, this may be also true when you're trying to make sure that you are paying attention to what the teacher says about, here's your assignment, or if you are also stopping and thinking and saying, I have a book report, or in the case of a high school student, I have to get ready for a test, I'm going to take some time to plan out what I should do and what materials I should look at. I think that if that's done enough times over and over again, it's likely to begin to have an effect of like saying, okay, I'm slowing down. And so maybe observations of hyperactivity might become different.

Dr. Maggie Sibley (22:07): What do you do if parents are not interested in psychosocial treatment or they feel like it's just too much work for the amount of demands they have in their life right now? Is there still a way in with them, or how do you handle that?

Dr. Richard Gallagher (22:21): I think you have a very good way of doing that with the teenagers’ parents, again, who are often burned out. In some cases, we have to be relatively strict and not in a harsh way, but say, we really can't do this work without you. So, that's one. Since we have evidence, we try to be able to present the evidence saying, here's a program that we have developed and it does involve parent involvement every meeting. We will try to make that convenient for you, but it does result in good outcomes. I think that helps. And I do think that in your work you have a really good way of talking with parents. We have begun to incorporate that in our clinical efforts and saying, Why are you concerned and why are you having some trouble thinking about being involved outside of convenience and outside of time commitment?

And then parents often will tell us there are things that they're frustrated with, their impression. “I tried to be involved, and my child is just so distressed about it and so irritable, I just can't do it anymore.” So, we try to be able to understand their concerns, and I think we do take that into account. I think we can do better, but it's like dealing with parents and understanding their possible frustration. It turns to what's been done with some things that are done in some pediatric settings and training settings, where one psychologist from a long while ago used to send psychology students and medical students to go live with a family and work with a kid that has a developmental disability or ADHD for the day, and then come away saying, so what's it like? All your behavior modification ideas? And they come back and say, “Oh my gosh, this is one of the most challenging things I've ever done.”

Dr. Maggie Sibley (24:04): I think that's probably validating for a lot of parents to hear that story. And for clinicians, too, what a great idea to give someone the real-life experience. So, a lot of it, it sounds like, is helping people solve their own barriers?

Dr. Richard Gallagher (24:16): I think so, yeah.

Dr. Maggie Sibley (24:18): Sometimes they're logistical barriers, sometimes they're almost like belief-based barriers, or things that people have come to think about the potential of their child to change or the potential of themselves to find time to do the strategies. You referred to the work we're doing with teens, and a lot of it has just been integrating motivational interviewing here and there into the conversations, helping parents who are burned out and frustrated, create the space to reflect and remember what they care about as a parent, who their identity is as a parent, what they want to instill in their kids, and what they feel like they need in order to be able to do that successfully. And any time we can take our treatments and make them flexible, where people can pick the possible modules that you could work on with a clinician to align them with what is most urgent for you, and what is most meaningful to you, I think we put ourselves in a better position to make things worth people's while. So, I would even front-end things that people feel most interested in getting help with, even if I might have my own personal opinion that they should really be doing something else, right, because sometimes you just have to put getting people interested in before what you think is going to be the most optimal way to work with someone.

Dr. Richard Gallagher (25:32): Getting them to buy in by saying, okay, we'll deal with what your priorities are first and then we'll see about doing the other parts. And as you know from the workshops we've done together, I think one of the smartest things about what you do with parents is to be able to use these motivational interview ideas to say to the parents, What would you like to gain for yourself by investing your time in this treatment and helping your child? Because it's more active than some parents want to do. And I think that that's really a very significant idea. And for the podcast audience, the ideas are not for parents to say, I would like this to happen for my child, that's why I want to be invested. It's more like what would the parents want to have happen for themselves? And it's like, oh, if things go better, maybe I can get a chance to read a book that I don't have to be so much involved with watching like a hawk over my child while they're doing homework. And I do think that that's one of the most genius elements of your program that has an awful lot of substantial research evidence behind it.

Dr. Maggie Sibley (26:32): So, we've talked about how there's programs that have been tailored to different ages. You and I have been putting it in two categories, childhood and adolescence. But really if we decided to get more nuanced, we'd see that there were people developing programs for children as young as preschool and as old as high school. But does that lifespan approach mean that we think that somebody with ADHD should be in psychosocial treatment every week of their childhood, or do we think that there is a more strategic approach? How do you think of that?

Dr. Richard Gallagher (27:02): I've done a couple of different programs on this and to different audiences, and we have a continuing education program that we do about ADHD through the lifespan every year for the last five years. I think it's not necessary in psychosocial treatment every week. I do think that we need a model of chronic illness. A person with diabetes, a child with diabetes, a child with cystic fibrosis, a child with asthma, they will often be involved with being tracked in pediatrics. And many pediatricians have learned that they need to also see young adults and then work on transferring them. But people see each other on a regular basis. There are check-ins, and I do think there's a way of doing this with ADHD that there becomes a person that—it could be the psychosocial family physician, so to speak, or it could be the medication physician—but somebody that checks in and says, okay, let's look at your stage of life. Let's look at the family's way of dealing with ADHD. And I do believe that there are programs that help with each of these steps. And if you'll allow me, I can go through some of the thinking of that.

Dr. Maggie Sibley (28:10): Yeah, go for it.

Dr. Richard Gallagher (28:11): When first diagnosed—and again, these are programs that have empirical support, some of them through randomized controlled trials—there's a program that's called the bootcamp program. It's been changed and I've forgotten the name, I apologize, but it's been tested out, and it's a program for parents to get information on the first diagnosis through a couple of different sessions of understanding the nature of ADHD and what medication treatment can be helpful and what behavioral parent treatment can be helpful. Most of the kids are young, the program results, and after having this information where parents are much more calm about the whole thing, but they also are more likely to start medication treatment. They're also more likely to get involved with behavior treatment. So, it has an impact of getting people engaged. So, people do that as the first step. They learn behavior modification and behavioral parent training.

They're in pretty good shape and by guiding their kids, getting them to be more cooperative, I think after that's done, you keep monitoring, maybe say, okay, let's check in every year. Let's think about the new transitions. I think that around elementary school, there may be a look to say, okay, how are you doing with handling elementary school and all the demands? Are there any behavior issues? Are there any issues with being organized? There's an organizational skills training that we have that's available for families in elementary schools that does have some effect and say, okay, let's get involved with that. There are also some things around that same time period, again with empirical support that say, let's take a look at social skills. And there's a parent friendship coaching program that parents learn how to coach their kids in play dates for younger kids. Again, nicely effective, having good results.

Linda Pfiffner has a program that does involve also, again, social skills primarily with kids with the inattentive presentation, and again, finds it really strong results with the kids getting much better at being socially adept with other kids and also with their parents and other adults. So, what I'm proposing is this idea of looking at things in sequence and being able to say, okay, let's look at the problems and let's see about adding something and having people dropping in and out of psychosocial treatment as they approach the teenage years. Then there's the program that you have, the STAND program for Supporting Teens’ Autonomy Daily. Again, that might be important to say, okay, let's take a look and see what's going on as you go into middle school and when you have these many more people that you have to deal with. And there's promising things with regard to, again, at this age of one program from a group in Virginia Tech regulating emotional life and being an expert.

It's called the Relax Program, where parents learn about their own emotional regulation, and then after they learn about their issues with emotional regulation, they work on transferring that to their teens. And I think that we just go through the whole lifespan of a kid and teenager. We can think about these time points and these specific areas where you take a look and say, okay, maybe nothing is needed right now, but if something is needed, let's look at these empirically supported programs and apply this. And again, dropping in and out, dropping in and out with a person consistently dealing with the family and the child for a number of years.

Dr. Maggie Sibley (31:23): Yeah, I think the key there that you raise is monitoring who's consistently in the healthcare setting or even the educational setting in this child's life that can have touchpoints with them throughout the years and detect when things might be trending in a direction that needs more support, thinking, how do we build those sort of systems around kids? I really like that. I think we're running a little low on time. Maybe a couple closing thoughts. Are there certain kids that you think respond particularly well to psychosocial treatments versus certain kids that maybe just don't respond as well? And, just in terms of helping clinicians think about who might be really well-suited to this approach at first contact, even when you're first learning about the diagnosis, first learning about maybe if you're taking medication or not.

Dr. Richard Gallagher (32:11): Yeah, I'd like to hear what your ideas are about this as well. Sure. I think that we do have some concerns in terms of some of the skills that we have, some concerns about kids, I would say, that are really young. It may be that we really need to say the psychosocial treatment really is directed toward parents and having them learn how to be able to bring out behaviors in their children as opposed to teaching kids skills. So, I do think that's one thing. I do think we have to be concerned with how oppositional the child is, and so that oftentimes we have to be able to help the parents a lot to be able to help get that oppositional behavior under control before we can see them and teach them skills. And I do think we have to watch out for comorbidities. I do think that we have to be tuned into anxiety; it makes it more challenging. And I do think we have to be possibly looking at kids with combined ADHD and also autism spectrum disorder. Sometimes with the skills efforts that we've tried with transferring our work to kids with autism spectrum disorder, [what we find] is that the kids are rigid and not ready to alter their ways of responding to, let's say, school demands.

So, I think we have to take a look at the receptivity of kids as one aspect, and I'd really be curious to hear what you have to say about that idea with regard to teenagers.

Dr. Maggie Sibley (33:32): One of the things that comes up in the teenage years that has shown up in our trials is when there's a lot of parenting conflict, it tends to lend better to working individually, one-on-one with families. We haven't really brought this up in this conversation, but some of these programs are developed for group delivery and others are developed for individual delivery. So, groups are really cost-effective, and if you have the logistics to get a bunch of people together at the same time, they can be fantastic. People can share stories with similar people that have gone through what they've gone through, and there's a lot of power to that. But when you're dealing with a really high-conflict teen-parent-teen diet, not to blame the teen, and there's just a lot of stress and chaos, a lot of times you just feel like the tips that you're pulling from a group aren't enough.

You need support in actually navigating the communication. So, that's one thing that we've pulled out of our work. In the review we did across the child and adolescent period, some of the common findings that came out of those studies, actually, girls responded somewhat better than boys, and also people with higher levels of anxiety responded somewhat better. There's this thought, and in older kids that may apply to all of that, of maybe these are factors that influenced the level of effort that someone puts into a behavior therapy approach. Girls may be more interested in pleasing and following directions and doing what they're asked by the clinician. Same with anxious kids, but I think there's benefit to everyone of some form of behavior therapy, but you just may get kids and families that engage at a higher level than others.

Dr. Richard Gallagher (35:07): Yeah, I think that makes good sense. Again, what I think would be in terms of pulling some things together is, I'd like that this information would be that people would be seeking out persons in their area that are cognitive behavioral therapists that are also paying attention to the literature in some fashion, because we want to be able to really expand at this point behind saying it's medication and only behavioral parent training. The field has moved past that, and more and more dissemination about these other efforts is out there. But it would be helpful for people to say, well, I need to get a good colleague that would help us understand what is available and what can be done.

Dr. Maggie Sibley (35:48): That’s right, not all referrals are the same. In fact, some of the research suggests that therapist quality has a big impact on the effectiveness of some of these programs. So, I think our research showed that the average community clinician isn't actually following best practices as well as they might, and so you do want to get to know who in your community seems to really have a handle on these things, so that you can provide good referrals if you're not someone who delivers these types of treatments yourself. I think that's important and worth taking the time to learn about.

Dr. Richard Gallagher (36:17): And I'd like to put in another little note with regard to that, which is that with what happened during the COVID pandemic, a lot more people are doing virtual work and they are able to provide services throughout their own state, and in some cases, and I know from your program in our most recent version, for example, we are finding that virtual delivery of these treatments is still effective. You might not have to rely only upon your own community, but perhaps a wider region where you might be able to connect a family with somebody that does things virtually.

Dr. Maggie Sibley (36:48): Oh yeah, that's right. For example, at Seattle Children's, we used to run all of our programs in person before the pandemic and mostly see kids in the Seattle area, but now we're able to see kids throughout the whole state, having moved a lot of it online and still having effective programming. So, I think if you're in a state that might have a specialty clinic somewhere in a big city and you're not in a big city, definitely keep an eye out for what you might be able to access virtually. I think that's a great tip. I think we're at the end of our conversation. Before we wrap up, Dr. Gallagher, is there anything else that you think is a really important take-home for our listeners that we didn't talk about?

Dr. Richard Gallagher (37:25): I think it's really helpful, again, just to put this point: Let's really think more creatively about how to work with ADHD. And again, I know many physicians are involved with seeing kids for a long time and with the medication and follow-up, but let's think about doing the same thing with psychosocial treatment, where there can be different things at different time points in their lives that might be useful for them.

Dr. Maggie Sibley (37:46): I think that's a really great note to end on. So, thank you so much for being a part of this podcast, and I think listeners could reach out to either of us if they have any follow-up questions related to the work we've been describing.

Dr. Richard Gallagher (37:58): Yes, of course. And thank you. Good talking with you.

Dr. Maggie Sibley (38:01): You too.

Announcer (38:02): Pocket MD is brought to you by CHADD with funding from the US Centers for Disease Control and Prevention, and in partnership with the Rainbow Center at Rainbow Babies and Children's Hospital.