Tuesday, January 11, 2011

Social Skills Training and ADHD

The 2 major studies of treatments for children with ADHD - the MTA study and Abikoff et al have raised serious doubts whether there is any advantage of adding behavioral therapy and social skills training to a well managed medication treatment plan. Children did benefit from all treatments, but there was no advantage of a combined medication and behavioral treatment plan over medication management alone. Alternative outcome analyses of the MTA study , however show that there is a small but significant advantage of combined medication and behavior treatment plans over medication alone. They also note , that parents whose children who received the combined treatment were more satisfied with the treatment than parents who received medication management alone , despite the fact that there were no differences between the groups on child outcomes . Medication and behavior therapies offered in the community were significantly less effective than treatments offered by the studies. This means that efforts must be made to improve medication treatments and behavior therapies offered in the community and a multi-modal approach including many strategies is the best option.

According to Abikoff , medication only helped to reduce negative behaviors but did not enhance positive pro-social behavior. Gains were only maintained while on medication with no gains after an initial improvement. There was also a decline in pro-social behaviors over time consistent with the general population.

In a review of Social skills training with children and young people , Spence – 2003, says that research suggests that SST alone – instruction, modeling, role play , feedback , reinforcement used in association with interpersonal problem solving and social perception skills - is unlikely to produce generalization of skills and significant and long lasting change in social skills and competence. Rather SST is just an important component of multi-method approaches to treatment of emotional, behavioral and developmental disorders including cognitive restructuring, self and emotional regulation methods and contingency management.

To my surprise , selected literature reviews of Interpersonal Cognitive problem solving approaches showed that ICPS had little or no impact on children's behavior. My understanding is that social skills are really based on interpersonal skills. ICPS and CPS –collaborative problem solving promote the language of problem solving , the ability to ask questions which are the foundations of communication, thinking and emotional regulation skills.

The Webster-Stratton et al study of 4-8 year old using the Dinosaur Child Social Skills and Problem Solving training program was successful in improving children's behavior over a spectrum of disorders including ADHD. Webster says that these findings are significant in the light of recent literature that suggests that cognitive- behavioral treatments do not provide significant changes in behavior. Children in the MTA study were older than the kids in her study - 8 years and older as opposed to 4-8 years old. She suggests that treating kids in the 'preoperational stage of thinking before negative thinking , behavioral interactions and reputations have been stabilized yields better responses to behavioral treatments.

While medication continues to play an important role for chronic key ADHD symptoms such as impulsiveness, hyperactivity and inattention ,medication should not be seen as a long term treatment goal and every attempt should be made to reduce dosages by combining medication with behavioral therapies with the ultimate goal of eliminating medication. Seeing ADHD as purely a medical problem pathologizes the child and therefore often obscures the fact that challenging behavior in kids is a complex, transactional phenomenon also involving the child’s interaction partners and environments and therefore underestimates the importance of care givers being trained , so that they contribute to the development of lacking cognitive skills and respond in an appropriate manner .

Back in the 50s, a prominent psychiatrist named Thomas Szasz characterized psychopathology as “problems in living.” ADHD kids have difficulty in handling frustration and demands placed upon their need for flexibility and adaptability. They display many skill deficits -in the main executive functions = planning , sense of time , separation of affect etc , but also language processing skills, social skills, emotional regulation skills and cognitive flexibility . Medication does not teach skills , but enables the child to benefit from learning and give him those extra seconds to process information and be in a better mood.

As mentioned above medication does not enhance pro-social behavior . Medication does not cure ADHD but merely compensates for developmental delays. The cure for ADHD or at least less reliance on medication is likely to come from changes in the brain , the formation of more and more neuron transmitters in the frontal lobes of the brain , a process acknowledges the neuroplasticity of the brain. Dr Gimpel , the author of the book ' How to cure ADHD ' says that BET , brain exercise therapy and CPS – collaborative problem solving effects changes in the brain because they involve cognitive behavior. According to Gimpel ADHD is a cognitive disability , not a behavioral problem . This is the reason that contingency management and behavior modification don't help or at best as Russel Barkley says just compensates for the kid lack of intrinsic motivation and don't help skills to generalize to other areas.

The question I want to answer is why has SST and interpersonal cognitive problem solving ICPS in the selective literature has proved to be not very effective.

In an article Social Problem-Solving can help children with ADHD (2007) Shure and Aberson conclude that for internalization and generalization of newly acquired skills to other settings caregivers – parents , teachers etc need to be the primary teachers of ICPS , the parenting approach is unconditional using problem solving rather than behavior modification and contingency management in the form of rewards, praise and consequences , and the dialog between themselves and children focuses on perspective taking , consequential thinking etc , the language of problem solving.

Research conducted in the 1970s and 1980s before ADHD was widely diagnosed , showed that many kids who displayed symptoms of ADHD benefitted from the ICPS programs when conducted together with parents rather in clinical settings satisfying the conditions mentioned above.

In the last 10 years the collaborative problem solving approach CPS created Dr Ross Greene has become a very popular treatment strategy for kids lacking cognitive skills and who may also have various diagnoses including ADHD. The philosophy is that children do well if they can . Children would prefer to be successful and act adaptively. Their inappropriate behavior describes a situation where the demands for skills of frustration tolerance , flexibility and adaptability outstrip their coping skills. They do not lack motivation but lack skills . Using behavior modification to ' make them wanna act good ' won't help. They are already motivated to do well and the most satisfying reward is being successful. These kids ( all kids) don't need rewards.

The teaching of skills is individualized for the particular child. It involves collaboratively solving real problems rather than teaching skills in a top-down manner . The initial focus is assuring the kid that he is not in trouble , that adults are not interested in imposing their solution and trying to get his concerns and perspectives on the table. The parent then puts his concerns on the table and defines the problem. Then the parent invites the child to engage in brain storming to come up with mutually satisfying solutions that are doable, durable and realistic , and also agreeing to review the situation. In this way real problems are solved , various cognitive skills are acquired and the relationship and trust between care givers and child enhanced.

According to researchers Deci and Ryan quoted at length in Alfie Kohn's book Punished by rewards kids become intrinsically motivated , internalize and integrate values , become active learners and competent when they are self determined . This is facilitated when their autonomy is supported , and they experience supportive and unconditional caring from peers and care givers whom they trust and helped to become competent .

CPS and ICPS support the child's autonomy – that his actions are expressions of his inner being , promote competence as the child is acquiring crucial life skills , and ' relatedness ' – a trusting relationship with caregivers and peers.

Behavioral and social skills treatment programs are characterized by the top-down learning of skills in a classroom accompanied by a behavior modification program with the use of mainly rewards and sometimes consequences. There is no collaboration with kids and their concerns are often ignored. Kids bring report s home of their behavior in school and a similar report is done for behavior in the home. Parental and teacher responses to the report and to behavior in the home and school usually takes the form of criticism, punishment, reward, praise or lecture. The child then experiences acceptance contingent on his academic performance or behavior. Instead of furthering learning and discussion and reinforcing skills , rewards or verbal praise stop the process , the kid is left with a feeling of being judged and the lessons are lost.

The researchers Deci and Ryan have shown that extrinsic motivation even in the form of rewards and praise undermine intrinsic motivation and interest in activities. Rewards can even set up kids for failure , causing the very behaviors they are targeting because kids feel pressured, anxious and controlled. Kids fail to integrate values because they come to believe that they only do good things because of the reward , known as the over-justification effect.    'In a troubling study conducted by Joan Grusec at the University of Toronto, young children who were frequently praised for displays of generosity tended to be slightly less generous on an everyday basis than other children were. Every time they had heard "Good sharing!" or "I’m so proud of you for helping," they became a little less interested in sharing or helping. Those actions came to be seen not as something valuable in their own right but as something they had to do to get that reaction again from an adult. Generosity became a means to an end. Praise and rewards really foster anti-social behavior because they teach the kid to ask what will I get or what will be done to me , what’s in it for me if I do ….. or don't do etc. According to Carl Rogers children who are conditionally accepted begin to view themselves in a negative light. When kids view themselves as essentially good people , they are empowered to act in a pro-social way. The use of rewards sends these kids a message that you don't trust them to succeed or act altruistic without being bribed to be generous or caring.'  - Alfie Kohn

Another reason why social skills training is unsuccessful is that social skills are taught ,' but not the traits of generosity , caring and altruism. Schools are rather competitive with no cooperative learning , kids ranked one against another, and academic and sports achievement glorified with award ceremonies. Schools themselves are under pressure of high stakes standardized testing and little time is left for promoting socio-moral learning or building a caring community of learners. We can't expect kids to internalize conflict resolution skills and values of community when the ' structure ' of school - the competitive nature and zero tolerance discipline policies go against collaborative solving of problems and cooperative learning needed to create a caring community of learners. In fact , since the introduction of zero tolerance discipline policies behavior problems have increased and kids feel less safer in schools.

The finding that schools become less safe as a result of adopting zero-tolerance policies will sound paradoxical only to those readers who believe that threats and punishment can create safety. In reality, safety is put at risk by such an approach. A safe school environment is one where students are able to really know and trust – and be known and trusted by – adults. Those bonds, however, are ruptured by a system that’s about doing things to students who act inappropriately rather than working with them to solve problems. “The first casualty” of zero-tolerance policies “is the central, critical relationship between teacher and student, a relationship that is now being damaged or broken in favor of tough-sounding, impersonal, uniform procedures. ' –     Safety from the inside out - Alfie Kohn

In conclusion :  There are areas such as chronic impulsiveness and hyperactivity were medication is the most effective treatment but should not be the long term treatment goal. The fact that medication treatment in the community is not optimal is even more reason to improve social skills training. SST needs to be given to kids by caregivers – teachers and parents and modeled in an environment where problems are solved collaboratively rather than using reward, consequences and punishments. I think we need to examine the environment and make it more conducive to pro-social behavior , making school a learning community where kids and teachers care about one another instead of the competitive environment that prevails in schools.

Instead of teaching kids how to behave and giving them skills , we should focus more on understanding kids, seeing the world through their eyes and then helping them acquire skills.

The most valuable reward in teaching ( both academic and socio-moral learning )  is hearing a student say :

  '  Thank you for understanding me '


  1. I admire the valuable information u offer in your message.
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    That is very authentic & fantastic.Child Behavior Problems

  2. Thanks for this review of the literature (I followed the link to this post from my blog). I agree that medication can get us to an optimal place for learning but that it will not teach the pro-social behaviours that our learners need in life. It is very rare for the families I work with to choose only one intervention option - they often have multiple treatments going on at once. When we're taking data to analyze effects we try to encourage parents to make one change (either the addition or removal of an intervention) so that we can monitor the effects more empirically over time.

    As a side, I do throw caution to the Deci & Ryan studies re: the effect of external rewards as the scenarios being experimented with are not skill-building in nature. If a person is already demonstrating a behaviour - let's say colouring - and they appear to enjoy it, then reinforcement is already in effect. The reinforcer might be the end product, it might be the automatic physiological effects of colouring that "feel good" to the learner (we don't know, we'd have to analyze the situation to find out). Adding an additional external reward can begin to pair the outcome with this reward. If that reward is not reinforcing, then yes, you might see a decrease in the behaviour, which would be, as Alfie Kohn called it, "punished by rewards". If reinforcement is present and the behaviour is at acceptable levels, then nothing needs to be done. No intervention is required. I would leave things be.

    I am a behaviourist and I would never walk into a room and decide that the people already performing whatever skill they need do for school or work now need a reward system for that skill. Instead, I might analyze the contingencies in place and try to understand what is reinforcing their behaviour (good or bad). I share your concern for rewards charts or overly-praising children for doing something they are already doing. It's not that the praise or reward chart is bad, it that it's being incorrectly applied and fails to take into account an analysis of what is already going on and what skills actually need learning. In my delivery of praise I try to emphasize what effect that behaviour had on people or the environment - e.g., It's nice that you shared your chips with Allison. She was sad she didn't have any and that made her feel better." Other times, I let things be. It's the peer's reaction and acceptance, continuation of the social interaction that can be the most influential.

  3. Tricia,
    Thanks for sharing your insights and perspectives.
    As far as monitoring interventions I would review the unsolved problems list, work -in-progess etc. Data usually focuses on behaviors rather than unsolved problems and does not tell much .
    my thoughts about reinforcers are here http://tinyurl.com/c8fbo9q