CASE 16

Attention-Deficit/Hyperactivity Disorder
250 CASE 16

Table 16-1

Dx Checklist

Attention-Deficit/Hyperactivity Disorder
1. Individual presents 1 or both of the following patterns:
(a) For 6 months or more, individual frequently displays at least
6 of the following symptoms of inattention, to a degree that
is maladaptive and beyond that shown by most similarly
aged persons:  •  Unable to properly attend to details, or
frequently makes careless errors  •  Finds it hard to maintain
attention  •  Fails to listen when spoken to by others  •  Fails
to carry out instructions and finish work  •  Disorganized 
•  Dislikes or avoids mentally effortful work  •  Loses items
that are needed for successful work  •  Easily distracted by
irrelevant stimuli  •  Forgets to do many everyday activities.
(b) For 6 months or more, individual frequently displays at least
6 of the following symptoms of hyperactivity and impulsivity,
to a degree that is maladaptive and beyond that shown
 by most similarly aged persons:  •  Fidgets, taps hands or
feet, or squirms  •  Inappropriately wanders from seat  • 
Inappropriately runs or climbs  •  Unable to play quietly 
•  In constant motion  •  Talks excessively  •  Interrupts
questioners during discussions  •  Unable to wait for turn 
•  Barges in on others’ activities or conversations
2. Individual displayed some of the symptoms before 12 years
of age.
3. Individual shows symptoms in more than 1 setting.
4. Individual experiences impaired functioning.

(Based on APA, 2013.)

Billy was his parents’ first child. He was born after a normal, uncomplicated preg
Although very low birth weight (less than 1,500 grams) presents contemplated doing some freelance accounting at home
a twofold to three to earn extra money. However, with her very first
fold risk for developing ADHD, most children with low birth
project she realized that this was completely unre alistic.
weight do not develop the disorder (APA, 2013).
Marie had hoped that she could contain Billy by keeping
nancy, an especially healthy baby who grew rapidly and
him in a playpen while she worked, but she found that
reached the standard de velopmental milestones—
he wouldn’t tolerate such confinement for more than 2
sitting, crawling, standing, walking, and so forth—either
minutes before he was yelling to get out. Once out, he
at or before the expected ages. His parents marveled at
was a roving accident scene. Within minutes, Marie
his exuberance and his drive to be independent at an
would hear a crash or some other noise that demanded
early age. He was sitting by the age of 5 months and
investigation.
walking at 11 months. Once mobile, he was a veritable
When Billy’s mother became pregnant with his sister,
dynamo (in fact, they called him “the Dynamo”) who
Billy was well into the “terrible twos” and his mother
raced around the house, filled with a curiosity that led
and his father, Stan, were beginning to doubt their
him to grab, examine, and frequently destroy almost
suitability as parents. Of course, other new parents
anything that wasn’t nailed down.
often remarked on how de manding children were, but
Attention-Deficit/Hyperactivity Disorder 251
Marie and Stan could tell that the other parents felt
nowhere near the same sense of desperation.
Billy From “Dynamo” to “Dynamite” With the arrival of Billy’s sister, Jennifer, Marie and Stan
During his toddler period, Billy’s parents had no inkling developed a bud ding awareness that their problems in
that his activity level was at all unusual and, in truth, in handling their son might not be due entirely to their
many ways it was just an exaggeration of tenden cies inadequacy. As an infant Jennifer—unlike Billy—did not
that most toddlers exhibit. Still, his parents found it try to squirm and break free every time she was held.
exhausting to cope with his behavior. Just watching Later, there were other differences. As a toddler, she
over him was a full-time job. Billy’s mother, Marie, had was content to sit quietly for long periods just playing
with her toys, and she listened until the end of the Half the children with ADHD also have learn ing or
entire story when Marie read to her, whereas Billy communication
problems, many per form poorly in school, a number have social
would get restless and run off within a couple of
difficulties, and about 80 percent misbehave (Goldstein, 2011;
minutes.
Mash & Wolfe, 2010).
When Billy reached school age, and Marie and Stan
received more objec tive feedback about his situation,
their sense of his difficulties became more defined.
After his first day of school, his kindergarten teacher
described him as “quite a handful”; then, at the parent-
teacher conference, the teacher informed Billy’s
parents that his activity level was well above that of the
other children. In the first and second grades, as the
academic component of the curriculum increased and
the demands on the children for behavioral control
increased correspondingly, Marie and Stan started to
get yet stronger complaints from his teachers. In
addition, Billy’s academic progress was slowed because
of his problems with attention. Although he eventually
learned to read, he didn’t re
ally begin to master the skill until the second grade.
Now 8 years old and in the third grade, Billy was falling
behind the other children in a wide range of academic
tasks. With encouragement—actually, insistence—from
his teacher, Mrs. Pease, his parents decided to seek
help for him at the Child Develop
ment Center.
252 CASE 16

Billy at Home A Parent’s Perspective

By age 8, Billy rarely carried out his parents’ requests or instructions, or he
carried them out only partially before becoming caught up in some other
activity. One evening in November was illustrative: Billy’s mother had just
finished preparing dinner when she went to her son’s room and asked him to
stop playing his video game, wash his hands, and take his place at the dining
room table. “Okay, Mom,” Billy answered.
“Thank you, Billy,” Marie said as she went back down to the kitchen to do
some final preparations. However, 5 minutes later she realized she still had not
 seen Billy. She went back up to his room and found he had never turned off the
video game.
“Billy, I mean it. Stop playing now!” she told him.
“Oh, all right.” he said, and turned the game off.
Although this was Marie’s second effort, for once Billy was coming without
too much of a struggle, so his mother was relieved. “Go wash your hands,” she
reminded him.
“Okay,” Billy replied. He headed down the hall toward the bathroom, but
caught a glimpse of his 5-year-old sister already seated at the dining room
table, holding a new doll. Jennifer was pulling a string that made the doll talk.
“Hey, neat!” Billy exclaimed. “Let me try.” He ran over, grabbed the doll
from Jennifer’s hands and pulled the string. The doll spoke in a squeaky voice,
while Billy’s sister complained that she wanted her toy back. “Does the doll
say anything
Twice as many boys as girls have ADHD. This ratio decreases to sister. If his mother was on the phone, he would think
1.6:1 when examining ADHD in adults. Females are more likely nothing of yelling out demands for a drink, a snack, or
to present primarily with inattentive features (APA, 2013).
help in finding some lost toy, despite Marie’s numerous
else?” Billy asked, ignoring Jennifer’s protests. He began
warnings not to interrupt her.
to pull the string over and over in rapid succession
Attention-Deficit/Hyperactivity Disorder 253
until, finally, it broke off.
“Uh, oh,” Billy observed.
“Mommy, he broke my doll!” Jennifer cried. Even playing out in the yard was not a solution, because
Billy’s mother emerged from the kitchen to find him if Billy wasn’t watched closely, in a flash he might run
holding the broken doll while his sister wailed. What out into the street after a ball, without any regard for
had begun as a simple attempt to get Billy to wash his traffic. When playing indoors with neighborhood
hands and seat himself at the dinner table had ended in a children, Billy was bossy, continually grabbing their toys
tumultuous scene. or refusing to share his own. Thus, his play dates had to
And so it would go. Unless Billy was escorted through be closely supervised by his parents to avoid squabbles.
every task of the day, he’d get sidetracked, and it Because of these problems, Billy had few friends.
usually ended with an argument or something get ting Instead, most of his leisure time was spent watch
broken. Consequently, his parents often found it easier ing television or playing video games, activities that
just to do things for Billy—wash his hands, clean his Marie and Stan were reluctant to encourage, but which
room, get him dressed—because getting him to do the they felt forced to accept since the 8-year-old could do
tasks himself was the greater effort. little else without supervision.
When left to his own devices, Billy’s behavior was
disruptive in other ways. He jumped on the beds, ran
Billy at School A Teacher’s Perspective
through the house, or played shrill games of hide and-
Billy’s third-grade teacher, Mrs. Pease, found his
seek under the dinner table with his unwilling parents or
behavior intolerably disruptive in school. She was also Mrs. Pease, her patience wearing thin, addressed Billy
concerned that Billy’s behavior problems were through gritted teeth. “Billy, come with me back to
interfering with his ability to learn. She believed he was your seat.” She took him by the hand and led him there.
a bright child, but his attention and behavior problems She also considered making good on her threat to send
were causing him to fail to complete his lessons and him to Miss Warren, the princi pal, but she glanced at
hamper the clock and realized Miss Warren would not be in her
ing the other children’s ability to complete theirs. office now. Finding someone else to supervise Billy
One day at school in mid-April Mrs. Pease had called would probably be more disruptive than disciplining
the class to attention to begin an oral exercise: reciting him within the class, so she settled for getting him back
a multiplication table on the blackboard. The first child in his seat, then took her place once more in front of
had just begun her recitation when, suddenly, Billy the class. By now she was almost I0 min utes into the
exclaimed, “Look!” The class turned to see Billy lesson period and still had not finished a single
running to the window. multiplication table.
“Look,” he exclaimed again, “an airplane!’’
A couple of children ran to the window with Billy to see
the airplane, but Mrs. Pease called them back, and they
returned to their seats. Billy, however, remained at the
window, pointing at the sky. Mrs. Pease called him back,
too.
“Billy, please return to your desk,” Mrs. Pease said
firmly. But Billy acted as though he hadn’t heard her.
“Look, Mrs. Pease,” he exclaimed, “the airplane is
blowing smoke!” A couple of other children started
from their desks.
“Billy,” Mrs. Pease tried once more, “if you don’t return
to your desk this in stant, I’m going to send you to Miss
Warren’s office.” Billy seemed oblivious to her threats
Approximately 5 per cent of children and 2.5 percent of adults
and remained at the window, staring excitedly up at the
have ADHD (APA, 2013).
sky.
254 CASE 16

Mrs. Pease tried to resume the lesson. “Who can tell me the answer to 3 times
The number of children ever given a diagno Symptoms of ADHD, par ticularly the hyperactive symptoms, are
sis of ADHD increased from 7 percent in 2000 to 9 percent in typically most pronounced dur ing the elementary school years.
2009 They become less conspicuous by late child hood and early
(Akinbami, Liu, Pastor, & Reuben, 2011). adoles cence (APA, 2013).
6?” she asked. Fifteen children raised their hands, but
before she could call on anyone, Billy blurted out the
correct answer. “Thank you, Billy,” she said, barely able period and the beginning of recess. Mrs. Pease was
to contain her exasperation, “but please raise your hand thankful to get some relief from the obligation of
like the others.” control ling Billy, but was frustrated that almost the
Mrs. Pease tried again. “Who knows 3 times 7?” This entire math period had been wasted due to his
time Billy raised his hand, but he still couldn’t resist disruptions.
creating a disruption. Out in the schoolyard during recess, Billy’s difficulties
“I know, I know!” Billy pleaded, jumping up and down in continued. As the chil dren lined up for turns on the
his seat with his hand raised high. slide, Billy pushed to the head of the line, almost
“That will do, Billy,” Mrs. Pease admonished him. She knocking one child off the ladder as he elbowed his way
deliberately called on an other child. The child up. After going down the slide, Billy barged into a
responded with the correct answer. dodgeball game that some younger children were
“I knew that!” Billy exclaimed. playing; he grabbed the ball away from one child and
“Billy,” Mrs. Pease told him, “I don’t want you to say began dribbling it like a basketball, while the other child
one more word for the rest of this class period.” cried in frustration. The supervising teacher told Billy to
Billy looked down at his desk sulkily, ignoring the rest of give
the lesson. He began to fiddle with a couple of rubber Attention-Deficit/Hyperactivity Disorder 255
bands, trying to see how far they would stretch before
they broke. He looped the rubber bands around his the ball back, but Billy kept dribbling, oblivious to her
index fin gers and pulled his hands farther and farther demands. Finally, she took the ball away from him, and
apart. This kept him quiet for a while; by this point, Billy wailed in protest.
Mrs. Pease didn’t care what he did, as long as he was “Hey, give that back!” he insisted.
quiet. She continued conducting the multiplication “You took this ball from someone else,” the teacher
lesson while Billy stretched the rubber bands until explained.
finally they snapped, flying off and hitting two children, “But you took it from me. That’s not fair!” Billy argued.
one on each side of him. All three children let out yelps The teacher sent Billy to sit on a bench, where he
of surprise, and the class turned toward them. remained sulking and feeling mistreated for the rest of
“That’s it, Billy,” Mrs. Pease told him, “You’re going to the recess period.
sit outside the classroom until the period is over.” This was an average day for Billy at school. On some of
“No!” Billy protested. “I’m not going. I didn’t do his better days, he was less physically disruptive, but he
anything!” still had his problems, particularly in attending to and
“You shot those rubber bands at Bonnie and Julian,” completing his schoolwork. In a typical case, Mrs. Pease
Mrs. Pease said. “But it was an accident.” would give the class an assignment to work on, such as
“I don’t care. Out you go!” completing a couple of pages of arithmetic problems.
Billy stalked out of the classroom to sit on a chair in the While most of the children worked without supervision
hall. Before exiting, however, he turned to Mrs. Pease. until the as
‘’I’ll sue you for this,” he yelled, not really know ing signment was completed, Billy was easily distracted.
what it meant. When he got to the end of the first page, he would lose
Soon, the school bell rang, signaling the end of the
his momentum and, rather than continuing, would begin Only approximately one
fiddling with some object on his desk. Other times, if lessness, teachers or parents often conclude that he or
another child asked the teacher a question, Billy would she suffers from attention deficit/hyperactivity disorder
stop his own work to investigate the situation, getting (ADHD). However, 25 years of practice had taught
up to view the other child’s work and failing to child psychiatrist Dr. Sharon Remoc that such a
complete his own. conclusion is often premature and inaccurate, leading
Finally, at a parent-teacher conference, Mrs. Pease told to incorrect and even harmful interventions. Thus, when
Billy’s parents that she thought Billy’s problems might Billy’s parents brought him to the Child Development
be attributable to an attention-deficit disorder. Center, Dr. Remoc was careful to conduct lengthy
Concerned about Billy’s growing academic and social interviews with the child, his parents, and his teacher; to
problems—not to mention feeling exhausted from arrange for Billy to be observed at home and at school
continually having to remind, encourage, and threaten by an intern; to set up a physical examination by a
their son to get him to do the most elemental things— pediatrician to detect any medical conditions (for
Marie and Stan decided to seek professional assistance. example, lead poisoning) that might be causing the
They arranged for a consultation at the Child child’s symptoms; and to administer a bat tery of
Development Center. psychological tests. In addition to obtaining a description
of Billy’s current problems and his history from his
parents, Dr. Remoc had Billy’s mother respond to
Billy in Treatment The Therapist in Action questions from 2 different assessment instruments: the
After repeatedly observing a child’s tornadoes of Swanson, Nolan, and Pelham Checklist, which contains
activity, inattention, and reck questions pertaining specifically to disruptive
third of children who receive a diagnosis of ADHD from
pediatri cians actually undergo
psychological or educa tional testing to support the diagnosis
(Hoagwood, Kelleher, Feil, & Comer, 2000; Millichap, 2010).
256 CASE 16

In a 2007 national study of children with and without ADHD, An estimated 3.5 per cent of U.S. children received stimulant
parents reported that 46 percent of children with ADHD had a medi cation in 2008 com
learning disability pared with 2.4 percent in 1996 (Zuvekas &
compared with 5 per cent of children without ADHD who had a Vitiello, 2012).
learn ing disability. In addition, behavior problems, and the Conners Parent Rating
27 percent of children with ADHD versus 2 per cent of those Scale, which contains ques tions specifically for assessing
children without ADHD were reported to have conduct ADHD. Similarly, Dr. Remoc sent the teacher’s
disorder (Larson, Russ, Kahn & Halfon, 2011).
versions of the Swanson, Nolan, and Pelham Checklist
and the Conners scale to Mrs. Pease.
Billy’s battery of tests included the Wechsler
Intelligence Scale for Children and the Wechsler (Dexedrine), and pemoline (Cylert), were first used to
Individual Achievement Tests (to provide scores in treat ADHD decades ago, when clinicians noted that the
reading, mathematics, language, and written drugs seemed to have a “paradoxical” tranquilizing,
achievement). The results of these tests con firmed the quieting effect on these children. Subse
impression already supplied by Billy’s parents and Mrs. quent research has shown that all children—both those
Pease: Billy’s intelligence was above average, and his with and those without ADHD—experience an
academic achievement was lower than his intelligence increase in attentional capacity when taking stimulant
scores would predict. These findings established that drugs, resulting in behavior that is more focused and
Billy’s academic problems were not due to intellectual controlled. This may create the appearance of sedation,
limitations. but the children are actually not sedated at all.
After completing this comprehensive assessment, Dr. Unfortunately, the drugs are not effective for all
Remoc was confident that Billy’s difficulties met the children, and only partially effec tive for others. And
criteria in DSM-5 for a diagnosis of attention-deficit/ even when a drug is optimally effective, other areas of
hyperactivity disorder, combined type. He exhibited a behav ioral adjustment may still need to be addressed,
majority of the symptoms listed both for inattention because the ADHD child may have little practice in the
(for example, difficulty sustaining attention, failure to more appropriate behaviors that he or she now is
follow instructions, oblivious to verbal commands, easily theoretically capable of producing. This is where
distracted) and for hy peractivity-impulsivity (for behavioral programs may come into play.
example, difficulty remaining seated, excessive motor Attention-Deficit/Hyperactivity Disorder 257
activity in inappropriate situations, difficulty waiting his
turn). The symptoms were apparent before the age of
In the ideal case, both parents and teachers are involved
12, occurred both at home and school, and caused
in implementing a behavior modification program,
significant impairments in both the social and academic
which is based on the ABC model of behavior. The A in
spheres.
the model denotes antecedents, the conditions that
Over the years, research has indicated that many
provide the occa sion for a particular behavior; the B
children with ADHD re spond well to either stimulant
denotes the behavior itself; and the C denotes the
drugs or systematic behavioral treatment. Although
consequences of the behavior. Thus, a given behavior is
some therapists prefer one of these approaches over
seen as prompted by certain antecedents, and
the other, Dr. Remoc had come to believe that a
maintained by its consequences. For example, Billy’s
combination of the interventions increases a child’s
sprint to the window was prompted by the antecedent
chances of recovery. By helping the child to focus
condition of a boring classroom exercise and the
better and slow down, the medications may help him
appearance of an exciting stimulus (the airplane). It was
or her to profit from the procedures and rewards used
maintained, according to the model, by the rewarding
in the be havioral program.
effect of viewing the airplane, which was much greater
Stimulant drugs, which include
than the punishing effect of Mrs. Pease’s warn
amphetamine/dextroamphetamine mixed salts
ings or even of being sent out of the room. In a
(Adderall), methylphenidate (Ritalin), methylphenidate
behavior modification program, the usual strategy is to
extended-release (Concerta), dextroamphetamine
increase the rewards for engaging in alternative what was expected of him, both in general and in
behaviors under the same antecedent conditions. Thus, response to the behavior modification plan. The
if the reward for remaining seated can be made to parental training, she explained, would acquaint Marie
exceed the reward for viewing the airplane, then, and Stan with principles of behavior modification,
theoretically, the child will be more inclined to remain allowing them to deal optimally with any remaining
seated. behavior problems, as well as with Billy’s behavior
Learning alternative behaviors may involve more than during pe
just adjusting incentives or antecedents. Some skills riods when he might not be taking medication (so-called
may have to be taught directly. A child who has never drug holidays). Social
practiced asking politely for a toy, as opposed to
grabbing it, will need to learn this skill before he or she
can respond to incentives to implement it. Direct
behavioral skills training usually follows a standard
sequence. First, the child receives an ex
planation of the skill; next, he observes a model
demonstrating the skill; then, he practices performing
the skill, first through role-playing in the training session
and then through real-life behavioral practice. After the
skill is learned, both parents and teachers can prompt
the child to employ it in a given situation. For example,
after the skill of sharing is well learned, the parent can
prompt the child to “share” in a situation calling for
cooperation with another child, and then praise the
child appropriately for so doing. Theoretically, the
more the skill is employed and rein
forced in a variety of appropriate circumstances, the
more the child will use the skill spontaneously,
receiving naturalistic positive reinforcement from the
environ ment in the form of friendly or gratified
reactions from others.
Thus, Dr. Remoc outlined for Billy’s parents four
treatment components: (a) stimulant medication, (b)
parental training in the use of behavioral modifi cation
principles, (c) social skills training for Billy, and (d) token
economy in the school environment.
Dr. Remoc explained that stimulant medication was
important for increasing Billy’s attention and impulse
control; this, in turn, would enhance his capacity to do
Research suggests that a combination of drug therapy and to children with ADHD (Parker, Wales, Chal houb, & Harpin,
behavioral therapy is often helpful 2013).
258 CASE 16

skills training seemed necessary, Dr. Remoc said, in light of Billy’s problems in
get ting along with other children and in cooperating at home. Finally, she
explained that, since a large portion of Billy’s difficulties occurred in the
classroom, it would be helpful for both Billy and Mrs. Pease to have a
behavioral program operating in that environment. Dr. Remoc spoke to Mrs.
Pease about the matter, and the teacher was agreeable to instituting a
program provided it wasn’t too burden some; but given Billy’s problems up to
now, Mrs. Pease said that almost anything seemed less burdensome than
simply doing nothing.

Stimulant medication After ruling out any physical problems (e.g., motor
tics) that might preclude the use of stimulant medication, Dr. Remoc discussed
the
According to the United Nations, the United States produces system for 3 to 4 hours after it is ingested. This
and con sumes approximately 85 percent of the world’s stimulant effect, she explained, seems to increase the
methylphenidate. (Medi cating Kids. Statistics on Stimulant Use.
capacity of children with ADHD to maintain their
Retrieved March 24, 2014 from http://www.pbs.org/
attention and to control their impulses. As a result,
wgbh/pages/frontline/ shows/medicating/drugs/ stats.html.
they are better equipped to meet the requirements of
school, home, and a social life.
In addition, she informed Billy’s parents that certain side
effects can develop, including weight loss, slowed
growth, dizziness, insomnia, and tics. Dr. Remoc noted,
however, that these effects usually are not severe and
often disappear after the body becomes accustomed to
the drug or whenever a drug holiday is sched
The use of stimulant drugs to treat children with ADHD has
increased by 57 percent since 2000 (Carlson, Maupin, & uled. The clinician noted that since most children with
Brinkman, 2010). ADHD respond well to Concerta without prohibitive
basic rationale for use of the medication with Billy’s side effects, she was inclined to try Concerta first. Dr.
parents. She explained that the medication had been Remoc pointed out that the decision to take medication
used for years to treat children with symptoms of inat was not carved in stone. Indeed, the parents should
tention, impulsivity, and hyperactivity. She also explained consider the initial medication regimen as a trial period;
that the medication is not a tranquilizer. On the if, during this time, they concluded that the medication
contrary, the medication stimulates the central nervous was not worth while, then it should be discontinued.
They could try a different medication or they could rely
on the behavioral methods alone. the phone, shouting his insistent requests for snacks,
Once Billy began taking the medication, it was apparent toys, and videos. Overall, however, the medication
that his behavior improved substantially, although not seemed to have many advantages.
completely. In class, for example, Billy still blurted out
some answers and turned around to talk to his Parental training To gain some knowledge of
neighbors during silent reading period, but he did these behavioral management tech niques, Billy’s parents
things only about one fourth as often as before. Most enrolled in a training group for parents of children with
noticeable from Mrs. Pease’s standpoint was that simply ADHD (at about the same time that Billy began taking
saying his name was often enough to get him to cease medication). The group, led by psychologist Dr. James
what he was doing. Grendon, was designed to educate parents about both
Out in the schoolyard, Billy was now less inclined to ADHD and the principles of behavior modification for
barge into other children’s games or push others aside. managing it. Group sessions were held three times a
But, he still did not have a good social sense. Either he month, and once a month Dr. Grendon met
drifted off by himself or, if he did join a game, he failed alone with Billy’s parents to discuss the child’s individual
to abide by the rules con sistently, which ended up situation. At the very first group session, Billy’s parents
provoking arguments. For example, in joining a game of found comfort in learning that other parents’
catch with four other children, Billy was inclined to hog experiences closely paralleled their own. All the parents
the ball after he received were able to share their experiences and found that
Attention-Deficit/Hyperactivity Disorder 259 they were all dealing with very similar concerns. Many
parents saw humor in some of the situations, and this
helped to soften the impact of what they had all been
it; he would then hold it and giggle, in spite of the other
going through.
children’s yells that he was supposed to throw the ball
It also helped Marie and Stan to know that some of
to the next receiver.
their marital disputes were shared by the other
At home, Billy seemed less driven physically. He sat at
parents. Like the others in the group, Billy’s parents
the dinner table for the entire meal, without constant
often argued over how to deal with their child.
requests to be excused and without getting up re
Although it didn’t solve the prob lem, it helped them to
peatedly to grab things or to play under the table. Also,
know that even their arguments were “normal,” given
his passion for jumping on the beds was gone, and he
the circumstances.
became more dependable in carrying out instructions.
In additional group sessions, Marie and Stan were
For example, if his parents sent him to wash up and sit
progressively introduced to the ABC principles of
at the table, they now could count on his following
behavior management. Among the points they found
through 75 percent of the time (as opposed to 25
helpful was the idea that parents can become unduly
percent, as before). Tendencies such as stubbornness
focused on discouraging problem behaviors through
and defiance remained a problem, however; it remained
criticism or punishments; the punishments, in turn, are
a struggle to get him to do chores, to get started on his
often ineffective and just fuel resentment. A different
homework, or to follow household rules in general. He
approach, Dr. Grendon explained, was to think in
continued to barge in on his mother when she was on
terms of the alternative behaviors (B) that parents
would like their children to perform under the same (or mishandling) many situations with their son. For
circumstances (A), and to provide praise and rewards example, a regular problem with Billy was that he
(C) accordingly. interrupted his mother when she was on the phone. She
Billy’s parents explored this principle in greater detail in had to lock herself in the bedroom in order to have a
individual sessions with the group leader, as they felt it coherent conversation with a pediatrician, repairman,
applied particularly to the way they were handling friend, or relative. Often, even locking herself in was
not enough to insure peace and quiet, as Billy might
start pounding on the door in order to convey his
demands, in spite of repeated scolding.
To address the problem, the psychologist asked Billy’s
parents to think of spe cific, alternative actions they
would like Billy to carry out under these conditions. At
first, all Marie and Stan could think of was “not
interrupt,” but Dr. Grendon reminded them of the
stipulation that they think of a tangible alternative behav
tives had ADHD are more likely than others to develop the
disorder (APA, 2013).

Although family conflict is often present in families with a child

with ADHD, negative family interac tion patterns are unlikely to
cause the development of ADHD (APA, 2013).

About half of children with ADHD, combined type, also have

Children whose par ents or other close rela opposi tional defiant disorder.
260 CASE 16 Conduct disorder is pres ent in about 25 percent of children and
adolescents with ADHD, combined type (APA, 2013).
ior for Billy to carry out under the same circumstances. rang. Eventually, he resisted interrupting almost
After some discussion, they came up with the idea of entirely.
having Billy write down his requests whenever his Other behavioral plans were then put into effect for
mother was on the phone. They noted that their son other matters, such as household chores and
loved to write notes, so this might be a tangible thing homework completion. In both cases, Billy’s parents
he could do to satisfy his demands temporarily, and found an effective formula by reversing antecedent
allow him to resist interrupting. With further discussion, conditions and behavioral conse quences. For example,
Billy’s parents and the psychologist worked out the they saw to it that television viewing would always
following procedure: Before Marie made a call or follow the completion of homework, rather than vice
answered the phone, she would hand Billy a special versa.
message pad, reminding him to write down any
questions or problems that he had while she was talking; Social skills training Marie and Stan also enrolled their
Marie would then give prompt attention to Billy’s son in a class where he could learn skills for getting
messages as soon as she was off the phone; finally, if along better with other children. The class was
Billy succeeded in using the pad, instead of interrupting, composed of other children receiving treatment at the
for the majority of calls in a given week (his mother center for ADHD.
would keep a checklist to tabulate Billy’s compliance), During each class the focus was on learning one
he would be given a special reward on the weekend particular social skill, such as sharing. First, the group
(such as eating out at his favorite restaurant). leader explained the concept of sharing, and then asked
This was the first behavioral plan that Billy’s parents put the children their own opinions of what it meant. Next,
into effect, and after ironing out a few wrinkles, Billy she demonstrated the implementation of the skill with
was able to follow the procedure, even to the point of several children in different, contrived, situa
fetching the message pad himself whenever the phone tions: sharing toys, sharing food, or sharing a seat. Then
each child came up,
Attention-Deficit/Hyperactivity Disorder 261

one by one, and practiced sharing in each of these hypothetical circumstances.

The group leader and the other children then gave the child corrective feed
back on how well he or she had shared. Similar classes were devoted to other
social skills, such as cooperating, speaking calmly, making polite requests, and
following rules.
Billy’s parents and Mrs. Pease received written guidelines for discussing the
so cial skills training sessions at home and in school and for guiding Billy to use
the skills in everyday situations. Many of the opportunities to prompt him
arose at home in his interactions with his 5-year-old sister. With continued
prompting, Billy started to share things with his sister spontaneously on many
occasions, which increased the harmony in the household.
 Because of these successes, and Billy’s additional successes using the social
skill of cooperation, Marie and Stan finally felt confident enough to invite one
of Billy’s schoolmates over for a play date. The last time a child had come to
their house, it had been a disaster, as Billy had refused to relinquish any of his
toys to his guest. Needless to say no child was likely to return after such
treatment. Although this play date was far from perfect and needed Marie’s
constant attention, it turned out to be reasonably pleasant.

Token economy The token economy is an element of the ABC behavior

modification system; it uses tokens, rather than immediate, tangible rewards, to
reinforce desired behavior. The tokens are exchanged for an actual reward at a
later time. Token reinforcement is particularly advantageous for ADHD
children, who can get so wrapped up in the attractiveness of the actual reward
that they find it difficult to remain mindful of the behaviors that the reward is
designed to encourage.
Mrs. Pease thought that some form of behavior modification might assist
her in regulating several of Billy’s behaviors. Accordingly, she and the therapist
decided to focus on encouraging three specific school behaviors in Billy: raising
his hand to answer questions (instead of blurting out answers), staying in line,
and finishing in-class assignments. As token reinforcers, Mrs. Pease would use
dinosaur stickers affixed to a piece of paper, with the number of stickers in
each of three columns reflecting Billy’s compliance with the three behavioral
objec
tives. According to the plan (explained to Billy in a meeting with his parents
and Mrs. Pease), Mrs. Pease would keep track of Billy’s compliance separately
for the morning period and the afternoon period, and award him one sticker if
he achieved full compliance with a given behavioral objective in a given period.
He would receive his morning stickers at lunchtime, and his afternoon stickers
upon dismissal. The stickers could then be redeemed at home for special privi
leges (going out to eat, going out to a movie, an extra half hour of television or
a video game, and so forth).
262 CASE 16

Billy liked the idea of getting stickers so he agreed to the plan. On the first
morning of the program, he received only one sticker: for finishing his
assignment within the allotted time (he had blurted out a couple of answers
and had wan dered off the line going to art class). In the afternoon, however,
 he received two stickers: for staying in line and for finishing assignments. After
a few more days on the program, Billy was averaging five stickers per day, a
level that he was able to maintain, and which reflected a substantial
improvement in all three areas. Within 2 months of the combined treatment
program, Billy had improved
In the DSM-II (1968), ADHD was known offi cially as further experience he was becoming increasingly ef
hyperkinetic reaction of childhood, and it was commonly fective. As a result, he was getting along well with his
referred to simply as hyperactivity or hyperkinesis (the lat ter
sister, and he now had a couple of friends who would
term from the Greek for over and motion).
come over regularly to play, and who invited him to
their homes as well.
Unfortunately, after about 4 months of this improved
functioning, Billy began to slip into some of his old
patterns both at home and at school. His parents felt
that the problems had to be addressed, as he seemed
to be losing ground. The recur rence of problems
seemed to coincide with the birth of his new baby
brother. In a discussion with Dr. Remoc, Billy’s parents
wondered whether their total preoc cupation with the
birth of the baby, and their consequent inability to
implement many features of the behavioral program
(including not following through on redeeming Billy’s
dinosaur stickers), was responsible for the slippage in
his prog ress. A renewed effort by the parents to apply
In addition to being
the behavioral program, and an adjustment in the
viewed negatively by peers and parents, chil dren with ADHD
often dosage of Billy’s medication, helped him to regain his
view themselves nega tively and have signifi cantly lower self- previous achievements within a few weeks.
esteem than children without ADHD (Mazzone et al., 2013;
McCormick, 2000).
considerably. He was conforming to classroom rules by
Epilogue
staying in his seat, not talking, and finishing his After 18 sessions of group parental training (over a 6-
assignments most of the time. When he deviated, he month period), 6 sessions of individual parent training,
required only gentle reminders from Mrs. Pease to get 6 sessions of social skills training for Billy, and 4
back on track. Similarly, at home, he was less frenetic. meetings at school with Billy’s teacher, his ADHD
He could carry out instructions more dependably, and symptoms stabilized at an improved level.
he usually accepted his household responsibilities Billy reported that he was happier at school and
without too much argu enjoying time at home with his family. He still took
ment. In peer relations, Billy was still learning the medication and saw Dr. Remoc for a checkup every 4
culture of give and take, but with periodic guidance and months. Billy’s parents planned to give Billy a drug
holiday in the summer and felt confident of their ability sometimes laughing, sometimes crying—
to manage his behavior during that time with just the but, overall, enjoying their lives and activities together.
behavioral techniques. They were a family again—
Attention-Deficit/Hyperactivity Disorder 263

Assessment Questions
1. When did Billy’s parents begin to suspect that of the treatment plan?
Billy’s “dynamo” personality might be a behav ioral 13. Describe the ABC plan that Billy’s parents devel
disorder? oped to control his “interrupting” behaviors. 14.
2. Describe at least 3 behaviors that suggest that What other childhood behavioral diagnoses are often
Billy’s activity level is beyond what’s normal for a comorbid with ADHD?
child his age.
15. Describe the concept of a token economy. 16.
3. When did Billy’s family finally receive more ob
What event disrupted Billy’s progress? 17. What was
jective feedback about Billy’s behavior? 4. How long
the ultimate outcome after 18 ses sions of group
did it take for Billy’s teachers to sug gest professional
parental training?
consultation regarding Billy’s disruptive behavior?
5. Why did Dr. Remoc, the therapist at the Child
Development Center, feel it was important to
conduct a thorough assessment of Billy before
diagnosing ADHD?
6. Describe at least 4 different assessment tech
niques used by Dr. Remoc to test for ADHD. 7.
What were the assessment results that led Dr.
Remoc to diagnose ADHD in Billy? 8. Why did Dr.
Remoc decide to use both medica tion and behavioral
therapy to treat Billy?
9. What are some potential problems with pre
scribing medication as the only treatment option
for children with ADHD? What are some side
effects of stimulant medications?
10. Describe the ABC model of behavioral therapy
and give examples.
11. What were the four treatment components out
lined for Billy’s treatment?
12. Why is it important for Billy’s parents to be a part