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Identify and correctly code the most comprehensive diagnosis that accounts for the unique client presentation. Succinctly and completely justify the diagnosis by linking symptoms with the specific diagnostic criteria they satisfyList and explain the rationale for the evidenced-based treatments and interventions that can alleviate the symptom severity and or treat the client. 9 y/o male I have attached a PDF that will help. 2 reference and 1 articleThe D/O is ATTENTION-DEFICIT/HYPERACTIVE D/O….. Code 314.01
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Evidence-based Psychosocial Treatment for ADHD Children and Adolescents
Comprehensive Treatment for ADHD should always include a strong psychosocial (that is, not medical)
component. Most professionals believe that effective psychosocial treatment is the backbone of good treatment
for ADHD. Medication is a very useful addition to psychosocial treatment in many cases, yielding a combination
approach that may be even more effective than psychosocial treatments alone (see “ADHD Medication
Information Sheet for Parents and Teachers”). Indeed, the scientific literature on treatment for ADHD, the
National Institute of Mental Health, and many professional organizations say that there are two treatments that
have a solid base of scientific evidence for short-term effectiveness: behavioral psychosocial treatments—also
called behavior therapy or behavior modification—and stimulant medication. Behavior modification is the only
nonmedical treatment for ADHD with a large scientific evidence base.
Why Use Psychosocial Treatments?
Why do professionals believe that behavioral treatment for ADHD is so important? There are several reasons.
First, the problems faced by children with ADHD go well beyond their symptoms of inattentiveness,
hyperactivity, and impulsivity. Most children with ADHD have problems in daily life functioning in many areas
including academic performance and behavior at school, relationships with peers and siblings, noncompliance
with adult requests, and relationships with their parents. These problems are extremely important because they
predict long-term outcome of children with ADHD. How a child with ADHD will do in adulthood is best
predicted by three things—(1) whether his or her parents use effective parenting skills, (2) how he or she gets
along with other children, and (3) his or her success in school. Psychosocial treatments focus on these problems
rather than the core symptoms of the disorder, so they are effective in treating these important domains. Second,
in contrast to medication, behavioral treatments teach skills to parents, teachers, and children with ADHD, and
these skills help overcome their impairments and are useful for a child’s lifetime. Because ADHD is a chronic
condition, teaching skills that will be valuable across the lifetime is especially important. Finally, when
medication is the only form of treatment, it has not been shown to improve long-term outcomes for children with
ADHD. Many professionals believe that when medication is combined with behavioral approaches, both the core
symptoms of ADHD and the associated problems in daily life functioning are best treated, and long-term positive
outcomes will be greatest. Others believe that treatment should begin with psychosocial treatments, and
medication should be added if and when it is necessary. Both are effective ways of treating ADHD and parents
must decide, in consultation with their treating professionals, what is best for their child.
Behavioral treatments for ADHD should be started when the child is as young as possible. There are behavioral
interventions that work well for preschoolers, elementary-students, and adolescents with ADHD, but there is
consensus that starting early is better than starting later. Parents, schools, and practitioners should not put off
beginning effective behavioral treatments for children with ADHD.
What exactly is behavior modification?
Behavior modification is a form of therapy in which parents, teachers, and children are taught skills by a therapist.
Parents and teachers then employ those skills in their daily interactions with their children with ADHD to improve
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the children’s functioning in the key areas noted above. In addition, the children with ADHD employ the skills
they learn in their interactions with other children. Many parents think of behavior modification in terms of the
ABCs—Antecedents (things that happen before behaviors that influence them), Behaviors (things the child does
that parents and teachers want to change), and Consequences (things that happen after behaviors that influence
them). In behavioral programs, adults are taught to modify antecedents (e.g., how they give commands to
children) and consequences (e.g., how they follow-up if a child obeys or disobeys a command) to change the
child’s behavior (that is, the child’s response to the command). By consistently changing the ways that they
respond to children’s behaviors, adults teach the children to learn new ways of behaving.
What is not behavior modification?
It is important to note that many psychotherapeutic treatments are not behavior modification. Thus, traditional
individual therapy, in which a child spends time weekly with a therapist or school counselor talking about his or
her problems or playing with dolls or toys, is not behavior modification. Similarly, family therapy in which a
family talks with a therapist about the dynamics of the interactions among the family is also not behavior
modification. Such “talk” or “play” therapies do not have teaching skills as their primary goals, and they have not
been shown to work for children with ADHD. Parents who want an evidence-based psychosocial approach to
working with their children with ADHD need to become informed about the characteristics of behavior
modification that we discuss below so they can recognize effective behavioral treatment and be confident that
what the therapist is offering will result in improved functioning for their child.
What are typical forms of behavior modification?
There are three parts of effective behavioral interventions for ADHD children—parenting training, school
interventions, and child-focused treatments. Although working with teachers and the children themselves are
critical in the vast majority of ADHD cases, teaching parents more effective ways of dealing with their children is
the most important aspect of psychosocial treatment for ADHD. Ideally, parent, teacher, and child interventions
must be integrated to yield the best outcome. Four points apply to all three parts: (1) always start with goals that
the child can achieve and improve in small steps (e.g., “baby steps”); (2) always be consistent—across different
times of the day, different settings, and different people; (3) ADHD is a chronic problem for the individual and
treatments need to be implemented over the long haul—not just for a few months; and (4) teaching and learning
new skills take time, and children’s improvement will be gradual with behavior modification. Characteristics of
parent, teacher, and child interventions are listed below.
(1) Parent Training
• Behavioral approach
• Focus on parenting skills, child behavior in the home and neighborhood, and family relationships (e.g.,





getting along with siblings, complying with parent requests)
Parents are taught skills by therapists and implement them at home
Typically group-based, weekly sessions with therapist initially (8 to 12 sessions); then faded to booster
sessions (monthly, quarterly)
Continually evaluate and modify what is being done to identify what works best and continue it as long as
necessary
Plan for what will be done if parents or child backslides
Reestablish contact with therapist for major developmental transitions (e.g.,entry to middle school)
(2) School Intervention
• Behavioral approach
• Focus on classroom behavior, academic performance, and peer relationships
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Teachers are taught classroom management skills by a consultant (e.g., therapist, school psychologist or
counselor) and implement them with the ADHD child during school hours
Two to 10 hours of training are necessary depending on the teacher’s prior knowledge and skills, as well
as the child’s severity and responsiveness
Continually evaluate and modify what is being done to identify what works best and continue it as long as
necessary
Plan for backsliding and spread; involve all relevant school staff; integrate with parenting classes so
parent learns to back up what the school is doing
Integrate with school-wide plans, and required, school-based programs (i.e., IEPs, 504 plans)
Reestablish contact with consultant for major developmental transitions (e.g., entry to middle school)
(3) Child Intervention
• Behavioral and developmental approach
• Focus on teaching academic, recreational, and social/behavioral competencies, decreasing aggression,







developing close friendships, and building self-efficacy
Paraprofessional implemented, supervised by professionals
Settings such as clinic-based weekly group sessions, after-school or Saturday sessions, and summer
camps
Typically more intensive rather than less intensive treatment is necessary (e.g., weekly clinic social skills
groups are typically not effective)
Monitor and modify as needed based on what works best; provide as long as necessary (e.g., multiple
years or when deterioration occurs)
Plan for what to do if backsliding occurs
Integrate with school and parent treatments
Reestablish contact with consultant for major developmental transitions (e.g., middle school entry)
How does a behavior modification program begin?
The first step in starting a behavior modification program is a complete evaluation of the child’s functional
impairment in all relevant domains, including home, school (both behavioral and academic), and peer settings.
Most of this information comes from parents and teachers, and that means that a professional will spend most of
his or her time during the information gathering process with parents and teachers. Interaction with the child him
or herself is needed for the therapist to get a sense of what the child is like. That assessment process should yield
a list of target areas for treatment. Target areas—often called target behaviors–should be behaviors that
differentiate the child being treated from other, nonproblematic children. They should be behaviors that, if
changed, will contribute to an improvement in the child’s functioning/impairment and a positive long-term
outcome. Target behaviors can be either negative behaviors that need to be eliminated or adaptive skills that need
to be developed. That means that the areas targeted for treatment will typically not be the symptoms of ADHD—
overactivity, inattention, and impulsivity—but instead the specific problems that those symptoms may cause in
daily life. Thus, common classroom target behaviors would be “completes assigned work at 80% accuracy” and
“followed classroom rules.” At home, “played well with siblings (that is, no fights)” and “complies with parent
requests or commands” are common target behaviors (lists of common target behaviors in school, home, and peer
settings that parents and teachers might find useful can be downloaded in Daily Report Card school and home
packets at http://ccf.buffalo.edu). Target behaviors are things that can be easily observed and measured so that
response to treatment can be monitored and treatment can be modified as necessary.
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After target behaviors are identified, behavioral interventions at home and at school follow similar formats.
Parents and teachers identify the environmental conditions (the A’s) and consequences (the C’s) that are
controlling those target behaviors (the B’s). Then behavioral treatment takes the form of parents and teachers
learning and establishing programs in which the environmental antecedents and consequences are modified to
change the child’s target behaviors. Treatment response is constantly monitored, and the interventions are
modified when they fail to have a sufficient impact or are no longer needed.
Parent Training
Behavioral parent training programs have been around for a long time. Nearly 40 years ago the psychologists who
developed behavioral parent training wrote the first books teaching others how to do what they had developed.
Parenting sessions usually use a book and/or videotape that has been specially developed to teach parents how to
use behavioral management procedures with their children; there are many good programs available (see list in
appendix). The first session is often devoted to an overview of the diagnosis, causes, nature, and prognosis of
ADHD. Thereafter, in group or individual sessions, parents learn a variety of techniques, some of which they
may be already using at home but not as consistently or correctly as needed. Parents go home and implement
what they learn in sessions during the week, and return to the parenting session the following week to discuss
progress, problem solve, and learn a new technique.
Although many of the ideas and techniques taught in behavioral parent training are common-sense parenting
techniques (everyone knows to praise their children when they are doing something good!), most parents need
careful teaching and support to learn and implement the parenting skills consistently. It is very difficult for
parents to buy a book, learn behavior modification, and implement an effective program with their child on their
own. Help from a professional who knows how to develop and implement behavioral programs is often essential.
The topics covered in a typical series of parent training sessions include the following topics in sequence.
1.
Establishing house rules and structure
• Posted chore lists
• Posted morning and evening routines
• Posted House Rules
• Review until child has learned them
2.
Learning to praise appropriate behaviors (praise good behavior at least five times as often as bad behavior is
criticized) and ignore mild inappropriate behaviors (choose your battles)
3.
Using appropriate commands
• Obtain the child’s attention: say the child’s name first
• Use command not question language (“Don’t you want to be good” is a bad command!)
• Be specific, describing exactly what the child is supposed to do (at the grocery checkout line “be good” is
not a good command! “stand next to me and do not touch anything” is more specific!)
• Be brief and appropriate to the child’s age
• State consequences and always follow through (praise compliance and provide consequences for
noncompliance)
• Have a firm but neutral (not angry) tone of voice
4.
Using when…then contingencies
• Give access to desired activities when the child has completed a less desired activity (e.g., ride bike when
finished homework; watch TV when finished evening chores, going out with friends after completed yard
work)
• For younger children, important to have rewarding activity occur immediately
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5.
Planning ahead and working with children in public places
• Explain situation to child before activity occurs
• Establish ground rules, rewards, and consequences
6.
Time out from positive reinforcement
• Assign short times away from preferred activities when the child has violated expectations or rules
• Give time off for appropriate behavior during time out and lengthen time for noncompliance with time out
• Base times on children’s ages—shorter for younger children—e.g., one minute for each year of age
7.
Daily Charts—Point/token systems with rewards and consequences
• Make charts with home rules/goals and post prominently in house
• Establish system for rewards for following home rules and consequences for violations
• Nickel jar for noncompliance or talking back (e.g., put a nickel in for each compliance, remove two for
noncompliance)
• Home Daily Report Card (see target list and creating a Daily Report Card for the home at
http://ccf.buffalo.edu)
8.
School-home note system for rewarding behavior at school and tracking homework (see description below in
School Interventions)
There are many other techniques that are part of a good behavioral parenting program. Those listed above are
included in almost all of the good programs. Some families can learn these skills quickly in the course of 8 or 10
meetings, while other families—often those with the most severely impaired children—require more time and
energy.
The techniques listed above are those typically used in teaching parents of children with ADHD. When the
presenting child is a teenager, parent training is modified somewhat. Parents are still taught behavioral
techniques, but they are modified to be age-appropriate for adolescents. For example, time out is a consequence
that is not effective with adolescents; instead loss of privileges (e.g., can’t take family car on date) or assignment
of work chores would be more appropriate. After parents have been taught these techniques, the parents are
typically involved in sessions that include the adolescent, with the therapist helping parents and adolescents in
structured discussions in which they negotiate mutually agreeable solutions to their disagreements. Parents
negotiate for improvements in the adolescents’ target behaviors (e.g., better grades in school) in exchange for
rewards over which they have control (e.g., the teen’s being able to go out with friends). The give and take
between parents and teen in these sessions is necessary to motivate the teenager to work with the parents to make
changes in his or her behavior.
Applying these skills with children and adolescents with ADHD takes a lot of hard work on the part of parents.
However, the hard work pays off. Parents who master and consistently apply these skills will be rewarded with a
child who behaves better and has a better relationship with his parents and siblings.
School Interventions
As is the case with parent training, the techniques used in classroom-based interventions for ADHD have been
around for some time. Many teachers who have had training in classroom management are quite expert in
developing and implementing classroom-based programs for their ADHD children. Others, however, are not
intimately familiar with behavioral principles and need assistance to learn and implement the necessary programs.
There are many widely-available handbooks, texts, and training programs that have been developed to teach
classroom behavior management skills to teachers (see list in appendix). Most of these programs are designed to
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be implemented by regular or special education classroom teachers with training and guidance from school
support staff or outside consultants. One of the most important things that the parent of an ADHD child can do is
to work closely with the teacher to support his or her efforts implementing classroom programs for their ADHD
child.
The following list includes typical classroom behavioral management procedures. They are arranged in order
from mildest and least restrictive to more intensive and most restrictive procedures. Some of these programs may
be included in 504 plans or Individualized Educational Programs that may apply to ADHD children (see
http://www.ed.gov/parents/needs/speced/edpicks.jhtml?src=ln) or may need to be integrated with such plans.
Typically an intervention is individualized and consists of several components based on the child’s needs, the
classroom resources, and the teacher’s skills and preferences.
1.
Classroom rules and structure
• Typical classroom rules:
o Be respectful of others
o Obey adults
o Work quietly
o Stay in assigned seat/area
o Use materials appropriately
o Raise hand to speak or ask for help
o Stay on task/c …
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