668 CHAPTER 14
The fi rst step of contingency management training with parents is psychoeduca-
tion—teaching the parents that the symptoms are not the result of intentional misbe-
havior but part of a disorder (Barkley, 1997, 2000). The training then is intended to:- change parents’ beliefs about the reasons for their child’s behavior so that
parents approach their child differently and develop realistic goals for their
child’s behavior; - help parents to institute behavior modifi cation, which includes paying attention
to desired behaviors, being consistent and clear about directions, and develop-
ing reward programs; and - teach parents to respond consistently to misbehavior.
Parent training, then, targets social factors—interactions between parents and child.
Changes in the way parents think about and interact with their child, in turn, change
the child’s ability to control behavior (psychological factor). Parent training may be
the best treatment for families who have children with mild ADHD or preschoolers
with ADHD (Kratochvil et al., 2004).Parent Management Training
Parent management training is designed to combine contingency management tech-
niques with additional techniques that focus on improving parent-child interactions
generally—improving communication and facilitating real warmth and positive
interest in the parent for his or her child (Kazdin, 1995).Multisystemic Therapy
Multisystemic therapy (Henggeler et al., 1998) is based on family systems therapy
and focuses on the context in which the child’s behavior occurs: with peers, in
school, in the neighborhood, and in the family. This comprehensive treatment may
involve family and couples therapy, interventions with peers, CBT with the child,
and an intervention in the school (such as meeting with the child’s teacher or di-
rectly assisting in the classroom to help the child manage his or her behavior). The
specifi c techniques employed are tailored to the systems in the child’s life that need
to be changed.A substantial minority of children with conduct disorder and oppositional defi -
ant disorder don’t respond to a given treatment or, if they do, their disruptive be-
haviors may decrease only to the point where the diagnostic criteria for a disruptive
behavior disorder are no longer met; usually, though, the disruptive behaviors do not
decrease to normal levels (Kazdin, 1995). Moreover, success in changing a child’s
behavior in one setting—at home, for example—does not necessarily generalize to
other settings, such as the classroom. Younger children who have relatively minor
symptoms are most likely to benefi t from the treatments that target social factors.FEEDBACK LOOPS IN TREATMENT: Treating Attention-Defi cit/
Hyperactivity Disorder
Let’s take a closer look at treatment for ADHD, examining the feedback loops
among the various factors (see Figure 14.5).
At fi rst glance, medication might seem to have its effects solely through neuro-
logical mechanisms, but this isn’t so. Taking medication (neurological factor) not
only leads to increased control of attention and hyperactive or impulsive behav-
iors, but it is also associated with higher levels of self-esteem (psychological factor;
Frankel et al., 1999) and improved social functioning (social factor; Chacko et al.,
2005). And better social functioning feeds back to improve self-esteem, which can
lead a child not to seek attention as vigorously.
Other feedback loops originate from programs for parents or the family (which
target social factors); such interventions in turn create feedback loops with psycho-
logical factors—improving the child’s thoughts, feelings, and behaviors.P SNP SN