A Case Study Using Cognitive-Behavioral Therapy- Management of ADHD

Attention-deficit/hyperactivity disorder (ADHD) remains one of the most prevalent mental health diagnoses identified in school-age children. Affected children show an increased risk for school failure, social difficulties, and the development of psychiatric co-morbidities. Despite the availability of evidence-based behavioral protocols for managing ADHD-related impairments, psychologists often encounter difficulties involving parents in the sustained implementation of these interventions. Cognitive-behavioral treatment aims to teach children with Attention Deficit Hyperactivity Disorder (ADHD) strategies to help them increase their self-control and problemsolving abilities, through modeling, role playing and self-instruction. Cognitive-behavioral treatment has shown mixed effectiveness regarding ADHD behaviors Cognitive-behavioral therapy (CBT) can address treatment obstacles through emphasizing psycho-education, the development of a collaborative treatment context. This article presents a case study of Jay, a 9year-old child with ADHD. He was supplemented with child-focused CBT strategies by the psychologist and parental behavioral management training by the parent. This case study outlines a central role of CBT intervention in collaboration with the Parent in managing ADHD children.

Most current models of ADHD emphasize the deficiencies in the executive functioning skills of behavioral inhibition and self-regulation (Barkley, 2006). These deficiencies in turn manifest themselves in overt behaviors, such as sustaining attention to academic tasks and inhibiting excessive motor activity. Cognitive behavioral proponents recognise the goodness of fit between these highlighted deficits in children with ADHD and the self-regulatory focus of cognitivebehavioral treatment (Hinshaw & Melnick, 1992). Relatedly, the proponents of cognitive behavioral approach contend that the maintenance of treatment gains can be achieved only through teaching a generalised set of cognitive mediational (self-talk) skills that children with ADHD can internalise.

CBT and Bandura's Theory
The cognitive-behavioral perspective can take a variety of forms and draws on a range of psychological theories. For example, Bandura"s theory of self-efficacythe view that one can achieve desired goals (1986,1997) and that the beliefs individuals hold about their capabilities have a strong influence on the ways in which they behave (Usher & Pajares, 2008) -is an early example of a cognitive-behavioral perspective. He posited that cognitive-behavioral treatments work in large part by improving self-efficacy.
Beck"s cognitive model makes the assumption that problems result from biased processing of external events or internal stimuli. These biases distort the way that person makes sense of the experiences he or she has in the world, leading to cognitive errors. Beck (2005) argues that underlying these biases is a relatively stable set of schemas that contain dysfunctional beliefs.
When the schemas become activated they bias information processing. The central focus in treatment is therefore to alter distorted and maladaptive cognitions and their underlying schemas; this is achieved through making individuals aware of and exploring the connections between thoughts and emotional responses and later learning and practicing strategies to better deal with difficult external events or internal stimuli. In the case of ADHD for example, the cognitivebehavioral approach helps pupils to understand links between thoughts, feelings and behaviors and that these may result in unhelpful, inappropriate or maladaptive consequences. The therapy also explores learning to change these thoughts, feelings and behaviors to produce more desirable outcomes (NICE, 2009).
Findings on the effectiveness of cognitive-behavioral interventions on ADHD behaviors have been mixed. Literature demonstrates the limitations of cognitive behavioral interventions in directly targeting central ADHD impairments (Abikoff, 1987;Abikoff, 1991). Indeed, despite some early claims of success (e.g. Cameron & Robinson, 1980), systematic investigations aimed at comparing the benefits of cognitively based interventions with stimulant medications have demonstrated the superiority of the latter (Abikoff, Ganeles, Reiter, Blum, Foley, & Klein, 1988).
However, other studies show that cognitive-behavior techniques are effective in moderating impulsivity (Kendall & Braswell, 1982). A recent review by Munoz-Solomando, Kendall, & Whittington (2008) also suggests that cognitive-behavioral interventions can have beneficial effects delivered in absence of medication or as adjunct to continued routine medication for children with ADHD. Furthermore, current NICE guidelines retain their support for cognitivebehavioral interventions for children with ADHD; they consider group-based cognitivebehavioral interventions to be both effective with children with ADHD and cost efficient. In light of these discordant views, combined with the fact that many reviews are now dated, a re-consideration of the area is necessary.
The parent"s role in supporting the child is crucial, yet literature highlights that parents of children with ADHD often struggle to manage their child"s problems, suffering from stress and exhaustion (Green, Mc Ginnity, Meltzer, Ford, & Goodman, 2005). Further, recent legislation has highlighted the importance of involving parents in treatment options and the treatment process, making the parent"s perspective of particular relevance to current practice. As such, this review will focus on the parent"s perspective.

CASE PRESENTATION Chief Complaints:
1. Hyperactive 2. Would grab whatever is in hands without prior permission 3. Does not pay attention to what is told 4. Always disturbing his peer group 5. Blurts out answers before a question is completed 6. Pays no attention in school work 7. Delays coping notes at school

HISTORY OF PRESENTING COMPLAINTS
Master L is 9 years old with a history of ADHD. He is an overactive child from early infancy, and his parents initially attributed his exuberant behavior to the natural tendencies of his sex. The parents tried their best to keep the behavior under control by verbally controlling his discipline and occasionally spanking him.
When he was 3 years of age, his parents came increasingly aware of his hyperactivity impulsivity. There were regular complaints from school regarding his inattention. At the age of 5 years he was diagnosed as ADHD by a psychologist. Their parents accepted the counseling done to help manage their son"s condition, but the parents declined use of medication. Later when the child was changed to a new school, teachers complained about his hyperactivity, inattentiveness and distracting peer group, he would never wait for his turn and always impulsive, he would never wait for the question to be completed, and would blurt out answers, which became an hindrance in his understanding and learn more. The parents were called and again adviced to seek the help of a psychologist.
A psychological evaluation was done again and recommended for medication. This time parents accepted and started giving medication. The parents were placed on the defensive all the time and began to feel threatened, stating that "the focus was no longer on the child"s condition but on the parental abilities". As a result to attend to children and coordinate their care, unable to navigate the different agencies that had become involved with their family and believing a more disciplinary and controlled environment might help, the parents kept away Mast L from his sibling, Master L was staying at his grandparents home and his other sibling was staying with his parents, they would both exchange visit to their home weekly once. Neither environment had an effect on his behavior. He continued to be inattentive, hyperactive and impulsive. Table 1 lists the DSM IV criteria for the 3 subtype of ADHD. These are 1. Predominantly inattentive (has at least 6/9 inattentive behaviors, 2. Predominantly hyperactive and impulsive (has 6/9 hyperactive and impulsive behaviors), and 3. Combined (has at least 6/9 for both inattention and hyperactive-impulsive behaviors).

Table 1. DSM-IV Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder
Six or more symptoms from the specified category (or categories) listed below must have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level.
314.01 Attention-deficit/hyperactivity disorder, combined type: categories A1 and A2 314.00 Attention-deficit/hyperactivity disorder, predominately inattentive type: category A1 314.01 Attention-deficit/hyperactivity disorder, predominately hyperactive-impulsive type: category A2 314.9 Attention-deficit/hyperactivity disorder not otherwise specified: prominent symptoms of inattention or Hyperactivity-impulsivity that do not meet criteria for attention-deficit/hyperactivity disorder A1: Inattention 1. Often Fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities 2. Has difficulty sustaining attention in tasks or play activities 3. Does not seem to listen when spoken to directly 4. Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) 5. Has difficulty organizing tasks and activities 6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) 7. Loses things necessary for tasks or activities (Eg, toys, school assignments, pencils, books, or tools) 8. Is easily distracted by extraneous stimuli 9. Is forgetful in daily activities A2: Hyperactivity-Impulsivity Hyperactivity 1. Often Fidgets with hands or feet or squirms in seat 2. Leaves seat in classroom or in other situations in which remaining seated is expected 3. Runs about or climbs excessively in situations in which is inappropriate (in adolescents or adults, may be linked to subjective feelings of restlessness) 4. Has difficulty playing or engaging in leisure activities quietly 5. Is "on the go" or often acts as if "driven by a motor" 6. Talks excessively Impulsivity 1. Often Blurts out answers before questions have been completed 2. Has difficulty awaiting turn 3. Interrupts or intrudes on others (Eg, butts into conversations or games) Additional required criteria B. Some hyperactive-impulsive or inattentive symptoms that cause impairment were present before 7 years of age C. Impairment in 2 or more settings (eg, at school, work, or home) D. Clinically significant impairment in social, academic, or occupational functioning E. Symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (Eg: mood disorder, anxiety disorder, dissociative disorder, or a personality disorder)

ADHD Rating Scale
Child's Name: ___________________________Age: ________ Date:__________________ Is "on the go" or acts "driven by a motor." Talks excessively. Blurts out answers to questions before the questions have been completed. Has difficulty awaiting turn Interrupts others or intrudes on others (e.g., butts into games)

Total for Hyperactivity and Impulsivity
Were some of these behaviors present before age 7? Yes __ No __ Unsure __ N/A __

Interpretation of the Scale
To look for the number of symptoms in the Inattention section in the "Always or very often" and the "Often" columns. To meet the criteria for ADHD inattentive sub-type, there must six or more of these. In other words, the child must have at least six of these symptoms which have persisted for at least 6 months to a degree that is maladaptive (significant impairment in social, academic, or occupational functioning) and inconsistent with developmental level.
Next to look at the totals for the Impulsivity and Hyperactivity section. To be consistent with the criteria for ADHD hyperactive sub-type, six or more of these symptoms should be in the "Always or very often" and the "Often" categories.
If the criteria for both inattention and hyperactivity are met (i.e., six or more in both), this is an ADHD combined sub-type.

Procedure
CBT was given for 45 minutes thrice a week. Twelve sessions were given, Cognitive-behavioral treatment sessions were carried out to teach strategies to help them increase their self-control and problem-solving abilities, through modeling, role playing and self instruction (Kendall & Braswell, 1985;Kendall, Padever & Zupan, 1980), medications was also used to decrease the core symptoms of ADHD (Hechtman, Weiss, & Perlman, 1984;Gittelman & Kanner, 1986) Where they have to: (1) Identify nature of the problem (2) Start acting on all the possible solutions (3) Take any one solution and evaluate its outcome Fehlings et al., 1991;Horn et al., 1990;Miranda & Jesús Presentación, 2000 in their studies also implemented cognitive-behavioural treatment that instructed children in similar strategies such as problem solving, self-instructional training, self-monitoring and self-control therapy. The studies used similar methods of training, such as modeling, role playing and guided practice. Parents were taught about CBT and that achieved significant findings across all measures and the authors felt that emphasis on generalisation of newly acquired skills played a key part in achieving this outcome measures.
Attention Deficit Hyperactivity Rating Scale (ADHD RS), was administered pre-post intervention to find the results in all the three specific domains, Inattention, Hyperactivity and Impulsivity

In addition to CBT, Parental Behavioral Training was done.
Parental Behavioral training has a long, successful history as a treatment for children with ADHD (Pelham et aI., 1998), oppositional defiant disorder (ODD) and conduct disorder (CD; Brestan & Eyberg, 1998), as well as many internalizing disorders (e.g., Silvennan et aL, 1999). Behavioral parent training explicitly provides parents with instruction in the implementation of behavior modification techniques that are based on social learning principles. Parents are taught to identify and manipulate the antecedents and consequences of child behavior, target and monitor problematic behaviors, reward prosocial behavior through praise, positive attention, and tangible rewards, and decrease unwanted behavior through planned ignoring, time out, and other non-physical discipline techniques (e.g., removal of privileges). The efficacy of parent training in treating ADHD has been evaluated in at least 28 published studies (for a review, see Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004). These studies employed manualized parent training interventions, included children between the ages of 3 and 14, were heterogeneous in design (e.g., randomized, controlled clinical trials, single subject case studies), and combined parent training with various treatment components (e.g., school interventions, social skills training).
Overall, these studies suggested that parent training results in improvements for children with ADHD in several important areas, most notably parent ratings of problem behavior and observed negative parent and child behaviors, with an average effect size of .87 (range=-.09-2.25; Fabiano, Pelham, Coles, Gnagy, & Chronis, in preparation). ln some cases, parent training has also resulted in improvements in other domains, such as parental reports of stress (e.g., Anastopolous, Shelton, DuPaul, & Guevern10nt, 1993), and social behavior and acceptance (Pelham et a1., 1988).

Techniques
Therapist Jay Outcome Delay in copying notes from the Black Board

Modeling and Self Instruction
The Therapist modeled Jay how to talk to self i.e give instructions to self without uttering but only in thought " I will complete copying my work from the black board today" Jay would talk to self in thought that he should complete copying the notes from black board and would try to do it as much as possible Jay could do this task to an extent of 75% by the end of 12 th session of therapy Controlling anger in peer provocation situations Self Instruction Jay was told by the therapist how to control anger with peers at provocating situations Jay would count numbers from 1 to 10 till he becomes calm and then leave the situation, where he will be provoked Jay could practice this technique, and was able to control his anger about 80% Covert modeling Jay was asked to use his imagination, visualizing not completing the work (copying notes from the board) on time as the therapist describes the imaginary situation in detail.

Role Playing
Behavior Technique Therapist Blurt out answers to question before having been finished asking question

Role Playing
Therapist demonstrates "blurting out answers with impulsivity" while doing a role play with other people and also the consequences were projected On the Go always Role Playing Role playing with other children showing hyperactive movements

PHARMACOLOGICAL INTERVENTION:
Jay was on drug Methyphinedate -Inspiral 10 mg which was given twice a day, 1in the morning and the other in the night

RESULTS
The effectiveness of cognitive-behavioral treatment on ADHD symptoms in children with ADHD, as measured, was determined by the interactive effect (pre vs. post intervention). Significant interactions were found in all the three specific behavioral areas, but this is likely due to the active "alternative" treatment (parental behavioral training).   Table 1 depicts the scores of Master L"s pre or baseline scores on Inattention and Hyperactivity, a score of 9 on inattention and 9 on hyperactivity and impulsivity, with total score of 18, Post intervention Table 2 depicts there was significant improvement in the three behavioral domains, the scores were 2 on inattention and 3 on hyperactivity and impulsivity, a total score of 8/18. There was significant difference in the domain of Inattention on items such as difficulty "organizing tasks and activities, which had a score of 1 post intervention it was 0, a score of 3 each on items such as "avoids or strongly dislikes tasks that require sustained mental effort"(eg home work) and" Is easily distracted by external stimuli", post intervention the score reduced to 1 on each domain, a score of 2 on the item of "Is forgetful in daily activities" has reduced to 1. Scores pre intervention on domain Impulsivity and Hyperactivity, a score of 3 on items such as "Is on the go or acts driven by a move", "talks excessively and blurts out answer to questions before the questions have been completed", has reduced to score1 each post intervention

Graph 4
Graph 3 and Graph 4: Interpret domain wise graphical representation of Inattention and Hyperactivity and Impulsivity behaviors from Table 2.

CONCLUSIONS
Cognitive neuroscience has permitted a greater understanding of ADHD. Recent research and novel drug developments have provided new treatment options for adolescents and adults with ADHD. New stimulant formulations have made it possible to tailor treatment to the duration of efficacy required by patients and to help mitigate the potential for abuse, misuse and diversion.
Although they tend to be less efficacious than stimulants, new non-stimulant options also allow for extended duration of treatment without the adverse consequences associated with stimulant therapy. Progress in non-medical therapies now provides several options for patients who cannot or will not use medications, and for the many medication-treated patients who continue to show residual disability.
Looking toward the future, research will need to address several unmet needs. Many treated people with ADHD continue to have problems with executive functioning and deficient emotional self-regulation. These problems persist in many patients even when the core ADHD symptoms (as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV)) are effectively treated. Future treatment development should aim at developing both psychosocial and medical treatments for these areas of difficulty. Future treatment research should also work to define and achieve optimal treatment outcomes for people with ADHD. Although current treatments are effective for achieving substantial symptom reduction in most patients, more work is needed to achieve full symptom reduction, and to reduce the burden of ADHD-associated disabilities. Is on the go or acts driven by motor Talks excessively Blurts out answers to questions before the question have been completed

Pre Post
There are also diagnostic challenges for clinicians that could be addressed by future research. ADHD symptoms, especially hyperactive-impulsive symptoms, tend to decline through adolescence into adulthood, so that the adult presentation of ADHD differs somewhat from the childhood presentation. Helping clinicians understand these differences, and how such differences should affect the application of diagnostic criteria requires more work.
Ideally, medical and psychological treatments should be tailored to the underlying pathophysiology of the patient. Theoretically, this should be possible by using the scientific literature on the neurobiology of ADHD with treatment outcome studies, as it is possible that patients with specific brain-imaging abnormalities or genetic variants would have different responses to treatments. To date, most of this work has been done in the area of pharmacogenetics which, although promising, cannot yet guide treatment choices.
In summary, although the science of ADHD and its application to diagnosis and treatment have made great strides, more work is needed to improve the lives of patients and families affected by the disorder.