Behavioural treatment

Various non-pharmacological therapies have been used for AD-HKD as an alternative to medication, as a means to improve aspects of the disorder that are not optimally treated by medication, or as a method of augmenting the beneficial effects of medication. These interventions can be administered in various settings (the classroom, home, summer camp, and playground) by a range of personnel (teachers, parents, and mental health professionals) in individualized or group formats.

Few well-controlled studies of non-pharmacological interventions are available for evaluation. (!Z!.) The effects of specific treatments are not easily appraised, because most studies of non-pharmacological interventions involve simultaneous treatment with multiple therapies (e.g. combined social skills training and behavioural parent training) or treatments tailored to the needs of particular families. (!90) Often studies are limited because of a small sample size, a lack of randomization and control, and recruitment from biased patient populations.

Behavioural parent training may be the most commonly prescribed non-pharmacological intervention for AD-HKD. Parent training is predicated on the observation that parents of children with AD-HKD use overly controlling and inefficient parenting strategies. (19!) Parent-training programmes are based on social-learning theory principles; these programmes use direct instruction, modelling, and role playing to teach parents to reinforce positive behaviour, decrease the use of punitive strategies, and manage oppositional behaviour effectively.(!.92)

Parent-training programmes improve the parents' child-management skills,(!.93,!94) enhance their self-confidence, and reduce the child's stress(!95) and oppositional behaviour/19.. The important advantages of parent training are its relatively low cost; its ability to be delivered in the community rather than in clinics, thereby reducing barriers to participation; and its adaptability to the needs of specific ethnic or cultural groups. (!92)

Parent training, however, does not reduce the core symptoms of AD-HKD as effectively as stimulant medication, nor is it able to enhance the effectiveness of stimulants.*!.96,.!97) The primary benefit of combined parent training and medication may be its reduction of secondary impairments such as the conflict between parents and children.

Behavioural therapy involves trained therapists (e.g. camp counsellors), parents, or teachers reinforcing positive behaviour, academic accomplishment, and response-cost procedures for disruptiveness (i.e. withholding rewards when inappropriate behaviour occurs) to alter behaviour. (!98) Cognitive-behaviour therapy attempts to enhance self-control by teaching children self-instructional strategies. These therapies may yield short-term improvement. (!99) Social skills training targets the child's problems with peers and adults, typically in a group setting. These therapies have been effective when administered on their own, (2°°,2.°!) but there little evidence that social skills training is as potent as medication.

A variety of books and videos provide instruction on the management of children with AD-HKD. Videotaped programmes have proven effective for parents of young children with conduct disturbance/202) Only programmes combining videotaped modelling with therapist-led group discussions result in stable improvement in their behaviour. (2°3) (See also Chapteri9.5.3.)

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