Use of Cognitive Behavioral Therapy and Token Economy to Alleviate Dysfunctional Behavior in Children with Attention-Deficit Hyperactivity Disorder

Abstract

Medication has proved highly efficacious as a means of alleviating general symptoms of attention-deficit hyperactivity disorder (ADHD). However, many patients remain functionally impaired by inappropriate behavior. The present study analyzed the use of cognitive behavioral therapy (CBT) with the Token-Economy (TE) technique to alleviate problem behavior for 25 participants with ADHD, all children (19 boys, mean age 10.11) on long-term methylphenidate medication, who were given 20 CBT sessions with 10 weeks of TE introduced as of session 5. Their ten most acute problem behaviors were selected and written records kept. On weekdays, parents recorded each inappropriate behavior and provided a suitable model for their actions. At weekly sessions, problem behaviors were counted and incident-free participants rewarded with a token. To analyze improvement (less frequent problem behavior), a list of 11 behavioral categories was rated: inattention, impulsivity, hyperactivity, disorganization, disobeying rules and routines, poor self-care, verbal/physical aggression, low frustration tolerance, compulsive behavior, antisocial behavior, lacking in initiative and distraction. Two CBT specialists categorized behaviors and an ADHD specialist ruled on discrepancies. Statistical analyses used were Generalized Estimating Equations with Poisson distribution and autoregressive order correlation structure. In the course of the sessions, problematic behaviors decreased significantly in seven categories: impulsiveness, hyperactivity, disorganization, disobeying rules and routine, poor self-care, low frustration tolerance, compulsive behaviors, and antisocial behaviors. Caregiver attitudes to children’s inappropriate behavior were discussed and reshaped. As functional improvement was observed on applying TE for 10 weeks, this type of intervention may be useful as an auxiliary strategy combined with medication.

Token economy to improve adherence to activities of daily living

“…Token economics have been used successfully in pediatric populations with attention‐deficit hyperactivity disorder; Coelho et al. demonstrated significant improvement in overall problematic behavior when patients were rewarded with token rewards when they exhibited improved behavior in between cognitive behavioral therapy sessions . Finally, Token economics have showed efficacy at improving memory and response inhibition performance in pediatric patients with acquired brain injuries …”

“…34 In patients with cystic fibrosis, positive reinforcement through a token economy supported improved exercise adherence. 35 36 Finally, Token economics have showed efficacy at improving memory and response inhibition performance in pediatric patients with acquired brain injuries. 37 There are several limitations to this study.…”

Group cognitive behavioral therapy for children and adolescents with ADHD

“…Therefore, these instruments were not initially developed to evaluate the impact of treatment over time, much less to detect the disorder's peripheral symptoms. Therefore, the use of functional measures, as the literature suggests, may provide a clearer view of the effects of cognitive behavioral interventions on ADHD (Coelho et al, 2015;Conners et al, 2001;Sonuga-Barke et al, 2013). A model capable of combining ICF and ICD concepts may shed light on ADHD's impacts on aspects of health and assess an individual's different levels in terms of functionality, activities, participation, and their limitations, as well as how environmental factors interact with these constructs.…”

“…As mentioned above, this protocol was developed in 2009 as part of a larger study (Coelho et al, 2015;Miranda et al, 2011). After its pilot study, there was a need to reduce the number of sessions to ensure this protocol's structure would match the aims of the larger project.…”

“…In relation to functional outcomes during a group CBT program for ADHD patients, Coelho et al (2015) reported that the token-economy technique alleviated behavioral problems. Participants presenting the most severe behaviors were selected, and their parents kept journals for 10 weeks to log their frequency, while using reinforcers for appropriate behaviors and modeling for inappropriate behaviors.…”