William E. Pelham Jr. and Elizabeth M. Gnagy
Programs for children with AD/HD ofen have two flaws: they fail to address the children's problems in peer relationships and they reduce or stop their services during summers. This article describes a program that avoids both pitfalls by using sports training during the summer months as an avenue to building participants' peer relationships and self-esteem.
Parents and therapists of children with AD/HD can offer many anecdotes about the children's dismal failure in organized sports activities. One parent told us the story of how she and her son were driving down the street and saw the other members of her son's Little League team in their uniforms. When she rolled down the window and told them she did not know there was practice that day, she discovered that they were not headed for practice – they were just coming from the championship game! The coach had intentionally not informed her so that her son would not attend the game, thus – improving the team’s chances of winning.
Other parents have shared many similar stories of having to withdraw their children from organized sports teams after coaches' complaints. One parent tried to keep his boy involved in soccer by becoming the team coach, but grew very frustrated himself when his son spent more time picking clover than following the ball.
Perhaps nothing can ruin the reputation of a child among playmates more quickly than when he or she is playing first base in a close game and misses a ball because of not paying attention. Not surprisingly, therefore, peer studies show that children with AD/HD are often chosen last to join in team activities like organized sports (Pelham and Bender, 1982). lt is likely that this is not only because of these children's poor sports skills and inattention during games, but also as a result of their lack of social skills and disruptive behavior. Children often respond to such behavior cruelly, causing children with AD/HD to suffer from low self-esteem.
Missing elements in treatment for AD/HD
One of the most important areas where usual treatment for AD/HD has not been effective is in addressing problems like these in peer relationships. The most probable reason for this is the difficulty involved in working on peer relationships in the office setting or in the classroom “the two locations in which standard outpatient treatments are used. Instead, therapists need to work with the children in the settings where these difficulties occur – that is, in groups of peers engaging in age-appropriate recreational activities such as organized sports.
Another common flaw in most treatment programs has to do with their calendars. Most mental health centers and professionals reduce 0r stop their contacts with families during the summers. However, the summer months, when children are out of school, constitute one-fourth of their lives. Children actually spend as many hours interacting with peers, siblings, and parents during the summer as they spend in school during the rest of the year. lf treatment is interrupted during the summer, gains made during the school year may be lost as children and parents both regress to old habits and pattems of behavior. In fact, if they simply spend the summer in unstructured activities around the neighborhood, children with AD/HD may well experience considerable failure and a consequent worsening of their problems and their self-esteem (e.g., being terminated from a traditional camp program due to behavior problems, getting in trouble around the neighborhood).
The Summer Treatment Program
The Summer Treatment Program (STP) is a comprehensive treatment for AD/HD that provides these frequently missing elements by treating children in peer group settings during the summer months. We treat children with AD/HD in a camp-like setting at which they engage in recreational and academic activities with age-matched peers (Pelham and Hoza, 1996; Pelham et al., 1996). The children stay together as a group all summer, along with five staff members (student interns), giving them many opportunities to interact with each other and to work together cooperatively. The staff members make constant use of positive social reinforcement and provide a supportive atmosphere, often a new experience for the children who have had primarily negative interactions with teachers, coaches, and other adults. By treating the children in a naturalistic setting, with an intensive focus on peer group activities, we are able to work intensively on the children's peer relationships.
Participants spend three hours each day in classroom sessions conducted by special education teachers and aides. The remaining four hours of each day are spent in recreationally based group activities. One hour is devoted to small-group skills training in an age-appropriate sport (e. g., softball, soccer, kickball); two recreation periods are devoted to playing age-appropriate sports and games; and a fourth hour is spent in swimming lessons and activities. Techniques that have been developed to optimize skill training for young children are used (Hopper and Davis, 1988; Houseworth and Rivkin, 1985; Krause, 1991; Smoll and Smith, 1987).
The STP has the following general goals:
Improving the children's peer interactions, problem-solving skills, and social skills;
Enhancing their academic performance and improving classroom behavior;
Developing the children's abilities to follow through with instructions, to complete tasks, and to comply with adults' requests;
Improving their self-esteem by teaching them skills in areas necessary for daily life functioning (e.g., interpersonal, recreational, academic) and other task-related areas;
Teaching the children's parents how to develop, reinforce, and maintain these positive changes; and, if necessary,
Evaluating the incremental effects of stimulant medication on the child's academic and social functioning.
Why focus on sports training in the STP?
It is commonly accepted among expert coaches that improvements in sports skills through practice are an excellent way to enhance children's self-efficacy (Gould, Hodge, Peterson and Giannini, 1989). This may be particularly true for children with low self-esteem who are most responsive to the coaching of enthusiastic, encouraging, and nonpunitive adults. We believe that for AD/HD children who are at extremely high risk for low self-esteem, skills training in a positive environment is particularly important. For these reasons, we emphasize sports skills and knowledge in the STP as a means of improving the children's status among peers and improving their self-esteem. The sports skills training is then carefully integrated with social skills training to provide a comprehensive, multifaceted intervention for peer relationship difficulties.
Two different models exist for teaching athletics to children: the professional model (“Win at any cost") and the developmental model (Smoll and Smith, 1987). The developmental model holds that athletics are not only a form of recreation, but a valuable way to teach children “real world” values such as good sportsmanship, self-confidence, self-discipline, leadership skills, and group cooperation. The premise is that these qualities will not only improve a child's athletic performance but will also improve his or her performance in other areas, such as peer relations and classroom performance.
Children with coaches who engage in these positive, effective methods of teaching have been shown to have greater increases in self-esteem through sports engagement than children whose coaches do not employ these techniques (Smoll, Smith, Barnett and Everett, 1983). These goals are consistent with those of the STP in general, and illustrate the ways in which sports skills training is a valuable part of treatment for children with AD/HD.
Teaching tools forsSports training
While teaching sports skills in the STP, we believe it is important to concentrate on several antecedents that make negative behavior less likely to occur. First, staff members are careful to use effective instructions “that is, instructions that are specific, clear, and able to be carried out by the child (e.g., “stand quietly in line” rather than a vague statement such as “be good"). Second, we establish clear, simple activity rules for every activity during the day that include typical, socially appropriate behaviors that are expected of the children, as well as specific rules of the activity. For example, in a softball game, rules include both sportsmanlike behaviors such as participating and making the best effort, as well as following the specific rules of batting and fielding. Before starting any activity, counselors review the rules. The children learn the activity rules quickly, and counselors therefore do not need to give constant reminders to perform the expected behaviors.
Activity rules are also used as a teaching tool in sports activities. One of the activity rules for games and skill drills is “follow the rules of the game.” Any time a child violates a game rule (for example, travels in basketball or runs outside the baseline during softball), the counselors stop the action of the game, explain to all the children what rule was violated, and specify the appropriate behavior.
Sports and medication
We have studied the effects of medication in the context of recreational activities in a 1990 study entitled “Methylphenidate and baseball playing in ADD children: Who’s on first?” We undertook this study because parents have often asked whether they should medicate their children for sports activities. We found that when they were not medicated, the children attended to the game only 25% of the time, illustrating their difficulty in sports that require sustained attention during periods of minimal activity, and medication did improve the children's attentiveness. However, as part of this study, we also measured the level of attention paid by the children by asking them frequent “attention check” questions about the score, the count, and the play of the game. We found that simply asking the attention check questions increased the attentiveness of the boys. We have therefore incorporated these questions into the standard sports program to further enhance the effectiveness of our sports training.
What other treatment components do we
include in the STP?
Social skills training. In addition to sports training, treatment also includes training in social skills that are necessary for effective peer-group functioning (e.g., cooperation, participation). Social skills training is provided in brief daily sessions that include instruction, modeling, role-playing, and practice. Children also engage in cooperative group projects designed to promote cooperation and contribute to cohesive group relationships.
Academic instruction. Because children with AD/HD exhibit many of their problematic behaviors in school settings, we include an academic component in the STP as well, both to treat these behavioral and academic problems and to ensure that children will not “backslide” academically during the summer months. Children spend three hours daily in classrooms conducted by special education teachers and aides. The content of classroom assignments is individualized according to each child's academic needs.
Parent training. Parents play a part in the STP as well. First, parents receive weekly training in how to implement behavior improvement programs at home. Second, children receive daily report cards that include individualized target behaviors from both academic and recreational group settings. Parents provide daily and weekly positive home-based reinforcements to reward their children for reaching report card goals.
Medication evaluation. In the STP, parents may choose to have an extensive, double-blind, placebo-controlled evaluation of the effects of stimulant medication on their child in a wide variety of domains of functioning (Pelham and Hoza, 1987; Pelham and Milich, 1991). Data gathered routinely in the clinical treatment program are evaluated to determine whether medication is helpful for a particular child. If medication is determined to have a beneficial effect for a child on the symptoms that are most important for him or her, beyond the beneficial effects of the ongoing behavioral treatments and without adverse effects, then medication may be recommended as an adjunct to ongoing behavioral intervention.
Is the Summer Treatment Program effective?
In Pelham and Hoza (1996), we present extensive data that suggest the STP is a very promising treatment. On a variety of measures, the STP was shown to be effective, regardless of subject or family characteristics such as problem severity, age, familial status, or whether children received medication.
Anonymous consumer satisfaction ratings. At the end of each STP, parents were asked to anonymously rate the program. More than 250 parents, surveyed over the course of two years, had overwhelmingly positive responses. More than 80% viewed the treatment as “very beneficial” both for their children and for themselves, and more than 95% of the parents reported that their children actually liked the program. In addition, parents reported that they would send their child again if given the opportunity (82% would “definitely"; 13% would “probably"), and 93% said that they would “definitely” recommend the STP to other parents.
Domain-specific improvement ratings. Counselors, parents, and STP teachers also rated children's improvement across a number of domains, including rule-following, relationships with peers and siblings, relationships with adults, and self-esteem, as well as overall improvement rate. All respondents rated an overwhelming majority of the children as improved. For example, parents rated 96% of their children as at least “somewhat” improved; counselors rated 91% of the children as at least “somewhat” improved overall.
Pre- and post-treatment child self-esteem ratings. Fifty-six children from the summers of 1991 and 1992 completed the Self-Perception Profile for Children (Harter, 1985) at the beginning and at the end of the STP. Children rated themselves on a four-point scale in five domains, as well as on global self-worth (higher scores indicate greater competence). The children's self-perceptions reflected improvement in all domains. For example, ratings of global self-worth increased an average of 10%.
Ratings on standardized scales. Finally, following the 1991 and 1992 STPs, parents completed a Disruptive Behavior Disorders Rating Scale. When compared to ratings gathered before the STP, there was a significant treatment effect. Scores on the AD/HD scale showed a 24% decrease, Oppositional Defiance Disorder scores showed a 28% decrease, and Conduct Disorder scores showed a 35% decrease.
Can STP be applied in other settings?
An important question regarding such a comprehensive and complex intervention as the STP is whether it can be applied in other settings. STP-like interventions have been used in settings ranging from private psychiatric hospitals and universities to community-based treatment centers. All sites have reported very high levels of parent and professional satisfaction with the programs. The fundamentals of the STP may also be applied in Saturday and after-school programs, and several professionals have implemented such programs successfully. However, because of the intensive practice that is necessary to effect changes in sports skills, this type of training could be optimally effective only in the context of a summer program or a daily after-school program.
When we combine state-of-the-art treatment
components with an intensive focus on sports and sports competency
training, AD/HD youngsters learn that they too can hit home runs!
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This feature: Pelham, W.E. and Gnagy, E.M. (1998). Summer sports: A recreationally based program for building peer relations. Reaching Today's Youth, 2, 2. pp. 52-55.