PSY3032 ( Chapter 2 ADHD) case study reading for quizzes PDF

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CHAPTER 2

Attention-Deficit/Hyperactivity Disorder

Ken Wilson’s mother contacted the clinic about her 7-year-old son because he was having trouble at school, both academically and socially. The school psychologist had said that he was hyperactive. The clinic scheduled an initial appointment for Ken and both parents.

Copyright © 2014. Wiley. All rights reserved.

Social History The case was assigned to a clinical psychology intern, who met the family in the clinic’s waiting room. After a brief chat with all of them, he explained that he would first see the parents alone and later spend some time with Ken. Mr. and Mrs. Wilson had been married for 12 years. He was a business manager, and she was a homemaker. Ken was the middle of three children; his older sister was 9 and his younger brother was 4. Neither sibling was having any apparent problems. Mrs. Wilson had a full-term pregnancy with Ken. The delivery was without complication, although labor was fairly long. According to his parents, Ken’s current problems began in kindergarten. His teacher frequently sent notes home about his behavior problems in the classroom. In fact, there had been concerns about promoting Ken to the first grade, resulting in a “trial promotion.” Everyone hoped that he would mature and do better in first grade, but his behavior became even more disruptive. His teacher sent home negative reports about him several times over the first 2 months of school. She reported that he didn’t complete his work, was disruptive to the class, and was aggressive. The therapist asked about the parents’ perception of Ken at home and his developmental history. He had been a difficult infant, much more so than his older sister. He cried frequently and was described as a colicky baby by their pediatrician. He did not eat well, and his sleep was often fitful and restless. As Ken grew, his mother had even more trouble with him. He was into everything. Verbal corrections, which had controlled his sister’s behavior, seemed to have no effect on

Oltmanns, Thomas F., et al. Case Studies in Abnormal Psychology, 10th Edition, Wiley, 2014. ProQuest Ebook Central, 14 http://ebookcentral.proquest.com/lib/monash/detail.action?docID=5106408. Created from monash on 2021-07-26 13:16:21.

Chapter 2

Attention-Deficit/Hyperactivity Disorder

15

him. When either parent tried to stop him from doing something dangerous, such as playing with an expensive vase or turning the stove off and on, he would often have a temper tantrum that included throwing things, breaking toys, and screaming. His relationship with his sister was poor. He bit her on several occasions and seemed to delight in trying to get her into trouble. Ken was also aggressive with the other children in the neighborhood. Many parents no longer let their children play with Ken. He had a low frustration tolerance and a short attention span. He could not stay with puzzles and games for more than a few minutes and often reacted angrily when he did not succeed after trying only briefly. Going out for dinner had become impossible because of his misbehavior in restaurants. Even mealtimes at home had become unpleasant. Ken’s parents had begun to argue frequently about how to deal with him. Toward the end of the first session, the therapist brought Ken to his office while his parents remained in the waiting room. Ken did not understand why he was at the clinic, but later he admitted that he was getting into a lot of trouble at school. He agreed that it would be good to try to do something about his misbehavior. Ken and his parents were brought together for the final minutes of the first session. The therapist explained that over the next several sessions he would conduct a thorough assessment, including visits to the Wilson’s home and Ken’s school. The parents signed release forms so the therapist could obtain information from their pediatrician and the school.

Copyright © 2014. Wiley. All rights reserved.

The Current Problem School records corroborated his parents’ description of Ken’s behavior in kindergarten. His teacher described him as being “distractible, moody, aggressive,” and a “discipline problem.” Toward the end of kindergarten, his intelligence and academic achievement were tested. Although his IQ was placed at 120, he did not perform very well on reading and mathematics achievement tests. An interview with Ken’s first-grade teacher provided information consistent with other reports. Ken’s teacher complained that he was frequently out of his seat, seldom sat still when he was supposed to, did not complete assignments, and had poor peer relations. Ken seemed indifferent to efforts at disciplining him. Ken’s teacher also completed a behavior checklist in which she identified that Ken had the most trouble with hyperactivity, frustration tolerance, and poor attention span, and not as much trouble with crying and mood changes. The therapist spent a morning in Ken’s classroom, during which Ken was out of his seat inappropriately six times. Once he jumped up to look out the window when he heard a noise, probably a car backfiring. He went to talk to other children three times. Ken got up twice and just began walking quickly around the classroom. Even when he stayed in his seat, he was often not working and instead was fidgeting or bothering others. Any noise, even another child coughing or dropping a pencil, distracted him from his work. When his teacher spoke to him, he did

Oltmanns, Thomas F., et al. Case Studies in Abnormal Psychology, 10th Edition, Wiley, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/monash/detail.action?docID=5106408. Created from monash on 2021-07-26 13:16:21.

Copyright © 2014. Wiley. All rights reserved.

16

Case Studies in Abnormal Psychology

not seem to hear; it was not until she had raised her voice at him that he paid any attention. Subsequent sessions with Ken’s parents focused on his current behavior at home. Ken still got along poorly with his sister, had difficulty sitting still at mealtimes, and reacted with temper tantrums when demands were made of him. His behavior had also taken on a daredevil quality, such as climbing out of his second-story bedroom window and racing his bicycle down the hill of a busy street. His daring acts seemed to be the only way he could get any positive attention from his neighborhood peers, who seemed to be mostly afraid of him. He had no really close friends. Mr. Wilson missed two of these sessions because of his business schedule. Most days he had to commute to work, a two-hour train trip each way. During a session he missed, Mrs. Wilson hinted that they had marital problems. When this was brought up directly, she agreed that their marriage was not as good now as it once had been. Their arguments centered on how to handle Ken. Mrs. Wilson had come to believe that severe physical punishment was the only answer. She described an active, growing dislike of Ken and feared that he might never change. The next time Mr. Wilson came to a session, the therapist asked about his child-rearing philosophy. He took a “boys will be boys” approach. As a child he was like Ken and had “grown out of it;” he expected Ken would, too. As a result, he let him get away with things even when his wife wanted to punish Ken. The couple’s arguments, recently more heated and frequent, usually happened when Mr. Wilson came home from work. Mrs. Wilson, after a particularly bad day with Ken, would try to get Mr. Wilson to discipline Ken. But Mr. Wilson would refuse and accuse his wife of overreacting. The next week, the therapist visited the Wilson home, arriving just before Ken and his sister got home from school. The first part of the visit was uneventful, but soon Ken and his sister got into a fight over who was winning a game. Ken broke the game, and his sister came crying to her mother, who began shouting at Ken. Ken tried to explain his behavior by saying that his sister had been cheating. His mother ordered him to his room; a few minutes later, when she heard him crying, she went up and told him he could come out. The children ate dinner early; Mrs. Wilson planned to wait until her husband came home to have hers. Ken complained that he did not like anything on his plate. He picked at his food for a few minutes and then started making faces at his sister. Mrs. Wilson yelled at him to stop making the faces and eat his dinner. When she turned her back, he began shoving food from his plate onto his sister’s. As she resisted, Ken knocked over his glass of milk, which broke on the floor. Ken’s mother was enraged at this point. She looked as if she was ready to hit Ken, but she calmed herself, perhaps because of the therapist’s presence. Although she told Ken that he would be in big trouble when his father got home, nothing happened. When Mr. Wilson came home, he downplayed the incident and refused to punish Ken. Mrs. Wilson was clearly exasperated but said nothing.

Oltmanns, Thomas F., et al. Case Studies in Abnormal Psychology, 10th Edition, Wiley, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/monash/detail.action?docID=5106408. Created from monash on 2021-07-26 13:16:21.

Chapter 2

Attention-Deficit/Hyperactivity Disorder

17

Copyright © 2014. Wiley. All rights reserved.

Conceptualization and Treatment The therapist conceptualized Ken’s problem in an operant-conditioning framework. Although open to possible biological causes of Ken’s behavior, the therapist believed that a structured program of rewards and punishments—contingency management—would help. Treatment would involve increasing the frequency of positive behaviors (complying with parental requests, interacting positively with his sister, staying in his seat in the classroom) by providing positive consequences for them. Similarly, undesirable behaviors would be followed by negative consequences. The therapist explained to Ken’s parents that many of his misbehaviors had actually been producing positive results for him. His tantrums, for example, frequently allowed him to have his own way. The complicating feature was his parents’ attitude. Would either of them be willing to put in all the work required to make this plan succeed? After the therapist explained the results of the assessment and the outline of his treatment plan, he asked both parents to agree to try a simple, scaled-down version of the overall plan. The hope was that a simple intervention, directed at only a couple of problem areas, would produce visible, quick results. This small change might motivate the parents to implement a complete therapeutic package later. Two target behaviors were selected—leaving his seat in the classroom and inappropriate behavior during meals at home. Mealtime behavior problems were defined as complaining about the food served; kicking his sister under the table; not staying in his chair; and laughing, giggling, or making faces. During the next week the parents were instructed to record the frequency of disruptive behavior at mealtimes as well as several other behaviors (temper tantrums, fights with siblings, and noncompliance with parental requests) that could be targets for later interventions. Ken’s teacher agreed to keep a record of the number of times Ken was out of his seat each day. During the next session, an intervention was planned. The records of the past week indicated that every meal had been problematic. Ken had also been out of his seat when he was supposed to be working at his desk for an average of nine times per day. The therapist explained to Ken and his parents that in the next week Ken would be rewarded if he was not disruptive at mealtimes and if he reduced the number of times he was out of his seat at school. If his behavior met the goal, Ken would have more time watching television, get a favorite dessert, or play a game with one of his parents. The initial criterion was being out of his seat less than five times per day at school and being nondisruptive for at least one of the two meals eaten at home each day. The therapist showed Ken’s parents how to make a chart that was to be posted on the refrigerator. Ken’s teacher would send a daily note home indicating how many times he was out of his seat and that number, along with checks for a “good” meal, would be entered on the chart. Ken’s teacher was contacted after the session, and the program was explained. She agreed to send home a daily record of the number of times Ken was out of his seat.

Oltmanns, Thomas F., et al. Case Studies in Abnormal Psychology, 10th Edition, Wiley, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/monash/detail.action?docID=5106408. Created from monash on 2021-07-26 13:16:21.

Copyright © 2014. Wiley. All rights reserved.

18

Case Studies in Abnormal Psychology

At the beginning of the next session, Ken’s parents were clearly pleased. They had brought the chart with them; some changes had clearly occurred. Ken had met the criterion on six of the seven days. The average number of times he was out of his seat went from 9 to 3.6, and he had been unpleasant at mealtimes only five times (two of these occurred on Saturday, resulting in his only failure to obtain a reward). During the next several sessions, the parents and the therapist worked on expanding the program. Temper tantrums, fighting with his siblings, and noncompliance with parental requests had all been frequent the previous week. Ken’s parents now were eager to focus on them. Of the three targets, noncompliance proved to be the most difficult to address. There were so many ways that Ken could misbehave that a specific description of a criterion was hard to create. The therapist and Ken’s parents agreed that temper tantrums would lead to a time-out procedure in which Ken would have to go to his room and stay quietly for 10 minutes. Fighting was handled first by a simple request to stop. If that was ineffective, the time-out procedure would be employed. When asking Ken to go to bed or to stop teasing his sister, his parents were instructed to make the requests calmly and clearly to be sure he heard them. If he did not comply, they were to give him one reminder, again calmly; if that failed, he would be sent to his room. The therapist stressed to the parents that their requests had to be made calmly and that Ken should be sent to time-out without anger. Finally, the parents agreed to socially reinforce cooperative play and being pleasant at meals by simply telling Ken how happy they were when they saw him playing nicely and behaving well. Based on the records from the previous weeks, it was estimated that Ken would have been in time-out about 20 times if the new system had been in effect. It was, therefore, decided that if Ken was sent to his room fewer than 10 times, he would receive a special end-of-week reward, a trip to the movies. The mealtime procedure was kept in effect, and as before, his parents agreed to keep a chart showing school behavior, mealtimes, and frequency of time-outs. This time, the parents were also asked to record the number of times they praised Ken and the specific details of instances of noncompliance, so the therapist could be sure the parents’ requests were reasonable. Meanwhile, the therapist contacted Ken’s teacher and increased the scope of the school program. The teacher was asked to keep noting when Ken was out of his seat, but she was also to praise Ken as often as possible when he was working appropriately. The daily report card was expanded to include the number of assignments completed and the number of aggressive interactions with peers, defined broadly to include both physical and verbal aggression. Other instances of disruptive behavior (being noisy, making faces) were also to be recorded. The records from this week would be used to plan another intervention during the next session with the parents. At the session following the implementation of the time-out procedure, the parents were much less enthusiastic than they had been the previous week.

Oltmanns, Thomas F., et al. Case Studies in Abnormal Psychology, 10th Edition, Wiley, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/monash/detail.action?docID=5106408. Created from monash on 2021-07-26 13:16:21.

Copyright © 2014. Wiley. All rights reserved.

Chapter 2

Attention-Deficit/Hyperactivity Disorder

19

Although the improvement in mealtime behavior had been maintained, Ken had been sent to his room 17 times over the course of the week and did not get to go to the movies. It seemed that time-out was not an effective consequence for Ken. The therapist asked the parents for more details on how they were using the procedure. It turned out that Ken had lots of toys in his room, so the therapist decided to change the system. Ken’s toys were put away so that time-out consisted of sitting on his bed with no toys to play with or books to look at. Furthermore, all the at-home targets were linked to a daily reward (one of the three described earlier). Specifically, Ken was to get 2 points for each pleasant meal, 2 points if he had only one time-out before dinner, and 2 points for none after dinner. The expanded school program was also converted to a point system. The teacher’s records for the previous week indicated that Ken had been out of his seat an average of three times per day, had completed 55 percent of his assignments, and was either aggressive or disruptive five times during the average day. A set of new criteria was adopted for school and linked to points: 2 points for being out of his seat less than three times per day, 2 points for completing 70 percent or more of his assignments, and 2 points for reducing the frequency of aggressive behavior or disruptiveness to less than three times per day. Thus, Ken could earn 12 points on each school day and 6 on weekends. The criterion for one of the daily rewards was set at 8 points on a school day and 4 points on weekends. In addition, a weekly total of 54 points would result in Ken’s being taken to see a movie. The system now appeared to be working well. During one typical week Ken earned 58 points and thus got his trip to the movies. In addition, he met the criterion for a daily reward each day. At home he averaged only one time-out per day, and 12 of 14 meals had been without incident. At school he was out of his seat slightly less than twice per day, completed an average of 70 percent of his assignments, and was either aggressive or disruptive fewer than three times per day. For the following week, the criteria for school behavior were increased again. Points could be earned for being out of his seat less than twice per day, completing 80 percent of his assignments, and being aggressive or disruptive less than twice per day. At home, the point system was left unchanged. The criterion for a daily reward was raised to 10 for school days and 6 on weekends; the criterion for the end-of-week reward was raised to 66. In addition, a new daily reward was added to the program—a bedtime story from Ken’s father. The parents were also encouraged to continue praising good behavior. The therapist called Ken’s teacher to discuss a similar tactic for the classroom. The program continued to evolve over the next few weeks, and Ken made steady progress. By the 14th week, it was clear that Ken’s behavior had dramatically changed, and his academic performance was improving. At this point, the frequency of sessions was decreased to every other week, and the family was followed for 3 more months. The therapist focused more on teaching Ken’s parents the general principles that they had been following so that when problems arose they would be able to handle them on their own by modifying the system.

Oltmanns, Thomas F., et al. Case Studies in Abnormal Psychology, 10th Edition, Wiley, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/monash/detail.action?docID=5106408. Created from monash on 2021-07-26 13:16:21.