The Effectiveness of an Interpersonal Cognitive Problem-Solving Strategy on Behavior and Emotional Problems in Children with Attention Deficit Hyperactivity

Abstract

Introduction

This study was designed to evaluate the effectiveness of the “I Can Problem Solve” (ICPS) program on behavioral and emotional problems in children with attention deficit hyperactivity disorder (ADHD).

Methods

The subjects were 33 children with ADHD aged between 6 to 11 years. The study used a pre- and post-test quasi-experimental design with one group. The researchers taught 33 children with ADHD how to apply ICPS over a period of 14 weeks. The Child Behavior Checklist for Ages 6–18 (Teacher Report Form) and the Diagnostic and Statistical Manual of Mental Disorders, 4th edition Text Revision (DSM-IV-TR) Based Disruptive Behavior Disorders Screening and Rating Scale (parents’ and teacher’s forms) were used to evaluate the efficacy of the program. The scales were applied to parents and teachers of the children before and after the ICPS program.

Result

The findings indicated that the measured pre-training scores for behavioral and emotional problems (attention difficulties, problems, anxious/depressed, withdrawn/depressed, oppositional defiant problems, rule breaking behaviors, and aggressive behaviors) were significantly decreased in all children post-training. In addition, children’s total competence scores increased (working, behaving, learning and happy) after the ICPS program.

Conclusion

According to the results, it is likely that, ICPS would be a useful program to decrease certain behavioral and emotional problems associated with ADHD and to increase the competence level in children with ADHD. An additional benefit of the program might be to empower children to deal with problems associated with ADHD such as attention difficulties, hyperactivity-impulsivity, and oppositional defiant problems.

Introduction

Attention deficit hyperactivity disorder (ADHD), which is one of the most prevalent childhood psychiatric disorders, is a neuropsychiatric disorder characterized by developmentally inappropriate levels of activity, distractibility, and impulsivity (1,2).

Behavioral problems in children with ADHD include acting without adequate forethought as to the consequences of their actions and inability to postpone gratification with impulsive decisions and behaviors. ADHD negatively influences social interactions with peers, interpersonal relationships with parents, teachers and peers as well as academic success and social functions (2,3). Children with ADHD face problems such as increased incidence of defiant and aggressive behaviors, and are at higher risk of comorbid disorders (such as oppositional defiant disorder, conduct disorder) compared to typically developing children (4,5). Behavioral problems commonly seen in children with ADHD affect the overall quality of children’s lives (2,6,7), and reduce the quality of life of their family members. Specifically, the family experiences overall increased levels of stress, decreased feelings of belonging and competence and disruption of routines and structure (2). Additional problems include: conflicts and exclusion among peers, inability to manage or prevent anger efficiently, communication/social skill difficulties, inadequate problem solving, and difficulties in relationships (2,5,8).

Multifocal treatment programs for children with ADHD may improve outcomes in a more robust manner than medication alone or behavior/cognitive management programs alone. Social skills training programs encourage problem-solving ability and support cognitive and behavioral skills (2,9,10). Some cognitive-behavioral approaches consisting of psychosocial treatments result in improved impulse control, increased assessment capability before reaction and enhance considered and tempered actions (11).

The “I Can Problem Solve” (ICPS) program is based on Interpersonal Cognitive Problem-Solving methods. The basic objectives of this program are developed mainly to deal with the social problems of children (12). The ICPS is a problem solving approach to prevention of high risk behaviors in children and provide children with assessment abilities to help them solve their problems (12,13,14). By strengthening the capacity of children with ADHD to solve problems that lead to socially undesirable behaviors such as physical and verbal aggression, impulsivity, inability to wait, inability to take turns, inability to delay gratification, over emotionality in the face of frustration, inability to maintain friendships, high risk behaviors may be reduced (12). It should be noted that, children with ADHD need extra support and structured training although other children easily can learn problem-solving skills through these programs and adapt them to real life as well (15). However, there is limited data relating the ICPS training program for children suffering from ADHD (10,12).

The primary aim of this study was to evaluate the effectiveness of the ICPS program on children with ADHD. It was hypothesized that ICPS program would be useful to decrease behavioral and emotional problems (oppositional defiant problems, attention problems, hyperactivity problems, anxious/depressed, withdrawn/depressed, rule breaking behavior, and aggressive behavior), and would increase the total competence scores (working, behaving, learning and happy) in children with ADHD.

Method

Study Design and Sampling

The main purpose of this study was to evaluate the improvements between pre- and post-ICPS training in measured behavioral and emotional problems in children with ADHD and their competence in term of the effectiveness of the ICPS program. This study was designed as a pre-post-test quasi-experimental design with a single group. The study group consisted of children diagnosed with ADHD in two elementary schools in Ankara/Turkey, between ages of 6 and 11, diagnosed with ADHD according to DSM-IV-TR criteria (1). The mean age of the participants was 9.1±1.1 years. All of the children were Caucasian. The socio-demographic characteristics of the children such as gender, grade, mother’s and father’s education years, father’s/mother’s profession as well as medication use for ADHD are outlined in Table 1.

Table 1.

The Socio-demographic characteristics of the participants (n=33)

Gender	n	%
Boy	30	90.9
Girl	3	9.1
Medication
Medication	7	21.2
No medication	26	78.8
Grade
First	3	9.1
Second	7	21.2
Third	8	24.2
Fourth	13	39.4
Fifth	2	6.1
Mother’s Education year
1–8 year	25	75.8
9–12 year	8	24.2
13 year and up	-	-
Father’s Education years
1–8 year	19	57.5
9–12 year	12	36.4
13 year and up	2	6.1
Mother’s Profession
Housewife	28	84.8
Employed	5	15.2
Father’s Profession
White Collar	4	12.2
Laborer	8	24.2
Own Job	21	63.6

Inclusion criteria were: the diagnosis of ADHD according to DSM-IV-TR criteria, 6 to 12 years of age, and child/parents volunteered for the research. Exclusion criteria were: the history of head trauma or neurological illness, developmental delay or any other axis I psychiatric disorder except for oppositional defiant disorder, making a change in her/his medications during the study if the child has been taking any medication for ADHD, and failure to attend the training.

Instruments

Data collection and assessment tools used in the research were as follows:

The DSM-IV-TR Based Disruptive Behavior Disorders Screening and Rating Scale

This is a screening and assessment instrument, which was developed based on DSM-IV-TR diagnostic criteria, consists of 9 items inquiring attention problems; 6 items inquiring hyperactivity; 3 items inquiring impulsivity; 8 items inquiring oppositional defiant disorder and 15 items inquiring conduct disorder. The adaptation of this scale to Turkish society, and the validation and reliability analyses were completed in the year 2001. The Cronbach’s alpha was 0.88 for the sub-scale attention problems and 0.92 for the sub-scale disruptive behavior disorder in the reliability analysis (16).

The Child Behavior Checklist for Ages 6–18 (Teacher Report Form-TRF/6–18)

This form was developed to evaluate 6–18 age group students’ adaptation to school and their faulty behavior through information obtained from teachers in a standardized way. TRF includes 118 items related to behavioral and emotional problems. 93 of these items correspond to the items on the Child Behavior Checklist for Ages 6–18. The scale provides information regarding adaptation as well as basic functions such as school- and student-related information. In the second part of the scale, behavior problems are inquired under the categories “internalizing” and “externalizing”. Within the “internalizing” category, there are withdrawn/depressed, somatic complaints and anxious/depressed subtests, while within the “externalizing” category, there are disobedience to rules and aggressive behaviors sub-tests. There are also sub-tests such as social problems, thought problems, attention problems and other problems that do not belong to either of the two categories (17). TRF was first developed by Achenbach in 1991, and verification and validation studies in our country were conducted by Erol at al. (18). The Validity and reliability of the Turkish version of the TRF was 0.82 for Internalizing; 0.81 for Externalizing and Cronbach alpha=0.87 for total problem.

Procedure

The 49 children from two elementary schools were interviewed and examined by a psychiatric practitioner trained in child psychiatry. To exclude other psychiatric disorders, the Children Depression Inventory, the State-Trait Anxiety Inventory and the Learning Disorders Checklist were applied. 37 of the 49 children met the diagnostic criteria for ADHD. The study was introduced to 37 children and their parents in an introductory meeting. Permission and written informed consent were obtained from them (n=37). Parent reports were obtained with the DSM-IV-TR based Disruptive Behavior Disorders screening and assessment scale; teacher reports were obtained with both the DSM-IV-TR Based Disruptive Behavior Disorders Screening and Assessment Scale, and “Child Behavior Checklist for Ages 6–18 (Teacher Report Form)(TRF/6–18).

Due to various reasons, such as being diagnosed with another psychiatric disorder besides ADHD and the failure to attend the training etc., four students were excluded from the study. Finally, the remaining 33 children were taken for evaluation.

The lessons of ICPS were taught to the children in small groups. The children fell into the groups based upon their school and whether they attended morning or afternoon classes resulting in 7–9 children per group. The training program was 14 weeks in length and included 83 structured lessons. Each lesson was completed in approximately 30 minutes twice per week which could be prolonged considering children’s motivation.

The ICPS training program is based on “Interpersonal Cognitive Problem-Solving Strategy”. The ICPS program was developed by Myrna B. Shure (1992) (19) for purposes of social skills training in children and adolescents. The adaptation of this training to Turkish has been made by Öğülmüş (14). The training was provided by a primary researcher who had previously been trained exclusively by Öğülmüş. The ICPS program teaches children how to think and how to evaluate their own thoughts. Behaviors are modified by focusing on the thinking processes. The ICPS program encourages children to think about finding as many alternative solutions as possible when they deal with a problem. It teaches children to learn how to think of solutions to a problem and of potential consequences to an act. The ICPS encourages children to do their own thinking instead of offering solutions and consequences (12,13,14). ICPS with enhanced critical thinking, creativity, and reasoning skills are concerned more with how a person thinks rather than what a person thinks. ICPS attempt to enhance interpersonal cognitive skills, and thus, lead to successful alterations in overt social behavior (12,13,14). The guideline book of ICPS program included 83 structured lessons using pictures, toys, puppets, games, stories, drama, role-plays, and dialogues based on real life conversations. There is a defined goal of each structured lesson in the ICPS program book (19). The examples of goals of the ICPS lessons are as follows:

To Think About their own Feelings

To learn to identify people’s feelings and to become sensitive to them (other’s feelings) or (to gain the ability to put themselves in other’s shoes)

To increase their awareness that other’s point of view might differ from their own

To recognize that there is more than one way to solve a problem

To learn being assertive without physical and verbal aggression

To learn that different people can feel different ways about the same issue

To think of both alternative solutions and means-ends plans (weighing pros and cons)

To be aware of what might happen next and to learn how to think of solutions to a problem and consequences to an act

To decide for themselves whether their idea was or was not good in the light of their own and others’ feelings and of the possible consequences.

To learn that sensitivity to the preferences of others is also important in deciding what to do in situations which situation?

To increase understanding that thinking about what is happening may, in the long run, be more beneficial than immediate action to stop the behavior

To control impulse, including to delay gratification and to cope with frustrations

Examples of ICPS Dialoguing (Problem-solving process) (12).

“What happened, what’s the problem, what’s the matter?”

“How do you think she/he feels when.. ?” (e.g., “When you hit him/her?”)

“What happened (might happen) next when you did (do) that?”

“How did that make you feel?”

“Can you think of a different way to solve the problem (tell him/her/me how you feel)?”

“Do you think that is or is not a good idea? Why (why not)?”

Ethical Approval

This study was approved by the local ethics committee of Gülhane Military Medical Academy and School of Medicine, and Ankara Provincial Education Directorate. For ethical considerations, the purposes and methods of the study were explained to the children and their parents. After receiving their consent, the study was started.

Statistical Analysis

SPSS Ver. 13.0 for Windows (SPSS Inc., IL, USA) was used for the statistical analysis. All descriptive statistics were presented as mean ± standard deviation (SD), median and number/percentage universal tests, then normal distribution fit tests (Shapiro-Wilk test) were employed for the data used. Pre- and post-test measurement data were evaluated as dependent variables scores were compared by using the Paired-Samples T-Test or the Wilcoxon Signed-Rank Test (when variances are unequal). The significance level was assumed p<0.05.

Results

The differences between pre-and post-training scores were statistically significant for all subscales of the DSM-IV-TR Based Disruptive Behavior Disorders Screening and Rating Scale (Table 2).

Table 2.

Comparison of the Subscales Scores of the DSM-IV-TR Based Disruptive Behavior Disorders Screening and Rating Scale before and after the ICPS Training

Subscales	Before ICPS Training (n=33)			After ICPS Training (n=33)			Comparison
	Mean	SD	Median	Mean	SD	Median	Z/t	p
Mother’s Rating
Attention problems	18.36	5.27	19.00	12.15	6.85	10.00	Z=3.99	<0.001**
Hyperactivity-impulsivity	19.27	5.77	20.00	13.24	7.55	12.00	Z=3.96	<0.001**
Oppositional defiant problems	12.70	5.87	12.00	9.03	5.30	8.00	Z=3.11	0.002**
Father’s Rating
Attention problems	17.24	5.17	19.00	12.06	6.13	13.00	t=4.63	<0.001**
Hyperactivity-impulsivity	18.79	6.34	21.00	11.60	7.43	11.00	Z=4.41	<0.001**
Oppositional defiant problems	12.36	4.77	11.00	8.03	4.09	7.00	t=5.50	<0.001**
Teacher’s Rating
Attention problems	20.82	5.43	22.00	13.33	7.74	14.00	Z=4.39	<0.001**
Hyperactivity-impulsivity	19.76	5.17	20.00	12.03	9.01	12.00	Z=4.14	<0.001**
Oppositional defiant problems	14.21	6.41	15.00	8.75	7.57	9.00	Z=4.16	<0.001**

t: Paired-Samples T Test, z: Wilcoxon Signed Rank Test (when variances were unequal),

^**p<0.01

According to the TRF/6–18 test scores for both pre-and post-training, the all internalizing problem behaviors including “anxious/depressed”, “withdrawn/depressed” and “somatic complaints”, and the all externalizing problem behaviors including “rule-breaking behavior” and “aggressive behaviors” were found to be significantly reduced after the ICPS training (Table 3). The sum of the scores for four adaptive characteristics (“working”, “behaving”, “learning” and “happy”) displays an “adaptive functioning profile” on the TRF/6–18. The difference between competence levels of these sub-tests were found to be statistically significant based on the comparison of these levels for pre- and post-ICPS training (p=0.03). The higher total competence scores indicate the better competence (Table 3).

Table 3.

Comparison of Problematic Behaviors Scores Identified by TRF/6–18 for Pre- and Post-ICPS Training

TRF/6–18 Problematic Behaviors	Before ICPS Training (n=33)			After ICPS Training (n=33)			Comparison
	Mean	SD	Median	Mean	SD	Median	Z/t	p
Internalizing
Anxious/Depressed	9.09	6.75	8.00	6.63	5.02	6.00	Z=2.02	0.044*
Withdrawn/Depressed	5.36	3.84	4.00	4.15	3.34	4.00	Z=2.23	0.026*
Somatic complaints	2.15	2.30	2.00	1.03	1.59	0.00	Z=2.70	0.007*
Externalizing
Rule-Breaking Behavior	5.58	3.72	5.00	4.30	4.17	3.00	Z=2.23	0.026*
Aggressive Behaviors	17.27	10.03	17.00	12.75	10.62	11.00	Z=3.80	<0.001**
Internalizing (total)	16.33	11.4	13.00	12.09	9.45	11.00	Z=2.29	0.022*
Externalizing (total)	22.84	13.20	24.00	17.06	14.30	15.00	Z=3.73	<0.001**
Others
Social problems	7.85	4.33	8.00	5.27	4.39	6.00	Z=4.04	<0.001**
Thought problems	4.52	3.66	4.00	2.27	3.29	1.00	Z=3.17	0.002**
Attention problems	30.78	10.15	33.00	24.48	13.29	25.00	t=4.02	<0.001**
Other problems	2.18	1.75	2.00	1.42	1.54	1.00	Z=2.19	0.029*
TRF/6–18 Total	84.51	35.42	96.00	62.61	39.30	65.00	t=4.78	<0.001**
Total Competence	12.93	3.33	15.40	13.88	3.22	16.20	t=2.25	0.031*

t: Paired-Samples T Test, z: Wilcoxon Signed-Rank Test (when variances were unequal),

^**p<0.01

Discussion

The effectiveness of ICPS training for children with ADHD resulted in significant improvement in ADHD symptoms as well as in such problem areas like internalizing and externalizing behavior problems. These results suggest that ICPS training might reduce problematic behaviors and improve problem-solving skills and behavior among children with ADHD.

Pharmacotherapy tends to be a first-line therapy targeting biological implications for children with ADHD. Approved pharmacological agents for the treatment of ADHD include psychostimulants and atomoxetine. Psychostimulant medication has positive effects on children with ADHD in their ability to focus and pay attention in school settings, thereby, resulting in improvement in the overall learning environment. The therapeutic effects of pharmacological agents may be temporary, as symptom reduction occurs only when medication is active in the system. The lack of long-term efficacy has been issue of concern (2,20). Although the effectiveness of psychostimulants for reducing ADHD symptoms have demonstrated efficacy (21,22), there are potential unwanted side effects of pharmacological agents (23,24). Because of worrying about potential and known/unknown negative effects of pharmacotherapy, some children with ADHD may be reluctant to use any medication for ADHD, and may possibly discontinue medication treatments without their prescribers’ knowledge. Furthermore, follow-up studies have demonstrated that ADHD frequently persists into adolescence and adulthood (2,25,26). In addition, adults and those in whom ADHD was diagnosed in childhood often continue to suffer ongoing significant behavior problems (2,9,27). Accordingly, if these people with ADHD use a medication as the first and only treatment for ADHD, they will have to use the medication throughout life. As a result, non-pharmacological treatment seeking, and the use of complementary are on the rise (26). In addition, children with ADHD have not only core ADHD symptoms, but have also comorbid disorders that increase complexity of treatment such as anxiety, disobedience to rules, aggressive behaviors, oppositional defiant behaviors and other social problems (2,4). These comorbid conditions and associated features not only add to ADHD’s clinical complexity, but also have significant implications for treatment (28). Therefore, alternative options, including psychosocial treatment approaches, may have utility for amelioration of ADHD symptoms, and have significance in reversing the risks and long-term outcomes associated with ADHD, especially if combined with medication (3,9,28,29). However, some studies indicated that treatment with a combination of medicine and psychosocial treatment has little or no better result compared to medicine only treatment (20,30,31). The Multimodal Treatment Study of Children with ADHD (MTA) compared four treatment options in a 4-group parallel design. Combination treatment and medication management were both significantly superior to behavioral treatment and community care in reducing the symptoms. In certain conditions (such as oppositional-defiant/aggressive symptoms, internalizing symptoms, teacher rated social skills, parent-child relations, and reading achievement), combined treatment was superior to behavioral treatment and/or community care (21).

On the contrary, other studies have demonstrated incremental results for adding behavior therapy to psychostimulant medication in terms of reductions of ADHD symptoms (32,33). Similarly, psychosocial interventions such as ICPS have been found to be effective for children with ADHD (34). In support of this, some studies have reported that, psychosocial therapies provided along with medication had positive effects on comorbid internalizing and externalizing behaviors (35,36). Diller and Goldstein (37) have emphasized: “more than one hundred studies demonstrate that parent and teacher training programs improve child compliance, reduce disruptive behaviors, and improve parent/teacher-child interactions and a number of short-term studies have scientifically demonstrated the effectiveness of psychosocial interventions for ADHD”.

Problem-solving strategies that is one of psychosocial treatments engages both the cognitive and social skills that arise from daily life experiences. Problem-solving skills are considered an important aspect that effects how one reacts and deals with these problems (38). ICPS program might be useful for both children with and without medication and may contribute to reductions in problematic behaviors. These strategies may also reduce the severity of comorbid disruptive disorders and emotional problems. ICPS training improve problematic behaviors by engaging children in thinking about their actions, the impact of their behavior on themselves and others, the possible consequences of their actions, and other options they have. However, previous studies evaluating the effectiveness of ICPS program in normal children (12,39) concluded that that non-ADHD children with naturally developed problem-solving thinking skills and behavior strategies benefit from ICPS as well as children with ADHD (12,38). There are limited studies related to children with ADHD in the literature to evaluate the effectiveness of ICPS program which we used in our research (12). In one of the initial studies with single subject design, Shure (1999) has cited that, Aberson (1996) taught ICPS to parents of 3 children with ADHD (12. ??, problem-solving skills and behavior may be improved through the use of ICPS strategies. It is important to recognize that children with ADHD trained in ICPS might learn how to find alternative ways to express their anger, handle anger, and to recognize consequences of their behavior. However, the above mentioned improvement in social and emotional adjustment lasted 4 years after training ended (40). In another study (10), also with single subject design, ICPS was conducted to teach 8 children with ADHD who already had been maintaining treatment with psychostimulant drug. While the researcher was teaching ICPS to 8 children with ADHD at an observation class, their mothers observed the ICPS lessons. The mothers applied the learned strategies to their children and used the ICPS dialogs during problem-solving process at home in real-life situations. It was suggested that ICPS program may make an additional contribution into the children treated with a psychostimulant medication to deal with their problems. In parallel with the emphasized idea of the studies (12,40), our data have shown that both ADHD related symptoms and non-ADHD related symptoms were observed to decrease through the use of ICPS strategies.

It was proposed that children with ADHD would need help in learning those skills and the training should be provided in a controlled setting, although normal children might easily learn problem solving skills (15). Aberson et al. (40) emphasized that, such initiatives, if applied under special circumstances, could have significant effects on problematic behaviors in children with ADHD. These special conditions were meant for parents to teach their children the skills, and to implement ICPS childrearing techniques altogether; the child learns to internalize the newly acquired skills, and to adapt them to real life. Children with ADHD may need help to generalize and internalize these skills because they could have difficulty to adaptation these skills for a changing environment and generalizing to conditions in real life. In addition, because, rehearsals through games could complement these techniques, during our study, drama and envisaging techniques were used in order to enhance and generalize the acquired skills.

The limitations of this study include: small sample size and the absence of a control group. Other significant limitations of the study could be regarded as not making a comparison with other treatment modalities and, the grading scales used were based on declaration rather than being objective. The present study was planned in a pre-posttest quasi-experimental design with one group. Further research comparing ICPS with other treatment modalities and different factors are needed.

Conclusions

ICPS training based on Interpersonal Problem Solving skills may reduce the level of problems in behaviors of children with ADHD and increase the quality of interpersonal communications. Although American Pediatrics Academy (41) stated that, psychosocial interventions were found to be effective in treating mild and moderate symptoms of such cases as in the ADHD treatment guidebook published, there is not sufficient evidence for this treatment to be applied alone. Hence, integrated and multimodal treatment approaches may be more convenient hypotheses. ICPS training is relatively easy to learn and to utilize in school settings, and may be conveniently used by most disciplines working with children. Consequently, it is thought that, the ICPS is beneficial training for children with ADHD in order to modify problematic behaviors that interfere with quality of learning, socialization and overall quality of life.

Figure 1.

Process of the study