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Boosting Social Skills for Children With ADHD: Follow-up After an Intensive Summer Program

by Karen Fleiss, PsyD and Tamra Holtzer, Ph.D.

Introduction

This article describes the New York University Child Study Center Summer Program for Kids (SPK) Booster Program, a follow up program designed to reinforce social skills learned in the NYU Summer Program for Kids. The SPK is an intensive, therapeutic summer experience, for children ages 7-11 diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD) and related disorders. The SPK, which is conducted 5 days per week, 8 hours per day, for eight weeks, focuses on skills building in the areas of social, academic and sports behaviors. One of the common denominators of children enrolled in the SPK is a deficit in social functioning. In addition, the program helps parents improve their ability to manage their children's behavior. The SPK model is based on the empirically validated summer program designed by William Pelham, Ph.D. However, there is no research to date that has systematically studied the generalization of the improved skills once the eight week program has ended. Parents report that much of the gains their children made during the summer have indeed continued well after the program ended. Specifically, they report that their children have improved self-esteem, improved social skills/relatedness, a more positive school experience entering in the fall, and a more positive parent/child relationship. The SPK Booster Program was designed to establish whether periodic intervention would sustain the gains from the SPK and whether the improved behaviors would generalize outside the therapeutic structure of the SPK to their natural settings (school, home, social, recreational activities).

Key elements of the SPK

In order to best understand the Booster Program, an understanding of the SPK is necessary. The SPK is a reward-based program which emphasizes achievement and success. It includes a variety of set activities that facilitate peer/group participation through which behavioral principles are applied. While the children are engaged in various activities (team sport, arts and crafts, swimming, etc.), their behavior is shaped through a point system. Children earn points for appropriate pro-social behavior and lose points for maladaptive behavior. One of the methods used to teach social skills is to focus on a "social skill of the day" such as "problem-solving". The selected social skill is taught, then practiced and reinforced throughout the day. New social skills are introduced after the previous ones are mastered; thus a repertoire of skills is acquired. Progress is systematically monitored and recorded via the point system and a Daily Report Card, and tracked continuously throughout the day and throughout the summer. Progress is rewarded in both the camp and home settings. Weekly field trips are used as the major incentive for children who mastered their individualized goals. Field trips are "off-site" so that the skills learned in the program can be practiced in more natural settings.

Moreover, in the SPK, there is predictability and immediate feedback; the daily schedule does not change, and individual goals are established and reviewed with the children daily, so children know how they are progressing towards rewards. Not only is there consistency within the camp environment (counselors receive 3-4 weeks of intensive pre-program training, daily supervision with a licensed clinical psychologist, reliability and fidelity checks throughout the 8 weeks to ensure treatment integrity), but the consistency extends into the home environment via weekly parent training sessions and a home behavior plan that mimics the individualized behavior plans set up for each child at camp.

Basics of the SPK Booster Program

As with the SPK, one of the goals of this program was to reinforce and help generalize the skills to the children's natural environment. The Booster Program was held on alternating Saturdays for two hours over a period of four months. The time and day remained consistent across the sessions. A high staff-to-child ratio was maintained. The key components of the SPK used in the Booster Program included; a social skill of the day, a behavioral point system, a home-based reward, practice and reinforcement system, close clinical supervision, and monitoring through use of a Daily Report Card.

Based on the Field Trip model of the SPK, 8 "field trips" were selected to maximize the opportunity for children to engage with peers (i.e. bowling, museum, dining at a restaurant) and used to reinforce and generalize skills. Field trip leaders were experienced/trained counselors who previously worked in the SPK. Counselors met with a clinical supervisor for regular supervision. As in the SPK, parents were given ongoing feedback and a home behavior plan was put in place. The integrity of the point system was maintained and children earned points, within both the program and home settings, for progress on their individualized goals. A "social skill of the day" was utilized in the Booster Program as in the Summer Program, but was specifically geared towards the social demands of the particular field trip. For example, when the children went to the zoo, the "social skill of the day" was problem-solving; that is, children had to use the social skill throughout the field trip to decide which exhibit/animals to visit.

The social skills, which include Problem Solving, Tone of Voice, Compromising, Cooperation, Being a Team Player, Turn-Taking, Personal Space, were monitored continuously for their use and application Feedback of their performance was provided to the children 6 times in 15 minute intervals throughout the Booster Program Session. During the 2 weeks between Booster Sessions, parents were instructed to prompt, reinforce and monitor on a daily basis the social skill that had been addressed during the field trip. Booster Program session data revealed that children were able to learn and demonstrate the social skill taught, and Home Data revealed that the social skill was maintained in between Field Trip sessions.

Similar to the SPK, individual target behaviors, (e.g. expressing feelings verbally) which may or may not necessarily be related to the social skill of the day, were established for each child and incorporated into the Daily Report Card used in the Booster Given that the goal of the Booster Program was to help maintain and to facilitate greater generalization of these behaviors to the natural setting, behaviors targeted were similar, if not identical to those behaviors targeted in the SPK. The behaviors were prompted, reinforced and monitored. The data collected revealed that gains persisted throughout the 5 month course of the booster program.

The SPK Booster Program began in October 2002 and ran through February 2003. All parents of children enrolled in the SPK were given an opportunity to have their child participate in the Booster Program. A large number of parents wanted to participate in this program; however, practical considerations such as the day of the week when the program was held, location of the field trips (i.e. NYC), families' prior commitments, made the Booster Program prohibitive to some families. The participants consisted of 6 children (4 boys, 2 girls) 9 -l0 years old, diagnosed with ADHD, 2 also had an anxiety disorder, and 1 had a learning disability. Prior to the start of the program baseline measures, including the Child Behavior Checklist (CBCL) Parent Conner's, Social Skills Scale were collected from parents. At the end of the 8- session Booster Program, the same measures were re-administered and completed by parents.

To illustrate sample behaviors targeted and their progress over time, below is a description of a targeted behavior for each of two children and their progression in relation to this behavior over the course of the 8 sessions. (To protect the confidentiality of the children, the names have been changed).

Ten -year-old Mitchell often had problems staying on topic when conversation began. He had difficulty focusing on what was being talked about and often made comments that were irrelevant and interfered with the flow of the conversation. Thus, a targeted behavior for Mitchell was to "engage in activity related conversation," and he earned points for verbal contributions he made that were related to the topic being discussed. Mitchell achieved 100% success on his Daily Report Card for this behavior throughout the course of the Booster Program, with the exception of the second week, when he experienced a "dip" in his percentage total.

Seth is a youngster who often had difficulty expressing his feelings verbally, and was prone to oppositional and defiant behavior when he was upset. One of Seth's targeted behaviors was to "express feelings appropriately when upset", and points were awarded for this behavior. Seth too, experienced consistent success with exhibiting the targeted behavior and earned percentage totals of 85 - 100% until the last session. During the last session, despite the considerable difficulty he was clearly having with termination, he nevertheless still achieved a 50% performance score, indicating that he was still able to express his feelings half the time during this emotional session. Seth, who historically would typically "leave the area and tantrum" to express his feelings was able to stay with the group and verbalize his upset more than he was able to in the past. Seth and Mitchell serve as examples of how the gains from the SPK carried over into the Booster Program, the typical trends of performance for the children, and the kind of clinical gains such as social functioning that the children made over time.

Summary

The Booster Program aimed to establish generalization of the social skills focused upon in an intensive summer program for children with ADHD. Indeed, the clinical data collected clearly demonstrated that specific social skills learned through the SPK were being utilized outside the program. Although counselor and parent reports indicated that the skills taught to the children generalized outside the program setting, it is still unclear how closely related to the normative population their social behavior truly is. Therefore, valid measures would need to be administered in order to compare the children who complete the SPK and Booster Program to peers who are not identified as having social difficulties. Moreover, teacher measures to assess social functioning in the school setting would be useful in further determining generalization. While a review of the clinical data shows benefits of this program with regard to ecological validity, further and more stringent study is required.

About the Authors

Tamra Holtzer, Ph.D., is a clinical psychologist at the Long Island Campus of the NYU Child Study Center the NYU Summer Program for Kids, and the Port Washington Alternative High School, of the NYU Child Study Center School Partnership www.AboutOurKids.org.

References and Related Books

Children's Summer Treatment Program Manual
by William E. Pelham, Jr., Andrew R. Greiner,
Elizabeth M. Gnagy

Intensive Treatment: A Summer Treatment Program for Children with ADHD
William E. Pelham, Jr. and Betsy Hoza. Pelham
W. E. & Hoza, B. (1996)

Psychosocial Treatments for Child and Adolescent Disorders: Empirically Based Strategies for Clinical Practice
by Euthymia D. Hibbs (Editor), Peter S. Jensen (Editor)
Publisher: American Psychological Association (APA); (May 1996)

Intensive Treatment for ADHD: A Model Summer Treatment Program
by William E. Pelham, Jr., Andrew R. Greiner, Elizabeth M. Gnagy, Betsy Hoza, Lynn Martin, Susan E. Sams, Tracey Wilson

Model programs for service delivery for child and family mental health
by M. Roberts & A. LaCreca (Eds.),
Hillsdale, NJ: Erlbaum, (1996)