Journal of Clinical Child & Adolescent Psychology

ISSN: 1537-4416 (Print) 1537-4424 (Online) Journal homepage: https://www.tandfonline.com/loi/hcap20

Evidence-Based Treatment of Attention Deficit/

Hyperactivity Disorder in a Preschool-Age Child: A
Case Study

Timothy L. Verduin , Howard Abikoff & Steven M. S. Kurtz

To cite this article: Timothy L. Verduin , Howard Abikoff & Steven M. S. Kurtz (2008)
Evidence-Based Treatment of Attention Deficit/Hyperactivity Disorder in a Preschool-Age
Child: A Case Study, Journal of Clinical Child & Adolescent Psychology, 37:2, 477-485, DOI:
10.1080/15374410801955904

To link to this article: https://doi.org/10.1080/15374410801955904

Published online: 09 May 2008.

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Journal of Clinical Child & Adolescent Psychology, 37(2), 477–485, 2008
Copyright # Taylor & Francis Group, LLC
ISSN: 1537-4416 print=1537-4424 online
DOI: 10.1080/15374410801955904

CASE STUDY IN EVIDENCE-BASED PRACTICE

Evidence-Based Treatment of Attention Deficit=Hyperactivity

Disorder in a Preschool-Age Child: A Case Study
Timothy L. Verduin, Howard Abikoff, and Steven M. S. Kurtz
Department of Child & Adolescent Psychiatry, New York University Child Study Center

This case study illustrates a behavioral treatment of ‘‘Peter,’’ a 4-year-old male with
attention deficit=hyperactivity disorder (ADHD) and oppositional defiant disorder.
Multiple evidence-based treatment procedures were implemented, affording the opport-
unity to explore issues common to the clinical application of empirically supported
interventions. Among the strategies utilized were behavioral parent training, school con-
sultation and behavioral training of educators, school-based contingency management,
and a behavioral daily report card. Numerous issues are discussed, including the limited
evidence regarding interventions for preschool-age children with ADHD, factors influ-
encing treatment planning and sequencing, collaboration with schools and parents, and
evidence-based assessment of treatment gains.

BACKGROUND LITERATURE ADHD symptoms in this age group (MTA Cooperative

Attention deficit=hyperactivity disorder (ADHD) is
among the most extensively studied childhood disorders
because of its high prevalence rate (5–8%; American
Psychiatric Association, 2000), impact on multiple
domains of functioning (see Hinshaw, 2002, for review),
and chronic, negative course (Barkley, Fischer,
Smallish, & Fletcher, 2002; Mannuzza & Klein, 1999).
In addition to pharmacotherapy, several psychosocial
evidence-based treatments (EBTs) for ADHD are avail-
able (see Hinshaw, Klein, & Abikoff, 2002; Pelham,
Wheeler, & Chronis, 1998). Notably, the evidence base
for these treatments is comprised almost entirely of
studies with school-age children, whereas the number of
preschool children diagnosed with ADHD has increased
threefold in recent years (Zito et al., 2000).
Pharmacotherapy remains the standard against
which other ADHD treatments are judged (Hinshaw,
2006). Psychostimulants are typically beneficial in 75%
to 80% of school-age children (Daley, 2004) and are
superior to psychosocial interventions at alleviating
Correspondence should be addressed to Timothy L. Verduin, NYU
Child Study Center, 577 First Avenue, New York, NY 10016. E-mail:
tim.verduin@nyumc.org
Group, 1999). Trials are less extensive for preschoolers
with ADHD. Results indicate that their symptoms
respond to psychostimulants, yet long-term effects are
unknown (Greenhill et al., 2006) and side effects appear
more common (Firestone, Musten, Pisterman, Mercer,
& Bennett, 1998). Among psychosocial treatments for
ADHD, behavioral approaches have the best empirical
support (see Hinshaw, 2006, for review). These treat-
ments include parent training (PT), contingency man-
agement (CM), and school-based approaches such as
the daily report card (DRC). As with pharmacologic
treatment, less is known about efficacy with preschool
children. Nevertheless, behavioral interventions are
often used as alternatives to medication, in part because
of controversy about medicating young children and
parent attitudes toward psychopharmacology (dosReis
et al., 2003; Rushton, Fant, & Clark, 2004).
PT was initially developed for treating childhood
conduct problems (Forehand & McMahon, 1981;
Webster-Stratton, 1982). Several programs were specifi-
cally designed for preschool children (e.g., Eyberg, 1988;
Sonuga-Barke, Daley, Thompson, Laver-Bradbury, &
Weeks, 2001). PT typically consists of multiple compo-
nents, including positive attending and contingent
rewards and punishments (see review in Barkley,
478 VERDUIN, ABIKOFF, KURTZ
1997). One model of PT, parent-child interaction
therapy (PCIT; Eyberg, 1988), appears to reduce
hyperactivity in young children diagnosed with ADHD
(Eyberg et al., 2001; Nixon, 2001). Home-based PT with
3-year-olds has also been reported to reduce ADHD
symptoms, but only when administered by highly
trained professionals (Sonuga-Barke et al., 2001,
Sonuga-Barke, Thompson, Daley, & Laver-Bradbury,
2004). Other studies have found improvements in
compliance and parenting behaviors, but little or no
reduction in ADHD symptoms following PT (e.g.,
Pisterman et al., 1992). Small sample sizes, inconsistent
findings, and the lack of follow-up data prevent strong
conclusions about the efficacy of PT regarding pre-
school ADHD symptoms. Yet this approach is often
beneficial given the high rate of comorbid oppositional
and aggressive behaviors in preschool children with
ADHD (Wilens et al., 2002) and PT’s utility with
conduct problems (e.g., Webster-Stratton, Reid, &
Hammond, 2004). More research is needed to clarify
the immediate and lasting effects of PT on core ADHD
symptoms.
CM procedures have demonstrated more convincing
effects on ADHD symptoms. The greatest support exists
for intensive CM implemented in specialized classrooms
or camps (Barkley et al., 2000; MTA Cooperative Group,
1999; Pelham et al., 1998). Such approaches involve fre-
quent monitoring and prompting of specific behavioral
targets and high rates of positive and negative conse-
quences. Effects on core symptoms of ADHD are often
dramatic, with other areas of functioning improving as
well (Barkley et al., 2000). Yet gains fade when reinforce-
ment is tapered, generalization is limited, and mainte-
nance is often poor (Barkley et al., 2000). Moreover,
the density of reinforcement and staff:child ratio are
difficult and costly to replicate in community settings.
Another promising technique is the DRC (e.g.,
Barkley, 2005; Pelham & Hinshaw, 1992). DRCs vary
in structure but have common elements. In the design
stage, target behaviors are operationalized. Specific,
observable, measurable targets are selected, such as rais-
ing hand to speak (Kelley, 1990). Monitoring intervals
are established so behaviors can be recorded several
times per day. Secondary reinforcers such as points or
stickers may also be awarded. The DRC is sent home
daily, and parents administer backup rewards as appro-
priate. The DRC is relatively easy to implement, allows
for shaping, and encourages school–home communi-
cation (Kelley, 1990). Despite inclusion in numerous
‘‘package’’ treatments for ADHD, the DRC has not
been evaluated as a stand-alone intervention for
ADHD. Little is known about efficacy in preschool-
age children with ADHD. As with most school-based
interventions, the success of this approach depends on
the willingness and ability of teachers to implement it.
In this article, we describe our treatment of ‘‘Peter,’’
a preschooler with ADHD. Peter’s story is representa-
tive of several common EBT themes. Rather than first
reviewing these issues, then addressing treatment
course, these themes are discussed within the context
of the treatment narrative. Of note, Peter’s treat-
ment was ongoing when this article was prepared.
Therefore, certain treatment decisions were in progress
as described next.
BACKGROUND INFORMATION
Peter B. was 4 years 1 month old at his initial evaluation.
He is of Caucasian and African American descent. He
has no siblings and lives with his mother, Ms. B., who
is a single parent and employed as a business consultant.
He never met his father, and there is no plan for them to
do so. His parents never married; their contact with each
other ended before his birth. Peter’s father was unavail-
able for interview. Ms. B. denied a family history of psy-
chopathology and reported that Peter has no significant
medical history and no developmental concerns apart
from behavioral symptoms detailed next. Ms. B. con-
sented and Peter assented to the use of their story in this
case report. They were informed that names and other
identifying data would be disguised to preserve their
anonymity.
Peter is currently attending his 2nd year of preschool
at a small, private school in upper Manhattan. His
school day begins in the morning and lasts 4 hr. His
class contains 14 other students, two teachers, and one
aide. Each of Peter’s educators has at least 4 years’
experience in the current setting. Peter was assigned a
Special Education Itinerant Teacher (SEIT) by the
Board of Education because of aggressive and disruptive
classroom behavior. Peter’s SEIT was charged with
helping him focus, aiding acquisition of social and aca-
demic skills, and managing disruptive behaviors. She
was not trained in behavior management techniques.
ASSESSMENT AND DIAGNOSIS
Ms. B. sought an evaluation at the New York University
Child Study Center (NYUCSC) because of worsening
hyperactivity; impulsivity; aggression; and defiance in
home, preschool, and social settings. The referring clin-
ician administered semistructured diagnostic interviews
with Peter and his mother (Kiddie Schedule for Affect-
ive Disorders and Schizophrenia; Puig-Antich & Ryan,
1986), telephone interviews with teachers, and parent-
and teacher-completed questionnaires. The Kiddie
Schedule for Affective Disorders and Schizophrenia
assessed mental disorders according to established
 PRESCHOOL ADHD CASE STUDY 479

diagnostic criteria (American Psychiatric Association,
2000). Teacher interviews provided information about
Peter’s classroom functioning. The referring clinician
also asked Peter’s mother and SEIT to complete the
Swanson, Nolan, and Pelham Rating Scale (SNAP-IV;
Swanson et al., 2001), a measure assessing ADHD and
oppositional defiant disorder (ODD) symptoms. Peter’s
SNAP-IV scores from his initial evaluation are
presented in Table 1, Baseline 1.
According to the evaluation, Peter’s mother and tea-
chers’ primary concerns were his noncompliance, impul-
sivity, hyperactivity, reactive aggression, and difficulty
concentrating. These symptoms led to considerable
impairment in his relations with his mother, who
described his behavior as ‘‘maddening’’ and ‘‘embarrass-
ing.’’ She reported having to repeat commands multiple
times before Peter appeared to have heard her. At other
times he was openly defiant, especially when told to stop
a preferred activity. She also reported that he would not
sit still for mealtimes and interrupted her ‘‘constantly.’’
His teachers also noted functional impairment,
especially in his ability to focus on and sit for activities,
accept limits, and make transitions. His peers reportedly
avoided him because of his intrusiveness and aggression.
In response to disruptive behavior, his SEIT would
usually talk to Peter about the behavior and initiate an
alternate activity away from the class—typically for less
than half and hour but sometimes for the rest of the day.
He in turn responded with increased aggression, yelling,
and defiance, but occasionally appeared to be engaging
in disruptive behavior to escape one activity in favor of
another.
Ms. B. denied that Peter experienced mood and anxi-
ety symptoms, tics, features of pervasive developmental
disorder, and symptoms of other disorders. Apart from
his ADHD symptoms, neither his mother nor his tea-
chers expressed concerns regarding other learning-
related abilities such as comprehension or speech. Prior
educational testing determined that he is of average
intellectual functioning. In his evaluation at the
NYUCSC, Peter was pleasant, alert, and well related.
He was very active during the interview, falling out of
his chair twice. He followed the referring clinician’s
directions but was openly defiant with his mother at
times, especially when limits were set (e.g., to put away
the toys). He often asked for interview questions to be
repeated, stating that he forgot or hadn’t heard them.
Based on evaluation data, Peter met diagnostic criteria
for ADHD, combined type and ODD.
Peter began treatment 9 weeks after his evaluation.
The treating clinician (TLV) gathered additional infor-
mation prior to the first treatment session. Because
Ms. B. reported defiant and disruptive behavior, she
was asked to complete the Eyberg Childhood Behavior
Inventory (Eyberg & Pincus, 1999), a scale assessing
noncompliance and aggression. Peter’s mother and tea-
chers had also reported inattention, impulsivity, hyper-
activity, academic problems, and social impairment

TABLE 1
Questionnaire Data

Baseline 1a (Week 1) Baseline 2b (Week 10) Midtreatmentc (Week 34)

Reporter Measure=Subcale Raw Score T-Score Raw Score T-Score Raw Score T-Score
Parent CBCL Total — — 68 67
63 66

Externalizing — — 31 70
30 65

Attention Problems — — 9 77
14 76

Aggressive — — 22 66
16 61

ECBI Total — — 140 62
110 54

Problem Score — — 19 65
7 50

SNAP-IVd
Hyperactive=Impulsive 2.67 Above cutoffe 2.56 Above cutoff 2.44 Above cutoff
Inattentive 2.44 Above cutoff 2.56 Above cutoff 1.44 Below cutoff
Oppositional=Defiant 1.63 Above cutoff 1.50 Above cutoff .89 Below cutoff
Teacher CBCL Total — — 96 80
58 64

Externalizing — — 65 85
41 69

Attention Problems — — 28 84
13 70

Aggressive — — 37 85
28 68

SNAP-IV
Hyperactive=Impulsive 2.77 Above cutoff 2.44 Above cutoff 1.67 Below cutoff
Inattentive 2.44 Below cutoff 2.22 Below cutoff 1.67 Below cutoff
Oppositional=Defiant 3.00 Above cutoff 2.86 Above cutoff 2.25 Above cutoff

Note: CBCL ¼ Child Behavior Checklist; ECBI ¼ Eyberg Childhood Behavior Inventory; SNAP-IV ¼ Swanson, Nolan, and Pelham Rating
Scale.
a
Initial evaluation. bTreatment Session 1. cTreatment Session 17. dNormed for children ages 5 to 11. eCutoff ¼ 95th percentile.


Above clinical cut score; Peter was 4 at Baseline 2 and 5 at midtreatment, resulting in different norms, as evident in CBCL t-scores.
480 VERDUIN, ABIKOFF, KURTZ
and were thus asked to complete the Child Behavior
Checklist (Achenbach, 2000), a broadband measure of
psychopathology. These data were used to clarify the
diagnostic picture, identify treatment goals, and assess
progress. The SNAP was given again to provide a
second baseline measure of Peter’s symptoms. A
summary of these pretreatment assessment results is
provided in Table 1, Baseline 2.
TREATMENT PLANNING
Given Peter’s age, lack of prior behavioral treatment,
and salient disruptive, defiant behaviors, it was recom-
mended that he receive behavior therapy prior to con-
sidering pharmacotherapy. Ms. B. reported no mental
health issues of her own, desired new parenting tactics,
and stated that the school was eager to participate, mak-
ing Peter a good candidate for behavior therapy. PCIT
was judged to be more fitting than parent-only PT, as
Ms. B. wished to receive in vivocoaching and to improve
the troubled parent-child relationship. PCIT would also
address Peter’s noncompliance, provide consequences
for aggression, and help replace impulsive and hyper-
active behaviors with positive, alternative behaviors.
His SEIT would be trained in PCIT so a school-based
plan could be started when school began. Medication
would be considered if hyperactive and impulsive symp-
toms remained impairing following this approach.
EBT issue: Treatment sequencing. Multiple EBT issues
inform treatment planning and sequencing. In Peter’s
case, the limited evidence base for pharmacologic treat-
ment of preschool-age children with ADHD, the greater
risk of side effects, and the dearth of information on
long-term effects of stimulants in young children were
all factors. As such, Peter’s referring and treating clini-
cians recommended sequenced rather than combined
treatment, despite the possibility that Peter might benefit
from both approaches. This plan also allowed the thera-
pist to test the hypothesis that teaching Peter’s mother
positive parenting skills would lessen impairment from
ADHD symptoms. Other factors influencing this
decision were his mother’s concerns about medication
and his diagnostic comorbidity. Peter’s comorbid ODD
made PT a clearer choice for addressing both his defiance
and his disruptive, ADHD-related behaviors.
TREATMENT COURSE
Treatment Phase 1: PCIT
Peter and Ms. B attended 10 weekly sessions of PCIT. In
the first session, Ms. B. learned Child Directed Interac-
tion (CDI), the first stage of PCIT. CDI teaches parents
to differentially attend to appropriate behavior and
ignore disruptive, nondangerous behavior in the context
of play. Subsequent sessions involved coaching and
assessing these skills with Peter and his mother.
Although disruptive behaviors are not formally tracked
in CDI, Peter’s therapist and mother observed that they
appeared to decrease during CDI practice, both in ses-
sion and in the home (by mother’s homework sheets).
By the third session, Peter quickly engaged in positive
behavior when his mother ignored disruptive behavior
(e.g., within 10 sec rather than within 30–60 sec, as in
early sessions). His mother also reported that he
appeared to enjoy the prescribed daily playtime very
much and that he began thanking her when she praised
him. She practiced CDI for the prescribed 5 min nearly
every day between sessions, as measured by CDI home-
work tracking sheets. Following mastery of CDI (see
treatment manual for criteria; Eyberg, 1988), Ms. B.
was trained in Parent Directed Interaction (PDI). PDI
involves use of commands and contingent consequences
(praise for compliance, time-out [TO] for non-
compliance). During PDI sessions, compliance with
commands increased (Week 14, 36%; Week 17, 75%;
Week 19, 100%) and TO decreased (Week 14, 5; Week
16, 2; Week 19, 0). His mother reported similar gains
between sessions, giving fewer TO per week by the end
of PCIT (Week 14, 6; Week 16, 4; Week 19, 1).
From PDI onward, Peter’s SEIT observed sessions.
The SEIT began actively participating after Ms. B.
reached PDI mastery (75% compliance with effective
commands; see Eyberg, 1988, for additional criteria).
Ms. B. paid for her and the SEIT’s sessions; although
she received partial, out-of-network insurance reim-
bursement, she could not afford a full course of PCIT
for the SEIT. The SEIT nevertheless mastered PDI,
requiring only three sessions. She approached but did
not reach CDI mastery because of frequent questions
and commands, which are prohibited during CDI. This
likely resulted from her abbreviated training and her
observation of PDI only, during which commands are
encouraged.
EBT issue: Departing from protocol. In clinical settings,
empirically validated treatments are often adapted
because of limited time, money, or treatment access.
Yet there is scant evidence for how such departures
affect outcome. Peter’s mother could not afford a full
course of PCIT for herself and his SEIT, and the
approaching school year quickened the pace of treat-
ment. Furthermore, although PCIT has been adapted
for use in classroom settings (e.g., McIntosh, Rizza, &
Bliss, 2000), there is little evidence for its efficacy with
teachers or aides. Our adaptations were based on clinical
judgment and the hypothesis that transporting PCIT to
Peter’s classroom would aid in generalization.
 PRESCHOOL ADHD CASE STUDY 481

Treatment Phase 2: School-Based Behavior

Management
Peter began his 2nd year of preschool as his SEIT
completed abbreviated PCIT. His teachers, SEIT, and
therapist met in Week 20 to develop a classroom
behavior program. Peter was observed in class, and a
brief functional analysis was conducted. Antecedents
to disruptive behavior were identified, including
extended periods of unstructured play, sitting on the
rug very near other children, being asked to engage in
activities for longer than 20 min, and being given nega-
tively stated, vague commands (e.g., ‘‘Stop horsing
around!’’). Consequences of disruptive behavior were
also identified, including teacher attention (often affec-
tionately given), and the ability to switch to desired
activities and escape from demands. A behavior plan
FIGURE 1 Peter’s daily report card, as completed with all points
was created based on the functional analysis. achieved.
Peter’s therapist and SEIT participated in six
biweekly coaching sessions at Peter’s school. Coaching
was conducted via bug-in-the-ear. The therapist pro-
or game) if he earned 6 of 8 possible points by the end
vided this equipment, which consisted of 2 two-way
of Period 2. If he earned 9 of 12 total daily points, Peter
radios, one equipped with a single earphone through
could choose an at-home reward (small toy, special
which coaching statements could be heard. The SEIT
dessert) from a menu developed by himself, his thera-
wore the radio and earphone in a concealed manner
pist, and his mother. Peter’s principal requested that
and the therapist was stationed 15 to 25 feet away so
punishment be introduced only if these initial methods
as not disrupt the students during coaching. The SEIT
proved insufficient. Although punishment is often a use-
was guided in structuring behavior with effective com-
ful component of CM for ADHD (e.g., Rosen, O’Leary,
mands and positive attention. Peter’s teachers were
Joyce, Conway, & Pfiffner, 1984), the importance of
taught selective attending, active ignoring, and princi-
preserving the relationship with school staff was judged
ples of effective commands (e.g., specific, positively sta-
a priority. Because of his significant defiance and
ted). Peter now sat in a chair (which he preferred) rather
aggression, Peter’s mother and teachers requested that
than on the rug during circle time. The therapist con-
the DRC be implemented immediately. Baseline rates
structed a DRC targeting aggression, impulsivity, hyper-
of DRC targets were consequently not assessed, signifi-
activity, and defiance. Proposed behavioral targets
cantly limiting conclusions regarding its measurement
included ‘‘Follows directions within two prompts,’’
of gains.
‘‘Asks permission to leave seat,’’ ‘‘Speaks in an indoor
Peter initially responded well to the system, receiving
voice,’’ and ‘‘Keeps body to self.’’ Four 1-hr monitoring
enough DRC points to earn rewards on 4 of the first 5
periods were proposed, and stickers served as a second-
days (see Figure 2, Week 21). His SEIT was observed
ary reward and a means of tracking compliance.
to use CDI skills and appeared comfortable with bug-
In-school and at-home rewards were to back up these
in-the-ear coaching. She and Peter’s teachers used selec-
DRC ‘‘points.’’
tive attention, ignoring, and DRC-oriented prompts to
Despite advice that DRC goals be positive, specific,
target disruptive behavior an average of three times
observable, and measurable, Peter’s teachers preferred
per hour, as assessed by observation and teacher-
that targets be changed to fit existing class rules (see
reported skills tracking sheets. However, by end of
Figure 1 for a completed DRC). They requested that
Week 22, Peter’s early gains had diminished. Peter
monitoring periods match the three school periods
earned enough points for rewards on 2 out of 5 days.
(before lunch, after-center activities, and before dis-
However, when he was redirected by teachers away from
missal). With therapist consultation, Peter’s SEIT con-
highly reinforcing activities (e.g., playing with a favorite
structed a laminated DRC containing Velcro-backed
toy) or when his play was disrupted by a peer, his
symbols that were placed in corresponding cells when
defiance, impulsivity, and aggression often increased.
a target was met in a given monitoring period. Peter
His teachers reported feeling hopeless, citing the lack
was periodically shown his progress, and the completed
of an agreed-upon punishment procedure.
DRC was photocopied, filed, and sent home each day.
In Week 23, Peter’s principal agreed to add negative
Peter earned a special activity at school (e.g., a walk
consequences to his behavior plan. The therapist
482 VERDUIN, ABIKOFF, KURTZ
FIGURE 2 School-based behavior management program data: daily report card points and time-outs.
suggested use of TO, as Peter usually became aggressive
or defiant when an attempt to gain reinforcement (e.g.,
toys, attention) was blocked by teachers or peers. He
typically ignored commands to put away materials, take
turns, or wait for help, and he often became aggressive
when he was physically redirected by staff or when peers
intruded on his play. These behaviors were hypothesized
to be primarily directed at increasing or maintaining
positive reinforcement. TO would provide an aversive
consequence for disruptive or defiant behavior by tem-
porarily limiting access to attention, items, or activities.
Were Peter’s disruptive behaviors directed at escaping
activities or demands, TO would have been contraindi-
cated, as it would have negatively reinforced disruptive
behavior. It was agreed that Peter would receive TO if
he broke standing rules (e.g., no hitting) or was noncom-
pliant after a warning (‘‘Either you put away the toy or
you will have to sit in TO’’). TO was to be taken on a
chair in the hallway outside of the classroom and to
be 3 minutes in duration. TO noncompliance would
result in longer duration, as TO would not start until
Peter was sitting in the chair. For TO to end, Peter
would be required to comply with the initial command
or agree to comply with the rule he had broken.
Introduction of TO in Week 23 corresponded to an
increase in average DRC points by Week 24. However,
Peter occasionally ran, hit, or spit when given TO, which
consequently lasted for 30 min or more at times. When
he did sit, his yelling was disruptive to multiple class-
rooms. A viable backup to TO was clearly necessary.
Eyberg (1988) prescribes a TO room (e.g., a child-
proofed spare room) to back up TO, but Peter’s school
had no such room, so alternatives were explored. At the
end of Week 25, Peter’s therapist added a positive rein-
forcement=response cost TO backup to Peter’s DRC.
Two points were awarded if no TO was given in a per-
iod. If TO was given but taken appropriately in a period,
1 point was awarded for that period. Each TO not taken
appropriately resulted in a 1-point DRC response cost.
This yielded increased DRC points and TO compliance
the first day, but thereafter Peter was again noncompli-
ant with TO, losing many points and appearing less
motivated by DRC rewards. His SEIT surmised that
taking TO was more aversive than point loss. By Week
26, TO had increased markedly and DRC points had
fallen. It appeared that this TO backup was not only
ineffective but was also compromising the positive, if
sporadic, initial DRC effects. Peter’s principal requested
an alternate TO backup, fearing DRC reinforcement
‘‘burn out.’’
Because Peter often ran from or hit staff when given
TO and other options were not available, the therapist
proposed brief therapeutic holds as a TO backup
(Hembree-Kigin & McNeil, 1995). If Peter hit or ran
when given TO, he was held for 30 sec, then redirected
to TO. If he left the TO chair, he was held again and
so on until he had complied with a full, uninterrupted
TO. TO was served in the stairwell instead of the hall-
way, allowing staff to ignore yelling. Peter’s therapist
provided coaching in these methods, which were imple-
mented in Week 27. Nearly immediately, Peter’s beha-
vior and verbalizations indicated that he found TO
less aversive than TO backup holds. By Week 29, Peter
was compliant with most TO; his DRC points had
increased; and running, yelling, and hitting during TO
had been nearly extinguished. By Week 31, TO had
decreased and DRC points had further increased. See
Figure 2.

EBT issue: Treatment collaboration. Clinical behavior
therapy with children with ADHD relies heavily on
therapist consultation with parents and school staff
(Hinshaw et al., 2002). In Peter’s case, the therapist
responded to initial resistance with a cooperative
problem-solving approach. Several weeks into the
consultation, staff reported increased confidence in the
recommended behavioral strategies. Their treatment
alliance was likely also strengthened by their tracking
of behavioral data, which provided evidence of clinical
utility. The collaborative relationship facilitated accept-
ance of an increasingly intense, comprehensive approach
that ultimately reduced Peter’s disruptive behaviors.
Treatment Phase 3: Assessing Gains
By Week 34 (Treatment Session 17), Ms. B. reported
decreased disruptive behavior at home. Per her com-
pleted tracking sheets, she continued to use CDI and
PDI skills daily to address noncompliant, disruptive
behavior. Consequently, she found Peter required TO
and other punishments less than once per week, a five-
fold decrease from early PDI. She reported a marked
improvement in focus and attention but less change in
hyperactivity, which nevertheless caused little impair-
ment because of her ability to redirect Peter effectively.
Peter’s SEIT reported a substantial increase in DRC
points. TO (which had replaced the practice of removing
Peter from class indefinitely) was now infrequent, lead-
ing to a marked increase in Peter’s time in class. She
reported reduced defiance and aggression, although
these problems remained at clinical levels according to
questionnaire data. Yet like Peter’s mother, his SEIT
spoke of increased confidence in her ability to manage
disruptive behavior. She also observed that peers
no longer avoided him, instead including him in
their play—a previously rare occurrence. As noted in
Table 1, her reports regarding ADHD symptoms were
less consistent. SNAP hyperactivity, impulsivity, and
inattention scores fell to subclinical levels, but the Child
Behavior Checklist indicated attention problems
remaining in the clinical range. His SEIT and teachers
anecdotally reported continued impairment from hyper-
activity and inattention. These varied reports may have
reflected what his teachers now reported observing—
that his ADHD symptoms presented inconsistently,
being present at times and absent at others. They perceived
this fluctuation as random, despite therapist attempts to
identify maintaining and exacerbating factors.
EBT issue: Assessing gains. Significant advances have
been made in measuring outcomes of behavioral treat-
ment in clinical trials (e.g., Abikoff et al., 2004; MTA
Cooperative Group, 1999). Yet it is often unclear how
best to assess gains in real-world clinical settings.
PRESCHOOL ADHD CASE STUDY 483
Measures such as the Child Behavior Checklist and
SNAP may clarify the baseline symptom picture and
can inform treatment if administered periodically. How-
ever, the sensitivity of such measures to daily or weekly
behavior change is less clear. Furthermore, symptom or
behavior rating scales do not always capture clinically
significant change (Kendall, Holmbeck, & Verduin,
2004) or functional improvements (Fabiano et al.,
2006). Idiographic data, such as points earned on a
DRC, may provide a more clinically relevant picture
(Abikoff, 2001; Arnold et al., 2003). In Peter’s case,
weekly DRC and TO data were considered in conjunc-
tion with less-frequent Eyberg Childhood Behavior
Inventory and SNAP-IV administration to track gains.
These data were not always consistent with anecdotal
reports of Peter’s behavior, making regular review of
these various reports essential to facilitate interpretation
of discrepancies.
FUTURE TREATMENT PLANNING
After the midtreatment assessment, Peter’s therapist
reviewed the DRC with the intent to replace high-
success behaviors with targets related to the hyperactiv-
ity and inattention that teachers complained were still
impairing. Yet Peter’s teachers were reluctant to replace
existing targets, fearing the loss of hard-fought gains.
Furthermore, they worried that adding more targets
would overcomplicate the DRC. Sensing that Peter
had little control over inattention and hyperactivity,
they were also reluctant to respond with punishment,
although they were willing to do so with oppositionality
and aggression. Because of the limited success in
addressing hyperactivity and inattention, Peter’s princi-
pal was pessimistic about targeting these symptoms. It
appeared that the current methods had leveled off,
successfully addressing Peter’s ODD but having mixed
success with ADHD symptoms.
Adding to this complex issue was the need to plan for
the next school year. Ms. B. intends to enroll Peter in a
public collaborative team teaching inclusion classroom
for kindergarten. His current principal felt strongly that
he would not succeed in such a setting without medi-
cation. She cited his enduring symptoms and the chal-
lenges of transporting the current CM system. Indeed,
there would be twice as many children in the collabora-
tive team teaching class and half as many teachers,
reducing the staff:child ratio by 75%. Unfortunately,
public special education settings with more favorable
staff:child ratios were academically inappropriate for
Peter, as they served children with significant cognitive
impairment and learning disabilities. Although Ms. B.
agreed to have the collaborative team teaching staff
trained in CM, it appeared likely that this new setting
484 VERDUIN, ABIKOFF, KURTZ
would be more challenging. At the urging of Peter’s
therapist, teachers, and principal, his mother attended
a medication consultation with a child psychiatrist at
NYUCSC.
GENERAL ISSUES AND SUMMARY
Although Peter’s treatment was informed by EBT prin-
ciples, some limitations are noteworthy. The desire of
Peter’s mother and teachers to quickly implement the
CM system precluded collection of data on DRC targets
before they were reinforced—information that would
have served as a key basis for comparison. Moreover,
with only pre- and posttest scores on measures, any
changes could be due to regression to the mean rather
than treatment effects. Furthermore, ideographic data
were not locally normed and were collected by only
one reporter (SEIT). Because of these limitations,
Peter’s actual treatment progress is difficult to unam-
biguously evaluate. Whenever possible, at least two
baseline assessments of reliable, normed data should
be obtained.
Some of these limitations were related to the degree
of involvement Peter’s mother and teachers had in his
treatment. Peter’s caregivers were clearly central to his
treatment in many ways. The interventions described
herein were shaped by their strengths but also by their
preferences, some of which were not consistent with
EBT principles. His mother’s consistent practice of
PCIT skills led to rapid, sustained gains. His principal
and teachers learned and skillfully implemented several
evidence-based interventions. Yet treatment may have
progressed differently were it not for initial resistance
to TO and reluctance to update the DRC with hyperac-
tivity and inattention-oriented targets. Although Peter’s
therapist had a responsibility to advocate for the best
known treatment practices, he had to do so flexibly to
maintain rapport and remain effective.
Peter’s age also presented unique challenges. Were he
a few years older, the assessing and treating clinicians
would have more confidently recommended combined
or sequenced pharmacologic and behavioral treatments
rather than behavioral treatment alone. As with phar-
macologic interventions, elements of Peter’s behavioral
treatment had little empirical support with preschool-
age children. For instance, the DRC and other
classroom CM elements have not been thoroughly stud-
ied in preschool students and could have proved too
sophisticated for Peter’s developmental level. The lim-
ited research on classroom interventions for preschool
ADHD not only made Peter’s treatment response diffi-
cult to predict, it also provided few guidelines for adapt-
ing these tools for use in a preschool setting. Clinical
judgment and careful consideration of treatment data
were therefore needed to determine whether these inter-
ventions were beneficial, ineffective, or even counterpro-
ductive. This ongoing process, aided by the dedicated
involvement of Peter’s mother and teachers, yielded a
treatment that was informed by research-supported
principles and techniques, yet tailored to Peter and his
environment—essential qualities of evidence-based
practice.
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