Remediating Organizational Functioning in Children with ADHD: Immediate and Long-Term Effects from a Randomized Controlled Trial.

Organization, time management and planning (OTMP) difficulties, features of Attention-Deficit/Hyperactivity Disorder (ADHD), adversely affect children’s functioning and persist through adulthood (Barkley & Fischer, 2011). During childhood, poor organizational skills, manifested by misplacing or losing materials, forgetting materials, failing to record assignments and due dates, can compromise school performance and scholastic attainment (Power, Werba, Watkins, Angelucci, & Eiraldi, 2006). Impairments in time management and inefficient planning lead to difficulties starting and completing daily and long-term assignments (Barkley, Koplowitz, Anderson, & McMurray, 1997), which can contribute to conflicts with parents and teachers around school performance. Family conflicts also occur when children are disorganized with their belongings at home. When OTMP difficulties result in problems such as misplacing or forgetting materials for games and sports, peer relations can also be adversely affected (Dimantopoulou, Rydell, Thorell & Bohlin, 2007). Despite the negative impact of OTMP problems, few systematic efforts have targeted these problems in elementary-school aged children with ADHD, the age when youth first encounter expectations for many independent, organized behaviors at home and school. Two studies, which did not require quantified OTMP impairment for inclusion, reported gains in organizational functioning with behavioral treatment. An eight-week after-school intervention with 4th–7th graders (N = 37) “identified by school personnel as having ADHD-related problems and in need of academic intervention” (p.416), improved children’s organization of school materials and parent-rated homework problems. However, teacher ratings of academic performance did not differ for intervention and control (n = 13) students (Langberg, Epstein, Urbanowicz, Simon, & Graham, 2008). A randomized controlled trial evaluated a 12-week home-school intervention for youngsters with ADHD-Inattentive type (N = 69) consisting of teacher consultation, parent training, child training in social competence and independent living skills including organization skills (Pfiffner et al., 2007). Children’s organizational skills improved significantly with treatment and gains were maintained at a five month follow up; however, the groups did not differ in organizational skills at follow-up because of improvements in the control group. In a small placebo-controlled trial in children with ADHD and OTMP difficulties (N = 19), organizational functioning improved with stimulants, presumably because of improvements in ADHD symptoms; however, OTMP functioning for the majority of children remained in the clinical range (Abikoff et al., 2008). OTMP problems may represent behavioral manifestations of poor executive function (EF) (Barkley, 2006; Pennington & Ozonoff, 1996). Impairments in arousal, inhibitory control, delay tolerance, working memory, and time perception likely impede self-regulatory behaviors and interfere with organizing actions and planning (Barkley, Koplowitz, Anderson, & McMurray, 1997; Willcutt, Doyle, Nigg, Faraone, & Pennington, 2005). Thus, one approach for ameliorating OTMP difficulties may be through interventions that address such EF deficits. However, to our knowledge, there is no evidence from controlled studies that efforts to improve executive processes in children with ADHD ameliorate their OTMP difficulties. It is also conceivable that OTMP difficulties result primarily from specific skills deficits. Our clinical work with children with ADHD and OTMP problems suggested that many of these youngsters lack the knowledge and proficiency to effectively organize materials, track assignments, manage time and plan their work. If a skills deficit is operative, behavioral treatment that emphasizes skills instruction, practice, and breaking skills into sub-steps would be expected to be useful. Support for this notion was obtained in a pilot study of an Organizational Skills Training (OST) intervention in 3rd–5th graders with ADHD and OTMP difficulties (N = 20). OST significantly improved organizational behaviors at home and school and reduced homework problems and family conflicts (Abikoff & Gallagher, 2008). Finally, OTMP difficulties may result principally from a performance deficit. Namely, children with ADHD and OTMP problems may have the organizational knowledge and skills, but fail to apply them due to insufficient motivation, lack of carry through, and/or task avoidance. Underlying this performance deficit are two factors: 1) a motivational or “delay aversion” deficit (Sonuga-Barke, 2003), which makes it difficult for children with ADHD to wait for desired outcomes and work effectively over extended periods of time without considerable structure and reinforcement; and 2) deficits in executive function that adversely affect the ability to connect knowledge with performance in a manner that results in efficient self-directed adaptive behavior. Barkley (2006), a proponent of the performance deficit model, has described ADHD as primarily “not a disorder of knowing what to do, but of doing what one knows” (p. 324), due to faulty executive functions. If OTMP problems reflect a performance deficit, then interventions should enhance motivation by rewarding goal (i.e., “end-point”) behaviors, which should increase the occurrence of these behaviors and ostensibly reinforce the behavior chain linked to goal attainment as well. Uncertainty regarding whether children’s organizational difficulties result predominantly from skills or performance deficits is not unique to this functional domain; it reflects longstanding speculations about the presence and impact of skills and/or performance deficits on the functioning of children with ADHD (Douglas, 1983; Green & Ablon, 2001; Gresham, Sugai, & Horner, 2001; Stein, Szumowski, Blondis, & Roizen, 1995). The current study was informed by several issues noted above; namely, clinical observations of knowledge gaps and organizational skills deficits in children with OTMP difficulties, pilot results suggesting utility of a skills-based treatment, and a dearth of controlled studies evaluating the impact of performance-based interventions on the OTMP functioning of elementary-school children with ADHD. The study was designed to test the specific and relative efficacy of a skills-based intervention in ameliorating the organizational difficulties of children with ADHD, and to evaluate long-term maintenance effects. We hypothesized that skills-based treatment (OST) would be superior to: 1) a wait-list control (specific efficacy); 2) a performance-based intervention (relative efficacy); and that 3) treatment gains would be maintained significantly better for skills-based than for performance-based treatment. The study also compared the performance-based intervention and controls, although no a priori hypotheses were made. To test these hypotheses, we conducted a dual-site randomized controlled trial evaluating OST’s efficacy compared to (1) a wait-list control (WL) and (2) a performance-based, contingency management intervention (“Parents and Teachers Helping Kids Organize”, PATHKO), which targets OTMP “end-point” goals and precludes skill training, allowing for evaluation of interventions derived from different underlying deficit models on children’s OTMP functioning and key functional domains adversely affected by OTMP difficulties. Difficulty achieving generalization across settings and time has been a long-standing issue in ADHD psychosocial research (Hinshaw, Klein & Abikoff, 2007) attributed to a range of factors such as insufficient learning of target behaviors and skills, a focus on inappropriate treatment targets, restricted settings where treatment procedures are implemented, and focusing on broad rather than circumscribed aspects of functioning (Abikoff, 2009; Abikoff & Gallagher, 2008). Maintenance problems are especially common in contingency management interventions. Once children are no longer systematically reinforced for achieving targeted goals, reductions in behavioral gains typically occur (e.g., Barkley et al., 2000; Carlson, Pelham, Milich, & Dixon, 1992). Because OST ostensibly helps children learn specific skills whereas children in PATHKO are contingently reinforced for meeting OTMP end-point behaviors, we hypothesized that OST would result in significantly better maintenance effects compared to PATHKO when children were in the next grade, confronted with new and more complex OTMP demands.