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Cognitive Behavioral Treatment
in Children with Attention Deficit
Hyperactivity Disorder1
Tratamiento cognitivo conductual en niños con trastorno
de déficit de atención e hiperactividad
2 3
Gladys Wilma Rivera Flores y Victoria Aymé Barreda Parra
Recibido: 26- Junio - 2014 ● Revisado: 15-Agosto- 2014 ● Aprobado: 09- Septiembre-2014
Abstract Resumen
This research determines the effect of the cognitive Esta investigación establece el efecto del tratamiento
behavioral treatment (CBT) in the core symptoms of cognitivo conductual (TCC) en los síntomas centrales
the attention deficit hyperactivity disorder (ADHD), del trastorno por déficit de atención e hiperactividad
impulsive cognitive style, sustained attention, self- (TDAH), estilo cognitivo impulsivo, atención sosteni-
esteem and anxiety. The subjects were 20 private school da, autoestima y ansiedad. Los participantes fueron
children aged 6 to 9 years with ADHD from Arequipa 20 niños de Arequipa de 6 a 9 años de edad con TDAH
distributed in control and experimental groups. Both de colegios particulares distribuidos en grupo control
groups completed before and after the CBT tests that y experimental. Ambos grupos respondieron antes y
assess inattention, hyperactivity-impulsivity, impulsive después del TCC pruebas que miden la inatención,
cognitive style, sustained attention, self-esteem and hiperactividad-impulsividad, estilo cognitivo impulsivo,
anxiety. The results show a significant decrease in inat- atención sostenida, autoestima y ansiedad. Los resultados
tention, hyperactivity, impulsivity, impulsive cognitive muestran una disminución significativa en la inatención,
style and a significant increase in sustained attention in hiperactividad, impulsividad, estilo cognitivo impulsivo y
the experimental group after the treatment. Contrary un aumento significativo de la atención sostenida en el
to what was expected, CBT did not affect self-esteem grupo experimental después del tratamiento. Contrario
and anxiety of children with ADHD after the treatment. a nuestras expectativas, el TCC no afectó la autoestima y
ansiedad de los niños con TDAH después del tratamiento.
Key words authors: Attention Deficit Hyperactivity Palabras clave autores: Trastorno de déficit de atención
Disorder, Impulsive Cognitive Style, Sustained Attention, e hiperactividad, Estilo cognitivo impulsivo, Atención
Self-Esteem, Anxiety, Cognitive Behavioral Treatment. sostenida, Autoestima, Ansiedad, Tratamiento cognitivo
conductual.
Key words plus: Attention Deficit Disorder with Hype- Palabras clave descriptores: Trastorno por Déficit de
ractivity, Attention, Self Concept, Anxiety, Cognitive Atención con Hiperactividad, Atención, Autoimagen,
Therapy. Ansiedad, Terapia Cognitiva.
1. Este artículo es derivado del proyecto de investigación doctoral “Efectos del tratamiento cognitivo conductual
para niños con el trastorno de déficit de atención e hiperactividad” presentado en la Universidad Nacional
de San Agustín (Arequipa-Perú).
Para citar este artículo: 2. Doctora en Psicología y Especialista en Educación Especial e Inclusiva con atención a la diversidad por la
Rivera Flores, G. W. y Barreda Parra, Universidad Nacional de San Agustín. Docente Auxiliar de la Universidad Católica de Santa María (Perú).
V. A. (2014). Cognitive Behavioral Correo electrónico: gladys_wrf@yahoo.es
Treatment in Children with Attention 3. Doctora en Psicología. Docente Principal del Departamento Académico de Psicología de la Universidad
Deficit Hyperactivity Disorder. Revista
de Psicología Universidad de Antioquia, Nacional de San Agustín. Investigadora del Proyecto Diseño y Atención a las Oportunidades de Género en
6(2), pp.79-94. la Educación Superior de la Universidad de Alicante (España). Correo electrónico:abarredap@hotmail.com
Vol. 6. No. 2. Julio-Diciembre 2014
1. Main features
of attention deficit “Hyperactivity is
characterized by fidgetiness
hyperactivity disorder or squirming in one´s seat,
but not remaining seated
Attention deficit hyperactivity disorder (ADHD) when expected to do so,
(American Psychiatric Association, 2013) or hy- by excessive running or
perkinetic disorder (World Health Organization, climbing in situations where
2004) is a childhood disorder with a neurobiolog- it is inappropriate, difficulty
ical etiology, responsible for the core symptoms, playing quietly, talking
inattention, hyperactivity-impulsivity, which, in excessively and acting as if
turn, may affect multiple areas of functioning driven by a motor”
that are considered secondary features of the
disorder (Rapport, 2001). The diagnostic cri-
teria of the Diagnostic and Statistical Manual
of Mental Disorders (DSM) for ADHD are widely running or climbing in situations where it is
recognized by teachers, parents and clinicians inappropriate, difficulty playing quietly, talking
of different geographic regions, ethnicities excessively and acting as if driven by a motor.
and cultures (Bauermeister, Canino, Polanczyk The impulsivity manifests itself as the difficulty
& Rohde, 2010). The prevalence of ADHD has to wait their turn and the delay of responses;
been estimated at 5 % in school-age children children diagnosed with ADHD blurt out answers
(American Psychiatric Association, 2013). before questions have been completed, inter-
rupt or intrude on others´ conversations to the
Children with inattention symptoms often have point of causing difficulties in social, academic
difficulty to pay close attention to details and or occupational settings (American Psychiatric
sustain attention in tasks or games, do not seem Association, 2013; Shillingford, Lambie & Wal-
80 to listen when spoken to directly, do not follow ter, 2007).
through on instructions and fail to finish school-
work or chores, have difficulty organizing tasks Impulsive individuals rush through assignments
and activities, are reluctant to engage in tasks missing correct answers. This is the impulsive
that require sustained mental effort (such as cognitive style, a tendency to solve cognitive
schoolwork or homework), lose things necessary tasks quickly and incorrectly (López et al.,
for tasks and activities, are easily distracted 2010). Children get incomplete information and
by extraneous stimuli and are forgetful in daily answer intuitively without thinking, because
activities (American Psychiatric Association, they miss key steps for the appropriate problem
2013; Colonna-Preti, 2005; Ayora, 2004; Cebrián solving approach such as observing, gathering
& Pérez, 2005; Avila & Polaino-Lorente, 2002). information, analyzing, rejecting unnecessary
data, drawing up an action plan, examining all
Hyperactivity is characterized by fidgetiness possible answers, foreseeing the possible con-
or squirming in one´s seat, but not remaining sequences of each answer, making a decision,
seated when expected to do so, by excessive checking answers, self-congratulating if the
Universidad de Antioquia
answer is right or analyzing the information
and all alternatives again if the answer is wrong “The therapist should
(Orjales, 2002). know the child in detail,
Another cognitive function impaired in children his cognitive behavioral
diagnosed with ADHD is sustained attention profile, the age and the
(Aguiar, Eubig & Schantz, 2010). This cognitive level of impairment, in order
function enables the subject to direct attention to select and adapt the
to one or more sources of information over a most appropriate cognitive
relatively long and unbroken period of time once behavioral techniques for
the alert state is entered (Tucha et al., 2006; the specific child”
Tsal, Shalev & Mevorach, 2005; Oken, Salinsky
& Elsas, 2006). ADHD hinders a child´s capacity CBT can facilitate treatment tailoring if de-
to sustain attention (Daly, Creed, Xanthopou- livered appropriately (Abikoff, 2001); it is ef-
los & Brown, 2007); children find difficulty in fective if a) each patient is well-assessed and
keeping the alert state in monotonous tasks well-understood and the treatment matches
that require continual responses from the indi- the assessed needs and cognitive skills deficits
vidual, usually in dichotomic terms or answers of each individual; b) key adults implement
too far apart with long alert periods (Servera & the treatment in the environments where the
Llabrés, 2004). performance of those cognitive skills are re-
The cognitive impairments associated with quired; c) the length of time for the treatment
ADHD are not diagnostic criteria for the disor- is sufficient to effectively train skills and ensure
der because they constitute secondary features positive treatment effects over a longer period;
that often accompany ADHD and need to be and d) the outcomes are clinically meaningful
considered as part of a comprehensive clinical (Greene & Ablon, 2001).
formulation and multidisciplinary treatment
The therapist should know the child in detail, 81
plan (Nigg, 2011). his cognitive behavioral profile, the age and the
level of impairment, in order to select and adapt
1.1. Cognitive behavioral the most appropriate cognitive behavioral tech-
treatment for ADHD niques for the specific child (Orjales, 2007). The
treatment cannot remain the same day after day,
The aim of cognitive behavioral treatment it must be tuned to a moving target with each
(CBT) is that ADHD children self-regulate their successive session based on progressive changes in
own behavior according to rules, self-regulate the child (Whalen, 2001, p. 138). The treatment
their daily habits, use strategies to behave adjustments are directed to the progressive ac-
properly, select relevant data from irrelevant quisition of cognitive skills and behavioral perfor-
information, self-evaluate and self correct their mance planned in the overall treatment.
behaviors, develop a healthy self-esteem and
satisfactory relationships with others (Orjales, In CBT, ADHD children are taught to use self-in-
2002). struction, self-monitoring, self-reinforcement,
Facultad de Ciencias Sociales y Humanas. Departamento de Psicología
Vol. 6. No. 2. Julio-Diciembre 2014
problem solving and motivational strategies thoughts for solving problems; they replace
to develop self-control of their attention and wrong thoughts created by impulsive children
impulse behavior problems (Purdie, Hattie (Orjales, 2007). The self-instructional training
& Carrol, 2002). For example, children with in this study is based on the model developed
ADHD exhibit stop-signal performance deficits by Miechenbaum & Goodman and adapted by
(Alderson, Rapport, Sarver & Kofler, 2008) due Orjales (2007); the sequence is as follows: 1)
to cognitive impairments rather than behavioral First, I watch and say what I see, 2) what do
inhibition deficit (Alderson, Rapport & Kofler, I have to do?, 3) How will I do it?, 4) I have to
2007); this means that children are so uninhib- pay careful attention (and look at all possible
ited that they cannot stop and take a moment answers), 5) I can do it!, 6) Great! I did a good
to think about something beforehand, they are job/ I didn´t get the right answer. Why? (I re-
doing the first thing that is generated in their view all steps) Ah! This is why! The next time I
mind (Rindge, 2002). ADHD hinders a child´s won´t make any mistake (Orjales, 2007, p. 25).
capacity to exercise age appropriate inhibition These strategies of verbal mediation or self-talk
in behavioral settings or in cognitive tasks (Daly let the children pay attention for an unbroken
et al., 2007). To overcome inhibition, in CBT period of time and stay on task.
children are taught to use cognitive strategies
and the contingencies encourage them to delay At the same time, the cognitive self-instruction-
responding and to apply cognitive strategies al training of Miechenbaum & Goodman assists
(Purdie et al., 2002). children with processing cognitive thoughts into
adaptative appropriate behaviors. This model
Cognitive interventions are most effective when is often employed to aid students with impul-
they are combined with behavioral contingen- sivity difficulties. For example, ADHD children
cies in the natural environment at the time that who blurt out answers before waiting their turn
the problem behavior occurs (in the classroom during classroom discussion must be taught to
or home rather than at the clinic) and when give the answers to themselves quietly, without
82 they focus on specific training that matches interrumpting the class; besides, they may be
the desired performance as closely as possible taught to say words of restraint to themselves,
(Purdie et al., 2002). CBT is almost a step-by- such as “I can wait my turn” or “I know the
step approach to dealing with the individual, answer, but I´ll wait my turn”. The steps of
familial and scholastic factors (Wagner, 1993). this training are the following: a) Students are
Besides, CBT has more positive effects when trained to become aware of their maladaptative
parents and/or teachers get involved to promote thoughts, b) the therapist models appropriate
the generalization of the techniques at home behaviors while verbalizing effective actions
and/or at school (Pfiffner, 2003). strategies, c) the students then perform the
targeted behavior while verbalizing appropri-
The basic techniques of the treatment are ate self-instructions and then trying them out
self-instructions, contingent reinforcement and (Shilingford et al., 2007, p. 106).
response cost (Calderón, 2001). The self-in-
structional training is a cognitive technique When children diagnosed with ADHD apply
that teaches children a sequence of useful self-instructions to cognitive or social tasks or
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