R&R2


R&R2 for ADHD Youths and Adults
A Prosocial Competence Training Program

This program was designed by Dr. Susan J. Young & Dr. Robert R. Ross in 2005 for the many youths and adults whose antisocial behaviour or offending behaviour is associated with some or all of the characteristics of Attention Deficit Hyperactivity Disorder (with or without a diagnosis). Attention deficit hyperactivity disorder (ADHD), is a neurodevelopmental disorder with core symptoms of inattention, impulsivity and hyperactivity that often result in significant impairment in academic and/or social functioning. The program has been field tested with offenders in secure forensic hospitals in England. Initial results of a controlled study in Iceland are summarized in the "News" section of this web-site.

ADHD and Antisocial Behavior

There is substantial evidence of a  relationship between ADHD and a variety of disruptive and antisocial behaviours including negativism, hostility, and defiance; frequent loss of temper, arguments with adults, and/or annoyance with others; frequent refusals to comply with rules; and sensation-seeking and risk-taking. ADHD has consistently been reported in studies of antisocial behaviours with incidence ranging between 25% and 60% (Young et at., 2003). ADHD youth with co-morbid conduct disorder are more likely than their peers to be sexually active at a young age, smoke, drink, use illegal substances, and engage in other risky behaviors. They are at much greater risk of academic suspension or expulsion, physical injury from fighting, and legal problems. ADHD youths are four to five times more likely to be arrested and to have multiple arrests and convictions.

ADHD and Cognitive Skills

Many individuals with ADHD evidence inadequate development in the social cognitive skills that are associated with antisocial behavior including making decisions without adequate information; errors in judgment; acting without thinking;  poor planning; excessive attraction to immedi­ate rewards; failing to recognize social cues; failing to understand the effects of their behavior on others or misinterpreting the behaviour of others. Many are rigid and inflexible in thought and behav­ior. Their inattention, distractibility and impatience and their frequent and unpredictable mood swings may be perceived by others as obnoxious behavior. Consequently, they encounter frequent rejection and fail to acquire adequate knowledge of social rules, roles, and manners and may become socially isolated or ostracized.

ADHD and Emotional Skills

They may also evidence difficulties in managing their emotions. They are likely to frequently experience depressed feelings. Many are hyperaroused in­dividuals with a tendency toward angry outbursts and violence. They may quickly respond with anger in the face of minimal provocation or they may build up frustration over a long period of time. They may vent their frustration and angry feelings by lashing out at others.

Just as in the case of many offenders with inadequately developed cognitive skills, the ADHD individual who has experienced failure in many of his/her academic and social endeavours is likely to evidence low self-esteem and to lack self-efficacy.

Adult ADHD

ADHD symptoms may be present not only during childhood and adolescence but throughout adult life. Many continue to be symptomatic in adulthood. Studies of prison populations in several countries indicate that between 22% and 67% of inmates had childhood ADHD. Many experience a gradual improvement in some of their symptoms with maturation. However, many are left with a sense of helplessness and significant per­sonal, social, and occupational problems.

Program Development

Many treatment programs, including R&R, have difficulty engaging individuals with ADHD related symptoms. Their behaviour in groups is likely to be disruptive. They may not pay adequate attention to the program. Their restlessness and their provocative behavior may disrupt other participants, distress them and/or incite them such that not only the behavior of the ADHD participants but that of the other participants pose significant management problems for trainers. Their poor concentration, hyperactivity and inattention may lead to their being viewed as untreatable. They may, in fact, actually be untreatable if trainers fail to recognize the underlying ADHD symptoms and fail to ensure that the program is designed to respond to and treat the underlying condition. Advancements in treatment options, however, have been minimal and rely primarily on pharmaceutical interventions.

Individuals who evidence ADHD symptoms require a specialized program. That is why R&R2 for ADHD Youths and Adults was developed. It targets the core dimensions of ADHD in order that the participants can benefit from the training in the prosocial cognitive/emotional skills and values that are taught in the R&R program. The program is designed to target not only individuals who have been diagnosed with ADHD but for the much larger population of individuals who have not been diagnosed but evidence some or all of the ADHD characteristics.

The program is designed for four groups of adolescents and adults (age 13+) who evidence ADHD symptoms:

  • a) adolescents who have poor behavioral control, exhibit disruptive behaviour, or conduct problems at home and/or school, and are "at risk" of progressing to more severe antisocial behavior;

  • b) youths under the supervision of social service agencies or youth justice agencies;

  • c) adults whose ADHD symptoms engenders interpersonal problems, poor productivity and/or disruptive behavior at work;

  • d) adults under the supervision of community criminal justice agencies or in institutions.

The vast majority of antisocial youths and adults are typically looked upon simply as having behavior problems and little, if any consideration is given to the possibility that they may have an underlying ADHD problem. Many of these individuals have ADHD or residual symptoms but are seldom adequately diagnosed. Only a small percentage of those with obvious ADHD symptoms are referred for specialized diagnosis for this disorder and most receive only pharmacological treatment.

The program provides specially designed training to target the inattention, lack of concentration, impulsivity and hyperactivity that are associated with poor interpersonal relationships, educational underachievement, employment problems and other social, financial, legal and/or relationship difficulties that reflect a lack of prosocial competence. 

The program provides neurocognitive skills training techniques to improve attentional control, memory, impulse control and to develop achievement strategies by teaching constructive planning and management techniques. Participants who apply those skills acquire specific prosocial competencies in coping with their ADHD symptoms. The behavioural control and listening skills they acquire help the participants to focus on the exercises that have been designed to develop pro-social attitudes, skills and values.

Field-testing

The program has been extensively field tested with some of the most serious offenders – mentally disordered offenders in secure hospital settings in England.  It is currently being translated by the Division of Psychiatry at the Landspitali-University Hospital for implementation in Iceland and evaluated through a doctoral dissertation at King's college in London.

Program Delivery

The program spans a broad age range designed to be taught in age-appropriate groups, e.g. 13-15, 15-18, 18-25 etc.    Thus the program has been designed to provide maximum flexibility for Trainers so they may be applied at the most appropriate developmental level of the participant. 

The program can be delivered in schools; learning centers; counselling centers; social service agencies; and in probation, prison or hospital settings.

Program Content

Five modules are included:

  • Neurocognitive Module which introduces techniques to improve attentional control, memory, impulse control and develop skills in constructive planning;
     

  • Problem Solving Module which engages the individual in a process of skilled thinking as opposed to automatic thinking, scanning for information, problem identification, generating alternative solutions, consequential thinking, managing conflict and making choices;
     

  • Emotional Control Module which includes managing thoughts and feelings of anger and anxiety;
     

  • Social Skills Module which includes the recognition of the thoughts and feeling of others, both verbal and nonverbal, social perspective taking and the development of empathy, negotiation skills and conflict resolution.
     

  • Critical Reasoning Module which teaches that individuals have choices to make in life, that there are alternative possibilities, and trains them in effective skills in thinking and behaving, in evaluating options, and in making good choices

Design

The program is manualized and highly structured and there are clear instructions for the Trainer to follow in a Trainers Guide.  A variety of innovative training techniques are used to engage the individual and to make the ‘training’ fun by incorporating games, individual and group exercises, role-playing, brainstorming, audiovisual material, and participants’ workbooks. 

There are 15 sessions. Each session requires 90 minutes of training (with breaks) and includes out-of-class assignments.  Sessions may be delivered once a week or more frequently.

Training Video

The program kit includes a video of the program developer, Dr. Young, modeling  training in the program in a secure hospital setting.

Assessment

A major problem, particularly in the juvenile and adult justice systems, is that individuals'  ADHD may be undetected. Routine assessment rarely includes adequate measures of ADHD. Moreover, many individualks with ADHD evidence comorbid problems of personality, mood, anxiety and/or substance misuse which become the focus of attention.
 

A screening measure, the “RATE” rating scale has been developed to determine the suitability of participants. It is specifically designed to identify individuals whose antisocial behaviour is associated with symptoms of ADHD. The RATE measure that is included in the program kit provides 4 sub-scales:
 

      • ADHD symptom scale

      • Emotional problem scale

      • Antisocial behaviour scale

      • Social functioning scale

The RATE can also be used as an outcome measure to evaluate progress. 

Participants Workbook

Participants are given a Participants Workbook which provides a summary of each session that includes a review of what they have learned and their 'homework' assignment. It also provides a variety of exercises for them to complete during or after the sessions.

PAL’s Guide

A novel feature of the program is the "PAL" (Participant’s Aide for Learning). Prior to attending the program, each participant is asked to select a PAL.  A PAL may be a parent, friend, or member of staff. The PAL must be in regular contact with the participant and must be able to meet with the participant at least once per week.

The PAL component of the program is designed to maintain participants' motivation and attendance and to reinforce their acquisition and practicing of the skills they are learning in the sessions. The PAL serves as a prosocial model and makes suggestions about how the participant can introduce new techniques and skills into their everyday life. This helps the transfer of skills and makes the program seem more personal.  The PAL has a Guidebook which defines the PAL's role, explains their role and provides helpful suggestions. The PAL helps to generalize the participants' skill acquisition from the classroom to their everyday living.

Booster Sessions

Another feature is the provision of a three-session follow-up or Booster Program.  The purpose of these sessions is to remind participants of the skills they have learned from participating in the main program, to reinforce them in order to further consolidate these skills, and to provide them with additional and longer term support. 

 

  • Link: International Collaboration on ADHD and Substance Abuse. ICASA strives to find answers and solutions for a better quality of life for people with ADHD and an addiction via high quality research. http://www.adhdandsubstanceabuse.org