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Summer Treatment for ADHD and Related Issues

A Summer Treatment Program (STP) provided through a partnership of
the University of Illinois-Chicago (UIC) and the Jewish Council for Youth Services (JCYS)

Children with Attention Deficit Hyperactivity Disorder (ADHD) struggle to fit in at typical camps
that do not provide the structure or resources to address hyperactive or inattentive behavior. These
children are often ridiculed or left out by peers because they can not sustain attention long enough to
follow rules of games, comprehend the directions for group activities or interpret the social cues of
others. Camp STAR, a summer treatment program for ADHD, therefore, gives children who feel
beaten down and their caregivers who are losing hope a chance to feel successful and enjoy their
summer. Camp STAR is located in Highland Park, IL and is the first STP to be run in the Midwest.
The University of Illinois at Chicago (UIC) and the Jewish Council for Youth Services (JCYS) are
proud to offer Camp STAR for its third summer to two or three groups of 12 campers, depending on
enrollment (24-36 campers total).
The effectiveness of the summer treatment program model is research based. The results of
the Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (MTA Study)
indicate that children who attended a summer treatment program while receiving medication
management show less anxiety, enhanced academic performance, reduction in oppositional
behavior, improved social skills and better familial relationships than those treated with medication
alone. Children who participated in summer treatment programs across the country also maintained
a high level of success with lower doses of medication than children who did not receive behavioral
treatment (National Institute of Mental Health [NIMH], 2006).
The summer treatment program model is a reward-based system in which the children’s
behavior is shaped through a point system. Throughout a day enhanced to promote participation and
peer interaction and filled with typical camp activities, children earn points for pro-social behaviors
(such as contributing to a group discussion or sharing with a peer) and lose points for maladaptive
behaviors (such as interruption or intentional aggression). Each week the children vote on a field trip
destination as a group and work to increase their point totals so they can earn the field trip. The field
trips are special because the children leave campus, which gives them an opportunity to use the skills
they learn in a natural setting.
One way the summer treatment program fosters social skills is though the introduction of a
“Social Skill of the Day” such as “taking turns” in the morning discussion. This skill is reviewed
throughout the day so the children practice and learn to use the social skill in a variety of settings.
Also in the morning discussion the children receive awards based on observations the counselors
made the prior day. The awards provide concrete specific labeled praise for behaviors such as
exemplary use of the social skill of the day, positive attitude or a making a great shot in basketball.
The children have two recreational activities (recs) each day. Before each rec there is a group
discussion, in which the rules are reviewed and a new skill or rule is introduced. The first rec of the
day is a skills drill, so the children are divided into three groups based on their ability. The groups
rotate through stations designed to help all kids feel successful. During the second rec of day the
group is divided in half and the children have the opportunity to play a game. Throughout the recs all
the counselors ask the children attention questions about instructions they have given or what has
happened in the game to keep the children engaged and help them earn points. After the rec there is
a group discussion to talk about what went well and what the campers need to work on. The
counselors help facilitate the pace of the drills and games to keep all children involved.
In addition to athletics there is an academic portion of the camp day. Children attend an
academic learning center (ALC) led by a teacher, who is assisted by an educational counselor. The
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first portion of ALC is seatwork, where the children are given worksheets to complete based on their
individual academic level. In the second half of ALC the children work with partners on a group
activity. The children are motivated to complete their work and follow the activity rules so they earn
“Star Student” which brings special privileges such as the opportunity to choose their partner, or take
a pick from the prize box. The campers also enjoy computers where they play exciting games and art
where they can express their creativity (A typical camp schedule can be seen on page #6). In the
MTA study when children returned to school after participating in a summer treatment program both
teachers and parents reported a higher level of satisfaction in the outcome of those children in
comparison to teachers and parents of children who received only medication management or
community based treatment (NIMH, 2006).
Throughout the summer the children’s progress is tracked and systematically monitored
through point totals and daily report cards. Each morning the campers have a one-on-one discussion
with a counselor to talk about their progress and individual goals. The summer treatment model can
maintain unparalleled consistency because dedicated psychology and education students participate
in an intensive training program to learn the behavior modification methods (the components of
training can be seen on page 7). The counselors meet daily with a clinical psychologist to discuss
individual treatment goals for the children, ensure progress is being made and address any clinical
issues that arise. There are checks throughout the summer to ensure fidelity to the point system and
the reliability of the counselors in each group.
This high level of consistency is maintained at home through a home daily report card.
Parents attend a training session each week led by a clinical psychologist and camp counselors so
they can learn to use the behavior programs the children are familiar with from camp in their homes.
Follow-ups to the MTA Study show that parents of children who participated in a summer treatment
program and received medication management began using more constructive parenting methods,
such a setting limits and defining clear expectations and consequences in comparison to the parents
of kids with only medication management, or community based treatment (MTA Cooperative Group,
2006).
At the summer treatment program children learn the rules for sports, how to initiate and
maintain friendships and what is socially appropriate in various situations while simultaneously
building self-esteem. Many of the children who will attend the summer treatment program enter
feeling defeated because they are constantly yelled at by teachers and adults, and thus have learned
to seek negative attention. At the summer treatment program counselors never raise their voice or
yell at the campers. If a negative behavior occurs the counselors announce the point loss in a neutral
tone and begin praise or positive reinforcement at the first available opportunity. This shows the
children they are capable of earning positive attention. The self-esteem the children develop at camp
gives them the confidence to succeed during the school year.
Camp STAR, the Midwest’s first and only Summer Treatment Program for ADHD and Related
Issues, serves children who do not fit in at typical camps as a result of their ADHD symptoms. These
children are given the opportunity to have fun and feel successful in a camp setting with the goal of
eventually entering a mainstream camp. The summer treatment program is a unique opportunity to
improve the quality of life for many Chicago-area children, while providing a setting for research
endeavors to help us learn more about effective treatments for ADHD.

Works Cited

National Institute of Mental Health, NIMH Research on Treatment for Attention Deficit
Hyperactivity Disorder (ADHD): Questions and Answers about the Multimodal
Treatment Study. Retrieved November, 17, 2007, from the World Wide Web:
http://www.nimh.nih.gov/health/trials/nimh-research-on-treatment-for-attention-deficit-
hyperactivity-disorder-adhd-questions-and-answers-about-the-multimodal-
treatmen.shtml
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Wells, K. C., Chi, T.C., Hinshaw, S. P., Epstein, J. N., Pfiffner, L., Nebel-Schwalm, M., Owens,
B., Arnold, L. E., Abikoff, H. B., Conners, C. K., Elliott, G., Greenhill, L., Hechtman, L., Hoza,
B., Jensen, P. S., March, J., Newcorn, J. H., Pelham, W. E., Severe, J. B., Swanson, J.,
Vitiello, B., and Wigal, T. (2006). Treatment-Related Changes in Objectively Measured
Parenting Behaviors in the Multimodal Treatment Study of Children With Attention-
Deficit/Hyperactivity Disorder. Journal of Consulting and Clinical Psychology. 74(4), 649–657.
Schedule

GROUP 1 GROUP 2 GROUP 3

Arrivals Arrivals Arrivals
8:00-8:10 8:00-8:10 8:00-8:10
Morning Discussion Morning Discussion Morning Discussion
8:10-8:25 8:10-8:25 8:10-8:25
Transition Transition Transition
8:25-8:30 8:25-8:30 8:25-8:30
ALC Seatwork Art Rec 1 (skills drill)
8:30-9:00 8:30-9:20 8:30-9:20
ALC Partner Time Transition Transition
9:00-9:30 9:20-9:30 9:20-9:30
Snack Rec 1 (skills drill) Art
9:30-9:50 9:30-10:20 9:30-10:20
Computer Transition Transition
9:50-10:20 10:20-10:30 10:20-10:30
Transition Computers ALC Seatwork
10:20-10:30 10:30-11:00 10:30-11:00
Rec 1 (skills drill) Lunch/Recess ALC Partner Time
10:30:11:20 11:00-12:45 11:00-11:30
Lunch/Recess Rec 2 (game) Lunch/Recess
11:20-12:20 11:45-12:35 11:30-12:15
Vehicular Transition Vehicular Transition Vehicular Transition
12:20-12:35 12:35-12:50 12:15-12:30
Locker Room Locker Room Locker Room
12:35-12:50 12:50-1:05 12:30-12:45
Pool Pool Pool
12:50-1:35 1:05 -1:50 12:45-1:30

Locker Room Locker Room Locker Room

1:35-1:50 1:50-2:05 1:30-1:45
Vehicular Transition Vehicular Transition Vehicular Transition
1:50-2:05 2:05-2:20 1:45-2:00

Rec 2 (game) Snack Rec 2 (game)

2:05-2:40 2:20-2:40 2:00-2:50

Transition ALC Seatwork Snack

2:40-2:50 2:40-3:10 2:50-3:10

Art ALC Partner Time Computer

2:50-3:40 3:10-3:40 3:10-3:40
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End of Day Discussion End of Day Discussion End of Day Discussion

3:40-4:00 3:40-4:00 3:40-4:00

*This is to show what a typical schedule would look like, and all the activities included in the day. It
could change based on what time the pool is available and other variables.

Training
• Overview of ADHD, ODD and Autism Spectrum Disorders
• Overview of the results of the MTA Study and why the STP format is effective
• Written and verbal testing on the operational definitions of all point system behaviors and all
activity rules
• Overview of medications children in the camp may be taking
• Explanation of how to give effective commands
• Lesson on appropriate tone of voice used to call points
• Lesson on recording and scoring point sheets
• Mock discussions
Morning Discussion - occurs first everyday of camp, run by the lead counselor
End of the Day Discussion – occurs last every day of camp, run by the lead counselor
Pre-activity Discussion – occurs before every game/skills drill, run by the sport leader
Post-activity Discussion – occurs after every game/skills, run by the sport leader
Reparation Discussion – occurs of there is an incident of stealing or intentional
destruction of property, run by the lead counselor
Problem Solving Discussion –occurs if the group as a whole is having a particularly
difficult day, or at a field trip if the number of rule
violations is close to causing the trip to end early
Fieldtrip Discussion- occurs Friday afternoon before the field trip, run by the lead
counselor
• Role-playing of soccer, softball and basketball games and skills drills (some counselors will
pretend to be kids, some counselors will act as counselors, and some counselors will record
points)
• Role-playing of the time-out procedure
• Role-playing of the academic learning center (partner time and seatwork)
• Crisis Prevention/Intervention Training
• Groups are given time to review the files of their campers and make a summary sheet
• Lesson on Daily Report Cards (creating effective target behaviors, and tracking)
• Lesson on daily clinical progress notes
• Posters are made by the sport leaders to chart the campers progress at the different skills
• Sport leaders meet to discuss potential skills drills to be used at camp
• Honor Roll counselor creates a poster to show the field trip levels

Summer Treatment Program Description

This document includes background information regarding ADHD and the Summer Treatment
Program (STP) model, which was developed by William Pelham, and is used at Camp STAR. Please
mark any information that is not clear to you so that we can provide more information later. Also,
please make a list of specific questions that you have regarding any of the treatment components,
counselor responsibilities, or general program procedures.
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Attention Deficit Hyperactivity Disorder (ADHD) is one of the major mental health disorders of
childhood. ADHD is present in 3% to 5% of the elementary school population, mostly boys, and it
accounts for more referrals to mental health counselors and pediatric services than any other
childhood disorder. Children with ADHD are unable to sustain attention to tasks, a problem that
results in difficulty following directions and failure to complete assignments at school and at home. In
addition, children with ADHD are unable to inhibit their impulses and to control their activity level. As a
result, children with ADHD are severely disruptive in settings such as classrooms in which they are
required to be quiet or to pay attention. Impulsivity also leads to serious disturbances in children's
relationships with parents, teachers, peers, and siblings. In addition, up to half of children with ADHD
are also diagnosed as having a learning disability (LD), or one of the other externalizing disorders of
childhood—oppositional/defiant disorder (ODD) or conduct disorder (CD). Children with
oppositional/defiant disorder show a pattern of disobedient, negative, and provocative responses to
adult authority figures. Children with conduct disorder exhibit such antisocial behaviors as aggression,
stealing, and lying.

Summer Treatment Program Overview

Goals of Treatment
A social learning approach is employed in the summer treatment program, and it focuses on the
following six general goals:

1. Developing the children's problem solving skills, social skills, and the social awareness
necessary to enable them to get along better with other children (e.g., reduction of aggressive
behaviors)
2. Improving the children's learning skills
3. Developing the children's abilities to follow through with instructions, to complete tasks that
they commonly fail to finish, and to comply with adults' requests
4. Improving the children's self-esteem by developing competencies in areas necessary for daily
life functioning (e.g., interpersonal, recreational, academic) and other task-related areas
5. Teaching the children's parents how to develop, reinforce, and maintain these positive
changes
6. Evaluating the effects of medication on the children's academic and social functioning in a
natural setting

Point System
This system is a token economy in which children earn and lose points contingent upon their
behavior. The specific problematic behaviors that the point system targets are commonly exhibited by
children with ADHD, ODD, Asperger’s Disorder, and other disorders of childhood. Children exchange
points for a variety of rewards, including privileges, field trips, and special honors. This type of
treatment program provides for the efficient use of incentives because it uses tokens or points as
mediators that let individuals know immediately the consequences of their behaviors without having to
provide an immediate reward.

Consistent implementation of the point system is important to insure maximally effective treatment for
the children, and to provide data for the various research protocols that are conducted during the
program.

The first step toward insuring consistency of implementation is that clinical staff members must
arrive for training having memorized, verbatim, the list of point system behaviors, including
point values and notes; the operational definitions of the point system categories, including
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notes; the rules for classifying point system behaviors, and the activity rules and notes. This
information is contained in the manual that is sent to all staff members prior to training.

Following is a list of the positive and negative behaviors that are included in the point system. The
negative behavior categories are weighted more than the positive categories to encourage relatively
higher rates of positive behaviors than negative behaviors. The children are provided with this list of
point system behaviors during the first week of the program.

Positive Interval Categories Points Earned

1. Following Activity Rules 50 points
2. Good Sportsmanship 25 points
3. Point Check Bonus 25 points
Positive Frequency Categories
4. Attention 10 points
5. Complying with a Command 10 points
6. Helping a Peer 10 points
7. Sharing with a Peer 10 points
8. Contributing to a Group Discussion 10 points
9. Ignoring a Negative Stimulus 25 points

Negative Frequency Categories Points Lost

1. Violating Activity Rules 10 points
2. Poor Sportsmanship 10 points
Negative Physical Categories
3. Intentional Aggression Toward a Peer or
Toward a Staff Member 50 points
4. Unintentional Aggression Toward a Peer or
Toward a Staff Member 50 points
5. Intentional Destruction of Property 50 points and reparation
6. Unintentional Destruction of Property 50 points and reparation
7. Noncompliance 20 points
8. Repeated Noncompliance 20 points
9. Stealing 50 points and reparation
10. Leaving the Activity Area Without Permission 50 points

Negative Verbal Categories

11. Lying 20 points
12. Verbal Abuse to Staff 20 points
13. Name Calling/Teasing 20 points
14. Cursing/Swearing 20 points
15. Interruption 20 points
16. Complaining/Whining 20 points

Counselors award and take points throughout the treatment day and share the responsibility of
recording points during the different daily activities. At the end of each day, counselors summarize the
point sheets and enter the data into the STP database.

Positive Reinforcement and Appropriate Commands

Staff members employ social reinforcement in the form of praise and public recognition to provide a
positive, supportive atmosphere for the children. In addition to the liberal use of social reinforcement,
staff members attempt to shape appropriate behavior by issuing commands with characteristics that
maximize compliance in children with ADHD (e.g., explicit, brief, firm).

Time Out
Campers receive time-out for engaging in intentional aggression, destruction of property, or repeated
noncompliance. The initial time assigned is relatively long (e.g., 15 minutes) but the child immediately
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begins to earn time off for “good behavior” (a 15 minute time out would typically be reduced to only 7
minutes). This puts the child in an earning situation—if the child brings his or her behavior under
control, the time-out is reduced. All staff members are trained in crisis intervention, which is only used
if a child exhibits a behavior that is potentially dangerous to herself or another person.

Social Skills Training

Treatment also includes daily training in social skills. Counselors conduct brief small group sessions
that include direct instruction, modeling, role-playing, and practice in the key concepts of
communication, participation, cooperation, and social reinforcement. Throughout the seven weeks of
the STP, the social skills taught are reviewed, monitored and reinforced by counselors during group
activities. The combination of a reward/cost program and social skills training has been shown to be
necessary to effect the development of better social skills in children with externalizing disorders.

Sports Skills Training

Counselors provide intensive coaching and supervised practice in sports and game skills. Children
with ADHD typically do not know and follow the rules of games, and they have poor motor skills. Poor
abilities in these domains contribute to children's social rejection and low self-esteem. Therefore, one
recreational period each day is devoted to small-group skills training in an age-appropriate sport (e.g.,
softball, soccer, kickball, basketball, tennis) and one recreation period is devoted to playing games.
Counselors also teach the fundamentals of swimming during the group's daily swimming period.

Daily Report Cards

Clinicians and counselors select individualized behavior goals for each child. Parents provide positive
consequences at home to reward their child for reaching her or his goals on the daily report cards.
Daily report cards provide feedback to parents regarding their children's response to treatment.

Group Problem-Solving Discussions

Children also have sessions in which they learn group problem-solving skills that involve the following
four-step procedure: (1) identification of problems that interfere with group functioning; (2) discussion
and negotiation through which resolutions to problems can be reached; (3) making written contracts
that specify the problems, their resolution, and the consequences that are to be applied if the
contracts are kept or broken; and (4) evaluation and modification of the contracts. Problem-solving
discussions are called by counselors or by children whenever the need arises. Counselors conduct
the discussions with all members of the group and discussions continue until the group reaches a
resolution and all members of the group sign a contract.

Individualized Programs
Clinical staff members should develop and implement individualized programs when the point system,
time-out procedure, daily report card procedure, and other standard treatment components are either
insufficient or inappropriate methods of producing necessary changes in behavior. These programs
may involve modifications to existing components of the existing program, although some
individualized programs may involve the addition of a procedure or reinforcement system.

Medication Assessment
Medication with a central nervous system stimulant drug is the most commonly used treatment for
ADHD children, with 90% of children with ADHD receiving a stimulant drug at some time. If parents
are interested careful assessments of medication efficacy and tolerability can be conducted in order
to insure that children are properly medicated.

Parent Training
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In addition to the children's involvement in the day treatment program, their parents also participate
in the STP. To facilitate transfer of the gains children make in the STP to their home settings, their
parents come to the STP for one evening per week to receive training in how to implement behavior
modification programs at home. The UIC clinical staff and the lead counselors conduct the parent
training groups.