The Adolescents are a punk band formed in 1980 in Fullerton, ..
Studies have found that exposure to rap music "tends to lead to a higher degree of acceptance of the use of violence." 11 In addition, several major rap artists have been charged with violent crimes in real life, 12 and many worry that their actions seemingly condone the violent messages in their music.
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To summarize the efficacy of training parents in behavior management methods, these methods receive a grade of B+ to A for use with elementary school aged children depending on which parenting approach is used. Compared to elementary school aged children, these approaches have not been as effective with preschoolers or adolescents with ADHD. Practical barriers, such as parental engagement, have seemed to limit studies with preschoolers. Innovations that improve the efficacy of parent-based interventions with teenagers with ADHD are sorely needed. Parent management training suffers from several practical limitations, such as the need for training providers, numerous demands placed on families, a commitment to use the methods consistently and persistently over a long period of time, and the need to tailor techniques in response to changing developmental and social factors. When used properly, these techniques can be very safe, but overly punitive or haphazard programs can actually make things worse. Paradoxically, some worsening of behavior (e.g., transient increases in tantrums when a parent starts ignoring the behavior) may suggest that parents are on the right track. This example illustrated the fact that the behavior methods that seem so simple at their basic conceptual level can be fraught with subtleties that confuse and frustrate parents. A limitation of these approaches is that many therapists do not have the skills and training to provide the sophisticated guidance that most parents need. Consequently, even though behavior methods can be used to get whales to jump through burning hoops, due to past failures with other providers many parents complain that their children’s behavior is completely impervious to change through behavioral methods. This is a significant limitation to the effectiveness of parent management training that must be handled delicately to recruit and retain parents in behavior management training. Intensive professional education and widespread public education to overcome ignorance and stigma associated with parent management training may be necessary for this to become truly grade A intervention for ADHD and related problems.
For teenagers with ADHD and oppositional behavior, there is little research on BPT. We have often recommended a family training program that includes the Problem Solving Communication Training Program (PSCT) developed by Robin and Foster (1989) combined with variations of Barkley’s BPT program. The efficacy of the Robin and Foster program used specifically with ADHD teenagers has been examined (Barkley, Guevremont, Anastopoulos, & Fletcher, 1992). This program was compared against the parent training program described above (Barkley, 1997a) that was modified somewhat for use with adolescents (e.g., token systems became point systems, time out was changed to grounding to the home, etc.). It was also compared against the family therapy program developed by Minuchin (Minuchin & Fishman, 1981). Families in each group received 8-10 sessions of therapy and multiple outcome measures of family conflict were collected, including videotaped parent-teen interactions. Results indicated that all three treatments produced statistically significant improvements in the various self-report ratings of family conflict but no significant improvements in the direct observations of parent-teen interactions. When statistics evaluating individual change and recovery were applied to these data, they revealed that only 5-30 percent of the families in these programs improved reliably from treatment and that only 5-20 percent had recovered (normalization) in their level of conflicts, with no significant differences among the groups in these reliable change and recovery percentages. Such results are quite disappointing and suggest that the power of treatment needs to be enhanced in various ways if it is to be of much value to most families of ADHD adolescents experiencing significant family conflict.
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Research specific to practical issues with stimulant medication is limited and the preliminary findings raise some questions about the effectiveness of this treatment in primary care settings. Although taking pills seems to be a simple intervention, there are some significant barriers to daily administration of stimulant medication including limited access to prescribing physicians, cost, inconvenience, uncertainty about dose or type of medication, side effects, and parent or child resistance to taking medication. Research on compliance is limited, but suggests that children and adolescents with ADHD tend to take less medication than prescribed due to missed doses and termination of treatment against medical advice (Jensen, Kettle, Roper, Sloan, Dulcan, et al., 1999). The high cost of some new formulations of stimulants ($60-100 per month) may contribute to an already tenuous compliance situation though their once-daily extended release delivery systems may counteract such a problem. The problems with compliance have high clinical liability because stimulants exert their effects only when taken as prescribed. Even the longest acting stimulants have no measurable effect 24 hours after administration, so missed doses mean the child is essentially untreated. Thus, although stimulants get high marks for safety and effectiveness, there are some practical barriers to effective use of stimulant medication.
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The following issues should be considered in the decision to employ medication for the management of ADHD: (1) the age of the child; (2) duration and severity of symptoms; (3) the risk of injury to the child if untreated (either by accident or abuse) by the present severity of symptoms; (4) the success of prior treatments; (5) relatively normal levels of anxiety (perhaps); (6) the absence of stimulant abuse by the child or adolescent or their caregivers; (7) the likelihood that the parents will employ the medication responsibly, in compliance with physician recommendations; and (8) the child does not live in a group setting such as a dormitory where supervision of the medication is poor and diversion of the medication to non-ADHD students may be more likely. Some of these latter concerns related to stimulant abuse (i.e., points 6 to 8) may be somewhat ameliorated by the longer-acting preparations of stimulants, such as Concerta, that have lower abuse potential than immediate release preparations.