Summer Treatment Program for Adolescents (STPA) - Cleveland Clinic

Program Description
Summer Treatment Program for Adolescents (STPA)
ADHD Center for Evaluation and Treatment (ACET)
The Children’s Hospital at the Cleveland Clinic
The Summer Treatment Program for Adolescents (STPA) is a comprehensive treatment program for
adolescents diagnosed with Attention-Deficit Hyperactivity Disorder (ADHD) and related problems. Adolescents
participate in developmentally appropriate activities from 8:30 AM until 5:30 PM for seven weeks. The program is
an integrated intensive treatment consisting of four major components:
1. behavior therapy in a summer day program setting
2. intensive academic skills training in a classroom designed to simulate a secondary school setting
3. development of prosocial interpersonal skills through constant feedback on social performance
4. a weekly parent training program that addresses the challenges frequently faced by parents of children
and adolescents with ADHD
Goals of Treatment
This cognitive-behavioral and social learning approach focuses on achieving the following six general goals:
1. Develop the adolescent's problem solving skills, social skills, and the social awareness necessary to
enable him/her to get along better with peers;
2. Teaching the adolescent appropriate behaviors and to improve his/her learning skills for success in
classroom situations to enhance academic performance and productivity;
3. Developing the adolescent's ability to follow through with instructions, to comply with adult requests,
and to complete tasks that he/she may commonly fail to finish;
4. Improving the adolescent's self-esteem by teaching him/her competencies in areas necessary for daily
life, such as interpersonal, academic, recreational, and other task-related areas;
5. Teaching parents how to develop, reinforce, and maintain these positive changes; and, if appropriate,
6. Evaluating the effects of medication on the adolescent's academic and social functioning in a natural
setting.
The program follows a set schedule from Monday to Thursday. This schedule includes classroom training
in note-taking, study skills, organization, and time management; athletic activities and sports skills training;
communication and problem-solving groups; a “Junior Achievement” style business meeting; and a daily job (e.g.
working as a junior counselor, swimming assistant, or business manager). During these activities, adolescents are
taught to use self-monitoring, feedback about behavior, and behavioral contracting to decrease rates of negative
behavior and increase rates of positive behavior. At least one evening a week, parents participate in parent training.
Adolescents and parents also participate in two 45-minute Parent-Teenage Negotiations (PTNs) which take place
after treatment hours with the facilitation of the Lead Counselor or another certified staff member. Adolescents may
earn the privilege to participate in special activities on Friday afternoons.
The behavioral component of treatment is designed to give adolescents the opportunity to succeed in
challenging, age appropriate activities. To accomplish this goal, the program is highly structured with an adolescent
to staff ratio of 3:1. Specific skill deficits common in adolescents with ADHD are targeted for intervention. The
major features of the behavior therapy program are immediate feedback, consistency, and clear consequences for
behavior. Staff members give feedback about important interpersonal behaviors (for example, interruptions, teasing,
and complaining) as the behaviors occur. The adolescents meet regularly with a primary counselor who has the
responsibility of providing the adolescent with individual and supportive guidance toward achieving individual goals
in a manner that is structured yet not confrontational. This precise feedback is made possible by having the
counselors periodically rate the adolescents’ performance and by the practice of recording the frequencies of
behaviors. Rewards or consequences for behavior are specified in the Adolescent Behavior Contract. This plan
includes general and individualized criteria for various privileges available in the program and at home.
Individualized goals are based on behavior observed in the program and these goals are evaluated each week and
written into a plan that is signed by the adolescent. As the adolescents successfully meet the demands of the ABC,
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the plan will grow to reflect increasingly difficult levels of behavioral expectations. Daily and weekly reinforcement
are provided both in the program and by the adolescent’s parents.
The STPA group is staffed by a Lead Counselor (i.e. a clinically experienced graduate student) and three to
four undergraduate counselors. Staff members receive more than 60 hours of training prior to treatment and are held
to a high degree of accountability through written tests of program knowledge and direct observation of clinical
skills. Clinical supervisors provide direct supervision to the Lead Counselors. The Lead Counselor and clinical
supervisors monitor and support the services provided by the undergraduate counselors. Furthermore, the Lead
Counselor works closely with parents by providing feedback at the end of each day, consulting about changes in
ABCs or otherwise exchanging information at arrival and departure times. In addition to helping to provide structure
and support for the entire group, Undergraduate Counselors serve as primary counselors for three or four
adolescents. Clinical supervisors are available every day to consult with parents about behavioral parenting
techniques or other clinical issues. The clinical supervisor also provides at least one hour of direct supervision and
another hour of feedback to the counselors every day. Lead counselors and clinical supervisors are the staff
members who should discuss clinical issues with parents. Other counselors may respond to parents’ general
questions regarding how well their child played during a soccer game or their child’s performance on daily target
behaviors, but they should politely refer parents to lead counselors or clinical supervisors when other questions
arise. This procedure is necessary to insure that only staff members with sufficient clinical training provide clinical
information to parents.
Typical Schedule
Below is a typical schedule for Monday-Thursday. On Friday afternoons, Academic Strategies Class,
Afternoon Rec, and Daily Jobs do not occur. For adolescents who have earned Friday afternoon privileges, a special
activity on or off site occurs. Adolescents who do not earn Friday afternoon privileges will remain in a supervised
detention during this time. Schedule varies depending on site.
7:45-8:00 Arrivals
8:00-8:15 Morning Announcements
8:15-9:15 Recreation I
9:15-9:25 Transition
9:25-10:25 Interpersonal Skills Group
10:25-10:35 Transition
10:35-11:05 Business Meeting
11:05-11:10 Transition
11:10- 12:10 Academic Learning Center I - U.S. History
12:10-12:20 Transition
12:20- 12:35 Lunch
12:35-12:45 Transition/BB
12:45-1:15 Issues Group
1:15-1:25 Transition/Break
1:25-2:25 Academic Learning Center II - Strategies Class
2:25-2:35 Transition
2:35-3:35 Recreation II
3:35-3:45 Transition to Jobs
3:45-4:45 Jobs
4:45-5:00 End of Day Meeting
Behavior Tracking System
The behavioral tracking system is a major component of the Summer Treatment Program for Adolescents (STPA)
intervention. This system is an age-appropriate modification of the STP point system (See Pelham, Greiner, Gnagy,
1998, for a review) where children earn and lose points contingent upon their behavior. The major difference
between the two systems is that adolescents do not use points- instead daily behavior counts are used to determine
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the adolescent’s program level on the subsequent day. Nonetheless, the behavioral tracking system is a response
cost system considering that the privileges the adolescent earn and lose during the STPA are contingent upon their
behavior. The specific problematic behaviors that the behavioral tracking system target are commonly exhibited by
adolescents with ADHD, ODD, CD, and other disorders of childhood/adolescence. Consequences and privileges are
associated with the exhibition of negative and positive behaviors. In adolescents this type of treatment program
provides immediate feedback on behavior and involves the use of privileges as incentives for good behavior. This
chapter describes the behavioral tracking system used in the STPA, including the list of behavior categories,
operational definitions of the behavioral categories, rules for classifying behaviors, and procedures for implementing
the point system.
Counselors implement the STPA behavioral tracking system throughout the day in all settings except the Adolescent
Daily Jobs. Counselors record all tracking system behaviors on a series of recording sheets referred to as tracking
sheets or point sheets. One counselor, referred to as the Tracking sheet Counselor, stands near the activity and
records behaviors that the other counselors report during the activity. At the Cleveland site, there are 7 positive
behaviors and 16 negative behaviors in the STPA behavior tracking system. Each behavior has an operational
definition that mandates whether feedback and associated consequences should be offered for a specific action or
verbalization.
The behavior tracking system serves two primary functions in the STPA. First, it is one of the main procedures used
to increase the frequency of appropriate behaviors and to decrease the frequency of undesirable behaviors exhibited
by the adolescents in treatment. Second, it is the primary source of data for the STPA. An accurate record of positive
and negative behaviors provides information that details the nature of an adolescent’s problems. For example, an
adolescent’s parents may report a high rate of noncompliance that is not reported by the adolescent’s teachers. By
evaluating compliance with commands in the STPA, it is possible to clarify discrepant parent and teacher reports.
Similarly, the tracking system data can provide useful information regarding the severity of an adolescent’s
problems. For example, an adolescent’s rate of teasing reflects the degree of his or her difficulties interacting with
peers. The rates of these behaviors observed during the first few weeks of the program are critical to making
decisions about the course of an adolescent’s treatment.
In addition to helping to determine the nature of the adolescent’s behavior problems, data from the behavior tracking
system are used to record and evaluate the adolescent’s response to treatment. Changes in behavior frequencies as
the adolescent progresses through the program reflect her or his response to behavioral treatment. Therefore,
accurate reporting and recording of positive and negative behaviors is as important as the actual awarding and
removing of privileges to facilitate interpretation of treatment response.
Thus, consistent implementation of the behavior tracking system is important to insure treatment integrity, to insure
maximally effective treatment for the adolescents, and to provide data for evaluating treatment response and
outcome. Consistent implementation means that all occurrences of tracking system behaviors are observed,
reinforced or penalized, reported, and recorded; that all staff members classify and record behaviors in the same
manner; and that there is stability of the system from activity to activity and from day to day. The first step toward
insuring consistency of implementation is that clinical staff members must arrive for the STPA training period
having memorized, verbatim, the operational definitions of the behavior tracking system categories. During the
training period, much emphasis is placed on learning to implement the behavior tracking system with a high degree
of reliability. Further, throughout the program, independent observers conduct regular reliability checks on each
group of counselors. Supervisors observe groups and complete Treatment Integrity and Fidelity Sheets that are
designed to evaluate counselors’ adherence to the treatment procedures.
The behavior tracking system provides the basic structure for treatment, and it is therefore critical that the
adolescents know the fundamentals of the tracking system, and understand that they will earn or lose privileges
contingent upon their behavior. Counselors must teach the adolescents the specific behaviors that they should refrain
from exhibiting to avoid losing privileges. To help adolescents learn the behavior tracking system and the rules for
each activity, they receive an Adolescent Summer Program Manual that includes explanations of the tracking system
definitions and the activity rules, written at the appropriate reading level. Counselors introduce the behavior tracking
system and give Adolescent Summer Program Manuals to the adolescents on the first day of treatment.
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The goal of treatment is to produce changes in behavior that will generalize to other settings and will maintain after
the STPA ends. Adolescent Daily Jobs has been developed to begin planning for continued intervention by reducing
the structure of the behavioral tracking system to make the STPA more like the adolescent’s natural environment.
This period provides probe periods during which adolescents’ response to less-structured treatments can be
measured over the course of the summer to evaluate generalization from times when the behavior tracking system is
in effect.
Conversely, it may be necessary to design and implement Adolescent Behavior Contract (ABC) targets or
Individualized Treatment Programs (ITPs) to supplement the behavioral tracking system for adolescents for whom
the standard system alone does not effect appropriate behavior change. For example, staff might develop an ITP for
an adolescent who swears at an exceptionally high rate, such that the adolescent loses one minute of job time each
time he swears. Modifications are made as needed, depending on decisions made by the lead counselors working
with clinical supervisors.
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Positive Categories
Interval Categories a
1. Following Activity Rules
2. Good Sportsmanship
3. Behavior Bonus
Frequency Categories
4. Attention Praise b
5. Ignoring a Negative Stimulus Praise b
6. Contributing to a Group Discussion Feedback only when appropriate a
7. Complimenting Feedback only when appropriate a
Negative Categories b
1. Violating Activity Rules
2. Poor Sportsmanship
Negative Physical Categories b
3. Intentional Aggression Sit-out immediately c
1. Unintentional Aggression Solicit an apology
2. Intentional Destruction of Property Sit-out immediately c
3. Unintentional Destruction of Property
e, f
Group Reparation Discussion
Individual Reparation Discussion g
4. Noncompliance Repeat Command
5. Repeated Noncompliance
Sit-out immediately c
6. Stealing
7. Leaving the Activity Area without Permission
Negative Verbal Categories
Group Reparation Discussion b
8. Lying
9. Verbal Abuse to Staff Sit-out after 3x d
10. Name Calling/Teasing Sit-out after 3x d
11. Cursing/Swearing h
12. Interruption h
13. Complaining/Whining h
Notes:
a Adolescents aren’t informed about this category; it’s simply for evaluating treatment response.
b Immediate feedback is given when the behavior occurs.
c Sit-out is assigned immediately.
d Sit-out is assigned after 3 instances of the behavior within the same activity period.
e Feedback is given when the behavior occurs or when the damage/theft is discovered and responsibility is
determined.
f Reparation for IDP and Stealing is determined by a group reparation discussion.
g Reparation for UDP is determined by a discussion between the adolescent and a counselor.
h If an adolescents exhibits the behavior 5x within a 2-min period, issue a command to stop exhibiting the
behavior for 2-min. Follow command sequence.
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e, f

Sit-Out Procedures
A Sit-Out (SO) is time out from positive reinforcement. It is a brief retreat of 2 minutes in a quiet place after an
adolescent has broken one of the rules that lead to SO. The counselor designates a specific area in which the SO
takes place. SO provides time for an adolescent to regain his/her composure in a setting that is quiet and calm.
Removal from the ongoing activity can be a powerful contingency and has been found to be effective when used
with discretion and clearly understood by the adolescent. Given that Sit-Outs are time away from positive
reinforcement, SO’s will only be effective if they occur during activities that the adolescent enjoys. In contrast, SO’s
will be ineffective if they occur as a result of an adolescent who is purposely escaping a certain activity. Counselors
should consult supervisors immediately if they suspect this type of situation is occurring. When giving sit-outs, it is
important to remain calm, neutral and non-judgmental, delivering all instruction in an even voice.
Adolescent Behavior Contract (ABC)
Each adolescent will have an Adolescent Behavior Contract which will include both universal and individualized
components. The ABC provides the adolescent with clear behavioral criteria that he or she must meet in order to
earn privileges within the program. An adolescent’s performance on his/her ABC contributes to his/her standing in
the levels system. Counselors may add additional contingencies (from home or the STPA) to this plan as needed, but
all must be discussed with the supervisor prior to implementation.
Interpersonal Skills Group
Treatment also includes daily training in social skills during the Interpersonal Skills Group. Counselors conduct a
half-hour, small group session that includes direct instruction, modeling, role-playing, and practice in the key
concepts of social skills, such as using self-control, making an appropriate complaint, responding to a complaint,
accepting a limit, knowing your feelings, recognizing other's feelings, expressing your feelings, negotiation, and
responding to failure, and other relevant social skills. Throughout the seven weeks of the STPA, 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.
Adolescent Issues Group
The Adolescent Issues Group is a half-hour, group session that follows a four-step problem solving approach to age
relevant issues (such as peer rejection, drug use, response to authority figures, and career plans). The following fourstep
procedure is taught and practiced: (1) identification of problems; (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 adolescents 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.
Business Meeting
Monday through Thursday, adolescents also participate in a separate half-hour session called the Business Meeting,
which is similar to a student council meeting. This session follows strict rules of participation, with the purpose of
planning, organizing, and evaluating group-wide business endeavors (i.e., food-sale to raise money for a special,
end-of-the-summer group activity). Meetings are called to order, and decisions are made based upon group votes.
Adolescents rotate through the various positions/responsibilities, including, but not limited to, secretary, treasurer,
and chairperson.
Job Assignments
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Job assignments involve the adolescents spending an hour a day working on a job (e.g., working as a junior
counselor, writing for a camp newsletter) for which they can be paid up to $20 a week. The goals of this activity
include development of responsibility and appropriate interaction with adult supervisors and teaching the critical
organizational skills, communication skills, and adaptability necessary to follow through with task. Adolescents
receive daily job performance ratings from his or her supervisor, and these ratings determine the dollar amount
earned for that day. Adolescents interview for jobs during the first week, and this process includes writing a personal
statement with references.
Sports Skills Training
In addition to training in social skills designed to improve their peer relationships, 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-efficacy. Therefore, one recreational period each day is devoted to small-group skills training
in an age-appropriate sport (e.g., softball, soccer, basketball) and one recreation period is devoted to playing the
sports and games. The sports skills training is integrated with the behavioral system and social skills training to
provide a comprehensive intervention for peer relationship difficulties.
Learning Centers
On Monday through Thursday, the learning center activities are broken down into 2, one-hour sessions and a halfhour
study hall. The first session of the Academic Learning Center (ALC) is devoted to lectures (e.g., American
History) and the second hour is devoted to organization skills and techniques (e.g., setting goals for long-term
projects). Friday procedures include written language assignments and cumulative tests.
*This manual is a collaboration of 2001 Buffalo STPA, STPA Manual 2008 by Steve Evans, and Cleveland Clinic STPA Manual
by Hilary Parsons.
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