Critical Analysis of The Total Transformation® Program (TTP) of Legacy Publishing Helping Behavior Disordered Children and Teens

Patricia O. Quinn, MD, FAAP Director, National Center for Girls and Women with ADHD

Over the last decade, pediatricians have been diagnosing and treating increasing numbers
of children with behavioral problems. These children with behavior disorders make up
approximately 15 percent of the children seen by pediatricians, but these physicians do
not always feel sufficiently trained to fill this new role. They, as well as the families they
serve, are in need of a structured program to aid in their work with behavior disordered
children and teens. The Total Transformation® Program (TTP) by James Lehman, MSW,
LCSW, is a program designed to address this need.

In an attempt to provide an objective assessment of the TTP, I will undertake to address
several questions in three areas (need/effectiveness/accessibility). These include:

• What is the need for a behavioral management program for children and teens
with ADHD and disruptive behaviors?
• How can the TTP meet the need of providing a behavior management program to
children and teens with ADHD and disruptive behavior disorders?
• What are the underlying premise and the goals of the TTP?
• What is the quality of the materials? Are they useful? Do they deliver what is
promised?
• What is the scientific evidence for the effectiveness of such a program?
• Lastly, what is the reputation of Legacy Publishing; and what is their ability to
deliver such a service?

What is the need for a behavioral management program for children and teens with ADHD and disruptive behaviors?

ADHD remains the behavioral problem most often diagnosed by pediatricians. Research
has established that disruptive behavior disorders are commonly seen with ADHD. From
30% to 50% of children with ADHD in a community sample, and 50% of children in a
clinically referred sample, are likely to have another externalizing, disruptive behavior
disorder. (Wilens et al., 2002; Busch et al., 2002) In clinical practice, children with
ADHD often have behavioral problems including ODD/CD. The presence of these
externalizing behavior disorders significantly complicates the acute presentation of
ADHD and is associated with more severe ADHD symptoms and overall impairment and
a worse overall long-term prognosis. Considering this negative prognosis, early
identification and treatment of behavior and conduct problems in children and teens with
ADHD cannot be overemphasized.

The American Academy of Pediatrics in their Guidelines for the Assessment and
Treatment of ADHD, recommend that pediatricians assess for coexisting conditions in
addition to ADHD symptomatology. They are then urged to begin treatment of diagnosed
children with "stimulant medications and/or behavioral treatment" after "negotiating
target outcomes." (AAP, 2001) Stimulant medications have long been known to be safe
and effective in the treatment of ADHD and should be considered the first line of
treatment for children and teens with ADHD and coexisting ODD/CD. However, if
ADHD symptoms respond but ODD/CD symptoms persist after medication intervention,
psychosocial treatment should then be added to the treatment regime. If symptoms
associated with ODD/CD are extreme at the time of diagnosis, multimodal treatment is
often needed from the beginning.

The role of psychosocial interventions alone or in combination with medication
for the treatment of ADHD have been studied extensively. The NIMH MTA study
(MTA Cooperative Group, 1999; MTA Cooperative Group, 2004) and the Multimodal
Psychosocial Treatment study (MPT, also known as the New York/Montreal study)
(Klein et al., 2004) have examined the effects of pharmacological and behavioral
treatments on ADHD symptoms when used alone or in multimodal treatment programs.
These large-scale, long-term, randomized clinical trials have greatly contributed to the
field as to the efficacy of long-term medication treatment and the role of psychosocial
interventions in ADHD.

How can TTP meet the need of providing a multimodal treatment program to these children and teens with ADHD and disruptive behavior disorders?

While most pediatricians can say that they understand the need for a multimodal program
for the treatment of children with ADHD and coexisting conditions, they are at a loss of
how to assist parents in acquiring the skills necessary to carry out such a program. The
behavior management component of the MTA program has been shown to be an ideal
program for obtaining positive outcomes for children with ADHD and coexisting
behavioral disorders, but few communities offer the support received in this program to
parents and their children with ADHD. Most parents must then “go it alone” or seek out
expensive mental health support within the community knowing the majority of these
services are not covered by health insurance.

Given the limited time available to clinicians to interact with patients and their parents,
how can professionals teach parents to more effectively deal with their children with
ADHD and ODD/CD and provide these services in a way that is both cost and time
effective? An “at home” training program like the TTP program seems ideal. Through a
series of compact disks, DVDs and an interactive parent workbook, the TTP can be used
by parents and professionals to decode a child’s behavior and understand why a child or
teen is acting in a dysfunctional way. The main focus of this non-judgmental structured
program is on teaching parents exactly how to react to and better understand their
children or teens with behavior disorders such as ODD/CD and then effectively empower
them to change.

What are the underlying premise and goals of the TTP?

The Total Transformation® Program is a guided training program for parents that utilizes
cognitive learning theory a behavioral management techniques to alter dysfunctional
family interaction patterns. The underlying premise of the TTP is that behaviorally
disordered children and teens need to be empowered with skills to manage their daily
functioning and social/behavioral interactions. TTP is an accountability based treatment
program that empowers parents to deal with their child’s inappropriate responses. It
offers them a means to decode and understand their child’s behavior. It places parents in
the training and coaching role and offers them a concrete plan that they can actualize in
the home.

What is the quality of the materials?

Overall, the TTP is extremely well organized and structured. Materials are presented
using a step-by-step approach. Once the child’s behavior is understood, scripts are
provided to empower the parent’s response. The Parent Workbook is very well done and
provides checklists to help the parent determine what skills need to be worked on at that
time (target behaviors) and provides excellent explanations of why a child acts in a
certain way.

The TTP was also found to have several features not found in other programs. This
includes Parenting Style self-assessments that allow parents to look at their role in the
interactive process. I especially liked the age appropriate consequences and rewards
charts, as I find this is a particularly difficult concept for many parents. In addition to
providing tools for acute behavior management, the TTP also focuses on teaching parents
exactly how to have a problem-solving discussion with their child utilizing an interview
format thus placing the parent in a coaching role.

What is the scientific evidence for the effectiveness of such a programs?

The current findings regarding the outcomes of ADHD and disruptive behavior disorders
indicate that all children presenting with symptoms of ADHD and ODD/CD need to be
assessed and treated with a view of targeting both the ADHD and the disruptive
behaviors. The link between behavioral disorders and poorer psychosocial outcomes only
reinforces the need to treat these disorders aggressively with both psychosocial and
pharmacologic interventions. In addition, these children are difficult to live with and
parents need to understand that they do not need to deal with their ADHD and ODD/CD
child alone. Programs that teach parents acute, simple behavior management strategies
(Parent Training) and those that help build and reinforce cognitive, problem-solving skills
(Collaborative Problem-Solving) have both been shown to be effective.

Parent Training (PT) has been shown to be effective for treating oppositional and
defiant behaviors. Standardized parent training programs are short-term interventions that
teach parents specialized strategies-including positive attending, ignoring, the effective
use of rewards and punishments, token economies, and time-out to address clinically
significant behavior problems. (Farley et al., 2005)

The long-term maintenance of changes following parent-child interaction therapy (PCIT)
for young children with oppositional defiant disorder (ODD) and associated ADHD has
been shown to be good. Three to 6 years after treatment, the mothers of children with
these disorders indicated that the significant changes found in their children's behavior
and their own feelings of control at the end of treatment were maintained at long-term
follow-up. Child behavior reported at the post-treatment assessment and the length of
time since treatment were strong predictors of long-term outcome. Mothers' reports of
disruptive behavior decreased with time after treatment. (Hood & Eyberg, 2003)

Collaborative Problem Solving (CPS) has also been shown to be effective for children
with ADHD and ODD. (Green et al., 2004) CPS is a cognitive-behavioral model of
intervention. The CPS model proposes that challenging behavior should be understood
and handled in the same manner as other recognized learning disabilities. In other words,
difficult children and adolescents lack some crucial cognitive skills essential to handling
frustration and mastering situations requiring flexibility and adaptability. The goal of
intervention is to teach these skills. In the CPS model, this is accomplished by helping
adults and challenging children work toward mutually satisfactory solutions to the
problems underlying behavioral difficulties.

In my opinion, the TTP incorporates both aspects of these psychosocial treatments and
does it in a way that educates and supports parents as they learn to understand and deal
with their child’s behaviors. The materials are also reinforcing and available for parents
to review as necessary, as opposed to a session that may provide few written materials
and concrete examples for the parent.

Lastly, what is the reputation of Legacy Publishing?

Legacy Publishing: Established was in 2004. While relatively new to the field of
Mission Statement: “Our mission is to provide families with life-changing programs
Ability to deliver a quality product: Over 85,000 units of the TTP have been sold to
Testimonials/Approvals: In August 2006, the National Association of Social Workers

References

American Academy of Pediatrics, author. (2001). Clinical practice guideline: Treatment
of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics.
108:1033-1044.

Busch, B., Biederman, J., Cohen, L.G., et al. (2002). Correlates of ADHD among
children in pediatric and psychiatric clinics. Psychiatric Services. 53:1103-1111

Farley, S.E., Adams, J.S., & Lutton, M.E., et al. (2005). What are effective treatments for
oppositional and defiant behaviors in preadolescents? Journal of Family Practice, 54(2):
162-165.

Greene, R.W., Ablon, J.S., Goring, J.C., et al. (2004).Effectiveness of collaborative
problem solving in affectively dysregulated children with oppositional-defiant disorder:
initial findings. Journal of Consulting and Clinical Psychology, 72(6): 1157-1164.

Hood, K.K. & Eyberg, S.M. (2003). Outcomes of parent-child interaction therapy:
mothers' reports of maintenance three to six years after treatment. Journal of Clinical
Child and Adolescent Psychology, 32(3): 419-429.

Klein, R.G., Abikoff, H., Hechtman, L., & Weiss, G. (2004), Design and rationale of
controlled study of long-term methylphenidate and multimodal psychosocial treatment in
children with ADHD. Journal of the American Academy of Child and Adolescent
Psychiatry. 43:792-801

MTA Cooperative Group (2004), National Institute of Mental Health Multimodal
Treatment Study of ADHD Follow-up: 24-Month Outcomes of Treatment Strategies for
Attention-Deficit/Hyperactivity Disorder. Pediatrics 113:754-761.

Wilens, T.E., Biederman , J., Brown, S., et al. (2002). Psychiatric comorbidity and
functioning in clinically referred preschool children and school-age youths with ADHD.
Journal of the American Academy of Child and Adolescent Psychiatry. 41:262-268.