Longer Eye Contact Improves Compliance in Children with ADHD

Many studies have shown that children diagnosed with ADHD are much more likely to exhibit non-compliant behavior than other children.  This is especially true for children who have co-occurring Oppositional Defiant Disorder (ODD).

The mechanism by which ADHD increases children's non-compliance is not fully understood, but one theory is that upon hearing a command to perform a task (e.g., "put away your toys"), many children - including those without ADHD - experience an immediate negative reaction to the command.  Children with ADHD, however, who are often impulsive, have greater difficulty containing their internal negative reaction.  As a result, their internal state is quickly translated into an oppositional response.  This can create ongoing struggles between parents and children, and learning  how to obtain better compliance from children with ADHD is an important challenge for many parents.

Several interventions are available to reduce impulsivity and non-compliance problems in children with ADHD.  Medication has clearly been shown to reduce non-compliance in many children with ADHD; it is likely that this occurs because medication reduces impulsivity, which makes it easier for the child to inhibit their initial negative reaction to a parent's command.  Medication alone, however, does not eliminate compliance problems for many children.

Training parents in behavior management skills is also a helpful intervention for improving children's compliance.  Parent training programs typically emphasize the importance of praising and rewarding the child for compliance, and also provide specific instructions about issuing commands in a way that are most likely to result in compliance.  This includes being in close proximity to the child when giving a command, using a calm but firm voice, giving only one command at a time, and being brief and to the point.

Maintaining eye contact with the child is another aspect of issuing effective commands that is often taught in behavior management programs.  In fact, all of the major parenting programs advise parents to obtain eye contact with their child before issuing a command.  Details about the specific length of eye contact to maintain, however, and what to do immediately after issuing the command if the child does not comply right away, are not provided. 

When a child fails to comply in a timely manner with a parent's command, parents frequently respond by applying pressure on the child to induce compliance.  One way that parents do this is to threaten a negative consequence.  In many instances, however, because these threats are made when parents are angry, the promised consequence may be excessive (e.g., "Your grounded for a week!"), and parents often fail to follow through on what was threatened.  As a result, the child may come to learn that parents' threats are rarely enforced, and problems with compliance continue or even escalate.

Parents also often attempt to induce compliance by raising their voice.  As a child's non-compliance continues, this can escalate to screaming and yelling, which is rarely effective in getting children to comply.  In fact, when parent-child conflict escalates to this level, children are often less likely to comply with their parents' command. 

For these reasons, which are familiar to many parents who have a child with ADHD, an approach to induce compliance that does not escalate parent-child conflict would certainly be helpful.

A study published in a recent issue of the Journal of Attention Disorders  examines whether the relatively simple technique of "staring" at the child when issuing a command will increase compliance (Kapalka, G. M. 2004. Longer eye contact improves ADHD children's compliance with parental commands, JAD, 8, 17-23).  The author notes that a parents' stare communicates to the child that "...the parent means business and expects compliance with the state instruction."  However, despite anecdotal reports from parents that "staring" is a helpful method for increasing their child's compliance with commands, there has been essentially no research on the actual effectiveness of this technique.  If it were shown to be effective, it could be a relatively simple method that parents could employ right away.

To study the effectiveness of the "stare technique", 76 families were recruited to participate in a parent training study.  All families had at least one male child with ADHD between 5 and 10 years old.  Families were randomly assigned to one of two treatment groups or a control group. 

As part of a comprehensive parents training program, parents in both treatment groups received instructions on giving effective commands.  Parents were advised to:

1) issue a command only after obtaining eye contact from the child;
2) issue only one command at a time;
3) issue commands as direct statements (e.g., "Put away the toys now") rather than as 
   questions ("e.g., "Will you put away the toys now?);
4) use a calm but firm voice when issuing commands;
5) minimize distractions that might be present - i.e., TV - when issuing commands; 
6) praise their child for compliance and administer a mild punishment (e.g., time-out or
   brief loss of privileges) for non-compliance.

Parents in the "stare technique" group received the additional instruction to look at the child for 20-30 seconds after the command was issued, even if the child initially did not comply.  They were also instructed not to repeat the command until the 20-30 seconds had elapsed.  The "stare technique" was intended to convey the seriousness of the parents' intent in a manner that would not lead to an escalation that often occurs when parents make threats or raise their voice.  Parents were not supposed to stare at their child in an "angry" way, but simply to maintain eye contact as best they could while maintaining an expression that conveyed that they were serious about their child complying.

Instructions on giving effective commands were given during the first week of treatment.  Prior to beginning treatment, parents in the two treatment groups completed a questionnaire that inquired about their child's compliance with commands during situations that are frequently problematic for children with ADHD.  On this questionnaire - the Home Situations Questionnaire developed by Barkley - parents rate the amount of difficulty they have getting their child to comply in 16 different situations.  Ratings are made on a 1 to 9 scale of increasing severity.  In the current study, ratings for each item were averaged, such that higher average scores reflect greater problems in obtaining compliance (i.e., greater non-compliance).

This questionnaire was completed a second time two weeks later, after instruction in giving effective commands had occurred. Parents assigned to the control condition simply had the start of their treatment delayed by two weeks, and completed the compliance questionnaire at comparable times to parents in the treatment groups.

By comparing the two compliance ratings (i.e., before treatment and after receiving instruction in giving effective commands) for each parent, the authors could learn whether: 1) parents given instruction observed an increase in their child's compliance compared to control parents; and, 2) whether parents instructed in the "stare technique" observed even greater increases in compliance than parents receiving standard instruction on effective commands.  


The baseline rating for parents in the control, regular instruction, and regular instruction + stare technique group were all about 7.7, which indicates significant difficulties obtaining compliance (remember, the highest possible score is 9).

Ratings obtained 2 weeks later - after parents in both treatment groups had received instruction in giving commands - revealed a significant reduction in non-compliance ratings.  Parents in both treatment groups reported greater reductions in children's non-compliance scores than parents in the control group, who had yet to receive any instruction on giving effective commands.  For these parents, there was essentially no change in the non-compliance ratings they gave to their child.

For parents receiving the standard instructions, children's non-compliance ratings declined by 32%. 

Among parents who received standard instructions + the stare technique, children's non-compliance scores declined even more substantially, by a full 44%, which was significantly greater than the reduction reported by parents receiving standard instructions alone.



Results of this study suggest that parents who use the simple technique of obtaining and maintaining eye-contact when issuing a command to their child - and who continue to look at their child for an additional 20-30 seconds after making the command -  will be more likely to obtain compliance.  Thus, rather than issuing a consequence when the child fails to comply right away, the subtle but apparently effective pressure experienced by children when their parent stares at them, may be a more effective way to obtain compliance.

The author suggests that putting appropriate pressure on the child through this non-invasive technique that does not lead to conflict escalation, "...provides the child with an opportunity to re-evaluate what may be an initial, impulsive reaction and to be able to make a choice as to how to proceed."  He suggests that while the parent is "staring", the child has the chance to weigh his choices while recognizing that compliance is expected.  This may actually encourage the child to consider the consequences of complying vs. not complying, and considering consequences before acting is an important skill for many children with ADHD to learn.

Results from this study are certainly promising, although it is important to note that this study does not provide any information about whether this technique would maintain its effectiveness over time.  It is possible that although better compliance was achieved initially, this would dissipate after the initial novelty of the parents' new approach wore off.  Thus, it would be especially important to learn whether the beneficial results reported over a 2-week period continue for any substantial period of time.  Because the study was limited to boys with ADHD, it is also unclear whether even initially positive effects would be obtained with girls.

Despite these limitations, it would seem that employing the "stare technique" in the context of other aspects of giving effective commands that were discussed above, is something that parents may wish to try if their child's health care provider agrees that it is appropriate. It is unlikely that such an approach could be harmful, and parents may find that they experience similar gains in their child's compliance to what was reported in the current study.  Of course, no single technique or approach is likely to adequately address the range of difficulties that a child with ADHD may have, but the use of a simple strategy like this may be a useful addition to the variety of strategies and interventions that are necessary.