Behavioral Treatment for ADHD/ADD:
A General Overview



David Rabiner, Ph.D. Research Professor, Duke University


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David Rabiner, Ph.D.
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(Note: If you are looking for information on Attention Deficit  Disorder (ADD) please be aware that much of what is discussed below should also be relevant.  Technically, the term ADD is no longer used.  Instead, children who have the inattentive symptoms of ADHD but who do not show hyperactive/impulsive symptoms are now diagnosed with ADHD, Predominantly Inattentive Type rather than with ADD.  These terms mean pretty much the same thing but the latter is no longer technically correct.)


Behavioral Treatment for ADHD/ADD:
A General Overview

The information presented below is intended to provide a general overview of a behavioral approach to improving children's behavior. Designing and implementing an effective behavioral plan will vary from one child to the next, however, and consultation with an experienced child mental health professional is recommended.

Despite the well documented benefits of stimulant medication for treating Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder, medication is no panacea and some children with ADHD/ADD should not receive it. There are several reasons for this. First, although medication helps the majority of children with ADHD/ADD, as many as 20% derive no real benefit from medication. Second, some children experience side effects that prevent them from receiving medication on an extended basis. Third, many children who benefit from medication still have difficulties with primary ADHD/ADD symptoms or associated problems which must be targeted via other means. Fourth, some children with ADHD/ADD can have their symptoms managed effectively without medication (this is most likely to be true, however, when symptoms are relatively mild.) In addition to these reasons, some children have extremely strong objections to taking medication - this may be more likely to occur with teenagers. In these circumstances, trying to force medication on a child can create more problems than it solves. For all these reasons, other treatments are often necessary - some would say always necessary - to effectively treat ADHD/ADD.

An important non-medical approach used in treating children with Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder is known as behavior therapy or behavior management. Behavior therapy is based on several simple and sensible notions about what leads children to behave in socially appropriate ways. One reason is that children generally want to please their parents and feel good about themselves when their parent is proud of them. When the relationship between parent and child is basically positive, this is a very important source of motivation. A second reason that children behave appropriately is to obtain positive consequences for doing so (i.e. privileges or rewards). Finally, children will behave appropriately to avoid the negative consequences that follow inappropriate behavior.

The goal of behavior therapy, therefore, is to increase the frequency of desirable behavior by increasing the child's interest in pleasing parents and by providing positive consequences when the child behaves. Inappropriate behavior is reduced by consistently providing negative consequences when such behavior occurs. This is a simplified, but not unreasonable view, of what behavior therapy is all about.

"My child and I seem to be in conflict almost all the time and I don't think he cares about pleasing me at all. How can I change this?"

Let's begin by focusing on children's desire to please their parents. Often times, relationships between parents and children become fraught with conflict and angry feelings in response to the frustration caused by ADHD/ADD symptoms. Good times between parent and child can dwindle to almost nothing, and the child's desire to please his or her parent can evaporate. After all, most of us are not interested in pleasing someone that we constantly argue with. Unfortunately, when this important positive source of motivation for good behavior disappears, parents have to rely more exclusively on the threat of punishment to induce compliance. This generally makes for ongoing conflict and struggle.

In many situations, therefore, the first step in behavioral treatment is to enhance the amount of positive feelings between parent and child. One helpful way to do this is to set aside a certain amount of time each day (30 minutes is certainly sufficient) that is designated as the child's "special time". During this time, the child gets to choose the activity (it must be within reason, of course), and the parent's sole focus is on trying to have a good time with his or her child. During this time, it is important to avoid asking too many questions or giving commands, and instead to simply tune in to what your child is doing in an interested and complimentary way. For example, if your child is building a tower with blocks, the comment "Don't you think it would be better if you used these bigger blocks first?", will be less helpful than a comment like "Boy, the tower your building is really getting tall!"

The goal of this time is build up good feelings between your child so that your child will become more invested in wanting to please you. When this occurs, discipline and limit setting generally go much smoother. When parents first begin to try this, they are often surprised to getting chores, homework, or errands done. The absence of this special time can be a real loss for both parents and children, and working to make it part of your routine can yield substantial benefits in parents' relationship with their children.

USING POSITIVE REINFORCEMENT

The second focus of behavioral treatment involves providing your child with positive consequences for behaving in appropriate ways. The simple logic is that you can increase the frequency of desired behavior (e.g. putting away toys) by providing rewards when such behavior occurs. At the simplest level, this requires nothing more than noticing when your child is doing something you want to encourage (e.g. playing quietly) and making sure to comment on it ("You're doing such a nice job of playing quietly. I really appreciate that."). Think about the kinds of behavior you want to encourage, make sure your child understands what you want him or her to do, and then be sure to praise your child whenever you happen to observe it occurring. This simple technique of noticing good behavior is easy to overlook and can be quite helpful. I often recommend to parents that they make a conscious effort to catch their child doing something good at least 5 times a day and to point it out. When children are convinced that their parents notice and appreciate their efforts at behaving well, it frequently increases their desire to do so.

In addition to these "social rewards", behavioral treatment also involves providing your child with concrete rewards and/or privileges for appropriate behavior. As an example, suppose your child has developed the problematic habit of talking back. You tell him to put away his toys and he tells you "not now, later". One way to increase your child's compliance is to make a tangible reward or privilege contingent on his following your request. For example, you could explain that each time he does what he is told he will earn a point. These points can then be used to "purchase" a privilege such as access to TV, computer time, ect.

Designing a good behavior plan and implementing it effectively is not easy, and parents may often require professional assistance to do this successfully. Although the specifics of a good plan will vary from child to child and from parent to parent, there are several general principles that are important to keep in mind:

* Be very clear about what behavior is expected of your child in order to earn the reward and make sure your child's understands this.

For example, "Listening to what I say" would be too vague; "Picking up your toys and putting them away the first time I ask" is more specific.

* Make sure that the expectation you have for your child is reasonable - do not set you and your child up for failure by having expectations that are not appropriate for your child's age.

It is always a good idea to reflect on what you expect from your child and consider whether your expectations are reasonable. For example, punishing a 5 year old for being unable to sit quietly at the dinner table for an hour will generally create problems because most 5 year olds simply can not do this. For children with Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder, behavioral expectations need to take this into account in addition to the child's age.

* Don't try to work on too many different things at one time.

It is generally better to focus on a couple of things that are really important rather than taking on everything at once. Choose your battles carefully and selectively!

* Let your child participate in choosing the types of rewards he or she can earn

Children are generally more invested in this type of program when they have some input in its design. Try to create the feeling that this is something that you are doing with your child rather than something you are doing to your child.

* Design the program so your child has a good chance to experience some initial success.

It is important that the child experience some initial success in order to maintain and enhance their motivation. As their behavior improves, you can gradually raise the criterion required to earn rewards.

* Be sure to provide lots of social rewards (e.g. praise) in addition to the more tangible rewards that can be earned.

This is a great way to increase your childish desire to please you and to increase the amount of positive feelings between you and your child.

* Be consistent.

For this approach to succeed you have to apply it consistently. Using the program one day but not the next, or failing to provide rewards when they are earned, is a sure fire way to keep this from being helpful.   

"Isn't this bribing my child? Why should he be rewarded for things he should do anyway?"

Parents are often concerned that providing their child with rewards for behaving appropriately is nothing more than bribery. The way I prefer to look at this, however, is that you are providing your child with the opportunity to earn extra privileges for behaving in a more mature and cooperative manner. An analogy to the adult workplace may be useful here. If your boss promises a promotion and raise for a specified level of productivity are you being bribed, or are you being given the chance to earn a deserved reward for a job well done? If your child's behavior improves shouldn't he or she have access to more privileges than when they were behaving poorly? That is really all that is being talked about here - the main difference with what most parents already try to do is that the expectations and rewards for meeting those expectations are made more explicit.    

USING NEGATIVE CONSEQUENCES TO REDUCE MISBEHAVIOR

In addition to using positive reinforcement to encourage good behavior, behavioral treatment also relies on negative consequences or punishment to reduce undesirable behavior. Simply stated, when a particular behavior is consistently followed by negative consequences for a child, it should diminish in frequency and intensity. 

For example, suppose you are trying to reduce your child's tendency to "talk back" and this is being targeted in your behavioral treatment plan. Here is a general approach one might take.

* First, your child would need to understand exactly what you mean by "talking back" so it is clear what should not be done.

* Second, you would want to teach your child an acceptable way to disagree with you - how he or she is allowed to express disagreement and how they can not.

* Third, as discussed above, you would review with your child the rewards they will earn for not talking back and for expressing disagreements in an acceptable way.

* Finally, you would discuss with your child what privileges they will lose each time they "talk back". For example, talking back could result in their having to take a "time out", losing TV time, having to go to bed early, ect. If you are using a token system where your child is accumulating tokens that can be used to purchase rewards, talking back can result in the loss of a pre-specified number of tokens.

By setting things up this way, what you are trying to do is to make sure your child understands that there is simply no pay-off for bad behavior. Instead, when he or she acts appropriately, it will always result in good things coming their way. In contrast, when behavioral expectations are not met, the consequences are always negative. 

IMPORTANT - Try hard not to overdo the negative consequences. Children tend to get discouraged if they are used too frequently and can lose interest in the program as a result. If you find yourself having to resort to negative consequences too frequently, it's important to take a careful look at what may be going wrong with an eye towards redesigning the program.  

HAVE A GAME PLAN!

Now it would be wonderful if the first time you used a negative consequence as discussed above, it effectively ended your child's misbehavior. As we all know, however, this is often not the case. Instead, you may take away TV time because of some misbehavior, and your child either ignores you or says he "doesn't care" and continues with the problematic behavior.

It is easy to become frustrated and angry in situations like this. At such times it is easy (I know from experience because this is a mistake I make myself) to blurt out a punishment that is born of frustration and will be difficult if not impossible to enforce: 

"You're grounded for the next 2 weeks!"

"That's it! No more birthday party for you!"

I know that I've had the experience of shouting out something like this, and realizing right away that it wasn't something I would stick with. In fact, it wasn't even something I should stick with because it was excessive and unreasonable. You are then left with the uncomfortable choice of enforcing something unreasonable to show your child that you mean business or backing down. Choose the former and your child is justifiably upset and you wind up feeling guilty. Choose the latter and your child gets the idea that punishments don't matter because you don't stick with them anyway.

One helpful way to avoid this dilemma is to plan out, IN ADVANCE, a graded series of punishments for persistent misbehavior. For example, when your child initially fails to comply you could impose a 5 minute time-out. If the non-compliance continues you could say "If you don't do what your told now, the time out will increase to 10 minutes." Continued non-compliance results in loss of TV in addition to the time out. After that, an earlier bed time could be imposed. You have to decide what specifics make sense, of course, but the general point is to have an escalating series of consequences that you can calmly but firmly announce and calmly but firmly enforce. (It is best that these consequences do not extend into the following day so the new day can get off to a fresh start.) Having this plan in mind can help you to keep your cool and prevent you from blurting out a punishment that is not going to be helpful. If you can stick with this, your child should learn that there is something nothing to be gained by persistent disobedience.  

DON'T TEACH YOUR CHILD TO MISBEHAVE!

Here is a pattern that is easy to fall into and which is associated with increasing misbehavior and non-compliance. You ask or tell your child to do something like pick up his toys. Your child ignores you and keeps on playing. You repeat your request and your child ignores you again. You get angry and intensify your demand; your child gets angry in response and starts to tantrum. After a few more cycles of this you are both good and angry. To keep things from exploding, you drop your demand, send your child away, and pick up the toys yourself because "it's not worth all the hassle and aggravation" trying to make your child do it.

Most parents have been through something like this, and with children who have ADHD/ADD and are also oppositional, this is a distressingly frequent occurrence. Unfortunately, what a child learns from this type of exchange is that if they just hang in there and persist in being defiant, they will eventually get their way. What happens, therefore, is that your child's disobedience is actually being REWARDED. This can really result in things going downhill because your child is being taught that defiance actually pays off.

This is why it is important to chose your battles carefully. Once you demand something of your child, BE SURE TO FOLLOW THROUGH WITH IT. If your child persists in being defiant, try using the graded series of consequences as discussed above. Your child needs to see that you mean business, and that there is ABSOLUTELY NO PAYOFF for being disobedient. 
 

"This type of behavioral approach sounds like something that would be useful with all children. Is there anything different about using this approach with a child who has Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder?"

Using a combination of special time, positive reinforcement, and negative consequences to encourage good behavior is, of course, a technique that can be useful with all children. Although the basic principles are similar for children with and without ADHD/ADD, factors specific to ADHD/ADD generally require certain modifications to be made. Several of these important modifications are:

* Children with ADHD/ADD generally require more frequent feedback about how they are doing in meeting the parent (or teacher's) expectations.

Research has consistently demonstrated that children with Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder perform better when they are given frequent feedback about their performance. Thus, if the behavior you are targeting is "following directions", it is better to provide your child with feedback about how well they are following directions every hour, rather than doing this once at the end of the day. The actual time interval is something to experiment with; the important point is that a child with ADHD/ADD needs frequent feedback for behavioral programs to be effective.

* Children with ADHD/ADD do better with short term goals than long term goals.

This follows from the above. Along with more frequent feedback, children with ADHD/ADD generally require shorter intervals between the opportunity to earn rewards. For example, promising a weekend reward for good behavior during the week may be too far in the future to function as an effective motivator for a child with Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder. Daily rewards, or even more frequent opportunity to earn privileges, will often be necessary. Providing a child with points or "tokens" for good behavior that can be used to purchase more tangible rewards (e.g. TV time; Nintendo time; getting to rent a video) can be useful because they can be frequently and easily dispensed, and have value because of their connection to desired activities and objects.

* Children with ADHD/ADD require more frequent reminders about what is expected of them and what they can earn for meeting those expectations.

For this approach to be effective, it needs to occupy a prominent place in a child's mind. Children who forget what their behavior goals are and what they are trying to earn by achieving those goals are unlikely to be successful. For a child with ADHD/ADD, frequent reminders about the goals and rewards are important. This can be done in the context of providing feedback on how the child is doing.

* Children with ADHD/ADD often require frequent changes in the program to remain interested in it.

Those of you who have already tried various behavior plans may be well aware of this. It is not uncommon for a child to get off to a great start and then lose interest in earning any rewards. The best way to combat this is to try change the program to keep it feeling "new". This can be done by changing the rewards (e.g. one day the reward to be earned in TV time, the next day it is getting to stay up an extra half hour, ect.) If your using tokens, changing the actual token can also be helpful. For example, one week pennies might be used, the next week marbles, the next week stickers, ect. Obviously, this all depends on the age of the child and what his or her interests happen to be. It certainly takes plenty of hard work and creativity on parents' part.

"What kinds of behaviors can be addressed with this type of approach?"

In theory, virtually any type of behavior can be targeted using a behavioral treatment approach. For example, primary ADHD/ADD symptoms such as not completing tasks can be targeted by providing rewards for task completion. Symptoms such as interrupting and talking out of turn can be targeted in similar ways. Associated difficulties such as deliberate non-compliance, aggression, ect. can also be targeted in a behavioral treatment plan. Regardless of what behavior is being targeted it is essential to be sure that:

* the child understands what is being expect of him or her;

* the expectation is reasonable and something the child is capable of doing;

* the child understands what rewards can be earned by meeting the expectation;

* the child understands what the negative consequences will be for not meeting the expectation;

* you follow through with what you say you are going to do;
 


REMEMBER, DON'T TRY TO TAKE ON TO MANY THINGS AT ONCE AND TRY TO SET THINGS UP SO THE CHILD HAS A GOOD CHANCE TO EXPERIENCE SOME EARLY SUCCESS. DON'T EXPECT OR REQUIRE PERFECTION. EVEN A SMALL IMPROVEMENT IS STILL AN IMPROVEMENT.

"I don't think this will work because it's impossible to enforce consequences with my child. Trying to enforce a punishment just makes him angrier.

Unfortunately, things can get to this point. Even in these situations, however, sometimes one parent has more success than the other. For children with Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder who are also oppositional, fathers often seem to have greater success than mothers.

If this is the case, one approach is for mom to calmly and firmly attempt to induce compliance from the child and to be clear about what the consequences for continued non-compliance will be. If the child refuses to comply, make it clear that when dad gets home they will need to do what is being demanded and that the consequences will be enforced at that time. PLUS, an additional negative consequence will also be administered. By refusing to listen to mom, therefore, they are not getting out of what they don't want to do, but only delaying the inevitable. In fact, by not listening to mom, they will actually be making things worse. The intent here is to keep mom from getting into an unsuccessful and escalating battle with the child while making it clear to the child that there is no pay off for not listening to mom. For this approach to work, cooperation between parents and support for each others efforts is essential.

"What if neither parent can get their child to comply?"

This is sometimes the case. If both parents are unable to induce compliance from their child, and their best efforts are not successful, consultation with an experienced child mental health professional is essential. The longer behavioral difficulties persist the harder they are to change and it is critical to stop an escalating cycle of misbehavior as quickly as possible.

The ideas discussed above are intended to provide parents with a general overview of a behavioral approach to improving children's behavior. In many cases, consultation with an experienced child mental health professional will increase the success that parents experience with this approach.


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