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Behavioral Treatment for ADHD: A General Overview
By David Rabiner, Ph.D.
Introduction
Using positive reinforcement
Isn't this bribing my child?
Using negative consequences to reduce misbehavior
Have a game plan!
Don't teach your child to misbehave!
What behaviors can be addressed with this type of
approach?
It's impossible to enforce consequences with my child
What if neither parent can get their child to comply?
About the author
Introduction
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
ADHD, medication is no panacea and some children with ADHD should not receive it. There
are several reasons for this. First, although medication helps the majority of children
with ADHD, 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
symptoms or associated problems which must be targeted via other means. Fourth, some
children with ADHD 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.
An important non-medical approach used in treating children with ADHD 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.
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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 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 ("Your 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, etc.
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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 ADHD,
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 child's 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.
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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, etc. 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:
"Your grounded for the next 2 weeks!"
"That's it! No more birthday party for you!"
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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 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 ADHD?"
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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, factors specific to ADHD generally require certain modifications to be made. Several
of these important modifications are:
Children with ADHD 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 ADHD
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 needs frequent feedback for
behavioral programs to be effective.
Children with ADHD do better with short term
goals than long term goals.
- This follows from the above. Along with more frequent feedback,
children with ADHD 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 ADHD. 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 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, 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 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, etc.) 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,
etc. 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.
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"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 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, etc. 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 too many things at once and try to set things up so that 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 ADHD 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.
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"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.
About the author:
David Rabiner, PhD is a clinical child psychologist
who specializes in the evaluation and treatment of children with ADHD. He teaches and
conducts research at Duke University.
Dr. Rabiner's research on children's social development has appeared in
leading national and international journals and has been presented at numerous
conferences. He has also served as a consultant on two federally funded grants involving
ADHD.
To visit Dr. Rabiner's Web site, click http://www.helpforadd.com/
To send e-mail to Dr. Rabiner, click [email protected]
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