How Does Behavior Therapy Work?

The American Academy of Pediatrics recommends that doctors prescribe behavior therapy before medicine for preschoolers with ADHD. Sadly, fewer than half do. Don't be on the wrong side of treatment for your child — whatever his age.

Basics of Behavior Therapy, Part 2

How It Works

Behavior therapy operates on a simple premise: Parents and other adults in a child’s life set clear expectations for their child’s behavior. They praise and reward positive behavior and discourage negative behavior.

“All behavior therapy programs should include four principles,” says Swanson:

1) Reinforce good behavior with a reward system--stars on a chart or extending a special privilege, like playing a favorite video game for an extra half-hour or going to a movie on Friday night.

2) Discourage negative behavior by ignoring it--according to experts, a child often uses bad behavior to get attention.

3) Take away a privilege if the negative behavior is too serious to ignore.

4) Remove common triggers of bad behavior.

If a child often misbehaves when sitting next to a particular buddy in the classroom, ask the teacher to re-assign your child to another seat.

“Behavior therapy isn’t a cure-all for ADHD behaviors,” says Quinn. “Parents who think they can change a long laundry list of behaviors will be disappointed.” Pick five or fewer that you deem the most important.

The most effective programs include parent training, teacher/classroom strategies, and social-skills training for children. Many are based on the COPE program, whose goal is to strengthen the parent-child relationship by teaching strategies in a group setting. Here is the program that Pelham uses with good results:

Parent Training

Goal: To learn strategies to encourage positive behavior in your child and strengthen your relationship with him.

How long: Eight to 12 weekly sessions, lasting one to two hours, with fellow parents and a counselor/therapist.

Format: A group of parents views a film of a parent and child confronting a common problem, such as a child’s tantrum in the grocery store. The group discusses better ways to handle it than by yelling at the child or threatening him.

One example: Parents state their expectations to the child before going into the store: “I’m going to shop for 15 minutes, and I expect you to walk beside me and help me look for things. If you whine, yell, or complain, we’ll go out and wait in the car until you settle down, and then we will go back into the store. If you cooperate, then we will finish shopping quickly and have time to play in the yard when we get home.” The counselor and parents practice the strategy on each other, and parents are asked to use it at home in as many situations as they can. At the next session, parents discuss the strategy’s success, view another film, and learn the next strategy.

Skills learned: To establish house rules and structure (posting chore lists and morning and evening routines); to praise appropriate behaviors and ignore mildly inappropriate ones; to use commands (“Sit down, please”) and not questions (“Why won’t you sit down?”) and to be specific (“You need to sit in the chair and not wiggle while I tie your shoelaces”); to use when-then contingencies (“When you finish your homework, then you can ride your bike”); to establish ground rules, rewards, and consequences before an activity; to use timeouts effectively (giving a child one minute of timeout for each year of age); to create daily charts and point/token systems to reward good behavior.

Child Training

Goal: To help children acquire the social skills needed to form lasting friendships. Research shows that kids with ADHD who learn to make friends do much better in life than those who don’t.

How long: Peer groups meet weekly in after-school or weekend sessions, for two to three hours, throughout the year. Another option is summer day camp, led by a therapist. The program runs six to eight weeks, six to nine hours a day.

Format: Sessions begin with a brief discussion of a social skill or a common peer issue, and the counselor offers strategies for mastering the skill or dealing with the problem. Then kids play games--soccer, basketball, board games--and the counselor looks for opportunities to praise them for positive interactions, good social skills, and sportsmanship. For example, during a basketball game, the counselor may compliment a child for passing the ball to his teammates.

Skills learned: To problem-solve (a child may role-play different ways to cope when someone calls him a name); to become more competent at games and sports, which can help a child fit in better socially; to decrease undesirable and antisocial behaviors, like bossiness and aggression.

Teacher Training

Goal: To help teachers adapt the goals of the parent-training program to the classroom.

How long: From one hour to one day to a weekend of training at the school or at an off-site seminar.

Format: This varies, depending on the school and the professional you’re working with. In many cases, the behavior therapist will agree to speak with the school psychologist and teacher about addressing the needs of your child. If not, you will have to set up an appointment to talk with them. “Perhaps the best approach,” says Pelham, “is developing a 504 Plan that allows you to establish behavior goals for your child. And it won’t cost you anything.”

Skills learned: To develop class rules and goals, using small rewards to encourage compliance (rewards are written on poster board and hung up in the classroom); to give positive reinforcement and specific instruction at a child’s desk (“Today, you are just reading about animals and picking one you would like to write about; you don’t have to write anything during this class period”); to use when-then contingencies (“When you finish your required assignment, then you can have some free time to play a game”); to use a daily report card to communicate with parents.

Program Particulars

“This three-part program is effective because it is so intensive,” says Quinn. “However, it’s tough to find this kind of program in many communities--and if you do, it is very expensive.” Full-blown programs, like Pelham’s, cost $5,000 to $6,000 a year, while summer treatment camps for children run from $2,000 to $4,000. Parent training with a therapist can cost $10 to $100 per session.

Most insurance plans cover 20 sessions a year with a therapist, according to Pelham, but generally won’t pay for summer camp or social skills training. Some do, however, so consult your plan’s administrator.

If you don’t have the time or money for an intensive program, there are less ambitious options. Check with your community mental health center or mental health hospital to see if they run behavior programs. According to Pelham, “community mental health centers are required to document that they are using so-called ‘evidence-based’ programs, like parent training, in order to receive federal funding. If they’re not offering it, ask the health center, ‘Why not?’”

No matter which program you use, look to include classroom strategies. “The teacher must be included and on the same page, or the therapy won’t be effective,” says Quinn. “You can’t change a child’s behavior only at night and on weekends. You have to do it all day long.”

While experts point to behavior therapy’s ability to change a child’s behavior at school and at home, Quinn says there are longer-lasting benefits--self-control and empowerment. “You don’t want a child with ADHD thinking he can act right only if he takes his meds,” she says. “He needs to feel that he is responsible for getting good grades, he is smart, he is taking the initiative to make his bed. Behavior therapy does that. It gives a child control of his life.” Every parent would consider that a great return on their investment.


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TAGS: Behavior in ADHD Kids, ADHD and Discipline

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