When Behavioral Parent Training is Working — But Tough to Maintain
Behavioral parent training can change bad behavior in a child with ADHD over time — but sometimes, the positive effects seem to run out of steam. Here are five common problems, plus solutions to keep the benefits coming.
Behavioral parent training is a natural, first-line treatment for attention deficit hyperactivity disorder (ADHD or ADD) recommended by the American Academy of Pediatrics for children younger than 6 on its own, and for children 6 and older in combination with ADHD medication. The efficacy of BPT is well documented in research and in patients’ experiences, but continued success requires continued time and effort, which is seldom easy for ADHD families.
Behavioral Parent Training Problem 1: “We’re just too busy!”
It can sometimes be overwhelming for parents to integrate the techniques they learned in behavioral parent training (BPT) into busy parent-child schedules at home. Here are some strategies for designing a home behavior plan that fits into your family’s lifestyle.
1. Prioritize target behaviors. Over the course of behavioral parent training, you may have identified several target behaviors for your child. You will have the opportunity to tackle each behavior eventually, but start simply by prioritizing one to three behaviors that are currently causing the most problems. An example of a single problem that can be tackled by behavior therapy: if your child is being aggressive toward siblings, you would target that before making the bed. By narrowing your focus, you will be able to more effectively treat the most pressing difficulties.
2. Start low and add as you go. Behavioral parenting strategies range widely in their intensity and in the time they require of parents. For some children, a token economy, in which the child earns and loses tokens (stickers, points) for each instance of appropriate or inappropriate behavior will be necessary to manage behavior. But for others, creating house rules and increasing labeled praise (“I love how you used respectful words!”) will be sufficient. Starting with less intensive strategies and adding more intensive strategies as needed will allow you to master simpler approaches before adding more complicated ones. This will prevent the home behavior plan from getting too difficult to implement.
3. Reward yourself. Initiating and maintaining a lifestyle change is hard work! Just like you reward your child’s consistency, reward your own by doing things you enjoy or scheduling some well-earned alone time.
Behavioral Parent Training Problem 2: “The magic has worn off.”
Parents will sometimes notice immediate improvements in children’s behavior when implementing a new home behavior plan. But, after a few weeks, they may see a drop-off in initial gains. There are many reasons that behavioral interventions may appear to stop working. Some common ones are listed below.
1. Are rewards rewarding enough? Just as with parents, children may lose their initial motivation once the novelty of a new behavioral system wears off. If tangible rewards (edibles, small toys) or privileges (screen time, later bed time) are a part of your home behavior plan, check in to see if current motivators are still interesting to your child or if there are other things he or she would rather earn instead. One way to keep rewards exciting is to design a “reward menu” that lists several possible rewards to choose from. Another option is to pair daily rewards with larger, longer-term rewards (e.g., a fun weekend activity, a video game) that can be earned after a certain number of “good days.”
Use visual aides to show your child his or her progress toward earning larger rewards to keep things exciting. If you currently use praise or other forms of social reinforcement instead, you may consider increasing the saliency of these interventions by backing them up with rewards and/or privileges.
2. Are rewards attainable? If goals are so challenging that rewards are never earned, your child may give up hope. In order to get some “buy in” from your child, you may consider making rewards easier to earn at first. Once your child meets initial goals consistently, you can gradually increase the difficulty to improve behavior over time. If your child is still not meeting goals, you may consider providing rewards at more frequent intervals. Waiting until the end of the day for a reward is often difficult for children, especially younger ones. Consider working rewards into your morning, after-school, and bedtime routines. For example, your child could earn choosing the radio station on the way to school for completing the morning routine appropriately.
3. Is your child getting too many potential rewards for “free”? If children already have access to many rewards and privileges without having to earn them, they may be less motivated to earn rewards that are tied to meeting a goal within a behavior plan. For example, if TV time is on the reward menu, but your child earns 30 minutes of iPad time regardless of whether goals are met, there is little motivation to earn TV time. Similarly, if children are given rewards without truly earning them, they will be less motivated to change their behavior, hoping that parents will “give in.”
4. Does your child understand how to earn reinforcers? As home behavior plans become more complicated, children may lose track of what they are supposed to be doing and what they get for meeting expectations. Check in with your child to ensure that he or she understands the system. Visual reminders, such as posting rules and routines, are helpful for keeping your child (and caregivers!) on track, especially in younger children. It can also be helpful to involve your child in tracking his or her progress toward meeting daily expectations. For example, your child can check off when tasks are completed or goals are met. This can take many forms, such as a whiteboard on the fridge, adding marbles to a jar, or using a mobile app like iRewardChart. Get creative and choose what works best for your family.
Behavioral Parent Training Problem 3: “Home behavior has improved, but what about everywhere else?”
If you are noticing stable improvements at home, congratulations! That means you have gotten the hang of implementing new strategies, and that your hard work is paying off. However, if you notice that these gains disappear when you leave your child with a babysitter or go to a birthday party, you are not alone. Children are very responsive to their environments and quickly learn who will implement consequences and who will let them get away with misbehavior. Therefore, it typically takes some additional work for behavioral gains to work in other settings. Below are some tips for accomplishing that.
1. Spread the word. Identify the settings in which it is most important that your child’s behavior improve, and start there. Carve out some time to meet with key adults (classroom teacher, soccer coach) to discuss your child’s behavior and help them develop achievable interventions for your child in that setting. Hearing from you that these strategies have been working is often an effective way to motivate teachers and other adults to try out new approaches as well.
2. Set up daily communication with key adults. Communicating with teachers, tutors, after-care staff, and other key adults every day lets your child know that he or she will be held accountable for behaviors that occur outside of the home. This communication can be as simple as a note in your child’s agenda or a more comprehensive Daily Report Card (DRC). For more details on setting up a DRC, click here.
3. Make your home behavior plan portable. If your child engages in disruptive behavior at the park, the grocery store, or other places, apply the same behavioral principles that you would at home in those settings. Let your child know that the house rules still apply and be consistent in implementing consequences for following and violating rules. Of course, some tweaks will be necessary to make your plan work in other settings. Anticipate problems (whining in the snack aisle at the grocery store) and develop rules specific to those problems.
Plan ahead so that you are ready to implement consequences if necessary. For example, if you typically use a time-out as a consequence, identify a good place to implement a time-out in public (the sidewalk, a bench). If a setting is particularly difficult for your child, set up a specific contingency for following rules in that setting (getting candy at the check-out line for following grocery store rules). Just like knowing expectations and incentives ahead of time helps to increase compliance at home, it can help improve behavior in public, too.
4. Seek help when needed. If you have difficulty getting others on board, such as a parenting partner, your child’s teacher, or another important adult in your child’s life, you may consider reaching out to the mental health professional who trained you in BPT. While seeing behavioral strategies work is often motivating to key adults, some individuals may need to hear how these strategies are implemented from an expert.
If you are having difficulty with your child’s school, see if your clinician would be willing to teach behavioral strategies to staff members at school. If the difficulty is with a parenting partner, it may be helpful to have other caregivers meet with the clinician or attend the same parenting group that you did. Consistency across settings is key to maintaining long-term behavior change, so the more people you can get on board, the better.
Behavioral Parent Training Problem 4: “New problems have come up!”
As children face changes in their environments, such as a new classroom or after-school activity, problems often arise. Some tips for applying existing strategies to new environments are listed below.
1. Identify your ABCs. Identify antecedents (say, a command from a parent), and consequences (parental attention) that may be maintaining problematic behaviors. It may take a few days of paying attention to the problem behavior to identify the antecedents and consequences that may be bringing it about.
2. Develop possible solutions. Make a list of the parenting strategies you learned in BPT training classes that will target either antecedents (giving clear commands) or consequences (implementing a time-out following noncompliance rather than giving attention) surrounding your child’s inappropriate behavior.
3. Try one out! Choose a solution and try it out. As mentioned previously, it is often best to start with a less intensive strategy and add more intensive ones if they are needed. Be sure to monitor your child’s behavior after you try the new strategy so you know whether it is working.
4. Adjust your strategy if necessary. If your first strategy was insufficient, try a more intensive strategy. For example, if your first strategy only targeted antecedents (adding a house rule), then add a strategy to target consequences (providing a reward for following the rules, or taking away a privilege for breaking a rule). Continue to monitor and re-evaluate as necessary.
Behavioral Parent Training Problem 5: “Will my child be reliant on these strategies forever?”
Managing behavior and fostering children’s independence often feels like a balancing act to parents. While using rewards is an effective means of increasing compliance, parents sometimes worry that children will become over-reliant on rewards, refusing to do anything unless a reward is given. The goal of BPT is to increase compliance using more intensive strategies (a behavior chart with tangible rewards) initially, but to fade these strategies over time so that children learn to comply even when more natural levels of intervention (positive attention) are in place. Strategies for scaling down treatment are listed below.
1. Evaluate current functioning. Before you begin scaling back, ensure that your child is meeting his or her goals on a consistent basis. We typically recommend that a child meet expectations at least 80 percent of the time for at least two weeks before changes are made to avoid reemergence of a problem behavior.
2. Go slow and monitor as you go. Slowly decrease the intensity of behavioral interventions. For example, if you are using a home reward system, you might scale down to “when-then” statements (“when you finish your homework, then you can use electronics”). Continue to monitor behavior and scale back up if behavior worsens. If behavior remains consistently well managed, continue to scale down until only less intensive strategies are in place (praise, effective commands, house rules).
3. Don’t drop everything. Just like we wouldn’t expect children to be expert baseball players after going to one sports camp, we don’t expect that children will be perfectly behaved after one round of BPT. Given that most children with ADHD continue to experience problems related to the disorder into adolescence and even into adulthood, some level of intervention as a child matures and grows older is likely necessary to ensure a successful transition into adulthood. However, a low level of intervention (setting limits and providing access to privileges for following those limits) may be sufficient for many children diagnosed with ADHD.
4. Be ready for new challenges. Be on the lookout for situations that may be challenging for your child. If new problems arise, refer to the problem-solving steps listed above for guidance. For major developmental transitions (moving from elementary to middle school, say), you may thing about checking in with a BPT professional to learn techniques that are most appropriate for your child’s current developmental stage.