A Pragmatic Parent’s Guide to Behavior Therapy
ADHD experts agree that the most effective pediatric treatment plan includes medication paired with behavior therapy. But what, exactly, does that entail? And how can parents ensure success? Read on for answers.
If your child has been diagnosed with ADHD, chances are, your physician has discussed or prescribed ADHD drugs. You may also have learned that behavior therapy, also called behavior modification, may be helpful. As you try to figure out the best treatment for your child, bear in mind that these two therapies are not mutually exclusive options. In fact, they often work best together in solving ADHD behavior problems.
This is clearly shown by the landmark National Institute of Mental Health‘s (NIMH) Multimodal Treatment Study of Children with ADHD. NIMH found that medication therapy alone, and medication and behavioral therapy together, resulted in the greatest improvement in children’s ADHD symptoms. In addition, the combination treatment worked best in improving ADHD-associated oppositional behaviors, as well as other areas of functioning, like interactions with parents and school.
Even if you opt for behavioral therapy alone — you’ve decided on a non-medical approach, your child’s too young for medication, or suffers bad side effects from it — your child can learn behavior, social, and academic skills that will be useful in managing ADHD throughout his life. Most children don’t get diagnosed until school age, so if you suspect your child has ADHD before then, it’s nearly always helpful (and never harmful) to treat him behaviorally as though he has the condition.
It’s About Focus
What is behavior therapy, and how can a parent use it on its own or as a component of combined treatment? While medication works on a neurological level to regulate the brain (kids with ADHD often have irregular brain-wave levels), behavior therapy addresses specific problem behaviors by structuring time at home, establishing predictability and routines, and increasing positive attention.
This may seem like a tall order, especially to the parent whose child must be reminded every five minutes to stay focused on homework. When ADHD is present, the most basic strategies can be a huge challenge to implement on a day-to-day basis. This is why Sharon K. Weiss, author of From Chaos to Calm: Effective Parenting Of Challenging Children with ADHD and Other Behavioral Problems, recommends that parents narrow their focus. Tackling too much at once will only frustrate a child who has trouble simply remembering to put on both of his shoes in the morning.
To figure out what to work on first, Weiss suggests asking yourself: What does my child need to do so that he can participate successfully in life? When you apply this litmus test, certain things will emerge as more essential than others. “The school doesn’t care if the child’s bed is made, but they do care if he shows up buck naked,” says Weiss. While many therapists and educators talk about creating a “behavior plan,” she asserts that this need not be intimidating. The plan should simply include three basic components: a narrow focus on essentials, documentation, and a commitment to note and reward improvement when it occurs.
If you identify getting to school on time as a top priority, you have a single goal to work on and easily measure progress for — progress-tracking being another important part of behavioral therapy. If your goals are too diverse (going to bed at a certain time, being dressed impeccably in the morning by 8, doing homework immediately after school, and remembering to take the trash out), you probably won’t be able to notice and keep track of your child’s accomplishments. “You can’t tell him he needs to be downstairs at a certain time each morning and then, when he succeeds in doing that, ask him why he forgot to comb his hair,” says Weiss. When success isn’t noticed and complimented, a child with ADHD feels increased frustration and lower self-esteem. He probably won’t achieve even one of the things you’ve asked of him, let alone all of them.
How to Get Real
Once you’ve chosen key behaviors to work on (say, getting to bed on time or not interrupting someone else when they’re speaking), you then must be clear — and realistic — about your expectations and what you’re going to look for. First, ask yourself if your child has the skills to accomplish what you ask of her. For instance, if she typically needs to be told 10 times a day not to blurt out what’s on her mind when others are talking, expecting her to hold her tongue without reminders is probably not wise. Instead, set the goal to remind her a couple of times a day. Or pick a certain time of day to assess how she’s doing (morning, for example), then cut her some slack if she’s not performing up to par at other times.
Unlike chemically-based intervention, behavior therapy will have an up-and-down quality to it. Just because he dressed himself and was downstairs for breakfast on time and out the door for school by 8 a.m. today, doesn’t mean your child will do it again tomorrow. What’s important: that if prior to the behavioral therapy he was succeeding only two out of five times a week, he’s now up to three. Don’t hassle him the other two times.
A Plan That Works
When you understand that your child can’t get it all right all the time, you’re ready to shape her therapy. To this end, Weiss suggests asking yourself the following three questions:
- What do I want my child to do that she isn’t doing?
- How can I relay my instructions in a visual format (so I won’t have to tell her what to do)?
- What would make it worthwhile for her to do it (i.e., something more powerful than what’s on her radar screen at the moment she’s engaged in inappropriate behavior)?
Set the wheels in motion at a time that demands routine — morning, when it’s time to get up and dress, mealtime, or bedtime. With an older child, homework time is another option. To fulfill the visual-format component, provide a checklist of selected tasks (for a preschooler, try a picture checklist). This gives your child a reminder of what she’s supposed to do and when, and relieves you of the task of constantly delivering it. It also offers a child more control over her actions, and cuts down on parental nagging (which children with ADHD tend to tune out as background noise — especially when they’re overwhelmed).
If she achieves what’s on the list, reinforce her positive actions with a reward. It doesn’t have to be expensive. For a younger child, it might be stickers or an ice-cream cone; for a teenager, it could be extra phone or car privileges.
In his book, ADHD: The Great Misdiagnosis, pediatrician Julian Stuart Haber, M.D., explains a method he’s used effectively in his practice. It involves pointing out the annoying behavior, stating the expected behavior, complimenting the improved behavior, then rewarding it. Says Dr. Haber: “If a child constantly interrupted you while talking on the telephone or with other people, you would say, ‘That’s interrupting. Now let’s practice waiting,’ without becoming angry and without otherwise responding to the child. When he waits for a few seconds or minutes, you respond by saying, ‘That’s very good. Now you’re practicing waiting.’ After a few times, offer to treat him to a milkshake. When he asks why, respond, ‘Because you’ve done such a good job practicing waiting.'”
Bear in mind that many children with ADHD have trouble transferring what they’ve mastered from one setting to another. So while you may get your child to be patient when you’re on the phone, he may not be able to keep from interrupting someone on the phone at your sister’s house. That’s why your role as your child’s advocate is ongoing.
To make sure he’s applying good home behaviors in school, you’ll need to clue his teacher in on what you’re practicing. If you’ve taught your son to ask “Can I join in?” before he steps into a game, pass that information along to his teacher. Another way to keep him on track is to make note cards (visual cues) to keep on his school desk. This traveling checklist might remind him to “raise your hand before you ask a question,” or “write down the homework assignment before you leave the classroom.” Ask his teacher to check things off his list as he completes them.
How to Get Ready
Parents are a lot less likely to get exasperated and give up if they see results. But when you’re in the thick of it, it’s all too easy to forget that even baby steps indicate that you’re getting somewhere. This is one of the biggest obstacles parents face in sticking with a behavior therapy program, says Karen Miller, M.D., assistant professor of pediatrics at the Center for Children with Special Needs at Tufts-New England Medical Center in Boston. That’s why she believes parents greatly benefit from professional coaching before they get started. Although many behavior modifications are common-sense parenting techniques, most parents need support to learn these skills and use them consistently. Parent training, whether individual or group-based, helps moms and dads stay with their goals even if they don’t see a change for several weeks — the amount of time it typically takes for progress to begin. If parents habitually toss out a plan too soon, children learn to wait it out, perceptively realizing that they can get away with not sticking to new rules for just the time it takes the folks to throw in the towel.
The involvement of a neutral person, such as a coach, also helps to alleviate tension between partners who disagree on which behaviors to tackle — and how. Dr. Miller prefers group-based parent therapy because “it has the added benefit of helping parents feel less alone and less blamed for their kids’ difficulties. They hear real-life tips from other people struggling with the same issues, learn how to make a behavior plan, and report back on how it’s working. It’s great stress management for them as well.”
Every child is different, and it’s impossible to predict what will work in any given situation. But creating a realistic behavioral plan that you can chart, getting coaching for yourself, and keeping up with your kid’s performance at home and away are all fundamentally important to behavior therapy. The golden rule for every parent is to stop asking your child “why?” If kids with ADHD could answer that question, the condition wouldn’t exist. Instead, live in the solution, which should include thoughtful behavior therapy. That’s when you’ll be on the road to your child’s healing — and his and your happiness.