Behavior Therapy

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.

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Imagine a treatment that could manage the behavior of a child with ADHD, make you a better parent, and enlist teachers to help him do well in school — all without the side effects of ADHD medications.

There is such a treatment. It’s called behavior therapy — a series of techniques to improve parenting skills and a child’s behavior. But how does behavioral therapy work?

“When I first diagnose a child with ADHD, I tell the parents they need to learn behavior techniques, whether I’m prescribing medication or not,” says Patricia Quinn, M.D., co-author of Understanding Women with AD/HD and When Moms and Kids Have ADD, and who has treated patients with ADHD in Washington, D.C., for more than 25 years.

“A pill decreases common ADHD symptoms like impulsivity and distractibility, but it doesn’t change behavior. A child on medication might be disinclined to punch someone, because he’s less impulsive, but he doesn’t know what to do instead. Behavior therapy fills in the blanks, by giving a child positive alternative behaviors to use.”

Quinn is not alone in prescribing behavior therapy for patients. According to the American Psychological Association, it should be the first line of treatment for children with ADHD who are under five years of age.

William Pelham, Ph.D., director of the Center for Children and Families at the State University of New York, goes further, suggesting that children of any age try it before medication.

“There’s clear evidence that a behavioral approach will work for the majority of children with ADHD,” says Pelham. “The benefit of using behavior therapy first is that, if a child also needs medication, he can often get by with a smaller dose.”

Recent evidence suggests that children who are put on medication first never try behavior therapy — or they try it years later, if medication has stopped working. According to a four-year study Pelham is conducting on medication and behavior therapy, at the University at Buffalo, “Parents who see that medication is working are less motivated to follow through with behavior therapy. That would be fine if the data showed that medication alone helped the long-term trajectory of kids with ADHD. It doesn’t.”

According to Pelham, a child can take medication for 10 years, and the day you take him off of it — or he decides not to take it any more, as some 90 percent of teenagers do — the benefits stop. Then what? “It’s a lot harder to learn from scratch how to deal with a teenager who’s acting out than it is with a five-year-old who is acting out,” he says. “The parent has lost five or 10 years relying on medication and not dealing with problems that behavior therapy could have addressed.”


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What Pelham doesn’t point out is that successfully implementing behavior therapy at home is hard work. It requires that you and your child change the way you interact with each other — and that you maintain those changes over time. Unlike the benefits of medication, behavioral improvements may not be apparent for weeks or months.

“The benefits a child receives from behavioral treatment are strongly influenced by the ability of the parent to consistently implement the program plan,” says Thomas E. Brown, Ph.D., assistant clinical professor of psychiatry at Yale University School of Medicine.

The Earlier, The Better

Although it’s never too late for a child to benefit from behavior therapy, evidence suggests that it works best when started early in the child’s life. Younger children generally have simpler problems, and these may be responsive to behavior therapy. For younger children, parent-child interactions aren’t ingrained and may be easier to change.

“Studies show that the average child with ADHD has one to two negative interactions per minute with parents, peers, and teachers,” says Pelham. “If you extrapolate, that’s half a million negative interactions a year. Either you sit back and let your child have those negative experiences, or you intervene early and do something to stop them.”

Quinn suggests that the longer a parent interacts negatively with her child, the greater the chances he will develop secondary behaviors, like oppositional defiant disorder, anxiety and/or depression, and low self-esteem. “You can avoid such problems by treating early with behavior therapy.”

An intriguing study suggests that using behavior therapy early in a child’s life may actually prevent ADHD or minimize its severity. Neuroscientists at the University of Oregon studied children ages 18 to 21 months old who had a gene called the “7 repeat allele,” which has been associated with ADHD. This gene is present in about 25 percent of children who have the condition.

The researchers observed the children’s behavior and their interactions with parents. They found that children whose parents scored highest in measures of “parent effectiveness” (gauged by how supportive they were and how well they interacted with their kids) were less likely to show symptoms of ADHD than children with the gene whose parents scored lower.

“It appears that, in children who have a genetic susceptibility to ADHD, things can be done to prevent it,” says Michael I. Posner, Ph.D., professor emeritus of psychology at the University of Oregon, who headed the study. “Good parenting may be part of that.”

“Although, in some cases, ADHD is inevitable, in a high percentage of children, ADHD occurs because of environmental influences, including the kinds of interactions they have with their parents early in life,” says James Swanson, Ph.D., professor of pediatrics at the University of California in Irvine.

Quinn disagrees. “Swanson seems to be saying that parents are the cause of ADHD,” she says. “Yet it’s been established that ADHD is a genetic or inherited disorder in a majority of cases. It is true that parents can make the condition worse or better. Employing appropriate parenting techniques is something they can do to make it better, and to modify the impact that ADHD behaviors have on the child and the family.”

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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