ADHD Therapies

How Parent-Training Programs Work

Children with ADHD are up to 11 times more likely than their peers to develop oppositional defiant disorder, which often means daily arguments, outbursts, and anger-management problems. Many parents find hope — and strategies — in parent management training programs that help break unhealthy cycles.

Father and son outside

Call it being strong-willed or spirited. Either way, argumentative and explosive behavior is common in children with attention deficit disorder (ADHD), and it can exhaust patient, loving parents. Whether your child’s defiance is limited to a handful of issues — doing homework or cleaning his room — or he meets the criteria for Oppositional Defiant Disorder (ODD), there are strategies that can turn around difficult behavior.

“About 65 percent of kids will develop ODD within two years of being diagnosed with ADHD,” says Russell Barkley, Ph.D., clinical professor of psychiatry at Medical University of South Carolina, and author of Your Defiant Child (Guilford Press). “Kids with ADHD are 11 times more likely to have ODD than anyone else in the population. The two conditions go together.”

Kids with ADHD find it hard to regulate their emotions. “Defiant children are reacting from the emotional centers of their brain, and they’re not thinking, ‘If I do this, I’ll get in trouble,'” says psychotherapist Joyce Divinyi, author of Discipline That Works: 5 Simple Steps (Wellness Connection). “Defiant behavior is an emotional impulse, not a thoughtful action.”

The more severe a child’s ADHD symptoms, the more likely he is to behave defiantly. Getting symptoms under control with medication, cognitive behavioral therapy, or both, may lessen defiant behavior. Parenting style also plays a big role in the severity of a child’s defiance — parent management training can help.

“Parents should understand that this is difficult behavior to address,” says Barkley. “Your child is yelling, screaming, fighting, pushing and hitting, and it can escalate to destructive behavior and, sometimes, violence. You may be tired. You may have had a tough day at work. You may have another child who’s demanding your attention. Maybe you’re depressed. Or maybe you also have ADHD, and have trouble regulating your own emotions.”

Parents of ADHD children face these situations many times more than other parents do, he adds, and are more likely to give in some of the time. That’s why parent training is so important. It gives you the skills, support, and help you need to be consistent.

[Self-Test: Could My Child Have Oppositional Defiant Disorder?]

How Parent-Training Programs Work

The American Academy of Child and Adolescent Psychiatry recognizes two treatments for defiant behavior — parent training and Collaborative Problem Solving (CPS). Since kids don’t develop the skills needed for CPS until they are 10 or older, parent training is probably the best option for younger kids.

The premise: Defiant behavior results when children realize that they can get what they want by behaving badly. You say to your child, “Turn off the video game and do your homework,” and your child refuses and argues with you. If you stand your ground only half the time, you set the stage for defiant behavior. “It doesn’t have to pay off every time to make it worthwhile for him to fight; it’s only got to pay off some times,” says Barkley. Experts call this pattern of interaction “the coercive cycle.”

How it works: The goal of parent training is to break the cycle and help parents discipline their children more effectively. “Kids who are defiant cause stress in families,” says Rex Forehand, Ph.D., professor of psychology at the University of Vermont, and coauthor of Parenting the Strong-Willed Child (McGraw-Hill). “To turn the behavior around — and I know everyone has heard this before — parents need to be consistent, set limits, create structure, and be positive.”

Parent training teaches you these skills in two parts. 1) You show your child what you want from her, give her incentives to behave that way, and reinforce positive behavior by giving approval, praise, recognition, points, tokens, and/or rewards. 2) You learn strategies to correct negative, defiant behaviors — ignoring minor bad behavior and enforcing consistent consequences, like time-outs.

What you learn: How to give instructions in an authoritative way, use time-outs effectively, teach your child to think about the consequences of his actions, praise him, and create and use a rewards system.

[Train the Parent, Help the Child]

4 Parent-Training Courses: How to Choose

There are many parent-training courses available nationwide. Each program offers something unique.

1. Parent-Child Interaction Therapy

Parent-Child Interaction Therapy (PCIT) is offered in university-based centers and by individual therapists.

Best for: Parents of kids ages two to seven. PCIT involves one-on-one therapy with the parent(s), and possibly other family members, as well as the defiant child. You interact with your child in a room with a one-way mirror. The therapist sits on the other side of the mirror, talking with you through a headset. “The advantage of communicating with the parent is that the child associates these skills with the parent, not with the therapist,” says Timothy Verduin, Ph.D., clinical director of the Institute for Attention Deficit Hyperactivity and Behavior Disorders at the New York University Child Study Center.

Find a therapist: PCIT International

2. Helping a Noncompliant Child

Helping the Noncompliant Child, a program used with children and their parents, is outlined in Rex Forehand’s book, Parenting the Strong-Willed Child.

Best for: Parents of kids ages three to eight. You read and follow the instructions in the book, participate in a group program, or work one-on-one with a therapist. “The child should be in the room with the parent, so the therapist can demonstrate the best response and encourage the parent,” says Forehand.

Find a therapist: Association for Behavioral and Cognitive Therapies (ABCT)

3. Your Defiant Child

Your Defiant Child program is outlined in Russell Barkley’s book of the same name.

Best for: Parents of kids ages four to 12, especially those who are severely or persistently defiant. In the first four weeks, parents learn to give approval, praise, and recognition, and to establish incentives and tokens to encourage good behavior. The second four weeks teach parents how to correct defiant behavior, using such strategies as focusing on one problem at a time and acting within 10 seconds of the problem’s occurring. Another element is called “Help the Teacher Help Your Child,” in which parents use a daily report card to communicate with the teacher. Parents also learn how to adjust the rewards system as a child ages.

A weekly allowance works for 13-year-old Christopher Covello, of Norwalk, Connecticut, who was diagnosed with ADHD at five, and had occasional meltdowns and defiant episodes. His mom, Jennifer, posts a list of chores on the refrigerator. If Christopher does them without argument, he is given an allowance at week’s end. If he doesn’t do them, or complains about it, he is docked part of his allowance. “He came up with the list himself, so he has ownership of this arrangement,” says Jennifer. “We drew up a contract and both of us signed it.”

4. Group Programs

Group programs teach the principles of PCIT to a group of up to 25 parents and have the added benefits of providing support to parents and costing less than private therapy. Three programs are: COPE (Community Parent Education), taught, continuing-ed style, at night by paraprofessionals to parents of children up to adolescents; Incredible Years, for parents of preschoolers, and focusing on early intervention to prevent defiant behavior from worsening; and Positive Parenting Program, targeting teens and also providing strategies for managing marital problems caused by defiant behavior.

Help for Violent, Defiant Teens

If defiant behavior hasn’t been resolved by the time the child reaches his teen years, parent training won’t help. You can’t put a teen who is bigger and stronger than you in time-out. Enter Collaborative Problem Solving (CPS), a program created by Ross W. Greene, Ph.D., associate professor of psychiatry at Harvard Medical School, and described in his book, The Explosive Child (HarperCollins).

The premise: Defiant children with ADHD aren’t being willful or manipulative. Their defiant behavior results from a shortage of emotional and behavioral skills. Proponents of CPS see defiant behavior as a learning disability. “Instead of having trouble with reading and math, these kids have trouble with problem-solving, flexible thinking, and frustration,” says J. Stuart Ablon, Ph.D., director of Think:Kids, at Massachusetts General Hospital.

How it works: The program gives kids skills they lack — from social skills to executive-function skills — instead of using a reward-and-punishment system. The first step is to identify and understand the child’s concern about a problem (completion of homework or chores), and reassure him that the problem will be resolved by the child and the adult together. The second step is to identify the adult’s concerns about the same problem. The third step invites the child to brainstorm solutions with the adult, to find a plan that is mutually satisfactory.

What you learn: How to ask your child questions in a way that helps him explain what sets off his defiant behavior; how to share your own concerns with him and help him share his.

CPS turned around 12-year-old Armen Afarian’s behavior problems at school. When he was in middle school, Armen was sent to detention for what the teachers saw as defiant behavior during recess. The rule was that, when the bell rang, students had to freeze and hold the basketball, and walk back to class. On some days, Armen would shoot another basket after the bell rang, causing him to wind up in detention.

Armen’s mom, Debra Ann, who had been through CPS therapy with her son, called a meeting with his teachers to discuss solutions to the problem. Armen said, “I do stop sometimes, because I’ve ended on an odd number of shots. If I don’t stop when the bell rings, it’s because I’m on an even number, and I can’t end anything on an even number.”

“We won’t punish you, because that’s not going to change anything,” said one teacher. “How do you think we could solve this problem?” Armen answered, “Recess is 15 minutes; I could stop on an odd number if I know we’re getting close to the end of recess.”

No matter which approach you take to managing your child’s defiant behavior, the rewards go beyond avoiding meltdowns. By improving the way you interact with your child, you’ll improve your relationship and boost his self-esteem and self-confidence. Those benefits last a lifetime.

[Free Download: 4 Parent-Child Therapies for Better Behavior]

5 Discipline Rules for Parents of Violent, Defiant Children and Teens

Tip #1: Combined therapy — a discipline program plus medication — is best for defiant behavior. ADHD medication can help a child manage his emotions better, so he’s less likely to react explosively, but it won’t change his defiant behavior.

Tip #2: Remember that a child’s behavior often gets worse after participating in a defiance program, says Tim Verduin, of New York University. Because he isn’t getting the response from you that he wants, and that he’s used to, he escalates his negative behavior to get it.

Tip #3: If your child’s tantrums seem more explosive and frequent than her peers’, she may have ODD. As many as five percent of all children have ODD, but 65 percent of kids with ADHD also have ODD, according to some estimates.

Tip #4: “It’s never a good idea to make a rule that you can’t enforce all the time,” says Joyce Divinyi, author of Discipline That Works: 5 Simple Steps. “Defiant kids play the odds. If they can get away with defiant behavior one time — it may be only one in six — they will shoot for that one.”

Tip #5: It takes six months to change defiant behavior, says psychologist Joyce Divinyi. “I encourage parents to get coaching or support during this challenging time. Tell a therapist, ‘I’ve read this book, or I’m doing that program. It makes a lot of sense to me, but I need support while we’re getting through it. What do you suggest?'”

A Discipline Makeover for Curbing Violent, Defiant Behavior

Before: You pick up your child at a friend’s house, and say, “It’s time to leave. Would you please put the toy back on the shelf?” Your child continues to play with the toy. You repeat yourself, a little louder. He continues to play with the toy. You say, “I’m counting to three, and if that toy is not back on the shelf, you won’t be able to play with Johnny again.” Your child hugs the toy closer. You grab the toy and put it on the shelf, and your child starts to cry, kick, and yell.

You’re embarrassed, and, to calm him down, you say, “OK, you can play with the toy for two minutes, and then we have to leave.” You turn to Johnny’s mother and make plans for next week’s play date. In less than a minute, you have taught your child that if he throws a fit, he gets what he wants. By not following through on a consequence, you have undermined your authority.

After: You say, “It’s time to leave. Please put the toy back on the shelf.” You wait five seconds for him to comply, but your child doesn’t move. You say, “If you don’t put the toy back on the shelf, you will have to sit in time-out.” You wait five more seconds. Nothing. You say, “Because you didn’t do what I told you to do, you have to sit in time-out.” Your child rushes to put the toy on the shelf. You take the toy from your child’s hands, put it back on the floor, and repeat what you said: “Because you didn’t do what I told you, you have to sit in time-out.” Then you bring your child to a time-out area, and say, “Stay there until I tell you to get up.”

Three minutes later, you ask your child, “Are you ready to put the toy on the shelf?” If your child says yes and does it, the time-out ends. If not, the time-out continues until he is ready to do it. When he finally does it, you say, “Fine” or “OK,” but do not praise him. Immediately after this encounter, give a command that is easy to follow, something like, “OK, now please get your coat.” If your child does it without being asked again, as most children will at this point, say, “Thank you for listening the first time. I’m very proud of you.” Then give him positive attention, so that he can see your relationship has not been damaged.

The time-out must end with the same command by which it started, so your child knows he has to do what you want eventually.