Behavioral Therapy

Nicer… Through Nurture

“Evidence shows that paying more attention to relationships can change a child’s behavior.” These 3 behavior therapy programs aim to do just that, by focusing on (and fixing) family dynamics.

A happy child playing with a slingshot, having improved ADHD symptoms through parent-child interaction therapy
Blond boy in blue striped shirt playing with yellow slingshot outdoors

Before Eric’s fourth birthday, he had been treated by half a dozen therapists, none of whom made life easier for him or his mother.

“I was always on edge at work, waiting for the phone call from his pre-school to come pick him up,” recalls Michelle, a single mom in New York City. (Her name, like Eric’s, has been changed to protect the family’s privacy.)

The trouble began when Eric was diagnosed with ADHD, which fueled his impulsive behavior — hitting, kicking, and biting. The worse Eric behaved, the more those around him scolded or avoided him, which caused him to misbehave even more.

Luckily, Michelle tried one more strategy. After reading an ad in a local newspaper, she signed up Eric for an eight-week clinical trial for Parent-Child Interaction Therapy (PCIT), and continued on for several weeks after the trial ended. Today, two years later, she’s less stressed. “I’m no longer walking on eggshells,” she says. “I’m starting to enjoy my son.”

Designed for children up to seven years old, PCIT looks beyond a child’s disruptive behavior to his troubled relationships. Originally developed in 1974, it is one of several behavioral therapies enjoying new popularity, as evidence shows that paying more attention to relationships can change a child’s behavior.

“In a sense, we’re moving back to where we were in the 1960s,” says Stephen Hinshaw, Ph.D., a psychology professor and researcher at the University of California at Berkeley, and an international expert on ADHD. Back then, the dominant treatment for children’s behavioral problems focused on how children were parented. Developmental psychologist Diana Baumrind, Ph.D., defined ideal parenting as an “authoritative” style that is warm and nurturing while setting clear limits and holding children to high expectations. And as late as 1982, the pioneering psychologist Gerald Patterson, Ph.D., described its antithesis, in “the coercive family process.” His thesis was that children’s behavior worsens when parents get too authoritative or domineering.

By the late 1980s, however, scientists discovered strong evidence of biological roots of mental disorders, making medication a more popular strategy to address ADHD and other conditions. In 1998, Judith Rich Harris’ best-selling book, The Nurture Assumption: Why Children Turn Out the Way They Do, seemed to settle the debate, arguing that parents have much less influence than they think.

Yet today, as Hinshaw notes, the pendulum of this long-running nature-versus-nurture debate may be swinging back again — although not as far back as before. As researchers continue to uncover reasons for children’s bewildering behavior, it is clear that both seem to be powerful factors. Nurture — specifically, parenting — can’t be ignored.

This notion has reinforced many parents’ beliefs that, with a little support, they could do a better job. The New York Times reported not long ago that moms and dads were watching The Dog Whisperer for clues.

How PCIT Helps

PCIT’s signature technique for helping parents become competent is real-time coaching. Parents interact with their kids while listening to advice from therapists watching behind a one-way mirror.

“The therapist helps you identify ways in which you’re contributing to the problem,” says Michelle. “For me, that meant getting ramped up when Eric got ramped up. I learned to ignore some of his behaviors.”

Most insurance companies don’t cover lengthy behavioral therapy, and the sessions demand a lot of time and effort. PCIT and similar programs, nonetheless, continue to attract new families, largely due to demonstrated results. A peer-reviewed 2007 study, in the Journal of Clinical Child and Adolescent Psychology, found significant improvements in children with disruptive behavior, as well as less parent stress, after a course of PCIT. In 2010, program supporters organized an international association to publicize these and other encouraging results, and to make sure that new therapists were trained in the procedures.

Melanie A. Fernandez, Ph.D., a New York City clinical psychologist and spokeswoman for the program, says PCIT is not a substitute for medication. Many kids in the program continue on their prescriptions. And the program does not lessen fundamental symptoms of ADHD. Rather, PCIT works to improve the comorbidities, such as irritation, anxiety, and depression, that often accompany biological attention deficits and do the most damage to relationships.

Lifeline for Older Kids

Intensive family therapy is catching on among parents of older kids. One increasingly popular program, the decade-old Vive, combines time-tested principles of parent training with a novel approach involving two separate therapists: a “mentor” for the struggling youth and a “coach” for the youth’s struggling parents.

Vive is aimed at families in serious crisis, who can devote substantial time, in addition to paying fees of up to $3,000 a month. Most of the appointments take place away from the therapists’ office. The teen’s mentor will meet him or her at school or work, while the coach usually speaks to the parents by phone. Family sessions are conducted in the family’s home. A unique aspect of Vive is that the mentor’s work extends to helping the youth with school or job-related problems. Similarly, the parent coach will try to reduce stresses, such as marital bickering and losing a job.

Vive, founded in Denver by Dave Herz, M.A., a therapist who had previously worked in a therapeutic boarding school, has opened offices in Atlanta, San Francisco, Los Angeles, Chicago, Boston, and New York.

“We liked the fact that Vive gave our son more control over his own therapy,” says Lauren, a mother in Atlanta. “Most of our treatments before then had consisted of our talking to the doctor, counselor, or teachers about our worries, with our son saying and interacting very little.”

Lauren used Vive after life with her teenager, Brad, who has been diagnosed with ADHD, became so chaotic that she and her husband were considering sending the boy to a wilderness program or a therapeutic boarding school. Brad was experimenting with drugs, failing at school, and arguing with his parents and two siblings every night. But Lauren balked at sending him away, afraid that it would damage him emotionally to be separated from his family.

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With Vive, Lauren’s son was in charge of scheduling his own weekly appointments with his mentor. The two went out to dinner, took in movies, and hiked. After a couple of weeks, Lauren said, she could see her son relaxing and becoming more reflective. At the same time, her parent coach helped her and her husband to find ways to reduce their stress. “Our son had his therapist, and we had ours, which made him feel he wasn’t the only one who needed help,” Lauren said.

They stayed with the program for six months, until the cost became an issue — even though they had saved several thousand dollars by not opting for a boarding school. (Herz says insurance plans pay less than 50 percent of Vive’s costs.)

Lauren says the half-year was enough to help Brad become more reflective about his ADHD and impulsivity. “We now all see the patterns in our ways of reacting to each other and focus on the strategies that work positively for all of us.”

One More Option

The Nurtured Heart Approach is another popular and effective behavioral therapy for kids diagnosed with ADHD. Designed by Tucson therapist Howard Glasser, it was practiced at Tucson’s Center for the Difficult Child from 1994 to 2001, and it has been used in classrooms in and outside of Tucson, including, most recently, several elementary, junior, and high schools in Michigan. The basic approach is for parents (and teachers) to strictly ignore negative behavior as much as possible, and to energetically reward progress. It’s similar to the strategies used by PCIT and Vive — and the teachings of The Dog Whisperer.

All three strategies have one thing in common: relationships matter — and what’s good for the pack is good for each pooch. That seems to work well for children with ADHD and their parents.

D-I-Y Behavior Therapy Program

“My son is 10 years old and has been diagnosed with ADHD. We were looking for strategies to deal with some of his challenging behaviors. What did we do? We gave up punishing our child — no time-outs, no taking things or privileges away from him. They weren’t helping at all. We only reward him now.

“I made a set of file cards and wrote down on each card a thing he likes. Some things are more valuable than others to my son, but the suspense of drawing a card is part of the reward. Rewards include: reading at the dinner table, chewing a piece of sugarless bubble gum, renting a movie for the family to watch, visiting the comic book store. Every time our son succeeds at improving a behavior we had on his chart, he gets to pick a card.

“The trick to this system is to be consistent, and to give the reward as soon as possible after the good behavior, so your child associates a reward with doing something right. Things we’ve learned over the past year:

  • choose the right rewards for your child
  • focus on two or, at most, three behaviors at a time
  • follow through every time your child demonstrates a behavior you”ve identified as worth rewarding
  • make sure both parents follow the program to the letter
  • be patient…it takes repeated rewards — over weeks — to cement a certain behavior in your child’s mind
  • don’t hand out things on the reward cards for anything except the desired behavior
  • don’t punish your child when he or she fails at the behavior; do your best to remain calm and matter of fact. Say something like, ‘Darn, I wanted you to get that reward. Next time you’ll do it.’ This is especially hard when you’re at your wit’s end and angry about how your kid is behaving.

“We haven’t done this program perfectly, but we have succeeded in getting our son to do some of the behaviors we agreed upon. More important, our program has made a huge difference in the tone and spirit of our household.”

—An ADDitude Reader