More Than Meds: A Guide to ADHD Behavior Modification
Behavior therapy helps children with ADHD learn to manage their everyday symptoms. That is an established fact. But how do you implement it? And what does it really entail? Skills training — demystified.
When parents and professionals treat ADHD, typically they focus on symptom improvement first and foremost. Often, medication is strategy #1. Yet many professionals believe that psychosocial, non-medical behavioral treatment is equally important. In fact, studies show that adult success is best predicted by three things: effective parenting skills, getting along with other children, and success at school. Many specialists argue that behavior therapy addresses all of these domains and can begin very young, before failures start to impact self-esteem.
The focus of behavior therapy is different than that of medication, which aims to eliminate symptoms. Instead, it concentrates on the ways that hyperactivity or inattention can impact academic performance, relationships with siblings, and noncompliance with adult requests. It treats for settings and domains of impairment, and hinges on strong collaboration between families, schools, mental health clinics, and primary care.
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What Is an Impairment?
No child starts treatment for ADHD because their parent is sitting in bed at night reading an article about the Diagnostic and Statistical Manual of Mental Disorders (DSM) symptoms of ADHD. Kids come in for treatment because the teacher calls the parents and says, "You need to come in for a conference. I'm having difficulty with your child in school." Or because things aren't going well at home with daily chores or sibling fights or getting into trouble around the neighborhood. The impairment is the difficulty that mediates the long-term outcome, or child’s success, so it’s what should be targeted in treatment.
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Treatments to Avoid
These treatments and interventions are commonly used with children following an ADHD diagnosis, but they are not proven to be effective:
Biofeedback/neural therapy/attention (EEG) training
Perceptual or motor training/sensory integration training
The only therapies that are proven effective for treating ADHD are behavior therapy/modification, stimulant medication, or a combination of the two. It works best to start with behavior therapy, and then see if you need to add medication as a supplement if behavior therapy doesn’t totally fix functioning issues. If needed, medication should be very gradually to find the lowest possible dose that works.
Since ADHD is a chronic issue, the most important thing parents and teachers can do is learn how to consistently implement strategies to manage children’s behavior. Medication has short-term effects, but not long-term effects. It doesn’t change the parts of the brain that make children learn better, it just makes kids more able to sit still and do seat work.
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How to Evaluate Impairment
The first step in starting a behavior modification program is to complete an assessment of daily impairment and adaptive skills. This is the most fundamental aspect of initial evaluation; it determines the target areas of treatment, and sets a baseline for ongoing assessment to evaluate treatment response.
Brief teacher and parent rating scales are sufficient to indicate if ADHD is a problem. Parents and teachers use the impairment rating scale (IRS) to describe what they see as the child's primary problems in narrative format. Raters then rate how the child's symptoms have affected each of the following domains:
relationship with peers/siblings
relationship with parents or teachers,
his or her academic progress,
your classroom/family in general
his or her self-esteem, and
overall problem/need for treatment
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The behavioral approach focuses on parenting skills, the child's behavior, and family relationships. Parents learn skills, like how to pay positive attention to your child when she's doing what you like, and how to modify the techniques as necessary.
The A, B, Cs of behavior modification for parents are: Modify Antecedents (things that happen before behaviors, e.g., a request of a child), Behaviors (the thing the child does in response that parents want to change), and Consequences (things that happen after the behavior e.g., the response to disobedience).
It's not trying to teach children to think differently, but rather teaching parents how to use their attention and positive consequences to shape the child's behavior and reinforce things they want the child to do more of, and gentle negative consequences to help the child learn.
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Parenting Skills Programs
The most common way to learn these skills is through group-based, weekly sessions with a therapist (8-16 sessions). Parents are taught a technique, go home and implement what they learned, and discuss progress, problem-solve, and learn a new technique each week. Then, sessions often fade to monthly or quarterly once behavior is under control.
Interventions need to be feasible and palatable for families so they can be maintained in the long run. Programs teach skills like rewards systems, and how to give proper commands. Improvement is often gradual, and there should be a plan in place if the child backslides, especially during major developmental transitions like entering middle school.
Behavioral intervention in schools can only happen if teachers focus on good classroom management practices, academic performance, and peer relationships.
Teacher training is widely available in school-wide programs that train all staff and administrators, or in a consultant model — beginning with initial weekly sessions with a therapist or school psychologist, then contact fades as teachers learn the skills to use with children with ADHD during school hours. Typically, teachers need 2 to 10 hours of training. The behavioral techniques should integrate with school-based programs like IEPs and 504 plans, and be available to all relevant staff.
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Daily Report Card
The one thing that’s absolutely essential for kids with ADHD is a daily report card. It’s a tool for ongoing monitoring of a child's progress, and can be used to titrate the appropriate dose of meds if necessary.
A parent or therapist works with the school to determine the child's goals — what will make the child function better in the classroom, the major things that need to be reduced in terms of problems or academic work. Then, together they set up a simple system for the teacher to evaluate how a child is doing periodically throughout the day, give the child feedback, and provide a note home. Parents follow up at home with rewards for the child having a good day at school.
This tool is necessary because kids with ADHD need specific feedback for their behavior more frequently than once a week. It costs little, and takes little teacher time, but is effective in changing kids' behavior at school. Once the daily report cards are set up, they reduce the amount of time teachers must spend dealing with the child’s problematic behaviors, and provide a tool for ongoing monitoring of the child’s progress.
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The behavioral and developmental approach used with children focuses on teaching academic, recreational, and social/behavioral competencies, decreasing aggression, increasing compliance, developing close friendships, improving relationships with adults, and building self-efficacy.
There are various levels of treatment: paraprofessionals, intensive treatments like 8-week summer programs, after-school sessions, and 6-hour Saturday sessions. All of the programs use a core set of procedures that include coaching, use of examples, modeling, role-playing, feedback, rewards and consequences, and practice.