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Behavioral Treatment for ADHD:
An Overview by David Rabiner, PhD
Introduction The information presented below is intended to provide a general overview of a behavioral approach to improving children's behavior. Designing and implementing an effective behavioral plan will vary from one child to the next, however, and consultation with an experienced child mental health professional is recommended. Despite the well documented benefits of stimulant medication for treating ADHD, medication is no panacea and some children with ADHD should not receive it. There are several reasons for this. First, although medication helps the majority of children with ADHD, as many as 20% derive no real benefit from medication. Second, some children experience side effects that prevent them from receiving medication on an extended basis. Third, many children who benefit from medication still have difficulties with primary ADHD symptoms or associated problems which must be targeted via other means. Fourth, some children with ADHD can have their symptoms managed effectively without medication (this is most likely to be true, however, when symptoms are relatively mild.) In addition to these reasons, some children have extremely strong objections to taking medication - this may be more likely to occur with teenagers. In these circumstances, trying to force medication on a child can create more problems than it solves. F or all these reasons, other treatments are often necessary - some would say always necessary - to effectively treat ADHD. An important non-medical approach used in treating children with ADHD is known as behavior therapy or behavior management. Behavior therapy is based on several simple and sensible notions about what leads children to behave in socially appropriate ways. One reason is that children generally want to please their parents and feel good about themselves when their parent is proud of them. When the relationship between parent and child is basically positive, this is a very important source of motivation. A second reason that children behave appropriately is to obtain positive consequences for doing so (i.e. privileges or rewards). Finally, children will behave appropriately to avoid the negative consequences that follow inappropriate behavior. The goal of behavior therapy, therefore, is to increase the frequency of desirable behavior by increasing the child's interest in pleasing parents and by providing positive consequences when the child behaves. Inappropriate behavior is reduced by consistently providing negative consequences when such behavior occurs. This is a simplified, but not unreasonable view, of what behavior therapy is all about. "My child and I seem to be in conflict almost all the time and I don't think he cares about pleasing me at all. How can I change this?" Let's begin by focusing on children's desire to please their parents. Often times, relationships between parents and children become fraught with conflict and angry feelings in response to the frustration caused by ADHD symptoms. Good times between parent and child can dwindle to almost nothing, and the child's desire to please his or her parent can evaporate. After all, most of us are not interested in pleasing someone that we constantly argue with. Unfortunately, when this important positive source of motivation for good behavior disappears, parents have to rely more exclusively on the threat of punishment to induce compliance. This generally makes for ongoing conflict and struggle. In many situations, therefore, the first step in behavioral treatment is to enhance the amount of positive feelings between parent and child. One helpful way to do this is to set aside a certain amount of time each day (30 minutes is certainly sufficient) that is designated as the child's "special time". During this time, the child gets to choose the activity (it must be within reason, of course), and the parent's sole focus is on trying to have a good time with his or her child. During this time, it is important to avoid asking too many questions or giving commands, and instead to simply tune in to what your child is doing in an interested and complimentary way. For example, if your child is building a tower with blocks, the comment "Don't you think it would be better if you used these bigger blocks first?", will be less helpful than a comment like "Boy, the tower your building is really getting tall!" The goal of this time is build up good feelings between your child so that your child will become more invested in wanting to please you. When this occurs, discipline and limit setting generally go much smoother. When parents first begin to try this, they are often surprised to getting chores, homework, or errands done. The absence of this ìspecial timeî can be a real loss for both parents and children, and working to make it part of your routine can yield substantial benefits in parents' relationship with their children.
USING POSITIVE REINFORCEMENT
The second focus of behavioral treatment involves providing your child with positive consequences for behaving in appropriate ways. The simple logic is that you can increase the frequency of desired behavior (e.g. putting away toys) by providing rewards when such behavior occurs. At the simplest level, this requires nothing more than noticing when your child is doing something you want to encourage (e.g. playing quietly) and making sure to comment on it ("Your doing such a nice job of playing quietly. I really appreciate that."). Think about the kinds of behavior you want to encourage, make sure your child understands what you want him or her to do, and then be sure to praise your child whenever you happen to observe it occurring.This simple technique of noticing good behavior is easy to overlook and can be quite helpful. I often recommend to parents that they make a conscious effort to catch their child doing something good at least 5 times a day and to poin t it out. When children are convinced that their parents notice and appreciate their efforts at behaving well, it frequently increases their desire to do so. In addition to these "social rewards", behavioral treatment also involves providing your child with concrete rewards and/or privileges for appropriate behavior. As an example, suppose your child has developed the problematic habit of talking back. You tell him to put away his toys and he tells you "not now, later". One way to increase your child's compliance is to make a tangible reward or privilege contingent on his following your request. For example, you could explain that each time he does what he is told he will earn a point. These points can then be used to "purchase" a privilege such as access to TV, computer time, etc. Designing a good behavior plan and implementing it effectively is not easy, and parents may often require professional assistance to do this successfully. Although the specifics of a good plan will vary from child to child and from parent to parent, there are several general principles that are important to keep in mind:
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