A carefully designed behavior modification program for the treatment of ADHD is labor-intensive (and therefore costly) and the beneficial effects are generalized poorly. When used alone, its contribution is quite modest. It is important to have incentive-based behavioral programs, since those based only on negative reinforcement or depriving privileges are not as effective as those with incentives (Garber, Garber and Spizman 1990).
For a behavior modification program to be successful with a school-aged child, the child should be an active participant in the:
- negotiation and design of the program;
- setting of the goals;
- definition of “progress”; and
- selection of incentives.
Cognitive behavior therapies
The emphasis of these therapies is to enhance competencies (eg problem solving abilities, social skills) that are associated with adaptive functioning at home, school and other important settings. Designed to facilitate self-control, it is appropriate for children who exhibit impulsive, non-self-controlled behavior and/or manifest deficits in problem solving, (both impersonal and interpersonal). In their multicomponent intervention program, Braswell and Bloomquist (1991) provide the following example of a set of problem solving self-instructions:
- What is the problem?;
- What are some plans?;
- What is the best plan?;
- Do the plan; and
- Did the plan work?
By using a number of methods (eg behavioral contingencies, modelling, role-play exercises), children are trained to use the instructions in academic, social and other situations. Although most children can learn to use self-instruction appropriately, few begin applying the strategies spontaneously in actual situations without support and assistance. Modelling, promotion and encouragement of self-instruction by parents and teachers seems to be necessary for generalization and maintenance of training effects.
Anger Management Training
Designed to increase the child’s ability to manage and cope with anger and frustration, anger management training is appropriate for the child whose anger is impulsive and behavior is aggressive. Anger management training typically involves education about anger/frustration, instruction in recognising anger signals, and training in various anger management and coping strategies. A number of management strategies, including relaxation methods and coping self-statements are presented.
Group anger management strategies can provide valuable training opportunities (eg learning to manage anger during verbal taunting by peers) and appear to be promising for future training efforts.
Data suggest that while cognitive behavioral therapy can reduce one of the main symptoms of ADHD – impulsivity (Kendall and Braswell 1993) – it has not been successful in treating other symptoms of ADHD. Treatment outcomes are, at best, inconsistent. After a decade of careful investigation, cognitive behavioral therapies have not been shown to be helpful, either alone or as an enhancer of the effects of medication (Abikoff 1991).
Given the limits reported to date, future clinical research should include a full array of the behavioral and cognitive components and look at the specific needs of the child in order to develop a more individualized program (Abikoff 1987), and put a greater emphasis on parent training in order to enhance the treatment program (Braswell and Bloomquist 1991).
If a diagnosis of ADHD is made, the child and parents/guardians should be offered:
- information about any relevant support groups; and/or
- summary information sheets; and/or
- inexpensive and accessible recommended reading.
In addition to the trial of stimulant medication, treatment for childhood ADHD should at the very minimum involve: concurrent parent support, and concurrent educational intervention. Although behavioral treatments have been found to have a limited efficacy with many of the symptoms of ADHD, family therapy is particularly useful in helping to develop more adaptive family problem solving and family interactions (Ziegler and Holden 1988).
Behavioral Training for Parents
behavioral parent training provides instruction in strategies that promote compliance and other appropriate behaviors, and minimize problematic behaviors, in the child. The specific strategies taught may include behavioral monitoring, attending to play and other appropriate behaviors, designing and implementing multiple target behavioral programs, using ‘timeout’ and employing punishment methods.
Behavioral Family Therapy
This is a broad term that describes a variety of approaches to family skills training. These approaches typically incorporate elements of behavioral parent training, but also may provide instruction in other problematic areas. These include systematic problem solving, open and effective communication and anger management/conflict resolution.
Key Points – Behavior Management
Behavior modification programs, as a strategy to manage ADHD, have been found to have modest success when used alone, although benefits are not widely generalized. Cognitive behavior therapies have been found to be successful for treating impulsivity, but outcomes are inconsistent for other symptoms of ADHD. Cognitive behavior therapies have not been shown to enhance the effects of medication. Family intervention psychotherapy is particularly useful in developing more adaptive family problem solving and interactions.