Nonpharmacologic Strategies

Behavior Modification

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Behavior modification is often recommended as part of a total management plan for children with ADHD, as it may help guide the child with ADHD toward age-appropriate behaviors.1 A wide range of behavioral interventions may be used. These interventions are categorized into 3 types2:

  • Those directed at proactively changing events to achieve target behaviors
  • Those focused on the consequences of behavior
  • Those that include both proactive and consequence-based components

Interventions that incorporate both proactive and consequence-based components tend to work best in children with ADHD.2

Four Hallmarks of Effective Psychosocial Intervention

Regardless of which class of intervention is selected, there are 4 hallmarks of effective psychosocial interventions that should be incorporated into the ADHD behavioral plan for a given patient2:

  • Consistency: Parents or caregivers and/or teachers must show consistent adherence to a specified behavioral plan and be willing to implement it in virtually all circumstances. In addition, the child should understand that the consequences of the plan are in place and will be enforced by all adults and at all times.
  • Immediacy: Once a behavior has occurred, the consequences should be immediately administered. A time lag between the behavior and consequence results in a weak association between the two, rendering the intervention ineffective.
  • Specificity: Parents or caregivers and teachers should be explicit about which behaviors are being targeted by the intervention and the specified consequences—whether reinforcement or punishment—of each behavior. Stating "Your careful attention to your math problems has earned you 10 minutes of screen time" is much clearer and more explicit than saying "Good job on your homework."
  • Saliency: To maximize effects on behavior, consequences should be meaningful and noticeable to the child. Consequences that go unnoticed or that hold no value for the child will have negligible effects on behavior.

Corrective statements can be a useful facet of psychosocial interventions, but only when balanced appropriately with positive reinforcement.2

Working With Parents/Caregivers and Teachers on Behavior Modification

Parents, caregivers, and teachers may seek training from you to learn how to implement techniques and strategies of behavior modification for ADHD. If this is not your specialty, you may need to gain expertise in this area, or you may need to refer to a therapist who has such expertise. Parent or caregiver training usually begins with weekly sessions. A typical program aims to improve the parent's or caregiver's understanding of the child's behavior and teaches him or her skills to deal with the behavioral difficulties posed by ADHD. The following areas are often covered during the sessions1,3:

  • Information about ADHD
  • Strategies for managing the child's misbehavior and administering reinforcement and rewards when the child complies
  • Establishing a reward system at home that positively reinforces target behavior (eg, use of stickers, granting children TV/computer time)
  • Using time-out effectively
  • Managing noncompliant behaviors in public
  • Using a daily school report card
  • Anticipating future misconduct

Due to the need for consistency among parents and caregivers and all others involved with the behavior modification plan for a child with ADHD, a variety of potential difficulties may interfere with the level of success actually attained.1,2 Some of these difficulties may include:

  • Disagreement between parents or caregivers about how to address the child's difficulties, including whether they are due to a "real" illness (ie, lack of acceptance of ADHD)1
  • Disagreement between the parents or caregivers and school support team members about how to carry through with the behavior modification plan when the child is at school2
  • Environmental stressors at home including, but not limited to1:
    • A single parent family
    • A parent's or caregiver's job loss
    • A recent move
    • Barriers to adherence to the behavior modification plan caused by other children in the household and their need for attention, as well as their lack of understanding about the needs of the child with ADHD

References

  1. Pliszka S; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(7):894-921.
  2. Tresco KE, Lefler EK, Power TJ. Psychosocial interventions to improve the school performance of students with attention-deficit/hyperactivity disorder. Mind Brain. 2010;1(2):69-74.
  3. Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011:128(5):1007-1022, SI1-SI21.