According to experts at the Duke University Medical Center, the number of elementary school-aged children diagnosed with attention-deficit/hyperactivity disorder (ADHD) has risen steadily during the last ten years. The Center for Disease Control (CDC) reports that as many as 1.6 million children carry an ADHD diagnosis. Methods for dealing with this growing problem have focused on medication. The Drug Enforcement Administration (DEA) reveals that prescriptions for pharmacologic agents to treat ADHD have increased 500 percent since 1991.
Russell A. Barkley, Ph.D., professor at the College of Health Professions at the Medical University of South Carolina, however, promotes a combination of different psychosocial interventions maintained for an extended period of time, together with psychopharmacology, as an effective tool for managing ADHD symptoms.
Treatment methods are intended to identify appropriate coping mechanisms to compensate for and accommodate developmental deficiencies, rather than cure ADHD. As a supplement, medications may provide symptomatic relief as well. Barkley cites three psychosocial strategies that have demonstrated efficacy in controlling the symptoms of ADHD: 1) parent training in effective child behavior management methods; 2) classroom behavior modification techniques and academic interventions; and 3) special educational placement.
Other supplemental programs, including family therapy sessions in problem solving and communication skills as well as the coordination of multiple school resources, may enhance the effectiveness of these three behavioral management strategies. One of the key factors in the success of any of these methods, Barkley reiterates, is the sustained application of the method over long periods of time, often years.
Since an ADHD diagnosis affects caregivers as well as the children who carry the diagnosis, behavioral therapy involving all members of the household may serve to restore balance within the family structure. Borrowing from research, Barkley developed a parent-training program in child-management skills with a two-fold rationale. First, since the disorder is thought to be the result of a neurophysiologic deficiency, parents must understand the need to use more explicit, systematic, externalized and compelling ways of presenting rules and instructions. Additionally, the prevalence of oppositional/defiant behavior typically found in ADHD children warrants specific training in behavioral techniques for parents.
Barkley’s program consists of ten steps with one-to-two hour weekly training sessions designed for families of elementary school-aged children. In the first session, information regarding the developmental course, prognosis and etiologies of ADHD is presented in order to dispel commonly held misconceptions. Appropriate reading materials may also be suggested to help parents improve their knowledge of the disorder as well as to identify the degree of deviance of their child’s behavior.
In the second session, parents discuss the four major contributors to the oppositional behavior in ADHD children: child characteristics (e.g., health, development disabilities and temperament); parent characteristics; situation consequences for defiant and coercive behavior; and stressful family events. Next, parents learn to ignore inappropriate behaviors, which are primarily attention-getting in nature, and focus on noticing and rewarding ongoing pro-social and compliant behaviors.
An extension of step three, the fourth session teaches ways to give effective, brief commands and frequent, systematic, positive attention when children engage in non-disruptive activities. Fifth, Barkley recommends creating a “home token economy” in which parents list most of the child’s home responsibilities and privileges and then assign a value to each. Depending on the child’s age, the rewards may be plastic chips or points recorded in a notebook and are awarded only for good behavior. Parents are encouraged to give bonuses for good attitude or emotional regulation, also.
The sixth session implements “response cost,” i.e., removal of points or chips, as well as time-out techniques when children exhibit specific serious, defiant behaviors. In the next session, the time-out method is extended to include additional non-compliant behaviors with which the child still struggles. The eighth step takes behavior management methods out-side the home. Using a “think aloud-think ahead” paradigm, parents learn to review two or three previously defied rules with their child before entering a public place. A shortened time-out method is often sufficient for use in public with a delayed punishment contingency plan, if necessary.
Barkley added a ninth step to the program that fosters cooperation between parents and their child’s teacher. By basing home rewards on school behavior as noted on a daily report card submitted by the teacher, consequences for classroom conduct can be applied at home. The final session serves as a review as well as a brain-storming exercise in which parents think of effective strategies for future non-compliant behaviors. According to Barkley, these ten sessions appear adequate for improving compliance rates in ADHD children. He recommends that parents of teens with ADHD also participate in a Problem Solving Communication Training Program.
Classroom Behavior Management
The second effective strategy – behavior management in the classroom – has been more widely studied. Findings indicate that academic performance is improved through manipulating the curriculum and antecedent conditions as well as peer tutoring, while cognitive-behavioral strategies are less effective.
Specifically, when tasks are “chunked” into smaller units and explicit time limitations and expectations established, the ADHD child succeeds more often. Increased stimuli (e.g., color, shape, texture) and presentation, as well as teaching style also impacts an ADHD child’s ability to concentrate and sustain attention. A meta-analysis of the more than 70 separate experiments conducted in an academic setting reveals that contingency management methods and tangible reinforcers demonstrate significant, short-term improvement in behavior and productivity.
Barkley points out that no one strategy is effective in and of itself. A combination of contingency management training of parents and teachers with stimulant drug therapies has been proven more effective than either therapy alone.
Early Intervention Project
Recently, Barkley and colleagues completed a multi-method Early Intervention Project targeting kindergarten children, 70 percent of whom qualified for a clinical diagnosis of ADHD. This project comprised four major components: parent training in child behavior management; classroom implementation of behavior modification techniques; social skills training; and stimulant medication.
“Research suggests that parent training programs work best with children under age 12, and especially under age seven or so,” said Barkley. “There seems to be a decline in the influence of parents on child misconduct that becomes even more marked after age 12, most likely owing to increased peer, out-of-home, and genetic influences.”
Although the interventions outlined may achieve a significant degree of effectiveness in a controlled environment, these methods must be adapted once the child with ADHD enters high school, college or the workplace.
“You need to increase frequent public accountability of the person to others across the day,” said Barkley. “For instance, in high school, the teen reports to a ‘coach’ or ‘mentor’ for five to ten minutes every few hours for monitoring of behavior across the interim period. That behavior is monitored by a school behavior report card completed by each teacher at the end of each class period and focuses on class conduct and participation.”
As promising as these strategies are for managing ADHD symptoms, Barkley notes that unless long-term intervention with periodic re-intervention as needed is practiced, behaviors will revert to pre-treatment levels.
Barkley RA: Psychosocial treatments for attention-deficit/hyperactivity disorder in children. Journal of Clinical Psychiatry 2002; 63 (suppl 12):36-43.
Roberta Lester-Britton and Lisa Celosse specialize in working with children with ADD/ADHD. David Britton and Michael Sherman specialize in working with adolescents with ADD/ADHD.
Dr. Gnap is a family practice physician and behavioral medicine specialist in suburban Chicago. Dr. Gnap developed the Inner Control™ Program in 1970 and has worked with thousands of people to improve and correct medical, emotional, behavioral and learning problems including performance. He started the Inner Control program because so many patients asked, “what more can be done along with traditional treatment methods?”