Behavioral interventions are one of two evidence-based classes of treatment for ADHD. Behavioral parent training (BPT), classroom behavior management, and interventions that target executive function challenges are examples of behavioral interventions. Key principles of behavior management apply across the different types of behavior treatment, and the age of a child will determine what type of intervention to use. BPT and classroom interventions are typically used for younger children, while older children, including teens, are taught strategies to cope with executive function challenges.
Margaret Sibley, PhD, associate professor of psychiatry and behavioral health at Washington School of Medicine, discusses the ADHD symptoms that children and teens struggle with and the behavioral interventions supported by research that can help to improve these symptoms. She also discusses the best times to implement these behavior therapies and the synergy between these strategies and medication management.
Margaret H. Sibley, PhD
Dr. Sibley is an associate professor of psychiatry and behavioral sciences at the University of Washington School of Medicine and Seattle Children's Research Institute. Her work focuses on the diagnosis and treatment of ADHD in adolescents and young adults. She developed a parent-teen therapy for ADHD (Supporting Teens’ Autonomy Daily) that combines motivational interviewing and skills training for parents and teens. She has authored or coauthored more than 80 scientific papers on ADHD and published a book with Guilford Press on treating executive functioning and motivation deficits in teens. She is a member of CHADD’s professional advisory board.
Listeners will be able to:
- Explain the importance of integrating behavioral and other interventions for people with ADHD.
- Describe the importance of interprofessional collaboration in treatment of ADHD.
Announcer: You are listening to Pocket MD, training on ADHD in children and adults.
Dr. Eugene Arnold: Hello, this is Dr. Eugene Arnold, professor emeritus of psychiatry and behavioral health at Ohio State University and CHADD's resident expert. Today we're talking about some of the non-pharmacological interventions for ADHD, and we have with us today, Dr. Maggie Sibley, who will introduce herself.
Dr. Margaret Sibley: I'm Maggie Sibley, and I'm associate professor of psychiatry and behavioral health at the University of Washington School of Medicine. I'm a researcher at Seattle Children's Hospital, and I'm a clinical psychologist by training.
Dr. Eugene Arnold: Before we begin, I might just say that there are two evidence-based classes of treatment for ADHD. One is the FDA-approved medications and the other is behavioral interventions. And we'll be focusing today on the behavioral and other non-pharmacological interventions for ADHD. Dr. Sibley, could you describe in general what those are?
Dr. Margaret Sibley: I'll start with what interventions look like in childhood. One of the main forms of behavioral intervention for children with ADHD is behavioral parent training. And behavioral parent training is a treatment that focuses on teaching parents practical everyday strategies that they can use in order to increase good behaviors and minimize negative behaviors in the home setting. And another piece of behavior therapy for younger children is classroom behavior management. What that is, it's establishing clear rules and goals and expectations for a child in the classroom and then delivering rewards, whether it's through a token economy system or through some sort of reward system in the classroom, in order to motivate the child to meet those expectations.
In terms of social skills, there's actually not a lot of evidence for social skills treatments for ADHD. Social skills groups and social skills training has not been shown to be highly effective, and so that's an area that we're still trying to learn how to improve for kids with ADHD.
When kids with ADHD get older and they start reaching adolescence, the nature of those behavioral treatments changes a little bit. We start focusing more on teaching kids skills that they can apply in their daily life. And because their brains, as they get older are capable of more learning and capable of more independent application of those skills, we can start teaching them organization skills strategies, time management strategies, cognitive strategies, to overcome difficulties like procrastination. And then usually what we do is partner with parents or other adults in their lives, to create rewards and consequences for the application of those skills. So, for example, we can teach a teenager with ADHD how to write every day in a daily planner to keep track of their homework assignments and to keep their schedules straight, and then we can make a rule at home that is overseen by the parents, that all electronics time has to wait until after homework is done, in order to help kids learn to use those skills independently without a lot of help and reminding from their parents.
Dr. Eugene Arnold: Just for completeness, I might mention that there's also another area of interventions there are called complementary and alternative, which includes things like nutritional interventions, diet, biofeedback, transcendental meditation, and so forth, which have varying levels of evidence and are under study by groups in various parts of the country. But are there other components of the behavioral interventions and educational interventions that you mentioned that should be brought up?
Dr. Margaret Sibley: I think it's important for people to understand what some of the key principles of behavior management are, that essentially transcend all of these treatments and sort of unite them as behavior therapies. So, one of them is defining clear expectations for behavior, whether that is that a child needs to raise their hand before speaking, or that an adolescent needs to get all of their homework done by 6:00 PM. It's teaching strategies to give positive attention or contingent rewards to good behaviors and to minimize negative attention to negative behaviors. So, pieces of that could be ignoring small negative behaviors by children, like complaining or whining instead of arguing with kids and then escalating conflicts.
It's also applying strategies like point systems in the home or the school setting, where over time kids can accumulate points for good behaviors and then rewards for those behaviors. And using principles like what we would call the Premack principle, so that would be making all exciting, enjoyable activities wait until responsibilities for the day are done.
And then there's also strategies that we can use for really disruptive, escalated behaviors, like timeout in younger children and in teenagers, it's things like taking away a really important privilege like driving, if something like marijuana use is discovered.
So all of these treatments, though they may look different for different ages, they have something in common. They're using basic behavioral principles to try to motivate children in adolescence to display appropriate behavior, which is hard for people with ADHD, because they often struggle with self-control.
Dr. Eugene Arnold: Now you mentioned that the differences by age, and of course the executive function of the ability to plan your work and work your plan, tends to change with age; hopefully, with maturation improving. How does that fit in with the strategy at different ages?
Dr. Margaret Sibley: So, around age maybe 10, 11, we start to see success with these interventions that teach skills that help people compensate for their executive function deficits. We haven't had a lot of success with treatments that directly target these executive function deficits and try to make them biologically better. But what we can do is teach people workarounds, so that they can let these executive functioning deficits have a less of a negative impact on their life.
As adolescents age and their cognition develops more and more, they start in a good way being able to control more of their behavior and apply these strategies a little bit more reliably. On the other hand, compared to their peers, they're still having a lot of dysfunction. And what happens is, the environment of adolescence is requiring teenagers to be more and more self-sufficient because that's what their peers can do. But when you have ADHD, being able to keep up with those demands is a lot harder, and so we see that treatments target executive functions a lot more as individuals age and the demands of their environment is that you need to be self-sufficient, you need to use your executive functions to be able to succeed in day-to-day life.
Dr. Eugene Arnold: Could you speak a little bit to the issue of positive illusory bias and whether there's a development of more insight as they age, and how that would affect the treatment?
Dr. Margaret Sibley: Sure. I like to call it self-perception bias because we're not exactly sure why children, adolescents, and adults do this. But one thing that seems to happen is that when you ask them to report on their own behavior, they tend to underestimate how severe their difficulties are, whether that's because they're doing something self-protective for their self-esteem, whether it's because they're just not paying attention to how they are because they don't pay attention well, or whether it's because every single human being tends to minimize their difficulties, is unclear. But what we do see is a trend of growing insight as people get older, although the biggest jump in that seems to be after age 25, if we look at the longitudinal studies like Russ Barkley's done, it's really not until they are approaching the 30s that we see a notable improvement of insight.
But all the same, there's still a group of kids who tend to have good insight, and the cognitive behavioral approaches, which is really kind of the family of compensatory skill-teaching interventions—teaching people to be more aware of what they're thinking right before they do something like decide to put off their homework towards later—are a lot easier to deliver and to have success, as people with ADHD tend to improve their insight.
In younger children, if the insight's particularly poor, it's really hard for things like talk therapy to be effective because it's just not landing with kids. They're not able to sort of see the deficit that they're having and then have the self-control to say, because I have this difficulty, I need to try harder or I just need to suck it up and do better. Those approaches have not been successful.
Dr. Eugene Arnold: Is there a downside to developing more insight into the problems one is having?
Dr. Margaret Sibley: Now that's a good philosophical question. One of the things that is important in people with ADHD is protecting their self-esteem and how they think about themselves. When you're a person with ADHD in childhood, there've been studies that just show that, exponentially, they receive more negative feedback from their environment—from their teachers, from their friends, from their parents, from the girl that somebody asks out on a first date in middle school—than the average child.
And so over time when you get a lot of those messages, unfortunately, we can see in research that people with ADHD by adulthood have pretty strong deficits in their self-esteem, their self-efficacy, which means, do I believe that there's any point in working hard towards a goal? Because if I don't think I'm going to be successful anyways, why try?
I think your question is well taken. On one hand, we want people to have insight because we want them to be able to make good choices about who they are in the world, and what they're good at, and what would be the best educational track for them, or the best vocational track for them. But at the same time, I think it's important to shine a light on the good things about the person and not just always have the light shining on the bad.
Dr. Eugene Arnold: Well, what would be the focus of these non-pharmacological interventions? Who would they be addressed to and does age make a difference in how that's handled?
Dr. Margaret Sibley: Usually people employ a family member, at least until a person's 18. And as you get older, you see the individual with ADHD's involvement becoming bigger, a bigger part of that. So, in the youngest children, behavioral parent training may not involve the child at all, other than sometimes bringing them in with the parent for something like parent-child interaction therapy, where the parent is being coached in real time about how they should interact towards their child, but not so much putting expectations on the child themselves to be practicing therapy skills. Parent training, parent behavior management, parent-child interaction therapy, this collection of parent based behavior therapies, is really the gold standard behavior therapy at least through elementary school.
When you get into classroom behavior management interventions, where you're working directly with the school, how it actually plays out in real life, is kids sometimes get an Individualized Education Plan or Section 504 plan, which gives them entitlement to services from the school. And then somebody like a school psychologist or a special educator will come in and they'll analyze what behaviors are causing problems in the classroom, and they'll figure out maybe some rewards that the school can administer to make those behaviors improve. But in a lot of situations, again, you end up engaging the parent, even in school-based interventions for something like a daily report card, where the school might be the one monitoring the behaviors, but ultimately it's the parent at home that's providing the rewards for the good behavior. So, really engagement of the family is probably the most important component.
As individuals move into the teenage years, you see more of what we would call parent/teen contracting. So, the parent isn't going to be imposing a behavior management system anymore. The parent and the teen will sit down together as equals and they'll negotiate rules for home that they both can agree are fair. They'll both have to compromise. The parent is going to have to be willing to allow more freedoms to the teenager if they've earned them, and the teenager's going to have to be willing to do some things that they may think are hard, boring, or unnecessary, in order to meet their parent’s wishes.
Dr. Eugene Arnold: Okay. So, when should these interventions be implemented? How about the timing of them?
Dr. Margaret Sibley: I think the most critical thing to think about with timing, is that there are certain points in an individual with ADHD life, where things get a little bit messier and a little bit harder. And we've seen in research, time and time again, that developmental transitions—like the transition to kindergarten, the transition to third grade, when all of a sudden there's a lot more seatwork and expectation to sit still, transition to middle school, high school, and even college or post-high school life—tend to really disrupt the functioning of people with ADHD. So, these might be the key times to deliver behavioral intervention.
There's also evidence out there that behavioral interventions do not necessarily have long-term effects. And, in fact, we see if we look at some of the contingency management literature, that a good contingency management program rewards-and-consequences point system, and a lot of parents will say, they've seen this with their own eyes, over time it will lose its potency. So, if we have the ability to use rewards as an important motivator, but we need to be smart about when we use them because they're not going to be able to work every single day, 365 days of a child's life, we want to be strategic about applying them during times when we really need them. So, I think those transitions, or if there's a certain time of year when a child is most vulnerable to doing poorly—for example, at the end of the school year a lot of times motivation wanes and kids really needed a boost to kind of get them back on track and make sure they pass their classes—those could be really good times as well to be implementing behavioral strategies like a reward system.
But there're some strategies like just catching kids being good and saying positive things to them, or ignoring those minor negative behaviors and not letting them escalate, that can be done every day, that there's really no downside to using. Making sure that every parent of a child with ADHD, when they get that diagnosis, just learns the nuts and bolts of those really basic things they can do to improve the child's functioning at home and at school, I think should be always administered right away. I think there's some evidence to support that when you do administer parent training when a diagnosis is first given, that it does have some benefits to family chaos and to just parents feeling more in control over the situation with their child.
Dr. Eugene Arnold: Well, what I derived from what you just said, is that behavioral intervention should be used to pull people out of a rut and get them in the right track, but not try to continue everything the same after they're in the right track. Is that a fair statement?
Dr. Margaret Sibley: I think so, because it's really not practical to think that somebody is going to be implementing a reward system every single day of a child's life. A, it's too hard to do; B, we know that kids gain tolerance to rewards after a while. The same thing that motivates them, if you give it every day, it stops to be motivating.
And we want those breaks from behavior management, just like we would want breaks from medication sometimes, so that kids can develop their own motivation for things. There's something to be said about learning from mistakes, especially as kids are getting older. We're not letting them have autonomy in their own choices and seeing the natural consequences of some of their actions, they're not going to be learning long-term about choices that are important and healthy to make. So, I do think that there's sort of a mix here that needs to be considered, and it's an individual choice for every family about what missteps you're willing to watch your child take and not rescue them from, so they can learn a lesson, versus what missteps are really important for you to avoid by doing something like a reward system.
In middle schoolers, for example, is it worth failing sixth grade, or do you want to implement a really strong contingency management system to avoid that, but at the same time, your child doesn't learn their own reasons for working hard. So, there is kind of a tradeoff that it gets, especially as kids get older, it gets really hard for parents to navigate, and there's no real perfect answer to the question what to do and when.
Dr. Eugene Arnold: So, both strategy and tactics are important?
Dr. Margaret Sibley: Yeah.
Dr. Eugene Arnold: Strategy being the management over the long-term, the big picture, and the tactics being the technical details of how you implement the program. I liked your analogy with tolerance and your mention of pharmacotherapy, because there is an issue among pharmacologists about developing tolerance to the FDA-approved medications for ADHD. And that brings up the issue of the synergism between the two and how it should be important to take advantage of the improvement from medication to implement and get the most out of the behavioral treatments and vice versa. Could you comment about the data there are about the synergism between the two?
Dr. Margaret Sibley: Yeah. So, I think one interesting piece of this is that, stimulant medication and behavioral therapies, they act through different mechanisms, right? So, what stimulant medication is really good at helping with is actually mitigating a chemical biological deficit in the brain and therefore, helping people self-control and better focus. But what behavioral treatments generally do is (a) they teach people skills that they can use to compensate, and hopefully long-term, having their arsenal toolkit of things they can do as they're growing older to manage their symptoms; and (b) it helps people identify the environments that they function best in, and what they need from the people around them, and from educational setting they're in, to succeed, so that detective work is really valuable. So, yes, if you just give somebody a symptom rating scale, a lot of times medication looks like it wins the horse race. But at the same time, the long-term effects of being able to gather some of these pieces of wisdom from behavior therapy shouldn't be forgotten.
There's not a lot of work on behavior therapy’s long-term effects or combined treatment effects in adolescents. My team is doing probably most of it right now. There's a couple of things that are convincing me that if you deliver psychosocial behavioral treatment in adolescence, it's probably having more bang for its buck in a lot of ways than in childhood. For one, we've found that there are four-year effects on organization skills and ADHD symptoms when you deliver behavioral treatment to high schoolers, and that's good to see because the MTA study wasn't able to show that in younger children.
And then, in addition, there's been no real, true combined treatment studies for adolescents as there have been for children, but we've seen a little bit of a blip on the radar that there are some effects of combined treatment, especially when dealing with family conflict, which is really big for teenagers with ADHD. So, you could imagine that the medication might help with something like verbal impulsivity, which leads to a lot of fights, but at the same time, the behavioral treatment might be helping with things like the organization, time management, planning problems, that are leading to the fights. And so they can kind of work in different ways to help the overall functioning go well.
Dr. Eugene Arnold: Could you kind of summarize the key take-home points from this?
Dr. Margaret Sibley: Sure. I think that behavior therapy is an important piece of the treatment toolkit for ADHD. I think that it could be applied at different times in one's life and it's going to look a little bit different, no matter how old you are. So, getting behavior therapy during key developmental transition points not only helps the child do their best, but it also equips the family with the strategies that they need to support the child, and those strategies should be applied in both the home and the school setting. Medication and behavior therapy are important complements for each other, though behavior therapy is more expensive and takes more time and energy to administer. It does have some benefits that are separate than the benefits of medication—for a lot of folks, it could be a really important piece of treatment, but ultimately I think family choice is a big part of this as well. Some families prefer medication, and some families prefer behavior therapy, and some people might want to do both, and I think that should be a part of the conversation as well.
Dr. Eugene Arnold: Okay. Thank you, Dr. Sibley.
Dr. Margaret Sibley: Thank you.
Announcer: Pocket MD is brought to you by CHADD, with funding from the US Centers for Disease Control and Prevention, and in partnership with the Rainbow Center at Rainbow Babies and Children's Hospital.
- American Academy of Pediatrics (AAP). Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics, October 2019.
- Society for Developmental and Behavioral Pediatrics (SDBP). Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder, Journal of Developmental & Behavioral Pediatrics, January 30, 2020.
- US Centers for Disease Control and Prevention. Parent Training in Behavior Management for ADHD
- Behavioral Therapy: What It Is and Finding a Therapist. CHADD NRC Ask the Expert webinar.
CDC, our planners, presenters, and their spouses/partners wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters with the exception of Dr. L. Eugene Arnold, MD, MEd, Dr. Craig Surman and Dr. Margaret Sibley and the wish to disclose research funding from commercial interests.
Planning committee discussed conflict of interest with Dr. Arnold, Dr. Surman and Dr. Sibley to ensure there is no bias.
Content will not include any discussion of the unlabeled use of a product or a product under investigational use.
CDC did not accept commercial support for this continuing education activity.