Psychosocial treatment is a critical part of treatment for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents. The scientific literature, the National Institute of Mental Health and many professional organizations agree that behaviorally oriented psychosocial treatments—also called behavior therapy or behavior modification—and stimulant medication have a solid base of scientific evidence demonstrating their effectiveness. Behavior modification is the only nonmedical treatment for ADHD with a large scientific evidence base.
Treating ADHD in children often involves medical, educational and behavioral interventions. This comprehensive approach to treatment is called “multimodal” and consists of parent and child education about diagnosis and treatment, behavior management techniques, medication, and school programming and supports. The severity and type of ADHD may be factors in deciding which components are necessary. Treatment should be tailored to the unique needs of each child and family.
Why use psychosocial treatments?
Behavioral treatment for ADHD is important for several reasons. First, children with ADHD face problems in daily life that go well beyond their symptoms of inattentiveness, hyperactivity and impulsivity, including poor academic performance and behavior at school, poor relationships with peers and siblings, failure to obey adult requests and poor relationships with their parents. These problems are extremely important because they predict how children with ADHD will do in the long run.
Research has shown that how a child with ADHD will do in adulthood is best predicted by three things:
- whether his or her parents use effective parenting skills
- how he or she gets along with other children
- his or her success in school
Psychosocial treatments are effective in treating these important domains. In addition, behavioral treatments teach skills to parents and teachers that help them deal with children with ADHD. They also teach skills to children with ADHD that will help them overcome their impairments. Learning these skills is especially important because ADHD is a chronic condition and these skills will be useful throughout the children’s lives.
Behavioral treatments for ADHD should be started as soon as the child receives a diagnosis. There are behavioral interventions that work well for preschoolers, elementary-age students and teenagers with ADHD, and there is consensus that starting early is better than starting later. Parents, schools and practitioners should not put off beginning effective behavioral treatments for children with ADHD.
What is behavior modification?
With behavior modification, parents, teachers and children learn specific techniques and skills from a therapist, or an educator experienced in the approach, that will help improve children’s behavior. Parents and teachers then use the skills in their daily interactions with their children with ADHD, resulting in improvement in the children’s functioning in the key areas noted above. In addition, the children with ADHD use the skills they learn in their interactions with other children.
Behavior modification is often put in terms of ABCs: antecedents (things that set off or happen before behaviors), behaviors (things the child does that parents and teachers want to change), and consequences (things that happen after behaviors). In behavioral programs, adults learn to change antecedents (for example, how they give commands to children) and consequences (for example, how they react when a child obeys or disobeys a command) in order to change the child’s behavior (that is, the child’s response to the command). By consistently changing the ways that they respond to children’s behaviors, adults teach the children new ways of behaving.
Parent, teacher and child interventions should be carried out at the same time to get the best results. The following five points should be incorporated into all three components of behavior modification:
- Start with goals that the child can achieve in small steps.
- Be consistent—across different times of the day, different settings, and different people.
- Provide consequences immediately following behavior.
- Implement behavioral interventions over the long haul—not just for a few months.
- Teaching and learning new skills take time, and children’s improvement will be gradual.
Parents who want to try a behavioral approach with their children should learn what distinguishes behavior modification from other approaches so they can recognize effective behavioral treatment and be confident that what the therapist is offering will improve their child’s functioning. Many psychotherapeutic treatments have not been proven to work for children with ADHD. Traditional individual therapy, in which a child spends time with a therapist or school counselor talking about his or her problems or playing with dolls or toys, is not behavior modification. Such “talk” or “play” therapies do not teach skills and have not been shown to work for children with ADHD.
How does a behavior modification program begin?
The first step is identifying a mental health professional who can provide behavioral therapy. Finding the right professional may be difficult for some families, especially for those that are economically disadvantaged or socially or geographically isolated. Families should ask their primary care physicians for a referral or contact their insurance company for a list of providers who participate in the insurance plan, though health insurance may not cover the costs of the kind of intensive treatment that is most helpful. Other sources of referrals include professional associations and Hospital and University ADHD centers.
The mental health professional begins with a complete evaluation of the child’s problems in daily life, including home, school (both behavioral and academic), and social settings. Most of this information comes from parents and teachers. The therapist also meets with the child to get a sense of what the child is like. The evaluation should result in a list of target areas for treatment. Target areas—often called target behaviors—are behaviors in which change is desired, and if changed, will help improve the child’s functioning, impairment and long-term outcome.
Target behaviors can be either negative behaviors that need to stop or new skills that need to be developed. That means that the areas targeted for treatment will typically not be the symptoms of ADHD—overactivity, inattention and impulsivity—but rather the specific problems that those symptoms may cause in daily life. Common classroom target behaviors include “completes assigned work with 80 percent accuracy” and “follows classroom rules.” At home, “plays well with siblings (that is, no fights)” and “obeys parent requests or commands” are common target behaviors. (Lists of common target behaviors in school, home and peer settings can be downloaded in How to Establish a School-Home Daily Report Card.
After target behaviors are identified, similar behavioral interventions are implemented at home and at school, through collaborative efforts between parents and teachers. Parents and teachers learn and establish programs in which the environmental antecedents (the As) and consequences (the Cs) are modified to change the child’s target behaviors (the Bs). Treatment response is constantly monitored, through observation and measurement, and the interventions are modified when they fail to be helpful or are no longer needed.
What about combining psychosocial approaches with medication?
Numerous studies over the last 30 years show that both medication and behavioral treatment are effective in improving ADHD symptoms. Short-term treatment studies that compared medication to behavioral treatment have found that medication alone is more effective in treating ADHD symptoms than behavioral treatment alone. In some cases, combining the two approaches resulted in slightly better results.
The best-designed long-term treatment study, the Multimodal Treatment Study of Children with ADHD (MTA), was conducted by the National Institute of Mental Health. The MTA studied 579 children with ADHD-combined type over a 14-month period. Each child received one of four possible treatments: medication management, behavioral treatment, a combination of the two or the usual community care. The results of this landmark study were that children who were treated with medication alone, which was carefully managed and individually tailored, and children who received both medication and behavioral treatment experienced the greatest improvements in their ADHD symptoms.
Combination treatment provided the best results in improving ADHD and oppositional symptoms and in other areas of functioning, such as parenting and academic outcomes. Overall, those who received closely monitored medication management had greater improvement in their ADHD symptoms than children who received either intensive behavioral treatment without medication or community care with less carefully monitored medication. It is unclear whether children with the inattentive type will show the same pattern of response to behavioral interventions and medication as have children with combined type.
Some families may choose to try stimulant medication first, while others may be more comfortable beginning with behavioral therapy. Another option is to incorporate both approaches into the initial treatment plan. The combination of the two modalities may enable the intensity (and expense) of behavioral treatments and the dose of medication to be reduced. For young children with ADHD, a behavioral approach is recommended first prior to considering medication.
A growing number of physicians believe that stimulant medication should not be used as the only intervention and should be combined with parent training and classroom behavioral interventions. In the end, each family has to make treatment decisions based on the available resources and what makes the best sense for the particular child. No one treatment plan is appropriate for everyone.
What if there are other problems in addition to ADHD?
There are evidence-based behavioral treatments for problems that can co-exist with ADHD, such as anxiety and depression. Just as play therapy and other non-behaviorally based therapies are not effective for ADHD, they have not been documented to be effective for the conditions that often occur with ADHD.