Behavioral Interventions for ADHD
by Daniel T. Moore, Ph.D.
Not paying attention, making a hundred different noises, not following directions, not turning in home work assignments, taking three hours to do a single page of homework, irritating other brothers and sisters, and losing personal belongings are just some of the negative behaviors given by children with Attention Deficit Hyperactivity Disorder (ADHD). Even the best teachers and parents have difficulty with ADHD children. It is easy to become frustrated and discouraged. The purpose of this chapter is to arm parents and teachers with tools enabling them to work effectively with ADHD children and adults. This chapter describes the most powerful behavioral techniques to deal with negative ADHD behaviors. The ultimate goal of these techniques is to help children and families learn ways to overcome the negative effects of ADHD behaviors.
Everything we do can be described as a behavior. As you read this sentence, you are doing a behavior called reading. If you are sitting in a chair, you are doing the behavior of sitting. An ADHD child or ADHD adult does many behaviors. Most behaviors are good. Only a few of the behaviors are truly irritating, disruptive, or interfere with school work. When working with children, mistakenly we overlook the behaviors that are appropriate or good. Adults tend to notice the bad behaviors.
This chapter is written to discuss ways that effectively reduce the bad behaviors and ways to increase the good behaviors. This chapter is divided into three sections. The first section deals with important concepts to learn before starting behavioral techniques. The next section offers a complete description of techniques to stop undesired behaviors (e.g., being hyperactive, irritating siblings). And the final section describes techniques that increase desired behaviors (e.g., paying attention, increasing memory). Before the techniques are described, there are important concepts that need explaining.
Section One: Important Concepts
Behavioral techniques refer to scientific methods to change behavior. The process of changing behavior is called behavior modification. Over the years, scientists have noticed interesting patterns regarding animal and human behavior when applying behavioral techniques. Understanding these patterns or principles can help increase the effectiveness or success of behavioral interventions. Important concepts to understand include clarity, consistency, patience, extinction bursts, spikes, and "honeymoon periods."
Clarity is making things very understandable to the ADHD child. It is common for ADHD children to misunderstand directions, mishear things, forget how things were, etc. Clarity helps prevent misunderstandings. It is important for you to be clear of which behaviors are acceptable and which behaviors are not. Behaviors to change should be written down. Consequences for mis-behaviors should be written in terms that children can understand. Interventions should be explained and written as much as possible. Interventions should be kept simple and easily understood. Not fighting with your sister is very unclear. Does fighting include bickering, arguing, slaps to the arm, name calling, or other behaviors. A more clear instruction is not touching your sister. A less clear but often clear enough instruction is not saying anything negative to your sister. The problem with this is that he parent often has to interpret if statements were negative or not. To help clarify this rule, examples can be given such as: No calling her a cry baby, ugly, slow, stupid, retarded, saying "duuhh". Once these rules and procedures are written in clear language, they should be posted in a spot where everyone can frequently review them. Often a hallway makes a good place to post rules, consequences, and written intervention procedures.
To make behavior modification work, two other concepts are important. The first is consistency and the second is patience. Being consistent in behavior modification is very important. If you are inconsistent, your child becomes confused and learning an acceptable behavior takes much longer. In fact, if you are not consistent, your child may not learn the correct behavior at all. For example, if you tell your child that every time he or she hits a sibling, you will take 25 cents away from the child, you will need to take 25 cents each and every time your child hits a sibling. Failure to do so one or two times is likely to keep the aggression going. If you are consistent for two weeks and then fail to deduct 25 cents, then the child is likely to increase the aggression and may become more resistive to other interventions to reduce aggressiveness.
Patience is also needed when setting in motion a behavioral technique. Many parents make the mistake of giving up on a procedure (intervention) too soon. They are often unaware of the effects of extinction bursts, spikes, and "honeymoon periods." To explain these concepts, hopefully a graph will be worth a thousand words:
The above graph illustrates the importance of being consistent and patient when applying an intervention. To explain this graph, let's use an example of Ms. Brown and her six-year-old child who refuses to sit still and eat at the dinner table. The child, Billy, will get up from the table or will play at the table instead of eating. After the dishes are put away, Billy complains that he is hungry and gets something to eat. Not knowing what to do, Ms. Brown went to a Psychologist who told her to use a behavioral technique called time-out. The plan was to give Billy the opportunity to return to his chair and focus on eating ty the time the mother counted to three. When she reached three, Billy was to receive a five minute time-out in the bathroom.
According to the above chart, the amount of Billy's bad behavior prior to seeing the Psychologist was 20. This meant that Billy would play at the table or attempt to leave the table twenty times during the course of one meal.
Intervention.The intervention was that Ms. Brown would count every time Billy attempted to leave the table or started playing at the table (i.e., not eating his food). If she counted to one, and Billy would act well for five minutes and then started playing again, Mrs. Brown would say "that's two." If Mrs. Brown reached the count of three, Billy would receive a five minute time-out and then return to the table. Mrs. Brown was told to follow these procedures each and every time Billy started to play at the table or get out of his chair while eating his food.
Honeymoon period. When Ms. Brown started this intervention, Billy's bad behaviors were reduced to two or three times per meal. Thus, only occasionally Billy had to sit in the bathroom during a meal. Billy responded well to this intervention. This improvement is called the "honeymoon" period.
Extinction burst. With Billy, this improvement was short lived and Ms. Brown noticed increases in misbehavior. Being consistent she counted to three and sent Billy to the bathroom. However, she was concerned because now Billy was misbehaving even more at the table. Behavioral therapists call this increase in bad behavior an extinction burst. Billy would come out of the bathroom and then again start playing at the table or try to leave the table. Many parents become discouraged when this happens. This is the hardest time to be consistent and patient. It is as if Billy was trying to show his mother that he was going to continue to misbehave no matter what she did.
While many parents give up or are inconsistent following an extinction burst, doing so is a terrible mistake. Often when parents are inconsistent (not counting to three or failing to send their child to time-out), their child's behaviors are worse than before. Too many parents have complained that their child's behaviors become worse after seeing a therapist than before. A better way to view the increase of misbehavior is to realize that if the behavior increases, then your intervention is working because of the phenomena called extinction burst. Just be patient and consistent and the behavior will eventually decrease.
Decrease in misbehavior. In animals and with humans, if the intervention is consistently applied, the decrease in misbehavior will come. The only exception to this is when the consequence is self rewarding. Then you will not see a decrease in misbehavior. However, for most children, being sent to the bathroom or even to their bedroom for five minutes is not self rewarding.
Spike. When consequences are consistently applied and if the consequence is not self rewarding then the behavior will decrease to the level during the honeymoon period. With time, it is normal for the misbehavior to increase. This is called a behavioral spike. But again, be patient and consistent and the misbehavior will decrease again. It is normal to have several spikes when applying behavior modification.
Hopefully armed with this information, you will be more successful in applying behavior modification. The main purpose of behavior modification is to help your child learn appropriate behaviors. There are many techniques in behavior modification. Time-out is just one technique.
When using behavior modification, only apply it to one or two behaviors you wish to change. Trying to change too many behaviors at once usually causes confusion. When your child has mastered one correct behavior, you can then move to another problem behavior. Dealing with one behavior at a time and using patience and consistency, you will be able to resolve many behavior problems through behavioral techniques. Now that these concepts have been explained, you are ready to apply specific techniques of behavior modification to stop bad behaviors or start appropriate behaviors.
Section Two: Behavioral Techniques to Stop Bad Behaviors
Parents often want their ADHD children to stop doing irritating and inappropriate behaviors. Behavioral techniques that reduce or eliminate these bad behaviors are called stop techniques. Some of the most useful stop techniques for ADHD children include time-out, response cost, and punishments. When properly used, they can be very effective at helping your family and the ADHD child become more peaceful.
Time-out is probably the most popular behavioral technique to stop inappropriate behaviors. Time-out is simply putting the child somewhere when the child is doing something wrong. Some parents make their children stand in a corner. Others make them sit in a chair. Professionals like to recommend sitting in the bathroom or sending the child to their room. The best time-out place is where a child can be alone to think about what was done and how to do better.
One symptom of ADHD is impulsiveness. These children often do not think before they act. Their impulsive behaviors frequently require a time-out. To help children become less impulsive, an additional technique of counting to three is often useful. When the child is breaking a rule, the parent can name the rule that they are breaking and then say "that is one". If the child continues, the parent can say "that's two". If the child still does not change the behavior, then the parent says "that's three". When parents reach three they must put the child in time-out. Giving two warnings before applying the time-out is very helpful for ADHD children because it helps them to think about what they are doing and modify it before they have to do the time-out. It is hoped that over time, it will reduce the child's impulsiveness.
Some children new to the time-out technique will resist going to the time-out area. Sometimes parents may have to lead or carry the child to the time-out area. Another problem for children new to time-out is learning how to stay in the time-out area. Parents may have to hold a door shut to help the child stay in time-out. With consistency, the child will eventually go to the time-out with little resistence. It may take as long as two weeks of being consistent until the child learns to be cooperative about time-out. Once they have learned to go and remain in time-out, time-out becomes an easy and effective method of discipline.
This technique should be used less as a punishment and more as a method to cool off and regain self control. Time-out allows children to relax and gain control over their behaviors. Below are seven helpful guidelines to increase the effectiveness of time-out.
After you have mastered the time-out technique at home, you are ready to apply the technique outside of the house. For example, when children misbehave at the grocery store, the time-out area could be a bench within the store. Another good location is out in the car. If you use your car as a time-out area, make sure you provide adequate supervision to insure your child has the windows rolled down in hot weather and that they remain within the car. If you have been using time-out effectively at home, children will rarely leave the car if you choose to use it as a time-out area. As you provide the supervision, try to do it in a way that your children are unaware of your vigilance, unless they are particularly fearful. If this is the case, then stay near by where the children can see you, but have no interaction with them until the allotted time is over. Time-out always works best if children do not receive attention from others. Delaying shopping for five minutes or so to achieve appropriate behavior from your children while out in public is worth the effort.
Time-out can be also be modified for traveling situations. When children are misbehaving in the car, simply pull over and park the car until they have settled down and are ready to ride in peace. Being consistent with time-out on the road can help children manage their behaviors under a variety of circumstances and situations.
Another powerful behavioral technique is response cost. Response cost is simply taking something away from the child when an identified negative behavior is performed. The following fictitious example illustrates how response cost can be used for children with ADHD symptoms.
Demetrius is an eleven year old ADHD child who appears to enjoy picking on his younger sister. It is not uncommon to find her in tears after something that Demetrius has done. Without question, Demetrius's mother would love her son to stop bothering his sister and get along better. Everything she has tried does not seem to help Demetrius' irritating behaviors.
To reduce Demetrius' behavior of tormenting his sister, his mother decided to use response cost. She determined that, on an average, she spent about a dollar a day buying him drinks and other things he wanted in the store. She decided she would use this money for a response cost behavioral intervention. She told Demetrius that he would have to stop asking her for things to buy. Rather she would give him a dollar a day to spend as he liked. She immediately gave him a dollar for that day. She then informed him that he needed to stop agitating his sister. She took another dollar, in quarters, and put them in a jar. She told him this was his money for tomorrow. There was a catch. Every time he was caught bothering his sister or calling her a name, he would lose a quarter from the jar. The first thing in the morning, he could have whatever was left in the jar. After he took the money, another four quarters were put in the jar for the next day's spending money.
As most children do, Demetrius soon spent his dollar and he kept pestering his sister. He was able to thwart every other intervention his mother had tried to get him to stop bothering his sister. He actually enjoyed seeing his sister upset. When Demetrius was bored, bothering his sister could stir up some action. He repeatedly kept irritating her. One by one, his mother kept taking quarters out of the jar. By the end of the day, Demetrius' money jar was empty.
The next day the children were in a store and they both wanted a drink. Mom bought her daughter a drink but not Demetrius. Demetrius protested saying it was unfair. Mom reminded Demetrius that she had already given him his drink in the form of four quarters, and she hadn't spent a dollar on his sister today. She reminded him that tomorrow he would get another chance to spend money. While it was difficult for her to buy her daughter a drink and not Demetrius, she knew that she had to be consistent and not sabotage the intervention by buying Demetrius what ever he wanted instead of using his own money.
As if to rebel, Demetrius pestered his sister even more and was out of quarters within two hours. He was then given time-outs for subsequent violations of bothering his sister and calling her names. Again, Mom was consistent and did not give into Demetrius when he wanted candy, gum or drinks. To be completely fair, she tried her best to spend only a dollar a day, on average, for her daughter's drinks, candy, and other similar items.
Through his mother's patience and consistency, Demetrius started to improve. Soon he was receiving money again. During the third week of the intervention, Demetrius had a dollar per day for four days straight. Mom praised Demetrius for doing much better at treating his sister with respect. Having increased peace in the home was worth the trouble of obtaining quarters, counting them out in the jar, keeping track of how much money was spent on her daughter, and having to be consistent with the program.
This technique can be used for a wide variety of misbehaviors and situations. The item taken away does not always have to be money. It could be points, stars, tokens or snacks. When working with children with ADHD symptoms, keep the rewards happening often. Too many response cost programs fail because the child had to wait too long to become rewarded. Expecting an ADHD child to wait a week before they can spend the money or obtain the reward is not likely to succeed. Below are some steps to increase the success of a response cost behavioral intervention.
Steps in using response cost.
1. Clearly define what behavior you wish to extinguish or terminate (e.g., irritating siblings, playing at the dinner table, fighting). Measure how often the behavior occurs and when it occurs. This is your baseline rate. Usually when you start an intervention this rate will decrease, then increase and finally decrease. If the intervention is effective, within a few months the behavior should occur much less frequent than this measure.
2. Determine what to use as the penalty and how much of the penalty to take away. If you are using money, you should next decide how much money to use. The amount of money should be a reasonable amount based on your income and the child's normal expectations for "spending money". For example, some families have children who feel $1.00 a day is much money. On the other hand, some families have children who can easily spend ten dollars a day in spending money. For our example, lets use a family whose children do not spend much. If the base line rate is 3 times a day and the penalty is 25 cents then the amount of money in the jar should be $1.00. If the base line is seven times per day and you did not want to spend more than a dollar, then the penalty could be a dime per offense. For baseline rates of 12 -17, then a nickel per offense would be appropriate.
3. If using money, give the child the day's money. If you are using snacks, have one day before implementing the response cost, where you allow the child to obtain all the snacks. This helps the child realize what he can achieve having a day where he is able to control his behaviors. Remember that each day starts off new. Many response cost programs have failed because the child was expected to wait a week to get the reinforcer. Short time periods to wait for the reinforcement are best for children with ADHD.
4. Put tomorrow's rewards in plain sight of family members. If using money as a reward, the child should at any time be able to look and see how much money is left in the jar. The jar serves as a constant reminder to the ADHD child of the intervention. You can even label the jar "Being nice to sister" or some other positive label.
5. Explain how the program works to your child. Make sure he can repeat back to you what the program is all about.
6. Be fair and consistent. If using money for the response cost system, do not buy your child things he/she could use the spending money for. Do not overspend on the other children. If another sibling is doing the same kind of behavior, they must receive an appropriate consequence (e.g., time-out). Every morning give your child the contents of the jar, then refill the jar.
7. Make sure that everyone is clear as to what is and what is not behaviors that will cause money to be taken.
8. When the amount of problem behaviors exceed the amount of money in the jar (or other reward), simply give another consequence (e.g., time-out). This will send the message that the problem behavior will not be tolerated.
9. When money (or other reward) is given to the child, give positive praise. Let them know that you appreciate their effort to change.
If you are consistent, response cost can be a very effective technique for stopping inappropriate behaviors. After a month of 90 percent compliance, then you can begin to fade out the reward system. Make sure you continue with verbal praise when the child behaves appropriately. In time, your child may revert back to old behavior patterns. If this happens, use your normal methods of disciplining. If normal methods of disciplining do not correct the problem, you may need to start the response cost system again. It should not take as long the second time as it did the first time of the response cost intervention.
A behavioral techniques that often works quickly is over-learning. It works best on simple behaviors (e.g., closing doors properly) and can also be used on complex behaviors (e.g., toilet training). Roland's situation will help us understand how over-learning works:
Roland's parents came home from work at 5:30 while Roland came home from school at 4:00. Like many children with ADHD, Roland would frequently lose things like the key to the house. His parents decided to leave the key under a flower plant on the patio so Roland could enter the home as he got in from school. He was instructed to open the door and return the key in the planter immediately. To his parents dismay, Roland had the irritating habit of losing the key by entering the home, turning on the Nintendo machine and playing games until his parents returned from work. The key would sometimes be in the lock, sometimes on the television set, and sometimes lost somewhere in the house. His parents would fuss at Roland, but nothing seemed to work. Finally their therapist told them of over-correction. It was easy. In one application, Roland learned to put the key under the flower pot. Two months later he was still putting the key in the correct spot.
Over-learning is one of the easiest behavioral techniques for parents to use. While it might not be one hundred percent effective in all situations, it is quite effective for a number of behaviors that need to be stopped. In the above example, Roland needed to stop losing the key. His parents had Roland practice 10 times walking down the sidewalk to their house, finding the key, unlocking the door, returning the key to the flower pot, and then going inside the house. Roland completed all ten trials while his parents watched. Roland was told that if he forgot again, they were to practice twenty times. Roland never needed to practice twenty times. Other children may not learn as fast.
The key to success is that the child practices the exact procedures from the very beginning to the end, repeatedly. Ten to twenty times is a good number for most behaviors. This technique is also used with adults. For example, airplane pilots practice emergency landing procedures repeatedly so that if an emergency ever did happen, they can perform the complex tasks without difficulty. The technique can be used on children when they slam doors habitually, forget to put up their coat, do simple chores incorrectly, and a number of other simple behaviors that often irritate parents. When working with a behavior that has become a habit, use over-correction immediately following the offense, and consistently. This technique is not appropriate for complex or time consuming tasks such as completing homework or paying attention in class. In addition, some habit forming behaviors do not respond well to over-correction (e.g., chewing with mouth open, bitting finger nails).
Step by Step Procedures for Over-learning
Another way to prevent future misbehavior is using a technique we call restitution. It may not be a behavioral technique per se, but many parents have used it with much success. Restitution is simply restoring what was lost during the misbehavior. It is simply "making right the wrongs". This principle can be included with other techniques such as over-correction. For example, suppose the ADHD child, Meagan, is grabbing the crayons from her little sister. This makes the sister cry. While Mom was folding cloths, she hears the cries and has to investigate what happened. The ADHD child practices asking nicely for the crayons ten times and gently taking one or two when offered by the little sister (if little sister is uncooperative, the ADHD child can practice with the mother). To restore the damage done, Meagan is required to give her little sister some markers to draw with the crayons. Next, Meagan helps Mom fold the rest of the laundry.
Another example of restitution is when a child steals something at the store (e.g., candy). The parent simply informs the child that the candy must be paid for. The child also has to tell the store manager that the candy was stolen and ask what they must do to make up what was lost. What ever the store manager suggests, within reason, the parent makes sure that the child complies. Some parents make their children pay up to three times the amount of something that they steal. Paying up to three times the amount as a consequence for stealing would be employing the behavioral technique called punishment.
The Use of Other Punishments.
Punishment is simply giving a consequence that children do not like when they misbehave. Common punishments are time-out, taking away privileges (a.k.a. grounding), pulling weeds, special chores, report writing, mouth washed out with soap, response cost, spankings, sitting in the corner, and making the child do push-ups. Research suggests that positive reinforcement such as praise, money, privileges are more effective than punishments. We recommend that you use punishments very sparingly. When you do use them, also remember that ADHD children's attention span is short. Never wait long to administer a punishment.
When using time-out as a punishment, we recommend that you use it with a counting system. This is explained further in the parenting section. Counting to three as two verbal warnings will often prevent a child from going into time-out and correct the behavior also. When a time-out is given, when three is reached, give the time-out immediately. Keep emotions out of it, just administer the time-out and do not give negative attention by scolding the child. Time-outs should be short. Usually several short five minute time-outs are more effective than one long time-out with children with ADHD symptoms.
Some children love to say "no". These are the ones who appear not to cooperate with adults and teachers. Children who are like this to the extreme are called oppositional and defiant. ADHD children with oppositional and defiant behaviors will often need two types of punishments. Some punishments require the child to cooperate with the punishment. Doing special chores, sitting in time-out, writing a report, saying you are sorry all require the child's cooperation. If the child is determined, a parent really cannot make him/her do any of these things. Some punishments do not require the child's cooperation. Taking television privileges away by locking all the televisions in the shed, not allowing the child to eat dinner, taking the child's CD's away are all punishments that do not require cooperation from the child. Paring these two types of punishments are often effective for oppositional and defiant children. For example, suppose a boy hits his younger sister. The consequence can be for the boy to clean the bathroom sink. The boy will not get to sit down and eat at the family table until he cleans out the sink. Parents must be firm and not allow the child to eat until the sink is cleaned.
Some parents feel that this is child abuse because they are withholding food from the child. Most children and adults can miss one meal without any detriment to their physical well being. This type of consequence is also not abusive because the child determines when he/she will eat. If the child cooperates and cleans out the sink appropriately (it passes parental inspection), then the child can eat dinner. Many oppositional children will challenge the parent on this one. For example, they may eat at the neighbors house to avoid cleaning the sink. Do not become discouraged with this. You can simply adjust the consequence that no evening meal will be served to your child in this house until the child cleans the sink. You can give your child all other meals, but forgo the evening meal continually until the sink is cleaned. Eventually the neighbor will tire of feeding your child because he is unwilling to clean the bathroom sink. Sometimes parents have to be creative when giving punishments. Use only punishments that you are willing to follow through with. Never threaten a child with something you are not willing to do. The child may call your bluff. If you do not follow through, you have lost trust. If you have an oppositional child who is also ADHD, you may wish to read more information on dealing with children diagnosed with Oppositional Defiant Disorder.
Section Three: Behavioral Techniques to Start Appropriate Behaviors
How to get ADHD kids or just any child to do something they do not enjoy doing? This could be getting dressed for school, doing homework, completing chores, or taking a bath. Some children have to be told repeatedly until they do something. Some parents cope with this by yelling at their children. This is not a positive coping skill. There are better ways to get your children to do things.
Again, punishments should be used sparingly. Rewards should be used often, especially verbal praise. The use of rewards play a great role in training children. The simplest definition of a reward is anything that increases behaviors. Every parent uses rewards. Rewards include verbal praise, affectionate looks, hugs, light touches, snacks, special privileges (e.g., playing outside, playing video games, computer time, talking on the phone, sleep-overs), money, movie tickets, video game rentals, etc.
Rewards do not have to cost money. Verbal praises, hugs, appropriate touching can all go a long way to motivate children. Special privileges are often good rewards that do not have much cost involved (e.g., playing outside, watching TV, going to the park). Frequently use rewards that are easy to use and do not cost much money (e.g., verbal praise, providing attention). There are times where rewards that involve money are useful.
Most children will attempt to perform a difficult behavior for an appropriate reward. Examples of these rewards include candy, money, toys, sports equipment and movie passes. If you can afford these rewards, use them sparingly. Some of the techniques used to create skills or increase attention are not fun for most children. Sometimes rewards are needed to increase compliance and motivation. Once a technique is mastered, rewards can be faded out. A mastered behavior is one that does not require many rewards to keep the behavior going. The child has integrated the behavior and uses it in a wide variety of contexts. Until then, some type of reward system can increase compliance.
Some parents resent using rewards because they feel their children are being bribed into behaving. Some worry that if you praise children too much, they will need it when they are older and they will not get it or they will always seek the praise of others instead of thinking independently. We do not agree with this type of thinking. We suspect people would do better by giving praise more often. It does people good to praise others. Children usually need more praise than what they get. Rewards are a fact of life. Few adults would continue their employment if they were not rewarded with money. On the job and in school, reward systems are part of everyday transactions between people. Using increased rewards at home may actually better prepare children for the real world.
A common reward sought by children with ADHD is their parent's attention or involvement. This attention can be positive or negative. Positive attention includes verbal praises, looking, smiling at the child, love pats, hugs while negative attention includes scolding, yelling, spanking, and disciplining the child. Some say that a child will do just about anything to get attention. If the child cannot get positive attention, the child will seek negative attention. We highly recommend that you give your child much positive attention when his behaviors are OK and good, than giving your child negative attention. One good method to effectively deal with negative behaviors is to ignore them if you can. If your children are misbehaving for attention, then ignoring the behavior or withholding attention will eventually cause the behavior to go away (i.e., extinction). When the behavior becomes too extreme to ignore or occurs too frequently, you will then need to give consequences or start a behavioral intervention.
Living with children with behavior problems and ADHD symptoms can be difficult. Some parents are so frustrated with their children that they feel their children do nothing right and are not worthy of praise. The truth is that even the worse behaved children do more things right than they do things wrong. For example, when was the last time your child put on his or her shoe on the wrong foot? If children are four-years-old or older, they usually are consistent about putting their shoes on the correct feet. Now how often do they get praised for that correct behavior? Children often put their pants on correctly, button themselves correctly, etc. Most parents are too busy finding fault in their children's behavior that they ignore all the good. Ignoring most of the good behaviors and paying too much attention to the occasional (in comparison) bad behaviors makes frustrated parents, which in turn results in frustrated children. Giving positive praise will help lessen some of that frustration. It helps put the problem behaviors into a perspective that increases hope. Below are other concepts that increase the effectiveness of using rewards.
Give rewards soon after the desired behavior. When using reward systems with children with ADHD symptoms, remember that their attention span is very short. They often do not look far into the future. Rewards need to be given immediately or without much delay. If you have a reward that is given at the end of the week, the likelihood for success is diminished. ADHD children respond better when rewards are given more frequently. Points, stars, stickers, tokens are all immediate rewards that can be traded in for a long term reward such as a movie ticket, sleep-over, or other long term rewards. Try to avoid making the child wait over a week to receive a reward. Some successful reward systems ADHD children involve giving rewards daily and allowing the child to start anew at the beginning of each day. Many therapeutic schools try to reward their students hourly to increase compliance. A motto for alcoholics in recovery is "A day at a time." The motto for parents of ADHD children with severe behavior problems may be "An hour at a time."
When a behavior is mastered, begin to fade out the reward system. When using praise, give your child much verbal praise at the beginning of learning a new behavior. Then fade the verbal praise out. This way children will not expect praise for every little good thing that they do. Even rewards that involve money should be eventually faded. Often the money can be applied to another difficult behavior that has not been mastered yet.
Always provide unconditional love. Unconditional means that there are no strings attached. Always give children much love and affection, even if it has been a rough day. Your love and affection should always be given and not dependent upon their behaviors. Children should never have to feel that they need to earn your love and affection. That should be given to them just because they our your children. It is OK for them to feel that they have to earn privileges and other rewards, but love should be given unconditionally. Even when you have to discipline your child it is good to let them know that you love them. Love is always a positive reward to children and when expressed they are often encouraged to keep trying to improve their behaviors.
Many behavioral programs use rewards as an integral component of the intervention. Tracking systems is a behavioral intervention that involves obtaining signatures from others if a desired behavior has been completed. If all is signed off in the positive direction, a reward is given. If not, then a punishment is given. The following true story illustrates the use of a tracking system.
Antonio lived in a group home and had severe symptoms of ADHD. His mother did many drugs and alcohol and Antonio's ADHD may have been inherited or due to the drugs she was on. At age 14 he was placed in a group home primarily due to the neglect of the mother and Antonio's legal problems (he would vandalize property). The group home experience really settled Antonio and his behaviors improved with the increased structure. However, when it came to school work he would rarely finish his assignments and if he did finish his assignments, he would rarely turn them in. The group home staff were very experienced in behavioral techniques and designed a tracking system with the school. Everyday each teacher in the Middle School (a.k.a. Junior High School) would list his homework assignments for the day and report if he turned in yesterday's assignments. The checklist also had some items related to class room behavior. The staff took that information to make sure Antonio completed his work in the afternoon. On the behavior checklist, if Antonio received all positive marks from every teacher (100 % compliance), then he would get his privileges, if not he would lose all privileges.
Antonio agreed to the new arrangement and basically improved, but not good enough to earn any privileges. It turned out that Antonio did not really care much about his privileges. Coming from a neglectful background, he had grown used to doing without. Just having meals everyday, clean cloths, and a nice bed was better that what he had before. Eventually the Tracking system deteriorated to near the base line level.
Again the experience staff knew that the tracking system was a good one, Antonio was capable of 100% compliance, so they had to figure out a good motivator. Antonio was simply not motivated by privileges.
A unique quality of the group home was that the boys were able to do yard work or landscaping to earn money. Twice a month they would get to spend most of the money on whatever they wanted. Antonio loved new designer clothes and loved how he looked in them. Most of his money went for clothes. The staff decided that Antonio's consequence for not getting perfect marks on the tracking system was that he could not spend the money that he earned.
Antonio did not think this was fair, but he did not have much choice. He rebelled passively by not complying with the tracking system. When the money was given out, Antonio did not receive any. All the boys spent their money in the way they wanted except for Antonio. Antonio still had the money, he just could not spend it. From then on the tracking system worked. Antonio made 100% compliance. His grades improved and the teachers gave him positive feedback.
This true story represents some important concepts about using tracking systems. With younger children, rewards should be as immediate as possible. Antonio's consequences for not having good checks from his teachers was an immediate loss of privileges. However, the consequence that worked was not an immediate consequences (not being able to spend his money in two weeks). With older children a delayed consequence can be effective, especially if it has a high value for the adolescent. That is the reason that groundings work much better for adolescents than do spankings or time-out. Spankings and time-out work much better for younger children because they are immediate.
This case scenario also illustrates the importance of not giving up on a tracking system. The tracking system was fine even though some would argue that 100% compliance on multiple measures from seven different teachers was unrealistic. In this case, the staff felt that the requirements were minimal expectations for all students and that Antonio could comply if he wanted to. When designing a tracking system, make sure the student can comply with what is being expected in the tracking system. Once you are sure that the child can comply, do not give up on the tracking system. If the child does not comply it is probably a motivation problem. The consequences are not good enough to motivate the child into compliance. Once the consequences were redesigned, compliance followed after a testing period. Many children do not believe that their parents will follow-up with the consequences.
Never make the mistake of saying you are going to do something if... and not follow through. Only pick consequences that are easy to follow through with. For the group home staff, not allowing Antonio to spend his earned money was a easy consequence to follow through with. Antonio knew that the money was still his, he just couldn't spend it. Having more money to spend two weeks after the consequence was given was even more motivation for Antonio to comply with the tracking system. In this example, the rewards were all natural: Antonio was allowed to spend money that he earned, his teachers and staff gave him verbal praise, and his grades improved. Natural rewards can often the best type of reinforcement.
4. In a parent teacher conference, or an IEP (Individualized Education Plan) meeting discuss the chart with each teacher to get an agreement of their participation. Inform them that you will be checking up to insure that the child is not checking the marks instead of the teacher.
A common problem for many ADHD children is turning in their assignments at school. Many can do the work, but are forgetful about turning it in. A tracking system is a good method to ensure the child is motivated to both complete the work and turn it in. Tracking systems can be an effective tool for children with ADHD symptoms. These children do better with structure. Having to get signatures from teachers may take time, but teachers can remind them. When it becomes routine, the children usually remember on their own. Such a system can prevent much wasted time looking for homework assignments or arguing about the content of the assignments. Another useful tool that adds structure for ADHD children are simple charts.
Young children with ADHD symptoms can often benefit from simple charts to increase certain behaviors. For example, if the goal is to have the child get ready by 7:45 every morning for school, a chart can be made to help that child achieve that goal. Below is a sample chart for a first grade boy named Rick. The chart can be laminated so that checks can be made with a grease pencil. Most charts are associated with rewards that interest children. Rick will be able to play fifteen minutes of video games or have fifteen minutes of computer time if he can accomplish all the tasks on time.
Let's suppose that on Monday, Rick accomplishes all tasks on time. His reward would be 15 extra minutes of video games or computer time after his homework is complete in the evening. A more immediate reward could be a pudding cup to put in his lunch, or a fruit roll up to eat on the bus. The reward should be something very desirable for the child. In addition to the immediate reward, since Rick completed all the morning tasks, he would circle the Monday at the bottom of the chart which counts towards a reward at the end of the week. On Saturday, if Rick has four check marks on the day row, he will be able to buy a toy from the dollar store. If he has a perfect week, then he will be able to buy two items from he dollar store.
This chart should be placed where Rick sees it often to help remind him of the tasks he needs to accomplish. Simple charts can be made for almost any behaviors. We recommend keeping the behaviors in positive terms. For example, instead of saying not missing the bus in the morning; the same behavior could be stated as being ready on time or being ready by 7:45 a.m. For Rick, ready is defined as having teeth brushed, hair combed, cloths on, and breakfast finished and waiting at the bus stop by 7:45.
Simple charts should be kept in use until the child can master the behaviors specified. Hopefully the behaviors will be habits. Once mastery is accomplished, the chart can be discarded or a new chart for another problem behavior can be developed. Sometimes, summer vacation disrupts the patterns of behavior and charts that involve preparing for school may have to be used again when school starts.
Section 4. Skill Building Techniques
Behavioral techniques do not limit themselves to effective parenting. They can also be used to teach skills that help improve attention, teach relaxation, and gain better control over Attention Deficit\Hyperactivity Disorder symptoms. Part of growing up involves learning new skills and improving behaviors in a wide variety of settings. As all children mature, they naturally become more coordinated, more intelligent, and even able to control their hyperactivity and impulsive behaviors.
Some mental health professionals may believe that medication is all that is needed to deal with ADHD symptoms. They suggest that once the child is able to concentrate and sit still, then most problems will work themselves out. With time, it is believed that grades will improve and others will treat the child differently. They mistakenly believe that as long as the child is on medication, the child's quality of life is within the normal range.
Our view is that medications are important and in many cases can make a big difference in the quality of life for the child with ADHD symptoms. However, medications only deal with symptoms. While medications create chemical changes within the brain, they do not create structural changes within the brain nor do they cure the cause of the ADHD problems. When the medication wears off, the child's brain returns to it's previous level of functioning and the brain's structure is unchanged other than the normal development that is expected in all children's brains. Unlike medication, skill training attempts to make structural changes within the brain and help the brain develop to the point that medication is no longer needed or greatly reduced. Behavioral techniques can be used to assist in the skill development process.
The disadvantage to skill training as compared to medication is that skill training requires time and effort. The effects of skill development may not be readily apparent. Taking medication does not involve as much time and the effects of medication are usually noticed quickly. In addition, not all skill development techniques will be effective for all children with ADHD symptoms. For example, skill development techniques for children whose ADHD symptoms are caused by food allergies will not be as effective as it would be for children whose ADHD symptoms are caused by genetics. For children with food allergies, these allergies will need to be treated and then skill development techniques will be more effective. Again, knowing the cause of the ADHD symptoms are very important for treatment. For more information on the common causes of ADHD, please refer to Chapter 2 of this book.
Again, this section is dedicated to using behavioral techniques that increase appropriate behaviors and teaches skills that will be useful for children with ADHD symptoms. This section focuses on several behavioral techniques that are useful in developing skills often needed to compensate for the effects of ADHD symptoms. These techniques include relaxation, memory skills, eye movement exercises, focus exercises, and self control techniques. Additional skill development exercises can be found in other chapters in this book.
Progressive Muscle Relaxation For Children
There are many ways to teach children to relax. Some techniques include autogentics, visual imagery, meditation, self-hypnosis, and progressive muscle relaxation. The explanation of all of these techniques is beyond the scope of this chapter, but progressive muscle relaxation will be explained in detail. Few relaxing techniques are as useful for children as progressive muscle relaxation. This form of relaxation involves teaching children to tense and then relax certain muscles throughout their body. It has a great calming effect. Often relaxed children are more in control of their ADHD symptoms than tense children. Some children with ADHD symptoms find it hard to relax. This technique is used to help calm children. Progressive muscle relaxation is also a good technique to use if the child is too hyper or nervous to benefit from deeper relaxing techniques such as self-hypnosis or visual imagery. Relaxation can even help with children who have trouble sleeping at night.
How to implement this technique.
Progressive relaxation is relatively easy to use. It should be used on a regular basis at first so the child learns to have control over their body through relaxation. Find a place where the child will not be distracted and then read the following script. The child simply follows along and does the tasks as directed. It is important that the child tenses hard enough to feel the difference between tension and relaxation, but not hard enough to cause injury or pain. Below is a script adapted from a progressive relaxation for children who's author is unknown. When you read the following script, do not read out loud the sub headings.
Today we're going to practice some special kinds of exercises called relaxation exercises. These exercises help you to learn how to relax when you're feeling up-tight and help you get rid of those butterflies-in-your-stomach kinds of feelings. They're also kind of neat because you can learn how to do some of them without anyone really noticing. In order for you to get the best feelings from these exercises, there are some rules you must follow. First, you must do exactly what I say, even if it seems kind of silly. Second, you must try hard to do what I say. Third, you must pay attention to your body. Throughout these exercises, pay attention to how your muscles feel when they are tight and when they are loose and relaxed. And fourth, you must practice. The more you practice, the more relaxed you can get.
Do you have any questions?
Are you ready to begin? Okay, first, get as comfortable as you can in your chair. Sit back, get both feet on the floor, and just let your arms hang loose. That's fine. Now close your eyes and don't open them until I say to. Remember to follow my instructions very carefully, try hard, and pay attention to your body.
Here we go.
Hands and Arms
Pretend you have a whole lemon in your left hand. Now squeeze it hard. Try to squeeze all the juice out. Feel the tightness in your hand and arm as you squeeze. Now drop the lemon. Notice how your muscles feel when they are relaxed. Take another lemon and squeeze. Try to squeeze this one harder than you did the first one. That's right. Real hard. Now drop the lemon and relax. See how much better your hand and arm feel when they are relaxed. Once again, take a lemon in your left hand and squeeze all the juice out. Don't leave a single drop. Squeeze hard. Good. Now relax and let the lemon fall from your hand.
(Repeat the process for the right hand and arm.)
Arms and Shoulders
Pretend you are a furry, lazy cat. You want to stretch. Stretch your arms out in front of you. Raise them up high over your head. Way back. Feel the pull in your shoulders. Stretch higher. Now just let your arms drop back to your side. Okay, kitten, let's stretch again. Stretch your arms out in front of you. Raise them over your head. Pull them back, way back. Pull hard. Now let them drop quickly. Good. Notice how your shoulders feel more relaxed. This time let's have a great big stretch. Try to touch the ceiling. Stretch your arms way out in front of you. Raise them way up high over your head. Push them way, way back. Notice the tension and pull in your arms and shoulders. Hold tight, now. Great. Let them drop very quickly and feel how good it is to be relaxed. It feels good and warm and lazy.
You have a giant jawbreaker bubble gum in your mouth. It's very hard to chew. Bite down on it. Hard! Let your neck muscles help you. Now relax. Just let your jaw hang loose. Notice that how good it feels just to let your jaw drop. Okay, let's tackle that jawbreaker again now. Bite down. Hard! Try to squeeze it out between your teeth. That's good. You're really tearing that gum up. Now relax again. Just let your jaw drop off your face. It feels good just to let go and
not have to fight that bubble gum. Okay, one more time. We're really going to tear it up this time. Bite down. Hard as you can. Harder. Oh, you're really working hard. Good. Now relax. Try to relax your whole body. You've beaten that bubble gum. Let yourself go as loose as you can.
Face and Nose
Here comes a pesky old fly. He has landed on your nose. Try to get him off without using your hands. That's right, wrinkle up your nose. Make as many wrinkles in your nose as you can. Scrunch your nose up real hard. Good. You've chased him away. Now you can relax your nose. Oops, here he comes back again. Right back in the middle of your nose. Wrinkle up your nose again. Shoo him off. Wrinkle it up hard. Hold it just as tight as you can. Okay, he flew away. You can relax your face. Notice that when you scrunch up your nose your cheeks and your mouth and your forehead and your eyes all help you, and they get tight too. So when you relax your nose, your whole body relaxes too, and that feels good. Oh-oh. This time that old fly has come back, but this time he's on your forehead. Make lots of wrinkles. Try to catch him between all those wrinkles. Hold it tight, now. Okay, you can let go. He's gone for good. Now you can just relax. Let your face go smooth, no wrinkles anywhere. Your face feels nice and smooth and relaxed.
Hey! Here comes a cute baby elephant. But he's not watching where he's going. He
doesn't see you lying in the grass, and he's about to step on your stomach. Don't move. You don't have time to get out of the way. Just get ready for him. Make your stomach very hard. Tighten up your stomach muscles real tight. Hold it. It looks like he is going the other way. You can relax now. Let your stomach go soft. Let it be as relaxed as you can. That feels so much better. Oops, he's coming this way again. Get Ready. Tighten up your stomach. Real hard. If he steps on you when your stomach is hard, it won't hurt. Make your stomach into a
rock. Okay, he's moving away again. You can relax now. Kind of settle down, get comfortable, and relax. Notice the difference between a tight stomach and a relaxed one. That's how we want to feel---nice and loose and relaxed. You won't believe this, but this time he's coming your way and no turning around. He's headed straight for you. Tighten up. Tighten hard. Here he comes. This is really it. You've got to hold on tight. He's stepping on you. He's stepped over you.
Now he's gone for good. You can relax completely. You're safe. Everything is okay, and you can feel nice and relaxed.
This time imagine that you want to squeeze through a narrow fence and the boards have splinters on them. You'll have to make yourself very skinny if you're going to make it through. Suck your stomach in. Try to squeeze it up against your backbone. Try to be skinny as you can. You've got to be skinny now. Just relax and feel your stomach being warm and loose. Okay, let's try to get through that fence now. Squeeze up your stomach. Make it touch your backbone. Get it real small and tight. Get it as skinny as you can. Hold tight, now. You've got to squeeze through. You got through that narrow little fence and no splinters! You can relax now. Settle back and let your stomach come back out where it belongs. You can feel really good now. You've done fine.
Legs and Feet
Now pretend that you are standing barefoot in a big, fat mud puddle. Squish your toes down deep into the mud. Try to get your feet down to the bottom of the mud puddle. You'll probably need your legs to help you push. Push down, spread your toes apart, feel the mud squish up between your toes. Now step out of the mud puddle. Relax your feet. Let your toes go loose and feel how nice that it feels to be relaxed. Back into the mud puddle. Squish your toes down. Let your leg muscles help push your feet down. Push your feet. Hard. Try to squeeze that puddle dry. Okay. Come back out now. Relax your feet, relax your legs, relax your toes. It feels so good to be relaxed. No tenseness anywhere. You feel kind of warm and tingly.
Stay as relaxed as you can. Let your whole body go limp and feel all your muscles relaxed. In a few minutes I will ask you to open your eyes, and that will be the end of this practice session. As you go through the day, remember how good it feels to be relaxed. Sometimes you have to make yourself tighter before you can be relaxed, just as we did in these exercises. Practice these exercises everyday to get more and more relaxed. A good time to practice is at night, after you have gone to bed and the lights are out and you won't be disturbed. It will help you get to sleep. Then, when you are really a good relaxer, you can help yourself relax at school. Just remember the elephant, or the jaw breaker, or the mud puddle, and you can do our exercises and nobody will know. Today is a good day, and you are ready to feel very relaxed. You've worked hard and it feels good to work hard. Very slowly, now, open your eyes and wiggle your muscles around a little. Very good. You've done a good job. You're going to be a super relaxer.
Learning how to relax helps children gain mastery over their body. Children with ADHD often feel that they have no control over their body. As your child masters relaxation techniques, you will also see a decrease in hyperactivity during the relaxation exercise. When children wish to control their impulsive behaviors and hyperactivity, they can practice relaxation. Other ways to relax are given in the chapter on biofeedback.
Many children with ADHD symptoms have problems with memory. To determine the amount of memory problems your child has, play memory games with them and compare them to their peers. Psychologists often look at memory by the scores on digit span sub-test of an intelligence test. If you feel your child can improve in memory, the following game can be a fun way to develop auditory memory.
The purpose of this exercise is to increase your child's ability to remember instructions that are given to him/her. Many children with ADHD cannot remember two, three or four instructions simultaneously. Often they will forget even single commands. Play this game often to strengthen your child's short term memory and help them become less distracted when following commands.
Start the game by telling your child about the game. If desired, other siblings can participate. The game's object is to see how many commands the child can successfully complete. Most children can get up to four, so four commands is a good starting point. For example, you may suggest: "First bring me a tissue, second, put the dish rag in the dirty laundry, third, turn on the light, and fourth, put the magazine in the magazine rack.
If the child is able to do all four, give him/her lots of verbal praise. Really make a big deal at being able to complete four commands. Next, ask the child if he/she is ready to do five commands. Make up five more simple commands. If he/she completes all five, give a lot of verbal praise. Keep playing the game until the child forgets one of the commands. It is not
important that the child complete the simple commands in the order that they were given.
When the child forgets one of the commands, the game simply ends for that day. Congratulate the child in getting the amount of commands he/she was able to do. This is the child's current record. Next time the goal will be to beat the child's record. If more than one child plays the game, parent's must stress for each child to beat their own record and not worry about how the other siblings are doing. A valuable principle can be taught when you stress competing against
yourself rather than comparing yourself with others. If your goal is to improve your child's short term memory, this game should be played at least daily, six times a week. Do not be authoritative about playing the game. Keep the game fun. You can add incentives to get the children to enjoy playing it. For example, you could say that if everyone breaks or matches
his/her own record, the family can go to McDonald's or rent a video.
1. Choose a time each day that you can play this simple game with your child. ________
2. Complete the following sheet each day to help you with your memory. Each line should have a specific task written in that the child can complete without leaving the room (e.g., bring me the book, turn on the lamp, put the blue ball on the coffee table).
Step 3. Play the game. Start off with Trial 1. Go as long as your child can remember the items without being prompted. When he fails, stop the game. If he does well, go to the next trial.
Note: You will not have to fill out Trial 10 each time you play the game. Keep the commands the same on Trial 10 until he masters Trial 9. You will have to rewrite the trials he completed successfully the day before. This way you are helping his short term auditory memory and not long term memory. It is usually the short term memory that is a problem. Some parents may feel that Trial 7 or Trial 8 is a good goal to work toward. Play this game at least 4 times a week. You can stop when your child's memory is at Trial 7 or Trial 10. If your child has mastered Trial 3, you need not start on Trial 1 each day. You can start on Trial 4.
Step 4. Provide rewards for successful work. This increases motivation so that your child looks forward to the game every day. A good attitude also helps memory increase faster.
Step 5. After the simple commands are mastered, your child is ready for complex commands (commands that take more that one or two steps). Complete the following form for complex commands (e.g., take out the trash, make a peanut and jelly sandwich).
Note: Only do one trial a day. Once the child has mastered Trial 1, go to Trial 2 on the next day. Trial 3 is enough memory for most children. When your child has mastered Trial 3 you should be proud of him/her. Keep giving the rewards to keep this a game and not just a bunch of chores.
Step 6. Encourage your child to use his/her memory in school, around the house and at play.
If your child can remember seven simple tasks and four complex tasks, he probably has enough short term memory to get him through most school assignments and home instructions. Short term memory can be a problem for many ADHD children. The command game can help develop memory ability.
Willie will not stay focused very long when doing schoolwork. While he can play video games for hours at a time without distraction, it takes him hours and hours to complete a simple twenty minute homework assignment. When it comes to school work, Willie does not stay on task. For example, Willie will begin a homework assignment and within seconds will break his pencil lead. On the way to sharpen his pencil he may find a baseball trading card that was out of place. When his parents learn that he is not at his desk studying, they tell him to get back to his assignment and stay on task. He returns and starts to play with his broken pencil. After many reminders and four hours later, Willie finishes his homework assignment. Now it is time for bed and Willie does not have anytime to play video games, watch TV, play with a friend or do his chores. Willie and his parents hate doing homework and cannot wait until the weekend.
Another ability lacking in most ADHD children is being able to remain on task when doing school assignments. Self-monitoring is a behavioral technique to help children like Willie stay on task when completing homework and school assignments. It is appropriate for children five years old and older diagnosed with attention deficit/hyperactivity disorder (ADHD). As with all behavioral techniques, self monitoring requires a systematic approach to increase its successfulness. A systematic approach means gathering information and following specific procedures. These procedures are broken down into five simple steps.
The first step is obtaining baseline data. Gathering baseline data simply means knowing how well the child is able to stay on task or focus on completing homework before the program is applied. The second step is implementing the self monitoring program. The next step involves assessing the results and making adjustments to the program. The fourth step is implementing the adjusted program and the final step is evaluating the program's outcomes. Evaluating outcomes simply means comparing the child's ability to remain on task at the end of the program with the child's baseline information. By the end of this program, the child's ability to remain on task at home and at school should be significantly increased. The goal of this program is for children to complete school work in twenty minute intervals.
Using a holistic psychology perspective, self monitoring, if followed correctly, should help your child grow the appropriate brain structures that allow them to stay on task or focused for at least twenty minutes without supervision or constant rewards. Most ADHD children can remain focused on video games because video games provide constant reinforcement. Homework assignments do not. Since ADHD children have the capacity to remain on task for 20 minutes under certain conditions (e.g., video game) this ability can be "shaped" or generalized to situations that are not as reinforcing (e.g., homework, school work). The theory of holistic psychology suggests that shaping stimulates the appropriate brain structures to grow in a way that allow this to happen. Practice this technique three or four times per week or every time the child has homework. Students in summer vacation may wish to wait until school starts if the parent cannot find enough work to be completed three to four times per week. As with most kinds of intellectual growth, it requires time, consistency, and patience to get the desired results.
STEP ONE: GATHERING BASELINE DATA
The program's first task is to obtain a baseline measure of your child's current ability to stay on task. Again, most ADHD children do not have problems staying on task on a good video game. They usually can sit for hours in front of a television playing the game. Make sure your child can play a video game for at least twenty minutes. If he/she can, then you are ready to proceed with this procedure. If your child cannot do any task for twenty minutes, then a different approach is likely to be needed. Children with developmental vision problems often appear with ADHD symptoms. Some of these children cannot play video games for long periods of time and often complain that their eyes hurt. A developmental optometrist may be needed if your child complains often about their eyes hurting when they read. Otherwise, gather baseline information making sure the task is related to school work. The following is an example of getting baseline data for school work.
1. Give schoolwork (e.g., homework) that would take a student at least 20 minutes to complete. Give the child instructions on how to do the work and then let them work independently on the assignment. Do not prompt the child or redirect the child. Just let the child spend 20 minutes working on the task without your assistance in anyway. If the child is in kindergarten or first grade, make the assignment last for only 10 minutes.
3. After 20 minutes count the number of checks in the "yes" column. You now have a baseline score. Save this information to use later in this program. The goal with self monitoring is to help the child improve on this score.
Special considerations. If the child has a high score (i.e., was on task most of the time), your child may have another problem besides ADHD. Further testing or consideration may need to be explored. Please feel free to contact the staff at Your Family Clinic for assistance via E-Mail.
Another consideration is that some children preform better when they know they are being watched. If you feel this is the case, you may not be able to rely on this baseline data to evaluate the program's effectiveness. Our recommendation is that you continue with the self monitoring procedure and use other data to evaluate the program (e.g., the amount of homework completed within 20 minutes).
You can also use this technique to gather baseline data at school. Simply watch the student in school for 20 minutes during individualized work (as opposed to group work) and record the results on the School Baseline Form (presented below). Some children will have a high score at home, but a low score at school. This is a special type of ADHD and may require specialized interventions. Again, please contact Your Family Clinic for assistance.
STEP TWO: IMPLEMENTING THE SELF MONITORING PROGRAM
Now that you have gathered the baseline information, the next step is to implement the program gradually. The key to success is to start small and build upon that. For example, some children just cannot handle twenty minutes on a school related task. You may need to start with just requiring ten minutes or five minutes on the task. Once your child has mastered the smaller time frame, add five minutes. Most ADHD children in third grade and above, should be able to handle twenty minutes. They may not get good scores at first, but they should be able to sit there for twenty minutes without producing open rebellion. If your child does complain excessively, simply reduce the time and remember that it is going to take a little longer to get to the desired end results.
To implement the program, the following steps are suggested.
1. Find a good place for the child to work independently on school work. This place should be relatively free of distractions.
2. Explain the procedure to the child, which is to complete some school work while listening to the audio tape. Most children should not use ear phones because they are often too distracting. The Record Form (listed below) is also used with this step. Every time the tape makes the sound (sound is presented every 45 seconds), participants are to ask themselves "Was I doing my work?" or "Was I on task?". If the answer is yes, then he/she places a check in the Yes column of the Record Form. If the answer is not on task, then the child places a check in the No column. The child's definition of "on task" will probably be different than the definition given on the form or in the baseline. Use your judgement to determine if the child's definition of "on task" is a good one. Some parents may need to assist their child's understanding so that the definition becomes similar to the one used during the baseline or consistent with your definition of "on task".
3. For the first few days of this program, you will need to be with the child and monitor his/her performance. Make sure that the student understands the procedure and completes the Record Form for 20 minutes (less time if 20 minutes is too long). Most children will get the idea within three or four practices.
4. Once you feel the child can complete the instructions, "wean" the child off your supervision by "spot checking" your child's work. This means that every two to three minutes, visit the child and insure that he/she is doing the work and completing the Record Form. After a while, you only will need to observe every five or ten minutes, until the child can be trusted to complete the Record Form and remain seated for 20 minutes.
5. To increase motivation, reward the child with verbal praise. Let them know that they are doing a good job. Also let them know you understand how hard it is for them to stay on task and you appreciate their diligence. Some children will need extra incentives. Extra incentives should be avoided, but if motivation is low it may be necessary. You can give the child money, snacks or privileges for sitting in the chair for 20 minutes and/or improving on their scores from the Record Form. If you offer rewards, make sure you also monitor their honesty. One way to check honesty is to see how much of their work is actually being completed. Another strategy is to look over their shoulder from time to time (spot check) as they work.
6. Self monitoring is considered mastered when the child can sit for 20 minutes and remain on task for 95% of the time or better without supervision. You should also see a great improvement in completing assignments. If you have followed the above procedures correctly, the child should reach this level.
Special considerations. Feel free to make the record form more interesting. Some parents may wish to make the record form look like train tracks (made with squares) or a house (made with square bricks). The child listens to the tape as before and records a + when "on task" and a - when "off task" in the next square.
STEP THREE: ASSESSING THE RESULTS AND REDESIGNING INTERVENTION
Constant evaluation is important. Often children with ADHD are smart at manipulating themselves out of work or unpleasant tasks. For most ADHD children, homework is an unpleasant task. They often manipulate by trying to sabotage your efforts. They also may find excuses as to why they cannot spend twenty minutes studying each night. As a parent you need to "see through" these manipulations and require them to follow the self monitoring procedures. They are progressing if over time their score of being on task is improving as compared to baseline information. In addition, they should be accomplishing more work.
If this technique is not working and you have dealt with manipulations effectively, consider that you may have been expecting the child to make too big of steps. Find the difficulty and simply break it down into a smaller step. For example, some children have difficulty in reading. If they cannot read, it is hard to complete homework that requires large amounts of reading. To break it down into smaller steps, the parent may need to read to the child the homework instructions.
Having pin-pointed the reason for lack of success, incorporate an effective adjustment (e.g., if reading is a problem, use self monitoring for math homework) and continue with self monitoring as described above. Breaking the task into smaller steps usually works for most problems encountered with self monitoring.
STEP FOUR: IMPLEMENTING THE ADJUSTED PROGRAM AND THE SCHOOL PROGRAM
The goal of this step is to see if the adjusted program is working and see if further adjustments are needed. For example, if your child cannot read and you are only using self monitoring for math homework, check your child to insure that the child is staying on task during the math work and is improving in scores from the record form and accomplishing more work. If your child is not progressing, you may have to adjust the program further by increasing motivation through a reward system or a punishment system.
Once your child has gained mastery at home (i.e., completing 20 minutes worth of homework in twenty minutes on his own), the next step is to have your child remain on task at school. Often behavioral programs do not generalize with ADHD children. This means that many times children will learn a procedure at home, but will not use that procedure at school. Of course you will want your child to be able to remain on task at school as well.
When your child has reached number seven of Step Two above, he/she is ready to implement the school procedure. The program is adjusted in the following ways:
Special considerations. For older children (e.g., high school children), twenty minutes may be too short of time to work for some school assignments. Longer periods can be considered if mastery of twenty minutes has been achieved.
STEP FIVE: EVALUATION
Evaluation is determining if the program has worked. Is the child able to stay on task for twenty minutes at home and at school? If so, the program was successful. You can also use this step to reflect on what you have learned about your child. Other questions to ask are what problems were encountered while doing this program? How do these problems relate to other areas of our child's life? What strengths and weaknesses does the child have related to school performance?
During the summer, many children lose good study habits. It may be necessary to start the program again soon after school starts after the summer break. The information from the evaluation may be useful in getting the program going again.
Hyperactive children do not sit in chairs very well. For young children with ADHD symptoms, sitting quietly in a chair can be a nearly impossible task. However, just like most behaviors, sitting in a chair can become a learned behavior. This means that with practice, children can learn how to do it.
This technique works with the most hyperactive child to the moderate or mild child with ADHD symptoms. It will not work when a child is engaged in a temper tantrum or experiencing rage.
This technique is best played as a game. The game is seeing how long the child can sit in a chair without moving. The object of the game is to beat the previous time period or sit still longer than another person. As the child becomes better and better, she/he should be rewarded. The rewards help the child with motivation and keeps the game fun. This game can be played four times a day or a minimum of once a day. Try to play the game every day of the week.
For children with severe problems, the game initially may only last five seconds. Instruct the child to sit still as long as possible without moving a muscle. Some call this the freeze game. If the child smiles or looks around the room, the game is stopped. Once the child "freezes", the time starts. When the child moves even a finger or eye, the game stops. Only blinking is allowed (and only light blinking).
Some people believe that this exercise stimulates the pituitary in the brain to produce chemicals that help the child's brain develop. This helps the child overcome the hyperactive tendencies. Since most children outgrow symptoms of hyperactivity, this game may help the body outgrow it quicker.
Play this game until the child can sit frozen for 20 minutes. If a child can stay frozen for twenty minutes, then they can sit still for most of the presentations at school. Make sure the rewards are great for twenty minutes. This is a good accomplishment even for adults.
Step by Step: The Freeze Game.
1. Explain to the child the nature of the game. The rules are being able to sit in a chair without moving. The only movement allowed is comfortable breathing and normal blinking of the eyes. All finger movements, eye movements, fidgeting are outlawed. Some parents may wish to allow eye movements without head movements.
2. Have a timer or watch with a second hand. When the child begins to be frozen, start the clock.
3. When the child moves, stop the clock, record the time, and end the game. If two people are playing, the first person to move loses. If more people are playing, the last one to move, wins.
4. Next time the game is played, the goal is to beat the previous time.
5. At first only give verbal praises.
6. With time, you will need more rewards. Use rewards that the child really enjoys and that you do not mind giving.
7. Play the game often (four times per day is fine at first), once a day when the time exceeds 10 minutes. Play the game at least five out of seven days.
8. Keep playing the game, always trying to beat the previous record. The game ends when the child can reach 20 minutes on a regular basis. Rewards should be high when the amount of time gets towards 20 minutes.
9. Every six months, play the game again starting with step one and ending at step nine.
Sitting still is an important part of overcoming symptoms of ADHD. Other symptoms that are bothersome to parents are general inattention and impulsivity. The next two exercises focus on the visual system or the eyes. One exercise attempts to reduce visual impulsivity and the other is designed to increase visual attention.
Eye Exercise to Reduce Impulsivity
Impulsivity is doing whatever comes to the mind without thinking about the consequences. Some practitioners feel that the eyes have an important role in impulsivity. Some scientist have observed that when the eyes are focused on a task, the person is able to concentrate. When the eyes shift their gaze, the mind automatically processes another thought. At this point the child may lose attention and get off task. This shift or movement of the eyes in some ADHD individuals is automatic and seemingly not under the person's control.
An observed characteristic of some ADHD individuals is their inability to follow simple instructions related to focusing visually on two objects in succession. When asked to look at a red pencil and then at a green pencil and back to a red pencil, they often look at the other pencil before instructed to do so. This behavior is called visual impulsivity. It is simple to measure and easily observed. Improvements in this behavior are easily monitored as well.
Many impulsive children have impulsive eyes. This means that it is difficult for them to hold their eyes on a fixed point until told to shift their gaze to another point. It is simple to test if a child has this ability or not.
To test if a child has this ability, simply take two pencils and place them 16 inches in front of the child's face. The pencils should be placed about shoulder length apart. Each pencil should look different (e.g., one green the other red). Instruct the child to first look at the red pencil. After a second or two, instruct the child to look at the green pencil. Repeat this process several times using variable timing patterns. Most impulsive individuals will look at the other pencil before being told. It will be difficult for them to follow your instructions.
Treatment is simply making a game out of this test. The child scores points if he/she can follow exact directions for eight trials (a trial is one instruction to look at a pencil). If the person holding the pencils spots the child moving his/her eyes too soon to the other pencil, a point goes to the person holding the pencils. The game can become more difficult by telling the child to look at the green pencil while he/she is already looking at the green pencil. This helps the child to pay careful attention to verbal instructions. At first, try to play the game for five minutes. When the child gets good, play the game for ten minutes. Count up the points and verbally reward the child for playing the game. The next time the child plays, he/she tries to earn more points than the time before.
Play this game often. Do this exercise four or five times a week. Over time your child will become good at keeping his/her eyes on the correct pencil until instructed to move them. This exercise is designed to decrease impulsivity of the eyes, to increase focus and attention, and to improve listening skills. While there is yet no scientific evidence that this ability will generalize into other behaviors (e.g., less impulsive behaviors at school), theoretically it should be helpful.
How does working with the eyes help decrease impulsivity? To answer this question, we will take a developmental approach. The brain is constantly developing. The older a child gets, the more cognitive skills he/she will develop. The symptoms of ADHD often change with time as well. Many ADHD children will loose their hyperactivity and become fidgety as adolescents. A few ADHD children even outgrow most of their symptoms. Training the eyes to stay on task should stimulate brain cells to grow dendrites connecting to other brain cells. This process strengthens pathways so the child has the ability to perform the desired skill.
This is a natural process. It happens with athletes, musicians, students in school, and every healthy person. When you daily practice something, you usually improve in ability. When you improve it is because you have altered your brain structure. Our goal is to alter brain structure to the point that children have abilities to attend and be less impulsive. In these exercises, we focused on the eyes. Some scientists believe that the visual pathways involve 85% of the brain. Thus training visual attention skills will stimulate a large number of brain cells to grow or develop in ways that contribute to attention skills and reduced impulsivity. The more practice, the more benefit will be obtained from these exercises.
There are other eye movement exercises to help increase skills often lacking in children with ADHD symptoms. Attention can be increased by having children practice following moving targets with their eyes.
Visual Tracking Exercise to Increase Attention Ability
This exercise involves having children hold their head still while following the moving target with their eyes. One way to accomplish this is to sit in front of a child (but towards the side of the child) and move an object (e.g., hand, marker, puppet) about 16 inches in front of the eyes. Usually, the younger the child the bigger the object has to be in order to get good tracking. Move the object horizontally for a period of time. Do it at a speed that is comfortable for the child. Tell the child to follow the object and do not get ahead or behind of the object. Some children will move their head while they track with their eyes. This may be acceptable at first, but it is better to have the child keep their head still and only move the eyes.
Many children with ADHD will have trouble following the object. Let them know when they are doing it correctly. You may need to stop to let them refocus on the object. Over time, they should get better and better at following the object. This exercise also tends to have a relaxing effect on some children.
The next step is to have the child follow the object moving in front of the eyes in a the pattern of a windshield wiper. Move the object in an arc from side to side, having the child follow the object. Again, if the child loses the object, let the child catch up or get refocused. Do this exercise for a period of time. The length of the time period will become longer as the child practices this exercise. Do the exercise until the child gets tired or seems to lose motivation. Always push your children to go as long as possible, but never push them to the point that they hate doing the exercise.
The third part of this exercise is like the second, except the object is moved in an arc at the lower part of the visual field. Again, move the object in an arc going from one side to the other and then back again. Make sure the child follows the object with his/her eyes. After a period of time, let the child rest. Again encourage the child to follow the object without moving his/her head. Sometimes you may need to hold the head still with one hand and move the target with the other. Over time, your child will not need this assistance.
The object of this exercise is to increase the amount of time that the eyes can comfortably track an object. A total time of 20 minutes for all three parts of this exercise is a good goal to work up to. Most tasks in school require 20 minutes or less of good concentration to complete.
One must be careful not to think that if a child is able to do this exercise for twenty minutes, he/she should be able to pay attention in school. While some children are able to generalize what they learn behaviorally at home to the school environment, research suggests that behavioral exercises learned at home do not always generalize to the school setting. Some children may need to practice this exercise at school and then try to use the same level of energy to focus on what is being presented in the classroom.
As time marches on, we are learning more and more about children with Attention Deficit/Hyperactivity Disorder. While there is much to learn, there are many behavioral techniques to address the effects of ADHD in children. Behavioral techniques can be used as tools for effective parenting. Consistency and patients are important virtues when implementing these techniques. Parents should expect behaviors to get worse following a "honeymoon" period when trying to change a child's behavior. With consistency, the misbehavior will eventually get better.
Behavioral techniques can also be used to develop skills that are often lacking in children with ADHD symptoms. Implementing these techniques also require patience because they often do not work immediately or as soon as medication does. The goal of these exercises are to change the structure of the brain so the child outgrows many of the ADHD symptoms. Other techniques that have this same purpose will be presented in the chapter on biofeedback.
Recommended Books for More Information
The ADHD Book and Video Toolkit by Gauchman R. Wong, A Shapiro, L.E. 1994 available through The Center for Applied Psychology, King of Prussia, Pennsylvania, Tel. 610-277-4020, ISBN: 1882732197.
Describes behavioral techniques for therapists and teachers working with elementary age children with ADHD sypmtoms. Also includes a video tape of sample procedures. Can be ordered through the Internet at www.childswork.com or at Amazon.com.
ADD/ADHD Behavior-Change Resource Kit: Ready-To-Use Strategies and Activities For Helping Children with Attention Deficit Disorder by Grad L. Flick, Ph.D., ISBN: 0876281447.
Written by a well known psychologist who offers practical strategies for individuals dealing with ADHD.
The ADD/ADHD Checklist: An Easy Reference for Parents and Teachers by Sandra Rief M.A., ISBN: 013762395X.
Provides quick information for teachers and parents. It is concise and easy to read focusing on proven strategies and techniques for helping children and adolescents with ADHD.
Healing ADD: The Breakthrough Program That Allows You to See and Heal the 6 Types of ADD by Daniel G. Amen, M.D., ISBN: 039914644X.
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