Psychosocial treatment refers to a variety of non-medication based approaches that are typically administered by mental health professionals, such as psychologists, psychiatrists, and social workers. Treatments may be provided on a one-to-one basis (individual therapy) or in a group format depending on the nature of the child's difficulties. Treatment with children with ADHD is typically administered either directly to the parent or to the parent and child together. Treatment for ADHD is rarely administered to the child alone, unless there is a co-occurring condition (i.e., depression, anxiety, divorce, abuse, etc.) that requires additional intervention. Typically, treatment for ADHD utilizes behavior management treatment, social skills training, collaborative problem solving, or a combination of these strategies depending on the child's and family's needs.
Behavior Management Treatment
Behavior therapy consists of several different interventions that are all intended to change behavior through the modification of social and physical environment. Behavior management training is the most thoroughly researched and commonly used form of psychosocial treatment used with children with ADHD. Behavior management involves training parents and children to change behavior using a structured system of rewards and consequences at home and school. During treatment, strategies are taught taught to parents and teachers, and then implemented at home and school. Strategies include:
Teaching parents how to give clear and effective instructions to children
Teaching parents and children how to set up structured routines and distraction-free environments for tasks such as homework and chores
Training parents and children how to use rewards and consequences to modify and improve the child's behavior
Improving the parent-child relationship by increasing praise and positive attention.
Teaching a child how to monitor his or her own behavior.
Research has indicated that behavior management treatment is particularly helpful for children with ADHD and co-occurring behavior, anxiety, or mood/frustration difficulties. Additionally, the MTA study indicated that children with ADHD and anxiety had better outcomes from combined medication and behavior management treatment than from medication alone. Therefore, it is important to ensure your child is receiving comprehensive care from both their pediatrician or psychiatrist and therapists.
Rewards and Consequences
When behavior management plans are implemented, a system of rewards and consequences are often at the heart of that system. Children with ADHD often need more explicitly stated goals and rules than children without ADHD, making it important that these
Positive reinforcement/praise for positive behavior
Positive reinforcement occurs when an a child is given something following a positive behavior. This does not have be a physical, monetary reward after every instance of good behavior. Often times, it may be very specific and intentional praise, or the use of a token as described in the token economy below. Positive reinforcement should be provided immediately following the positive behavior you are rewarding.
For example, positive reinforcement is being used if a child completes chores and is allowed to watch an extra half hour of television
Time-out for negative behavior
Time out is a consequence for negative behavior that research has shown is effective for reducing targeted behaviors. Time-out occurs when children must be removed from the situation and sit in one location for a short period of time. It is important that this location is not somewhere fun or exciting, like a bedroom. Being send to the bedroom may seem like a great option, however this location may be very reinforcing for a child and therefore not reduce the negative behavior in the future. Instead, optimal locations for time out include sitting at the kitchen table or a dedicated " time out" chair in a corner. This also allows you to supervise the child, so that they do not get up and you know that they have calmed down. While many programs suggest putting children in time out for one minute per age, this may not be the best system. It may be overly punitive on older children, while not strict enough for younger children. Instead, we suggest sending children to time-out for 3-5 minutes. If they get up from their chair, argue, or are otherwise non-compliant then the time is re-started until they are calm. One example
For example, time-out is being used if child hits a sibling and must spend 5 minutes sitting in a corner
Response cost for negative behavior
Response cost can also be called removal of privileges or removal of reinforcement. During a response cost procedure, the child loses or is "fined" something that is reinforcing for negative behavior. This can include removal of points or tokens in the token economy described below, as well as actual items or activities. What the response cost is should be determined ahead of time so that the rules and consequences are clearly understood by the child, as well as by the parents. This also prevents overly-punitive or unrealistic punishments, such as months of grounding or weeks without television. Instead, the consequence should be short - somewhere between a few hours and a day. Like with reinforcement, the response cost should occur immediately following the misbehavior.
For example, response cost is being used when a child does not complete homework and loses television privileges
Behavior management training often involves developing a "token economy" or "point system," whereby a child earns points/tokens for specific positive behaviors and loses points/tokens for specific negative behaviors. Points/tokens are then "cashed in" at the end of the day or week for rewards, such as special privileges or positive one-on-one time with a parent. Parents often find this system easier and more manageable than using only physical rewards and attention, which can be overwhelming and easily forgotten. It is often suggested that parents focus only on 3-5 daily behaviors in the reward system at once so that children can focus and not become overwhelmed at the expectations.
Collaborative Problem Solving
Collaborative Problem Solving is a treatment method developed by Ross Greene, Ph.D. It focuses on reducing parent-child conflict and emotional distress in children by training parents and children in effective problem solving techniques. Collaborative Problem Solving was designed specifically for children who experience outbursts of emotional and behavioral distress (i.e., "meltdowns") in addition to noncompliance or defiance. As explained by Dr. Ross Greene, many times noncompliance is related to skill - or not being able to complete the task competently, rather than will - or deciding they do not want to do something. Initial research suggests that Collaborative Problem Solving is effective at reducing parent-child conflict in children with high levels of irritability and/or emotional distress This system helps improve behavior, problem solving and emotion regulation skills The Collaborative Problem Solving system relies on two primary techniques:
A "pick your battles approach," whereby the parent assigns common areas of conflict to 1 of 3 "baskets."
"Basket A" is where the parent is willing to endure misbehavior and emotional distress to enforce compliance. Only a few items should be placed into this area, such as problems with safety and wellness
"Basket B" is where the parent is willing to collaborate with the child to find an acceptable compromise. The goal is to put as many behaviors into "Basket B" as possible once the parents and children have developed adequate skills.
"Basket C" is where the parent is willing to allow the child to select their desired outcome. At the outset of treatment, parents often put behaviors into "Basket C" and will focus on them when their skills become stronger. This allows for a reduction of conflict while skills can be developed.
A 3 step problem solving technique, where the parent empathizes with the child's distress, clearly articulates their concerns, and then collaborates with the child to develop a solution that is acceptable to parent and child. This three-step process is used for behaviors that have been placed into "Basket B." It's important to note that this is not "giving in" to your child, but rather finding the middle ground that works for both you and your child. This process is also the time you are working with your child to develop important skills that can be used in everyday life.
Social Skills Training
Many children with ADHD also experience frequent problems interacting with peers. Social skills training focuses on the social deficits demonstrated by children with ADHD and other social difficulties. Training helps children with ADHD improve their ability to relate appropriately to peers and monitor their own behavior around peers. Social skills treatments are typically administered in groups of children to allow for the opportunity to practice skills in a safe and supportive environment. Examples of skills commonly taught in social skills groups include initiating social interactions, socializing in groups, taking turns, sharing with others, and responding to teasing.