Behavioral interventions for ADHD

Dr. Lindsay Evans is a child and adolescent psychologist at the Austin Psychology & Assessment Center (ApaCenter). In her work with children and families, she is often asked about the best interventions for individuals with Attention-Deficit/Hyperactivity Disorder (ADHD) or similar concerns. In particular, many families want to know if there are any effective treatment options for managing ADHD without medication. We’re grateful to Dr. Evans for addressing these questions here as a guest contributor.

Many parents are surprised to hear that comprehensive ADHD treatment should always include a strong psychosocial (non-medication) component. Behavior therapy has been shown to be an effective behavioral treatment for child and adolescent ADHD. In fact, for preschool age children (under 5), the American Academy of Pediatrics recommends behavior therapy as the first line of treatment for children. For older children, research indicates that when medication is the only form of treatment, it generally does not lead to positive long-term outcomes. And, importantly, a substantial percentage of children and adolescents with ADHD may be able to avoid using medication if good behavioral treatments are employed. If behavioral interventions are not sufficient, the combination of medication and behavioral modifications strategies can be considered.

Behavior therapy involves using positive reinforcement and structure to help modify a child’s behavior and environment. The interventions can improve the parent-child relationship, and teach children concrete skills to help them function better at home and school. Because they work best when coordinated across settings (home, school, and community), behavior therapy typically involves three components:

  1. Parent training
  2. Teacher consultation/school interventions
  3. Child-focused treatment

Behavior therapy often helps to reset the “magic ratio,” or the frequency of positive to negative interactions and feedback that a child receives. A more in-depth description of behavior interventions for ADHD can be found at the Center for Children and Families

Parent Training

The first and most important aspect of behavior treatment for ADHD is parent training. As we often tell parents in our practice, although many parents know standard (good) parenting strategies, having a child with ADHD can require a “black belt in parenting,” which is where Behavior Parent Training comes in. Parent training programs (such as Parent Management Training/PMT and Parent-Child Interaction Training/PCIT) are typically provided in weekly individual or group sessions, lasting 12–18 weeks. Parents are taught specific strategies and are asked to practice those in the session with their child or to go home and practice for a week. At the next session, the family reviews their progress with the therapist, problem-solves, and learns new skills to assist their family. Here is a more detailed description of Behavior Parent Training and how to find a provider in your area.

Consultation/School Interventions

School interventions typically involve having a child’s teacher provide more structure and positive reinforcement (e.g., specific verbal praise and a sticker chart) in the classroom to help a child reach specific behavior goals. Teacher involvement is critical because behavior therapy is most effective when it is consistent across settings, times of day, and people. A “Daily Report Card” coordinated between teacher and parent can be a very effective method for helping a child reach specific goals at school (a parent guide for starting one can be found here: ADHD parent resources). Coordinating with teachers is an integral piece, and we have listed some tips about parent and teacher collaboration at our ApaCenter blog.

 Child-focused Treatment

The third part of behavioral treatment involves teaching children how to improve their interactions with other children. Social skills interventions are typically most effective when they are implemented in school or recreational settings, and the training typically needs to take place frequently for the child to learn the skills (e.g., such as through daily practice at school or in Saturday or summer therapeutic recreational programs). Besides social skills training, a new intervention called Organizational Skills Training has also been shown to improve organization, time management, and planning skills in elementary school children with ADHD.

Finally, it is important to note that individual or small group counseling sessions with children in a therapist's office (such as “Play Therapy”) are not effective for treating child ADHD because they do not help a child practice new skills in other settings. Behavior therapy is effective because it teaches concrete skills to parents, teachers, and the children themselves.

And, a quick note: When I am providing guidance to families about how to help their child, I rely on recommendations that are backed by scientific evidence. Some great websites for finding unbiased information about interventions for children are and Treatment guidelines for ADHD in children can be found at the Center for Disease Control website (believe it or not, a great resource for parents!). Importantly, ADHD is a chronic condition and children with unmanaged ADHD are at risk for poor academic performance, greater problems (such as substance use) in adulthood, and difficulties in their relationships.

Some parents at this point may be thinking, “Gosh, that seems like a ton of work!” And they’re right that behavior therapy does require time and commitment from parents on the front end. But, once learned, the skills quickly become a more natural part of a family’s routine, and they set up a child for more success both in academics in their relationships. The extra effort on the front end can help a child overcome challenges in daily life functioning, which can be valuable in managing ADHD throughout a lifetime.

Dr. Lindsay Evans

Is it ADHD or a kinesthetic learning style?

Continuing our summer mini-series on learning styles, I’m pleased to share this guest post and video from Madison McWilliams, who runs The Joule School. This unique program is now enrolling for Fall 2014.

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At The Joule School, we serve students who are considered bodily-kinesthetic learners. These are children who learn best when they are allowed to engage their hands and feet as well as their minds. To some, there may appear to be an overlap between these children and those who have been diagnosed with ADHD, a neurological condition characterized in part by hyperactivity (the need to move often and difficulty in sitting still).  

Introductory material on learning styles is available here, here, and here. In short, a learning style is the method by which a student takes new information and converts it into knowledge. Learning styles influence the entire educational process, including which strategies children use when studying for tests and the types of subjects that they prefer. Many education experts recognize three primary learning styles: auditory, visual, and kinesthetic.

A kinesthetic learning style is characterized by an ability to retain (memorize) information best when it is related to movement.  When presented with new material at school, kinesthetic learners zero in on action that can be performed with the human body. They have an innate ability to copy movement and tend to excel in gross and fine motor activities such as dance, sports, art, or playing instruments. While telling a story, they will likely act out the scene or role-play while they speak.  Kinesthetic learners function best in a classroom where they can role-play, build, measure, jump, sing, and experiment because all of these actions help them process information into long-term memory.  

Kinesthetic kids have a long history of being unsuccessful and/or unhappy in traditional schools because their natural tendency toward movement is at odds with desk-and-lecture classroom structure. These children

  • tend to “zone out” when listening to a teacher for a long period of time and may daydream or doodle;
  • have difficulty concentrating on paper-and-pencil assignments;
  • get “the wiggles,” which may lead some students to fidget, kick, or get out of their seats;
  • may interrupt a student or teacher (likely with requests to show or demonstrate something);
  • may drop things on purpose, in order to have an excuse to get out of the seat to pick it up; and
  • walk to the pencil sharpener or bathroom an unnecessary number of times.

Misinformation has led many adults to automatically assume that behaviors like these (especially from boys) are the result of ADHD. Teachers of these students may respond with discipline or by contacting parents with a referral for ADHD testing. In fact, while the rate of ADHD in youth is approximately 8 percent of the total population, one recent study noted that when given a diagnostic checklist, schoolteachers rated 20–23 percent of the entire male population at their schools as having ADHD.*  This is not surprising, as the symptoms of ADHD in the classroom are almost identical to those of a kinesthetic learning style.  ADHD students often

  • blurt out answers to questions;
  • fidget in their seats, kicking the seat in front;
  • daydream;
  • have difficulty listening to a teacher for long periods of time;
  • may get out of their desks and wander around the classroom at an inappropriate time; and
  • interrupt the teacher or classmates.

Since the manifestations of ADHD and a kinesthetic learning style are so similar, it is prudent to address an ADHD referral by first screening a child for a kinesthetic learning style. This helps ensure that the child's behaviors are not simply evidence of a mismatch between his or her needs as a student and the learning environment. Two simple questions can help establish whether or not the student is challenged by ADHD or is simply a bodily-kinesthetic learner:

1. When provided with a bodily-kinesthetic lesson, do the “ADHD symptoms” disappear or appear to be dramatically reduced?

True kinesthetic learners will be able to stay engaged in a lesson that allows them to use their bodies. For example, a kinesthetic learner who is offered the opportunity to classify roots by movement and touch will probably be quite successful during the lesson and subsequent evaluation, because such an activity stimulates his or her mind. Students with ADHD, which is characterized by impulse control issues, may still find themselves distracted, fight the urge to disrupt or abandon the lesson, or have difficulty explaining what they are doing when prompted by a teacher to describe their learning.  

If a child is suspected of having ADHD because he or she struggles to sit still in class, stakeholders should try a kinesthetic lesson in a subject that the student ordinarily does not enjoy. (This is recommended because we all tend to concentrate better if we like the subject being taught.) If the student can remain focused during the lesson and retain the material taught, then it is likely that he or she simply has a mobile learning style. If the child completes the hands-on activities but shows little or no retention of the concepts covered, or seems far too stimulated by the hands-on environment to focus on the lesson, then an appropriate expert in ADHD should be consulted.

 2. Do appropriate ADHD accommodations help the child focus or achieve in school?

ADHD accomodations are designed for visual and auditory learners who need additional help to overcome their struggles with distractibility and hyperactivity. These children often retain material best if it is taught in a traditional format with traditional assignments, but they simply cannot focus on the lesson long enough for the material to sink in. There are dozens of research-based accommodations for these children. For visual learners, an appropriate ADHD accommodation might be a written checklist of tasks to help them organize and complete an assignment, which they can cross off as they progress through each task. Using audiobooks as a supplement to text-based materials can help hold the attention of an auditory student with ADHD. If appropriate accommodations are implemented and they facilitate gains in student learning, then the child may be a visual or auditory learner who simply needs assistance in focusing, and a specialist in ADHD can make recommendations for that student.

A Sample Lesson for Kinesthetic Learners

I will leave you with a brief video I made to demonstrate one example of a simple and effective math lesson geared to kinesthetic learners. Please feel free to leave questions or comments below; I’d love to continue the discussion.

Madison McWilliams

* Nolan et al. (2001), Teacher reports of DSM-IV ADHD, ODD, and CD symptoms in schoolchildren, Journal of the Academy of Child and Adolescent Psychiatry 40, 241—249.