Other ADHD Treatment Options - Environmental Approaches
As previously mentioned, the largest study to date of ADHD treatment found that combining medication and psychosocial interventions is the best strategy for helping individuals deal with their symptoms. An individualized combination of medication and various psychosocial treatment options is more effective than either one by itself. Parents should be prepared for the reality that treatment response will vary and that as such, the most effective treatment will be tailored to the unique needs of their specific child and family. Psychosocial interventions include environmental behavior modification, peer interaction interventions, educational intervention, parent and child education, individual therapy, and family therapy, to name a few.
Environmental Behavior Modification techniques involve changing the environment to reinforce (increase) desirable behaviors while punishing (diminishing) undesirable behaviors. These techniques can be used at home or in school settings. Reinforcements or rewards must be considered positive by the child (not the just the adult!) in order to be effective. Token reward systems, a behavioral system that provides tokens as a reinforcer for desirable behavior that can be exchanged for desired goods, can be an effective technique with children and teens. In contrast, timeouts (i.e., removing the child from a social environment in order to sit quietly alone and consider their behavior) can be used as a punishing consequence for undesirable behaviors, so long as the child experiences the timeout as unpleasant or undesirable.
Children with ADHD require clear structure and incentives in order to focus on behavioral change. This type of plan should be presented as a loving, positive, and focused approach rather than a way to continually "catch" the child misbehaving. General behavioral modification principles that have proven effective with ADHD include:
- Establish clear rules and behavioral expectations
- Write contracts for specific behavioral change
- Establish routines
- Allow natural consequences to occur; provide opportunities for redemption
- Reinforce desired behaviors or the attainment of behavioral expectations
- Do not reinforce (e.g., give lots of attention to) inappropriate behavior
- Gradually increase expectations for self-regulation
- Set up the environment to support the child's efforts (e.g., minimize distractions during homework)
- Use shaping to teach desired behavior. Initially reward the child for getting close to the desired behaviors. Across time, increase expectations for behaviors to gradually move closer to the goal before they are rewarded.
This type of behavioral system is a lot of work to set up. However, once the rules are established, the system can begin to run itself. Some other pointers:
- Set up a predictable routine. Since organization is a challenge for those with ADHD, having set times for different tasks (e.g., homework comes right after dinner) can be both helpful and soothing to a child. However, the ability to be flexible when the situation warrants it is also important. A calm rhythm to the routine should be the norm, not rigid insistence.
- Provide directions and corrections in a loving but firm manner. Make sure the child understands the task being requested, as well as your expectations. Have the child repeat the directions.
- Teach organizational skills. Assist children in organizing their study material and toys. Consider using a color coding system (different colored folders) for different school subjects and developing a chore chart (reward adherence with stars or other colorful stickers).
- Help divide larger tasks into smaller, easily accomplished pieces. This skill can be used across the child's life in high school, college or at work.
- Research has shown that children with ADHD do not tend to benefit from punishment in the same manner as other children. Therefore, an effort should be made to utilize a system based on rewards for positive behavior. Rewards should be based on behavior, not given without objective cause, and occur immediately, or as soon as possible, following the desired behavior.