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LISA CLARK: All children know that good behavior will earn them a gold star or an A in school. But how do parents and educators help children with behavioral problems caused by Attention Deficit Hyperactivity Disorder? With an estimated 3-5% of school age kids suffering from ADHD, it's a real concern.
Today we'll take a look at some behavioral techniques that can help make a real difference in your child's life. And joining our discussion are two experts in the ADHD field. Dr. Patricia Quinn; she is a Developmental Pediatrician in private practice in Washington, D.C. And Dr. Peter Jensen, a Professor of Child Psychiatry at Columbia University in New York.
One thing we should mention is that medication is probably the first line of treatment that a doctor will suggest with ADHD. But what other components increase the effectiveness of the medication, Dr. Jensen?
DR. PETER JENSEN: Well we know that when you add behavior therapy to medication, we often get a little more bang for the buck. Parents really like it; teachers like it. And it often helps some other areas of the child's functioning, like self-esteem and social skills. It's basically a little reward system. And like you said, it's a little star—it's a gold star. It might literally be gold stars, but it might be also other rewards or consequences the child might actually have a role in selecting that he or she would want to actually work for and earn.
LISA CLARK: Dr. Quinn, in your practice you've talked about patients who come in and they say that they just feel like they're bad all the time. How do you help them get past those feelings of negativity with behavioral therapy?
DR. PATRICIA QUINN: Well Lisa, nothing succeeds like success. So what we try to do with these kids is, first of all, explain what the disorder is about. But then work with their parents on teaching them skills, on teaching them new behaviors in place of the old ones. For example, medication will help a child pay attention, but it doesn't teach them a new skill. He may bite other children. On medication, he's not impulsive and no longer bites other kids, but he doesn't know what to do instead in order to join in. So what we try to do then is work on various skills. And we can do that by working with the parents on helping them with a behavior management program.
LISA CLARK: I've heard that the Three C's are what's important in any behavioral program. Clarity of expectations, Consistency of the direction and follow through, and Calmness. Dr. Jensen, talk about how a parent or a teacher might implement these Three C's for a child
DR. PETER JENSEN: Sure. Well very frequently one of the things we do when we work with a teacher in a classroom is get them actually to develop some classroom rules that they, with great clarity, will write up on the blackboard. And so these might be the classroom rules, that might say, like, “No touching. No interrupting.” But very simple rules that become well understood.
But if the teacher doesn't follow through in a very consistent manner, and ignores when a child violates one of those rules, and doesn't have a set of consequences or fallback positions, then children basically learn that the rules, while they're up there on the board, really don't apply. At least some children will learn that. Some children will still probably follow them. But some of the children with ADHD, if they don't have a little behavioral program in place that's consistently implemented, then often they won't follow those rules. They need the consistency.
LISA CLARK: And calmness, which is not something that's easily maintained under those circumstances, but is vital to helping the ADHD child.
DR. PETER JENSEN: Absolutely. You know, these children, they're especially sensitive to when the parent or the teacher loses their temper. These children seem to just wilt frequently, or basically it gets their spine up. And they don't mind too terribly cutting their nose off to spite their face. And so a very calm approach is often one that the child can work with and respond to, and doesn't over-stimulate or provoke the child in a negative way. You really need all three of those pieces together.
DR. PATRICIA QUINN: A lot of times I find that with parents, you know, this is a genetic disorder, and sometimes the parents have ADHD as well. And they may also have difficulty remaining calm. And I find if the parent can't remain calm, it tends to escalate the situation. So a lot of times parents need to take time out from the situation before they can deal with their child's behavior. And I think that's a real important point.
DR. PETER JENSEN: I've had children say to their parents, “You need a time out.”
LISA CLARK: I guess we're all guilty of that occasionally. Let's talk about targeted behavior modification and how that works. Giving a child, say, one particular task in a time segment. Say, you have to finish your homework by such and such a time. Does that work well?
DR. PETER JENSEN: It can work well. Different children respond to different kinds of behavioral programs. When we talk about behavioral therapy, there's five or six actually different techniques that we can use. And certainly setting a goal, with a time limit and a certain amount of a task that's fairly short to be accomplished, with a consequence or reward, is one good way that some children can actually work. And other children might work under more global kind of a reward system where they are able to kind of earn a point or reward for each time they do a behavior.
Other times, you may want to extinguish a behavior. I've had situations where I was working with a child to try to get them not to swear. And they were swearing like 20 times an hour. And so where did we go? Well the first goal we set was to get them to swear only 15 times an hour. And we were rewarding them for swearing only 15 times an hour. The parents thought, this is bizarre. But in actual fact, we got that child so he was able to totally curb his tongue in terms of swearing. But you had to kind of shape them into that new behavior onestep at a time.
LISA CLARK: How effective are these kind of treatments for ADHD children if they're able to be implemented well?
DR. PATRICIA QUINN: They can be very effective to learn new skills and to learn new behaviors. I'm always concerned, though, if we try a behavior program in an unmedicated child who is still very impulsive and can't control himself, you're just setting up another area for failure in his life. So you need to be very careful because some of these children, no matter how hard they want to, no matter how hard they try--they really want to be good; they want to be able to complete this; they want your approval—and yet if you set up a program and haven't given them the means to control themselves, you may be just opening them up to another area of failure. And it's very important to make sure you're not doing that with a behavioral program.
LISA CLARK: That's a very good point. And you also said something about not confusing rewards with bribery.
DR. PATRICIA QUINN: Absolutely. I always say bribery is being paid to do something illegal. What we're trying to do is just reward these children for behaviors that are very difficult for them to achieve or accomplish.
LISA CLARK: What are good rewards for parents to set up for their kids?
DR. PETER JENSEN: Well frequently, a parent has to think probably about short-term rewards and longer-term rewards. So on a daily basis, for example, maybe the child might get to choose a dessert or a little extra snack. Or 15 minutes of extra TV time or staying up late. Frequently rewards that don't cost a lot, that are easily implement, that fit within the family's values. And when you earn those rewards, they might also mount up for points. And so these points might be a special fishing trip with Dad, or the family goes out to MacDonald's on the weekend or something. And so you want to encourage both short-term daily behavior, as well as maintenance of the behavior over longer term periods, which is the purpose of the longer term rewards.
LISA CLARK: Where can parents go to find somebody to help them set up a behavioral therapy program at home?
DR. PATRICIA QUINN: Well certainly referrals from their pediatrician to other mental health professionals. But one place is, if we're going to use a behavior program, we want the same behavior program in school and at home. So frequently I ask the parents to talk with the school psychologist or someone in the school setting, so you can set up a program that will carry over in both places. Or other mental health professionals in the community. But you need to make sure, again, that it's consistent—for example, if the child is living in two homes in a divorced family, that it's the same program in both places. Or if the child's visiting the grandmother, it's the same program there. But also that it's the same program at school as well.
LISA CLARK: A team approach.
DR. PATRICIA QUINN: A team approach.
LISA CLARK: Thank you both for joining us for this discussion.
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