Behaviour strategies for ADHD
Management of ADHD may involve medication, non-medical treatment or a combination of both. Medications used in ADHD are in Explanation 5 – this Explanation (Explanation 4) only deals with non-medical treatment.
Behaviour strategies for ADHD usually focus on the areas of functioning where the child is having the most problems. This may involve additional learning support or other assistance related to the executive functioning deficits (less efficient thought processes), such as help with organisation. However, the main emphasis is usually on behaviour management strategies. The conventional behavioural strategies are not specific for children with ADHD but can be thought of as more and better good parenting and more and better good classroom management. This means that the same strategies may be useful for the whole family or even the whole class or school. Some of the strategies can also be helpful for interactions between adults or couples. At an individual level, emotional self-regulation may be valuable as a means of promoting and maintaining a positive mood and co-operative outlook. It may also involve managing anger and frustration.
Helping a child to achieve despite inefficient mental processes
Additional learning support
A child with ADHD is likely to have more difficulty concentrating in class than other children. A child whose brain ‘switches off’ at intervals, or who only attends to the first part of the lesson, is likely to be missing out. The effort required for concentrating may be greater, making schoolwork more laborious so that the child is inclined to give up (see Explanation 1).
Reading is one of the most important skills that a child has to learn at primary school. Reading is a complex activity which and involves several different components. The child first has to recognise the letters and relate them to their sounds. The letter sounds are then blended together to make the words. Although the words are read individually, their meaning depends on the other words in the sentence. The sentences have to be understood and their meaning remembered long enough to make sense of the passage. The main reward of the task is in the interest from the information contained in the passage. The early stages of learning to read can be slow and laborious and the reward from the information may be lost unless the sentences are very simple. With practice the child starts to recognise common words without having to sound out each one individually and reading becomes easier and more fluent. This allows more attention to be focussed on the meaning. The information is received at a faster rate and the balance of effort to reward improves. As reading becomes more rewarding, the child may start to read books for pleasure and thereby further practice and develop their skills.
Children vary in their strengths and weaknesses. Some children pick up their reading skills easily. Others find reading more difficult. ADHD tends to cause more problems for a child in learning skills that he or she finds more difficult. A child who naturally finds reading difficult will have to concentrate longer and harder than other children in order to make progress. Therefore minor degrees of ADHD become more significant in children with learning difficulties or intellectual disability.
When reading, a child with ADHD may have difficulty attending to the meaning of a sentence while concentrating on deciphering the individual words. This is likely to reduce the level interest for the child. At this stage, additional one to one teaching may help the child develop fluency for reading. As reading is a necessary part of almost every area of schooling, good skills that enable a child to read without putting all their attention and effort into sounding out the words will be highly beneficial.
Modifying the tasks and expectations
A child with ADHD is likely to need a higher level of parent or teacher attention. The tasks may also need to be modified to make them achievable for a child with a limited attention span. This may include keeping tasks short and varied and moving on to a new topic before the child gets bored. Instructions need to be easily understood and repeated if necessary, perhaps with a written task list. A child with ADHD may need to be reminded to remain on task. Breaks may be factored in, such as sending the child out on an errand.
Teaching organisational strategies
Organisational skills can also be taught. These can include strategies to keep track of homework, including structuring the tasks, using checklists and long-term planning of tasks with their completion dates.
Increasing motivation by making tasks more rewarding
Behaviour management strategies are designed to make positive behaviour more rewarding and negative behaviour less rewarding for the child. These strategies usually involve a combination of rewards for good behaviour and negative consequences for behaviour that is being discouraged. For such strategies to be effective the child has to be able to consider the consequences of their behaviour when making a decision. The behaviour strategies have to be carefully thought out according to the points listed below, with achievable goals and meaningful rewards and consequences.
1. The child must be capable of carrying out the required behaviour.
The chosen goals should be realistic. Targeting small, manageable tasks is often the more effective approach because if the goals are too difficult the child is likely to give up. In children with a lot of problem behaviour, the goals should be prioritised. For example, if a child regularly refuses to do any homework, rewarding the child for concentrating for 5 minutes and writing a single sentence and gradually working up to completing their entire half hour of homework may be more successful than choosing homework completion as the initial goal.
2. The child must understand the rewards and consequences and be able to relate these to their behaviour.
The child needs to understand that there will be consequences for their behaviour and to make an emotional connection with the consequences. Children with ADHD often appear to live for the present and not care about the future. The child might be well aware of the rules but at the moment of making a decision, the punishment may appear to have no meaning for the child. Afterwards the child may show no interest in the reason for their punishment, experiencing it only as a frustration. This tendency to care only about the present can make behaviour management difficult in ADHD.
3. The rewards and consequences need to be meaningful and appropriate.
Rewards and consequences should be chosen carefully. A child might be rewarded with time to play on a computer; a meaningful punishment might be taking away the child’s favourite toy or game. Rewards and punishments that are small and repeatable are often more effective than larger ones. For example if a parent is very angry with a child, there may be a temptation to extend the duration of the punishment, perhaps taking away the favourite toy or game for a week. Returning the item may be made dependent on unrealistically good behaviour for the week. To a child with ADHD a week may be such a long time that they consider the item lost forever. Furthermore, if the child misbehaves again during that week, the parent has already used their most valuable option for punishment. A better alternative may be to make the punishment milder. For example, if the child can earn the game back by being good for only five or ten minutes, the same punishment can be repeated again as often as necessary.
4. The strategies should be applied consistently.
Effective behaviour management requires consistent effort from the parent or teacher. If there is any leeway a child may become skilful in picking the time when they can get away with breaking a rule.
5. The child must choose to co-operate.
Co-operation is likely to depend on the child’s own assessment of the balance of effort to reward (see ADHD Explanation 2). If the child’s ADHD means that the task requires a super-human level of effort, the child may try to insist on a reward that appears similarly outrageously high. Behaviour management strategies often involve consistent, small rewards, such as adding a sticker to a chart for every task completed. Such strategies often work better for children who do not have ADHD. A child with ADHD may discover within the first few days that the stickers are not worth the effort. At that stage, in order for the behaviour management to continue to be effective, a higher reward may be negotiated. This cycle may continue until the child will not even consider doing any homework unless rewarded with a very substantial sum of money. Alternatively the child may perceive that he or she will experience greater satisfaction through non-co-operation. Figure 1 of Explanation 3 categorises bullying – behaviour designed to upset of hurt another person – as being one of the more highly rewarding activities for people with oppositional tendencies. If the child perceives that the parent or teacher is emotionally committed and genuinely wants to see the child carry out the task, this may provide an opportunity for bullying. This might take the form of deliberate and blatant non-co-operation. For example a child may deliberately destroy their work, perhaps by scribbling on the page. Observing the resultant surprise, anger or frustration may be immensely satisfying for the child.
Another very common strategy for non-co-operation is arguing. This may be a delaying tactic and a parent may be baffled that their child may spend twenty minutes and considerable effort arguing over ten minutes of homework, which ultimately still has to be done. To the child arguing may serve several purposes. Firstly, time spent arguing may be considered time well-spent because the homework is not actually being done. Secondly the child may be negotiating a better deal, such as a higher reward or a reward for the task. Winning such a concession would also be rewarding in itself. Thirdly the child may be bullying the parent, enjoying the effect of the argument on their parent’s emotions, for example observing an increasing level of frustration or anger.
It is important for adults to understand the value that a child may place on observing an emotional response. Withdrawing attention from a child who has misbehaved is often effective, but is even more important if the parent is becoming upset or angry. Being separated from the child in a different room gives the parent an opportunity to calm down while out of sight.
Emotional self-regulation for improving the mood
Conventional behaviour management has the drawbacks that because the rewards and consequences are external and often tied to particular tasks and situations, they may not carry over to other tasks and settings. Conventional behavioural strategies often use emotional rewards, with the parent or teacher praising the child and showing delight if the child has achieved or put considerable effort into the task. The child may respond by trying harder in order to gain the satisfaction of making another person happy. Therefore a child will work better for a teacher who cares and may work less well following a change of teacher. However, the long-term aim of behaviour management is that the favourable behaviour becomes increasingly established as the child matures, so that the rewards may be provided internally by the sense of satisfaction generated.
People with ADHD may have their baseline mood set at a lower level than normal, making them feel somewhat irritable for much of the time (see Explanation 2: Mental Effort-Reward Imbalances Model (MERIM)). Therefore it would make sense to develop strategies for improving the mood. This means that strategies would not simply focus on task completion, but would also aim for satisfaction. Therefore, for example, if a child completes homework with the sole aim of gaining a reward or bribe, this might be considered an acceptable outcome as the work is done. However, if the attitude towards the work is poor, it is likely that the child will complete it to the lowest acceptable standard. Therefore an important additional aim would be to teach the child to value their work and gain the internal reward of the satisfaction of a job done well. In other words, the positive aspects of the task would be emphasised. If an achievement is valued and leads to a feeling of satisfaction, this will help to promote a happier mood and a readiness to take on the next challenge to achieve.
Unlike conventional behaviour management which relies on external rewards, emotional self-regulation aiming to promote positive emotions has a theoretical advantage that its techniques may directly address the underlying reward deficit. Furthermore it can be applied to all aspects of daily life. Once taught and adopted, individuals can evaluate and provide their own reinforcement for their positive behaviour, leading to a better mood and self-esteem.
Positive rumination
Rumination involves repetitive thoughts that can influence an individual’s emotional state. Rumination is conventionally considered to be negative as the repetitive thoughts are distressing and can lead to a range of mental health problems mental including depression and anxiety. However, positive rumination involving spending time reflecting on a positive achievement could increase the level of enjoyment or satisfaction obtained. Positive rumination is a strategy that may help happy people to sustain their positive mood and amicable outlook. However, as it is a cognitive process that would involve some mental effort, it may come less easily to individuals with ADHD. For positive rumination to be practiced effectively, a person needs to be able to recognise their emotions. This may also be a problem in ADHD. Therefore positive rumination may need to be specifically taught and practised in order for a person with ADHD to be able to use it effectively and understand and recognise its value.
An example of positive rumination would be for a person to spend a bit of time admiring the good points about a piece of work that they have done and then reflecting on the sense of satisfaction that this generates. Initially the positive attributes may be pointed out by the parent or teacher but ultimately the individual would be encouraged to identify for themselves the value in their work. Times of positive reflection may also be built into the daily routine, for example at bedtime thinking of the positive and enjoyable experiences and achievements of the day. These might include being helpful, playing, learning or doing sport or exercise. In positive rumination the individual needs to pause and reflect and have awareness of their mood, together with mood changes following on from their positive reflection.
Positive re-appraisal
Positive re-appraisal involves redefining an adverse event in terms of any possible positive aspects. For example, when a child is in trouble, if his or her mood and self-esteem can be preserved, the child may be less tempted to resort to bullying in order to feel better. This might be by the teacher expressing confidence in the child being able to do better in future. Initially the parent or teacher would need to assist the child, perhaps with a response such as: ‘Although you lost your temper, you only hit him once, you calmed down quickly and you’ve learned that you should avoid him in future’. With time the child may learn to practise positive reappraisal by actively looking to benefit from experience.
Anger management
Anger is often a significant problem for people with ADHD and ODD (see ADHD Explanation 2). Anger may consist of a low or irritable baseline mood, or it may involve acute episodes of rage. Anger makes it far more difficult for a person to behave rationally. It is as if the anger takes over the decision-making process so that the brain cannot function properly.
During a rage attack a person may lose all control, perhaps afterwards having cause to deeply regret their actions, particularly if they have injured someone. If this loss of control is to be avoided, the person needs to recognise that they are getting angry so that they can move away to a safe place to calm down. Being aware of feeling hot and having a pounding heart may help with anger recognition. Calming strategies may include concentrating on controlled breathing, taking deep breaths with self-instructions such as ‘calm down’ or ‘relax’ while breathing out. Imagining reducing the body temperature and heartbeat may also help. Sometimes releasing the energy in a harmless way may help, such as going for a run or screaming and hitting a punching bag.
Some people with ODD may have a low baseline mood and may easily be triggered to anger. If this is associated with impulsiveness, the potential for conflict may be substantial. Such a person may misinterpret other people’s actions as hostile and therefore easily become angry if another person’s motive is unclear. An example might be impulsively retaliating with violence to an accidental push or shove. If questioned afterwards he or she may try to justify the aggression by blaming the other person. As people mature they often realise that they make better choices if they delay making any impulsive response while they are feeling angry. Therapy may emphasise thinking of non-personal reasons to explain another’s behaviour instead of taking offense (for example: ‘she must have been having a bad day’).
Emotional self-regulation with the dual aims of promoting a good mood and also recognising the signs of anger so that loss of control can be prevented, appears logical and sensible. If strategies can be used effectively by people with ADHD, they could lead to improvements in mood, functioning and self-esteem which would not be linked to specific tasks and situations.
