Eight Principles to Manage ADHD Children

Here are some behavior management tools to help children with ADHD manage their behavior both at home and in school.

Over my 17 years of clinical experience, I have found it very useful to distill eight general principles that serve as touchstones in the daily behavior management of ADHD children. From these, parents and teachers have deduced what particular methods might work for their ADHD children, often proving to be quite inventive in the procedures they create. These general principles stem from the recent conceptualization of ADHD as a biological deficit in persistence of effort, inhibition, and motivation.

If ADHD involves a reduced sensitivity to behavioral consequences, such as rewards and punishments, as current theorists believe, then certain rules of managing behavior would be predictable from these theories. To date, such principles have proven very useful in designing both home and classroom management programs for ADHD children. Practitioners and educators should always bear these in mind as they advise parents in the management of ADHD children or engage such direct management themselves. Follow these eight principles and it will be hard to go wrong in designing management programs:

1. Use More Immediate Consequences

ADHD children require more immediate feedback or consequences for their behavior and activities than do normal children. Where it may seem acceptable to occasionally praise normal children but a few times a day for particularly positive behaviors they perform, ADHD children require much more frequent feedback about their prosocial or acceptable behavior than this. As Virginia Douglas and others noted long ago, ADHD children seem much more governed by immediate consequences, or moment-to-moment changes in contingencies. I have also noted elsewhere that ADHD children seem less rule-governed in daily situations and more contingency shaped (controlled by the momentary consequences) than their normal peers. This is particularly so where parents are attempting to systematically change the negative behaviors of ADHD children to more positive or productive ones. This feedback must be clear, specific, and occur as close in time after the behavior that is the target of change as circumstances permit, if it is to be maximally effective in developing and maintaining positive behaviors in ADHD children.

The feedback can be in the form of praise or compliments, but if so, should state expressly what the child did that is viewed as positive. It can also be in the form of physical affection or even rewards, such as extra privileges or occasionally a food treat. More often, when the ADHD child's behavior must be altered more quickly, artificial reward programs like token, point, or chip systems may need to be systematically introduced and maintained for several months. Regardless of the nature of the feedback, the more immediately it can be provided, the more effective it will be for ADHD children.

2. Use a Greater Frequency of Consequences

ADHD children will require these behavioral consequences more frequently than do normal children. Thus, although responding immediately is important, caregivers of ADHD children must also respond more often than do those of normal children in letting ADHD children know how they are doing. Admittedly, if this is done too often, it can get irritating and intrusive in ADHD children's daily activities. Although this can also become tiring for caregivers as well, they should be counseled to try to increase their frequency of feedback and consequences to their ADHD children.

One means of doing this is to have the parent or teacher place small stickers with smiley faces on them around the house in locations where the children frequently look each day. Some examples might be in the corner of bathroom mirrors, on the edge of the face of a kitchen clock, on the inside of a refrigerator, on a bread box, and on the back and front doors. Whenever caregivers sight a sticker, they are to comment at that very moment on what they like that their ADHD child is doing. Another way for parents or teachers to achieve this goal might involve simply setting a cooking timer for brief and varied intervals throughout the day. When it rings, this is a reminder to the parents to find ADHD children and let them know how they are doing. If behaving well, then the children should be praised and even rewarded. If violating rules, then a reprimand or mild punishment may be required.

Another device that can be used to train parents to give frequent feedback initially is called the MotivAider. This is a small, vibrating box with a built-in digital timer that can be programmed to go off at various times throughout the day, say, every 20 minutes. (For more information, call ADD Warehouse, 800-233-9273.) The caregiver wears the small device on a belt or in a pocket. Whenever it vibrates, this is a cue for the parents to provide feedback to their ADHD child. This method has the added advantage of being less obvious to the child as a prompt for parental or teacher reward, and therefore the praise prompted by the device may appear to the child as more sincere or genuine. We have used this device in current kindergarten research classes for ADHD children with great success and cooperation by our teachers. In any case, the important point is to act quickly and frequently in giving feedback to ADHD children.

3. Employ More Salient Consequences

ADHD children require more salient or powerful consequences than do normal children to motivate them to perform work, follow rules, or behave well. Since ADHD may involve a reduced sensitivity to rewards and other consequences, it makes sense that larger, more important, or salient rewards may have to be used with ADHD children. This also explains why verbal positive comments or praise are rarely sufficient, alone, to motivate ADHD children to behave well.

In addition to such praise, caregivers will often have to provide more substantial consequences, such as physical affection, privileges, special snacks or treats, tokens or points, material rewards like small toys or collectible items, and even, occasionally, money, as back-up consequences to motivate ADHD children to work or continue following important rules. This may, at first, seem to violate the common wisdom that children should not be materially rewarded too often, lest it come to replace the more intrinsic rewards that an act or activity provides, thereby maintaining interest in continuing to perform the activity. Such intrinsic rewards might be the pleasure of reading, the desire to please one's parents and friends, the pride of mastering a job or new activity, or the esteem of one's peers for playing a game well. But these forms of reinforcement or reward are not as likely to govern the behavior of ADHD children and consistently motivate them to behave well, inhibit their behavior, and persist in their work, since ADHD children are probably less sensitive to these forms of reward as sources of motivation. Therefore, the nature of their disability dictates that larger, more significant, and sometimes more material consequences may need to be used to develop and maintain positive behaviors, at least initially, in ADHD children.

4. Start Incentives Before Punishments

It is critical to avoid the all-too-common drift toward using punishment first to suppress unwanted behavior. Caregivers must be frequently reminded of the rule positives before negatives in instituting behavior-change programs. This rule simply means that when an undesirable or negative behavior is to be targeted for change in an ADHD child, a caregiver should first redefine the behavior problem into its desirable or positive alternative. This will instinctively lead to watching for that positive behavior, and praising and rewarding it when seen. Only after this new behavior has been rewarded consistently for at least one week should parents or teachers be advised to begin punishing the undesired opposite behavior. Even then, they must be cautioned to use only mild punishment and to do so consistently but selectively, only for the occurrence of this particular negative behavior--not for everything else the child may be doing wrong. Mild punishment, when used in conjunction with an incentive program, and when kept in balance such that only one punishment is being dispensed for every two to three instances of praise and reward, can be a powerful means of effecting behavior change.

5. Strive for Consistency

Just stating the rule to caregivers is not sufficient, however; defining the term is what is important. Consistency means three important things.

First, caregivers need to be consistent over time. This means that the manner in which they react to a behavior they are striving to change today is how they should seek to respond to it each time it occurs over the next few days and weeks. Inconsistency, unpredictability, and capriciousness in this respect is one of the greatest contributors to failing in a behavior-change program with an ADHD child. An important corollary of this rule is not to give up too soon when you are just starting a behavior-change program. It has taken months to years for an ADHD child's behavior to fall into this pattern. Common sense dictates that it isn't going to change overnight. Don't lose hope or give up just because a new method of management does not produce immediate or dramatic results. Behavior modification can be like medication, it can take time before a therapeutic effect is noticeable. Try a behavior-change program for at least a week or two before deciding it isn't working.

Second, consistency also means to respond in the same fashion across different places and settings. Parents working with ADHD children too frequently respond to behaviors one way at home but an entirely different way in public places, like stores and restaurants, or at others' homes. They should try to avoid this. The ADHD child needs to know that the rules and consequences expected to occur at home will also apply, whenever possible, away from home.

And, third, consistency means that each parent should strive to manage behavior in as similar a fashion as possible to the other parent. Granted there will always be differences in parenting styles between mothers and fathers. However, it should not be the case that one parent punishes an ADHD child for a certain act of misconduct, while the other overlooks reacting to it entirely, or actually rewards its occurrence.

6. Plan for Problem Situations and Transitions

Often times, caregivers of ADHD children, particularly those children who are also defiant, find themselves frequently faced with difficult, disruptive, or noncompliant behavior. These situations arise not just at home, but frequently in public places, such as stores, restaurants, churches, and others' homes, and even in school. When they occur, caregivers can become flustered, bewildered, and frustrated, and may be unable to think quickly as to how best to handle such problems. These feelings are often combined with a sense of anxiety and humiliation when these child behavior problems arise in front of others, especially strangers in public settings.

In interviewing many caregivers of ADHD children, I have often been struck by their ability, when pressed to do so, to predict ahead of time where their children are likely to disrupt and misbehave. Yet, many simply have not put this information to good use in preparing for such problems to arise again. That is why we teach parents to anticipate problems, consider ahead of time how best to deal with them, develop their plan, share it with the child just beforehand, and then use the plan should a problem arise. People may find it hard to believe that merely sharing the plan with the child before entering a potential problem setting greatly reduces the odds that behavior problems will arise. But it does.

By following four simple steps before entering any problem setting, caregivers can improve the management of ADHD children.

• Stop just before beginning the potential problem situation.
• Review two or three rules that the child often has trouble following in that situation; then ask the child to repeat these simple rules back. For instance, they can be rules like "Stand close, Don't touch, and Don't beg" for a young ADHD child about to enter a store with a parent.
• Review with the child what rewards they may be able to earn if they obey the rules and behave well. These rewards can be chips or points that are part of their home or school token system, a special treat or privilege to enjoy later, such as some additional time to play, watch TV, or even, on occasion, the purchase of a small treat or toy while in the store at the end of the trip.
• Review the punishment that may have to be used with the child. Typically, these involve loss of points nor fines, the loss of a privilege later in the day, or, if necessary, time out in the situation. Whichever punishment is used, the key to effec- tive management of a child is the quickness or immediacy of responding with the consequence when the problem arises, as noted earlier.

Now once these four steps have been followed, the caregiver and child may enter the potential problem context, and the caregiver immediately begins to give the child frequent feedback and occasional rewards or tokens for good behavior.

7. Keep a Disability Perspective

At times, when faced with a difficult to manage ADHD child, caregivers lose all perspective on the immediate problem, become enraged, angered, embarrassed, or at the very least, frustrated, when management does not work. Often, they may even argue with the child about the issue, as another child or sibling might do. This is ineffective, looks silly, and may even encourage continued confrontation by the child on future such occasions. Teach caregivers to remember at all times, they are the adult; they are this child's teacher and coach. If either of them is to keep their wits about them, it clearly has to be the adult. Losing their cool won't help, will likely make the problem worse, and will often lead to considerable guilt once they recover their senses.

Therefore, they must try to maintain psychological distance from the child's disruptive behavior, if necessary pretending that they are a stranger who has just happened upon this encounter between caregiver and ADHD child. In addition, they should not allow their sense of self-worth and dignity to become derived from whether or not they "win" this argument or encounter with the child. Counsel them to strive to stay calm if possible, maintain a sense of humor about the problem, and by all means try to follow the other seven principles in responding to the child. Sometimes this may even require caregivers to disengage from the encounter for a moment by walking away and gathering their wits as they regain control over their feelings. Above all, they must not personalize the problem encounter with the child. Advise them to remember that they are dealing with a handicapped child! ADHD children cannot always help behaving in the ways that they do; the caregivers can.

8. Practice Forgiveness

This is the most important but often the most difficult guideline to implement consistently in daily life.

First, each day after the children are put to bed, parents should take just a moment to review the day and forgive the children for their transgressions. Let go of the anger, resentment, disappointment, or other personally destructive emotions that have arisen that day due to the children's misconduct or disruptions. Forgive them, for they are disabled and cannot always control what they do. Do not misunderstand this essential point. It does not mean the children should not be held accountable for their misdeeds or be taught to make amends with others they have harmed, for they should. Teachers can practice this at the end of the school day, once the children have left their class. Teachers should stop, take a cleansing breath, and upon exhaling let go of the day's conflicts with the ADHD child.

Second, parents should concentrate on forgiving others that day who may have misunderstood their children's inappropriate behavior, acted in ways offensive to them and their children, or simply dismissed their children as lazy or morally bereft. Such people are often ignorant of the true nature of ADHD, typically blaming the parents and family of the ADHD child for all of the child's difficulties, when such is clearly not the case. This in no way means that parents should continue permitting others to mistreat their ADHD children or misunderstand them. Corrective action and advocacy for these children are critical to seeing that such misunderstandings or maltreatment by others does not occur again. It does mean having parents learn to go beyond the hurt, anger, and resentment such instances may have effected in the parents. This may be much less necessary for teachers who are less personally invested in the ADHD child than are parents. Even so, truly empathic teachers may also feel ashamed that they cannot control an ADHD child when in the presence of other teachers, who may deride them for their management problems. Such teachers may also need to practice this aspect of forgiveness.

Finally, caregivers must learn to practice forgiving themselves for their own mistakes in the management of ADHD children that day. ADHD children have the capacity at times to bring out the worst in adults, which frequently results in those adults feeling guilty over their own errors in handling the children's behavior. This does not mean that parents or teachers should not strive to improve their management or to evaluate how successfully they have approached and managed the child's problem behaviors. Forgiveness does not mean granting oneself license to repeatedly make the same errors without consequence. It does mean letting go of the self-deprecation, shame, humiliation, resentment, or anger that accompanies such acts of self-evaluation, replacing them with a frank evaluation of one's performance as a caregiver that day, identifying areas to improve, and making a personal commitment to strive to get it right the next day.

Forgiveness is, admittedly, a tall order for humanity. Caregivers will find this principle the hardest to adhere to, but the most fundamental of all the principles reviewed here as to the art of effective, and peaceful, management of ADHD children.

SOURCES: The ADHD Report Volume 1, Number 2, April 1993, published bimonthly by Guilford Publications, Inc.

About the author: Russell A. Barkley, Ph.D., is an internationally recognized authority on attention deficit hyperactivity disorder (ADHD) in children and adults. Dr. Barkley has specialized in ADHD for more than 30 years and is currently a Research Professor in the Department of Psychiatry at the SUNY Upstate Medical University in Syracuse, New York