Nonpharmacologic Approaches to Treating ADHD

Michele Dadson, PhD; Adelaide S. Robb, MD


July 31, 2006

In This Article

Defining Behavioral Treatments

Behavioral treatments for ADHD can be divided into 2 broad categories: clinical behavior therapy and direct contingency management.[11] Clinical behavior therapy is usually conducted by a mental health professional (eg, psychologist or social worker) in an outpatient setting. Although meetings with the child will occur on occasion, the primary focus of treatment is the significant adult in the child's life. The treatment typically consists of parent training in child behavior management plus teacher consultation in behavior modification.

In parent training programs,[12,13] the initial sessions focus on psychoeducation. Parents are taught to consider their child's behavior as a function of the disease, rather than as noncompliance or evidence of failed parenting. This first step is essential; studies have shown that parents' beliefs about themselves, their ADHD children, and their parenting are associated with child treatment outcomes.[14] Subsequent sessions focus on teaching parents to pay attention to appropriate behavior, ignore minor inappropriate behavior, give clear and concise directions, and establish effective incentive programs, such as token or point reward systems. Reward programs allow parents to deliver immediate, tangible rewards for appropriate behavior. In developing a reward program, parents and children must first agree on a set of desired and reasonable rewards (eg, computer time or playing a favorite game). Parents then construct a list of desired behaviors (remaining on task during homework completion, keeping room clean, etc), assigning point values for each. Behavior is monitored throughout the day and points are assessed accordingly. At the end of the day, a portion of the points may be redeemed for small rewards. Unredeemed points may be applied toward the purchase of larger weekly rewards. Contingency programs are adjusted regularly to account for changes in behavior and to prevent satiation of rewards. In parent training programs, parents are also taught the importance of anticipating misbehavior and providing immediate, specific, and consistent consequences in response. Strategies for managing noncompliant behavior in public are also offered. Parents are encouraged to monitor school behavior through review of a Daily School Behavior Report Card, completed by their child's teacher. Appropriate school behavior is rewarded with a privilege at home. Although most parent training programs (eg, Barkley[12]) were originally designed to be delivered in a group setting, with modest adjustments, many can be implemented individually. Typical training programs take approximately 8-10 sessions to complete.

Through school consultation, mental health professionals directly assist teachers of ADHD children with implementing various behavior management strategies in the classroom. Examples of academic adjustments include reducing workload to fit the child's attention span, altering teaching style and curriculum, setting time limits for work completion, dividing longer assignments into smaller steps, and increasing the immediacy of consequences.[15,16] Specific interventions are selected on the basis of a constellation of attentional and behavioral difficulties displayed by the child. Progress is closely monitored throughout the academic year, either through routine phone contact between teachers and the mental health professional or through periodic meetings at the school. Depending on the level of impairment, a child with ADHD may also be eligible for special services through certain federal statutes, ranging from minor accommodations (eg, untimed testing) through a Section 504 plan to the development of a full Individual Education Plan (IEP) allowing for more extensive special education services. (For further discussion, see Latham and Latham[17]).

With many of the same principles that are emphasized in clinical behavior psychotherapy, direct contingency management[18] programs are conducted in highly controlled settings (ie, summer treatment programs, specialized schools) by paraprofessionals. In addition to implementing behavioral interventions (eg, point systems), contingency management programs tend to focus on enhancing social skills. This approach differs from a clinic-based social skills group because the training occurs in the setting where the child is experiencing the social difficulty (ie, at school), thereby improving its effectiveness.[7]


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