What is a “behavioral” approach to working with ADHD?

Behavioral approaches to managing ADHD are one of the two methods of treatment that are currently considered “well-established” treatments based on scientific research (the other is stimulant medication). Behavioral approaches may be implemented in the home environment and/or in the school environment. In general, behavioral approaches identify specific problem behaviors (e.g., bringing home assignments, noncompliance) that impact a child’s functioning in school and/or at home. Once these behaviors are identified, specific strategies are developed to promote positive changes in these behaviors. In general, these strategies will involve changing aspects of the environment (e.g., sitting closer to the teacher, reducing distractions) and/or modifying the consequences of behavior (e.g., rewarding positive behaviors, time-out or loss of privileges for undesirable behaviors).

How does a behavioral approach differ from other approaches?

Because behavioral approaches emphasize changing aspects of the environment or consequences for behavior, they generally require active involvement of the parents and, ideally, the school. Although a provider will likely work directly with your child, you can also expect that a significant portion of the treatment will involve working with parents and other caregivers. A therapist may only spend an hour a week with your child, but parents and teachers will spend nearly 100 hours in a given week with the child. Therefore, to maximize the impact of treatment, behavioral approaches focus on helping parents and teachers develop the skills to work effectively with the child. In some sense, the therapist may serve as a coach to parents — a person to help guide them through the challenges of addressing their child’s behavior.

Behavioral approaches also tend to emphasize the importance of frequent feedback on a child’s behavior. Getting systematic and specific information on changes in the child’s behavior is a vital step in tailoring the treatment to meet the needs of an individual child. Therefore, you can expect the therapist to ask you (and a teacher) to actively monitor your child’s behavior over time. This may involve keeping a log or journal of problem behaviors or completing rating scales. Behavioral approaches also emphasize the importance of home-school communication and may use specific strategies to promote better communication (e.g., daily report card).

How can I tell if a provider uses a behavioral approach?

Unfortunately, it is not always easy to tell what kind of approach a particular therapist will use and sometimes the term “behavioral” is used inconsistently to refer to a wide range of strategies. Many times, a parent only has a list of approved providers and little guidance to select among them. Some characteristics are important for all no matter what approach they take. For instance, you should feel comfortable with the therapist and be sure that they have appropriate experience and credentials. However, here are some questions that may help inform you about the particular approach to treatment.

Here are some questions you can ask your child’s provider:

Could you describe your general approach to working with children with ADHD?

Aside from an emphasis on collaboration between the family and school (see above), behavioral approaches also tend to emphasize focusing on positive behaviors in addition to reducing negative behaviors. By the time a child begins receiving treatment for ADHD, a large percentage of family interactions involve correcting problem behaviors. Therefore, most well-established behavioral treatment programs tend to work on increasing desirable behaviors before addressing undesirable behaviors. If a provider only describes strategies for addressing problem behaviors (e.g., using time-out), ask them about the role of rewarding appropriate behavior.

Do you work primarily with the child or with the parent(s) as well?

As mentioned above, providers who work almost exclusively with the child are probably not using a behavioral approach. ADHD is not a matter of motivation or will. Working only with the child removes several important elements of the child’s environment (i.e., parents and teachers). It is important to note, however, that spending more time individually with the child may be appropriate depending on the specific needs of the child (e.g., for older children or when ADHD is accompanied by depression or anxiety).

To what extent are you willing to work with my child’s school?

In general, more involvement is desirable. The school is an extremely important environment for children with ADHD. Not only is it the setting that is likely to present the greatest challenges for the child, it is often a major target of effective interventions. Some providers may not routinely involve the school and others may communicate with the school regularly about the child’s behavior and progress. In some cases, the provider may be willing to visit the school to observe behavior, consult with teachers, or facilitate communication between the parents and the school.

What percentage of your practice focuses on children with difficulties similar to my child’s?

It is often a good idea to inquire about a therapist’s level of experience. It may be helpful to ask how long they have been practicing. Perhaps more important, you may also want to ask about the therapists’ level of experience with the specific issues for which you are seeking help. Many mental health professionals will work with a wide range of presenting problems. It is generally desirable to find providers who spend more time working with children and families who are likely to share some of your concerns and challenges (e.g., ADHD, learning disabilities).