Pre-teen in the classroom
Treatment Strategies for ADHD
It is important to realise that multiple treatment modalities are necessary in managing the behaviours associated with ADHD. Medication often fulfills an important role, but frequently fails to eliminate all of the problem behaviours. Hence, behaviour management strategies are an important aspect of treatment. For older children, adolescents and adults, counselling is often very effective in helping them to reduce the impact of ADHD on their daily functioning.
ADD/ADHD is not an Excuse
ADD/ADHD is not an excuse for poor behaviour although it does explain why such behaviour is more likely to occur. Children must learn that they are expected to behave in an acceptable manner although we can understand that it is harder for them to do so.
Instructions
ADHD children have difficulty in following instructions. Instructions should be given in a direct declarative manner rather than in the form of a question or a request. They are more likely to be followed if distractions are removed and the child has made eye contact with the person giving the instructions. Instructions should be kept short and the number of steps in the instruction should be matched to the child's ability to cope. Asking the child to repeat the instruction in his/her own words can help to ensure that the instruction has been understood correctly. The child should be supervised for a short time after the instruction has been given to ensure that he/she understands what to do, and is carrying out the instruction. It goes without saying that, if the child hasn't understood the instruction, he/she will be unable to do as required and will appear to have been uncooperative and lazy.
Supervision
ADHD children need to be supervised when doing independent work in order to prompt them to return to task. Prompts should not be punitive, but should serve as a gentle reminder to return to task. The aim should be to be able to provide prompts when necessary rather than to punish a child who has drifted off-task.
Reinforcement
Reinforcement should preferably be immediate and frequent. It should be specific and relevant to the behaviour, and meaningful to the child. Tokens may be used for immediate reinforcement provided that a specified number of tokens may be traded for a specified reward. Positive reinforcement is much more effective than the application of negative consequences, i.e., punishment.
Planned Behaviour Strategies instead of Ad Hoc Strategies
It is better to consider the problem behaviours in the context of what precedes them and what follows them in order to determine effective ways of reducing or eliminating problem behaviours. A planned approach is likely to be more effective than an ad hoc approach. Planning how to avoid problem behaviours in the future is more effective that reacting to such behaviours once they have occurred.
Frequency and Specificity of Feedback
ADHD children require more frequent and more specific feedback in order to improve their performance. Initially, reinforcement should be on an almost continuous basis with intermittent reinforcement being introduced gradually and cautiously. Children with ADHD respond better to small immediate reinforcers than to long-term major reinforcers. These children are often keenly aware of their failures but do not notice their partial successes or the steps they have successfully taken towards the achievement of a goal.
Specific Goals
It is better to specify particular outcomes rather than vague behaviours which are difficult to quantify. For example the child might be expected to complete a specific task by a specified time rather than being expected to stay on task. The work cannot be completed unless the child is on task, but it is easier to evaluate the outcome. The preference for an academic response as the treatment target shifts the focus to a behaviour which is incompatible with inattentive behaviour.
Types of Reinforcers
Preferred activities are more effective than concrete rewards, and can be made available contingent on specific conditions being met. Reinforcers must be of value to the child. A reinforcement menu may be useful in a class so that children can choose the reinforcement which appeals to them. Such a menu may have reinforcers ranked in value so that a child who has earned the highest level of reinforcer may select any reinforcer from Bands 1, 2, or 3. The child who has achieved a medium level reinforcer may choose from Bands 2 or 3; while the child who has only earned a base level reinforcer must choose only from Band 3.
Are Special Rules for One Child Necessary?
Children with ADHD do not respond to many of the more traditional methods of behaviour management. However, most children will respond to the techniques which are effective with ADHD children. It is often more effective to use a strategy with the whole class.
Rationality of Behaviour
ADHD children are impulsive. They do not consider consequences, and do not plan behaviour with a reason in mind. They do not "choose" to behave inappropriately. For this reason,
Don't ask why the behaviour occurred. Don't ask for an admission of guilt.
A spontaneous apology is to be appreciated, but don't insist on getting one.
Don't rely on reasoning - be assertive, brief and direct. Children with ADHD can easily sidetrack you so that what you wanted to say is lost in a sea of words.
Briefly review the rule involved when the child gains a reward, or loses a point etc.
Keep the structure predictable. The child knows the limits. Use built-in incentives
Response Cost
This is an excellent technique for helping the child to manage his/her behaviour appropriately.
The child starts the day with 10 tokens, each of which represents one minute of a desired activity. The child knows in advance what rules must be observed in order to keep all of the tokens. Each time the rule is infringed the child loses one token. The child verbalises the rule that has been broken. At the end of the day the child trades the remaining tokens for time on the chosen activity
Verbalising the rule is not meant to be a punishment. The aim is to reinforce the link between the behaviour and its consequences.
It is useful to have a few children on this program, since it avoids stigmatising the child. However, having too many children on the program may be unworkable.
Concentrate on one or two problem behaviours at any one time.
Turtle Control
This allows the child time to reflect and regain composure rather than reacting inappropriately.
Everyone needs Turtle Control. Why does the turtle retreat into his shell? He needs to relax in a secure space, while he considers what to do about the problem. N.B. This is different from the technique of having the child think about what he has done wrong. In the turtle technique the child is thinking of solutions rather than merely focusing on guilt.
Sit back, take a slow deep breath, relax, think about the problem.
Teach relaxation training between activities. Don't limit relaxation training to problem times. Teach children to use the turtle technique to help themselves to control impulsivity.
Utilise any technique which will encourage children to stop - think - act; rather than merely reacting to a stimulus
CAUTION: Do not try to implement too many strategies at the one time. Pick one or two which you feel would be most appropriate and implement those. Review progress regularly as you may need to fine tune the strategy you have chosen.
If strategies are implemented on a whole class basis, it is likely to be less time-consuming and more effective. In addition, it avoids placing a very public focus on the individual child.
Copyright Dr Stephen Dossel, and the ADD Association Queensland. This article may be reprinted but should not be modified in any way. Any such use should be acknowledged in the normal manner and must include the author's name and the source of the article.
