One of the biggest challenges that parents of a child with ADHD face is managing and changing disruptive or inappropriate behaviors at home and in school. The best way to meet that challenge is through a behavioral parent training program (BPT), a well-studied and well-established first-line treatment plan for children with ADHD.
For those who are not familiar with BPT programs, here’s how they work: BPT is typically taught by a mental health professional over 10 to 12 individual or group sessions. The program focuses on teaching parents the major ways in which children learn: 1) by observing others in their environment and 2) by receiving positive and negative consequences based on their behavior. Parents are trained to identify antecedents, or the conditions or family behaviors that set the stage for the unwanted behaviors, and learn a core set of strategies to adjust them. They also learn how to respond to the child’s behavior, including enforcing consequences for inappropriate behavior or offering praise or earned rewards for good behavior.
As effective as BPT can be in changing a child’s behaviors, sometimes the plan needs adjustments. So how do you do that? Meet four families who adjusted their BPT plans because they weren’t working. They tweaked the strategies over time to find what works best for their child and their family.
Problem: Aggressive Behavior — Hitting a Sibling
Joshua Robinson is an eight-year-old who refused to do what his mother asked and talked back. He also argued with his younger brother. In BPT, his mother prioritized these behaviors, since they caused the most problems at home. She created house rules to “obey adults” and “use respectful words.” Joshua and his brother earned screen time in the evening for following the rules. These strategies improved Joshua’s relationship with his mother, but he continued to argue with his brother. Lately, Joshua started to hit his younger brother when things didn’t go his way. His mom wanted to work on Joshua’s aggressive behavior.
> First, Joshua’s mom evaluated the antecedents, or the situations that seemed to be allowing this behavior to occur. She revisited the house rules she created during BPT, and added a rule to “keep hands and feet to yourself.” Ms. Robinson held a family meeting to describe the new rule to both children. She went through several examples to make sure that both children understood which behaviors were OK and which behaviors were not. She reminded them that they will earn 30 minutes of screen time in the evening for following the house rules throughout the day. The rules applied to all members of the family, including parents.
> Mom monitored how things went over the next week. While losing screen time improved Joshua’s behavior toward his mother, it wasn’t enough to keep him from hitting his brother.
> Ms. Robinson decided to change the consequences for breaking house rules. To make the consequence more immediate, she added a time-out for breaking rules. She decided that Joshua would go to time-out for eight minutes, since he is eight years old, and that his brother, who is six, would go for six minutes. Ms. Robinson had another family meeting to explain the new consequence to both children. They identified a chair in the kitchen as the time-out area. This spot was easy for her to supervise, and it was far away from fun things, like electronics.
> The next day, Joshua hit his brother because he took his toy. Ms. Robinson told Joshua to go to the time-out chair and started the timer. Joshua went to the chair, but kept complaining that it wasn’t fair that his brother got to play with his toy. When the timer went off, Joshua ran to the living room to get his toy back. To prevent this from happening again, she decided that time-outs wouldn’t end until there had been a minute of quiet, giving Joshua a chance to calm down.
> After their mom explained the new time-out procedure, Joshua and his brother got into an argument, and Joshua pushed his brother. Mom assigned Joshua a time-out, and reminded him that the time-out would not end until he sat quietly for one minute. He went to the chair, but kept yelling. Rather than redirect this behavior, Ms. Robinson extended Joshua’s time-out. After 20 minutes, Joshua was able to calm himself down, and he sat quietly for one minute. Joshua slowly got better at calming himself down during time-out. After a few weeks, he spent only an extra minute or two in time-out, and was less aggressive with his brother.
> Ms. Robinson applied the same BPT strategies for activities outside the house. When Joshua and his brother were invited to a birthday party, she worried that Joshua would have a hard time keeping his hands to himself. Before the party, she explained to both children that the house rules apply during the party, and anywhere else they go together as a family from now on. She said that if they broke the house rules at the party, they would have a time-out, just like they did at home. Setting up the expectations ahead of time helped things go more smoothly during the party. Joshua did get a time-out, but he sat through it quietly and was ready to go back to having fun as soon as it was over.
Problem: Transitioning from Video Games to a Bedtime Routine
Dylan is a six-year-old who was recently diagnosed with ADHD. Dylan whined when his parents asked him to do something, which often escalated into a tantrum. During the BPT program, Dylan’s parents worked on creating more structure at home by establishing house rules and routines. This helped Dylan know what to expect, and he had fewer tantrums. But Dylan still had trouble stopping activities he enjoyed, like video games, when asked to do something else, like getting ready for bed.
> Dylan’s parents evaluated antecedents to see if they could change anything about video game time to ease Dylan’s transition to the bedtime routine. One thing they noticed is that Dylan whined much more when they asked him to stop playing when he was in the middle of a level. They decided that, about five minutes before video game time was supposed to be over, they would give him a warning that the next level was his last one before getting ready for bed.
> Dylan’s parents tried out the new strategy for a couple of days. The warnings helped Dylan stop playing when video game time was over, but as he got ready for bed, he whined that he wanted to play his game. His parents looked at the consequences, what happens after he whines. They noticed that they often responded to his whining by saying things like, “You’ll get to play tomorrow,” which often made him whine more.
> They tried “planned ignoring,” a strategy that they learned during BPT. For the next few days, they ignored Dylan’s whining — they didn’t make eye contact with him or talk to him while he whined. Dylan got frustrated over the fact that his parents ignored him, so his whining got louder. In order to avoid a tantrum, Dylan’s parents often found themselves giving in and letting Dylan play another level of the game before bed. This led to another round of whining when they had to take away the game for the second time.
> Dylan’s parents knew they are supposed to ignore Dylan’s behavior until he stopped whining, but in the moment they were so desperate for him to stop that they found it hard to do. They tried a different consequence strategy. They realized that they had forgotten to praise him for doing what they asked. During the next few days, they caught Dylan being good and said, “Thank you for turning off the game” and “I love the way you’re heading upstairs.” Focusing on the positives reduced Dylan’s whining, making it easier for them to ignore it until he stopped.
> Dylan’s parents continued this routine. After a few weeks, Dylan realized that whining wasn’t going to get him his way. He still whines a little, but he stops much more quickly now.
Problem: Managing Schoolwork in Middle School/Poor Grades
Isaac Joseph, 12, recently started middle school. When Isaac was in elementary school, his mother went through a course of BPT where she learned to manage his inattention and disruptive behavior during homework time and to set up daily home-school communication with his teachers. Now that Isaac was in middle school, Ms. Joseph tried to give him more independence with his schoolwork. Isaac had a tough time managing the work on his own, and his grades suffered.
> Isaac’s mom approached her son to see if they could work together to improve his grades. They pulled up his current grades in the school’s grade portal to see where the problems were. He participated a lot in class and completed in-class assignments, but he was missing lots of homework assignments and performed poorly on tests.
> The missing assignments affected his grades the most, so they decided to start there. In evaluating antecedents, Ms. Joseph asked to see Isaac’s agenda. She discovered that Isaac didn’t write down his assignments. They agreed that Isaac has to write down assignments in his agenda every day in order to play video games. They set a goal of writing down homework in three classes.
> During the first week, Isaac wrote down almost all of his assignments and Ms. Joseph let him play video games. However, when the grade portal was updated at the end of the week, Ms. Joseph saw that Isaac was missing many homework assignments. Isaac admitted that he forgot to write the homework down a few times, so he made it up before she checked his agenda. Ms. Joseph restricted video games for the weekend. On Monday, she emailed Isaac’s teachers to see if they would initial his agenda so that she knew whether Isaac wrote down the correct homework. Isaac’s teachers agreed if he brought the agenda to them.
> Isaac did a better job of remembering to write down his homework and get his agenda initialed, and he frequently earned video game time. Ms. Joseph kept checking the grade portal and Isaac had fewer missing assignments. He also wrote down when he had to study for tests, so those grades improved as well. Mom made his goal more challenging: write down assignments in four classes.
> A few weeks later, Ms. Joseph’s work schedule changed and she couldn’t be home with Isaac during homework time. He was doing so well writing down and completing his homework that she thought he would do OK. However, after a week, Ms. Joseph saw that his grades had dropped again. Isaac admitted that he had been playing video games before finishing his work. Ms. Joseph restricted video games for the weekend for lying to her all week and researched parental control options for the gaming system.
> The next week, Ms. Joseph remotely restricted access to the gaming console until Isaac texted her photos of his agenda and his completed assignments. When she checked the grade portal at the end of the week, she saw that he had completed most of his assignments.
> Isaac kept up the good work for a couple of weeks, but he got annoyed that he had to check in with his teachers and his mom. Ms. Joseph and Isaac agreed that if he could write down his homework in all of his classes for a month, she wouldn’t check the grade portal. However, if his grades started to slip again, she would monitor homework time again.