Train the Parent, Help the Child

Sometimes, medication alone does not turn around a child’s negative behaviors. If you’re a parent at the end of her rope, don’t lose hope — behavioral parent training may be your best shot at a calmer household and a better relationship with your child

Jennifer Roshaven knew she had to do something soon. Her twin six-year-old sons had recently been diagnosed with ADHD. They had challenges with impulsivity and following directions and rules, and they were starting first grade in the fall. She knew how those challenges affected them, and she wanted to get the school year off to a good start.

Roshaven enrolled her twins in a summer behavioral therapy program for children ages four to 12 who have ADHD, at the Center for Children and Families at Florida International University. The program was an eight-week summer day camp, plus a weekly two-hour parent training session. Through games and other group activities, the children learned problem-solving, academic functioning, and social skills, while the parents learned ways to turn their children’s negative behaviors into positive ones. At the end of the program, Roshaven noticed improvements in her sons’ behavior, and gained new perspective on her own parenting.

“Those two hours each week helped me to slow down and to be more mindful of what and how I communicate to my kids. I became aware of how many negative and positive statements I made each day,” says Roshaven. “Now, I make sure I tell my children clearly what’s expected, what the ground rules are, and what’s going to happen if those rules aren’t followed. Things are running more smoothly.”

Behavioral Parent Training Basics

As a parent, you did not cause your child’s ADHD, but you hold a key to helping your child get better. New research is revealing that you can help treat your child’s ADHD, improve your relationship with him or her, and boost your child’s social skills by taking behavioral parent training (BPT). You can learn skills that last a lifetime, and, maybe, change the path your child is on.

BPT is about setting up house rules and establishing procedures for rewards when your child follows the rules. It also teaches you to focus more on what your child does right rather than wrong. Parent training is typically done as part of a group, although it can be done in one-on-one therapy with a parent training expert either in person or online with a webcam. The skills taught in parent training are similar across all programs. Those skills may include:

1. Catching a child being good by noticing and rewarding appropriate behavior and ignoring (or, when necessary, providing appropriate punishment for) negative behavior.
2. Creating a daily routine, with rules about doing homework, bedtime, getting ready for school in the morning, and other key moments in the day.
3. Giving your child specific rather than general directions (“Please put your clothes in your hamper,” for example, rather than “clean your room”).
4. Minimizing distractions in your home.
5. Minimizing choices, so that your child is not overwhelmed by options.
6. Creating an organized home.
7. Helping your child break down large tasks and set small, achievable goals that, over time, add up to more substantial accomplishments.
8. Establishing age-appropriate rewards and discipline.
9. Working with a teacher to create a daily report card (DRC).

How BPT Works

In a typical behavioral parent training program, professionals lead groups of (usually) 15 to 30 parents, all of whom have children diagnosed with ADHD. The parent training groups usually meet once a week for eight to 12 weeks, and one skill is addressed in each session. The session facilitator may start off by showing a video in which a parent makes a common mistake when interacting with her child. The group watches the video together, and the leaders ask the parents to comment: “Can you describe what happened and what the parent did? What was right and what was wrong? What would you do in a similar situation?” The leader or facilitator shares exercises for mastering the skill, and parents practice the exercises, often by role-playing or brainstorming with each other.

“There is a cohesiveness that develops, and you find yourself listening to other people and learning from each other’s experience, as well as from the instruction of the leader,” says James Swanson, Ph.D., professor of pediatrics at the University of California at Irvine, who frequently works with parents of children who have ADHD at the UCI Child Development Center. “The group carries you along; you don’t get that same support if you’re just listening to a lecture.”

After each session, the leader gives the parents a homework assignment that involves using and practicing the skill at home. At the next class, parents discuss their experiences using the strategy with their children. What worked for them? What didn’t work? How might they try something different next time?

“As I went through parent training, I felt a bond with the parents whose children were in the program for the same reason mine were,” says Roshaven. “There is automatic commonality, and it creates more candidness in what parents share, more openness. There’s a sense that ‘this is hard, so let’s help each other.’ If the facilitator asks a question, many hands go up; sometimes when the class is over, parents continue to talk, because there’s so much value in exchanging information.”

During the school year, a key component of behavioral parent training is the daily report card. Early in the school year, the parents and teacher decide on certain behaviors that they want to see improved, behaviors that, if changed, would lessen the child’s problems in daily life. The behaviors might involve:

1. Peer relations. Goals might include not interrupting other children, not teasing other children, or not fighting at recess.
2. Academic work. Goals might include having all materials necessary to do tasks, or completing assigned tasks and/or homework on time.
3. Relationships with adults. Goals might include obeying the teacher’s directions, not talking back to the teacher, or following classroom rules.

At the end of each day, the teacher reports on whether the child has achieved his goals for the day (which might be as simple as putting a smiley face or a sad face on the report card). On days when the child reaches his goals, he can expect a small reward at home, such as a half an hour of playing outside or watching TV. “The daily report card is a mainstay of behavior therapy,” says Swanson. “It can link the home and school environments, improve parent-teacher and teacher-student communication, and shape behavior.”

The Results You Can Expect

Could behavioral parent therapy be what your child needs to improve his symptoms? The answer depends on several factors, including the severity of your child’s symptoms, your own commitment to the training, and the consistency with which the rules and skills learned are implemented at home and in school. Some children need more behavior therapy, or the addition of medication, to see improvement in behavior. Studies have shown that children who have behavior therapy first can often get by on a lower dose of medication.

Some families who go through BPT see improvements as early as the first week of treatment, but parents should not expect overnight miracles. Unlike medication, which can improve behavior quickly, BPT involves teaching and learning, and that takes time and practice.

Your child’s behavior may get worse before it gets better. Psychologists call this phenomenon an “extinction burst.” “Typically, when parents come to us, they are giving a lot of attention to negative behavior, such as tantrums or oppositional or annoying behavior, and the child has learned that this behavior is the best way to get attention from them,” says Matthew Rouse, Ph.D., clinical psychologist in the ADHD and Behavior Disorders Center at the Child Mind Institute, in New York City.

“In parent training, we shift the balance; we teach parents to ignore bad behaviors and shift their attention to the things the child is doing right, in between negative behaviors, to feed those positive behaviors,” says Rouse. “This shift can cause children to act out more to get the attention they’re used to getting. Extinction bursts don’t last long, and most parents can get through them just fine by sticking to the strategies they’ve learned.”

As your children start to realize that you are giving more attention to positive behaviors, they will shift from negative actions to positive ones. That’s the magic of behavioral parent training, and it often results in better communication and a happier parent-child relationship.

Be Patient

“Taking medication can produce results in 30 minutes, but the behavior returns when the medication wears off,” says William Pelham, Ph.D., chair of the department of psychology and Director of the Center for Children and Families at Florida International University. “Behavior therapy is a learning process that takes time and effort, but it pays off with changes that last a lifetime. You would never hear a first-grade teacher say, ‘I’m going to teach everyone in the class to read in one day,’ nor can you change behavior in one day. You start small and build, but most parents find that the results are worth it.”

Jennifer Roshaven’s parent training classes are over for now, but she says the techniques she learned have made her a better parent. She plans to keep using them, and if she needs a refresher as time goes by to meet new challenges, she won’t hesitate to seek help.

“My kids are six, and their behavior challenges are probably mild compared to those of some older kids,” she says. “But I look at some of their behaviors now and I think, ‘When they’re mad, they might throw a toy, but if this continues, when they’re 16, and a lot stronger, they could hurt someone else or themselves.’ If I can ingrain positive behaviors in my children now, and stop the negative ones, it will prevent a lot of anguish later.”

Medication or BPT: Which Should You Try First?

About 75 percent of American children diagnosed with ADHD are treated with medication and nothing else, according to the Centers for Disease Control and Prevention (CDC), even though several health organizations, including the American Academy of Pediatrics (AAP), have recommended behavior therapy as the first line of treatment for all children diagnosed with ADHD who are under age six. In children age six and older, the guidelines say that either behavior therapy or medication alone can be helpful in treating ADHD, and a combination of treatments may be best.

New research indicates that for all children with ADHD — including those age six and older — starting treatment with BPT is the best strategy. In the study, researchers at Florida International University, in Miami, found that if medication, instead of BPT, is tried first and fails, it becomes much harder to treat ADHD successfully — because increasing the dose of medicine does not appear to work, and BPT is less effective when medication has been tried first.

“Parents are less committed to parent training once their kids show some improvement from medication,” says the study’s lead author William Pelham, Ph.D. “Medication produces a quick response, and parents are less motivated to go through the work of BPT once some symptoms improve. Increasing the dose of medication is a common strategy among doctors today, but our study showed that it doesn’t work to improve behavior in most kids. The message for parents is clear: Tell your child’s doctor you want to start with behavioral parent therapy.”

6 Tips for Finding a BPT Program That Works for You

Start by asking your own pediatrician for a referral. If there is a local teaching hospital near you, call them to see if they offer behavior therapy and parent training. You can also look to ADHD parent support groups in your area for referrals, or log on to chadd.org.

Here are points to consider:

1. Talk to the program coordinator or doctor. “If they don’t use the word ‘behavioral’ in describing the therapy, don’t go there,” says William Pelham, Ph.D., of Florida International University. “Other types of therapy have not been shown to be helpful for ADHD. You want a behavioral therapy program.”
2. Make sure the program curriculum is “evidence-based.” This means that scientific studies have shown that the type of therapy and parent training being offered works to treat ADHD. Here are a few widely available evidence-based programs: Parent-Child Interaction Therapy (PCIT), Parent Management Training (PMT), the Positive Parenting Program (Triple P), The Incredible Years, and COPE.
3. Consider your child’s age. “Parent-child interaction therapy is best for kids up through six years old,” says Matthew Rouse, Ph.D., of the Child Mind Institute. “If you have an eight-year-old child, you might use parent management training or The Incredible Years or Positive Parenting Program.”
4. Decide if you want to be part of a group or have one-on-one training. BPT in groups gives you the advantage of hearing different perspectives, and sometimes the best tips you get are from other parents. One-on-one training with a therapist allows you to work on the specific challenges that affect your child. “One-on-one parent training might work better for parents of children with severe symptoms of ADHD,” says Rouse.
5. Consider your schedule. In order for parent training to work, you must go to the sessions, and that’s more likely to happen if you can get there easily. Some facilities offer programs in the summer, which might be better for parents who work on a school calendar. Others offer intensive one-day Saturday programs, which might be better if you have to travel out of town to get to the session. Some experts offer parent training via a webcam, so you never need to leave your home.
6. Find out the cost. Check with your insurance company to see what they cover. Ask if the program offers any financial aid; some do. Remember that, while BPT costs may seem higher, recent research shows that, in the long run, they cost less and the benefits last longer than other therapies.