Applied Behavioral Analysis has become famous over the years for the skills growth it produces in children on the Autism Spectrum. But it is less well known that ABA has also been proven to be an effective treatment methodology for a host of other diagnoses and challenges, including ADHD.
In fact, research indicates that a combination of medication and ABA therapy produces best outcomes for children with ADHD. The National Institute of Mental Health reports that adding behavioral therapy to stimulant medications can help children with ADHD and their families to more effectively manage and tackle day-to-day challenges . Moreover, behavioral therapy is unique among non-drug treatments in that it has been actually shown to work in improving skills and reducing impulsivity in children with ADHD. The proof is in the pudding: according to the chairman of the Washington area chapter of the American Academy of Child and Adolescent Psychiatry Dr. Tomas Kobylski, children who pair medication with behavioral therapy are able to take lower doses of medication.
How does it work?
ABA uses behavioral principles to teach new skills and reduce problem behaviors. Children with ADHD can suffer from increased impulsivity, hyperactivity, and inattention. The severity of ADHD can range from mild, to moderate to severe. The following ABA techniques are commonly used to operationally condition alternative, more functional behaviors in children with ADHD:
- Differential reinforcement of behaviors – Positive reinforcement is offered for appropriate behaviors while no reinforcement, or in issues of safety, “punishment” is given when negative behaviors are expressed.
- Discrete Trial Training/Task Analysis – This method involves breaking down complex behaviors into a number of elements, which are separately and sequentially reinforced to build up into the desired behavior.
- Self-management training – Used primarily with older patients, this technique teaches self-awareness and provides a toolbox of skills, including self-praise, that can help with the self-management of problematic behaviors.
Dr. William Pelham, Ph.D., director of the Center for Children and Families at the State University of New York, reports that studies indicate children with ADHD have 1-2 negative interactions per minute with parents and/or educators that are linked to disruptive behaviors. It may be surprising just how frequent ADHD affects everyday life, but maybe not: educators, and therapists all know well that adults often react negatively to disruptive behaviors. After all, they are disruptive. The challenge in a treatment protocol is therefore two-fold.
Primarily, an accurate ADHD diagnosis means an underlying chemical imbalance affecting impulse control and attention spans at a biological level. This is where stimulant medication comes in. As many parents of ADHD children know well, stimulant treatment can be highly effective in counteracting chemical imbalances and the challenges they present for functioning successfully in society.
Secondarily, however, an ADHD diagnosis bespeaks a set of differential behaviors in how the child engages with the world. And, most likely, how the world responds back. Every child is constantly learning from the feedback they get from their environment, and the child with ADHD is no different. For such a child, this feedback loop is constantly adding information about what kind of behaviors would produce certain reactions in the world: for instance, when and how to get attention, when and how to produce a desired reaction, and when and how to avoid things that are aversive. And children invariably use this kind of information to guide their decisions about how to behave. All children experience such a feedback loop, but for the child with ADHD, the feedback loop can quickly increase disruptive behaviors rather than non-disruptive behaviors. These disruptive behaviors are easier to engage in for the child and often produce the results desired by the child. In other words, the underlying challenges of a chemical imbalance become metastasized through information learned via behavioral engagement with the world. These learned behaviors of children with ADHD—and learned responses of their parents—can create a persistent legacy of behavioral habits, customs, and predispositions that extend above and beyond an underlying chemical imbalance.
Given the nature of these twin challenges and how they intersect, it is easy to see why a behavioral intervention plan developed, supervised, and/or provided by a Board Certified Behavior Analyst (“BCBA”) (licensed as a Licensed Behavior Analyst in New York State) can be an important and effective part of a treatment protocol for a child with ADHD. Medication can be important, but it is not a perfect or complete solution. At best, even where medication is effective at meeting its objectives, it is addressing just one part of the problem. The entire edifice of behavioral engagement with the world—and the learned behaviors that come out of that engagement—is an equally important domain. And, crucially, a child’s previous experience with the world can continue to inform his or her behavioral choices and forward-looking interaction even after effective stimulant treatment.
ABA treatment targets the behavioral domain by looking at individual levels of functioning across domains. Proper ABA treatment begins with one or more assessments made by a BCBA. The BCBA will often start by interviewing parents, teachers, and other caregivers to understand the child’s behavioral history. Then, the BCBA may conduct one or more observations of the child. For a child with ADHD, a crucial assessment is a “Functional Behavior Assessment,” which assesses the child’s motivation for engaging in particular behaviors, i.e. by evaluating the “function” of the behavior in question. The BCBA may also conduct an assessment of the child’s skill levels (i.e., a “skills assessment”). Once all of this information is processed, a BCBA can write a plan, or a series of programs, for therapists and caregivers to engage with the child in their home, community and/or school environments. Under any good plan, the therapist will interact with the child with the aim of increasing the child’s strengths, teaching replacement behaviors, and reducing or extinguishing disruptive behaviors by teaching that they do not work. Over time, the therapist is likely to better understand the function of the child’s behaviors (which often evolve), and can use this information to help parents to meet their child’s needs and thus prevent disruptive behaviors from arising in the first instance.
In short, ABA therapy with a BCBA can be an important and effective part of a treatment protocol for children with ADHD. If you have a loved one with ADHD who you think could benefit from ABA, the BCBA’s at Manhattan Psychology Group would be glad to assist.
Written by Dorrie Barbanel, LMSW, BCBA, LBA