CHAPTER 33

BEHAVIORAL AND
SELF-REGULATORY
MANAGEMENT OF ADHD
THOMAS A. BLONDIS, MD
LINDA PFIFFNER, PHD

Attention-deficit hyperactivity disorder (ADHD) is a lifelong neurobiologic disorder that is chronic and refractory in nature.
Stimulant medication can produce some improvements throughout childhood; however, more intensive interventions by parents and teachers are most likely to make an impact in the social-emotional spheres. Research is only beginning to test the longterm benefits of a multimodal treatment that includes intensive medication titration, parent training, behavioral modification applied at home and in school, and social skills training with parent generalization.

ADHD is a chronic neurodevelopmental disorder characterized by abnormally high levels of inattention, impulsivity, and overactivity (American Psychiatric Association
[APA], 1994). Some children are not hyperactive at all, but
have significant deficits in alertness, attention, and active
working memory. These children are currently referred to
as ADHD, inattentive type (APA, 1994). This, too, is a neurobiologic disorder of attentional processing. ADHD is
developmental in nature and its core symptoms change
with age. For a diagnosis of ADHD to be considered, the
person must not only demonstrate the core behavioral
symptoms listed in the APAs Diagnostic and Statistical
Manual (DSM-IV), but must also demonstrate significant
impairment in life functions. Controlled longitudinal studies that tracked children with ADHD into early adulthood
have demonstrated that comorbid disorders are common,
underscoring the seriousness of this condition. Antisocial
personality disorder affects more than 30% of the adult
ADHD population, and depressive or anxiety disorders
occur in one-third of adults with ADHD.
The ADHD diagnosis has been challenged in recent
years. This led to a National Institutes of Health (NIH)
consensus conference, held in November 1998. The meeting included speakers who have questioned the disorders
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2005 Bernard L. Maria, All Rights Reserved
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existence. Those who believe in the scientific basis of this

disorder and critics of the disorder presented their views
to a panel that consisted of scientists who were not affiliated with the NIH and had no research interest in ADHD.
Afterward, the panel issued a statement supporting the
existence of and referring to it as a prevalent disorder that
should be viewed as a major public health problem.
No single test can be used to diagnose ADHD. To be
diagnosed as having ADHD, the child or adult not only
must have the field-tested core behaviors described in the
DSM-IV but also must show significant dysfunction related
to these behaviors. These areas of functional impairment
include delays in academic achievement, social skills, activities of daily living, school achievement, and other skills,
such as organization and communication. The disorder is
commonly associated with one or more comorbid disorders, such as conduct disorder, oppositional defiant disorder, a learning disorder, or an anxiety disorder. ADHD
symptoms, areas of functional impairment, and comorbid
conditions are important targets for intervention. Because
adult outcome studies find social development to be the
leading deficit in adults with ADHD, social development of
the child with ADHD should be a targeted area of behavioral and developmental intervention.

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Behavioral and Self-Regulatory Management of ADHD / 199

Management of the child who has a diagnosis of ADHD

has been a controversial topic in North America.
Numerous empiric studies demonstrate the success of
stimulant medication in reducing ADHD symptomatology, yet its use is continually questioned. The most wellresearched alternatives or adjunctive treatments to medication are behavioral interventions. These interventions
generally focus on the functional impairment associated
with the disorder. They can be implemented at school (eg,
classroom behavior modification), at home (eg, parent
training), and with peers (eg, social skills training). The
best outcomes occur when behavioral interventions are
used in all settings.

Evidence Basis for Behavioral Therapy

Behavior modification, applied to ADHD, begins with
identification of child behaviors to be targeted for change
by parents and teachers. Social learning principles are then
applied for the purpose of changing these behaviors. This
typically involves modifying environmental antecedents
(eg, routines, commands) and consequences (eg, rewards,
negative consequences) of the target behaviors in a way to
increase predictability, salience, clarity, and contingency.
Behavioral approaches for management of ADHD children have received a good deal of empiric support. Both
behavioral parent training and classroom-based behavioral interventions are well-established treatments for
ADHD. More recently, social skills training has shown
promise for improving peer relationships. Each of these
interventions is discussed below.
Although cognitive-behavioral approaches have had
intuitive appeal for treating ADHD and have been effective
for some disorders, well-controlled empiric studies fail to
support efficacy for children diagnosed with ADHD. This
approach teaches verbal self-instruction and problemsolving strategies to help children self-regulate and modify their own problem behaviors but does so outside the
realm of social development. At one time, these interventions were hoped to reduce the need for external contingencies. Unfortunately, for a number of possible reasons
the approach has not been effective with children who
have ADHD. Chief among these may be that children with
ADHD (even when taking medication) have problems
applying more complex tasks that demand more active
working memory and verbal-executive control of their
behavior to their everyday life, and these skills are critical
to the success of cognitive behavioral interventions.
The evidence base for behavioral interventions has
expanded as a result of the most recent large-scale study of
ADHD funded by the National Institute of Mental Health,
the Multimodal Treatment Study of children with ADHD
(MTA). The MTA evaluated an intensive package of behavCurrent Management in Child Neurology, Third Edition
2005 Bernard L. Maria, All Rights Reserved
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ioral interventions, including parent training, a summer

treatment program (including classroom behavior modification, individualized behavioral programs, peer interventions, and educational programs), and behavioral aides
in the childrens mainstream classrooms. Four treatment
groups were compared: (1) behavioral treatment alone,
(2) medication management alone, (3) combined behavioral treatment, and (4) medication management and a
community comparison group. Initial treatment effects
show that after 14 months, stimulant medication was the
single most powerful intervention for reducing core
ADHD symptoms when the physician used a much more
intensive titration methodology than is typical in office
practice. After 14 months, the study showed support for
behavioral interventions. In fact, on measures of functional impairment, children receiving behavioral therapy
showed as much improvement as those receiving medication. The combination of behavioral therapy and medication appeared to be the most efficacious treatment when
outcome means on most measures were ranked. Also, parent satisfaction was higher when behavioral therapy was
used than when medication was the sole intervention. It is
notable that these benefits accrued despite the fact that
behavioral interventions had been faded at the time the
outcome measures were collected.
New MTA data at 24 months demonstrate that the combined behavioral and medication group (Comb) and medical management (Med/Mgt) group for ADHD symptoms
withstood statistical control between 14 months and
24 months. The investigators are interpreting this new data
cautiously because self-selection factors for continued medication use after 14 months could interfere with actual medication effects. New data also show that medication doses
are higher in the Med/Mgt group than in the Comb group.
The investigators cannot conclude that early use of behavioral interventions reduces the need for higher doses of
medication, but they do conclude that the new data suggest
this might be the case. Limitations with regard to the
24-month data are due to a slight attrition across groups.
Some patients dropped out of the study because they were
disappointed with the group they were in during the first
14 months. Overall, the Comb group may be gaining on the
Med/Mgt group, which indicates that we need to pursue
behavioral intervention at this time. At this time the practitioner should view combined therapy as a medically necessary approach. This also means we need to create more
behavioral training centers in our communities to deliver
what now appears to be the best form of management.

Parent Training
For the majority of families with children with ADHD,
parent training is a critical intervention for optimizing

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management of their childrens behavior in the home. The

premise holds that if a targeted behavior draws parental or
teacher attention and rewards, the person will perform the
targeted behavior more often. Over the past 15 years, it has
become increasingly clear that even a relatively short-term
course of parent training can result in substantial improvement in child behavior at home. Parent training appears to
play an equally important role in effective social skills
training for children with ADHD.
Parent training typically includes review of behavioral
principles, functional analysis of problem behaviors, and
individualized application of behavioral programs to
changing target behaviors. Parents implement the programs
as a part of weekly homework assignments, which are then
reviewed at the subsequent session. Treatment sessions may
be with individual families or in groups. The parents of the
child with ADHD derive the most benefit if they attend all
meetings and complete the assigned homework.
A number of behavioral strategies are usually taught to
parents. Key strategies include attending and ignoring
skills, praising, using activities and tangibles as rewards,
token economies, giving effective commands, time-out,
loss of privileges, setting up planned activities and routines, and strategies for maintenance and generalization of
gains. The general focus is on teaching parents how to
design home environments that are consistent, contingent,
emphasize positive approaches, and when necessary,
include the prudent use of negative consequences.
Although the efficacy of parent training is well substantiated, the reordering of the family environment necessary
for effective behavior management may be more than some
families are able to provide. A major factor limiting the
success of parent training is poor attendance, which is more
of a problem among disadvantaged, socially isolated, singleparent, ADHD parent, and depressed parent families.
Cunningham has developed an approach to parent
training to address some of these limiting factors. In this
program, parents meet in large groups in a nonstigmatizing community setting. They learn to identify and discuss
the consequences of various parenting strategies (effective
and ineffective) through the use of videotaped models.
Parents suggest alternative strategies they find more suitable and explain their preference for these strategies over
others. The proposed solution is modeled by the leaders of
the group, and then parents practice skills using both roleplay and homework exercises. This program is similar to
other parent training programs, but the process relies less
on instruction and more on collaborative group problemsolving among parents. Uniqueness of each participating
family is respected so all parents play an active role.
To have the most impact, the parent is best advised to
become a case manager of their child with ADHD. They
should be helped to understand the neurobiologic part of
Current Management in Child Neurology, Third Edition
2005 Bernard L. Maria, All Rights Reserved
BC Decker Inc

the disorder, which makes it a chronic disorder and not a

problem that can be completely fixed. Parents should
expect they will need to support this child throughout his
or her childhood. Renewing contracts and utilizing a token
system can at times be tedious for working parents, so they
need to be reminded that a positive outcome is likely best
achieved by their investment in behavioral management.

School Consultation
Children with ADHD function best in school environments
that are consistent, predictable, and well structured and
which include clear instructional approaches and frequent
positive reinforcement. A number of accommodations can
be made in mainstream classrooms that can greatly benefit the ADHD student. These accommodations can be provided as part of a formal 504 plan (mandated by the federal
government). On the basis of a policy memorandum, children with ADHD also can be classified as other health
impaired under the Individuals with Disabilities Education
Act, and, therefore, qualify for an Individualized Education
Plan. This plan can include behavioral interventions and
accommodations tailored to the needs of the ADHD student. One of the most effective approaches is the daily
report card. In this system, teachers monitor selected target
behaviors at least several times per day (preferably during
each subject) and rate whether the child exhibited that target behavior. At the end of the day, the student takes the
card home and parents provide rewards based on the childs
ratings that day. This type of program can be implemented
throughout the school year. Additional accommodations
may include, but are not limited to, preferential seating
away from distractions and close to the teaching action,
modified curricula (eg, shortened assignments, fewer problems on a page), extra time to complete tests, increased
immediate feedback, active participation in class lectures,
simplified directions, an extra set of books for the home,
and instruction in organizational and study skills. The bottom line is to create a school environment in which the
child with ADHD can be successful.
Teachers at school also can implement strategies used to
help parents. Several basic techniques and guidelines used in
behavior modification programs are outlined in Table 33-1.
These include (1) positive feedback, (2) ignore-attendpraise, (3) teaching interaction, (4) direct prompt, and
(5) sit-and-watch procedure. These are taught during any
behavioral therapy training.
Positive feedback should be used frequently, whenever the
targeted behavior occurs. When the behavior occurs, the
parent or teacher makes a positive statement, specifically
indicating that what was done was done appropriately. The
statement is made immediately after the behavior, and it
must always be true. An example would be: Melinda, you

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TABLE 33-1. Five Modules of Behavioral Training
Module

Usage

Components

Positive feedback

To be used whenever positive target behavior occurs

A positive statement
Specific statement indicating what was done that was appropriate
Statement is made immediately after behavior
Statement is true

Ignore-attend-praise

Used when one or more groups are engaging in

inappropriate behavior (useful when attention-getting
behavior is exhibited)

Ignoring the child behaving inappropriately

Attending to child behaving appropriately
Praising child behaving appropriately
Praising misbehaving child when appropriate behavior is resumed

Teaching interaction

Used to correct child who is behaving inappropriately

and child who has not learned part of a skill. It is used
to have the child practice an appropriate alternative
or practice the part of the skill that was missing.

Interrupt inappropriate action or make a positive statement related

to the situation
Ask the child for an alternative way of behaving
If child is unable, verbalize or model alternative behavior or
missing step of skill
Have the child practice the appropriate behavior or skill
Give the child positive feedback for improvement
Give the child homework to practice appropriate behavior or skill

Direct prompt

Procedure used for highly disruptive behavior when the

ignore-attend-praise has not worked

Isolate child from group or playing area

Use a calm voice and direct eye contact
State the expected behavior
Watch for appropriate behavior
Praise the behavior when identified

Sit-and-watch procedure

Technique used for highly disruptive behavior; used

when children have become aggressive or destructive

Remove child from the group for 2 to 5 minutes (time out)

Totally ignore child
Admit child back to the group only if he or she behaves quietly

Adapted from Cousins LS, Weiss G. Parent training and social skills training for children with attention-deficit hyperactivity disorder: how can they be combined for
greater effectiveness? Can J Psychiatry 1993;38:44957.

really did a good job. I thought the way you worked through
all of your problems without any help was excellent. The
use of such praise is important, yet research clearly demonstrates that more potent positive reinforcement programs
are necessary. These include use of activities and tangibles
as rewards and use of token economies (eg, daily report
card) with back-up rewards. These more powerful positive
interventions are almost always required to achieve significant improvement in the child with ADHD.
Ignore-attend-praise is a method used when someone in
a group is engaged in negative behavior. Usually this is
behavior that is attention-getting behavior. The use of
this method includes several steps:
Ignoring the child behaving inappropriately
Praising the child behaving appropriately
Praising the misbehaving child when appropriate
behavior resumes
For example, Peter starts talking to Mike, and Steve is
sitting right next to them working on his science assignment. The teacher praises Steves work while ignoring Peter
and Mike. Mike stops talking to Peter and begins to answer
these questions. The teacher praises Mike for stopping
himself from being distracted and beginning to do his
work. If Peter then begins to do his work, the teacher can
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2005 Bernard L. Maria, All Rights Reserved
BC Decker Inc

praise Peter for getting back to his assignment or wait and

later praise him for finishing his assignment.
Teaching interaction is when the parent or teacher
intervenes to correct a child who may have missed a step
in a problem or who is simply misbehaving. The parent/teacher interrupts the offensive behavior by stopping
the childs actions, indicating an alternative way of behaving, and then having the child practice the alternative.
The parent/teacher should make a positive statement at
the time of the unacceptable behavior. For example, if a
child interrupts a teachers conversation, the teacher
might respond, John, great that you have something to
add. Hold that thought until I call on you. When her
conversation is completed the teacher might tell the child,
You did a great job of waiting until I finished hearing
what Ron had to say. The teacher would then ask the
child what he wanted to say. Afterward, the teacher might
encourage the child to practice waiting, I want you to
practice holding your thought until you are called on,
recognizing that she will need to reinforce this behavior
to encourage its expression.
When the ignore-attend-praise technique fails, the
teacher or parent can use direct prompting. In this case, the
teacher or parent should not be negative in the response.
The child will interpret a negative tone as nagging. Make

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direct eye contact and say in a neutral voice, You have a

direction to take out the trash, Bill. When Bill gets up to
take care of his chore, he would be praised (eg, I like how
you followed directions).
Sit and watch (time-out) is reserved for behaviors that
are extremely disruptive. For example, Joe shoves Bill at the
party. Joe is told to sit in a specified area outside of the
group for several minutes. The group is told to ignore him
while he is sitting out of the group. After a specified
amount of time has elapsed, Joe can return to the group
and join in the ongoing activities if he acknowledges that
he was wrong.
During the course of parent training sessions or consultation sessions with the teacher, the strategies and their
components are reviewed. Emphasis is always on ignoreattend-praise, teaching interaction, and direct prompting.
Parents and teachers should be encouraged to match techniques that seem to best fit a particular situation. In groupbased parent training sessions, parents also may be helped
to learn the skills by role-playing the techniques with a
partner, who plays the child. To supplement the parent
and teacher-directed interventions, the children can be
taught self-monitoring and self-evaluation skills. A good
way to start this is by drawing up a contract with the child
that includes target behaviors, tokens earned, and back-up
reinforcement. The children would then monitor how well
they think they did during each rating period (eg, did they
exhibit the target behavior?) and how many tokens they
think they should earn. To encourage this skill, they could
be provided with extra tokens for matching the parent or
teachers rating. This approach encourages children to be
active participants in their own treatment.

Social Skills Training

Clearly, many children with ADHD have deficits in social
skills, and these are among the more difficult of their
problems to treat. Scientific investigations have shown
that rejection by peers remains stable across time even
when children with ADHD make behavioral improvements. Peers then form negative attitudes and continue to
reject the child who has ADHD on the basis of his or her
initial bad reputation.
The child with ADHD, combined type tends to be
rejected by peers, whereas the child with ADHD, inattentive
type tends to be ignored by peers. The rejection of the child
with ADHD, combined type occurs when the child
attempts to socialize but becomes disruptive and sometimes aggressive. The child with ADHD, inattentive type
tends not to become aggressive or disruptive. This child is
likely to be more passive and withdrawn when peers neglect
him or her. Generally, these children have a slower cognitive tempo and suffer from delays in skills that may cause
Current Management in Child Neurology, Third Edition
2005 Bernard L. Maria, All Rights Reserved
BC Decker Inc

them to be inhibited about engaging in activities that

require confidence and speed. Less research has been done
regarding social skill failures of children with the ADHD,
inattentive type and also with girls who have ADHD.
Medication has been shown to improve social skill
intervention by decreasing disruptive and aggressive outbursts and, in some cases, improves the childs social standing. However, medication does not have a normalizing
effect on social behavior, and some children with ADHD
actually show social withdrawal while receiving stimulants.
Medication also does not improve the skills of children
having frank social skill deficits. In some cases, it improves
the output of children with inattentive-type ADHD, but
social skill deficits remain.
Research of direct social skills training with children
who have ADHD has been modest. Generalization of social
skills has been a major problem. However, investigation of
newer broad-based social skills training has been encouraging. Pfiffners broad-based social skills training program
for ADHD targets teaching skills of social significance
through motivational systems that reduce performance
problems. It is built upon the understanding of verbal and
nonverbal social cues. It promotes generalization by incorporating parents, teachers, and other caretakers.
In a study that produced large effects, children assigned to
the parent-generalization group received concurrent sessions
with parents, wherein the parent and clinician discussed the
importance of social skills and social status. The parents role
was to help their child improve peer relations. Both the social
skills training group without parent-generalization involvement and the parent-generalization group demonstrated
improvement on parent reports of social interaction and
home behavior problems. The parent-generalization group
showed some generalization in the school setting, which was
maintained the following school year with new teachers.
This program encompasses the modules listed in
Table 33-2. Teaching includes didactic instruction, symbolic (puppets, etc.) role-playing, behavioral rehearsal,
and modeling. A response/cost-based point system is
implemented to address behavioral concerns during the
group. Childrens points are exchanged for childselected activities when the formal session is concluded.
Parents review the teaching that their children received
throughout these modules.
Parents can be taught to support their childs social
development by planning and organizing their childs social
life outside of school. For example, to develop friendship
skills, parents might identify children who are good play
date matches for the child and obtain suggestions from
teachers. Initially, the parents are advised to be involved
during play dates to supervise the play, with the idea that
as success occurs they can withdraw this supervision. A
proactive stance on the part of the parent in helping the

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TABLE 33-2. Six Modules of Social Skills Treatment
Module

Components of Module

1. Good sportsmanship

Following directions
Participating and staying in game
Following game rules
Sharing with and encouraging teammates
Being polite to players from the opposing
team

2. Accepting consequences

Accepting negative consequence without

loss of control
Ability to reflect upon cause of consequence
Resolution to avoid cause of consequence
in the future

3. Assertiveness

Distinguishing among passive, aggressive,

and assertive responses
Using assertive communication

4. Ignoring mild provocation

Inhibiting verbal reactions

Inhibiting nonverbal interactions

5. Problem-solving

Identifying and solving a problem

Use of a five-step approach to problem solving

6. Recognizing and dealing

Identifying feelings in others with feelings

Dealing with anger

deficits and hyperactivity in children and adults. New York

(NY): Marcel Dekker; 2000. p. 56992.
National Institutes of Health. Diagnosis and treatment of attentiondeficit hyperactivity disorder. Consensus Developmental
Conference Statement. Bethesda (MD): NIH Consensus
Statements; November 168, 1998.
Pelham WE. The NIMH multimodal treatment study for
attention-deficit hyperactivity disorder: just say yes to
drugs alone? Can J Psychiatry 1999;44:98190.
Pelham WE, Wheeler T, Chronis A. Empirically supported psychosocial treatments for attention-deficit hyperactivity disorder. J Clin Child Psychol 1998;27:190205.
Pfiffner LJ, Calzada E, McBurnett K. Interventions to enhance
social competence. Child Adolesc Psychiatr Clin North Am
2000;9:689709.
The MTA Cooperative Group. A 14-month randomized clinical
trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 1999;56:107386.
Wigal T, Swanson JM, Douglas VI, et al. Effect of reinforcement on
facial responsivity and persistence in children with attentiondeficit hyperactivity disorder. Behav Modif 1998; 22:14366.

Adapted from Pfiffner LJ et al, 2000.

child plan the play date activities is key for facilitating the
success of the get-together.

Summary
ADHD is a lifelong neurobiologic disorder that is chronic
and refractory in nature. Stimulant medication can produce some improvements in symptoms throughout childhood; however, more intensive behavioral interventions
by parents and teachers are most likely to maximize outcomes in the social-emotional spheres. Research is only
beginning to test the long-term benefits of a multimodal
treatment that includes intensive medication titration, parent training, behavioral modification applied at home and
in school, and social skills training with parent generalization. This research needs to continue to address this major
public health concern in the United States. A large percentage of individuals with ADHD end up leading a life of
disability rather than a life of productive creativity. We
should invest our time, energy, and money if we seriously
want to address this substantial public health problem.

Suggested Readings
Blondis TA, Boyd PA. Multidisciplinary approaches. In: Accardo
PJ, Blondis TA, Whitman BY, Stein MA, editors. Attention-

Current Management in Child Neurology, Third Edition

2005 Bernard L. Maria, All Rights Reserved
BC Decker Inc

Practitioner and Patient Resources

Children and Adults with Attention-Deficit Disorder (CHADD)
499 NW 70th Ave., Suite 101
Plantation, FL 33317
Phone: (800) 233-4050
http://www.chadd.org
Founded in 1987 by a group of concerned parents, CHADD
works to improve the lives of people with ADHD through education, advocacy, and support. Working closely with leaders in the
field of ADHD research, diagnosis, and treatment, CHADD offers
its members, and the public, information they can trust.
ADD Warehouse
Phone: 1-800-233-9273
http://www.addwarehouse.com
ADD Warehouse offers a large collection of ADHD-related
books, videos, training programs, games, professional texts, and
assessment products, as well as a newsletter and free articles.
Neuropsychology Central
http://www.neuropsychologycentral.com
Neuropsychology Central is sponsored by the American
Psychiatric Association. The primary objectives of this Web site are
to describe the importance of neuropsychology as a science of
brain and behavior, to increase public knowledge of neuropsychology as a branch of practical medicine, to indicate the contribution which neuropsychology is making to the neurosciences,
and to act as a resource for the professional and layperson.

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