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A Behavioral Strategy to Control Impulsivity
Although not every child or adult with ADHD is impulsive (i.e. those with the predominantly inattentive subtype), impulsive behavior is one of the most problematic aspects of this condition for many individuals. For children, this frequently takes the form of talking out of turn and blurting out answers without first raising one's hand. This can be an enormous source of frustration to parents and teachers alike.
A study appearing in a recent issue of Behavior Modification describes a procedure for dealing with this specific symptom - to get children to raise their hands before talking (Posavac et. al., (1999). A cueing procedure to control impulsivity in children with ADHD. Behavior Modification, 23, 234-253). Although this is a small-scale study - actually almost a case study involving 4 different individuals - I wanted to present it because it gives a good overview of behavioral treatment procedures and exemplifies the assets and liabilities inherent in this approach. As such, it has important implications for understanding the use of behavioral interventions in general.
Participants in this study were four 8-year-olds diagnosed with ADHD, Combined Type (i.e. they had both the inattentive and the hyperactive/impulsive symptoms) who were participating in an 8-week outpatient summer treatment program. These particular participants were selected for the study because they all identified similar target behaviors (i.e. low rates of hand raising and high rates of talking out of turn). As part of their summer treatment program, all boys participated in daily social skills training groups that contained a total of 9 boys. It was in the context of these social skills groups, that the behavioral intervention to increase the boys' hand-raising behavior was implemented. (Although 9 boys were in the social skills group, the behavioral intervention to increase hand-raising behavior was implemented with just 4 of the boys).
Note: The notion of clearly identifying a behavior to change - i.e. the target behavior - is a important concept within behavioral therapy. The idea is to identify a specific behavior, or behaviors, that one wants to enhance through the intervention and to be clear about exactly how that behavior is defined. In this study, the target behavior was clearly defined as "raising one's hand in the group before talking". One can then observe how frequently the behavior is occurring prior to treatment (i.e. before the intervention was implemented, how often each boy raised his hand in the group before talking) and how often did it occur after the intervention began. By comparing these two measures, one has an "objective" account of whether the intervention is affecting the target behavior in the desired way.
Also note that the target behavior was selected so that the intervention involved increasing something positive - i.e. raising one's hand - rather than decreasing something negative - i.e. talking out of turn. In general, one tries to design behavioral interventions to increase the child's rate of engaging in desired behaviors rather than reducing the rate of negative behaviors. The latter happens naturally as the more desirable behaviors increase in frequency. The reason for designing interventions this way is that it requires the child to do something active and prosocial. Not doing something negative, in contrast, does not necessarily require active prosocial behavior from the child.
Finally, the target behavior was selected to be one that has potentially important ramifications for the child's functioning more generally. In this particular study, targeting "raising one's hand" was intended to have the effect of making the boys less impulsive, thus enabling them to participate in the social skills group more effectively overall.
One problem that parents can often have in trying to use behavioral plans themselves is they are not clear or specific enough about what the "target behavior" is. For example, trying to get your child to "cooperate" is certainly a laudable goal, but can be problematic from the perspective of a behavioral treatment approach because "cooperate" is not specifically defined and can mean lots of different things. As a result, the parent may be somewhat inconsistent in the exact behaviors they try to target for reinforcement and the child may not know exactly what he or she is supposed to do in order to "cooperate". Instead, if the target behavior is defined as "Complying with requests within 1 minute of when they are made" - a more specific although limited definition of what it means to cooperate - one can much more easily monitor whether the targeted behavior is being demonstrated.
In this study, the authors developed what they called a "cueing procedure" that was specifically designed to increase the frequency with which the boys raised their hands before speaking. Four measures of "cueing" were included in this procedure:
1. Visual reminder - During each social skills group, the boys wore a badge on their shirt on which the target behavior of raising one's hand before talking was recorded. The logic behind this type of strategy is that children with ADHD have difficulty using internally generated rules to guide their behavior and thus need to be provided with as much external structure and reminders of those rules as possible.
2. Goal Evaluation - A timer was set to go off every 5 minutes and each child would then be individually evaluated as to whether the behavioral goal had been met. Each child evaluated his own behavior, peers evaluated each other's behavior, and the group leader considered these determinations and then made the final evaluation as to whether or not each child had met the behavioral goal (i.e. raising hand before talking in the group).
Note: This also illustrates one of the fundamental aspects of behavioral interventions for children with ADHD - frequent feedback about how they are doing. Children with ADHD tend to have difficulty using goals to help guide their behavior over long periods of time (e.g. telling a child he/she will get a reward for a good week in school is unlikely to be effective because a week is too long a period to expect most school-age children with ADHD to be able to focus on a goal and use it to direct their behavior). So, time needs to be broken up into much shorter intervals with feedback about progress towards the goal provided at the end of each interval. This helps to keep the goal fresh in the child's mind so it can be used to help direct his or her behavior during the relatively short time span.
Of course, this also illustrates why effective behavioral interventions can be so difficult to carry out. Clearly, one can not provide feedback about the child's behavior and progress towards goals over such brief intervals for an extended period of time. While this procedure may have been practical to implement in a 50-minute social skills training group, it would be next to impossible to implement over the course of an entire school day. It does illustrate what some would consider to be the ideal, although modifications to make such a procedure practical for use in real world settings are obviously important and necessary.
3. Rewards for Goal Attainment - Rewards for desired behavior are a key aspect of virtually all behavioral interventions. In this study, when the child was determined to have met the goal, he was rewarded with praise and with a large sticker that was publicly posted. If the goal was not attained but progress was made, a smaller sticker was posted. When no progress was made, the group leaders discussed with the child what needed to be altered in their behavior to attain the goal the next time.
Results
As one might expect, this intervention had clear and dramatic effects on the frequency with which the boys raised their hands in the group before talking. In fact, for each of the 4 boys, the rate of hand-raising before talking at least doubled - for some boys, the increases were even more dramatic. As one would expect, the corresponding behavior of talking out of turn showed a large decrease when the intervention was in place.
Other aspects of these results are less encouraging, however, and illustrate the limitations inherent in programs such as these. First, when the intervention was withdrawn, the rate of the desired behavior returned to pre-treatment levels, as did talking out of turn. In other words, the intervention did not seem to produce any lasting change in the targeted behavior. Of course, the same is true for medication - after it has cleared out a child's system, levels of symptoms typically return to their prior level.
Second, even when the treatment was in place and having the desired effect, it did not seem to generalize to other aspects of the boys' behavior. That is, parents did not report any improvement in their child's behavior at home. This is one of the most important limitations of such narrowly focused behavioral treatments - they generally have a strong effect on the specific behavior being targeted but tend to have little or no impact on behavior that is not a specific focus of the treatment. In addition, even for the behavior being targeted, the results do not necessarily generalize to settings other than the one where the intervention was implemented.
For this reason, it is important to try and target behaviors that are really important for the child's functioning. I usually suggest that parents think about 2-3 things that really matter - i.e. the kinds of behavior where an improvement would result in a meaningful difference for the child and family, even if lots of other things were still staying the same. For example, if a child is showing high levels of aggression towards peers, than targeted and reducing this via behavioral treatment can make a real difference in a child - and parents' - life, even if he or she still does a number of annoying things like forgetting to turn out lights or put away clothes. The bottom line is to focus on the stuff that really matters and learn to live with what is less important.
Discussion
As noted above, this study is useful because it provides a nice illustration of traditional behavioral treatment and highlights both the strengths and weaknesses of this approach. It also highlights the care and effort that needs to be put into designing and implementing a behavioral intervention. Such interventions can be enormously helpful in managing the behavior of children with ADHD, either alone or in conjunction with medication treatment. For children receiving medication, they can be essential in targeting problem areas that remain even if medication is providing a number of important benefits.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.