Behavior Management for

S c h o o l - A g e d C h i l d ren w i t h
ADHD
a, b
Linda J. Pfiffner, PhD *, Lauren M. Haack, PhD

KEYWORDS
 Attention-deficit/hyperactivity disorder  Children  Parent training
 Behavior management  Evidence-based treatment

KEY POINTS
 Behavior management treatments are well-established, evidence-based treatments for
school-age children with attention-deficit/hyperactivity disorder (ADHD) and should be
widely recommended to families.
 Behavioral parent training can be augmented with classroom-based intervention or child
components to extend results across home, school, and social settings.
 Combined behavior management and stimulant medication often produce the most
potent outcomes and when used in combination may reduce the dose needed for
each, although family/cultural preferences for treatment modalities should also be
considered.
 Continued research is needed to better tailor treatment to families with multiple stressors,
parent mental health concerns (eg, ADHD, depression), and those from varied family
structures and cultures.
 Translation and dissemination of evidence-based behavioral treatments to school and
community settings are sorely needed to increase accessibility. Feasible, cost-effective
models for treatment and training of school-based and community-based providers are
crucial.

INTRODUCTION/BACKGROUND
Target of Treatment
School-aged children with attention-deficit/hyperactivity disorder (ADHD) show a
range of inattentive, hyperactivity, and impulsivity symptoms that translate into serious

Disclosures: Work on this article was supported, in part, by grants from the National Institute of
Mental Health R01 MH077671 (L.J. Pfiffner) and F32MH101971 (L.M. Haack) and Institute of Ed-
ucation Sciences, US Department of Education, R324A120358 (L.J. Pfiffner).
a
Department of Psychiatry, University of California, San Francisco, 401 Parnassus Avenue,
Box 0984, San Francisco, CA 94143, USA; b Department of Psychiatry, University of California,
San Francisco, 401 Parnassus Avenue, G06, San Francisco, CA 94143, USA
* Corresponding author.
E-mail address: lindap@lppi.ucsf.edu

Child Adolesc Psychiatric Clin N Am 23 (2014) 731–746

http://dx.doi.org/10.1016/j.chc.2014.05.014 childpsych.theclinics.com
1056-4993/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
732 Pfiffner & Haack

Abbreviations

BPT Behavioral parent training

CLAS Child life and attention skills
CLS Collaborative life skills
DRC Daily report card
EBT Evidence-based treatment

academic and social/interpersonal impairment at home, at school, and in other set-

tings as well (eg, public places, sporting events, camps). Behavior management inter-
ventions primarily target functional impairments rather than ADHD symptoms per se.1
At home, common problems targeted for behavior management treatment may
include:
 Noncompliance and lack of independence in completing daily chores and
routines (eg, getting ready in the morning and going to bed at established
times)
 Homework problems (eg, unrecorded assignments, forgotten materials, need for
frequent reminders to start and complete homework, disorganization, and lack of
attention to details/careless mistakes)
 Co-occurring aggression and defiance toward parents or siblings
Dysfunctional parenting is usually a key target of behavior management interven-
tions. Parents of children with ADHD show more negative and ineffective parenting
(eg, power assertive, punitive, inconsistent) and less positive or warm parenting, rela-
tive to parents of children without ADHD,2,3 and family conflict tends to be high.
Behavior management interventions, such as behavioral parent training (BPT), directly
target these parenting styles to improve child behaviors and family relationships and to
reduce overall family conflict.
At school, students with ADHD are often inattentive, disorganized, off-task, and
disruptive, which often leads to low rates of work completion both in class and at
home.4,5 Children with ADHD also show a variety of peer-related problems, including
overly intrusive and negative peer interactions,6 which can be further exacerbated by
associated aggression, argumentativeness, disruptiveness, and lack of self-control.7
Behavior management interventions at school target behaviors across all of these
domains.

Need for the Treatment

The need for treating children with ADHD during the school-age years is crucial. The
short-term consequences of ADHD symptoms and organizational impairments
include poor scores on class tests, report cards, or academic achievement tests.8
The short-term consequences of these children’s social interaction problems include
conflicted family relationships and few friendships, as well as frequent rejection or
neglect from peer groups.7 Prospective follow-up studies show that children with
ADHD are at considerable risk for interpersonal and educational problems as they
grow older, as shown by frequent placement in special education classrooms, grade
retention, school failure, early dropout, and juvenile delinquency9,10 and girls in partic-
ular are at risk for self-harm and suicide.11
Several behavioral treatments are available that target the multiple impairments and
risk factors for ADHD across settings. This article focuses on behavior management
treatments developed for the home setting, known as BPT (also variously referred
 Behavior Management for Children with ADHD 733

to as parent management training, parent training, or behavioral family therapy), as

well as those home-focused treatments that include additional components to
enhance generalization to other settings (eg, schools). Readers are referred to other
articles in this issue for coverage on social skills training (Mikami, Jia, Na), summer
treatment programs (Fabiano, Schatz), and school-based interventions (Evans, Lang-
berg, Egan, Molitor).

BEHAVIOR MANAGEMENT INTERVENTIONS

Theoretic Overview
The theoretic underpinnings for the practices taught to parents and teachers in
behavior management treatment are grounded in contingency theory.12 Consistent
with this theory, child behavior can be increased by following it with rewarding stimuli
(ie, positive reinforcement) or by removing aversive stimuli (ie, negative reinforce-
ment). Alternatively, behavior can be decreased by following it with aversive stimuli
(ie, punishment) or by removing rewarding stimuli (ie, extinction). With consistent
use of contingency management over time, the child’s behavior can be shaped to
achieve desired goals. Behavior management treatment is also grounded in social
learning theory,13 which considers contingency theory principles alongside other fac-
tors, including modeling and imitation of observed behaviors (eg, parent behaviors)
as well as cognitive factors (eg, parental appraisals and attributions of child
behavior).

Functional behavioral analysis

The first step in designing a behavior management intervention involves conducting
a functional behavior analysis, which includes identifying target behaviors to in-
crease (ie, positive behaviors) or decrease (ie, negative behaviors) and then identi-
fying factors in the child’s environment related to the occurrence of the target
behavior. Specifically, factors in the child’s environment occurring immediately
before and after the behavior (ie, antecedents and consequences, respectively)
that may be precipitating or maintaining the likelihood of the behavior are identified.
In this way, the function of the behavior can be determined (eg, to gain attention or
avoid work). Target behaviors typically represent areas of functional impairment
affecting the child in their everyday life and sometimes, but not always, map directly
onto the symptoms of ADHD defined in the Diagnostic and Statistical Manual of
Mental Disorders.14,15 Behaviors, as well as their antecedents and consequences,
are defined so as to be objective and measurable. Based on this analysis, a behavior
plan can be developed that changes the antecedents and consequences that have
been maintaining the target behavior, thereby modifying the likelihood of the
behavior in the desired direction (eg, increases positive behavior and reduces nega-
tive behavior).

Parent-child interaction alterations

In addition to using functional behavior analysis, behavior management treatment fo-
cuses specifically on altering negative parent-child interaction patterns, which are
often present in families with a child with problem behavior, including ADHD. These
interaction patterns, referred to as the coercive process, are cycles in which parents
and children control one another’s behavior via negative reinforcement.12 An example
of this process occurs when children show problem behaviors (eg, noncompliance to
a parent request) and parents respond negatively, creating a cycle, each time esca-
lating in severity or emotional tone. Either the child or parent complies with the other’s
demand, ending the cycle, and reinforcing the escalated negative behavior pattern.
734 Pfiffner & Haack

Many of the functional impairments and related conduct problems shown by children
with ADHD become reinforced through this process. Thus, although not a cause of
ADHD, the coercive parent-child interaction cycle predicts poor educational out-
comes, peer relations, social skills, and aggressive behavior.16,17 Furthermore,
parenting styles associated with the coercive cycle mediate the effects of contextual
risk factors, such as stress, parental depression, and social disadvantage, on child
behavior problems.18 Behavior management training directly targets these dysfunc-
tional parenting practices by teaching families how to modify antecedents and conse-
quences to reduce the likelihood of the coercive process and improve child behaviors
and family relationships.
The usefulness of behavioral approaches with ADHD is supported by studies
showing that ADHD is associated with neurally based motivational systems that
respond poorly to the kinds of contingencies commonly used by parents and teach-
ers. Specifically, children with ADHD relative to those without ADHD are less respon-
sive to inconsistent, delayed, and weak reinforcement and are less responsive to cues
of punishment or nonreward.19,20 Integral to behavior management interventions is a
focus on modifying parent-delivered and teacher-delivered rewards and conse-
quences. These practices, together with the additional external structure provided
by behavioral interventions, can also help address the executive weaknesses that
are a part of ADHD.

Intervention Description: How Is the Treatment Delivered?

BPT is the predominant mode of behavior management treatment targeting home-
based problems for school-age youth with ADHD.15,21 BPT typically includes 8 to
12 group or individual sessions focused on 3 main objectives:
1. Providing psychoeducation about ADHD and the behavioral framework for
treatment
2. Teaching effective parenting skills for improving desired behavior and decreasing
problem behavior through altering antecedents and consequences, as discussed
earlier
3. Practicing/troubleshooting effective implementation of such skills
To accomplish these goals, each session is usually structured to include a didactic
portion, in which new material is presented, as well as an interactive portion, in which
parents discuss the implementation of parenting skills. A crucial aspect of the treat-
ment is the homework assignments, in which the parents apply the newly learned skills
at home and track child improvement for discussion and troubleshooting in the next
session.

Parenting skills
BPT programs tend to cover a set of similar topics. Psychoeducation about ADHD and
the behavioral model for treatment is often covered first. Thereafter, most BPT pro-
grams begin with teaching parents positive attending skills to improve the parent-
child relationship and promote a positive family climate, as well as contingent positive
consequences (eg, praise, activity rewards, token economies/point systems) to
encourage appropriate child behavior. Positive strategies are discussed first, because
they can interrupt the coercive cycle often shown in families of children with ADHD. In
addition, parents often find it easier to implement reward rather than punishment pro-
grams consistently and effectively, and the initial use of reward programs may result in
substantial improvement, reducing the need for negative consequences. BPT also
emphasizes setting the stage for child compliance and independence by teaching
 Behavior Management for Children with ADHD 735

parents to provide clear, specific commands (eg, effective vs ineffective instructions),

to establish consistent routines and expectations, and to implement when/then con-
tingency systems (eg, when you complete your homework, then you can have screen
time). BPT programs also cover effective use of negative consequences for rule viola-
tions (eg, noncompliance or aggression). For example, time-out and response cost
(eg, loss of desired activity or tokens) as well as extinction strategies for attention-
seeking behavior (eg, planned ignoring) are commonly taught. Information about
school accommodations and advocacy and troubleshooting future problem behaviors
are also a part of BPT.

Teacher involvement
BPT can be expanded to include adjunctive empirically supported behavioral interven-
tions to address a broader range of problem behavior and enhance generalization of
treatment gains across settings. Many BPT programs add school-based interventions,
such as a daily report card (DRC) system (see article on middle school–based and high
school–based interventions for adolescents with ADHD by Evans and colleagues else-
where in this issue for full description of school-based interventions). DRCs are indi-
vidually designed for each child and include target problem behaviors in academic
or social domains (eg, turning in schoolwork, following directions, getting along with
others) shown in the classroom. Teachers provide a rating for each target behavior
on the DRC, which is sent home daily, and the child is provided with home-based re-
wards based on the ratings at school. This system provides the child with frequent and
immediate feedback on their classroom behavior and facilitates regular communica-
tion between the parents and teachers. In BPT programs that include DRCs, parents
are taught how to work with teachers to support the program at home. In addition, the
clinician may provide support and guidance for establishing, implementing, and trou-
bleshooting the DRC through conjoint consultation meetings with the teacher, parent,
and child.22–25

Peer involvement
BPT has also been combined with child treatments including behavioral peer inter-
ventions (eg, summer treatment program; see article on summer treatment pro-
grams for youth with attention-deficit/hyperactivity disorder by Fabiano and
Schatz elsewhere in this issue) and child skills training. These treatments generally
focus on improving social interactions or study/organizational skills. For example,
Pfiffner and colleagues24,25 combined BPT and school consultation (including a
DRC) with child training in executive/organizational and social interaction skills in
an integrated program for the inattentive presentation of ADHD (child life and atten-
tion skills [CLAS] program). CLAS uses BPT adapted for inattentive-related target
behaviors and executive function problems through rehabilitation psychology tech-
niques. Child training modules focus on skills for independence (academic, study,
and organizational skills; self-care and daily living skills) and social skills (eg, good
sportsmanship, assertion, conversational skills, dealing with teasing, friendship mak-
ing, playdate skills). These skills are taught to children in a group setting through a
combination of didactic instruction, modeling of skills by group leaders, behavioral
rehearsal, corrective feedback, and in vivo practice in the context of a reward-
based contingency management program. An important feature of the group is
that it serves as a vehicle to introduce and support/reinforce behavioral programs
at home and school. Crucially, parents and teachers are taught the same skills
and coached to effectively reinforce their child’s use outside the group to promote
generalization.
736 Pfiffner & Haack

Nontraditional caregiver adaptations

Recently, BPT has been adapted for use with caregiver populations underrepresented
or less responsive to traditional programs, such as single mothers,26 depressed
mothers,27 and fathers.28 These treatments largely follow the structure and topics
described earlier but modify certain aspects of program delivery or content. For
example, the strategies to enhance positive parenting program, designed for single
mothers of children with ADHD, uses an enhanced intake procedure to increase
parental motivation and to troubleshoot potential barriers to treatment adherence
and also uses group problem-solving activities to encourage development of social
support networks. Integrated parent intervention for ADHD is an adaptation of BPT
for depressed mothers of children with ADHD, which integrates mood monitoring,
cognitive restructuring, and behavioral activation through pleasant activities and relax-
ation into the standard BPT curriculum.27 BPT has also been adapted for fathers of
children with ADHD.28 The adapted intervention integrates standard BPT with a recre-
ational sports activity (ie, soccer game) for fathers to practice newly learned parenting
skills with their children.
Specific child problems
BPT has also been tailored to specific child profiles and problems. For example,
Mikami and colleagues29 modified the scope of BPT to target friendship problems,
a commonly associated impairment domain for children with ADHD. This treatment,
called parental friendship coaching, teaches parents strategies for encouraging and
reinforcing their children in the practice of successful peer interactions.29 In another
case, Abikoff and colleagues30 used a modified BPT approach focused on improving
children’s organizational problems. Treatment involved training parents and teachers
to reinforce children contingently for meeting end-point target goals for improving
organizational, homework, and school performance and included a DRC, token econ-
omy for achieving home goals, and homework rules and structure. In addition, Pfiffner
and colleagues24,25 adapted BPT for the inattentive presentation of ADHD (CLAS), as
described earlier.
Improved accessibility
Recent efforts have been made to improve accessibility and feasibility of behavior
management interventions by delivering treatment via convenient, trusted, and
cost-effective environments and modalities. For example, a more practical alternative
to clinic-based BPT has been developed relying on handbooks, videos, and weekly
telephone sessions for intervention delivery.31 The collaborative life skills (CLS) pro-
gram32 trains public elementary school social workers to deliver a school-home treat-
ment incorporating BPT with school-based treatment and child skills training entirely
within the school setting.
Empirical Support
Several systematic reviews and meta-analyses of behavioral interventions, based on
more than 40 years of research with more than 3500 youth, have been published in
recent years.33 In the most comprehensive meta-analysis of behavioral interventions
to date, Fabiano and colleagues34 reported large between-group effect sizes (ES 5
0.83) for behavioral interventions when collapsed across outcome measures. The
largest effects were seen for parent-rated functional impairment, teacher-rated
ADHD symptoms, and academic productivity. Large ES were also found across
pre-post (ES 5 0.7), within-subject (ES 5 2.64), and single-subject designs (ES 5
3.78). These ES are in the same range as those for stimulant medication.35 Although
a different meta-analysis reported smaller effects for behavioral interventions,36 the
 Behavior Management for Children with ADHD 737

criteria for study inclusion in the latter review were restricted (eg, only randomized clin-
ical trials with an ADHD symptom outcome), and the review focused exclusively on
ADHD symptom outcomes, with an emphasis on blinded measures of ADHD. As a
result, much of the literature supporting behavioral intervention effects on functional
impairment, a crucial clinical outcome, was not considered in that review.

Evidence-based treatment validation

Of particular relevance to this discussion, BPT has been confirmed as a well-
established treatment based on strict evidence-based treatment (EBT) evaluation
criteria for evaluating psychosocial treatments in 3 separate reviews since
1998.1,33,37 Combined behavioral treatments, which add school or child components
to BPT, also meet criteria as well-established treatments based on the most recent re-
view.37 Furthermore, numerous studies of BPT alone and combined with other behav-
ioral treatments meet evidence criteria based on What Works Clearinghouse
standards (Institute of Education Sciences), and are categorized as type 1 and 2
controlled studies that use rigorous scientific methodology using Nathan and Gorman
categorization criteria.33 Outcomes from these studies include improvements in child
compliance, conduct problems and parenting as measured through blinded observa-
tions and ratings and improvements in parent-rated ADHD and oppositional defiant
disorder symptoms, disruptive and aggressive behaviors, homework problems, and
overall functional impairment compared with alternative treatment, waitlist, or usual
care controls. Reduced parenting stress and increased parenting self-confidence
are also reported. Evidence exists for maintenance of treatment gains for several
months after treatment ends. Based on these multiple systematic reviews of random-
ized clinical trials, BPT alone and combined with other behavioral interventions meets
the criteria for level 1 (most stringent level) regarding treatment benefits in the levels of
evidence framework specified by the Oxford Center for Evidence-Based Medicine
guidelines.

Benefits of therapy adaptations

The recent adaptations of BPT to reach fathers, single mothers, and depressed
mothers all show benefit in terms of better engaging the families in treatment,26–28
and father involvement may enhance treatment maintenance.28 Adding cognitive-
behavioral treatment of maternal depression to BPT results in additional reductions
in maternal depressive symptoms. Adaptations of BPT to include school-based inter-
ventions through home-school partnerships have been successful in improving the
quality of family-school relationships and homework relative to psychoeducational
support.23 When BPT and home-school interventions are combined with child skills
training for the inattentive presentation of ADHD, greater improvement is found on a
broad array of school-based measures (inattention symptoms, organizational and so-
cial skills, global impairment) and parent report of organizational skills than BPT alone
or usual care.25 Additional adaptations of BPT focused on specific child problems
have been successful in improving children’s social skills and friendship quality on
playdates,29 as well as organization and academic skills.30 Initial findings examining
interventions designed to be more accessible and feasible show promising effects
on ADHD symptom reduction,31 academic and organizational skills, social behavior,
and classroom engagement32; a randomized trial comparing the latter intervention
(CLS) with usual school services is under way.

Limitations of therapy
Several important limitations in behavioral treatment effects have been reported.
738 Pfiffner & Haack

1. Outcomes from behavioral interventions tend to be setting specific, so that behav-

ioral interventions implemented in one setting (eg, home) often do not generalize to
another setting (eg, school) without behavioral intervention in that setting as
well.25,38
2. Although treatment effects can persist for at least several months after treatment
ends, beyond that time, periodic treatment may be necessary.
3. Although they are large, the effects from behavioral treatments may not achieve full
normalization.

CLINICAL DECISION MAKING

Who Is Most Likely to Respond
Several parent factors affect response to behavioral interventions, because parents
serve such a critical role in provision of treatment. As might be expected, families
who are able to attend treatment sessions regularly and consistently implement the
interventions at home tend to have the most favorable outcomes.39,40 Families with
sufficient resources tend to be able to follow through more consistently. Such re-
sources might include finance/health care, transportation, time available to attend
sessions, and caretaking for siblings while they attend sessions. Two-parent families,
those with social support, and those with low levels of parental stress and psychopa-
thology (eg, ADHD, depression) tend to have more favorable outcomes.33 Behavioral
interventions tend to be successful across races and ethnicities,41 although there may
be a need for some cultural adaptations.42 In addition, positive parental expectations
and beliefs about the child’s capacity for change can improve engagement in BPT and
child outcomes,43 and including a child component can reduce premature termination
in BPT,44 suggesting that including the child in treatment may exert a positive effect on
parents’ motivation for treatment.
The severity of child symptoms and impairments can also influence outcomes. For
example, Langberg and colleagues45 found that, at 24-month follow-up in the Multisite
Treatment Study for ADHD (MTA) study, the benefits of the combined intervention on
homework problems were strongest for children with moderate (rather than severe)
parent-rated ADHD symptoms. Behavioral interventions seem to be equally effective
for those with or without co-occurring oppositional or conduct problems or comorbid
anxiety, and both boys and girls through the school-age range (age 6–12 years)
respond well to behavioral interventions.46

Which Outcomes Are Most Likely Affected by Treatment

Treatment-related gains are found across several child, family, and parent outcomes,
with the greatest impact occurring in treated settings. For BPT, effects are reliably
observed on parent report of their child’s ADHD symptoms, oppositional and conduct
problems, homework problems, and overall functional impairment.33,34 Increased
compliance and reductions in problem behavior are also observed on blinded obser-
vations of child behavior during parent-child interactions in the clinic or home.47
Changes in child behaviors are often a direct result of improvements in parenting,
which is the most immediate target of BPT. Parenting outcomes include increased
use of positive parenting strategies (eg, praise, attending) and effective commands
and decreased negative and ineffective discipline, as reported by parents and as
observed in blinded observations of parent-child interaction.16,47 Parents also report
less stress and depression and an increased confidence in their ability to manage their
child’s behavior after participation in BPT, as well as generalized improvement in
parent-child and family relationships, and report high satisfaction with treatment.48,49
 Behavior Management for Children with ADHD 739

When BPT is combined with school-focused or child-focused interventions, a

broader range of risk factors and settings contributing to child problems are targeted,
and as a result, a broader array of improvements is expected. For example, combined
BPT and school-based interventions show improvements that extend to family-school
relationships23 and child outcomes at school, as shown by reductions in teacher-
reported ADHD symptoms and externalizing behaviors.24,25 When BPT is combined
with a child component, improvements occur in outcome domains addressed in the
child component, such as in organizational or social skills and academic
performance.25

Contraindications for Treatment

Behavioral treatments are effective across a broad population of families and children
with ADHD. However, traditional BPT may be contraindicated for those parents unable
to meet the varied demands of this intervention, most notably, the time and effort to
attend weekly sessions and implement behavioral plans between sessions at home.
For example, parents with significant psychopathology (such as anger management
problems, ADHD, depression, substance abuse), limited cognitive capacity, or those
in highly conflicted marital/partner relationships may be unlikely to participate in the
treatment.50 In these cases, alternative formats, such as a more graduated and
tailored introduction of skills, may be successful or adjunctive treatment such as anger
management, individual counseling, or couples therapy may be indicated concurrently
or before initiation of BPT.

Potential Adverse Effects of the Treatment

Adverse effects from behavioral interventions tend to be low. The most common
adverse effects are likely related to frustration that children may feel if they are not suc-
cessful (eg, in earning the rewards) or that parents may feel if the program is not work-
ing as well as they would like. Modifying the program in some way (eg, revising the
behavioral requirements or changing rewards) is usually effective in mitigating these
problems. More serious complications may occur in the case of a parent who is overly
critical or potentially violent and misuses or overuses punishment or a child who is
aggressive toward a parent when punished. An errorless learning approach,51 which
minimizes child noncompliance by using a success-based gradual introduction of
more demanding requests or reward-only programs, may be beneficial in these cases.
Misuse of rewards may also lead to untoward effects. Studies show that rewarding
behaviors that already have intrinsic value decreases their intrinsic value.52 Also, as
discussed earlier, rewarding the termination of a problem behavior may inadvertently
increase that behavior through negative reinforcement (eg, “If you stop the tantrum,
you can have dessert” or in the case of children demanding rewards to complete
tasks). In addition, recent studies have shown that children who receive ability-
focused praise are more likely to become discouraged and give up during challenging
tasks; whereas effort-focused praise is best for improving motivation and persistence
on challenging tasks.53 These studies highlight the need to carefully design and judi-
ciously use praise and other reward-based programs.

How Should the Treatment Be Sequenced or Integrated with Drug Therapy and with
Other Nondrug Treatments (eg, Stand Alone, Combination)
Behavioral interventions are often applied in tandem with medication treatment of
optimal effects. In the large-scale multisite MTA study54 comparing the separate
and combined effects of behavioral interventions and stimulant medication, combined
treatment showed incremental benefit on composite measures of parent and teacher
740 Pfiffner & Haack

behavior ratings. Consistent with the respective targets of these 2 treatment modal-
ities, medication seems to have greater impact on ADHD symptom reduction,22
whereas behavioral intervention seems to have greater impact on some areas of func-
tional impairment, including homework success45 and parenting.47 Professional prac-
tice guidelines often recommend multimodal approaches for school-age youth.55 The
decision about whether to use 1 or both interventions is based on a variety of factors.
Child symptom severity is an important consideration, and severe levels of ADHD
symptoms and impairment often dictate combined treatment approaches.55
Parent preferences and cultural factors are also important to take into account,
because adherence to treatment regimens is a requirement for the success of either
approach. Most parents favor the use of behavioral interventions over medication,
and an initial trial of behavior modification before medication use is supported by
the literature. For example, the MTA study found that approximately 75% of children
assigned to the behavior modification alone condition were successfully treated
without medication, and nearly two-thirds of this group were maintained without medi-
cation for the 1-year and 2-year follow-ups.1 In addition, previous use of behavior
modification has been shown to reduce the optimal dose needed for medication.56,57
In general, optimal sequencing and integration of behavior management and medi-
cation requires taking into account the dose or intensity of each treatment. Based on
recent studies of varying doses/intensities of behavioral and medication treatments,
fewer benefits of combined treatments are observed when the dosage of either treat-
ment is high.56,57 Therefore, the optimal dose needed for medication is less when
behavioral interventions are in place and the combination of low doses of each inter-
vention is equivalent to a high dose of either treatment alone. Given the interactive ef-
fects of behavioral interventions and medication, it is imperative that treatment
providers closely collaborate to optimize outcomes.8

Clinical Vignette
The following case vignette shows processes involved in behavior management treat-
ment, including the application of functional behavior analysis, description of treat-
ment strategies, and common outcomes associated with implementation.

CLINICAL VIGNETTE: BEHAVIOR MANAGEMENT TREATMENT PROCESSES

Mr and Ms Jones brought Ethan, their 8-year-old son, to an outpatient child mental health clinic
because of concerns about their son’s behavior at home. During the initial assessment, Mr and
Ms Jones described that their primary concern was getting Ethan to school on time each morn-
ing. According to the family, Ms Jones typically needed to wake Ethan multiple times before he
got out of bed, and often his parents had to physically go in his room to get him up. Once up,
Ethan would become easily distracted from what he was supposed to be doing and required
frequent parental reminders to brush his teeth, get dressed, and pack his backpack. In addition,
Mr and Ms Jones reported that they were getting into daily power struggles with Ethan about
taking healthy food in his lunch. As a result of these behaviors, Ethan had been arriving late to
school almost every day. In addition, Mr and Ms Jones felt frustrated and deflated, describing
the climate of their house in the morning as “an angry circus.” At the end of the interview,
Mr Jones disclosed, “Sometimes I wonder if Ethan even has the capability of being independent
and I worry that I will be getting him out of bed until he’s 40. Other times, it’s like he’s doing
these things on purpose to drive us crazy!”
A functional behavior analysis identified the following problem behaviors:
 Daily noncompliance to parental instructions to get out of bed
 Frequent distraction during task completion
 Daily arguing/negotiating with parents about his lunch
 Behavior Management for Children with ADHD 741

The lack of a structured morning routine was identified as an antecedent reinforcing the prob-
lem behaviors. Ethan’s staying in bed despite multiple warnings, parental attention/assistance
given to Ethan in the form of constant reminders to stay on task, and Ethan’s failing to take rec-
ommended food for lunch were all identified as consequences unintentionally increasing the
likelihood of the problem behaviors. A coercive cycle in which Ethan and his parents were rein-
forcing this pattern was also identified. Specifically, the more noncompliance, distraction, and
negotiation Ethan showed, the more nagging, supervision, and giving in his parents showed.
Thus, Ethan had learned that he could wait through his parent’s multiple instructions, and if
he avoided and complained long enough, he could get out of tasks altogether. Mr and Ms Jones
learned that they either needed to give multiple instructions/reminders for Ethan to comply
with requests, or they needed to give in and forget about the tasks altogether to get out of
the house on time.
After this analysis, Ethan’s independent compliance with a structured morning routine program
was set as the main treatment goal. Ethan’s parents altered their antecedents and consequences
by creating a structured morning routine incentive program in which Ethan was rewarded for
independently getting out of bed, getting dressed, brushing his teeth, and packing a healthy
lunch, without whining or arguing (described on a checklist displayed in his bedroom). If Ethan
completed all steps of his morning routine with 2 or fewer parental reminders, he was allowed
to play on Ms Jones’ tablet or build with Lego until they left the house at 7:45 AM (rewards that
he chose to maximize motivation). Mr and Ms Jones made a concerted effort to ignore all
whining/negotiating and praise Ethan each time a task was completed. Within a few days of
consistently implementing the new system, Mr and Ms Jones reported that Ethan was
completing all steps of his routine by 7:15 AM, with 1 or no reminders. They also noticed a dra-
matic decrease in his whining/negotiating and an improvement in their parent-child relation-
ships and overall family climate. By the end of the treatment, Mr Jones proclaimed, “Now I
know he can do it. It’s just a little harder for him to be independent, and we as his parents
need to work a little harder to be organized and structured, but it’s much more manageable
than I ever thought it would be!”

FUTURE DIRECTIONS

Strong support exists for the efficacy of behavior management interventions for ADHD
during the school-age years. Despite this situation, not all families and youth show a
similarly positive response. Continued research on mechanisms of change and mod-
erators of response is needed to inform treatment adaptations tailored to individual
family needs. Strategies to improve parents’ and teachers’ implementation of behavior
management approaches are especially important, given the association between
these factors and treatment outcome.39,40 In addition, questions persist about optimal
methods for combining and sequencing various behavioral treatment components as
well as behavioral treatments and medication for individual children and families.
These areas of study are especially crucial given the limitations of each approach in
addressing the long-term adverse outcomes for ADHD.
There is a pressing need to improve accessibility, feasibility, and acceptability of
empirically supported behavioral treatments, especially for broad, high-risk popula-
tions. Interventions are seldom implemented in other settings such as schools or com-
munity clinics and are therefore not reaching many of those in greatest need.58 The
extent to which these interventions can be directly exported to the community is
not known, although recent efforts have suggested that with some minor modifica-
tions and focused training for providers, this should be possible.31,32 Issues of training
requirements and intervention cost-effectiveness are critical for successful translation
and dissemination into community settings. To this end, innovative approaches may
include greater use of existing community resources and emerging technologies
(eg, interactive Web-based treatment and training). Culturally modified treatment
742 Pfiffner & Haack

programs may be necessary to encourage participation, engagement, and optimal

treatment outcomes across diverse ethnicities and cultures.42,59

SUMMARY

Behavior management treatments in the form of BPT for school-age children with
ADHD are well-established, EBTs meeting rigorous criteria for level 1 in the levels of
evidence framework specified by the Oxford Center for Evidence-Based Medicine
guidelines. These approaches can be combined with empirically supported school-
based and child treatments to enhance potency and generalization of effects.

Recommendations for clinicians

 Behavior management treatments are recommended for most caregivers of children with
ADHD. Many parent training programs are available for school-age youth with ADHD or
related conduct problems.60–63
 Families with multiple stressors, including parent mental health problems, may be less
responsive to BPT and require adjunctive treatment (eg, stress management, cognitive-
behavioral therapy for depression, couples therapy) either before or concurrent with BPT.
 When both home and school impairments are present, clinicians should partner school
personnel to implement home-school interventions (eg, DRC), because generalization of
child gains from BPT to school settings should not be expected without direct intervention in
the school.
 Multicomponent treatments, which include parents, teachers, and child components,
provide the most comprehensive approach and likely result in the greatest yield across all
domains of difficulty for youth with ADHD.
 Combined behavior management and medication often produce the most potent outcomes
and may be especially important for cases with more severe ADHD symptoms and related
problems. However, when behavioral interventions are sufficiently intensive, there may be
less need for medication, or lower doses of medication may be sufficient. Similarly, the
intensity of the behavioral intervention needed is less when medication is simultaneously
delivered.56,57
 Parent preferences should also be considered when making decisions about medication use
and sequencing with behavioral interventions to maximize treatment engagement and
adherence.
 Periodically reinitiating treatment during school-age years and adolescence may be needed,
especially during periods of developmental transitions, given the chronic and pervasive
nature of ADHD.

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