Transcript Applied Behavioral Approaches to ADD/ADHD Richard T. Cook, Jr.

Applied Behavioral Approaches to ADD/ADHD
Richard T. Cook, Jr.
Penn State University – Harrisburg Campus ABA Masters Program;
Applied Behavioral Medicine Associates, Hershey PA
Ruth Pauline Cook Foundation for Health and Healthcare Advocacy, Access, Research, and Education, Hershey PA
Abstract Applied Behavior Analysis is a discipline ideally suited for helping to change behaviors and develop
Cues Stimuli that most directly precede the behavior
Infrastructure - the “stuff” needed for the behavior to occur
-Often contrived in initial training, then transitioned to those
of the natural setting
-Associate end of previous task to cue the next
-Do some of the reminding (“nagging”), decreasing the
amount of negative parent/child interaction
-Important aspects include salience, consistency,
appropriate generalization, and the strength of association.
Association with salient SDs increases the likelihood that a
behavior occurs.
-Checklists, timers, sticky notes;
..
-Checklists:
allow the child, and parents, etc., to see what
has been done, and prompt the rest
- are reinforcers for jobs well done (can even include
categories like “completed all requirements” or even to start
the habit, “referred to the list.”)
-maintain behavioral momentum
-build habits, enhancing the likelihood that future such
checklists provide helpful stimulus control
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Medications simply a tool to help the child attend to that
habits in the child or adult diagnosed with ADD/ADHD. Methodically facilitating the performance of agreed upon
behaviors in specified situations, and then engraining them as routines/habits generalized and maintained in the
natural environment, is a noted strength of the discipline. Arguably better described as “Attention Regulatory
Disorder” (an imbalance of lack of focus and hyperfocus), the ADD/ADHD child who is able to decrease the
performance of behaviors others find annoying, and instead perform behaviors that let the “gifts of ADD shine,” will
have more positive interactions, setting up a “self-perpetuating feedback loop” that helps the child flourish.
True “behaviorally based” approaches, which actually spend the bulk of the time assessing and practicing the
behavior (including those relevant from disciplines of public health, medicine, ABA and the other natural sciences of
biology, chemistry, physics, and mathematics) provide a disciplined framework for systematically identifying and
manipulating relevant factors in an efficient and effective manner. This is important for both for the child, in
preventing ADD’s undesired effects, and the adult whose long learning history is robust not only with “issues,” but
likely also with many excellent compensatory mechanisms , baselines for shaping other behaviors to be corrected.
The Many and Varied Factors of the Antecedent State
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Physical: Having the ingredients readily available increases the likelihood of making the meal successfully, just
as NOT having them certainly decreases it. Having a desk, pencils, stapler, etc. for homework; stamps and
envelopes for bills and thank you notes; a watch!!!, maps, and reliable car for getting places on time. Making an
effort to specifically attend to such details increases the likelihood of development of the desired habits - failure
to attend to these “ingredients” can limit success. It is also important to know where and how to get ingredients.
Behavioral: Actions, skills, patterns of behavior, habits already in one’s repertoire: consistently leaving a bit early
to allow for contingencies; knowing “cold” the times tables; holding a door or giving up one’s seat; saying “’Bless
You!,’ ‘Thank You!,’ ‘You’re Welcome!’” The presence of the strength of “neural networks” governing the behavior
can arguably be considered as part of the antecedent state.
Attitudinal/thought: From a behavioral perspective, “thoughts” and “attitudes” are simply “private behaviors,”
which follow the same “rules” as verbal and motor/physical/muscle behavior: being “mindful” of a commitment to
being on time; or at least accepting as a “truth” that, at least sometimes, there really IS a “final” deadline
Living/Social Environment:
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Home life: Given that often one or both parents of the child with ADHD also may have it (even if not formally
diagnosed), the disorganization and compensations of parental ADHD are part of the child’s baseline state.
Parents establish rules, family routines, and customs, and also model responses, patterns of their behavior, in
approaches to organizing, problem solving, and time management. The home life is robust with salient factors of
the child’s antecedent state milieu, and habit development, requiring assessment , and often adjustment.
School: While an accepting, embracing scholastic environment can be very helpful, especially following
traumatic experience in a less understanding school, TOO much “unconditional acceptance” hurts the, typically
bright, child with ADD by not developing the self discipline, organizational skills, and adherence to scholastic
expectations that are going to be expected by most institutions of higher learning, jobs, and generally speaking,
adult life itself. Being too kind is cruel - balance is needed.
Similarly, any child needs to be pushed a bit, but the child with ADHD will often glom onto low response cost,
high intensity reinforcing activities, like computers and DVDs. Often they will enjoy other activities when pushed
to do so, but if they are given unlimited access to LCD screen reinforcement, it can become difficult for them to
engage in other behaviors. Limits should be agreed upon by all, and consistently enforced, by BOTH parents.
which is being taught, to help adjust the antecedent brain
state to be more optimal for learning desired behaviors;
enhancing the likelihood of repeatedly performing the
behavior of “attending” helps form a habit of paying attention
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Shaping the behavior with successive approximations,
sometimes starting with the tiniest effort (consistently
performed) “3 minutes of piano each day” ”Put on the
running shoes and at least walk to the driveway.”
Often, the natural reinforcement inherent in doing the
activity will then keep the behavior going.
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A child’s messy room is an opportunity to sit next to the
child and teach not only the room cleaning skills, but
help teach the organizationally challenged ADD brain
the process of organizing which can be generalized to
other areas of life. The child with ADD and parent will
get plenty of opportunities to practice this skill as it
becomes a habit.
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Don’t forget to build in “booster sessions” for
strengthening behavior patterns that might not get
enough practice in the natural life setting.
Consequences - can be artificially
manipulated in order to change the likelihood that the
behavior will be repeated, with the eventual goal that
natural consequence will maintain the behavior, including
simply the performance of the behavior itself.
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Consistency in consequences is essential for the
development of the habits of organizing and performing
daily responsibilities – self discipline – that those with
ADD often lack but so much need.
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ABA includes many validated approaches for helping
to choose and apply consequences in ways that will
enhance the habit development process.
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“Reinforcing or punishing” is from the patient's
perspective, e.g. sending the child to his (fun stuff
filled) room to “punish” him for being hyperactive at the
dinner table?.
Behaviors – lacking the “skills,” the desired
behaviors can’t occur.
A task typically has a series of steps, each leading to the
next. Strengthening that connection between them limits
getting distracted.
Parenting (from the Latin “paratus” – to prepare), teaching,
coaching, and counseling in shaping a child’s behaviors
often requires being physically next to the child, not
downstairs or in another room. Guiding practice decreases
mistakes and distractions, and helps maintain momentum.
The child with ADD/ADHD will engage in more behaviors,
thus proportionally greater effort will be required to monitor
and guide that child’s learning, but that given the richness of
that learning experience, the outcome can be awesome!
- Behavioral momentum is both a phenomenon and a tool;
includes consideration of factors that initiate and perpetuate
behaviors and chains of behaviors, including the “choice
points, forks in the road, nodes in the algorithm” as well as
concepts of rhythm and cadence.
Conclusions
The problems, and successes, of ADD/ADHD are directly
related to the behaviors of the individual. Applied Behavior
Analysis is rife with concepts and techniques directly
applicable to assessing the many factors ,changing
behaviors, and enhancing the lives, of those with
ADD/ADHD.
The author welcomes questions and comments at
[email protected]