Of the nonmedical or psychosocial interventions, behavioral interventions have perhaps the best efficacy and contain the best documented methods (Martella, Marchand-Martella, & Cleanthous, 2002; Pelham, Wheeler, & Chronis, 1998). Interestingly though, the number and scope of research investigations on behavioral and school-based interventions pale in comparison to the extensive research base on stimulant medication (DuPaul, 2007). Many of the behavioral approaches involve parent and teacher training (see Kern et al., 2007). Parents and teachers are taught management strategies based on behavioral techniques. Since most of us cannot prescribe medication, our focus must be on what we can do in the environment to change behavior. We can use behavioral methods to improve the lives of children with ADHD. Following is a brief description of the behavioral principles that serve as the foundation of these behavioral techniques (Cooper et al., 2006; Martella, Nelson, Marchand-Martella, & O'Reilly, 2012).
Behavioral methods are based on the fact that changes in behavior can be produced by manipulating the environment in which the behavior occurs. Professionals are able to determine the situations (or antecedents) that give rise to a particular behavior and provide certain environmental changes for the behavior exhibited. One of the most important advantages to using behavioral methods is that they are well grounded in decades of experimental research (Chance, 2003; Martella, Nelson, Marchand-Martella, & O’Reilly, 2012; Pierce & Cheney, 2004). Out of this research, some general laws of behavior have emerged:
A second advantage of using behavioral methods is that they define procedures based on their functions or their effects on behavior. Thus, a stimulus (e.g., an object, event) is not a reinforcer unless it increases the likelihood of a behavior's occurring following either the presentation of a stimulus or the removal of a stimulus (this will be discussed later). For example, if we give a student a star for remaining on task but on-task behavior is not maintained in the future, we have given a reward, not a reinforcer. Similarly, punishment is defined in a functional manner in that a stimulus is not a punisher unless the likelihood of the behavior decreases. For example, if we give a child a star for on-task behavior but the likelihood of on-task behavior occurring decreases, we have punished the child. This is an absolutely critical concept to understand. Please study it carefully. Reinforcers are not things that we necessarily need, want or desire. Punishers are not things that we necessarily dislike. Whether something is a reinforcer or a punisher depends on its effect on behavior.
So, suppose a parent reprimands her child for destroying a toy; if this destructive behavior continues to occur, the reprimand may have been a reinforcer. You see, given the right conditions (it is beyond the scope of this course to define these conditions), anything--such as a spanking, a poor grade or isolation--can function as a reinforcer. On the other hand, given the right conditions, anything--such as a hug, a kiss, candy or a good grade--can function as a punisher. Consider the effects on the behavior before defining something as a reinforcer or a punisher.
A third advantage to behavioral methods is their emphasis on observable behavior. If a behavioral technique is effective, you will have to see its effects on observed behavior. For example, if you wish to get a student to maintain attention for a longer period of time, you should see "attention" behavior. Some behaviors, such as anger, cannot be seen. Yet we can see aggression that we infer is anger. So, if we wish to decrease aggression, we work with the observable behavior of aggression rather than with the inferred behavior of anger.
The final advantage of behavioral methods is that the methods and their results can be replicated. This advantage is why these methods are considered to have a strong research base. The results they produce can be produced again and again. However, they must be used correctly to produce the same results. This is why the necessary level of training in these methods is high. In its simplest form, behavior analytic theory can be broken down into three terms: antecedent, behavior and consequence (Kazdin, 2001; Martella, Nelson, Marchand-Martella, & O’Reilly, 2012). These are called the three-term contingency. (Note: This is a simplification of the system. A more advanced discussion of the theory is beyond the scope of this course.)
The three-term contingency is a dynamic system. In other words, the antecedents, behaviors and consequences work together and affect one another. The antecedent produces the behavior because the behavior, under similar circumstances (antecedent conditions), has received reinforcement in the past. The consequence will determine whether the behavior will be emitted again in the future under similar circumstances (reinforcement) or will not be emitted again in the future under similar circumstances (punishment or extinction). Thus, antecedents, behaviors and consequences rely upon and affect one another.
Mr. Dodd gives Marco several homework sheets to complete. Marco says he does not want to do them and throws them on the floor. Mr. Dodd tells Marco that he made the wrong choice and picks up the homework and puts it away. The next day, Mr. Dodd gives Marco homework again. The same behaviors result. Mr. Dodd does the same thing following this behavior. Mr. Dodd is negatively reinforcing Marco. The homework is the stimulus. This stimulus is removed contingent upon (when) Marco exhibiting the misbehavior. This removal of homework increases the future occurrence of Marco’s misbehavior.
Positive Reinforcement
Reinforcement is the most important aspect of behavioral methods. If a behavior is to be displayed in the future, it must be reinforced in the present or it must have been reinforced in the past. Then the behavior will be emitted again in the presence of the same or similar antecedents. Reinforcement is a consequence. Reinforcement is defined by what happens in the past or present. It is not defined in the future. Therefore, we behave because we were reinforced in the past under similar circumstances, not because we anticipate reinforcement in the future. The old picture involving a child chasing after a carrot on a stick is wrong.
A more appropriate picture of reinforcement would be of a child running forward with an eaten carrot left behind. A number of things must occur for positive reinforcement to be in effect:
Negative Reinforcement
Unfortunately, many people view negative reinforcement as punishment. Negative reinforcement results in an increase in the likelihood of a behavior, as does positive reinforcement. The difference is that while positive reinforcement is the presentation of a stimulus, negative reinforcement is the removal of a stimulus. For example, we may warn a child with ADHD that if he does not finish his work within the next 30 minutes, he will not go to the store with us. In this case, the warning is a stimulus that will be removed if the student completes his work. If the student completes his work, we have negatively reinforced him by not repeating the threat. Think about it this way. What do you do when you are on the highway going 20 miles over the speed limit and see a police officer up ahead? Most of us slow down to the speed limit. Our behavior is controlled by negative reinforcement. Going the speed limit is more likely when there's a threat of a speeding ticket.
Unfortunately, negative reinforcement has negative side effects. The most important negative side effect is that there is some evidence that negative reinforcement tends to slow the learning process. In other words, it is more difficult to learn when you are trying to avoid a failing grade than when you are trying to earn a passing one. A number of things must occur for negative reinforcement to be in effect:
Punishment
Punishment works in a manner opposite to that of reinforcement. It can be either the presentation of a stimulus or the removal of a stimulus to decrease the likelihood of the behavior. Punishment has some negative side effects and should only be used in a mild form when other reinforcement-based interventions have failed. In addition, punishment should never be used in isolation, but should be combined with a reinforcement-based system to prevent some of the negative side effects associated with punishment. A number of things must occur for punishment to be in effect:
Extinction
Extinction is the permanent removal of reinforcement. Based on the Law of Effect, if a behavior is not reinforced, it will cease to exist. Thus, if a child with ADHD is engaging in an unwanted behavior (interrupting) and the behavior is not reinforced (doesn't gain your attention), the behavior will decrease in occurrence. However, the reinforcement must be removed. One difficulty with the use of extinction is that there may be an extinction burst. This burst of activity usually occurs for a short period of time and then the level of behavior gradually decreases. Unfortunately, many people are unable to live through this burst of behavior and will attend to it, thus reinforcing the burst of activity. For example, we have a child with ADHD who frequently interrupts us when we are talking on the phone. We could ignore (put on extinction) the child's interrupting behavior.
Take, for example, when a friend becomes angry with you and ignores you. You may find yourself getting louder, speaking faster, or getting physical, maybe tapping the friend on the shoulder, to gain her attention. This is an extinction burst. Therefore, before you use extinction, be sure that you and those around you are willing and able to live through the extinction burst.
Stimulus Control
Stimulus control is an increased likelihood that an individual will respond in a given way to a particular situation and will not respond that way in the absence of the situation. Reinforce a behavior if a particular stimulus is present and do not reinforce a behavior if the stimulus is absent. The behavior is extinguished in the presence of any other stimulus except the one that the child has been trained to respond to. Two shortcuts in planning for stimulus control involve modeling the desired behavior in the presence of the desired controlling stimulus (e.g., saying "We need to sit quietly," and doing so), or instructing (teaching the individual how to enter the room and sit quietly).
Fading
Fading is defined as the transfer of stimulus control from one stimulus to another, as when one stimulus is faded out, and the other is faded in. For example, we wish the child with ADHD to come into a classroom quietly, sit down, and be ready to begin. We can start by providing verbal prompts each step of the way, such as, "Sarah, you need to come into the room now." Next we tell her, "Sarah, please sit down." Then we say, "Sarah, please take out your paper and pencil." Fading is accomplished when these verbal prompts are faded out and the natural environmental cues, such as the ringing of the school bell, are faded in. This fading can be accomplished in several ways, including time delays, graduated prompting and graduated guidance.
Time Delays
Two types of time delays can be used to achieve fading. A constant time delay can be used. In this method, the teacher waits for a constant amount of time, say one minute from the time of the bell, before providing a verbal prompt. This delay permits the desired natural cue to be separated from the faded verbal prompt. A progressive time delay occurs when the time between the natural cue and the delivery of the teacher's prompt is increased gradually. Graduated prompting involves up to three levels:
Verbal:
Say, "Sarah, please come into the room."
Verbal with hand gesture:
While waving, say, "Sarah, please come into the room."
Verbal with gestural prompt combined with a physical prompt:
While beckoning Sarah into the room, take her hand and lead her into the room.
Slowly removing the prompts is referred to as “graduated guidance.” Remember when you learned to ride a bike? Your parent held onto the bike to hold you up and then gradually let you go. This procedure is similar to the procedure called scaffolding.
Shaping
Shaping involves reinforcing successive approximations of behavior to achieve a desired goal. For example, one difficulty children with ADHD have is maintaining concentration. A mistake we make is requiring the child to concentrate far longer than she is capable. In this case, we can use shaping to our advantage. The amount of time a student can concentrate may be increased systematically. First, determine how long the student can maintain attention--let's say for only two minutes at a time--as compared to 30 minutes for others of her age. Limit her concentration activities to two minutes, and praise her on success. Slowly increase the concentration time by a minute every fourth or fifth day until she reaches 30 minutes. This sounds easy. However, the keys are patience and consistency.
Chaining
Chaining teaches new behavior by linking smaller component behaviors together. For example, take Sarah and her inability to enter the room independently. What we would do with chaining is to determine all of the independent behaviors that must come together to allow her to be sitting and ready to learn by the time the teacher begins instruction. We would distinguish the links in the chain as follows: Enter the room, go to desk, sit at desk, open up desktop, take out paper and pencil, close desktop, place paper and pencil on top of desk, sit with hands clasped on top of desk, and look toward the teacher. Once these behaviors are defined, we can teach them. There are three ways to teach through chaining--whole or total task, forward, and backward.
The efficacy of these behavioral techniques has been shown in many controlled studies to have both short- and long-term positive effects. The research demonstrates that the more intense the intervention, the better the outcome. In addition, some research has shown that a combination of behavioral interventions and stimulant medications may have greater effects than either treatment alone (Martella et al., 2002; Pelham, 1998). However, due to the side effects of medications, a combination approach should be attempted only when behavioral approaches have been tried in isolation and have failed.
If behavioral approaches are so effective, why aren't they more widely used? A major difficulty with behavioral approaches is that they take a high level of skill to implement appropriately. Although behavioral approaches seem simple to many laypersons, the level of training it takes to become proficient in their use is out of reach for many people. For example, few, if any, teacher education programs teach how to use behavioral approaches effectively; however, many special education programs include such training. Additionally, many psychology programs provide a very basic foundation for behavioral techniques, but rarely train students to a level of proficiency.
Unfortunately, this basic understanding misleads people into thinking that the techniques are simple to implement. When implementation is tried, failure usually results, not because of the techniques themselves, but because of the skill level of those attempting to implement them. Since there are so few well-trained behavior analytic professionals across the country, it is no wonder that the technology is not more widespread and accepted. Later exercises will provide a basic overview of several of these techniques; however, if one wishes to become proficient in their use, it is recommended that supervision by a competent behavior analytic professional be arranged.
Cognitive behavioral approaches are generally defined as strategies that attempt to change how individuals respond to their environment by changing how they think or process data about the environment. Several interventions have been developed (Martella, Nelson, Marchand-Martella, & O’Reilly, 2012; Watson & Tharp, 2002), which include:
Self-Instructions
Self-instructions involve providing your own verbal prompt to engage in a behavior (Martella, 1994; Martella, Nelson, Marchand-Martella, & O’Reilly, 2012). For example, suppose you had a student who was not entering your room and sitting down to begin instruction. You may teach him to state to himself prompts such as:
Self-Recording
Self-recording entails teaching the child to record his own behavior when he engages in it when a prompt to do so is provided (Martella, Leonard, Marchand-Martella, & Agran, 1993; Martella, Nelson, Marchand-Martella, & O’Reilly, 2012). For example, you teach the child to place a mark on a slip of paper every time he interrupts another person. When he does interrupt you say, "Put a mark on your paper for interrupting." Self-recording is similar to self-monitoring except that self-monitoring does not involve the prompt (Martella, Leonard, Marchand-Martella, & Agran, 1993; Martella, Nelson, Marchand-Martella, & O’Reilly, 2012). Thus, instead of telling the student to place a mark on his paper for interrupting, he must determine when he interrupts and prompt himself. Obviously, self-monitoring is a high level skill for children to learn (Dalton, Martella, & Marchand-Martella, 1999). The hope for self-recording or self-monitoring is that the act of marking when one does something will be reactive. In other words, becoming aware of one's own behaviors will usually lead to a lessening of the behavior.
Cognitive Modeling
Cognitive or imagined modeling involves having the child think about what behavior he or she will be doing, and then do the behavior. For example, the student who does not come into your room appropriately may be taken through several exercises in which he visualizes himself coming into the room and sitting down ready to learn. Once you have taken him through these cognitive exercises, then you ask the student to perform the behavior.
Self-Evaluation
Self-evaluation involves teaching children how to measure their behavior against some standard. For example, you could teach a child to determine whether he was playing appropriately with other students or whether he was maintaining attention as long as his peers. Self-evaluation is used in self-monitoring because one must be able to determine whether an inappropriate behavior has occurred, which can be done only by comparing the behavior against some standard.
Self-Reinforcement
Self-reinforcement, and punishment, involves providing consequences for one's own behavior (Martella, Nelson, Marchand-Martella, & O’Reilly, 2012). For example, we could teach a child who is frequently off task to provide a piece of candy to himself for finishing his work (self-reinforcement); we could also teach a child to provide a reprimand to himself for not concentrating, such as, "I must stop looking around and get back to work." There is a problem with self-reinforcement and self-punishment that must be mentioned. Self-reinforcement and punishment are probably not possible theoretically (Catania, 1992). Here is the reason. Say you were studying this chapter and decided to go to the movie once you passed the chapter test. After you passed the chapter test, you went to the movie. You may be more likely to continue to study in the future, but why? Was it because you "reinforced" yourself with the movie or because of something else? It was more likely due to something else. That something else can be determined by considering what kept you from going to the movie before you passed the chapter test. In other words, you can provide yourself with a consequence at any time. The factor that keeps you from presenting this consequence until you finish the behavior is the reinforcer (positive, such as the comment, "I'm proud of you for finishing so soon," from your roommate, or negative, such as the comment, "You had better get a move on if you want to get this course done sometime in your lifetime!").
Problem Solving
Problem solving involves teaching individuals how to respond appropriately to a wide variety of problem situations (Martella, Agran, & Marchand-Martella, 1992; Martella, Nelson, Marchand-Martella, & O’Reilly, 2012). Problem solving is usually taught by having the individual go through a process that should result in a solution. For example, we would teach a child first to determine whether a problem is present. Second, we would have the child brainstorm as many solutions as possible to the problem. Third, we would have the child determine the consequences of each solution. Fourth, we could have the child select the most appropriate solution. Fifth, we would require the child to implement the solution. Finally, the child would go back and determine whether the solution worked, to evaluate its effectiveness for future situations. Therefore, problem solving can be used to resolve conflicts (U.S. Department of Education, 2006).
These techniques have a long and rich history of effectiveness (Martella, Nelson, Marchand-Martella, & O’Reilly, 2012; Watson & Tharp, 2002). The claim is that these techniques work because individuals who learn them are able to self-regulate their behaviors; this aids them in transferring or generalizing to new situations. Unfortunately, when these techniques are implemented in isolation (meaning without any behavior analytic procedures), they are not effective. The research on the use of cognitive-behavioral techniques with children with ADHD indicates a uniform failure to provide information indicating that such techniques have any effects on these children.
The conclusion, then, is that these approaches are ineffective when used with children with ADHD (Pelham, 1998; U.S. Department of Education, 2006). However, if these techniques are added to the behavior analytic ones described above, they can be effective. Of course, the reason for the effectiveness seems to be the use of the behavior analytic techniques, with the cognitive-behavioral techniques adding little, if anything, to the total package. Therefore, adding a cognitive-behavioral component is probably not worthwhile unless one is attempting to appeal to other concerns or others' acceptance of the program.