When ADHD is accompanied by oppositional defiant disorder, conduct disorder, and mood and anxiety disorders, these coexisting conditions can compound the behavioral challenges presented by children and adolescents with ADHD and can contribute to aggressive behavior, poor tolerance for frustration, inflexibility, poor problemsolving skills, heightened difficulty in complying with parents’ instructions, and significant family conflict. When such conditions are present, additional treatment approaches may be useful.
One such model, developed by Dr. Ross Greene, is called the collaborative problem-solving (CPS) approach. This cognitive-behavioral approach arises from some of the same theoretical underpinnings of parent training, but focuses more on helping adults and children become proficient at resolving problems collaboratively as a means of defusing conflict and teaching kids the cognitive skills they may lack. Through this joint approach, both parent and child learn to resolve issues in a mutually acceptable way.
According to this model, the manner in which adults solve problems with their children is a major factor influencing the frequency and intensity of oppositional outbursts. The CPS approach describes 3 basic options for solving the problems that are reliably and predictably precipitating adult-child conflict:
- imposition of adult will (unilateral problem-solving), often accompanied by adult-imposed consequences;
- collaborative problem-solving
- deferring resolution of the problem, at least for now
Imposition of adult will is the most common cause of oppositional outbursts. Deferring resolution of a given problem removes low-priority adult expectations, at least temporarily, so that the adult and child can focus on higher-priority problems first. This option is effective at reducing tension between the child and parent and decreasing explosive outbursts. The second option, the proactive, collaborative resolution of problems, helps adults pursue their behavioral expectations without increasing the likelihood of oppositional outbursts. It also gives parents and children training and practice in regulating their emotions, dealing with frustration, and solving problems in a realistic and mutually satisfactory manner. Treatment sessions focus on helping children and adults successfully master the CPS approach.
Adults are viewed as the “facilitators” of the collaborative problem-solving process. In fact, adults are often told that their role is to (a) help their child reduce the likelihood of oppositional outbursts in the moment and (b) help their child develop skills to handle frustration and resolve problems over the longer term. Adults are helped to identify the specific “unsolved problems” that are reliably precipitating challenging episodes.
Common unsolved problems include teeth brushing, getting to bed at night, waking up in the morning, homework, screen time, dietary choices, and sibling interactions. The process of identifying specific unsolved problems helps adults come to recognize that a child’s challenging behavior is, in fact, highly predictable and that the problems setting the stage for the challenging behavior can be resolved proactively. Thus, rather than simply reacting to the outbursts by imposing consequences, parents are instead helped to resolve the problems giving rise to those outbursts. In other words, adults are strongly encouraged to adopt a “crisis prevention” mentality instead of a “crisis management” mentality.
Adults are then helped to master the “ingredients” involved in solving problems collaboratively, including (1) achieving the clearest possible understanding of the child’s concern or perspective on a given unsolved problem, (2) entering the adult’s concern or perspective on the same unsolved problem into consideration, and (3) brainstorming solutions that are realistic and mutually satisfactory (meaning the concerns of both parties are addressed).
The CPS approach differs from other anger management and problem-solving training programs in its emphasis on helping adults and children develop the skills to resolve disagreements collaboratively. The process of solving problems collaboratively can be applied right at the moment that the oppositional behavior is about to occur, but is far more effective when problems likely to precipitate oppositional episodes are resolved proactively, well in advance, and when all of the adults at home, and even teachers, are involved and trained. More information about this approach can be found at www.livesinthebalance.org.
You may hear or read of other behaviorally oriented treatments for ADHD. Some with limited or no evidence of effectiveness include cognitive-behavioral therapy (although this can be quite valuable for some of the coexisting conditions and shows a bit more promise for adolescents with ADHD), social skills training, insight-oriented psychotherapy, and play therapy. Other more alternative therapies, such as vestibular stimulation, biofeedback, relaxation training, electroencephalographic biofeedback, and sensory integration exercises, lack the sufficient scientific support needed to be recommend as effective treatments. Remember that these behavioral treatments, just like medication management, are not curative. In addition, no one would claim that ADHD arises from faulty learning or that several months of contingency management would produce sustained benefits for children with ADHD once treatment is withdrawn. Behavioral methods are largely a method of rearranging environments by artificial means to yield improved participation in major life activities.
No matter what approach you ultimately use, seek the guidance of a professional specifically trained to provide effective behavioral therapies. Not all approaches sometimes recommended for ADHD are helpful for children with ADHD, including play therapy and talk therapy, which have not been shown to be effective in treating the core symptoms of this condition. Remember also that ADHD is a highly heritable condition, making it likely that one or both parents may also have some of the same difficulties as their child. Because of that, the successful outcomes for your child may be more difficult to achieve. Behavioral therapy techniques can also be more difficult to use if either parent is depressed, has other emotional or mental health problems, or is under undue stress. This is just a reminder that taking care of yourself and your needs is one of the primary considerations for helping your child.