Professor David Daley Hello, I’m Professor David   Daley from Nottingham Trent University  and I’m here today to talk a little bit   more about psychological interventions for  attention deficit hyperactivity disorder. Before we talk about the essential ingredients  that make up most psychological interventions   for parents who wish to help their children  with ADHD, I thought I would address one of   the major controversies in this area, which  is in the past, these interventions have been   called ‘parent training programmes’. And the  assumption has been that parents need to access   these interventions because they have deficits in  their parenting, and that’s actually not correct. Most parents of children with ADHD parent  perfectly fine, or they parent their typically   developing children perfectly fine. The problem  comes when they try and apply those same parenting   practices to children with, or at risk of,  attention deficit hyperactivity disorder,   and there, they find that those normal parenting  practices don’t work very well. And that’s why we   have specialised parenting interventions to help  these parents to alter their parenting style so   that they can parent their children with ADHD in  a way that best fits the needs of those children. So, with that in mind, let’s take a little  bit of time to think about what are some of   the key ingredients of most of the different  interventions for parents of children with   ADHD? And most of those interventions  include elements of psychoeducation. So,   psychoeducation is where you provide information  to the parent to help them to better understand   ADHD in their child. The aim of psychoeducation  is to help parents understand why their children   with ADHD actually behave in the way that they do.  And once those parents have a better understanding   of why their children behave in the way that  they do, they then have a better understanding   of the strategies that are made available in the  interventions, that aim to disrupt that process. So, for example, lots of parents of children  with ADHD will say that their children are very   impatient, and they cannot wait a couple  of minutes when they make a request. So,   mum or dad may be on the phone, having an  important telephone call, and the child is hungry,   and the parents, quite reasonably, say, “Once  I finish my call in a few minutes, I’ll make   you a sandwich.” And after a couple of seconds,  that child is back pestering for that sandwich. What psychoeducation would do in this situation  is it would help the parents understand that ADHD   children have a very poor understanding  of time and that when the parent says,   “Wait five minutes,” the child thinks  that really is five seconds. And so,   the child waits five seconds, thinking  it’s five minutes, and then, wonders why   the parent isn’t making a sandwich for them,  and so, goes back to the parent to remind them   that they’re hungry and to remind them that  the parents promised to make them a sandwich. From the parents’ point of view,  the parents know what five minutes   feels like. They know the child  has only waited for five seconds   and they think the child’s behaviour is  actually really unreasonable. And so,   this is an example of where psychoeducation can  help parents understand why their child with   ADHD behaves in the way that they do and can  also help guide the parents in communicating   with the child in a way that will better suit  the needs of both the child and the parent. Other key features of psychological interventions  for ADHD also focus on improving parent-child   relationships. Parenting a child with ADHD  is actually a very difficult task and even   in the preschool period, the relationship  between the parent and child can become   quite fraught. Relationships can deteriorate  quite rapidly. Parents can feel like they’ve   put a lot of effort into parenting the child,  yet the child doesn’t respond to requests,   doesn’t follow instructions, won’t  listen to the parent. And over time,   that can have a really negative impact on the  relationship between parent and child, and so,   most psychological interventions aim to try  and foster or promote better parent-child   relationships. Mostly through the form of play  when children are much younger, so teaching   games that help parents to rediscover the joy  of spending time with their child, but also by   using games to help parents better understand  their child’s ability and also, to, perhaps,   help teach the child some skills that they may  struggle with, such as planning or working memory. Nearly all psychological interventions  for parents of children with ADHD include   a focus on core behavioural strategies. So,  these are standard behavioural techniques,   nothing particularly new, we’ve known about  them for a long time, but we use them because   we know they work. And most interventions for  parents of children with ADHD would have a   focus both on antecedent techniques and also,  consequence-based techniques. So, antecedent   techniques are strategies that parents would use  before a behaviour actually is exhibited. So,   that might include distraction, it might  include anticipation, where the parent knows   the child is going to have a tantrum and would  intervene early to help the child calm down. Consequence-based strategies are behavioural  strategies that the parents would implement after   a behaviour has been exhibited. That might involve  using rewards, it might involve using praise or   even sanctions, depending on whether the behaviour  that was exhibited was positive or negative. Behavioural techniques also, in most of  these interventions, also focus on ways in   which parents can increase the amount of reward  and incentives available to children with ADHD   and they particularly focus on things like  reward charts. Helping parents to shape the   child’s behaviour by having a much clearer focus  on reward and making sure that behaviours that   the child engages in are rewarded and are  rewarded immediately. So, that the child   makes the connection between engaging in the  behaviour, it might be putting your shoes away,   it might be keeping your seatbelt on in  the car, and the reward that follows it. Nearly all interventions for parents of  children with ADHD also have a focus on   either coaching or scaffolding. So, coaching is  where we – the intervention teaches the parents   how to help the child acquire some of the skills  that they may be struggling with. For instance,   lots of children with ADHD don’t pay attention  to what’s going on in their environment and so,   they don’t listen as well as children without  ADHD. That means they don’t learn as well and so,   interventions either teach the parent how to coach  the child so that they can acquire those skills   that they’re missing, or they teach scaffolding.  And scaffolding is a particular technique where   we, first of all, encourage parents to become  observant about the child’s true level of ability. Often, parents overestimate their ADHD child’s  level of ability. A classic example of that for   a young child is where the parents ask the  child to get dressed. So, they may hand the   child their clothes and say, “Get dressed,”  and then, the parent may get very cross when   the child doesn’t follow the instruction. And  when we teach parents to scaffold, first of all,   we encourage them to be curious about what is  it that my child can and cannot do? And when   parents become observant and start questioning  what their child can or cannot do, they suddenly   realise that their children with ADHD often  struggle with things that they’re surprised by. So, for example, perhaps the child isn’t  able to do up buttons correctly. So,   there’s no point handing the child their  clothes to put on if they can’t do up   the buttons themselves. Other children with ADHD  really struggle with planning and getting dressed   actually requires quite a lot of planning.  Underwear, usually, unless you’re Superman,   needs to go on underneath the outer clothes, so  you need to plan to put on underwear first and   then, put on your trousers and your T-shirt.  And even that simple amount of planning can   be too much for young children with ADHD,  and this is where scaffolding comes in. Scaffolding helps teach parents techniques for  how they can support their children so that they   can better learn. And scaffolding would involve  providing the child with just the right amount   of sensitive support at any one point in time so  the child can complete whatever task it is that is   required. So, for some children, scaffolding might  just be about selecting the clothes for the child   to put on. For children who find it very difficult  to plan, scaffolding might involve monitoring the   child’s behaviour and constantly reminding them  to put their underwear on before putting on their   trousers, or reminding them to turn their  socks inside out before they put them on,   or to make sure that the arms of their shirt are  free before they put their hands into the arm. And by teaching parents scaffolding, it helps  the parents understand the child’s level of   ability. It helps the parent better support  the child in a much more sensitive way and so,   therefore, avoiding the child getting upset  or having a tantrum, and it helps extend the   child’s learning. And so, scaffolding is a  really key ingredient to these interventions,   as it is an amazing way in which parents  of children with ADHD can better support   their child with ADHD and better  mitogen – mitigate against some   of the problems that arise for the child  as a consequence of their ADHD symptoms. In addition to some of these interventions,  there are also some very ADHD specific   strategies. For example, I’ve already  mentioned that ADHD children find   waiting very difficult because they have  a very poor understanding of time, and so,   some of these interventions teach ADHD specific  strategies, such as how do we help children   with ADHD become more resilient to waiting? A  problem with waiting for children with ADHD is   that ADHD children rarely wait long enough in  order for waiting to have a positive outcome. Two young children with ADHD might both have  an equal desire to go on the zipwire at the   local park, but because it’s a sunny day,  there’s a big long queue for it. And both   children will join that queue, but after a  short period of waiting, the ADHD child will   decide that they don’t want to go on the  zipwire anymore and they’ll go off and do   something else. The non-ADHD child will stay in  the queue and have their go on the zipwire. So,   the non-ADHD child’s waiting is rewarded. The  ADHD child’s waiting is not rewarded. They waited,   they gave up on waiting and so, waiting had  a negative, rather than a positive, outcome. So, some of these interventions also build  in strategies that help to ensure that ADHD   children have positive outcomes to waiting. The  idea being that we want to move children with   ADHD from being delay averse, where they always  assume that waiting has a negative outcome,   to being delay neutral, where sometimes waiting  has a positive outcome, sometimes waiting has a   negative outcome. And because it’s delay  neutral, the child is much more likely to   wait a little bit longer because they’re  not sure what the outcome is going to be.