Because of his attention-deficit/hyperactivity disorder (ADHD), the 10-year-old boy rarely even tried to answer the questions on the math and language arts worksheets his
fourth-grade teacher asked students to complete during class.
Not only that, he often bothered the students who did.
Then the teacher made an important change to the boy’s
worksheets: She wrote the correct answers on them with
invisible markers so that the boy could reveal the correct
answer by coloring over the space as soon as he finished a
question. The teacher also randomly inserted stars he could
uncover by coloring and told him he would earn a reward for
collecting four stars. The strategy paid off: The boy was soon
answering every question and getting 84 percent of them
Giving immediate feedback is just one of many simple
and effective behavioral approaches to improving children’s
attention, says psychologist Nancy A. Neef, PhD, who described
the invisible marker experiment in a chapter on treating ADHD
she co-authored in the 2012 “APA Handbook of Behavior
Analysis.” With ADHD affecting an estimated 7 percent of
American children ages 3 to 17, psychologists are developing
behavioral interventions that parents, teachers and others can
use to help kids focus and control their impulses. Others are
conducting research that demonstrates that more exercise and
longer sleep can help.
That’s good news for kids, says Neef, who believes that
parents, teachers and pediatricians are sometimes too quick to
jump to prescribing medication for ADHD.
“Particularly in the case of stimulant medications, which
are the most common treatment for ADHD, we don’t know an
awful lot about the long-term side effects,” says Neef, a professor
of special education at The Ohio State University.
And medication doesn’t address problems related to
children’s academic performance and relationships with family
members, peers and others. “Even though medication can be
effective and very helpful, it’s not a panacea,” Neef says.
Surprisingly, nonpharmacological approaches are also
controversial, especially among the medical community.
“If you read the professional guidelines for psychiatrists or
sometimes pediatricians, the treatment that is emphasized for
kids with ADHD is a pharmacological one,” says Gregory A.
Fabiano, PhD, an associate professor of counseling, school and
educational psychology at the State University of New York at
That bias toward pharmacological approaches has its
roots in a large study by the Multimodal Treatment of ADHD
(MTA) Cooperative Group, published in 1999 in the Archives
of Psychiatry. The study, which compared medication, intensive
behavioral treatment, a combined approach and standard
community care, concluded that medication worked best. “The
field took that result and ran with it,” says Fabiano.
But since then, a number of papers have followed up on
the original study participants. “They have found that some
of those conclusions may have been if you just looked at the
immediate post-treatment results,” he says. “If you look at how
well they work over time, any differences seem to subside.”
He points as an example to a 2007 article in the Journal of the
Academy of Child and Adolescent Psychiatry. A three-year follow-
up of the MTA study, the paper found that while medication
and the combined approach had a significant advantage at the
14- and 24-month follow-up, that advantage faded over time.
At the 36-month point, the treatment groups didn’t differ
significantly on any measure.
Fabiano’s own work, a meta-analysis published in 2009 in
Clinical Psychology Review, found that behavioral treatments
for ADHD are highly effective. Fabiano and his co-authors
examined 174 studies of behavioral treatments in 114 papers.
These treatments fell into three broad categories:
• Parent programs. These interventions focus on teaching
parents strategies for helping their children succeed. One such
approach is to catch children being good. “If you think about
the typical child with ADHD, they’re always noticed when
they’re messing up,” says Fabiano. “One of the things we try to
teach adults to do is to also notice them when they’re doing the
right thing and then label and comment on it so they’re getting
attention for good behavior.”
• Teacher programs. Like the invisible marker example,
these interventions offer teachers behavioral strategies for
the classroom. They include giving straightforward, one-step-at-a-time instructions to children and announcing the
consequences of not paying attention ahead of time. Another
effective approach is contingency management. With this
strategy, children receive daily report cards that outline how
well they have met such goals as speaking in turn or bringing
their homework back to class. When they meet those goals, they
• Therapeutic recreational programs. In these programs,
children with ADHD interact with each other at summer
camps and similar venues. The programs offer crafts, sports
and traditional camp activities in addition to behavioral
interventions. In contrast to the usual ADHD treatment, these
interventions last all day long for several weeks at a time.
Programming typically includes brief social skills training
sessions plus coached group play incorporating contingency
management strategies. In addition to learning social skills,
participants also learn sports and team membership skills.
“A lot of this isn’t rocket science,” Fabiano admits. “The hard
part is keeping these interventions going.”
But the key is early intervention, says psychologist George
J. DuPaul, PhD, co-author of the 2011 book “Young Children
with ADHD: Early Identification and Intervention.” Even the
American Academy of Pediatricians’ 2011 treatment guidelines
say that behavioral strategies should be the first line of
treatment for young children with ADHD.