This programme is a treatment manual written for mental health professionals. It assumes clinical training, experience of working with children and families, and access to supervision. It replaces neither your clinical judgement nor your professional responsibility. The diagnostic criteria here are reformulated in our own words and never reproduced: consult the original manuals for the letter of the text.
1. The programme at a glance
Indication. Attention deficit hyperactivity disorder in children aged 6 to 12: inattention, hyperactivity and impulsivity, present before twelve, in at least two contexts, for at least six months, with an impact on school, family or social life.
Reference model. Behavioural and organisational interventions, recommended alongside medication by the British guidance (National Institute for Health and Care Excellence, 2018) and the American guidance (American Academy of Pediatrics, 2019). They rest on Barkley's executive model, on the motivational model of delay aversion, and on the evaluated parent training and organisational skills training protocols.
Format. Twelve sessions with the parents, of 50 minutes; six sessions with the child, interleaved; a school intervention, which is not optional; two booster sessions at one month and then at three months.
Mechanism targeted. Not making the child attentive, but four changes: putting the organisation in the environment rather than in their head, making consequences immediate and frequent, rebuilding a picture of themselves that is not made of reproaches, and making school a place where they can succeed.
| Session |
Object |
Product of the session |
| P1 |
Feedback on the assessment, and the record |
Record set up |
| P2 |
Explaining ADHD to the parents |
Written formulation of the case |
| P3 |
Positive attention |
Three behaviours spotted |
| P4 |
Instructions, and attention that drifts |
Instructions rewritten and practised |
| P5 |
The external frame: time, space, reminders |
Three supports installed |
| P6 |
Immediate consequences and the chart |
A chart that pays several times a day |
| P7 |
Homework |
Homework sequence rebuilt |
| P8 |
Mornings and evenings |
Two routines displayed |
| P9 |
Emotions and impulsivity |
Signal and pause installed |
| P10 |
Siblings and friends |
One social objective chosen |
| P11 |
School |
Liaison sheet in place |
| P12 |
Review, plan, and what follows |
Plan written by the parents |
What the family takes away. Seven printable worksheets, listed in section 38 and downloadable from this page: our record, what I notice, my instructions, my external frame, my chart, my homework, our plan.
What distinguishes this programme from attention training. Cognitive training improves the tasks that are trained and transfers poorly to everyday life. This programme does not seek to increase attentional capacity: it modifies the environment, the contingencies and the supports, so that the child can do what they already know how to do.
2. Before you begin
Who this programme is for
This text is written for psychologists, psychiatrists, child psychiatrists, neuropsychologists, psychotherapists and doctors trained in cognitive behavioural therapy with children. It assumes that you can conduct a multi-informant assessment, that you know the presentations that must be ruled out, and that you can work with a school.
It is not written for parents or teachers. It contains the procedures, the thresholds and the criteria for non-response, and it raises questions — medication, prognosis, non-response — that must be put differently when addressing a family.
The prior question: is this really ADHD?
This is the most important decision in this manual, and it is not taken in a single session.
This programme supports an established ADHD, that is, a picture of inattention and/or hyperactivity-impulsivity present before twelve, in at least two contexts, with a real impact, and not explained by something else.
It does not treat age-appropriate restlessness. A six-year-old who fidgets, interrupts and cannot last thirty minutes on a worksheet is behaving their age. Section 3 gives the landmarks.
It does not treat situated inattention. A child who is attentive everywhere except in maths lessons probably has a problem with maths.
It does not treat the presentations that must be ruled out first: lack of sleep, learning disorders, anxiety, depression, autism spectrum disorder, the consequences of a context of violence or insecurity, sensory disorders, and certain medical problems. Section 8 is devoted to them, and it is not optional.
It does not replace a medical opinion. The diagnosis may be made by different professionals depending on the country, but the question of medication is a doctor's business, and so is the physical work-up.
What this programme is not
It is not attention training. See section 37.
It is not a drug treatment, and it is not a substitute for one. The place of medication is stated in section 13, clearly and without detour.
It is not a method for keeping a child still. The objective is not immobility, and a manual aiming at that would do harm.
It is not a therapy of the child alone. In pre-adolescent children, what has most effect goes through the environment: the parents, the school, the supports. Six sessions with the child are included here, and they have a different purpose — that the child understands what is happening to them and stops believing themselves bad.
How to use it
Read the whole before the first session, in particular sections 8, 13, 31 and 32: the differential, medication, external organisation, and work with the school. These are the four places where things go wrong.
Each session is described according to the same frame: the objective, the step-by-step run-through, what you say, the frequent errors, and the criterion for moving on.
A warning specific to this disorder. Progress is irregular and context-dependent: a week of holidays, a supply teacher in class, a short night, and everything seems to have come back. That is not a relapse, it is the nature of the disorder. Saying so from the outset avoids a discouragement that makes families give up.
3. What is normal, by age
The first task is not to treat, it is to know whether to treat. Attention, inhibition and tolerance of boredom are built slowly, and a proportion of consultations concern children who are fine and environments that ask too much.
From three to five years
The child moves a great deal, changes activity every few minutes, interrupts, cannot bear to wait. They cannot sit at the table for more than ten to fifteen minutes. All of that is ordinary.
What is not age-appropriate: restlessness with no moment of calm at all, a total absence of constructed play, constant risk-taking, or a glaring difference from every other child of the same age.
From six to eight years
The child can hold a short task, ten to twenty minutes depending on interest. They forget their things, they drift, they get up from their chair. They wait their turn most of the time, but not always.
What is not age-appropriate: never finishing a task even an interesting one, losing equipment every day, being reported by the school every week, being unable to stay seated for a meal.
From nine to twelve years
The child can work twenty to thirty minutes, check their work a little, anticipate in the short term. They begin to organise themselves with a diary, imperfectly.
What is not age-appropriate: never writing down homework, never handing in a complete piece of work, forgetting half of oral instructions, being punished several times a week for interrupting.
The four questions that sort things out
Since when. ADHD does not begin at ten. Look for signs before twelve, and ask about nursery and the start of primary school.
In how many contexts. Home, school, activities, at other people's homes. A picture present in a single place is not ADHD.
With what impact. Marks, punishments, friendships, self-esteem, family life. A child who is distractible but who succeeds, who has friends and who is fine does not call for treatment.
Compared with what. With children of the same age and the same level, not with an ideal nor with a calmer brother.
What the answer changes
Three outcomes.
Age-appropriate functioning, in a demanding environment. Two to four sessions of information and adjustment, with the school if necessary.
ADHD. The programme starts, and the question of medication is raised with a doctor.
Something else in the foreground. See section 8.
4. The clinical picture
What the parents describe
They describe a repetition. You have to say it ten times, he forgets everything, he loses everything, he starts and does not finish, he interrupts, he cannot keep still, homework takes two hours for twenty minutes of work.
And they describe something that baffles them: when he likes it, he lasts three hours. That sentence is almost always spoken, and it is the one to explain first — see section 5.
The phrases that recur: "he could if he wanted to", "we cannot spend our lives behind him", "the teachers say he is intelligent but that he does not work", and "he is starting to say he is useless". This last one is the most important.
What the child says
Often that they do not know why. They cannot explain why they did not write down the homework, why they answered before the end of the question, why they lost their jumper. They have no reason, and they are asked for one several times a day.
Many of these children have already built an explanation of themselves: I am useless, I am stupid, I am a nuisance. It is the most costly consequence of the disorder, it appears early, and it is a treatment target in its own right.
The three dimensions
Inattention. Difficulty sustaining attention on what is not immediately interesting, distractibility, forgetting, losing things, disorganisation, avoidance of long tasks, careless errors. It is the dimension most linked to school impact and the most often missed, in particular in girls.
Hyperactivity. Moving, getting up, running, climbing, talking a lot, being unable to play quietly. It decreases with age, and often turns into inner restlessness.
Impulsivity. Answering before the end, not waiting one's turn, interrupting, acting without thinking, taking risks. It is the dimension most linked to conflict and accidents, and the one that costs most socially.
These three dimensions do not predict the same thing. Note them separately.
What ADHD is not
It is not an attention deficit in the strict sense. The child can concentrate intensely on what interests them. The problem is regulation: allocating attention according to importance and not according to interest.
It is not a lack of intelligence. The disorder is independent of intellectual level.
It is not a lack of will. This is the most important sentence of the feedback, and it must be supported by the model rather than by an assertion.
It is not the parents' fault. Child-rearing practices modulate the expression of the disorder; they do not create it.
What makes the picture worse
Lack of sleep, which mimics and worsens ADHD. Screens at the end of the day, through sleep and through the contrast in stimulation. Days without structure. Noisy environments. Long, unbroken tasks. And the accumulation of reproaches, which produces secondary opposition.
Epidemiology, in two useful figures
The prevalence of ADHD in children is estimated at around 5 %, with considerable variability depending on criteria and sources of information. Boys receive the diagnosis two to three times more often than girls, and this difference is partly due to under-recognition of the inattentive presentation.
The disorder persists into adulthood in a substantial proportion of cases, in an often modified form. That is an argument for treating early, and it is also a reason not to promise that it will disappear.
5. The model that guides this programme
Two complementary models, to explain to the parents
This is the most profitable explanation in the programme, and it takes fifteen minutes in session P2. It makes comprehensible what has baffled the family for years.
The executive model. What is affected is not knowledge of the rules, it is the capacity to apply them at the right moment: inhibiting a response, keeping a goal in mind while doing something else, remembering the next step, resisting a distraction, estimating time.
A useful formula: it is not a disorder of knowing, it is a disorder of doing. The child knows what to do; they do not do it at the moment when it must be done.
The motivational model. The child with ADHD is more sensitive than others to the delay of a reward. A consequence in a week does not reach them; the same consequence in ten minutes works. That explains why they last three hours on a game that gives feedback every second, and two minutes on an exercise that gives nothing before tomorrow.
What these two models imply
They give the four principles of the programme, and they should be written down with the parents.
We put the organisation outside. Not in their head: in the environment, at the point of use. A visible reminder in the place where the action is needed is worth more than a repeated instruction.
We make consequences immediate and frequent. A chart that pays at the end of the week is a chart that does not work here. The same chart paying three times a day works.
We break things up. Short tasks, planned breaks, visible steps.
We protect self-esteem. Because it is attacked daily, and because a child who has given up no longer responds to any arrangement.
What the model explains to the parents
Why he lasts on games. Immediate feedback, constant novelty, adjusted difficulty. It is not proof that he could, it is a demonstration of the model.
Why repeating is no use. The instruction is understood, it is not maintained. Repeating it louder does not change working memory.
Why he does the opposite of what he has just said. He knows, and he does not inhibit.
Why deferred punishments have no effect. The delay cancels the consequence.
Why he does better when you are behind him. You are his external frame. The aim of the programme is to replace part of your presence with supports.
What the model implies not doing
Do not aim for autonomy straight away. A child with ADHD is about two to three years behind on these functions. One expects of a ten-year-old what one would expect of a seven-year-old.
Do not remove the supports because things are better. Things are better because the supports are there.
Do not confuse slowness with bad will.
Do not explain a second time more loudly.
Frequent questions
The parents ask whether it is really ADHD or just character.
Answer with the method rather than with an assertion: show what the conclusion rests on — the onset before twelve, the presence in two contexts, the impact, and what has been ruled out. A family that understands the reasoning argues less with the conclusion, and it is better armed against the contradictory opinions it will receive.
He spends three hours on a video game. How can he have an attention deficit?
It is the most frequent question, and it is a demonstration of the model rather than an objection. The disorder is not an inability to concentrate: it is a difficulty in allocating attention according to importance rather than according to interest and immediate feedback. A game gives feedback every second; a grammar exercise gives nothing before tomorrow. Explain it with the motivational model, and use it to justify immediate consequences.
Is medication necessary?
It is the best-evaluated treatment for this disorder, and it teaches nobody anything — both sentences are true and both must be said. The decision belongs to the family and to the doctor. Your role is to inform, to pass on elements useful to the prescriber, and to measure the effect. See section 13.
Are we not going to make him dependent on all these supports?
No, and the comparison that works is that of crutches: you do not make someone dependent by helping them to walk while their leg repairs itself, you make them dependent by taking the crutches away too soon and letting them fall. The supports are lightened when the child has been using them alone for several weeks, one at a time, and they are put back at the first sign of deterioration.
The school says he could if he wanted to.
That is the sentence to be dealt with, calmly and with facts. Offer a meeting rather than a letter, bring a page explaining what the disorder does in the classroom, and above all offer something concrete and inexpensive: a three-item liaison sheet, four adjustments. A teacher who is given a tool becomes an ally; a teacher who is given a lesson does not.
Homework lasts two hours every evening.
Set a duration, not a quantity, and stop at the end even if not everything is done — then tell the teacher what could not be. It is the measure that changes most in family life, and it requires a prior agreement with the school, which accepts it more often than one thinks. Also check the actual level: part of those two hours may be a learning disorder.
The points chart worked for two weeks then ran out of steam.
Three causes, in this order. The payout has become too rare — go back to three times a day. The rewards have become predictable — change the menu, novelty counts particularly in this disorder. Or the bar is too high — lower it until he earns something every day.
He says he is useless.
It is the most important symptom to treat, and it must be taken seriously rather than reassured away. Three things help: explaining to him what he has, with an image, and explaining it to him again several times; building with him the list of what he does well, which is always longer than he thinks; and finding a domain in which he really succeeds, outside school if necessary.
The grandparents say that in their day none of this existed.
Do not enter the debate, it cannot be won. Ask instead for one single thing: not to undo what is in place. And give them a short written version of what helps, treating them as allies. Most adapt when they see the results.
Does it go away with growing up?
Answer honestly: the picture changes with age — visible hyperactivity decreases, inattention and disorganisation often persist —, and a substantial proportion of children keep difficulties into adulthood, in a different form. That is not bad news provided it is said with what follows: what is treated is the consequences, and they are treated well.
Is a neuropsychological assessment needed?
Not to make the diagnosis: normal tests do not exclude it and abnormal tests do not confirm it. It is very useful for something else — spotting a learning disorder, a particular cognitive profile, an intellectual functioning that changes expectations. Ask for it when it will change something in the management, not on principle.
What should one think of neurofeedback, training games, supplements?
See section 37. Say what is known, say what it costs in time and in money, and let the family decide if it is harmless and if it replaces nothing. What you refuse: that a method without data should replace what works, or that a child should be subjected to a demanding device without demonstrated benefit.
The new school year undid everything.
That is predictable, and that is why a start-of-year consultation is planned in the plan. A new teacher, new timings, supports put away over the summer, a liaison sheet to rebuild: it takes three weeks to put everything back, and one session in September is worth three sessions in January.
Twelve sessions, is that a lot?
What counts is not the number of sessions, it is the number of supports actually installed and the fact that the school is involved. A family that leaves after six sessions with three supports in place, a chart that pays three times a day and a liaison sheet is better treated than a family that has heard everything in twelve.