- Slides: 133
Craig Wiener Ed. D. Assistant Professor: University of Massachusetts Medical School, Department of Family Medicine and Community Health Clinical Director: Family Health Center of Worcester Private Practice: 48 Cedar St. Worcester, Ma. 01609 Phone: 508 756 -4825 Website: www. craigwiener. com
This presentation is based on two recently published books by Craig Wiener
And a third book for parents Parenting Your Child with ADHD: A No Nonsense Guide For Nurturing Self-Reliance and Cooperation New Harbinger Publications
Current view • Biogenetic problem that causes – Hyperactivity/impulsivity & distractibility • 9% of children U. S. Department of Health & Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics
Inferior biological/mental inhibitory mechanism Less able To stop, look, listen, and think before taking action (Douglas, 1972). They will not manage their futures effectively
Unless people can • Inhibit immediate reactions – engage “executive functioning” • And concentrate long enough • To generate effective longer-term responses (Fuster, 1997; Barkley, 2006).
They will be • Enticed by immediate gratifications
Biological causality for ADHD is based on three pillars (research findings) (Pliszka, Mc-Cracken, and Maas, 1996).
It runs in families
Identical twins are almost always concordant If one shows ADHD than the other will too
People with ADHD more often have certain genes – 7 -repeat allele (DRD 4) – Increases chance of diagnosis by 50% La. Hose et al. , 1996; Barkley, 2006
Different Brain – • Structure smaller and less differentiated Responding Diminished arousal and activation And Chemistry – Less availability of neurotransmitters Barkley, 2006; Brown, 2010 dopamine and nor epinephrine
Medications work instantaneously • Since changing biology improves ADHD – the etiology of the behaviors must be biological
But these pillars are fragile
Genetic research does not establish a biological etiology – There are many people diagnosed with ADHD without the genetic variations – There are many people not diagnosed with ADHD with the variations Shaw et al. , 2007; Swanson et al. , 2000; Chang et al. , 1996
In comparison to other medical problems – No biological markers (or dysfunctions of any kind) that can be used to make the diagnosis • Too many false positives and false negatives
A 50% increased risk from having the genetic constitution • Only means that: A person’s chance of being diagnosed rises from 9% to 13. 5% Hardly a reason to panic
With ADHD • Genetics is not destiny or fate – Nurturing can be influential
A psychological perspective anticipates that family members will show similar behaviors • Related people have similar bodies and environments – So their probabilities for learning are similar • Extreme with identical twins – A heightened confounding of genetics and learning
It will not matter if you are the birth parent or adopted parent – Biology changes the probability of what is learneda temporal (not causal) origin – Height Basketball player – Physically Attractive Popular – Physically Awkward Low Social Status, Sports Avoidance
Parents are not blamed
Children with particular kinds of problems are more likely to develop ADHD Behavior – Developmental Delay • Coordination Disorder – Specific speech or learning problems – Health complications – Short attention span with objects – High activity levels – Negative infant temperament (Barkley, 2006)
While there are • Many people with ADHD – who do not have these kinds of early occurring problems • ADHD is more likely to develop under these conditions of adversity
Functional Delay in ADHD Traditional View New Model Functional Delay ADHD
But Remember • You can influence heritability quotients by changing the typical course of development
Yes, people with ADHD tend to have different brain biology • But the way you live and learn can also affect the biology of your brain – Dopamine levels can increase with positive experiences Schultz, Dayan, & Montague, 1997; Wickelgren, 1997
Differences in brain response may relate to learning • MRI data shows – Brain blood flow varies in relation to observing someone with the same or different political affiliation – Patterns of brain activation and arousal can be a function of what you are doing and what you have learned Elias, 2004
With musicians The planum temporale –becomes larger –more asymmetrical As a consequence of playing a musical instrument Gaser and Schlaug, 2003
Brain differences can show • Relationships between –patterns of living and biological developments • The consequence of the co-occurrence of biology and environment
So it is not surprising that • ADHD responding alters biological development and impairs skills and achievement (including performance on psychological tests) • As the saying goes: If you don’t use it, you lose it.
IN REVIEW: Biological Causality is not established by the first two Pillars • We may have biology or impairment that comes before ADHD – But that does not demonstrate incipient ADHD – It only demonstrates an increased probability that ADHD behaviors will evolve. • Many different outcomes can occur as development unfolds. • We may have biology or impairment that occurs with or after ADHD – But co-occurrence does not show causality • Biology and skill acquisition are influenced by the way a person lives in the world.
YES- medicine reduces ADHD Behavior • But it does not identify the cause of ADHD – Alcohol helps with sociability, but this does not tell us why the person was not social
ADHD medications can be a potent and practical solution o Due to urgency and resources of participants o But they do not tell us about the cause of ADHD
There is yet another looming concern with traditional view: – Why would a biological disability respond so remarkably to • Bribery • Personal interest • Instruction source Child initiated expected by others – How can you exceed your disability? • Many parents ask, “Why can my child function so well when she is doing what she wants to do? ”
Psychology must be involved if the problem relates to personal interest
History of conditioning • Can account for the frequency rates of ADHD • Situational patterns – indicate that the behaviors are reinforced
by Brian Nelson Sun Spott Studios Hyperactivity occurs when parents are on the phone
But not if bedtime is extended while the parent talks
Distractibility prevails when writing a “thank you” note
But not when writing a Christmas list
Blurting occurs when vying for attention or provoking
But not when there could be incrimination
Unpleasant appointments are often missed
But it’s first in line for scheduled trips to the movies
The daily planner • Is cast aside
While plans on “Facebook” are being made
Personal belongings are –scattered about
While battle scenes are meticulously arranged
Chores are left undone
But the house sparkles when “buttering up” the parent
Contemplation is evident when making a purchase
But not when shopping for a sibling
What increases ADHD behavior?
Being loud has its advantages
Examples of the “Five A’s: • Your child is dancing in front of a stranger in a waiting room while you are reading a magazine. You ask her to come to you and look at pictures in the magazine you are reading. Attention
Your child sticks out his leg and trips his younger brother. You yell at him, send him to his room, and go after him. Antagonism
Your child reaches quickly to get food before others and knocks over his milk. You clean up the spill while your child continues to eat. Acquisition
You ask your daughter to help you put away the groceries, but she keeps watching the television without responding. You keep calling her and continue to put things away. Avoidance
Your child is groaning and covering his face while doing his homework assignment. You go over to his desk and ask him if he needs help. Accommodation
As Sigmund Freud professes • Malfunctions such as: Blurting out, Risk taking Not following through Forgetting Breakage Misplacing and losing objects, etc. • Are not devoid of psychological meaning – – – even if not conscious to the individual (1924)
For example, compared with others of similar age The child more often yells especially when near an open window • Is he unable to access executive function – Remember the privacy rule – And self-regulate the negative emotion? • Or • Are his parents more often roused when he responds in that fashion?
In sum • ADHD is not caused by the environment or biology • ADHD is reinforced by the environment • High frequencies indicate frequent reinforcement – A detailed history of conditioning is developed for each individual
Remember – Learning does not mean environmentally caused – Biology always factors in • Every behavior needs a biological substrate
Adverse situations that may trigger ADHD – – – Disapproval Failure Insecurity Difficulty comprehending Loss of authority Unwelcomed transitions Assignments Social exclusion Evaluation Extended speaking Being denied
Comfortable situations that infrequently trigger ADHD – Initiated and enjoyed activities – – competence success discretionary authority social acceptance
A Useful Tip: Whose agenda • Someone else’s agenda: – ADHD is more probable • The child’s agenda: – ADHD improbable – failures to accommodate to social limits/expectations – Kinds of immature infringements and avoidances
Concerns regarding traditional ADHD treatments
Medication and Stringent Discipline Key Benefits Rapid results Ease of use
Drugs: The most powerful tool • Lifetime medication treatment advised • The safest and most studied of all psychiatric medication Barkley, 2008
Problems with Medicinal Treatments – – Most positive data is short-term Connor, 2006 Diminishing effects over time Lawlis, 2004; MTA Study; Johns Hopkins Unwanted biological changes Breggin, 2007 Difficulty stopping • Acclimation • Failure to learn without medication – Reliance • Drugs are the cure • Can’t succeed without the drug • Increasing usage Bhatara et al. , 2000; Wilens et al. , 1995 – Other treatments ignored • Urgency removed • Problems remain years later Fabiano, 2008; Barkley, Murphy and Fischer 2008
Consumer Reports • ADHD Drugs: Summary of Recommendations • Most children and teenagers (60 percent to 80 percent) • become less hyperactive and impulsive • are better able to focus • and are less disruptive at home and school • However, there is no good evidence showing those benefits last for longer than two years.
What about interventions that rely on surveillance and coercion? • Remind • Signs • Set Timers • Rewards • Punishments
There can be considerable side effects – When others employ those tactics – But the presumption of disability takes treatment in this direction
Behaviors are learned when managers are involved • But are less likely to occur without management – Adding a reward will reduce the achievement that occurs without the reward Lepper et al. , 1973
Traditional methods do not nurture self -discipline
The child may learn – – – Evasion Maneuvering Procrastination Withholding Submission/anxiety Minimal conformity – – Retaliation Selfishness Rigidity Coercion
But if ADHD is unlikely when the child is interested Why not design a treatment that increases the child’s interest in doing what others value?
A Proposed Alternative Intervention: Develop Self-reliance & Cooperation • Where individuals learn to do valued responses with less supervision and coercion • Where the child’s self-managing skills are cultivated
Parents Help the Child • Understand what is reinforcing current behaviors without criticism or blame • “Why would you give that up? ” • Identify positive alternative actions and outcomes • Explore complications, harms, and obstacles that are likely to be encountered when particular solutions are enacted • Increase the child’s awareness of past successes in similar situations • Address and resolve problems that disrupt their relationship with their child
When developing Self-reliance and Cooperation • Treat the child as competent to succeed – Seek her opinion and value her input • Facilitate “buy in” – Strive for affirmation- e. g. , positive head nod, something she wants to do – Not • Promote the child’s problem solving initiatives and independence – The child specifies when, where, and how a solution will be autonomously enacted – The parent asks, “Would you like to complete this on your own so you will be able to do it when I’m not around? ”
The adult helps the child • Identify solutions that are positive to the child – “How do you want to handle that problem? ” – “What could you do to take better care of yourself when you are in that situation? ” – “Will that be an improvement for you? ” – “What changes will help us? ” – “What do we do if the problem keeps happening? ”
Parents develop the child’s concern for others They model the behaviors they want the child to enact – “When the advertisement comes on, would you please pick up the toys? ” • Instead of giving a command that negates the child’s interest • Parents teach mutual caring and respect
Children and parents – Learn to consider multiple perspectives • They learn to understand the difficulties that others face in particular situations– compassion develops • They focus on “what’s in it for both of us” when resolving problems
Nurture a positive relationship – – Sharing Compromise Turn taking And consistent routines
Parents develop core values and take firm action when necessary – They stop facilitating when the child is intrusive or exploiting others • They do not accommodate to negative behaviors – And they are unyielding when risks are too great • e. g. , kindly lock up the child’s bike
Utilizes “Evidenced Based Practice” with diverse groups Methods that are known to promote positive therapeutic outcomes: • Facilitate goal-achievement Latham, Erez & Locke, 1988; Locke & Latham, 2002 • Stop avoidance behaviors (Ehrenreich et al. 2007) • Nurture positive relationships, resiliency, and empathy Horvath & Bedi, 2002; Martin, Garske, & Davis, 2000; Henry, Schacht, & Strupp, 1986, 1990; Brooks & Goldstein, 2001)
When Developing Self-reliance and Cooperation Use Ten Guiding Principles
1. Use coercion as a last resort – When behaviors are learned with reduced coercion • interest is increased – Your child is more likely to cooperate and achieve even when you are not there
2. Stay calm • “I know you’re angry, but I can hear you better if you talk quietly. ”
3. Take steps to address and resolve problems • “I haven’t been getting enough time on the computer. Let’s figure out a way to take turns. ”
4. Be patient • It can take many trials to learn a new behavior – We all know that old habits are hard to break
5. Suspend judgment “This report card looks terrible. ” “How do you feel about this report card? “What do you like about it? ” “Is there anything you want to change? ”
6. Say it positively • Negative: “You can’t have snacks before dinner. ” • Positive: “Let’s keep our appetites. We can eat together real soon. ”
Negative: • “If you don’t let me finish my shopping, you won’t get your allowance. ”
Positive: • “Instead of having to come back to finish our shopping, we can finish now and have time to play later. ”
Negative: • “You’re wasting time again. ”
Positive: • “Maybe it will work out better for you if you start that project now rather than later. ”
Negative: • “Don’t bother me right now. ”
Positive: • “I can play in a little while. ”
Negative: • “If you can’t keep up, you’ll have to get a tutor. ”
Positive: • “We’re willing to set aside money to get a tutor for you. ”
7. Treat your child as competent to succeed. “You have to read the directions. ” • “How can you find out what to do?
Incompetent • “Do you remember that we have an agreement? ”
Competent • “Do we still have an agreement? ”
Incompetent • “I’m going to set a timer. ”
Competent • “Would a timer help? ”
Incompetent • “I want you to study for a least a half hour. ”
Competent • “How much preparation do you want before you take the test? ”
Incompetent • “Let me help you. ”
Competent • “I’m available if you’d like to talk things over. ”
Incompetent • “I’m going to lock this up so you won’t touch it. ”
Competent • “Can I count on you to leave this alone? ” • “Will you wait until we can do this together? ”
Incompetent • “You’re not allowed to play with those toys because you didn’t pick them up yesterday. ”
Competent • “After you finish playing, are you okay with picking up when it’s time to stop? ”
8. Establish “buy in” • When your child is comfortable with what is happening, he is more likely to cooperate and do his part.
9. Assert yourself • “I’m happy to keep buying these snacks if we figure out a way to share them. ”
10. Foster Independence • For example: – Instead of ordering your child’s meal at a restaurant, encourage him to order his own meal.
A plan for success • Maria: Looks like you’ve been forgetting to take your backpack to school. Has that been a problem for you? • Sonia: Yes. I need it for my lunch and homework. • Maria: Would you like to figure out a way to remember it? • Sonia: Yes. • Maria: Okay. Let’s work out the details. Is there something that you always take with you in the morning? • Sonia: My bracelet.
A plan for success • Maria: How do you remember to take your bracelet? • Sonia: I always keep it on my bureau. I see it when I’m getting dressed. • Maria: Would it help if you could see your backpack in the morning, just like your bracelet? • Sonia: Yeah. Hey, I could put it next to my bureau. • Maria: Would that help you remember to take it with you? • Sonia: Well, I’d see it, but I put my bracelet on as soon as I get dressed, and I don’t leave until later. I might still forget it if it’s in my room.
A plan for success • Maria: So where do you want to put it so that you’ll always see it and remember it before you leave? • Sonia: If I leave it next to the door, I’ll always see it. • Maria: What will help you remember to put it next to the door each night? • Sonia: (after a moment) When I finish my homework in the evening, I’ll put it near the door. • Maria: What might help you remember to do that? • Sonia: When I finish my homework, I always put it in my backpack. I can put my backpack next to the door when I finish my homework.
IN CONCLUSION: The debate is not about data • The debate is about the interpretation of data –ADHD empiricism may be understood within a learning paradigm
This understanding is not in vogue But is it a reasonable way to interpret data based on: • Parsimony • Consistency • Coherence • Precision and Scope
Traditional View has many shortcomings • If ADHD does not occur: • It is asserted: The situation must not have taxed the inhibitory system or the person’s interest must have compensated. – But all you know is that the person didn’t do an ADHD response • No corroborating data is presented- simply post hoc assertions • The inhibitory model seems flawed: If you have to inhibit to know, how do you know when to Inhibit? – You pause when you are aware of a problem. It is not that the pause enables the awareness. • By their own admission; there is no reliable way to distinguish lack of compliance from ADHD
A Final Thought • Is ADHD incurable as traditionalists claim? • Or are poor outcomes the consequence of treatments that rarely produce impressive long-term results?
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