Craig Wiener Ed.D . Assistant Professor - PowerPoint Presentation

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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

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This presentation is based on two recently published books by Craig Wiener

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And a third book for parentsParenting Your Child with ADHD: A No Nonsense Guide For Nurturing Self-Reliance and Cooperation

New Harbinger Publications

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Current view

Biogenetic problem that causesHyperactivity/impulsivity & distractibility 9% of children U.S. Department of Health & Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics

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Inferior biological/mental inhibitory mechanism

Less ableTo stop, look, listen, and think before taking action (Douglas, 1972).They will not manage their futures effectively

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Unless people can

Inhibit immediate reactionsengage “executive functioning”And concentrate long enough To generate effective longer-term responses (Fuster, 1997; Barkley, 2006).

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They will be

Enticed by immediate gratifications

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Biological causality for ADHD is based on three pillars (research findings) (Pliszka, Mc-Cracken, and Maas, 1996).

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It runs in families

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Identical twins are almost always concordantIf one shows ADHD than the other will too

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People with ADHD more often have certain genes

7-repeat allele (DRD4)

Increases chance of diagnosis by 50%

LaHose et al., 1996; Barkley, 2006

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Different Brain

Structure smaller and less differentiatedRespondingDiminished arousal and activation And Chemistry Less availability of neurotransmitters dopamine and nor epinephrine Barkley, 2006; Brown, 2010

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Medications work instantaneously

Since changing biology improves ADHDthe etiology of the behaviors must be biological

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But these pillars are fragile

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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

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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

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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

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With ADHD

Genetics is not destiny or fateNurturing can be influential

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A psychological perspective anticipates that family members will show similar behaviors

Related people have similar bodies and environments So their probabilities for learning are similarExtreme with identical twinsA heightened confounding of genetics and learning

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It will not matter if you are the birth parent or adopted parent

Biology changes the probability of what is learned- a temporal (not causal) originHeight  Basketball playerPhysically Attractive  PopularPhysically Awkward  Low Social Status, Sports Avoidance

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Parents are not blamed

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Children with particular kinds of problems are more likely to develop ADHD Behavior

Developmental DelayCoordination DisorderSpecific speech or learning problems Health complicationsShort attention span with objects High activity levels Negative infant temperament (Barkley, 2006)

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Many people with ADHD who do not have these kinds of early occurring problemsADHD is more likely to develop under these conditions of adversity

While there are

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Functional Delay in ADHD

Traditional View

New Model

Functional Delay

ADHD

Functional Delay

ADHD

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But Remember

You can influence heritability quotients by changing the typical course of development

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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

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Differences in brain response may relate to learning

MRI data showsBrain blood flow varies in relation to observing someone with the same or different political affiliationPatterns of brain activation and arousal can be a function of what you are doing and what you have learned Elias, 2004

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With musicians

The planum temporalebecomes largermore asymmetrical As a consequence of playing a musical instrument Gaser and Schlaug, 2003

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Brain differences can show

Relationships betweenpatterns of living and biological developmentsThe consequence of the co-occurrence of biology and environment

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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.

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IN REVIEW: Biological Causality is not established by the first two Pillars

We may have biology or impairment that comes before ADHDBut that does not demonstrate incipient ADHDIt 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 ADHDBut co-occurrence does not show causality Biology and skill acquisition are influenced by the way a person lives in the world.

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YES- medicine reduces ADHD Behavior

But it does not identify the cause of ADHDAlcohol helps with sociability, but this does not tell us why the person was not social

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ADHD medications can be a potent and practical solution

Due to urgency and resources of participants But they do not tell us about the cause of ADHD

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There is yet another looming concern with traditional view:

Why would a biological disability respond so remarkably toBribery 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?”

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Psychology must be involved if the problem relates to personal interest

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History of conditioning

Can account for the frequency rates of ADHD Situational patterns indicate that the behaviors are reinforced

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by Brian NelsonSun Spott Studios Hyperactivity occurs when parents are on the phone

Cartoons

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But not if bedtime is extended while the parent talks

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Distractibility prevails when writing a “thank you” note

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But not when writing a Christmas list

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Blurting occurs when vying for attention or provoking

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But not when there could be incrimination

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Unpleasant appointments are often missed

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But it’s first in line for scheduled trips to the movies

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The daily planner

Is cast aside

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While plans on “Facebook” are being made

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Personal belongings are

scattered about

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While battle scenes are meticulously arranged

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Chores are left undone

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But the house sparkles when “buttering up” the parent

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Contemplation is evident when making a purchase

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But not when shopping for a sibling

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What increases ADHD behavior?

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Avoidance

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Antagonism

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Accommodation

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Acquisition

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Attention

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Being loud has its advantages

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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

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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

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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

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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

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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

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As Sigmund Freud professes

Malfunctions such as:Blurting out, Risk taking Not following throughForgetting BreakageMisplacing and losing objects, etc. Are not devoid of psychological meaning even if not conscious to the individual (1924)

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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?

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In sum

ADHD is not caused by the environment or biologyADHD is reinforced by the environmentHigh frequencies indicate frequent reinforcementA detailed history of conditioning is developed for each individual

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Remember

Learning does not mean environmentally caused Biology always factors in Every behavior needs a biological substrate

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Adverse situations that may trigger ADHD

DisapprovalFailure InsecurityDifficulty comprehending Loss of authorityUnwelcomed transitionsAssignments Social exclusionEvaluationExtended speaking Being denied

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Comfortable situations that infrequently trigger ADHD

Initiated and enjoyed activities competencesuccessdiscretionary authoritysocial acceptance

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A Useful Tip: Whose agenda

Someone else’s agenda:ADHD is more probableThe child’s agenda:ADHD improbablefailures to accommodate to social limits/expectationsKinds of immature infringements and avoidances

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Concerns regarding traditional ADHD treatments

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Medication and Stringent Discipline

Key Benefits Rapid resultsEase of use

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Drugs: The most powerful tool

Lifetime medication treatment advisedThe safest and most studied of all psychiatric medication Barkley,2008

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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

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Consumer Reports

ADHD Drugs: Summary of RecommendationsMost children and teenagers (60 percent to 80 percent) become less hyperactive and impulsive are better able to focusand are less disruptive at home and school However, there is no good evidence showing those benefits last for longer than two years.

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What about interventions that rely on surveillance and coercion?

Remind

Signs

Set Timers

Rewards

Punishments

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There can be considerable side effects

When others employ those tacticsBut the presumption of disability takes treatment in this direction

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Behaviors are learned when managers are involvedBut are less likely to occur without management Adding a reward will reduce the achievement that occurs without the reward Lepper et al., 1973

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Traditional methods do not nurture self-discipline

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The child may learn

Evasion ManeuveringProcrastination Withholding Submission/anxietyMinimal conformityRetaliationSelfishnessRigidityCoercion

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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?

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A Proposed Alternative Intervention: Develop Self-reliance & Cooperation

Where individuals learn to do valued responses with less supervision and coercionWhere the child’s self-managing skills are cultivated

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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 outcomesExplore complications, harms, and obstacles that are likely to be encountered when particular solutions are enactedIncrease the child’s awareness of past successes in similar situations Address and resolve problems that disrupt their relationship with their child

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When developing Self-reliance and Cooperation

Treat the child as competent to succeed Seek her opinion and value her inputFacilitate “buy in”Strive for affirmation- e.g., positive head nod, something she wants to do Not Promote the child’s problem solving initiatives and independenceThe 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?”

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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?”

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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 interestParents teach mutual caring and respect

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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

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Nurture a positive relationship

Sharing CompromiseTurn taking And consistent routines

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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 greate.g., kindly lock up the child’s bike

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Utilizes “Evidenced Based Practice” with diverse groupsMethods 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 empathyHorvath & Bedi, 2002; Martin, Garske, & Davis, 2000; Henry, Schacht, & Strupp, 1986, 1990; Brooks & Goldstein, 2001)

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When Developing Self-reliance and Cooperation

Use Ten Guiding Principles

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1. Use coercion as a last resort

When behaviors are learned with reduced coercion interest is increasedYour child is more likely to cooperate and achieve even when you are not there

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2. Stay calm

“I know you’re angry, but I can hear you better if you talk quietly.”

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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.”

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4. Be patient

It can take many trials to learn a new behavior We all know that old habits are hard to break

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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?”

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6. Say it positively

Negative: “You can’t have snacks before dinner.”Positive: “Let’s keep our appetites. We can eat together real soon.”

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Negative:

“If you don’t let me finish my shopping, you won’t get your allowance.”

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Positive:

“Instead of having to come back to finish our shopping, we can finish now and have time to play later.”

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Negative:

“You’re wasting time again.”

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Positive:

“Maybe it will work out better for you if you start that project now rather than later.”

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Negative:

“Don’t bother me right now.”

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Positive:

“I can play in a little while.”

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Negative:

“If you can’t keep up, you’ll have to get a tutor.”

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Positive:

“We’re willing to set aside money to get a tutor for you.”

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7. Treat your child as competent to succeed.

“You have to read the directions.” “How ca “How can you find out what to do?

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Incompetent

“Do you remember that we have an agreement?”

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Competent

“Do we still have an agreement?”

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Incompetent

“I’m going to set a timer.”

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Competent

“Would a timer help?”

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Incompetent

“I want you to study for a least a half hour.”

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Competent

“How much preparation do you want before you take the test?”

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Incompetent

“Let me help you.”

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Competent

“I’m available if you’d like to talk things over.”

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Incompetent

“I’m going to lock this up so you won’t touch it.”

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Competent

“Can I count on you to leave this alone?”“Will you wait until we can do this together?”

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Incompetent

“You’re not allowed to play with those toys because you didn’t pick them up yesterday.”

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Competent

“After you finish playing, are you okay with picking up when it’s time to stop?”

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8. Establish “buy in”

When your child is comfortable with what is happening, he is more likely to cooperate and do his part.

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9. Assert yourself

“I’m happy to keep buying these snacks if we figure out a way to share them.”

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10. Foster Independence

For example: Instead of ordering your child’s meal at a restaurant, encourage him to order his own meal.

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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.

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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.

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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.

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IN CONCLUSION: The debate is not about data

The debate is about the interpretation of dataADHD empiricism may be understood within a learning paradigm

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This understanding is not in vogue

But is it a reasonable way to interpret data based on

:

Parsimony

Consistency

Coherence

Precision and Scope

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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

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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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______.

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______.

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