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 ableTo 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 (DRD4)

– Increases chance of diagnosis by 50%

LaHose et al., 1996; Barkley, 2006

Different Brain

– Structure • smaller and less differentiated

– Responding• Diminished arousal and activation

– And Chemistry • Less availability of neurotransmitters

– dopamine and nor epinephrine

Barkley, 2006; Brown, 2010

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 learned- a 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)

• 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

While there are

Functional Delay in ADHD

Traditional View New Model

Functional Delay ADHD

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?

–Avoidance

Antagonism

Accommodation

Acquisition

Attention

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 resultsEase 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 ca “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?

Works Cited Barkley, R. A. Advances in ADHD: Theory, Diagnosis, and Management. J & K Seminars, 1861 Wickersham Lane, Lancaster, PA 17603, 2008.

______. Attention Deficit Hyperactive Disorder: A Handbook for Diagnosis and Treatment . New York: Guilford Press, 2006.

______. Attention Deficit Hyperactive Disorder: A Handbook for Diagnosis and Treatment.. New York: Guilford Press, 1998.

Breggin, P. R. 2007. Brain-Disabling Treatments in Psychiatry: Drugs, Electroshock, and the Psychopharmaceutical Complex: 2nd ed. New York. Springer Publishing.

Brooks, R., Goldstein, S. Raising Resilient Children, McGraw Hill, 2001.

Brown, T. Recognizing and treating adult ADHD. In Shnitzer, N. New England Psychologist. Vol. 18, no. 5, p. 2, June 10, 2010.

Chang, F., Kidd, J., Livak, K., Pakstis, A., Kidd, K., “The World-Wide Distribution of Allele Frequencies at the Human Dopamine D4 Receptor Locus”, Human Genetics, 98, (1996): 91-101.

Ehrenreich, J. T., Buzzella, B. A., & Barlow, D. H. (2007). General principles of the treatment of emotional disorders across the lifespan. In S. G. Hoffman & J. Weinberger (Eds.), The art andscience of psychotherapy (pp. 191–210). New York: Routledge.

Elias, P. “Brain Scans a Political Tool?” Telegram & Gazette. October 29, 2004, A13.

Gaser, C., and G. Schlaug. “Brain Structures Differ between Musicians and Non-Musicians.” The Journal of Neuroscience 23, no. 27 (2003): 9240–45.

Henry, W. P., Schacht, T. E., & Strupp, H. H. Structural analysis of social behavior: Application to a study of interpersonal process in differential psychotherapeutic outcomes. Journal of Consulting and Clinical Psychology. 54 (1986): 27-31.

Henry, W. P., Schacht, T. E., & Strupp, H. H. Patient and Therapist intoject, interpersonal process, and differential psychotherapy outcome. Journal of Consulting and Clinical Psychology 58 (1990): 768-774.

Horvath, A. O., & Bedi, R.P. The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (p. 37-69). New York: Oxford University, 2002.

Johns Hopkins. http://www.hopkinsmedicine.org/news/media/releases/adhd_symptoms_persist_for_most_young_children_despite_treatment. 2/20/13

LaHoste, G. J., J. M. Swanson, S. B. Wigal, C. Glabe, T. Wigal, N. King, et al. “Dopamine D4 Receptor Gene Polymorphism is Associated with Attention Deficit Hyperactivity Disorder.” Molecular Psychiatry 1 (1996): 121–24.

Latham, G., Erez, M & Locke, E., “Resolving scientific disputes by the joint design of crucial experiments by antagonists: application to the Erez-Latham dispute regarding participation in goal setting.” Journal of Applied Psychology 73 (1988): 753–72.

Lepper, M. R., D. Greene, and R. E. Nisbett. “Undermining Children’s Intrinsic Interest with Extrinsic Rewards: A Test of the Over-Justification Hypothesis.” Journal of Personality and Social Psychology 28 (1973): 139–87.

Locke, E. A., and G. P. Latham. “Building a Practically Useful Theory of Goal Setting and Task Motivation.” American Psychologist (September, 2002): 705–17.

Martin, D. J., Garske, J. P., & Davis M. K. Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology. 2000; 68: 438-450.

MTA Cooperative Group. 1999. “Moderators and Mediators of Treatment Response for Children with Attention-Deficit/Hyperactivity Disorder: The Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder.” Archives of General Psychiatry 56: 1088–96.

———. 2004. “National Institute of Mental Health Multimodal Treatment Study of ADHD Follow-up: Changes in Effectiveness and Growth after the End of Treatment.” Pediatrics 113: 762–69.

Pliszka, L. R., J. T. McCracken, and J. W. Maas. “Catecholamines in Attention Deficit Hyperactivity Disorder: Current Perspectives.” Journal of the American Academy of Child and Adolescent Psychiatry 35 (1996): 264–72.

Shaw, P. et. al. Polymorphisms of the Dopamine D4 Receptor, Clinical Outcome, and Cortical Structure in Attention-Deficit/Hyperactivity Disorder, Arch Gen Psychiatry. 2007;64:921-931.

Schultz, W., P. Dayan, and P. R. Montague. “A Neural Substrate of Prediction and Reward.” Science 275 (1997): 1593.

Swanson, J. et. al. “Attention deficit/hyperactivity disorder children with a 7-repeat allele of the dompanine receptor D4 gene have extreme behavior but normal performance on critical neuropsychological tests of attention”, Proceedings of National Academy of Sciences, 97: 4754-4759.

U.S. Department of Health & Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, Hyattsville, MD 20782, USA. 2009.

Wickelgren, I. “Getting the Brain’s Attention.” Science 278 (1997): 35–37.

Visit my website

www.craigwiener.com