Transcript File - Dr. Craig Wiener

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
(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
–
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
Functional
Delay
ADHD
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 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 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?
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