ADHD Article September 1999

For the most part, you will see no interuption in service. The new server will pick up where the old one leaves off, however there are a couple of changes that you need to know about.

1. Due to the move, we will be losing the message boards. :( In their place, I have created email discussion groups which will provide users with more options than the message board we previously had. Email discussion groups are like forums/message boards that are sent to your email address. No more logging in with a password and username and you need not go any further than your mail box to participate.

The ADDult Message board: For adults, a mailing list called ADDadults has been created. You can join ADDadults by sending an email message to addadults@onelist.com or by going to www.egroups.com/group/addadults This mailing list provides serveral features such as digest, no mail, file attachments, archives and more. This list will be for the discussion of add/adhd and how it affects adults in the work place, at home, in relationships etc. I know that at times, parenting is an issue for add/adhd adults but I prefer that parenting issues be addressed through addtalk@onelist.com

The Main Message Board:

addtalk@onelist.com has been operating for more than a year now and has a large support group of parents dealing with parenting issues and special education issues. This list already has over 165 users participating in daily discussions. To join, send a message to addtalk-subscribe@onelist.com or visit www.egroups.com/group/addtalk and comes with the same features as addadults.

Last but not least, any of you who still show bookmarks reflecting the original address of www.ns.net/users/BrandiV/ or www.ns.net/users/~brandv should redirect them to www.adhdnews.com over the next 30 days. Also, anyone still using the email address BrandiV@ns.net should change that to Contact Us

My thanks and gratitude to everyone for their patience and understanding in this matter.

Hugs Brandi

THE RELATIONSHIP CONNECTION

Two teachers were talking in the hall sharing information about some of their more challenging students. "I don't know," said one teacher "I have tried everything with Tom and nothing works." Behavior modification, extra gym time, phone calls home, parent conferences, restrictions and rewards, it almost seems useless." The other teacher responded, "Tom, he is one of my better student's. I have very little difficulty with him at all."

The Limbic System

This sounds like a familiar scenario. But, why is it that some teachers have all kinds of problems with one student while others who have the same student have little or no trouble at all. In order to completely understand the problem, it is helpful if we have a basic understand of how our brain is wired. If we were to take a cross section of the brain, we would discover that the top part of the brain, the neo-cortex is where we do most of our higher order thinking and where we process information. The middle part of the brain, the limbic system, is where our emotions, the mind (the conscience and collective un-conscience) and will are located. The bottom part of the brain, the stem is where the survival instinct is found. When we are under emotional stress, our first response is to survive. The two basic methods we have for survival are to either attack or escape. For any incoming information to be processed by the brain, it must first go through the emotions.

Respect and Responsibility

Imagine that a teacher made one of the following statements to a student: "When are you going to get this information right?" "I am so sick and tired of explaining this to you what are you dense or something?" Because your natural tendency is to survive, the emotional response of the student would be to either escape or attack this verbal put-down. (Criticism) Children and adults who have a tendency to escape usually have clinical problems. These might be your students who are habitually late, sleep at their desk, are chronically absent, and ultimately have substance abuse problems. These students require careful observation. In education generally the squeaky wheel gets the grease. So we may not even be aware of these students who have undetected clinical problems, until some event occurs that is potentially catastrophic in nature. In extreme cases, this can even result in a violent incident that could impact lives for generations to come. In contrast to the former, students who have the attack mentality are usually argumentative, disrespectful, and non-compliant. They are always in school and are looking for someone they can victimize to alleviate their anger. Usually, they vent their anger on the most convenient authority figure, such as a teacher or an administrator. These students frequently spend time in the Vice-Principal's office, have problems in their homes, in the community and ultimately with the police.

The key to working successfully with both types of these students is understanding the qualities they will need to develop, so they can lead productive and happy lives. The student who tends to escapes needs to develop a sense of responsibility; the student who tends to attack needs to develop respect. Before the desired behaviors can be elicited from the students they must first learn to comply with the rules of the system that they are in.

It is crucial that these students perceive that a relationship has been established between an authority figure and themselves. When the students grasp the idea the person in authority sees and understands them as an individual they will obey more frequently and will display a respectful and responsible attitude.

We must realize that there are bricks in the wall of these students' limbic system that were put there by other adults who responded to them in an angry and reactive way. Our goal must be to remove these bricks one by one. This will help foster a trusting relationship. Although behavior modification is an excellent extrinsic structure, it usually teaches students to behave in an adult's presence, not in their absence. Our aim is to develop an intrinsic mechanism that will change the child's attitude and help him develop a value system with high standards, which will sustain him as an adult.

Here are some practical tips that you can use to help develop a relationship with your students or children and when utilized with improve behavior, and more importantly develop their sense of self-acceptance. These techniques are universal and can be used by parents and teachers

1. Praise character not achievement.

In many families today love is performance based. Build self acceptance by recognizing those qualities in a child that can't change. Recognize the positives in his personality.

2. Keep promises

Many children today have lost complete trust in adults because they have lied or disappointed them. Say what you mean and mean what you say.

3. Keep things clear

Teach your children what it takes to please you and recognize it when then they do it. Self-Acceptance is developed through the recognition of righteous living.

4. Be sincere and honest

Offer constructive feedback for the student to learn from. Don't flatter the student but rather provide alternatives for the student to draw from.

5. Never say no if you can say yes

If a request is reasonable allow it. Don't say no just on a whim.

6. Say good morning, afternoon, or evening

This builds communication skills.

7. Call by name - No nicknames or derogatory remarks.

8. Offer genuine appreciation for things that are accomplished and for the initiation of compliance.

"I noticed you were really trying to control yourself when John was picking on you. Good job!"

9. Attend Events if possible. Let the students see you in a different light.

10. Have a conversation with your students/children like you might have with a friend. Try this, every day for 10-day straight converse with your students and offer no advice or correction. At the end of the 10 days they will look for you for more conversation. It work.

11. Last but not least apologize when necessary for discipling in anger or for violating their sense of fairness.

In this month's column, I'd like to review a study on the effects of behavioral and medication treatment for children who had both ADHD and Oppositional Defiant Disorder. This article appeared in a recent issue of the newsletter I publish, ADHD RESEARCH UPDATE <http://www.helpforadd.com/nresearch.htm> Children with ADHD often develop other behavioral disorders such as Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD), and such conditions are associated with more negative long-term outcomes. Learning about the most effective ways to treat children who show these types of behavior disorders in addition to ADHD is thus an extremely important task for parents, clinicians, and researchers.

A recent study appearing in the Journal of the American Academy of Child and Adolescent Psychiatry (Kolko, D. J., Bukstein, M.D., and Bafron, J. (1999). Methylphenidate and behavior modification in children with ADHD and comorbid ODD or CD: Main and incremental effects across settings. Journal of American Academy of Child and Adolescent Psychiatry, 38, 578-585) provides interesting and important data on this issue.

Before getting in to the specifics of this study, let me briefly review the symptoms of ODD and CD. Listed below are DSM-IV symptoms for ODD:
1. often loses temper;
2. often argues with adults;
3. often actively defies or refuses to comply with adult requests or rules;
4. often deliberately annoys people;
5. often blames others for mistakes or misbehavior;
6. is often touchy or easily annoyed by others;
7. is often angry and resentful;
8. is often spiteful and vindictive;
For ODD to be an appropriate diagnosis, at least 4 of the symptoms listed above must be present for at least 6 months; the behavior must occur more frequently than is typical for a child of comparable age, and the behavior must create significant impairment in a child's social or academic functioning. In addition, the oppositional behavior can not occur only during times when a child is depressed. An important difference that you will note from the symptoms of ADHD is that none of the ADHD symptoms involve behavior that is considered to be deliberate and willful. Thus, although children with ADHD often engage in behavior that annoy others and fail to follow through on requests, such behavior is not deliberately and willfully initiated. Conduct Disorder (CD) is a more severe form of behavioral disturbance. According to DSM-IV, the publication of the American Psychiatric Association that provides current diagnostic criteria for all recognized psychiatric disorders, the essential feature of CD is "...a repetitive and persistent pattern of behavior in which the basic rights of others or age-appropriate social norms or rules are violated." These behaviors fall into 4 main groupings:
* Aggressive behavior that causes or threatens to cause harm; Examples: initiating fights; cruelty to people or animals;
* Non-aggressive conduct that causes property loss or damage; Examples: fire setting with intent to cause damage; deliberate destruction of property;
* Deceitfulness or theft; Examples: shoplifting; breaking into someone's house; frequent lying to obtain goods or avoid obligations;
* Serious violation of rules; Examples: truancy from school; running away from home; staying out at night prior to age 13;
For the diagnosis of CD to be correctly assigned, at least 3 of the specific symptoms must have occurred during the prior 12 months, with at least one criterion present in the last 6 months. In addition, the disturbance in behavior must clearly result in clinically significantly impairment in the child or teen's social, academic, or occupational functioning. These criterion are intended to assure that the diagnosis is not assigned for an isolated antisocial act, but is instead reserved for youth who show a pattern of antisocial behavior over a significant period of time.

It is very important to recognize that the symptoms of ODD and CD are quite different from those of ADHD. When one of these disorders is present in addition to ADHD (note that if a child meets diagnostic criteria for both ODD and CD, which is almost always true for children with CD, only the CD diagnosis is assigned because it is the more severe condition), making sure that this is a clear target of treatment is critical. I mention this because I have seen many instances where parents whose child had one of these conditions in addition to ADHD was not aware of this, and was not pursuing anything other than medication treatment for the primary ADHD symptoms.

Now back to the study. In this investigation, 16 children with ADHD and one of these other behavior disorders completed a randomized placebo-controlled study examining the separate and combined effects of 2 dose of methylphenidate (i.e. MPH, the generic form of Ritalin) during a partial hospitalization program. During the study, which took place over a 6 week period, children received two administrations daily of either a placebo, or a low or higher dose of methylphenidate. In addition, every other week a comprehensive behavioral treatment was added to the mix. Thus, over the 6 week study, children were observed both with and without behavioral treatment in place, and with and without medication. To make things a bit more complicated, separate observations were made when children were in a classroom environment and a non-academic environment. Children were rated on a variety of dimensions including ADHD symptoms, oppositional behavior, peer conflicts, overt aggression, and positive mood. By comparing ratings of children's behavior both with and without medication, and with and without behavioral treatment, the researchers were able to examine both the individual and combined effects of these 2 treatment approaches.

As one might expect from a complicated study like this, the results are not entirely straight forward. Basically, the authors were able to look at whether medication and behavior modification - when administered without the other treatment present - produced gains in each outcome area, and, whether the addition of either treatment to the other resulted in any incremental benefits. This breaks down into 4 different questions:

1. Does medication alone produce gains?
2. Does behavior modification alone produce gains?
3. Does adding behavior modification to medication treatment result in greater benefits than medication alone?
4. Does adding medication to behavior modification treatment result in greater benefits than behavioral treatment alone?

In some ways, it is the last two questions that are most interesting. I will try to summarize the major findings below as I understand them:

1. In the classroom environment, medication alone was associated with reductions in ADHD symptoms, and improvements in mood and positive behavior. In the non-classroom setting, medication was found to improve ADHD symptoms, oppositional behavior, peer conflicts, and mood. 2. In the classroom environment, behavioral treatment alone was associated with reductions in ADHD symptoms, oppositional behavior, and peer conflicts, and an increased in positive mood ratings. In the non-classroom setting, behavioral treatment resulted in significant improvement only for oppositional behavior. 3. Behavioral treatment did not add significantly to the gains produced by medication alone for any of the outcomes studied. When added to behavioral treatment, however, medication had significant incremental effects (i.e. children did better than they were doing with behavioral treatment alone) on several of the outcomes. 4. When examining the outcomes for individual children, it was evident that for some outcomes in some settings, some children did better with the combination of medication and behavioral treatment than they did with either treatment alone. In sifting through the results of this study, there are several general conclusions that are worth highlighting.

First, the results indicate that both medication and behavioral treatment can be effective for children with ADHD and co-occurring behavior disorders. Although this may vary somewhat between the two approaches in different settings, some improvement in primary ADHD symptoms, and in oppositional behavior and peer relations can be expected.

Second, it seems more likely that medication will add to the gains produced by behavioral treatment than the reverse. Nonetheless, the latter clearly does occur for some children. Third, and I think this is especially important, the complexity of these results indicate that questions like "Is medication an effective treatment for ADHD?" or "Is behavioral treatment effective for ADHD?" are in some ways too general to help develop the most effective treatment for an individual child. At a broad level, the answer to such questions is "Yes". But, what studies such as this highlight is that the effect of any treatment can vary depending on what outcome you are looking at (e.g. academics vs. oppositional behavior) and what setting you are examining that outcome in (e.g. classroom vs. home). This means that what is most effective for a child in terms of one outcome or setting may not be as helpful in alleviating problems in a different area or setting. Thus, you may find that medication helps a child's academic work at school but does not result in meaningful behavioral improvements at home. Or, you may find that behavioral treatment enhances a child's behavior with adults but does not produce similar gains with peers.

Developing the most effective treatment for an individual child thus requires carefully evaluating how the child is doing in different domains (e.g. academics, behavior, peer relations, mood) and in different social contexts (e.g. classroom, home, peer group). One should not assume that just because a particular treatment such as medication is producing important benefits in one domain and setting, that this will necessarily translate into gains in all domains in settings. If it does not, than the task becomes one of determining what needs to be done to try and achieve similar gains in these other domains and settings.

Although this may seem complicated, but it really doesn't need to be. As long as you are observant to how your child is functioning in the different important areas of his or her life, you will get a picture of how some things are going better than others. If you identify areas that continue to be problematic, even if other things have gotten much better with treatments that have already been initiated, you would want to speak with your child's health care provider about ways to try and address the difficulties that you still observe. This type of vigilance and effort should really pay off in the long run.

David Rabiner, PhD http://www.helpforadd.com

A letter from a parent reads: "In addition to Parent Coaching Cards, what else can I do to help my child develop higher Social And Emotional Intelligence? My child is resistant to my attempts to talk about these issues."

Of the many contributions to a child's ultimate success in life, the presence of mature social skills and robust self-control ranks among the top. Parents can make a significant contribution to helping their children's growth in these vital areas. While most of us are not short on good intentions we must be careful not to be short-sighted in how we go about fulfilling these intentions. Children can quickly recoil at our efforts to "help them to grow up," leaving us feeling like our pearls of wisdom are going in one ear and out the other. Therefore, I offer the following pointers to facilitate this process:

Mark those moments of maturity. So often we are quick to point out when our children depart from their "thinking side" path, but overlook those opportunities when they display self-control in the face of challenging circumstances. Children may also disregard their self-control successes unless we tag those times with our praise. And once we do, we might find out that our child is intrigued enough to learn more about "life skills." Parents can offer a brief but pointed reference to their child's achievement with comments such as "now that was a well thought out decision,"or "I've got to hand it to you for keeping your cool when you faced that challenge." If such validations prompt the child to question or comment, that's a sign that they are opening the door to further discussion. Don't unwittingly cause them to slam it shut by comparing their success with another event when they were clearly in the throes of their "reacting side." Instead, explain that everyone gets trapped by tough times in their lives and it's nice to see how well they steered clear of reacting to one of their traps this time. If your child allows it, you can then elaborate upon the different traps that people fall into and strategies to avoid them. These traps might include feeling accused, feeling ignored by others, having to change plans, being annoyed by others' behavior, etc. Parents can refer to the "thinking side" as the lifeguard of decision-making, i.e., " we train it to watch over our behavior to keep our lives going smoothly."

Learn from your own coaching mistakes. If your coaching approach is leading to an dead end, find another coaching path. Children may thwart our efforts to "step into the coach's shoes" for a variety of different reasons. Perhaps we are too dogmatic about it ("Look, I'm a lot older than you and know more..."), or perhaps we are too wishy-washy about it ("I really wish you would just listen to me once in a while..."), or perhaps we inevitably leave our child feeling criticized and put down ("Yes, you did what I asked but what about all those other times that you could have cared less...?"). These and other approaches can leave parents feeling like their coaching words are marked "refused delivery" by their children. Therefore, parents are wise to examine how their delivery path might be re-routed. As the prior paragraph indicates, a direct approach is not necessarily the best approach to having your coaching offers accepted. Instead, it can often be helpful to wait for a "window of opportunity" when your child expresses an observation about themselves or others. If this occurs, parents can respond with an open-ended and validating comment, such as "that's a good point and probably one worth talking about."

These ideas will help parents make a more positive coaching impact. In general, my advice is to try to match your coaching approach to your child's temperament. More about this important issue will come in future columns.

ÓDr. Steven Richfield
The Parent Coach: A Column For Proactive Parenting
www.parentcoachcards.com
August, 1999

That's it for this edition of ADDed Attractions. Please remember to visit my sponsors. It is because of their contributions and support that this site and newsletter remains FREE to anyone who wishes to use it.

ACROSS THE SPECTRUM: www.naceonline.com
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GRANDMA'S PET WILDEBEAST ATE MY HOMEWORK: A practical guide for teaching and parenting adhd kids: www.adhdcounselorguy.com
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DR. DAVE RABINER: www.helpforadd.com
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Copyright 1999 Brandi Valentine. All rights reserved. This Newsletter is copyrighted by the authors and/or publisher.

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Appropriate credit should be given to this resource and it's authors if It is reproduced in any form. Brandi Valentine

I am not a Doctor nor a professional. The information on this site is not intended to take the place of the diagnosis or advice of a trained professional. Neither I, nor this server, endorse any service or product mentioned on this site. As a parent, I encourage all of you to investigate the safety and integrity of any product or service you may find, anywhere, before you consider its use with your child or family member.