ADHD Zone: Introducing a New Series on Attention Deficit Hyperactivity Disorder

Many families come to us for help with ADHD and related behavioral problems.  Some children (and adults) have previously received that diagnosis; then we examine the evidence and determine if the assessment seems to be correct and proceed with treatment. 

For other children, parents describe a variety of behaviors which, coupled with observation of the child in the office, lead therapists to assess the child for ADHD.  

We have written a series of practical articles for families of children 5-12.   These articles make the principles for helping these children clear and simple.    The Behavior Management principles in these articles apply, with adaptations, to children younger or older than this range of ages.

Many families stumble by using the same methods which worked for another child who does not have ADHD; they learn those methods do not work with the child who has ADHD.  Then the family may be adrift or frustrated.  Relationships become tense or hostile.  Some parents employ the same methods their parents used to rear them.  But those methods – “Good enough for my parents, then it’s good enough for me” – are not working. 

In this series, we will lay out principles which have worked well to help families coming into our clinic with an ADHD child.  The ideas in these articles work well with our ADHD families.  We will even have an article on some of these common mistakes in managing ADHD.

Here are the topics in the series:

1. ADHD Assessment and Smart Goals

• The information which will lead to a careful, adequate evaluation of the child         
• An overview of the ways we help with ADHD behavior.    
• Best TIPS for success for your child.
• A description of SMART Goals for changing the child’s behavior. 

 2. Behavior Therapy with Your ADHD Child

• The principles of how to accomplish our first priority, helping your child to become more successful, using behavior change methods.      

3. Behavior Contracting: Let’s Do It the Right Way

• Setting up an agreement with the child to change specific behaviors and to monitor the child’s performance.  Agreements work better than lectures or demands – they make sure the child fully understands the changes we want.        

4. Choose and Use Positive Reinforcement

• Picking reinforcements which will make a difference.  Selecting “rewards” can be more challenging than most parents realize.  Making consequences work effectively can be tricky.        

5. Daily Logs for Improving Child Behavior

• Using Daily Logs as part of the behavior contract. You need feedback from school in order to know treatment is working or to know whether the child’s behavior for the day merits reward.  

6. Shorehaven’s Double Reward-Double Cost Model for Changing Behaviors

• Explaining how to use immediate and short term reinforcement in order to change behavior quickly.         

7. The Troubling Ten: Mistakes Families Commonly Make Trying to Control the ADHD Child

• Listing and explaining the most common behaviors we see from parents, the ones which can change from ineffective to effective with a little guidance.

8. Executive Functions: ADHD Is a Disorder of Self-Regulation

• Explaining how an understanding of the brain’s behavior control functions can help us determine a profile of the deficits of a child and lead to more specific strategies to help.  Current research shows that problems with frontal lobe Executive Functioning, most notably Working Memory, are the cause of ADHD.  Knowing about these functions can lead us to better strategies for compensating for those problems       

9. Tips for Teachers of ADHD Children

• Listing dozens of tips and suggestions we have made for teachers of ADHD children over the years.       

10. Understand “Impairment” and Ask for Accommodations

• Using Section 504 of the Rehabilitation Act of 1973 and the IDEA (Individuals with Disabilities Education Act) to help ADHD children receive accommodations in school, changes which will support their learning.  Here are some places to learn about these federal laws.        

            http://www2.ed.gov/about/offices/list/ocr/504faq.html

            http://www.hhs.gov/ocr/civilrights/resources/factsheets/504.pdf

            http://en.wikipedia.org/wiki/Section_504_of_the_Rehabilitation_Act

            http://en.wikipedia.org/wiki/Individuals_with_Disabilities_Education_Act

            http://idea.ed.gov/

11. Important Research Findings on ADHD

• ADHD is the subject of a large amount of research.  We will focus on a few findings with major implications for parents.    

We hope these ideas will prove helpful to your family.  We welcome your feedback and comments.

In the News- If Your Child Is Aggressive: Seven Major Steps for Parents

Many of the children in Shorehaven’s In-Home or Outpatient mental health and psychiatry programs display aggressive or hostile behaviors.  We work to change these behaviors, to replace them with more effective, appropriate behaviors.

In this essay, we are going to go over seven steps for parents to take when a child has persistent aggressive behavior.  Such behaviors may be mostly verbal threats or negative remarks, such as “I hate you,” “You’re the worst parent,” “You’ll pay for this.”  The behaviors may be mostly physical abuses, such as throwing or breaking objects, holding kitchen knives while make threats, or hitting.  The behavior may be frequent or intermittent.  The behaviors may be in several environments such as home, school, and with peers, or only in one environment, such as at mother’s house, but not at father’s house.                      

You may have tried everything you can think of to change the behavior on your own.  Or you may have sought treatment or medications without seeing the behavior change.  If this sounds familiar, then consider these steps.

In The News: Talking with Children About Violence

In the wake of recent shootings in school, children are very aware of such events in the world.  Their understanding may be accurate or may be filtered and distorted in some way.  The child could be very anxious or concerned.  Here are some simple recommendations for talking with your child about these events.

1. Make it OKAY to talk to you.   The child’s feelings and concerns are very serious to the child. Take your child’s concerns seriously.  Don’t dismiss his or her feelings or think those feelings are silly or unwarranted.  “You are pretty worried.”  “Of course that bothers you.”  “Isn’t it sad that happened?”  “I’m glad you came to talk to me about it.”  “I see you are worried, and it’s okay for us to talk about it.”

The best time to talk is at or after a meal, but not before bedtime.

Find out what the child knows or heard about recent events; often the information is incomplete or distorted through a child’s lens, so you can correct that.

2. Empathize with the child’s feeling.  The child needs to know his or her sense of what is real and important is accepted by adults.  Otherwise the message is to hide those feelings.  So we can say, “You are really worried.”  “You feel for those children.”  “You wonder if it’s safe for you.”

Clinical News You Can Use: New Medicaid Rules for Trainees

Medicaid has paid for psychotherapy for over 30 years, long before mental health professionals were licensed in Wisconsin.  So Medicaid created a credential, Approved Provider, to identify those who could be providers of reimbursed services.  The purpose of the credential was to identify persons who had met a minimum level of presumed competence. That credential is the well-known “3000-hour letter” formerly called the “Dan Crossman letter,” then when he retired, the “Otis Woods letter,” and more recently the “Mark Hale letter.”

Psychologists have been licensed since around 1977 and approved for insurance payments since around 1978.

In the early 1990s, a law was passed creating certification of Marriage and Family Therapists, Social Workers and Clinical Social Workers, and Professional Counselors.  Certification only meant that no one could use those titles unless they met certain minimum requirements and were approved by the Department of Regulation and Licensing.

A law passed in 2001 upgraded certification to licensure.  That meant not only were the titles protected, but the very practice of psychotherapy was limited to those with one of these licenses.

All along, graduate students could practice under Medicaid and bill under a supervisor.

All this time, around 34 years, those who had graduated with a masters or doctorate, but who had not completed the Approved Provider credential or, after 1993, certification, could not practice under Medicaid – their services could not be billed to Medicaid.  This gap left new Masters level clinicians scrambling to get 3000 hours.

Finally, this week, Medicaid issued a bulletin, 2012-64, rectifying this long-standing problem.  From now on, masters-level clinicians who procure a training license and PhD/PsyD level clinicians who are on post-doctoral training will be able to credential as Medicaid providers.  They will be known as Qualified Treatment Trainees (QTT), a title defined under DHS35.03.  These provisions ONLY apply when the clinician works for a licensed mental health clinic.

This a major step to enable clinicians to train for licensure and to increase the capacity of the mental health community to serve Medicaid clientele.

Therapy Gem: Reification and Action with Comments on Anger Management and Intervention

Freud’s Study in Vienna

Two Errors in the Application of Psychological Constructs. Since psychoanalysis and psychology first became popular decades ago, the public has absorbed many of their tenets into popular thinking.  Many of those adoptions no longer represent the scientific or exact meaning psychoanalysts or psychologists gave to these terms and ideas.

For example, “ego” means the organization of personality functions which adapt a person’s needs and drives to his or her guiding ideals and/or reality constraints.  These personality functions of self-control, coping, sensation, perception, thinking, judgment, and will, among other functions, help us to satisfy our needs given the realities we face. So “Ego” only means an organized use of these functions in service of satisfying our drives and needs while adapting to 1) our physical and cultural environment, 2) all of our past learning, and 3) our internalized ideals.  “Ego” does not actually refer to any place or thing inside of us.

But since the late 1960s, the term “ego” in common parlance means something quite different, namely, narcissism or egotism, self-absorption.  When we say, “You have a big ego,” meaning something on the order of “You think you are important” or “You are self-centered,” we are almost implying the ego is a place inside of us.

So, many ideas in psychology have become popular, but the precision of meaning has been lost in the translation.  In some cases, the idea has been treated as if the concept represents a real thing.  For example, the term “ego,” as in “Your ego,” implies a tangible structure, a stable characteristic.  Whether people mean by “ego” merely self-absorption or whether they cross a line and treat the “ego” as something tangible certainly is an important discrimination!  As we shall see, the latter is an example of a fallacy named reification, treating a theoretical construct as if it is a reality.

So we have two errors in the popular use of psychological constructs.  First is that the meaning changes from a more precise construct to a more general, imprecise trait or characteristic of people.  The second is the reification of constructs.  That means the constructs are treated as if they were real parts of us.

Note: Before we become psychotherapists, we professionals are members of our culture.  So we grow up using language in these imprecise and sometimes reified ways.  We need to be much more careful in our use of constructs and language.  After all, as therapists, empathy and language are two of our very most crucial tools for promoting change.

Therapy Gem- Diagnosis By Event: We Do Not Diagnose By What Has Happened

“My 13 year-old son, Carlos James, has reactive attachment disorder,” reported an anxious mother to start the first interview.

The therapist asked, “What makes you come to that conclusion?”

“He was adopted from Columbia.  He never felt bonded to me.  He always seemed to keep a distance from me.”  As she said this, her husband sat quietly at the far end of the couch shifting his jaw in a gesture of doubt.

“Adopted at what age?  From what kind of situation?”

“He was two months old. From an orphanage.  I think it was an okay place, but didn’t have a lot of staff or resources, from what I heard.”

“How was he when you met him for the first time?”

“He seemed okay.  He was well-fed.” [Further inquiry regarded early attachment signs, eye contact, comfort, consolability, timing of milestones.  From the description given, nothing seemed unusual.]

The therapist then asked, “What does he do or not do that makes you think it’s RAD now?”

Therapy Gems: Leave Yourself Out

Often we hear therapists begin a reflection, clarification, or suggestion with one of these stems:

I hear you saying…

My opinion is…

What I am getting is…

It seems to me…

I guess that…

I’m impressed that…

Sometimes clinicians end a statement with these questions:

Do I have it right?

What do you think?

These introductions or add-ons to an intervention seem superfluous and even counter-productive. These statements shift the focus onto the therapist and away from the client’s internal world.   Consider these two formulations of the same intervention.