05 ADHD

Self Control

Introduction

We are the sum total of what we think. One cannot act different than the way they think [unless, of course they are ‘acting’!]. Therefore, change can only occur when the person thinks differently. Interventions that help people think about how they think have the most impact on change. For a group of children having significant deficiencies in sustained attention, impulse control and the regulation of activity level in response to situation demand, the problem can be described as one of mental control. The notion that people have preferences about their own thoughts, emotions and motives, and that there are things that they can do to influence these states is the basis for change. Mental control occurs when people suppress a thought, concentrate on a sensation, inhibit an emotion, maintain a mood, stir up a desire, squelch a craving, or otherwise exert influence on their own mental states (Wegner, 1989; Wegner & Schneider, 1989).

Addressing Attention-Deficit/Hyperactivity Disorder

Due to the considerable variability among children with ADHD, there is significant disagreement regarding our understanding of this disorder and how to address it. We will attempt to clarify our understanding of the characteristics of those children who have been labeled ADHD by defining ADHD, and explaining successful instructional and cognitive practices for use with children who have ADHD [Daily, 1998]

Defining ADHD

Most medical professionals, clinicians, and educators refer to the American Psychiatric Association’s description of ADHD, which includes the discerning characteristics: inattention, hyperactivity and impulsivity. Children may have any of these attributes.

Specifically, inattention refers to such behaviors as: failing to give close attention to detail, lacking sustained attention in tasks or play, not listening when spoken to, not following through on instructions, difficulty in organizing tasks and activities, avoiding or disliking schoolwork or homework, losing things necessary to tasks, such as pencils, being distracted by extraneous stimuli, and forgetting daily activities. [Daily, 1998]

Children having ADHD, by definition, display difficulties with attention relative to typical children of the same age and sex. However, attention is a multidimensional construct that can refer to problems with alertness, arousal, selectivity, sustained attention, distractibility or span of attention, among others [Hale & Lewis, 1979]. Research to date suggests that children with this characteristic have their greatest difficulty sustaining attention to tasks or vigilance [Douglas, 1983]. The problem is not so much of heightened distractibility, or the ease with which the child is drawn off task by extraneous stimulation. Instead it appears to be one of diminished persistence in responding to tasks that have little intrinsic appeal or minimal immediate consequences for completion. [Barkley, 1989]

Hyperactivity, on the other hand, refers to behaviors such as fidgeting with hands or feet, leaving a seat when sitting is required, running about or climbing excessively, and difficulty in playing or engaging in leisure activities. [Daily, 1998]

Numerous studies have shown children with ADHD to be more active, restless and fidgety than typical children. As with poor sustained attention, however, there are significant fluctuations in this characteristic implying that it is the failure to regulate activity level to setting or task demands that may be problematic. It has not been convincingly shown that hyperactivity distinguishes these children from other clinic referred groups of children. Recent studies suggest it may be the pervasiveness of the hyperactivity across settings that separates ADHD from other diagnostic categories of children. [Barkley, 1989]

Somewhat similarly, impulsivity refers to behaviors such as blurting out answers before questions have been completed, difficulty in awaiting a turn, and interrupting or intruding on others. More concisely, individuals with ADHD identify their disorder as trouble focusing on one thing, paying attention, thinking before acting, keeping still, keeping track of things, and/or learning in school. [Daily, 1998]

The deficiency in inhibiting behavior in response to situational demands is also multidimensional in nature. It remains unclear which aspects of impulsivity are impaired in children with ADHD. The problem is often defined as a pattern of rapid, inaccurate responding to tasks as measured by Kagan’s Matching Familiar Figures Test [MFFT; Kagan 1966]. But it may also refer to poor sustained inhibition of responding, poor delay of gratification or impaired adherence to commands to regulate or inhibit behavior in social contexts. Furthermore, factor-analytic studies have failed to differentiate an impulsivity dimension from that measuring attention, calling into question its existence as a separate dimension of behavioral impairment. [Barkley, 1989]

Although the notion is not widespread, many have come to accept the idea that difficulty with adherence to rules and instructions may also be a primary deficit of such children. Children with ADHD have demonstrated significant problems in compliance with parental and teacher commands, with experimental instructions in the absence of the experimenter, and with commands to defer gratification.

These primary characteristics show significant fluctuation across various settings and caregivers. Some of the variables in determining this variation have been delineated.

• First, the degree of ‘structure’ – or more specifically, the extent to which caregivers make demands to restrict behavior – appears to affect the degree of deviance of the child’s behavior from typical children. In free-play or low-demand settings, these children are less distinguishable from typical children than in highly restrictive settings.
• Second, these children appear to be more compliant and less disruptive with their fathers than with their mothers.
• Third, on tasks where instructions are repeated frequently, problems with sustained responding are lessened.
• Fourth, these children display fewer behavioral problems in novel or unfamiliar surroundings.
• Finally, settings or tasks that involve a high rate of immediate reinforcement for compliance or punishment for non-compliance to instructions result in significant reductions in, or in some cases, amelioration of, attentional deficits. [Barkley, 1989]

Such dramatic changes in the degree of deviance of behavior across situations has led several scientists to question the notion that ADHD is actually a deficit of attention at all. Instead they suggest that it may be more of a problem in the manner in which behavior is regulated by its effects or consequences, in essence, that it may be a motivational deficit rather than an attentional one, [Barkley, 1989], or perhaps, even a learned behavior. If the latter is the case, a social learning family intervention in which there is particular emphasis upon child management strategies is a required option.

Parental distress over child care management is likely to reach its zenith when the child is between three and six years of age, declining thereafter as the deficits in attention and rule-following improve. The mothers of these children have been shown to be more directive and negative, less rewarding and responsive to their children’s behavior. Such maternal behavior may be either a cause or effect, since reaction to noncompliant behavior and poor self control is likely to frustrate mothers.

By the time of entry into formal schooling, most children with these characteristics have become recognizably different from normal peers. The actions of the school to identify and separate children from typical peers, to create self-fulfilling prophecies that lead to reduced student performance, and the change in child management strategies, may add to the difficulties of such children. Secondary characteristics with aggression, defiance or oppositional behavior may now emerge, if they have not already done so. Children developing these secondary characteristics are likely to suffer a greater degree of maladjustment than those who do not. Learning disabilities, which may or may not be directly related to their other characteristics, in areas of reading, spelling, math, handwriting and language, may also become manifest in a significant minority of children and require corrective instruction.

In adolescence, a small percentage of these children will have ‘outgrown’ their symptoms. However, perhaps as many as 75% will continue to have difficulties with home school and community adjustments. When one combines the secondary characteristics that develop because of responses to the initial characteristics, and the learning disabilities that may or may not be influenced by the other characteristics, the outcome of the syndrome is far more negative than most clinical lore has postulated. As interpersonal problems continue to plague as many as 75% of these children, depression and low self appraisal are commonplace. [Barkley, 1989]

Finally, it has been repeatedly shown that children with such characteristics have more minor physical anomalies, allergies and accidental injuries than typical children.

Regardless of whether children are inattentive, hyperactive, and/or impulsive, the overriding effect on children with these characteristics is that they lack the self control necessary to succeed in home, school and community. In essence, Quinn and Stern, (1991) state that children with ADHD have difficulty accessing and coordinating the cognitive abilities necessary to become efficient learners. This deficit is applicable to both social and academic learning [Daily, 1998]

The fact that the deficit can lead to distortions of thinking patterns, particularly in terms of beliefs about themselves and others, provides opportunities for creating other significant problems in living that range from oppositional defiance to drug addiction.

Creating a Plan of Change

Creating a plan of change for such children requires that the planners take into account the specific characteristics presented by the child, the question of cause and effect reflected in the variable performance, the age/time of the intervention plans and the various secondary clients that may need to be served.

If early identification [between three and six years of age] has occurred and the child is displaying only the initial characteristics of inattentiveness, hyperactivity and/or impulsivity and the impulsivity is not such that it places the child in danger, one can consider using a social family learning intervention as the major plan. The goal here would be twofold, 1) to teach the parents how better to address the issues already manifest, and 2) to diminish the modeling of aggressive and antisocial means.

However, later involvement may require that the following areas be addressed:

Inattentiveness
Hyperactivity
Impulsiveness
Rule Governed Behavior/Oppositional Defiant Behavior
Specific Learning Disabilities
Depression
Self Appraisal
Physical Fitness and Health
Child Management Practices

As with all children with problems in living, the helper should first seek to establish a motivational norm with the child. If the child wants to achieve greater control over the development of mutually satisfactory and gratifying relationships, achievement in school and productive work, etc., the Plan of Change can be shaped to help him/her address these desires.

Since this protocol is focused on children with a lack of self control in the areas of inattentiveness, hyperactivity and/or impulsivity, and the other characteristics are addressed elsewhere, we will discuss only the techniques and practices that address these issues.

Intervention Practices

Many children displaying these characteristics have a clear and pronounced electroencephalograph [EEG] pattern , which, given the data already specified, may be a cause or an effect. Nonetheless, with high amplitudes in the slow brain wave (Theta) part of the EEG spectrum, these children have traditionally been treated by physicians with chemical stimulants in the amphetamine family, which increases neuronal firing speed and results in enhanced focus and attentional abilities, in many of these children. In some cases the results are strikingly positive, and have resulted in parents, teachers, and doctors alike, being impressed by the change in behavior and cognitive ability [Padgitt, 1998].

The downside of this approach is twofold. While maintaining a child on stimulants for the majority of his or her young years may enhance certain aspects of brain function, learning under the influence of certain stimulants is state dependent, i.e. what is learned under the influence of the drug may not be accessible, absent the presence of the chemical [Padgitt, 1998].

The second major problem is one of psychological and social dependency production. Specifically, not only does the child learn to depend on chemicals to control his/her behavior and thinking, but the child also receives a message that s/he does not and cannot have self control. These messages are consistent with drug abuse and dependency. In short we as a society have subtly, and without consciousness, promoted the very drug abuse problem we now find rampant in our culture and desperately seek to eliminate [Padgitt, 1998].

Obviously, any opportunity to avoid these downside effects is worth consideration. Research has indicated that ideas are not just responses of the brain, but can be used to ‘trigger’ brain activity as well. Neuroscientists have learned that thoughts are electrical impulses that trigger electrical and chemical switches in the brain. Thoughts are not just psychological in nature, they are physiological – electrochemical triggers that direct and affect the chemical activities of the brain. When given an electrical command – a thought – the brain immediately does several things: it responds (to the thought) by releasing appropriate control chemicals into the body and it alerts the central nervous system to any required response or action [Helmstetter – 1987].

Two non-medical methods of monitoring brain waves have been scientifically documented and provide, perhaps, a better approach. The first, EEG biofeedback training, may work to monitor and separate the six different brain wave patterns and then, via visual feedback, train the individual to produce more of the desired frequencies [Michael Antone, 1998].

As currently understood, the six different brain-wave patterns are:

Frequency Band
0 to 4 Hz Delta
4 to 8 Hz Theta
8 to 12 Hz Alpha
12 to 15 Hz Sensorimotor
15 to 30 Hz Beta*
30+ Hz Gamma

* Values assigned to the upper range of Beta can vary according to different researchers.

Delta and Theta are known as slow wave activity and are associated with states such as deep non-dream sleep, deep relaxation, daydreaming, meditation and ‘out of body’ experiences. Alpha frequency – amplitude and band width [alpha density] reveal an individual’s temperament – the way that the individual processes and interacts with the world s/he perceives. Beta and Gamma are referred to as fast wave activities, best found in older children, adolescents and adults and are characterized by a state of alert wakefulness, concentration and focused attention [Beta] and states of hyper alertness, certain psychic phenomenon and mystical/transcendental experiences [Gamma] [Antone, 1998].

Children with ADD/ADHD produce excess Theta brainwave activity and lower amounts of Beta activity. Thus, these people are thought to be neurologically inclined to daydream and less inclined to focus and concentrate – when circumstances require this state of mind.

EEG biofeedback training functions to correct this inclination by rewarding the inhibition of one frequency [i.e., Theta] while simultaneously rewarding the production of another [i.e., Beta]. This is accomplished by making it progressively more difficult to receive the reward [points on the screen] while the trainee plays a video game using his/her mind to control the size of colored boxes or moving the ‘pac-man’, etc., via pick-up electrodes pasted and clipped to the scalp and ears. Nothing is sent directly to the brain; it’s activity is merely being monitored [Antone, 1998].

Meditation can also, according to Wilson [1985], produce a dramatic change in brain waves. There is an increase in slow alpha waves, which are usually only present when you are wide awake and relaxed. At the same time as these alpha waves are evident there is a definite presence of delta waves, which occur only in the deepest sleep. Brainwave patterns during meditation indicate a similar state of mind – one that is highly alert but in deep relaxation. By all conventional physiological standards, this is impossible. To compound the mystery even further, there is virtually no rapid eye movement [REM] – an indication of sleep and dreaming – recorded in the meditative state.

The metabolism is also affected. Oxygen consumption decreases about 20% and the body produces significantly less carbon monoxide. Even in the deepest sleep, the decrease in oxygen consumption fails to equal those figures. Heartbeat and respiration rates decrease almost as dramatically. The lactate level in the blood decreases by up to 50%, nearly four times faster than in a state of deep relaxation! Lactic acids are produced during the ‘fight or flight’ syndrome and contribute to feelings of anxiety, tension and fatigue. Blood pressure drops, and there is a definite increase in the electrical resistance of the skin [tension and anxiety induce a decrease in electrical resistance]. These remarkable physiological phenomena are unique to the meditative state and contribute to a sense of harmony and well being. Furthermore, these characteristics are opposite to those you would find in a state of anxiety or anger [Wilson, 1985].

Both of these strategies substitute for the control aspect of drug treatment, in that both provide a means for the individual to control his/her own mental state as opposed to having that state controlled. This message of self control has profound impact upon the attitude assumed by the child concerned. Whether or not children who display inattention, hyperactivity or impulsivity are neurologically deficient, the importance of self control should be obvious. The aspects of ADD/ADHD of anger, violence and antisocial behavior are responses of the child to the frustrations associated with interpersonal interactions and must therefore be considered as secondary characteristics. Avoidance of the development of these secondary characteristics is imperative if one is to enable the child to create and maintain mutually satisfying and gratifying relationships.

A number of professional organizations have taken positions on appropriate educational and clinical interventions for children identified as having ADHD. For example, Lockerson (1991), has indicated that successful practices should increase the attentional value of the specific lesson material, decrease the attentional value of materials irrelevant to the lesson, and provide a structure that makes expectations as consistent and predictable as possible. Such practices will assist children in becoming more efficient learners [Dailey, 1998]. We would add that increase of self-control, which is demonstrated by these interventions, has additional merit.

Three of the more prominent techniques used in classroom and clinical settings are self-instructional training, self-monitoring and strategy instruction [Dailey, 1998].

Self-instructional training is a method of developing verbally mediated self-control that consists of verbal statements to prompt oneself or direct one’s behavior. The behavioral components of self-instruction training include modeling, successive approximations, graduated difficulty, prompts, feedback and social reinforcement (Harris, 1982).

Self-regulation is stressed and children are trained in the use of private speech. Private speech is used as a guide and control over behavior and is gradually faded from overt verbalizations by an adult to covert verbalization by the child.

Michenbaum and Goodman (1979) state that training is built around four basic steps:

1. Cognitive Modeling: The adult model performs a task while talking aloud while the child observes.
2. Overt Guidance: The child performs the task, using the self- verbalizations, assisted by the adult at first, then alone.
3. Faded self-guidance: The child whispers the instructions (often in an abbreviated form) while going through the task.
4. Covert self-instruction: The child performs the task, guided by covert self-speech.

Self-Instructional training has demonstrated the most promising results with attentional problems and with the improvement of impulsive behavior. In general, self-instructional training has shown promise in establishing inner speech control over a number of behaviors associated with ADHD – such as attention to task, impulsive responding, and disruptive classroom behavior.

Rosenbaum and Drabman (1979) describe a second technique called self-monitoring. In self-monitoring or self-recording, a behavior is monitored and recorded by the individual. Kauffman (1993) describes how it has been extensively used to assist children who have difficulty maintaining task-orientation. The technique typically begins by teaching an individual or small group to record the occurrence or non-occurrence of a target behavior such as attention to tasks. The child is then taught how to use a cueing tape, a tape recorder, and/or self-monitoring record. Each time a child is cued, s/he is to silently ask, “Was I engaged in the target behavior?” and to mark the record appropriately. Lloyd, Landrum, and Hallahan (1991), through a number of research efforts, have demonstrated that self-monitoring interventions help to manage and resolve some of the troubling behavior of children with these characteristics.

Strategy instruction is a method for teaching children specific learning strategies that help them to acquire, comprehend and retain knowledge, and has shown significant promise. Deshler, Schumaker, Lenz, and Ellis (1984), and Schumaker and Lyerla (1991), for example, have found that a core group of strategies can be taught to children to enhance their academic and social functioning. This core group of strategies includes seven key components: motivation, acquisition, generalization, curriculum, communication, transition and evaluation. Using these key components, these researchers have developed strategy-based instructional packages to promote basic academic skills such as reading, comprehension and writing of sentences and paragraphs.

Although self-instructional training, self-monitoring and strategy instruction have been successful in assisting these children to become more efficient learners, each of these practices is a labor intensive process that requires considerable mentor-child interaction. A teacher cannot expect learners with attention deficits to acquire and master the use of a strategy by merely ‘telling’ or making them aware of it. Considerable direct instruction and significant amounts of practice with the strategy are necessary if children are to acquire and use it regularly. Moreover, much of the practice needed falls into the category of ‘controlled practice’, that is, prompts, guiding questions, feedback, and repetitions to ensure acquisition of the material taught (Barnes & Rosenberg, 1985). The need for such intensive instruction for strategy acquisition and generalized use has prompted Graham (1983) and Robin, Armel and O’Leary (1975) to claim that self-instruction and strategy instruction procedures are not cost-effective for educators.

An additional argument can be made that children with these characteristics acquire many secondary characteristics that demand clinical intervention that is beyond the capacity of the teacher. Determination of the dividing line between clinical and educational practice is somewhat moot when one is primarily concerned with the development of a child. These interventions can be seen as developmental, and therefore educational, or preventative or remedial of mental disorder, and therefore of a clinical order.

Integrating Successful Instructional Practices and Computers

One way to address the cost-effectiveness and labor intensive issues of strategy-based instruction is to combine the procedure with the computer. The benefits of the computer have been clearly noted in the literature since the 1980s. For instance, Schiffman, Tobill, and Buchanan (1984) indicated that computers: 1) are user friendly and nonthreatening, 2) give their undivided attention, 3) allow individuals to learn at different rates, 4) provide reinforcement, corrective feedback, and immediate praise, 6) provide drill and practice activities, 7) are well suited to the discovery method of learning, 8) assist individuals in developing problem solving skills, and 9) help individuals focus attention on tasks.

Many of the characteristics of the computer address the unique needs of children who have been identified as having ADHD. First, children do not have to raise their hands and wait for the teacher to recognize them. Consequently, teachers are not plagued by children who blurt out the answers even before questions are posed. Second, time limitations, which are often inappropriate for children with ADHD, can be eliminated through the use of the computer. It can allow students with ADHD to move at their own pace, no matter how quickly or slowly. Third, children with these characteristics often need immediate feedback, something the computer can readily offer. The computer corrects the response immediately and provides corrective feedback. This feedback provides insight into the cognitive processes that such children often lack. Fourth, children with these characteristics often display a great need for routine and repetitious practice. The computer can provide such practice while displaying infinite patience. It does not mind repeating itself many times. Fifth, the computer can help focus the child’s attention by presenting a limited amount of pertinent information; therefore, the child does not have to distinguish relevant from irrelevant stimuli. These real-life situations can help children develop socially appropriate responses such as waiting one’s turn, sharing, and completing activities.

In essence, the computer, unlike the teacher, can provide an individually based highly sequenced, strategy-based lesson designed to promote individual requisite academic tasks, monitor errors and self-regulate behavior. Moreover, the computer, which is uniquely suited to providing controlled practice, can provide children with prompts, guiding questions, feedback and repetitions. These features are essential to strategy-based instruction if children are to acquire and use the strategy effectively. In short, the combination of the computer and strategy based instruction can make children with ADHD aware of their own thinking processes, develop a plan of action prior to reacting, and monitor and evaluate whether or not their plan of action is appropriate or effective. If these instructional practices are to continue to be successful, new efforts must seek to integrate self-instructional training, self monitoring, and strategy instruction with the computer.

Summary

The etiology of the group of characteristics that make up what has been called ADD/ADHD is unclear at best. Regardless of the etiology, however, significant question can be raised about the traditional methods of addressing the problems in living that such characteristics cause. The use of drugs, even with apparent success can create as many problems in living as it corrects. Therefore clinicians need to find other methods to address the issues. Self control is a major factor in the rehabilitation of children with problems in living, and the interventions selected should be empowering rather than simply treatment. We have outlined here some of the approaches that might be selected. However, the planner will need to develop the plan of change according to the unique manifestation of the characteristics in the individual child. Secondary clients, such as parents and teachers cannot be overlooked as their behaviors can contribute to the amelioration or the escalation of the problems in living that the child experiences. A typical plan of change to address the specific issues might be as appears in the table below. Obviously, if the child has developed aggressive or antisocial responses, or displays self appraisal or depression issues, these will additionally need to be addressed. Since most of the recommended interventions are social learning based, teachers can be the implementation experts, with content and supervision being supplied by the clinician, or the clinician can directly intervene. When early detection and intervention are applied in a direct and effective manner, the secondary characteristics that often lead to tertiary characteristics of delinquency and drug abuse can be avoided, thereby making life for the child, the family, the school, and the community far more satisfactory.

RECOMMENDED PROTOCOL

Social competence is determined by the degree to which a child finds acceptance from others during social interaction. Since many of the behaviors that characterize ADHD are behaviors that both children and adults may find ‘irritating’, the responses of others may be less than optimal. It is probable, that there are primary, secondary and even tertiary aspects of the syndrome. The primary aspects may trigger social responses from caretakers and peers that generate the secondary characteristics such as difficulties with aggression, defiance or oppositional behavior, which may now emerge if they did not earlier in development.

Tertiary characteristics of academic deficits often occur during elementary school. The majority of children with ADHD have varying degrees of poor school performance, usually related to failure to finish assigned tasks, disruptive behaviors and poor peer relations.

Greater directiveness and negative behavior of the mothers may be a cause of the difficulties of the child or a reaction to their child’s noncompliance and poor self-control. Conflicts in social interactions appear to exist in the relations with parents and siblings as well as peers. It is important to identify performance modeling for social aggression which includes:

• the extent to which the child is rejected or perceived as antisocial by others;
• the likelihood of the child’s unprovoked negative behavior toward parents and sibling, and its duration;
• the extent to which parents monitor their children and spend time with them; and
• the parents’ inept discipline, as reflected in their use of explosive forms of punishment, negative actions and reactions and the parents’ inconsistent/erratic behavior.

Given the relatively high incidence of marital discord, major affective disorder, and general psychological difficulty among parents of children with ADHD, assessment of the family becomes imperative. If these factors are causal, there is the potential that the child is manifesting a conduct disorder that carries similar characteristics; if reactive, it is more likely that a diagnosis of ADHD is appropriate. In either case, the development of supportive prosocial interventions and environments is important.

Characteristic behavioral activities: rule following and turn taking, poor emotional recognition and inappropriate or absent responding to another’s emotional display, and poor problem solving skills often result in difficulty making friends with same aged peers. The behavior and outcomes are likely to lead to ‘punitive and controlling responses’ by both adults and peers. Such responses both ‘model’ inappropriate behavior and send a cognitive message to the child that s/he is unliked, unwanted and unworthy. Such cognitive messages may lead to a ‘sad’ &/or ‘mad’ reaction in the child so that s/he may develop a conduct disorder &/or depression in addition to the original ADHD behaviors. Because of this pattern of increasing conduct difficulties, separation between ADHD behaviors and responses as an original cause or modeled behavior as in conduct disorder is a diagnostic issue. Assessment of the family to determine the degree of cause and effect may be an important factor.

In a similar way that families influence secondary characteristics, schools can influence both secondary and tertiary effects. Schools are one of the most important settings in which children acquire, develop, and refine the skills that are essential for establishing and maintaining interpersonal relationships. Most ADHD students lack the necessary social skills to achieve social competence. Social competence can be enhanced and improved through careful and systematic training. In order to experience social success, a child must accurately evaluate social situations and arrive at appropriate actions based on his or her perceptions. Further, the social climate in the school environment provides an optimal situation for social skill training programs along with support for academic achievement. Assessment of the school environment and providing necessary training to school staff to enhance the climate of positive expectation and diminish the punitive response are essential components of an effective protocol.

Since ADHD as presently defined includes conduct problems, it is probably safe to assume it has multiple etiologies rather than a single causative factor. As such it remains a controversial disorder.

Clinical Protocol Guidelines

It would appear that early identification and intensive response between the ages of three [03] to six [06] years of age would be significant. Since disruptive actions can escalate into antisocial behavior, such interventions need to be multi-dimensional and include secondary [family] and tertiary [school] clients. Since punitive interactions have little effect and may, in fact, escalate negative cognitive notions about self, others and future prospects; helping caregivers avoid being drawn into child management behaviors that are spurred by frustration and anger is imperative.

• Early identification and assessment. An educational process should be developed which encourages parents to refer a child with such behaviors to the Early Intervention program for assessment as early as possible.

The child can be assessed using a variety of tools, which might include:

• behavior rating scales
• continuous performance testing regarding vigilance and sustained attention [Gordon Diagnostic System – normed for ages three (03) to seventeen (17)]
• Matching Familiar Figures Test [MFFT] regarding impulsiveness [normed for ages five (05) to twelve (12) years of age]. MFFT was developed by Kagan et al., as a measure of conceptual tempo. A child’s tempo could be determined to be reflective [e.g., slow and accurate] or impulsive [e.g., fast and inaccurate] based on the child’s latency and error scores. The test itself is a single picture of a familiar object and the child is instructed to select from six [06] variants the one picture that is identical to the stimulus figure. Also see Gordon and Porteus Maze Test [a series of paper and pencil mazes of graded difficulty that measure aspect of planning ability, foresight and impulsivity].
• Actometers [modified wrist watches, pedometers, motion transducers, mercury switches, pneumatic pads and sound-wave generators. To measure activity level.
• Sociometric measures designed to measure the interpersonal relationships of the child.
• direct observational procedures of the child, the family and the school.

It is important that the child’s social skill difficulties be understood as either a skill acquisition or skill performance deficit. Social skill acquisition deficits refer to the absence of particular skills from a behavioral repertoire. Social performance deficits represent the presence of the social skills in a behavioral repertoire but the failure to perform these skills at acceptable levels in given situations. These issues must be differentiated and addressed in the development of a social skills curriculum. In the case of skill acquisition deficits, individual social skills must be taught and rehearsed before the individual can be expected to integrate a given skill into their social behavior. Alternately, performance deficits require close analysis of the maladaptive thoughts that inhibit or prevent the implementation of an already developed skill.

The family should be assessed [See Social Learning Family Interventions]. Since the criteria for judging problems in living for children are to a large extent social in nature, what constitutes a problem and the likelihood of needing professional supports will depend greatly upon the norms and expectations of key individuals in the child’s environment. Areas to be addressed include:

• child management strategies
• child monitoring strategies
• emotionality
• family conflict
• family members’ psychological fitness

The school environment [if applicable] should be assessed [See Teacher Expectancies and Student Achievement (TESA)]. Since the criteria for judging problems in living for children are to a large extent social in nature, what constitutes a problem and the likelihood of needing professional supports will depend greatly upon the norms and expectations of key individuals in the child’s environment. Areas to be addressed include:
– child management strategies
– child monitoring strategies
– emotionality

Interventions

Child

Interpersonal Cognitive Problem Solving [Technique #20]: taught by mother for boys, and by either parent for girls, after age four [04]. The historical assertion that relief of emotional tension can help one think straight is reversed – the ability to think straight can help relieve emotional tension. Children learn to:

• think about what to do when they face a problem with another person;
• think about different ways to solve the same problem;
• think about the consequences of what they do; and
• realize that other people have feelings and think about their own feelings too.

Relaxation [Technique #04]: refers to the regular practice of one or more of a group of specific relaxation exercises. These exercises most often involve a combination of deep breathing, muscle relaxation, and visualization techniques that have been proven to release the muscular tension that the body stores during times of stress.

Sitting [The Calm Technique #26]: It should be obvious that a child with ADHD needs to learn the skill of sitting quietly. An adult should sit with the child twice a day, building up to one-half hour in each session. You can begin this skill by practicing the relaxation techniques. But later, you may need to add a mantra that is repeated as a focus of concentration. Usually when you practice sitting, you set up an ideal or goal that you strive to attain or fulfill. When you are idealistic, you have some gaining idea within yourself. So long as your practice is based on a gaining idea, and you practice in an idealistic way, you will be sacrificing the meat of your practice. Just do it, forgetting the physical and mental feeling, forgetting all about yourself in the practice. There is no particular way in true practice. You should find your own way, and you should know what kind of practice you have right now, knowing both the advantages and disadvantages. The best way to practice without having any goal is to limit your activity, or to be concentrated on what you are doing in this moment. When your mind is wandering about elsewhere you have no chance to express yourself. But if you limit your activity to what you can do just now, in this moment, then you can express fully your true nature.

Biofeedback: Technique in which the individual is given electronically amplified information on certain [somewhat] controllable physiological systems [such as heart rate or blood pressure] and trained to control that response. for purposes of ADHD, the program would be to change brain waves.

Self Management Strategies [See Self Verbalization Training #21]: This technique involve teaching students how to manage their own behaviors. Students actively participate in the selection of the target behavior for improvement and the behavioral goals, in the antecedent and consequent events, and in the recording and evaluation of the behavioral changes. External or teacher/Mentor control is minimal.

• Self monitoring [with self reinforcement]
• Self instruction [with self reinforcement]

Social Skill Training: This is a direct approach to improving a person’s interpersonal relationships. Critical elements in their approach are:

• definition of the problem or target behavior for improvement
• assessment of the extent to which the problem or behavior occurs, and
• development and implementation of a systematic intervention plan.

Goals associated with general affective growth, such as enhancement of self concept or the development of a personal set of values, are not a primary focus. Instead, friendship skills, such as greeting, asking for and returning information, inviting participation in activities and leave taking are taught. Other programs target social maintenance skills [such as giving positive attention, helping or cooperating], or conflict resolution skills [such as nonaggressive, compromising or persuasive behaviors]. Any behaviors believed to contribute to successful interpersonal functioning may be the focus.

Educational Interventions: These might include a variety of approaches, including, but not limited to:

• increased intra-task stimulation and novelty and reducing task complexity.
• repeat task instructions frequently throughout a task
• increase the use of externally and concretely represented time limits and rules that are associated with particularly tasks. [Place portable timer on child’s desk and set to reflect elapsed time available for task performance, or place small ‘reminder’ cards on the desk during individual work. Such reminders might list in bold print four or more rules for on-task behavior similar to the internal self-statements; OR clip a small portable tape player to the child’s belt with an earphone attached to permit the child to listen to ‘nag’ tapes while performing individual desk assignments. These tapes are recorded by the parent and consist of periodic reminders (“Stay on task, finish your work, and don’t daydream”) as well as reminders as to how pleased the parent will be if the child completes the assignment on time. These techniques should be paired with a program of response consequences.]

Structured Teaching: A technique that, along with limited numbers of students, usually 8 to 15, uses:

• physical space organization of the classroom
  • consistent, visually clear boundaries for activities
  • transition area [check schedules]
• scheduling to help anticipate and predict events
  • reduces problems with time and organization
  • minimizes strain on attention and memory; anxiety
  • compensates for language impairment
  • fosters independence
  • increases motivation to complete work before play
• individual work stations
  • informs students about what to do while in independent work time
  • informs students of amount of work to be done
  • helps students see when almost finished
• learning task organization
  • individualized ‘jigs’ or templates to demonstrate how task is to be completed
• work systems sequencing
• prompts and reinforcement

These procedures are usually used to help a child with PDD/autism achieve in class, but some may also be helpful for children with ADHD.

Other Considerations:

• consider diet changes
• consider intensive behavior analysis for specific responses
• consider medical consultation [only after the age of five [05] should medication be administered]. Stimulant medication may be administered under medical supervision as a last resort. Monitor for mild insomnia and appetite reduction; irritability, crying and/or increased hyperactivity late in the day when medication may be wearing off. For children for whom stimulants are contraindicated [e.g., ADHD with tics or Tourette syndrome] antidepressants can be considered. Less is known about the effects. Monitor for drowsiness, dry mouth, constipation and flushing.

Family:

Regardless of whether the modeling of aggressive behavior is a response to the irritating behaviors of ADHD or is an outcome of family culture, these issues, if they exist, need to be addressed if the child’s behavior is to improve.

• train in child management strategies [contingency management such as contingent application of reinforcement or punishment following appropriate-inappropriate behaviors]
  • Review information on ADHD
  • Review causes of oppositional/defiant behavior
  • Develop and enhance parental attention
  • Attending to child compliance
  • Establishing a home token economy
  • Implementing time out for noncompliance
  • Extending time out to additional noncompliant behaviors
  • Managing noncompliance in public places
  • Managing future misconduct
  • One month review/booster session
• train in child monitoring strategies
• provide social learning family technique
• provide individual clinical services to other family members as needed
• train in Interpersonal Cognitive Problem Solving [ICPS]

School

• Train in child management strategies
• Train in specific child strategies [See interventions for the child]

Time Cycle

Since ADHD must be considered a chronic syndrome, the intervention may be lengthy, particularly if secondary characteristics have already manifested. Started early enough, the outcome expectation is to avoid the most negative impact of the secondary characteristics [antisocial behavior] and to give the child and family hope that the problems in living will improve. We may speculate that a four year intensive involvement from age three might ensure the diminishment of academic and social behavior difficulties in elementary and secondary school, allowing the emerging adult to acquire cognitive skills that will diminish the impact of the situation. Obviously, the length of time required may increase if the child is identified later.

References:

Michael Antone, EEG Biofeedback in the treatment of attention deficit disorder in children and adults, shell5ba.best.com, 1998

Barkley, Russell A., Attention Deficit – Hyperactivity Disorder, Chapter 2 of Treatment of Childhood Disorders, Eric J. Mash & Russell A. Barkley, Eds., The Guilgord Press, 1989.

Richard Clark, [Extracts] Self-control and Self-control Therapy: Part III Self-control Techniques, www.target-reactions.com, 1990.

Evelyn M. Dailey, Addressing Attention-Deficit/Hyperactivity Disorder through Technology: Implications for Teacher Education Programs, www.coe.uh.edu, 1998

Steven T. Padgitt, Treating ADD/ADHD Individuals with EEG Biofeedback, www.brainwavetx.com, 1998

Daniel M. Wegner & James W. Pennebaker, Changing Our Minds: An Introduction to Mental Control. Chapter 1 of the Handbook of Mental Control, Wegner & Pennebaker, Eds, Prentice Hall, 1993

Shad Helmstetter, The Self-Talk Solution, William Morrow & company, 1987