Caregivers' Skills Program

WHAT ARE WE DOING?

Do we as parents, educators, and doctors realize what we are doing? We are shoving some of the most highly addicting substances - amphetamines - down the throats of our children in the name of treatment.

Any drug in the category with the amphetamines can trigger an addiction process that, once started, probably cannot be readily reversed. Why parents and professionals are willing to take this risk with children?

DOCTORS' CONFUSION ABOUT RITALIN

Does Ritalin work? Yes! But, no one knows for certain exactly how. Some say that it increases the activity of what is called the inhibitory centre of the brain. This is believed to be a tiny part of the brain that helps us to slow down or stop a behaviour, but there is no proof for this supposition. This theory is only a guess (a hypothesis), not a fact. In addition, Ritalin does improve alertness, but only when first used. All stimulants do. However, Ritalin does these things for all people, not just attention-deficit-hyperactive children. I believe it produces these effects because it makes us high, calms us down, and makes us feel good. Because it is a stimulant drug, far more powerful than caffeine, it perks us up and makes us more alert.

So what's the problem? Isn't it a safe drug? No, it is not! It has many dangerous and risky properties such as the potential for addiction, short-term side effects, and long-term side effects.

THE GROWING ANTI-RITALIN MOVEMENT

In the last several years a number of changes have occurred in the way we view attention disorders and in the way we treat them. As we shall see in this section, more and more doctors are no longer viewing attention disorders as diseases. In addition, there is mounting evidence against the safety of putting Ritalin and related drugs into the bodies of children. If there is no disease underlying the behaviours and if the medications are truly risky - perhaps not even necessary - the development of more effective behavioural treatments becomes more essential. More effective treatment without drugs is what this program is about.

Let's look at the changes in thought about attention disorders being the result of an underlying disease.

THE DISEASE ERA

In the 1980s psychologists began to turn their attention to the treatment of attention disorders. We can call this the Barkley Disease Era, because it was psychologist Russell Barkley who led the way to the popular belief that the disorders were incurable diseases. No evidence to support the disease concept existed then and it remains unsubstantiated to this day. However, the symptoms of this so-called disease, according to Barkley, could be controlled by a combination of Ritalin and behavioural treatments.

The movement took off with Barkley's (1981) book, Hyperactive Children: A Handbook for Diagnosis and Treatment. The book offered a few behavioural suggestions, including a technique that had been around for some time called a token economy. The token economy involves giving a child some type of symbolic reward, such as check marks on a chart or poker chips, after a "good" behaviour. When enough tokens are accumulated, the child may purchase a treat or a privilege.

Barkley later found support for his disease theory in the research of Alan J. Zametkin (Zametkin, Liebenauer, Fitzgerald, and King, 1993), a medical doctor whose research focused on scanning the pattern of cell metabolism in the brain using a machine called a PET (position emission tomography) scan. Metabolism is the energy emitted by the brain cells when consuming glucose, and the PET scan can measure metabolism in areas of the brain that give off low-energy emissions and compare them to areas with high-energy emissions. Zametkin claimed to have found different patterns in ADHD children than in normal children. However, his research was not originally conducted on children but on adults who were believed to have been ADHD when they were children. Furthermore, researchers reviewing his studies refuted the conclusions he drew and found flaws in his methods of analysis (Breggin, 1998). Unfortunately, both Barkley and Zametkin persisted in their claims. A couple of years later Zametkin came forth and admitted that in follow-up research he could not substantiate his own earlier findings, as they were described in Breggin's (1998) book, Talking Back to Ritalin.

Zametkin and Barkley have since collaborated on numerous PET scan studies and continue to make the same claims. They seem to ignore the very basic fact that PET scans are not, at this time, an accurate device (Sedvall, 1992; Mayberg, 1998). To make claims of the discovery of a disease when using a machine that does not yield precise readings is poor science. Remember that their claim has paved the way for two million children being placed on amphetamines.

After Zametkin's first studies appeared, researchers claimed that other areas of the brain and nervous system were implicated as "the disease" causing the inattentive and overacting misbehaviours. Claims of malfunction have been attributed to brainstem dysfunction, caudate nucleus dysfunction, corpus callosum abnormalities, the dopamine hypothesis, folic acid abnormalities, frontal lobe dysfunction, imbalances of brain chemicals, prefrontal cortex dysfunction, and serum lipid imbalances.

This scientific-sounding list is included to show you how out of hand things have become in the attempt to find an elusive disease that causes children to not pay attention and move around a lot.

DOCTORS REFUTE DISEASE THEORIES

Well-known paediatric neurologists such as Gerald Golden (1974) and Fred Braughman, as well as Breggin, have refuted all claims that disease is present. Braughman, in a 1997 newspaper article, writes, "In plain words, ADD [and ADHD] is an expensive, elaborately woven illusion of a disease - not a disease at all" (pp. 1-2). Even agencies of the federal government have weighed in on the matter. The Drug Enforcement Administration stated in 1996 that no "specific neurological lesion or deficit" has been found and that studies making such claims cannot be replicated by other scientists.

Did you know that in psychology and psychiatry there is no agreed upon definition for the term "disease"? Not having a precise definition opens the door for anyone to label the slightest or subtlest of physiological (body) differences a disease. What one doctor calls range for the diversity of normal human behaviours, under which lies an equally wide range of physiological differences. It is important, therefore, that psychologists and psychiatrists not loosely use the term disease, as some are currently doing, because the consequences mean putting powerful chemicals into the bodies of our children.

HOW A DISEASE OR NO-DISEASE DIAGNOSIS DETERMINES TREATMENT

The assumption that disease exists is important because it has major implications for the way we approach treatment. If we assume there is a disease, treatment takes the direction of medication coupled with the assistance of a few behavioural helping aids. If we assume no disease, medication isn't really necessary and well-designed behavioural methods should work alone.

In addition, if children are assumed to have a disease, they cannot help themselves; it follows that behavioural methods should be designed to assist them in every way possible, as opposed to making them function correctly and completely on their own.

David Stein's methods are designed to treat them as normal kids who can function quite well with proper behavioural intervention. But before we consider his recommendations, let's take a closer look at recent changes in treatment.

THE MOVE AWAY FROM RITALIN

Ritalin and other amphetamines have been viewed as safe for over 20 years. However, new evidence is calling this point of view into question. The short-term side effects-those appearing within a day or several days after beginning Ritalin or related drugs-have been documented. I review these in more detail in the next chapter but they include irregular heartbeat, rapid heartbeat, elevation of blood pressure, nausea, and sleeplessness. Usually doctors handle the emergence of short-term side effects by a trial-and-error process of switching to another drug. Of even more concern are long-term side effects that may take years to show up and are often irreversible.

Only scant research on long-term effects exists, but the little that does is cause for concern. First and foremost are concerns about triggering the addiction process. Ritalin or any amphetamine is a more dangerous gateway or starter drug than marijuana. More and more children aged 10 to 14 abuse Ritalin as a Street drug (International Narcotics Control Board, 1996). Ritalin and closely related drugs are amphetamines, which are acknowledged in almost every text on drugs as the most addicting category of all drugs.

In addition, for over 20 years Ritalin and related drugs have caused concern about normal physical growth in children. It is well documented that normal growth is stunted in children while on Ritalin, or related drugs. Once the child is taken off the drug, a growth spurt follows. Weiner (1982) stated that there is no way to determine if these children ever catch up to the size they could have been. If a child's growth, including head and brain growth, is interrupted during critical developmental years, then the question remains about damage that may only surface 20 or 30 years later. No research exists on this issue. Common sense tells us that it can't possibly be good to interfere with children's normal growth patterns.

Ritalin and other drugs may also cause permanent brain damage (Giedd and others, 1994; Nasrallah and others, 1986; Mathieu, Ferron, Dewar, and Reader, 1989). Another study (Auci, 1997) indicates that Ritalin may interfere with a healthy, functioning immune system. All of this points to the need for better and more effective behavioural treatments.

CHANGES IN BEHAVIOURAL TREATMENTS

To understand the evolution of the behavioural treatments, we must understand a basic behavioural concept, which can be illustrated as follows:

Preceding Stimuli => Responses => Consequent Stimuli

The preceding stimuli are environmental events that cue or trigger a behaviour to occur, such as a red light warning you to stop the car. The responses are the behaviours. In attention disorders we typically focus on responses such as impulsivity, pushing, not sitting still, not paying attention, or interrupting. The consequent stimuli are the environmental events that follow the behaviours, such as rewards (reinforcements) and punishments.

During the Barkley Disease Era the predominant focus of behavioural treatments has been on the preceding stimuli. Because certain children are considered sick-they have a disease-it follows that they need lots of help. Thus we've seen books that advocate "helping" the child with an abundance of social and environmental cueing and prompting (preceding stimuli) to direct the child in performing the desired behaviours. These helping methods include giving more individual attention in the classroom, helping children with their homework, reminding them to think about how they should behave before entering any place, tutoring them individually, coaching them when organizing their schoolwork, and coaching them to stop and think before doing a behaviour. Also needed: lots and lots of reminding by adults and lots and lots of warnings before children earn a bad consequence. Token economies provide lots of visual cueing using charts, to-do lists, and physical tokens, such as poker chips. These cues serve as reminders that interfere with children's learning to remember on their own what they are to do.

A NEW METHOD

Stein's approach is quite different. First, he sees ADD and ADHD children as completely normal. They are quite capable of behaving, attending, and thinking. The problem is a thinking problem. They don't think or pay attention to what they are doing, especially in activities they simply don't like, such as schoolwork.

This program decreases or eliminates the emphasis on preceding stimuli - the reminding, the coaxing, the helping, the warning. All these techniques contribute to making mental invalids of our children. Using them makes children mentally dependent on helpers. Excessive helping, with no teaching to function on their own, makes children thoroughly dependent and totally helpless for the rest of their lives. This is exactly what the current behavioural approaches are doing.

The current approaches make parents into ever-present reminder machines, creating what is called cognitive (thinking) dependency in these children. They can't think or function without someone constantly reminding them. Is it any wonder that we have to continue coaching them and filling them with drugs well into adolescence and adult life? We haven't taught them to function, so when all this excessive assistance is removed and the drugs are stopped, they can't make it on their own. This is not because of some mysterious disease that no one seems to be able to find but because we failed to make them stand on their own two feet and learn how to function. Psychologist Claude Steiner (1974) writes that making children helpless and dependent invalids is the worst of all things parents can do to their children.

A basic premise of this program is that these children are normal and can function. I focus on how we can effectively control the consequent stimuli by teaching them and requiring them to behave themselves and to pay attention when they are supposed to. This program is a rigorous, systematic, sensible parenting approach.

CHANGES IN PARENT ADVICE BOOKS

Because the way we view attention disorders as diseases or not diseases has changed, and the evidence of the risks associated with the drugs has increased, the advice given in books for parents has changed in orientation as well.

1980 to 1992

During this period, attention disorders were viewed as diseases and the medications to treat them were considered safe. Starting with Barkley's book in 1981 and a number of books that followed, treatment consisted of a strong recommendation to use Ritalin or related drugs coupled with the type of behavioural methods in which lots of help is given to a child who is viewed as sick, diseased, and therefore helpless.

1992 to 1997

More recently, the titles of books began to demonstrate the growing concerns about Ritalin. These include Do We Really Need Ritalin? (Wright, 1997), Beyond Ritalin (Garber, Garber, and Spezman, 1996), The Ritalin-Free Child (Hunter, 1995), Ritalin-Free Kids (Reichenberg-UlIman and Ullman, 1996), and No More Ritalin (Block, 1996). These books review the mounting evidence of the risks of drug therapy and express a growing negative point of view toward the use of these drugs.

However, the books do not readily acknowledge the evidence against the disease concept. Therefore, the behavioural approaches in these books still offer the methods cited earlier in which the child is viewed as diseased and helpless. Prominent psychiatrists and psychologists such as L. E. Arnold and others (1994), Phil Kendall (1987), and Peter Breggin (1998) point out that these methods have not been very successful.

1998 - A New Era

Breggin's book, Talking Back to Ritalin (1998), makes a strong and thorough argument against the disease concept for attention disorders and an equally powerful argument against the use of Ritalin and related drugs. Breggin also questions the effectiveness of currently available behavioural methods.

Other writers and researchers such as Kendall and Braswell (1993) note the limited success with current methods and point to the need for developing a comprehensive parenting approach designed specifically for ADD and ADHD treatment.

Each of these writers sees ADD and ADHD as manifestations of cognitive (thinking) problems in normal children who don't think or pay attention to what they are doing. They especially see problems in the motivation of these children to behave and perform well in school.

A NEW MODEL FOR PARENTING THE ADD OR ADHD CHILD WITHOUT MEDICATION

When David Stein sees ADD or ADHD children as clients, he blocks off several sessions in order to train the parents. It's like a class. He teaches and the parents take notes and ask questions. Few other therapists do this. It always makes sense to thoroughly train the people who spend time with the children.

Parent training was introduced in the early 1970s by Wes Becker (1971) and Gerald Patterson (1971) and has proved enormously successful with most children. Stein has redesigned the parent-training methods specifically for ADD and ADHD children. He has devoted almost 25 years of practice and research to refining this approach, gradually learning what works with these children and what doesn't.

Be patient. It takes the rest of this program to teach you the specifics. What you will learn here is neither vague nor piecemeal. This is a systematic, comprehensive, nuts-and-bolts book. Everything you will learn has been practiced and refined over many years with hundreds of ADD and ADHD children.

ALTERNATIVES FOR PHYSICIANS

Physicians are trained to heal. They really want to help. They often claim that they don't have an alternative-that the only way to help these children is with drugs. Besides, parents and teachers are constantly at their throats for them to write these prescriptions. They want their disruptive kids under control immediately. Some doctors dislike doing this; many wish for an alternative.

Doctors! Here now is an alternative. Take your prescription pad and write down the URL of this website and the title of this program. Recommend that parents (and teachers) read it each evening at bedtime. Mind-altering drugs are not the right way to teach children to learn and behave. Before putting powerful chemicals into the developing bodies of children, try this prescription first.

Parents! Stop being bullied by the system. Protect your children. Do not let the teachers, doctors, psychiatrists, or psychologists tell you that they know what is best for your child. What is presented here is safe, non-addictive, healthy, and sensible. And most important, it works.

In the following sections we will dispel a number of myths surrounding this growing epidemic of attention disorders and the monumental reliance on chemical behaviour control. When finished with this program, you will have learned rigorous parenting skills to overcome your child's difficulties. What is covered in this program is not complicated, nor is it difficult to implement. However, it will require work on your part. We are not offering a quick fix. You will have to roll up your sleeves. But if you practice what you will be taught, you should see a well-behaved and motivated child. You will enjoy being with your child more and hopefully develop a closer, more loving relationship. You will develop more confidence in your parenting skills.

Typically, in our last sessions with parents, we hear, "He seems so much happier," when referring to their child. This is where we want you to be.