Caregivers' Skills Program

UNDERSTANDING THE MYTHS OF ATTENTION DISORDERS, THE EPIDEMIC OF ADD AND ADHD AND THE GROWING USE OF RITALIN

Each study or report indicates different figures, but it seems that in the United States somewhere between one-tenth to one-quarter of all school-age children are diagnosed as having some form of attention disorder-attention deficit disorder (ADD) or attention deficit hyperactive disorder (ADHD). The ratio of diagnosis of boys to girls is about 5 to 1. It also seems that most of these youngsters are being treated with Ritalin or some other type of mood-altering medication.

With so many children on Ritalin, is there an epidemic or plague? Do you wonder where this plague came from and why it is spreading so fast? Are ADD and ADHD caused by a highly contagious airborne virus or resistant bacteria? If it were a disease, could it completely disappear-be cured-solely with behavioural management? Is it genetic? But if parents are transmitting an attention disorder to their children, why didn't they suffer from it when they were kids?

DEALING WITH ADD AND ADHD MYTHS

Obviously, this program is anti-medication and differs drastically from the medical and psychological treatment practices that are currently popular. The intention is not to confront the medical, psychological, and educational communities but to win them over. The hope is that the Caregivers' Skills Program will lead to further research and improvements in drug-free treatment for children with attention problems.

If parents are willing to say no to the use of these drugs when being pressured by the professional community, it's best they understand some very important issues. The best way to do this is to arm people with an understanding of some of the myths about ADD and ADHD.

Let's look at the seven most common myths:

Myth 1: ADD and ADHD Are Diseases

The diagnostic manual for psychiatry and psychology states that no laboratory tests can diagnose these disorders (American Psychiatric Association, 1994, p. 81). No findings have produced reliable evidence of a disease. Yet just about every form of treatment currently in vogue is aimed at treating a disease with chemicals-a disease no one can prove even exists.

There is no evidence that any bodily, brain or nervous system malfunction causes these behaviours. A lot of scientists have been searching for this so-called disease for years, with no substantiated results. Fortunately, more and more professionals are beginning to believe that this is not a disease but a problem of poor thinking patterns and lack of motivation (Kendall, 1996; Breggin, 1998).

David Stein deeply believes that there are no medical causes for children not to pay attention and to misbehave. They simply do not pay attention and they do misbehave.

You may ask why these diagnoses have exploded and become so prevalent in the last 15 or so years? Depending on which literature you read, it's estimated that between two to four million children in the United States are diagnosed as ADD or ADHD, a growth of over 400 percent since 1988. Where did this mystery disease come from? Why did we not see so many children in previous generations with these patterns of behaviour?

Consider that there are other psychiatric diagnoses of even more severe behavioural disorders. Examples are conduct disorders, where children break the law or become violent, or oppositional-defiant disorder, where children are openly defiant and rude to their parents. Few mental health professionals think of these last two conditions as diseases; they are seen as behavioural problems. What is this difference in viewpoint based on? Certainly no scientific or empirical rationale exists for the difference. Yet some persist in viewing attention disorders as diseases and present this opinion as if it were irrefutable fact.

Let's consider the disease issue a little more closely. There are four categories of diseases: infectious, contagious, traumatic, and systemic. In infectious and contagious diseases a germ of some sort causes the diseases. We know ADD and ADHD cannot be that. Trauma diseases require an outside insult to the body, such as a blow to the head. We can rule that out. That leaves systemic disease in which the cells or chemicals of the body begin to malfunction, such as with cancer. However, if a systemic disease runs in families, that means it is genetic but cannot increase in the percentage of diagnosed cases in succeeding generations. A systemic disease remains fairly stable from one generation to the next or may increase only slightly. But it cannot increase between 400 and 500 percent in ten years, as has the occurrence of ADD and ADHD. Non-genetic systemic diseases also cannot increase unless there is a dramatic, toxic change in the environment, like massive radiation. So how can the attention disorders be increasing at the reported rates? Someone has to explain where this massive disease epidemic is originating.

There are about ten different theories, each implicating a different problem with the brain, the nervous system, or the chemicals of the nervous system as the culprit causing this mysterious disease. Are all these theories correct or are none of them correct? The scientists responsible for each theory claim that their theory and research are correct. Research by other scientists consistently fails to support the claims made by the original theorists.

What if one of these theories eventually shows changes in the brain or nervous system? This still does not mean disease is present. The environment produces changes in the brain and nervous system, as Breggin (1998) points out in his book. How we are raised, what stresses we face, and where we grow up - in the city or country -are registered in the brain by chemical and cellular changes. To define a disease it must be shown that these bodily and nervous system malfunctions come first and actually cause the ADD or ADHD behaviours. If the environment causes the behaviours and brain changes, the result is a disorder, not a disease. If we define the changes that result from the environment as diseases, then everything we do or say is a disease. That is absurd.

David Stein believes that all bodily or brain changes that have ever been measured in ADD or ADHD children are the result of their environment and therefore are disorders and not diseases. Disorders can be treated behaviourally, without the need for medication.

Are you beginning to understand that so far there is no disease and that amphetamines are only a pretext disguised as a treatment for something that is not there? The amphetamines only camouflage the problem. Is it worth the risks to let the confused professionals bully you into putting these chemicals into your child's body when, after thirty years, researchers have failed to support their disease theories?

Even if well conducted research were to reveal physiological differences, it would still not mean the presence of a disease. Such differences could not only be the result of environment but also from long periods of being on Ritalin, or related drugs, or even the result of the constant, self-induced state of agitation ADHD children keep themselves in. If these differences were truly ever found, they'd have to be very subtle because we're having so much trouble finding them. And even then these differences would probably be within the normal range for kids that merely have more active levels of behaviour and not a disease.

It is important to remember that if such differences were found it really doesn't matter as far as the content of this program is concerned; the methods you'll be learning work anyway. It would make for some interesting research should any physiological differences ever be found to see if they subside after successful behavioural intervention. Once the child is calmed down, would these hypothetical differences also calm down?

Myth 2: Psychological Tests Support the Diagnosis of ADD and ADHD as Diseases

No psychological test can indicate an ADD or ADHD disease. These tests are merely checklists, rating scales or observations of a child's attention during the test administration. They are merely alternate ways of observing that the child is either not paying attention or is misbehaving. If the child gets enough points or check marks, he is arbitrarily labelled ADD or ADHD. If he gets a lower score, he does not get the label. Save yourself hundreds of dollars. You can get an even better diagnosis by merely observing the child. These tests are only structured guides for observing behaviour. They do not measure abnormalities in the body or brain. They do not measure a disease.

When a psychologist says your child tested positive for ADD or ADHD, parents are deluded into a misperception that this is a disease. Do not confuse a psychologist's label with a disease. The tests only confirm the labels. They do not indicate or detect any disease entity.

Myth 3: But the Doctors Say My Child Has ADD or ADHD

Your child "has" nothing of the sort. The doctor has assigned a label that sounds like it names a disease. If we change the names of the diagnoses to inattentive and highly misbehaving - IA and HM - notice the change in the way you perceive the problem behaviours. Merely changing descriptions of problems can change the way we perceive them. If the labels were IA and HM, parents and professionals could alter their perceptions from the idea of disease to one of normalcy.

Myth 4: Ritalin Has a Paradoxical Effect That Supports the Disease Notion

If you are unfamiliar with the term paradoxical effect, it means that giving a child a stimulant drug such as Ritalin has the opposite effect from stimulation, that is, it causes them to slow down their behaviour and pay better attention. It was believed that this paradoxical effect only occurred in ADHD children and therefore was proof that these children were different-that they had a disease.

Yes, Ritalin does slow down behaviour, but it neither supports the disease idea nor confirms the diagnosis. Amphetamines produce the same effects for everyone: adults, normal people, people with conduct disorders, and people with oppositional-defiant or anxiety disorders. They affect healthy animals the same way. They have a calming, subduing effect. These drugs were popular in the 1950s and 1960s with college students; amphetamines helped them study for exams and pull all-nighters. They were even given to soldiers in combat in several wars to calm them down and help them stay alert. This paradoxical effect works for just about anyone.

Here's an interesting idea: Why not give these children cocaine? You might get even better results! If we're going to load them down with drugs to control them, let's go all the way. Sound ridiculous? Well, Sigmund Freud used cocaine around the turn of the century to help him work late at night; it helped him stay alert and concentrate for long hours. He liked the drug so much that he wrote a scientific paper on it ("On Coca") praising its use. Later, when the negative consequences of the drug took over his life, he publicly reversed his position.

Myth 5: My Doctor Says Ritalin Is a Mild and Safe Drug

If you believed the chemicals prescribed for your children were perfectly safe, there would be little quarrel with medicating them. But our current level of research on these chemicals is primitive and we don't want to risk our sons' and daughters' well-being. Do you remember any drugs that were supposed to be perfectly safe but were later proved harmful? How about Thalidomide?

Yes, many articles state that Ritalin is a relatively mild amphetamine. However, please recall that in the United States, under the Federal Government Control Act of 1988 Ritalin is classified in Schedule II, the same category as cocaine, opium, and morphine. This indicates that it has a high potential risk for abuse and addiction.

Short- and Long-Term Side Effects

In addition to the dangers of addiction, there are other serious problems. Do you think these drugs only go directly to the brain parts that control behaviour? No. They go all over the body and can have effects for which they were neither designed nor intended.

These unintended side effects are divided into (1) short-term side effects, which occur either immediately or within several weeks after beginning the drug, or (2) long-term side effects, which may not appear for many years. Short-term side effects of amphetamines, including methylphenidate (Ritalin), in children include insomnia, tearfulness, rebound irritability, toxic psychosis, personality changes, nervousness, skin rash, fever, nausea, dizziness, headaches, heart palpitations, dyskinaesia (strange tongue and face movement), drowsiness, blood-pressure changes, cardiac arrhythmia, angina (chest pain) and abdominal pains.

Toxic psychosis (which means that the drug is at a poisonous level and the child is losing reality contact) can occur in rare instances. Anorexia and weight loss may occur. Complications such as depression, suicidal thoughts, or even Tourette's Syndrome (a neurological disorder characterized by tics and bizarre verbalizations) can occur unless the drug is carefully monitored.

Of most concern are the effects that occur years later - the long-term side effects. Long-term studies are rarely conducted on drugs. There are several reasons. First, studies that take years to conduct are extremely expensive. Second, researchers are usually professors. They want raises and promotions that are typically determined by publishing research findings in scientific journals. Do you think they want to wait ten or twenty years to publish? Therefore, they rarely embark on long-term research projects. And third, the pharmaceutical companies are not required to perform long-term research on their drugs. In addition, it is not in their interest to conduct long-term studies because adverse findings would have a negative impact on sales that is the last thing they want.

However, the results of a few medium-term studies have recently been published in the scientific journals and they do not look favourable for Ritalin. One issue is the long-term side effect that Ritalin interferes with normal growth in children. This is called growth inhibition or growth suppression. Ritalin suppresses growth while a child is on it by interfering with growth hormones. We have no way of knowing how big or how tall a child would have become if he had never taken the drug (Weiner, 1982). A recent study seems to indicate that height and weight gain may indeed be somewhat impaired by these drugs (Rao and others, 1997). Another study may indicate problems with the immune system (Auci, 1997). Please note the dates of these studies. Only recently are the data coming in on longer-term effects. Much more long-term research is needed.

Are you willing to accept these possible risks to control your child's behaviour? Or is the course of treatment proposed in this program beginning to sound more and more inviting?

Drug Holidays

What about drug holidays? These are time periods such as evenings, weekends, and holidays from school during which a child does not take the drugs. Ask your doctor this: "If these drugs are so safe, why are drug holidays so necessary in the first place? And furthermore, why is it OK for my child to be controlled in school but not when he's with me?"

If you teach children drug taking, they will learn drug taking. We should fear training children to use drugs in order to handle their emotional and behavioural problems. Drugs are useful when they are necessary and when they are restricted to the shortest term possible. A good physician is one who is most reluctant to write a prescription for any type of chemicals.

Your child's doctor may have assured you that Ritalin is not addictive. Your doctor may truly believe that. But doctors tend to think of addiction as a physical condition; the concern here is about the psychological addiction, which is much more powerful. Each textbook on psychopharmacology makes this same point. The euphoria, the sense of peace and calm, and the escape from stress, anxiety, and depression make these drugs extraordinarily and powerfully addictive psychologically. Do you know that these drugs, especially Ritalin, are being sold on the streets for the express purpose of getting high?

Physicians are not as knowledgeable about medications as you might think or hope. Too many medications are on the market for physicians to remain current in every detail and research finding.

Physicians generally have a limited arsenal of about forty or fifty drugs from which they typically prescribe. When morning rounds are conducted in a university medical setting, doctoral-level pharmacologists consult with the doctors. Most of pharmacists' training focuses exclusively on medications, and therefore they are more familiar with hundreds of drugs. Doctors have to study numerous other things like diagnosis of diseases, anatomy, physiology, and so forth, in addition to seeing patients all day. They can't keep up with it all.

So do not rely so readily on your doctor's opinion. You are a consumer and you have a right to question any drugs recommended for your child. If you wish, call a medical school and talk to a pharmacologist before beginning your child on a highly questionable medication. They mostly do not like Ritalin or any of the other amphetamines. 

Myth 6: If ADD and ADHD Are Not Diseases, I Must Have a Lazy Child

Since the 1970s the composition of the American family has drastically changed. Two-parent families make up fewer than 50 percent of households; in 85 percent of these, both parents are working. The single-parent household makes up the other 50 percent. Extended families - grandmothers, grandfathers, aunts, uncles, and cousins - are rare because relatives often live in distant states.

All of this has had an impact on the way we children are brought up. With parents being stressed and rushed, the time for tender nurturance of children is drastically reduced. Child development studies indicate that children who are given little nurturance have trouble later in life with giving nurturance. They are also prone to depression, as psychiatrists Beck (1988) and Lewinsohn and Rosenbaum (1987) have pointed out. Most important, as Breggin (1998) suggests, they have trouble controlling their behaviour and are often labelled ADHD.

In his research, David Stein has stressed the importance of values in the developing personalities of children. The careful and delicate moulding of values such as loving to learn, being willing to work hard, developing long-range goals, and deferring gratification underlie children's motivation to take school seriously and to work hard. If we fail to instil these values, which takes years of patient teaching, He deeply believes we create children who do not wish to pay attention in class and do not care about controlling their behaviour, that is, ADD-ADHD or IA-HM children.

Beck (1988) states that modern psychology and psychiatry are in the midst of a "cognitive revolution" (p. 1). What he means is that cognitive therapy is becoming the predominant form of therapy in practice. This form of therapy focuses on our thinking patterns and on our beliefs as determinants of the way we behave. Cognitive therapy was introduced in the 1960s by Albert Ellis. In the l970s this form of therapy merged with the well-researched and scientifically based techniques of behaviour modification and formed what is now called cognitive-behavioural therapy - the focus of this program.

We will not only be working to change your child's behaviour but we will also be changing his or her thinking patterns and belief systems.

This program offers solutions. It teaches you effective and rigorous parenting skills so you can stop the ADD or ADHD behaviour and thinking patterns. However, this is not a quick fix. What is offered here requires you to parent your children actively. You must give the requisite time and attention for this system to work. And once you get the ADD or ADHD behavioural patterns under control, you still need to give your children time, attention, love, and guidance in order to train their thinking and beliefs. We can control their behaviours, but you must tenderly nurture them and patiently teach them the values they need in order to want to behave and to succeed in school. The true key to success is not merely getting children's behaviour under control but teaching them values.

So it is not accurate to say that ADD or ADHD children are lazy. They are confused. Their values are confused. We are failing our children by not being there for them. If they are to change, we must change. We must slow our lives down, decide the values we wish to teach them and then patiently cultivate these values in our children.

Myth 7: The Teachers and School Systems Are at Fault for So Many ADD and ADHD Children

The answer to this myth needs to be divided into four parts:

• teachers,
• curricula,
• school discipline, and
• class size.

Teachers

Children who come from families that instil deep values, such as a love for learning, hard work, integrity, and achievement, do well in school, whereas children who come from families in which there is little time and nurturance devoted to the development of values do poorly. As a matter of fact, motivated children with strong values pay attention and work hard and do not wind up with ADD or ADHD labels. It is time we stopped blaming teachers.

Curricula

If educators and psychologists collectively search for the elements of curricula that can excite children, we will have fewer cases of ADD and ADHD. New, inventive, and creative approaches can be found. Why can't the traditional classroom activities be taken outside in such a fashion to make learning fun and exciting? Content and presentation that can excite students are empirical issues that can be answered through more research. We can find these answers, especially for children who don't pay attention well.

Breggin (1998) says, "Children labelled ADHD do not differ from other children in what they need. If a child doesn't focus in class, it means that the child doesn't have a relationship to the teacher that fulfils the child's educational needs." Think about that: If the teacher were empowered to grab the child's imagination, the child would pay attention" (p. 252). We need to find a combination of teaching methods and subject matter that get young people excited about school. As Palmer (1998) points out in his book The Courage to Teach, we can connect with students by a combination of approaches, including being active in the community, using electronic media, leaving the classroom for outside activities, and finding other inventive ways to reach students. This is consistent with turn-of-the-century educator and philosopher John Dewey, who wrote that education should be part book learning and part experience. Thus finding inventive ways to enrich both the curricula and pedagogical techniques will perhaps get more and more children to love school.

Discipline

Unfortunately, schools have few effective methods they can use to discipline children who are disruptive in class - often the so-called ADHD children. In addition, the most frequent complaint from teachers is that when children are disruptive, they often cannot get parents to cooperate and enforce discipline at home in order to get their children under control. What then can teachers do? The typical solution is a pill and a glass of water.

This program offers specific methods of discipline for parents to use in controlling a disruptive child when the teacher brings the problem to their attention. Parents can use this program and cooperate in a partnership with teachers. (If a highly disruptive child interferes with the learning environment for other children and his or her parents refuse to help get the situation under control, then the child should not be permitted to return to school until the parents do cooperate.) Unfortunately, laws will in many places not permit this. The irony is that instead of meaningful discipline, we are willing to shove poisonous chemicals into our children's bodies.

Class Size

Studies show that smaller class size creates a more effective learning environment. A study by Finn, Achilles, Bain, and Folger (1990) found that smaller classes yield significant improvement in reading and math performance for inner city and minority children. Smaller classes help with early school adjustment (Gullo and Burton, 1992). Russell Barkley, for many years, has advocated smaller classes for children with attention problems.

However, other studies show that slightly larger class size is important to help the young develop social skills and peer relationships (Feld, 1991). David Stein found that too small a class size fosters the cognitive dependency problem discussed earlier. The solution lies in finding optimal class sizes-large enough to foster the development of social skills and independent cognitive abilities, but small enough to provide sufficient individual attention. Classes should also be small enough to minimize distractions, such as excessive noise and to allow teachers to control the behaviours of more rambunctious children.

A review of the research literature indicates that the prevailing opinion leans toward a class size of about fifteen to eighteen. Unfortunately, class size in many places exceeds thirty students, sometimes forty. No teacher can maintain control of classes that large, and few children can get their academic needs met under these conditions.

CAREGIVERS'
SKILLS PROGRAM

01 INTRODUCTION

02 WHAT ARE WE DOING?

03 UNDERSTANDING THE MYTHS

04 CAREGIVERS' SKILLS PROGRAM

05 TARGET BEHAVIOUR

06 IMPROVING BEHAVIOUR

07 PUNISHMENT

08 LEARN DISCIPLINE

09 USING TIME OUT

10 REINFORCEMENT REMOVAL

11 SCHOOL PERFORMANCE

12 HELPING THE IA OR HM CHILD TO FEEL BETTER

13 TEN WAYS TO STOP CREATING AN ATTENTION DISORDERED CHILD

Acknowledgement: The content of this program is based on Ritalin Is Not The Answer: A Drug-Free, Practical Program for Children Diagnosed with ADD or ADHD by David B. Stein, PhD (Jossey-Bass, 1999 paperback) 

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