Here is your simple “to do list” as a parent of an ADHD child.  Parenting young children conceptually can be simple.  It is the execution that is the challenge.  Here is our critical conceptual list:

1. Stop aggression.  We discussed this in a previous blog post. You did that? Yes? Check.
2. Nurture social skills.  He or she needs a friend.  Also, covered previously in this blog.  You’re facilitating that? Yes, it is a work in progress, but you are working on it.  Ok, good.
3. Is Cogmed next? 

Cogmed might be the next step for your preschooler.

Keep reading and you will find out if it is.    

When is the best time to do Cogmed? 

Arguably, the earlier a child does Cogmed the better. 

Yet, it is more complicated than that.

A better frame for the question is this:  

What are the distinct benefits of doing Cogmed Working Memory Training ^TM with young children, say, preschoolers? 

THE ARGUMENT FOR “EARLIER THE BETTER”

The argument for the earlier the better is persuasive because working memory relates to so many areas of cognitive functioning. Take reading and math achievement as examples. Working memory has been found to be related both to reading and math achievement. The logic is simple.  Instead of just letting your child get behind when you notice concerns in preschool, you have the possibility of preventing problems or reducing them. Not only that, it could even assist your child in staying in step with their  classmates and possibly even getting ahead. 

The argument for “the earlier the better” is further bolstered by the burgeoning self-concept. As we all recall, we were separated into the “accelerated” reading and math groups as early as 1^st grade. This obviously affects a child’s developing sense of self. You may remember being placed in the “smart” group.  Or, maybe you remember being placed in the “slower” group. These groupings contribute to a child’s sense of self. So, the logic is if we can help him or her earlier, why not?

THE CHALLENGE OF PRESCHOOLERS DOING Cogmed Working Memory Training ^TM:

The biggest challenge of this age is the more limited research on them with Cogmed.  This is due to the fact that the program for working with preschoolers called “Cogmed JM” was only recently introduced to the public in 2009.    A study by Thorell, L B, Lindqvist S, Bergman S, Bohlin G, Klingberg T. was published in Developmental Science, December 2008:  “Training and transfer effects of executive functions in preschool children”. 

The investigators reported that the children trained in the program improved both on the training tasks themselves but also ‘on non-trained tasked of visual-spatial WM and verbal WM than control children’.  (*define WM.) The magnitude of these differences would be considered large by conventional standards, i.e., effect sizes greater than .80. (*Do you need to include effect size; will that mean anything to your audience?) They also showed greater improvement on computerized tests of visual and auditory attention; although the effect sizes here were moderate.

The results of this study introduce an important possible distinction between training preschoolers compared to training school-aged children:  “Generalization to improvements in inhibitory control was not found.” In other words, the preschool children were not better able to sit still, not more calm and not less hyperactive.  (*Add more about inhibition:  defince/explain [I know—again]).  What does this mean for parenting of young children?  If your child predominantly has problems with inhibition, hyperactivity and impulsivity and he does not struggle that much with attention training in preschool, Cogmed may not be a wise choice for your child at this point.  Waiting until they are school age may be a better strategy.  This is in contrast to the studies of school-aged children who have been found to have a reduction in hyperactivity, impulsivity or an increase in “inhibition”.  However, keep in mind that one study does not establish a distinct trend.  Even with that in mind this distinction may be supported by further research.  Also, the positive gains on working memory are consistent with the larger developing body of research supporting the effectiveness of this program improving working memory and attention. 

Yet, in contrast, if your preschooler is not predominantly hyperactive but is inattentive then Cogmed in preschool could prevent academic and social struggles.  With preschool children, who are not hyperactive but are inattentive, doing Cogmed early seems quite persuasive.  With children who are mildly hyperactive, it would seem a reasonable judgment call for them to do Cogmed in preschool.  However, for preschoolers who are excessively hyperactive, doing Cogmed would seem less reasonable with the given research results unless the child were possibly medicated for the hyperactivity.

So, to summarize. Cogmed for preschoolers with primarily inattention issues has the potential to prevent social and academic problems.  If hyperactivity or impulsivity is very high in your child it may be better to wait until grade school to do Cogmed and he may still need medication to manage impulsivity.

Dr. Charles Shinaver

Located in Carmel, Indiana near Indianapolis, Noblesville, Fishers, Zionsville, and Westfield.

Parent of Children at Guerin Catholic and Our Lady of Mount Carmel Schools.

 Host of                                        And provider of

 Clarity4Health.com            Cogmed Working Memory Training^TM

Life Coaching, BeachBody Coaching and ADHD & Cogmed Coaching you through web and phone: 

No matter where you are.

371-641-7794, clarity4health@gmail.com

Give him empathy without accurate feedback and he begins in the world with delusions of his greatness. This will likely blossom into the notion that the world revolves around him.

Critical feedback given to him without an empathic connection and he is likely to begin feeling empty, disconnected, criticized, wounded. Over time this may sow the seeds that tend to grow into perfectionism.

A balance between an empathic connection and feedback is important, but err on the side of empathic connection. Your sons and daughters will have many people who will find their mistakes. They need you to feel for them and be compassionate but honest when they need to improve. Bottom line: They need to know you are always on thier side!

I used to work in residential treatment. In that setting you get children who have been abused and neglected. The empathic bond with the parents has been broken or severely damaged. What we used to use was a ratio of 4:1. It was 4 positive comments to each corrective or critical comments. Believing that the critical is sufficient is far from the truth, but it is more than that. The time and effort you take to make these positive observations gives your child emotional energy but it also continues to build the empathic bond you have with your child. Establishing trust comes much earlier in the child’s life when you are consistent and reliable in feeding, soothing and comforting your child. However, if you focus only or mostly on correcting your child you can sap the emotional energy, fun and love from the relationship. So, when you consider behavior charts keep this in mind.

Behavior charts can be as simple as a chore chart that you check off as your child completes his work. Yet, it can be much more specific (as it often is in residential treatment.) But behavior charts delivered without empathy turn the family stomping ground into frozen tundra; shaping the giving of feedback into a cold and often excessively critical process.

This is not to say that parents should not be clear and specific about expectations and behavior.   Clear and specific boundaries are a loving gift parents need to give their children if they want to facilitate maturity through time. 

Parents who refuse to give their child direct, honest and critical feedback miss a great opportunity to help them grow. The issue is not refusing to give them critical feedback for fear of “damaging their self-esteem”.  The issue is whether you have an empathic bond with them. If you do and they sense you “get” how he or she feels then when you level the critical feedback it is upon a foundation of trust.  That solid ground is the place in which you have your child’s best interests in mind and their feelings in your heart. If that is the case then there is no person better situated to give them critical and challenging feedback.

What develops self-esteem is the development of skills. This does not come without critical feedback. A lack of skill development in any area simply leaves your child as less competent and an easy target for those who don’t have his or her best interests in mind and feelings in their heart. So, be judicious and strive for that 4:1 ratio which is exceedingly hard to do.

The second point I want to make is behavior, in my view, largely tends not to change unless you track it. Behavior charts are the simplest way to track it. I found some very cool sites with free behavior charts here and I want to share them with you.

http://www.freeprintablebehaviorcharts.com/link_exchange.htm

Free Printable Behavior Charts  Free
printable behavior, chore, potty charts and more with lots of helpful parenting tips and information!

3 strikes chart

Sticker Chart

So, if you brave the world of behavior charts do it with a hug, kiss, smile and a large dose of empathy.

Dr. Charles Shinaver
Located in Carmel, Indiana near Indianapolis, Noblesville, Fishers, Zionsville, and Westfield.
Parent of Children at Guerin Catholic and Our Lady of Mount Carmel Schools.
Host of And provider of
Clarity4Health.com Cogmed Working Memory TrainingTM
Life Coaching, BeachBody Coaching and ADHD & Cogmed Coaching you through web and phone:
No matter where you are.
371-641-7794, clarity4health@gmail.com

What they found in this study was that during interactions with friends the two children were more attentive, emotionally positive, talkative, active, involved, relaxed, and playful.  They were, what I would call, truly engaged with each other.  This was not the case with an acquaintance.  Saliva analysis suggested that when interacting with a friend that a child feels lower stress. They spent more time in these interactions in interested and animated states. They also assigned higher ratings of liking to their actions and interaction with friends. The pairs of friends more often shared the same behavioral states (e.g., playful). 

In contrast, acquaintances paid more attention to each other’s turn taking signals, so that when one person was talking the other person was silent. To me, this summarizes the difference between these two states.   It captures the real sense of playful connection children feel when interacting with a friend.  When talking with friends, the children were more playful, more relaxed, more engaged, more positive,  had more fun etc.  Consider the thought of your child interacting in that way most of each day with friends at school and at home.  Then, consider your child in the somewhat perfunctory way of interacting with an acquaintance in which both are trying to behave well by taking turns, but there is a real lack of connection, playfulness, and arguably, of joy.  It seems from these types of interactions that synergy emerges.  I was listening to an interview on NPR today in which the lead singer, guitar player was sharing that his best friend from when he was 10 years old is also his band mate in his band Green Day.  What is possible from such a sense of connection?  What can come out of years of positive interaction?  How do you want your child to spend his days?  How do you feel when you are around friends versus acquaintances?  Without friends at school, can you really consider your child to be in a “warm supportive atmosphere?”  How do people learn in an atmosphere of acquaintances in which taking your turn trumps the joy of really connecting with friends and synergistically creating fun, just plain old fun together?

Your child needs friends.  Friends make life a lot more fun.  Past this, imagine spending your whole life in the acquaintance stage.  Would that not stymie further growth and development as well as exploration by the caution that is required to learn about another person and to initially relate to them?  Based on this research, don’t you think it is worth keeping up on your child’s friendships so you know when to your child may need more “friendship time”?

This study also brings many good questions to the surface.  It is something to think about, something to not take for granted and something to look at more closely.  If your child has any special needs you may find that this affects his or her abilities to make and keep friends.  If that is the case or you see your child is “low” on “friendship time”, is there anything you as a parent can do to assist your child in finding and keeping friends? 

First, it is obvious there is much you cannot do.  However, keep an eye out.  There may be simple things you can do to help.  For example, if you are concerned about the amount of “friendship time” your child has, try to find more opportunities rather than less for your child to do activities with the children that are friends.  This could include keeping a child in the same league because that is where his or her friends are instead of moving to a more competitive league, inviting those friends over more often or even letting your child expand to join activities his or her friends are already doing.  

You won’t believe this but I just got this email as I was finishing this post, an email from my youngest son’s teacher:

“Dear Mr. and Mrs. Shinaver,

I wanted to pass along praise for your son for a kind gesture that he did in class.  Another student did not have beans for the day and did not want to ask for them, so out of the kindness of his heart, your son sacrificed one of his beans and gave it to this student.  Beans are my reward system and for him to give one up for a friend is such a kind gesture and great act of kindness.  I just thought you might like to know this.  It really has been a great year having him in the classroom.

Thank you,

Miss Mindy”

Who knows where friends can take each other, even friends from when you were 10 years old…

More importantly, life lived with friends is such a rich and fulfilling life without them it is more than a bit empty.

Dr. Charles Shinaver

Located in Carmel, Indiana near Indianapolis, Noblesville, Fishers, Zionsville, and Westfield.

Parent of students at Our Lady of Mount Carmel School and Guerin Catholic High School.

 Host of                                        And provider of

 Clarity4Health.com               Cogmed Working Memory Training^TM

Life coaching, BeachBody Coaching and ADHD coaching through web and phone: 

No matter where you are.

371-641-7794, clarity4health@gmail.com

1 Field, Tiffany; Greenwald, Paul; Morrow, Connie; Healy, Brian; Foster, Tamar; Guthertz, Moshe; Frost, Patricia “Behavior state matching during interactions of preadolescent friends versus acquaintances.”  Developmental Psychology. Vol 28(2), Mar 1992, 242-250. doi: 10.1037/0012-1649.28.2.242

He has to have a friend too, and a good friend at that.

If you’re still concerned about my last blog post in which I focused on:  First Things First Stop Aggression in ADHD Children then you need to get in touch with me.

If you’re in Indiana I can do child counseling with you. However, I will also offer a coaching program for parents in the coming weeks who want to improve their ability to manage their ADHD children. Obviously partly this would relate to managing aggression and or anger management for children.  However if you’re not in Indiana I would use more of a coaching format which I will describe at a later date. The issue of aggression is the inverse of today’s blog post. ADHD? Got a Friend? Why do you need a friend to graduate from high school?  You will see…

Does your child with ADHD have a friend, a chum or a buddy?  If not it is time now to address that.  I consider developing friendships as #2 in the sequence of prevention of all those upsetting co-morbid problems that can come with ADHD.  Arguably, having a good friend is the antidote to aggression. If you know how to develop and keep friendships it has an inoculating or buffering effect.  You will be less stressed out and as you will see in later posts, better able to pay attention.  (Think of the lunch money bully.  If he’s on your mind, school isn’t.)

I think one of the biggest mistakes that many parents make in the development of their children is a lack of focus on their social development.  You see lots of parents willing to buy unusual gadgets with the hope that it will develop their child’s intelligence. They’ll spend tons of money on sports coaching or equipment.  However, are parents willing to take the effort to schedule a play date? I know, I agree the term play date sounds a little bit too cute for me too. Do you choose your house based upon the fact that there are kids your son’s age for him to play with?  Maybe you should.  Having a good friend, a good buddy for a boy or a girl is very important. I won’t even get into the other social and emotional reasons why it’s important and there are obviously many of those.  Today let’s just consider academic achievement as a reason why developing friendships is important.  Yes, you got that right.  It will help his academic achievement. 

Harry Stack Sullivan developed this idea called “chum”. To put it in simple terms your chum, is your best buddy. If your child can’t name his best buddy then you should put some time and effort into helping him find a good friend.  Then you should spend your time and effort providing a context in which he can play with that friend. This means that he needs oversight from you, adult supervision.  He needs some independence, but he also needs some supervision.  Having friends when he’s young very much relates to success when he gets older.

As you may recall from previous post studies with larger sample sizes that are better designed weigh more heavily in their empirical importance. This means that longitudinal studies are particularly important albeit very difficult to do. So when I found this 17 year long longitudinal study that tested whether low peer-perceived acceptance in association with aggressive disruptive friends during preadolescence predicted student’s failure to graduate from high school I opened my eyes.

In this study, there were 997 Caucasian French speaking boys from low social economic status in urban neighborhoods in France.  The boys were recruited during kindergarten at age 6 and followed through age 23. Greater childhood aggression and disruptiveness predicted friends’ preadolescent aggression and disruptiveness. Having aggressive and disruptive friends was related to a lower likelihood of graduation from high school.  Yes, this was in France, but these concepts and data trends do not know cultural barriers. 

Before you quickly dismiss this, remember this is a large scale study which is well-designed.  You need to take these results seriously.  However these results do not surprise me at all given my experience as a child psychologist.  When you look at the research you find that having a good friend matters very much. In fact the sense of connection or attachment to your primary caregiver, often your mother, is absolutely critical.  Then your sense of connection to your teachers (Remember your favorite grade school teacher?  I do.  Mrs. Lorton at Mohawk Trails.)  also matters.  And, your connection to your classmates has an impact on a variety of achievement variables, academic achievement not just social achievement. I will consider some of those in later posts.

The primary point I want you to consider now is that it really does matter that he has a friend.

If he’s complaining that he doesn’t have any friends. Then your ears should perk up and you should get to work on doing something about it.

Having a good buddy, a chum, really is #2 in prevention of the more problematic co-morbid ADHD problems. 

If he doesn’t have a chum it’s time to do something about it.

He needs your help and your guidance.

“Do peers contribute to the likelihood of secondary school graduation among disadvantaged boys?”Véronneau, Marie-Hélène; Vitaro, Frank; Pedersen, Sara; Tremblay, Richard E. Journal of Educational Psychology. Vol 100(2), May 2008, 429-442.

Dr. Charles Shinaver

Located in Carmel, Indiana near Indianapolis, Noblesville, Fishers, Zionsville, and Westfield.

Parent of Children at Guerin Catholic and Our Lady of Mount Carmel Schools.

 Host of                                        And provider of

 Clarity4Health.com            Cogmed Working Memory Training^TM

Life Coaching, BeachBody Coaching and ADHD & Cogmed Coaching you through web and phone: 

No matter where you are.

371-641-7794, clarity4health@gmail.com

The question is:  Does the research support this logic?  The resounding answer is yes.

A very large study, a developmental trajectory study by Broidy et al., 2003 was conducted in 2003.  A way to think about developmental trajectory is the study of the pathway that a child takes over time in his development and what critical factors relate to that trajectory.  A good trajectory would be to finish college and get a job.  A bad trajectory would be to end up in jail. 

When considering research the logic again is fairly simple. Consider a scale. When you look at data studies that have a larger number of subjects get proportionally weighted more heavily. Similarly, studies with better research design get weighted more heavily.  Studies with fewer subjects and poorer research design might be on the other side of this scale and therefore be outweighed by the results of a study like this.  This is why study size and design must be considered when reviewing research.  It is also why one can make conclusions on “trends of research” even though within the trend a few studies might contradict some of the other studies.  Otherwise much smaller studies that are poorly designed, yet emotionally compelling, like the anecdotal story my neighbor jus told me about his sister’s daughter get taken with much more gravitas then they merit.  Certainly personal stories are compelling. I tell them about my work.  It is what engages our heart and soul as human beings.  They are persuasive.  However, if those stories lack any empirical foundation they remain just that from a research point of view, stories.  They go on the weaker side of empirical weight. 

Obviously in a blog post, we will not consider all existing research on this topic but keeping this scale in mind is useful when reviewing individual studies and deciding how seriously to take them. 

This study had both a very large sample size and a good research design.  Simply put, it is a very impressive study. As such of the results should be taken very seriously and they are very educational in understanding a possible critical point of prevention for later problems by intervening earlier. 

This developmental trajectory study had a sample size of 6176 children (boys) and was conducted across six countries. They started collecting data on disruptive behavior problems between the ages of 5 to 7 years old. Yearly assessments were done until the children were ages 15 to 17 at those sites but as old as 26 at one site.  Teacher reports were used at all sites and at most sites used mother reports of externalizing behavior (e.g. aggression) were obtained also. That is a phenomenal data set.  These results are very informative and should be taken with a comparatively heavy load of empirical weight.

Results:

In the United States disruptive behavior scores tended to show increases over time. What’s that about in our culture?  Not sure, but something to think about.  In contrast in Canada they tended to show declines. In New Zealand mean disruptive behavior scores were stable.  This result should make all of us Americans wonder.

At all the sites it was a small group of less than 10% who were the high aggressors over time.

The next result is much more eye-opening. At all the sites it was a small group of less than 10% who were the high aggressors over time. The majority of children 15 to 60% showed no physical aggression over time. So typically, contrary to the “boys will be boys” theory, among most boys there is very little physical aggression over time. However for this small group of high aggressors that can be identified between ages 5 to 7 and those poor souls continue to be aggressive for the next decade or more. There was no evidence of a sudden and dramatic change in disruptive behavior over time. There is a caveat to this in that there is some evidence from other studies that shows that there sometimes can be a short-term increase in aggression during junior high. However, this data set did not support that conclusion.  So, what you have here is less than 10% of the boys committing all the aggression!  Maybe not that surprising, but it is the same boys who when they are much are older are still aggressive.  So, why not do something about it when they are not twice the size of their mothers?

MOST IMPORTANT FINDING #1: Chronic aggression by boys during elementary school increases the risk for continued violence and other forms of delinquency during adolescence.

This top group of aggressors or is at risk for these continued problems not everyone else.

MOST IMPORTANT FINDING #2: Hyperactivity was not associated delinquency at any site.

Physical aggression was a distinct risk factor for violent and nonviolent delinquency in boys.  Many studies have found that hyperactivity is not correlated with criminal outcomes once the influence of other conduct problems is taken into account (Farrington, Loeber, and VanKammen, 1990; Fergusson, Horwood, and Lynskey, 1993; Fergusson, Lynskey, and Horwood, 1996; Lahey, McBurnett, and Loeber, 2000; and Lynskey and Fergusson, 1995).  Trajectories reflect patterns of gradual change as opposed to sudden increases or decreases in these behaviors in this study there was no evidence of late onset of physical aggression.  These results supported the conclusion that the “onset” of physical aggression occurs during the preschool years, prior to the initial assessments in these data sets, before ages 5 to 7 years old.  This really gives a whole new meaning to the idea that everything you need to learn you learned in kindergarten. That is, unless you didn’t. Unfortunately the ones who don’t learn those lessons in kindergarten appear to be in a great deal of trouble. 

In my next blog post I will consider preschoolers and aggression.

Dr. Charles Shinaver

Located in Carmel, Indiana near Indianapolis, Noblesville, Fishers, Zionsville, and Westfield.

Parent of Children at Guerin Catholic and Our Lady of Mount Carmel Schools.

 Host of                                        And provider of

 Clarity4Health.com            Cogmed Working Memory Training^TM

Life Coaching, BeachBody Coaching and ADHD & Cogmed Coaching you through web and phone: 

No matter where you are.

371-641-7794, clarity4health@gmail.com

These rather underwhelming results make the prevention line of reasoning presently being reviewed in this blog all the more important. The logic is simple. If you wait to intervene until all these problems develop it is much more difficult to do so effectively. However, if you plan ahead and think of ADHD treatment as a marathon you then can strategically pick your focus of treatment at any one time. By gathering your resources and focusing them in this way I believe your interventions will be more effective. What do you have to lose? Not much if you base your thinking on what people are doing in a traditional model of treatment. I think you will find my logic compelling.

Note: Normally I will write distinct posts for all of my blogs, but the importance of these two posts supersedes that practice. You need to read the post linked above and part one. Part one at this link will give you the larger context of these results of the best study ever done on ADHD treatment.
How you would go about doing that will be addressed in my coming posts.

I will pick up on the discussion of intervention and prevention with my next several posts.

Dr. Charles Shinaver

Located in Carmel, Indiana near Indianapolis, Noblesville, Fishers, Zionsville, and Westfield.
Host of And provider of
Clarity4Health.com Cogmed Working Memory TrainingTM

Life coaching, BeachBody Coaching and ADHD coaching through web and phone:
No matter where you are.

371-641-7794, clarity4health@gmail.com

PS: Summer is the best time to train. Ask about our Summer Program.

My primary point in that last post was this:”Preventing social disability has the potential to prevent many of the worst problems associated with ADHD, the slew of co-morbid problems commonly cited as a concern for children with ADHD. “

The researcher in me felt this post was important before we went further with this line of argument. The reason is that some of the more research-minded people who may read my blog may object that one study does not make a trend and is not enough upon which to build an intervention strategy. You are exactly right. However there is much more data than one study. I felt that this was important enough to address in one post.

The concept of “social disability” is actually supported by a different vein of research. In fact, this body of research had similar findings. These findings regarding the predictive validity of social impairment were consistent with longitudinal sociometric findings reported by Ollendick and his colleagues (Ollendick, Greene, et al., 1991; Ollendick, Weist, et al., 1992), which showed that, at 5-year follow-up, socially rejected children were perceived by their peers as less likable and more aggressive and by their teachers as having more conduct problems and aggression. Socially rejected children also reported higher rates of conduct disturbance, substance abuse, and school failure and were more likely to drop out of school and commit delinquent offenses than socially popular children.

The striking similarity in outcome observed in children identified as socially rejected by means of sociometric methodology and socially disabled by means of the methodology described in the article in my last post is noteworthy. So, essentially two different but related bodies of research found this pattern.

Also, regardless of its underlying mechanisms, the construct of social disability was defined independently of the symptoms that characterize ADHD and its co-morbid disorders. In other words, although there is clear overlap between social disability and these disorders, there is virtually no overlap between the content of the SAICA items and diagnostic criteria for ADHD, conduct disorder, and major depression. The construct of social disability may be less vulnerable to methodological artifacts associated with symptom overlap.

In other words this “social disability” was not just what would be automatically expected when a child has ADHD.

.

Again, as I noted in my last post, this finding is critical. It suggests that preventing social disability has the potential to prevent many of the worst problems associated with ADHD, the slew of co-morbid problems commonly cited as a concern for children with ADHD.

Dr. Charles Shinaver
Located in Carmel, Indiana near Indianapolis, Noblesville, Fishers, Zionsville, and Westfield.

Host of And provider of
Clarity4Health.com Cogmed Working Memory TrainingTM

Coaching you through web and phone: No matter where you are.
371-641-7794, clarity4health@gmail.com

1 “Adolescent outcome of boys with attention-deficit/hyperactivity disorder and social disability: Results from a 4-year longitudinal follow-up study.” Greene, Ross W.; Biederman, Joseph; Faraone, Stephen V.; Sienna, Melissa; Garcia-Jetton, Jennifer, Journal of Consulting and Clinical Psychology. Vol 65(5), Oct 1997, 758-767. doi: 10.1037/0022-006X.65.5.758.

Have a good weekend and go back to my other blog Monday for the follow up post. Clarity4Mind.com

I will pick up on the discussion of intervention and prevention next week on Tuesday. 

Dr. Charles Shinaver
Located in Carmel, Indiana near Indianapolis, Noblesville, Fishers, Zionsville, and Westfield.
Host of And provider of
Clarity4Health.com Cogmed Working Memory TrainingTM

Life coaching, BeachBody Coaching and ADHD coaching through web and phone:
No matter where you are.
371-641-7794, clarity4health@gmail.com

Now that you have read that post you have a better handle on many of the co-morbid problems associated with ADHD.

Before we dig into the details here let’s first broaden the scope to consider a big question.

What is a good life?

Let’s go with Freud:  Success in Work and Love.

We all need something to do and someone to love and love us.

How does ADHD in childhood relate to success in love and work as an adult?

To have a successful and rewarding life one would need to carve out meaningful work and healthy relationships.  Before you go to work and get a fulfilling job you have to achieve in school.  Your ability to achieve in school relates to your ability to succeed in work.  Similarly, before you can have a loving relationship with a spouse you have friends in school.  Those friendships in school set up some of the dynamics for how you have relationships generally and specifically with your spouse in the future.

Yet, as we saw in my last post, most kids don’t grow out of ADHD so what can you do?

This was in my mind when I did my research for a talk in November of 2004 titled:

“ADHD Treatment Outcome, Deaconess Family Practice”

I was thinking about these two questions:

What can I do to help children with ADHD?

When do I need to do it?

My thinking was influenced by my doctoral program at DePaul University that included a community psychology program in which there was significant focus upon prevention.  I realized my goal was to prevent certain problems from developing for my son and my clients who had ADHD.  Interestingly these problems were factors which were associated with ADHD, but were not ADHD itself.

Prevention is defined this way:

Reducing vulnerability and protecting against cumulative risk in the developmental period must take into account the particular factors that are most relevant for the outcomes of interest.

What were the factors most relevant to a successful outcome for a child with ADHD?

Or, conversely, what were the factors most associated with a poor outcome for a child with ADHD?

Study shows that most and worst co-morbid problems associated with ADHD were related to social disability.  Aggression would be considered possibly the most prominent characteristic of social disability.

What is interesting is that it is not the problems specific to ADHD which created the worst outcomes for children with ADHD.  It is the co-morbid problems which are associated with ADHD that create the worst outcomes for children with ADHD.  So determining what factors are associated with the worst co-morbid problems and preventing them is a key to facilitating better outcomes for children with ADHD.

What was unclear to me when I began to dig into the literature in 2004 was just how early these preventive factors came into play. I found they came into play in Preschool. I will get to even more detail on that in my next blog post but today I will consider the first study which caught my attention on this topic.

I realize that the rest of this post is somewhat technical and has some jargon, but understanding these ideas is very important for you to understand your role in facilitating better outcomes with your child.

Here is a brief synopsis of the first critical study that caught my attention:

Results showed that, at follow-up, boys with ADHD who also had social disability evidenced significantly higher rates of mood, anxiety, disruptive, and substance use disorders, compared with nonsocially disabled boys with ADHD and comparison boys without ADHD. Findings also showed that social disability at baseline in boys with ADHD was a significant predictor of later conduct disorder and most substance use disorders after baseline mood and conduct disorders and behavior checklist ratings of aggressive behavior and attention problems were controlled.  Greene, Biederman, Faraone, Sienna & Garcia-Jetton (1997).

This study opened my eyes.  An important factor was that it was a 4 year follow up study. So, it studied these children over time which is not easy to do but is critically important.

Secondly, there are a number of problems that co-occur with ADHD which are called “co-morbid” disorders.  This study showed that most of the co-morbid problems associated with ADHD were related to social disability.  This list of problems associated with social disability is legion and includes the following: anxiety problems, problems with substance abuse, problems with mood and disruptive problems (includes violating other’s rights, fighting, breaking rules and the law, etc.).  Additionally social disability was associated with the most problematic of psychiatric diagnoses in childhood:  conduct disorder (often bullies, threatens, or intimidates others, initiates physical fights, has used a weapon, been cruel to people and/or animals, has stolen while confronting a victim, destroyed property and stolen).  In other words, conduct disorder encompasses many of the problems parents want to avoid, was associated with social disability.

This finding is critical in that it points the direction to prevent many problems associated with ADHD.  Preventing social disability has the potential to prevent many of the worst problems associated with ADHD, the slew of co-morbid problems commonly cited as a concern for children with ADHD.

Also, in a coming post I will consider aggression.  The data is very interesting and instructive.

Dr. Charles Shinaver

Located in Carmel, Indiana near Indianapolis, Noblesville, Fishers, Zionsville, and Westfield.

Host of                                        And provider of

Clarity4Health.com Cogmed Working Memory Training^TM

Coaching you through web and phone: No matter where you are.

371-641-7794, clarity4health@gmail.com

In my previous post I reported that mentalhelp.net reported that 60-80% of children with ADHD have co-morbid disorders.  That seems slightly high to me so I will review more research on that at a later date, but today we will work with this data.  According to this data, three of the top 4 most common and arguably the worst ADHD common Co-morbidities are Oppositional Defiant Disorder, Substance Abuse and conduct disorder.  (My last post:  ADHD Common Co-morbidities how bad?) These problems have a relationship to one another.

Some data suggests that oppositional defiant disorder tends to precede conduct disorder in time. 

Conduct disorder plays a role in predicting substance abuse and dependence.

If we can treat oppositional defiant disorder and conduct disorder we may also be preventing substance abuse and use.

In terms of prevention, if we can prevent oppositional disorder from developing or intervene to improve it you could be preventing conduct disorder and substance abuse and use. Or if conduct disorder is already an issue then treating it may prevent substance use and abuse.
So, intervening with oppositional defiant disorder and conduct disorder could also be framed as preventing substance abuse and use. In the prevention model we would be reducing vulnerability and protecting against cumulative risk in the developmental period by taking into account the particular factors that are most relevant for the outcomes of interest: disruptive behavior.
There are Other Substance Abuse Factors which would need to be addressed.

The process of abusing substances is complicated but most research has found that friends’ use and community norms are more important as predictors for starting drug use. Psychological variables (e.g., negative emotion, psychopathology) and biogenetic variables (e.g., neurochemical systems, family history of alcoholism) are more important in the transition to regular and frequent use. So, clearly these other factors that put a child at risk for developing substance abuse and later substance dependence must be addressed when one is attempting to prevent substance use and abuse.

Now let me get back to oppositional defiant disorder. How can we intervene with it or prevent it? As noted in my last post Oppositional defiant disorder is the most common co-morbid disorder with ADHD.

Oppositional defiant disorder includes arguing, refusing to comply, a person who is frequently angry, resentful, vindictiveness, deliberately annoys others, is easily annoyed and blames others for his mistakes.

Disruptive Behavior Treatment Studies Reviewed from 1985 to 2000 Shows Improvements Made and Kept.

An impressively thorough review of studies by Farmer, Compton, Burns & Robertson, 2002 found that disruptive behavior or aggressive behavior which included both conduct disorder and oppositional defiant disorder were improved and the progress was sustained for significant periods of time post intervention. A variety of approaches worked best but those which included both parents and children worked best. There was also positive support for multifaceted approaches to interventions presented in either a treatment or a prevention framework. The biggest limitation of this study was that it was limited to children between 6 to 12 years old. Also, the most conspicuous among the omissions (due to dates studied) are Patterson’s Living with Children curriculum (e.g., Patterson & Guillion, 1968; Wiltz & Patterson, 1974) and Barkley’s work on treatment for youths with ADHD (e.g., 1981, 1987, 1990; Barkely et al., 2000).

What this means is child counseling especially family counseling is a critical intervention if your child shows aggression and or oppositional defiant disorder behavior.

Oppositional defiant behavior includes arguing, refusing to comply, and a person who is frequently angry, resentful, shows vindictiveness, deliberately annoys others, is easily annoyed and blames others for his mistakes.  Conduct disorder includes aggression and various rule and law breaking behaviors. 

So, if we intervene between ages 6 to 12 we can possibly prevent the development of conduct disorder and substance use dependence. 

However, there is another very strong predictor of conduct disorder I will consider in my next post.

Dr. Charles Shinaver

Located in Carmel, Indiana near Indianapolis, Noblesville, Fishers, Zionsville, and Westfield.

 Host of                                        And provider of

 Clarity4Health.com               Cogmed Working Memory Training^TM

Life coaching, BeachBody Coaching and ADHD coaching through web and phone: 

No matter where you are.

371-641-7794, clarity4health@gmail.com