A discussion of an alternate treatment group for students with behavioral attention deficits and impulse control.
By David and Barbara Kenney
[Towards a Psychology of Possibilities - An ecological perspective that makes changes in the environs of a child’s life through collaborative efforts between school staff and family, in order to encourage greater understanding and develop optimal performance.]
In physics, there is a principal of uncertainty. It is based on a phenomenon of measurement. It states that when observing an electron, you can either view it as a particle or as a wave, as either matter or as energy. Either way you choose to view it, it behaves in the appropriate manner. So if you behold it as matter, it is matter. If you behold it as energy, it is energy. It can not be both at any one time in your frame of reference. So, to some degree, its behavior is contingent upon your choice as the observer. We believe that this principal holds true in psychometrics and education as well. It follows, then, that what our children become is a partial reflection of the possibilities we see in them.
As long as we remain a psychology of disability, we will never see many possibilities, neither for our children nor for ourselves. We are spending far too much time finding out what is wrong and far too little time trying to fix it. The worst example of this today is ADHD. This article is aimed at discussing children with inattention. At first it may look like another article about ADHD but it is essentially about what ADHD is not. It is aimed at suggesting other possibilities.
Attention Deficit Hyperactivity Disorder (ADHD) is a disorder defined in major part, by a list of symptoms/behaviors, such as: “often fidgets”, “has difficulty remaining seated”, “is easily distracted by extraneous stimuli” , etc. Currently, the state of the art in diagnosing ADHD is to gather information verifying these positive symptoms. Tools, such as: questionnaires, structured observations, and social/developmental histories are of greater or lesser reliability in detecting the presence of such behaviors. If it is well done, the diagnosis takes into account information from various sources. Information from caretakers, family members, and school personnel is analyzed, summarized, and sent to the medical personnel, who judge its reliability.
At some point, after the above information has been collected, some doctor, somewhere, makes a decision to diagnose the child as having ADHD. It could be a pediatrician, a neurologist, or a psychiatrist who makes this diagnosis. It’s almost always someone in the outer fringes of the child’s daily ecosystem. However, the decision is made and the prescription is filled out. And we all wait to see if it “works”.
Doctors may have a clear idea of what they mean by attention. Psychologists another. Parents, teachers, social workers, counselors, therapists, et. al. may also have an understanding of the construct of attention commensurate with their experience, training, general education, and interest. It is probable, then, that definitions generated by the above groups would be quite different from each other, making a discussion between them as effective as a conversation among the workers at Babel.
There are a few things left out of this diagnostic process. We quote from DSM-IV :
* It is important that DSM-IV not be applied mechanically by untrained individuals. The specific diagnostic criteria included in DSM-IV are meant to serve as guidelines ... and are not meant to be used in a cookbook fashion.
* It may be difficult to distinguish symptoms of ADHD from age-appropriate behaviors in active children.
* Symptoms of inattention are common among children with low IQ who are place in academic settings that are inappropriate to their intellectual ability.
* In children with Mental Retardation, an additional diagnosis of ADHD should be made only if the symptoms of inattention or hyperactivity are excessive for the child’s mental age.
* Inattention in the classroom may also occur when children with high intelligence are placed in academically under stimulating environments.
* ADHD must also be distinguished from difficulty in goal-directed behavior in children from inadequate, disorganized, or chaotic environments.
* ADHD is not diagnosed if the symptoms are better accounted for by another mental disorder (eg. Mood disorder, Anxiety Disorder, Dissociative Disorder, Personality Disorder, Personality Change Due to a General Medical Condition, or a Substance-Related Disorder).
Then according to DSM-IV, there are many reasons why children are inattentive. There are many things which must be ruled-out before we can claim to have correctly diagnosed a child with ADHD. The absence of the application of systematic, differential diagnostics has lead to many false positives in the identification of ADHD and it should be clear by now that, we, as a larger, societal group are over-identifying these disabilities in our children.
In our opinion, we have observed many children who have been misdiagnosed. What follows is a list of the conditions that have been missed, in our purview, due to a label of ADHD. From it could have been drawn a list of solutions for the recovery of these children’s attention. These then represent possibilities missed.:
• Abused Children
• Neglected Children
• Children with Anxiety Related Disorders
• Children with Obsessive Compulsive Disorder
• School Phobic Children
• Worried Children
• Children with Post Traumatic Stress Disorder
• Children with performance anxieties
• Children with Learning Disabilities Only (i.e. Central Auditory Processing Deficits)
• Depressed Children
• Developmentally Immature Children
• Mentally Retarded Children
• Borderline Mentally Retarded Children
• Indulged Children
• Bored Children
• Stressed Children
• Angry, Oppositional Children
• Children with Medication Side-Effects (ie. asthma)
Formative Evaluation and the Invasiveness of Interventions
The traditional psychological evaluation does not address the topic of differential diagnosis well because it views the evaluation process as an event. A traditional evaluation is a subset of observed behaviors that represent the child’s general behavior. This subset is observed at points in time relatively close together. Like a snapshot of a child, it is either a better or a worse description of that child, but it is only descriptive of one period in that child’s life. (It is very hard to differentiate a child who is abused from an over-anxious child by looking at a snap-shot.)
The children in this list of mis-identifications may share similar looking behaviors but they do not share the same behavior goals. Since all behavior has a purpose and the purpose of all these children’s behavior is different; then it is possible to differentiate these psychological states by observing and interacting with these children over a period of time within the environments where these behaviors manifest naturally. You can differentiate these children by analyzing their behaviors and by manipulation of the conditions in their lives to either frustrate or fulfill their behavioral goals. In other words, a possible solution to the problem of differential diagnosis in ADHD, is the application of formative evaluation. The most certain way to identify the cause or causes for a set of behaviors is to identify those variables in the child’s ecosystem that, when manipulated, effect a corresponding change in the intensity and frequency of the target behaviors (i.e. a one subject ABAB research design). The prevailing thought in the education of children with ADHD today is that we must first identify “their ADHD” in order that we, testers, may treat and then educate them. It is our thought that we must first intervene and educate in order that we might identify those with ADHD accurately.
The degree of intervention invasiveness necessary to effect change in a child’s behavioral patterns is determined by the causes of those behaviors and where in the child’s ecosystem those causes are located. If the cause of a child’s inattention is a mismatch between their academic skills and the work required of them in class, then the behavior change can be achieved with minimal intrusion into the child’s life. If, however, a child’s inattention is due to a severe seizure disorder, then effective treatment needs to be much more invasive. These extremes represent the near end-points of a continuum on which all the reasons for a child’s inattentiveness can be placed. If a child is developmentally immature, all they need is to be left alone for awhile. If they are hungry, then they need to be fed. If neglected, they need to be cared for and instructed. If abused, they need assistance in healing their trauma.
As a rule of thumb in a Psychology of Possibilities, an intervention should intrude into a child’s life only to the extent necessary to effect desirable change, as any change has unpredictable and possibly negative effects in the child’s life. This will help in assuring us that we will live up to the maxim that “first we shall do no harm.” Because the consequences of our actions can never be fully predicted before hand, the Ends never can justify the Means. We also think a second principle should be that in the absence of significant and dangerous pathology, the care-takers most involved in the child’s natural ecosystem should be the ones who administer the intervention.
So what is the point of saying all this? Is it merely another criticism to bandy about? The point then is this: let’s find ways of solving our current ADHD dilemma. There are many of us and so there could be many ways developed in dealing with the mismatch between our ideals and our everyday actions. In presenting the following possibility, we would like to encourage further dialogue on this issue.
How, then, do we identify the children which are inattentive due to a sluggish neurology and which children have attentional concerns due to a variety of other physical and/or psychological states, often in conflict with the various demands from the environment (ie. academic, social, and behavioral)? What if we created a group aimed at developing attentional/social skills and placed into it children having difficulty with the behaviors listed in the ADHD criteria? What if we systematically eliminated and/or controlled for the possible causes of these maladaptive behaviors? We would be doing an excellent job of differential diagnosis while being fully engaged in attempts at remediation. In essence, killing two birds with one stone.
In the Wayne-Westland School District, for several years, we were lucky enough to be able to develop and conduct groups like this. We started with the least intrusive interventions (ie. stressed-reduced time, training, etc.). As should happen in a mixed group, some children required no more than the simple attention garnered by being in a fun activity, while the behavior of others did not alter a bit. Through collaborative interactions with teachers and a series of modifiers increasing in complexity (i.e. behavior note systems, parent consultation, etc.), we were able to differentiate this group of inattentive children based on their individual behavior goals. With this differentiation accomplished, the verification of the pervasive presence of the positive symptoms/behaviors in the children whose behaviors had not changed was accomplished easily with little wasted time.
So what did this group look like? We used the list of positive symptoms of ADHD as both referral criteria and target behavior. We had group one hour a week for at least six months. We taught social skills. We trained them to stop, to look, and to listen.
How were we able to teach these children these things? By what leverage did we refocus their attention? Looking back to behavior modification, we found: “The Premack Principle - A behavior that occurs frequently can be used to reinforce a behavior that occurs less often.” So, we asked, what was the single behavior in a group of hyperactive, inattentive, impulsive children that occurred most often, and then, therefore, was the behavior most motivating to these children. Why, Nutsy-Coo-Coo Time, of course. Nutsy Coo-Coo Time is a highly technical term. My Father, who invented Nutsy-Coo-Coo Time, is a chemist, so I asked him to write me a systematic formula for generating it.
This was his reply:
about 7 hyperactive, inattentive, impulsive,
and/or socially inadequate children
47 red rubber balls,
5 soccer balls,
4 gymnastic mats,
2 climbing ropes,
12 paper airplanes,
10 colored hula-hoops,
and other various available gym equipment.
If the Premack Principle holds true, then Nutsy-Coo-Coo Time can be used as a powerful, positive reinforcement to the development of desirable attention and self-control behaviors. By the systematic attempt to better attentional skills in cooperation with powerful, positive motivation; by the observation of the child’s efforts to achieve those attentional skills and their frustration tolerance if those new, learned behaviors are not learned easily; the evaluator can determine which children do not display these skills in their natural environments due to social/emotional/motivational issues and which children displayed these behavior deficits due to processing disorders less effected by motivation. Having made this determination, it is easy to finish the evaluation for ADHD, utilizing more formal evaluation techniques on the smaller, second group of students while, at the same time, directly addressing the remediation of these children’s inattention. Thus, knocking down two school needs with one psychological stone.
The group begins by teaching the reinforcer. For one or two weeks, the members of the group are taken to the gym and exposed to Nutsy-Coo-Coo Time for one hour. At first there is only one rule, that is to freeze and then sit with legs folded when the whistle blows twice. Nutsy-Coo-Coo Time resumes as soon as everyone is sitting quietly. Sitting still and quiet is reinforced immediately and, therefore, conditioning begins with the first session.
In other words, the first several weeks of the group consists of nothing more than free play (training to the reinforcer) alternated with brief, discrete trials of stimulus discrimination training (with the whistle being the stimulus and the sitting still being the response). Since the one rule states that the group can continue to play once everyone has sat still for a period of time, the children are highly motivated to control their impulses quickly in order to resume their play. Thus, initially, the group is trained in impulse control in its most basic dimension. With little distress or concern to the participant, the periods of sitting still can be gradually increased. Therefore, the group’s structure, almost unintentionally, begins the shaping of desired behaviors. By determining the group’s level of self-control skills and adjusting the level of success required at the level of their emerging skills this shaping process quickly becomes reinforcing in itself.
After the initial stimulus discrimination training becomes manageable for a few minutes of sitting still, the group begins each session with circle time. Each circle time has something to learn, at first just a word or two, later larger concepts. Each circle time lesson teaches a concept about listening, self-control, or social skills. Free play is then only begun after the participants learn the lesson and the Nutsy-Coo-Coo Time reinforcement is applied to learning the language of self-control (concepts which can help the child link into their executive, cognitive functions as they become available.)
Group topics over the course of the year are listed under one of three rubrics:
The Listening game
The more you listen - the more you play.
Stop, look, and listen... and think.
Sammy the frog - think before you act.
The story game
What is self-control?
What is impulsive behavior.
What are consequences?
Responsibility - taking consequences.
Freedom, rights, and responsibility.
Work and play.
Why games have rules.
Why apologize for accidents.
The accident game
Specific social skills.
Fairness and choosing sides.
Turn–taking (Bubble-gum, bubble-gum in a dish...).
After circle time each week, free play continues but “freezing” becomes less random and is used for teachable moments. The free time portion of the group eventually becomes a social skills laboratory within which the children can practice new skills in an environment which closely matches their normal ecosystem, therefore facilitating the generalization of learned behaviors into the greater parts of the child’s life.
Children are picked-up and delivered back to their rooms each week in order to: 1) touch bases with their teachers; 2) practice hallway behavior; and 3) act as “cooling-off” transition back into class. Each week, it is important to touch basis with the children’s teachers in ongoing consultation. As the year progresses, children whose behavior does not improve receive more individual attention. Various interventions can be introduce depending upon the behaviors and the perceived reasons for them. As this “stepping up” process continues, fewer children need to be focused on. These interventions are fairly typical but should be used in a systematic manner as to facilitate greater understanding of the cause(s) of the child’s inattentiveness, and thus aid in on-going formative evaluation. What follows is a partial list of interventions which can be brought to bear on a child’s inattention:
* Use group attendance as a reinforcer.
* Consult with teacher concerning classroom
* Model appropriate behavior in class.
* Consult with parents on parenting issues.
* Act as coordinator between home and
* Set up behavior program in class.
* Start a daily note system, reinforced at home.
* Standardized testing.
This brings us once again to the greater possibility; namely, change in our schools. Until we give our teachers, students, and parents more possibilities, we will have few of our own. If we want to change our schools so that they will be more inclined to the application of more than a test-and-place psychology, we must change the way we respond to their problems. For those of you who are now saying “but I have a hundred evaluations a year,” we say that a psychological evaluation is an evaluation a psychologist makes. You have the obligation of choosing the tools you will employ with each evaluation. The year we had 28 students in our Nutsy-Coo-Coo Time group at Edison Elementary school, we did 28 evaluations there but only four or five WISC’s. 28 traditional evaluations (with MET, IEP, and written report) might easily take 280 work hours while the groups for these 28 students took four hours a week for approximately 25 weeks, thus only requiring 100 hours, a savings of 180 hours! At that same time that school saw us as active participants in the education of all the school’s children and not just as gate keeper to special education.