The Presumption of Incompetence: Why Traditional ADHD Treatments Fail 

Craig B. Wiener, EdD
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While there are flaws to this belief (see my previous blogs), the most popular and accepted view of ADHD is that the behavioral criteria provide evidence of a biological delay that renders individuals less able to manage their affairs. This so-called endogenous problem leads to numerous deficiencies in functioning throughout development. Because of ADHD, proponents assert, we must curtail our expectations for change. Children diagnosed with ADHD are thought to be – no fault of their own – distracted, impulsive and hyperactive because of their inherent biological condition. This problem is predicted to – when unchecked – create havoc and limit the ability to meet responsibilities and conform to limits.

The two most popular interventions for ADHD are drugs and stringent control. Those who believe in the traditional biological determinist view assert that others must provide the control that people diagnosed with ADHD lack. In this treatment protocol, diagnosed individuals are remanded into treatment that mimics institutional care (i.e., others control their access to resources and their behavior is restrained with drugs).

While both of these impositions can yield some short-term benefits, they can also produce unwanted side effects much like what happens when there is incarceration (Bonta & Gendreau, 1990). However, the presumption of incompetence justifies the increased coercion and the neglect of fostering mutuality. Everyone involved (including the child) adopts the belief that there is permanent incompetence and the necessity for others to provide constant surveillance and force. Therapy that promotes self-management does not occur.

So What is the Problem? 

Stringency, supervision and drugs can induce compliance for everyone, but those interventions are usually not very effective in helping the ADHD diagnosed person (or anyone else) develop autonomy and concern for others. And if no one is helping these individuals learn to behave acceptably without medication, pressure, and supervision, how can we ever expect them to? Because these individuals will be more difficult to monitor, as they grow older, this problem increases with each passing year.

So let’s take a more detailed look at the specific shortcomings of commonly utilized ADHD interventions. 

Drugs

The first (and most popular treatment for ADHD) is the administration of drugs. These drugs purportedly address the structural and biochemical deficiencies present in the brains of people diagnosed with ADHD. Advocates proclaim that individuals will benefit from ingesting these substances on a daily basis. However, despite all the accolades, ADHD drug therapy has commonly occurring problems that make the intervention a less than stellar choice (especially when viewed over the longer term).

Here is a short list of the complications that occur when utilizing ADHD drugs to stop the occurrence of ADHD actions and reactions. While the drugs calm the individual and increase productively on certain kinds of tasks, the medications have drawbacks that are difficult to ignore.

  1. Prescribers will assure you that ADHD medicines are powerful yet harmless, but how much of any medication is entirely safe. Side effects can worsen over time, and biological and psychological changes can be more difficult to reverse the longer a drug remains in the body. Already there are reports that ADHD drugs can take a toll on the brain (Higgins 2009; Breggin, 1999), and long-term effects on very young children are still unknown (Rappley 2006).
  2. Medicinal treatment can also take away the urgency of a problem. Urgency is what drives people to work hard and change, and lack of urgency can lessen a person’s desire to seek psychotherapy. People end up relying solely on medications. But what if the drugs stop working? Postponing psychotherapy can make things significantly more difficult when children are older when it is not as easy for them to change their habits and routines. As the saying goes, “You can’t teach an old dog new tricks.”
  3. Keeping a child on long-term medicinal treatment can also mean higher dosages and multiple drugs as time passes. With growth and drug tolerance, the child may need more medication. Sadly, the potential for side effects increases with the amount and number of drugs needed to achieve the desired effects.
  4. Medicinal therapy may also create the belief that medication is necessary for success, when in fact there might be other ways to resolve the problem. Individuals may learn to seek psychiatric drugs as a primary way to address difficulties and never explore whether they might resolve their problems in a different way.
  5. It is also difficult to stop medicinal treatment once it’s begun (even when supervised by a physician). Stopping medication can mean that a person has to adjust psychologically and biologically to not having a chemical boost. Unwanted behaviors typically reappear when there is withdrawal from the drugs. Everyone involved is reinforced that the drugs are needed to avoid relapse.
  6. While medicinal therapy is certainly a reasonable treatment option when the benefits clearly outweigh the harms, the long-term advantages of ADHD medications have not been outstanding. A case in point is the massive 1999 MTA Cooperative Group study on ADHD. While the initial results reported that medications were the best treatments, later results showed that the benefits did not last. In as few as three years, medicated children were no longer behaving better than children who had received other treatments (MTA Cooperative Group 2004). (Note: a similar finding occurred in the more recent six-year John’s Hopkins (2013) study.)  It is therefore not surprising that Consumer Reports states “there is no good evidence” that ADHD drug benefits last for longer than two years.

Stringency 

The second intervention within traditional protocol is to structure the environment of the person diagnosed with ADHD so that deficiencies in competence to self- manage are addressed. For children, this means that parents (and other adults) must administer contingency management. This means that the people responsible for the child must take ownership of the child’s resources and limit the child’s access to those resources until compliance is obtained. The social arrangement is based on dominance and submission; the child is inherently incompetent and unable to self-manage, so the adult must govern unilaterally. The thought is that only this kind of stringent parenting will keep a child from the chaos that ADHD generates.

Often parents like this message, as they are told that dominance is better (who doesn’t like to get their own way). And no doubt, disciplining in this fashion works quickly. It’s easy to do, and all parents know that stringency is sometimes necessary to protect a child. Yes, coercion—disciplining with rewards and punishments—has a significant role in child rearing, but it has some downsides that are worth considering.

When you manage your child’s behavior, using special incentives and penalties, things will seem fine as long as there is no controversy and your child keeps earning the rewards you control. The child may even be happy that he is getting something extra for showing the behaviors that adults expect. However, there are typical side effects when this method is the primary way to socialize a human being.

  1. Research shows that connecting a bribe to an activity will reduce a child’s interest in doing the activity when the bribe is removed (Lepper et al., 1973). This means that once you introduce a reward system, you must keep doing it to avoid a significant drop in performance. Your discipline increases your child’s desire to obtain the reward and makes the activity seem less enjoyable.
  2. Any reward system that you control is also limited by the extent of your personal involvement. You want a child to be successful without you, but the invented system of rewards and punishments trains compliance only under supervision. You will not be able to monitor every action that the child takes, and so you will not have influence over him sometimes. Sadly, this will increasingly be the case as the child grows older and spends more time away from the adults in his world.
  3. But that’s not all. What happens when your consequence is not strong enough to outweigh the hassle of meeting the expectation? For example, it’s just not worth it to lug the trash outside when it’s snowing just to get another star on the chart. Many children recognize this problem, and it’s common for them to resist until the bribe or threat is increased. Relationships spiral into a power struggles. The child extorts as much as possible before conforming, and the adult gives as little as possible to gain compliance.
  4. There are other problems as well. Some children may stop liking a reward so that adults cannot pressure them. Some may become overly concerned about unwanted consequences and develop anxiety. Some may stop telling adults what they like so that the adult cannot use it to “pull their strings”. Some may lie or sneak to beat the system.  And sometimes, failure to obtain a privilege makes little difference to a child as long as the child remains in the center of everyone’s concern.
  5. As you can see, when the purpose is to create discomfort or give something extra to get a child to obey, the child learns to overpower rather than to cooperate. The child sees others trying to force submission, and the child duplicates the same behavior to gain authority over others. You take away what he wants, so he takes away what you want.
  6. Even if it means putting himself in jeopardy, he may find a way to gain the upper hand. You pressure him to be more productive, and he learns ways to get you to reduce your expectations. He tries to outmaneuver you, and you work to close the loopholes. You end up struggling for dominance, and your child is not learning to self-manage. Empathy, attending to each other’s perspective, scratching each other’s back, and finding a middle ground are often set aside when you get into this arrangement.

An Alternative: Develop Self-Reliance and Cooperative Interacting 

Instead of presuming that children diagnosed with ADHD need control from others and stimulant drugs, what if it was assumed that they could improve in their self-management? What if moderation, dependability, and concern for others could be nurtured by helping these individuals learn self-reliance and cooperation?

So ask yourself, does a child with ADHD really need drug enhancement, extra payment or the threat of “time out” to achieve or to be kind and honest? Most parents already know that ADHD children (who are not mentally deficient) can organize their toy figures into intricate battle scenes, can remember appointments to visit a toy store, and can refrain from blurting out when being interrogated. Their problems have to do with compliance for activities that they do not initiate and have not enjoyed. What a strange form for a “biological delay” to take.

So ask yourself, do you want these children to learn to cooperate only if they get something extra in the deal, or do you want them to derive pleasure from building a caring relationship with family, teachers, and friends? Even if the reward is spending time together, do you really want to turn your time with each other into a business deal or make it an obligation? Of course you don’t.

With all the potential adverse effects associated with traditional ADHD intervention, let’s take a different approach. You can focus these children on the ultimate reason to cooperate and develop competency: They will have happier, more fruitful experiences, if they are kind and skillful. And, they will find, being kind and skillful feels good. There is no reason to distract them from this powerful motive. A child – with or without ADHD – needs no other incentive. Lack of connection with others and lack of competence are the most potent negative consequences, and mutual caring and knowhow are the most wanted treasures.

The key is to learn how to nurture these behaviors, and to help the child cope with adversities in ways that are more positive. This will be the topic in upcoming blogs.

See more in Parenting Your Child with ADHD: A No-Nonsense Guide for Nurturing Self-Reliance and Cooperation by Craig Wiener  

 

References

Bonta, J., and Gendreau, P., “Reexamining the Cruel and Unusual Punishment of Prison Life,” Law and Human Behavior14, 347 (1990)

Breggin, P. R.  Psychostimulants in the treatment of children diagnosed with ADHD:  Risks and mechanism of action. International Journal of Risk & Safety in Medicine 12 (1999) 3–35 3.IOS Press

Higgins, E. S. 2009. “Do ADHD Drugs Take a Toll on the Brain?” Scientific American Mind, July/August: 38–43.

John’s Hopkins (2013) ADHD Symptoms Persist for Most Young Children Despite Treatment

Lepper, M. R., D. Greene, and R. E. Nisbett. 1973. “Undermining Children’s Intrinsic Interest with Extrinsic Rewards: A Test of the Over-Justification Hypothesis.” Journal of Personality and Social Psychology 28: 139–87.

Rappley, M. D. 2006. “Actual Psychotropic Medication Use in Preschool Children.” Infants and Young Children 19: 154–63.

27 COMMENTS

  1. I’ve often thought that, perhaps, the problem is a family’s/society’s inability to cope with brilliance. So a highly intelligent, energetic, and creative kid gets marginalized because he or she won’t comply with the limits imposed by an unenlightened, fear-based society. Hard to blame the kid for acting out, that would be infuriating.

    • p.s…perhaps if their talents and gifts were valued, and they could be perceived as an example of individuality, courage, and authenticity, rather than shamed and labeled for how they express themselves because it challenges the norm (stigma), then they would be more trusting, and in turn, more relaxed and kinder…yet highly productive!

  2. “Yes, coercion—disciplining with rewards and punishments—has a significant role in child rearing, but it has some downsides that are worth considering.”
    Yeah, that may work for some kids. For other kids (speaking from experience) it will produce a “I’ll show you effect” and a permanent temper tantrum. As far as I know treating a child with respect as any other more developed human being rather like an animal that has to be conditioned produces better results in the long-term. Giving a child freedom to make own choices is teaching the responsibility.

  3. I went through twelve years as a student of the American educational system. I spent four years getting a college degree. I taught high school for fifteen years. Never in all that time did I ever run into anyone that I would label as having anything as spurious as ADD or ADHD. I saw difficult kids, I say kids needy for attention, I saw bored kids, I saw kids struggling with impossible things in their family lives, but I never once saw kids that I would say had anything like this fake “disease” that was made up and voted on and placed in the DSM, so that drug companies could push their expensive and dangerous drugs to be used on kids.

    I agree with you about all the problems that you point out about the use of drugs and controlling kids lives, but I do not and never will ever accept that there is anything called ADHD. I will claim that there are parents who don’t want to deal with the difficulties of parenting and I will admit that there are teachers who don’t want to deal with difficult students in the classroom, especially when the numbers of students in classes is too high, but I will never admit that there are people running around with ADHD. I will also admit that the American educational system is BORING and I can’t believe that kids put up with it as well as they do. I was a teacher for fifteen years. It’s BORING. And we send our children to school at younger and younger ages and have unreal expectations for what they should accomplish in the classroom. We have come to the point in our society that we won’t allow kids to be kids and we’ve come to the point where controlling behavior is more important than real learning.

  4. “You can focus these children on the ultimate reason to cooperate and develop competency: They will have happier, more fruitful experiences, if they are kind and skillful. And, they will find, being kind and skillful feels good. There is no reason to distract them from this powerful motive. A child – with or without ADHD – needs no other incentive. Lack of connection with others and lack of competence are the most potent negative consequences, and mutual caring and knowhow are the most wanted treasures.” Dr. Wiener

    If you ask a child to read and follow the instructions you’ve written on the blackboard, but he will not, we can consider several reasons for this. We could try various means to motivate him, including behavior modification, unconditional love, yoga, one on one tutoring, etc. Each has benefits.

    But, what if he needs glasses?

    • There’s a fairly well established institution for that problem – school nurse. When I was a kid we had basic school health check-ups every half a year done by a school nurse and once a year there was a doctor coming. They checked our eyesight, weight, teeth, skeleton development and whether we had hair parasites. If something was wrong they would inform the parents and they could take you then to the relevant doctor. It has worked pretty well.

      • Exactly. Simple. The child wasn’t trying to be difficult. The child wasn’t necessarily being mistreated in some way or catered to or inundated with too much modern and maddening trivial input from t.v. and computers. He might need glasses! Get him screened. Go from there. Boom! The kid no longer refuses to follow instructions!

    • Or what if the child has sleep apnea since according to various statistics, about 35% of kids diagnosed with ADHD turn out to have sleep apnea. So if you put them on stimulants, you are compounding instead of solving the problem.

      Or the child could have learning disabilities that are commonly misdiagnosed as ADHD. Stimulants do nothing to solve reading problems that are commonly associated with LD. So maybe the kid who can’t read needs testing to find out why.

        • If it is sleep apnea, it is not ADHD. If it can be explained by anything other than ADHD, it is not ADHD. Onset begins by 7 years of age.

          Stimulants help people without attentional deficits to concentrate. The ability to pay attention runs along a continuum. Even those with severe ADHD pay attention on occasion and even Einstein couldn’t pay attention perfectly. Most can attend well enough to function without much difficulty. Those with ADHD do not and cannot fully tap the other mental skills we have, whether they are unexceptional or extraordinary.

          I like the eyeglasses analogy. You can be a genius but if you are legally blind or completely blind, without being aware of it and compensating for it with corrective lenses, or by becoming proficient in braille, reading is going to be tough! If you operate at about 100 FSIQ, same thing.

          Putting on a pair of corrective lenses that yields 20/20 vision, will rock your world. At the same time, glasses don’t teach you to read suddenly. Glasses don’t teach you how to identify mathematical terms, to be able to name the colors of the spectrum, to know what beauty is and what kind of impact it will have on your life. Yet, for the first time in your life, you can begin to learn all about everything you missed.

          And that is a reason to celebrate. That is a reason to feel grateful-for glasses/drugs. (If you stop wearing them after 14 months, don’t expect to keep reading. The silly study that recorded no additional gains in teens after they ceased taking their meds at 14 months, proves my point.)

          Then, you will meet people who will insist you can not see, or that you always could see, you just never knew. They will sneer and tell you your glasses are made by the Mafioso. They only want to rip you off. They charge too much and bribe optometrists and ophthalmologists to push their brand of eyewear. Glasses break, too, don’t forget. Kids have been blinded from sharp pieces of glass from busted glasses. But, the mob doesn’t care. All they want is your money. They don’t care if you stare at the sun with your glasses on! They don’t warn you you’ll burn your retinas right out of your head. They don’t tell you how hideous you’re going to appear to your friends and how your girlfriend will start heaving with one glimpse of your 4-eyed, ugly mug! O no! They just want your bread, man. No, you don’t want to go down that road of wearing glasses. Besides, only nerds wear glasses.

          In your heart you can only shout, I was blind but now I see!

          • That’s a good way to eliminate the objection that ADHD is not really a singular disease, by eliminating all possible alternatives and saying “If that’s the problem, it’s not ADHD.” Kind of a scientific cheap shot. The fact is, ADHD is not objectively distinguishable from a number of other conditions based on the criteria provided, nor is it particularly distinguishable from normal childlike behavior. Until there is a way to know who specifically “has ADHD” and who has something else and who has nothing but a boring classroom or incompetent or abusive parents, it really is nothing more than a description of kids who the teacher/parent finds annoying.

            —– Steve

  5. “I will claim that there are parents who don’t want to deal with the difficulties of parenting and I will admit that there are teachers who don’t want to deal with difficult students in the classroom, especially when the numbers of students in classes is too high, but I will never admit that there are people running around with ADHD” S. Gilbert

    If a child/student has demonstrated over the years that he does not pay attention in class to his detriment, despite attempts to utilize every reasonable approach to help him by competent teachers, counselors, doctors, loving wise parents, etc., do you have any thoughts on what might be done?

  6. If a child/student has demonstrated over the years that he does not pay attention in class to his detriment, despite attempts to utilize every reasonable approach to help him by competent teachers, counselors, doctors, loving wise parents, etc., do you have any thoughts on what might be done?

    If you find the time, I’d appreciate hearing from you Dr. Wiener. Thank you

    • What is “every reasonable approach”? Plus any existing studies on long-term benefits of ADHD drugs show that they don’t improve educational outcomes, only make kids and their caregivers feel better about themselves because the kid behaves like he/she is trying.

  7. The two most popular interventions for ADHD are drugs and stringent control. Those who believe in the traditional biological determinist view assert that others must provide the control that people diagnosed with ADHD lack. In this treatment protocol, diagnosed individuals are remanded into treatment that mimics institutional care (i.e., others control their access to resources and their behavior is restrained with drugs). While both of these impositions can yield some short-term benefits, they can also produce unwanted side effects much like what happens when there is incarceration

    What do you recommend when nothing works?

    • I am about to give a talk on that subject this very evening. There are many, many things that can be done besides overcontrolling rigidity. In fact, a structured degree of flexibility seems to be a much better way to proceed, hence the effectiveness of the “open classroom” I described in another thread. Power struggles are to be avoided at all costs. Putting the child in a position where s/he has to think about consequences and about others’ feelings in order to get what s/he wants is also a very powerful approach. The key is to teach them the skill and value of planning and forethought without crushing their exuberant spirits.

      All these kids who are so labeled have in common is that they are looking for extra stimulation. We can provide it artificially through drugs, or we can provide a stimulating environment where they are challenged to learn to overcome the drawbacks of their particular personality traits. All personalities have pros and cons to them. The trick is to use the strengths to overcome the challenges. It can be done, because I’ve done it with my own kids. Twice, even. But non-traditional classrooms were an essential part of the plan.

      —- Steve

      • “The fact is, ADHD is not objectively distinguishable from a number of other conditions…” But, you already made distinctions.

        “nor is it particularly distinguishable from normal childlike behavior.” But, you have already distinguished it.

        “Until there is a way to know who specifically “has ADHD” and who has something else and who has nothing but a boring classroom or incompetent or abusive parents…” Steve, you already identified kids who have it. Remember the hunters and gatherers, too.

        “it really is nothing more than a description of kids who the teacher/parent finds annoying.” You have more, no, you have way, way too much intelligence to make that statement with conviction.

        Have you seen a top notch medical doctor who is a specialist in ADHD diagnosis and treatment like Ned Hallowell, out of Harvard? Have you read, Driven To Distraction?

        • And have you read Samuel Rowbotham’s ‘Zetetic Astronomy’? He’s a specialist in flat Earth theory:
          http://www.tfes.org/
          Sorry but argument from authority is a very poor one.
          Steve did not make any distinctions. He pointed out the same old thing: ADHD is assigned to kids who are subjectively found to display, at least some of the time, a certain percentage of behavioural symptoms out of a checklist. It tells you nothing about the etiology of them. It can be an abused kid acting out, it can be a kid who’s developing a bit slower than others (I don’t know if you have kids but that’s what they do – they develop different abilities, mental and physical, at different rates), it may be a kid with a physical issue (bad eyesight or hearing, hormonal problems), it can be a kid who has an anti-authoritarian streak and does not want to put up with standardized test bulsh*t… a lot of reasons. It’s like saying that fever is caused by high body temperature. It’s circular. You have to find out what causes fever (infection, allergy, injury…) not go in circles trying to define subtypes of fever.

  8. “Everyone involved (including the child) adopts the belief that there is permanent incompetence and the necessity for others to provide constant surveillance and force. Therapy that promotes self-management does not occur.” Dr. Wiener

    Unless that is provable, I don’t think that statement can be made with integrity.

    “6. While medicinal therapy is certainly a reasonable treatment option when the benefits clearly outweigh the harms…”

    Dr., you are making a powerful point. You recognize ADHD exists, number 1 and that #2, medication to treat it makes sense.

  9. “1. Prescribers will assure you that ADHD medicines are powerful yet harmless…” Dr., would you name a doctor who prescribed these drugs while making that promise?

    “2. Medicinal treatment can also take away the urgency of a problem…”
    Can you offer examples where this has been a problem with these meds and ADHD patients?

    “These drugs purportedly address the structural and biochemical deficiencies present in the brains of people diagnosed with ADHD.”

    What do you think doctor? Purportedly doesn’t mean positively.

  10. “Putting the child in a position where s/he has to think about consequences and about others’ feelings in order to get what s/he wants is also a very powerful approach.” If that doesn’t help?

    “The key is to teach them the skill and value of planning and forethought without crushing their exuberant spirits.” What if no one can teach them those skills and values?

    When you wrote, “the goal is to help people with ADHD with their difficulties in organization and focus” you gave away, you revealed, your true nature as a human being and your real agenda, didn’t you?

    • What if the sky was green and the moon made of jelly? I can ask question like that about any topic ab infinitum. I guess the answer you want is “oh, well, if NOTHING helps then one has to give the kid amphetamines”. The problem is that is a wrong answer to a wrong question.

  11. blakeacake,

    When you were put on stimulants, did you ask your psychiatrist, what if meds didn’t work for you? The reason I am asking is when people give you alternative remedies to meds, you keep asking the “what if” question. So I was curious if you did this also with meds since you seem to believe they are the solution to everything and that nothing else can work.

  12. The memory-enhancing dose (1 mg/kg MPH) showed little evidence of reinforcement. In contrast, 10 mg/kg MPH not only produced sensitization, place preference, and a marked stimulating effect, but it also impaired memory. This dissociation is supported by our observation that memory-enhancing doses of AMPH (0.005 mg/kg) and COC (1.5 mg/kg) also showed little evidence of reinforcement, while high, addictive, doses impaired memory (Fig. 4). Together, these results substantiate the view that psychostimulant dosage explains the “paradox” of cognitive enhancements in patient populations and cognitive deficits in addicts (Rapoport et al. 1980; Ellinwood et al. 1998; Rapoport and Inoff-Germain 2002; Berridge and Devilbiss 2011; Wood et al. 2013). As dosage dramatically dissociates psychostimulants’ procognitive and reinforcing effects, it is likely that one can develop an MPH-like drug, which retains all of MPH’s procognitive effects, but lacks any reinforcing effects. Though, to date, such efforts have been limited.

    Overall, we found a clear long-term enhancement of memory by MPH at doses similar to those prescribed for ADHD; these memory-enhancing effects were not confounded by effects on locomotion or anxiety and were readily dissociable from the reinforcing effects seen at high doses. Together, our data suggest that fear conditioning will be an especially fruitful platform for modeling the effects of psychostimulants on LTM in drug development
    Animal model of methylphenidate’s long-term memory-enhancing effects

    Stephanie A. Carmack1,
    Kristin K. Howell1,
    Kleou Rasaei1,
    Emilie T. Reas2 and
    Stephan G. Anagnostaras1,2,3