The Presumption of Incompetence: Why Traditional ADHD Treatments Fail 

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 Behavior, 14, 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.