Craig Wiener – ADHD: A Return to Psychology

On MIA Radio this week, in the first of a number of podcasts focussed on parenting issues, we interview Dr. Craig Wiener, a licensed psychologist based in Worcester, Massachusetts, who specializes in the treatment of children, adolescents, and families.

In addition to over 30 years of private practice, Dr. Wiener is an assistant professor in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School. Dr. Wiener is the author of three books. most recently Parenting Your Child with ADHD: A No-Nonsense Guide for Nurturing Self-Reliance and Cooperation. Earlier this year he debuted his three-part video series “ADHD: A Return to Psychology,” which appears on the Mad in America website and also on YouTube.

What follows is a transcript of the interview, edited for clarity.

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Miranda Spencer (MS): Hello and welcome to the first Mad in the Family podcast. I’m Miranda Spencer, editor of Mad in America’s Parent Resources section. Today we’re going to talk about a different approach to helping children with behaviors that often get labeled as ADHD, Attention Deficit Hyperactivity Disorder. That’s the kid who can’t sit still, who disrupts the classroom, who has trouble concentrating, who never seems to complete tasks, and who can be very impulsive.

Today Craig will summarize the approach that he talks about in the videos, which is a new way of looking at ADHD-type behaviors and steps the parents can take to help their children, which he says are more effective than standard medicalized treatments.

Welcome. So let’s look back a bit to get started. How did you come to be interested in ADHD in your psychotherapy practice? And when did you realize that the standard way of viewing ADHD-type behaviors was problematic?

Craig Wiener (CW): Well, I did a postdoctoral program in a youth guidance center, so many of my clients were diagnosed with ADHD. And I had been trained in a more classical way, where I would investigate a person’s history of living-in-the-world to try to figure out how to account for what they were doing under their situations and circumstances. And I saw behavior as reinforcing the fact that their behaviors were solutions to difficulties of living-in-the-world that the person encounters. At the time—this was in 1979—the biological model was already getting to be, kind of taking over psychology, with the drugs being on the market and the metaphor of diagnoses and disorders being promulgated.

But I had always held a very different view of psychology as something a person does in terms of coping. So the idea was somewhat at odds anyway from a medical perspective, which was positing that individuals who have these very heterogeneous list of behaviors are somehow suffering from some singular problem. And for me, it was very difficult to even see the groups of people being labeled as having that much similarity! They might have “qualified for” the diagnosis. But what would account for their hyperactivity under some conditions and not others? And when were they distractable or very emotional?

All of this seemed to be much more easily explained in terms of investigating their history of living-in-the-world, and how those particular responses might have been responded to [by others], and how those responses would have either increased the frequency of the behaviors or decreased the behaviors.

The other thing was that the notion that they had some impairment of functioning was questionable, because there was never any particular thing that was consistently impaired. So unlike IQ, which shows a little more consistency and is much more difficult to alter, these kids would show the behaviors that were supposedly weakened, but they were doing just fine under some conditions. Particularly conditions where they were initiating the activity, or the activity had a history of success for them. So all of a sudden they didn’t show the problems that were evident when they did their score or when they responded to parental expectations or societal limits. So for me it is part of psychology, a learning paradigm, much more consistently than a biological view, which is positing some kind of “deficit in functioning.” I didn’t know what the deficit in functioning was.

MS: So it sounds like almost a little more intuitive approach. Is there an evidence base for the new biological approach versus what you had always done?

CW: Well the biology people would say that if they give a kid these particular drugs and look, the behaviors change. But that just says that if you change a person’s biological system, they have different responses. It doesn’t tell you why they were doing the other behaviors. With alcohol, an alcoholic person becomes more sociable, but it doesn’t mean they had a biological problem; they might not have been sociable for all sorts of reasons. Alcohol might help them. So I think it doesn’t tell you the cause of anything.

At that time they were starting to get into this “brain differences” stuff where they would take diagnosed individuals and they would do brain scans and say the brains are different. But that only says that if you behave in the world in a particular way, your brain organizes in a particular way. They can do the same study with cab drivers in London, where they show the visual-spatial cortex was much more developed for cab drivers because that’s how they live in the world. In fact I think they do studies that if you take any group of behaviors, that any group of people that do the same kind of behaviors with a great deal of frequency, you then get different brain organizations as a consequence of the co-occurrence of how they live and how their body develops, as the consequence of their biology and their environment co-occurring.

And then, of course, the twin studies are always used to support the biological view, but the twin studies are problematic. Now, in my view, biology changes the probabilities of what you’re likely to learn. So if you’re seven feet tall, there is a tremendous increase in probability that you’re going to learn to play basketball at a very high level. But that doesn’t mean there is a Basketball Gene. It means that if you have a certain kind of physiology, then your learning patterns are going to be different than the case otherwise. If you’re a kid who’s got motor coordination problems, your psychosocial history is likely to include more reliance on others to facilitate, more failure rates for sports, certain kinds of consequences socially. So it’s not like biology has nothing to do with it, [but] it changes what you learn. As you learn, your biology changes. So all behavior is biology, but it doesn’t mean the biology is defective biology, it means it is evolved biology.

And I think the people who look at biology are looking at it as if, oh, if your kid’s distracted, versus the population at large, they say “Well, it’s proof that this is some kind of biological disorder.” Rather than, “People who show these kinds of biologies might be more likely to learn in particular ways” or “People who show these biologies have learned to behave in particular ways.” It doesn’t say that they’re uncovering some kind of entity called ADHD that causes other behaviors to occur.

So, on twin studies, you’re more likely to have similar bodies and similar environments for identical twins, and your probabilities for learning are going to be similar. And there’s no doubt about it, but doesn’t tell you how different you could make people with the introduction of new conditions. And I’m always interested in what conditions can be introduced that might change the outcomes that we’re seeing. Not all kids with developmental coordination delay are going to end up doing ADHD behaviors and not all active kids at the starting point end up doing ADHD behaviors, so it must be something that could happen along the way that will change their developmental trajectories.

MS: Well speaking of those trajectories, can you please summarize what you say in your videos about how your approach works differently from the usual approaches to kids with the label of ADHD? What do you do instead?

CW: The usual way is you can induce new behaviors with drugs and you can also induce new behaviors by greater supervision, which essentially becomes coercion because the management means that one person controls the other individual’s access to resources. And you can essentially change behaviors by overseeing somebody and controlling your access to resources. So you can get all kinds of behavior changes in the short term with the drugs and with somebody constantly overseeing your actions, just like you would do in any institution. The problem’s going to be: What other behaviors are learned when one person attempts to control another person’s actions and what behaviors generalize when the overseer is no longer available to manipulate the environment? Because the reinforcement patterns are going to be different when the monitor is not available.

So the problem with any institutional training is you don’t get much generalization. When a person leaves jail they may not learn how to function in society if they haven’t learned to function in these situations and circumstances that are evident when they live a free life. So the problem for people is that they, yes, get a short-term benefit [from conventional approaches]. People with type 2 diabetes get short-term benefit from drugs, but they might get a different kind of benefit from lifestyle changes. But of course it’s a very difficult problem to get somebody to change their lifestyle. So in my view you’re more likely to get generalization of [desired] behavior if the person has a sense of buy-in, or the activity is reinforced not in relation to an overseer but in relation to the kinds of situations and circumstances that the individual encounters, regardless of particular overseers who are controlling their access to resources. They have to learn to enjoy school because of what school does in terms of their own sense of what they want. They want to do a behavior because of how it facilitates the relational pattern that’s important to them. Not because they’re going to get some reward from somebody else who controls and rewards them. We get all kinds of very difficult problems when we try to control people, and I think that’s the limitation of the official view.

So you know the remarkable thing is that ADHD doesn’t occur when a person is interested. So whenever you get the notion of buy-in or the person has learned to do the activity on his or her own discretion or authority, you’re also not getting the kind of loudness, intrusiveness, distractability, emotionality where the person is comfortable doing something that they have a history of success with. So why not try to get them to adapt to social expectations in a more comfortable way, so that they do the same behaviors that they do already with those behaviors they initiate and enjoy? My view says I’m just taking what’s already occurring and trying to generalize those behaviors to other things that are currently associated with negativity or coercion or failure or some kind of power struggle or some kind of adversity, that the person is having trouble dealing with the limits of intrusiveness and avoidance that they struggle with under those conditions where ADHD is diagnosed.

MS: So how does this work in real life? A parent brings in their child and they have these so-called classic symptoms that you’ve described and the school or some doctor or someone has given the diagnosis of ADHD to them. How would you work with that child and how would you work with the parents also to help matters?

CW: We’ve got some people who’ve been indoctrinated into the view that the child is disordered. Of course the child is doing behaviors that we want to modify because the behaviors aren’t helping them. But they’ve been indoctrinated into the view that this represents some kind of biological deficit playing out and they have been encouraged to have medication. They’ve noticed that medications have good instantaneous effects. Their kids are sociable and more likely to be intensely concentrating on a task, so they may have less dysfunction in school. So they’re getting some immediate results.

[But] a lot of parents in today’s day and age are kind of learning not to always buy into the drug scene. So a lot of parents read about me and what I can do and they might come to me knowing that I’m going to encourage other kinds of things. Now if a parent has adopted the view that the child has a deficit or is delayed, then I try to help the parent recognize what are the exceptions to this delay? And they start to see that, you know, “[They] do fine when they’re hiding an object from their sibling, they know where they kept it, where they put it, and it’s not lost in the way they lose other things.” And then if you’re on the phone and the child makes noise and the parent then gets off the phone, it is different than when the child is quiet because they don’t want the parent off the phone because then their bed time’s going to be extended. So they notice that the child’s behavior varies remarkably with situation and circumstance.

It starts to make sense to people when they start to investigate in more detail that the patterns of living-in-the-world, these things aren’t derived from the doctors at the pediatrician’s office. These are uncovered through analysis through time of what it meant for the child to start to grow up, and what they did at first, and what the parents did, and what happened in the parents’ childhood that would have led them to have difficulty with certain kinds of limits setting, or certain types of rescuing behaviors, or separation issues, or dealing with a child’s emotionality. What happened when a child first learned to walk? And how did the parent establish ways to touch and ways not to touch? It’s not conscious, but what did the parents do when a child was curious or was calling them? And it takes time [in therapy] to go through what it meant to live in a world together and what people did. Are there different kinds of situations? What were the child’s experience with school? How did they react, was the school associated with success, were there some kind of difficulties? It’s basically a study of history, and it depends on the subtleties of the parent and the therapist or the child, in trying to understand: What are the possible reinforcements for these [ADHD type] actions one place or another and what could be done instead?

And once you start to get into it, it makes sense, because we can account for “OK, it doesn’t happen here, or how come it didn’t happen here but it happens there?” So you can get a sense of consensus once we start to uncover the patterns of behavior.

MS: So it sounds like it’s a very individualized approach. It’s not a one-size-fits-all.

CW Yeah, that’s beautiful. That’s very important, because once we move to a diagnostic system then we’ve lumped everybody into either depression, ADHD, bipolar, or anxiety. When you look at each person’s history of living-in-the-world, all these so-called symptoms have different histories and different times in which they occur and different consequences when the behaviors are emitted. So we’re lumping people as if we’re talking about a common group, when I don’t understand the commonality. It’s only that they do this particular behavior more frequently than others. But when they do it, why they do it is a very difficult problem to uncover.

MS: I see. Can you share an anecdote or two about what you’ve seen in your practice or elsewhere of before and after? Someone that showed up with these behaviors and then you worked with them and saw change.

CW: Sure. You get a kid that comes in and was adopted and lost his parents. His father died of drug abuse. The mother died of some other drug abuse, and the youngster was rescued by the girlfriend of the father, and she was told right off the bat “This youngster has ADHD.” And problem was that a lot of the time what will happen is as soon as a child is seen as deficient, what happens is we then compensate for his deficiencies. And that leads to a reinforcement of being deficient, so that not being able to do things becomes a pattern of behavior that gets accommodations and gets people to overlook, to lower expectations, [and to provide] extra help. Now for a youngster who wants people to love him and care about him, having extra help and having less failure rate is a wonderful thing. So he …very quickly learns to say “I can’t.”

This kid was often going for walks, he’d fall down all the time. Everybody had to kind of watch and make sure you’d pick him up, and make sure he wasn’t going to fall and get hurt. So there’s a whole reinforcement of “I can’t, I need help. Do you love me if I’m struggling?” And once you do an ADHD [diagnosis], you’re always dealing with what special circumstances you have to introduce to remediate this “biological” problem. So what happens is year by year goes on where the youngster doesn’t function without somebody sitting there reminding them, lowering expectations, doing for them. And yeah, you can get a kid to get through school, but they really don’t get very far because they get totally reliant on the management of others.

Once they start therapy with me, I say “Well, how do we account for these behaviors differently? What’s the reinforcements? How is this child getting almost encouraged inadvertently, unwittingly, to do these behaviors? And how can we slowly but surely encourage a different psychosocial pattern where the child starts to see there’s some benefits to competency?” Or that they can get into a different kind of relationship with those around them. And that’s a very difficult problem because once you learn to live in a world one way, what’s the difficulty to change it? It takes parents time to learn, and it takes children time to see, that different things can happen with different kinds of effort and a tolerance for failure. And what it means to fail and accepting failure. So it’s very complex, but I think it’s worth it, rather than have a lifetime of rescuing and compensating. The outcomes of traditional methods really haven’t been that good. So you can see how it’s feasible to talk about something new.

MS: Right. So what do your peers in the mental health field think of the return-to-psychology approach to dealing with so-called ADHD behaviors? Are you getting validation or pushback from psychiatrists, schools and so on? How is that going over?

CW: Well that’s a great question. I think a lot of people going to therapy see the power of the environment. It’s not a negation of biology, but it is saying that you can sometimes understand that a historical study of the individual– which is what we’re trained to do– is much more likely to [create] buy-in to this kind of an intervention. It can put everybody at odds with the most accepted paradigms. People who control insurance companies are often controlled by psychiatry and so they can push pretty hard with that [biomedial] stuff. But many people start to see that this is a much more subtle and predictive way of understanding what would account for the [child] doing the [ADHD type] behavior now and not at some other time.

So I get good responses from people I work with and therapists I work with when they start to see the category system that I’m imposing….doctors only know to do the diagnosis using medications, they don’t study the system. This is a profession in itself to become a therapist. It’s a study of individuals’ development over time, it’s not something that physicians are well versed in, so I’m not even sure they understand what to look at and to investigate.  I wish we could have a different kind of training because I know in medical schools, …in psychiatry, they don’t get a great deal of developmental history and the notion of behaviors being reinforced. We’re generally shifting to a disorder model of depression, all these things, they are not seen as evolved, psychosocial behaviors that get patterned over time. It’s a loss of understanding in general. And so I think it just depends on whether a person is interested in exploring a different way of understanding how people come to be in the world.

MS: Is there anything that you think listeners might want to know that I haven’t asked yet?

CW: That the notion of learning, to say that these behaviors are reinforced, doesn’t mean that parents cause the behaviors. And it doesn’t mean that the [child] is responsible for behaviors. So there’s no blame thing. The notion that it’s reinforced or learned — all your behaviors are biological in that your response to the world has to do with your biological state, which is a function of all things you’ve experienced, biologically and in interaction with the environment up to the point within that situation. So it’s not a negation of biology but is saying that you can change responses over time, including biology, as you learn to respond differently. And some kids are very difficult to socialize because they have all kinds of problems. It becomes a problem to find a way to work with particular kids so that certain kinds of behaviors are inadvertently, unwittingly reinforced. That doesn’t mean you caused it.

And the other important issue is that a strategy that tries to get some buy-in from the child or some consideration of the child’s comfort to do the activity doesn’t mean permissiveness. It means that you could always coerce something as a last resort or you can probably get help finding a way for the child to want to do something. Rather than force them or to somehow be controlling the resources or imposing some kind of anxiety-provoking outcome, because you’re creating other kinds of side effects that you might not always be aware of.  Those side effects in the long term play out in a very subtle way in terms of their [future] relationships with their employers and spouses. What you’re looking for is somebody that understands how to relate mutually with others and construct relationships that have some kind of viability both for the person and the person they’re interacting with. So there’s a kind of comfort level for everyone involved. So it’s not permissiveness and it’s not a blame issue.

MS: Thank you very much for joining us. We’ve been talking with Dr. Craig Wiener, psychologist from Massachusetts. This has been Mad in the Family.

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Relevant Links

ADHD: A Return to Psychology Video Series

Parenting Your Child with ADHD: A No-Nonsense Guide for Nurturing Self-Reliance and Cooperation

Mad in America’s Parent Resources pages