Drug-free Treatment of "Attention" Problems1

by Bruce L. Bachelder, PhD2

Morganton, NC 28655-3729

Our methods have evolved since 1980 when we started our independent practices of psychology and education, specializing in school learning and adjustment problems. We started out with a fairly conventional approach combined with a determination to learn from experience and professional publications. Gradually, based on our experience with many children and their families as well as a good bit of old-fashioned book work, our approach evolved to something quite different from the way we began.

Some would view our methods as contrary to customary good practice, but they are actually in close accordance with a) diagnostic procedures presented in The Diagnostic and Statistical Manual of Psychiatric Disorders, IV (DSM-IV), b) scientifically validated behavior change procedures, c) broad clinical wisdom from diverse traditions, and d) a recent statement by a psychiatrist, Peter R. Breggin, MD, in his book, Talking back to Ritalin. Dr. Breggin is critical of over-reliance on drugs in treating these problems and states that the "best treatment" for "children labeled ADHD" are interventions which "include family counseling aimed at improving relationships and childcare practices in the family, and individualized educational approaches that inspire children in school" (2001, p. 142).

Our strategy includes the following components:

1) Keep in mind that virtually all credible sources insist that appropriate treatment must include comprehensive psychological and educational components. Even the insert in Ritalin packages specifies that Ritalin should never be used as the sole treatment for attention problems, but must always be combined with psychological-educational treatment.

2) Perform a careful differential diagnosis to rule out the many other conditions and disorders with the identical symptom picture. This is explicitly part of the diagnostic procedure specified in The Diagnostic and Statistical Manual of Psychiatric Disorders, IV. It also appears to be the most neglected of the DSM-IV diagnostic procedures.

2) Avoid premature use of diagnoses based on hypothetical neurological disorders (the so-called attention disorders). This is an application of the ancient medical wisdom captured colorfully by the [heuristic], "When you hear hoofbeats, think horses, not zebras." In all diagnosis you first consider more-likely disorders than less-likely disorders. Not only is it rare to encounter a child with demonstrable neurological disorder, but in our experience there are almost always situations and conditions present which make psychological formulations the much more likely problem. Common examples are school work which is mismatched to the ability level of the child; harsh, angry teachers combined with extra-sensitive students; death or illness of a parent; bullying at school or after school; comparatively harsh parenting practices; substance abuse by a parent; some other psychological disorder in a parent; or abusive parenting practices.

3) Acknowledge that an accurate psychiatric diagnosis or psychological formulation is rarely possible through the usual one-shot evaluation procedure of a battery of tests and questionnaires in a single-visit session. For the most part, reliable and valid diagnoses and psychological formulations emerge gradually in the process of intervention and reactions to interventions. As people develop a trust in the evaluator, and as the bigger picture emerges detail by detail, the diagnostic picture often, even typically, changes dramatically. There are actually some fairly obvious reasons this happens. Parents often have a good understanding that their own situation is part of the problem. These include excessive irritability, excessive reliance on punishment and threat of punishment, and mental disorder in a parent (depression, alcohol or other substance abuse, physical abuse by a father of a mother). People simply keep such matters secret as long as possible. Boys in particular, are likely to deny their own depression or anxiety disorder.

4) Do not use drugs as a first-line intervention. This is based on two factors. The most important reason is that once a diagnosis is made and drugs prescribed, people think it is a "medical" problem not a "psychological" problem and decline to pursue a psychological matters, even when all credible sources recommend psychological and educational interventions as key components of a total treatment program. The second reason is that we frequently encounter people with medical diagnoses who are taking drugs as prescribed, who are satisfied with the diagnosis and their drugs, but who are not actually doing well. That is, the drugs are obviously an insufficient intervention and the addition of a comprehensive psychological approach is indicated. Finally, for some individuals, the drugs have potent side effects. In my small practice I have seen elevated anxiety, depression, anorexia, and psychotic reactions. Given the success of a psychological approach it is hard to justify an initial treatment with the risk of these side effects.

5) Focus on building trust and rapport in both parents and the child. Pay close attention to family factors and the strategies the student and his or her family have attempted in order to resolve the problem. Pay special attention to discouraged attitudes and distortions of academic self-image which are often a significant part of the presenting situation. Help the student and family achieve a coherent understanding of the problem as a basis for a coordinated approach to solve it themselves under close professional supervision. Relevant family factors include a) disagreement between Mother and Father on how to deal with the problem which neutralizes their efficacy and increases the overall stress level on the child; b) chaotic family situations which remove the normal foundation for success in school; c) marital problems; d) illness or death of a parent; and d) one or another psychological disorder in a parent.

6) Explore potentially sensitive issues and watch for "reactions" which indicate the sensitivity. Typical issues include school performance, parental discipline, parental relationship, death, illness, criticism, adoption, and sexual matters. Reactions often include a) increased motor activity, b) outright hyperactivity, c) surprisingly adept, facile, and rapid topic switching, d) refusal to discuss certain topics, e) mild verbal agression: snappish, rude comments, insults, etc.

7) When sensitive issues are identified, begin desensitizing them using the normal methods of cognitive-behavioral therapy, via exposure, conversation, identifying and replacing irrational thinking, etc.

8) Help parents understand the role of stress in exacerbating or causing their child's "symptoms" and behavior problems so they cope with them more effectively rather than attributing them to a brain abnormality, mental disorder, "meanness," or "Satan."

9) Help parents abandon ineffective and needlessly stressful methods and replace them with more effective and less stressful methods. These typically include a) learning to avoid "The typical twelve or Dirty Dozen" and more effective use of "I messages" and "active listening;" and b) Replacing threats of strong punishment with effectively applied milder punishment.

Suggested Readings

Breggin, Peter R. (2001). Talking back to Ritalin, revised ed. Cambridge, MA: Perseus Publishing.

Gordon, Thomas )1970), P.E.T. Parent effectiveness training. New York: Wyden.

Bachelder, Bruce L. Attention Problems: Frequently asked Questions

Bachelder, Bruce L. Kids have stress too!

1 This is a working draft started in July, 2003. Please do not quote or reproduce it without permission. Check www.brucebachelderphd.com for the most recent version.

2 Dr. Bachelder is a psychologist who has retired from independent practice. Contact information: 828-437-1068, Bruce@BruceBachelderPhD.com Morganton, NC, 28655-3729, www.BruceBachelderPhD.com