SURGEON GENERAL DAVID Satcher's recently released position paper, "Mental Health: A Report of the Surgeon General," is inaccurate and misleading, because its conclusions are not the result of valid, scientific research. Satcher's report maintains that about one in five Americans - or 53 million people - are mentally ill during any given year, and that about 50 percent of Americans suffer from mental illness during their lifetimes. These assertions are neither new nor scientific.

In the early 1990s, the National Institute of Mental Health (NIMH) made precisely the same claims. The statistics came from surveys by "lay interviewers."

Along with the American Psychiatric Association, the NIMH recommended in the ill-fated 1993 Clinton health care plan that Americans should be insured for 30 outpatient psychiatric visits a year with unlimited psychotherapy sessions.

Let's do some math. If 53 million Americans had 30 outpatient visits, the insurance companies would have to pay for 1.6 billion psychiatric sessions a year. This would lead to the birth of what has been described by critics as "the Therapeutic Society."

If the recommendations and claims of the surgeon general's report were taken seriously, it also would mean that mental illness would rank as the most common chronic disease in America.

According to the latest "Statistical Abstract of the United States," it would surpass arthritis, which afflicts about 32.7 million, and hypertension, from which about 30 million suffer.

Psychiatrist Kay Redfield Jamison claimed in a Dec. 17 letter to the New York Times, "The science underlying the numbers and treatments in the surgeon's report ... is reliable and replicable." What she doesn't claim - what she cannot claim - is that the numbers are valid.

Psychiatry uses reliability of psychiatric disorders (testing to see if diagnosticians agree on which psychiatric disease patients suffer from) in the place of a search for validity (ascertaining whether psychiatric diagnosis measures what it claims to measure). This has been pointed out most recently by Dr. Paul McHugh of Johns Hopkins University in an article in last month's Commentary magazine.

The surgeon general's report maintains that mental health should not be viewed as "separate and unequal" to general health, and that there should be public support for the long-standing goal of "parity" for mental illness, which means insurers would have to treat mental illness on an equal basis with physical illness.

The costs of parity are widely disputed, but they are likely to be exorbitant.

In an article in The Washington Post, Carmella Bocchino, vice president for medical affairs of the American Association of Health Plans, said, "We've seen estimates that mental health parity would cost increases of 1 to 5 percent. ... Do we give up other parts of the benefits package, or are we looking to rising health care costs?" The Employee Benefit Research Institute, a nonprofit think tank, has determined that, at a minimum, parity will lead to increases in employer costs and possible elimination of other benefits in some cases, including health insurance coverage altogether.

The report also promotes the mental health system's second major goal in addition to the addressing of parity: the elimination of stigma, which produces public reluctance to pay for care and adds to the indignities of mental illnesses. In the words of the report, stigma "must be overcome."

There are three "severe mental illnesses" - schizophrenia, bipolar disorder and major depression - and they are arguably caused by brain disease. The stigma should be removed from them.

But stigma serves a useful purpose with the hundreds of other so-called mental disorders: It deters many who would frivolously claim to suffer from those "diseases."

One would think that the report's conclusions would be more tentative given its caveats, such as, "It is sometimes difficult to determine when a set of symptoms rises to a level of a mental disorder" and "No single gene has been found to be responsible for any specific mental disorder." Then there is this unqualified non sequitur: "For about one in five Americans, adulthood is interrupted by mental illness."

There is a reasonable alternative to the seemingly endless calls to expand the categories of mental illness and to exaggerate the incidence and prevalence of mental illness.

Instead of allowing a large number of Americans to get coverage for nebulous maladies such as "adjustment disorder" or "social anxiety disorder," the insurance companies should provide full coverage for everyone suffering from schizophrenia, bipolar disorder or major depression, all of which may result from authentic brain disease.

The American Psychiatric Association estimates that only about 3 percent to 4.5 percent of the public suffers from "severe mental illness." Focusing on the true brain disorders would save the nation millions of dollars and allow the money to be spent where it is really needed.

(Mr. Vatz is a professor of communications at Towson University and has written extensively on mental health issues.)

next: More Children Undergo Shock Therapy
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Local shock treatment victim Wayne Lax is giving his support to a woman in Montreal who is suing the federal government for $4.6 million after most of her life was blanked out by shock therapy, induced comas and a mixture of drugs.

"I back this woman 100 per cent because I know what she went through," said Lax. "Shock therapy treatment was abused. It blanks the mind out and damages you permanently."

Gail Kastner, now 56, was admitted by her father to the Allan Memorial Institute when she was 19 for depression. She was given electroconvulsive therapy (ECT treatments) otherwise known as electroshock treatments in 1953 by a doctor notorious for his brainwashing experiments.

She is blaming the federal government for supporting Dr.Ewen Cameron's research, which left her with bizarre behaviour including screaming nightmares, persistent seizures and a complete blank about her past. Kastner was ostracized by her family and left nearly homeless after she reverted to childlike behaviour such as wetting the living room carpet, sucking her thumb, babytalk and wanting to be bottle fed. Her trial is presently underway in Montreal.

Lax, who currently lives in Kenora, is presently involved in his own series of lawsuits which he says are not out of revenge, but out of concern for others.

Lax said he spent 25 years in a state of confusion and despair, undergoing 108 admissions to mental institutions, 80 ECT treatments and taking up to 17 different pills per day.

"I am missing large portions of my memory and suffer from chronic, severe back pain when I broke a bone in my back because I didn't have enough muscle relaxant during ECT treatments," said Lax.

"People need to be aware of what shock does to human beings. And we are human beings, not just patients."

Lax is presently drug free and is a member of numerous psychiatric survivors groups.

next: Sister Fights Brother's Involuntary Electroshock By State Hospital
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~ all articles on depression

It is possible to get Social Security benefits for your ADHD child. Read my experience plus helpful tips about applying and links.

My Two Cents on Social Security

Several years ago, I applied for Social Security benefits for my son James who has ADHD. I did this for several reasons. The first was because of his medical condition and the second was for the medical benefits. Being disabled myself left me with no other medical coverage for my son other than the states med-i-cal program which was hit very hard in the mental health services for children shortly after James was diagnosed.

On top of already scarce mental health clinics with large and long waiting lists, children's mental health services took huge budget cuts. This left help for children such as James at a minimum and only children who were in danger of being removed from their homes and placed into foster care or children who had crossed the boundaries into the Judicial system were given access to mental health services. Having social security benefits did several things for my son.

1). It opened the doors to doctors that before would not see him because he was on the state med-i-cal program, and two. Secondly, it allowed a cash benefit to obtain services that were not covered by giving us the extra cash we needed to pay for those services. It also allowed me to put James into programs that helped him tremendously with self esteem and social issues that we could not otherwise afford.

Social Security Benefits for Children with ADHD

I had a reader write to me and ask me for my best advice on applying for social security benefits for children with disabilities, so I thought that I would share what I learned with all my readers. At the time I applied for SSI for my son, I felt, as did his doctors, that James had a severe case of ADHD. It was explained to me that I should apply for social security in order to get the medical benefits that would allow me to obtain treatment for James and that due to the severity of the James' condition at the time, his doctors felt that there would be no problem getting him approved. Needless to say, I was surprised when James was denied SSI and also a bit angry when I had knowledge of other children, not nearly as affected by ADHD, as James that had been approved. This didn't make sense to me and hinted that there must be other factors involved when approving someone for social security other than medical fact. So I appealed the decision and started making phone calls and you'd be surprised what I learned.

One roadblock I ran into was the school district. Not only did they provide only minimal information during the first SSI inquiry, but they refused to even fill out the information for the appeal. The school psychologist and the teacher decided not to comply with the new request for information citing that paperwork had been done once before and that they were busy and couldn't stop what they were doing to fill out more paperwork. I felt this attitude was not only typical of the school district, but I was outraged at their audacity! How dare they take it upon themselves to assume that my son didn't need the benefits which SSI could provide for him which is how I interpreted their actions and attitude.

I started making phone calls after my son was denied and I learned that each worker is assigned X number of cases and they have X number of days once that case hits their desk to process it and move it off of their desk by either denying the case or approving it. Part of their evaluation for job performance is based on how effectively and timely cases pass through their hands. I found out that the worker who initially had my case denied it the day before he went on vacation. I concluded that the decision on my son's case was influenced by a worker, who in an attempt to clear their calendar before leaving on vacation, hurriedly and careless passed judgments on my son's disability in order to maintain their performance record.

The individuals and agencies that they contact in order to gain information on your child are not bound by any laws or regulations to comply with Social Security. If they send the information in by the time the file has to be processed or moved on that's fine. If not, the decision is made without the information. The next thing I learned was that the worker who was in charge of my son's appeal, had some education in psychology and felt that ADD/ADHD was not a disorder but basically a parental problem and issue of environment. These children don't have a disorder, they suffer from bad parenting and parents who have no desire to parent their children in a fashion that commands discipline or forces them to function. She went on to tell me that if these parents would simply spank these children and enforce penalties for bad behavior, these children would straighten up!

In retrospect, if I had to do it all over again, my best advice is this:

• Be very complete and thorough when answering the questionnaires you will be sent. Take time to explain every item in detail and don't be bashful about using additional paper. In fact, I used a separate piece of paper for each question and numbered them to correspond with the questionnaire and used my word processor to compile a neat and legible report and....it leaves you with a file you can return to if needed.

• When you initially apply, do not leave it in the hands of others to insure that Social Security gets all the information they need to make an accurate and fair decision in your case. Gather as much information from every source that has documentation on how ADD/ADHD and any related disorders or issues affects your child's ability to function, day to day activities, and his/her ability to operate as other children. If you can do this before hand and send it in with your application, all the better.

• Keep tight tabs on the progress of your application. I was able to call the Main Social Security Office to find out if my son's case had been assigned, and to whom it was assigned and also left a message for that worker to contact me.

• I kept in close contact with my doctors, asking them if they had been contacted by social security and followed up to make sure they sent the records being requested.

• Without harassing the worker about approving the case, I simply kept in contact to ensure that those contacted were complying with social security's requests. The worker was more than happy to tell me who had complied and who had not and I was able to contact the individuals and agencies involved and be sure they send the information requested out in a timely fashion. I did this because I learned during the appeal that those contacted for information on your child are in no way obligated by any laws or rules that they comply with any request for records. If any agency should fail to send in requested info, Social Security will make it's decision based on what they have which may not be enough.

• Last but not least. DO NOT be afraid to stand up for your child's rights! YOU are his/her only advocate. In the end, I went to my Congressman to be sure that my child was getting an impartial, unbiased and fair judgment in his case.

One more note before I get off my soapbox :) Another valuable lesson I learned was that when you initially apply for Social Security benefits for your child, they have a certain time frame in which to open/close the case. When you appeal a decision, your case comes under a whole new set of guidelines and rules and and can sit on someone's desk for months before it becomes active again.

I was told off the record, by a social security worker, that I would have been better off had I chose NOT to appeal the decision, waited the allotted time limit, and then just re-applied. This would have placed the case back at the beginning, with the original time table and minus, any bias or judgmental input from previous workers. The down side to this is that if you choose to do this, you lose your original filing date and you start over which will affect what Social Security will owe you once you are approved.

For the latest information on Social Security benefits for children with disabilities.

next: Classroom Coaching: Bringing Skills On-Line
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When it comes to your ADHD child and school, you need to know your rights and the school's responsibility concerning Special Education. Trust me, most schools offer little help in this regard.

Warrior Beginnings

Kindergarten wasn't much better than preschool. In fact, it was worse.

My son James, who has severe ADHD, was unable to concentrate or focus, was all over his classroom, laying under the tables, wandering around the room, playing in the bathroom and rarely able to focus or stay on task. His teacher, burdened with too many students and no aids, allowed him to wander aimlessly as long as he didn't bother the other children. She did not have the time, the energy, or the help to redirect James.

I was told that I needed to sit in class with him or remove him from school. I wasn't aware of my rights or my child's education rights when it comes to how a school needs to accommodate a child with disabilities. I didn't realize I had choices. The school didn't tell me I had choices. So, I quit my job and went to school with my son.

I'm not sure which was more heartbreaking, seeing James' inability to function in class or watching the way the teacher and other students treated him. On top of all of James' other problems, now I was afraid that his self-esteem was suffering as well. I also added a new emotion to my list: shame.

The Importance of Knowing Special Education Laws and Your Child's Rights

As an ignorant parent, putting my trust and faith in the "trained professionals" that were teaching my son, one day while in class, I participated in their efforts to "teach him a lesson". To this day, the shame remains with me and tears come to my eyes when I think back to that day.... but it was a beginning. It's what it took to get the teacher to agree that my child needed help.

Asking for help and actually getting help was a different story. In addition, I must use a different dictionary than the school does because their idea of "help" and MY idea of "help" were two different things.

This is where knowledge of my rights, and my child's rights, would have empowered me and given me the tools I needed to ensure that the state and federal laws that grant my child's right to a free and appropriate education would have been honored. Had I simply known my rights, I could have prevented a lot of the horrific things that happened to my child.

This is why you need to know your rights and the school's responsibility concerning Special Education. Due to my ignorance at the time, and the belief that the "trained professionals" knew best, I settled for the school's promises of help.

Knowing what I do now, and having been there, here are some tips and ideas that could work for your child.

next: Being a Mother of an ADHD Child
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Several well conducted studies have shown that children with ADHD are more likely than others to become depressed at some time during their development. In fact, the risk for developing depression is as much as 3 times greater than for other children.

A study published in the Journal of Affective Disorders (January 1998, 113-122) examined the course of depression in 76 children with ADHD in order to learn more about the relationship between ADHD and depression. The authors were especially interested in whether depression in children with ADHD represents an actual clinical depression, or whether it may be better understood as a kind of "demoralization" that can result from the day-to-day struggles that children with ADHD often have.

Depression Defined

Lets begin by reviewing what mental health professionals mean when they talk about depression. The important point to emphasize is that the clinical diagnosis of depression requires the presence of a collection of different symptoms - just because one is feeling down or depressed does not necessarily mean that the diagnosis of major depression would be appropriate.

According to DSM-IV, the publication of the American Psychiatric Association that lists the official diagnostic criteria for all psychiatric disorders, the symptoms of major depression are as follows:

• depressed mood most of the day nearly every day (in children and teens this can be irritable mood rather than depressed);
• loss of interest or pleasure in all, or almost all, activities;
• significant weight loss when not dieting or weight gain, or a decrease or increase in appetite
• insomnia or hypersomnia (i.e., sleeping too much) nearly every day;
• extreme restlessness or lethargy (e.g., very slow moving;
• fatigue or loss of energy nearly every day;
• feelings of worthlessness or inappropriate guilt;
• diminished ability to think or concentrate nearly every day;
• recurrent thoughts of death and/or suicidal thoughts;

For the diagnosis of depression to apply, 5 or more of the symptoms listed above need to be present during the same 2 week period (i.e. the symptoms must have persisted for at least 2 weeks), and at least one of the symptoms must be either 1) depressed mood (irritable mood in children can qualify) or 2) loss of interest or pleasure.

In addition, it must be determined that the symptoms cause clinically significant distress or impairment, are not due to the direct physiological effects of a medication or general medical condition, and are not better accounted for by bereavement (i.e., loss of a loved one).

As you can see, the important point is that true clinical depression is indicated by a collection of symptoms that persist for a sustained time period, and is clearly more involved that feeling "sad" or "blue" by itself.

Is Depression in Children the Same as in Adults?

Let me also say a few words about depression in children. Research has shown that the core symptoms for depression in children and adolescents are the same as for adults. Certain symptoms appear to be more prominent at different ages, however. As already noted above, in children and teens the predominant mood may be extreme irritability rather than "depressed". In addition, somatic complaints and social withdrawal are especially common in children, and hypersomina (i.e., sleeping too much) and psychomotor retardation (i.e., being extremely slow moving are less common).

What, then, would a "typical" depressed child look like? Although there, of course, would be wide variations from child to child, such a child might seem to be extremely irritable, and this would represent a distinct change from their typical state. They might stop participating or getting excited about things they used to enjoy and display a distinct change in eating patterns. You would notice them as being less energetic, they might complain about being unable to sleep well, and they might start referring to themselves in critical and disparaging ways. It is also quite common for school grades to suffer as their concentration is impaired, as does their energy to devoted to any task. As noted above, this pattern of behavior would persist for at least several weeks, and would appear as a real change in how the child typically is.

Many Depressed ADHD Children Have Relationship Problems

With this brief overview of depression behind us, lets get back to the study. The authors of this study started with 76 boys who had been diagnosed with both major depression and ADHD and followed them over a 4 year period. Because depression can be such a debilitating condition they were interested in learning what factors predicted persistent major depression, and how the course of depression and ADHD were intertwined.

The results of the study indicated that the strongest predictor of persistent major depression was interpersonal difficulties (i.e., being unable to get along well with peers). In contrast, school difficulty and severity of ADHD symptoms were not associated with persistent major depression. In addition, the marked diminishment of ADHD symptoms did not necessarily predict a corresponding remission of depressive symptoms. In other words, the course of ADHD symptoms and the course of depressive symptoms in this sample of children appeared to be relatively distinct.

The results of this study suggest that in children with ADHD who are depressed, the depression is not simply the result of demoralization that can result from the day to day struggles that having ADHD can cause. Instead, although such struggles may be an important risk factor that makes the development of depression in children with ADHD more likely, depression in children with ADHD is a distinct disorder and not merely "demoralization."

Depression in children can be effectively treated with psychological intervention. In fact, the evidence to support the efficacy of psychological interventions for depression in children and adolescents is more compelling than the evidence supporting the use of medication.

The Importance of Recognizing the Symptoms of Depression in Children

The important point that can be taken from this study, I think, is that parents need to be sensitive to recognizing the symptoms of depression in their child, and not to simply assume that it is just another facet of their child's ADHD. In addition, if a child with ADHD does develop depression as well, treatments that target the depressive symptoms specifically need to be implemented. As this study shows, one should not assume that just addressing the difficulties caused by the ADHD symptoms will also alleviate a child's depression.

If you have concerns about depression in your child, a thorough evaluation by an experienced child mental health professional is strongly recommended. This can be a difficult diagnosis to correctly make in children, and you really want to be dealing with someone who has extensive experience in this area.

About the author: David Rabiner, Ph.D. is a Senior Research Scientist, Duke University, an expert in ADHD and author of the Attention Research Update newsletter.

next: Adult ADHD Numbers Growing
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Dr. Steven Ritchfield on how to help your ADHD child with school skills and social skills.

Helping Your ADHD Child with School Skills, Social Skills

One of the many challenges faced by teachers, counselors, and parents when coaching emotional and social skills to children is how to foster the use of tools at the point when they are most needed, i.e., the point of performance. Many children can learn new skills when they are presented in a neutral environment, free of environmental pressures. But when the pressure heats up in the form of teasing classmates, teachers who ignore their raised hand, and temptations to misbehave, it can be hard for these children to summon the internal language needed to bring the skills "on-line."

In addressing the classroom issues, I will focus upon how to coach "anticipation skills" so that children can prepare themselves to respond skillfully to environmental pressures and demands. This begins with an explanation by the "coach" (teacher, counselor, or parent) about the importance of anticipation. For the sake of practicality, narrative examples will illustrate a variety of ways that coaches can translate the coaching model into classroom application. (Classroom coaching is not necessarily conducted by a teacher, but only assumes that the instruction is being delivered to a large number of children.) In this first illustration, a teacher offers a framework for introducing anticipation skills:

"Imagine that you are driving to a vacation with your family. It's going to take a few hours to get there, and none of you have been there before. Your parents have directions, but they need more to get to where you all want to go. Think about it. What else makes it possible for people to drive places they have never been before, and actually arrive there without getting lost? (pause for answers)"

" Those of you who were thinking about road signs are right. Road signs help drivers because they direct us to our destinations. In order to do that, they give helpful information about how many miles it will take, how fast we should go, and just as important, what we should look out for along the way. Signs do that by telling us about upcoming twists and turns in the road, traffic lights ahead, and exits that we need to prepare for so that we can slow down and turn off where we need to."

This opening example uses metaphor to introduce the subject. Driving serves as a useful analogy because it requires practice, skill, and many relevant issues (laws, accidents, penalties, etc.) have counterparts in the interpersonal world of children (rules, conflict, consequences, etc.) Thus, classroom coaches may find it helpful to refer to the driving metaphor during coaching discussions. Next, I return to the narrative, with the teacher demonstrating how driving a car and being a kid have similarities:

"Signs allow us to anticipate what is down the road, so that when we get there we won't be too surprised. For instance, exit signs tell drivers to get ready to slow down and change lanes so that when it is time to turn it can be done safely. Anticipation means the ability to prepare ourselves for what's ahead of us, whether it be driving or anything else. Why is this important to kids?" (pause for answers)

"Just like speed limits that change depending upon where we drive, kids go from place-to-place, and must deal with different rules in different places. In school, the rules change a little depending upon whether you're at recess, lunch, in the library, free time in class, or group lesson time at your desk. In each one of these places, the rules are a little different, whether it be talking, walking around, running around, raising your hand, and so on. Kids who anticipate what the rules are in these different places don't get into trouble as much and do a better job at steering themselves."

"Sometimes the rules in different places are posted on the walls, just like road signs. But most times, the rules are not posted and kids may not use their anticipation skills to keep themselves within the rules."

Once the classroom coach has brought the discussion to this point, it's time to explain how kids can improve their ability to anticipate what skills will be needed, and how to "hold them in mind" in order to be accessed when necessary. This latter concept refers to the ability to use mental scripts, or self-talk messages, that can be matched to the specific demands of the environment. The goal is for children to retrieve the right "mental road sign" for their present place, but this requires varying degrees of coaching assistance depending upon needs of each child:

"Let's go back to driving for a minute. Even though drivers use signs to get to where they want to go, there are many rules that do not appear on signs. So how do drivers know what to do?" (pause for answers)

"If it starts to rain, there's no sign that tells them to turn on their windshield wipers. If there's a car pulled over on the side of the road, there's no sign that says slow down because somebody might need help. The rain and the car on the roadside are clues that drivers look out for. Drivers need to watch carefully for clues to anticipate what to do. And as clues appear, drivers give themselves directions about what to do. Inside their minds, drivers think about what they should do as they keep their eyes on the road."

"Most kids do the same thing. They learn how to look out for clues that help them stay within the rules. Clues help kids anticipate the rules. But if kids don't notice the clues, they can't use them to anticipate what to do. For instance, if a kid is clowning around and walks backward into the classroom, he won't see the teacher motioning for everyone to be quiet as they enter. Let's say he's laughing out loud about something he heard at recess, retelling the joke, and wham - he slams right into the teacher! Now, there's a kid in for a bumpy ride."

"But what if the kid had been looking out for clues as he walked back into the school building from recess? Most kids use walking-back-into-the-building as the clue to change behavior from clowning around to straightening out. If this boy had picked up that clue, he could use it to anticipate what to do. Maybe he could have directed himself, 'I'm back in school now. I've got to stop laughing and acting silly. I'll find a good time later to tell my friends about this joke.'"

"When kids pick up clues they are much better at figuring out what to do. Walking into school is only one clue. Who knows other school clues that tell kids to give themselves directions?" (pause for answers)

At this juncture, coaches can offer a list of clues that help reinforce observation skills.

Children are taught how clues may be auditory, visual, kinesthetic, or a combination. Auditory clues include verbal instruction, ringing of the school bell, singing of others, etc. Visual clues include facial expression, body posture, hand gestures, etc. Kinesthetic clues include walking into school, opening doors, etc. Depending upon the age of the group, others may be added to this list. Next, comes a discussion of the need for self-instruction:

"Once kids have picked up the important clues around them, it's important to know what to do. This can also be tricky for some kids who are not used to giving themselves the right kind of directions. Let's go back to our backwards walking friend for a moment: he first told himself, 'I've got to tell all my friends this incredibly funny joke, no matter what.' We all know that was the wrong direction to give himself because it didn't anticipate that he was going to crash right into the teacher and her rules.

"Giving yourself the right directions is kind of like figuring out the road signs that fit the place you are in at any given time. Sometimes the road signs are simple to figure out, such as "BE QUIET" or "SAY THANK YOU" or "RAISE YOUR HAND BEFORE YOU SPEAK." But sometimes the road signs are a lot harder to figure out and you need to pay much closer attention to the clues. For instance, "RESPECT THEIR PRIVACY" or "ACCEPT NO FOR AN ANSWER" or "I CAN'T ALWAYS EXPECT TO BE CALLED ON EVEN IF I KNOW THE RIGHT ANSWERS."

"These road signs are harder to figure out for a lot of kids. They require that kids carefully look out for clues. Some clues come from watching the people around you and thinking about what keeps things going smoothly for them. Other clues come from thinking about what happened the last time you were dealing with this kind of situation. The way things did or did not work out in the past gives kids clues about what they should direct themselves to do the next time around."

Coaches can proceed from this point with a discussion of typical self-instruction messages that children can employ for improved social and emotional functioning.

The text from Parent Coaching Cards can be used as examples and/or as a springboards for coaching sessions targeting specific skill areas. Once the coach has chosen a finite number (between 5-10) to begin with, children can be made aware of which self-instruction messages fit with which situations. Increased reinforcement will also come from teachers encouraging children to figure out in advance of transitions, which skills need to be brought to mind. Social and emotional skills can also be woven into discussions within subject areas (social studies, reading, science. etc.) that reflect the skills in question, i.e., teachers can ask children which skills were displayed by Thomas Edison, Martin Luther King, etc.

About the author: Dr. Steven Richfield is a child psychologist and father of two. He is also the creator of Parent Coaching Cards. His articles focus on helping your child with school-related skills.

next: Learning Disabilities Association of Washington Life Skill Program
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If your child with ADHD has learning difficulties, here are some inside tips about Individualized Education Plans (IEP).

IEPs (Individualized Education Plans) can be intimidating, especially if there is tension or conflict between you and the school. Here are some of the things I've learned along the way that I hope might help you.

1. I always ask for a copy of all the test results prior to the meeting date. This gives me a chance to read over what they found and, if needed, get input from my child's pediatrician or therapist. It also allows me to absorb what I've learned before I sit down and ask for services for my son.
2. Feel free to take a support person with you. Not only can they help calm you and keep you focused on the task at hand, but they make excellent witnesses if you should ever need one. A support person can be anyone-- family member, friend or even your child's counselor or therapist. Counselors and therapists come in handy when there are some issues concerning services. They can be more persuasive given their education and medical training when it comes to accessing services the school is reluctant to give.
3. You do not have to sign any papers at the IEP meeting. You are not obligated to sign any papers at the IEP meeting. You may want to take the papers home, review them with your child's therapist or doctor or even get input and feedback from a relative. You might just want to think about and absorb everything that transpired at the meeting. Don't feel pressured into signing an IEP, especially if you do not agree with it.
4. Remember... School personnel cannot start services, change services or stop services unless you sign an IEP stating so. If the school is asking that you make changes that you do not agree with, do not sign the IEP papers.
5. One thing that worked really well for me was taking my manual of Special Education Rights and Responsibilities with me to the IEP. I made sure it was in plain view but did not flash it around. The principal asked me about the book and I explained what it was. I was treated differently once they knew that I was aware of my rights. Once they realized that I was a fully informed parent and that I was aware of what they could do and what they couldn't, I seemed to have a much easier time getting the things I asked for.

next: My 2 Cents on Alternative Treatments for ADHD
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Insights into how to deal with teachers and school districts in helping your ADHD child.

My Two Cents on Schools and Districts

Here is my two cents worth on what I've learned dealing with the schools over the years in trying to get help for my son who has severe ADHD. While I realize that not all school districts and teachers are out to avoid providing educational services to your ADHD child, the fact is that many are.

If you happen to have a school staff that is not working with you, here are some things I have learned. Remembering that I am not a professional, just a mom who's been there and done that. Here is my best advice:

• It's extremely important that if you want to advocate successfully for your ADHD child that you remain polite and in control at all times. Losing your temper does not get you anywhere. You do not have to be rude or obnoxious to be aggressive. The same goes for letters you might write. Remember that strangers not associated with your case may be reading your letters and you do not want to offend or alienate them.

• Write everything down!! If your child is having problems in school and you are not getting the cooperation that you think you should be, start a journal. Get names, dates and times and any facts regarding any issues or incidents. Make sure you have copies of documents, notes, letters, a log of phone calls, etc. You may never need this information, but if you do, you'll have it.

• Know your chain-of-command and use it. If you find yourself in the position of not getting your calls returned, go up the chain-of-command. If excuses such as "Mr. Brown is out of the office. He's in a meeting. He's on another line," etc. are growing old, then take action.

  If Mr. Brown is away from his desk or on another line, ask to hold. If he continually is not in, get his supervisor, and if he or she is out, get their supervisor. I don't stop until I find somebody who can talk to me even if it means going to the state or county boards of education.

• Don't make empty threats. While there are times when you really, really wish you could sue the school district, and they deserve to be sued, the facts are, the threats of lawyers and lawsuits don't even make them flinch. Unless there is cause for large sums of money, in the way of damages through injury, death, etc., lawyers do not like to take on the school districts because taxpayer-funded pockets run deep.

  Very few of us have the means to pay for such suits out of our pockets and lawyers are unwilling to front the costs themselves. For the same reasons, school districts know that lawsuits are unlikely and if taken to court, can be dragged out and tied up forever.

• The chain-of-command works both ways. I have found that when there is a possibility of trouble, ranks close. The principal protects the teacher and the district protects the principal, and the school board protects the district.

• Because lawsuits are costly and because school staff never hestitate to make my son take responsiblity for his behavior/actions, I have started filing written complaints against school staff that mistreat my child, endanger his health/welfare/or safety, (including self-esteem) or who I feel need to be held accountable for their conduct. I also cross-file the complaint with the Special Education office if the action warrants it.

  Each district has certain rules they follow concerning written complaints, but the great part about these types of actions is that they become a permanent part of that employee's record. A superintendant once told me that written complaints are often the only way they find out that an employee has problems. When their file is reviewed, or an employee is up for promotion, this is when the complaints will be found and taken into consideration.

• While school districts may laugh at the mere mention of courtrooms and lawyers, they do not appreciate publicity. If you are suffering through some real injustices, do not hesitate to notify your local paper, t.v. station or reporter. They might get action where you haven't been able to.

• Question Authority! I realize it's not the 70's, but the same holds true even for today. I believe that a lot of schools and districts depend on parents taking their word as gospel. Why not? They are educated professionals with lots of training. Why would a parent question a trained professional? If you don't ask questions, or know your rights, how can you be sure that you are being treated fairly and that you are being made aware of all your options?

  Some educators depend on the fact that you don't know your rights and that you won't question their recommendations or actions. That's the best reason there is to question everything and make sure that you are indeed being given all the facts and options.

• Last, but not least, KNOW YOUR RIGHTS! I can't stress this enough. I can't say it enough and I can't impress upon you enough, how important this is. Some schools do not volunteer information, especially when it's going to cost them money in the way of services and accomodations.

  You can be sure that these types of districts are not going to advertise what your child is entitled to and the only way to find out is to KNOW YOUR RIGHTS!

  My son suffered because I didn't know my rights. Don't let this happen to you!

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Figuring out which ADHD medication works best and the proper dosage for your ADHD child may involve a process of trial and error.

"What guidelines should be used to determine the ADHD medications your child should be taking? And which guidelines are used to let parents and teachers know if the ADHD medications are working properly?"

These are really important questions because although there is considerable research evidence that medication is quite helpful for the vast majority of children with ADHD, it is frequently prescribed and monitored in such a way that prevents children from getting the maximum benefit possible.

In regards to the first question raised above, there is simply no way to predict in advance which of several medications will be most helpful for a child with ADHD, nor the optimal dose will be. Physicians generally start with Ritalin, which is certainly reasonable since it is the most extensively researched. A child who does not respond well to Ritalin, however, may do very well on other stimulants (e.g. Adderall, Concerta, Dexedrine). Similarly, a child who does not do well on the initial doses tried may do very well on a different dose. In some cases, side-effects that are prominent with one medicine may be absent with another.

The bottom line is that because there is no way to know in advance what ADHD medication will be best for an individual child, the child's response needs to be monitored very carefully. One very useful procedure is to begin a child on medication using a careful trial in which a child is tried on different doses during different weeks, and is also put on a placebo for one or more weeks during the trial. The child's teacher is asked to complete weekly ratings of the child's behavior and academic performance, and side effects forms are completed by both parents and teachers.

Why have a child receive a placebo during the trial? This is important because no matter how good one's intentions are, it is very difficult to be objective about a child's behavior when one know the child is on medication. Thus, one study found that when children with ADHD were given a placebo, the child's teacher reported significant improvement over half the time. This is probably because teachers expect the child to do better which can color what they see. Also, when children believe they are on meds they actually may do a bit better, at least for a period of time.

By using the placebo procedure outline above, the information obtained is less likely to be effected by such potential biases because the teacher does not know when the child is getting medicine and when he or she is not.

By comparing the teacher's ratings for the different medication weeks with the placebo week, one has a more objective basis for deciding if the medicine really helped, whether it helped enough to be worth continuing, what dose produced the greatest benefits, whether there were adverse side effects, and what problems may remain to be addressed even if the medicine was helpful.

Compare this type of careful trial with what is often done: the doctor prescribes medication and asks the parent to let him know what happened. Parents ask the teacher for feedback about how their child did on medication for ADHD, and passes this along to the physician who then decides whether to continue, try a different dose, or try a different medication. Here are possibilities that are much more likely to occur with this procedure:

1. Because of the "placebo" effect, medication may be reported to have been helpful even though no real benefit was produced. The child then continues to take medicine even though he or she is not really benefiting.

2. Because a systematic comparison of different doses is not made, the child is maintained on a non-optimal dose, and thus fails to get al the benefits that are possible.

3. Medication is discontinued because of "side-effects" that actually had nothing to do with the medication (see below).

4. Because a careful assessment was not made of how the child did on medicine, problems that may have remained even though the medicine was helpful are not targeted for adjunctive forms of treatment.

Let me say something about side-effects of ADHD medications. I do these type of trials all the time and often find that what would otherwise be assumed to be side-effects of medication actually occur during the placebo week! Several carefully controlled studies have reported similar findings, as well as the fact that problems presumed to be side-effects of medicine are often present prior to starting medication.

Suppose a good trial has been done and the proper dose selected - now what?

After this has been done, it is VERY important to monitor how the child is doing on a regular basis. In fact, guidelines published by the American Academy of Child and Adolescent Psychiatry, recommend that at least weekly ratings from teachers be obtained. This is because a child's response to ADHD stimulant medication can change over time, so what starts out as being very helpful may become less helpful over time. Some of you may have already had the unfortunate experience of believing that things were going along pretty well, and then finding out at report card time that this was not the case. With regular, systematic feedback from teachers about how well a child's ADHD symptoms are being managed, the quality of work being completed, peer relations, etc., this type of unpleasant surprise does not need to occur. This is not difficult to do, but in my experience, is rarely done.

Allow me to put in a plug for procedures I have developed and use regularly to help parents with these important issues. If you visit my site www.help4add.com, you'll find overviews of a medication trial program to assist with initial medication trials and a monitoring system to carefully follow how a child is doing. I use these programs all the time and know how useful they are. Please consider giving them a try if you are considering the use of medication for your child or have a child who is already on medication.

Dr. David Rabiner Ph.D

Dr. Dave Rabiner received his Ph.D in clinical psychology from Duke University in 1987 where he also completed a one-year internship in child psychology at Duke University Medical Center. From 1987-1998, he was a professor in the psychology department at the University of North Carolina at Greensboro. During this time, he maintained a part-time private practice where he worked primarily with children diagnosed with ADHD (Attention Deficit Hyperactivity Disorder). In addition to this direct clinical work, he has consulted with numerous pediatricians and family physicians in North Carolina to assist them in evaluating and treating children with ADHD.

Dr. Rabiner has also published a number of papers on children's social development in peer-reviewed journals and presented his work at professional conferences. He's also served as a consultant on two federally funded grants to study ADHD.

Currently, Dr. Rabiner is teaching and conducting research on ADHD at Duke University in Durham, NC.

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Information for parents planning to coach their ADHD child. Are you a helicopter parent or one who will help your child achieve autonomy?

To Coach or Not to Coach: The Fine Line Between Helping and Hindering

Parents planning to coach their ADHD children to social and emotional success need more than tools, such as Parent Coaching Cards, to get the job done. Along with the virtues of patience, determination and insight, is the need for an often overlooked, but key coaching ingredient: support for autonomy. In this context, I define autonomy as the child's capacity to independently achieve healthy and desirable goals in life. Among these goals include completion of homework, satisfactory resolution of a peer problem, or choosing a sensible course of action from a variety of options. The ability to attain these goals without parental involvement allows children with ADHD to take complete ownership of the pride that flows from them. This pride translates into fuel for the developing sense of autonomy, a critical building block to self-esteem.

The dilemma for many parents begins with the fact that children's path towards autonomy doesn't take place without our help. As we strive to guide our children towards independence we must provide some of the necessary "scaffolding" within which they can grow. Some of these external supports include rules, expectations, consequences for misbehavior, and so on. Coaching is also included within this framework since it helps children develop self-management skills. Each parent shares a similar goal: for their child to develop the skills to be self-sufficient in a challenging and unpredictable world. Yet, the goal is much clearer that the individual steps we must take in assisting children in reaching this destination. As we provide "parent coaching" we must be mindful of the need to step back and allow our children the chance to venture forth on their own.

The delicate balance between coaching skills and supporting autonomy was recently epitomized by the mother of Kenny, a seventeen-year-old boy with AD/HD (Attention Deficit Hyperactivity Disorder), "There's a real fine line between coaching and not coaching. My husband and I are not sure which side to be on. Sometimes we get it right and Kenny accepts our help, but a lot of times he rejects it. This confuses us because we're not aware of doing anything different each time; it's more like he's the one who feels differently about receiving our help. And when we blow it, and try to force our help upon him, it's liable to backfire." This astute mother's comments highlight several issues that parents are wise to consider when approaching their child with coaching help: children's mood, parents' presentation, and the potential for coaching backfires.

Is Your Child in the Right Mood to Accept Help?

Mood acts as a filtering mechanism, coloring a child's internal experience of external events. Therefore, it plays a pivotal role in how children interpret help. If a child's mood is on a downturn due to a recent disappointment, or even on an upswing after a success, a parent's help may be perceived more like a hindrance than a help. For the parent, the child's rejection of help is confusing and frustrating, emotions that don't peacefully combine with the child's fragile mood. In the exchange of verbal crossfire, parents may get easily sucked into the role of attempting to enforce "help" upon the unwilling child. This coaching backfire results in distance and distrust between parent and child, leaving both feeling wary of offering or asking for help.

To minimize these backfires, I recommend that parents "take their kid's emotional temperature" before being generous with help. This means asking open-ended questions or making non-threatening observations to find out how receptive the child may be towards help. Comments such as "Maybe we could talk about that since I think we could both learn a thing or two," doesn't present the parent as the one with all the answers. Instead, it places parent and child in the same role of learning from events.

Of course, some kids don't offer a lot about what's happening in their lives, but they may demonstrate how they're feeling about those events. Angry expressions, attempts to discredit parents' help, and/or rampant justifications for why they don't need help, suggest that the coaching bridge between parent and child may be closed for the time being. Parents are wise to back off in the face of these barriers to help, but they should stress that help remains available should the child be ready at some other point.

The importance of how parents present their offers of coaching cannot be overestimated. It's much easier to send a child reeling away from our offers than it is to establish a safe dialogue within which to receive it. Comments such as, "I want to give you some help with that," or even "Let's talk about that," can quickly send a child into a defensive mode. Some children are so sensitive to having their autonomy threatened that they experience a parent's coaching as the imposition of control.

When the child sounds off with protests such as "You're pressuring me!" or "Stop pushing so hard!" this signals the need for some preliminary groundwork. The groundwork can be likened to preparing soil for cultivation; don't expect a child's self-management skills to grow and flourish without the proper environment. The proper environment for coaching considers the whole child, not just their areas of need. A forthcoming article addresses the many concerns inherent in the "whole child" concept. For the purposes of this column I will continue to confine my comments to autonomy.

A Little Humor Goes A Long Way

Cultivating acceptance of coaching in a child whose feelings of autonomy are easily threatened is a daunting task. One of the first steps is to establish a dialogue wherein the two of you can safely discuss what coaching is supposed to be and what it isn't supposed to be. It may even be helpful to write down two headings, such as "good coaching" and "bad coaching" and then start placing examples under each heading.

A little self-effacing humor on the part of the parent can go a long way towards helping to cultivate a more receptive mood in your child. Humor can also effectively set the stage for parent and child to reflect upon some of the coaching backfires in the past, and unearth what went wrong and why. For instance, in the "bad coaching" example, it provides the parent with the opportunity to suggest that in her zeal to help, she actually made the child feel controlled by her approach.

Another important step in "coaching cultivation" is to talk about every child's need for autonomy. Many children experience relief to hear parents say something like the following: "Being a kid who needs help every once in a while but also wants to be able to do without it, is not an easy position to be in. And sometimes when you need help the most, you want it the least! That's because a lot of kids reject help when they're feeling touchy about not knowing something as well as they think they should." These words convey a parent's empathic understanding of the Catch-22 that kids find themselves in.

Once a child acknowledges that this is true of them, parents might follow with a comment such as this one: "Maybe you could tell me a way that I could let you know that I've got some help to offer without you feeling like I'm trying to take control away from you?"

Such a comment diminishes the child's feelings of being controlled by placing them in the advice-giving role. Apart from the various factors that parents can weigh in considering their "coach approach," there is the option of not offering help. Sometimes this choice is made by default because circumstances require it, while other times it can be voluntarily determined by parent and child.

If a particular situation arises that lends itself to a child "going solo," parents can highlight that perhaps this time the child might want to handle things on their own from start to finish. For instance, in the case of a child who has always relied on the parent to format a study plan for upcoming tests, the parent might suggest that this time they do it alone and give themselves the directions that they have relied upon the parent to give them in the past. In fact, the expression, "Give Yourself The Directions," may be the only coaching advice the parent offers in those situations that lend themselves to such tests of autonomous functioning.

Much more can be said about supporting our children's needs for autonomy. As Kenny's mother put it, parents must walk that "real fine line" that tends to keep moving as the child's mood and surrounding circumstances shift it's position. Parents are advised to pay particular attention to the balance between coaching and supporting autonomy by not emphasizing one side to the exclusion of the other. Many factors will help you stay abreast of where the line is, especially an open communication channel between you and your child.

About the author: Dr. Steven Richfield is a child psychologist and father of two. He is also the creator of Parent Coaching Cards. His articles focus on helping your child with school-related skills.

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