Autism / New On-Line Parent Training Program: Requesting your Suggestions

April 18th, 2014

We are delighted to announce:

Apple Tree Institute

AppleTreeInstitute.com is an Online Training program offering videos and webinars to help parents of children with autism and/or with behavioral problems.

Our goal is to make the site as helpful, user-friendlyand cost-effective as possible.

We would be indebted if you would view the Web site at AppleTreeInstitute.com, and share your thoughts with us about other topics that you’d like covered, and any suggestions to improve the Web site?

Please forward your thoughts to Dr. Robert Lowenstein, M.D. at r4lowe@gmail.com and Dr. John Carosso at jcarosso@cpcwecare.com.

Thank you again – your feedback is vital and appreciated.

How is ADHD Diagnosed? (and is it over-diagnosed?)

March 27th, 2014

Pathologizing?

There is wide-spread belief that children are over-diagnosed and over-prescribed, which implies that some kids are ‘just being kids’ and we’re pathologizing them, i.e. giving them a diagnosis, counseling, and medication when we should, rather, be sensitive and accommodating to the wide-spectrum in children’s activity-level and ability to attend. Is this an accurate perspective?

Just the facts Mam’

First, lets look at the stats: Rates of children, ages 4-17, diagnosed with ADHD are at about 7.8% (according to a recent National Health and Nutrition Examination Survey), which is not especially high, and stimulant prescription rates range between 4.3% and 4.4%, which you can see is substantially lower than 7.8%. Also, in that same survey, it was found that only 48% of the ADHD sample had received any mental health care over the prior 12 months, which would suggest children are, actually, being under-treated.

How is the diagnosis made?

To make the point further, if a clinician uses a strict clinical protocol, false-positives (inaccurate diagnosis) should be kept to a minimum. I provide a thorough explanation of the evaluation process in my video on the ‘evaluation process’

But here is a quick overview of specifically what is needed for an ADHD diagnosis: Click Here to Watch YouTube Video

-The child must have a long-history of demonstrating the core ADHD symptoms of inattention, impulsitivity, and hyperactivity. ADHD does not suddenly ‘spring-up’ one day after years of attentiveness. It’s usually something teachers and parents see from as early as the pre-school years.

-The signs are seen in multiple locations (school, home, community…).

-The problem is really getting in the way of the child’s functioning.

-Someone else in the family also has a similar problem with inattention, impulsivity… (ADHD tends to run in the family).

The problem cannot be explained better by some other malady. For example, if the child is distressed, depressed, anxious, or has learning issues, that may explain the symptoms better than ‘ADHD’. In that regard, if a child is experiencing some sort of stress or serious problem, it’s likely he or she will be preoccupied and subsequently have trouble concentrating.

So you can see…

If this protocol is followed, it’s far more likely that there will be an accurate diagnosis, and an effective treatment plan can then be established. I’ve written at length about proper strategies to address ADHD (please see my prior blog posts) that include a consistent and predictable routine, visual reminders, an organized environment, extra attention and assistance, counseling to improve insight and coping strategies and, in some cases, a medication consultation.

Questions?

If you have questions about this process or your child’s diagnosis, email me at jcarosso@cpcwecare.com or call the office. I’d be happy to answer your concerns.

Top Ten Parental Discipline Strategies!!!

March 6th, 2014

Without further ado, here they are:

1. ASSUME CONTROL
Control based in Action/Relationship
Don’t entertain explanations
Project self-confidence
Business-like
Give direction, don’t make requests

2. AVOID ARGUMENTS AND EMOTION
Cut-off communication if child becomes belligerent
Avoid reasoning with child
Give direction and walk away
Communicate: It’s your problem, not mine
1-2-3 Magic

3. PLAN FOR NEXT TIME
Discuss ahead of time what will happen if noncompliant
Also discuss between parents – PLAN AHEAD and BE ON THE SAME PAGE
Predetermined expectations and consequences (behavior charts…)
Most problem behavior is predictable and patterned
Be consistent
Don’t give a direction if not ready to back-it-up (each time you do that, you lose some control)

4. DON’T LECTURE
Brief and to the point
Humor
No emotion (be the James Bond of parents)
Don’t explain or lecture
1-2-3 Magic

5. FOCUS ON THE PROBLEM BEHAVIOR; BE SPECIFIC
Be specific (what you want, and what you like)
No emotion, model self-confidence
Don’t focus on “attitude” – focus on behavior

6. AVOID DISTRACTIONS
Turn off TV, video games
Remove siblings
Remove siblings, friends
No distractions during confrontations and chores

7. USE POSITIVE PRAISE AND EMOTION
Catch them being good
Whisper (softer and closer)
You get what you praise
Attention-Tank (fill child’s attention tank with positive praise)

8. SELF-DISCLOSURE
Use judiciously and cautiously
I-Feel Statements (“I feel frustrated when you ignore me…”)
Tell them how you feel, don’t show them (control your emotional response)

9. ROLE MODEL APPROPRIATE PROBLEM-SOLVING
‘What you do speaks so loudly, I can’t hear what you say’
Words and emotion are your enemy (brief, no emotion)
Role model effective problem-solving

10. PICK YOUR BATTLES
Be flexible
Check-in later

Research Findings: Can We Trust them, Part II

February 27th, 2014

Two years ago I wrote about the problems we face trusting research findings. To bring you up-to-date, here is my follow-up post. Unfortunately, the situation isn’t much improved.

The information, or misinformation, we face daily

You may have read the recent study out of Warwick Medical School in the UK suggesting that kids from families that frequently moved when the child was young (resulting in child often-changing schools) have an increased risk of psychosis. I imagine there a bunch of parents feeling guilty that they may have “caused” their child’s mental health issues because they frequently moved years ago. This type of interpretation, or misinterpretation, is all too common. Hardly a day goes by when we don’t hear another such aspersion from the news media. Why might this be off-base? That is correlational and observational-type research (not randomized or double-blinded); it’s not cause-effect. It’s simply indicating an apparent association between these two things; moving, and later evidence of psychosis. There are ample alternative explanations; for example, given that schizophrenia is predominately genetically-based, and can lead to job and housing instability, it’s reasonable to assume that families with a higher schizophrenia-loading are more apt to move, and it’s more likely that one of the children will later show some signs of psychosis. One may not have “caused” the other as the news reports would have you believe.

What made all the difference?

How are we able to cease making such associations between likely unrelated events? Historically, such capacity is relatively recent; think about it, how did we come to stop using ‘bled-letting’ to “cure” illnesses? What made the medical community finally realize these approaches were ineffective, and how did we come to realize that subsequent medical treatments were effective beyond simply doing nothing (or draining the blood out of somebody)?

Randomization

Yes, that simple word, but not so simple a process, saved the day for medicine and all subsequent treatment approaches to this day. The concept is relatively recent; first hypothesized and documented in the 1930’s, but not used to assess surgical treatment until the 1960’s. In the absence of randomization and, even better, single or double-blind controls, there are all sorts of things that can make you think the treatment works, or doesn’t work, when it really does, or doesn’t. These things are called confounding variables, and they wreak havoc on a study’s or a “treatment’s” apparent result or effect. Keep in mind that blood-letting was the treatment of choice for 2000 years and continued into the late 19th century. So much for basing a treatment on one’s clinical observation.

How much havoc?

Well, here’s the sad truth; when it comes to the predictive value of studies, randomized trials have an 85% Positive Predictive Value (PPV) rate. However, once you leave the world of randomization, it gets really bleak, really fast, with PPV dropping to between 20% and .1% for nonrandomized epidemiological studies (you know the ones, announced daily on the news saying that if you eat something in particular you’re going to get some type of horrible malady; or if you move, your child may become psychotic). This led to the prominent researcher, Dr John Ioannidis, asserting that half of all research findings are false (even worse, he suggested that 90% of all medical research is inaccurate, and 50% of the research deemed ‘most reliable’, in the most reputable journals, is inaccurate). In that regard, it doesn’t matter if the research is coming from the most reputable of journals; it was still found to be flawed (see hormone-replacement therapy, vitamin D for heart disease, and coronary stints, among countless of other research topics).

It’s also common to find a self-serving statistical sloppiness. In a 2011 analysis, Dr. Wicherts and Marjan Bakker, at the University of Amsterdam, searched a random sample of 281 psychology papers for statistical errors. They found that about half of the papers in high-end journals contained some statistical error, and that about 15 percent of all papers had at least one error that changed a reported finding—almost always in opposition to the authors’ hypothesis. These errors have far-reaching implications. For example, claims based on fMRI brain-scan studies are increasingly being allowed into court in both criminal and civil cases. However, study in 2009 found that about half of such studies published in prominent scientific journals were so “seriously defective” that they amounted to “voodoo science” and “should not be believed.”

What to do?

We’re bombarded daily with news of the ‘latest research’ asserting one thing or another. What can we believe? I wish I had an easy answer for you. All I can communicate, as emphatically as possible, is that if the research is not based in randomization, then it’s a crap-shoot. Moreover, factor the all-too-common politicization of research findings that further bias the results. Bottom-line: always be skeptical, always look below the surface, study the research design, do not take the news reports at face value, and don’t take the reseacher’s findings, as reported directly in the study, at face value. In that respect, lots of researchers will report findings that sound convincing (they want to get published, get tenure, and be seen on 60 Minutes) but are based in correlational or even purely observational designs, both of which are ripe for errors. To make the matter worse, even randomized designs can have problems and inaccurately skew the results in a favorable light (see “enriched” design).

Where do we go from here?

We have a few options:

1.) read and accept research results, as the mainstream press and journals would prefer,

2.) believe nothing and remain skeptical about everything you read and hear,

3.) learn how to effectively analyze research, or

4.) don’t read anything and turn off your TV.

Option 4 doesn’t sound so bad, but I suggest options 2 and 3. It’s not easy, but the alternative is, in my opinion, worse.

If you want some resources to learn about effectively interpreting research, email me at jcarosso@cpcwcare.com.

God bless you in your ongoing pursuit of the truth.

When Should You Tell Your Child The Diagnosis?

January 16th, 2014

To tell or not to tell

I am often asked by parents whether or not they should tell their child the diagnosis? It’s a good question, and of course the answer is somewhat complex.

Focus on symptoms, not the diagnosis

I find that it’s rarely beneficial to place a ‘label’ on the symptoms, and subsequently on the child. Rather, I find it helpful to focus on the two or three primary issues or behaviors and explain to the child that you, your child, and the treatment team are going to work improving those issues, e.g. compliance, social skills, safety awareness… The more specific you can be in describing the targeted behavior(s), the better. So, rather than tell a child that he or she has “ADHD” or “autism” and you’re going to treat that “disorder”, I find it more helpful to explain to the child that they have challenges, for example, paying attention in class, or with standing too close to friends, and they’re going to be helped in that regard by specific strategies.

Why not explain the diagnosis?

Explaining the diagnosis can be counterproductive. The child can feel ‘stuck’ in their diagnosis, which often can be stigmatizing and have negative connotations, and people often come to identify with their diagnosis, ie. “I’m ADHD”, or “I’m autistic”, or “I’m Bipolar…”. No, your child is not ADHD, or autistic; rather, your child has a diagnosis of autism; or has a diagnosis of ADHD…; the diagnosis is not ‘them’ as a person but is only a small part of their many wonderful traits and characteristics. Also, sometimes kids will use the diagnosis as an excuse, “I did that because I’m ADHD…” that too is counterproductive.

When to explain the diagnosis?

I find that, as children mature, they become increasingly inquisitive and insightful. At some point, it’s not uncommon that a child begins to sense that something is ‘different’ about them compared to their peers. It’s not uncommon that, in those situations, the child may approach the parent and ask “what’s going on with me… why am I different… I’m not like other people….” In those instances, it’s likely time to explain the diagnosis while, at the same time, focusing on strengths, abilities, and that the child IS NOT their diagnosis, but that the diagnosis simply reflects a cluster of signs and symptoms with which the child and parent will continue to target in treatment.

It’s also important to emphasize that the symptoms can be improved, and you can site examples of your child having risen above the ‘diagnosis’ in any number of ways.

At times kids will find the information about their diagnosis to be a relief (“I always knew I was different, but never knew why”) but others may feel quite distressed with the news. Use a reflective approach (see my earlier posts on that technique) and remain supportive and reassuring. It may help to allow them the opportunity to meet other kids with the same diagnosis (a support group can be quite helpful).

Sum it up

I find that, in general, it’s best to not focus on labels and diagnoses but, rather, describe signs and symptoms that are going to be targeted and overcome. This strategy is empowering, motivating, and directive. However, there are times to discuss the diagnosis, especially if the child is relatively mature, has good self-awareness and insight, and is asking questions about why he or she seems or behaves ‘differently’ from peers. There are a number of helpful books and resources to help with this process; feel free to email me if interested.

Hope that helps. Feel free to email any questions at jcarosso@cpcwecare.com

God Bless!

Our Christmas Gift: The Wonderful Counselor

December 19th, 2013

Hope you enjoy this Christmas message:

What I’m expected to do…

As a psychologist, I’m expected to talk about traditional and clinically-relevant approaches to help kids, and parents, work through difficulties. This of course would include helping people to think in more reasonable ways (cognitive therapy), behave in ways that are productive and healthy (behavioral approaches), be emphatic (Rogerian techniques), stay in-the-moment (Gestalt), incorporate the family (systems approach), and use praise in systematic ways (Applied Behavioral Analysis).

Is there more?

Well, yes there is. I’m usually not expected to discuss spiritual options but, in some cases, it’s like watching somebody drown and tossing a small life preserver when I have ready access to a large life-boat. Don’t get me wrong, the life-preserver is effective but, well, wouldn’t you rather be in a boat?

Seems only fitting

During this Christmas season, it seems fitting to offer a reminder that God gave His Son not only to rescue us from sin, but also to rescue us from ourselves and, in the process, heal us, soothe us, and relieve us during our times of stress, burden, and strife. Think about it, in Scripture, He’s referred to as our Advocate, the Almighty, All in All, Breath of Life, Comforter, Counselor, Cornerstone, Creator, God Who Sees Me, Goodness, Guide, Hiding Place, Hope, Intercessor, Keeper, Leader, Life, Light of the World, Living Water, Loving Kindness, Maker, Mediator, Our Peace, Physician, Portion, Potter, Teacher, Refuge, Rewarder, Rock, Servant, Shade, Shield, Song, Stone, Stronghold, Strength, Strong Tower, Truth, Wisdom, and Wonderful to cite just a few of His names. Hmmm, I wonder if maybe God is trying to tell us something about turning to Him for help?

Tap into the Source

Those strategies I cited above (cognitive-behavioral…) are undoubtedly worthwhile and helpful. God gives people like me lots of ways to help and give relief (not to mention that most of those strategies have a basis in Scripture). However, there is something quite powerful and life-changing about tapping directly into the Source (another one of His names, by the way). Give it a try, what have you got to lose? May God deeply bless you and yours during this Christmas season. I’d love to hear your comments at: jcarosso@cpcwecare.com

Which Wolf are you Feeding?

December 13th, 2013

Which Wolf are you Feeding?
I don’t usually post stories such as this, but this one is too good not to share:

One evening an old Cherokee told his grandson about a battle that goes on inside all people. He said, “My son, the battle is between two ‘wolves’ inside us all.”

“One is Evil. It is anger, envy, jealousy, sorrow, regret, greed, arrogance, self-pity, guilt, resentment, inferiority, lies, false pride, superiority, and ego.”

“The other is Good. It is joy, peace, love, hope, serenity, humility, kindness, benevolence, empathy, generosity, truth, compassion and faith.”

The grandson thought about it for a minute and then asked his grandfather, “Which wolf wins?”

The old Cherokee simply replied, “The one you feed.”

There is debate over where this story originated and who wrote it. No matter, I hope you find it to be moving, motivating, and inspiring.

God bless.

Teens and Spirituality

November 21st, 2013

The Study

A study funded by the John Templeton Foundation and carried-out at The University of Akron, Case Western Reserve University (CWRU) and Baylor University found that teens with substance abuse issues had significantly better outcomes to the extent they had a foundation of spiritual beliefs.

In fact…

Spiritual belief resulted in overall better outcomes in terms of increased rates of abstinence from substances, a decrease in narcissism, and an increase in pro-social behavior.

It was also found that a good portion of teens not uncommonly transitioned, over the course of their stay at the facility, from less to more spiritual, and those who did had the aforementioned better outcomes.

By the way…

Teen Challenge has been touting those types of outcomes for decades.

Other teens too?

Based on my own clinical and personal experience, spirituality has a highly beneficial grounding effect; it is far more compelling to ‘stay on the straight and narrow’ if one believes that there is bigger, better, and far more powerful entity who makes the rules, and to whom one will have to answer. Otherwise, we’re just dealing with rules made by men with no ultimate authority and, really, in that scenario, it’s hard to be inspired. Of course, those who are spiritually-minded can also take comfort in believing that that this same omnipotent entity is on our side, more than willing to intervene when asked, and knows precisely how to resolve the problem to make things right.

Treatment approaches

In my humble view, it seems foolhardy to have any broad-based treatment approach not include sound and empirically-based therapeutic approaches, sound nutrition, exercise, and a heavy dose of spirituality. Try it for yourself, your children, and teens. I’ll bet you’ll like the results.

How to get kids to listen: Action, not Re-Action

November 7th, 2013

As parents, we expect kids to follow directions when told to do so; and often we have expectation that the response will be immediate. Much to our despair, it’s not, and likely shall never be. That’s the important point; kids are not automatons (or at least mine aren’t – I suspect yours aren’t either).

I tell parents during workshops that we don’t expect a table or chair to move if we tell it to; so why do we expect our kids, who have their own agendas, wants, and distractions, to immediately follow our commands with a sense of urgency? In fact, we might have better luck with that wooden table.

So, should we simply give-up? Okay. Well, maybe not. Instead, how about changing our expectations and, in doing so, lower our blood pressure. Recognize that, often, kids need that ‘softer and closer’ approach (see former blog on the subject) and close proximity if not gently taking their arm and getting them started on the task. Offering to help them begin the chore also helps.

Backing-up our direction with firm consequences always helps, with accompanying soft-spoken reminders of both rewards and consequences that can be earned with compliance.

However, to our avail, we as parents tend to rely on pestering with an ever-increasing volume. This approach is the least favorable and results in the most frustration and bad-feelings for all involved. Remember that emotion and words are your enemy, while a softer and closer approach, and clear expectations and consequences, are your friend. Try it, you’ll like it. Now, go get softer and closer with your kids.

Relationship: The Foundation of Discipline

October 31st, 2013

The discipline trap

How beneficial is time-out, taking away the TV, or ‘grounding’ a child from going outside? Of course, as most parents have come to find, all of these discipline strategies can be effective. However, what happens if you rely too heavily on these strategies? Well, first, your household can become like a gulag; not too pleasant. Second, you and your child will be miserable. Third, the discipline strategies become less effective.

Relationship: Beyond Softer and Closer

That’s why I recommend relying on the ‘softer and closer approach (see the blog, “softer and closer approach”). However, no matter what discipline you attempt, it will all go to waste, and you’ll feel like banging your head against the wall, if you don’t have a healthy, positive, and pleasant relationship with your child.

Quality and Quantity

The key to parenting and discipline is you and your child doing things together, laughing and enjoying each other’s company, and spending time (quality and quantity time) in fun activities. Actually, even ‘not so fun’ activities can be quite bonding and reinforcing (e.g. helping with homework or school project, assisting in getting your child ready for bedtime…). In any case, absent a healthy relationship, there is no glue to connect a parental directive to the subsequent (hopefully) compliant behavior. Kids comply because, ultimately, they love their parents, want their parents to be happy, want to get-along and have a good relationship, and realize that ‘we’re all in this together’ so I might as well do my part.

The fear factor

If your child is complying predominately due to a fear of punishment, then you’re in trouble. In that case, your child’s ‘compliance’ is based in manipulation and fear, and tasks are often completed superficially and marginally.

The fun factor

Instead, build the relationship and you’ll have a disciple (a willing follower) and be less reliant on discipline. Don’t get me wrong; both are vital, but the former is a lot more fun☺

God Bless.
If this was helpful, forward to a friend, and then go have some fun with your kid.