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**What Do We Do About The Impulsive "Driver?"**
**Coaching The Rules Of The Road, Part II**
One of the most aggravating, and sometimes frightening, aspects of parenting, teaching, and counseling children is impulsive behavior and unthinking decision making. Whether it be the prospect of a child crossing the street without looking both ways, bothering his classmates with incessant noises and talking, or repeatedly committing poor judgment calls, parents, teachers, and counselors are continually confronted by the question: What do we do about Impulsivity?
The coaching approach to Impulsivity guides children toward self-regulated activity and "outcome-oriented" behavior and decision making. These skills must be coached with an eye to each child's unique Impulsivity style and the problems this creates in his/her life. Without taking into consideration the path of each child's Impulsivity, coaches' exasperated pleadings to "think first!" may fall upon inattentive ears! Therefore, it is essential that we have creative, yet potent, Impulsivity management tools in our coaching repertoire.
Within three articles I will address the "impulsive driver" from the standpoint of different children, each representing distinct age groups, and depicting different Impulsivity styles tending to occur within those groups. As was the case with the prior article, I will use composite profiles of my own patients to illustrate the recommended coaching formats. Each format offers typical narratives appropriate to each age group, interwoven with an explanation of the skills.
Before introducing the first child, I will briefly address the frustration this creates in us, the generally supportive and well-intentioned adults. I don't know about all of you, but Impulsivity really pushes my buttons. I suspect that many readers of this article have just silently conceded with something similar to "me too." Since our own triggers can interfere with our ability to be effective coaches, I suggest that we all take the time to do one thing before approaching the impulsive child: find our coaching voice.
The coaching voice is calm, clear, and affectionate. The calming qualities soothe the impulsive child's excitability and/or anxiety about their infraction, the clarity focuses their attention on the skill to be coached, and the affection supports the image of us as being on their side against the problem behavior. The coaching voice also supplies a "container" for the impulsive child's free-floating energy and undirected activity. Since Impulsivity can easily escalate to anger and even physical attack, coaches must be certain not to precipitate more problems by responding with harsh, intimidating, or some other tactic communicating threat to the impulsive child. Even firmly placing one's hand on a impulsive child's arm, without informing them in advance, might backfire. Therefore, it is critical that our coaching voice is matched by similar calm, clear and affectionate coaching actions when approaching the impulsive child.
Impulsive behavior has it's roots in the earliest years of a child's "driving history." As soon as their child is walking, or perhaps even crawling, parents become aware of how much Impulsivity is part of the "auto-pilot program." (see Parenting Pointers, 1/99) Within a few years, those children born with a greater than average degree of Impulsivity might be unable to sit still during circle time or frequently hugging, tugging or pulling their preschool classmates. Once they have entered formal education, Impulsivity tends to be the chief presenting complaint that brings the 5 and 6 year old "drivers" to my door.
Kenny is a 5 year old boy who demonstrated social poise and self-control when talking with me on a one-to-one basis but became wiry and unwieldy when a parent was included during consultations. He epitomized the "reckless driver" who disregarded the body parts of familiar others. But at the same time, he could slow his engine down when in the presence of an unfamiliar authority figure. Within his kindergarten class, Kenny sometimes helped himself to other children's belongings and generally had much difficulty controlling the "hands and body roaming impulse." Kenny scared children due to his unpredictability, angered teachers due to his disruptiveness, and exasperated his parents due to his tirelessness.
Children who fit Kenny's profile are often filled with a zest for life but lack the skill that helps them adjust their "quest for zest." Coaching reckless roamers requires an understanding of what it's like to be in their bodies: it's like driving a car with a mind of it's own and you're not sure when it's going to decide to take over the steering function. Kennys' can steer themselves just fine at times, but when something interesting appears on the scene, or the ride begins to get a little boring, watch out! At certain points, they are driving entirely on impulse and it doesn't matter who or what they are about to crash into. Therefore, the coaching approach aims to put Kenny's "thinking side"in charge of the steering by offering him simulated experiences that challenge his impulse control. This is accomplished via narrative explanation, impulse control exercises, steering tools and discharge paths. The following narrative is offered to Kenny-like drivers after the coach (teacher or counselor) has sufficiently contained their raw energy in some mildly appealing kinesthetic activity, such as throwing a soft ball back and forth:
"Boy, do you have a lot of energy. If you were a car, I would be a little worried about getting on a road where you were driving because I'd be thinking that you might crash into me! Even though that sounds funny it's really kind of scary. Other kids are getting scared of how fast you drive yourself around here. Sometimes it seems like you don't even look where you are going, sort of like somebody who drives a car with a blindfold. You know the terrible things that would lead to - accidents, destruction of things that belong to others, and hurt bodies and feelings. And some of those things have almost (or already) happened right here (give examples). But I think that you and I can solve this problem if we really work hard at it. I am willing to work hard to help you with your body driving abilities. Are you willing to work hard so that kids won't be so scared and grown-ups won't be honking their horns at you all the time and telling you to watch where you're going?"
In this opening appeal, the coach gets Kenny's attention by bringing up evocative images and sprinkling in the costs of real life examples. Kenny must recognize the significance of what is going on before the following impulse control exercises are introduced. Otherwise, he is liable to simply enjoy the challenge of the exercise but not link it to coaching goal. Therefore, a "outcome-oriented" coaching message is woven throughout the coaching formats for impulsive children. And as in prior articles, the coach constructs a "chalkboard" where the child and he/her can discuss the problem behaviors without the child feeling unduly blamed:
"My plan is to keep you in control of your body so no one gets hurt and you don't lose friends. One of the biggest problems you are having is all the energy that flows through your body and takes control of you. Sometimes it makes you wild. When Mr. Wild comes around, Mr. Kenny stops steering his body and bad things happen.
But I know a way that we can practice controlling Mr. Wild by telling ourselves, 'I'm not going to let Mr. Wild control me. I can be in charge of how I want to act.' and taking deep breaths to let out Mr. Wild's energies. Once you've practiced, we can do some exercises where Mr. Wild will try to take control but you can push him away so that he doesn't."
The advent of "Mr.Wild" begins the chalkboard for meaningful discussion about the problem behaviors. Not only will Kenny more likely participate in these discussions but he may also offer other "Misters" (Mr. Opposite, Mr. Helpful, etc.) to further the dialogue. It is much easier for the child to reveal vulnerable feelings and observations now that there is a place to put them. The next step finds the coach explaining how the impulse control games are played:
"Ok, here's how we do it. I will throw a ball right passed you, and you are supposed to let it go without a moving an inch. You can't raise your hand to catch it or move any body part. Mr. Wild is going to try to get you to catch it or do something but let's see how well you've learned to control him. (practice) The next game has you sitting in a chair within a circle of four empty seats. You imagine that three other kids are sitting in that circle with you, each one in a chair. The four of you are talking about something and Mr. Wild is trying to get you to touch one of them, or talk louder than all the rest, or bang your chair into the next one."
These games serve to simulate impulse triggers for Kenny. Coaches are free to introduce others that are similarly structured. Steering tools can be directly removed from the set of Parent Coaching Cards, especially the "Find The Brakes" card. Coaches can also fashion customized cards for Kenny-like children. One child simply used a picture of a steering wheel to remind them of the need to stay in charge of their body. Discharge paths refer to outlets where Kenny can safely express his restlessness, such as a special foot-printed path at the back of the classroom where Kenny can "drive" at a slow speed and not interfere with other children. This "driving path" can also be used by other children when needed.
Dr. Steven Richfield
- Dr. Dave's AddVice -
"I read somewhere about a study that showed behavioral treatment was not as good as medication and that adding behavioral treatment did not improve on the results of medication alone. Does this means that behavioral approaches don't work and are a waste of time and money?"
I received this question recently from a parents who was concerned about the best approach to take in treating their child with ADHD. This is a really good and important question. The study referred to is the largest and most extensive treatment study of ADHD ever conducted. It is sponsored by the NIMH (i.e. National Institute of Mental Health) and involves 576 children being treated at four different research sites across the county. The major goal of this study was to compare and contrast 3 different treatment approaches: state of the art medication treatment alone; state of the art behavioral treatment alone; and combined medication and behavioral treatment. Children were assigned to one of these 3 groups and the effects of the different types of treatment have been studied over about a 14 month period. In addition, a comparable group of children who were treated by community practitioners were also followed.
Let me first say that the results of this study have not yet been published. They have been presented at a recent psychiatric meeting, and the reports in the media have been based, I assume, on this presentation. Actual published results, however, are not yet available for close scrutiny.
With that important caveat in mind, the general description of the results that I have seen indicates that medication alone was superior to behavioral treatment alone, and was not appreciably different from the combination of medication and behavioral treatment. (Please keep in mind that these general conclusions are not the same thing as being able to carefully examine published results that have been through the editorial review process). In other words, extensive behavioral treatment was found to be less helpful than carefully prescribed medication, and did not add significantly to the beneficial effects produced by medication alone.
It is also interesting - and very important - to note that children who received medication as part of the study were doing much better than children who received their medication from community physicians. This is probably because children in the study were followed much more closely than is typical, and changes/adjustments to medication were made whenever difficulties began to emerge. Children in the study were receiving 3 doses per day, 7 days per week which is also different from what is typically done. Finally, it is my understanding that the medication treatment also included significant amounts of parent education and guidance - it was not just like parents popped in to pick up their child's prescription and that was it.
Now, if these general conclusions are accurate, does this mean that behavioral treatments are unnecessary and a waste of time/money? I think the answer to this is it depends. It is important to recognize that studies like this compare the effect of different treatments on groups of children. If children in one group did better overall than children in another group, this does not mean, however, that every child in one group did better than every child in the other.
For example, it is easy to imagine that there was a child in the combined treatment group who did not have an extremely positive response to the medication. For this child, the additional behavioral treatments may have made a very big difference. For children who showed a very positive response to carefully prescribed medication, however, which would be the vast majority, the behavioral treatments would not be expected to make much of a difference. After all, if medication alone eliminates the vast majority of a child's difficulty, what else is left for behavioral treatments to address?
Here is what I think is a reasonable way to think about these preliminary results, which others may certainly disagree with. If the published reports really do support the summaries that have been floating around, it would suggest that a reasonable approach to treatment would be to start by finding the optimal medication and dose for each individual child, making sure that no problematic adverse reactions are produced.
Once this has occurred, the child needs to be followed carefully and regularly, with frequent feedback obtained from teachers and parents about the ongoing functioning of the child at home, at school, and with peers. If everything is going well, and there are no indications of difficulty in any of these areas, than adding anything to the medication treatment may not be necessary.
If problems with behavior, school work, peer relationships, etc. are apparent, however, EVEN if the medication is helping in important ways, than developing and implementing adjunctive treatments that specifically target these residual difficulties should be pursued. The key thing is to monitor how your child is doing on an ongoing basis, and to make sure that if difficulties emerge, treatment adjustments are made to address these problems. For many children, I believe that treatment approaches besides medication will continue to be an important part of their overall management.
Let me say that I am really looking forward to seeing the published papers that come out of this study, and anticipate that there will be much to be learned here beyond the general summaries that have been available so far. I will certainly include reviews of these papers as they become available.
That's all for this month...
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** Essay Exams…..Made EASY!!**
By Dr. Alice D’Antoni-Phillps
Life is to be lived in a forward motion, but we can only understand and learn from life in a backwards motion. In other words, we learn from out mistakes. Wisdom comes from living and learning. And it takes a heap of livin’ to gain this wisdom! While this is probably correct “most” of the time, it is not the way to approach your tests in school. Here, your objective should be to make as many of the errors and mistakes BEFORE the exam, learn from them during your practice, and avoid making these types of mistakes on the real test! Essay exams or essay questions on tests can be your chance to shine and gain lots of points (even “BONUS” points) IF you know how to prepare for them and tackle them on the actual test. Students who sharpen their skills in essay test responding can create a competitive edge for themselves.
Preparing for essay exams can be done one of two ways. The first way is easy…..the teacher tells you what the essay questions “may” be and that any of these may be seen on the real test.. If this doesn’t happen, then YOU have to figure out what possibly could be asked as essay questions. Now, you can probe your instructor a little more to get some ideas or if you’ve had several tests in his teacher’s class then you should have gleaned some good ideas of how the teacher develops questions. You don’t have to flounder around in a helpless fashion “wondering” what may be on the test….don’t consult a crystal ball or Ouija board….start thinking and practicing your own predictions. Invariably, over time with this approach you will find yourself getting more and more into the “teachers head”!
Plan Ahead!! In your advance preparation, keep a stack of 3 X 5 cards and as you are studying, reading the textbook or reviewing or recopying notes, keep in the back of your mind the question, “What would make a good essay question, for this material?” You’ll be amazed at how your brain will start churning out better and better questions. Write these down immediately on the 3 X 5 cards then return later to answer them in detail. Another advance preparation technique is to review all the headings of each section or the entire chapter (if not divided into sections) and think about how they all weave together; what is the theme? Once you identify the central idea, presto…you have a great essay questions or questions! This same strategy can be used if several chapters are being covered on a test. For instance, if you are in U.S. History and have covered a chapter on FDR prior to WWII and the next chapter is “America in WWII,” then pre-think a global question that could encompass aspects of both chapters. After you have your questions drafted, then take time to develop your outline and pre-write the essay. Certainly, this pre-writing should be done if the teacher supplies you with possible questions prior to the exam. Students who don’t take the time to pre-write essay questions (especially those that are handed to you on a “silver platter”) are definitely short changing themselves….without mincing any words, it’s just plain dumb!
Full Steam Ahead!! On the actual exam, first read the question CAREFULLY. Oftentimes, students do not thoroughly answer ALL aspects of the question which may have multiple parts. Secondly, know what specific words and terms used in the question are asking you to do. For instance, “EVALUATE the impact of FDR’S foreign policy citing specifics and their impact upon WWII.” In this case, the word “evaluate” means to consider the merits and demerits, using your own opinions, and possibly the opinions of others (opinions are usually supported by evidence). The POWERORGAINZER SUCCESS SYSTEM Coaching Tips section has an entire list of key terms for essay questions with explanations of each. Next you need to make a draft sketch/outline of your ideas. If there are other parts on the test (multiple choice, true/false, etc.), scan these for any help you can get. Sometimes you’ll find neat little bits of information that can help! Again, don’t skip the outline stage because you’ll start writing and may forget points. Your outline also tightens your focus and forces better organization of ideas.
Finishing touches are important to your essay. Use an erasable pen or pencil for neatness. SKIP lines when writing on your paper unless the teacher instructs otherwise. Lastly, proof your essay. This means you should have budgeted your time wisely so as to have a few minutes to check spelling, punctuation, complete sentences, vocabulary and general organization. If you find yourself with time left over …sit…relax… let your brain decelerate. Inhale deeply and with regularity, lean your head back, look up at the ceiling. You may even want to rub your neck. This may be what’s needed if you’ve had any mental “blocks”. Now, do your last big check of the test. It’s ready to turn it in…no doubt, you’ve done a great job. Oh! Yes…before you turn in the test…make sure your name’s on it.
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