CCPR: Do you ever start medications right away?
Dr. Diller: For a small percentage of kids, about one-eighth of my practice, I find that they are so hyperactive that they need to be on medications immediately before we can do anything else. But the vast majority of kids get a trial period of from two to three months where behavioral and educational interventions are tried. Of this group, about 50% will end up on meds, eventually, but 50% will be fine without medicines.
CCPR: What are the specific behavioral interventions that you usually recommend?
Dr. Diller: My first point is usually to address the common misconception that the child is incapable of doing certain things because of ADHD. I’ll say, “You should throw out the idea that Johnny can’t do this or that, because based on my experience, certain things are just harder for him to do, and require specific strategies.” The key behavioral strategy is immediately linking demands and consequences, and this leads right to my main recommendation, which is a parenting skills intervention based on the book “1-2-3 Magic” (Phelan TW. Glen Ellyn, IL: Parentmagic Inc.; 2014). This is a deceptively simple technique, in which parents count kids to three and then give them a time out if the behavior continues. I’ll often introduce this by saying to parents, “You know when Johnny hit his sister and he immediately looked at you to see your reaction? That’s called a test.” I ask if they agree, and they usually say “yes.” Then I say, “Why do children test their parents? They test boundaries to develop consistent responses because it makes them feel more secure.” A child has huge anxiety when he thinks, “I’m too little to take care of myself but I’m stronger than my parents.” Most parents understand that this is a reasonable justification for enforcing limits.
CCPR: What’s so magical about 1-2-3 Magic?
Dr. Diller: Parents only need to explain it to the kid one time, and that’s it. Sometimes while they are explaining it, the kid starts mouthing off, and the parents say, “That’s ONE.” I tell the parents that for the first 72 hours it will be horrible torture as you make the shift from being powerless to having consistent power. But I’ll say, “If you stick with this plan, I guarantee (I’ll sound like a car salesman) improvement in 72 hours. If you don’t see improvement in 72 hours, then you are to call me, even on the weekend, because you must be doing something wrong.” The magic is that after the kids have been sent to time out once or twice, the parent says “ONE” and the kid freezes like a lightning bolt has hit him. The other part of the magic is that over a period of a couple of weeks, especially with the younger kids, it looks like they are on Ritalin, because the behavioral change can be quite profound. However, for some of the parents, it’s not a natural way of acting. Down the line, for these families the “magic” compliance wears away as they do what is natural to them.
CCPR: Are there other behavioral interventions?
Dr. Diller: The other intervention is to make sure the parents go to the school and get a basic educational evaluation rolling. An SST (Student Study Team) evaluation has to be completed within two weeks, whereas an Individualized Education Plan (IEP) evaluation, which is much broader, can take up to 120 days. I also recommend a school-based behavioral intervention, appropriate mainly for children fifth grade and younger, which is called the daily report card. This is just a piece of paper on the kid’s desk, and when he completes a task without any or only one reminder, then the teacher puts a dollar sign or a sticker in one of the boxes immediately upon completion. I tell the kids, “This is an opportunity for you to win fabulous cash prizes and trips to the Bahamas.” The stickers equal computer time, or trips to the ice cream store, or his choice of a DVD at the end of the week if he gets enough of them. It’s even better if the teachers have lottery boxes or treasure chests at the end of the week—you wouldn’t believe what the kids are willing to do get an extra ticket to put into the lottery box.
CCPR: After your evaluation, as you follow the family, are there any tips that help the parents be successful in their behavioral interventions?
Dr. Diller: I use the “swordfish” technique. This helps parents support one another in effectively using 1-2-3 Magic. If one parent is trying to engage the child in setting limits, but is not doing well, the observer parent says “swordfish” to remind the disciplining parent to get back on track. “Swordfish” is from the Marx Brothers’ Horse Feathers movie. It’s the password Groucho uses with Chiko to get into the speakeasy.
“I think stimulants are underprescribed, misprescribed, and overprescribed.”
~ Lawrence Diller, MD
CCPR: I like the thoroughness of your evaluation process. But there are certainly some doctors who are either unable or unwilling to budget their time this way. If we did want to farm out some of these aspects of the evaluation, how do you recommend that we find someone who works well with parents and the schools in this way?
Dr. Diller: Unfortunately, it’s hard to find. In my middle/upper middle class community, I can think of only two or three therapists who will do a conjoint family interview or talk to the teacher. Most therapists do individual work with kids, which often will not lead to much improvement in ADHD symptoms. In fact, in my practice a typical pattern is for parents to send their kids to therapy for six to 12 months, see no change, and then to come to me. Sadly, child psychiatrists in my area are typically not doing conjoint family interviews, because the field has moved to a medication model.
CCPR: Thank you, Dr. Diller.