In episode 74, ADHD Parenting Coach Siope Kinikini talks with Dr. Gray and Dr. Crohan about the importance of getting the right diagnosis and how behavior skills can help kids with ADHD.
Understanding ADHD symptoms isn’t enough when getting an ADHD diagnosis.
This is episode 74. Let’s begin.
Smarter Parenting welcomes you to our podcast series, The Parenting Coach for ADHD. Here to heal and elevate lives is your Parenting Coach, Siope Kinikini.
Siope Kinikini: Hello everyone. How’s everyone doing? I hope you’re doing great today. During the podcast we are talking to Dr. Samuel Gray and Dr. Donald Crohan, both of whom work for The Methodist Home for Children, which is located in North Carolina. Dr. Gray and Dr. Crohan are both psychologists and they’re actually shaking things up in the world of assessments. When your child is brought to a professional for a diagnosis, they often receive the diagnoses from the therapist or from the physician. The work that Dr. Gray and Dr. Crohan are doing is actually enhancing the way that we look at diagnoses and being sure that we cover all the bases, so treatment is appropriate for our children. It’s actually innovative stuff. So listened to it because it’s fantastic. And near the end of this episode you’re going to hear us talk about how they implement the Teaching-Family Model. Now during the discussion, Dr. Crohan refers to it as the Teaching Model because it is a Teaching Model, but when he’s mentioning that, just keep in mind that we’re talking about the Teaching-Family Model.
Siope Kinikini: I’m hoping that the work that they are doing will be the foundation of work that will continue throughout the nation and other agencies and in other places because currently it’s not done this way. When your child goes into a physician or goes into a mental health counselor for a diagnoses, it’s usually up to that one individual to make a diagnosis and then it builds from there. So the work that they’re doing is fantastic. I think it’s super helpful and I know it will be super helpful for a lot of you parents out there who are wondering about diagnosis, whether or not ADHD is the appropriate diagnoses and what other options are available to you in being sure that your child is receiving great treatment. So Dr. Gray and Dr. Crohan.
Dr. Gray: Yeah, we’re both psychologists working for Methodist Home For Children. I oversee our Assessment Centers and Dr. Crohan.
Dr. Crohan: And I’m Dr. Crohan. I am the Director of Clinical Strategies and Outcomes. So I develop the programs and analysis for the entire agency including the assessment centers.
Siope Kinikini: Okay. What’s fascinating is they presented during this conference about the importance of assessments and so we had talked previously about ADHD and the misdiagnosis of ADHD. I just want you to share a little bit about what you presented because I think this will be super-helpful for the parents who are listening.
Dr. Gray: Yeah, and I can start basically just by saying that what our presentation has covered has been the importance of using good evidence-based measures for assessment of all mental disorders. But, certainly more specifically to your question to for ADHD purposes.
Dr. Crohan: And I think it’s also important to remember that although the diagnosis of ADHD is so prevalent, the research shows that it should only be between six and 10% of the population. And we’re seeing in some cities we’re looking at 60% or more youth diagnosed. So in some ways ADHD has become the go-to phrase to politically justify what the youth is doing. When really we need to talk about self-discipline, self-management, and the skills necessary to become an adult and not immediately pathologize a kid for just being a normal child who needs to learn how to manage his behavior.
Siope Kinikini: Right. What I find interesting about the work that you guys are doing is the whole gamut of doing the assessment, the whole process. So can you explain how you guys are working with the youth in your area?
Dr. Gray: Right so, we have a youth who are referred to us to the juvenile justice system in North Carolina. And so our task is to do evaluations on them so that we can understand kind of who they are and what kinds of issues they’re having and to make the proper recommendations to hopefully prevent them from going further into the juvenile justice system and hopefully prevent them from becoming adult criminals. And so Dr. Crohan has developed a fantastic system of assessment which we utilized to really evaluate these youth from an objective and evidence-based standpoint to understand what’s going on with them.
Siope Kinikini: Okay. And so what does it look like? Let’s say that the court refers a youth to you that has some behavioral issues. What do you do at that point?
Dr. Crohan: Well, the first thing when they come in, there’s a two phase set up. The first phase is for them to get psychosocial personality, educational, and IQ testing. And we were very careful in the development of these tests, or I should say in their selection of these tests to make sure that none of them assume pathology. So it’s a strength-based approach. We want to learn who the youth is before we treat or diagnose a youth as having any problems. Only if one of those tests or more of those tests indicate there is a potential problem that we then go into a second phase to diagnose that problem. So we set a system up so that we in our own biases will be countered by the testing. So we won’t be too quick to diagnose that which doesn’t need to be diagnosed or label a kid who doesn’t deserve or need a label.
Siope Kinikini: So this is super important for parents to understand. A lot of times they’ll bring a kid into or their child into a therapist, they’ll report what’s going on. Then the therapist will give the diagnoses. Now a lot of times therapists are have proclivities towards certain diagnoses and sometimes the diagnoses is incorrect based on the biases of the therapist. So your approach is to let’s test them, let’s not even put diagnoses on the table and let the tests dictate how we’re going to provide services.
Dr. Crohan: Exactly. Instead of us labeling the youth to figure out what to do, we use the testing to inform us where we need to go. So we put our egos at the door. We use standardized measures and good structured instruments to determine things. And I think Dr. Gray will tell you about how, what really happens with the number of diagnosis of youth coming in versus what we see.
Dr. Gray: Yeah, and I’ll give you a specific example. We had a young man who came in and he was 14-years-old at the time carrying a diagnosis of ADHD and came into our center and he was certainly fidgety and had some issues sitting still. But we did our testing with him and we measured what was going on with him. And interestingly, what we found in our testing was that his attention and focus and measures of attention and focus showed he was able to pay attention to focus as well as most kids his age. And so the testing was really pointing against him in the other direction of ADHD, against ADHD. But what we found with him was measures of anxiety were quite high. And so frequently what I have seen in cases with youth are that sometimes anxiety can be mistaken for ADHD. And so in his case, what had happened was this is a youth who had anxiety and was placed on a stimulant medication. And a stimulant medication given to somebody who’s already anxious, can cause all kinds of behavioral reactions.
Dr. Gray: And in his case it did. And so what we saw was that after he had been put on the stimulant medications, now his behavior problems actually increased and he became more aggressive. But what we were able to do through the testing was to identify that no he did not have ADHD. But what he did have was high levels of anxiety, which were not responding well to a stimulant medication.
Siope Kinikini: Now that’s fascinating because again, misdiagnoses leads to medication and the medication is not appropriate for history or his treatment.
Dr. Crohan: Right, because some therapeutic techniques can actually be harmful to a child.
Siope Kinikini: Yeah. Now this actually to the parents who are listening is very novel because this is not the way it’s done. You guys are kind of shaking the boat and the way to approach this, although it seems very logical like this should’ve been done years and years ago.
Dr. Crohan: To be honest with you, this was kind of my passion project. For years I worked in this field and I’ve never been able to do it the right way. And I finally found a place that said they’d let me do it right. And so that’s why I’m here, because it sure isn’t for the amount of money I’m getting paid. But I really, I have confidence that we collaborate constantly. We use these tests with a great deal of fidelity and I am confident that we make a big difference in these people’s lives every day, and we’re not just doing it and it looks good. We’re seeing the results. We’re doing outcome measurement to show that these kids like you could share what happened with that youth later. These kids really benefit from are very short, but informed intervention.
Siope Kinikini: So tell me how long is the intervention that you guys provide?
Dr. Crohan: The first tier or phase of testing is about one week. We usually do a test per day. And then the second one depends on whether they need it. It depends on the number of tests I need. It could be anywhere between one and four. So we could be done with testing within two to three weeks. And during that whole time where although gathering information from trained observers who are giving us behavioral observations.
Dr. Gray: Documenting their behavior on a daily, hourly basis.
Siope Kinikini: Oh wow, okay.
Dr. Crohan: So we’re not just using just tests.
Siope Kinikini: Right, you’re using observations from somebody else who can give you the information unbiased. No offense to parents, but sometimes we’re biased in our approach to our own children. And so we’ll report sometimes things that may not be completely accurate.
Dr. Gray: And I think it’s reasonable for parents to ask the question, “What type of testing have you done on my youth to come up with this diagnosis?” Because there are a lot of folks out here who are using the good testing and doing it properly. And that’s not to say we don’t see children who have ADHD, because we certainly have, but that’s confirmed in our testing. And so then we know maybe they are already on the right track. But it is important to ask those questions because there are certainly, there are a lot of cases of youth who come in who have not had that objective testing, who are carrying that diagnosis or carrying those medications. And sometimes parents just don’t know that they need to ask those questions. That we need some objective testing before we diagnose this and confirm this.
Siope Kinikini: Okay.
Dr. Crohan: And I think it’s also important for parents to be careful about the power of label. We get the perception that if we can put a name to something, we have power over it. Sometimes the getting a label so that we feel like we have a handle on it is less important than getting the right information. But we’re in a society where getting that label, getting the term is what someone’s expected to get as soon as they come into the center. We take the time to get the right information and we encourage anybody else to do the same thing.
Dr. Gray: And I would say too that one of the interesting things that we’ve found in measuring is that a lot of the youth who have come into our centers with diagnoses of ADHD when they get into our centers and we’re providing the Teaching-Family Model, they respond incredibly well to that. And so what we see very frequently with these youth is an immediate reduction in distress, immediate reduction in behavioral issues and things that may have been mistaken for undiagnosed, really just needed that proper kind of structure, discipline organization and a Model of care to help them get in line. And so we see a lot of those kids respond well to it. So I would certainly encourage parents to try those things certainly before going down that road of looking at medication.
Siope Kinikini: Yeah. That has been the recommendation from other medical professionals too, is that first you seek a behavioral, you try and work it out and then medication comes after you’ve done that, if you feel like you need to continue to do that. So that’s fantastic. Tell me about the Teaching-Family Model and the way that you guys implement it. You mentioned that it’s effective. Tell me how it works in your group or with the population that you work with.
Dr. Crohan: Well, the Teaching Model is a behavioral model. So it’s founded on over a hundred years of very well supported research. And one of the things that Dr. Gray was talking about, which is 100% right, is that parents are looking for a solution and the medication will come first. But the Teaching Model actually sets a structure for people who don’t need either medication or even need to be pathologized. They don’t need the label at all. And a lot of times what happens is that it’s very hard to turn to a parent and say your kid needs more self-discipline, or your kid needs to learn how to discipline to manage their behavior better because that’s politically not something a parent wants to hear. So a teacher or some other type of social worker or someone who’s looking for a solution, we’ll say, “We’ll go to the diagnosis because it seems to be kind of a safe way of approaching the topic.”
Dr. Gray: And absolving parents sometimes their responsibility.
Dr. Crohan: So what the Teaching Model does is sets up a structure so that this youth who’s used to responding in a more impulsive way now has guidelines with regard to their structure. Their discipline. The way they interacted with other people. Learning how to wait before they speak. Learning how to think before they act. And that sets up guidelines where they have an ability and a structure internally that will guide their behavior. And that’s really what we’re talking with ADHD is does the person have these specific damage to the brain or the specific undeveloped portion of the brain that does not allow them to have it? Or, is this a situation where they’ve never been taught it? If you had a youth that’s never been taught to read, you wouldn’t presume a learning disorder. You would say you need to teach them how to read.
Dr. Crohan: If you have someone who’s never been taught impulse control, or who has had a lot of distractions or life regarding different types of entertainment so that the impulse control wasn’t that important, you don’t presume they have a deficiency. Maybe they just need to learn the skill. And that’s what the Teaching Model does, it teach you skills.
Siope Kinikini: So those skills are super-important. You implement those, you teach them to the child also to the parent, so they’re both aware and they know how to set up the structure in their own homes.
Dr. Crohan: That’s a good point. I think that’s in fact that’s a unique thing about the Teaching Model is that it isn’t focused purely upon the youth, which is what almost all of our approaches are in society. The Teaching Model literally sets up a system so that the parents are instructed how to actually intervene with youth in a more effective way. So it’s comprehensive. It does take care of the youth that you have concerns about, but it also teaches the parent how to more effectively deal with the youth and brings down a lot of the pressure and a lot of the conflict.
Siope Kinikini: Fantastic. I’m curious, so if you’re talking to a parent and you have to give them advice on what they should be doing, you had mentioned that they should ask what testing has been done. Are there any other gems that you think they should be asking before going down the medication route?
Dr. Crohan: Ask about the practitioner’s licensure and their area of expertise. If someone doesn’t have a strong psychological background, you should be worried about their presumptions about psychology. It’s the same thing as if you took a child because he’s having some type of rash. You would want them to go to someone with a medical background, not someone with just a really good idea or who’s enthusiastic. And I think also ask about the theoretical orientation of the individual that you’re dealing with. Even a psychologist or a psychiatrist or another high-level doctor should be able to explain how they methodically work with your youth and justify the steps they take. If you hear someone get defensive about that, that’s not the right practitioner. A practitioner needs to be confident and open.
Siope Kinikini: That’s great. I actually make that suggestion as well to parents that they need to be comfortable with who they’re working with. And a lot of times you tend to just pick up whoever somebody recommends, but that may not be a good fit. So you’ve got to find and you got to be sure. It’s like buying a car. That’s usually what I tell them. If you want to get a car, you have to go the rounds and you have to take your time to be very selective on what you need and what you want. So.
Dr. Gray: And I’d be very careful about using any kinds of tools and things that are offered or sold certainly on the Internet and things like that because what we have seen is that people overreact to those kinds of things quite readily. And so again, they may use that confirmatory bias and start finding problems that maybe they just think are there and this is just what they’re looking for. So they answer questions in a way that confirms in their mind something, but the tool that they’re using off the Internet really has no evidence-base. And no validity or reliability behind it.
Siope Kinikini: I love this idea of being able to test and find the evidence that you need. And again, there’s a podcast we cover on confirmation bias. If you haven’t listened to it go and listen to it because a lot of times suggestions can come up and we confirm that it’s true, when in fact it may not be true. So definitely be very, very cautious and careful.
Dr. Crohan: It’d be weird that snake oil has been around for very long time.
Siope Kinikini: That’s a very productive business. Let me tell you.
Dr. Crohan: It is. And it’s something that whether you’re a parent or a practitioner, you’ve taken on the responsibility for someone else’s life. So when you do, you need to avoid following the trend, or the theme, or the fad, and focus upon what does the science tells us. Because science has been around for a long time and science is not set up to be believed but challenged. So anybody who’s practicing the science should be comfortable being challenged. And anybody who’s engaging in a science needs to justify what they’re doing. So like you said, I mean, the car analogy is a good one. Test drive your practitioner. Check them out and make sure that they’re able to answer all your questions and if they’re not comfortable doing it, probably because they’re not comfortable with what their knowledge base.
Siope Kinikini: That’s great. Is there any other gems of wisdom that you want to provide to parents who are struggling with children with ADHD? That’s really a general question. I know, but I’m just kind of curious.
Dr. Crohan: No, it’s a fair question. I think one thing is always look to see what your child can learn before you get a label on them. We’re not in a society that really supports self-discipline. It’s actually in a lot of ways in many circles, but seen as a kind of a negative term. We don’t talk about discipline in a positive way. But I think it’s very hard for a young person growing up today to think of managing themselves because there’s so many messages that you’re the result of what somebody did to you. Or you’re the result of how somebody offended you. Or you’re a result of what somebody did to affect you. And ADHD like so many other things that we see with these kids is that they’re not the result of what has been done to them, these kids can have the resiliency to manage themselves in a very effective way. They just need, might need some guidance. I’ll tell you what, it’s hard to be a parent today. There’s not a whole lot of support.
Dr. Gray: Yeah, and I would just add to that that one of the findings that we’ve found pretty consistently in our assessment centers, with the youth that we’re working with, is that they don’t seem to have enough structured pro-social physical activities in their life. And so whether a child has ADHD or not, but certainly with ADHD, very important to keep them involved in those kinds of things because a lot of the lessons that they learn in those settings can help them develop those skills that they need to manage some of those symptoms. And so if you’ve got a child who’s exhibiting a lot of hyper-activity, get them engaged in activities, get them involved in more structured things. And frequently what you may find is it may be more of a developed developmental issue and a child just needs to learn those skills and they have opportunities to learn those skills if they’re in those types of activities.
Dr. Crohan: And that’s actually a very good point you bring up, which I think we as practitioners fail to acknowledge. Sometimes we need to not jump on the bandwagon, figure out what’s wrong with the kid. Sometimes you just need time to develop. Childhood is awkward and children are learning about the universe for the first time. And sometimes they do it in a clunky, awkward manner, which we all did. But I think we look back at our lives and think it was some streamlined three act play.
Siope Kinikini: Right.
Dr. Crohan: It wasn’t.
Siope Kinikini: It wasn’t.
Dr. Crohan: So sometimes a kid needs time to make mistakes and needs time to stumble, but that’s what we’re there for. We’re there to help pick them up again. Not label them because they fell.
Siope Kinikini: I’m curious on your thoughts, and this may be a little off-topic, but the role of technology now because it is very different. I mean I grew up at in time I had to listen for my mom yelling from the porch for me to come home. That’s the way it worked. With the growth of technology, do you see more problems happening or do you feel like that is a contributor to some of these issues that we’re seeing?
Dr. Gray: I think it’s certainly a factor because what we have is children’s attentions, who are frequently pulled away moment’s notice and the cell phones and other kinds of devices that call for their attention on a regular basis, and pull them away from what’s happening in the real world. And so they do develop, I’ve seen them develop sort of habits of inattention and that type of thing, which can very much be traced to technology at times. And so I think it’s certainly a factor.
Dr. Crohan: But I just want to add to that. I agree with everything you said. I just want to add to it that we can’t advocate our own responsibility because the child can’t use technology that we don’t let them use. And a child can’t become immersed in bad habits that we don’t allow to develop. So whether we be parents that need to monitor our youth, or whether we need teachers who need to be not letting the technology take over the classroom, anybody in the environment who’s dealing with children, we can’t blame the technology because even though it can contribute, we ultimately have the responsibility of shaping the environment. So I think we ultimately, I’d be careful, we don’t blame something when we have responsibility.
Siope Kinikini: We have a responsibility over those things. You had mentioned something about training our inattentiveness with the devices. That’s a real thing, right? I mean people can train themselves to be inattentive and so they can obviously train themselves not to be inattentive. Is that a fair statement, would you say?
Dr. Crohan: Well, it’s been proven in research. There has been a series of studies just in the last two to three years that were shown not only do youth show a less attentiveness with the increase of technological use.
Dr. Gray: Hang on, I just got a text. Sorry.
Dr. Crohan: We got to stop everything.
Siope Kinikini: It’s a little.
Dr. Crohan: But also mood disorders. We found that individuals, young people the more they use technology and the more they use social media, the more we’re finding difficulties with depression and social isolation. And so again, it’s not the technology that’s the issue. Just like it’s not the drug that’s the issue. It’s not the weapon that’s the issue. It’s what we do with these things, and whether we allow ourselves to externalize responsibility on an object as opposed to take the responsibility on how to manage all of these things. Someone doesn’t get really, really overweight by looking at food.
Siope Kinikini: No, don’t remind me. Anyway, I know there are practitioners listening as well to this podcast because we always get questions from them as well. The biggest question on their mind is how in the world do you pay for all those assessments? So, what is the cost of doing all those assessments?
Dr. Crohan: It’s expensive.
Siope Kinikini: It is expensive, okay.
Dr. Crohan: But, and I think it needs to be noted that it’s not inexpensive in the tests themselves. And then there’s a scoring programs, if you choose to use them. Some of the tests actually require scoring programs, they get written up where it’s almost possible to do it by hand now. But, really the expertise. And I think that this again comes to an issue of priority. I run into this issue all the time where people saying we can’t afford this, we can’t afford that. Well, then don’t take on the job of treating kids. If you don’t want to take on the expense and the obligation to do it well, we would not tolerate a hospital that does not have pain medication when a used arm is getting set.
Dr. Crohan: We would not tolerate a hospital that does not have blood pressure cups and thermometers when they walk in and do the proper testing to set the stage of what care they need. But we are very quick to tolerate social service environments that don’t do triage type testing right off the bat. And I think it’s a social challenge and we as practitioners sometimes get caught up in all these other different types of debates or social issues and we really need to be arguing for the expertise and the proper tools to treat people properly. It’s an obligation.
Dr. Gray: Yeah. And I think that insurance companies haven’t made it easier for us because I think what they’ve done is sort of tried to dumb down the process of diagnosis because they don’t want to pay for those kinds of things. And so frequently with families that want to get those types of testing and evaluation done, what their finding is insurance companies are denying that. Then they send them to the social worker or the family practitioner or somebody else who provides the diagnosis that doesn’t do the testing. And again, that helps the insurance company because they haven’t had to pay for that type of stuff. But again, I think as Dr. Crohan indicated, is that we do have to advocate for the importance of using these kinds of measures and being and especially when we’re working with children, we really have to use objective testing and be careful about the process by which we’re going about diagnosing them.
Dr. Crohan: And that does when we get politically involved.
Siope Kinikini: Yeah. This is, it really is almost a political thing. It’s funny that when you go into be assessed by a physician in a hospital, the first thing they do is they run a battery of tests. That is kind of the that’s the format. Go have some blood tests, we need a urine sample and need a stool sample. And then they make their decisions. In mental health, it’s different. And so you guys are actually pushing it into that kind of mindset of let’s do the testing first and then let’s determine where we’re going to go.
Dr. Crohan: Responsible practice.
Siope Kinikini: Yeah, it is responsible practice. It’s one of the things mental health has been missing, obviously, in this country because we just tend to rely on whoever we visit to give us what we need, which isn’t always reliable.
Dr. Crohan: Which goes back to what you said about the car analogy. We need to vet the practitioners. We need to find out what their procedures are. We need to determine whether or not they’re competent, capable, and invest in doing it the right way as opposed to the easy way. And this is where we need to, as members of the society say, if the system isn’t working, we need to challenge the system to change for us, not change for the system. Because we’re not going to create a healthy generation by treating them with unhealthy means.
Siope Kinikini: Yeah. Well, one of the things I do want to say with the parents is it does come down to price and practitioners, how much does this cost? It is expensive. However, when your child is in the hospital and they need cancer treatment, that’s expensive and yet we’re willing to do whatever it takes to pay for that. And so it’s kind of an interesting dynamic when we think about what we’re willing to do and what we can do.
Dr. Crohan: Well, you’ve got a good point and I’d like to augment your point, but pointing out that if you had a physical disease that you didn’t treat, it’s only going to get worse. It’s the same thing as psychological. The amount of time and money you’re going to spend in therapy, the amount of time and money you’re going to spend in legal fees if your youth gets caught in the juvenile justice system.
Dr. Gray: Hospitalization.
Dr. Crohan: Hospitalization. So it’s again, it comes down to any good health practice. Find out what’s going on, use good methodology to determine it, and then use the right types of techniques to treat it. Otherwise, what’s the old phrase, if you don’t mind me exploiting a phrase that Benjamin Franklin said, “Have you diagnosed in haste, you’ll repent more expensively at leisure?”
Siope Kinikini: He also said, “An ounce of prevention is worth a pound of cure.” Which is, I mean, if you’re willing to pay upfront, then you’re.
Dr. Crohan: An hour of testing, will be worth a lifetime of misdiagnosis.
Siope Kinikini: Yes, exactly. And a lifetime of constant visits to psychiatrists or therapists or whatever else. So it’s worth it to do that upfront. I am a strong advocate of what you guys are doing and I hope it spreads like wildfire. I really hope it becomes adopted in all the agencies that deal with kids.
Dr. Crohan: And we’re not proud. So feel free to. We accept.
Dr. Gray: Certainly not.
Dr. Crohan: All major credit cards. But no, we really want to get this message out now because we think we’re unique. We think that this has been good practice for the last a hundred years. It’s just been not attended to because it’s become politically inadvisable for people in our profession.
Dr. Gray: And the consequences to children at this point have become too great to ignore this.
Siope Kinikini: Wow. But the consequences to our children, we’ve reached a point and it is a tipping point now because of the way the world is that we have to make a change in the way that we’re dealing with issues. I mean we really do have to change the way we’re doing it. So fantastic. I think that’s it for me. Do you guys have anything else you want to share?
Dr. Crohan: Just that you said the way the world is, I just want everybody to remember the way the world is, the way we’ve made it. We chose to create this environment. We can choose to change it.
Siope Kinikini: There’s a lot of power in that too. But just to know that there are people on the front lines fighting for your kids to be happy and healthy and they’re looking to change the system and it needs changing. So feel free to leave a five-star rating and also subscribe, share this podcast with family members and friends that you feel would benefit from it. And also you can find a transcript of this on the Smarter Parenting website and that’s it from us from here in Cincinnati. And I will see you later.
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