ADHD RESEARCH UPDATE - New issue preview

[ADHD RESEARCH UPDATE]

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Greetings:

I hope you are doing well.

Below you will find a preview of the June issue of
ADHD RESEARCH UPDATE that was recently sent out to
subscribers.

The preview contains the full text of one of the articles
from this month's issue, along with a listing of the other
studies that were reviewed this month. The article included
in this month's preview reviews a very interesting book by
Dr. Ross Greene in which he presents his approach for dealing
with "explosive children" - i.e. children who are inflexible,
become easily frustrated, and have frequent extreme outbursts.
Although this certainly is not true of all, or even most, children
with ADHD, these characteristics do seem to be more common among
children who have been diagnosed with ADHD. I thus thought
Dr. Greene's ideas would be of interest and value to many readers.

Please feel free to forward this information to others you know
who may be interested in it.

I hope you are doing well and that you enjoy the article below.

Sincerely,

David Rabiner, Ph.D.
Duke University

P.S. Are you a health care professional? You can sign up for my
professional list by sending a message to
mailto:[EMAIL PROTECTED]

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***********************************************
ADHD RESEARCH UPDATE - Preview of June issue
***********************************************

In this issue...

* Adderall vs. methylphenidate in the treatment of ADHD

* A new approach for handling "explosive" children

* Social functioning and emotional regulation in children
with different subtypes of ADHD


* A NEW APPROACH FOR HANDLING "EXPLOSIVE
CHILDREN"

One of the most frequent questions I receive from parents
concerns how they should deal with their child's temper
outbursts and "explosions". Although such characteristics
are not part of the core symptoms of ADHD (go to
http://www.helpforadd.com/criteria.htm for complete diagnostic
criteria), and can certainly occur for a variety of reasons
besides ADHD, such explosiveness does seem to be more common
among children with ADHD and is often a major source of concern.

I just finished an excellent book called The Explosive Child:
A New Approach for Understanding and Parenting Easily
Frustrated, "Chronically Inflexible" Children. The book is
authored by Dr. Ross Greene, a clinical psychologist on the
faculty at Harvard Medical School. I purchased this book
hoping for some helpful insights for dealing more effectively
with my own charming but difficult 3-year-old. The approach
described by Dr. Greene impresses me as a very thoughtful
and useful approach that may be helpful to many parents,
and I wanted to share his ideas with you.


WHAT ARE THE COMMON CHARACTERISTICS
OF INFLEXIBLE-EXPLOSIVE CHILDREN?

It is important to begin by noting that the label "inflexible-
explosive" is certainly not a diagnostic term recognized
in DSM-IV - the official diagnostic guide for psychiatric
disorders. Instead, it is used by Dr. Greene to capture
the key features of children who can be extremely difficult
for parents to manage. According to Dr. Greene, the
key features of such children are the following:


1. A remarkably limited capacity for flexibility and
adaptability and a tendency to become "incoherent"
in the midst of severe frustration.

These children are much less flexible and adaptable than
their peers, become easily overwhelmed by frustration,
and are often unable to behave in a logical and rational
manner when frustrated. During periods of incoherence,
they are often not responsive to efforts to reason with
them, which can actually make things worse.

Dr. Greene refers to these episodes as "meltdowns",
which strikes me as a very apt description. Because a
child's ability to think clearly during a meltdown is
essentially nil, their behavior can appear exceedingly
wild and irrational. Cursing, screaming, breaking things,
and physical aggression are quite common during these
episodes, which can last from several minutes to several
hours. Dr. Greene believes that the child has little or no
control over his/her behavior when in the midst of a
meltdown.


2. An extremely low frustration tolerance threshold.

These children often become overwhelmingly frustrated
by what seem like relatively trivial events. Because their
capacity to tolerate frustration does not develop at the
same rate as their peers, the child often experiences the
world as an extremely frustrating place filled with people
who do not seem to understand what they are experiencing.


3. The tendency to think in a concrete, rigid, black-
and-white manner.

These children fail to develop the flexibility in their thinking
at the same rate as peers, and tend to regard many
situation in an either-or, all-or-none, manner. This greatly
impairs their ability to negotiate and compromise.


4. The persistence of inflexibility and poor response to
frustration despite a high level of intrinsic or extrinsic
motivation.

In other words, even very salient and important consequences
do not necessarily diminish the child's frequent, intense, and
lengthy "meltdowns". This means that typical approaches of
consistently rewarding a child for desired behavior and punishing
negative behavior may not make a dent in the child's tendency
to "fall apart". According to Dr. Greene, traditional behavioral
therapy approaches for such children often don't work at all
and can actually make things worse.



In addition to these key features, Dr. Greene notes that a child's
"meltdowns" often have an "out-of-the-blue" quality, occurring
in response to an apparently trivial frustration even when the
child has been in a good mood. As a result, parents never
know what to expect - i.e. all hell can break loose at seemingly
any moment. These children may have a specific issue about
which they are especially inflexible (e.g. the food they will eat,
the order in which certain things need to be done), or can be
this way about multiple issues.


WHAT "CAUSES" A CHILD TO BE THIS WAY?

According to Dr. Greene, there are a variety of "pathways"
that a child may move along towards developing these
"inflexible and explosive" characteristics. For the most part,
he seems to believe that all of these pathways are predominantly
biological in nature, and that most children who become extremely
inflexible and explosive do not do so in response to
"poor parenting". How parents respond to these biologically-
based vulnerabilities in their child, however, can have
important implications for how well their child is able to
master his or her problems over time.

Below is a brief description of the different characteristics
that are identified as predisposing a child to become highly
inflexible and explosive. Bear in mind that this is probably
not an exhaustive list (some would suggest that allergies -
especially food allergies - should be on this list) that not every
child with any of these characteristics will display the kinds of
problems that Dr.Greene describes, and that some children will
possess more than one of these "predisposing" attributes.


Difficult Temperament

By nature, some infants come in to the world being more finicky,
emotionally reactive, and more difficult to soothe than others.
For example, with my younger daughter, almost anytime she was
awake during her first 6 months she was crying. Calming her down and
soothing her was all but impossible with anything other than
letting her nurse. As she grew older, she continued to get
upset easily, to be virtually impossible to distract when she
got her mind on something (which is a real problem when it
is something she can't have or do), and to display her negative
emotions in intense and persistent ways. Undoubtedly, we've
made mistakes in how we have tried to deal with these
difficulties, and these have probably contributed to their
ongoing nature. The bottom line, however, is that this was
essentially how she came into the world. These "innate"
aspects of personality are what psychologists refer to as
temperament. (Note: It is important to recognize that even
very difficult temperaments can be modified over time and
this in no way "dooms" a child to a life of ongoing difficulty
and struggle.)


ADHD and Executive Function Deficits

Many children with difficult temperaments also wind up being
diagnosed with ADHD at some point. As discussed in a
prior issue of ADHD RESEARCH UPDATE, current
conceptualizations of the core difficulties associated with ADHD
focus on deficits in a crucial set of thinking skills called
"executive functions". Although there is no universal agreement
on the specific skills that constitute executive functions, the
typical list of such skills would include such things as: organization
and planning skills, establishing goals and being able to use these
goals to guide one's behavior, holding information in memory,
selecting strategies to accomplish these goals and monitoring
the effectiveness of these strategies, being able to keep emotions
from overpowering one's ability to think rationally, and being
able to shift efficiently from one cognitive activity to the next.

Deficiencies in these skills are believed to help explain
not only the core symptoms of ADHD (i.e. inattention and
hyperactivity/impulsivity), but also to the poor tolerance for
frustration, inflexibility, and explosive outbursts that are seen in
"inflexible-explosive" children. For example, if a child has
difficulty shifting readily from one activity to the next because
of an inherent cognitive inflexibility, it may explain why he or
she becomes so frustrated when parents request that he/she
stop playing and come in for dinner. Such a child may not
be intentionally trying to be non-compliant, but their non-
compliance may instead reflect trouble with shifting flexibly
and efficiently from one mind-set to another.


Language processing problems

Language skills set the stage for many critical forms of thinking
including problem solving, goal setting, and regulating/managing
emotions. Thus, it is not surprising that children with less well-
developed language abilities - either in receptive language
(i.e. taking in and understanding what is said) and/or expressive
language (i.e. communicating their thoughts and ideas clearly
to others) would be at risk for dealing effectively and
adaptively with frustration. Dr. Greene believes that such
language difficulties often contribute to the problems displayed
by children he describes as "explosive".


Mood difficulties

Some children are born predisposed to perpetually sunny and
cheerful moods; others, unfortunately, tend to experience sustained
periods of irritability and crankiness. Clearly, our moods are
effected by what actually happens to us in the world. Green notes,
however, that there is an important biological component to one's
general mood state. This is not just true for children who experience
full-blown mood disorders such as depression or bipolar disorder,
but can apply to "sub-clinical" mood difficulties as well.

Imagine for a moment how you tend to handle things when feeling
cranky and irritable. If you're like most people, you probably
become frustrated more easily and lose your temper more readily
as well. So, for children who are prone to these kinds of moods,
more chronic difficulties with frustration and temper are likely to
be evident.


What can parents do?

How does a parent go about helping their "explosive" child
become less explosive, and thereby create a better quality of
life for everyone in the family?

Dr. Greene begins by describing common recommendations
from the mental health field that often fail to bring the desired
relief. First, of course, is the use of medication. Dr.Greene
does not appear to be anti-medication, and we certainly know
that for children with ADHD, properly prescribed medication
often helps, not just with the core symptoms of ADHD, but
also with the associated behavior problems such as the explosive
outbursts that are the focus of this book. For a number of
children with ADHD, however, and certainly for children who
are prone to explosions for a variety of the other possible
reasons outlined above, medication may often fail to provide a
significant benefit. In the book, Dr. Greene describes a
number of children he worked with who had been tried on
a variety of different meds with limited or no success.

Another common approach - and one that is especially
likely to be recommended by child psychologists - would
involve behavioral intervention. The basic idea is that by
consistently rewarding a child for good behavior,
and consistently "punishing" them when they "explode" (e.g
get angry, throw stuff, curse, etc.) the child will eventually
learn that their tantrums fail to produce any desired
consequences for them and these tantrums would then
diminish. Essentially, through this approach, children learn
that they need to obey parents when commands are given
because things go better for them when they do then when
they don't.

Certainly, behavioral approaches can be enormously
helpful for many children and parents. The literature on the
benefits of well executed behavioral treatment is voluminous,
and this is one of the best-validated psychosocial interventions
that exists. For children whose explosiveness stems from
one or more of the reasons that Dr. Greene identifies,
however, behavioral interventions may not be effective. In
fact, he thinks that they can actually make things worse in
many cases - increasing rather than decreasing the frequency
with which a child loses control.

Here's why. According to Dr. Greene, a child who is
developmentally compromised in the skills of flexibility
and frustration tolerance may have difficulty switching from
their agenda to their parents' agenda (i.e. responding to
a parental command) regardless of how enticing the reward
or how aversive the punishment is. So, if I'm a child who
currently lacks the capacity to behave logically and coherently
when frustrated, then punishing me for telling you to "shut
up" when I've become frustrated may make you feel better
because you "didn't let me get away with it", but it won't make
me any less likely to do the same thing next time. Why? Because
the threat of consequences simply can't have an effect on a
child who is in a state of mind where they are so upset that
the likelihood that they will consider the consequences of their
actions is nil. The analogy is that punishing a child with a reading
disability for doing poorly on a reading test won't result
in better performance on the next test.

It is important to note that this notion runs counter to what
many parents and professionals instinctively believe to be true.
The widely held belief is that if a child misbehaves, then he or she
needs to be punished. If the child is not punished, they will simply
not be deterred from continuing to misbehave, and even to get
worse. Thus, Dr. Greene's thesis here is a controversial one.
I am certainly not suggesting that these ideas are "correct", but do
think this is a very useful perspective to consider. From my
own experience, I can honestly say that no matter how consistently
I might "punish" my younger daughter for getting angry and telling
me to "shut up", the impact this has had on helping her to stay
in better control - or at least to refrain from telling me to "shut
up" when she loses control - has been a BIG FAT ZERO.
Perhaps this is not an unfamiliar situation for some of you as well.


If these options don't work, than what?

Developing an effective approach to dealing with explosive
children is the heart and soul of Dr. Greene's book, and I
can not really do justice to it in this brief review. I will, however,
try to convey the basics of his approach to provide you with
a general understanding of the framework that he recommends.
Specific strategies about what to do are provided in
abundant detail in his excellent book.

===========================================================
The first step is to develop a clear understanding of the
reasons for your child's explosiveness.
===========================================================

This is the key first step. To the extent that parents - and others -
regard a child's explosiveness as reflecting deliberate and
willful attempts to "get what they want", the overwhelming
tendency will be to respond in punitive ways. As noted
above, however, punishments will not be successful with
a child who lacks the skills to handle frustration more
adaptively and, who, when frustrated, can not possibly use
the anticipation of punishment to alter their behavior.

When one's mind set changes from "my child is acting like
a spoiled brat" to "my child needs help in learning to deal
with frustration in a more flexible and adaptive manner",
one can move from a punishment-oriented approach to
a skills-building approach.

Dr. Greene talks about how parents can create a "user-
friendly" environment for their child that can dramatically
reduce the number of explosive outbursts. Doing so
involves a combination of steps including:

Making sure that all adults who deal with the child
have an accurate understanding of the child's unique
difficulties, especially those that contribute to the child's
explosiveness. (Note: Consultation with a mental health
professional to get an accurate understanding of these
difficulties can be absolutely essential.)

===========================================================
Parenting goals are judiciously prioritized such that
the demands for flexibility and frustration tolerance
that are placed on the child are reduced.
===========================================================

In other words, parents have to make a concerted effort
to make life easier and less frustrating for their child. Just
like a child with a reading disability requires accommodations
in what they are expected to do academically, a child with
a "disability" in tolerating frustration requires analogous
accommodations. This can be difficult for parents - and
teachers - to do, particularly as long as the child's
behavior continues to be regarded as deliberate and willful.
Specific recommendations that Dr. Greene provides to
accomplish this task are presented below.

===========================================================
Efforts are made to identify in advance the
specific situations that tend to trigger inflexible-
explosive episodes.
===========================================================

Although not all explosions can be predicted, parents can
often get a very clear picture of the situations that tend to
be consistently difficult for their child to handle (e.g. going
shopping, having to do homework, getting ready for bed.)
Once these triggering situations are identified, parents can decide
whether they can be avoided altogether to reduce the child's
frustration, which can be altered in ways that make it easier
for the child to deal with, and which are, unfortunately,
unavoidable. For example, for a child who has meltdowns in
a store when he/she can't get what she wants, simply not
taking them with you as infrequently as possible can be
quite helpful until they develop the skills to handle their
frustration better. With homework, accommodations can
often be made in terms of the amount of work the teacher
requires the child to do.

=========================================================
Parents recognize that a child's behavior during
meltdowns for what they really are: incoherent
behaviors.
=========================================================

When a child has begun to lose control - or has already
lost control - and starts screaming and cursing at a parent,
it can be excruciatingly difficult not be become angry and
hurt. As a result, it is all too easy for parents to get drawn
into making a punitive response, or a demand on their
child ("You apologize now!") that only serve to add fuel
to the fire.

As tempting as such responses are, Dr. Greene suggests
that parents carefully consider whether they really accomplish
anything positive. For example, he talks about asking many
parents whether their history of punishing their child for
such behavior has had any effect at all in reducing the
likelihood of such behavior occurring the next time the
child becomes frustrated. When many parents consider
this question, they realize that it has not. So, if the primary
reason for punishing a child is to change the child's behavior,
and this is clearly not working, one can legitimately question
the utility of punishment.

When behavior that occurs in the midst of a meltdown is
seen instead as incoherent behavior that the child can not
currently control, a different mind set is possible. One can
focus instead on how to help the child regain control, which
will inevitably lead to the end of the behavior that parents
find so upsetting and offensive.

A critical belief that underlies this approach is that the
vast majority of explosive children really do want to behave
better and feel badly about their outbursts. Thus, they are
already motivated to change their behavior but just lack
the skills to do it. Therefore, they don't need more
motivation to behave better (increasing motivation is what rewards
and punishments are supposed to do). Instead, they need
to acquire the skills that will help them to achieve something
they are already motivated to accomplish.


THE "BASKET" APPROACH

When a child is experiencing frequent meltdowns, the
toll on the child, parents, and siblings can be enormous.
Unfortunately, I speak from some experience on this topic,
as my younger daughter is prone to the types of episodes
that Dr. Greene describes.

Because such explosions are so difficult for everyone in
the family to endure, the primary objective in working
with such children is to first reduce the frequency of
such episodes. For example, just reducing the number
of meltdowns from several per day to one per day, and
eventually to just a handful per week, can make an
enormous difference in the quality of family life. Initially,
this is accomplished largely by reducing the demands to
tolerate frustration that are made on the child. Dr.
Greene refers to this as the "basket" approach.


Basket A

Some behaviors are clearly so important that they have
to remain non-negotiable, even if enforcing them will
result in setting off a meltdown. Initially, Dr. Greene
suggests that the only behaviors to be placed in
Basket A are those that are clear safety issues
(e.g. wearing a seat belt in the car; not engaging
in dangerous or harmful behaviors such as hitting
others). These core behaviors that have clear
safety implications are where parents must continue
to stand firm and require compliance on.

As important as these Basket A behaviors are, it is
also important to note the kinds of things that may
not initially be placed in Basket A. Dr. Greene
suggests that these can include such things as homework,
not yelling at parents, brushing one's teeth, etc. To
make it into Basket A, 3 criteria must be met:

1. The behavior must be so important that it is really
worth enduring a meltdown to enforce:

2. The child must be capable of exhibiting the behavior
on a fairly consistent basis.

For example, Dr. Greene would argue that there is no point
insisting that completing assigned homework be placed in Basket
A when there is little chance that he or she has the skills and
frustration tolerance to do this consistently.

3. It must be something that you are actually able to
enforce.

There are many things we wish our child would do that we are
simply in no position to control. For example, you may want to
insist that your child not hang out with certain peers during the
school day, and there may be some very legitimate reasons for
this. This, however, is not something that most parents are in any
position to be able to enforce. As a result, you can wind up
triggering meltdowns for no real reason and wind up undermining
your credibility to boot.

Simply by greatly reducing the number of behaviors for which
compliance is non-negotiable to those that are really essential,
that the child is capable of performing, and that the parent is
capable of enforcing, the number of exchanges that are likely
to set off explosive episodes is drastically reduced.


Basket B

B - the most important basket according to Dr.
Greene - contains behaviors that really are high priorities
but are ones that you are not willing to endure a meltdown
over. These can include such items as completing school-
work, talking to parents with respect, complying with
reasonable expectations, etc.

It is around Basket B behaviors that Dr. Greene believes
that critical compromise and negotiation skills can be
taught to your child. For example, suppose your child is
watching TV and you know it is time to stop and get started
on homework. You tell your child to turn off the TV and get
started, and he refuses.

The temptation here would be to insist on immediate
compliance and to threaten punishment (e.g. no TV for the
rest of the week) if your child does not comply. But, in
Dr. Greene's framework, this is not a safety issue, and
thus should not be placed in Basket A. He would ask
what is likely to happen if you make such a response?
One likely consequence is that your child's frustration will
increase, he or she will lose control, and a full-fledged
meltdown will ensue.

Is this worth it? Now, if standing firm and tolerating this
meltdown really made it more likely that your child would
readily comply the next time you made such a demand,
the answer might be yes. If, however, standing firm and
triggering the meltdown in no way increases the likelihood
of future compliance or decreases the likelihood of future
meltdowns, Dr. Greene would suggest it was definitely
not worth it. Unfortunately, this can often be the case.

What to do instead? Dr. Greene argues that these Basket
B behaviors provide wonderful opportunities to try and
engage your child in a compromise and negotiation process.
In the scenario above, the parent could say something like,
"I know that it is important to you to keep watching TV. I
would like for you to be able to do this, but I also know
that you have homework that needs to get done. Let's
try to come up with a compromise where you'll get some
of what you want, and I'll get some of what I want."

The goal here is not just to get the child to give in and do
what you want, but to begin to help your child learn the
compromise and negotiation skills that will contribute to
his or her gradually becoming more flexible over time.
Dr. Greene points out how this process can be extremely
difficult for inflexible-explosive children, and that it is not
unusual for them to become increasingly agitated when
trying to negotiate a solution.

As a parent, if you observe this starting to occur, and sense
your child is getting closer to a meltdown, the goal becomes
trying to diffuse the tension so that a meltdown does not take
place. This can mean offering compromise solutions for the
child in an effort to help things calm down. When this does
not work, Dr. Greene suggests just letting things go so that
the meltdown is avoided. In the example above, should the
efforts to negotiate fail and lead the child to the verge of
a meltdown the parent might say, "Well, I can see you are
getting really upset about this. I appreciate that you tried
to work out a compromise with me but we have not been
able to come up with a good one yet. So, why don't you
just watch a bit more TV for now and we can try again in a
little while to work out a good compromise."

This can be very difficult to do. Certainly, many parents - and
mental health professionals - would be concerned that such
actions would result in teaching the child that he or she can
get what she wants simply by refusing to give in and becoming
upset. This is certainly what a traditional behavioral therapist
would argue. From Dr. Greene's perspective, however,
insisting that the child turn off the TV when a compromise was
not reached would accomplish little more than triggering a
meltdown that would also prevent homework from getting
started on and be much more upsetting for everyone. So,
instead, you do your best to help your child develop some
much needed negotiation skills, but drop things when it is clear
that an explosion is imminent. Later, when the child has
settled back down, you can resume your efforts to negotiate.
(By the way, this can also be quite beneficial in helping
parents to keep their composure as well - it has certainly
been that way for me.)

Developing these skills to compromise and tolerate frustration
don't happen right away. Dr. Greene points out that progress
in these areas can be painstakingly slow, but that over time,
the approach he recommends can lead to substantial gains
for explosive children.


Basket C

Basket C contains those behaviors that once seemed like a
high priority but have since been downgraded considerably.
These are behaviors that you simply don't mention anymore
let alone endure meltdowns over. By placing a number of
previously important behaviors in Basket C, the opportunity
for conflict producing meltdowns between parents and
their child is greatly diminished.

What kinds of things belong in Basket C? This depends on
the specifics of each situation but may include such things as
what a child will and will not eat, what clothes they wear, how
they keep their room, etc. The question to ask in determining
whether a particular behavior falls into Basket C is "Is this
so important that it is really worth risking a meltdown over?"
If not, and you've already identified a number of behaviors
that seem more important and worth negotiating over (i.e.
those in Basket B), then into Basket C it goes.

Isn't this just giving in to a tyrannical child?

Not necessarily. Dr. Greene points out that there is an important
difference between giving in and deciding what behaviors are
important enough to stand firm on. It remains the responsibility
and prerogative of parents to be clear about what is non-negotiable,
when compromise is a reasonable way to go, and what things
to let slide for the time being. As the child becomes better able
to tolerate frustration and learn much-needed compromise and
negotiation skills, more and more behaviors can be moved from
Basket C into Basket B, thus providing your child with increasing
opportunities to practice learning to compromise.


DOES THIS APPROACH WORK?

It is important to emphasize that although Dr. Greene is a well-
regarded researcher in child psychology, the approach described
in this book is based primarily on his own clinical experience.
He does not cite any studies in which the approach he recommends
has been rigorously evaluated. So, the data to support this system
is not yet available to the best of my knowledge.

That being said, I will say that I found many of his ideas to be
quite sensible and compelling. For children who are prone to
frequent explosions, the goal of reducing the frustration in their
lives to decrease the frequency of their outbursts is critical. Also,
recognizing that these explosions often reflect a real lack of
ability to handle themselves more adaptively rather than being
willful and intentional certainly applies to many children with
these difficulties. If you buy this premise, then it is reasonable to
argue that punishments won't be effective in altering this behavior.
Instead, such children need to learn the skills that can help
them maintain better control.

I have been trying this approach for the past several weeks
with my own child and have been encouraged with the change
in her behavior that has occurred so far. Things are a little
better. The number of explosions has diminished and this has
seemed like a major blessing. Hopefully, this progress will
continue.

If you have a child who shows the characteristics that Dr.
Greene describes, I would strongly recommend that you go
out and purchase his book. It is thoughtful, well-written, and
offers a set of ideas for helping your child that may be quite
different from what you have considered. I think that it is
certainly worth a careful look.


______________________________________________________________________

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Here is what you will receive as a subscriber:

1. Twelve new issues of ADHD RESEARCH UPDATE - Each issue
reviews 4-5 new studies that will help you to better
understand how ADHD can affect your child's development
and research based strategies that can help you help your
child succeed. This information will probably result in
your being better informed than your child's health care
provider and enable you to advocate for your child in a
more confident and effective manner.

2. The ADHD MONITORING SYSTEM - You can use this simple but
effective system to track how your child is doing in school
and determine when changes or adjustments to your child's
treatment are necessary.

3. Online discussion groups for subscribers only - I hold
monthly chat sessions for subscribers to receive detailed
feedback on their specific questions and concerns.

4. An experienced professional "on call" for you - Do you
have a question and can't attend the monthly chat? As a
subscriber, you'll receive a special mail box to send your
questions to. I do my best to respond to subscriber's questions
within a week. This is not intended as a substitute for
medical advice from your child's health care provider, but
offers you convenient access to information from an experienced
child psychologist who is well versed in the current research
literature.

You'll receive these valuable services for only $19.95/year which
I believe you will find to be an excellent value.

"WHY NOT HAVE THE ADVANTAGE OF THE LATEST RESEARCH
INFORMATION FOR HELPING CHILDREN WITH ADHD?"

You can find complete information about becoming a subscriber at:

https://www.helpforadd.com/subscribe.htm

The more you know about ADHD the more confident and effective
you can be in promoting your child's healthy development. By
subscribing, you will be assuring yourself of receiving the
knowledge and information you need to assist you in this
important task, and your satisfaction is FULLY GUARANTEED.

Sincerely,

David Rabiner, Ph.D.
Licensed Psychologist
Duke University







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