Dr. Bose Ravenel

  

Training for Self-Control – An Evidence-based, Common-sense Solution 

A Pediatrician’s Perspective

DuBose Ravenel, M.D., F.A.A.P., F.C.P.          November 24, 2008

Copyright 2008

            Primary care physicians, educators, and psychologists are faced with a veritable flood of children who are referred for ADD/ADHD evaluations and/or learning  problems, most through their preschool or school.  These children have been identified as having some combination of inattentive or impulsive behavior and under-performing academically in school.  Many have been given a “screening test” in school and the results interpreted as suggesting ADD. Their parent(s) have been advised to get their child “tested” for ADD.  This, of course, ignores the fact that there actually no true test for ADD – only questionnaires describing relevant behaviors in subjective terms and results interpreted with arbitrary cut-offs to distinguish normal from supposedly disordered. 

My busy pediatric practice is no exception.  I have faced the mounting pressure to diagnose and medicate increasing numbers of these children, all the while intuitively sensing that there must be a better way to help them than to rely upon medical diagnoses and giving medication as the primary means by which they are enabled to restrain their behavior and to pay attention in school.  This concern  increases when I am asked by a parent of a child who has been on stimulant medication for a number of years already, “Dr. Ravenel, when will we be able to stop (Johnny’s) medication?”

            My heart sinks, because I know that a truthful answer to this question is that this child may well “need” to rely on his medication for an indefinite number of years, and with the now exploding diagnosis of “ADD” in adults, he may well never develop sufficient self-control and self-discipline without these medications.  Furthermore, I know but am presented with a dilemma to tell the parent, that there is no reliable research on the potential risks from the long-term use of these medications if taken for years, or even decades, as has become increasingly common. This lack of long-term properly designed scientific evidence for safety and effectiveness of methylphenidate (and other stimulants) has been noted by Australian researcher Natalie Sinn in her comments relating to her research on providing nutritional supplements to help with the behaviors that define ADD discussed later.[1]

The two most frequent diagnoses I encounter with regard to otherwise normal children who display common problems of behavior and learning are attention-deficit disorder (ADD) or attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD).  (For purposes of simplicity, in this essay the term “ADD” will be used to indicate both forms of the diagnostic nomenclature.)  The prevailing medical model for conceiving and managing these children assumes that there is a neurological or biological cause, with strong genetic influence, and effectively relies completely upon psychotropic medications.  Although this medical model for ADD gives lip service to the idea that one should “try behavioral methods first,” in reality this is seldom done, or if so, relies upon ineffective reward-based or primary self-esteem-building approaches. 

One of the most widely quoted research studies cited by proponents of the prevailing neuro-biological conceptualization of ADHD (referred to herein as the “ADD Establishment”) is known as the MTA study (Multimodal Treatment Study for ADHD), widely accepted among prescribing practitioners as the definitive study to date.  The behavioral approach used in this study was so intensive and expensive as to be impractical for widespread application – yet even this rigorous attempt to manage these children without medication, according to usual interpretation, led to insignificant improvement in the core behaviors defining ADD.  It is understandable that behavioral management of ADD and ODD behaviors is generally ignored or only receives token commitment.  The prevailing reward-based behavioral approach, modeled after that used by researchers in the MTA study, has been found inadequate for highly inattentive or misbehaving children.

            And so it was with some hope balanced by skepticism that a few years ago I began to consider seriously alternative approaches that might provide an effective way to manage children with ADD or ODD without relying on drugs.  Beginning tentatively with select parents who were highly motivated to avoid medicating their children, I found that it is possible, in fact, to put in place behavioral approaches and other changes in the child’s environment that are followed by resolution of ADD or ODD behaviors within weeks to a few months when parents (caretakers) buy into the ideas and commit to implementation.

First, I used the Caregivers Skills Program (CSP) described by Dr. David B. Stein in his book for parents[2] and in the paper describing for professionals his clinical research and rationale for his approach.[3]  Stein assumes that inattentive and impulsive behaviors exhibited by these children reflect a lack of training and motivation for appropriate behaviors rather than stemming from neurological or biological causes.  Behavioral management consists of avoiding prompts, reminders, and rewards, while implementing a rigorous though non-punitive system of consequences for target behaviors of inattention or impulsivity.

Further successful experience followed parent training based on best-selling parenting author and speaker John Rosemond’s parenting approach.[4]  His writing reflects similar assumptions with regard to the cause of the behaviors defining ADD and ODD and teaches  child-rearing principles predicated upon parents using powerful love and powerful discipline, avoiding over-indulgence, over-protectiveness, and reactive, emotional responses to the child’s misbehaviors, along with restricting exposure to television and other forms of electronic media.

Psychologist and author Howie Glasser’s Nurtured Heart approach used  in Tucson Arizona for a large number of “hard case” referred children with ADHD and ODD problem behaviors was found to utilize similar behavioral principles.[5]  An opportunity for Dr. Glasser and myself to share our individual experiences  during a Nurtured Heart Conference in a nearby city further encouraged me to offer my own developing approach to parents.

            My analysis of various cultural forces that have been reported to impact children’s behavior and learning led to developing an alternative non-medical model for conceiving and managing common problems of inattentive and oppositional behavior in otherwise normal children.  I assume that most children with ADD or ODD behaviors are not neurologically or genetically defective and therefore incapable of learning adaptive behavior, but rather that they are suffering primarily from the effects of reversible or correctable cultural and developmental influences in their lives.  I assume furthermore that most of these children are perfectly capable of learning to pay attention and to learn self-control and to assume responsibility for their behavior.  This paradigm for ADD was described in a psychology journal[6] and has been updated since.[7]  With success in a number of cases and as the developmental model for ADD and ODD emerged, I began systematically to offer this approach to parents of children with problems that fit into these categories. 

Training parents in the principles of authoritative parenting centers about training the child for self-control rather than the prevailing self-esteem-promoting approach favored by psychological theory.  This was combined with restriction of exposure to rapid passive electronic stimuli.  More recently, screening for potential nutritional and dietary influences on the child’s behavioral and learning problems has been utilized and recommendations provided for changes in diet and/or provision of supplements such as omega-3 fatty acids when indicated.   

My experience has been that most parents of children with the ADD or ODD behaviors, if offered a way to deal with their child’s problems in a corrective manner without relying on drugs, are enthusiastic about taking such an approach.  With rare exceptions, these parents have never previously been offered a non-drug based approach, undoubtedly because practitioners are unaware of non-medical ways to deal effectively with these children’s behavioral problems.  I do not fault these practitioners, because research literature on ADD and ODD is influenced overwhelmingly through direct or indirect pharmaceutical company support, as well as  pharmaceutical company reps visiting prescribing practitioners, providing lunch, and directly presenting pharmaceutical company data.  It goes without saying that this kind of support is lacking for alternative non-drug approaches.

 Furthermore, because this approach is unproven, it may not covered by insurance.  It is recognized that in order to gain widespread awareness and acceptance among professionals, as well as to increase the probability of insurance coverage, it will be necessary for carefully designed studies to be done comparing results in children managed by this approach with those managed with conventional medications and with the course in comparable control children.  Since pharmaceutical company support has enabled generation of thousands of published studies relating to the use of medications, it is obvious that some other source of research funding will be necessary before the proper studies can be done.  It should be obvious that correcting the underlying behavioral or attention problems within a few weeks to months promises to be cost-effective when compared to the prevailing medical approach leading to years if not decades of reliance on physician visits and expensive medications, leaving aside the potential harmful effects from these medications.  The potential for much of the initial parent-training to be done in group sessions should provide additional opportunity for cost effectiveness. 

Parents respond well to the idea that a few weeks or months of their commitment to this approach, although with no guarantee of a successful outcome, does provide a realistic possibility that their child can be enabled to learn the trainable skills of paying attention and assuming self-control – in essence, to “cure” their child’s ADHD or ODD behaviors. It further fulfills the ideal  to “try behavioral methods first” in cases of this type before resorting to medications.   Parents intuitively understand and embrace the approach with a high degree of acceptance. Due to unfamiliarity of professionals with the potential of this approach and their virtual “brainwashing” over the years with the extensive pharmaceutical industry-influenced research literature, it is not unusual to encounter skepticism upon their first exposure to these ideas. When asked if there is any published body of research that establishes this model for interpreting and managing the behaviors that define ADHD and ODD and challenged to justify rejecting the pharmaceutical-centered model, I respond with the following:

 

1. There is no research study comparing this approach with the prevailing neuro-biological model and medication-centered treatment. It must be realized, however, that the potential exists for “cure” of the behavioral symptoms, while the medical model relies upon ongoing medication treatment, and its proponents virtually never even consider, let alone discuss, the concept of correction as opposed to control with ongoing reliance upon powerful medications.
2. As outlined herein and discussed at length in cited sources, there is a quality evidence base that supports the individual components within the model. Despite the long-standing widespread acceptance of the medical model and the almost incalculable amount of money spent to produce the vast literature promoting it, firm supportive evidence is lacking. There are no long-term studies demonstrating favorable outcomes compared to untreated ADD individuals years to decades after taking the medications.  Furthermore, the risks of long-term  harmful effects upon the brain are unknown.  It has been confirmed by recent research that stimulant treatment may impair growth, both in height and weight,[8] as well as already recognized possible side effects of cognitive constriction, or loss of creativity,[9] psychotic episodes,[10]^,[11] addiction in case of abuse (classified as Schedule II drug), and serious cardiovascular risks if there is any undiagnosed cardiac abnormality.[12]  The Director of the National Institute of Mental Health and  a noted molecular psychiatry researcher  have described changes in the function of nerve cells that occur as adaptations to prolonged treatment with psychotropic drugs, whereby stimulant- induced increases in neurotransmitters act as initiating events for longer-term changes in nerve cell function.  In their words, “the result of these types of repeated perturbations or initiating events is to usurp normal homeostatic mechanisms within neurons, thereby producing adaptations that lead to substantial and long-lasting alterations in neural function.”[13] (emphasis added)

For the interested reader, an in-depth discussion of the flaws in interpretation of existing research that characterize the medical model and the logical and evidence base suggesting an alternative explanation for the causes of the behaviors that define ADD and ODD can be found elsewhere.[14]^{,[15],[16],[17]  Â} There is no risk in “trying behavioral methods first” as virtually all professional guidelines recommend before resorting to potentially long-term use of medications, in contrast to risks of reliance upon powerful psychotropic medications, on some of which are mentioned above.

       Although the role of nutritional and dietary factors is usually downplayed in mainstream ADD circles, a number of sources have in recent years suggested that this skepticism is unwarranted:

Ø  Researcher Laura Stevens and her colleagues reported beneficial effects of essential fatty acid (EFA) supplementation in children with inattention, hyperactivity, and other disruptive disorders.[18]

Ø  Recognized nutritional medicine expert Leo Galland, MD. has summarized research in the role of these therapies for ADHD and his experience in successfully managing hundreds of children with ADHD without medications over the past twenty years.[19]  He provides a user-friendly, practical survey instrument with which to screen ADHD children for a high probability that nutritional factors play a significant role in the genesis of their ADHD behaviors, along with specific recommendation for supplementation in cases where screening suggests this is appropriate. 

Ø  Dr. Alexandra Richardson in carefully designed studies comparing the effects of placebo with administration of omega-3 fatty acid supplements has shown a remarkable positive effect on both behavior and learning among those receiving supplements.[20] Although subjects did not have a formal ADHD diagnosis, 31% of the children were found to have measures of behavior that would place them within the usual range for an ADHD diagnosis according to the standard mental health reference guide known as the DSM (Diagnostic Statistical Manual).  After 3 months of treatment 7 of 16 of these children no longer fell into this category compared with only 1 of 16 in the placebo group.  The magnitude of the beneficial effect of this nutritional intervention over 6 months compares favorably with the improvement from methylphenidate (Ritalin) -  with  almost as much improvement at 30 days but longer lasting favorable effects than medication according to a summary of published research.[21] 

Ø  A well designed study of children in Australia recruited for ADHD-related learning and behavioral problems compared the effects of a supplement containing an average dose of one of the important essential fatty acids known as EPA of 496 mg daily with that of a placebo over 15 weeks.  A one-way crossover trial was then conducted in which all participants received active supplements, with those taking placebo initially changing over to active supplement half way through the trial and a similar switch from supplement to placebo by the others.  During the initial 15-week trial, medium to strong positive treatment effects were found on parent ratings of core ADHD symptoms such as inattention, and impulsive behaviors on the Conners Parent Rating Scale (CPRS) in the active supplement groups compared with the placebo group. These favorable results were replicated in the placebo group after the one-way crossover and further improvement was found among the initially supplemented group.[22] 

Ø  Another study found significant improvement in behaviors defining ADHD and ODD following eight weeks of daily supplementation with a high-dose (16.2 g) of two important omega-3 fatty acids, EPA and DHA concentrates, with the dosage adjusted at four weeks dependent on the ratio of chemicals in the blood.  Supplementation resulted in significant increases in the levels of EPA and DHA, as well as a significant reduction in another key ratio of essential fatty acids, correlating with improvement in behavioral assessment scores.[23]

Ø  Researchers found fifteen ideally structured trials that studied the impact of artificial food colorings (AFC) on the behaviors of hyperactivity syndromes.  Their review of all studies available at the time confirmed that there was a modest effect of AFC and concluded that “this study is consistent with the accumulating evidence that neurobehavioral toxicity may characterize a variety of widely distributed chemicals.”[24]

In summary, developmental and cultural factors implicated in this non-medical model for ADD and ODD  include the following:

1. A predominant psychological theory-based parenting philosophy that advocates direct elevation of self-esteem, rather than training a child for self-control.  The widely accepted theory that raising self-esteem will lead to improved behavior and achievement in children has for the most part proven wrong – in retrospect, naïve.  Noted social science researcher Roy Baumeister and colleagues in 1996 concluded that a contributing cause of violence in our society is high self-esteem combined with an ego threat.[25] A more recent review of more than 15,000 published articles on self-esteem found that direct efforts raise self-esteem in children fails to lead to improved outcomes but tends to result in narcissism.[26] A carefully designed research study of the association between parenting style and the kind of problem behaviors found in ADD and ODD children found that parenting style seemed to cause  subsequent problem behaviors.[27] This model is consistent with noted social learning theory psychologist Albert Bandura’s research on the importance of what he terms “self-efficacy”[28] (an individual’s being responsible for his own welfare) and avoids the external agency or control implicit in a medical, pharmacological method of management.  In a review of existing research on self-control, Strayhorn  concluded that “Self-control is a psychological skill whose high development could potentially prevent, or aid in the treatment of, vast amounts of psychopathology.”[29]  He further found that this skill can be achieved through training.
2. Exposure to electronic stimuli during childhood. Educational psychologist Jane Healy, former advocate of early exposure of children to computers to prepare them for the computer age, has written extensively about the negative impact of such exposure upon children’s later attention level.[30] This followed an earlier book in which she argued that exposure of young children to television and other electronic media led to a similar negative impact of their ability to pay attention and to impulsivity.[31] Seattle, Washington researchers in a prospective study found that a one-standard deviation increase in television viewing between ages one and three years was followed by a 28% increase in attention problems at age seven.[32] Researchers in New Zealand in their prospective study on television viewing by children followed from age five years through adolescence found that childhood TV viewing predicted adolescent attention problems.[33] Pychologist Richard DeGrandpre has argued that early life exposure to these kinds of rapid, passive stimuli can lead to “hard-wiring” changes in the brain that perpetuate the individual’s experiencing a form of dis-equilibrium when not in the presence of these stimuli.[34]  He describes this as a sensory addiction that causes the child to become  impulsive and inattentive  in the absence of these stimuli.   
3. Nutritional and dietary factors.  Contrary to the prevailing belief among advocates of the neuro-biological explanation for ADHD that such factors play little role in the origin of these behaviors other than for a small subset of children, research has demonstrated a surprising impact on behavior and learning as  described earlier. 
4. The impact of educational trends in contemporary America pushing formal instruction down to younger ages.  Kindergarten for today’s child is equivalent to first grade for children a generation ago with regard to expectations for learning, while children’s ability to pay attention and to learn by formal instruction is probably less now than it was then.  In a Position Statement the National Association for the Education of Young Children (NAEYC) observes that during the kindergarten and early primary grade years learning expectations are imposed upon children that are not justified for their age, “pushing down” educational expectations to younger ages.  The result is said to be that Children entering kindergarten are now typically expected to be ready for what previously constituted the first grade curriculum. As a result, more children are struggling and failing (emphasis added).[35] This may provide the explanation for psychologist Gretchen LeFever’s finding in a community survey in Tidewater, Virginia to determine the prevalence of treatment for ADD with medication.  Among some 770 children who were one year younger than their peers at the same grade level, 79% were estimated to be on treatment.[36] 

After conceiving this model for the etiology and potential non pharmacological approach to ADD/ADHD and ODD, it occurred to me that if this theoretical explanation for the etiology of ADD is valid, one would expect to find a relative absence of these clinical behavioral problems among the Amish. This cultural group in America largely avoids exposure to electronic stimuli, embraces authoritative parenting that stresses early training of children for self-control, and follows dietary and nutritional practices best described as organic, locally grown produce without the use of artificial fertilizers, insecticides, and herbicides, and educational practices that most would consider “old fashioned.”  Several sources  support this idea:

Ø  Psychiatrist Dimitri Papolos and his wife, during the course of their research on genetic factors in the Amish related to bipolar disorder, have written that “symptoms of ADHD were unusual.”[37] 

Ø  In his analysis of the flaws in popular interpretation of research underlying the prevailing medical model for ADD/ADHD, Indiana pediatrician Michael Ruff describes his experience in a small group private practice with the large number of Amish families who are part of his practice:

 

Similarly, our small group private practice has over 800 Amish families and not a single child in this group has been referred to us by the schools for evaluation or recognized by us as having ADD. One culturally induced aspect of the ADD phenomena, which the Amish don't have to contend with, is medication use in borderline cases to enhance performance.I have personally spoken with other non-Amish teachers in that community that echo those same sentiments. Notable of course is that this culture has no television or video games. The children also do physically demanding chores and often play outside. Physical exertion promotes mental exertion and good attentional function.   Although disparate in many ways, the Amish and Indochinese preserve family and cultural values that mitigate strongly against the expression of school problems.[38]

          Ruff’s experience is even more significant when one considers that Amish families tend to be larger than non-Amish families in our culture, and if one assumes that the average Amish family in Ruff’s practice included only two children, this would equate to some 1,600 children – none of whom had been even referred for evaluation of ADHD, nor diagnosed in the practice! Although the above does not prove categorically that ADD does not occur among Amish children, it is certainly dramatic indirect evidence suggesting the likelihood that ADD is unusual among them.  Ruff and his colleagues encounter and diagnose ADD in non-Amish children similarly as do most pediatricians. 

I engaged in conversation with a young Amish adult during a visit to an area with a large Amish community in the Shenandoah Valley area of Virginia.  The young man responded to a query as to what he and other Amish community members heard and said about ADD, he responded: “We don’t hear anything about ADD other than people outside our community talking about it.”[39]

Taking this approach training parents as described above, restricting their child’s exposure to electronic stimuli, and addressing nutritional and dietary influences with children fulfilling research criteria for ADD/ADHD and/or ODD has led to some encouraging results.  A number of children have demonstrated  resolution of the problem behaviors within a few weeks to a few months.  Follow-up as much as three years later has documented stability in the gains observed. Following are examples of successful resolution of ADHD behaviors through use of this approach:

®    ME - An eleven-year-old boy in sixth grade who had been evaluated and diagnosed at a specialty behavioral center was on combined stimulant and antidepressant medications for ADHD and depression, yet was continuing to struggle academically and socially.  He was withdrawn from medications over several months (Dec 2005) with the cooperation of his primary care physician, and parent-coaching begun along with restriction from heavy involvement with electronic stimuli, and making nutritional and dietary changes.

Within three months he had begun to improve in both social and academic functioning.  A follow-up questionnaire one full year after initial improvement showed that of the 18 behaviors defining ADHD, parental observation showed not one of the 18 behaviors reaching the cut-off score, and among three teachers, the only responses reaching the cut-off for a positive score on any of the ADHD behaviors were for two attention items on only one of the three.  This must be placed within the context of the fact that to qualify for the diagnosis, at least six of the nine behavior items on the list of the behaviors relating to attention or to those in the impulsive behavior category must be present to a significant degree.  The process led to both the child and his parents to view him as a special child with unique gifts along with his weaknesses and to abandon the idea that there was something wrong with his brain or with his neuro-chemistry. 

In Oct 2008, after his first quarter in high school (9^th grade) he was making 3 A’s and 3 B’s, receiving positive feedback from teachers and peers, and was becoming self-reliant and self-motivated with minimal parental supervision.

®    JG – Impulsivity and attention problems led to a diagnosis of ADHD by the family pediatrician at age seven years in 2^nd grade and treatment begun with a long-acting stimulant. This was followed by adjustment of doses, then adding medication for sleep problems from his stimulant treatment. He was then treated with Strattera plus clonidine for sleep problems. His parents sought non-medication based management and discontinued all medications. Baseline DSM criteria for ADHD and ODD were met (home and school) as well as criteria in the home only for anxiety/depression.

Parent training for self-control was instituted, and he was made to assume total

responsibility for his homework (this had been a major “battleground”) and consistent expectations for his appropriate behavior imposed. Within two weeks, his teacher expressed amazement at the improvement in his behavior in school, and his class work improved substantially. The teacher, who had expressed skepticism when JG’s parents had informed her of their determination to manage him without medications, was so impressed that she recommended to parents of other children in her class with similar problems to seek the same kind of help.

      Four months following the intervention, repeat Vanderbilt questionnaires documented the absence of any remaining functional impairment and normalization of all areas other than impulsive behaviors in only the school environment – and the teacher’s overall assessment was that JG had improved dramatically. In the absence of any further contact, Dr. Ravenel inquired about JG’s progress 3 ½ years later during an unrelated office encounter with his parents. Now in the sixth grade, he was doing well academically and socially, making A’s and B’s consistently and receiving consistently positive teacher evaluations. He finished the sixth grade with the highest score on his math EOG testing.

®    TP – A seven-and a half-year old 2^nd grade boy was brought for evaluation after his teacher and principal recommended an evaluation for hyperactive and impulsive behavior. Concerns about his ability to pay attention and being hyperactive had been expressed from the time he was three. Evaluation documented the presence of ADHD and ODD behaviors fulfilling DSM criteria.

His parents were determined not to resort to medications, so parent coaching to

train the child for self-control were implemented along with restriction from previous heavy exposure to electronic stimuli. Within six weeks dramatic improvement was observed in both home and school environments. His parents described a transformation of their relationship with TP, whereby he had become more affectionate and the parents enjoyed his company. Follow-up Vanderbilt questionnaires for DSM behavioral criteria showed  resolution of all behavioral symptoms for both ADHD and ODD nine weeks after the initial evaluation appointment.

      In the absence of any further follow-up, Dr. Ravenel called to inquire about TP’s progress three years later.  He was reported to have been a “model child” ever since his initial improvement and in his 5^th grade year at age 10 ½ years was now doing well academically and socially.  It is noteworthy that his parents were able to deal with his behavioral problems successfully despite going through a divorce during this period of time. 

®    JH – This eleven-year-old 6^th grade homeschooled boy was brought for evaluation of problems with reading, writing, and reading comprehension. He had continued to lag about one year behind grade level for reading despite ongoing special educational help with reading. His history included heavy exposure to electronic stimuli and a dietary history of a high intake of processed carbohydrates and sugar. DSM criteria for ADD were present in the home environment.

Because the history suggested that his problems were primarily a consequence of

his dietary habits and the heavy exposure to electronic stimuli, intervention consisted primarily of dietary changes along with restriction of electronic stimuli, along with regular exercise. Processed carbohydrates were sharply reduced, and he was given an omega-3 fatty acid supplement. Two months later he was markedly improved, and repeat Vanderbilt questionnaires for behavioral criteria for ADD demonstrated resolution of all inattentive behaviors. He has continued to do well since.

      JD illustrates a child whose inattentive behaviors comprising ADD-Inattentive were clearly caused by his diet and exposure to electronic stimuli and which resolved shortly after correction.

Increasing reports of diversion and abuse of stimulants, side effects of medications often used in managing ADD and ODD, and growing controversy from the use of powerful psychotropic drugs even for younger, preschool age children in whom long-term effects are not known, suggest that the prevailing medical model must be reconsidered. Parents and professionals are looking for alternative approaches, and it is time to revisit the traditional medical primary commitment, primum non nocere (do not harm).   

Ultimately one is faced with a fundamental choice if intervention is adopted: To train and motivate a child to assume responsibility for his or her behavior and to learn self-control, - or alternatively to rely upon an external locus of control in the form of a pharmacological agent, the very success of which becomes highly reinforcing and likely precludes the individual from developing skills for autonomous self-control and self-efficacy. The words of Harvard University- affiliated psychologist Anthony Rao[40] serve as a fitting conclusion to this discussion: