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87 Cards in this Set

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Attention-Deficit/Hyperactivity Disorder (ADHD)
--Classification of Child Psychopathology
Externalizing – most common, problematic
ADHD
Oppositional-Defiant Disorder
Conduct Disorder (Delinquency)
Internalizing
Same diagnostic criteria as adults
Several other diagnoses unique to children
Theoretical Issues Illustrated
Abnormal behavior from child’s verus adult’s perspective
Effects of labeling – good or bad
Quantitative versus qualitative differences
The effect of context on child behavior, especially school
Genetic influences
Reciprocal causality – how ADHD kids affect/are affected by others
Background History
“Brats” until George Still in 1902
Minimal brain dysfunction
Hyperkinetic reaction of childhood
Attention deficit disorder (ADD)
ADHD – primarily HA/Impulsive versus primarily AD
(Impulsive will be part of name soon)
Misunderstandings
Minimal brain dysfunction/damage (MBD) and circular reasoning
--Still's hypothesis, no data. Later some data showed brain damage can cause ADHD occasionally. Neurological soft signs: finger to nose; shadowing finger moving in other hand; infer from overactive beh that MBD exists. Cannot logically draw conclusion - circular reasoning.
Misunderstandings
So-called “Paradoxical Effect” of psychostimulant medications
Speed slows ADHD children down vs nomral people. As of 1980 no normal children studied, unethical. Children of PhD's were volunteered. *Small dosages; overactivty has no brain structure effect.
Major Symptoms
--Inattention
Selective versus sustained attention
- Distractable problems w/ selec attention (background noises): not the main attention problem. Sustained attention: focusing for a long time on a boring task.
--Over activity
--Impulsivity (acting before thinking)
Fidgety vs large motor activity (ex. Stabilometer - woopee cusion; self winding watches; move more even in sleep - more than attention problem)
- Structured vs unstruc settings: more likely to be overactive in struc settings. Not on playgound; not usu diag before kindergarten. After high school some difficulties of that env are mitigated.
Treated like a contiuum, but cut-offs:
Six or more of the following problems; how much is enough attention? Count of symptoms but then a cut-off. Qualitative, arbitrary.
Video: Jimmy
Rapid speaking, mother's role. Not on the border. Mother is loving yet firm and directive to keep ODD from developing. Blinking (tics usually disappear w/ age. Medic can also cause tics to devel). Difficult to diag on interview or one session; teachers help to diagnose.
Subtypes
Primarily inattentive; different problem? ADD
Primarily hyperactive or combined
Comorbidity
Oppositional defiant disorder (ODD) (aggression, viol of rules)
Learning disability (LD)
Mood disorders (depression, bipolar)
Comorbidity
50% to 80% overlap with ODD
20% or more with LD
Separate disorders not same or subtypes
- Some overlap with mood disorders. What percent will later devel bipolar disorder? Some small subset probably has early signs.
- ADHD children more likely to abuse drugs, but not those comorbid with ODD.
Developmental Course
Infancy – difficult temperament?
Preschool – often not an issue, although drug use has increased (x3 in 1990s; less struc than elementary school)
Developmental Course
(More car accidents in ADHD children, now continued medic)
School aged – key period for diagnosis; medication also shows school focus
Adolescence – not outgrown, but HA less (treatment was usu stopped)
Developmental Course
Adulthood – adult ADHD; niche picking
Continuity due to ADHD or comorbid problems?
ADULT ADHD – a growing diagnosis; inattentive and impulsive; should have been diag as child? First diag as an adult though: broadening of diag category and overlooked. [Change in residence more often, go less far in school; still as happy.] Criminals as adults: b/c of comorbidity ODD can be from ADHD rejection.
Attention-Deficit/Hyperactivity Disorder (ADHD)
--Classification of Child Psychopathology
Externalizing – most common, problematic
ADHD
Oppositional-Defiant Disorder
Conduct Disorder (Delinquency)
Internalizing
Same diagnostic criteria as adults
Several other diagnoses unique to children
Theoretical Issues Illustrated
Abnormal behavior from child’s verus adult’s perspective
Effects of labeling – good or bad
Quantitative versus qualitative differences
The effect of context on child behavior, especially school
Genetic influences
Reciprocal causality – how ADHD kids affect/are affected by others
Background History
“Brats” until George Still in 1902
Minimal brain dysfunction
Hyperkinetic reaction of childhood
Attention deficit disorder (ADD)
ADHD – primarily HA/Impulsive versus primarily AD
(Impulsive will be part of name soon)
Misunderstandings
Minimal brain dysfunction/damage (MBD) and circular reasoning
--Still's hypothesis, no data. Later some data showed brain damage can cause ADHD occasionally. Neurological soft signs: finger to nose; shadowing finger moving in other hand; infer from overactive beh that MBD exists. Cannot logically draw conclusion - circular reasoning.
Misunderstandings
So-called “Paradoxical Effect” of psychostimulant medications
Speed slows ADHD children down vs nomral people. As of 1980 no normal children studied, unethical. Children of PhD's were volunteered. *Small dosages; overactivty has no brain structure effect.
Major Symptoms
--Inattention
Selective versus sustained attention
- Distractable problems w/ selec attention (background noises): not the main attention problem. Sustained attention: focusing for a long time on a boring task.
--Over activity
--Impulsivity (acting before thinking)
Fidgety vs large motor activity (ex. Stabilometer - woopee cusion; self winding watches; move more even in sleep - more than attention problem)
- Structured vs unstruc settings: more likely to be overactive in struc settings. Not on playgound; not usu diag before kindergarten. After high school some difficulties of that env are mitigated.
Treated like a contiuum, but cut-offs:
Six or more of the following problems; how much is enough attention? Count of symptoms but then a cut-off. Qualitative, arbitrary.
Video: Jimmy
Rapid speaking, mother's role. Not on the border. Mother is loving yet firm and directive to keep ODD from developing. Blinking (tics usually disappear w/ age. Medic can also cause tics to devel). Difficult to diag on interview or one session; teachers help to diagnose.
Subtypes
Primarily inattentive; different problem? ADD
Primarily hyperactive or combined
Comorbidity
Oppositional defiant disorder (ODD) (aggression, viol of rules)
Learning disability (LD)
Mood disorders (depression, bipolar)
Comorbidity
50% to 80% overlap with ODD
20% or more with LD
Separate disorders not same or subtypes
- Some overlap with mood disorders. What percent will later devel bipolar disorder? Some small subset probably has early signs.
- ADHD children more likely to abuse drugs, but not those comorbid with ODD.
Developmental Course
Infancy – difficult temperament?
Preschool – often not an issue, although drug use has increased (x3 in 1990s; less struc than elementary school)
Developmental Course
(More car accidents in ADHD children, now continued medic)
School aged – key period for diagnosis; medication also shows school focus
Adolescence – not outgrown, but HA less (treatment was usu stopped)
Developmental Course
Adulthood – adult ADHD; niche picking
Continuity due to ADHD or comorbid problems?
ADULT ADHD – a growing diagnosis; inattentive and impulsive; should have been diag as child? First diag as an adult though: broadening of diag category and overlooked. [Change in residence more often, go less far in school; still as happy.] Criminals as adults: b/c of comorbidity ODD can be from ADHD rejection.
Epidemiology, Associated Features
Prevalence 3-5% (UK: <1%)
Cultural differences in activity
Differences in diagnostic practice
Ethnic issues in US diagnosis
Boys 3 to 1
IQ slightly lower than average (testing problem?)
Impaired relationships, self-esteem
Although MEASURED self-esteem is elevated…
Epidemiology, Associated Features
US consumes 90% of world's psychostimulants; illegal in sweden (social control drugs); some inner city schools have 1/2 of children on medic; easy solution instead of changing school sys. Self reports - over higher self esteem (defensiveness? appears lower)
Etiology
Florescent lights
Hand-eye coordination
Sensory-motor integration
--Failure to develop program of motor skills - walking before crawling. Food additives; flourescent lights which were new in schools in 1950s, 60s. Visual motor integration: hand eye exercises.
Bottom line –
multiple caused; need to subdivide diagnosis in future
- Brain damage can cause ADHD; trauma; infections (mengingitis, encephalitis).
Minimal brain damage
Soft signs (thought to reflect neurol problem vs lesion which is a hard sign; behavioral vs clear evidence)
Minor physical anomalies (assymetries in facial features in ADHD children as a group)
PBCs (preg and birth conflicts)
Frontal lobe
Evolutionary differences? (may explain a small subset)
Diet
Feingold diet – salicylates (30 yrs ago; food additives; best selling book; sugar only leads to tooth decay and overweight; lead poisoning; congressional hearings - about to be made illegal. Then trials; parent effort-placebo effect. Maybe .001% of children do have strange reactions. Sugar does not make children hyper)
Sugar
Lead poisoning
Toxic level (which is?) causes brain damage esp in children; LDs, overactiviity. Now unleaded gas. Paints used to be lead based until 1970s; older houses, poor family, peeling paint, children may yeat; small percent of adhd problem.
Genetics – Levy et al study
Goal: Heritability of ADHD for category vs. continuum
Huntington’s analogy
Method: Twin study; general population sample; largest N to date
Results: ~80% MZ; ~40% DZ
Same 5/8 symptoms; same category or continuum
Implications
ADHD = Extreme variation on normal genetic trait
Issues: Equal environments (DZ dissimilarity); polygenic characteristics; possible subtypes might involve single gene
Heritability caution
Environment constant = 100% genes
Quantitative versus qualitative differences (gene not = qualitative either/or)
Etiology (cont.)
Response to environmental stress
Mothers are “worse” (25 yrs ago, mothers more neg w/ adhd children)
Cause or effect?
Probably a cause in some cases… Random psychstim medic (immed effect), interactions diff: more pos (better mom) if children appear on medic.
Treatment
Psychostimulants
(inc alertness, dec appetite, inc attention. Major adhd treatement: alternative treatment is beh th (struc parent and teacher training, rewarding for beh). Other treatments: Play therapy (NO EVIDENCE) APA refuses to say treatment offers must have a research base as in hospitals!
Psychostimulants
Ritalin (no effect after 4 hrs but immediate, get another pill after lunch), dexedrine (extended release ritalin), adderall (extended release, mixed amphet salts)
--Effective in about 70% of cases; stat sig; but clin importance more sig (ex grade inc from 88-89%); these are clin sig for adhd. Study: give medic w/o telling teacher, dramatic enough that they noticed, not placebo effect.
Psychostimulants
Dramatic inc in usage; 3 - 7x inc in 15 yrs (1.5 mill children every yr); 3x inc for preschools; used 3-10x more in US vs England, canada, australia. Combined w/ ssri's. Other medic: strattera: only approved, nonstim, for adhd, usu for adults: less potential for abuse; specific noreph uptake, inhib. Antidep if others do not work.
Beh therapy vs stimulants in MTA study
Multiple sites, 100s of children, experiment. Multiple researchers, randomizing for cause and effect. Combined 68%; medic manag 56%; beh th 34%, community care 25%. Objective: category outcome measure; sec outcome study; based on guaranteed improvements of clinical sig. Right after treatment ends. Twice as many w/ clin importance if combined condit vs beh th or cc. (CC also on medic)
MTA: Behavior Therapy vs. Psychostimulants
Swanson et al. (2001)
Significant results
Combined superior to medication management
Combined/medication management superior to behavior therapy
Behavior therapy not different than community care
Clinically significant, not just statistically significant
Is adding behavior therapy worth the cost?
Medication is cost effective
MTA: Results at 3 Year Follow-Up
(study done by psy and psychiatrists, competing interests)
Substantial improvements for all groups
Only about 50% now meet ADHD diagnosis
Differences between treatments disappear
Important changes in medication use (50% of time) from 14 to 36 months
MTA: Results at 3 Year Follow-Up
Combined/med mgmt 91% later 71%
Behavior therapy 14% later 45%
Community care 60% later 62%
MTA: Results at 3 Year Follow-Up
Long term results:
Why is cc 25%? Don't change dosage or getting advice from doctor - focused effort helped (not a placebo).
-- No diff btwn groups: less faithful as before on medic manag to cc level. Psy treatments more lasting: parent changes accumulated over time. No study has found that long term effects for medic maybe b/c children do not stay on consistently. No long term grade/SAT score benefits: medic for teacher's sake? Or b/c not staying on medic?
Potentially serious medication side effects:
((Diabetes: with careful management leads to longterm medic effects, but many do not))
Growth
One to 1 ½ inches shorter
Six to nine pounds lighter
(25 yrs ago, thought stunted growth, then that growth would rebound. Now weight and height are stunted 3 yrs later! Still rebound by 18?
MTA review
--clin trials
Gold standard, biggest study of adhd treatmt; first major clin trial of ANY childhood disorder. -- large samples, mult sites, many therapists, random assignment***; standardized treatments (usu 2+ well accepted alt, not new vs placebo); careful assessment of chnage: longit follow ups (often diminish over time).
MTA results 3 yrs later
Substantial improvements for all groups, only 1/2 now meet adhd diag criteria (were the others borderline?) Diff btwn treatments disappear. Important changes in medic use (1/2 of time) from 12-36 months.
((Random assignment now mixed up; side effects. medic use among groups))
Issues with Stimulants
Short versus long-term effects
Effects on behavior versus learning
Dose-response effects?
Short term beh: clear benefit. Short term learning: attention, not grades. Long term beh: no effect/support of benefit, long term learning: no effect/support of benefit.
Issues with Stimulants (cont)
Mechanism of action is ?
Overused? (Definition of ADHD)
Used much more commonly in U.S.
State-dependent learning
Side effects – sleep, appetite, growth
---Mech of action? Transient tics, appetite, etc. Over used in US? School problem? (drug holidays; after school should not take b/c won't eat dinner, but what about hw?) Maybe schools with MORE struc? Attributions. Not specific to adhd.
Behavior Therapy
Will cover with ODD; really same treatment for ODD and ADHD
Diagnostic Issues
Distinct from ADHD? Co-morbidity (school age, not nec diag at age 6 for this)
Different from CD?
Later developmental manifestation?
Heterotypic and homotypic continuity
Certainly developmentally related
Symptoms of ODD
Pattern of negative, hostile, defiant behavior
DSM IV definition (compare with Conduct Disorder)
Aspects of behavior considered include
Form (aggression, noncompliance, lack of self-control, interpersonal problems)
Intensity
Frequency
Impact
Intent (accident?) --These factors used in law as well. Repeat offenders more harshly, effect on victim. CD label: not influential for legal sys, not real diagnosis. Depression would effect punishment.
Symptoms of ODD
-What is often? (prosocial skills...) Many 15 yr olds also meet criteria. Probably should have age related criteria. CD: bully, phy fights, weapons, cruel, sexual agg, breaking and entering, truancy, run away. Law violations! Juvenile delinquency.
Heterotypic vs homotypic:
(Referring to SYMPTOMS not underlying problem)
Het: same underlying disorder but symptom expression changes. Hom: problem where symptoms remain same across devel (type/category is the same) ex. autism (communic, sameness). -- ODD and CD probably same underlying problem. Just defiant in age appropriate ways; antisocial beh feature same. ODD children at high risk for CD.
Case Examples
Shane (4 y.o. coercion)
Mom, young single parent. Emery observed him in class, spoke to teacher (saw from car, rel break, jk). Coercion: reinforcing their ESCALATIONS in reg beh. Reinf parent's beh. Parent training: best empirically supported treatment. Ex. Grocery store: cannot avoid? Leave - short term costs for long term benefits; sat in car - back in store, left, etc. Difficult in classroom w/ many children. Shane borderline vs Erik.
Cote: agg is normative in young children. Shaw: intervene early on.
Kazin: help parents. Stams: metanaly. Blair: method - sad/fearful faces. Schaffer: long term follow up, multisys th, many still delin.
Case Examples
Eric (8 y.o. social services and hospitalization)
Foster care system
Epidemiology
--female cotwins with boys have more androgyn hormones in pregancy, more aggressive.
3-10:1 Boys. Biology? partly. Socialization?
Poor prognosis (aggression is trait-like)
Early onset BETTER predictor of adult antisocial behavior (age 8 vs 15, norm)
Correlates include peer problems, learning problems, stimulation seeking (lower resting autonomic arousal - need stim...)
Family Adversity
Poverty, overcrowding, depressed mom, criminal dad, family conflict, removal from home
Gene-environment correlations?
Etiology: Many Theories
1) Normative 2) Irritable agg 3) Learning; Indiv diff
Normative: Human nature – Are we born selfish? Aggressive? Yes - adaptive (read dawkins)
Terrible twos and beyond…
Irritable aggression – “Hard wired” aggression in response to certain environments
Learning involved too
Does this explain reciprocity of aggression?
Individual differences: Behavior genetics – less delinquency, more younger, older ((b/c environ of adol contributes to rule breaking so genes are less important. ODD and ASD are (more or less?) herit than ASB delin; peak when young and old)
Etiology (cont)
Psychological
Aggression is rewarded
Coercion but
Power
Development
Love
Reciprocity of aggression
Inadequate socialization – parenting styles INTERNALIZATION MEANS: (begins w/ ext control but goal is internal control. EXT->INT. Psy lives residing in env first)
Indifferent and firm disc:
Indifferent and lax:
-- Authoritarian.
vs. neglectful
Loving and firm:
--lax and loving:
Authoritative. --indulgent.
Discipline:
Coercion. POWER (bad for children to win. Son stops getting yelled: neg reinf. Hierarchy vs inverted hierarchy. In general, not everything.) Devel: Ex. tantrums: parents do not have to win every battle (ex friends, curfew) learn to control own env. LOVE: ex. attention as rein...not looking to win but attention. Solution: not for parent control but give more attention/love/sec att.
Reciprocity of aggression
Extend time btwn immediate act; ex. winning delayed for yrs; iritable/agg/wired to fight back. How and why (immediate and ultimate awards) ex. short term punishment for longer term reward (ex football). Inad soc: parenting styles... More worrisome: NEGLECTFUL VS indulgment. Little guidance or loving (low power, low love).
Etiology (cont)
Cognitive (internalized in child)
Delay of gratification (time horizons -- work more for short term reards)
Biased decision making (attribute aggressive intentions to others; preemptive attack)
Incomplete moral development (conscience, superego)
Incomplete moral development (conscience, superego)
-Stams et al. (2006)
Meta-analysis (convert to standard scores)
Kohlberg’s theory of moral reasoning
Preconventional – responding to authorities
Conventional – internalizing, meeting social expectations
Postconventional – internalized, principled (broader social contracts) --Delinquents show less devel moral devel (lower levels - precon; det action by likelihood of getting caught).
Etiology (cont)
Society
Culture and aggression
TV violence
Imitation, disinhibition, desensitization
Selection – aggressive kids prefer aggressive shows
-Culture: children's shows have violent act every 2 min. Model agg; disinhibit; culture sets STANDARD.
Treatments
Cognitive Behavior Therapy - Parent Management training
Change attention patterns – focus on positive
Extinction (punishment) for misbehavior – time out
Reward positive behaviors
Focus on specifics (for child and parent)
Reward positive achievements – natural rewards better
Is this a secret systems intervention?? b/c focus on parents.
(Time out from reinf, technically; time out: depends on age, 5 yr olds do not remember 1/2 an hr later why they're in their rooms - no connection. Half of age; 2 yr olds set timer)
Treatment (cont)
Problem-Solving Skills training
(not wking for adhd)
Focus on the child not the parents
Identify (stop, look, listen like for lights; some evidence; maybe environ should be changed first)
Brainstorm
Evaluate
Implement
Re-evaluate
Prevention – Prevent family adversity; prevent less serious ODD from becoming CD
Conduct Disorder and Juvenile Delinquency
--Do not have to be caught to have a problem violating laws - mental health help - still CD vs delin.
DSM IV Conduct Disorder
Contrast with ODD (rule viol from social to legal norms)
Legal violations whether detected or not (intensity, freq, impact, intent)
“Hidden” delinquency
Who has never violated the law?
But intensity, frequency, impact, and intent distinguish serious delinquency
Delinquency – Legal term not psychological
Two types of delinquent offenses
Criminal – also applies to adults
Status – only illegal because of age of minor (1899 juv justice sys - separate philosophy)
Conceptual Distinctions
Life course persistent versus adolescence limited antisocial behavior
Antisocial personality disorder (psychopath; sociopath) (aspd: subset of life course persistent. Can we distinguish from other delinquents?*)
Impaired recognition of both sadness and especially fear (Blair et al., 2001)
Callous; emotionally insensitive
Epidemiology and Associated Features
(viol crimes dec since 1990s and drug abse after 1997 peak; Lib: better economies in 1990s, decent jobs. Conserv: more prisons, tougher laws, etc.
Rule violations normative but about 5% of offenders commit 50% of crimes
Delinquency is serious
30.9% of index offenses in 2003 committed by people under the age of 21
Index offenses = murder, rape, robbery, aggravated assault, burglary, motor vehicle theft, arson, and larceny-theft
Contrary to popular perceptions, juvenile crime is falling
Epidemiology and Associated Features (cont.)
Firearm (and Nonfirearm) Homicide Rates Far Higher in U.S.
Many more males are delinquent and males more aggressive
Female delinquency – some violence, but also drug and sex crimes
Guns play a substantial role in violent crime – children killing children. See:
http://www.ncjrs.org/html/ojjdp/194609/contents.html
Percent of murders involving a firearm 2000
Ages 12–17: Males 86% Females 49%
Whites 70% Blacks 85%
Epidemiology and Associated Features (cont.)
- some different from ODD; Desistence despite risk factors. ***Alternative opportunities: seems logical to be agg in some communities. Ex. bok: A hope in the unseen. *Social attachments - intimate; these topics have not been studied.
Epidemiology and Associated Features (cont.)
Family factors -- antisocial father; depressed mother; overcrowding; poverty; removal from the home; conflict
Disengaged (neglectful) parenting
Poverty, especially urban poverty – most victims are from same environments (not inner city preying on suburbs)
Chronic problem, especially early onset
Etiology
Same factors as oppositional defiant disorder
Life-course persistent antisocial behavior
Biological -- neuropsychological challenges
Psychological-- troubled environments, selection of more troubled environments
Social -- societal standards; environment sets threshold
Etiology: Adolescent Limited
Biological
A role in life course persistent but not so much adolescent limited?
Psychological
Adolescent rebellion
Negative identity
Cognitive – Adolescent decision making
Adolescents often seem to make bad decisions (e.g., driving, substance use sex)
Teens have same cognitive capacities as adults (Piaget)
Social/emotional factors may influence teens more
Peer influence (go along with the crowd)
Risk perception (focus on rewards, underestimate risks)
Future orientation (short-term thinking [delay of gratification])
Impulsivity (more impulsive)
Etiology
What predicts desistence of antisocial behavior?
Opportunity – alternative paths
for success
Social attachments – intimate
relationships among adolescents and young adults, but also close relationships (attachments) throughout life
Treatment – Juvenile Justice System
Philosophy
Rehabilitation v. punishment in criminal justice
Parens patriae v. due process
History
First juvenile court – Cook County, IL, 1899
Save wayward youth
Status offenses, informal proceedings, social work
Undoing of juvenile court?
In re: Gault
Transfer – adolescents tried as adults
Death penalty – Supreme Court eliminated for under 18 in 2005
Treatment – Juvenile Justice
Practice – Diversion
Most arrests don't make it to court – keeping youths out of system may be one of best “treatments”
Diversion happens at all levels
Police
Prosecutors
Judges
Court staff
Treatment – Juvenile Justice
Recidivism
Correctional facilities – “Learning Centers”
What is learned? More crime…
Recidivism -- 1/2 to 3/4 of 1st admits come back
Deinstitutionalization… until 1990
Building prisons – taking criminals off the streets
Can we divert less serious and imprison most serious? Prediction? Equal justice?
Treatment – Psychological
Group homes, e.g., Achievement Place
Hot topic of the day?
Scared straight
Boot camps
Outward bound
Treatment – Psychological
--Multisystemic Therapy
Work with individual, family, school, courts, peers
Positive initial effects, but ?
Significantly less recidivism: 81% vs. 50% 13+ years later (Shaeffer & Borduin, 2005). Impressive but…
Still a lot of recidivism, which underestimates crime
Diversion, self report, and official arrest rates
--Does not often work.
Treatment – Psychological
Allegiance effect, psychotherapy “placebos,” and “use a new treatment quickly while it still has the power to work”
Prevention – Can we prevent delinquency?
Outreach therapy (McCord) – negative effects
Criminal behavior -- 2nd crime more likely
Death and disease -- alcoholism, stress, emotional problems
Occupational satisfaction – lower
Occupational status -- lower
Where and when (the earlier the better) to focus efforts? Individual, family, peer, society (schools/opportunity), society (jails/punishment)
Why are we more willing to devote resources to putting out fires than preventing them?