It just sounds cool: Hemispheric Asymmetries

We take a lot for granted during our waking hours: our bodies’ automatic breathing, automatic walking, automatic speech production. In fact, a problem for people with ADHD is the automatic speech production — words get blurted out that they wish had some filtering before exiting their mouths.

Both automatic and volitional actions start in our brains. While we often cannot “sense” this, when there is damage to the brain, we see the actions are impacted. A common trauma to the brain is a stroke. Depending on where the injury happens in the brain, different actions — speech, walking, memory recall — get affected.

This is explained brilliantly in a book by Dr. Jill Bolte Taylor, My Stroke of Insight. The first few chapters describe what happens physically inside the brain organ, where blood vessels can rupture and create damage to the surrounding tissue. For me, the more fascinating aspect of Dr. Taylor’s descriptions are of the differences in perception from alternate halves of the brain.

The brain is shaped symmetrically, sort of like a walnut. walnut-brain2There is a right half and a left half, or hemisphere. While it looks similar from the outside, different kinds of activities get processed in specific sites in the brain. That’s why some people who have a stroke have trouble recalling words, while others lose the use of one side of their body (the opposite side to where the stroke happened in the brain, which is interesting). Also, there is a tube that connects the two hemispheres called the corpus callosum that allows communication between the different sites to coordinate.

The term hemispheric asymmetry refers to the idea that specific actions take place in only one part of the brain. We process language on the left side of the brain; we process attention, memory, reasoning and problem solving on the right. There is an interesting article from the American Speech, Language and Hearing Institute on this topic — teaching speech therapists how to help stroke victims recover their ability to communicate. So, while it’s not polite to accuse a person with ADHD as having “brain damage,” it is useful to look at it as a phase in brain development which might need the same kind of attention and training as a person who’s suffered an injury in that part of the brain.

While a stroke is a traumatic event that can be devastating effect on a person’s ability to function, what is hopeful and useful to study about it is the way patients heal, and rebuild skills that were lost. It is really incredible to think that we can re-build networks of thoughts and actions even if the roadway we used previously has been destroyed. We can actually generate new nerve cells as we practice skills! (This post on BrainBlogger gives a good description.) Yet, I cannot help but see how kids with ADHD can also build or rebuild neural networks to help them master the skills they need for daily living.

By looking at improving outcomes for people with ADHD as a brain-based, developmental problem, we can take away the stigma of a person being lazy or unmotivated. After working with people with ADHD, I quickly so how willing and capable they were — but a lot of things simply did not occur to them. Homework just didn’t bubble up as something they had to do. Other things — usually visual — caught the attention of the right side of their brains, and they focused on a TV show or a video game or sports instead. Part of our job to help people with ADHD is to put the things they need to do in front of them.

Virtual Reality Tests Reality of Executive Functions

OK, parents, you’ve decided to take the plunge and have your kid tested for ADHD. How does this happen in the doctor’s office? You’re nervous, your child is nervous, you’re all alone in the room with the doctor, and your child is perfectly still and silent. Where are the signs of ADHD? In a medical setting, how you and your child describe his or her behavior count for most of the diagnosis. The doctor will probably not witness these behaviors him- or herself, but will most likely ask some pointed questions and conclude that your child struggles with attention in a variety of settings, and may prescribe medications.

 However, there are tests, called “psycho-educational” assessments (shortened to “psycho-ed,” a rather unflattering moniker), which probe a bit deeper for some of the real-world or everyday problems associated with ADHD, particularly executive functioning deficits. They also look at some psychological issues, such as anxiety, depression, rule-breaking, etc.

Still, these psycho-ed assessments are also anecdotal, ”paper-and-pencil” tests. An examiner (usually a psychologist) asks you, your child, and/or your child’s teacher, a series of questions, and you answer them with “Always,”  “Frequently,” “Sometimes,” “Rarely,” or “Never”. These tests probe more deeply into whether the student falls within the norms of these behaviors for their age and gender, or whether there are indications of a deficit, disability, or some other dis-word.

The authors of a study[1] were verifying whether a virtual reality (VR) “computer game” could predict whether or not a person has deficits in executive functions (EF). A problem with traditional paper-and-pencil assessments of attention is that they are administered in a quiet office, with few distractions, in a one-on-one setting. The examiner does not get to visit the child’s classroom, witness his or her behaviors when trying to control him-/herself in a quiet classroom, becoming easily distracted by someone or something in his/her environment, or forgetting to write down a homework assignment and having no idea what to do once he or she gets come.

I’ll quote directly from the published paper:

 In this study, performance on a VR-Stroop-like task of inhibition correlated with more traditional forms (paper–pencil and parent questionnaires) of EF assessment, but VR performance more accurately reflected everyday behavioral EF.

A “Stroop” task is a brain puzzle where you are shown a name of a color, for example, blue, but it is printed in a different color. When you see this: blue, and you are asked what color is written, you might say “red” because the color you see is red. This is supposed to test how often you can juggle conflicting information in your brain and come up with a correct answer, even when there is interference.

…the “Virtual Classroom” was originally developed as a controlled environment with varying levels of distraction in which attentional processes can be assessed in children (Rizzo et al., 2000b)… The environment also incorporates systematic and controlled presentations of typical classroom distracters, such as classroom noises and movement of virtual classmates or cars in the street.

Blair Middle School, Pasadena, CA

Blair Middle School, Pasadena, CA

This idea struck me as quite brilliant. They are simulating a real environment, with distractions, while administering the test. It’s adding an extra level of distraction, which is usually present in everyday situations, so the child’s performance should be equal to or worse than a typical child’s.

…by its ability to explain outcome on well-recognized scales of behavioral EF and externalizing behavior, while a similar paper–pencil EF test (D-KEFS CWIT) failed to predict the same outcomes. These results support the idea that VR does not only look like the real world, it also includes demands that require real world functional abilities.

btw: D-KEFS, the Delis–Kaplan Executive Function System,  is an assessment that has five sub-tests that measure some facet of executive functioning: ability to reason, ability to prioritize, being flexible, juggling conflicting information in working memory, etc. The CWIT is the Color Word Interference Test, which is a version of the Stroop color name/word test.

The researchers concluded that “VR appears to be a strong predictor of everyday life executive functioning and behavior.” While they could not conclude the VR game could predict similar results on all of the paper-and-pencil tests they compared it to, it did at least produce results that confirm that executive function deficits are present in the child.

Finally, another reason to use this kind of technology when looking for indicators of “real” ADHD (and not just anxiety, or some other behavioral disturbance) and EF deficits is that kids like to do it:

VR technology seems to enhance participant enjoyment leading to increased motivation (Rizzo et al., 2004). The use of VR appears to reduce motivation problems and ceiling effects reported in paper–pencil cognitive tests (Rizzo et al., 2004; Schultheis et al., 2002).

So let’s get those goggles going in our doctors’ offices, and help people realize how real – and not virtual – this attention problem is!


[1]  “Assessment of executive function in adolescence: A comparison of traditional and virtual reality tools” by Gabrielle Lalonde, Mylène Henry, Anne Drouin-Germain, Pierre Nolin, Miriam H. Beauchamp, who are based in Montreal or Quebec, Canada.

Published January 2013 in the Journal of Neuroscience Methods: 219 (2013) 76–82

1,000 most (81) commonly (423) used (149) words (250) in (6) English (524)

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When writing, one way to check to see if a student’s work contains some original words is to see if they are NOT on this list: http://www.insightin.com/esl/1000.php

Truthfully, this brings up a deeper issue of personal originality. People who perceive themselves as “different from the mainstream” usually are (until they hit 35 years old). Many people find their identity in being different and unconventional. Some people with disabilities are so well-adjusted that they demand to be accepted as they are. I have been so impressed with the “Don’t Cure Autism Now” movement that came out as a response to the fundraising organization, “Cure Autism Now!” or CAN. http://winklett.com/about/jonahs-journey-a-journal-3272005-72808/dont-cure-autism-now-62806/ (This is an older blog post from 2006; I don’t know how to cite it correctly.).

Please let me clarify this — I’ve received a comment about it — I am not against research to understand autism, which is the basis of CAN’s work. (CAN is merged today with another organization, and they are called Autism Speaks.) What I admire about the “Don’t Cure Autism Now” is the sense of identity that some people with differences have. They don’t want to be “cured” — they want to be accepted as they are, and are comfortable being defined as “different” and not “neuro-typical”.

However, many people, especially adolescents, who have ADHD wish there was a cure for it. They wish there was a cure that did not mean taking medication for “it”. Having a disability means instantly not belonging to “normal”. Most kids fear this state of being. Particularly in early adolescence, they will do anything to fit in. We have witnessed dire consequences of this kind of thinking, such as taking drugs to fit in with a crowd — even a crowd a person is not really comfortable being in.

A more commonplace experience, though, is fitting in at school, which means (1) not asking questions, (2) not admitting that you don’t understand something, (3) not admitting that you have a learning difference, (4) never letting anyone know that you take medication, (5) not advocating for yourself when you have a 504 plan or IEP in place to support you, and the more than 1,000 variations on this theme of hiding your disability and suffering in silence.

An important process in dealing with ADHD — and any learning disability — is demystification. The family with a person who is different needs some help: the parents must mourn the child they thought they had, and embrace the one they do have. This wise saying has stayed with me for years, and I keep trying to spread it to as many parents as I can. Demystification means learn as much as you can about yourself as well as about a particular disability. Stop looking at it like an unpredictable monster. Start seeing what really is presenting itself. Find out… what is common about it! (I think the Don’t Cure Autism Now adherents also want to understand how their way of interpreting the world is *not* understood well by neuro-typical people. They help demystify the experience of autism by writing about it and sharing their understanding of themselves.)

Since I work with adolescents, I also see their burgeoning self-concepts develop, and they, too, need to know what a typical brain is like, what their brains are like, and how they can compensate when their atypicality interferes with success. Again, that is another, deeper conversation in itself.

But getting back to writing, which is so hard for people with ADHD to accomplish, be as original in your writing as you are in your person! Find some unusual, awkward, blurt-worthy words and use them in your sentences! Embrace that you’re not one of the 1,000 most common students, and thank the Lord/Creative Life Force for that!

Diagnosing ADHD with Brain Imaging

brain-scans-structures

In a related field, autism research, new findings show a brain-scanning measurement of “grey matter (GM) volumetric data, to assess whether individual ADHD adolescents can be accurately differentiated from healthy controls based on objective, brain structure measures…”

from Autism Speaks, http://asdresearchinitiative.wordpress.com/2013/05/24/grey-matter-adhd-autism/ 

While this study is looking for biological measurements to identify people with autism spectrum disorders AND ADHD, it explains that the screening mechanism is a good way to detect ADHD. Rather than compare brain waves (see my blog post here), it looks at actual structures of different parts of the brain.

Many doctors and psychologists say that there are usually enough (subjective) behavioral reports from parents and teachers to determine if a person suffers from ADHD. However, these objective biometric tests may be useful in deciding on medication/s, which could be enormously helpful.

 

The “Myth” of ADHD?

CHADD logoThe Myth of the ADD Myth

Review of The ADD Myth: How to Cultivate the Unique Gifts of Intense Personalities by Martha Burge (San Francisco: Conari Press, 2012)

Ms. Burge asks some provocative questions in this book, such as, “Intensity: Gift or Disorder?” While the word intensity here has a specific meaning, as described by Dr. Kazimierz Dabrowski as a particular giftedness, I appreciate her implication of how “intense” a person with ADHD can be. People with ADHD really are intense people; they feel intensely, they think intensely, they play intensely… and they fall apart intensely.

Ms. Burge, a life coach who practices in Southern California, has written this book to discuss the positive aspects of being intense in both the general and technical senses of the word. She writes compassionately about the people she has worked with who have a “deep sensitivity, a fullness of experience, a capacity for fantasy and creativity, and an intellectual curiosity” (p. xx), and who are not merely marred by attention problems.

She states that she developed her own theory of “intensities,” and then later discovered the work of Dr. Dabrowski, whose concepts described the same behaviors she had described. (See, for example, the Supporting the Emotional Needs of the Gifted (SENG) site for more information, or my blog post.) She came up with a great acronym for these different types of giftedness: SPICE. A person might be intensively Sensual, Psychomotor (Physical), Intellectual, Creative or Emotional. Generally, people who are gifted tend to be more “intense” in one of these 5 areas, and may have strong tendencies or talents in some of the other.

I want to point out that her approach may apply only to adults, and I am not sure all her ideas or suggestions can be used with children or adolescents. I have some criticisms of this book which mainly apply to how to help students function in a typical classroom setting.

A good point that she makes is that ADHD is “too common to be a disorder” (p. 18). There are many estimates of how many people have ADHD; I’ve seen research reports with 3%, 4%, 8%, 10% and even 15%. Over time, the numbers just keep creeping up. She poses a good question: “At what point do we look at a pattern of behaviors as within the normal range?” (pp. 18-19).

However, some points she makes are simply wrong. She claims that the National Institute of Mental Health (NIMH) estimates the number of people with autism is less than 1% of the population; their website states 2% (see http://www.nimh.nih.gov/news/science-news/2013/prevalence-of-parent-reported-autism.shtml). She states on p. 20 that “there are no objective tests that prove the existence of ADHD or any other psychiatric disorder,” but there are some biometric tests now for ADHD.  She skirts the issue of the efficacy of medication; she states that meditation can help most people – without using drugs. She has a section of her book, pp. 4 – 11, entitled “Medication Goes in Search of Patients” which has misleading information. She states that CHADD, Children and Adults with ADHD, was funded and founded by a big pharma company. She implies that they were set up to support giving out medications, as if all the other very helpful advice they offer is mere placebo. Yes, the pharmaceutical companies have something to gain by funding a resource like CHADD, but much of the information requires a lot of education even to understand whether or not your child has a disorder or disability. Frankly, I can’t think of anyone who would want to identify as having ADHD — how can she say that “the disorder seemed to go in search of patients” (p. 4)?

She throws in a very scary comment, that “the very same people,” i.e., doctors, who encourage parents to buy medications, are the ones who “will also tell you that stimulants are deadly” (p. 5). Hold on now! Of course abusing any substance is deadly! But death-by-overdose affects a very small percentage of patients, usually those with a pre-existing condition, and the medication is prescribed so that it will not be abused! Of course stimulants can be deadly, but so can hormone replacement therapy, aspirins, and sugary foods that lead to diabetes. It’s just not fair to scare people into ignoring a valid treatment, medication, just to serve your own pet theories. I distrust this kind of non-objectivity.

She calls meditation “the drug to end all drugs” (p. 52). Her approach to helping her adult clients includes meditation, mindfulness, and understanding some intellectual constructs, such as “the internal map of reality” (p. 46). It has been my experience to witness people with ADHD to be able to relax and focus only after they have taken medication to regulate their brains. I agree that meditation is wonderful and that developing a sense of your “inner voice” is an essential part of growing up and healing. But I do not think it is fair to tacitly discredit the use of medication. Some people can’t get to the state of being able to meditate until after they medicate. As with most conditions, every person is somewhere on the spectrum … some people have an “intense” case of ADHD, and many of those people when undiagnosed turn to drugs and alcohol to soothe or self-medicate – leading to an unproductive life of addiction and substance abuse.

As Burge points out, many people choose not to meditate, or believe they can’t meditate, because it takes too long – and a pill is a lot more convenient. I would ask her and all the anti-medication people out there – please leave room for both. If you can succeed without medication, great. But if you are a child or a young adult who is failing in school, you may be limiting your future choices if you can’t perform tasks that require focus, concentration and completion. There are minimum requirements to get into college, and we all know that earning a college degree is one of the most predictable ways to be financially secure as an adult.

While I respect a parent’s desire not to give medication to his or her child, I hope that parent is able to provide the time and energy to support that child – including sitting with them during a daily meditation period – to teach them how to utilize the non-medication tools of meditation, visualization, deep breathing, stretching, and developing an inner voice. My experience is that most 10-year-old boys who have ADHD – it’s not a myth – do not have the self awareness yet to benefit from this kind of training. Yet, they struggle and suffer and lose their self-esteem as they watch, mystified, their grades plummet and the respect of their teachers and peers diminish. That can cause permanent damage.

I used to think that ADHD was a myth, too. “We never heard of it when I was a kid in school!” Then, I walked into an elementary school classroom, where I hadn’t been in over 35 years, and saw a young man sitting backwards on a chair, his torso hanging over the back of the chair, his shoes off, as he attempted to work on a piece of paper with a pencil. He was not a myth. His disability was real. He didn’t want to be that way; he didn’t know why he felt like he was crawling out of his skin when forced to sit properly. He just couldn’t pay attention because he was physically – and yes, to use Dabrowski’s term, sensually – out of balance.

Twice Exceptional Learners Are “2E”

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The term “2E” refers to being Exceptional, as in gifted, and Exceptional, as in having special learning needs. Many children who have learning differences/disabilities are also gifted, perhaps in math, the arts, or other areas.

A thought-provoking theory about giftedness is that these special traits or talents are “intensities”.  I like this description for many reasons, one being that it honors the basic abilities that most people have to create, to think mathematically, to understand literature, to relate on some level to the creation they are witnessing. For example, most people shudder at the thought of public performance, but they still love to hear music performed because they can appreciate the melodies, the interplay between the musicians, or some other aspect of the performance.

If you or your child has ADHD, and yet you can see areas of unexpressed talent, it may very well be that they are functioning at two different extremes. Because a lack of executive functions can impede productivity and follow-through, you or your child may not believe that you or he could be “gifted”. The common belief is that gifted only applies to academic subjects; people forget that dancers, designers, engineers, architects and so many other professions require creativity, novel approaches to problem solving, and a willingness to try many options (perseverance) until the most suitable solution is found.

Kazimierz Dabrowski, a Polish psychiatrist, developed this theory of human development, or “theory of personality.” One very nice book that details various aspects of intensities is Living with Intensity, edited by Susan Daniels & Michael M. Piechowski, Great Potential Press, 2009. Dabrowski’s theory has many fascinating insights into human development and what educational therapists call “temperament”. The most widely-known concept from his work is called “Over-Excitabilities,” or OEs. This term is an unfortunate translation of the Polish term nadpodbudliwos’c’ “superstimulatability” or “superexcitability” (p. 8). Dabrowski identifies five areas where a person might be intensely sensitive: psychomotor, sensual, intellectual, imaginational and/or emotional.

This book is a collection of works by psychologists, therapists and educators who apply Dabrowski’s concepts to behaviors in children, adolescents and adults. The articles range from the theoretical to the practical to the spiritual. Most of the authors imbue their texts with hopeful outcomes once their clients are liberated with the idea that they are gifted and worthy of appreciation. Many of their clients have experienced only the awkward parts of being gifted: being rejected for being “too intense”; not having peers to match their interests; feeling different but not knowing why; being depressed or anxious; and many other scenarios.

Seeing a person’s gift(s) in a more specific way can also be helpful in understanding his or her temperament. A person with an OE in the sensual realm, for example, may “catch details and may, for example, be captivated by the beauty of a glistening drop of oil floating and swirling across a rain puddle” (p. 40). Someone with a psychomotor OE may appear to be hyperactive, because they may like to move around a lot or use rapid speech. Chapter 3 of this book has wonderful suggestions on how to talk with a child about his or her gift, such as “You have wonderful enthusiasm and energy” or “Your curiosity fuels your intelligence.” There are also strategies listed for each type of OE.

Brain Screening Can Help Diagnose ADHD

QEEGcap

This technology, called electroencephalogram (EEG) or quantitative electroencephalogram (qEEG), has been around for many years. It can help diagnose ADHD by detecting brain-wave patterns that are distinctive to people with ADHD. People with ADHD have areas of their brains that are *under-aroused* or hypoaroused. When the ratio of under-aroused brainwaves is greater to active brain waves, it may indicate a disorder that responds well to stimulant medication. As stated by Edward Hallowell and John Ratey in Delivered from Distraction(2006), “New studies have shown that people who show the characteristic pattern of cortical hypoarousal are likely to respond well to stimulant medication. This provides an elegant physiological link between diagnosis and treatment” (p. 124).

Very recently — July, 2013 (9 years after Delivered from Distraction was published!), the NY Times reported that this method has finally been approved by the Food & Drug Administration. So, if you are unsure whether you or your child has ADHD, this non-intrusive test can help you determine the diagnosis.

From the New York Timeshttp://www.nytimes.com/2013/07/16/health/brain-test-to-diagnose-adhd-is-approved.html: “The test uses an electroencephalogram, or EEG, with sensors attached to a child’s head and hooked by wires to a computer to measure brain waves. … The test takes 15 to 20 minutes, and measures two kinds of brain waves — theta and beta. Certain combinations of those waves tend to be more prevalent in children with A.D.H.D.”