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. There 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.

taken from http://www.dailymail.co.uk/sciencetech/article-2356854/The-gaming-headset-transforms-video-games-virtual-reality-worlds.html

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

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!

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[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

The slings and arrows of outrageous fortune and chocolate

Stress. It happens to everyone, but it happens every day to someone with ADHD, particularly a child or adolescent. Somehow there is something that they do “wrong,” sometimes just by being thoughtless. Of course, a better description would be “thought-free” — his or her thoughts were not on what someone else was thinking, or might do, or might think. Nonetheless, it is considered rude, and the ADHD sufferer gets told that he is wrong just for being the way he is. The cause of just being born with ADHD, or just being born a prince in a dysfunctional family, cause a lot of Shakespearean suffering.

taken from http://theelearningcoach.com/learning/what-is-cognitive-load/

Most people come around to seeing that their weaknesses can be useful, or that their unvalued qualities can be strengths; the old “challenge/opportunity” dilemma. If you have ADHD, you might be able to hyper-focus on something — which could be good or bad. Good if it helps you perform in ever-changing environments, like an emergency room. Bad if you are 12 years old and stuck in a traditional classroom with a teacher lecturing you on something you are not interested in.

In an opinion piece in the LA Times by Robert M. Sapolsky, a noted neuroscientist at Stanford University, he links  stress to performance, or “cognitive load“. Learning new information, and making important decisions, are interrupted by stress.  His example is called “Rich Brain, Poor Brain.” He describes how the stress that affects poor people creates hardships that are just not as bad for people with comfortable income. A car problem: does it stop you in your tracks, as you decide what bill not to pay so that you can fix your car and get back on the road to work, or do you have a comfortable enough income that you can get the car taken care of while you continue with your regular routine? The stresses that poor people deal with interfere with their “regular routine” — worrying thoughts, i.e., stress, increase the number of things that they have to juggle.

Sapolsky describes a creative experiment done by Anandi Mani, testing people who will experience a great stress over money on their cognitive functions before and after the stressful time (harvesting a once-a-year crop). The farmers’ performance on the cognitive tests plummeted dramatically when they had not yet received their annual income. The conclusion is that worrying about money (being poor) increases the cognitive load — leaving less memory and attention to thinking and planning.

Try to think about anything else but these Lillie Belle Chocolates! http://www.lilliebellefarms.com/belle-of-the-berries-box-12/

An excellent example involves chocolate! If you need to get something done, you are using your executive functions to plan, prioritize, and pull up ideas out of your memory. This happens, most neuroscientists think, in the pre-frontal cortex area of your brain. Well, you can’t remember everything all at once, obviously, so you juggle the current ideas in your working memory.

According to Sapolosky, “Extensive research shows that ‘frontal function’ is impaired in people who increase their cognitive load with such things as distracting tasks, stress, sleep deprivation, pain or even resisting temptation (for example, if you make someone’s front cortex work hard in order for them to resist eating chocolate, they are less capable immediately afterward of performing frontal cognitive tasks.)”

If (not) resisting chocolate is something you can relate to, then you can imagine how terrible it is to have stress caused by something bad: a punishment for not remembering an assignment, poor grades in school, knowing how angry your parents are going to be at you, and hatred for yourself for being “stupid.” Let’s increase our awareness of the stress that children with ADHD are going through, and find ways to reduce that stress, to give them a fairer chance to do their school work.

The “Myth” of ADHD?

The 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.

Middle School & High School – Organizing Materials

This is not “my” system; I have been inspired by several other people who have worked out functional systems. In particular, I refer to these two authors:

That Crumpled Paper Was Due Last Week by Ana Homayoun (2010)
& Seeing My Time by MaryDee Sklar (2012)

Supplies needed:

• A 1” binder for each subject – total 5 binders – different colors
• 5 packs of 5 tabbed dividers for each subject
  For an example, see: http://www.staples.com/write+on+tab+dividers/directory_write-on+tab+dividers?
• A pack of 5 dividers – transparent, with pockets (sometimes these are with the folders) For an example, see: http://www.staples.com/Avery-Two-Tone-Double-Pocket-Insertable-Plastic-Tab-Dividers-5-Tab/product_710149?cid=PS:GooglePLAs:710149&KPID=710149
• Loose-leaf paper, with a reinforced edge, 3-hole punched
• A backpack that is big enough to fit 5 binders, plus a planner, and an electronic device, comfortably
• 3-hole punch
• Planner, provided by school, or a “friendlier” one, such as http://orderoochaos.com/shop-products#!/~/product/category=5059090&id=21117059

1. Have a separate binder for each subject. Each binder should be 1”, with 5 tabbed dividers. (Of course, if a teacher specifies a 2″ binder, get that for his or her class. If there is a subject with very little paperwork, like wood shop or health, get a ½” binder for that class.)
2. Put one clear/transparent pocket divider in the 3-rings, in the front of everything else. This is where you will stuff any papers that need to go back and forth from school to home.
3. Behind the transparent pocket divider, put one pack of 5 dividers: (1) notes, (2) homework, (3) handouts, (4) tests/quizzes and (5) blank paper. Write these labels on the top of each tabbed divider. I like the plastic kind that you can write directly on the tabs; those little white slips can fall out and that’s kind of frustrating.
4. In the very front of the first divider, put the syllabus for the class.
5. Do not use spiral binders or spiral notebooks. Use loose-leaf paper from the back of the binder. If a teacher specifies a spiral binder, he or she may want you to paste papers into it, such as science labs or history hand outs. This can get very messy, since the handout is usually the same size as the spiral binder. See if you can find a Science Lab Book, which is bound and bigger than 8 ½ x 11, or a spiral binder with the spiral on the top rather than the side. These are easier to work with over the semester. For an example, see: http://shopping.netsuite.com/s.nl/c.ACCT126734/it.A/id.195/.f

Using This System:

At school, take the binder you need for your class with you (you’ll either carry it in your backpack or get it out of your locker). Put the binder on the desk and open it up. If you have to turn in some homework, take it out of the pocket in front and hand it in. Take out one piece of paper to take notes. When taking notes is finished, put it in the “Notes” section.

If you are in a rush, just put any notes or other papers you get in the clear pocket in front.

When you get home, take out all your folders, one at a time. Go through the papers in the front clear pocket. Put any notes in the Notes section. Do any homework you need to do, and put it back in the clear plastic folder to turn in.

This binder has 5 tabs. Since it is for science, one tab is for “Labs” instead of “Homework”.

If you get back any handouts or quizzes/tests, punch them with the 3-hole punch and put in the correct place.

• Everything should be 3-hole punched.

• At the end of every semester or quarter, take everything out of the binders and file them at home.

HANDOUTS: Papers of information that the teacher hands out go here. This is not homework. Sometimes, it might make sense to put some of these under the “notes” section. You decide in that case.

QUIZZES/TESTS: Quizzes are the bases for tests; tests are the bases for final exams. Keep all quizzes and tests, even ones that don’t have a good grade. It is useful to go back and review those ones in particular! (Parents: do not stress out so much about a bad score – your child may try to “hide” those quizzes from you, and then they get lost.)

PAPER: Reinforced paper is one of the best things ever invented. The back of each binder should have twenty to thirty sheets of this paper. (Otherwise the backpack gets too heavy.)

SCHEDULE A TIME WEEKLY TO ORGANIZE EACH BINDER. Find a time that works for both of you and one of your parents. For example, Saturday afternoon at 3:00 pm. Once you get used to this, you can go through 7 binders in less than 30 minutes.

Our evolving system at home. My middle school son takes a binder that he puts ALL of his handouts in, plus whatever binders he needs for that day (his school follows a block schedule). He keeps the others at home on this desk, and we go through the main binder every night to put away the papers in their proper binder.

Some students, especially those with ADHD, need to organize their binders daily. “Having a time every night to check binders and planners, organize papers, and get assignments sorted out will probably be an essential part of their daily structure. … For many of these kids, a timer is essential. For instance, setting a timer for twenty minutes before your son starts a homework block for him to clean out his binders, recycle necessary papers, make sure all homework is in his planner, and get any necessary materials to the space where he or she will be doing homework will help him or her to be able to complete the work with less distractions.”

PLANNER: Ideally, the school planner will have the block schedules noted on each page. It should have enough room in each block / column to write down the assignments. If it is too small or crowded, find another (larger) planner at an office supply store.

Good Nutrition Can Lessen ADHD Symptoms

I just recently read this information in “ADDitude” magazine online. They outline several ways to relieve symptoms of ADHD without medication.

I have seen these ideas discussed over the past several years, and some in particular ring true:

– fatty oils / fish oil

– iron, zinc & vitamin C and vitamin B6

– lots of protein in the diet to keep energy steady throughout the day

They note that for the fish oil, “The best supplements have two or three times more EPA than DHA.”

I know that the “gentle” forms of iron work much better — the other types are constipating. I buy my “gentle” iron at Whole Foods.

Vitamin B is very helpful in reducing anxiety. While a student may not exhibit outward signs, he may feel stressed at school when he gets reprimanded for not being on task, or when he realizes that he forgot something.

http://www.additudemag.com/slideshow/21/slide-1.html

http://www.additudemag.com/adhd/article/9136.html

I really like most of the suggestions. However, the slideshow veers away from nutrition into lifestyle recommendations. I must caution that the “brain games” they recommend, such as CogMed (or Lumosity), do not have research to support long-term results. They are expensive and put a kid in front of a screen even longer.

I think a good antidote for our computer-addicted kids is some time outdoors.

Furthermore, I have not found compelling research on the effectiveness of NeuroFeedback. There is a lot of promising marketing, but it’s expensive — too expensive to experiment with at this time, in my opinion. I love the idea behind it — teaching yourself to control your inner systems — but I don’t know how it works with younger children.

ADHD Medication Advice from Most Experts Is Positive

While some parents prefer no medications for their children with ADHD, many others are administering them with good results.

The most common recommendation I hear is, “Use medication AND behavioral interventions.” Don’t just pop a pill and expect everything to come into focus. If a child or young adult does not know how to organize his school work, taking a pill that stimulates a neuro-receptor in his brain will not help him learn that executive skill.

For parents struggling with this decision, I would like to present the many “pros” I have read about medication. Yes, there are some “cons,” but these may happen to people who have other pre-existing conditions. The only way you can get these medications is from a medical doctor; you must discuss your child’s behaviors with an MD / psychiatrist before getting a prescription and giving them to your child.

Dr. Ed Hallowell is considered one of America’s leading experts on ADD — starting with the fact that he has ADD himself!

When medication works, it works as safely and dramatically as eyeglasses. Medication helps about 80% of the time in the treatment of ADD. Make sure you work with a doctor who can explain the issues around medication to you clearly. Most people do not realize how safe and effective stimulant medications truly are, when they are used properly. Make sure you work with a doctor who has plenty of experience with these medications. The stimulants include medications like Ritalin, Concerta, Adderall, Vyvanse, Focalin, and others. As long as you take them under proper medical supervision, they can help you immensely. from http://www.drhallowell.com/add-adhd/add-adhd-treatment/

Dr. Brown’s book on ADHD and Executive Functions

Dr. Thomas Brown, Associate Director of the Yale Clinic for Attention and Related Disorders, Fellow of the American Psychological Association, and developer of the Brown ADD Scales for Children and Adults. These quotes are from his book, A New Understanding of ADHD in Children and Adults, Executive Function Impairments (NY: Routledge, 2103).

For ADHD, adequate education of the patient and family about the nature and treatment of ADHD is an essential aspect of minimizing suffering and damage; it is also a critical factor in eliciting willingness of the patient to engage adequately in the treatment process (p.98).

A regimen of appropriate medication, well-tailored to the specific individual, cannot cure ADHD, but for about 80% of those affected it may provide significant reduction of impairment and substantial improvement of functioning (p. 99).

Side effects: Stimulants are the most widely used medications for treatment of ADHD; some types have been available since the late 1930s, others since thelate 1950’s… Large studies of children and adults with aDHD taking stimulants compared with others of similar age have shown that the rate of serious adverse cardiovascular events such as sever hypertension, heart attacks or strokes is no greater among those treated with stimulants than in the general public of the same age without such treatment (p. 10).

Judith Warner is a best-selling author and journalist. In her recent non-fiction book, We’ve Got Issues: Children and Parents in the Age of Medication (NY: Riverhead Books, 2010), she admits that she started her research on this book assuming that doctors were over-medicating kids, and parents weren’t doing enough “parenting” and just wanted a quick fix. She concluded that not enough people are getting the medication they need for attention disorders! Here, she shares a conversation she had with a parent of a 9-year-old boy who was finally given Ritalin after struggling every year in school:

Judith Warner’s book: We’ve Got Issues

“My son said, ‘My brain is like a chameleon. You know, chameleons have eyes that don’t look straight ahead — that’s how my brain is. But when I take the vitamins’ — that’s what we called the Ritalin — ‘my eyes look straight ahead.’ The chameleon image — it’s hard to refute that. If your kid has chameleon eyes, it’s really hard to tell him to make them go straight ahead” (p. 89).

Dr. Martin L. Kutscher, a medical doctor who specializes in working with children with ADHD, has written a book called ADHD: Living Without Brakes (Philadelphia, PA: Jessica Kingsley Publishers, 2010).

Practically speaking, medication is never our first or only choice of treatment. By the time a child is brought to my office, years’ worth of attempts to finesse, cajole and punish have already been tried… The largest, national US study on ADHD treatments, called the MTA (1999) study, clearly showed that medication — especially tightly, professionally supervised use of medication — was clearly the most effective treatment strategy (p. 108).

 

Cognitive Behavioral Therapy (CBT) for ADHD

A great book on the effectiveness of cognitive-behavioral therapy, or CBT, for people who have ADHD has just been released in paperback. While it is intended for therapists who want to help people with ADHD to build skills in executive functioning, the first half of the book presents evidence about the areas in life where working adults may struggle and fail, in spite of being talented, articulate and hard-working. It’s called Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction by Mary V. Solanto. She is a psychiatrist at the Mount Sinai School of Medicine in New York City. I’ve taken some important definitions and descriptions from this book which hopefully will shed light on behaviors (usually negative) that you may observe in yourself or your children.

Personally, I am very impressed with the quality of the writing in this book, both by Solanto and her other contributors. She provides evidence of the success of such a program, whether or not the person with ADHD is taking medication or not. She focuses on the challenges that adults face, those adults who did not “grow out of” ADHD (which is estimated to be about half of the population who has ADHD as children – about 8% of the population). I wish there were more programs here in the Los Angeles area which used this approach. While some mental health facilities offer classes on CBT (such as Kaiser Permanente), they do not gear it to the challenges faced by people with ADHD.

“Insufficiency of Medication as a Comprehensive Treatment for ADHD”

Even with medication – which is not effective for all patients with ADHD – there are skills and behaviors which were never learned as children that the medication cannot “teach” the person how to do (pp. 13 – 14). Mainly these are the executive functions or the ability to self-manage: organizing, planning, self-monitoring, accessing working memory, utilizing self-inhibition, shifting/ transitioning attention from one task to another, etc. (p. 14). This lack of executive functions is developmental – many of these skills eventually do “stick” but usually about 2 – 3 years behind their peers. This delay may be caused by a physical difference in the brain. “Structural and functional neuroimaging studies both in adults (Seidman, Valera & Bush, 2004) and in children (Seidman, Valera & Makris, 2005) have revealed deficits in the volume and activation of regions of the prefrontal cortex known to subserve these executive functions” (p. 15).

Some researchers frame this as “a fundamental deficit in inhibitory control” (Barkley, Murphy & Bush, 2001; Nigg, 2006) – whether it is to stop an automatic impulse in a given situation, or to “prevent interference from extraneous stimuli.”  Russell Barkley is a well-known proponent of this description of ADHD: “Inadequate inhibitory control results in a a proneness to respond to immediate external or internal stimuli, and is manifested cognitively as poor working memory, distractibility, failure to carry tasks through to completion, inattention to detail, and ‘careless’ errors. Tasks that are lengthy, multistep, or inherently challenging will be particularly vulnerable to disruption. Inadequate working memory may result in difficulties in monitoring and adjusting current behavior so as to maximize timely progress toward overarching goals” (p. 15).

Another area that medication does not help someone suffering from ADHD is an insensitivity to reinforcement. That is, consequences of current behaviors simply don’t enter their minds. This has been described as having an “elevated reward threshold in ADHD” (p. 16). Another way of looking at this is having a “steeper delayed reinforcement gradient” (p. 16). This means that people with ADHD can’t be satisfied sticking to an unpleasant task with the knowledge that “it will matter later when you apply to college” or “this could help you get a job promotion later.”

An unfortunate word is used medically to describe someone who suffers from two or more disorders simultaneously: “comorbid.” Some practitioners now use the word “co-occuring” which makes more sense and is less… morbid. It is quite common for people with ADHD to develop anxiety or depression, caused by years of failure and underachievement. “Adults with ADHD complete fewer years of education, have higher rates of unemployment… and higher rates of marital separation and divorce. In addition, adults with ADHD have higher rates of substance and alcohol abuse disorders (18%) as well as increased rates of anxiety (51%) and depression (32%; Kessler et al., 2006), and adult women with ADHD are at greater risk for eating disorders (Biederman et al., 2010). (pp. 8 – 9).

All of these symptoms and outcomes are probably well-known to you already, as a parent with a child with ADHD. There is hope, of course, in several types of treatments, starting with medications that help the neurotransmitters in the brain focus better and longer.

CBT is a treatment that is psycho-social; that is, it is information that is taught to individuals who seek to change their behaviors. A person with ADHD may not have that “inner voice” that warns them to keep their mouths shut during a sensitive conversation, or to look at a long-term outcome, or to consider at least three bids before deciding on a contractor. CBT helps people become aware of the specific types of situations that can get them into trouble, then to identify what they normally think and do in those situations, and then to think and do something different – in order to achieve a different (positive) outcome.

CBT is founded on the work of Aaron Beck, Albert Ellis, and others (p. 20). The program described by Solanto in this book has key ingredients to help people make changes in their behaviors:

• Explicit skills training
  • Time management: how to use a planner
  • Time management: how to prioritize activities
  • Organization: how to use the space around you for your work – placement of tools and other materials needed on a daily basis
• Development of Compensatory Strategies
  • Setting up a work environment to minimize distracters
  • Setting a timer to get work done
  • Maximizing important external prompts, like post-it notes or an electronic calendar
• Generalizing positive statements/maxims
  • Use of Take-Home Exercise activities that the person can do by himself
  • Frequent repetition of positive statements so that they will automatically start popping up in the person’s consciousness (development of that “inner voice”), such as “Out of sight, out of mind,” and “Getting started is the hardest part.”

There are many more ideas presented in this book about how to accomplish this “brain training,” including a complete 12-week training manual written for therapists to take a group of participants through these ideas and give them specific and practical tools to change their behaviors.

Hopefully with such a well-written guide now available in paperback (just published in 2013; I received my copy on September 12, 2013), we will see more utilization of this healthy therapy, CBT.

UPDATE 9-16-13: I received a message from the author, Dr. Mary Solanto, who recommended contacting the Association of Cognitive and Behavioral Therapies at www.abct.org to find a cognitive-behavioral therapist in your area. He or she can use this book as a guide to address the specific needs of people with ADHD — building executive functions.