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What is sensory integration and sensory integration therapy?

Sensory integration refers to the process by which the brain organizes and interprets external stimuli such as touch, movement, body awareness, sight, sound, and gravity. Sensory integration therapy is an occupational therapy intervention that uses individually tailored  activities in an effort to facilitate adaptive responses and functional behaviors. The therapy sessions typically involve months to years of 1-3 times per week, 30-60 minutes sessions and some homework.

Practitioners of sensory integration therapy propose that there is something called “sensory integration dysfunction” or “sensory processing disorder” that impairs the central nervous system, affecting the vestibular, proprioceptive, and/or tactile systems. The vestibular system provides sensory input to the brain about the body’s movement through space. Ostensible signs of vestibular impairment include poor posture and dyspraxia (difficulty planning motor activities). Therapy intended to stimulate the vestibular system might include swinging, rolling, jumping on a trampoline, or riding on scooter boards. The proprioceptive system provides sensory input from the muscles and joints. Proprioceptive impairment is said to be revealed by the presence of stereotyped body movements, such as flapping one’s hands or rocking one’s body back and forth. Impairments in the tactile system are supposed to be evidenced by over- or under-sensitivity to sensory stimuli. Activities to stimulate the proprioceptive or tactile systems might include “smooshing” the child between gym pads or pillows to provide “deep pressure,” brushing the child’s body, providing “joint compression” by repeatedly tightening the joints at the wrist or elbow, and playing with textured toys.

The goal of sensory integration therapy is to remediate sensory difficulties so the child’s overall functioning will improve over time, and allow the child to process and react to sensations more efficiently.

Is there really such a thing as a “Sensory Processing Disorder?”

Practitioners of sensory integration therapy are the sole users of the terms “sensory processing disorder” and “sensory integration dysfunction.” The prevailing view in the broader scientific community is that “sensory symptoms” are ill-defined for purposes of diagnostic categorization and also for identification of a course of treatment or intervention. Sensory “issues” are seen as a nonspecific indicator of neurodevelopmental immaturity rather than as a distinct disorder.

In 2012 the American Academy of Pediatrics (AAP) issued a policy statement recommending that pediatricians not use sensory processing disorder as a diagnosis. The AAP left the window open for therapy by adding that while there may not be a diagnostic category, occupational therapy using sensory-based therapies “may be acceptable as one component of a comprehensive treatment plan.”

Why would sensory integration therapy be recommended for a child with Asperger’s/autism?

Many children with Asperger’s and autism have “sensory issues,” such as over-sensitivity to touch, sounds, smells, tastes, brightness, and movement. They may have trouble tolerating scratchy clothing, shirt tags, or “squishy” substances on their skin. They may be overly sensitive to loud noises or very picky about what they eat. They may evidence repetitive motor acts such as hand flapping. These difficulties can make ordinary situations overwhelming, create extreme stress, and trigger meltdowns. In fact, the latest edition of the American Psychiatric Association’s diagnostic manual, the DSM-5, lists sensory problems as a criteria for autism diagnosis.

Similar symptoms may occur with other neurodevelopmental and behavioral problems, especially ADHD and anxiety. My daughter, who has both, had sensory integration therapy. She couldn’t tolerate labels in clothing and loud noises (automatically flushing toilets were to be avoided at all costs). After a family vacation to Disneyland where she was overwhelmed by the noises and smells, she said “that would have been a great vacation except for that awful theme park.” For the most part, she’s outgrown her sensitivities. And I think she would have outgrown her sensitivities without a year of OT. But many children with autism continue to have sensory issues of one kind or another throughout their lives.

Is there a sound theoretical argument for sensory integration therapy? 

Not really. A major limitation with sensory integration theory is the dearth of evidence for its main tenet, which is that the integration of sensory input is necessary for higher level functioning. This tenet is based on the outmoded view that the development of the child mirrors the evolutionary development of the species. The argument is that sensory systems arose relatively early in the evolutionary history of humans and were a prerequisite for the emergence of more complex cognitive skills. The vestibular, proprioceptive, and tactile systems are thus said to reside in the “primitive” subcortical pathways that need to develop before the formation of more advanced cortical systems. There is no sound scientific basis for this idea, and it sounds a lot like the specious arguments made by Brain Balance Centers (see my Myth Busters Blog on that topic). Rather, the functional organization of the nervous system is better conceptualized as a co-occurring and interactive network of cortical and subcortical systems that mediate voluntary and involuntary responses to stimuli. As such, a linear model that posits that one system must reach some prerequisite level of development in order for a “higher” system to function properly is just inaccurate.

In some of the sensory integration literature biological theories are complemented by hypothetical constructs such as “inner drives” for self-actualization, “sensory deprivation and/or overload,” and “sensory defensiveness.” These constructs do not have any demonstrated scientific basis or even clear definition that would permit their valid and reliable measurement.

O.K. So maybe there’s not much scientific logic to support the theory. But does it work anyway?

Does sensory integration therapy help children with Asperger’s/autism? 

Many parents think it does. Many colleagues who I respect think it does. More colleagues who I respect think it doesn’t. The research evidence (so far) is rather unconvincing.

I took a close look at four analyses published since 2012. Lang, et. al.  reported in 2012 in the journal Research in Autism Disorders that when 25 studies were analyzed, 3 studies suggested it was effective, 8 studies found mixed results, and 14 reported no benefits. Not very compelling. Many of the studies (including the 3 that found positive results) had “serious methodological flaws” (e.g. no experimental design), precluding any valid conclusions. The authors concluded: “There is insufficient evidence to support the use of sensory integration therapy for children with ASD.”

Case-Smith and Scaff reported in 2014 in the journal Autism that among 5 studies, 1 was a case study so could not be generalized, 1 found no treatment effect, and the other 3 had mixed results. Of the 3 with mixed results, one utilized scientifically rigorous methodology (e.g. a control group). The findings from that study were positive according to parent and teacher report: children who received sensory integration therapy had a greater reduction in ASD symptoms. However, the authors cautioned: “additional rigorous trials using manualized protocols for sensory integration therapy are needed to evaluate the effects for children with autism spectrum disorders.”

Barton, et. al.  reported in the journal Research in Developmental Disabilities in 2015 on the findings from 30 studies. They concluded that there was so much heterogeneity in implementation, measurement, and study rigor that not much could be ascertained. They wrote: “The research on sensory-based treatments is limited to insubstantial treatment outcomes, weak experimental designs, or high risk of bias. Although many people use and advocate for the use of sensory-based treatments and there is substantial empirical literature on sensory-based treatments for children with disabilities, insufficient evidence exists to support its use.”

Finally, there is a chapter on sensory integration in the 2015 book  Controversial Therapies for Autism and Intellectual Disabilities: Fad, Fashion, and Science in Professional Practice by Foxx and Mulick. In addition to reporting in detail on prior studies, the authors report their own review of  data from 2011-2014. When they analyzed 10 studies, 3 were single-subject (one child) studies that did not show any benefit. 4 studies reported positive results but were criticized as “speculative at best” because they did not randomly assign children to groups and examiners were not “blinded” to group assignment. The 2 studies that did utilize sound scientific methodology provided inconclusive results, The authors conclude that sensory integration therapy has “limited scientific support,” but note that it “remains popular despite professional ethical guidelines that call for the use of evidence-based practice.” In other words, they feel it’s unethical for professionals to recommend sensory integration therapy because its not an evidence-based practice.

Why do families engage in sensory integration therapy if the evidence is so scanty? 

In an online survey about 60% of parents of children with ASD reported that their children engaged in a course of sensory integration therapy.

Why do they do it given the weak scientific evidence?

Maybe they haven’t looked at the science. Maybe they were convinced by the pseudoscientific arguments. Maybe they hope scientific research will someday catch up with practice and show it to be efficacious. Maybe they relied on a story from a friend or a friend of a friend that was convinced it helped their child. I think this happens a lot. Or maybe parents are so desperate to do anything to help their child they will grasp at straws.

Recommendation: While it probably won’t do much, if you want to do sensory integration therapy as one part of a comprehensive treatment plan, there’s probably no harm in proceeding. But please don’t divert time, money, and attention away from therapies that are scientifically validated as effective.

 

Finally, some good news on “alternative” approaches to helping 2e learners! Thus far in the Myth Busters series I’ve panned vision therapy for dyslexia, The Amen Clinics for ADHD, essential oils for ADHD, and Brain Balance Centers for most anything. Now I turn my attention to the question of whether dietary changes can reduce ADHD symptoms, and find the answer can be “Yes!”

There are loads of studies showing a relationship between diet and ADHD symptoms. Of course poor diet and eating habits do not cause ADHD, but there is a connection between the kinds of foods children eat and their behavior and symptoms. This is true whether a child has ADHD or not, but may be even more true of children who have ADHD.

Why would this be the case?

Let’s look at the biology of ADHD. ADHD is caused by neurological, brain chemistry differences. There are millions of neurons densely packed into various regions of the brain, with each region responsible for particular functions (e.g. motor cortex, visual cortex). For the regions to do their jobs in a coordinated way they must link to other regions, with extensive “wiring” carrying information from one region to another along neural circuits or pathways. Information is transmitted along neural pathways via the action of neurotransmitters. Each neuron produces tiny quantities of different neurotransmitters that are released into the space that exists between neurons (called the synapse), stimulating the next cell in the pathway – and so on down the line. It’s kind of like a series of dominoes cascading down a line, but with the fall of each domino triggered individually.

In ADHD, there is a deficiency of one or more neurotransmitters in the brain. There are three subtypes of ADHD: inattentive type, hyperactive/impulsive type, and combined type. We believe that inattentive ADHD is linked primarily to deficiencies in the neurotransmitter norepinephrine, hyperactive-impulsive ADHD to deficiencies in dopamine, and the mixed type of ADHD with altered choline transporter genes. In addition, the emotional dysregulation (e.g. impulse control and aggression) aspect of ADHD is linked with a serotonin transporter gene.

How would different foods and nutrients affect ADHD brain chemistry? Let’s look at the main categories.

Bad Carbs and Sugar: The rate at which sugar from a particular food enters brain cells, and other cells of the body, is called the “glycemic index.” Foods with a high glycemic index (e.g. sugar and bad carbs like pastries) stimulate the pancreas to secrete high levels of insulin, which causes sugar to empty quickly from the blood into the cells. This gives the child a nice dopamine “rush” and may be one reason children with ADHD crave carbs and sugar – their bodies may (in effect) be trying to “self-medicate.” The rush of energy is, however, short-lived (1-2 hours). As blood sugar drops, the child plummets from peak energy to trough, and may get irritable, sleepy, and be less able to focus. Their body may crave more sugar to get the rush back. It can become quite a hormonal roller coaster. Plus ADHD and obesity are linked (probably though this process combined with weak impulse control) so you want to try to avoid letting your child get “addicted” to sugar and bad carbs.

Suggestion: Shift to foods that have a lower glycemic index. Say “yes” to most fruits and vegetables, beans, steel-cut oats, low-fat dairy foods, and nuts. Say “no” to candy, white bread, rice cakes, most crackers, bagels, cakes, doughnuts, croissants, and most packaged breakfast cereals.

Protein: Proteins affect brain performance by providing the amino acids from which neurotransmitters are made. Proteins also produce the amino acid tyrosine which, in turn, produces dopamine and norepinephrine – two areas of deficiency in ADHD. In addition, sugars from carbohydrates are digested more slowly when they’re consumed with protein, resulting in a more gradual and sustained blood sugar release.

Suggestion: Add plenty of protein to your child’s meals.

Iron: Since certain proteins (meat, fish) have the highest concentrations of heme iron, I’ll address iron next (if your child doesn’t eat meat or fish there are other sources). Iron is a cofactor for tyrosine, the rate-limiting enzyme of monoamine synthesis, so it regulates dopamine production. A 2017 review and meta-analysis of studies on ADHD and iron found that serum ferritin levels are lower in many children with ADHD than in healthy controls. For these children, iron supplements can improve ADHD symptoms.

Suggestion: Add more iron-rich foods to your child’s diet and/or consider giving an iron supplement. I advise that you do a ferritin test first to see if your child actually does have low iron before giving supplements.

Zinc: After brain cells release dopamine into the synapse, they “vacuum” it back up using a dopamine transporter. Zinc binds to the dopamine transporter and slows it down, allowing dopamine to remain active in the synapse for a longer period of time before being pulled back into the cell to be recycled. Thus, zinc is a natural dopamine reuptake inhibitor. Ritalin also inhibits the reuptake of dopamine (but less naturally). Lower levels of zinc have been reported in some children with ADHD. While I found a few solid studies that looked into the effects of zinc supplements, two showed improvement and two showed no effect. (1) I hypothesize that the children who benefited may have been those who had a zinc deficiency to start with.

Suggestion: Have your child’s zinc levels tested, and if they’re low, consider zinc supplements and/or adding zinc-rich foods to your child’s diet (red meat, poultry, pumpkin seeds, chickpeas).

Fatty Acids and Fish Oil: Omega-3 fatty acids have anti-inflammatory properties and can alter central nervous system cell membrane fluidity and phospholipid composition. Cell membrane fluidity can alter serotonin and dopamine neurotransmission. A thorough meta-analysis conducted in 2013 at Yale (2) found that “Omega-3 fatty acid supplementation demonstrated a small, but significant effect in improving ADHD symptoms.”

Suggestion: There’s modest potential for a benefit from giving your child fish oil.

Amino Acid Supplements: The amino acids phenylalanine, tyrosine and tryptophan are used to make the neurotransmitters dopamine, serotonin and norepinephrine. Among the few studies  examining how amino acid supplements affect ADHD symptoms, some show modest benefits, and some don’t show any. Amino acid supplements taken by mouth are considered to be “possibly safe” when taken on a short-term basis (up to 6 months) due to potential side effects including fatigue and loss of coordination.

Suggestion: Because of the risks and uncertainty of benefits from such supplements, go to the source and provide amino acids naturally through foods including: red meat, dairy products, whey, milk, soy proteins, chicken, fish, and eggs.

Elimination Diets: An elimination diet is a short-term eating plan that eliminates foods that may be causing allergies, sensitivities, or other digestive reactions – then reintroduces the foods one at a time in order to determine which foods are, and are not, well-tolerated. While it’s tough to implement this kind of strict, restrictive diet and closely monitor the results, the information gained can be helpful. The incidence of asthma, allergies, and skin infections appears to be higher among children with ADHD than those without. Children with food sensitivities can feel tired, itchy, nauseated, and have trouble focusing or difficulty controlling their emotions when they eat foods that don’t agree with them. Finding out which foods trigger these kinds of reactions and eliminating them can improve symptoms. Food dyes, milk, and gluten, are common culprits. The best synthesis of studies I found in this area is by one of my favorite ADHD researchers, Joel T. Nigg (3) He found statistically significant ADHD symptom reduction when children were given a narrow diet of foods unlikely to cause reactions.

Suggestion: If you suspect your child has food sensitivities and you have the discipline to test your hypothesis through an elimination diet, go for it!

In sum, I feel the evidence does suggest that dietary changes can help some children with ADHD symptoms. I’ve gotta say – that is one thing Brain Balance centers get right. But you don’t need to pay them over $10,000 to tell you that!

(1) Hariri, Mitra and Azadbakht, Leila. “Magnesium, Iron, and Zinc Supplementation for the Treatment of Attention Deficit Hyperactivity Disorder: A Systematic Review on the Recent Literature.” International Journal of Preventative Medicine, 2015: 6:83.

(2) Bloch, Michael H., and Qawasmi, Ahmad. “Omega-3 Fatty Acid Supplementation for the Treatment of Children with Attention-Deficit/Hyperactivity Disorder Symptomatology: Systematic Review and Meta-Analysis.” Journal American Academy Child Adolescent Psychiatry. 2011 Oct; 50(10): 991–1000.

(3) Nigg, Joel T., and Kathleen Holton. “Restriction and Elimination Diets in ADHD Treatment.” Child and Adolescent Psychiatric Clinics of North America, vol. 23, no. 4, 2014, pp. 937–953.

What is it? In 2006 Dr. Robert Melillo – a chiropractor – entered into a partnership with his nephew to launch the Brain Balance franchise model. Since then, over 130 franchises have been purchased across the country. The concept is based on Dr. Melillo’s book: Disconnected Kids: The Groundbreaking Brain Balance Program for Children with Autism, ADHD, Dyslexia, and Other Neurological Disorders. He describes his program as a “non-medical and drug-free approach” based on “cutting edge brain science” for achieving “optimum body and brain balance.” He argues that kids who have learning or behavioral issues have “inadequately developed sensory and motor systems” and because “the brain is built from the bottom up,” sensory and motor work must be done “before any higher learning, behavioral or academic changes can truly happen.”

He addresses this presumed deficit with “motor” exercises (e.g. rhythm and timing, primitive and postural reflexes, eye-muscle balance) and “sensory” exercises (e.g. hearing, vision, smell, taste, touch). Academic skills are also (briefly) addressed. The sensory, motor, and academic work is all condensed into 3 one-hour sessions per week at a center. Your child is taught by a “coach” – an unlicensed person who need have no background in education, health, occupational therapy, chiropractic, or any related field. A blogger who got details from a former center employee insider’s perspective reports that “most staff are very young (21/22 on average), with no real relevant qualifications, and there’s a high turnover; most don’t stay longer than a few months. That could be partly because of the wages; $10 an hour.”

In addition to the 3 hours per week your child gets at a center, the program includes nutritional recommendations and exercises to be done at home.

Most families are advised that their child requires two 3-month sessions at a cost of $6,000 per session, plus several hundred dollars for the assessment and proprietary nutritional supplements (including KidGenius vitamins “that help promote brain growth!”). Total cost is approximately $13-14,000. Cost per session works out to about $182/hour, of which the coach gets approximately $10. None of the cost is covered by health insurance.

Can it help? Let’s break the question down into what part (s) of it work, and for who?

Let’s start with “who.” I’m skeptical that children with all the different issues they claim to treat can be helped with the same basic treatment. A blog titled Total and Utter Neurobollocks states: “They claim to effectively treat pretty much any developmental disorder under the sun, including autism, ADHD, Asperger’s, Tourette’s and dyslexia, without the use of any drugs. This is because all these disorders are (apparently) caused by an “underlying functional imbalance or under-connectivity of electrical (brain) activity within and between the right and left sides of the brain.” Any alarm bells ringing yet? They should be. Whenever someone comes along with a miracle-cure for a range of unrelated conditions, and has come up with the equivalent of a Unified Field Theory of neurodevelopmental disorders, something must be a bit fishy.”

There are also multiple parts of “it” to consider – sensory motor exercises, academic skills tutoring, and dietary changes each would be expected to have different effects (if any). Some aspects of the program’s interventions might prove helpful to individual children. I’m all for good nutrition, academic skills tutoring, and parents spending quality time exercising with their children, for example. But there is no indication that the core theoretical basis of the program – that sensory-motor exercises will “balance” the brain and improve “functional connectivity” – has any basis in fact. That aspect of the program is based on speculation, not on credible evidence.

One parent, Natalie Hanson, chronicled her family’s experience in a blog. She wrote: “We went into it very hopeful.” “So…he’s a chiropractor. Whatever. If the program works, who cares?” Two years later she wrote: “many of you have reached out via the blog and via email for guidance about whether to pursue Brain Balance for your children. It’s so hard to hear your stories and your desperation, which (in many cases) mirrors our own.” But, “knowing what we know now, I don’t think we would do it again… The most valuable thing we’ve done is remove gluten and dairy from our kids’ diet, and get their genome mapped so that we can address underlying issues with their biochemistry through food, supplements, and ultimately medications.” Later that year she wrote: “I continue to get so many questions about Brain Balance from hopeful parents. I would just like to reiterate again that I WOULD NOT recommend investing in this program for your kids. It is extremely expensive, and the results are fleeting at best. You’re better off changing their food habits and finding other ways to address the behaviors. I know this may be unpopular for those of you looking for answers, but these programs are not what you’re looking for – what they are promising is, sadly, too good to be true.”

Dr. Harriet Hall, a retired family physician who writes about pseudoscience and questionable medical practices on the website Science-Based Medicine, wrote a critical review, saying she was initially skeptical because “miraculous results are reported (“He spoke for the first time!”),” but says the biggest red flag is that they claim their program is “clinically proven,” yet they provide mostly testimonials as evidence. Anecdotal reports do not provide evidence of the efficacy of a treatment. Dr. Hall examines the one research study then mentioned on the website in which “They speculate that ADHD is related to a “functional dysconnectivity,” hemispheric imbalance, subcortical dysfunction, a lack of temporal coherence, and a difference in arousal level between the hemispheres. They provide no evidence that these are characteristic of ADHD or were present in their subjects, or that their treatments specifically changed any of them. They assumed an underactive right hemisphere (it was not clear why) and they provided interventions that they assumed (without any supporting evidence) ought to remedy the alleged imbalance.”

When I checked the Brain Balance website for listings of research I found that several articles and a few studies are now listed. Some sound astonishingly compelling. A 2013 randomized control study (that part sounded good!) reports the “elimination of ADHD symptoms in 81% of participating children after completing a 12 week program.” As if that weren’t enough, 60% also achieved a two-grade level academic increase and 35% achieved a four grade level increase in academic skills! Sounds too good to be true, doesn’t it?

The lead author was Dr. Gary Leisman. I googled his name, and the fifth hit that shows up is a Finding of Scientific Misconduct published by the NIH in 1994. Apparently, this “authority” falsely claimed to have earned an M.D. degree he never earned, to have been a professor of neurology at Harvard Medical School (he had no such affiliation), and to have been awarded 13 U.S. Patents (he never was). Since that time, he has been working in Cuba and Israel.

Other articles include tenuous links to Brain Balance methodologies from some solid research findings. For example, the finding that children with autism have higher than normal connectivity between certain areas of the brain was extrapolated to “lend further support to the Brain Balance theory of Functional Disconnection…The Brain Balance Program combines customized sensory-motor and cognitive activities to repair the miscommunication.”

Why isn’t their more research? Well, first of all, neuroscience has moved far beyond the simple left brain/right brain dichotomy. Furthermore, the idea that diverse conditions are caused by a disconnection syndrome between the two hemispheres is preposterous enough to fail to get research funding.

Why don’t the people making money from Brain Balance programs fund some research? Melillo has argued that Brain Balance is too busy treating patients to do rigorous scientific studies. How convenient.

Can it hurt? Yes – your pocketbook.

What should parents do? Spend their time and money on treatments that are efficacious. Dietary changes, academic skills tutoring, exercise, and maybe even some sensory-motor therapy – depending on the child’s needs – provided by someone trained and licensed to provide it (a good occupational or physical therapist, for example).

(This topic has been moved ahead of the queue by popular demand)

What is an essential oil? Let’s start with what an essential oil is. An essential oil is an extract taken from the leaves, roots, stems or blossoms of a plant that is distilled into a concentrated form and sold in health food stores and by homeopaths, chiropractors, aromatherapists, wellness advocates, and others. The word “essential” refers to the extract being highly condensed. They are meant to be inhaled through a diffuser or applied to the skin. Often they are mixed into blends, such as doTerra’s product InTune Focus, which is marketed for “difficulty paying attention and staying on task.”

The two largest companies selling essential oils are Young Living and doTerra, and together they have over a billion dollars a year in annual sales. It’s big business. The essential oils market has boomed in the last 20 years as “wellness” and “natural” living have trended simultaneously with self-care through online sources and reduced trust in “traditional” medicine and governmental institutions. Young Living introduces a new product each year, with last year’s blend of pepper, spruce, and frankincense called: Fulfill Your Destiny. According to the company, it “encompasses the complex and beautiful journey that leads to achieving your goals and highest potential.” There’s a fascinating article in The New Yorker (October 9, 2017) called “Something in the Air”  about the big business of essential oils if you’re interested.

Surveys suggest that more than 50% of families of children with ADHD try some form of alternative medicine. Part of the appeal to parents of essential oils is that the products are supposedly “natural,” “safe,” and have been used for centuries.

Essential oils recommended for ADHD include: vetevier (an Indian grass), lavender oil, cedarwood, coconut oil, Roman chamomile, mandarin, ylang-ylang, rhodiola, helichrysum, rosemary, valerian, peppermint, and frankincense. It’s a long list, and the matching of any individual oil to a specific symptom it’s supposed to treat varies quite a bit by source.

Do they help? It’s hard to say, as there is very little research into whether, or how much, they may help. Many of the theories on mechanisms of action involve vague statements that would be extremely difficult if not impossible to test such as “balances the nervous system” and “stabilizes the energy field.” In some cases this is deliberate as the companies marketing the products try to avoid claims that could get them into trouble with the FDA.

Evidence from randomized clinical trials examining the efficacy of such oils in treating ADHD is sparse, to say the least. The few studies that do exist, whether yielding positive or negative results, tend to suffer from inadequate trial design (e.g. small sample size, short duration), incomplete reporting, and/or lack of an appropriate control group.(1) This doesn’t mean the oils don’t work – it just means we don’t have much scientific evidence either way.

Most of the “evidence” in support of essential oils for ADHD is anecdotal and comes from testimonials. “Testimonials” are personal accounts of someone’s experience. They are generally subjective: “My child was less hyperactive,” “He was calmer,” and so on. Testimonials are inherently selective. People are more likely to talk about an “amazing cure” than about something that didn’t work. Companies selling products are certainly more likely to quote positive testimonials. And for many people stories are more powerful and convincing than statistics published in hard-to-read and hard-to-find scientific journals.

Are the stories true? In all honesty, I don’t know. Maybe your child’s symptoms really were improved by inhaling vetevier. Or maybe you or your child thought they were.

The placebo effect is a phenomenon in both traditional and alternative medicine. A person’s expectations when they ingest a medicine can have an influence on its real effectiveness. A study published in the Journal of Essential Oil Therapy in 2007 with Spanish sage oil separated participants for a memory task into a group told that the oil would impair their memory and a group told it would have a positive influence. The positive expectancy group did better and the negative expectancy group did worse than a control group who ingested the oil but were told nothing of its potential impact. We want things to work, so sometimes they do. As long as they work, though, that’s great – right? I’d say yes – if they’re not harmful in any way.

Are they safe? Maybe. Maybe not. Similar to prescription drugs, essential oils and blends contain biologically active compounds that can elicit pharmokinetic and pharmodynamic responses. There’s real medicine in there! Once consumed such substances are absorbed, distributed, metabolized, and eliminated by the body, often inhibiting or inducing metabolic enzymes or transporters. While composed of natural substances like leaves or roots, “natural” does not equate to “safe.” Approximately 50% of the drugs used in mainstream medicine were originally developed from “natural” substances. Remember the discovery of penicillin from mold?

Because essential oils are not regulated for quality control, the chemistry, potency, purity, and safety of any given oil is largely unknown and can vary from one product to the next. Differences in plant chemistry caused by weather or pesticides, as well as harvesting, storage, manufacturing and formulation processes introduce variability. Variability can influence responses and health.

From the government’s perspective, if a product is intended for a therapeutic use, such as treating or preventing disease, it’s considered a drug. The fact that an essential oil comes from a plant doesn’t keep it from being regulated as a drug. Under the law, drugs must meet requirements such as FDA approval for safety and effectiveness before they go on the market. The FDA determines a product’s intended use based on factors such as claims made in the labeling, on websites, and in advertising, as well as what consumers expect it to do. So, when the marketing of an essential oil for ADHD steps over a line and makes drug-like claims, the FDA may step in. In 2014 they warned an online company selling valerian for ADHD that it was in violation of interstate commerce laws for selling products that “in light of their toxicity or other potentiality for harmful effect, the method of their use, or the collateral measures necessary to their use, are not safe for use except under the supervision of a practitioner licensed by law to administer them.”(2) The same year they scolded doTerra and Young Living for their claims about treating ADHD. So the companies changed their marketing literature to downplay promises made.

Why aren’t there more studies? Most plants and raw botanicals can’t be patented, so why should a company spend money proving they’re effective? Any negative results could harm future sales. The big companies involved in this booming market are making a lot of money as things stand. Why rock the boat?

What about scientists doing research in the academic realm? Research with essential oils is hard to do because patients can’t be blinded to the odors. But probably the main reason there hasn’t been more scientific research is that obtaining funding for research from governmental agencies for “alternative medicines” is a challenge. I wish this were different.

What should a parent do? Proceed cautiously. There’s very little scientific support for positive effects of essential oils in the treatment of ADHD. Evidence of the safety of essential oils with children is also scarce. Essential oils contain potentially powerful substances that may help, but they may hurt. We just don’t have enough information to know.

(1) Complementary and Alternative Medicine use in Pediatric Attention-Deficit Hyperactivity Disorder (ADHD): Reviewing the Safety and efficacy of Herbal Medicines by Hajrah Mazhar, Emrson Harkin, Brian Foster, Cory Harris in Curr Dev Disorders Rep (2016) 3:15-24.

(2) https://www.fda.gov/ICECI/EnforcementActions/WarningLetters/2014/ucm418714.htm.

 

I’ve decided this series on alternative therapies will first tackle the mistakes I made myself as a parent. The last blog (Part 1) was on vision therapy as a cure for dyslexia. Today, in Part 2, I’ll address Dr. Daniel Amen’s Brain Clinics and how they purport to diagnose and cure ADHD.

Dr. Amen is larger than life. A media star, best-selling author of 30 books (5 New York Times bestsellers), producer of a t.v. show aired on PBS (or rather, infomercial) about his theories, paid motivational speaker, and master salesman promoting proprietary nutritional supplements.

He has 8 clinics in California, New York, Washington, D.C., Chicago, Atlanta, and Washington State. They claim to treat pretty much anything, from ADHD, addiction, anxiety and depression, autism, bipolar disorder, concussions, Lyme disease, marital conflict, dementia, and sleep disorders to weight loss. That claim alone should be enough to make anyone skeptical. Claiming to be an expert at everything is usually overreaching.

But let me zero in on how they “treat” ADHD.

I read Dr. Amen’s book: Healing ADD: The Breakthrough Program That Allows You to See and Heal the 6 Types of ADD when it came out in 2002. It sounded convincingly scientific. Neuroimaging was on the uptick and being heralded as a huge scientific breakthrough. Amen claimed he could cure ADHD by looking inside the brain with a single-photon emission computed tomography (SPECT) scan using gamma rays and with injected radioactive dye and tailoring treatment to 7 different types of ADD: Classic, Inattentive, Overfocused, Temporal Lobe, Limbic, Ring of Fire, and Anxious.

As my 2e son wasn’t responding to anything else we tried, the idea that he might have a specific subtype of ADHD that required a targeted treatment was appealing. So we paid a substantial fee and drove to an appointment at Dr. Amen’s first clinic in Northern California – somewhere in the Central Valley between San Francisco and Sacramento. We went through the intake process and were scheduled for SPECT scans. But something didn’t feel quite right, and I didn’t follow through. My response was instinctual at the time. But since then I’ve earned a PhD and reviewed the literature and scientific consensus from a more informed perspective.

First, there is no research evidence (other than what comes out of Amen’s presumably biased clinics) to support the idea that there are  seven different subtypes of ADHD. Real science – the kind backed by double blind studies, NIH supported grants, and published in reputable peer reviewed journals – has identified two types (Primarily Inattentive and Primarily Hyperactive/Impulsive). We’re kind of working on a possible third type tentatively called Sluggish Cognitive Tempo. There certainly is no such thing as “limbic” or “ring of fire” ADHD.

Second, to do a SPECT scan, the child must be injected with an IV carrying radioactive material directly into his or her bloodstream. Its radiation-emitting particles are carried to every part of their growing body. There is an increase in the possibility of cancer being caused as a result of this kind of radiation exposure, particularly for children, as their growth means more cells are dividing, providing a greater risk of radiation disrupting cell development. This is why they ask you if you’re pregnant before giving you a mammogram. The risk may be small, but it’s there.

Third, the idea that you can diagnose ADHD by looking at SPECT images of blood flow in the brain is a huge leap of faith. The key question in evaluating a diagnostic test is whether or not its findings are useful in determining what treatment the patient should have. SPECT scans are not FDA-approved for diagnostics, partly because they only have a 54 percent  sensitivity, meaning they are only accurate half the time. Scientists have yet to identify reliable diagnostic markers using far more advanced technologies such as fMRIs, which provides better temporal and spatial resolution. There is no scientific evidence to suggest that SPECT scans are a useful diagnostic tool for ADHD and can inform treatment plans. The American Psychological Association has twice issued papers that dispute “claims being made that brain imaging technology … is useful for making a clinical diagnosis and for helping in treatment selections.” The most recent paper was the work of 12 scientists who spent three years assessing the latest research. The summary: “There are currently no brain imaging biomarkers that are currently clinically useful for any diagnostic category in psychiatry.”

None of the nation’s most prestigious medical organizations  — including the American Psychological Association, the National Institute of Mental Health, the American College of Radiology, the Society of Nuclear Medicine and Molecular Imaging, and the National Alliance on Mental Illness — validate his claims. Literally no major research institution takes his SPECT work seriously.

Here in New York, the extremely well-respected APA president and chairman of Psychiatry at Columbia University, Dr. Jeffrey Lieberman, says: “In my opinion, what he’s doing is the modern equivalent of phrenology…The claims he makes are not supported by reliable science, and one has to be skeptical about his motivation.” Former director of the National Institute of Mental Health, President of the Society for Neuroscience (the leading professional organization for neuroscientists), and director of the Center for Psychiatric Research at MIT and Harvard, Dr. Steven E. Hyman, says: “I can’t imagine clinical decisions being guided by an imaging test.” Dr. Thomas Insel, director of the National Institute for Mental Health, says “entrepreneurial zeal capitalizing on scientific advances needs to be tempered by reality checks.”

Dr. Amen thinks he’s a “maverick” onto something that no one else in the field understands. I guess I might respect that (I do like mavericks) if he weren’t a self-promoter making a ton of money by preying on the fears and hopes of desperate families using invasive, potentially dangerous, and ineffective technology. Don’t be fooled by his brand of pseudoscience.

When interviewing parents about their child’s strengths and weaknesses, I often hear statements like the following: “I don’t think my child has a problem with attention – he can focus really intensely on his cartoon-drawing (or video-gaming or Lego-building or reading) for hours at a time! In fact I can barely get him to stop. But his teachers complain he’s inattentive and distracted in the classroom. Maybe he’s just not stimulated by the material being taught?” Does this sound like your child – or one you know?

Some of the questions I need to help answer are: Is the child gifted? Does the child have ADHD? Is the child gifted and does he or she also have ADHD (i.e. is twice-exceptional)? Which of these factors are impacting the child’s ability to thrive in and outside of school? And what can be done to help.

My friends Xavier Castellanos, MD and Felice Kauffman, PhD wrote a monograph for the National Research Center for the Gifted and Talented on this very topic. It is reproduced here in short form on SENG’s website. They note that “Some people erroneously assume that a child who demonstrates sustained attention, such as a gifted child engaged in a high-interest activity, cannot have ADHD. It is understandable that an observer might discount the possibility of ADHD because from all appearances the child is so absorbed in a task that other stimuli fade into oblivion.”

While in fact: “This state of rapt attention can be described as “hyperfocus,” a condition that individuals with ADHD frequently experience.” Hyperfocus is the tendency for children and adults with ADHD to focus very intensely on things that interest them. At times, the focus is so strong that they become oblivious to the world around them. For more on hyperfocus see an article from Additude magazine here. Felice and Xavier point out that: “Activities that are continuously reinforcing and “automatic,” such as video or computer games or reading for pleasure, do not distinguish children who have ADHD from children who do not have ADHD, whereas effortful tasks do.” So it’s not whether the child can focus – it’s whether they can focus on effortful tasks.

They continue: “Evidence suggests that the gifted child with ADHD is particularly predisposed to exhibit this state of “hyperfocus.” While this can be a positive aspect of task commitment, it becomes a problem when the child is asked to shift from one task to another.”

Does this scenario sound familiar? You ask your child to stop doing what he is hyper focused on and come to dinner and he ignores you or objects strenuously?

Xavier and Felice write: “While cognitively this state (hyperfocus) can have positive aspects, behaviorally it can cause problems. It is important to understand that ADHD is not characterized by an inability to sustain attention, but rather by the inability to appropriately regulate the application of attention to tasks that are not intrinsically rewarding and/or that require effort. Such tasks are, sadly, characteristic of much of the work that is typically required in school, even in programs for gifted students.” So if school isn’t intrinsically rewarding, interesting, and/or requires effort, the gifted child with ADHD may tune-out and turn off.

To complicate matters, “By virtue of their giftedness, the range of tasks that are perceived as “effortless” is broader for gifted children, which is why their ADHD may be less apparent than in children who struggle more obviously and to lesser effect.” Something that would be effortful for a typical child (e.g. understanding a new math concept or comprehending sophisticated text) might not be effortful for the gifted child to whom such things come easily. So when a gifted child does have ADHD, their teachers may under-report symptoms because they appear to breeze through so much of the material. I see this most often when the child happens to be likable and internalizes rather than externalizes their frustrations.

It can take an assessment by a psychologist experienced in working with gifted and twice exceptional learners to tease out the subtleties.

It’s important to find out what’s going on because the student may be under-performing, or may be losing confidence and self-esteem. Their over-reliance on strengths to get by may “inadvertently obscure the disability.” They may get B+’s by answering questions based on superior reasoning skills, not necessarily having learned the actual material being tested. They may be frustrated and grow to distrust their abilities because they realize (consciously, or subconsciously) that they have to struggle to maintain them. They may feel they aren’t very smart after all. There may be negative impacts outside of academics: socially, emotionally, with friendships, and within the family dynamics.

When the student is accurately diagnosed, he or she can be given the opportunity to learn appropriate compensatory and coping skills. It’s especially helpful to address these issues at an early enough age before the student has turned off school, become a behavioral problem, become the class clown, or internalized frustrations in the form of anxiety or depression. While an adult can (if lucky) be happy and successful intensely pursuing their interests, few achieve success and satisfaction if they are unable to push through the less rewarding phases of an activity and keep working when something becomes effortful. These are skills and mind-sets we need to teach our twice exceptional children who are gifted and have ADHD.

If I can help you ascertain whether your child is gifted, has ADHD, or both, reach out to me at dm@drdevon.com. I do not charge for an initial 60 minute conversation.

I thought it would be helpful to post a list of the books and other resources I most frequently refer my clients to.

Books:

8 Keys to Parenting Children with ADHD by Cindy Goldrich (2015). Excellent “instruction manual” for how to parent children with ADHD including behavior management strategies. Author available for consultations.

Bright Kids Who Can’t Keep Up by Ellen Braaten and Brian Willoughby (2014). How slow processing speed impacts students and what can (and can’t) be done to help.

Executive Skills in Children and Adolescents by Peg Dawson and Richard Guare (2004). This is a manual – a “how-to” guide with specific interventions to be implemented at home and/or school for executive function weaknesses. I used this guide to help my son get through high school.

Misdiagnosis and Dual Diagnoses of Gifted Children and Adults: ADHD, bipolar, OCD, Asperger’s, depression, and other disorders, by James T. Webb, et al. (2005). In my view a bit extreme in suggesting that many behaviors characteristic of disability are actually just signs of giftedness, though I agree that does sometimes occur. I find that more often giftedness and disability coexist and that giftedness alone is not always (or even often) associated with dysfunction.

Overcoming Dyslexia by Sally Shaywitz (2003). Primarily about how to properly remediate reading problems but also specifically addresses challenges faced by bright dyslexics (Shaywitz is at Yale so discusses and works with students there).

The ADHD Explosion by Stephen P. Hinshaw and Richard Scheffle (2014). Chapters on the causes of ADHD (where biology meets culture) and diagnosing and treating ADHD are well worth the cost of the book. Much of the rest delves into social and educational policy issues. Anything by Stephen Hinshaw (one of my mentors at Berkeley) is recommended.

The Dyslexia Empowerment Plan by Ben Foss (2013). Focuses on strengths associated with dyslexia, explains assistive technology, and argues in favor of “reading” by listening rather than scanning text with one’s eyes. My son has taught himself to listen at 3x normal speed and says it is a “game changer” for him.

The Dyslexic Advantage by Brock and Fernette Eide (2011). Focuses on identifying the 4 main strengths associated with dyslexia. Powerful reading for adult dyslexics as well as parents. I give a copy to any parent of a dyslexic child who thinks they, too, might  be dyslexic. The book launched a foundation and website listed below.

The Mislabeled Child: How understanding your child’s unique learning style can open the door to success by Brock and Fernette Eide (2006). Covers misdiagnosis  and has chapters on different issues including communication challenges, ADHD, dysgraphia, dyslexia, and giftedness.

Websites, Facebook, and Other Resources:

2e Twice-Exceptional Newsletter. 2e Newsletter. An online bimonthly publication dedicated to understanding twice exceptional children. Modest fee for  online subscription. I think it’s well worth it.

Davidson Institute. Davidson Young Scholars. Non-profit providing free counseling to families of exceptionally gifted students accepted as Davidson Young Scholars. Many of my clients find the counseling to be very helpful.

Devon MacEachron, PhD. www.drdevon.com. That’s me! 2e assessment and educational advising. Facebook:  https://www.facebook.com/2Egifted/. Twitter: https://www.twitter.com/2egifted.

Dyslexic Advantage. Dyslexic Advantage Foundation. Focused on uncovering and celebrating the strengths associated with dyslexia. Testimonials, famous people, advice, assistive technology, etc. Premium membership gives access to a wonderful magazine and other resources.

Gifted Homeschoolers Forum. GHF. Primarily for families who are homeschooling, but much of the material and resources are of interest to all.  Publish articles, books, active online community, blog, ask the expert “column,” and have a section of their website devoted to twice-exceptionality.

Hoagies Gifted Website. Hoagies . Huge resource on giftedness and 2e with a plethora of articles, chat groups, blogs, etc.  Hoagies Gifted Discussion Group is a related Facebook group with 4,835 members you must apply to participate in.

Johns Hopkins Center for Talented Youth. CTY. Students testing as highly gifted in math or verbal qualify for their summer camps, online courses, family vacations, and day programs. The programs are not inexpensive, but they are phenomenal and can change a child’s life.

National Association for Gifted Children. NAGC. National advocacy group, posts articles, position papers, annual conference, offers Parenting for High Potential magazine, program and camp lists.

Parents of Twice Exceptional Children (2E): Closed Facebook group with 7,762 members you must apply to join. Active discussion with responses from parents in similar situations.

Raising Poppies: Closed Facebook group with 13,279 members you must apply to join focused on issues raising gifted children.

Twice Exceptional Children’s Advocacy (TECA): www.teca2e.org. Modest membership fee to access moderated online parent support groups, message board, and other specifically 2e resources.

TilT Parenting: www.tiltparenting.com. Features a weekly podcast focused on parenting 2e learners, referred to positively as “differently wired” kids, in the TilT manifesto.

I was asked to write an article on this topic for TECA (Twice Exceptional Children’s Advocacy), an online community providing service and program directories and information about advocacy. I decided to enlist the help of Benjamin Meyer, a therapist specializing in young adults with NVLD and Asperger’s in the workforce. Here’s what we wrote:

By Benjamin Meyer, LCSW and Dr. Devon MacEachron, PhD

You did it! Your child has finally received an acceptance letter to a college or university and is beginning his or her first steps toward adult life. All your hard work navigating the treacherous path of diagnosis, remediation, social skills training, OT, PT, gifted programming, IEP’s and 504’s has paid off. You deserve a lot of credit for all that you have done to guide your child through the process, and you certainly deserve to celebrate!

While high school has come to an end, it is important to keep in mind that even after college, your child may face challenges related to their disabilities. These can include identifying and finding a career they enjoy, adapting to the world of employment, making friends with peers, and adult dating. Many young adults with learning differences are unemployed or underemployed due to the more nuanced social and executive functioning demands of the workplace, The National Center for Learning Disabilities reports that only 46 percent of work-age adults with an LD are employed (Cortiella, 2014) . “Failure to launch” has become a national epidemic, with many young people returning home to live with their parents due to challenges with the professional and social demands of adulthood. Your high school grad will be at an advantage if they take a few practical steps while in college to prepare for the “real world”.

Young adults in our practices often identify specific challenges at work related to their learning profiles. The dyslexic who chose engineering or architecture due to his gifted visual-spatial skills may find that slow speed and miscalculations made in math problems hinders his ability to complete tasks efficiently. The ingenious marketing professional with ADHD may experience difficulty organizing her ideas into action plans. The gifted writer with Asperger’s Syndrome or NVLD may struggle to hold regular employment due to difficulties reading their peers’ body language. Young adults who plan in advance for a career or job that will be a good fit for their unique profiles are most likely to be successful transitioning to the world of work.

Finding the Sweet Spot

When deciding on a career, young adults can search for the “sweet spot” where their strengths, interests, and values coincide (see diagram). The blue circle represents strengths. These should include intellectual talents as well as people skills, executive function, willingness to work hard, artistic, musical, and any other abilities. The green circle encompasses interests: sports, outdoor activities, academic subjects – any and all interests the individual may have. Lastly, it is important to identify and “own” the personal values that can impact career satisfaction. These include: how important a flexible work schedule is, how much social interaction is desired at work, the hours one is willing to work, desire for autonomy and independence versus taking direction from a boss, whether one enjoys working on a team, being outdoors versus in an office building, how important a high salary is, how important it is have a high prestige position, whether one wants to be considered an expert or authority, how important it is to feel one is helping others or making the world a better place. Values go in the yellow circle. By identifying the key factors that influence career success and happiness, young adults can begin to see which careers might fall within their “sweet spot.”

Acknowledging and Factoring in Areas of Challenge

While students are searching for their “sweet spot,” they will also benefit from being honest with themselves about their challenges. There are certain skills that are important in practically any job. Relating to colleagues, keeping your emotions in check, taking initiative, and having an organizational system are a few of them. There are also specific skills required in different fields, e.g. math skills for an actuary or writing skills for a journalist. If the student feels they have a weakness in an area important to a career they feel they would like to pursue, they can work on developing those skills while still in college. For example, they might learn to create an organizational system with a coach or work with a therapist on professional social skills. The student will also benefit from consulting with professionals who are in the field they are considering, especially those who have a similar profile of strengths and weaknesses. This will help them assess how suited their specific strengths and weaknesses are with the demands of the job and will aid in identifying some strategies for compensating for their weaknesses. Internships and mentorships are ideal opportunities to practice compensation strategies while building on strengths, experience and expertise.

Case Studies

Jacob is a verbally gifted 2e student with nonverbal learning disability interested in becoming a social worker. He realizes that he may find meeting documentation requirements challenging due to executive functioning deficits, while also facing obstacles reading nuances in body language from colleagues and employers. On the other hand, his strengths in writing and verbal skills will help him to produce well-written progress notes and describe cases in detail. As is the case for any 2e student, expressing specific strengths to potential employers during and after the interview process is a critical skill for landing a good job. Twice-exceptional students have exceptional strengths and these can be a major attraction to employers. But prospective employers may not know what those are until the applicant articulates them in a clear and concise way, convincing the employer of their value. Jacob needs to sell his verbal and writing skills. At the same time, he should anticipate concerns about weaknesses and consider addressing them up front. If a prospective employer knows that Jacob has NVLD and what NVLD means, they might be concerned about Jacob’s organizational abilities. Jacob would be wise to highlight in the interview process that he worked on developing a unique filing system at his last job, and explain how this skill will help him be an effective social worker.

Neil is a brilliant mathematician and visual-spatial thinker with Asperger’s and ADHD. He struggled with attention and making friends in college, however he successfully identified a strong interest and talent in architecture. Neil knows that he will no longer have access to a note taker, extra-time on tests, and academic coaches to help him stay on task in the work world. Also, an understanding of business social skills will be critical for him to engage effectively with clients in this field. During his last two years of college, Neil decided to work with a therapist building business-savvy social skills. During the summer when he is interning at an architecture firm he intends to consult with a business organizational coach and mentor who understands some of the demands he is likely to face in an architecture career. When Neil interviews for full-time jobs after college he may request “reasonable accommodations” that will not create an excessive burden for the employer. These could include extra filing space, access to a computerized organizational system, and a co-worker to accompany Neil to organizational meetings and provide professional feedback, etc.

Caroline is a 2e student who is dyslexic and has ADHD. She wants to be a journalist. She hit some road-bumps along the way in college from her ADHD and as a result it took her 6 years to graduate. She’s decided she needs to address this up-front in her interviews by explaining that she has ADHD, what happened, and what she learned from it (e.g. how to be organized, how much she cares about learning). When she mentions her ADHD she intends to emphasize that she thinks it is part of the reason she is so creative as a journalist and point to examples of creative stories she has published. But she doesn’t think her dyslexia will negatively impact her future work because she knows to get her pieces edited for spelling and grammatical errors. So she’s not planning on mentioning that exceptionality.

Does Your 2e Learner Have to “Tell All?”

It depends. In an ideal, open-minded, accepting-of-neurodiversity world one would be up-front about such things. No one wants to end up in a position that’s a bad fit. On the other hand, although they legally cannot discriminate, prospective employers may be concerned about hiring someone who brings challenges along with them. Many people don’t know about twice-exceptionality and may not get that one can be gifted and have a disability. We recommend the student decide in advance how much information would be in their best interests to divulge. The decision of what to share may be influenced by how overt the student’s weaknesses are. If you can’t hide it, own it. The decision may be influenced by the culture in the specific career field or company. Technology firms and academia tend to be more open-minded to differently-wired people. Traditional businesses like manufacturing and law may be less so. Of course if the student does decide to share, thought should be given to how to frame such information in the most informative light.

When a 2e student is proactive in preparing for future employment during the college years, their chances of success are greatly improved. These steps can include: researching and selecting a career that fits well with their unique profile of strengths, challenges, and values; working to address organizational and “soft skills” deficits while still in college; and finally deciding what and how much to self-disclose. Although 2e young adults may face challenges adapting to the workforce, they can be proactive about creating strategies for overcoming these boundaries, especially if they start doing so during the college years.

Benjamin Meyer, LCSW is a bilingual psychotherapist who provides psychotherapy and coaching services to young adults with High-Functioning Autism and Nonverbal Learning Disorder post-college in New York City. Dr. Devon MacEachron, PhD is a psychologist with expertise in twice-exceptional learners who provides psychological assessment and educational planning services to children, young adults, and their families in New York City.

Works Cited

Cortiella, C. &. (2014). The State of Learning Disabilities: Facts Trends and Emerging Issues . New York, NY : The National Center for Learning Disabilities.