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Learning Styles: Part 10 of Mythbusters: Alternative Therapies for 2e Learners

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As many of our children head back to school they will be handed short self-report questionnaires to determine their “learning style.” A recent study found that over 90% of teachers still believe that children learn better if they receive information in their preferred learning style. Despite the evidence.

It’s a well-meaning notion – most teachers sincerely want to reach all of the children in their classes. And children generally find it fun to be given an opportunity to tell their teachers how they prefer to learn (of course many children would probably say they learn best by video gaming, but that isn’t likely to be among the options on the questionnaire!)

What are “Learning Styles?” There are more than 70 different theories or models of learning styles including: “left vs right brain,” “concrete vs abstract,” holistic vs serialist,” and so on. But by far the most popular model sorts children into three “types:” visual, auditory, and kinesthetic. The visual learner is said to learn best by seeing graphs, charts, videos, and other visual displays. The auditory learner is said to learn best though aural or heard information – by listening. The kinesthetic learner needs movement and hands-on tasks to maximize their learning.

The way students are identified as being one “type” or another is by filling out a self-report questionnaire with items such as: “I like to learn with posters, videos and pictures” and “If I have to solve a problem, it helps me to move while I think.”

Where did the notion originate? The idea likely grew in popularity from the combined effects of the self-esteem movement (all children are special and deserve respect of their differences), the need for teachers to teach a wide variety of children utilizing differentiation in mixed classrooms, and findings in neuroscience that different areas of the cortex have specific roles in visual, auditory, and sensory processing. I believe it caught on because it’s one of those ideas that sounds scientific and intuitively reasonable.

Is there any scientific evidence to support of the notion of learning styles? The answer is no.

And it’s not simply a matter of “the absence of evidence doesn’t mean the evidence of absence.” On the contrary, for years researchers have tried to make a connection through hundreds of studies. In 2009, Psychological Science in the Public Interest commissioned cognitive psychologists to evaluate the research on learning styles to determine whether there is credible evidence to support using learning styles in instruction. They came to a clear conclusion: “Although the literature on learning styles is enormous,” they “found virtually no evidence” supporting the idea that “instruction is best provided in a format that matches the preference of the learner.” Many studies suffered from weak research design, rendering them unconvincing. Others which did have effective experimental designs “found results that flatly contradict the popular” assumptions about learning styles. In sum, “The contrast between the enormous popularity of the learning-styles approach within education and the lack of credible evidence for its utility is, in our opinion, striking and disturbing.”

Students who implement study strategies based on their self-reported learning style do no better than students who don’t.

In addition, evidence shows that learning style questionnaires are unreliable because people’s self-reported preferences are poorly correlated with their actual performance. In other words, a person might think they learn better, say, visually rather than verbally, but their performance may say otherwise. And of course learning will depend on the nature of the material we’re being taught. Can you imagine trying to learn French grammar pictorially or learning geometry purely verbally?

Learning will also depend on the distinct cognitive abilities profile of the learner – something far more complex than any simple notion of a “learning style.” A student with dyslexia may well learn better by listening than reading. A student with an auditory processing disorder may learn better by reading. A student with ADHD may benefit from opportunities to get up and move around.

What should parents do? If your child brings home results from a learning styles questionnaire, explain to them that what it means is that their teacher wants them to learn and that they should help their teacher out by letting them know when they don’t understand a concept being taught.

Categories: ADHD, Assessment, Dyslexia, Learning Disabilities/Difficulties, Psychoeducational Assessment

CAPD: Part 9 of Myth Busters: Alternative Therapies for 2e Learners

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What is Central Auditory Processing Disorder?

Central Auditory Processing Disorder (CAPD) – also known as Auditory Processing Disorder (APD) – is an umbrella term for a variety of disorders that result in a breakdown in the hearing process. It is not due to peripheral hearing loss, but rather has to do with the way the brain processes sounds. It’s what the brain does with what the ears hear. The American Speech Language Hearing Association (ASHA) defines CAPD as a deficit in one or more of a number of skills, including difficulties knowing where a sound is coming from (sound localization); the ability to detect changes in the duration of, and time intervals between sounds (temporal processing); and the ability to detect spectral variations in sounds (particularly those that differentiate sounds between phonemes). CAPD affects between two and 20% of children.

The debate

A debate flares up about auditory processing disorders frequently between disciplines.

One side of the argument – often coming from psychologists –  is that CAPD is not a valid and reliable “diagnosis,” that the tests assessing auditory processing have poor psychometric properties (lack reliability and validity), and that information gained from an auditory processing evaluation doesn’t help us develop treatment plans in any event. This side often points out that there’s a lot of overlap between CAPD and ADHD, CAPD and developmental language disorders (e.g. speech and language), and CAPD and dyslexia, and that it’s very hard to distinguish among these conditions and between their symptoms. Psychologists may point out that the clinicians testing for CAPD are audiologists who have little to no training outside their specialty, which may be one reason they tend to think everything is an auditory problem.

The other side of the argument – often coming from audiologists – acknowledges that while there are overlaps and comorbidities between CAPD and other disorders, it nevertheless exists as a separate entity. They argue that there are measurable, replicable decrements in central auditory processing that cannot be otherwise accounted for by overlapping diagnoses such as ADHD or language disorders. Some children who are perfectly able to pay attention in quiet environments cannot do so in situations with high levels of background noise like the typical elementary school classroom. An audiologist may argue that this is because they have difficulty processing speech sounds embedded in ambient noise – not because they have an attention deficit. However, over time they may begin to look as though they have ADHD if the effort of trying to listen grows so tiresome that they “give up” and “tune out.” And they may begin to have speech and language and reading difficulties as auditory processing underlies both phonemic processing (which underlies reading) and linguistic processing (which underlies speech and language).

Who’s right? Is it a real diagnostic entity?

I think it is “real.” It’s now listed in the American Medical Association’s International Classification of Diseases, Tenth Revision (ICD-10) code as a distinct medical condition separate from mixed expressive-receptive language disorders, where it used to be lumped.

But I agree it’s really hard to distinguish it from other disorders. The primary professional organization for diagnosticians of CAPD, ASHA, states on their website description of CAPD that “there is no universally accepted method for screening for CAPD,” “there is currently no reference standard for diagnosing CAPD,” and that even among clinicians who do diagnose it that “diverse perspectives among interdisciplinary team members involved in the evaluation process may result in different diagnoses.” If you take your child to an audiologist you may get a diagnosis of CAPD, but if you take your child to a Speech-Language Pathologist (SLP) you may get a diagnosis of a language disorder. A psychologist may provide a different diagnosis altogether.

I can tell you from my personal experience that audiologists and speech-language pathologists and psychologists speak entirely different languages and do not often know much if anything about each other’s areas of specialty. I took my son to a speech-language pathologist who diagnosed a language disability. I took him to an audiologist who diagnosed CAPD. And I took him to a psychologist who diagnosed ADHD and dyslexia. It reminded me of the parable of the blind men and the elephant.Does it help to get a diagnosis?

I’m not so sure. It can help to know why your child behaves in certain ways. Parents who are aware their child has an auditory deficit may be more sympathetic when they appear to not be listening to oral instructions (how many times did I have to tell my son to brush his teeth…?) and consider school options with lower levels of noise (e.g. small classes, no open classrooms, homeschooling). And it can help to know there is CAPD if it really seems there is nothing else going on. But usually there is something else. And I honestly feel there isn’t a whole lot to be gained from the additional knowledge that CAPD is in the mix.

Interventions for auditory processing disorders fall into two categories: therapy and accommodation. Dr. Theresa Bailey, a pediatric neuropsychologist who has written extensively about this topic, feels that neither has sufficient documentation to meet an evidence-based standard of care. Therapies like Fast ForWord and auditory integration therapies like Berard AIT should be considered experimental at best, despite widespread clinical availability. Accommodations include the use of a sound-field FM amplification system in which the child wears a special headset and the teacher wears a headset with a microphone and transmitter. How many kids (or teachers) want to do that? And they may not help much anyway. The research on benefits shows contradictory findings. We just don’t know what kinds of interventions or accommodations provide measurable benefit to a child with auditory processing deficits. There may be treatments that are effective for CAPD developed in the future, but they aren’t available yet.

But we do know what kinds of interventions and accommodations help with speech and language, reading, and attention deficits. Since estimates are that 84% of children with CAPD have ADHD and as much as 100% of children with CAPD have impaired language abilities, our attention might be better focused in these areas.

What should parents do? If you decide you want to assess your child for auditory processing deficits, have a multidisciplinary team involved. The measurement of central auditory functions should be conducted as just one component of a comprehensive evaluation in order to understand the totality of what is contributing to the child’s learning challenges. And try to have a professional involved who is knowledgeable about the multiple disciplines who can help you figure out what it all means.

Categories: ADHD, Assessment, Dyslexia, Learning Disabilities/Difficulties, Psychoeducational Assessment

Neurodiversity

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I’m going to interrupt the Mythbusters series I’ve been publishing this month because something extraordinary has been happening in my world. Something I hope will make a difference.

My daughter, who is a journalist/producer at online news company NowThis, asked me to do a piece on mental health. I decided to do it on the subject of neurodiversity. The piece we did was published about 12 days ago and as of today has over 6 million views and a lot of shares. Here’s a link: http://nowthisnews.com/videos/news/what-you-need-to-know-about-neurodiversity.

I’m wondering why this message has “gone viral.” What is it that so interested and touched people? It certainly wasn’t the messenger (oh my gosh could I have been any stiffer?)

I’ve received a tidal wave of responses. Some – especially those from neuropsychologists – have been critical of the piece for not emphasizing how important disability diagnosis and treatment are. I want to say here that I agree diagnosis is appropriate when needed for identification and services and that addressing areas of challenge is always very important. For everyone, whether they have a disability or not. I have always believed, though, that there are two sides to the coin. Areas of weakness and areas of strength. Some of my colleagues neglect the latter. I think we should all be focusing more on people’s strengths.

I also received an e-mail from a person who had acquired ADHD as the result of an illness and did not see it as an evolutionary advantage. I agree. But even in the case of disability or a debilitating illness I feel that focusing on what we can do, or what we might be able to do with some help and support, can help us more than focusing exclusively on what we can’t do. When my daughter (the one who produced the video) was diagnosed with ADHD and dyslexia we and her school initially focused exclusively on “fixing” what was “broken.” She developed learned helplessness – a condition in which she felt powerless to do things she actually could have done and asked for help with practically everything. By focusing more attention on her strengths (creativity and story-telling skills) she began to bloom.

Most of the e-mails and responses on Facebook pages and Twitter have been positive. Some people shared their personal experiences or those of their child, said they had felt alone, but now felt recognized and more hopeful. Hopeful that society can change and see the beauty in diversity. Some asked how they can volunteer to help the movement – the neurodiversity movement. I’m not sure how to respond to that as I’m not a social activist. I know the movement originated from the autism community and has spread to others. I wish someone would take on a role uniting all of us who believe in this. We need an organizer, a foundation, or a conference. Debbie Reber of Tilt Parenting has taken on the charge of revolutionizing the parenting of differently wired kids in her podcast and new book. I hope others step up to the table. It seems the time is right for this conversation. I sure hope so!

 

 

 

Categories: ADHD, Asperger's/Autism, Assessment, Strengths, Talent Development

Giftedness and Overexcitabilities: Part 8 of Myth Busters: Alternative Therapies for 2e Learners

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Where does the concept of overexcitability come from?

Overexcitability was introduced to psychology by Polish psychiatrist Kazimierz Dabrowski in the 1960’s as part of a “Theory of Positive Disintegration.” The theory proposed that psychological tension and anxiety are necessary to achieve the highest levels of personal and moral growth. Hence these “disintegrative” processes (tension and anxiety) were seen as “positive.” Dabrowski believed that some people have more “developmental potential” than others, and that high intelligence (giftedness) and overexcitability were predisposing factors.

So what exactly is overexcitability?

Dabrowski defined overexcitability as a heightened physiological experience of stimuli resulting from increased neuronal sensitivities that cause a person to experience life more intensely and to feel the extremes of joy and sorrow more profoundly. He called it a “tragic gift.”

He outlined five forms which have been elaborated by others over the years:

Psychomotor overexcitability manifests as a capacity for being active and energetic. It can include loving to move and being physically active, restlessness, speaking quickly, frequent impulsivity in action, and having high stamina.

Sensual overexcitability manifests as increased pleasure from the senses (e.g. tastes, smells, textures, sounds, and sights) and, conversely, extreme negative reactions to unpleasant sensations. It can include an exceptional dislike for particular stimuli or sensations, like the sensation of a shirt’s tag on one’s neck or the texture of certain foods.

Intellectual overexcitability manifests as an extreme desire to seek understanding, gain knowledge, and analyze and categorize information. It can include asking a lot of questions, being a quick thinker and observer, love of ideas and theoretical analysis, and the search for truth.

Imaginational overexcitability manifests as an intensified play of the imagination and vividness of imagery. It can include fantasizing, day-dreaming, a craving for novelty, and dramatization.

Emotional overexcitability manifests as a capacity for feeling emotions intensely and deeply. It can include being highly sensitive, empathetic, anxious, sad, lonely, nervous, fearful, having a heightened sense of responsibility, and a tendency toward self-examination.

What’s the link between giftedness and overexcitability?

Dąbrowski’s followers suggest that the gifted disproportionately display overexcitabilities, positive disintegration, and hence the potential to attain higher levels of personal and moral growth. The notion was popularized in the gifted education and research communities by Michael Piechowski initially in the 1970’s, Sal Mendaglio, who edited the book Dabrowski’s Theory of Positive Integration (2008), Susan Daniels and Michael Piechowski, who edited Living with Intensity (also published in 2008) and by Linda Silverman of the Gifted Development Center in Colorado, who worked with Piechowski and others on the development of the Overexcitability Questionnaire II, a self-report form widely used as a research instrument. You can try it out yourself by following the link.

I think parents find the concept appealing because it links giftedness and experiences and behaviors that could otherwise seem problematic or dysfunctional (like melt-downs over labels in clothes and extreme emotional reactivity), suggesting these are just part of the child’s gifted temperament. I personally found solace in the idea when my daughter was hypersensitive as a young child. However I have seen parents who take it to an extreme by attributing everything to only one aspect of their child’s profile (their giftedness), and ignoring areas of challenge that need to be addressed.

Is a link validated by the research?

I don’t think so. But I may get in trouble with my friends and colleagues in the gifted community for saying so. The idea that overexcitabilities are higher in the gifted has so captured the imagination and loyalty of researchers, practitioners, and parents that it has, in effect, become accepted as an article of faith or ideology. Practically every website and book written for parents on the social and emotional aspects of giftedness promulgates the view. There’s very little debate about it in the presentation to the public – it’s simply accepted as truth. That’s why I’m writing about it. It bothers me when everyone jumps on the same bandwagon without questioning where it’s going. Also, I have a problem with the idea that the gifted are more capable of attaining higher levels of moral and personal growth than the non-gifted.

Let’s look at the research literature:

On the “pro” side, in 1984 Colangelo and Piechowski summarized the literature, noting that overexcitabilities were consistently present in the gifted. Falk and Miller conducted a literature review of 28 studies in 2009, reporting that gifted individuals were significantly more overexcitable than the non-gifted, especially in the Emotional, Intellectual, and Imaginational areas. In Taiwan, Kuo and Chang (2013) concluded that gifted persons are significantly overexcitable. Many professionals involved in counseling the gifted (e.g. Linda Silverman, Ann Marie Roeper, Susan Daniels) have cited their personal professional experience as evidence that the gifted are more intense, sensitive, and overexcitable.

On the “con” side, in 2006 Mendaglio and Tillier conducted a literature review and concluded that gifted groups did not significantly outscore non-gifted groups. When Pyrt (2008) analyzed the effect sizes (strength) of the relationships reported in research studies he found most to be “small” and “trivial.” The only relationship that had a decent-sized effect was with Intellectual overexcitability. Jane Piirto, a researcher who’s made overexcitabilities her primary research focus, has administered the overexcitability questionnaire to over 600 gifted students, and who personally organized three of the first Dabrowski conferences in the U.S., was an “early adopter” but has grown skeptical over time. In an article titled “21 Years with Dabrowski Theory” she wrote that almost all the studies conducted have had small numbers of participants, making conclusions suspect, and that the only consistent finding has been for Intellectual overexcitability. A 2014 meta-analysis conducted by Daniel Winkler focused on answering the question: “Do the gifted have greater excitabilities than the non-gifted?” He did find a relationship between Intellectual overexcitability and giftedness. For the Emotional and Imaginational overexcitabilities he found that more studies failed to find a relationship than succeeded. The findings for Sensory overexcitability were deemed “insufficient.” And he reported that no studies conducted in the United States have found that the gifted have greater Psychomotor overexcitability.

I agree that the data indicates a link between giftedness and Intellectual overexcitability, but this doesn’t impress me.  I expected it. When you look for a relationship between two things that are conflated – like height and basketball prowess – you are likely to find one. The Big Five Factor Model of Personality, which has been strongly validated by the research, has a factor called “Openness” which is near identical to the concept of Intellectual overexcitability. Openness is the degree of intellectual curiosity that a person has. Of course it is associated with giftedness, and of course Intellectual overexcitability is associated with giftedness as well. As for the other excitabilities, it seems the evidence is just not there.

Why, then, is there such a strong ideology built up around this notion?

This makes me wonder why the gifted community has been so dogmatic about its belief in overexcitabilities, despite the lack of empirical evidence. It may be that people decided they liked the idea when it was just a hypothesis and haven’t kept up with the research findings. It was striking how fast thought-leaders in the gifted community jumped on the wagon when the hypothesis was first popularized in the 1980’s, despite a near total lack of any evidence at the time. I think it could also be due to the “halo effect.” Professionals in the gifted community want to see the people they work with through a positive lens. For parents, the idea that their child is oversensitive as part of their giftedness and that’s a good thing may be more appealing than an additional diagnosis of AHDH or Asperger’s or anxiety. Finally, we all want to think that pain and suffering will prove, in the long run, to be for the best. We want to believe it, and so we do.

Why does this matter, and what should parents do?

It matters because making the assumption that a gifted child is more excitable because they are gifted and that it’s fine (even good) to be that way can focus attention away from challenges that need to be addressed. Let’s remove the halo of giftedness, and look at the whole child. The potential for a child to realize their potential and to grow into a happy and productive (and personally and morally developed) member of society is increased when we support both their strengths and their weaknesses.

Categories: ADHD, Asperger's/Autism, Gifted, Psychoeducational Assessment

Mindfulness Meditation: Part 7 of Myth Busters: Alternative Therapies for 2e Learners

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Mindfulness meditation has enjoyed a tremendous surge in popularity in the past decade. The practice has moved from a largely obscure Buddhist concept founded about 2,600 years ago to a mainstream psychotherapy and educational construct.

What is Mindfulness Meditation?

It’s a technique of meditation that focuses awareness on breathing and encourages positive attitudes to distracting thoughts and feelings that are not ignored, but are rather acknowledged and observed nonjudgmentally as they arise to create a detachment from them and to gain insight and awareness. It involves training attention and awareness in order to bring mental processes under greater voluntary control. It promotes metacognitive awareness. Mindfulness meditation is a western adaptation of Vipasna, or mindful breathing meditation, with influences from other methods.

Other forms of meditation include: transcendental meditation, in which one sits in lotus position and chants internally with the goal of “enlightenment;” Kundalini meditation in which one tries to channel an upstream of energy and experience an altered state of consciousness; Qi Gong meditation from ancient China which utilizes breathing, movement, and posture to circulate energy through the bodies “energy centers;” and Zazen Zen Buddhist meditation, a straight-backed, seated meditation in which one aims to forget all judgmental thoughts, ideas, and images.

One of the main influencers behind the popularity of mindfulness meditation in the west is John Kabat-Zinn. Dr. Kabat-Zinn has written a number of best-selling books including: Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness; Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life; and Everyday Blessings: The Inner Work of Mindful Parenting. He approaches mindfulness as a scientist (PhD in molecular biology, MIT) and has published scientific articles in peer-reviewed journals (e.g. Journal of the American Medical Association) on mindfulness in medicine. His Mindfulness-Based Stress Reduction (MBSR) program, developed in 1979 at the University of Massachusetts Medical School, has been used in hospitals and health clinics to help patients improve the quality of their lives.

What has my personal experience been with it?

My 26-year old 2e son got me into it. He gave me Full Catastrophe Living for Christmas and we did an 8-week self-guided MBSR meditation course based on Kabat-Zinn’s teachings. We’d text each other when it was time to meditate then text again afterward and call to chat about the experience. I also took a 6-week online course from Mindful Schools for educators. I still feel like an amateur! In my experience this is not something one can read a book about or take one course and immediately implement successfully. I think that’s one reason it’s called a “practice.” You have to practice a lot to get it down and even then you may lose direction. My son, who has been practicing on a daily basis for several years now, feels it is very helpful for improving his attention and focus (he has ADHD) and for reducing anxiety and a tendency to ruminate on negative thoughts. He thinks one of the biggest challenges with implementing it as a “treatment” is that teaching and coaching methods are not standardized and one often doesn’t know if one is “doing it right.”

How could it help 2e learners?

Mindfulness meditation could help 2e learners who have ADHD, autism, anxiety, and/or depression. The following benefits are mentioned:

• Improved attentional control and focus. Boosts to working memory.
• Stress reduction.
• Less emotional reactivity and emotional dysregulation.
• Reduced rumination via disengagement from perseverative cognitive activities.

Is it effective?

A 2017 article was published by science reporter Brian Resnick on Vox.com called: Is mindfulness meditation good for kids? Here’s what the science actually says. Resnick read more than a dozen studies — including systematic meta-reviews, which accounted for thousands of other papers — analyzing the research on mindfulness in both children and adults (there was much more research available on adults). He writes: “The evidence for mindfulness in adults is limited but promising” – especially for anxiety, depression, and stress reduction. He found less evidence for children, in part because there were so few studies.

Dr. Erica Sibinga, a pediatrician  at Johns Hopkins, conducts well-controlled trials using mindfulness in Baltimore’s poorest public schools. She and her colleagues recently conducted a randomized clinical trial with 300 fifth- to eighth-graders. Half the students got mindfulness instruction for 12 weeks. The other half got 12 weeks of health education and were the study’s controls. The results were quite strong: depression, anxiety, self-hostility, coping, and post-traumatic symptoms moved from “concerning levels” to “normal levels.”

A 2014 review published in Frontiers in Psychology found, across 24 studies (11 which had not been published in peer-reviewed journals), that mindfulness improved measures of cognitive performance but had less impact on stress and coping.

A second 2014  meta-analysis published in Education Psychological Review looked at 15 studies of school meditation programs and found “school based meditation is beneficial in the majority of cases,” but “the majority of effects of meditation upon student outcomes are small.”

And a third meta review, published in the Journal of School Psychology in August 2017, compiled 72 mindfulness studies of youth both in and outside of classroom settings. They found “universally small, positive therapeutic effects” for attention, introspection, and emotion regulation.

Overall, the evidence suggests that mindfulness does appear to have a positive effect for children, especially on anxiety and cognitive measures. The studies suggest that it is most beneficial for children who are disadvantaged or at-risk, and may not be as effective for children who are closer to a “normal” baseline. I feel our 2e children are “at-risk” and stand to benefit.

How do you teach a child how to do it?

Some schools incorporate the teaching of mindfulness in the school day. Mindful Schools  and MindUP are great programs designed for implementation in schools. Parents might be able to find a local private instructor, parent/child, or child-centered course to enroll in. They might find a therapist to engage their child in mindfulness-based therapy. There are numerous apps designed for children including Headspace for Kids and Mindfulness for Children. Parents willing to develop their own knowledge and skills might “home school” their child in mindfulness. Practitioners suggest that however a parent chooses to teach their child mindfulness, parents who also practice it themselves tend to have the greatest impact on their children.

Recommendation: 

I often recommend mindfulness meditation to the families of 2e learners I work with, as I do think it can help. I am concerned, though, that instruction and methodology can be a bit vague and many families may not know how best to go about it. Also, it’s not a “quick fix” but more of a “lifestyle change” requiring a  significant commitment to see results. I feel that the most benefit is gained when some rigor is put into implementation (e.g. scheduled daily family practice, instruction and ongoing guidance by a trained professional). Practice makes perfect!

Categories: ADHD, Asperger's/Autism, Executive Function, Gifted, Learning Disabilities/Difficulties, Twice-Exceptional

Sensory Integration and Autism: Part 6 of Myth Busters: Alternative Therapies for 2e Learners

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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.

 

Categories: ADHD, Asperger's/Autism, Executive Function, Gifted

Dietary Changes and ADHD: Part 5 of Myth Busters: Alternative Therapies for 2e Learners

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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.

Categories: ADHD, Assessment, Executive Function

Brain Balance Centers: Part 4 of Myth Busters: Alternative Therapies for 2e Learners

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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).

Categories: ADHD, Asperger's/Autism, Executive Function, Learning Disabilities/Difficulties, Psychoeducational Assessment

Essential Oils for ADHD: Part 3 of Myth Busters: Alternative Therapies for 2e Learners

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(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.

 

Categories: ADHD, Exceptional Learners, Executive Function, Underachievement

The Amen Clinics: Part 2 of Myth Busters: Alternative Therapies for 2e Learners

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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.

Categories: ADHD, Assessment, Exceptional Learners, Executive Function, Gifted, Psychoeducational Assessment

Vision Therapy: Part 1 of Myth Busters: Alternative Therapies for 2e Learners

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I’ve been thinking about writing about pseudoscience and alternative therapies in the 2e world for some time, but worried about offending the usually well-meaning people providing such services and the often desperate families who choose to believe in them. But I’ve decided that in the current climate of fake facts it’s important to take a stand on the side of science.

I understand why alternative therapies can be appealing. Most are non-invasive, do not involve medication, and can sound logical intuitively. One hears anecdotes about how they changed a child’s life. Someone you trust and who seems to care may be recommending it. I get it. And I’ve been there myself as a parent, prepared to try anything and everything that had even a remote possibility of helping my child. But I wasted a lot of valuable time, energy, and money doing so. I hope you won’t make the same mistake.

So I’ll be writing a blog every two weeks in a series called: Myth Busters: Alternative Therapies for 2e Learners.

I’ll start with Vision Therapy.

I have to say it up-front. I’m astonished by how many people still think vision therapy can cure dyslexia. It simply can’t.

Let’s approach this logically from the perspective of where the breakdowns are cognitively in dyslexia. Dyslexia involves weaknesses in one or all of three brain processes: phonological processing, rapid naming, and orthographic processing. There is a great deal of evidence that the main mechanism is usually phonological, namely a basic defect in segmenting and manipulating the phoneme constituents of speech. This has nothing to do with vision. There is evidence (my PhD thesis was in this area) that rapid naming speed can be involved, as the dyslexic brain often has difficulty performing tasks requiring processing of brief stimuli in rapid temporal (time) succession. Again, this has nothing to do with vision. It has to do with timing. Orthographic processing is the formation of visual long-term memory representations of letters, letter patterns, and sequences of letters that serve to map spatially the temporal sequence of phonemes within words. In effect, it’s memorizing what letters and strings of letters look like (for example “ing”), and being able to identify them quickly and efficiently in a word. This does have to do with vision. But it’s a higher-level function. Figuring out what a word says is an iterative, interactive process drawing simultaneously on phonological, rapid naming, orthographic, and additional processes (e.g. word meanings or semantics). It involves higher level cortical functions. It occurs in the brain after visual signals are transmitted from the eyes. We know this from functional MRI’s of children reading.

Vision therapy addresses lower level ocular function. Its directed at improving visual acuity, eye tracking, ocular alignment, convergence, and other issues. For example, a series of convergence exercises may be recommended to treat convergence insufficiency, a condition in which the eyes are inefficient at working together when looking at nearby objects. This condition causes one eye to turn outward instead of inward with the other eye creating double or blurred vision. It affects between 0.1 and 5% of the population and is most common at high school or college age, when there is an increased demand for near work, and early middle age, when the use of bifocals leads to decreased accommodative convergence. Symptoms include eye strain and blurry vision. A younger child can have convergence insufficiency, and might complain of eye strain or blurry vision. Blurry vision would certainly make reading hard. But ocular function problems like this should not be confused with dyslexia.

When I took my dyslexic son to a vision therapist I was told he required 6-12 months of twice-weekly therapy for eye tracking due to frequency of eye saccades. Saccades are eye movements between two or more fixation points, for example backtracking and jumping ahead while reading. I later learned that a tendency toward frequent saccades is a symptom of, not a cause of dyslexia. When a dyslexic reader is having trouble decoding words, their eyes tend to go back and forth trying to figure things out more often than a non-dyslexic reader. So what my son needed was to learn how to read, not how to control his eye movements.

It is possible for a child to have both dyslexia and a lower-level ocular defect. But children with dyslexia are no more likely than any other child to have an ocular motor deficit. To automatically assume that a dyslexic child has an ocular motor deficit is a fallacy. And to assume that vision therapy can treat dyslexia is a fallacy too. The child who has dyslexia needs dyslexia remediation. The child who has both dyslexia and an ocular motor defect may benefit from vision therapy as well as proper remediation of his or her dyslexia. In that case I’d recommend doing dyslexia remediation first, then checking to see if the ocular motor defect is still there. But please don’t rely on vision therapy alone.

The strength of expert opinion against vision therapy for dyslexia is remarkably strong. My ophthalmologist has a binder in his waiting room full of articles refuting claims that vision therapy helps with dyslexia, ADHD, and other behavioral disorders. Key professional organizations have spoken out, issuing policy statements urging their members not to recommend it. The American Academy of Ophthalmology, the American Academy of Pediatrics, and the American Association for Pediatric Ophthalmology have issued joint statements, reaffirmed in 2014. Referring to dyslexia and ADHD, they state: “Scientific evidence does not support the efficacy of eye exercises, behavioral vision therapy, or special tinted filters or lenses for improving the long-term educational performance in these complex pediatric neurocognitive conditions. Diagnostic and treatment approaches that lack scientific evidence of efficacy, including eye exercises, behavioral vision therapy, or special tinted filters or lenses, are not endorsed and should not be recommended.” Even the professional association serving most of the optometrists who perform vision therapy, the American Optometric Association, has come out with the statement that: “vision therapy does not directly treat learning disabilities or dyslexia.” This is very clear-cut.

The preponderance of evidence and the consensus of experts point in the same direction. Vision therapy cannot cure dyslexia. I urge parents to prioritize evidence-based dyslexia remediation over vision therapy when deciding on treatments for their children.

Categories: Dyslexia, Learning Disabilities/Difficulties, Psychoeducational Assessment, Twice-Exceptional

ADHD, Giftedness, and the Ability to Hyperfocus

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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.

Categories: ADHD, Assessment, Executive Function, Gifted, Psychoeducational Assessment, Strengths, Twice-Exceptional

The Positive Student/Teacher Relationship

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I was asked to write an article for the December, 2017 issue of the 2e Twice Exceptional Newsletter, a bi-monthly subscription ($35/year) online newsletter for “those who raise, educate, and counsel high-ability (gifted) children who also have learning challenges.” It’s a wonderful publication and one I recommend for everyone who lives and breathes 2e. As the focus of the December issue was on relationships, they asked me to write about the importance of the student/teacher relationship, and what might be done to try to facilitate the development of positive ones. My article, in full, can be found here: 2E Newsletter Student Teacher Relationship Article.

But let me summarize a few key points as we head into a new semester.

Positive student-teacher relationships are important to virtually all students. But they are especially important for students who are “at risk.” And twice exceptional learners are at risk for underachievement, boredom, bullying, anxiety, depression, social disconnectedness, being misunderstood, and are prone to daily frustration. A good school year can be “made” by a relationship with a teacher who appears to like and bond with the student. A bad year can be “made” by a teacher who doesn’t. Strong student-teacher relationships can increase student motivation, grades, social outcomes, and emotional well-being at every stage in the student’s development, from early elementary school through college and graduate school. Clearly, they’re important.

Here are some things parents and students can each do to try to facilitate them.

Steps Parents can Take:

• Teach your child to be his or her own advocate. For obvious reasons (power differential, age difference) parents often need to take on the role of advocate for their child in school. However to the extent that the student can advocate for his or herself, it can be particularly effective. Teachers tend to be more open to requests and concerns expressed by students (and can be somewhat wary or skeptical of what they perceive as “helicopter” parenting).

• Teach your child social skills helpful in developing sound relationships with all people, including teachers (e.g., listening, turn-taking, conversational give-and-take, respect, complimenting others).

• Ask for a meeting to provide a “heads up” about your child. Explain their strengths and weaknesses, susceptibilities and personality. Ask for help addressing both exceptionalities – your child’s strengths and areas of weakness.

• Check in on a regular (but not excessive) basis to see how things are going and ask what you can do on your end to  help. Perhaps you can reinforce desired behaviors at home (e.g., waiting before blurting out an answer).

• Be a squeaky wheel – but a polite one. The squeaky wheel often does “get the grease.” Don’t hesitate to be direct about asking the teacher to meet your child’s needs. Stay on top of what’s going on in the classroom. But try to be polite and collaborative. A teacher may make more of an effort for a family they like.

• If things go wrong – your child comes home in tears or the teacher sends home behavioral warnings on a daily basis – it’s time to take action. Ask for a meeting with the teacher first. Go with an open mind. Listen, take notes. Patiently explain what you think may be happening from your child’s perspective. Try not to be too defensive. Suggest strategies that may be effective. If things don’t improve, then enlist the help of the principal, school psychologist, or an outside consultant.

Steps Students can Take:

• The more mature student can work deliberately on personal and advocacy skills conducive to developing good student-teacher relations, but even young children can learn helpful strategies.

• Make efforts to establish a personal relationship with your teacher. Ask if you can meet one-on-one so you can get to know each another. Talk about your needs. Stay after class to chat for a few minutes. Go to office hours. Share your interests and successes outside of school with your teacher. The better your teacher knows you and understands the person you are and the person you want to be, the more likely and better able he or she will be to help you toward your goals.

• Show appreciation by thanking your teacher for a lesson you enjoyed, for their feedback on a paper you wrote, or for the way they made a topic come alive for you. Positive feedback makes people feel warmly toward the person giving it.

• Show respect. Be polite. Try to listen and not talk to peers when the teacher is talking. Say “please” and “thank you.” If you feel that instruction is pointless or boring, explain this privately to the teacher rather than as an aside to your classmates.

• Ask for and accept help. Let your teacher know when you don’t understand something. Or when you already know the material and need something different or more advanced.

• Try to be patient, but also (politely) persistent in asking for the additional help, clarification or any accommodation you may need.

A good relationship with even one caring teacher can literally change a student’s life. We shouldn’t rely on chance and hope that such a relationship will develop spontaneously, but rather can try to set the stage and take proactive steps to try to help it happen.

Categories: Exceptional Learners, Twice-Exceptional, Underachievement

Top 5 Mistakes in Diagnosing and Treating ADHD

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There’s a big gap between how ADHD should be diagnosed and treated and what too often happens in the real world. Far better outcomes would occur if we avoided these pitfalls and did it right. Here’s what I see as the five mistakes that are often made:

1. Cursory evaluation. While it’s tempting to just examine whether the child has ADHD, often there are complicating factors arguing in favor of a comprehensive evaluation. The child might be inattentive because he or she is gifted, has dyslexia, is depressed, has a growth disorder, or a multitude of other factors. If these alternatives remain unexamined we may never know if the child actually does have ADHD, or whether another problem is the real cause of their symptoms. Even if the child does have ADHD a failure to identify commonly accompanying conditions leaves those challenges unaddressed. Comorbidity is the coexistence of physical or psychological challenges. ADHD and dyslexia are comorbid in 25 to 40% of cases, ADHD and depression in 20% to 30%, and ADHD and anxiety in more than 25% of cases. For autism, comorbidity rates with ADHD range from 37% to 85%. So I’m a big advocate of comprehensive evaluation.

Even when an evaluation focuses solely on whether the child has ADHD, it is often too limited in scope. I see this most often when a general pediatrician who has not received much training in ADHD bases a diagnosis entirely on two 10-minute forms: one filled out by a parent and one by a teacher. A lot of children are put on ADHD medications based on just this sort of brief evaluation. A proper ADHD evaluation should include at least: a thorough developmental history; parallel behavior rating scales filled out by multiple reporters at home, school, and self-report; neuropsychological tests of attention performed in an office; observations of parent-child interaction and child behavior; and – optimally – classroom observations.

2. Willing the results to go one way or another. Since a good chunk of the information contributing to an ADHD diagnosis comes from parent and teacher reports of behaviors they feel they observe, bias and perspective can come into play. Often I see teacher reports weighing strongly in favor of a diagnosis and parent reports suggesting there is no problem whatsoever. Or the opposite. Or a father who sees no symptoms and a mother who sees many. As beauty is in the eyes of the beholder, so is ADHD. A highly structured teacher who values control and compliance may be more likely to see a child’s behaviors as indicative of ADHD than a permissive, creative teacher who values spontaneity. Sometimes parents or teachers are eager for a “quick fix” in the form of a “magic pill.” Sometimes teens or young adults want an ADHD diagnosis to get their hands on a pill they feel may give them a leg up in the competition for good grades and college admissions. Sometimes parents are reluctant to have their child given a potentially stigmatizing diagnosis. A good evaluator needs to see beyond these motivations.

3. Pursuing treatments that have no (or very little) scientific evidence to support their effectiveness. I can’t begin to tell you how often well-meaning parents are drawn to alternative, untested therapies that have little or no scientific evidence of effectiveness. These include neurofeedback, CogMed, acupuncture, special diets, fish oil, and the like. I understand why parents do this. They are hoping for a solution that avoids medication. But the majority of these approaches are not evidence-based (there is no scientific evidence to suggest that they actually do any good). Most will do no harm, but a lot of time and money can be wasted. The “evidence” that does exist supporting many of these approaches is purely anecdotal and there may be a placebo effect at play. I don’t work for the pharmacology industry and I have no vested interest in reporting that the scientific evidence, over 75 years of research, indicates that stimulant medication is effective at improving concentration and reducing impulsivity and lack of control in 80% of individuals with ADHD.

4. Not taking the time to carefully trial type and dosage of medication. When a family decides to try medication, too often the prescribing doctor doesn’t take the time to carefully trial the different types of medication available and find the best dosage for that particular child. It’s not a “one size fits all” science, and there is no way to predict in advance which medication and what dosage will work best. Sometimes a 160 pound teenager needs less than a 6-year old. Sometimes an amphetamine like Adderall is better than a methylphenidate like Ritalin. Sometimes short-acting formulations are better than long-lasting. What should happen is a careful trial of several different dosage levels and different medications with feedback from parents, teachers, and the child on effectiveness. Far too many clinicians fail to take the time to do this. Even when an optimal medication is found, it’s important to continue with regular, ongoing evaluations of its effects and monitor changes over time.

5. Failing to also implement behavioral interventions. While medication certainly can help it can’t solve everything. A child with ADHD usually doesn’t have the same kinds of intrinsic motivation for task completion and performance as others. Regular, consistently delivered rewards (and punishments) may be needed in the classroom and at home to optimize performance. Clinically-administered behavioral therapy and/or social skills training may be needed. For older children cognitive behavioral therapy can have real benefits. Parent training can be very helpful for learning how best to manage the child’s behavior.

I urge my clients to take the time to do it right. Get a good evaluation, try to be impartial about the results, be scientific about the treatments you pursue, and realize that a pill can’t fix everything.

And in the midst of all this please don’t forget to focus on your child’s strengths (see my blog titled  Top 10 ADHD Superpowers).

Categories: ADHD, Assessment, Learning Disabilities/Difficulties, Strengths, Underachievement

Does giftedness matter? Or is it all about effort?

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The nature/nurture debate has been going on for centuries. Is it our genes (nature) that predict success? Or is it the environment (nurture)? In the past 20 years this topic has evolved into the innate ability/natural talent vs. practice/effort debate. One side argues that success is all about innate ability and natural talent, while the other argues that it’s all about how hard one is willing to work. In the early and mid-1900’s as researchers studied intelligence and developed tests to measure it, it was generally believed that one’s “natural endowments” predicted success. In the 1950’s and ’60’s the cold war space race was a boon for gifted education, as national polices were implemented in an effort to identify and educate the “best and the brightest.”

The pendulum swung hard from ability toward practice and effort in the 1980’s and 90’s. In a politically correct world, the practice/effort argument was appealing because it posits that anyone can achieve success if they are willing to work hard (and the right environmental factors are supplied). In 1993 Dr. Anders Ericsson published a paper arguing that training and deliberate practice could explain performance differences that had been previously ascribed to innate talent. Studying expert performance in sports, music, mathematics, and other areas he found that so-called innate ability was unnecessary to predict who would become most successful. The single greatest predictor of success was hours devoted to the activity. The more someone practiced, the better they were. It’s a provocative argument, and one that Ericsson still espouses over two decades later. If it’s true, anyone with any ability profile can follow their dreams and, with enough effort, reach them. Ericson did add one caveat: when it comes to athletics, height and body size do make a difference. Along the same line, in the book Talent is Overrated (2008), George Colvin argued that investing the right type of practice on a focused pursuit is far more important than natural ability in predicting performance. In 2011 Malcolm Gladwell popularized the “10,000 hour rule” in Outliers, attributing the success of the Beatles and Bill Gates almost entirely to intensive practice. 10,000 hours of practice was identified as the threshold level required to achieve the level of mastery associated with being a world-class expert in anything.

If this is true – that success is all about practice and effort, and that anyone can achieve anything they set their heart to – does giftedness as a construct even matter?

Recently, the pendulum has swung the other way – toward innate ability. In a 2014 meta-analysis, a study analyzing the results of 90 other studies carried out across disciplines ranging from sports to the arts to academia, authors Hambrick, et. al. reported: “More than 20 years ago, researchers proposed that individual differences in performance in such domains as music, sports, and games largely reflect individual differences in amount of deliberate practice, defined as engagement in structured activities created specifically to improve performance in a domain. This view is a frequent topic of popular-science writing—but is it supported by empirical evidence? To answer this question, we conducted a meta-analysis covering all major domains in which deliberate practice has been investigated. We found that deliberate practice explained 26% of the variance in performance for games, 21% for music, 18% for sports, 4% for education, and less than 1% for professions. We conclude that deliberate practice is important, but not as important as has been argued.” In  2017 authors Wai & Rindermann studied what factors contributed to high educational and occupational achievement by examining a sample of 11,745 high achievers across disciplines. They found that about 50% of these super successful individuals were in the top 1% in terms intellectual ability (in other words, they were gifted).

I agree that innate ability is important, and I don’t think all the practice in the world can take someone who has poor native ability to a level of super high achievement in most areas. But I also feel that innate ability alone is rarely enough.

What does it take to turn giftedness into success – for gifted children to become high achievers?  Giftedness is a raw ability. In his “Differentiated Model of Giftedness and Talent” Robert M. Gagné made an important distinction between natural abilities or giftedness and talents. He defined giftedness as: “the possession and use of untrained and spontaneously expressed natural abilities in at least one ability domain, to a degree placing that student in the top 10% of age peers.” Talent, on the other hand, implies “the superior mastery of systematically developed abilities (or expert skills) and knowledge in at least one field of human activity to a degree that places a student in the top 10% of peers in that field.” This is an important distinction because the terms “gifted” and “talented” are often used synonymously. Gagné differentiates between giftedness as raw capacity and talent as a developed ability. Talents progressively emerge from the transformation of high aptitudes into the well-trained and systematically developed skills characteristic of a particular field of human activity or performance.

Thus, a young child might be described as gifted to highlight that they have exceptional abilities and, when they have favorably developed these abilities may be described as gifted and talented. While such a child will always (barring exceptional mishap) remain gifted, only when a high level of performance has been attained can they also be described as talented. This alludes to the common phenomenon of gifted underachievement, and points us in the direction of beginning to understand and therefore remedy this.

Gagné’s model  illustrates the process and factors influencing whether a child’s giftedness will develop into a talent. Chance is a significant factor, but so are the environment and intrapersonal catalysts. Environmental influences include culture and family, teachers, peers, and the provision of programs and services. Intrapersonal catalysts include health, motivation, concentration, and temperament. Efforts can be made to facilitate the development of gifts into talents through a developmental process encompassing informal and formal learning and practice, enriched curriculum and training, a goal of challenging excellence, systemic and regular practice, regular and objective assessment of progress, and personalized accelerated pacing. Sounds like a great gifted education program to me!

So, to answer the question posed at the beginning of this blog: giftedness does matter. I feel that in many domains, it’s a necessary but not sufficient condition to predict high achievement. The development of gifts into talents is a process impacted by environmental, intrapersonal, and chance factors.

Let me add a caveat of my own that the discussion above focuses solely on the outcomes of “success,” “high achievement” and  “talent.” I believe it is quite possible for a gifted person to eschew such outward measures of achievement, and perhaps not contribute their talents to society at large in any measurable way, but to still be a happy and fulfilled person in part because of their giftedness. Giftedness can provide the individual with a rich inner life entirely separate from societal measures of success.

Categories: Gifted, Talent Development, Underachievement