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Breaking News! Full Scale IQ is out for identifying 2e students as gifted! Measures that capture their strengths better are in!

What is the WISC-V? The most common IQ test most of us use to assess intelligence is the Wechsler Intelligence Scale for Children (WISC). It was first published in 1949 and is updated about every 10-12 years. We’re now on the WISC-V which came out in 2014.

What was wrong with the WISC-IV? Why did they have to change it? There are several reasons the WISC is updated. One is to reflect what we’ve learned about abilities. For example, the WISC-V places a greater emphasis on fluid intelligence which we’ve learned is a critical higher order process. It also separates fluid and visual-spatial reasoning into separate processes, as they should be. Tests are also updated in order to re-norm them. The “norm group” is the group of people in the test sample that constitute the comparison group. Newer versions of the WISC try to ensure that the norm group is representative of the current population, with representative samples from different ethnic groups, income levels, IQ levels, etc. Also, re-norming is important to compensate for the Flynn effect. I could write a whole blog about the Flynn Effect, but the gist of it is that IQ scores in the population are increasing, so if we use older IQ tests today we are likely to get inflated scores. This is one reason why scores on tests like the Stanford Binet-LM are suspect (in my opinion) as that test was published in 1972. There are newer versions of the Stanford Binet but some testers prefer to use the older version partly because it results in higher IQ scores.

But I’m supposed to be talking about the WISC-V. At first I was excited to see it conformed better to what we know about intelligence today. But then I began noticing that there are some problems, especially for 2e gifted identification. I reached out to some colleagues and it turned out a number of us were concerned. So we decided to figure out what was going on and try to do something about it.

Why is it harder to identify gifted and 2e students with the WISC-V? There were a number of changes from the WISC-IV to the WISC-V which have made it less useful in identifying gifted and 2e learners. One was to have the Full Scale IQ score calculated from only 7 tests rather than the prior 10 subtests. I can only imagine this was to make it shorter to administer. They also reduced the number of subtests in each of the key composites (Verbal Comprehension, Working Memory, etc.) from 3 subtests to just 2. They added a fifth index (visual spatial). Nice, but the use of five indexes skews the longtime balance between verbal and visual reasoning toward visual. Yet, children are often referred for testing for giftedness based on articulate verbal expression, and we need robust measures of verbal intelligence to identify them. Furthermore, substitutions are no longer allowed to accommodate disabilities; only one substitution is permitted within the Full Scale IQ score. In the past we could substitute certain tests emphasizing higher order reasoning processes which are better measures of giftedness. Discontinue criteria (the point at which the tester stops asking questions when the student has gotten several in a row wrong) on the WISC-V (compared to the WISC-IV) were shortened from four or five items missed in a row to three for most subtests. This again makes the test shorter to administer but may prevent a student from showing all they know. Use of timing on subtests has increased on the WISC-V. Two key subtests allows only 30 seconds for the most difficult items. Gifted students who are more contemplative in nature and not as speedy are really disadvantaged. Plus – and this is egregious in my opinion – they haven’t yet published an Extended Norms table for the WISC-V for calculating IQ’s of super-bright children. That deserves another separate blog post…

But let me get to the good news. We discussed the matter in the assessment committee of the National Association for Gifted Children (NAGC), and decided to take the issue on. In August 2018 we published this Position Paper with recommended guidelines for use of the WISC-V in the assessment of gifted and twice exceptional children.

All position statements are approved by the NAGC Board of Directors and are consistent with the organization’s position that education in a democracy must respect the uniqueness of all individuals.

The NAGC recommends that the WISC-V Full Scale IQ score not be required. In fact, it states: “The Full Scale score may…impede efforts to ensure that gifted classrooms, programs, and schools are accessible to children with disabilities.” This is a disability rights issue!

Instead, the NAGC recommends that any one of the following WISC-V scores (subtests in parentheses), should be accepted for use in the selection process for gifted programs:

• The Verbal (Expanded Crystallized) Index (VECI): (Similarities, Vocabulary, Information and Comprehension),
• The Nonverbal Index (NVI): (Block Design, Matrix Reasoning, Coding, Figure Weights, Visual Puzzles, and Picture Span),
• The Expanded Fluid Index (EFI): (Matrix Reasoning, Figure Weights, Picture Concepts, and Arithmetic),
• The General Ability Index (GAI): (Block Design, Similarities, Matrix Reasoning, Vocabulary, and Figure Weights),
• The Full Scale IQ Score (FSIQ): (Block Design, Similarities, Matrix Reasoning, Digit Span, Coding, Vocabulary, and Figure Weights), and/or
• The Expanded General Ability Index (EGAI): (Similarities, Vocabulary, Information, Comprehension, Block Design, Matrix Reasoning, Figure Weights and Arithmetic).

Note: The test developers (Pearson) have a technical report in progress with tables for calculating this last index. All the other indexes can be calculated by test scoring software or the use of tables in the test manual and technical reports.

Why is this important? Because now gifted children can be more readily identified for their strengths without their relative weaknesses pulling them down. This is especially critical for the twice-exceptional who have cognitive profiles full of extreme ups and downs. You don’t want to “average” that profile to the 50th percentile! In addition, if a child is gifted in one higher order reasoning area but not the other, their strength can still shine. I often work with children who are exceptional at fluid reasoning but not verbal comprehension. Or the reverse. They’re still gifted.

What should parents do? First, make sure whoever tests your child administers enough subtests to calculate the above indexes. If they just give the 7 subtests in the Full Scale IQ you won’t have what you need. You will need at least the following 13 subtests to be administered: Block Design, Similarities, Matrix Reasoning, Digit Span, Coding, Vocabulary, Figure Weights, Visual Puzzles, Picture Span, Information, Picture Concepts, Comprehension, and Arithmetic.

Second, lobby for your child using the Position Paper as support!

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.

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.

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!

 

 

 

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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).

The frequency of misdiagnosis, especially of gifted and twice exceptional students, is one of the reasons I decided to go into the field of assessment as a specialist in these populations. Too many families go to the trouble and expense of having an assessment conducted only to be given incorrect or incomplete information about their child. I have been through this myself as a parent. And I have seen it time and time again among the families I work with. Misdiagnosis can create lasting damage, derail children’s educations, and result in worried days and sleepless nights for children and parents.

Why does this happen? Here are the top ten reasons  gifted and twice exceptional children are misdiagnosed:

1. Hidden abilities and weaknesses: Most gifted and twice-exceptional learners have complex profiles with unique patterns of strengths and weakness. Their strengths often camouflage the expression of their weaknesses (resulting in failure to identify learning difficulties or disabilities) and their weaknesses often camouflage the expression of their strengths (resulting in failure to identify strengths and giftedness). What on the surface may appear to be an average student is often a student with exceptional abilities and exceptional weaknesses “averaging” one another out.

2. “Symptom” confusion: The markers of conditions may appear to overlap. Gifted learners and learners with ADHD both have low tolerance for boredom. Gifted learners and learners with Asperger’s both have a tendency to focus intensely in areas of personal interest. Students with dyslexia may appear to have ADHD if they act distracted or disruptive when its time to read aloud or write.

3. Interaction of the organism (the child) with its environment: Remember gene-environment interaction from high school biology? The influence of the environment on development cannot be overstated. A child who appears to have ADHD in a school where he or she is having to sit through boring classes in which they already know most of the material may not appear to have ADHD at all when placed in a challenging gifted program. And sometimes it is the interaction with a specific teacher that causes the problem. Have you heard the expression “I don’t have a learning disability – my teacher has a teaching disability?”

4. Lack of training in giftedness and twice exceptionality: The psychologist conducting the assessment may not have received much training, if any, in these areas. You may be surprised to learn how little time is spent in most psychology training programs on the assessment of intelligence and learning. Most programs include no training in giftedness or twice exceptionality whatsoever. Furthermore, because many psychologists who conduct assessments work with a broad variety of children and do psychotherapy or other kinds of work in addition to assessment, their knowledge of giftedness and twice exceptionality may not grow much with experience. Some may see only one or two gifted or twice-exceptional students a year. Teachers tend to be equally unfamiliar with the characteristics of these children.

5. “Gifted” is seen as a four letter word: Some kind-hearted people think that it is elitist or unfair to describe or think of a child as gifted because it implies that they are “better than” or “superior” to others. This may be driven by a desire to be inclusive, treat everyone equally, and make people feel good. Strangely, not every child is expected to be equally gifted at sports where it is “allowed” to describe a child as athletically gifted. But it isn’t very “politically correct” to focus attention on intellectual giftedness and really hasn’t been since the 1950’s.

6. Misinterpretation of diagnostic criteria: The criteria psychologists use to make diagnoses are generally taken from the APA’s Diagnostic and Statistical Manual (DSM-5). One area of misunderstanding is that psychologists and school staff may be under the impression that a student has to be performing below the average level (e.g. below the 25th percentile) for their age or grade to be diagnosed with a learning disability. This is actually not true. Under “Diagnostic Features” the DSM-5 states: “academic skills are distributed along a continuum, so there is no natural cut point that can be used to differentiate individuals with and without specific learning disorder,” and “specific learning disorder may also occur in individuals identified as intellectually gifted. These individuals may be able to sustain apparently adequate academic functioning by using compensatory strategies…” Thus the code acknowledges that a gifted student may perform at the average, or “apparently adequate” level, yet still have a learning disability. But many school staff and even psychologists haven’t read the fine print.

7. Incomplete, cursory assessment: To do a top-notch assessment requires gathering a lot of background data and test data while applying critical thinking skills, testing hypotheses, and being willing to keep looking until the answers are revealed. While some diagnoses are clear-cut and relatively easy to make, most gifted and twice exceptional learners are harder to figure out. Not every psychologist is eager to dedicate that much energy and time. Time is money. Sometimes parents are the ones hoping for a quick fix to what may actually be a rather complicated problem.

8. Emotions get in the way: Parents may want their child to be diagnosed with a learning disability because it seems more hopeful than being told their child has a general intellectual disability. Or because it explains why they are under-performing despite high ability when the real problem is social, emotional, or family problems. Conversely, they may not want their child to be diagnosed with a disability because they feel it would be stigmatizing. Sometimes the emotions or preconceptions of the psychologist influence them to downplay findings to protect parents and child from disappointment. I’ve seen reports that pussyfoot so timidly around a diagnosis that parents are left mistakenly thinking there was nothing they really need be concerned about. This seems to be particularly common with autism/Asperger’s diagnoses. And ADHD. And emotional and behavioral problems.

9. Not observing and listening to the student: It never ceases to amaze me how much even very young children know about themselves. Of course they may not come right out and say it, but if they are observed carefully and asked the right questions in a welcoming and nurturing environment, amazing insights come out. Perceptive, sensitive gifted learners have finely tuned antennae making them profoundly aware of exactly where they are not doing as well as their peers or as they’d like. All one has to do is observe and ask.

10. Not observing and listening to the parent: Even though few parents have been professionally trained in picking up these kinds of clues, I find that they often are the first to notice something is up – and the most persistent to find solutions. If they raised the issue with their pediatrician they may have been told it was probably developmental and not to worry. If they raised the issue with their child’s teacher they may have been told their child was at grade level and not to worry. But parents are really good at worrying. When they “know” or “feel” something is up, they should trust their instincts. They’re often right.

If I can help you understand your gifted or twice-exceptional student better, schedule a time to talk with me by e-mailing dm@drdevon.com.

Are you familiar with the 5 stages of grief?

They describe the stages people go through when they learn they have a serious illness, or have lost a loved one, or have gotten divorced or broken up with a significant other. I find these stages helpful in understanding how parents may feel after their child receives a diagnosis of learning disability, ADHD, Asperger’s, and even giftedness.

For many parents there is a natural “mourning period” – a period of time in which they eventually let go of the image they may have harbored of a “perfect” child with idealized characteristics, and accept the child they have instead been given – for all his or her unique and wonderful differentness. It’s natural for parents to have expectations and dreams about the child they will have one day. And it’s natural to be shaken up when one’s expectations and dreams are threatened. That’s where grief can come in. Parents may go through “stages of grief” as they “mourn” the loss of the child they thought they’d have before accepting the child they do have.

Stage 1 is Denial. The first reaction for some is denial. This stage can serve the function of providing emotional protection from being overwhelmed with the idea all at once. Parents may believe the diagnosis is incorrect or mistaken, and try to cling to a false, preferable reality of a “perfect,” or “normal” child. Second opinions may be sought. Symptoms may be dismissed as “developmental” or attributed to generalities like “boys will be boys.” The assessment report might be filed in the wastebasket. Of course it is possible that the diagnosis is inaccurate, and parents should challenge it if it doesn’t seem right. But at some point – if the shoe fits – it is in the child’s best interest for parents to stop denying it. It is very important that the professional charged with first explaining the child’s profile to parents do so with empathy, recognizing and pointing out the child’s many strengths, and providing recommendations that address strengths as well as areas of weakness. No child should be defined entirely by weaknesses, deficits, or disabilities.

Stage 2 is Guilt. As the shock wears off, it may be replaced with pain and guilt. Parents may feel it is their “fault.” Mothers may wonder if it was that one glass of wine they had when they were pregnant. Should they have embraced a more structured parenting style and told their toddler “no” more often? Should they have used organic baby food? Should they have asked their future spouse for a genetic screening test before they accepted a proposal of marriage? I find the guilt stage to be particularly prevalent among mothers who work outside of the home.

Stage 3 is Anger. Some parents may become angry and frustrated, especially at proximate individuals like school staff, teachers, and spouses. They struggle with “Why my child? It’s not fair!”, “How could this happen?”, and “Who brought those genes into the family anyway?” They may go to war with their child’s school, focusing their anger on trying to get the services he or she needs. They may hire an advocate to accompany them into battle. Often this is a good thing and results in the child’s needs being met. But sometimes parents get stuck in this stage and spend years locked in battle. This may not be the most beneficial thing for the child, who is waiting in the sidelines for services, and can create a “battle zone” mentality which is not conducive to a happy home life. Marriages may suffer, especially if one spouse is in the anger stage while the other is still in denial or guilt.

Stage 4 is Depression. A period of sadness, loneliness, and hopelessness may come next. Parents may feel a sense of despair that their child might not be able to lead a normal life, go to college, find a partner, and have a successful career. Sleepless nights may ensue. Parents may isolate themselves from relationships with others (e.g. friends with children who appear to be thriving in school) who they feel can’t understand what they’re going through. This stage can be particularly difficult for parents who feel they are in it alone – single parents and those whose spouses do not “buy in” to the diagnosis and plan of action.

Stage 5 is Acceptance. Acceptance is the final or “goal” stage. Acceptance means that parents bury the expectation of the perfect, normal, idealized child (whatever that means) and accept the wonderful child that they have – in all his or her uniqueness. Acceptance means realizing: “It’s going to be okay;” and maybe even: “It’s going to be great!” Equanimity comes with acceptance. Equanimity involves the ability to be calm and maintain composure even in a difficult situation.

As the parent of two twice exceptional children with learning disabilities and ADHD I’ve been through these stages myself. Disbelief and denial that there could be anything “off” given how bright my children seemed. Guilt that maybe this wouldn’t have happened if I’d parented with more structure or had them assessed when they were younger. Anger that their schools seemed unwilling to address their disabilities or their giftedness. Isolation, sleepless nights. Friends and relatives who didn’t “get it.” And finally…acceptance. And pride and joy that my children are unique and fascinating individuals with strengths they probably would never have had if they weren’t wired differently.

I’m still working on the equanimity bit. Calm and composed? Too much to expect!