Saturday, September 14, 2013

Cognitive-Behavioral Therapy Is Effective for Behaviors Caused by ADHD


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


“Insufficiency of Medication as a Comprehensive Treatment for ADHD”
Personally, I am very impressed with the quality of the writing in this book, both by Solanto and her other contributors. She provides evidence of the success of using a cognitive-behavioral therapy program, whether or not the person with ADHD is taking medication or not. She focuses on the challenges that adults face, those adults who did not “grow out of” ADHD (which is estimated to be about half of the population who has ADHD as children – about 8% of the population). I wish there were more programs here in the Los Angeles area which used this approach. While some mental health facilities offer classes on CBT (such as Kaiser Permanente), they do not gear it to the challenges faced by people with ADHD.
Even with medication – which is not effective for all patients with ADHD – there are skills and behaviors which were never learned as children that the medication cannot “teach” the person how to do (pp. 13 – 14). Mainly these are the executive functions or the ability to self-manage: organizing, planning, self-monitoring, accessing working memory, utilizing self-inhibition, shifting/ transitioning attention from one task to another, etc. (p. 14). This lack of executive functions is developmental – many of these skills eventually do “stick” but usually about 2 – 3 years behind their peers. This delay may be caused by a physical difference in the brain. “Structural and functional neuroimaging studies both in adults (Seidman, Valera & Bush, 2004) and in children (Seidman, Valera & Makris, 2005) have revealed deficits in the volume and activation of regions of the prefrontal cortex known to subserve these executive functions” (p. 15).
Some researchers frame this as “a fundamental deficit in inhibitory control” (Barkley, Murphy & Bush, 2001; Nigg, 2006) – whether it is to stop an automatic impulse in a given situation, or to “prevent interference from extraneous stimuli.”  Russell Barkley is a well-known proponent of this description of ADHD: “Inadequate inhibitory control results in a a proneness to respond to immediate external or internal stimuli, and is manifested cognitively as poor working memory, distractibility, failure to carry tasks through to completion, inattention to detail, and ‘careless’ errors. Tasks that are lengthy, multistep, or inherently challenging will be particularly vulnerable to disruption. Inadequate working memory may result in difficulties in monitoring and adjusting current behavior so as to maximize timely progress toward overarching goals” (p. 15).
Another area that medication does not help someone suffering from ADHD is an insensitivity to reinforcement. That is, consequences of current behaviors simply don’t enter their minds. This has been described as having an “elevated reward threshold in ADHD” (p. 16). Another way of looking at this is having a “steeper delayed reinforcement gradient” (p. 16). This means that people with ADHD can’t be satisfied sticking to an unpleasant task with the knowledge that “it will matter later when you apply to college” or “this could help you get a job promotion later.”
An unfortunate word is used medically to describe someone who suffers from two or more disorders simultaneously: “comorbid.” Some practitioners now use the word “co-occuring” which makes more sense and is less… morbid. It is quite common for people with ADHD to develop anxiety or depression, caused by years of failure and underachievement. “Adults with ADHD complete fewer years of education, have higher rates of unemployment… and higher rates of marital separation and divorce. In addition, adults with ADHD have higher rates of substance and alcohol abuse disorders (18%) as well as increased rates of anxiety (51%) and depression (32%; Kessler et al., 2006), and adult women with ADHD are at greater risk for eating disorders (Biederman et al., 2010). (pp. 8 – 9).
All of these symptoms and outcomes are probably well-known to you already, as a parent with a child with ADHD. There is hope, of course, in several types of treatments, starting with medications that help the neurotransmitters in the brain focus better and longer. What may not be familiar is a treatment called Cognitive-Behavioral Therapy, or CBT.
CBT is a treatment that is psycho-social; that is, it is information that is taught to individuals who seek to change their behaviors. A person with ADHD may not have that “inner voice” that warns them to keep their mouths shut during a sensitive conversation, or to look at a long-term outcome, or to consider at least three bids before deciding on a contractor. CBT helps people become aware of the specific types of situations that can get them into trouble, then to identify what they normally think and do in those situations, and then to think and do something different – in order to achieve a different (positive) outcome.
CBT is founded on the work of Aaron Beck, Albert Ellis, and others (p. 20). The program described by Solanto in this book has key ingredients to help people make changes in their behaviors:
·      Explicit skills training
o   Time management: how to use a planner
o   Time management: how to prioritize activities
o   Organization: how to use the space around you for your work – placement of tools and other materials needed on a daily basis
·      Development of Compensatory Strategies
o   Setting up a work environment to minimize distracters
o   Setting a timer to get work done
o   Maximizing important external prompts, like post-it notes or an electronic calendar
·      Generalizing positive statements/maxims
o   Use of Take-Home Exercise activities that the person can do by himself
o   Frequent repetition of positive statements so that they will automatically start popping up in the person’s consciousness (development of that “inner voice”), such as “Out of sight, out of mind,” and “Getting started is the hardest part.”
There are many more ideas presented in this book about how to accomplish this “brain training,” including a complete 12-week training manual written for therapists to take a group of participants through these ideas and give them specific and practical tools to change their behaviors.
Hopefully with such a well-written guide now available in paperback (just published in 2013; I received my copy on September 12, 2013), we will see more utilization of this healthy therapy, CBT.

Solanto, MV. (2011). Cognitive-Behavioral Therapy for Adult ADHD. New York: Guilford Press.


Monday, September 2, 2013

Medication Advice from Most Experts Is Positive

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

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

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

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

Dr. Thomas Brown, Associate Director of the Yale Clinic for Attention and Related Disorders, Fellow of the American Psychological Association, and developer of the Brown ADD Scales for Children and Adults. These quotes are from his book, A New Understanding of ADHD in Children and Adults, Executive Function Impairments (NY: Routledge, 2103).
For ADHD, adequate education of the patient and family about the nature and treatment of ADHD is an essential aspect of minimizing suffering and damage; it is also a critical factor in eliciting willingness of the patient to engage adequately in the treatment process (p.98).
A regimen of appropriate medication, well-tailored to the specific individual, cannot cure ADHD, but for about 80% of those affected it may provide significant reduction of impairment and substantial improvement of functioning (p. 99).
Side effects: Stimulants are the most widely used medications for treatment of ADHD; some types have been available since the late 1930s, others since thelate 1950's... Large studies of children and adults with aDHD taking stimulants compared with others of similar age have shown that the rate of serious adverse cardiovascular events such as sever hypertension, heart attacks or strokes is no greater among those treated with stimulants than in the general public of the same age without such treatment (p. 10).


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

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

Dr. Martin L. Kutscher, a medical doctor who specializes in working with children with ADHD, has written a book called ADHD: Living Without Brakes (Philadelphia, PA: Jessica Kingsley Publishers, 2010).
Practically speaking, medication is never our first or only choice of treatment. By the time a child is brought to my office, years' worth of attempts to finesse, cajole and punish have already been tried... The largest, national US study on ADHD treatments, called the MTA (1999) study, clearly showed that medication -- especially tightly, professionally supervised use of medication -- was clearly the most effective treatment strategy (p. 108).

Saturday, August 31, 2013

Good Nutrition Can Lessen AHDH Symptoms


I just received this information today from "ADDitude" magazine. They outline several ways to relieve symptoms of ADHD without medication.
I have seen these ideas discussed over the past several years, and some in particular ring true:
- fatty oils / fish oil
- iron, zinc & vitamin C and vitamin B6
- lots of protein in the diet to keep energy steady throughout the day

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

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

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


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

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

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

Friday, August 30, 2013

Organizing Binders for School


Suggestions for Organizing School Work
From That Crumpled Paper Was Due Last Week by Ana Homayoun (2010)
& Seeing My Time by MaryDee Sklar (2012)

Supplies needed:


1.     Have a separate binder for each subject. Each binder should be 1”, with 5 tabbed dividers. (If there is a subject with very little paperwork, like wood shop or health, get a ½” binder for that class.)

Obviously, if a teacher requests something different, such as a 2” binder, get that for that class.

2.     Put one clear transparent pocket divider in the 3-rings, in the front of everything else. This is where you will stuff any papers that need to go back and forth from school to home.

3.     Behind the transparent pocket divider, put one pack of 5 dividers: (1) notes, (2) homework, (3) handouts, (4) tests/quizzes and (5) blank paper. Write these labels on the top of each tabbed divider.

4.     In the very front of the first divider, put the syllabus for the class.

5.     Do not use spiral binders or spiral notebooks. Use loose-leaf paper from the back of the binder.

If a teacher specifies a spiral binder, he or she may want you to paste papers into it, such as science labs or history hand outs. This can get very messy, since the handout is usually the same size as the spiral binder. See if you can find a Science Lab Book, which is bound and bigger than 8 ½ x 11, or a spiral binder with the spiral on the top rather than the side. These are easier to work with over the semester. For an example, see:
http://shopping.netsuite.com/s.nl/c.ACCT126734/it.A/id.195/.f

Using This System:
At school, take the binder you need for your class with you. Put it on the desk, open it up, and take out one piece of paper to take notes. When taking notes is finished, put it in the “Notes” section.

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

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

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

·      Everything should be 3-hole punched.

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


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

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

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


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

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

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