Showing posts with label ADHD. Show all posts
Showing posts with label ADHD. Show all posts

Monday, November 25, 2013

A Quick Look at Barkley's Theory of Executive Functions

Here is a post for theory lovers.
 
Psychologist Russell Barkley's new book, Executive Functions (Guilford Press, 2013), contains a large-scale theory of executive function and self-regulation skills. 
He begins the book by arguing that we do not have a clear picture of what executive function is. Next he uses logical reasoning and a method derived from the work of evolutionary biologist, Richard Dawkins'(The Selfish Gene) to create a model of executive functioning consisting of five distinct layers or levels that we move through as we develop and mature. Finally, he describes each layer, how it works, what can go wrong and what types of interventions are helpful. The material in this last section rests firmly on the advances of neuropsychological research. Before he has concluded the book, he claims that executive function and self-regulation are equivalent and further claims that ADHD is the chief disorder of executive function.  
Here are the five levels:
 1. Pre-EF underlies true executive function (EF) in the brain. This is our raw sensing, attention /awareness, motor, emotions, language and our automated responses. We may respond to what we feel, see and hear but do not exert anything but primitive control over our reactions.
 2. Self-directed EF is the first level of true EF. With this level's set of skills we create our first set of reactions to what is happening within us and around us. These reactions are directed inward rather than outward to others. This level allows us to regulate our response to our body, emotions and environmental input (via our senses). The functions are:  Self-awareness, self-restraint (inhibition), sensory-motor actions, private speech or self-talk, appraisal including calculating the emotional cost of an action, play, reconstitution of memories and thoughts, and problem-solving.
Here is an example: if I am confused and don’t want anyone to know, I will work to keep my face from showing confusion. To the degree that I keep my body still and hide my emotions, no one is privy to what I am feeling.
3. Self-reliant EF gives us the self-management skills necessary to be independent with activities of daily living (ADLS) such as dressing, preparing food, eating and so on. Barkley compares the person operating at this level to Robinson Crusoe who was able to manage his life on his own without social support. However, at this level, we may find ourselves occasionally competing for resources. People operating at this level are performing in a social context, but it is “everyone for themselves.” A child at this level will be competing for toys or play-space during parallel play, or competing with a sibling for a parent’s affection.
 4. Tactical-reciprocal EF: At this level, we use social relationships to achieve our goals. We learn to share and we provide mutual help to friends. We learn what it means to be a friend, and we begin to act accordingly. We begin to regulate our actions, emotions, sensory behaviors, and social behaviors for the purpose of successfully interacting with others. For the first time, moral rules come into play.
5. Strategic-cooperative EF is more an extension of tactical-reciprocal EF than a set of new functions. At this level, our actions have a larger scope. We may make career decisions, volunteer to help with a community project, get involved with political activities, or organize a large group for a united goal. The concerns of this level are adult-oriented, but an older teen can begin to work through issues that involve strategic-cooperative EF skills.
Knowing these five levels of executive function can guide those of us who work with children and young adults with ADHD. It helps us select interventions that are appropriate to their EF development level as opposed to their age level. In this way, we can help them move from where they are stuck into the next level of their growth.
 

 

 

 





Nurtured Heart Approach


When I mentioned Howard Glasser's work, The Nurtured Heart Approach during one of my seminars as an example of a program for developing positive parenting/teaching/therapy skills, someone in the back asked, ‘Is that back in style again?’

The question caught me by surprise. Things go in and out of fashion, it’s true. But this method seems to have a great deal of relevance today: 

     “Parenting skills training helps parents learn how to use a system of rewards and consequences to change a child's behavior.Parents are taught to give immediate and positive feedback for behaviors they want to encourage, and ignore or redirect behaviors they want to discourage.”

 There are other “flavors” of positive interaction programs including Love and Logic and Positive-Parenting. It is the simplicity of the Nurtured Heart Approach that draws me to it.

 Glasser’s three big lessons are:

1)      Do not feed a child’s negative impulses with attention to him when he is acting-out
       2)      Give tons of positive attention to the child at times when he is not acting out
3)      Absolutely follow through with consequences when a rule is broken rule so that there is no confusion regarding what is okay and what is not okay.

 A 6-hour internet-based training class (for CEUs) is available from Glasser that very clearly describes his philosophy and shows how his techniques can help the challenging children and adults in your life.  

Saturday, April 13, 2013

The Sun and ADHD Diagnosis

Another brief post: the Questioning Answers blog has a nice discussion on the topic of solar intensity and the occurence of ADHD. Also go here for a discussion of the research on this topic by its key author.

*Corrections made to links on 6/2/13

Thursday, March 21, 2013

UCLA Mindfulness Meditation

I found a source of Guided Mindfulness Meditation at UCLA. And best of all, the meditations (7 for PC, 15 for iTunes) are free. If you have an iPod, iPhone, iPad you can download them from iTunes. If you are using a PC, you will select to play the meditation on your computer. Bookmark the web page so that you can easily get back to it.

Remember, 15-20 minutes of Mindfulness Meditation a day increases attention skills in teenagers and adults with ADHD by 30% - with or without meds. And by the way, this is 30% over and above the effect they are getting from meds if they are on them. Meditation also decreases anxiety and makes people happier :)

If you want to learn more on the topic, there are two lectures on the UCLA site including a Ted lecture on Mindfulness Meditation by Diana Winston.

Friday, January 18, 2013

Videos on Diet and ADHD

I am a fan of psychiatrist, Dr. Charles Parker - author of The New ADHD Medication Rules. Dr. Parker makes a study of the roles our gut and brain chemistry play in sensitivities to meds. He has put together a set of short videos that speak to those issues and to food sensitivities. There are related articles on his website at CorePsyche.com. Check it out!

Friday, August 10, 2012

ADHD Alternative to Meds

Here is some infromation for parents looking for alternatives to ADHD meds.

Dr. Weil, the alternative medicine guru cites a study in Australia (1) that compares the results of taking methylphenidates such as Ritalen and Concerta versus a supplement of omega-3 fish oil and omega-6 in the form of evening primrose oil. The omega-3 and omega-6 supplements showed the best results. Dr. Weil's blog post is here.

There is a recent book on the topic by Dr. Sandy Newman: ADHD Without Drugs. Dr. Newman recommends that the child also take a multivitamin and a probiotic daily to help keep the gut healthy.

Dr. Weil also says to "be sure to rule out hearing or vision problems, allergies, thyroid disorders, depression, or even boredom in a gifted child" before resorting to medication. Here is a link to his blog on ADHD.  

Monday, February 13, 2012

Coaching Cards



Check out the Parent Coach Cards available at www.ParentCoachCards.com. There are 20 cards on a ring. Each card has a lively illustration on a topic such as flexibility, reactivity, organization skills, impulsive speech, and other ADHD-related behaviors.

The back side of each card contains text that parents can read to help coach their child on avoiding the problem behavior. The cards are set up for on-the-spot usage. A parent can grab a card, show it to the child and read text such as: "Finding your brakes means using your 'thinking side' to control your energy."

There is also first-person text for the child to read. Within that text are a number of 1-liners such as "I need my 'thinking side' even when I'm having fun", that can be used for quick reminders.

An associated coloring book is also available for sale on the site and on Amazon.com.



Friday, February 11, 2011

ADHD Meds and Therapies Update

I have mixed feelings about meds. Here is a little about the pros and cons, and an update on therapies.

The teachers who want to see a child with ADHD takes meds are right when they say it will help keep him from falling behind in school. Once behind he may have a hard time catching up.

However, meds do not cure , they only help with attention, etc. for the hours after the child takes the pill. And the side effects can sometimes be difficult. There is a new med out called Intuniv that works in a different way, lasts 24 hours and appears to have fewer side effects. This is an option for parents to consider and discuss with their doctor.

A lot of the experts these days are suggesting that you try to not go the meds route until you have tried other things for 6-12 months. Here are things to try:

1. Neuro-feedback, which is expensive but has the best results record around.

2. Interactive Metronome (IM) - usually found in a pediatric occupational therapy setting. I sometimes mix IM with sound therapy and get good results - but you'd have to find an OT who knows how to do that.

3. Cognitive therapy in which a psychologist or social worker helps the child to see what his challenges are and offers some approaches to meeting them.

4. Self Management techniques in the classroom in which the child scores himself for staying attentive and then is rewarded at the end of the day if he succeeded 75% of the time. (To get this started, another adult scores with him so that he understands what is expected).

5. There are also programs that help with working memory (another problem for kids with ADHD) - I do not have personal experience with this, but evidence is good.

6. Nutritional help - some children have food sensitivities that mimic ADHD symptoms. The best way to find out is to eliminate a variety of common allergens - milk (cheese, yogurt and whey), wheat, soy (soy oil is everywhere), and corn (don't forget corn syrup) are the usual culprits. Do them one at a time for 2 weeks and be religious about it - reading the labels of everything. And forget about eating out while you are doing it unless the restaurant you are going to has an allergy menu.

By the way, new research shows that a daily vitamin with minerals is very helpful. So is a high protein breakfast. And if he is a picky eater or has poor bowel movements, a visit to a DAN doctor (austim) may help to correct gastric issues.

The children who do best with getting rid of ADHD symptoms are those who have done multiple therapies. Which means that the parent has to shell out for lots of pricey therapy. How a parent with limited means accomplishes that is to browse the book store books, settle on an approach and go from there - working step by step through the book. And then on to another one.

Wednesday, December 30, 2009

Overlap in Sensory, ADHD and Autism

I am doing tons of reading right now to prepare for a class on self-regulation I'm giving in April.

Current literature is looking at ways to separate out ADHD from Autism and to identify sensory characteristics of each. This is a technical post, but if you read lightly, you can find some interesting tidbits.

There is a technical term: nosology that refers to the hieracrchy of diagnoses. The new nosology for sensory processing disorder (SPD) has several layers. There are 3 types of SPD: Sensory Modulation, Sensory Motor Issues (motor planning and posture) and Sensory Discrimination. Here is a quick look at it. See the Miller article referenced below for details.

Sensory Processing Disorder (SPD):
1. Sensory Modulation
------Over response
------Under Response
------Seeking/ Craving
2. Sensory Motor Issues
-----Dispraxia (Motor Planning)
-----Posture Disorder
3. Sensory Discrimination
-----Visual
-----Auditory. touch, vestibular, proprioception, etc.

The reason I taxed you with the nosology is to highlight the modulation piece. Modulation from sensory causes appears similar to ADHD, but ADHD is not caused by sensory issues. An assessment such as the Sensory Profile can tease out which is which.

ADHD as you probably know has characteristics of impulsivity, poor attention, hyperactivity, etc. that can also be found in SPD. Typically, ADHD is treated with therapies, patience, etc, etc or meds. SPD is treated with sensory therapy. Completely different.

Now we get into autism. What they are finding is that 42-88% of children with autism have sensory processing disorder. Some also have a sensory modulation disorder. 50%-80% of children with autism have ADHD. However (back to nosology) ADHD in the DSM-IV (Psychiatric Manual) is a level 2 disorder. Autism is a level 1 disorder and takes precedence. So technically, if a child has autism, they cannot be also diagnosed with ADHD (a disservice in my opinion).

Children with ADHD have communication and social issues, but they are not the same sort of issues as those found in autism. Hartley & Darryn (2009) pose the question "Is high functioning autism distinguishable from ADHD and from anxiety in older children?" The short answer is yes, but they share a number of seemingly similar characteristics in the areas of communication skills, social skills, and repetitive behaviors. Lots of overlap to sort through with children who are neurotypically different than their peers.


1. Miller, L., Anzalone, M., Lane, S., Cermak, S., & Osten, E. (2007). Concept evolution in sensory integration: A proposed nosology for diagnosis. American Journal of Occupational Therapy , 61, 135-140.
2. Hartley, S., & Darryn, M. S. (2009). Which DSM-IV-TR criteria best differentiate high-functioning autism spectrum disorder from ADHD and anxiety disorders in older children? Autism , 13, 485-509.

Monday, October 19, 2009

ADHD Overfast Response to Tapping

When I have children with ADHD get started on an IM program, I automatically adjust the tempo to 63 beats per minute rahter than the standard tempo of 54. Why, they almost always over-anticipate the beat with the standard tempo and so miss clapping or tapping in rhythm. But when I change it to 63, most find their sweet spot and can perform admirably. IM's recently released bibliograpy of temporal studies points to research that came to the same conclusion. Check it out. That paper and others are found at this site. Here is the citation:

Hilla Ben-Pazi, Ruth S. Shalev, Varda Gross-Tsur, and Hagai Bergman. (2006). Age and medication effects on rhythmic responses in ADHD: Possible oscillatory mechanisms? Neuropsychologia 44: 412–416

This question came up for me recently. Does ADHD meds suppress timing? In this case, the meds are Adderall. I see a 6 year old girl who had excellent scores on IM prior to starting Adderall. Afterward, her score fell into the severely deficit range. Interesting. The above study found that there was no difference in timing skills for those on Methylphenidate (i.e. ritalin). I'd love to see a study on Adderall. Adderall is a combination fo amphetamine and dextroamphetamine. It has a known side effect of appetite suppression.

Wednesday, December 10, 2008

The Meds Alternative

I see a very sweet 7 year old boy who has autism, OCD and ADHD. Whew, that's a lot. I've spent the better part of a year with him on modulation - and made a lot of progress - relative progress, that is. But then I hit the wall. His OCD and anxiety symptoms were too pronounced for him to attend to therapy. For example, when I tried to teach him to tie his shoes, he created a new OCD ritual around shoe tying.

His parents had him on a low-dose medication and were not certain about what to do next. I suggested going back to his doctor for a new approach. The boy was given an increase in his meds dosage, and finally, he was able to focus. His OCD settled down enough to do the more powerful interventions in my toolkit (IM and sound therapy), and now we are off and running again. We've been making incredible progress with social skills, modulation and play skills. Hooray!

I think that meds are a God-send for certain children. For my small buddy, it's the difference between running in circles much of the day versus significant interaction with adults and peers.

Will he be on them forever? Can't say, of course. I truly hope that he gets a reduction of symptoms with the next round of therapy ... and then maybe meds can be revisited.

Saturday, October 4, 2008

Another Blog

I am starting up and new blog and that will slow my activities on this blog. The new blog will cover some of the same territory, but be focused on new interventions, technologies and clients aged 12 - 99. The new blog is called Brain Tune-Ups - that's the name of my Ann Arbor clinic. The blog is at http://braintuneups.blogspot.com/

A big factor for the change is that a small flood destroyed all of my research articles on peds and autism. But the change would have come in any event, since I am shifting my practice into teens and adults away from children. The title of this blog just doesn't do justice to where my practice is heading. I will continue to work with clients whose main concerns are self regulation or the symptoms of autism and so I will continue to have material for this blog.

On the Brain Tune-Ups site, I will continue to write about Interactive Metronome, Therapeutic Listening, Samonas, stress reduction, etc. And I'll publish the results of the adult study there.

By the way, my clinic's website is http://www.braintune-ups.com/

Sunday, February 24, 2008

Interactive Metronome Research

I wrote earlier of being "blown away" by the capabilities of the Interactive Metronome™ (IM) product. The literature shows that IM increases mental fluency which in turn increases the efficiency (and skill level) of many brain and body functions including motor planning. (See the TickTockBrainTalk blog and the IM site, for much more on this!)

There has been substantial research done on IM for children. (The article cited below finds that IM "appears to facilitate a number of capacities, including attention, motor control, and selected academic skills in boys with ADHD.) There are a few studies on the effects of IM on adults in rehabilitation recovering from varied disabilities such as stroke, TBI and loss of limb. None of the studies I've seen address softer issues such as stress, organization, or well-being.

I have launched a small research project studying the effects of the IM protocol on parents of children with special needs. It's a convenience study being done at Building Bridges therapy Center, where I work. I am asking the question: Does IM help parents of children with special needs become better organized such that they are better able to accomplish their goals. And does this is turn help reduce their stress levels? These parents operate at a very high level of challege and stress (lots 0f OT journal articles have documented this).

I may also look at another factor -- SI. Since many of the children at my clinic have autism and sensory integration issues, as a result, I may assess parents for sensory integration issues using the Adult/Adolescent Sensory Profile. If indeed they do, I wonder if any symptoms lessen at the end of the study....and if not, perhaps, I could re-enlist them in another short study with a different intervention. H-m-mm.

Article

Shaffer, R. J., Jacokes, L. E., Cassily, J. E., Greenspan, S. L., Tuchman, R. E., & Stemmer, P. J., Jr. (2001). Effects of Interactive Metronome™ training on children with ADHD. American Journal of Occupational Therapy, 55, 155-162.

Abstract

(This was copied from the IM site)
The purpose of this study was to determine the effects of a specific intervention, the Interactive MetronomeÒ, on selected aspects of motor and cognitive skills in a group of children diagnosed with attention-deficit/hyperactivity disorder (ADHD).

The study included 56 boys, age 6 to 12 years, pre-diagnosed as having ADHD who were pre-tested and randomly assigned to one of three matched groups. The 19 children receiving 15 hours of Interactive MetronomeÒ rhythmicity training exercises were compared with a group receiving no intervention and a group receiving training on selected computer video games.

A statistically significant pattern of improvement across 53 of 58 variables favoring the Interactive Metronomeâ treatment was found. Additionally, several statistically significant differences were found among 12 factors on performance in areas of attention, motor control, language processing, reading, and parental reports of improvements in regulation of aggressive behavior.