Self-Regulation and ADHD: Misusing Shanker's writings and the Calm, Alert and Learning concept.

Self regulation is something I write about and teach all the time.  Right now, on my desk, is a lesson for a 7 year old on self regulation. We are going to use a book called "The Incredible 5 Point Scale" to understand emotions, and practice some CBT (Cognitive Behavioural Therapy) techniques to regulate them. It's a very simple lesson, but often very helpful for children with anxiety who over react to stressful situations. I also go to schools and demonstrate class wide (universal) techniques to teach and learn these self regulation skills. This is not new stuff, it's the focus of many of the programs in our schools already, especially for children with social-cognitive disorders such as Asperger's Syndrome or High Functioning ASD.  POPARD, the Provincial Outreach Program for Autism and Related Disorders has an excellent team of professionals who teach this all across the province.

So why am I so upset by the recent article in the Vancouver Sun about using self-regulation techniques in our classrooms?

Here is a direct link to the article:
(http://www.vancouversun.com/technology/schools+promote+student+self+discipline/7287707/story.html)

Here is the part that scares me:


"Former education minister George Abbott echoed that view and predicted during an interview last month before he left the ministry that the project now underway will bring significant change to all 60 districts within two to four years. “This is hugely exciting,” he said. “I think it can reshape the way we manage the challenge of special needs in the 21st century.”

He expects it will move schools away from their emphasis on diagnosing a child’s special need, attaching a label — which may or may not bring additional funding — and developing an individual education plan (IEP). The goal, instead, will be for schools to make better use of groundbreaking neuroscience research on self-regulation to benefit all students.
“Let’s not be blowing our resources on trying — at often too early an age — to diagnose precisely what the challenge is,” Abbott told leading school officials at a self-regulation conference earlier this year. Regardless of what the challenge is — whether the child is the next Isaac Newton or has attention deficit hyperactivity disorder (ADHD) — the strategies to help with learning are the same, he said."

Wow. So a subtext to this is to cut the waste of time we spend doing psychoeducational assessments, "Let's not be blowing our resources on trying -at often too early an age -to diagnose precisely what the challenge is."  This is in stark contrast to volumes of research on the effectiveness of early intervention, and the ability of most other jurisdictions in North America to provide early assessment and intervention, often BEFORE students enter school, to make sure they do not fall behind and have adequate supports.  But as he also notes, why bother, because these "labels" "may or may not be bring additional funding."

By the way, here in BC students, often students who have failed academically for two or more years, are placed on waiting lists to be assessed. They often remain on those waiting lists for two or more years! At the end of every year the waiting list is often reworked, and those with severe behavioural problems go to the top, so a student who almost got to the top this year might be at the bottom of the waiting list next year. Compare this to getting an assessment in Washington State. It take 50 working days for an assessment to be completed. Just keep this issue in mind as you read the article.

Mr. Abbott's most frightening statement is, "Regardless of what the challenge is - whether the child is the next Isaac Newton or has attention deficit hyperactivity disorder (ADHD) - the strategies to help with learning are the same..." 

This is the most uninformed and misinforming statement I can imagine making. You use the same strategies to help a child who is "gifted" as a child with ADHD, autism, Aspeger's, a disorder or written expression, dyslexia....really? There is some research that supports this? You mean that all of the programs designed to address specific visual, motor, cognitive, auditory, and sensory deficits are ....the same? And I guess that means lets just stop with all this assessment stuff, stop wasting our time understanding the individual child, and apply a blanket procedure to everyone...because if children would just learn to "remain calm, be focused and alert" everything would be fine.

This attitude dismisses the real nature of disorders such as depression, anxiety, learning disabilities, ADHD and many, many others. Can you imagine this attitude in any other field? Would you like your doctor to think like this? "Hey, we don't need a diagnosis, who cares if its mumps, an allergy, cancer ..... just learn to eat healthy and exercise." Besides, we don't have enough funding!

Don't misunderstand me. Preventative interventions, like Shanker's, are great! Let's implement them, today! But for students with real learning disorders they are not a replacement for real assessment, diagnosis and focused interventions and support. When you read that and local school officials members of our government think that promoting "self-discipline" and "self-regulation" is a proven therapy for children with diagnosable learning disorders, be skeptical. And when you read that they also suggest we just skip over that unnecessary diagnosis stuff ....because it won't lead to funding...be angry!

The deep deep message here is that it is through personal responsibility and self-discipline that change will occur. That simplistic message is what is appealing to people here. That's really  hard to argue with. To disagree makes you sound like a total quack. But for many disorders, such as ADHD (which British Columbia is famous for addressing poorly) children, teens and adults know what they should do, they understand their behaviours, but cannot help themselves. THAT is the nature of the ADHD - a brain based neurological disorder, not poor attitude. I suggest George Elliot and others supporting the further gutting of school psychology services read about ADHD in science based books and articles by professionals like Russell Barkley, PhD). Students with ADHD are helped through specific classroom environmental changes, externalized prompts and cues and, sometimes, medical intervention. There are many proven and effective classroom based interventions for these students, with years of research backing them up. But when was the last time you heard a school district was providing training for teachers in addressing the needs of their students with ADHD, learning disabilities or Aspeger's Disorder? 

The tone of self-discipline and self-regulation to address disorders like these leads to blaming the victim mentality. We expect them to fit the program rather than "to diagnose precisely what the challenge is" and providing appropriate supports. Something Mr. Elliot says directly is a waste of time and money. 

After reading those comments I need to be "calm and alert" myself.



Kids with ADHD deserve action: One Year Later

Today I reread this great letter to the editor about ADHD, ADHD treatment and ADHD in the schools here in BC. The link is below and you should read this letter yourself, it's a cry from a parent for the local school districts to do SOMETHING for students with ADHD in the schools, anything! Because what BC schools are doing for students with ADHD is totally unacceptable. It's actually nearly nothing. Here is a link to the web site and letter to the editor: http://www.burnabynow.com/health/Kids+with+ADHD+deserve+action/3699644/story.html

Here are some of the comments from the letter, and my additional comments: First, the writer talks about being "anxious and frightened on how we'll try to navigate through an education system that doesn't recognize my child's ADHD as a disorder." This is perhaps the most shocking and incomprehensible part of the letter. And it's true. ADHD, one of the disorders most likely to cause school failure, academic failure, lead to low graduation rates, low employment rates and even relates to many co-morbid disorders (such as specific learning disabilities) is IGNORED by many of our local school districts. Some districts will provide help, but only if the child is a "behavioural problem." Academic stress and failure in school aren't enough. We need to wait until there is "behavioural disruption" due to the ADHD. Strange. Backwards. And it's no wonder British Columbia is tied with two other provinces for the worse services for children with ADHD.

 The writer notes, "it is a neurological disorder that is medically recognized and that requires treatment." The writer needed to have her child tested privately to finally get the diagnosis. Let me make clear, when we say it's a neuropsychological or neurological disorder that means we can put a child into an MRI and SEE areas of the brain failing to function. ADHD is one of the most researched and tested diagnoses of all childhood disorders, yet some school district personnel still fail to accept that it even exists! The writer goes on to say, "each year, we are frustrated at the stigma associated with a chronic lack of awareness of ADHD, and lack of support and resources for a disorder that affects thousands of children." If your child has autism, the school gets funding, usually assigns an aide, and for children under 6 parents get over $20,000 in funding for treatment. Over six years of age they continue to get thousands of dollars of funding a year, both the school and directly to parents for treatment they find and make use of. In BC we have zero funding. A child suspected of having ADHD needs to be assessed and usually this means not just an ADHD assessment but also a full psychoeducational assessment as nearly 50% of these children have other disorders such as anxiety, depression, OCD, ODD or specific learning disabilities. Yet MSP will pay zero, and most private insurance will pay from 100-500 dollars for services. (A full diagnostic evaluation can cost from $1,200-2,600.00) When visiting schools I am usually there to see students with autism spectrum disorder or Aspergers Syndrome. These children have funding and get classroom aides, teacher training and consultation from professionals like myself or the provincial organization 9POPARD- the Provincial Outreach Program for Autism and Related Disorders). Yet the teachers I meet who are burned out, confused, need the most help and are most likely to be the ones going out on sick/stress leave are the teachers of students with ADHD. For them, regretfully, there is little support.

 In the past few years I have been invited to consult on hundreds of students, and present workshops for teachers during their professional development periods. Only twice has a school thought it important enough to bring me in to speak about ADHD. Autism, Aspeger's Syndrome, general classroom management,and severe behaviour problems. I always tell them, the biggest bang for your buck is training your teachers in techniques and skills to work with and support students with ADHD. Every class has 1-3 students with ADHD, and the techniques and tools we teach that address ADHD work for almost every other issue. But before teachers and administrators ask for help with ADHD training they need basic education to understand and recognize ADHD.

Regretfully, we still have teachers and administrators who think ADHD is a made up excuse for laziness and poor parenting. It's time BC moved out of the dark ages of mental health. "ADHD Assessment and Treatment" are written by Dr. Jim Roche. These autism notes are not meant to provide a guide to either diagnosis or treatment. For information on diagnosis and treatment contact your medical doctor or a registered/licensed psychologist for an appointment and assessment. Information about Dr. Roche's services can be found at these addresses:

 At Relatedminds: http://www.relatedminds.com
 At ADHDHelp BC: http://www.adhdhelp.ca
 At Psychology Today: http://therapists.psychologytoday.com/rms/70682
 At the BCPA website: http://psychologists.bc.ca/users/jimroche
 At CounsellingBC: http://www.counsellingbc.com/listings/JRoche.htm
 At Psyris: http://psyris.com/drjimroche

KEYWORDS: ADD, ADHD, Attention Deficit Hyperactivity Disorder, ADD Coaching, ADHD Coaching, ADHD Coaching Vancouver, ADHD Coaching Burnaby, ADHD Coaching Langley, ADHD Coaching Coquitlam, Psychoeducational Assessment, Learning Disability, ADHD Diagnosis

Think Your Child Has ADHD?

WebMD has an excellent and short video on the initial steps to diagnosing ADHD in children. This ADHD video on diagnosis also addresses the use of medication for children and teens with ADHD. As usual, medication is not the first step one should necessarily take after finding your child has ADHD. Common, well known behavioural interventions in the home and classroom are the recommended first step, and these remain important parts of treatment for ADHD no matter if you make the choice to use medication or not. Certainly it is clear that parent education, student/child psychoeducation and behavioural therapy and ADHD Coaching are step one and are always part of any good treatment plan.

Here is the link to this ADHD video: Think Your Child May Have ADHD? Learn More - Watch WebMD Video http://www.webmd.com/add-adhd/video/diagnosing-adhd

For more information on the diagnosis of ADHD in children, adolescents or adults, see my web page at www.relatedminds.com ADHD can be diagnosed by either a medical doctor or registered psychologist with appropriate training and experience. An initial medical exam is always necessary to rule out possible disorders that cause the behaviours of concern that may not be ADHD. To find a registered psychologist who can diagnose ADHD contact the British columbia Psychological Association.

More information about my practice can be found at: "ADHD Assessment and Treatment" are written by Dr. Jim Roche. These autism notes are not meant to provide a guide to either diagnosis or treatment. For information on diagnosis and treatment contact your medical doctor or a registered/licensed psychologist for an appointment and assessment.

Information about Dr. Roche's services can be found at these addresses: Relatedminds: http://www.relatedminds.com
ADHD Help BC: http://www.adhdhelp.ca
At Psychology Today: http://therapists.psychologytoday.com/rms/70682
At the BCPA website: http://psychologists.bc.ca/users/jimroche
At CounsellingBC: http://www.counsellingbc.com/listings/JRoche.htm
At Psyris: http://psyris.com/drjimroche

 KEYWORDS: ADD, ADHD, Attention Deficit Hyperactivity Disorder, ADD Coaching, ADHD Coaching, ADHD Coaching Vancouver, ADHD Coaching Burnaby, ADHD Coaching Langley, ADHD Coaching Coquitlam, Psychoeducational Assessment, Learning Disability, ADHD Diagnosis

New ADHD Widget added to web page


You will find the new ADHD Widget on the right side of most pages of my web page. This new widget guides you through making a decision about ADHD - that is, it helps you decide if it might or might now be a good idea to see you psychologist to medical doctor. It's not meant to diagnose ADHD. It's a handy interactive means of helping you put things into perspective. Deciding if a child has ADHD is a several step process. There is no single test to diagnose ADHD, and many other problems, like anxiety, depression, and certain types of learning disabilities, can have similar symptoms.

The American Psychiatric Association's Diagnostic and Statistical Manual-IV, Text Revision (DSM-IV-TR) is used by mental health professionals to help diagnose ADHD. The criteria are presented here in modified form in order to make them more accessible to the general public. They are listed here for information purposes and should be used only by trained health care providers to diagnose or treat ADHD.

If a parent or other adult is concerned about a child’s behavior, it is important to discuss these concerns with the child’s health care provider. A diagnosis is made up of more than a simple checklist.

See my web page for more information at www.relatedminds.com
                                   

ADHD Services for Children, Adolescents, Adults and Families

How can I help you? If you or your child have ADHD (Attention Deficit Hyperactivity Disorder - or ADD) I provide a number of services that can be of help to you, your child or your relationship. For over the past 25 years I have worked with children with ADHD, adolescents with ADHD, adults with ADHD and families dealing with ADHD. Unlike many other "counsellors" and "coaches" who work with individuals with ADHD but have never worked in a school, work or family setting, I bring nearly three decades of experience working with individuals in the schools - as a classroom teacher with students having behavioural and academic problems due to ADHD, in the workplace, as a rehabilitation and community based neuropsychologist with adults returning to work with ADHD and related issues of impulsivity and concentration due to head injuries, and as a registered marriage and family therapist and clinical member of AAMFT (American Association of Marriage and Family Therapy). Because of my classroom experience as a teacher (and licensed school psychologist) I understand how teachers can implement classroom based interventions to help a child or adolescent with ADHD, and understand the interaction between ADHD and Specific Learning Disabilities (my offices located in both Burnaby and Vancouver) offer not only psychological assessments for ADHD but also full psychoeducational assessments for the diagnosis of learning disabilities and other co-morbid disorders often found with ADHD. Often this includes school based observations and consultation with the teaching/school staff. I have offered teacher workshops on ADHD throughout British Columbia, California and New York State. I also offer parent training and education programs which focus on teaching parents and other caregivers specific skills to help them teach their child with ADHD necessary behaviours and skills. I also work with adolescents, young adults and adults in dealing with both workplace problems and relational problems stemming from the symptoms of ADHD. This might include on site observations and consultation, as well as ongoing coaching and skills development. My years as a community based neuropsychologist working with programs such as Gentiva's Rehab Without Walls focusing on helping individuals with focus, concentration and executive skills development after workplace injury or strokes has provided me with specialized and focused skills in this area. Finally, many individuals with ADHD come to see me about issues such as depression, anxiety, stress and relationship (including parenting and marriage) problems. The services of a REgistered Psychologist are not covered in BC under MSP, however many extended health care plans do cover the cost of psychological services, including therapy, counselling, coaching and assessments. Check with your provider. For those with limited funds who do not have medical coverage for ADHD I often try to work with individuals using one of several self-help programs that are science/evidence based. Please feel free to call me and set up an initial consultation. As these consultations last for approximately an hour, there is a cost, however, usually during that hour we are able to establish a good outline of a program for you, based upon your individual needs and abilities. My offices are located near Lougheed Town Center (near Fitness 2000 on Salish Court) and near the Cambie Bridge and City Hall on 8th Ave. More information can be found at my web page at www.relatedminds.com or www.adhdhelp.ca

News for those with ADHD and Bipolar Disorders

There is a new study about ADHD (Adult ADHD) and Bipolar Disorder. If you have ADHD and Bipolar Disorder you may want to send this study to your doctor. here's the basic information, and a link: (This study was published as an abstract and presented orally at a conference. These data and conclusions should be considered to be preliminary as they have not yet been reviewed and published in a peer-reviewed publication.) SAN DIEGO, May 24 -- When attention deficit hyperactivity disorder meets bipolar disorder in an adult, the diagnosis is hard and the course is poorly understood but the co-morbidity appears to exacerbate matters, researchers said here. A systematic review of rates of bipolar disorder and ADHD in adults revealed that co-morbidity ranges anywhere from about 5% to 47%, reported Aliza P. Wingo, M.D., and S. Nassir Ghaemi, M.D., M.P.H., of Emory University in Atlanta. But patients with the co-morbid conditions may benefit from the addition of bupropion (Wellbutrin) to their antimanic agents, said Dr. Wingo, who co-authored the study with Dr. Ghaemi. The full study review of the study can be downloaded here: APA: Co-Morbid ADHD in Bipolar Adults May Respond To Non-Stimulants Click http://www.medpagetoday.com/MeetingCoverage/APA/5764 Co-morbid conditions (ADHD PLUS something else) can be very complicated to treat. A referral from your family doctor to a properly trained psychiatrist is always advised.

ADHD and Executive Function

Dr. Russell Barkley is a leading expert in ADHD/ADD and Executive Function Disorders. In this short video Dr. Barkley addresses this critical issue for everyone with ADHD. Executive Dysfunctions have been found to be a critical part of ADHD, and may even be THE critical issue at the heart of ADHD. The "Executive Functions" that we talk about are those that help us maintain goal directed or related behaviour. If you have ADHD, or your child has ADHD, you will know what this means because you know "what's missing." Dr. Barkley, in this short video and in his books and articles, suggests that there are five essential "Executive Functions": 1. The ability to "inhibit your behaviour,":stop what your doing, and stay on task by not reacting to other outside, distracting stimuli; 2. The ability to use non-verbal working memory- visual memory- in order to imagine working your way through a task. This is especially true with math. Often individuals with ADHD score lower on tests of visual memory than what would be expected by their overall intellectual capabilities; 3. The ability to "talk to yourself," to have a voice in our head to instruct ourselves- also called "verbal working memory." Most of us have this inner voice, and we use it to guide our behaviour throughout the day. Those with ADHD do not seem to have this skill (but it can be practiced and learned!); 4. The ability to control our own emotions, and to moderate those emotions so that we want to stay on task, and are able to maintain mental and emotional energy throughout the stages of longer, more complex tasks; 5. The ability to plan and problem solve - to manipulate information to figure out how to get complex things done. This, like many of the other skills listed above, are not simply fixed with medication, but instead need to be worked on individually through education, modelling, practice and reinforcement. These are the "mind tools" Dr. Barkley and others suggest we focus on when addressing ADHD in counselling, therapy and coaching. Most of them are addressed through basic behavioural therapy and interventions, as well as Cognitive Behavioural Therapy. Below is a link to Dr. Barkley's brief, but informative video. In addition to the video there is also a more in-depth written explanation of these "executive skills" and how they effect ADHD. That can be found by clicking here: http://www.russellbarkley.org/content/ADHD_EF_and_SR.pdf For more information on ADHD services I provide in my offices in Burnaby, Vancouver and San Francisco, please check my website at http://www.relatedminds.com or http://www.adhdhelp.ca This page is not meant to offer diagnostic services or suggest specific services to address ADHD. ADHD is a complex disorder, and many symptoms and behaviours taken for ADHD can actually be signs and symptoms of other disorders such as anxiety, depression, Autism spectrum disorder, Asperger's or even depression. See a licensed or registered mental health professional for an appropriate diagnosis.

ADD & Loving it?! Trailer

Click here to find the video: ADD & Loving it?! Trailer

Dr. Russell Barkley, a leading in ADHD research, mentions this video on one of his New York times blogs.  Give it a try. There are several different sections, so you don't have to watch them all. One, in particular, has been useful to my patients, the section on ADHD and medication. Take a look at that for some good, simple facts about ADHD and medication.

ADHD or ADD (Attention Deficit Hyperactivity Disorder) is treatable with medication, cognitive behavioural therapy and behavioural therapy. For information on diagnosis and treatment in my offices in Vancouver, Burnaby or San Frncisco, visit my web site at www.relatedminds.com or www.adhdhelp.ca

Early ADHD Treatment May Save Math Skills

Here is British Columbia we are very reluctant to test children in the early school years. Often, from parents, I hear that their child, who is failing academically at school, is not a "priority" as there are no severe behavioural issues. So, they are placed on a waiting list, which usually is rewritten every school year, and they never get assessed. Parents are often waiting for the school assessment - a psychoeducational assessment - to tell them about ADHD. They are often surprised when the psychoeducational assessment is completed to find out the schools neither diagnose ADHD, nor do they provide any structured and measurable treatments for ADHD (for the most part.) While there are some individual school districts here in BC that do have organized interventions for ADHD, they are few and far between, and BC is known for providing the fewest services for children with ADHD of all the provinces. So, we often wait through grades 1,2 and 3 and maybe in grade 4 or 5 we finally get a psychoeducational assessment and are old to visit either a medical doctor or a registered psychologist for a diagnosis of ADHD. Only after all of this waiting around are we ready to begin treatment interventions. And one thing we have known for sure is that early intervention for ADHD is critical, because its a developmental disorder, and developmentally appropriate skills are often not learned, and are hard to teach at the "wrong" developmental stage. Math is often the first academic skills to suffer. And trying to catch up in math in grades 5,6 or 7 is very difficult. This review article from Medpage looks at the results of EARLY treatment for ADHD, and how early ADHD treatment may be critical in saving math skills. Click http://www.medpagetoday.com/Pediatrics/ADHD-ADD/33441 for the full story The research points out two critical facts that I want to make clear at the beginning: 1) Starting treatment for attention-deficit/hyperactivity disorder (ADHD) sooner rather than later appears to lower the likelihood of a decline in academic performance as children move from elementary to middle school, and 2)that the timing of ADHD treatment had little influence on the risk of a decline in language arts performance.This is also important because parents, and teachers, often assume that because language based skills -reading, writing - are pretty much up to par the student only needs to be further encouraged to take academic work seriously. "They can do the work they want to do ...so we know they can do the work," is the false, misinformed and unfortunate thing I often hear. Here are the basic findings from the article, found at Medpage: "Starting treatment for attention-deficit/hyperactivity disorder (ADHD) sooner rather than later appears to lower the likelihood of a decline in academic performance as children move from elementary to middle school." "Among Icelandic children receiving ADHD medications, those who started treatment later had greater risks of a decline in math performance (RR 1.7, 95% CI 1.2 to 2.4), an association that was stronger in girls than in boys." Fairly early meds lead to better academic outcomes. Here is an interesting historical fact: "In 1937 -- 75 years ago -- when children were treated with stimulant medication for the first time, the boys referred to the medication as their 'arithmetic pills' since they noticed their math performance improve." Even the kids knew this was helping, and helping specifically in math. "More recently," the researchers continued, "math performance (speed and accuracy) has proven to be a very sensitive and reliable clinical measure of medication effectiveness in many research studies." The researchers noted that previous studies have shown that mathematics disabilities and language disorders involve different parts of the brain. "Possibly," they wrote, "stimulant drug treatment has more positive effects on the cognitive function underlying mathematical ability than on that underlying language ability." Although stimulants have been shown to improve the core symptoms of ADHD, there are few long-term data on their effect on academic progress. To explore the issue, the researchers, Zoëga and colleagues looked at data from 11,872 children ages 9 to 12 born from 1994 to 1996 who took standardized tests in the Icelandic school system in the fourth and seventh grades. Information came from the Icelandic Medicines Registry and the Database of National Scholastic Examinations. About 8% of the children were treated with ADHD drugs at some point during the study period. Nearly all of those treated received methylphenidate (96%); 9% also received atomoxetine and 34% received another psychotropic drug concurrently. The children who started taking ADHD drugs between the fourth and seventh grades were more likely to decline in test performance -- defined as a drop of at least 5 percentile points -- compared with nonmedicated children. So we see that while the medication might be helping, it is not enough alone. But they noted, "There were also differences seen within the treated group; later treatment initiation (25 to 36 months after the fourth grade tests) was associated with higher rates of performance decline compared with earlier initiation (within 12 months of the fourth grade tests).Declines in math were seen in 73% of those who started later and 41% for those who started earlier. Language arts declines were seen in 43% of those who started later and 39% of those who started earlier." They also note that, "When broken down by sex, the relationship between starting treatment later and a decline in math performance was stronger for girls than for boys (RR 2.7 versus 1.4). That finding could be due to chance or could be related to sex differences in ADHD symptoms, according to the researchers, who noted that girls with ADHD typically present with symptoms of inattention and have less hyperactivity than boys." They noted, "It is possible that children who started ADHD treatment earlier may have more family or social support to help them in school." However the results are fairly clear. Here in BC we find ourselves in an educational system that is over focused on math. You can't get into a university here without completing specific high school math courses - even if you have high grades in all your other courses and plan on majoring in history or fine art, problems in math will hold you back in BC (while the schools essentially ignore ADHD and other neurological deficits that are at the root). You may agree or disagree with this emphasis on math. The problem is that it is real. So EARLY intervention is critical. Talk to your medical doctor, see a registered psychologist for information on ADHD diagnosis and non-medical interventions, and speak up for services at school. For those interested in the problem of math education, the New York Times had an excellent article this morning on just this subject. It can be found here: http://www.nytimes.com/2012/07/29/opinion/sunday/is-algebra-necessary.html?smid=pl-share Information on ADHD assessment and treatment services I provide can be found at www.relatedminds.com or www.adhdhelp.ca.

Cogmed and ADHD. Well, maybe Cogmed +

Someone recently wrote to me about using Cogmed, a computerized training program to address problems with "working memory" and ADHD (Attention Deficit Hyperactivity Disorder or ADD) That's the part of memory that holds something in your head while you do something else - like hearing a phone number, getting a piece of paper and pencil and writing it down. One writer pointed out that Cogmed isn't designed for "curing" ADHD. The writer is correct, Cogmed training isn’t supported for helping with ADHD. When you are certified to provide the services, you are told not to make such claims. Sorry, generalization with these techniques is pretty poor. None of these "brain games" work well with something as complex as ADHD. But Cogmed is good for working memory, and if working memory is an issue improving working memory can really help. And sometimes working memory is holding someone back ...so, get your working memory assessed and see if it's a significant part of the problem. Any registered or licensed psychologist can help you with that. (Regretfully many ADHD coaches seem to rush people off into using these programs when they are simply inappropriate. Make sure your ADHD coach is a registered or licensed mental health practitioner, and not simply someone certified in "coaching.") While there are always suggestions that some treatment will “fix” ADHD, one critical issue is always missed. ADHD is a developmental disorder. During normal childhood development,because of ADHD, a number of developmental skills are either not learned, or learned improperly. Because of core neuropsychiatric impairments in attention, inhibition and self-regulation individuals often fail to learn to use appropriate compensatory strategies to be successful at organizing, planning and managing procrastination/avoidance/distractibility. This leads to a functional impairments which none of these "quick fix" methods including neurotherapy, biofeedback, brain games, diets and supplements helps with. There is no pill or simple intervention to fix the functional impairments of ADHD and teach these skills, just like there is no pill to teach French, hockey or cooking. Organization is something you learn very early in life, usually in play, and it is reinforced naturally in the environment. (Parents clap, say ”what a nice job!” or the blocks stand up really tall!) When we work with an adult who might be having trouble at work with organizing, well, honestly, learning the skill is one thing, using it, is NOT reinforcing. Most of my adult clients need to deal with the fact that if they become more organized at work they will most likely ..... get more work! If you remember to do 10 things on your to-do list, it’s most likely not 10 “fun and exciting” things to do... and not terribly reinforcing things either. If they were, you would have done them. "Getting better can be a bummer," someone once said to me. And to top it off, then mood disturbances can develop. After a history of failure, underachievement, the development of negative thoughts and beliefs takes over (get the CBT manual out!). People really do need a coach, therapist or a very supportive friend to do this kind of work. Someone specifically trained in dealing with the cognitive issues involved in most mood disorders. A good program for ADULTS with ADHD should address medication, health and exercise, teaching organization and planning skills, working with multiple tasks, learning to prioritize, problem solve, reducing distractibility, understanding and gauging your attention span (there is a really neat device suggested by Russell Barkley called “The Motivator” - a timer/buzzer/reminder you wear to remind you to stay on task. Most of my clients love it!). Clients also need help modifying their environment to reduce distraction, and need help with adaptive thinking (it’s a frontal lobe issue!) It’s really a plate full. Usually the key to success, as Dr. Russell Barkley would stress, is externalizing key information. Giving clients something to rely on more than their own memory. About 1/2 of my practice is adult ADHD cases, and most clients come already taking medication or after using some other specific technique. Many spend a lot of time with these “brain games” and try all sorts of diets, supplements and “alternative” treatments. After some initial success, there are set backs. In the end, anyone seeing adults with ADHD should remember the majority of the work we will be doing together is old fashioned therapy - maybe people would call it “coaching” now - but it involves assessing and understanding the FUNCTIONAL deficits each client has, and not just implementing a single technique or intervention. It means addressing each, one after another. A good, structured approach works best, but there are simply no quick and dirty cures, fixes or ways to avoid the problems of ADHD. With the help of a properly trained mental health provider you can learn the skills you missed out on, improve those that you know to a degree, and together develop a holistic plan to make your life better, easier and more successful.

Help with Procrastination - and an alternative to medication for ADHD!

OK, if procrastination is a big part of your ADHD, start by going to this web site: http://habitchange.com/ There you will find a product called The MotiAider. Several years ago I notice this and similar products were endorsed by Dr. Russell Barkley, the leading researcher in ADHD (Attention Deficit Hyperactivity Disorder, sometimes called ADD). There you are going to find a simple, inexpensive and useful device called the MotiAider. It's a simple reminder system that can help with staying on task, changing behaviours, and avoiding procrastination. Why would I suggest this device. Because it simply makes sense. It does what I always asks parents and teachers to do: Provides a positive prompt or cue - an EXTERNAL CUE - to you, your child or student, about a simple skill, task or behaviour they should engage in. It doesn't step in AFTER a mistake and correct - instead, at a steady rate -in preloads you or your student to be successful. Lately I've been emailing back and forth with Steve Levinson, PhD, President at Behavioral Dynamics, Inc. who makes this device (there are several other similar ones, including wrist watches) and want to share some of what he has given me permission to put on the website: "Let’s face it, procrastination sucks. It’s exhausting, stressful, and it can do a number on your self-esteem and career. Even though you eventually finish most of the unpleasant tasks you put off, you pay dearly for having postponed them. It takes lots of extra energy to avoid doing something you know you must do. One of the world’s most famous psychologists, William James, put it best when he said, “Nothing is as fatiguing as the hanging on of an uncompleted task.” "If you’re a chronic procrastinator, learning time management techniques can be, well, a waste of time. That’s because time management is like dieting. It’s not enough to know what you really should do. To get results, you have to actually do it. You probably already know that it makes sense to tackle unpleasant tasks right away. But when a truly unpleasant task is staring you right in the face, doing what makes sense is no match for the powerful urge to put it off." "To avoid procrastination, you must first understand the psychology of procrastination. Although chronic procrastinators may assume that their brains are wired entirely differently from the brains of people who make a habit of jumping in right away and doing whatever needs to be done, I disagree. Procrastinators and non-procrastinators are more alike than they are different. We all do what we’ve decided we should do only when we actually feel like we must do it." "When faced with an unpleasant task, we don’t get moving until we reach the point where leaving the unpleasant task undone actually feels worse than doing it. In other words, we all wait until the last minute. The only difference between non-procrastinators and procrastinators is that for non-procrastinators, the last minute comes sooner!" "If you’re willing to think about procrastination as the result of being slow to reach the “Get Moving” point, I have good news for you. There is a solution. The way to stop procrastinating is to make the last minute come sooner. By making the last minute come sooner, you can dramatically reduce the amount of time and energy you’d otherwise waste avoiding an unpleasant task that you’ll eventually have to do anyway." "Suppose there’s a report that you absolutely dread working on that’s due in a month. You estimate that the report will take several extremely unpleasant hours to complete. You have the time available, and you tell yourself that you really should just tackle the task right away and get it off your back instead of letting it nibble away at you for the next few weeks." "Yes, that’s what should happen. But you know yourself well enough to know what actually will happen. Despite your good intentions, you’ll end up putting off the unpleasant task until the very last minute − maybe a couple of days before its due − and in a panic, with the clock feeling like a knife in your back, you’ll get the report done on time − like you always do." "But suppose this time, instead of just relying on your good intentions, you deliberately change the situation to make the last minute come sooner. You do it in a way that at first glance seems nearly insane. You write out a check for $5,000 to a political party you absolutely despise. Then you give the check to your assistant with strict orders to mail it next Tuesday unless you show up with the finished report before then." "Now that you’re in the new situation you created, you still dread doing the report. In fact, you still put it off until the last minute. But this time, the last minute comes much sooner! Because you reach the “Get Moving” point sooner, you won’t have to wait so long or suffer so much to get the pesky job done and off your back. And you’ll have a delightfully smooth ride through the rest of the month. To conquer procrastination: Realize that what eventually gets you in gear is the pressure of the last minute. Treat pressure as your friend rather than your enemy − as the solution rather than the problem. Be willing to deliberately create situations that make the last minute come sooner." I think this is all GREAT advice, and working with the MotiAider it's something that we have a much, much better chance at succeeding in. Theres an excellent book for adults available on using this system, and a FREE downloadable book for using it with children and teens. (Some may want to use a less conspicuous device such as the wrist watch system ...that should be discussed and decided before you make any purchases). Now clearly this is just one step in helping those with ADHD (Attention Deficit Hyperactivity Disorder or ADD). Medication is also highly effective, especially with issues of hyperactivity, impulse control, managing emotions, focusing attention and transitioning from one task or activity to another (switching mental sets). And neither medication nor the Motiaider is going to help you work with complex problems, large issues, planning, picking out what is important or developing study skills. Addressing ADHD is a multi-phased problem, and most people need a therapist or professionally trained coach (who has a background in behavioural psychology). But just as the Cogmed System can help with working memory issues -which are often a hugh stumbling block for individuals with ADHD, finding a way to get positive, external prompts and cues out there in the environment is critical to successfully treating all of the components of ADHD. (We also need to remember that nearly 50% of individuals with ADHD/ADD also have a comorbid condition such as a specific learning disability, depression, anxiety or mood disorder. These need to be assessed and treated as well.) If your interested, take a look at the website above. I don't think this is a one step cure all for ADHD. But it's a good and smart component of a total program. Feel free to call me, and look at my web page at www.relatedminds.com or www.adhdhelp.ca. We can set up an appointment, review your history, arrange any testing or assessment that might be necessary and start you on a comprehensive program to deal with ADHD.

Basic Facts About ADHD (ADD)

Patients often come in to my office asking for a basic, simple book or other materials about ADHD. They suspect they may have ADHD (or ADD as some call it) and want to know where to begin. "Where can I find some simple information about ADHD?" I have one good suggestion for a source of ADHD information, it's the New York Times' ADHD web site. It's full of great information, videos from parents and adults with ADHD and articles by leaders in the field of ADHD. Here is the link: http://health.nytimes.com/health/guides/disease/attention-deficit-hyperactivity-disorder-adhd/overview.html Regretfully the web if full... really full...of misinformation, bad ideas and science doubting nonsense when it comes to ADHD. A simple search will bring you to stuff that is often more wrong than right, usually placed there to go with an ad for a naturalistic health solution that has no backing what-so-ever. So try this Times page. It's simple, clear, personal and science based. While ADHD is the most commonly diagnosed behavioral disorder of childhood it is regretfully not the most well understood disorder in our schools, or by our family doctors. It is also not the most highly funded. Very few school districts provide any training for teachers in dealing with ADHD in the classroom. And school psychologist, in most jurisdictions, aren't allowed to diagnoses it, so getting school based help involves two different systems of services, the school and either a private psychologist or medical doctor. ADHD affects about 3 - 5% of school aged children. ADHD is diagnosed much more often in boys than in girls and is actually often overlooked in girls. Yes, there are some problems getting an appropriate diagnosis, so go to a mental health practitioner who focuses on ADHD. Science demonstrates that ADHD may run in families, but it is not clear exactly what causes it. Whatever the cause of ADHD may be, it seems to be set in motion early in life as the brain is developing. Imaging studies suggest that the brains of children with ADHD are different from those of other children. But these brain scans are not, regretfully, useful in diagnosis. Diagnosis is made through clinical history and observation. Depression, lack of sleep, learning disabilities, tic disorders, and behavior problems may be confused with, or appear with, ADHD (co-morbid is the term used in mental health). Every child, adolescent or adult suspected of having ADHD should be carefully examined by a doctor to rule out these possible other conditions or reasons for the behaviour. Often this is more than can be done in a regular doctor's office, but it's critical to good diagnostics. Most children with ADHD also have at least one other developmental or behavioral problem. They may also have a psychiatric problem, such as depression, learning disabilities (almost 50%!) or bipolar disorder. A full psychoeducational assessment is almost always appropriate with children, or adults moving into the workplace. This helps us understand the strengths and weaknesses we ALL have, and how this individual might use their strengths to overcome weaknesses. It also helps us understand what skills and tools might be particular difficult for the individual with ADHD and guides our treatment interventions. ADHD isn't caused by poor parenting - but if you have a child with ADHD you most lively will need to learn some special parenting skills. Same with teachers - it's not caused by the teacher, but a teacher with 2 or 3 children with ADHD in his or her classroom needs to learn and use some special techniques and interventions they may not be familiar with. Sugar and diet are usually unrelated to the ADHD behaviours. TV watching and excessive video game playing doesn't cause ADHD, but it doesn't help and usually makes things worse. There is little research supporting diet changes or supplements as having any effect on ADHD, in spite of the hundreds and thousands of web pages that suggest and try to sell you these products or books about these products. Your best bet is to find a well informed psychologist or paediatrician to work with you in developing a treatment plan to help you deal directly with the symptoms of ADHD. I provide both diagnostic services and therapy for children, adolescents and adults with ADHD in my offices in Burnaby, Vancouver and San Francisco. Please visit my web page for more information and feel free to contact me for further information. Dr. Jim Roche http://www.relatedminds.com http://www.adhdhelp.ca

The "Gift" of ADHD (ADD) ....watch what you wish for!

Again I've heard it ...."You know this person and that person is successful BECAUSE of their ADHD (ADD)." During the week parents and adults with ADHD have come in, after working with local coaches and unlicensed "counsellors" saying they don't want to consider medication, or even INFORMING their school that their child has ADHD because they feel their child (or themselves in the cases of adults) will somehow be stifled by medications, teachers or behavioural therapy and lose their creativity, abilities...their "spirit" that the "gift" of ADHD has given them. People are creative. Not creative BECAUSE of their ADHD, but IN SPITE OF IT! People find life fulfilling and exciting, not BECAUSE of ADHD, but in spite of it ..with work and effort they are successful. They are not successful BECAUSE of ADHD but because they work hard, put in effort and are innately creative and competent. Why do I come back to this issue time after time? Because on Monday I attend a school meeting with a family whose child has ADHD trying to get the school to provide appropriate accommodations and positive behavioural supports. The school is,as often the case, skeptical about ADHD and skeptical about their ability to provide these accommodations and services. They have no one trained, no training budget, and many other children with mental health disorders they take to be much more serious such as Aspeger's Disorder, autism or other cognitive deficits ( The truth is, the child with ADHD is often LESS likely to graduate than those children!). On Tuesday a local ADHD coach, with no background in education or psychology, no degree, no training in anything other than "coaching" comes to the school with another child and proclaims that ADHD is a gift and the real problem is we aren't letting the second child release his creativity and "be who he really is." This coach actually portrays those of us in the field as doing damage to these "creative" children ....and harming them forever. What's a school to do or think? Well, they could start by reading the clear research on creativity and ADHD (this is available in books by Dr. Russell Barkley, and from his website). There they will find that there is no correlation between ADHD and creativity ...or anything else positive. As a matter of fact, untreated ADHD is far more likely to lead to academic failure, professional failure, risky behaviour, increased physical injuries...all sorts of things. The research ...over 20 years of research...is clear about this. But there is good news!!! GOOD NEWS! That long list of individuals these coaches and ADHD deniers give us are actually a list of highly successful individuals who did what they wanted ...sometimes with a lot of effort...and made it. They succeeded! ADHD is HIGHLY TREATABLE. We have many effective ways to approach ADHD, ranging from medication to behavioural therapy to coaching (by someone who doesn't deny the basic research ...or at least is familiar with it!). My advice: Start by reading a good, SCIENCE BASED book on ADHD. I would suggest starting with something by Dr. Russell Barkley. He has two excellent books about ADHDS for children, and adults. Then, find a professional familiar with both ADHD - and by familiar I mean familiar with the science, someone licensed in a scientific/medical/psychological field - not certified as a "coach" or "organizer." Get a licensed mental health professional involved. Often they work directly with someone who does the "coaching" part of things in order to cut down on costs, but someone with appropriate mental health and/or a medical background should be aware of the treatment interventions and suggestions your "coach" is making! And, finally, make sure that the mental health professional has experience in the second area of importance: if your working with a child at home, they should have experience in marriage and family therapy, in a school, they should have school based experience (they might have been a teacher, school counsellor or school psychologist themselves), or if it's the work place, someone with appropriate rehabilitation experience. Someone who has actually stepped into a work place and watch their interventions work...or not work. Someone, basically, with real world experience in the area you need help with. Here is a video on this issue of "The Gift of ADHD" by Dr. Russell Barkley. I want you to know I'm not complaining all by myself here. Dr. Barkley has started to bring up this issue at every meeting, speech and presentation because the damage being done by those who portray ADHD as a gift is far more serious that the individuals they harm. They cause harm to the entire field, lose us funding, and damage our chances of getting legislation in place that guarantees the rights of those with ADHD to get and maintain appropriate accommodations. Because if it's a gift ...what more do you want? For more information on my services please visit my professional web page at http:www.relatedminds.com or http:www.adhdhelp.ca I see patients for ADHD Assessments (and full Psychoeducational Assessments) in my offices in Burnaby and Vancouver, as well as San Francisco.

Memory and ADHD (ADD)

Memory and Attention Deficit Hyperactivity Disorder Many clients come to my office who exhibit signs and symptoms of ADHD (Attention Deficit Hyperactivity Disorder or ADD) and seek two things: An ADHD or ADD diagnosis, and help with what they feel is poor memory. In actuality often these individuals don’t have any significant “memory” issue, but instead have other problems that mimic memory problems. They report problems remembering to do things, to finish tasks, or difficulty with reading (and remembering who the characters are) and so on. Some of these are memory related, some are not. For these individuals we provide help by not only providing a clear diagnosis of ADHD, but also looking at issues that might relate to what appears to be memory problems. Difficulty with remembering details, following a story line or conversation, or simply “tuning out” may be caused by other issues. This include depression, anxiety, and similar problems. These are ruled out or ruled in by taking part in a more comprehensive personality assessment than you might have received in the medical doctors office. This might include self report “tests” as well as a structured history and clinical interview. Now that you may have anxiety, or depression, doesn’t mean that you don’t ALSO have ADHD. But the anxiety or depression needs to be treated before out interventions for ADHD can be expected to work. Anxiety and depression can lead to all the symptoms you might have checked off in the doctor’s office when you completed the little “test,“ he or she administered, really nothing more than a self report. So we often start there and rule out these possibilities. Still many people with ADHD (or ADD, which is an older term for ADHD no longer used) actually do have problems with memory. But there are other possibilities as to why you might have trouble remembering things besides “memory” in and of itself. These include the following: First, some executive dysfunctions or deficits that might interfere with your ability to “remember and learn:” Response Inhibition (the ability to think before you act. You may simply be missing the opportunity to act on information stored in your brain because you are too impulsive to stop, think and then act. Working Memory. Working memory is a specific part of memory that people often have difficulty with. It’s the ability to hold information in mind while performing complex tasks. Remembering a phone number while writing it down is an example. Medication often helps with this problem. Sometimes it doesn’t. There are some specific training tools that help with working memory and there are dozens of on line computer games that claim to help with improving working memory. Most of these have very little science behind them and can be a waste of time, as well as frustrating. One computerized learning program that has been shown to help with working memory is called CogMed. Cogmed uses a specific series of changes in the level of difficulty in the computer program that makes a big difference, and it has been scientifically shown to help many with issues of working memory. But here is something to remember: Improving working memory doesn’t mean curing or fixing ADHD. If one of the main problems you have is por working memory, it most likely will be helpful, but working memory does not equal ADHD. Self Regulation of Affect: This involves your ability to manage your emotions in order to achieve goals, complete tasks and stay on task. If you can’t regulate how you feel, anxiety, depression or anger may have serious consequences on how well you can think and remember things that are important. Sustained attention: The capacity to maintain attention over a period of time is critical to following through on tasks, and remember to get everything done. Boredom means getting off task. Medication can help those with problems with sustaining attention. We also have several simple environmental cues, prompts and techniques that can help with this issue. Organization: An inability to be organized often means, for the individual with ADHD, not “remembering” what is important to do. Time Management: Poor time management skills can also lead to difficulty following through, and lead to anxiety, anger and confusion. These are just a few of the executive deficits that can add to your difficulty “remembering.” But remembering itself can have many different aspects, and we often need to look at how you are doing at these many different components of remembering. These include (but are not limited to: Working memory: We have already discussed this. The ability to temporarily hold a bit of information in your mind while you do another task (like writing it down!) Long term memory: This is what most people thing of when they talk about memory. I tell you a story and you remember the details in an hour or day Visual memory: This involves an ability to remember visual cues, that might be shapes, letters, words or pictures. And this skill relays upon a number of other skills that might be specific deficits for you such as an ability to see the difference between figure and ground. Filling in missing parts of a figure. Remembering visual items in a specific sequence. We call this “temporal sequential order.” Verbal memory. Like visual memory there can be a specific problem with verbal memory. You may have good verbal memory and poor visual memory, or the other way around. And with verbal memory the problem may be an issue of “memory,” or it may be a problem with auditory processing. Hearing and understanding what is said to you. Auditory processing deficits are often taken to be ADHD. Learning. Learning is a different process than memorizing and remembering along. Your ability to learn new material depends upon a number of factors, including working memory, long term memory, auditory processing, basic understanding and cognition, and how these and other specific neurological systems connect and work together. Often we use tests such as the Test of Memory and Learning-2 (TOMAL-2) or other specific memory scales to understand if you are learning at a rate similar to others your age and with your cognitive abilities. So as you can see, having a “memory problem” may or may not mean you have ADD (Attention Deficit Hyperactivity Disorder or ADD). It can mean a number of different problems and often a comprehensive psychological or neuropsychological assessment is necessary to determine where the problem is. Besides picking out your deficit areas it is also helpful to understand your strengths as well. This helps you determine how you can use these strong points to help in the areas you are weaker. Finally, individuals who have memory problems and ADHD often have developed ways to make up for these problems. Sometimes these are positive (like using a notebook) and sometimes not (like avoiding and procrastinating). Therapy helps you address these issues and develop skills that are more useful and positive, and avoid ...well, avoiding. For more information on understanding how all these elements can come together to cause you or your child difficulty I would suggest a couple different books: Dr. Mel Levine, The Myth of Laziness Dr. Russell Barkley’s books Taking Charge of ADHD and Taking Charge of Adult ADHD For Teachers: Peg Dawsons’ Executive Skills in Children and Adolescents My website (http:www.relatedminds.com) also contains several articles that are short and useful on the ADHD page. In both my Burnaby and Vancouver offices I provide testing and assessment of ADHD as well as therapy and coaching services. Please feel free to contact me.

ADHD and Procrastination (again)

Again this week 3 or 4 patients coming to see me are visiting my office because of problems with procrastination relating to ADHD. Attention Deficit Hyperactivity Disorder (ADHD or sometimes called ADD) is a neurological disorder, and executive disfunction, that effects not only our ability to focus, stay on-task, concentrate, plan and follow through, but also effects our ability to get started - we procrastinate and out things off. And this is one of the most disturbing aspects of ADHD. 

Dr. Russell Barkley, a leader in the field of ADHD says this about executive dysfunction and ADHD: ""In ADHD, if the information that is suppose to be generated by executive functions is being generated at all, it appears to be extraordinarily weak in controlling and sustaining behaviour towards the further..." We seem to get stuck in the here and now and can't ...well move forward.

What Dr. Barkley says about treating this aspect of ADHD is that, "clinicians treating those with ADHD must beat the environment at it's own game. They must put into the immediate context the sorts of cues, prompts, physical reminders, and other captivating information that will guide behaviour towards the intended goal."

That's a very fancy way to say that you need to develop prompts and cues that help you move from one state of mind (maybe watching TV or lying in bed) and move to the next (getting up and taking a shower, or getting out the door to get in the car and get to work.).  That means alarms, signs, signal and prompts. But it isn't as easy as it sounds.

Two things inter fear with just setting up a system of prompts and cues and moving forward. They include  anxiety and ...the lack of reinforcers for engaging in the behaviours you want to be doing.

One of the dangerous things about procrastination is that it is "self reinforcing." If I have to work on a task, go do something I don't particular want to do, to avoid it ..to wait a few minutes before I do it, is rewarding - reinforcing. For that few moments the anxiety associated with the task is gone. I need to get to the office ....but I wait. When I first thought about going to the office I had some anxiety -about what I'm going to do there, getting there on time, maybe about my ability to get there ...since I procrastinate and avoid so much. Just the thought of going to work is a negative experience. And avoiding it makes me feel good, immediately ....if only a little bit. For those of use who understand behaviourism we know an IMMEDIATE reformer is VERY powerful, even if small and short lived. So, avoiding and procrastinating in itself reinforces the behaviour of procrastinating. You may have had one or two things you were avoiding and this reinforcement was very strong. Then avoiding itself started being reinforcing and spread through everything. Now avoiding is your preferred way of dealing with things.

The second issue is reinforcement. A simple rule of behaviour is this: Anything we do that is reinforcing we will do more often, for longer periods and with more intensity. Things that are not reinforcing, we do less often. As adults, the plain and hard truth in life is this: When you stop procrastinating and actually get things done...your more likely going to be rewarded with more hard work. More things to do. Not very reinforcing, is it?

Both of these issues need to be addressed through understanding them, applying your understanding to the situation, and changing the environment so getting things done IS reinforcing rather than the opposite. Through coaching and planning we can usually find ways to do this. Setting up a variable schedule where work completed (non-preferred tasks) are followed by preferred tasks (and remember, the reinforcement or reward can be small...but needs to be immediate). We can use check lists, visual schedules, there are all sorts of things we can do to help with this depending upon the situation.

Now one step back: While all this is going on with procrastination we also have the issue of needing to increase the environmental prompts and cues to help you "switch mental sets" and move from one task to another. SIMPLE visual, auditory and other types of prompts help. and setting things up so that small initial changes are rewarded and reinforced ...one, two, three...before we get to bigger changes.

So, ADHD and procrastination may be difficult to deal with, but there are things we can do.  Understanding the nature of the disorder is critical, and a good deal of the time I spend with clients is spent explaining how the brain works ...and how ADHD effects the brain. Knowledge is the first step towards health.  Often CBT is also recommended for clients with ADHD, this is because we have been worn down by failed attempts to control these behaviours caused by ADHD. And friends, relatives and work mates often turn ADHD symptoms into what they think are signs of your personality. Often they turn this into a moral or ethical issue. "If you would just put more effort in to this!" Well, ADHD is a complicated disorder, and more effort doesn't necessarily lead to success. Understand and ADHD specific interventions are what help. CBT (Cognitive Behavioural Therapy) helps individuals with the issues of inappropriate and negative thinking that comes from repeated exposure to failure. CBT is a critical part of dealing with ADHD.

For more information on ADHD (ADD) and procrastination, along with help in making an ADHD diagnosis, ADHD (ADD) coaching in Vancouver or Burnaby, please visit my website at www.relatedminds.com or call me directly to set up an appointment. There are also a number of science based self help books on ADHD listed on my web page.


This blog is not meant as treatment or diagnosis. For treatment and diagnosis please see a registered or licensed professional in your community. Both medical doctors and registered psychologists can diagnosis and treat ADHD (ADD or Attention Deficit Hyperactivity Disorder).
.....................................................................................................................
KEYWORDS:  ADD, ADHD, Attention Deficit Hyperactivity Disorder, ADHD coaching Vancouver, ADHD coaching, Burnaby, ADHD coaching Coquitlam, ADHD coaching New Westminster, psychologist, diagnosis, treatment, procrastination, executive disorder, psychoeducational assessment, psychological testing

Executive Skills and ADHD (Attention Deficit Hyperactivity Disorder)

Often patients come to the office for a diagnosis of ADHD (Attention Deficit Hyperactivity Disorder) and they have heard that ADHD is related to what is called "Executive Function." This is true, and deficits in executive function are a critical issue in ADHD. Coming up with useful interventions for ADHD usually brings us right to the front door of executive disorders. Schools are often at a loss as to how to approach ADHD in the classroom, and the last set of IEP's I reviewed from school districts here in BC (including IEP's from Burnaby, Vancouver, North Vancouver, Coquitlam, Langley, New Westminister and Maple Ridge all seems to fall off the track and miss the point that ADHD is primarily a function of executive deficit and dysfunction.

Too many times the Individualized Education Plans, usually developed from the Psychoeducational Assessment, focused on increasing academic outcome, getting work completed and increasing scores with very little understanding of the effect of executive deficits and their relationship to ADHD.

(For instance, starting a task may very well be related to difficulty with switching mental sets, changing what we are doing, moving from one task to another. This is an executive deficit ...sometimes we might call it "procrastination" or simply ADHD, but we need to understand the nature of the executive disfunction in order to develop an appropriate intervention plan. This might include both environmental changes, such as cues and prompts, and teaching new skills such as what to do next, how to set up a project and move forward with a step to step plan. There is additionally the problem that changing behaviours, not procrastinating but instead changing tasks and moving forward, may not be inherently rewarding or reinforcing. Honestly, if you have been avoiding work for two years and now someone gets you to deal with it ....your reward is usually more work! And for an 8 year old, more work isn't the reward he or she was looking for (And it's even worse for adults with ADHD!) So, developing a plan means not just following a script but also finding a good behavioural therapist to help develop and watch the plan.

So where can yo get some help in developing an intervention plan for ADHD, including a school IEP, that takes into account issues relating to executive dysfunction and deficits? Here are two good executive dysfunction and skill resources:

First, an excellent book from the Guilford Practical Intervention in the Schools Series: Executive Skills in Children and Adolescents: A Practical Guide to Assessment and Intervention by Peg Dawson and Richard Guare.  This book covers the basics of executive skills and brain development, reviews methods that we use in psychoeducational assessments and neuropsychological assessments to assess executive skills, talks about how to make behavioural observations with formal assessment measures of specific executive skill areas such as 1) Self Regualtion of Affect, 2) Metacognition, 3) Goal-Directed Persistence, 4) Cognitive Flexibility, 5) Sustained Attention, 6) Working Memory, 7) Response Inhibition (Impulsivity), 8) Planning and Prioritizing, 9) Time Management, 10) Organization, 11) Task Initiation (avoiding Procrastination).

The book also gives home simple case examples of developing and implementing simple plans to address each of these specific areas of deficit. This list (above) should give you some idea of how your school should be assessing your child and addressing specific deficits for intervention in the classroom.

The book also addresses developing interventions that promote executive skills for those with ADHD. These plans involve addressing the psychical and social environment; changing the nature of the tasks at hand; improving how cues and prompts are given; and for the schools, changing how adults and students interact.

Specific interventions for the classroom and individual are also discussed, as well as applications of these interventions to specific populations, such as children with Aspergers Syndrome or autism spectrum disorder who may also have ADHD symptoms or executive function deficits that interfere with learning. This is an great, evidence based book that any school team should have.

On my ADHD website page (http://www.relatedminds.com/adhd-attention-deficit-hyperactivity-disorder/) you will also find information and a link to a short article by Thomas Brown on executive dysfunction and it's relationship to ADHD.

Finally, Russell Barkley has an excellent article on ADHD and Executive Function which you can download here: http://www.relatedminds.com/wp-content/uploads/2011/06/ADHD_EF_and_SR.pdf

KEYWORDS:  ADHD, ADD, Attention Deficit Hyperactivity Disorder, Psychologist, Diagnosis, Treatment, Registered Psychologist, Burnaby, Vancouver, Port Moody, Coquitlam, New Westminster, North Vancouver, Coaching, ADHD Coaching, Professional Coaching, Assessment, Psychoeducational Assessment, Testing.

For more information on the services I provide you can find help at these links:







How to Diagnose ADHD (ADD)

Often it is a child's teacher who is the first person to suspect that a child has ADHD, especially if he or she is hyperactive and often disrupts class. However, parents may notice signs of ADHD before the child begins school. These signs may include problems with social skills and disruptive behaviour. If you or your child’s teacher suspect your child might have ADHD, your child should be assessed by a medical doctor or a doctor of psychology. Often a medical doctor will send your child to a psychologist for a diagnosis of ADHD as it is rather complex, and ADHD is often not the only issue. Almost 50% of children with ADHD also have a learning disability and require a psychoeducational assessment. Psychoeducational assessments need to be completed by a registered or licensed psychologist.


What is ADHD (Attention Deficit Hyperactivity Disorder)? 
ADHD is very common. It is estimated that between 5% and 12% of children in the general population have ADHD. For this reason, a medical doctor or psychologist will consider ADHD when they see a child who:
  • is doing poorly or failing at school
  • disrupts class
  • cannot sit still or is hyperactive
  • acts without thinking
  • does not pay attention or does not seem to listen
  • cannot concentrate
  • daydreams
  • has problems with friendships and other social relationships
  • has low self-esteem
If your child has signs or symptoms that make your child's medical doctor suspect your child has ADHD, he or she will do a thorough assessment. In Canada we have specific recommendations as to what that assessment will consist of, and it is more than a simple checklist or screening form. ADHD is not always easy to diagnose, for several reasons:
  • The symptoms of ADHD are inattention and/or hyperactivity and impulsivity, but it is normal for all children to be restless, impulsive, or inattentive sometimes.
  • There is no one specific test for ADHD.
  • Children behave differently in different settings and with different people.
  • The symptoms of ADHD look different in different children, in boys and girls, and at different ages.
  • Children with only symptoms of inattention are often overlooked.
For these reasons, the  medical doctor will need as much information as possible from you, your child, your child's teacher, and other caregivers. It may take some time to figure out whether your child really has ADHD or another disorder (see below). Once the medical doctor knows what is happening with your child, he or she will sit down with you and explain the diagnosis and together you will develop a treatment plan. Often this process involves or is directed by a child psychologist who is familiar with child behaviour issues as well as education regulations and expectations.

Why isn't there an easy test for ADHD?
Children mature at different rates and have different personalities, temperaments, and energy levels. Most children get distracted, act impulsively, and struggle to concentrate at one time or another. Sometimes, these normal factors may be mistaken for ADHD. ADHD symptoms usually appear early in life, often between the ages of 3 and 6, and because symptoms vary from person to person, the disorder can be hard to diagnose. 
For more information on the suggested guidelines in Canada for diagnosing ADHD see this webpage: http://www.caddra.ca/cms4/index.php?option=com_content&view=article&id=26&Itemid=70&lang=en


For information on my services for ADHD, including diagnosis, psychoeducational  assessments or treatment please visit my web page at http://www.relatedminds.com or http://www.adhdhelp.ca 


ADHD Diagnosis Rates in US

The Northwestern University issued the following news release:

Diagnosis of ADHD on the rise.They note that 10 million American children diagnosed with ADHD during doctors' visits. The number of American children leaving doctors' offices with an attention deficit hyperactivity disorder (ADHD) diagnosis has risen 66 percent in 10 years, according to a new Northwestern Medicine study.

The study also found that over this same timeframe, specialists, instead of primary care physicians, have begun treating an increasing number of these young patients. The study, which was published in the March/April issue of the journal Academic Pediatrics, analyzed ADHD trends from 2000 to 2010 among children under the age of 18 who were diagnosed and treated by office-based physicians.

Researchers analyzed changes in the diagnosis of ADHD and treatment of the disorder over this 10-year time period. "ADHD is now a common diagnosis among children and teens," said Craig Garfield, M.D., first author of the study. "The magnitude and speed of this shift in one decade is likely due to an increased awareness of ADHD, which may have caused more physicians to recognize symptoms and diagnose the disorder."

Garfield is an assistant professor in pediatrics and medical social sciences at Northwestern University Feinberg School of Medicine and a pediatrician at Children's Memorial Hospital and Northwestern Memorial Hospital. Symptoms of ADHD, such as trouble paying attention and controlling impulsive behaviors and being overly active, can affect children and teens both academically and socially, Garfield said. In the past decade several important regulatory and clinical changes regarding ADHD and the medications used to treat it have occurred, yet it was unknown how these factors have affected ADHD management, Garfield said. For the study, Garfield and his team of researchers quantified ADHD diagnosis and treatment patterns among people under 18 using the IMS Health National Disease and Therapeutic Index.

This is a nationally representative sample of office-based visits and included 4,300 office-based physicians in 2010. According to the study, in 2010, 10.4 million children and teens under age 18 were diagnosed with ADHD at physician outpatient visits, versus 6.2 million in 2000. Researchers also found that psychostimulants have remained the most common medication prescribed to children with ADHD. Psychostimulants were used in 96 percent of treatments in 2000 and 87 percent in 2010. The exact reason for the decrease is unclear, but there was not an increase in treatment with other, substitute medications, Garfield said.

While the majority of children and teens with ADHD are still managed by primary physicians, the study found that there has been a substantial shift away from primary doctors and towards specialists, such as pediatric psychiatrists. "Recently, there's been more public health advisories issued about problems or side effects of different ADHDmedications," Garfield said. "It may be that general pediatricians are shying away from treating patients themselves and instead rely on their specialist colleagues to provide the treatment and management of these medications."

Given the short supply of psychiatrists specializing in pediatric ADHD, Garfield said this trend might make it difficult for many children to receive medical treatment of ADHD in the future.


What is regrettable is the lack of information on non-medical treatment of ADHD. While the AMA (American MEdical Association) and the association of paediatricians clearly suggest that non-medical interventions be the first intervention tried, especially with younger children, there is little research on the number of cases seen by trained psychologist or other educational | behavioural specialist who would provide training, supervision and direct treatment of children and families effected by ADHD. Environmental and behavioural interventions remain the first line of interventions, however research and funding remains focused on medication and medical providers. Often, while medical intervention is critical and necessary for treatment success, behaviour and educational  intervention are just as necessary. ADHD is a developmental disorder, and being able to focus, maintain focus, start tasks on time, plan and organize are not not taught by medication. These are skills that are learned during our development, and need to be taught in a new way when they are being learned at a later point in development. These are the tasks and interventions mental health professionals such as psychologists are there to help you with. They are necessary components, but as the above research shows, they are too often ignored.


For information on my practice and support services for children, adolescents and adults with ADHD (Attention Deficit Hyperactivity Disorder) in Burnaby, Vancouver, New Westminster and Coquitlam, please visit my web page at www.relatedminds.com or www.adhdhelp.ca

ADHD Page now on PDF

My ADHD page, with information on diagnosis and treatment of ADHD (Attention Deficit Hyperactivity Disorder) now has a simple button to download a clean PDF of the page. Click here: http://www.relatedminds.com/wp-content/uploads/2011/06/adhd-vancouver-burnaby1.pdf
You can also find general information about my services at http://www.adhdhelp.ca


About Dr. Roche
I am a Registered Psychologist and a Registered Marriage and Family Therapist (RMFT) in British Columbia. In addition to my doctorate in clinical Psychology (The Union of Experimenting Universities), I hold a master’s degree in family therapy from Goddard college, a certificate of advanced graduate studies (CAGS) in school and educational psychology from Norwich University, and have completed two years of post doctoral studies in neuro-psychology at The Fielding Institute in Santa Barbara, California. I am also a certified school psychologist, certified teacher of special education (New York and California), and a Clinical Member of the American Association of Marriage and Family Therapists (AAMFT). Finally, I hold a doctoral degree in law (JD) with an emphasis in medical malpractice and education law. Beyond my academic credentials, I have completed two years of supervised clinical experience in both hospital and community based clinics and two years of post doctoral training in neuropsychology. I have served as director of behaviour programming for several school districts, as a consultant on autism for the province, and have held numerous academic positions including Clinical Instructor in Psychiatry at New York University and Bellevue Hospital in New York as well as being a faculty member at NYU, Brooklyn College, SUNY New Paltz, and Norwich University.

Psychological services (including assessment, testing and therapy) provided in my offices include (covered by most extended health care insurance):
ADHD (click here: http://www.relatedminds.com/adhd-attention-deficit-hyperactivity-disorder/)
Anxiety and Stress (click here: http://www.relatedminds.com/anxiety-stress/ )
Autism and Asperger’s Disorder (Click here: http://www.relatedminds.com/autism/)
Individual Counselling (click here: http://www.relatedminds.com/individual-therapy/)
Child Counselling / Therapy (click here: http://www.relatedminds.com/child-therapy/)
Testing and Assessments and Learning Disabilities (Click here: http://www.relatedminds.com/testing/)
Couples Counselling / Therapy (click here: http://www.relatedminds.com/couples-therapy/)
The Angry Child (click here: http://www.relatedminds.com/dealing-with-angry-aggressive-and-explosive-children/)
Anger Management (Click here: http://www.relatedminds.com/anger-management/)
Pain Management and PTSD (Click here: http://www.relatedminds.com/pain/ )

My offices in Burnaby and Vancouver serve Burnaby, Vancouver, Coquitlam, Port Moody, Port Coquitlam, New Westminster and Maple Ridge. Clients often come to my Vancouver office from North Vancouver, West Vancouver and even as far as the Sunshine Coast. For more information on the location of my Burnaby and Vancouver offices, please see my “Office Location” page, which contains a Google map.


Key Words
ADHD | Anxiety and Stress | Autism and Asperger’s Disorder | Individual Counselling | Child Therapy | Testing and Assessments and Learning Disabilities | Couples Counselling | Depression | The Angry Child | Anger Management | Pain Management and PTSD | Forensic Services | Attention Deficit Hyperactivity Disorder | Vancouver | Burnaby | Coquitlam | New Westminster | Maple Ridge | Port Moody | Child Psychologist | Psychologist | Learning Disability | Assessment | Testing | Psycho-educational Assessment | Neuropsychological Assessment