Hyperfocus or Lack of focus? ADHD problems and misunderstandings

Hyperfocus ....or lack of focus? Almost everyone assumes that ADHD comes with a very short attention span. It is ADHD-with the first D standing for "Deficit." But it’s really more accurate to say that a person with ADHD has an uncontrollable attention span. They have difficulty with what we call "switching mental sets." An executive dysfunction, the part of the brain that controls what you pay attention to and what you don't. A person with ADHD may pay attention to one thing, but not another. And the problem is, it's seldom under their control. Another problem is this switching of focus can be different from day to day. People often observe that on Monday a student was able to do their work (because they were hyper focused) and on Tuesday they could not. Then they accuse the student with ADHD of making a choice to do something ...." because he was able to yesterday! He just needs to take it serious!" Not so. Hyperfocus is the term used to describe when a person with ADHD is immersed in an activity he or she finds interesting - a preferred activity, that is somehow reinforcing. TV, computer games, or occasionally a book might be an activity that one becomes hyper-focused on. But the issue is one of self-regulation. Individuals with ADHD cannot regulate their attention, so they will be engrossed by something they find interesting while neglecting important areas of their lives. They then lose track of time, other things that need to be done, and what is going on in the world around them. This can also lead to social isolation. While there may be situations where we need to really focus to understand something or complete a task, hyper-focus in itself isn't as useful as many coaches and "ADHD is a gift" types would make you think. And when medication is used, often this hyper-focus is lost...and individuals then reject medication. Instead, they need to be taught specific skills to learn to maintain and shift focus appropriate -at will. (But so often I hear the ADHD is a gift types appealing to those with ADHD telling them that instead they need to take "advantage" of their gift .....usually because they don't understand or know of techniques to train attention control.) The best way to approach the issue of attention switching- or switching mental sets - is to use external prompts and cues of significant enough impact to help the individual move from one task to another ....or to stay on a task for a significant period of time. A well trained and licensed/registered mental health professional can guide you along that path, because this is one task where an outside coach is tremendously useful. Below is a short, funny little video on hyper-focus. I don't agree with everything it says, but it's part of a very helpful series that is science based. Hope you enjoy it.

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.

ADHD Questions and Ansers

I was reading some really basic, but important, questions and answers about ADHD in the New York Times today. Here are the questions, and they are the kinds of questions every paretn of a child with ADHD has, as well as adults with ADHD. The answers, done nicely, can be found by following this link to the New York Times ADHD web page - a really great resouce I've recommended several times. Take a look, first for the answers to these ADHD rquestions, and second,all the other great science based information, stories and resources. Click here for the answers: http://www.nytimes.com/ref/health/healthguide/esn-adhd-ask.html The Questions: What’s the difference between your average high-energy kid and a child with attention-deficit hyperactivity disorder? Is there one medical test, like a brain scan, that diagnoses A.D.H.D.? My child was just diagnosed with A.D.H.D., and it’s supposed to run in families. Should I be evaluated for it? Our daughter’s pediatrician thinks she may have inattentive-type A.D.H.D. — A.D.H.D. without the “H”. Can you have A.D.H.D. without being hyperactive? I hear a lot about lax parenting or too little discipline causing A.D.H.D. Could our parenting style have caused our daughter’s A.D.H.D.? How do stimulant medications work in A.D.H.D.? Isn’t Ritalin basically speed? What other kinds of treatments besides medication are available for children with A.D.H.D.? Is A.D.H.D. different in girls from in boys? At what age is it appropriate to tell a child that he’s been diagnosed with A.D.H.D.? I had A.D.H.D. as a kid, but it was never diagnosed or treated back then, and I still survived. Why does my child with A.D.H.D. need treatment in order to get through it?

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.

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.

Is ADHD ever a "gift?" While some ADHD "specialists" and anti-medical treatment folk like to say that, most experts disagree.

Today there was an excellent article in the New york Times in which Dr. Russell Barkley, one of the leading researches and consultant/practitioners in ADHD (Attention Deficit Hyperactivity Disorder) answered questions from readers. The perennial question about ADHD (sometimes called ADD) came up: "Is there a time ADHD is considered beneficial or a gift?"

Well the answer is no for many reasons, however, we are often taken down a path that is misleading at best and destructive and harmful at worse by those who like to say "ADHD is a gift." This is reflective of a group of individuals who somehow think "diagnosis" in and of itself is harmful - that having your child or yourself diagnosed with ADHD will cause more harm than ADHD causes (got that?) and that first and foremost we need to avoid "labeling." This thinking leads parents to avoiding a diagnosis, it leads to children failing year after year in school because no one diagnoses or treats this very treatable disorder because they know their child's problems and failures are really "an issue of people not appreciating his/her gifts or special personality," and the avoidance of simple and effective cognitive behaviour therapy, psycho-education (which is simply impossible if we can't say "ADHD")and the avoidance of medications that has been show in study after study to be effective.

Often you will hear, "I don't want to step on his or her creativity" or "I don't want to change his personality." But it's not creativity or personality that is making this child struggle at school. It's a dysfunction of the executive parts of the brain, an inability of the child (or adult) to in reality make choices rather than being pushed into them.

Here is the real danger of this "gift" belief. Often, after years of struggle and frustration, an individual with ADHD sees a medical doctor and considers treatment. But at the last minute they say, no. The reason- the symptoms that are problematic are considered a "gift" or "special ability" by him or her, and he's been told that for years. Taking medication, or getting behavioural treatment, is going to make the "specialness" go away.

This is confused thinking.

People with ADHD report that they can really be "in the zone" at certain points, when they are able to think fast, clear and creatively. But this often varies from day to day, and varies from task to task. If it didn't, they never would have been concerned about ADHD/ADD in the first place. When doing something of interest, something they enjoy or is reinforcing, they are able to remain focused, concentrate and get down to work. It is when situations becoming demanding, are anxiety producing or are not preferred that problems quickly become apparent. Dr. Barkley makes a distinction between accepting your ADHD and pretending it's some sort of gift that makes you different in a positive way. As he says, "There is NO EVIDENCE that ADHD is a gift or conveys any advantages beyond what other people in the general population might have. People are individuals, like anyone else, and may have been blessed with particular talents that are superior to levels seen in most people." But these talents and abilities have nothing at all to do with ADHD. "they would have had them anyway." There is no research that certain jobs or careers are better for those with ADHD/ADD. There are careers that may be more ADHD "friendly." But that means that those jobs or careers don't have overwhelming requirements that fly in the face of ADHD.

One of the things we try to do in any good assessment is make you aware of your individual strengths and weaknesses, this includes your individual neurological strengths and weaknesses. Knowing those will help you understand what situations might be good for you, and what situations might pose a problem, as well as help you understand what strengths you have which you can use to bolster any deficits ADHD may have produced. Honestly, this is no different than what everyone does in life. What am I good at? What am I not good at? What do I want to do? And how can I fit all this together. The first step though is understand and accepting that you have ADHD.

Here's what Dr. Barkley says (click here for the entire article in the New York Times):

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The ADHD blog is not offered as medical advice or as a means of diagnosing or treating ADHD or any other disorder. My recommendations: Don't go on-line and take an ADHD "test." The diagnosis of ADHD is complex and involves not just looking for symptoms of ADHD, which is all that those “tests” do, but also involves ruling out other disorders that might look just like ADHD. Often individuals who think they have ADHD have other disorders, and may have co-morbid disorders such as depression, anxiety or OCD. A simple check off sheet of “symptoms” doesn’t differentiate these. So avoid these on-line "tests" which are nothing more than a collection of symptoms. You need to see a licensed or registered professional for a real diagnosis. Medical doctors can diagnose ADHD, but the diagnosis is complex and often they will make a referral to a Registered Psychologist for a full understanding of a patient’s symptoms. You can obtain a referral for a psychologist with expertise in ADHD from the British Columbia Psychological Association (BCPA).

I also recommend against programs that seem just to easy. Vancouver has many "ADHD cure" programs, quick fixes involving everything from neurofeedback to diet. There is very little evidence for most of these programs. I suggest you look up any of these ideas on the "Quack watch"website or simply by adding the word "skeptic" to any google or other web search you do.

In my practice I offer Attention Deficit Hyperactivity Disorder (ADHD) assessment and treatment services for individuals, couples, families, children and adolescents in the Burnaby, Vancouver, Coquitlam, Port Moody, New Westminster and Maple Ridge areas of the lower mainland. This includes neuro-developmental assessments, psycho-education, cognitive rehabilitation for problems with memory and concentration and cognitive behaviour therapy. I also provide diagnostic assessments for autism and Asperger's Disorder in my Burnaby office.

My web page lists a number of resources you can make use of yourself in dealing with Attention Deficit Hyperactivity Disorder (ADHD). Please visit it at www.adhdhelp.ca or one of my other sites at either Psychology Today, AAMFT, PSYRIS or my professional site. Please feel free to call if you have questions about ADHD or other cognitive issues.


Dr. Jim Roche
Registered Psychologist, British Columbia 01610
778.998-7975
www.relatedminds.com
www.adhdhelp.ca

First direct evidence that ADHD is a genetic disorder: Children with ADHD more likely to have missing or duplicated segments of DNA

ScienceDaily (2010-09-30) -- New research provides the first direct evidence that attention-deficit/hyperactivity disorder, or ADHD, is a genetic condition. Scientists in the UK found that children with ADHD were more likely to have small segments of their DNA duplicated or missing than other children.

Click here for the story

I am still amazed that I hear people say, "So called" ADHD. And teachers who doubt it is a real disorder, or the general public who assumes people with ADHD are either stupid, lazy or somehow immoral. amazed, but not surprised.

The evidence of this disorder, in it's various incarnations (inattentive vs hyperactive type) is overwhelming. And the science is there to prove it. Again, I urge anyone who has doubt to visit Dr. Russell Barkley's web page (click here).

This study, however, is something new. Researchers found overlaps in the DNA segments, that is, children with a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) were found to have small segments of their DNA that "overlapped" or were duplicated. These are called "copy number variants (CNVs) and this kind of genetic problem is being seen with many disorders including autism, mood disorders and schizophrenia. ADHD is one of the most common problems found in children, it is highly heritable, is found to be a strong component in twin studies, But until now we have not been able to see the actual genetic material that might be at the source of this issue.

A team at Cardiff University analysed the genomes of 366 children who were diagnosed with ADHD and compared them to 1000 children who were not diagnosed. They found these rare CNVs were more than twice as likely to be found in children diagnosed with ADHD. The chances were even higher for children with co-morbid learning disorders. ADHD, however, is not necessarily the result of a singe genetic change, it is most likely the result of multiple causes. Screening for these CNVs will not help diagnose a child, as it appears that it is the number of repetitions of the gene produced, in combination with other conditions, that cause the disorder.

Research is clear that there are multiple causes of ADHD, that it is a real disorder, and that there is little we can do to cure ADHD ....but we can treat the child, make environmental changes and teach appropriate coping skills to help overcome many negative effects of the disorder. Promises of cures by diet, which assumes diet is a major cause (there are no scientific studies backing this theory) are a waste, as are chiropractic manipulation, neurotherapy and similar "natural" treatments. For more information go to Dr. Barkley's web page.

The best advice is to get a complete assessment so that you know exactly how this disorder is affecting you or your child. This usually consists of a comprehensive history, a clinical interview, cognitive and neuropsychological tests. And find a professional who also has experience working in the environment when the changes need to take place, for children that means someone who has worked in the schools and understands the school system and the issues confronting children. For adults that means someone with several years of clinical experience with adults with ADHD- but also someone with experience working with children and developmental issues.

My web page lists a number of resources you can make use of yourself. Please visit it at www.adhdhelp.ca or one of my other sites at either Psychology Today, AAMFT, PSYRIS or my professional site. Assessment and treatment services are offered for individuals, couples, families, children and adolescents in the Burnaby, Vancouver, Coquitlam, Port Moody, New Westminster and Maple Ridge areas of the lower mainland.

Dr. Jim Roche
778.998-7975
www.relatedminds.com