In getting with these modern times, you can follow my facebook page Wright Behavioral Health. For the sake of patient privacy, I do not add friends, but my page is public. You'll be able to see many links to information and fascinating developments in psychology and neuroscience.
ADHD has got to be one of the most talked about disorders in the media today. I see everything from radio show posts to facebook memes talking about it. And I’ll admit to you that almost nothing stresses me more than seeing so much faulty information about ADHD out there in the media. I have been working with children who have ADHD for more than 25 years, and it pains me to see so much misinformation still so prevalent.
There is a lot of information about medication for ADHD and other types of treatment. How can a parent know what is best? How do you know if it really is ADHD?
In order to know what treatment is best, you must first start with a proper diagnosis. You don’t go to your family physician and have them just start handing out antibiotics, right? They have to know that what they are treating is the right match for the treatment.
Well, it is my opinion that really the only way to determine whether a child has ADHD is with something called “cognitive” testing done by an experienced Neuropsychologist.
Brain scans do not show ADHD… no, not even PET scans. A lot of very wealthy investors want you to believe that ADHD shows up on these scans, but in blind studies, the people giving these scans could not differentiate ADHD from other disorders, or no disorder at all.
Psychiatrists, psychologists who do not do “testing,” and pediatricians are permitted to diagnose ADHD, but they do so primarily based upon reports from the teachers and the parents. And since teachers and parents are not qualified to diagnose ADHD, or understand how it mimics other problems and greatly over-diagnose ADHD, this has lead to the current situation in which ADHD is overdiagnosed in our nation as a whole. Almost all people, including children and adults who do not have ADHD, focus better on medications for ADHD; so if a pediatrician gives a medication for ADHD, and the child does better, they assume they had the right diagnosis. This is very problematic.
With cognitive testing, a Clinical Neuropsychologist can look at the FUNCTIONALITY of the brain. We give many many types of tests, designed to tap into how the brain is functioning in many different ways and in different parts of the brain. When we see a pattern of function that is showing us clear deficits in the prefrontal cortex, compared to other areas, it is likely to be ADHD. These evaluations also allow us to look at many other types of factors: emotions, behavior, family dynamics, school and environment, health, injury history. They also allow us to rule out other causes or multiple causes. Remember that the point of diagnosis is to match the treatment to the problem. This is never so effective as when conducted by a neuropsychologist.
Is medication the only solution? What can be done?
The issue of whether to medicate a child with stimulant drugs is a deeply personal choice that should be made between the psychologist, the physician, and the parents of the child. No one has a child’s interests at heart more than their parents, but at times, parents can be too either eager to use medications (because the lifestyle and schooling has become so unmanageable) or too resistant to medication (because they’ve heard myths about their kids getting “hooked” or turning into “zombies.”)
A big part of the equation on whether or not to use medication stems from how severe the child’s symptoms are. If the symptoms are relatively mild, other approaches may be helpful. In very severe cases, I am a proponent of medication because severe ADHD can have long-lasting and very harmful effects on learning and educational achievement, later occupational successes, self-perception, depression, anxiety, friendships, romantic relationships, and being able to function in society. The child’s health history and reaction to medications must be considered. A psychologist can see how much of the difficulties can be addressed behaviorally, as to minimize the need for medications.
There are other treatment approaches. And while none of them show the efficacy of medications in clinical studies, there are many families which prefer to use these options, especially if the symptoms are milder or this is a better fit for their value system. These interventions may involve changes in nutrition, exercise, changes in environment, pacing and scheduling, holistic care, and alternative (and soothing) options like yoga. I often say to parents that there is no real harm in throwing all of these options at the child, and then see if it is enough to give the child the improvements and benefits before going to medication.
But if you do decide to go the medication route, realize that if your child is now a “zombie,” then something is wrong with their dosage. The best result is when your child is able to enjoy life and learning, not fit into a perfect mold of the perfect child. If your child seems too sedated, or has an unusual reaction, go BACK to your physician, talking about your fears and what you see, and allow your doctor to try some different medications or dosages before giving up. It can take up to a couple of months to find just the right fit for a child.
Stimulant drugs can be habit inducing, and there is good reason not to take them if they are not needed. They have been abused by teens and adults alike, often as a way to lose weight. But, this rarely happens at the doses that are prescribed for children, and rarely if the child indeed has ADHD. It is in taking stimulants when there is NOT a true ADHD that the drugs run a higher risk of dependency. This is another argument for taking the time, effort, and care to have the diagnosis confirmed by a Clinical Neuropsychologist.
Here are some non-medication options:
Nutrition – the research is still out on this. It may not be the presence of sugar, but the lack of overall nutritional support. There are some theories that children who have a gluten sensitivity are not getting the nutritional support they need. This has not been shown sufficiently in the Neuropsychological literature, but try focusing your child’s diet on a very well rounded access to vegetables, protein, and fruit, minimizing cereals, sugars, flour, and snack foods.
Chiropractic care – Again, psychological-chiropractic studies are few and far between, but chiropractors believe that by balancing the central nervous system through adjustments, the child’s overall neural function will improve, and they point to many correlational studies that suggest this may be the case.
Acupuncture – There are some early studies that may show benefit here. Acupuncture has been shown in correlational studies to temporarily decrease some of the ADHD symptoms, but not everyone benefits in the same way. It won’t hurt to try.
Behavioral and Environmental Changes – Issues such as organization, sleep, discipline, scheduling, etc. may have an impact on how severe the ADHD manifests. Seek a behavioral specialist/psychologist to evaluate possible improvements or ideas in these areas.
Sleep – Sleep is essential, and yet children with ADHD universally have complaints of insomnia. Consider working with a psychologist or sleep specialist to address these matters.
Exercise – Kids with ADHD NEED to move. They have to move like a fish needs water. Get them outside, running, biking, playing sports. That endorphin benefit may help them calm.
Yoga – For some kids who have mild ADHD, yoga alone may be helpful in mitigating their symptoms. The ability to self-sooth through yoga, combined with the physical movements may allow them to “teach” their brain how to self-sooth and self-calm.
Educational interventions – Working with a Clinical Neuropsychologist and/or school specialists may allow for changes in the classroom that may help the child with ADHD. For example, shorter instructions, more frequent breaks, moving their desk to the front of the classroom, minimizing distractions (such as unnecessary decorations and toys), altering how much time they have to complete a task, studying with headphones (with or without music), all of these interventions may allow the child to focus better in the classroom.
Back in the 1970s, my father was the Director of Health Education, Research, and Development at the University of Wichita, School of Allied Health. He created a program with his colleagues to provide medical information and articles "over the telephone," a brand new idea at the time! This was in the days not only before cell phones, but before personal computers! The university acquired a phone number any citizen could call, and simply by pressing a number of your choice, it would connect you to recorded information on everything from A to Z. I remember it was the first place I ever learned about a disease called "epilepsy." I listened to almost all of these recordings (many of them in my dad's own voice), precocious child that I was, and who knows if that contributed to my focus on behavioral health today.
Telehealth today, of course, is a way of linking health providers with patients who may not be able to make it to an office. Surgery second opinions from experts in other states, folks who are bed-ridden, people who live in rural areas too far too drive... all of these are amazing uses for telehealth.
Of course, psychotherapists have been asking the question over the last few years: Can you do THERAPY via telehealth?
See, most of us were trained using time-tested skills of therapy that also involve seeing a person's facial expression, body language, demeanor, eye contact. Really good and experienced therapists have a heightened awareness and sensitivity to "non-verbal" cues in therapy when someone is speaking... do these get lost in "telehealth" translation? What about the comfort level of therapy in front of a monitor instead of therapy in a recliner or comforting chair? Does the patient "connect" to a therapist as deeply, if they aren't in person... after all, therapy is nothing if it isn't personal. These and other questions are still being considered.
In my practice, I use telehealth under very specific conditions, because not all of these questions have been answered. Firstly, I meet with clients in person to start... until we have that connection, I don't use telehealth. I have to have a pretty good sense of my client's subtle expressions before I trust this. Second, I use telehealth when sessions are less "didactic" (meaning, free-flowing talk oriented) and more in a skills building use, or when someone just needs a check-in. Third, I only do this with clients who I can see at least on occasion, in person. Telehealth is a great tool for keeping up with clients, but I don't feel it will ever fully replace the benefits of in-person therapy.
Here is an article I have abbreviated published by Reuters today talking about this issue, and specifically a study done by Dr. Leonard Egede, at University of South Carolina. It is great food for thought:
Telemedicine can widen access to depression therapy for seniors
REUTERS, July 29, 2015
*Many seniors face obstacles to getting help for depression, including mobility issues and fear of social stigma, researchers say, so telemedicine might expand their access to treatment.
*Depression is a particular problem among veterans, whose risk is two to five times that of the general population, the researchers note. Another barrier for this group is disability, with many veterans home-bound and unable to go to a clinic for care, Egede said.
*Past studies have found telemedicine to be as effective as in-person talk therapy for treating post-traumatic stress disorder, but there has been less research on depression.
*Comparing in -person therapy with telehealth therapy, after four weeks, questionnaires showed that only a small proportion of patients in either group had reduced their symptoms by that much, and only half as many in the telemedicine group (5 percent to 7 percent) as in the in-person therapy group (15 percent). But by the three-month point, 15 percent of telemedicine patients and 19 percent of in-person therapy patients were responding. At the one-year mark, the groups were about even, with 19 percent to 22 percent of the telemedicine patients and 19 percent to 21 percent of in-person patients meeting the treatment-response definition based on the questionnaires.
*The researchers also assessed improvement using a structured clinical interview, in which a clinician determined if the veterans would still be diagnosed with major depressive disorder. 39 percent of telemedicine patients and 46 percent of in-person therapy patients were no longer depressed. The small percentage-point difference between the groups is not statistically significant, meaning it could have been due to chance.
*Dr. Charles Hoge, a psychiatrist and senior scientist at the Walter Reed Army Institute of Research wrote a commentary and noted that in-home therapy raises the question of safety, because there are no professionals present if an emergency arises..., such as if a patient reports intent to commit suicide or homicide,” Hoge said in an email.
The Lancet Psychiatry, online July 16, 2015.
A friend of mine proudly proclaimed they had an IQ of 164. Another friend felt disappointed, theirs was "only" 124. Someone else had bragged they hit 175. None of these friends have particularly powerful jobs and all are on a budget, but none of them are doing terribly, they all have nice homes and good lives. Does IQ even mean anything?
The fact is: those internet sites that tell you your IQ are scams. They exist solely to collect data on you, mostly for the purposes of advertising. And none of those tests actually measure IQ, or anything close to intelligence.
When neuropsychologists measure IQ, we use a very specific family of tests that actually measures many tasks that the brain does, including use of language, spatial relations skills, problem solving skills, even certain kinds of memory. Most people have strengths and weaknesses, and the tests help measure a variety of abilities, not just how "smart" you are. In fact, those tests generate multiple scores, not just one.
The tests used by psychologists also utilize what are called "standard scores." That means that 100 is always average, with a consistent type of cutoff for high and low scores. The tests on the internet do not have standard scores, so a score of 175 on a different test, testing only one kind of skill, may, in fact, be average, or even low. But when you pair that score with an advertisement for a new men's underarm spray, the businesses that run those sites can correlate certain types of scores to who buys their products.
Why measure IQ at all? Well, neuropsychologists use it to determine if a person is able to stand trial, or perhaps if they have lost some skills after a brain injury, or perhaps to see if there are strengths and weaknesses that would help them in picking a career. These are just a few examples. But what psychologists do not use IQ testing for is bragging rights for how "smart" a person is.
If you are interested in your own skills and talents, perhaps consider getting some testing by a professional who can help you understand not just your score, but how that score translates to meaningful information that can be a positive contributor to life choices, such as career or education.
Why do patients with reported brain injuries sometimes have MRI or CT scans that are negative?
CT scans and MRIs are types of images that allow physicians to see if there are any structural abnormalities to the brain, such as bleeds, tumors, or hematomas. However, they are limited in seeing all brain injuries, especially mild injuries, in which the person did not lose consciousness or did not lose consciousness for more than a few moments.
Your brain is made of billions of cells (called neurons) that communicate with each other through chemical and electrical processes. It is the stimulation of cells that creates cognitive and emotional functioning. Everything humans and animals do, 24 hours a day, is a complex pattern of cells firing. From watching television to cooking an omelet to talking to a friend to just simple breathing and sleeping… it’s all just neurons firing.
An MRI or CT might show you areas where there is something foreign (like a tumor) or where cells are damaged, but they won’t show you very small changes or changes in electrical signals or chemicals (neurotransmitters). Even if your brain is relatively free from structural damage, damage may have occurred that affects keeps the cells in your brain from firing strongly, quickly, and effectively.
Think of it this way: A photograph can show a picture of two people who may appear to be talking, but it can’t show whether those people are talking quickly or slowly, whether they are making any sense to each other, or if they’re talking about anything important versus just chatter.
Neuropsychologists use Neurocognitive Testing to see if you are having any problems related to your brain injury, such as difficulties with focus, problem solving, spatial skills, language, etc. These tests do not show what damage there may be to the brain, but they show the outcome of that damage. They show how it is affecting your thinking and your life!
There are new types of scans being developed called Diffuse Tensor Imaging (DTI) and likely one day very soon, these types of scans will be used by more and more doctors. Why? Because these scans actually show tracts or roadways of cells as they fire. They can help doctors see that a patient is having trouble with certain kinds of tasks that range from paying attention to learning but probably cognitive testing will still be needed since each patient is different and each patient has different strengths and weaknesses. Here is a beautiful picture of all those pathways of cells that fire in patterns. Pretty neat, huh?