Thursday, August 2, 2007

Educating the Child about his Brain - Understanding is the first step in taking charge

By Gloria Kay Vanderhorst, Ph.D.

Neurocognitive Psychotherapy is a brain-based treatment approach that is a unique blend of cognitive-behavioral therapy and cognitive rehabilitation. This approach is a team approach based in the most recent research on brain functioning and ADHD. This article is the first in a series that will illustrate how neurocognitive psychotherapy is applied in treating children with ADHD.
The key to building a treatment plan is to understand how the brain works in general and to discover how the brain of a particular child is functioning specifically. This brain based approach starts with a neuropsychological evaluation that enables us to measure various aspects of executive function, memory function, and processing abilities. This evaluation may also examine emotional strengths and resources that the child has been using to cope with the stress of learning and living.
Once a diagnosis of ADHD has been made, educating the child about the specific strengths and weaknesses in their brain is the next step. I will use a variety of techniques to help the child see and understand how his or her brain is functioning. Pictures of brains from web sites showing fMRIs have been very helpful. With the fMRI, we can see different areas of the brain light up as one thinks and problem solves. You may want to log on to to take your own tour of different brain images. We may also use brain models, or build our own using found objects in the office. Sometimes we will make drawings or abstract art that represents the various functions of the brain and how they interact with each other.
As a child comes to understand how his own brain is working, he is encouraged to present his understanding in a family session as a means of educating others in the family. In this way, the child is given power over the ADHD. The stigma that has been associated with inattentive or hyperactive behavior is replaced by knowledge that empowers the child to take more control over his life. The earlier this empowering process can begin, the more opportunity the child has to build compensating strategies, make changes in his environment and develop supportive relationships. Educating the child about his own brain, how it works, and how he can help make it work best is a central part of neurocognitive psychotherapy - de-stigmatizing the brain patterns we refer to as ADHD and giving the child a sense of understanding and control.

Saturday, June 30, 2007


My Dad carries his baseball glove in the trunk of his car. It is very old and battered. The padding has become thin with age. The fingers are short and stubby, not long and laced as in today’s gloves. Today’s gloves are made to reach above the fence and snatch a home run away from the batter. Dad’s glove was made for catch and from the trunk of his car, it was always at the ready. He tore his rotator cuff about a year ago, swinging an ax. So, I doubt that he could toss a ball anymore, but the glove still travels. The potential is there.
The research on fatherhood shows that children listen more easily to the voice of father than they do to mother. Something about the tone or quality of the voice communicates a seriousness that is easily processed by even the youngest child. The research also shows that girls who spend more time with their father are brighter in school and more successful in math and science. Fathers are designed to have a powerful impact. Think of the wisdom to be imparted or the fun to be had. Yet, on the average, fathers spend only minutes with their children each day. Father’s rarely say “I love you” to their children, especially after the child becomes school age.
Inside of each of us is the desire for a Daddy. “Daddy” is someone who will be there all the time, someone who will know what we should do in this difficult situation someone who will support us and love us. We look for him first in our own fathers and if we don’t find him there we look in one relationship after another, in search of the strength and acceptance that we need.
We formulate our idea about a supreme being based on our earthly experience with father. That is a heavy burden for any Daddy.

Sometimes on long car trips we would stop at a roadside park for a break and Dad would break out the glove. We would toss the baseball to him, chase after high flies and dive for grounders. The energy and relaxation in those brief moments was exciting. That glove represented the potential for relationship, any time and any place. He was always ready.
As we got older and moved away from home, the relationship did not change. Daddy was always there to listen and to guide.

Dad’s are more likely to act out their feelings of love than they are to say it. Something about the words causes their tongues to get stuck or twisted. When they do fall out, they often get embedded in sentences like, “you know that your mother and I, we love you, don’t you son?” If he was familiar with that concept, why would you have to ask such a stupid question? When will they fall out in simple, direct form and just say “I love you”. Daddy must have practiced in the mirror or something. It always sounded so right.

Dad’s are special. They have a big responsibility. Their voice is often the one that we carry in our heads when big decisions are to be made. Fulfilling that responsibility takes a plan. One cannot be a Daddy without planning and setting the time aside to be in relationship. Too often, men are caught up in building castles for their families or inheritances for their children, rather than in building relationship. Being a Daddy takes a vision. What is your picture? How are you doing? When you review the year, can you list the times that you connected with your children? And a year from now, what will the picture include? Do they still call you Daddy?

Sunday, May 13, 2007



Every family seems to have that one relative that is difficult to approach or be with and seems to have very hard edges. Of course, that person is never you! She could be your sister: the one who never calls unless she wants something or wants to let you know that you have really made her mad. It could be your brother who seems to know all of the vulnerable spots and takes advantage of this knowledge to hit you when you’re down. Sometimes it is the busy body aunt who seems so sympathetic and really understands what you’re going through, but next week when you hear your story coming back around through the grapevine, you realize that she was just out to grind the gossip mill.
So, just what is a body to do when the bad egg is on you?

My husband tells me that if I want to boil an egg, I should let it warm up a bit before immersing it in the water. I have never had the patience to watch an egg warm up. I plunk that sucker into the pot, cover it with water and turn the flame up to just below ‘trigger the smoke detector’. Then my usual routine is to go get into something else and forget about the 3 minute rule. Maybe Mr. Perdue will one day invent an egg with an alarm built in. By the time that I return to the pot, a white stringy scum indicates that the shell has cracked allowing the white insides to leak out into the boiling water. The chemistry here invariably causes the pot to boil over creating a gooey mess on the spill tray under the burner. Suddenly my three minute egg has turned into a half hour scouring project. Eggs are like toasted cheese. Yes, I manage to burn those all the time too!
The mess created by the rapid boil takes more time to clean up than watching the egg warm. Maybe I could learn to warm up to that prickly relative too.

Do you check the egg carton before you leave the refrigerated case? Turning each egg to be sure that none are stuck to the carton because of a hair line fracture? Not me. Oh, I flip the lid alright to be sure no oozing mass is in there, but jiggling each egg seems to be a bit much. It’s not the time that it would take that gets to me, its more the looks from the other cart drivers.
Sometimes I care too much about what someone else might think. The prickly relative brings out the same dynamic. If I talk to her for too long at the reunion, someone will think that I like her or that I might be on her side in the next dispute. Truth is that I need to spend that time with her to learn what it is really like for her. Underneath all of the difficulty, she is fragile just like me. I could gently check out how she thinks or feels rather than slamming the lid shut with my assumptions.

Remember the Dr. Zeus book about green eggs? What a disgusting thought. Same feeling waves over me when that prickly person is on the phone or looking to visit. A green sickness comes over me and inside of 3 seconds, I have run a complete video of how this weekend will go. It’s the Titanic in fast forward. That rush to disaster makes it hard to come back to the present and prepare for the visit.
Have I ever been curious about this person’s history or hopes or needs or longings? If I can stop feeling sick and start being curious, this visit can help me see her as a complex person rather than a vile entre’.

A QUESTION OF MENTAL HEALTH: Are There Really Witches in the Basement?


A mother's story:
She is 5 years old going on 6 and first grade is just around the corner. The summer will soon end and the serious business of school will begin. She knows where she will be going because we drive past the building regularly. Each time, I cheerfully point to the sprawling brick façade announcing that she will soon be in first grade. I describe my first grade teacher with fondness in hopes that her fears will be calmed. She usually sits quietly in the seat next to me staring straight ahead. Occasionally she will boldly announce that she is not going to school. She sees no need for the exercise. She is perfectly content learning at home from her siblings or neighbors. She already knows how to read and assures me that she can learn anything that she needs on her own. I sigh and steel myself for the battle that I know will ensue in the fall.
Lately, she has been drawing pictures of the school building. It is usually quite large on the page and the basement windows are particularly menacing. The latest version has a black figure oozing between the bars on the windows. The fingers are pointed, the mouth is full of teeth. This is the witch that lives in the basement of the school. I try to explain the modern construction technique of slab building that eliminates the need for a basement. I know that the building has no basement, but my arguments are to no avail. Someone has convinced her that a witch lives under the classrooms. I go looking for her brother.
At first he pleads innocent then admits that it was a great tease. He knows that she is afraid of beginning first grade and he just couldn't resist the story about a witch living in the basement. He defends himself by saying that a few of his elementary teachers were witches so it is not really an exaggeration. This is going to be a long year.

Reflect on your own experience of elementary school. Tell the stories that you haven't thought of for years. My second grade teacher put a large wire cage in one corner of the room. In that cage we watched "Bitty Hen" live and lay eggs and hatch baby chicks. It was marvelous! Looking back, I do not know how "Bitty” survived the stress of all of those voices, and noses pressed against the wire each morning. For all I know, the teacher may have gone through numerous chickens without our knowing. "Bitty" was the center of attention and our class was the talk of the school.
Even if your stories are tragic, they are worth telling. Your child will take comfort from knowing that they are not the only one who has ever been afraid of school.

The witch in the basement is more than a brother's tease. The child who is afraid of separating from mother or afraid of performing in school is trying to communicate that fear. Your child's fear should be taken seriously. Listen to the fear and draw out more information by saying “tell me more", " tell what will happen next". Using these specific phrases will encourage your child to explore the fear and help your child to feel secure because you are taking the fear seriously. Leave questions behind. They demand rational and specific answers. Fears are usually not rational or specific. You will learn more with the "tell me" approach.

Once you know more of the nature of the fear, you can draw protective fences to create a sense of safety and comfort for your child. You may want to consult with the school psychologist before school opens to get more ideas of how to create a sense of comfort that your child can carry from home to school. The child who is afraid of leaving mother behind, can be comforted by taking some specific token or symbol of Mom to school. These treasures can help to calm a child's fears and refocus the child on the task at hand. The child with learning problems or fears of performance can be comforted by clear expectations that are easily attained. Do not be afraid to set lower expectations at first and gradually raise the bar as your child's comfort increases. Stay away from asking your child to do his or her best. Make the expectation specific and concrete. At the end of the day, you should both be able to easily see that the child has been successful. Even the simple task of bringing your lunch box home can be a mark of success for the first week.
If the fear persists beyond week 2, consult a professional. Early intervention will save a lot of heartache for you and your child.

ADHD The Price We All Pay

ADHD: The Price We All Pay - An Argument for Early Identifiication and Treatment
Gloria Kay Vanderhorst, Ph.D.

ADHD is a life long condition. Like other chronic conditions, interventions lead to improvements and early interventions are beneficial. Edward Hallowell, M.D., a leading expert in ADHD, is a strong advocate for early identification because he recognizes the emotional damage caused by the child’s experience of frustration and failure and the pain of being labeled as ‘stupid’ or ‘difficult’. When identification is delayed, emotional costs easily translate into higher social costs. The price we all pay can be examined by looking at four areas of social significance: work force productivity costs, direct and indirect medical costs, auto accident related costs, and incarceration costs.
Work force productivity can be examined by looking at educational success and household income figures. According to studies conducted by Joseph Bierderman, M.D., professor of psychiatry at Harvard Medical School, ADHD is present in over 8 million adults or 4.3% of the adult population in the United States. These adults tend to be undereducated with fewer graduating from high school. Those who do graduate are less likely to finish college or go on to complete graduate degrees. Therefore, they end up under-employed and more frequently experience periods of unemployment throughout their working years, resulting in a dramatic loss of household income. A 2003 survey estimated that the annual loss of household income attributable to ADHD ranged from $67 billion to $116 billion. For an impact comparison, consider that the medical cost associated with cigarette smoking in the United States in 1998 was approximately this same amount when the country began to declare legal warfare on the tobacco industry.
The direct and indirect medical costs associated with ADHD are related to work force productivity and comorbid conditions. Workers Compensation claims are higher among adults with ADHD and unofficial absences from work are four times more prevalent in this population. A 2000 study extrapolated to the national level from data for a large corporation indicated that employers spend $13.7 billion for medical costs related to employees with ADHD. When you add in the cost of comorbid disorders, the price nearly triples. Adults with ADHD are more often diagnosed with asthma, anxiety, bipolar disorder, depression, drug or alcohol abuse, antisocial or oppositional behavior. The medical impact of these comorbidities costs an employer three times more medical dollars than they would spend on an employee without ADHD. The estimated total cost for employers in the United States for the year 2000 was $31.6 billion.
The social impact of lost work productivity and associated medical costs should cause us to mobilize our resources to intervene earlier. However, neither of these has the life threatening impact that has been associated with auto accidents. Automobile accidents are the leading cause of death among teens between the ages of 15 and 20. This statistic has resulted in some states increasing the legal age for obtaining a driver’s license. According to a study at the University of Virginia, teens with ADHD are two to eight times more likely to have an auto accident and four times more likely to be at fault for the accident. When teenage passengers are in the car, the likelihood of an accident increases along with the fatality rate. According to Russell Barkley, Ph.D. teens with untreated ADHD have a higher incidence of traffic violations than their peers, especially speeding. In 2005, the Insurance Information Institute noted the average cost of an auto accident involving bodily injury was more than $10,000. Jury awards in auto liability cases are also a factor in the social cost of auto accidents. According to Jury Verdict Research in 2003, which is the most recent year for complete data, the average jury award in personal injury auto accident cases was $261,000. The insurance industry spent over $4.1 billion defending their policy holders in liability cases in 2004 and that cost has continued to rise in 2005 and 2006. For insurance premiums that translates into about 60% of the cost. None of these surveys can calculate the social cost of the lives lost.
Lost lives are also visible in the justice system where people with ADHD comprise almost 40% of the population. A recent study by Dr. Paul H. Wender in the state of Utah prison system indicated that inmates with ADHD are often misdiagnosed with bipolar disorder or depression. The total prison population across ages and types of incarceration in the United States today is approximately 1.71 million people. This is the highest rate of incarceration for any industrialized nation in the world today. The only nation to remotely approach this rate was South Africa during apartheid. In fiscal year 2005, maintaining one inmate in a Federal Bureau of Prisons facility cost $23,431.92 and $20,843.78 to keep a Federal inmate incarcerated in a community correction center. That means that the country was spending over $40 trillion to house Federal prisoners in 2005 and if 40% of those have ADHD, we are spending over $16 trillion on that population alone.
Each of these social costs is significant by themselves: lost income of $67 billion to $116 billion, corporate medical costs of $31.6 billion, incarceration costs of $16 trillion and uncountable loss of life due to auto accidents. Where is the outcry for early identification and intervention to aid us in reducing these costs? Most children are not identified until they attend elementary school at age six and here the identification favors boys who are physically acting out or have difficulty following the rules. Often children are not identified until the 4th grade when the child’s performance is no longer heavily dependent on memorization, repetition and basic skills. This pattern of later identification still neglects the needs of most girls as well as boys who are academically gifted and more inattentive than hyperactive. Many girls go undiagnosed until late high school or college.
Why don’t we require screening for ADHD at the preschool level? A major deterrent for early identification has been fueled by parents, teachers and pediatricians who see the symptoms of ADHD as too close to the developmental characteristics of the typical preschool child: high energy, impulsivity, and a short attention span. The lack of knowledge about the life long cost of ADHD also contributes to this failure of early identification and intervention. Multiple research studies clearly point out that early experience is critical in brain development and shaping later behavior; therefore, early assessment for ADHD is critical for later success. A thorough physical examination, neuropsychological battery, full family history and clinical observation of the child can discern between the normal exuberance of a preschooler and the processing difficulties of an ADHD child. The cost of delaying assessment is too high a price for the individual and for our society.

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