How Much Does a Psychoeducational Assessment Cost?


How much should a Psychoeducational Assessment Cost?
Well, I hate to say this, but "it depends."

Not All Assessments are Alike
The exact nature of the Psychoeducational Assessment you need can be very different from case to case. This includes assessments because of in class behaviour such as aggression towards peers to a student who are struggling..and then the student who isn't doing work and seems bored and we suspect is really "gifted" and whose needs we are not meeting. And that's the issue we should be focusing on when it comes to psychoeducational assessments: what needs does any student have that need to be met for this student to be successful as they can be?

So any individual psychoeducational assessment may be very different. Let's first look at what usually is the same:

A common feature, if not a necessary feature, is a comparison of a students cognitive or intellectual abilities and their academic abilities. Usually this means administering a cognitive-intelligence test (this might be any of the following: The Cattell Culture Fair, Kohs block, Leiter International Performance Scale, Otis-Lennon School Ability Test, Raven's Progressive Matrices, Stanford-Binet IQ test, Wechsler Adult Intelligence Scale. Wechsler Intelligence Scale for Children, Wechsler Preschool and Primary Scale of Intelligence, the Wonderlic Test or the more recent and very popular Reynolds Intellectual Assessment Scale or RIAS). In addition to the intelligence test a test of academic skills is also administered (This might include anything from the Wechsler Individual Achievement Test to the Wide Range Achievement Test-4 or a any of several others).

The most common combinations are one of the Wechsler Tests of intelligence and a Wechsler test of academic skills, or the Reynolds (RIAS) and Wide Range Achievement Test.  The next step is usually to compare these scores and see if there is any reason to suspect a specific learning disability. This is done several ways, but is most often referred to as a "discrepancy analysis." The basic question is: Does the student work at an academic level we would expect, based upon their intelligence.

After this most basic analysis a psychoeducational assessment can go in several directions. If there are behavioural issues it might include testing for personality issues, anxiety, depression, or ADHD. One problem is that school psychologists are neither psychologists or doctors (usually ...some school psychologists here in BC actually are Registered Psychologists) and should not be diagnosing mental health disorders. They look for educational problems, often perform "coding" which is the process of classifying students for different types of services based upon ministry guidelines, and make suggestions for classroom supports. But they usually do not diagnose something like ADHD. You need your family medical do cot or a Registered Psychologist to do that.

If your wondering if your child has autism you need to have a specially trained medical doctor or Registered Psychologist perform a specialized examination using several tools that most psychologists and family doctors do not have training in, and simply don't own.

So to start usually we take a look at cognitive/intellectual ability and compare that to academic ability. From that we determine if there might be a specific learning disability. After that step other tests are usually used to look at specific areas of concern. This might include tests of reading, specific math skills (Key Math is one commonly used test), tests of pragmatic language, visual perceptual skills, auditory processing, balance, gait, motor skills and so on. So the initial phase of the assessment is only the beginning.

Each psychoeducational exam is different, or should be. Often the psychoeducational exam is just a starting point, and to understand the issues a student may also need an assessment by an occupational therapist and/or a speech pathologist. A medical examination should also have been administered to rule out medical reasons for the issues of concern.

So, when a parent asks me how much a psychoeducational examination will cost, I have to ask questions to determine what kind of psychoeducational examination we will be doing. Many parents tell me they are told by other professionals that "a psychoeducational assessment will cost $2,600." A straight forward price. But in reality, until we meet and look at the situation, we aren't sure. Sometimes a psychoeducational assessment isn't even appropriate until a child is seen by his or her medical doctor, an occupational therapist and a speech pathologist, so that other causes of academic difficulty are mistaken and misunderstood. This is why I personally suggest an initial meeting to gather information, history and concerns.

The cost of a psychoeducational exam? Well, it can range from $1,200 -$2,600. It depends. It depends on the situation, the information we need, the amount of testing and how cooperative and able the child is. One price does not fit all, and one "psychoeducational assessment" does not fit all. After an initial meeting we usually know, and together can shape a plan to fit your needs.

Finally, remember, your school should provide a psychoeducational exam....for free. Yes, there are sometimes long waiting lists. And sometimes a school psychologist can't make a diagnosis of a disorder such as ADHD (Attention Deficit Hyperactivity Disorder) or Autism Spectrum Disorder. Some parents also prefer to have an outsider look at their child and give an opinion. All of these are reasons for looking outside the school for an assessment. (Psychoeducational Assessments are not covered by MSP, but most Extended Health Care Plans do provide some or complete coverage for an assessment).

Talk to your family doctor, your school psychologist and give a Registered Psychologist a call. All would be more than willing to talk to you about this subject. (Registered Clinical Counsellors are not qualified to complete Psychoeducational Assessments. An independent Psychoeducational Assessment must be completed by a Registered Psychologist.)

In my offices in Burnaby (serving Burnaby, Coquitlam, New Westminster, Port Moody, Port Coquitlam and Maple Ridge) and Vancouver (serving Vancouver, North Vancouver, West Vancouver and Richmond) I provide comprehensive psychoeducational assessments. I also provide diagnostic assessments for ADHD and Autism Spectrum Disorder). Please feel free to contact me if you have any questions about these services.
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About Dr. Roche
My name is Dr. Jim Roche and I am a Registered Psychologist and a Registered Marriage and Family Therapist (RMFT) in British Columbia. In addition to my doctorate in clinical psychology, I hold a master's degree in family therapy, 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. In addition to being a registered psychologist, I am 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). I also hold a doctoral degree in law 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.
Key words
ADHD | ADHD coaching | workplace coaching | 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
http://www.counsellingbc.com/listings/JRoche.htm



What is Attention Deficit Hyperactivity Disorder (ADD | ADHD)?


What is ADHD or ADD (Attention Deficit Hyperactivity Disorder) ?
Attention deficit hyperactivity disorder (ADHD) is a condition in which a person has trouble focusing, paying attention, sustaining attention and focus, exhibits impulsivity (tends to act without thinking) and sometimes exhibits more movement than we would expect - he or she has trouble sitting still. It usually begins in early childhood (we now are able to diagnose ADHD at 4-5 years old) and can continue through the teen years into adulthood. 50% of individuals with ADHD continue to have symptoms in adulthood. Without treatment ADHD can cause problems at home, school, work, and with relationships. ADD is an older tern for ADHD without the hyperactivity, but today we always use the diagnosis: ADHD, and if there is no hyperactivity we would diagnose ADHD, Inattentive Type, meaning there is no hyperactivity. Often problems with attention and focus are dismissed because teachers, parents and medical professionals don't see hyperactivity. ADHD can still be the problem, hyperactivity or not.
What causes ADHD?
The exact cause is not clear, but ADHD tends to run in families and is most likely a generic disorder. We can sometimes see it on brain scans, and we have actually found genetic keys to ADHD.
What are the symptoms?
There are four types of ADHD symptoms including:
Trouble paying attention. People with ADHD are easily distracted by the environment and have a hard time focusing on any one task for a sustained period (but yes, they CAN focus on a preferred task for extended periods, and this "hyper-focus" or extreme attention is another sign of an individual's inability to control and regulate focus and attention).
Trouble sitting still for even a short time. This is called hyperactivity. Children with ADHD may squirm, fidget, or run around at the wrong times. Teens and adults often feel restless and fidgety and are not able to enjoy reading or other quiet activities.  Not all cases of ADHD show signs of hyperactivity! But the majority of cases do.
Acting before thinking. People with ADHD sometimes talk too loud, laugh too loud, or become angrier than the situation calls for. They are impulsive and have difficulty regulating their emotions. Children may not be able to wait for their turn or to share. This makes it hard for them to play with other children, often causing them to become socially isolated as time goes by. Teens and adults seem to "leap before they look." They may make quick decisions that have a long-term impact on their lives. They may spend too much money or change jobs often. It's important to differentiate impulsivity from manic behaviour, and an assessment of this is part of any good ADHD diagnostic assessment.
How is ADHD diagnosed?
ADHD is often diagnosed when a child is between 4 and 12 years old. Teachers may notice symptoms in children who are in this age group. We always recommend that you first haver your child see a medical doctor for a full physical exam, to rule out the many other possible causes for the symptoms that may look like ADHD, but may not be ADHD at all. For children a more comprehensive assessment is often called for because nearly 50% of children with ADHD also have a learning disorder, anxiety, depression or other co-morbid disorder. This is usually done by a licensed, registered or certified psychologist. Usually school psychologists are not trained or able to diagnose ADHD. This differs from state to state, province to province.
How is ADHD treated?
There is no cure for ADHD. Treatments, such as medication, therapy, behavioural interventions, only help control the symptoms.  Treatment often includes both  medicines and behavior therapy. Parents and other adults (teachers) need to closely watch children after they begin to take medicines for ADHD as initially they may cause side effects such as loss of appetite, headaches or stomachaches, tics or twitches, and problems sleeping. Side effects usually get better after a few weeks. If they don't, the doctor can change the dose.
Therapy focuses on making changes in the environment to improve the child’s behaviour. This often includes positive reinforcement systems, external and visual cues and prompts, and changes in the way a child is taught (especially changes in the expectation that they need to sit all day, be still and work on task for extended periods. These tasks are often impossible for children because their symptoms make them impossible. With medication and behavioural intervention can help tremendously, but education adults, parents, relatives and teachers about how to react to ADHD symptoms, and how to change the environment so the child can be successful is critical. This is often the focus of parent education and training. Counselling and extra support at home and at school help children succeed at school and feel better about themselves. A child's IEP (Individual Education Plan) usually addresses these issues, but again, staff education and training is critical!
How does ADHD affect adults?
Sometimes adults don't realize that they have ADHD until their children are diagnosed. When completing history forms they realize they had, and continue to have, many of these same symptoms and difficulties. Sometimes a change of job or promotion makes these problems more evident.  Many adults have problems with work and relationships due to impulsivity and problems regulating their emotions. Some report "memory problems," which are really issues of focus and attention. 
How is Adult ADHD Treated?
Treatment with medication, counselling, and behavior therapy can help adults with ADHD. Some therapists provide structured training programs, and for both children and adults with what seems like "short term memory" problems, what we call "working memory" deficits.  One program proven to be effective is called "Cogmed." 
What is Cogmed Working Memory Training?

Cogmed Working Memory Training is an evidence-based, computerized training program designed by leading neuroscientists to improve attention by effectively increasing working memory capacity over a 5 week training period.
Who is Cogmed training for?

Cogmed training is for people who wish to improve their ability to concentrate and are constrained by their working memory. Cogmed users range from young children to senior adults. Some have diagnosed attention deficits, some have suffered a brain injury, some feel the deteriorating effects of normal aging, and others find they’re not doing as well as they could, academically or professionally, given their intelligence and their efforts.
What is working memory and why is it important?

Working memory is an essential cognitive function necessary for a wide-range of tasks related to attention and focus. It is the ability to keep information in your mind for several seconds, manipulate it, and use it in your thinking. It is central to concentration, problem solving, and impulse control. Working memory is closely correlated to fluid intelligence and is a strong indicator of academic and professional success. Poor working memory is the source of many problems related to attention and is often linked to ADHD, and other learning disabilities.
What are the effects of Cogmed training?

Cogmed training improves attention, concentration, focus, impulse control, social skills, and complex reasoning skills by substantially and lastingly improving working memory capacity. The goal is improved performance and attentional stamina. The best way to learn about the effects is to talk to the Cogmed practice of your choice and to read the Cogmed User Stories.

Do the results last?

Yes, our research and our clinical experience show that the effects of Cogmed Training last after training. The reason is that once working memory capacity increases, you naturally continue to use it at its new level, which serves as constant maintenance training. Each Cogmed user also has access to optional Cogmed Extension Training at no extra cost.
Summary
There are many ways to treat ADHD. The best advice is to work closely with your medical doctor and psychologist, using techniques and interventions that have been proven to be effective. Regretfully there are a lot of programs and interventions on the internet that claim to work for which there is little evidence, or sometimes evidence they do not work (for instance, there are claims that acupuncture and homeopathic "medicines" work, yet there are no studies, and the rationale for these interventions often make little sense. Rely upon your licensed and registered medical doctor or psychologist for guidance. There are things you can do, intervention and medicines that have been proven to be effective with many years of research to back them up. Don't wait, don't procrastinate (especially for children). See your doctor and understand your choices.
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For information on counselling and therapy services in Burnaby, Vancouver, Coquitlam and surrounding areas contact Dr. Roche at: (Office phone) 778.998.7975
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As usual, let me warn you that this blog, any of my other blogs, or my web pages are not designed to provide you with an assessment, diagnosis or treatment. If you are concerned you have a health issue such as ADHD, anxiety, depression or Asperger's | autism please see your health service provider, either a medical doctor or Registered Psychologist. What may appear to be symptoms of one disorder can often be caused by another unexpected disorder. Other disorders, such as ADHD, are very likely to exist at the same time as another disorder (called co-morbid disorder) such as anxiety, depressing or OCD. You need to see a professional to find this out. On-line symptom checklists will not provide this, and are often misleading.
Services provided in my offices include: (covered by most extended health care insurance)
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/)
Anger Management (Click here:http://www.relatedminds.com/anger-management/)
Pain Management and PTSD (Click here:http://www.relatedminds.com/pain )
Forensic Services (Independent Medical Examinations or IME)
About Dr. Roche
My name is Dr. Jim Roche and I am a Registered Psychologist and a Registered Marriage and Family Therapist (RMFT) in British Columbia. In addition to my doctorate in clinical psychology, I hold a master's degree in family therapy, 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. In addition to being a registered psychologist, I am 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). I also hold a doctoral degree in law 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.
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

ADHD Medications (Ritalin) could be used with four year olds!

Scary headline, isn't it? The Vancouver Sun likes to create these headlines, which pretend to be balanced but really are designed to get you to worry ...and feel the need to read the article. The problem is, many people skim or never even look at the article itself. 


Let's go over what it says: 


The American Academy of Paediatricians released updated guidelines for treating ADHD. These guidelines expanded the ages for both the diagnosis and treatment of ADHD. The diagnosis of ADHD use to be restricted to the ages 6-12. Recently, with children attending pre-school and a careful eye on how the disorder progressing in adolescents and adults, we have expanded the ages when we think it's appropriate to diagnose ADHD. There is nothing nefarious about that.


But Sun writer Sharon Kirkey warns us that children may be misdiagnosed and may receive unnecessary medications. I suppose that's true of any medication or treatment, isn't it? But why is that the focus of this article? Here in Canada we actually have some decent diagnostic standards to determine who has and who doesn't have ADHD. I really think it would be have been helpful to tell the readers about that. Tell readers that a diagnosis should include more than a simple checklist a parent fills out, and should include some testing if necessary, and follow-up. Regretfully a major problem here in Canada is that children are seen, diagnosed, and then not seen again for a long time. Or seen by a different doctor because it's so difficult to get your own family doctor. But we do have standards of practice that are aimed at protecting us against misdiagnosis. ( see http://www.caddac.ca ) If we are really worried about misdiagnosis of ADHD maybe we should suggest that a parent ask their medical or psychological service provider what experience they have diagnosing ADHD, if they have observed children in school settings, and what guidelines they are following (see Caddac above).  That, I would suggest, is a simple step in avoiding misdiagnosis of ADHD any parent can take.


Well, the article gets worse. We further read that there will be a "further frenzy of aggressive marketing by drug companies..." Sounds scary. (I would suggest there will be a frenzy of marketing by holistic health care providers offering unproven and disproven treatments. Treatments that do nothing, and often have been proven to do nothing. Why our focus is on a treatment that has decades of research behind it and has been proven to be effective, is a puzzle to me. An online search for ADHD treatment in Vancouver shows some really unconscionable results.) This statement seems way out of line...especially if you actually read what the Academy suggests.


If your wondering if this is an anti-medication article ...well read on. The article then addresses the issue of heart problems and deaths due to medication. This is a tricky area for any parent to understand. Yes, children taking this medication have died. Did they die because they were taking these medications? Children die taking aspirin, cold medications, all sorts of medications. But bringing this issue up scares parents, and they should worry, be concerned, and deal with that concern by getting good information. A simple place to get information on this risk, an obvious place, is by asking your prescribing medical doctor. Here is what one doctor on the web says in answer to a parents concern about harmful effects of ADHD medications:


"There were 186 Ritalin related deaths in a ten-year period. In contrast there are 11 million prescriptions for Ritalin a year. If you divide the number of children who died from Ritalin by the number of annual prescriptions, that is 186/11,000,000= .000017. That means .0017% of children who take Ritalin are at risk for death. Now I realize that this is not really an exact calculation. The real way to determine the exact death rate is to divide 186 by the number of people who took Ritalin during the last decade. I couldn't find any data on this. The point is that whatever the death rate is, it is very small. It is probably more likely for a child to die from a Tylenol overdose than to die from Ritalin use. 

 

 


If your child has ADHD and Ritalin is helping, then I feel that benefits she gets from taking a drug like Ritalin far outweigh the risk of death from the drug. The bottom line is that no parent wants her child on Ritalin or some similar drug. However, if the child needs it, you as a parent should not worry that your child will be the one child in 60,000 that has a serious problem." (Anthony Kane, MD)"

Still confused? Ask your doctor. Why doesn't the Sun suggest you ask your doctor? I always wonder why they don't.

And finally, this is a comment you'll find in the middle of the article: "The authors emphasize that - for preschoolers - behavioural therapy should be tried first, such as group or individual parent training in behaviour management."  Only after that fails should medication be tried.

Actually they suggest first, foremost, and only after it fails, psychological, behavioural treatment and parent education. But this gets mentioned as an afterthought.

So I wonder, why isn't the headline of this article "American Paediatric Association Strongly Suggests Behavioural and Parent Training for Children ages 4-6 with ADHD."

I'm a psychologist. Here in Canada I can't write prescriptions for medication (although psychologists can and do in other jurisdictions). I provide behavioural therapy, parent education and teacher training to address ADHD. I offer these services all the time to schools (Burnaby, Coquitlam, Vancouver, Maple ridge), and almost always they turn ADHD specific training down, instead asking for training on ASD, Aspergers and other related disorders. ADHD, even though it's the most highly diagnosed disorder and causes the most problems in school and for the child (and teacher) is not a priority. ADHD and behaviours relating to ADHD are THE MOST RESEARCHED issues in school behaviour management we have. We know what works, we know how to change classroom environments and teach teachers skills that improve outcomes. Still, we do nothing. I wish the local papers would focus on the lack of training for etchers, and the lack of training for parents (MSP will pay for the medication, but will not pay for one single hour of parent education!)

But the American Academy of Pediatrics already suggested we do that, didn't they?

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For information on counselling and therapy services in Burnaby, Vancouver, Coquitlam and surrounding areas contact Dr. Roche at: (Office phone) 778.998.7975

About

My name is Dr. Jim Roche and I am a Registered Psychologist and a Registered Marriage and Family Therapist (RMFT) in British Columbia. In addition to my doctorate in clinical psychology, I hold a master's degree in family therapy, 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. In addition to being a registered psychologist, I am 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). I also hold a doctoral degree in law 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.

 

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

 

http://www.relatedminds.com

http://Therapists.PsychologyToday.com/rms/70682

http://www.therapistlocator.net/member?183420

http://www.bcpsychologist.org/users/jimroche

http://www.actcommunity.net/jim-roche.html

Phone: 778.998-7975

Homeopathy for ADHD? Cure or Con? A CBC Report Checks the Facts!


In my practice I provide services for the diagnosis of ADHD, Learning Disabilities and other cognitive disorders, as well as evidence based treatments for ADHD. These include classroom based interventions, behavioural treatments, specific skill training and Cognitive Behaviour Therapy. You can learn more about my services from my web page at www.relatedminds.com or www.relatedminds.com/adhd. Other information on my practice can be found at: http://Therapists.Psychologytoday.com/70682, http://www.bcpsychologist.org/users/jimroche or http://psyris.com/drjimroche.
This month, again, I met several individuals who were frustrated with the progress their children were making at school. ADHD was causing all sorts of problems. Their child was off task, couldn’t get an assignment completed, had fallen behind in reading and math ...and recently was engaging in risky behaviour and fighting. I asked when their last medical check-up was, and what their doctor had suggested.  As with many parents they didn’t want to discuss this in any detail, but finally told me they were seeing a “holistic practitioner” of some sort, and were using “natural remedies” at home? I asked “What do you mean by natural remedies?”
Usually for ADHD they mean fish oil, some vitamins, avoiding certain foods...and often supplements and homeopathic “medicine.” When asked how they came to this choice they talk about their fear that their child will become a “zombie” and how the “big drug companies” can’t be trusted. Often they have been attempting these unproven..and often disproven treatments for years because of the fears that their child will “become a zombie” or “He will become addicted.” By the way, research is pretty clear, for kids with ADHD taking medication and receiving appropriate treatment will make them LESS likely to use drugs...but honestly, the research seems to have no effect. Often they persist in their views and refuse to read the scientific literature.  Let’s start here:
Read Dr. Russell Barkley. He is the expert on ADHD. Period. Yes, his research and publications are supported, in some cases, by research grants from big companies. He tells you. Most people supporting the use of “natural remidies” don’t tell you about that, and ....well...guess how big the natural remedy lobby is? Here is his website:
Another really good - and free - source of information is from the National Institute of Mental Health in the US.  Here is a link to their brochure that explains EVERYTHING about ADHD and medications:
Now medication is not always the answer. Because of the nature of ADHD medication can’t fix problems that have developed over time. Training, coaching, support and therapy can help with those.  And medication is simply not always needed. But you can’t make a good decision if you refuse to learn about it, talk about it and understand it. Canada and it’s mental health services have similar publications, but this NIMH  one is really excellent.
Now, back to my topic ....Homeopathy ...is it a cure or a con? 
CBC recently had a short investigation of homeopathic medication which I thought you might enjoy watching. Homeopathy is often an idea that my patients present to me in these meetings, however they seem to know nothing about how it works (or doesn’t work) and often have been told some startlingly misleading information. 
There is no evidence published in science based journals (except those published by homeopathic practitioners) that I am aware of that shows homeopathy works for ADHD, or any of the other may illnesses, disorders and diseases it makes a claim to cure. Yes, they will argue the opposite, and below I’ve provided some information to counter their arguments. An interesting read are the comments by the supporters of homeopathy on the CBC website which went up after the program viewed. They can best be described as void of evidence, name calling and paranoid ideas about big pharma, government and mistrust of medical doctors. 
It’s a sad and scary read. Here in BC we actually have several practitioners who offer “homeopathic vaccines” to children and travelers! I suggest several good web sites to clients to help them understand the story behind homeopathy. These are listed below. Start with the CBC report, as it’s actually entertaining. Then take a look at the other sites.
 
The CBC report on Homeopathy:
A good quick rundown of the history of this practice can be found at “Quackwatch:: 
For an in-depth analysis of Homeopathy, I always suggest Science-Based Medicine, this article is a great resource for ideas about “plausibility: and why so many of the “research” protocols used by homeopaths are simply wrong:
http://www.sciencebasedmedicine.org/index.php/homeopathy-and-plausibility/
The UK Government has made this finding on the efficacy of homeopathy: 
"The Committee concluded—given that the existing scientific literature showed no good evidence of efficacy—that further clinical trials of homeopathy could not be justified.... The Committee carried out an evidence check to test if the Government’s policies on homeopathy were based on sound evidence. The Committee found a mismatch between the evidence and policy.... The Government acknowledges there is no evidence that homeopathy works beyond the placebo effect (where a patient gets better because of their belief in the treatment). The Committee concurred with the Government that the evidence base shows that homeopathy is not efficacious and that explanations for why homeopathy would work are scientifically implausible.... Given that the existing scientific literature showed no good evidence of efficacy, further clinical trials of homeopathy could not be justified."
The article can be found here:
http://news.discovery.com/human/uk-government-study-homeopathy-worthless.html
Oddly, when doing a web search for this article 90+ percent of the search results were pro-homeopathy. right below the article above was one that claims “Homeopathy is an evidence-based science.” 
A great website about "alternative medic" and especially Homeopathy:
Finally, here is an excellent article on the efforts in the UK and other parts of Europe to put some controls on homeopathic practice:
http://theness.com/neurologicablog/index.php/uk-ban-homeopathy/
Cure or Con?
Well, you have got to make up your own mind, and getting through all the hype and nonsense on the web isn’t easy. It is especially difficult because understand homeopathy means understanding medical research design, statistics and probability (Hey, great book: The Drunkard’s Walk ...explains it well, easy to understand and funny!) What I know is that regular folk, who haven’t majored in biochemistry and math, can be very VERY easily fooled by the reports they read on the web. I think the article by Steve Novella on “plausibility” helps clarify some of the odd outcomes that are published, and helps you understand how people misuse statistics ...and misuse the very idea of “published in a professional journal.” Good grief, many of these organizations have created journals that do nothing but publish favorable articles that support their practice! 
You can laos watch the CBC report. Ontario homeopaths are about to become the first province in Canada to regulate homeopathy — the goal is to lend credibility to this unproven practice. “We are credible because we are regulated...” (We could regulate fortune tellers ....actually, they need a business license ...no proof of efficacy ...no proof of anything!)
In the report we read, “For the first time in Canada, we conduct a test of homeopathic medicines, investigating the science behind these so-called medicines. In light of our results, we ask both the Ontario government and Health Canada why they are lending credibility to the homeopathic industry. Johnson also meets up with a rep from the world's leading manufacturer of homeopathic medicines, who admits that even the company says how homeopathty works is a mystery.”  (Notice just asking the question and answering “It’s a mystery as to how it works” is MISLEADING.  Most scientic evidence I’ve read says it doesn’t work ..it’s a placebo effect, or ...the natural course of an illness.”  This reminds me, here is another great resource for information on homeopathy, “”Quackcast.” This is a podcast available from either the website below or from iTunes. Dr. Mark  He concludes, “Clinical trials of homeopathy are of poor quality and treat self limited diseases. The better the study, the less well homeopathy does. In the best meta analysis to date, it is concluded that homeopathy doesn't work.”
http://www.quackcast.com/epodcasts/files/077c17cfb5bb4f80cb4a008246563446-6.html

If you like listening instead of reading, here is another great source of podcasts that can help you learn to use the scientific method (Brian Dunning- SKEPTOID:
http://skeptoid.com/episodes/4034
Back to the CBC broadcast: in it “we witness a Vancouver group of skeptics taking part in a group overdose of homeopathic remedies. Perhaps most disturbing we learn that some homeopaths are treating cancer patients with homeopathic remedies. A leading cancer specialist says there is no role for homeopathy in the treatment of cancer, that it is a "scam that is not evidence-based."
The reaction to the CBC story, as is often the case, was complaints from those who support homeopathy, one person actually filed a complaint with the CBC Ombudsman, Kirk LaPointe. He has now ruled on that complaint, and you can find his report at The Office of the Ombudsman website
Here is part of the Ombudsman’s answer: “Homeopathy, from the Greek words homeo (similar) and pathos (illness or disease), is a form of medicine in which practitioners treat patients using highly diluted preparations of substances associated with ailments. It abides a belief that the body’s own healing systems can be stimulated by these ultra-dilute substances. It furthers the view that the human soul perceives the presence of these minute substances, even when there are practically no atoms of them detectable, and that the remedy stimulates defense. This belief is commonly referred to as the “like cures like” Principle of Similars. It defies principles of allopathic medicines. Homeopathy also subscribes to the view that water has a form of memory. The online resource, Wikipedia.org, concludes: “The collective weight of scientific evidence has found homeopathy to be no more effective than a placebo,” an inert treatment that simulates a  medical intervention and can generate a perceived or real patient improvement. The most recent significant study of homeopathy came from a 2009 British Commons committee following months of testimony. The committee considered the ultra-dilution notion “scientifically implausible” and that systematic reviews and analyses “conclusively demonstrate that homeopathic products perform no better than placebos.”
It is pretty common practice for those selling homeopathic cures to try to silence their opponents. As to why? I don’t know.  They seem to control the internet. Just do a search for treatment for ADHD, autism, Aspergers and other serious childhood or adult disorders and you are going to be overwhelmed by pages supporting homeopathy and other alternative medicines, and usually selling them.  MY suggestion is: Have an open mind, but as they say, not so open your brain falls out! Openness doesn’t mean ignoring or inventing facts.

Kids do well if they can: Dealing with angry, aggressive and explosive kids

Often parents and teachers ask me about readings, videos and other materials that might help with their child who has anger management problems. Well, it's difficult to make one or two suggestions because kids who have anger problems, are explosive, fight, act-out and disrupt can be doing it for a number of reasons. One child may have a mood disorder, another may have an executive function deficit, another may have sensory issues and yet another is responding to cumulative failures due to learning disabilities, ADHD and other causes. So, not every difficult child should get the same treatment, either at home or at school. This is especially true for children with ADHD. Kids with ADHD are very likely to have a co-morbid disorder, something going on besides ADHD. And just treating the ADHD with medication isn't going to solve all the problems. So, start with  real diagnosis. Not just a simple 15 minute office interview where the parents and teacher fill out a form (usually the SNAP-IV) that only asks about ADHD and was given because even before we started looking at things we had made a decision it was ADHD. No, start with a good diagnostic assessment by a psychologist, either a school psychologist or a registered psychologist. That's important to rule out learning disabilities, personality disorders or mood disorders (depression or anxiety). From there you will be ready to move on.

But if you are a parent with an aggressive, acting out child you might start by reading two books. First, Dr. Russell Barkley has an excellent book on parenting skills called The Defiant Child. A great book that will set you on the path to being a behaviour expert. ( He also has one called The Defiant Teen).  Barkley's book is a guide to behavioural interventions, and if your having these kinds of problems, you need this book.  Oh, and watch "Super Nanny" too. She's not always right, but she's right enough of the time, and you'll see, managing a difficult child isn't easy for ANYONE.

The second book I would recommend is from Dr. Green called The Explosive Child. This book is a very, very different take on child management. It might be hard to think of using them together, but if you can, your doing everything right you can do.  Dr. Green has a simple philosophy, "Kid's do well if they can." Remember that. Kids do do well if they can, and most of the kids I've seen over the past 25 years who were not doing well knew it and felt awful.... they just couldn't help themselves. Greens program is called "Collaborative Problem Solving" and I think it's the goal everyone should be working on. Teaching your child to deal with problems by engaging with others. Green has a really great web site, and here is a place to start:

http://www.livesinthebalance.org/what-is-collaborative-problem-solving-cps

Watch these videos. Get the books.

People often ask me why I am so willing to share materials? I have a fairly well stocked library of books and DVDs for parents. They think that if I suggest a self-help book you'll use that and ...well, what happens to my practice? Just watch an episode of Super Nanny and you'll see. These skills and techniques are easy to write down, but hard to implement. I'm here to help you, answer questions, walk you through the skills, role play and practice. When your ready for some parent training or coaching, take a look at my web site and give me a call. I can be found at http://www.relatedminds.com

Now go to the book store or library and get these materials!

What causes ADHD (ADD)?

My professional web page is located at: http://www.relatedminds.com
I'm often asked "What causes ADHD?" and thought today's blog might just address that.

How many people have ADHD? Isn't it over diagnosed?
ADHD occurs in approximately 3-7 percent of the childhood population. Studies find that approximately 2-5 percent of the adult population have ADHD. Boys more likely to have the disorder than girls by 3:1. Among adults, the gender ration falls to 2:1 or lower. The reason for that seems to be that girls don't exhibits some aspects of ADHD that boys do, such as hyperactivity, but later do show signs of inattention. 


ADHD has been found to exist in virtually every country in which it has been investigated, including North America, South America, Great Britain, Scandinavia, Europe, Japan, China, Turkey and the middle East. It is NOT something made up by Western doctors, as some would tell you. The disorder may not be referred to as ADHD in these countries, and may not be medically treated as in North America. Still  there is little doubt that the disorder is universal among human populations everywhere. 


One of the things we have found is that ADHD is more likely to be found in families in which others have the disorder or where depression is more common. Dr. Russell Barkley (most of the information provided here can be found in his writing, and I highly recommend his website) has found that ADHD is also more likely to occur in those with conduct problems and delinquency, tic disorders or Tourette’s Syndrome, learning disabilities, or those with a history of prenatal alcohol or tobacco-smoke exposure, premature delivery or significantly low birth weight, or significant trauma to the frontal regions of the brain.  Almost 50% of individuals with ADHD also have another comorbid disorder. This is why, especially with children, you should consider getting a more comprehensive assessment than often given in a medical doctors office, as learning disabilities and other comorbid conditions need to be ruled out.


What causes ADHD?
Scientific evidence is overwhelming that ADHD "has very strong biological contributions to its occurrence." What those are have not yet been identified, but there is little question that heredity/genetics makes the largest contribution to the expression of the disorder in the population.  How big of an influence does genetics have on ADHD? Approximately 80 percent, meaning that genetic factors account for 80 percent of the differences among individuals in this set of behavioral traits. This is about the same as for how tall you are, or how smart you are. Several genes associated with the disorder have been already been identified. There are some situations where heredity does not seem to be a factor.  These include "difficulties during pregnancy, prenatal exposure to alcohol and tobacco smoke, prematurity of delivery and significantly low birth weight, high body lead levels, as well as post-natal injury to the prefrontal regions of the brain have all been found to contribute to the risk for ADHD." But these are usually the exceptions. For the most part, the vast majority of ADHD seems directly related to genetics.


Dr. Barkley points out, "Research has not supported popularly held views that ADHD arises from excessive sugar intake, food additives, excessive viewing of television, or poor child management by parents."  Full moons and sugar highs seem to affect the parents and teachers more than the children. Therefore, most medical interventions are not aimed at these disproven theories, which remain popular because they have quick miracle cures attached to them...which do not work.


I hope the brief and basic outline is helpful.

Excessive Video Gaming Not Just a Symptom: Issues in ADHD

Medical News: Excessive Video Gaming Not Just a Symptom - in Pediatrics, Parenting from MedPage Today

to start, I remind you again that due to Apple Computer ending it's web hosting services I've moved my website to a new host. The website is still found through the url: wwwrelatedminds.com or www.relatedmindsbc.com. My blog is also move. For the time being most blogs, in addition to being posted on blogger, will be reposted at the new site at: http://www.relatedmindsbc.com/blog
Now, back to video gaming.

Many families come in with their children, who often have a diagnosis of ADHD or ADD, and complain about excessive video gaming. They can't drag their kids away from the machines, and can't get them to stop. They ask me if the video gaming is, in itself, pathological, or if it can cause pathology such as excessive anger, violent behaviour and poor concentration (this is a big concern for parents who already have a diagnosis of ADHD for their child). There really hasn't been much research on this issue until recently, and the research there is isn't very clear. However, this study by Douglas Gentile, PhD, of Iowa State University, has found some interesting...and worrying...connections.

So the real question is, does excessive gaming cause pathology, or does pathology cause excessive gaming? This two year prospective study (with over 3,000 children identified in the data) identified several baseline psychological factors that predicted excessive gaming. These include: impulsivity, depression, social difficulties and poor overall school performance.  These conditions seemed to act as outcomes of pathological gaming. But this excessive pathological gaming seems not to simply be secondary to these other disorders, but to be predictive of poorer functioning overall. This poor overall functioning can last for several years.

For instance, while impulsivity is a risk factor for excessive and pathological gaming, impulsivity worsens after a youth becomes a pathological gamer. The study found that increases in pathological gaming were predictive of depression, anxiety, social phobia and poor school performance.  The relationship between these factors was especially strong for depression.  Some limitations of this study were: it's location (Singapore -can it be generalized to Western cultures?) and that the study relied on self reports from these children.

What can we learn from this? First, I think, that we should not ignore the possibility that there is an underlying depression or anxiety with children who spend too much time gaming. This can often be determined through a clinical interview and further assessment if necessary. And second, that impulsivity is a critical factor in helping the child reduce gaming activity. This is especially true for kids with ADHD who seemingly can focus on an XBox game for several hours, but can't spent 10 minutes reading or doing math problems. (This is the student who often really agitates the teacher, who assumes that it's a matter of choice rather than a result of the child's disability or cognitive deficits such as ADHD or depression.)

Overall if your child is having problems with excessive time spend at the computer gaming, has become isolated and seems non-compliant when asked to get off the computer: get professional help. There seems to be a strong relationship between pathological gaming and psychological problems such as impulsivity, depression, anxiety, social isolation and poor academic performance. You may have difficulty directly addressing the gaming at first, but working on these other areas may very well help.  A psychologist with expertise in diagnosis and treatment of these disorders can help you set up a home program to teach skills necessary to disengage from the video game, address irrational thinking that comes with anxiety and depression, teach social skills and skills to reduce anxiety and finally develop a positive sup[port plan to address issues relating to learning difficulties.

Feel free to contact my office or contact the British columbia Psychological Association to locate an expert near you.


ADHD (Attention Deficit Hyperactivity Disorder) in the classroom

For nearly 20 years I have been providing consultation and training to school districts about how to support the student with ADHD /ADD in the classroom.  This has included ADHD consultation with individual teachers and school wide training on the subject. I've worked in Vancouver, Burnaby, Maple Ridge, West Vancouver, North Vancouver, Coquitlam and throughout BC with individual teachers, and have provided school wide consultation and training on ADHD in BC, California and New York.

The student with ADHD / ADD has special needs that can be supported by some very simple classroom or environmental changes, and some specific individual supports. For an individual teacher I have several info sheets available on my website. You can start here with this sheet on Executive Function, Emotions and ADHD in the classroom (click here),  or you can seek out general information on ADHD from my ADHD / ADD page by clicking here: http://www.relatedmindsbc.com/adhd. Other genreral information on children with anger control issues and difficulty with emotional control can he found here: http://www.relatedmindsbc.com/the-angry-child. Other general information can be found on my websites "Forms" page.

In this first post on ADHD / ADD in the classroom I'd like to review several general rules. In my next post I'll address some simple classroom interventions, and then in the final post on in this series address the issue of reinforcement systems. So here are some basic rules, following the guidelines for Accommodations for Children and Teens with ADHD by Russell Barkley (The complete guide is available free from his web page).

1. Rules and Instructions provided to children with ADHD must be clear, brief and delivered more clearly than to regular students.  Start by making sure the child with ADHD has given you his or her full attention ("Mike, are you ready? Yes.") Have the child repeat the instructions out loud, or to themselves. Support the rules or instructions with visual prompts such as signs. Use prompts such as pointing to your ears, eyes, etc. Don't give multi-part instructions unless they are supported with an external aide such as a list, hand gestures, or picture cues.  Ask yourself, "Did he get enough of a warning? Did he get a prompt to pay attention? Did I have his FULL attention before we started? What could help him focus on what I am saying?

2. Consequences for students with ADHD must be "swift and immediate." ANY delay, even just a couple minutes, in giving a consequence to a student with ADHD significantly degrades the power of the consequence.  It is not the size or harshness of the consequence that matters as much as how quickly it is given after the inappropriate or unwanted behaviour.  Frequent feedback is essential. Token systems, visual cues and prompts and hand signals all can help deliver minor but immediate feedback. Remember, these "consequences" for a student with ADHD are meant to be feedback, not so much punishment.

3. Every consequence should be counted!  Consider how many positive feedback moments the student has compared to negative. If you are giving more negatives than positives, consider how environmental changes can help change this to positive feedback. Too often students with ADHD are given constant, low level, late and ineffective negative feedback that becomes nothing more than a drone to their minds. Then then begin to associate the classroom environment with negative consequences. The classroom should be associated with positive experiences, positive feedback for successful behavioural efforts. Ask, "What supports does my student need to get positive feedback more often?"

4. The type of consequences used with students with ADHD must be "of a higher magnitude" than that provided to regular students. That means that positive reinforcers must be more powerful for the student with ADHD. And they must be more frequent and most important more IMMEDIATE for the student with ADHD. If you need help developing these skills, get feedback or consultation. Avoid going down the negative/punishment only path.

5. Positive Feedback must be more powerful and more frequent than negative feedback. Usually token or other reinforcement systems start with two or three weeks of positive only feedback before any negative feedback or consequences are provided to the student with ADHD / ADD. The rule is "Positives BEFORE negatives." Often students with ADHD do not respond to punishment or time out. If punishment is failing, you should seek out professional and experienced help before increasing the magnitude of punishment for a student with ADHD.

6. Reinforcers work only for a little while. Be ready to change them, increase them, provide them in new ways and provide new types of reinforcers for the child with ADHD. This is significantly different from other students in your class, expect that and be prepared to provide it.

7. Behavioural programs for students with ADHD often only work for a short period of time before needing to be modified. Be prepared. Monitor how the program is working, and when you are no longer seeing success alter the program in a manner that makes it effective. Also remember that for the student with ADHD the behavioural changes occur while the program is in effect, and are very likely not to work when you stop them. Does this mean behaviour programs don't work? No. It means they are an effective technique to use to assist you in finding ways to support the student while learning of other kinds occur. For a program of behaviour modification to work for longer periods you need to develop a program that includes components for decreasing the frequency of reinforcers, to generalize the behaviours to new environments and substitute natural reinforcers, prompts and cues for the artificial ones you have been providing. This may be beyond your knowledge and experience. If it is, ask for consultation with a specialist. These types of behavioural programs have been show to work effectively and are generalizable by those who know the techniques and have the experience. Don't be afraid to ask for help. That's what you expect from your student with ADHD.

These are some of the most basic components of a classroom program that can supports students with ADHD / ADD and other related cognitive and emotional deficits. A good classroom program includes visual supports, a means of tracking behaviour, specialized environmental supports and a systematic method of providing positive feedback or reinforcement. This type of program will help you design a classroom that can support these students, and thereby make teaching all of your students  easier.

There are some excellent books on classroom modifications and individual intervention planning for students with Attention Deficit Hyperactivity Disorder available from Dr. Russell Barkley, as well as some very helpful DVD/video training. I am also available to provide individual teacher/student consultations or school wide training in setting up classrooms that are friendly to and support of those with ADHD. Feel free to contact me for more information.

In the next post I'll address some specific classroom and student interventions. Then I'll address using reinforcement systems (such as token systems) that have been found to be one of the, if not THE most effective means of supporting children with ADHD in the classroom. Finally, I may have a few words to say about writing behaviour plans and completing a  Functional Behaviour Analysis (FBA) with a student with ADHD.

Food Colouring DOES NOT cause ADHD, FDA

So here is the SCIENTIFIC consensus: There is no proof that foods with artificial colorings cause hyperactivity in most children and there is no need for these foods to carry special warning labels, a government advisory panel voted Thursday. Yes, in spite of the fact that you have read in almost every newspaper that there is proof it does, those stories reflected the fact that the United States Food and Drug Administration was taking a look at this issue ....and everybody jumped the gun because it made a good story. Sad reporting, again.

The Food and Drug Administration convened this expert panel after agency scientists decided that while typical children may be unaffected by the dyes, those with behavior problems may see their symptoms worsen by eating food with synthetic color additives. Notice the word MAY.

Now this debate over artificial dyes began in the 1970s with Dr. Benjamin Feingold, a pediatric allergist from California, had success treating the symptoms of hyperactivity in some children by prescribing a diet that, among other things, eliminated foods with artificial colouring. The problem was the effect that he measured, the positive behaviour changes, were the result of parent expectations and parent / environmental changes.

Let's understand the agency conceded that some children might be negatively affected by the foods. Remember, the committee voted 8 to 6 that even a warning was not needed. So to clarify, there is SOME evidence that SOME children, children with pre-exisiting problems, are further effected by food colouring and all the rest parents worry about. Will removing these things from your child's diet make changes? Not likely. But for some children, yes. But ADHD IS NOT caused by these additives. Even with the most likely diet claims, what we are saying is that children WITH ADHD may have even bigger behaviour problems due to the effects of these additives. We are talking about very few children. If your ADHD child is reacting negatively to these additives, they are saying he or she will still have ADHD after removing them, but may not be reacting to the additive any more.

Should you control your child's diet? YES! Many children with ADHD react strongly to all sorts of environmental stimuli that has little effect on those who do not have ADHD. I have an allergy to wheat. If I eat wheat early in the morning, before anything else...my stomach feels a little yucky. Rumbles. Noises. A little pain. Later in the day, after eating other things, wheat has no effect. Now if I were a kid with ADHD and ate wheat early in the morning, I would very likely react not just to the wheat, but react to my discomfort ...over react. /Because most kids with ADHD have low frustration tolerance. So my reaction is a reaction to my reaction.

If I had a child with ADHD (my kids are all at least 30+ now) I would, yes, avoid junk food. I would avoid soda, pop, bright green, yellow and orange stuff. But I wouldn't think my child has ADHD BECAUSE he ate some M&Ms!

This is important because so many parents put so much effort into finding a solution that is easy, fast and clear. Regretfully solutions for ADHD are none of those things. To help your child be successful you need to educate yourself (read Dr. Russell Barkley!), educate your child (there are a lot of good books to explain "differences" to children), make changes in the environment, changes in you, changes in school and behaviour expectations and consider if and when medical intervention is necessary. That needs to be determined between you and your medical doctor.

This week I have read and re-read so many postings about this FDA / Food Colouring issue that I just felt it needed to be addressed again. Most of the coverage consisted of jumping to conclusions the scientific panel did not jump to, and people reading and seeing only those parts of the story they wanted to see. The horrible state of science news reporting didn't help. Go talk to your MD. And if your worried about your child, get him or her assessed ASAP!

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This blog is NOT meant to provide medical advice (did you notice how many times I told you to see an MD or a psychologist?). If you would be interested in speaking with me in my Burnaby or Vancouver office about ADHD (in either children or adults) check out my web pages at: www.ahdhhelp.ca or www.relatedminds.com

The Daily School Note: A proven intervention for children with ADHD.

In my last post I mentioned Daily School Notes. These are little feedback forms that let you know how your child is doing in school. That sounds simple enough, but often they are misused and abused, causing more harm than good. Here are some really simple rules:

1. This note is designed to emphasize what went right, not what went wrong. It's a means of measuring progress, not failure!

2. The goal of every day at school is a "good day at school," it's as simple as that.

3. Point systems and other reinforcement programs should ALWAYS be used in a manner that point to success. NEVER to deny something, or to punish. (I don't get NEGATIVE pay checks, do you?)

Look at the research on behaviour management of children in schools. The most successful method of teaching new behaviours and getting them to happen more frequently is a positive reward / token system. For the past 30 plus years school/home notes have been a component of nearly every successful behaviour intervention program written about. If you hear "I've tried that, it doesn't work," it's most likely because it wasn't done properly. Regretfully teacher education programs no longer seem to require any training in classroom management. So, we need to make these changes back to what we know works "one classroom at a time."

So what does a daily school note look like? Usually it's a SHORT series of questions relating to behaviour, on-task behaviour, academic completion (should be effort!) and so on. Usually it has no more than 5 issues, and a line about homework. Every day the note goes home and in the morning comes back. Some schools do these on line now.

A problem with many of these is that they are used to punish children, to inform parents of bad behaviour, and to get parents to "do something" at home about what went on at school. These are all really bad ideas. By 6 pm it's too late to have much of an influence on a child's behaviour from 10 am that morning. Punishing and criticism won't make a change. If they would, it would have happened by now.

Instead a good school note should offer some feedback on the day that is on a scale, say 1-5, and not a scale of success or failure. Here is an example:

1. On-Task behaviour (focusing on your work for 5 mins at a time)
(Circle) Had difficulty 1-2-3-4-5 Great day!

So the child gets a score of 1-5. Now often these scores are then taken to be an opportunity to punish a child. You got a 2! What was wrong? And the child loses some privilege or reward. This is not a good idea. Soon the home note becomes something to avoid, and school becomes a negative, also to be avoided.

Instead the reinforcement and correction happens WHEN THE SCORE IS GIVEN, and that should be right when the behaviour happens. The immediacy of the feedback and reinforcement is what makes it work. You can't wait 25 minutes to give feedback and reinforcement to a child with ADHD. It just doesn't work. So the feedback should be immediate, corrective, specific and emphasizing the positive whenever possible. Home notes used to punish, where the feedback occurs a long time after the behaviour don't work.

So give the feedback right away. Writing on the note helps reinforce it. THAT is the reinforcer. Later when the child takes it home the points should be totalled up and are always, ALWAYS, leading to some greater reinforcer.

So a note that had five threes gets 15 points, and Tommy needs 100 to get to go to the movie. Rather than saying "Well, you didn't earn your reward today..." and ending up with crying and hating the school note you should say, "Fifteen points today, well, your getting closer, just 70 more to go! What gave you trouble? Anything we can do to help?" The response to the note should be specific and positive. Now the teacher has had an opportunity to correct inappropriate and reinforce appropriate behaviour, a method to give the reinforcement has been provided (the note), the child is learning to put off rewards (it might take several days to earn enough points) and don't we all want our children to learn that they need to wait for good stuff and earn it over time? And finally, the parent has feedback that whatever is going on needs some improvement. There are simply too many 2 and 3 point days. So you need to ask ourself "What can we change to support Tommy better so he is getting 4's and 5's?"

That's basically how a positive support system is used. And as you probably know that's often NOT how home notes re used. We end up with kids crying, parents yelling, kids hating school and teachers expecting parents to fix their kids behaviour after it happened.

I often provide training and consultation on setting up feedback systems with schools, and moving from the punishment mentality to the support, model, reinforce model isn't easy. But it's the only way to go with a child with ADHD (Attention Deficit Hyperactivity Disorder).

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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).

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

ADHD Collaborative: We could learn something from this very simple program.

About the ADHD Collaborative, a program at Cincinnati Children's Medical Center: The goal of the ADHD Collaborative is to improve functioning, quality of life, and access to care for children with ADHD. This is accomplished by training community primary care providers to implement the American Academy of Pediatrics (AAP) and Cincinnati Children's Hospital Medical Center evidence-based guidelines for the diagnosis and treatment of this disorder.

As a process improvement initiative, the Collaborative emphasizes using best – practice recommendations and quality improvement science to achieve desired long-term outcomes.ADHD
Best-practice means using those interventions, tests, techniques that are scientifically supported, and taking a close look at how they are working. Here are the simple steps they have taken. They are SO simple, yet most of the time they aren't followed by physicians or psychologists:

Guideline Summary
For the diagnosis of ADHD, the guidelines recommend:
␣ PCP initiates an evaluation for ADHD in a child 6-12 years old
␣ Child must meet DSM-IV criteria.
␣ The assessment requires evidence obtained from parents or caregiver AND classroom teacher.
␣ Evaluation should include assessment for coexisting conditions. (This is the differential diagnosis issue I often write about. Do these symptoms mean ADHD, or might they mean something else that we are missing because we jump on the ADHD bandwagon?) Other diagnostic test are not routinely indicated to establish the diagnosis of ADHD, but may be used for the assessment of other coexisting conditions.

For treatment of ADHD, the guidelines recommend that primary care clinicians:
␣ Establish a treatment program that recognizes ADHD as a chronic condition
(Chronic means long term, not going away, BUT something we can treat and do something about)
␣ Specify appropriate target outcomes to guide management
(Determine what the goals of treatment are. What are we to expect from the treatment? How long should it take? How will we know it's working? This means follow-up forms and maybe testing that pinpoints performance levels in specific cognitive areas. This is often better than simple self reports.)
␣ Recommend stimulant medication and/or behavioral therapy as appropriate to improve target outcomes.
(Always ask, when medication is suggested, what symptoms is this medication for? How long will it take to work? What should I see as a result of it working? And what will it not help with?)
␣ Provide a systematic follow-up for the child with ADHD. When a child has not met target outcomes, evaluate: the original diagnosis, medication, and/or behavioral therapy as appropriate to improve target use of all appropriate treatments, adherence to the treatment plan presence of coexisting conditions when a child has not met target outcomes.
(This is THE critical part of their program. If you go to the hospital's web site you will find they supply doctors with forms to TRACK changes in behaviour. Those initial self-reports and parent reports you might have filled out were often originally designed to be used to track the effects of treatment interventions or medication. You were suppose to fill them out weekly, so you could track change. Without some structured way to track change we end up relying upon verbal reports from parents and teachers which might suffer from what we call "confirmation bias," see what you expect or want to see. OR they may be influenced by the environment, a change in teacher, holidays, home situation. Without ongoing assessment of treatment, including medication, we really don't know how things are going.)

Besides their ADHD Collaborative program the hospital has a great ADHD information page. Click here to view it.

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This blog is not offered as medical advice or as a means of diagnosing or treating ADHD or any other disorder. Don't go on line and take an ADHD "test." The diagnosis is complex, and it involves not just looking for symptoms of ADHD, but also ruling out other disorders that might look just like ADHD. 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 that. Medical doctors can diagnose ADHD, but the diagnosis is complex and often they will make a referral to a Registered Psychologist. You can obtain a referral from the British Columbia Psychological Association for a psychologist near you.

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.

Attention Deficit Hyperactivity Disorder (ADHD) 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. This includes neuro-developmental assessments, psycho-education and cognitive behaviour therapy. I also provide diagnostic assessments for autism and Asperger's Disorder in my Burnaby office.

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

ADHD Rates Are Increasing - in Pediatrics, ADHD/ADD from MedPage Today

Medical News: ADHD Rates Are Increasing - in Pediatrics, ADHD/ADD from MedPage Today

MedPage Today reports that more parents are reporting that their children have been diagnosed with attention deficit hyperactivity disorder (ADHD) at some point in their lives than earlier in the decade, this according to the US Centre for Disease Control. The percentage of children and teens ranging from ages 4 to 17 with a "parent-reported ADHD diagnosis" increased from 7.8% in 2003 to 9.5% in 2007. These are children and adolescents whose parents report their children have ADHD according to what they have been told by any medical provider. This does not mean a formal diagnosis took place, only that a medical provider gave them this opinion at some point. This data was reported by researchers from the agency's National Center on Birth Defects and Developmental Disabilities and from the National Center for Health Statistics reported in the Nov. 12 issue of Morbidity and Mortality Weekly Report.

These findings are consistent with other reports using different sets of data. According to the editorial notes from this article, "Increasing rates of estimated ADHD prevalence might indicate an actual increase in the number of cases of ADHD or changes in diagnostic practice over time, which might have been influenced by increased awareness of the disorder over the period of study...additional studies are needed to understand other geographic or environmental risk factors associated with rates of ADHD diagnosis, such as state-based policy and healthcare provider characteristics," the editors continued. "Ongoing surveillance is critical to understanding the public health effect of ADHD and the needs of a growing number of families affected by this disorder."

The 22% relative increase in the number of parents who answered yes to this question about being told their child may have ADHD over the interval from 2003 to 2007 shows an increase of roughly 1 million children (from 4.4 million to 5.4 million) who were ever diagnosed with ADHD. The rate of parent-reported ADHD was significantly higher in 2007 for almost all demographic subgroups, with the greatest jumps in teens ages 15 to 17 (+42%), multiracial and Hispanic children (+46% and +53%, respectively), and children with a primary language other than English (+82%).

Twelve US states saw significant increases in the rate of parent-reported ADHD ranging from 31.7% to 67.1%; none had a significant decrease. "Changes in the sociodemographic composition of states or state-based policy or practice changes, such as widespread behavioral health screening, might have contributed to the increasing rates," according to the MMWR editors. In other words, the increase may be real, and may be due to the fact that over the years more children have been either informally or formally screened. Many of these subgroups have medical care and options available to them that were not there several years ago due to changes in government programs and the availability of medical services to children and families with lower incomes.

A question about whether the child currently had ADHD was added to the 2007 survey. Of those who had ever received a diagnosis, 78% currently were found to have the disorder. Of those with current ADHD, two-thirds were taking medications for it. Overall, 4.8% of the children included in the survey were taking medications for ADHD. The MMWR editors noted that the analysis was limited by the use of parental report for ADHD diagnosis, the fact that the survey included a question about current ADHD status in 2007 only, and the inability to reach families that did not have a landline telephone. Still the data demonstrates that there is most likely fewer children being treated than should be. Regretfully the survey did not ask direct questions about what services or interventions were being used, or where helpful.

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This blog is not offered as medical advice or as a means of diagnosing or treating ADHD or any other disorder. Don't go on line and take an ADHD "test." The diagnosis is complex, and it involves not just looking for symptoms of ADHD, but also ruling out other disorders that might look just like ADHD. 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 that. Medical doctors can diagnose ADHD, but the diagnosis is complex and often they will make a referral to a Registered Psychologist. You can obtain a referral from the British Columbia Psychological Association for a psychologist near you.

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.

Attention Deficit Hyperactivity Disorder (ADHD) 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. This includes neuro-developmental assessments, psycho-education and cognitive behaviour therapy. I also provide diagnostic assessments for autism and Asperger's Disorder in my Burnaby office.

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

Children with ADHD at increased risk for depression and suicidal thoughts as adolescents

Click here for link to the original article

ScienceDaily (Oct. 4, 2010) — Children diagnosed with attention deficit/hyperactivity disorder (ADHD) at ages 4 to 6 are more likely to suffer from depression as adolescents than those who did not have ADHD at that age, according to a long-term study published in the October issue of the Archives of General Psychiatry. Although it was an uncommon occurrence, the children with ADHD also were somewhat more likely to think about or attempt suicide as adolescents.

"This study is important in demonstrating that, even during early childhood, ADHD in is seldom transient or unimportant" said study director Benjamin Lahey, Ph.D., a professor of health studies and psychiatry at the University of Chicago. "It reinforces our belief that parents of young children with ADHD should pay close attention to their child's behavior and its consequences and seek treatment to prevent possible long-term problems."

Children with ADHD have trouble paying attention and controlling impulsive behaviors and are often overly active. This can cause poor performance in school, difficulties in social situations, and a loss of confidence and self esteem. The Centers for Disease Control and Prevention estimate that about 4.4 million children, including about four percent of those aged 4 to 6, have ADHD. While many of us hear that there is an "over-diagnosis" of ADHD, in reality there is an under-diagnosis, and many children, adolescents and adults go untreated, either with medications or cognitive therapy.

Most of the earlier studies of the long-term connections between ADHD, depression and suicidal thoughts produced mixed results. The current study benefited from a more comprehensive assessment of depression taking place over a decade, a focus on specific child and family factors that predict which children are most at risk, and consideration of other factors associated with suicidal ideation - suicidal thoughts.

The study was performed by researchers at the University of Chicago and the University of Pittsburgh. It followed 123 children diagnosed with ADHD at age 4 to 6 for up to 14 years, until they reached ages 18 to 20. It compared these diagnosed children with 119 other children from similar neighborhoods and schools, matched for age, sex, and ethnicity. The children were assessed annually in study years 1 through 4, 6 through 9, and 12 through 14. During the course of the study researchers found that 18 percent of children diagnosed early with ADHD suffered from depression as adolescents. That's about 10 times the rate among those without ADHD. They found that children with early ADHD were five times more likely to have considered suicide at least once, and were twice as likely to have made an attempt.

"Suicide attempts were relatively rare, even in the study group," cautioned Lahey. "Parents should keep in mind that more than 80 percent of the children with ADHD did not attempt suicide and no one in this study committed suicide."

"Although the subtypes of ADHD--based on whether they had attention deficit or hyperactivity or both--predict subsequent depression and suicidal thoughts, distinct forms of the disease at age 4 to 6 were moderately predictive for specific problems later on. Children with inattention or combined subtype were at greater risk for depression. Those with combined type or hyperactivity were at greater risk for suicidal thoughts."

"Far more boys that girls suffer from ADHD, but being female increased the risk of depression. Children whose mothers suffered from depression were also at increased risk. Children with more complicated ADHD were most at risk, the authors conclude. Greater numbers of depression, anxiety, oppositional defiant disorder, and conduct disorder symptoms at ages 4 to 6 among children with ADHD robustly predicted risk for depression during adolescence. Children with uncomplicated ADHD with few concurrent symptoms of other disorders were at low risk for depression, but children with many concurrent symptoms were at very high risk."

What does this mean for you and your child or adolescent who you suspect has ADHD? For one thing it means if you suspect ADHD, attention Deficit Hyperactivity Disorder, you need to do more than complete a simple form or self report and obtain a diagnosis and medication. Often, regretfully, that is all that takes place in an MD's office. A "SNAP-4" is given to the parents and the teacher, and after a brief and cursory history 9"Has he been like this for a long time?") a diagnosis is made. I often tell parents we don't "do a diagnosis" but instead engage in a "differential diagnostic process." That means gathering basic information, looking at how the child, adolescent or adult with suspected ADHD presents during the interview (a Mental Status Exam is often the formal means of doing this), collect an extensive history and whenever possible information and observations from a number of people and settings, and complete a battery of tests, self reports and other assessments that RULE OUT other possible causes of the behaviours that are of concern. Remember, there are actually many different possible causes for the behaviours that concern you, and we need to rule out other possible causes and not just jump to a conclusion that ADHD is the cause. Finally, we need to look at a full range of cognitive and academic or workplace results of the behaviour to see exactly how it is affecting the child or yourself. Part of this more in-depth diagnositic procedure includes assessments for depression, mood disorders, neurological disorders, anxiety, autism...all other possible causes and co-morbid (at the same time) conditions. One thing we don't want is to treat ADHD with a medication or treatment that would make another condition w that was masked by the ADHD worse!

So, if your child has ADHD (attention Deficit Hyperactivity Disorder) you also need to be asking yourself, is he or she also depressed? Does he or she have anxiety? Are there specific learning disabilities that also make school difficult? And if my child or adolescent has ADHD what skills did they not learn properly that either I should re-teach or the school should re-teach?

What do we learn from this on-going research? Get a complete evaluation to start.

This study was funded by The National Institutes of Health.

This blog is not offered as medical advice or as a means of diagnosing or treating ADHD or any other disorder. Don't go on line and take an ADHD "test." The diagnosis is complex, and it involves not just looking for symptoms of ADHD, but also ruling out other disorders that might look just like ADHD. 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 that. Medical doctors can diagnose ADHD, but the diagnosis is complex and often they will make a referral to a Registered Psychologist. You can obtain a referral from the British Columbia Psychological Association for a psychologist near you.

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.

Attention Deficit Hyperactivity Disorder (ADHD) 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. This includes neuro-developmental assessments, psycho-education and cognitive behaviour therapy. I also provide diagnostic assessments for autism and Asperger's Disorder in my Burnaby office.

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

Does Time-Out really work for behaviour problems? Especially for children with ADHD, autism, Aspergers or bipolar disorder?

Another parent comes by with tales of woe from attempting to use "Time-Out" to change behaviour. Well, this doesn't surprise me at all. Time Out is a very difficult procedure, and it really isn't designed to do what most people expect: get a new behaviour started. It is especially difficult to use with children with ADHD, autism, Asperger's and other disorders that have a high percentage of problems with executive function.

Time Out is designed to reduce the frequency of a behaviour by reducing the reinforcement it gets. If a behaviour isn't reinforced, eventually it will fade away. The problem with this is that often times we don't do Time Out well, and because we argue, occasionally give in, and sometimes the child simply wins or gets other reinforcement (like attention) Time Out is very hard to do. This is especially true with children with attention deficit hyperactivity disorder, autism or those kids we think of having paediatric bipolar disorder. Even if we do it wrong one time out of five, we are providing what we call "intermittent reinforcement" and the child will become even more difficult to change. Intermittent reinforcement is what keeps people going back to gamble, in spite of the fact they only win occasionally. Face it, if you've watched "Super Nanny" you know she uses Time Out a lot, calling it the "naughty circle." And in every episode she needs to return and retrain the parents.

But eventually things do improve, and that's often because other behaviour techniques are being used that work better for ADHD, autism and bipolar disorder. These include setting up a family visual schedule, which helps reduce anxiety and depersonalizes the parent-child interactions, and there is always a positive reinforcement system (sometimes a token system) being used.

Whatever the inappropriate and unwanted behaviour is, somehow it works for the child. Somehow it is reinforcing. It may not have been at first, but sooner or later something about the behaviour and the response to it is reinforcing. Otherwise the behaviour would have stopped. It's our job to find out what is reinforcing the behaviour, what its "function" is, and teach our children new, more appropriate and functional "replacement behaviours." Behaviours that serve the same function as the original one, but are appropriate. We call this behaviour the FERB or Functionally Equivalent Replacement Behaviour. Every behaviour plan worth it's salt has a FERB. The replacement behaviour is taught, reinforced, and at the same time the inappropriate behaviour is ignored (as much as humanly possible ....we aren't all Super Nanny!). In this way we are teaching a new skill, and ignoring something we want to go away. We also make environmental changes to decrease the need to engage in the inappropriate behaviour (that's the purpose of that visual family schedule).

Notice, we are ignoring, and teaching, but what are we not doing? We aren't punishing. It isn't really a "naughty circle." It's a Time Out space where what your doing doesn't get reinforcement. Punishment is seldom an important component of successful parenting!

A really good book to learn interaction techniques to deal with children who have frequent and excessive temper tantrums is Dr. Ross Green's "The Explosive Child." It teaches you the skill and philosophy behind providing positive behaviour support to your child rather than trying to use punishment, which, you may have noticed, might stop a particular behaviour, but fails in one big way: It doesn't teach new skills!

For more information about child and adolescent parenting you can visit my web page at www.relatedminds.com, or www.adhdhelp.ca or my Psychology Today Website. You can also call my office at 778.998-7975 to make an appointment for a consultation.

Teaching Empathy, an overview.

I am often asked about teaching empathy in the schools. How? Well I suggest different programs depending upon the situation. One is a component of the Anger Replacement Training program from research press, another are materials from Michelle Garcia Winner focused on "social behaviour mapping." There are several, and I'd be more than happy to recommend specific programs for specific schools. But recently I came across this great article from The New York Times that discusses one private school in New York and how they approached it. And the reaction as well! Not everyone likes being taught "empathy" because they don't like being told what to think. But if your teaching it right your not teaching what to think. Programs like Anger Replacement Training instead put an emphasis on the skill of seeing things from the other person's perspective. This is done through exercises and experience. This article is a great overview. Take a look.

Gossip Girls and Boys Get Lessons in Empathy
By WINNIE HU
Published: April 5, 2009
Privileged teenagers at one middle school are learning to empathize this year, whether they like it or not.


http://www.nytimes.com/2009/04/05/education/05empathy.html

ADHD - Medication or not?

I just did a web search for information on treatments for ADHD. I do this every few weeks to check what parents and adults are finding. I was again shocked. Nonsense on food colouring causing ADHD so switching to a new diet will help, sugar causing ADHD. This one is so tiring. Again and again real scientific studies show there is virtually no relationship between any form of sugar and ADHD symptoms. And finally, rant after rant about the evils of medication. This little video with Dr. Russell Barkley addresses that issue and in the next few weeks I am going to try to provide more information in video format as I find it.

ADHD is a life long disorder, and if it is severe enough, and especially if there IS NOT hyperactivity but instead just inattentive behaviour, you need to speak with your medical doctor about medication. As a psychologist one thing I can do is fully assess you for ADHD. And I can give you specific neuropsychological tests that will help us determine what behavioural treatments and skills will help. And finally, if you and your doctor want, we can do repeatable test batteries that measure cognitive changes that happen, or don't happen, as the result of medication. This helps us understand how you are being affected by the medication. For more information on this and other interventions I provide for ADHD / Attention Deficit Hyperactivity Disorder, including an eight week training program for adults, contact me through my web page at www.relatedminds.com

Our offices serve Burnaby, New Westminster, Coquitlam, Maple Ridge, Port Moody and Vancouver.

ADHD: Changing a behaviour? How about teaching a new one instead?

Often parents and teachers approach me with questions about changing, or more specifically, getting rid of, a behaviour that is driving them crazy, disrupting their family or classroom, or maybe even dangerous!

I'd like to start by describing a very formal procedure we use in the schools when dealing with a problematic behaviour, and take it from there.

Sam, an 8 year old boy who becomes upset when given math work often rips it up, hides it, or just starts acting out by disrupting other students. His teacher says he's "just trying to get away with it! He knows he can do it, he just doesn't want to!"

Following the philosophy of Dr. Green, I try to think "kids do well when they can" rather than "kids do well when they want to." And I wonder about why he might not be able to do well. I assume Sam would rather complete the work and get a good grade and bring it home to show his parents. Something is keeping him from doing that. And that's the first of two interventions we are going to engage Sam in. This one we call the environmental intervention. We ask "What allows or causes Sam to engage in this behaviour?" It's tempting to think that more punishment, stricter rules or some other form of control will help, but that is usually not the case. Such interventions, if they would work, would already have worked.  We want to check out the environment and make some decisions. This often includes academic testing. More often than not students object to academic work because it's at the wrong level. Too hard, or maybe too easy. If that's the case we change the work to meet his ability level. That means Sam can do whatever work we give him at about an 85% level of efficiency. We call this his level of "efficacy." It's that point where doing the work is easy enough to not cause stress, but not so easy as to be boring or meaningless. This is especially hard to do in today's classrooms where everyone is suppose to operate at exactly the same level! Even though we know there are hugh developmental differences between students in every class. At any rate, we try to determine what in the environment allows this to happen, or makes it happen. With his math it may be the work is too hard, so we change the work to meet his level of competence. It might also have been he has ADHD and can only focus for 15 minutes before becoming distracted. So, we might set a timer for him to react to and come and get feedback. Or simply shorten the work by making a line that says "get here, see me" so that he comes to the teacher for feedback.  Sometimes a student may get in arguments on the playground because he isn't supervised. What allows his behaviour to happen? A lack of supervision. So we either provide it or we put him in a more successful environment. That's step one. We figure out what environmental changes we need to make to reduce Sam's need to engage in the behaviour. And we mean positive, support based changes.

But that isn't the end of the problem. We need to also understand the specific function of the behaviour to teach a new skill that helps Sam meet that goal next time in an appropriate way. We do what is called a Functional Behaviour Analysis (FBA). We observe Sam and try to figure out WHY he doesn't do his math. What is the function of his behaviour? He makes noises and disrupts to? In this case we determine he does this to avoid work he finds difficult.

Yes, we have changed the work so it's difficulty level is reduced, but step two of changing a behaviour is teaching a new skill that meets the function of the previous behaviour. In this case Sam was avoiding difficult work. Instead of avoiding difficult work by being disruptive we might teach him to ask for help. We could do this any number of different ways. We might start assignments by having Sam look them over and asking one question that will make it easier. We might give him "question tokens" he can use to ask for help, or give him yellow tabs he can attach to any piece of work and use to get rid of the work and complete it at another time with the help of a classroom aide. Every day he gets three stickers he can place on work he is having difficulty with and place it on the teacher's desk. When the aide comes in she takes Sam aside and quickly and painlessly (a key element) helps him get his work done and answers questions.

The key point here is that we are teaching Sam what we call a Functionally Equivalent Replacement Behaviour. Previously, when confronted with something he found hard and difficult, he acted out and disrupted the class. Now when confronted with something he finds hard and difficult he knows how to ask for help. He still is avoiding doing the work alone. But we all do that. Think of how many times a difficult project at your job was given to a committee and divided up. It's an appropriate replacement behaviour. And we can't make the behaviour go away by changing the work and be satisfied, because the real problem was Sam's behavioural response to this kind of situation. Now we have taught him a new skill.

This is how to deal with almost every behaviour of concern. You make environmental changes to reduce the need to engage in it, and then you teach a new functionally equivalent replacement behaviour. For an excellent, complete and FREE set of training materials for yourself or your school you can go to the State of California's PENT (Positive environment Network of Trainers) site. There you will find complete programs for working with children in the schools, for training teachers and for completing a Functional Behaviour Analysis. Their site is located here.

This blog isn;t written to teach you everything you need to know about dealing with school or home behaviours. But I do hope it helps you understand that there is a formal way to look at, understand and intervene in schools. And if your child is having behaviour problems, especially if they are "coded: H or R, ask your school "Where is the FBA?" You want to make sure both of these important components of a behavioural intervention are present.

For more information on children and behavioural issues you can visit my web site at www.relatedminds.com

Dealing with Angry and Explosive Children

There are a number of children who parents, siblings, schools and friends have a difficult time dealing with because of their apparent mood swings, what appears to be angry attitude towards others and often explosive, angry and sometimes aggressive response to requests or instructions.
Sometimes these children are diagnosed with a mood disorder (paediatric bipolar disorder, mood disorder NOS), sometimes with ODD (oppositional defiant disorder) and often with related neurological disorders which might be referred to as NVLD (non-verbal language disorder), high functioning autism, Asperger’s disorder or even a sensory disorder.
Treatment interventions range from simple behavioural programs using reinforcement schedules to the use of visual cues and prompts and medication. While one of the main interventions I teach in my office is a simple 8 part behaviour management program based upon the book Your Defiant Child by Dr. Russell Barkley. However, with certain children there is more to the problem than can be fixed with behavioural interventions in the home. This is especially true because for behavioural interventions to work they must be done in an environment we can control, and finally, besides changing an inappropriate behaviour and replacing it with a new appropriate one, there is often a much more complex task we need to teach- problem solving.
With these children we often use the work of Dr. Ross Green and his “Collaborative Problem Solving” approach. To teach this technique we strongly recommend parents read the book The Explosive Child (available on my web site, go to the home page and click “books recommended by Dr. Roche). We also suggest parents watch the video Parenting the Explosive Child and then practice the skills taught for several weeks under the support and supervision of a trained clinician.
What is the Collaborative Problem Solving approach?
Dr. Green thinks that challenging children have often been poorly understood. All to often their challenging and difficult behaviour is seen as willful and goal oriented. (In spite of the fact it rarely gets them to their goal.) In other words the explosive and angry behaviour is seen as a means to getting attention and coercing people to give in to their demands. In fact, based upon research by Dr. Green and others, the basis of their difficult and explosive behaviour can best be seen as a learning disability or developmental delay in the executive functions of the brain that support flexibility in thinking and frustration tolerance. When the situation calls for the cognitive skills that are part of mental flexivbility (seeing things from the perspective of others) or handling frustration, they have difficulty. They may appear to be choosing to be non-compliant and explosive, but they are making that choice no more than the child who acts out in reading class when the work becomes too hard due to a reading disability.  Dr. Green compares the typical view of these acting out children: “Children do well if they want to,” with the collaborative problem solving approach’s philosophy of, “Children do well if they can.”
How do these children get this way? Is it poor parenting?
There are a number of different factors that leads to this lack of appropriate developmental skills. For some it is a developmental issue. For others it might be a combination of neurological (hard wiring) and neurobiological (chemical) issues. Dr. Green has identified five major areas of deficit that may be at the heart of the problems:1. Executive Function Skills; 2. Language Skills; 3. Emotional Regulation Skills; 4. Social Skills; 5. Cognitive Flexibility Skills. Luckily we have simple and effective ways to evaluate and determine where the child’s weaknesses as well as strength are. This can help us make intervention choices on a day to day basis that begin to address skill deficits rather than just make life more quiet and peaceful temporarily.
That’s a nice philosophy, but how do you make changes in my families day?
The approach Dr. Green and others have developed (actually this is a rather old idea, you can find it in the treatment interventions of the Teaching Family Model at Boy’s Town) is called the Collaborative Problem Solving Approach (CPS). There are three major goals to this approach: 1. Allow adults to pursue expectations; 2. Teach lacking thinking / cognitive skills, and; 3. Reduce meltdowns and angry outbursts.
We do this by first understanding what are called the pathways (skills deficits) that underly the explosive behaviour; decide which plan will be used to handle any specific problem or situation (There are three plans, A,B,C); and then executing some form of plan B to teach the lacking skills. Plan be is the teaching of collaborative problem solving. Teaching your child how to work out a conflict with another person, whether it is another child, adult, teacher or you. Using this plan B is a way to support your child’s lack of executive control. Making up for and supporting your child with a structured interaction that naturally leads to solving problems. What’s in your mind and mouth are the phrases, “Let’s work it out,” and “We worked it out.”
How does this interaction style help control anger and meltdowns?
The plan consists of three steps. First: Empathy and reassurance, then we define the problem, and next there is what is called the invitation. (This process is similar to other interventions taught for working with aggressive individuals such as CPI, the Boy’s Town Teaching Family Interaction, most mediation training, the approach to parenting found in Dr. John Gottman’s book Bringing up Emotionally Intelligent Children and many others. Green, however, has made it simple and emphasized the philosophy behind this positive support approach.) 
Empathy is communicated through reflective listening and letting the child know that “you heard them.” This may sound simple, but we need practice, practice and more practice. This helps the child calm down, and ensures them that their issues are “on the table” and being heard. In a very specific order we ask what is going on with the child, let them know they have been heard, get them to tell us more (this is where language deficits might come in) and give them reassurance (Green says, “I’m not saying no....”)
We then clearly define the problem and invite the child to use problem solving skills to solve our mutual problem. All through the process you are teaching and modelling skills that address the child’s deficits as defined in the pathways assessment. This is a process that takes practice, can often use feedback, and honestly doesn’t guarantee there will be no more blowouts. But it does reduce the risk of them, it increases the chances you will have a pleasant and successful interaction with a usually angrey and easily frustrated child, and it will, over time, teach you child the executive problem solving skills they need to be not just compliant with your commands and requests, but able to negotiate and collaboratively problem solve with others out in the real world.
How long does this process take? And who comes to therapy?
It’s my kid who needs therapy, not me.

Honestly, while in my practice I see your child for an initial evaluation, and then may see them a few more times throughout the process, the most effective and successful way to treat children with anger problems of this magnitude is through education those who they interact with during the majority of their day. This usually means parent meetings and sometimes training and consultation with schools. It’s hard to give a length of time or number of sessions that you can expect. What I can say is that I have divided the process into eight parts, and each week we review some of Green’s work, usually watch and discuss Dr. Gottman’s video or book on emotionally intelligent children and review the basics of parenting skills found in Dr. Barkley’s program. Eight weeks is the usual length of family treatment. We then often meet a month later for a check up and then as needed. (Even Super Nanny comes back to visit!) I’m afraid that many people expect children can see a therapist in their office and play therapy or other interventions will make a dramatic change. There isn’t really any scientifically based proof that this kind of therapy is effective. Your best changes for significant positive change involves everyone, and we need to remember it’s about your relationship with your child.
Final Word
Finally, I want to remind you that there are other techniques and interventions that are effective and may be used in conjunction with collaborative problem solving, and sometimes are more appropriate. These include using visual supports, teaching anxiety reduction skills, using cognitive behaviour therapy through a structured child focused program like “The Incredible Five Point Scale” and positive behavioural supports. Often school is a critical area where we need to intervene. This might include an assessment aimed at “coding” to obtain school based support, conducting a functional behaviour analysis (FBA)  and developing a positive behaviour support plan and the possibility of medical interventions. Whenever there are serious behavioural concerns you should start by visiting your medical doctor for a full check up.
For more information on child  therapy you can visit my website at www.relatedminds.com or www.socialcognitivetherapy.com I have offices in Burnaby (serving New Westminster, Coquitlam, Port Moody and Maple Ridge) and Vancouver, BC.
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