Monday, June 13, 2011
Saturday, May 14, 2011
Monday, April 25, 2011
The Out-of-Sync Child Has Fun, Revised Edition: Activities for Kids with Sensory Processing Disorder
101 Games and Activities for Children With Autism, Asperger’s and Sensory Processing Disorders
Attention Games: 101 Fun, Easy Games That Help Kids Learn To Focus
Early Intervention Games: Fun, Joyful Ways to Develop Social and Motor Skills in Children with Autism Spectrum or Sensory Processing Disorders
photo: Nailia Schwarz
Wednesday, March 9, 2011
J - Will this bring me joy? Real, deep down, happiness? A sense of what Denise calls "well-being"?
photo: eye spot shoot
Thursday, March 3, 2011
There are a number of great technologies out there to assist students and adults with attentional and learning challenges. One of these is speech recognition software. I've been struggling with Dragon on my laptop for a year now. Could have read the manual, I guess. I wanted a "plug and play" experience and this software is just not that simple.
Everything was illuminated yesterday after my consultation with Patty Vaillancourt. I think I get it now, and have some good ideas about how to better implement speech recognition software in my practice.
Patty ("The Dragon Lady") is a training consultant from Manchester, NH. After my time with her I determined that the next time I recommend Dragon software for individuals with ADHD, I'll also recommend some 1:1 time with a really good trainer like Patty!
Sunday, January 23, 2011
For over a decade now, one of the central themes of positive psychology has been the nature of happiness. At first blush it can seem trivial to focus on frivolous emotions. What is the value of happiness?
It may be that good feelings are a worthwhile end goal in themselves. But there are also practical and pragmatic reasons to boost happiness. Barbara Fredrickson’s “Broaden and Build” model of positive emotion suggests that when we are happier we are better problem solvers. We do better thinking when we’re happy. Which leads to better decisions. And better outcomes increase our future happiness. Which leads to better problem solving. And so on.
But what is happiness, really? You can’t show me a cubic yard of it, and I can’t point to it on an MRI of the brain. Sure, it’s a feeling, but what – exactly – does it feel like?
What does dopamine feel like?
Various neurotransmitters are involved in the brain-based phenomena behind “feelings.” Dopamine is one of these. Increasingly, we are coming to understand that dopamine is the neurotransmitter not only of reward but also of motivation. And the phenomenology – the felt experience - of motivation is person - specific. Your feelings of engagement, "flow," and passion are unique to your history, your body, and your neurology.
Typically, if we ask what someone why they persisted with a difficult task, they will identify an end-goal. They wanted the extra money, for example, so they worked an extra shift. Or they wanted to see their partner's expression of delight after they had spent a Saturday morning waxing her car. But behind that in the goal is, in fact, the actual reason that any of us do anything: a feeling, or state.
Nobody wants a hunk of red metal
Nobody wants a red sports car, really. If someone is passionate, driven, or "crazy" about having a particular car, it's because he or she wants what they think they'll feel when they get that car, when they are driving it, or when a specific person or type of person sees them in that car. Some type of feeling state is the actual goal.
No one wants to spend a week on a mound of sand dotted by palm trees. They want what they think they will feel on a Caribbean vacation.
And nobody wants to wrap a measuring tape around his or her waist and come up with a particular number. Rather, we want what we think we will feel in our bodies when we are svelte, healthy, lean, or athletic.
Three of us had a great experience at the Grand Canyon
Imagine that three of us are chatting in the elevator, and one of us brings up the topic of a fantastic experience he had at the Grand Canyon.
It turns out the all three of us have visited the Canyon and, for that reason, we feel that we can say "I know exactly what you mean, I know exactly the experience you had at the Grand Canyon." In fact, we have absolutely no idea what any other person experienced at the Grand Canyon. We don't know what was so great about that, for that person. What made it a reward or motivating or "good."
For one of us, the really great part of the Grand Canyon was the IMAX film at the visitors center several miles south of the canyon itself.
For the second person, the best part of a trip to the Grand Canyon was reconnecting with a romantic partner after a protracted dry dull period in the relationship. In fact, the couple spent so much of the vacation "reconnecting" at the national park lodge that they actually forgot to take a look at the canyon itself.
For the third person in our conversation, the really special feature of her trip to the Grand Canyon was approaching the edge of the canyon and taking in the view for the first time. This experience happened at just the right time for her because some philosophical or spiritual questions had begun to emerge. And something about looking at the vastness of that space seemed to answer some of those essential questions .
For all of us, there was pleasure in our trips to the Grand Canyon. And you could imagine that a similar future trip would be "motivating" for each of us. But the nature of that motivation would be as different as each of our histories, bodies, and neurology.
What’s the one thing you need to do now?
The thing you know you should do but have been putting off. It's that thing you would do if only you had the resources -- the time and money and support. Or it's the commitment our obligation he would take on if you could just find the courage.
When you think about this one important thing, what's the end-goal? How will you feel when you’ve done that?
Beyond rat pellets
When we talk about motivation here, were talking about the common theme of reward or reinforcement. And the types of reinforcers that adults, teenagers, and even children are able to appreciate can be subtle and nuanced.
We are not, then, speaking only of pellets of rat food, or "good job" stickers, or bland verbal praise. We're speaking specifically to that which makes life juicy for you, and for me.
For some of us, there is real reward in being number one, the top of the class. For others, there is real satisfaction in surveying the social landscape and seeing a level playing field, feeling that everyone is equal here.
Motivation can "feel like" comfort, predictability, and sameness for some people. While for others, the feeling-in-the-body of motivation is one of adventure, "wind in my hair," living on the edge.
Behavior modification is hard work
None of this is easy. Whether it is our own behavior, or the behavior of students and clients and loved ones, that we seek to change, this is hard and courageous work.
Our hero in this regard is Odysseus. Knowing in advance what he wanted for himself, and knowing what would be his temptations, he lashed himself to the mast of a ship, so that he would not be tempted by the call of the sirens. It is as though Odysseus were protecting himself from Odysseus.
Likewise, knowing that I'm sluggish and uninspired in the morning, I might place my gym bag near the front door, to protect me from myself. And knowing that what you really want for yourself is a lean and healthy body, you might choose to keep your pantry free of junk food. To protect yourself from yourself.
Lend me your brain
Finally, if you parent or teach or coach young people, you will frequently be in a position to protect them from themselves. The best of that protection is in advance, like Odysseus.
We are, temporarily, the guardians of young people who are not yet cognitively and emotionally capable of making these types of choices. Essentially, we "lend them our brains" until they emerge into neurological, cognitive, and social maturity and begin to take on the Odyssean task themselves.
Tuesday, January 18, 2011
"The best defense against the manipulation of our attention is to determine for ourselves – in advance - how we want to invest it." – Elkhonon Goldberg
What neuropsychologist Goldberg is saying here is that our social and physical environments are full of distractions. Things that distract us from our core tasks. Pull us away from what we know to be the best next thing to do.
There’s a seductive sweetness to not doing that next thing we know is best. But effective time- and self-managers are able to stay in the saddle.
Do, Be, and Have
Some of us are convinced that we are here on the planet to have some set of experiences, or to manifest some fine quality, or to have a particular type of relationship. Here to do and be and have something specific.
And the key that unlocks our motivation – our burning, passionate, nothing-can-stop-me motivation – is to consistently take actions and pursue relationships and make commitments that connect to those core do/be/have’s. And to say no to anything, even very good things, that do not.
As you’ve probably already noticed, time is a limited resource. Whatever it is that I'm here to do and be and have will need to take place in this pretty narrow window of opportunity. World Bank data suggest that life expectancy for children born in the US in 2008 is about 78 years. But if you're reading this I'm guessing that you've got such excellent health habits and are surrounding yourself with such positive people that you've got 85 years in you. That’s 85 years to do what you’re here to do, to experience what is exactly most important. Eighty five years at 365 days each year. Not a lot, really.
But you don’t have 85 anymore. If you’re reading this when you’re 30, for example, we might say you’ve got 55 years still on the clock. So there’s a formula that you might keep tattooed in your memory the next time someone invites you into a 3-year dead-end relationship. Or asks you to exchange a valuable evening for overtime at work when in fact you might need the time more than the money. The formula is this:
(85 – X) x 365
In the formula, “X” equals your current age. Check my math here, but I think that if you’re 40 right now you’ve got about 16,425 days left to do/be/have whatever it is you need to do. And if you’re 28 you’re right at 20,805 days still on the clock.
So if you’re 52 (12,045 days left) how much of that will you allocate to commuting in and out of the city? Watching television shows about people who have too many cats? Talking about how you really ought to join a gym?
The question here is not “what are people in my zip code doing and being and having?” And it’s not “what are my siblings doing”? The core question here is how do I want to inhabit and embody these 12,045 days?
“I’m going to eat all the gum and candy I want!”
When an 8 year old says that when they grow up they’re going to eat all the candy they want, I chirp something like “Oh boy, you betcha! Being an adult is awesome.” What I don’t tell them, because it would be soul-killing, is that being an adult is really hard work.
I do eat all the gum and candy I want. And when I overdo it, I pay for it in my body. One of my fondest dreams as a boy was to be grown up so that I could decide how late I’d stay up at night. And now that I’m an adult, I do. And if I stay up too late I pay for it my emotional and cognitive experience. I don’t feel quite well, and my concentration is off. And my clinical presence with clients suffers.
And there’s no Mom to tell me to go to bed now. Or to stop eating that. Or to turn that off or stop reading that.
Eating just the right amount of gum and candy is hard work. And having just the right amount of small talk at work is a tough call. It bears repeating:
"The best defense against the manipulation of our attention is to determine for ourselves – in advance - how we want to invest it."
Honestly I’ve heard 70 year olds and 35 year olds and 23 year olds express their belief that the best part of their life is behind them. Do you really think high school is as good as it’s gonna get? If you’re old enough to remember the 1980s do you really think that was the high mark?
The best part of your life may be in the part of (85 – X) that still lies ahead.
Ted Williams and Susan Boyle
When we think of individuals who later in life moved squarely into the center of their life mission, the examples frequently offered are Colonel Sanders and Grandma Moses. Sanders was at the front end of fully exploiting the concept of the food franchise. But not until he’d tried lots of other less phenomenal business ideas. And Anna Mary Robertson Moses didn't take up painting, the medium for which she became beloved, until her 70s.
But we’ve got a couple of more recent examples of mid-life moving into something really important or meaningful. As everyone with internet access knows at this point, Susan Boyle was a 47-year old hopeful on Britain's Got Talent when she wowed the judges and the world with her amazing voice.
Ted Williams was a 53 years old, homeless, and unemployed when a YouTube video went viral and helped him re-connect with one of his real gifts, his "golden" announcer's voice.
Like most of us, Susan and Ted haven't enjoyed entirely smooth sailing since their "discoveries." Just like real life, there hasn't been a happy -ever-after for either of them. But both have indicated a commitment to working through their obstacles and sticking with their do/be/have.
So how, specifically, do we “defend ourselves” against the activities and entanglements that would distract us from our core tasks? What specifically does it mean to “decide in advance”?
For me that means setting aside some at the end of each year to consider how I’m doing. Am I doing what I’m really here to do? Do my relationships and commitments reflect my core purpose? Is my mission evident from a review of how I’m stewarding my time?
And before the week starts, it could be valuable to spend some time “determining in advance” how my day to day scheduling is consistent with my do/be/have core tasks.
Finally (and this may be the most important part) we do well to invest some time each morning reviewing our hour by hour tasks and obligations. How exactly does each of these connect to what you most want to express and experience?
So our tools here are:
- real clarity about our core goals and values
- a good daily planner or smartphone app
- a regular commitment to review - hour by hour - our activities in the light of what we know to be most important
Doing this “deciding in advance” work is not just for you, by the way. When you’re really on-purpose, living squarely in the center of your do/be/have, others will benefit as well. If you’ve been around people who are living this type of life you know what I mean, you know how you’ve benefitted from being around that person. There are people in your circle that only you can inspire and affirm. And living your best life is part of that.
photo: beach sand waves
Thursday, January 6, 2011
- an interview,
- behavior observations,
- review of pertinent medical records, and
- collateral report (interview with a roommate, spouse, parent, or teacher).
Would that we had some objective "test"! Such wishful thinking was displayed several months ago, in an article in the New York Times which described a souped-up continuous performance test as a "biomarker for ADHD." An example of a true biomarker would be, for example, specific cerebrospinal fluid protein abnormalities in Alzheimer's disease. Or a positive dexamethasone suppression test in the case of clinical depression. The concept has been extended, in psychiatry, to include cognitive phenotypes in addition to "substances" like proteins.
In the case of, ADHD, however there is in fact no "biomarker." In fact, as a clinical entity ADHD is heterogeneous, with multiple genetic risk factors, multiple environmental risk factors, and a variable clinical presentation.
But how might a continuous performance test, or some other type of neuropsychological indicator, improve upon the interview and clinical history for determining the presence and functional impact of ADHD? Is it recommended to have a complete neuropsychological assessment?
One consideration is the patient's and family’s time. A neuropsychological evaluation requires a greater commitment of time than a briefer office consultation. A second consideration is the considerable expense of neuropsychological evaluation. We want to direct our resources -- time and money -- in the most helpful direction.
There are times when I've committed 8 or 10 hours to a formal neuropsychological evaluation, only to confirm what the client herself, or the client's parents, already know. And in retrospect I wondered if we might have spent those 8 to 10 billable hours in a different way? For example, patient education, spouse education and support, specific parent training, or ADHD coaching supports?
So how do we make this determination, To Test or Not to Test?
My perspective as a clinician who conducts this type of evaluation is threefold:
First, consider the complexity of the clinical presentation. If in addition to attention/focus/impulsivity are there are other clinical concerns? Such as depression or substance abuse or trauma related anxiety, or attachment disorder, or questions about general intellectual functioning? If so, then a complete neuropsychological evaluation may help "tease out" these factors so that we may speak to the specific functional impact of ADHD versus some of these other concerns.
A second consideration comes to mind when I think of the unsavory, but unforgettable, advice of a graduate program supervisor. When it comes to performing psychological testing, there's always the option of yet more evaluation. One more personality test, for example, or one more approach to verbal learning.
My supervisor’s advice was this: "It's like picking your nose - if you find something, where you going to do with it?" And likewise when we are considering a neuropsychological evaluation, we ask ourselves "what will we do with this information?" Practically speaking, how will these test scores facilitate services or treatment or predict success in an academic or vocational setting? What will you do with these data?
In my own practice, I do frequently conduct an abbreviated neuropsychological battery when the referral question is related to ADHD. This battery might include intellectual assessment, academic testing, evaluation of various aspects of memory and learning, as well as targeted evaluation of attention and concentration and focus.
The diagnostic impression of ADHD will not, however, be based on this testing. The diagnosis is offered, again, on the basis of history, clinical interview, and mental status exam.
And what test scores might provide me, over and above that clinical history, is a context. A way of understanding the client and his/her ADHD symptoms as it impacts academic or vocational settings. After confirming an ADHD diagnosis, I am sometimes asked whether or not this 17-year-old will be able to manage the demands of college or university. And I will make use of my test scores to better answer that question. Can a 17-year-old with ADHD reasonably expect college success? If the full scale IQ score is 100 or 110, my response might be “yes.” He can likely manage college coursework if he has a good academic and study skills supports, starts out with one or two college course is to "ease into" the demands of college coursework, lives at home with supportive family for a semester or so before making the transition to dormitory life and campus social life, and if he/she is really motivated and inspired by the particular course of study.
On the other hand, the 17-year-old with ADHD whose IQ score is 85 might find college coursework unmanageable. And the 17-year-old with full scale IQ score of 110, but reading achievement score in the low 80s may find college coursework overly demanding.
So, the additional neuropsychological data provides a context for understanding an individual client and making some useful recommendations her predictions.
A final concern, when it comes to the Test or Not question, is the extent to which a client actually needs my consultative input. Many parents, or adult patients, come to me fairly certain, they have some of the attentional and executive challenges associated with ADHD. And what they need from me is not a confirmation of this diagnostic label but, rather, some specific advice or direction or coaching type support.
In summary, the decision to pursue this type of evaluation will depend on:
- the client's time and financial resources and how best to allocate those,
- the complexity of the clinical presentation,
- the practical "what will you do with this information" consideration, and
- the extent to which you actually need diagnostic confirmation, or on the other hand could benefit from direction and advice.
To test or not to test? What's certain is that there's no need to to suffer the slings and arrows of outrageous fortune. Talk to your doctor or healthcare advisor about your concerns, and decide your next step. You can also contact me at David@DrNowell.com