ADHD Part 2

Hmmm… I said I would get back to you (my own ADD / ADHD is currently under control and I actually recalled that I would finish my discussion on ADD / ADHD interventions)… so here it is…

…while not a “magical” treatment or even a “new” healing program (this will not make Oprah or the Early Morning Shows), research also clearly indicates hat behavioral interventions are of significant benefit among children with features of disinhibiiton including ADD / ADHD symptoms. In addition to the previously identified environmental and parental interventions, research suggests that introduction of cognitvive behavior therapy (CBT) interventions have promise particularly among children over the age of about ten years. Great thing about CBT … you don’t need to drop $120,000 on an education to learn or use it!

CBT is a step-wise intervention strategy that includes:

(a) increasing self-observer functions by labeling emotions (ie., “it looks like you are feeling…”) (to assist in articulation of negative emotions)

(b) providing cues/assistance in identification of antecedents or triggers for negative emotions (ie., “when did you begin to feel that way? where were you?, etc.) (to assist in identification of trigger zones or antecedents)

(c) learning to identify that behaviors are choices (ie., “what did you choose to do with those negative emotions?”) (to enhance higher level executive contributions to behavior)

(d) assistance in identification of outcomes (ie., “how did that work out for you?”) (to facilitate self-observation and utilization of feedback)

(e) assistance in recognition of the extent to which outcomes influenced triggers (“did those outcomes change the triggers?”) (to avoid vicious cycles in which behaviors have no impact on the triggers).

Existing research indicates that cognitive-behavioral therapy (CBT) – type interventions are among “what works” among high risk children and adolescents involved in juvenile probation. Parental instruction in the use of these techniques is critical to success because the therapists are the parents. So, finally, you get to do something! In addition to formal programming or therapeutic strategies, avoidance of emotional trigger words including “should”, “why”, “have to” and “try” often proves beneficial. These four words (or phrases) are often viewed as parental words that tend to elicit child responses including oppositionality, aggression, withdrawal, etc. See the old stand-by book I’m OK, You’re OK (Thomas Harris) for an explanation (read chapters 1-7). In lieu of these four curse words, insert choices (ie., what might you choose to do?) and questions (ie., what happened? when did it happen? what could you do?, etc.).

So… tired of waiting for the doctors to make things better? Want to get some control over your life and participate in the development and maturation of your child? Please do not “try” these interventions… but you could choose to implement them.

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Dr. Richard Dowell is a Neuropsychologist located in Pennsylvania. Dr. Dowell evaluates upwards of 400 children and adolescents each year. In addition, Dr. Dowell is recognized as one of the top Forensic Neuropsychological witnesses in the North East.

Dr. Dowell can be contacted at DrDowell@NeuropsychologicalServices.net

For more information on Neuropsychology visit NeuropsychologicalServices.net

The ADHD Bell Curve

“My seven year-old son is inattentive, off-task, distractible and has a short attention span. At home, he hops from one activity to another, never picks up anything … sort of an energizer bunny. The school suggested that we have him tested for ADHD. Does he have ADHD?”

“I was told (I love this one because the person who told them is never identified) that if your child was a climber as a toddler, then they have ADHD, that you can tell true ADHD in a child if he cannot fall asleep at night … if he stays up late.”

My first thought?, to be redundant, the doctors and nurses at the hospital should have told you about these things when you brought the baby home from the hospital. Children are inattention, they do not stay on task, they hop from one activity to another. Toddlers climb and infants are not always great sleepers.

The issue is not whether a child demonstrates or does not demonstrate a specific behavior or problem, but whether the frequency, duration and/or intensity of identified behaviors or problems are within the middle of the bell curve (the norm).

An understanding of the bell curve is critical to the concept of diagnosis. Ever heard of the bell curve? Well, this is what we know; all human performances (what people do) follow the normal bell curve. An example, a few people are fast, a few people are slow, but most people fall within the middle. A few people are strong, a few people are weak, but most people fall within the middle. The bell curve can be graphed as performance (horizontal axis) by the number of people (vertical axis) and when we graph these two factors, the graph looks like a bell with the highest number of people falling in the middle (called the mean) and progressively fewer people as one moves towards the extremes or tails.

The task is not to identify whether your child is inattentive (because we know that he is) but how much does his inattention (performance) differ or deviate from the mean or average child of the same age.

It turns out that not all children who are average fall exactly on the mean so we need to establish a “tape measure” to determine how much a child deviates from the mean. This measure of deviation from the mean (or “gold standard”) is called the standard deviation. About 2/3 children fall within about one standard deviation above or below the mean. This group of children is called the “middle of the bell curve” or average range.

So, does your child have clinically significant features of inattention? It depends on how much his behavior or problems differ from the mean. Behaviors that deviate from the norm by more than two standard deviations (less than about 5% of the children) are generally labeled as having features that are clinically significant or important. While the presence of clinically significant or important features of inattention (more prevalent than about 95% of children) is important to know, it still does not nail down an ADHD diagnosis.

My point? Objective measurements of behaviors or problems with subsequent comparison to age norms (bell curves by age) is the first step in understanding whether a behavior is a clinically significant issue. In the absence of standardized observations and normative comparisons, the diagnostic process boils down to the “mean” and “standard deviation” that that the professional has in his or her head based on clinical experiences. Maybe part of our confusion regarding diagnostic processes is because each clinician develops his or her own norms (means) including normal ranges (standard deviations) without recognition of their inherent bias.

Do your child’s behavior problems fall within the norm? Does your child still drive you crazy even if it’s not clinically significant? Hmmmm…the doctors and nurses should also have told you about that part too!

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Dr. Richard Dowell is a Neuropsychologist located in Pennsylvania. Dr. Dowell evaluates upwards of 400 children and adolescents each year. In addition, Dr. Dowell is recognized as one of the top Forensic Neuropsychological witnesses in the North East.

Dr. Dowell can be contacted at DrDowell@NeuropsychologicalServices.net

For more information on Neuropsychology visit NeuropsychologicalServices.net

Autism Part 2

So, what causes autism? The person who answers that question wins the Nobel Prize in Medicine! Unfortunately, my best guess is that there will not be an answer, but multiple answers since there is no autism, but multiple autism spectrum disorders each of which may have its own unique etiology (cause) and biological features.

The research on the causes of autism appears to bear out this hypothesis. In an article, entitled “Neuropathological Findings in Autism”, (Brain 2004 127(12):2572-2583; doi:10.1093/brain/awh287), that extensively reviewed the research on autism spectrum disorders Saskia J. M. C. Palmen, Herman van Engeland, Patrick R. Hof and Christoph Schmitz conclude that “the majority of the neuropathological data (on autism) remain equivocal” with studies variously relating autism spectrum disorders to: (a) a decrease in the number of Purkinje cells throughout the cerebellar hemispheres without significant gliosis, (b) features of cortical dysgenesis, (c) increased cell packing density of smaller neurons in the limbic system, (d) age-related abnormalities in the cerebellar nuclei and the inferior olive, (e) abnormalities in nicotinic and muscarinic cholinergic neurotransmitters/neurons and (f) abnormalities in the GABAergic system.

While neuroimaging and neuropathology studies have yielded equivocal (and occasionally polar opposite) findings, several functional features of autism spectrum disorders remain constant and implicate involvement of several brain functions.

• Studies have consistently demonstrated abnormal fear (ie., “fight or flight”) responses among individuals with autism spectrum disorders with references to social anxiety, poor eye contact (avoidance), sleep disturbances, obsessive-compulsive features, anger, poor impulse control, depression and paranoia… and these abnormalities in behavior coincide with research showing abnormalities in the size and function of the amygdale which is a relatively small almond-shaped region embedded within the limbic system, the same limbic system that govern “fight or flight” distress responses. This brain (amygdala) – behavior (fight or flight) connection appears to account for a cluster of symptoms/problems associated with autism spectrum disorders. Unfortunately, the cause of amygaloid abnormalities is not clear. While it is possible that the amygdaloid abnormalities reflect a breakdown in the blueprint (genetic/DNA), it remains quite possible that this abnormality is related to a breakdown in other brain regions connected to the amygdala (ie., other regions whose input to the amygdala spurs development). The possible role of a breakdown of the myelinated axons that connect brain regions (ie., limbic-frontal lobe connections) has been suggested.
  
• Research has consistently demonstrated the presence of abnormal sensory gating (ie. inhibition, selection, direction, etc.) among individuals with autism spectrum disorders with references to no pain responses, exaggerated pain responses, needs for deep pressure/touch, avoidance of touch, ear guarding under high stimulation settings, limited visual searches, … and these abnormalities in behavior coincide with research showing abnormalities in the size and function of the thalamus. The thalamus is located deep within the subcortical region and has been described as being the Grand Central Station of the brain with a primary function of routing sensory information (ala passengers) to their appropriate locations. Poor routing may account for sensory over-load along with failure to attend to some relevant stimuli… along with the bizarre symptoms of sensory contamination (see Born on a Blue Day in which the author reports seeing numbers in color). This brain (thalamus) – behavior (sensory routing) connection appears to account for a cluster of symptoms/problems associated with autism spectrum disorders. Unfortunately (does this sound familiar… see the amygdala above) the cause of thalamic abnormalities is not clear. While it is possible that the thalamic abnormalities reflect a breakdown in the blueprint (genetic/DNA), it remains quite possible that this abnormality is related to a breakdown in other brain regions connected to the thalamus (ie., other regions whose input to the thalamus spurs development). The possible role of a breakdown of the myelinated axons that connect brain regions (ie., cortico-thalamic and upper brainstem-thalamic connections) has been suggested.
  
• Research has consistently demonstrated the presence of abnormal social responses among individuals with autism spectrum disorders with references to poor eye contact, limited initiation of reciprocal play, limited attachment/empathy, failure to follow the gaze of others and failures to maintain social relationships… and these abnormalities in behavior coincide with research showing abnormal “mirror neuron” activity. “Mirror neurons” have been named due to the fact that the neurons appear to be activated when an animal performs an action and when the animal observes the same action performed by another animal. These “mirror” neurons have been implicated in observational or social learning, social interest and language development. “Mirror neurons” have been identified within the prefrontal cortex….and the “frontal lobes” tend to function as our executive or coach with functions of organization, planning, use of feedback to adapt/change, observer functions and internalization of social rules. This brain (frontal) – behavior (poor executive function) connection appears to account for a cluster of symptoms/problems associated with autism spectrum disorders… including disorganization (ie., lining up is not organization), poor planning (ie., inability to utilize the future for present decision-making), failure to use feedback (ie., perseverative responses), poor observer functions (ie., difficulties seeing the world through the eyes of others) and deficient internalization of social rules (particularly unwritten rules). Unfortunately (does this sound familiar… are you getting the picture?) the cause of frontal abnormalities is not clear. While it is possible that the frontal abnormalities reflect a breakdown in the blueprint (genetic/DNA), it remains quite possible that this abnormality is related to a breakdown in the myelinated axons that connect the frontal lobe to other brain regions.

So, what causes autism? We do not know but several lines of evidence appear to implicate a disruption in the development of the myelinated axons that connect various brain regions and that there may be a multitude of etiologies or causes that result in this final common pathway and then again, maybe there are simply a variety of etiologies and that our decision to group these disorders into a single category reflects our tunnel vision or narrow view. But the bigger question is…. WHAT DO WE DO? Hmmmm… maybe another time we can start that.

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Dr. Richard Dowell is a Neuropsychologist located in Pennsylvania. Dr. Dowell evaluates upwards of 400 children and adolescents each year. In addition, Dr. Dowell is recognized as one of the top Forensic Neuropsychological witnesses in the North East.

Dr. Dowell can be contacted at DrDowell@NeuropsychologicalServices.net

For more information on Neuropsychology visit NeuropsychologicalServices.net

Autism Part 1

“Our two year-old son is a beautiful boy but we have become concerned. He still does not speak, actually, he doesn’t really look at you when you speak or appear to have any interest in what you say. We had his hearing tested by our physician and nothing appeared wrong. Our son does not initiate play with other children nor does he actually appear to have any interest in his peers. While he is a loving little boy, he does not really hug you back. Someone suggested that we have him tested for autism and we’re scared. Is he autistic? What do we do?”

Autism refers to a neuro (brain) developmental disorder that affects an estimated 1/166 to 1/500 children each year in the United States with an annual growth rate in diagnoses of 10 – 17%. Staggering statistics? Surely, but even more importantly notice the incidence of 1/166 to 1/500. Why the significant range?

I recall being horrified (as a youth) when Dalton Trumbo in Johnny Got His Gun indicted the United States government when he revealed that their own offices could not provide an accurate statistic on the number of soldiers who died in Vietnam, often missing the number by thousands. Were the lives lost so insignificant? I now find myself in a somewhat similar position. Why the significant variability or range in estimates of the incidence of autism? Why doesn’t someone know how many children have autism? Are the children with autism lost and insignificant? Hmmmm…

The answer may lie in the fact that autism is not a thing but rather the diagnosis refers to a constellation of symptoms/problems with a developmental onset or emerging during first three years of life. The diagnostic criteria or symptoms/problems required for the diagnosis of autism reads something like a Chinese Restaurant menu including “A total of six (or more) items from (1), (2) and (3) with at least two from (1), and one each from (2) and (3)”… that should clear everything up. Want to know what criteria (1), (2) and (3) are? Google Autism Disorder DSM.

But what are the core or essential characteristics of autism? Hmmm… the answer is that the symptoms vary as a function of age. What is normal in a one-year old may be abnormal in a four year-old.

• Early signs (during the first 6-12 months of life) of an autism spectrum disorder may include poor eye contact during parent-child interactions, an absence of cooing/babbling, an absence of reciprocal smiling and apparent indifference to others that may include tactile sensory features ranging from recoiling from touch to requirements for swaddling/holding close.
  
• During the 12 – 24 month age range, symptoms of a potential autism spectrum disorder include persistence of early signs along with no attempts to speak with associated gestural communications, limited communicative intent, limited play, repetitive body movements (ie., hand flapping, rocking, etc.), fixation on objects (ie., moving fans, prisms, balls, etc.), resistance to change and a tendency for the child to become overwhelmed in high stimulation settings.
  
• Later (age 24 months+) emerging features of a potential autism spectrum disorder include (in addition to persistence of other symptoms noted previously) a lack of initiation to engage in reciprocal play with peers, limited play, emergence of over-select behaviors (ie., lines up objects, requirements for sameness, etc.) and difficulties following the gaze of others. In addition, emergence of exaggerated fear responses ranging from extreme rage to total indifference (ie., to pain) is often observed.

So, does your child have an autism spectrum disorder? I do not know but I tend to have infinite faith in the gut feelings of mothers. If a mother informs me that she has fears that something may be amiss in the development of her child, I generally believe that something may be wrong. The answer? Sorry if I sound repetitive on this… but… you may wish to consider an evaluation to shed some light on the fears. So, if it is an autism spectrum disorder, what causes it? Hmmmm… let me think about that one (see you next week)…

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Dr. Richard Dowell is a Neuropsychologist located in Pennsylvania. Dr. Dowell evaluates upwards of 400 children and adolescents each year. In addition, Dr. Dowell is recognized as one of the top Forensic Neuropsychological witnesses in the North East.

Dr. Dowell can be contacted at DrDowell@NeuropsychologicalServices.net

For more information on Neuropsychology visit NeuropsychologicalServices.net

HWAT's a Paretn to oD? dyslexia and your Child

“My child cannot read. She’s in second grade and she still reverses letters, omits letters in common words, guesses words when she reads rather than actually reading the words. It’s a constant struggle to get her to read. It takes all evening to get through a book, she gets so frustrated and is constantly in tears and we (her parents) feel horrible. Its not supposed to be like this. We took her to a professional who told us she has dyslexia but, now what?”

Dyslexia simply refers to a disturbance (dys) of reading (lexia). Enlightening, huh? Hope you didn’t pay too much to have it revealed that your daughter has a disturbance in reading (which, by the way, I assume you actually told the professional about two minutes into the interview).

The real challenge is to understand the underlying breakdown in processing that result in dyslexia or a reading disorder.

Reading is like a chain with each link providing its own unique and necessary contribution to reading. While professionals with different educational backgrounds and training may identify some different individual components (or links) that compose reading, most breakdowns of reading indicate links that include:

(a) visual acuity (can the child see)

(b) oculomotor functions (can the child scan a row of letters/words),

(c) visual-perception (can the child recognize and discriminate visual configurations)

(d) auditory acuity (can the child hear)

(e) auditory perception (can the child recognize and discriminate speech sound units)

(f) grapheme (letters) - phoneme (speech sounds) integration (can the child link sounds with letters)

(g) sequential grapheme-phoneme processing of units (can the child read individual words)

(h) sustained attention (can the child keep track of what was read)

(i) storage of data (can the child store a series of words)

(j) linking ideas/themes with words (can the child create mental pictures/images of what the words “say”)

(k) development of a general theme (can the child understand what was intended in the written communication)

(l) development of a response (can the child respond to the written words) and motor programming a response (can the child articulate the words or formulate a motor plan based on what was read)

So… your child has dyslexia? What are you supposed to do? It all depends on the stage at which reading breaks down. A chain is only as strong as the weakest link. Therefore, interventions directed towards “weak links” or components in the reading process are likely to result in the greatest benefits. The first step… complete a comprehensive evaluation of reading components or links. The intervention?… direct or focus interventions on weak links to obtain the greatest benefits or “bang for your buck.”

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Dr. Richard Dowell is a Neuropsychologist located in Pennsylvania. Dr. Dowell evaluates upwards of 400 children and adolescents each year. In addition, Dr. Dowell is recognized as one of the top Forensic Neuropsychological witnesses in the North East.

Dr. Dowell can be contacted at DrDowell@NeuropsychologicalServices.net

For more information on Neuropsychology visit NeuropsychologicalServices.net

Defiant Johnny

“Johnny is oppositional and defiant! He doesn’t listen… and when you tell him “no” or to do something, he explodes… he screams, hits, kicks… he used to bite… but now he generally just throws things and yells at me. We’ve been at this since he could walk (unspoken: “… and we are very tired”). I can’t even leave him at school (the respite center for most parents)… they call a couple times each week with more complaints… he doesn’t stay in his seat, he doesn’t listen, he hits other kids… plays too rough on the playground. He saw a couple counselors but nothing helps.” This scenario, in various terms by various parents, plays out during the initial screening about 200-300 times each year in our clinic (from among 400 referrals). Interesting (to us), but frustrating to the parents, Johnny sits stoically during the recitation of his “crimes” with nary a complaint nor hint of the symptoms that are tearing this parent (and usually family) apart. Occasionally a parent may go so far as to prod the child into a negative response simply to show that they (the parent) are not lying. Other parents support their argument with a recitation of the teachers, service providers, family, etc. that have been ravaged by their child’s behaviors and concluded the ominous diagnostic verdict, “Your child has oppositional defiant disorder.”

A child who is oppositional and defiant has “oppositional defiant disorder?!?” As professionals, we may need to guard the diagnostic secret that all we do is say “disorder” after the child’s symptoms! Given this line of reasoning, secondary diagnoses for this child could include “scream disorder and kick disorder.” Labeling the child’s symptoms as “oppositional defiant” does not advance understanding of the etiology of symptoms nor potential treatment avenues. Unfortunately, this scenario plays out millions of times each day for children across the country with similar conclusions. The primary cost of this labeling approach to diagnoses is that it tends to result in termination of the search for the underlying etiology or cause for the presenting symptoms. The solution… complete an evaluation or assessment to search for factors that may contribute to the symptoms.

Existing research irrespective of diagnosis indicates that outcomes are related to three factors including: (1) abilities (ie., “hardware” or central nervous system-based processing capacities), (2) skills (ie., acquired responses based on the environment including academic skills, daily living skills, social skills, etc.) and (3) coping resources (ie., “software” packages written by a child in response to the world in which they live). Given this background, a logical extension is that failures of positive outcome (ie., oppositional defiant behaviors) must similarly be related to limitations or deficits related to abilities, skills and coping resources.

What about Johnny? Test results showed strengths across measures of verbal (language), perceptual-motor, learning/memory and higher level reasoning abilities. In contrast, deficits were observed across measures of lower level executive or “conductor” functions including: (a) inhibition (b) rhythm/background tone and (c) “select” (ie., multi-tasking, shifting mental sets, etc.) functions. Deficits in inhibition (or disinhibition) were reflected across external stimuli (ie., short attention span, distractible, etc.), motor responses (ie., hyperactive, hurried, fidgeting, messy, etc.), behavior (ie., rule violations), mood/emotions (ie., irritable, anger, temper tantrums, etc.) and arousal level (ie., difficulties falling asleep, constant motion, broken sleep, etc.). Poor rhythm/background tone was reflected in low frustration tolerance and difficulties adapting to change. Deficient “select” functions were reflected in difficulties with respect to multi-tasking (ie., performing two tasks at once or in rapid/alternating succession) with a high frequency of off-task behaviors (ie., failure to complete assignments, requirements for re-direction and difficulties completing assignments on time). The conclusion…. Johnny’s collection of symptoms/problems (his “ODD”) was related to a breakdown in abilities that warranted a similarly biologically-based (central nervous system) intervention program foundation. Research suggests that an estimated 90% of children with this profile (who also meet ADHD criteria) show benefits to psychostimulant medications.

My Lazy Kid

“Teachers have been telling me that my child is lazy and that if only she just worked harder, was more motivated, etc., then she could do very well. We have responded by setting aside daily study times, requiring her to complete all homework before going out to play, providing her with stars for success, taking away all video games and grounding her for poor grades. Our interventions have resulted in study times that take all night, angry outbursts, depression (“I just wish I was dead”), loss of friends, no free time and… poor grades. Help!” The parent saying these words generally looks the part of the beleaguered parent with the wear and tear of endless nights of battles over homework and being the target of child anger being etched in their face.

Hmmm….. First, a quiz. Which would be easier? To put in forty-five minutes of study time, go out and play, be the recipient of parental praise and have extended free time… or… take four hours to complete a homework assignment while having your parents relentlessly harass you, lose privileges, have your videogames taken away, lose friends and have no free time to play? I’m thinking that it would be much easier to just do the work in the shortest amount of time and receive the benefits… and so would every child. Present to each child in school (through about age 12 years) a request that “Who ever wants an “A” in all their classes for this year, just raise your hand” and you will see 100% compliance or agreement. If the ante was raised slightly, “Who ever wants an “A” in all their classes for this year, raise your hand and walk around the track one time (400 meters)” and you may see a slight reduction in compliance. How about “Raise your hand, walk around the track one time and run the 100 yard dash in under 11 seconds” and you will begin to lose some more hands.

The point?…. everyone wants success, but at some point the child may not have the tools to achieve that success. For the child that is working four hours while screaming and crying, losing privileges and enduring parental harassment, these conditions are obviously more readily available than success by studying 45 minutes. I see about 350 children each year… and during the past 20 years, I believe that I have seen about three “lazy” children (and each of these were adolescents with psychopathic features). The rest? The rest were children with undiagnosed learning disorders that have variously included deficits in attention, visual-spatial processing, visual-motor integration, auditory processing disorders… or children that were the victims of significant life stressors, neglect, deprivation, etc. that undermined their capacity to translate abilities into “real world” performance on a consistent basis.

Your child has been labeled “lazy”? Consider the probability that your child has an undiagnosed learning disorder or other stress-related disorder. The solution… consider having a formal evaluation completed to rule out this potential.

Generic Treatment - Sex Offenders are not all Created Equal

I just finished reading a March 6, 2007 New York Times article on adult sex offenders that indicates dismal outcomes (high recidivism or repeat offending) among individuals who participate in sex offender programs. The article appears to relate this failure (in part) to our failure to complete research on treatment programs and effective interventions (when I thought that the major cause of sex offending was due to the presence of perpetrators). Sometimes I feel like a broken record... but my belief is that one of the major problems in the area of sex offender treatment programs is that the programs tend to treat "sex offenders" using "programs". There is not a thing that is a "sex offender"... only individuals who engage in sexually inappropriate behaviors... and a as a result, any “program” that treats sex offenders is bound to be associated with limited results.

About twenty years ago, I had the wonderful opportunity to experience and be mentored by Dr. Jan van Eys in the Dept. of Pediatrics at M.D. Anderson Hospital and Tumor Institute (who mentored everyone who had the good fortune to be near him). During one of our discussions, he indicated that existing treatments for ALL (acute lymphocytic leukemia) were not 60% effective (which is what I recall the literature stated at that time), but that the existing treatment was probably 100% effective for 60% of the children and 0% effective among 40% of the children. Wow… the thought changed my life. The task in cancer treatment… like ADHD treatment… like sex offender interventions… is to learn to identify those individuals who benefit from specific treatments and to develop alternative interventions among individuals who do not respond to specific treatments. The critical factor to this type of undertaking? …perform evaluations that provide data to allow us to differentiate among responders and non-responders for treatment.

My experience with child & adolescent sex offenders has really been enlightening, maybe 30-40% (I'm making up these numbers... but an estimate) are Asperger's Syndrome / Nonverbal Learning Disabled adolescent males who are unable to engage peers in social (or sexual) relationships and, as a result, tend to drop down to engage with younger children (i.e. the 16 year-old Asperger's male who cannot "get" the 16 year-old girl and drops down to engage with 10-12 year old females and proceeds to act out 16 year old sexual behaviors with a 10-12 year old female); another 20-30% may be low IQ - low frontal lobe processing - very disorganized, poor planning, failure to perceive consequences of actions, failure to identify with the victim or see the world from the perspective of others and violations of social rules/norms in the service of personal needs/wants and as a result act out more primitive drives; maybe 30-40% have a history of early sexual experiences and abuse that results in early sexualization, sort of like they "taste" sexual experiences/pleasures before they are in a position to appropriately channel it, they often attach sexual drives to children (since they were sexualized as a child) and subsequently as they become older repeat the attachment. They also tend to internalize or identify with their perpetrators and act out the sexual abuse they experienced. For another maybe 10%, sexual offending is about dominance, same-sex offending to dominate other males. This group tends to have high scores on the Psychopathy Checklist - YV. Generally "scary" to the community… repeat offenders who will use other means of domination including bullying, aggression, threats, etc. While I recognize that children / adolescents who are sexual predators have a high rate of exposure to sexual abuse, this exposure does not affect each child the same. Some become sexual offenders (maybe if they have other risk factors like Asperger's Syndrome, limited frontal lobe processing, etc.) some do not.

I’m not sure about the percentages (above), but in our practice, we have some prototypes that we tend to see as recurring and the interesting fact is that each group (and each child) is different and requires an equally individualized treatment plan that addresses their specific needs. I don't mean to criticize others for classification of all sex offenders in one group, and then embark on my own classification that simply has several groups, but I thought I would share some of my experiences & perceptions (since if I reviewed each individual child that we have seen, this blog would be even more cumbersome than I already have made it). Anyway, I feel like we embark on interventions, treatments or programs for individual children & adolescents before we have completed the evaluation to identify the cause…and the result?… catch the NY Times article… read your own local papers…

Pharmaceutical Guinea Pigs

You enter your physician’s office… once again you are greeted by a smiling nurse that escorts you quickly into an examination room where moments later the physician enters the room. She nods pleasantly and greets you with a smile. You inform her that you are experiencing abdominal pain. The smile does not leave her face as she begins to write vigorously on a prescription pad. After a few minutes, you are greeted with the product of her efforts…. a prescription for gall bladder surgery. You gulp… “Surgery???” you ask imploring a different response, “… but how do you know?… couldn’t it be something different?” Your physician smiles and unveils the explanation, “We have found that statistically speaking, the highest base rate disorder to account for your somatic distress is a gall bladder problem and the definitive treatment for gall bladder problems is surgery… so we’ll do the surgery first… if you still have the symptoms one month after surgery, then we may consider doing some testing.” Ludicrous?!? I hope you are nodding “yes”.

Unfortunately, many parents who present their children to professionals (physicians, psychologists, etc.) with symptoms of inattention and hyperactivity receive psychostimulant therapy since statistically speaking it is the most common childhood disorder associated with inattention and the definitive treatment for inattention is psychostimulants. The parents are subsequently informed that if the child fails the psychostimulant trial (ie., meaning the child develops insomnia, crying spells, shakiness, emotional lability, tremors, tics, etc.), then an evaluation may be considered. Ludicrous?!?! I hope you are still nodding. Managed care organizations (HMO) and insurance carriers support this approach by encouraging treatment of children but denying or limiting insurance coverage for evaluations. In other words, you (the consumer) are actually paying for and supporting the strategy of using medications to rule out or rule in a diagnosis. While the American Medical Association and its various branches decry this strategy, the reality is that medications, and psychostimulants in particular, are commonly used as a tool in diagnosing attention deficit and attention deficit hyperactivity disorders (ie. “Let’s give this a try… if its ADD/ADHD, then the medication will work…”). The Solution… ask “…and what will happen if it does not work?… adverse symptoms? delays in treatment? child perceptions of being a guinea pig. Parents need to be empowered to say “no” to medical testing on their children and request evaluations prior to treatment.

Hmmm… let’s open up the skull and see if there is a tumor or just nothing.

Time: A Marker for Change Part 2

OK… I was not dodging the first part of the last question (even though it may resonate with my life and I would probably feel better dodging it). “My child always did well in elementary school… but since about 5th or 6th grade, his performance has really deteriorated… he is disorganized, does everything at the last minute, makes repeated careless mistakes. I’ve been told that a lot of kids have difficulties at that age due to the transition into middle school along with the hormones kicking in. Is this just a maturity thing? Will it just get better with time?”

The first part… “is this just a maturity thing?”. The answer is most likely “yes”, “no” or “yes and no” (which philosophically-speaking should cover all states of the universe). Helpful? Let me expand. The collection of “coaching” functions including organization, planning, utilization of feedback to adapt responses (along with assumption of an “observer role” to perceive the world through the eyes of others, internalization of social rules and inhibition of lower level emotions), has been related to the frontal lobe. Studies indicate that this frontal lobe or “social” part of each of us shows a trend for progressive development or maturation throughout childhood. Existing social institutions (ala Erik Erikson) have evolved to mirror this maturation process. During the first few years of life, the frontal lobes play a very limited role…ergo the egocentric (“terrible”) under-socialized two year-old tramples social rules in service of self. At about age 3-4, children complete toilet training. Completion of toilet training reflects initiation of frontal lobe processing (and inhibition of lower level behaviors). At about 5-6 years of age, children start kindergarten. Initiation of formal schooling parallels a phase of rapid growth or maturation of the frontal lobes. At about age 12 years, children begin to change classes in school and manage social interactions independently. This time frame corresponds to a phase when the frontal lobe development has progressed beyond 50% development. This frontal lobe development also corresponds with reduced parental input (as the “external hard drive frontal lobes”). At about age 16 years, we (and other drivers) hope that the frontal lobe development has developed to at least about 85% to sustain executive driving skills and by age 21 years of age, frontal lobe processing should approximate the adult level or about 100%.

Children at age 12-13 years show very dramatic differences in rate of growth secondary to hormonally-drive growth spurts. As a result, children in this age range often show dramatic variations in the extent to which the frontal lobes are maturing. Children who are later maturing (with respect to the frontal lobes) often present with features of disorganization (ie., desk, backpack, outlines for writing, study notes, etc.), poor planning (ie., spur of the moment), failure to use feedback to adapt (ie., repeatedly make same mistakes), poor observer functions (ie., difficulties understanding how others may see the world, difficulties with peers, etc.) and limited control of basic emotions with resulting dramatic mood swings, irritability, acting out and rule violations. While “maturity” or growth results in changes, it is the quality of the environment (ie., parenting) that channels the growth into effective processing. Therefore, while maturity may result in positive changes, the positive changes are not a given unless the parents are able to establish and develop a good “frontal” lobe environment that includes: (a) high levels of organization (ie., desk, backpack, room, etc.), (b) high levels of planning (ie., schedule, daily planner, daily study times, etc.) and (c) consistent and predictable feedback (ie., require child to correct tests, study after tests to learn areas of weakness, well-defined rules and consequences, consistent and predictable consequences, etc.). Stability during this stage of instability is critical to positive growth.

Time: A Marker for Change

“My child always did well in elementary school… but since about 5th or 6th grade, his performance has really deteriorated… he is disorganized, does everything at the last minute, makes repeated careless mistakes. I’ve been told that a lot of kids have difficulties at that age due to the transition into middle school along with the hormones kicking in. Is this just a maturity thing? Will it just get better with time?” The last two questions posed by beleaguered parents take on the quality of a hopeful plea.

Last things first. “Will it get better with time?” Check out your garden… some weeds crop up. Will the weeds get better with time? How about the rusty fender on your car… will the rust go away over time? Unfortunately, nothing changes as a result of or due to time. Time is a marker for change, but time actually causes nothing. So, the belief (or perhaps wish) of parents that “time” will make things better is unfortunately not true. What actions you take across time, however, definitely have the potential to make things better. Unfortunately, some actions have the potential to have no effect and some actions have the potential to make things worse. Actions, like treatments, need to address the specific underlying problem or issue. Weeding the garden will enhance the quality of the garden, but has no known effect upon the rust in your car’s fender. Likewise, the actions of trimming away the rusty fender, sanding, painting, etc. may enhance our fender, the garden weeds tend to show limited effect (unless you pour the solvent on the weeds). Getting the point?! An effective intervention (or parental action) must address the underlying problem or issue. The solution… treatments, interventions or parental actions must begin with a comprehensive assessment of the problem and factors contributing to the problem.

My Child is Inattentive and Hyperactive

“My child is inattentive and hyperactive!” I hear this as a presenting complaint about two hundred times each year (from among our clinic’s 400 referrals each year). My first response (after my unspoken… “And?!?!… you had to have been told something about children and this behavior before becoming pregnant?”) is to tell parents that all children (and adults) are inattentive and hyperactive. The question is, “How much does the inattention (or hyperactivity) differ from the norm?”. Einstein aptly informed us that “all is relative” and that a behavior cannot be understood independent of the observer. A parent who exhibits significant symptoms of inattention and hyperactivity may perceive similar child symptoms as the norm. A parent who resides within a chaotic, unpredictable and inconsistent home environment may not recognize features of inattention as a problem. The symptoms defined as the “norm” in one home or “not a problem” in another home may be perceived as disruptive, disabling or catastrophic to the parent whose world corresponds to a Franklin Covey Day Planner. The central role played by the parent (observer) in the diagnostic process is obviously problematic since the presence of a diagnosis is potentially more dependent upon the parent than the child.

The solution to the dilemma introduced by observer bias is the use of standardized tests to assess processing capacities/abilities and deficits/impairments. Standardized tests are measures (or tests) that are presented to children (or adults) using a standardized (consistent, predictable, etc.) method with specific (standardized) instructions to maximize consistency among observers (testers). The diagnostic task is to identify whether the presenting symptoms/complaints (ie., inattention, hyperactivity, etc.) are part of the normal bell curve (within the norm for children the same age) or are outside of the normal bell curve relative to the child’s peers.

All human behavior or performances tend to be normally distributed such a low number of people exhibit a high level of performance, a low number of people exhibit a low level of performance and most people fall in the middle. As an example, a few people are very fast, a few people are very slow, but most people fall in the middle. A few people are very strong, a few people are very weak, but most people fall in the middle. Standardized tests are simply measures of behavior or performance and, as a result, performance on tests is normally distributed with a few children scoring high and low, and a large number of children scoring in the middle. Within the standardized testing method, observations obtained on a single child are compared to this normal bell curve. The task is to identify the extent to which the child’s behavior deviates from the norm. Definitions (often referred to as “cutoff scores”) regarding what constitutes abnormal behavior or the presence of a disorder differ. However, most clinicians tend to classify scores that deviate from the norm by over two standard deviations (ie., observed among less than five percent of children) as abnormal or of sufficient severity to warrant a “disorder” diagnosis.

So… is “my child is inattentive and hyperactive?” The answer is “yes”… and so are you. “Does my child’s inattention and hyperactivity deviate from the norm sufficiently to be an impairment relative to the demands of the normal environment (home or school)?” The answer is “I don’t know” and it is very unlikely that any other single observer will have the answer to that question (including physicians, psychologists, etc. are also biased observers). The solution… complete an evaluation that utilizes standardized measures.

A Dennis the Menace Incarnation

Johnny is a six year-old boy who appears to have missed his calling for the leading role in the remake of “Dennis the Menace”. He is blond-haired with two teeth missing. When I introduce myself, he steps behind his mother allowing one eye to remain trained on me. He follows his mother and me into the office, sits quietly while his legs swing rather quickly under his chair. He tells me that he has no idea why he is here today (although mother swears they had a thirty minute talk about the visit on the trip to the office), but later relents to suggest that his mother wanted him to come here because he doesn’t “listen”. Mother subsequently describes a child history of significant inattention at home that includes not following instructions (ie., he may recall only one step in an instructional set), not attending when she calls him name and becoming overwhelmed in high stimulation (noise) conditions. Mother indicates that problems intensified when Johnny entered kindergarten. In addition, the teacher reports an increase in social withdrawal and limited peer interactions on the playground. However, mother suggests and the kindergarten teacher concurs that perhaps symptoms are due to immaturity. Mother reports that the situation deteriorates in first grade. Johnny is off-task when the teacher is talking, he turns and looks at the papers of other children, he cannot answer questions posed by the teacher, he looks puzzled during class sharing/discussions and he constantly draws or plays with small items in his desk. Mother reports that she took Johnny to see the family physician with a handful of checklists in which the Inattention boxes had been checked by the teacher. Do you know him? Classic ADD, right?

Mother reports that Johnny was started on Strattera (since its not a “stimulant”). After a month of no benefits, the medication is discontinued and replaced with a more potent psychostimulant (fill in the brand name). Mother reports that since taking the psychostimulant, Johnny is restless, has trouble falling asleep and appears to be more “fragile”. Mother indicates that the dose of the medication is increased since the physician suggests that perhaps his symptoms are intensifying in the school setting. Johnny reportedly responds with insomnia, crying, agitation and irritability. Johnny is seen by a counselor who discusses issues of low self esteem with mother. Mother reports feeling overwhelmed and anxious… she is failing her child. Which brings us to today’s clinic visit….

…findings of our comprehensive neuropsychological evaluation reveal that Johnny has a receptive language disorder. While statistics on the frequency or base rate of this disorder are unclear, research suggests that perhaps 4-8% of children with “classic ADD” symptoms may have receptive language disorders. For Johnny, the English language is like a second language (recall taking Spanish in high school?). He cannot decode speech sounds at the rate necessary for comprehension and, as result, he cannot follow instructional sets, cannot comprehend the discussion of the teacher and cannot decode the rapid-fire playground speech of his peers (with resulting social withdrawal). Reading, which is dependent upon integrating speech sounds with letters is labored for Johnny (and no fun) and, as a result, he learns words based on the visual configurations (which appears to reflect “impulsive” guessing). On the playground, Johnny retreats since he cannot keep pace with the conversation rate and slang of his peers.

Application of a symptom-based diagnosis (which Johnny fits all ADD criteria) resulted in termination of the search for the underlying cause with resulting delays in introduction of intervention strategies, social isolation, loss of self-confidence, dislike of reading, treatment using medications for a disorder that he did not “have” and counseling sessions after school. . The solution… demand evaluations that search for the underlying cause while ruling out other alternative or possible causes.

Symptom-based diagnostic models

You enter your physician’s office holding your head from a throbbing headache. The nurse cordially smiles at you and takes you to an examining room. Minutes later (hey… this is my dream… I can keep the wait short)… the physician enters the office. You inform him or her that you have a headache. Your physician gives you a long look, sighs then pronounces the diagnosis “You have a headache disorder!” Nonplussed, huh? Thinking that perhaps its not too late to get your co-payment back?

Unfortunately, each day millions of parents take their child into offices of physicians, psychologists, therapists, etc. proclaiming that their child has a deficit in attention and is hyperactive and are told by well-meaning professionals, “Your children has an attention deficit hyperactivity disorder!” Nonplussed? I hope so. Attention deficit hyperactivity disorder is a symptom-based diagnosis much like a “headache disorder” would be a symptom-based diagnosis. The unfortunate aspect of this scenario is that labeling the symptom (ie., “headache disorder”) does not explain the underlying cause or etiology of the symptom. Headaches are non-specific symptoms and may be related to underlying etiologies ranging from muscle tension, cervical neck strain, migraines, cluster headaches, increased intracranial pressure, hemorrhagic strokes to brain to tumors. As a patient-consumer you (and your physician) want to know the underlying cause of the headache so that subsequent treatment may be directed towards the cause, not simply the symptom, of the headache. Similarly, inattention, distractibility, off-task behaviors, restlessness, etc. are non-specific symptoms. A review of the DSM-IV-TR (Diagnostic and Statistical Manual – IV Text Revision) and other diagnostic manuals reveals that this cluster of symptoms is consistent with multiple diagnoses ranging from anxiety, depression, Tourette’s Syndrome, post-traumatic stress disorder, neurologic disorders, pervasive developmental disorders to learning disabilities.

The unfortunate effects of this symptom-based diagnostic model of “ADHD” include: (a) the simplistic labeling of symptoms (ADHD) with resulting termination of the search for an underlying cause, (b) evaluations that are limited to symptom counting, (c) a delay in the development of effective intervention plans among children with more pervasive developmental disorders or other deficits, (d) utilization of the child’s response to medication as a tool for confirming the accuracy of the diagnosis and (e) the “mis-diagnosis” of children with resulting public perceptions that oftentimes effective medications (ie., psychostimulants) are of no value or counter-productive. The solution… hmmm…

See you next week.

Neuropsychological Services

During the past twenty years, Dr. Dowell has completed neuropsychological evaluations among over 5000 patients. Neuropsychological Services currently completes consultations among over 300 – 400 children/adolescents each year presenting with a variety of symptoms/problems including features of attention deficit hyperactivity disorders (ADHD), learning disabilities, behavioral disorders (ie., oppositional defiant disorder, conduct disorder, etc.), pervasive developmental disabilities (ie., autism, Asperger’s Syndrome), post-traumatic stress disorders, neglect/deprivation, reactive attachment disorders and other adjustment disorders. He has served as a forensic neuropsychological witness within the county and federal court systems throughout Pennsylvania and New Jersey and testified in front of the State Department of Education.

Here Dr. Richard Dowell will share insights to common issues seen within the clinical and forensic neuropsychological arenas. At times humorous, other times a bit sarcastic, examples given are taken from real world experience, with the any names being changed to protect the innocent, and the doctor of course. While certain matters may be shown in a lighthearted manor the illnesses and people suffering from any type of mental or physical pain is not taken lightly.

The intent of Inside Neuropsychology is to open a dialogue between patients and their loved ones and the medical staff serving them. It is also a means to uncover some of the lunacy often common in diagnosis and treatment.