ADHD - Ain't What It's Cracked Up To Be

There seems to be an onslaught of attention regarding ADHD lately, due to the recent reports of psychopharmaceutical overuse within the foster care system, mixed with the shortage of generic Adderall.  I thought it was a good time to blog about ADHD, and recalled an article I read on the Huffington Post by Dr. Lawrence Diller regarding children, ADHD diagnoses, and prescription medications.  Dr. Diller had been berated for his middle of the road stance, neither advocating meds nor discouraging them.

In general, everyone seems to have an opinion about what causes ADHD.  And for every opinion on the cause, there are ten more on the "solution".  The truth of the matter is there is seldom a blanket answer or quick fix in mental health.  There are mitigating factors to consider such as family history, home and school environment, and past trauma or abuse.  If you combine these complex factors with the daily social demands placed upon us all (adults and kids), an ADHD diagnosis can be confusing and riddled with questions.

There are several strong points made by Dr. Diller, who has eloquently coined the term, “Adderall Wars” to describe our nation’s unique dependency on this drug.  These are a selection of Dr. Diller’s arguments regarding the roots of ADHD.  I chose to list these in particular because I believe they are, outside of the neurobiological reasons, the most impacting and contributing factors of ADHD. 

His arguments include the following: (I’m paraphrasing and will provide a direct link at the end of this blog)

• Poverty, racism, adult violence and substance abuse are the main reasons for all children's mental health problems, including ADHD.

• Class sizes are larger, yet the pressures and expectations are higher.  In 1991, a kindergartner was expected to “sing” the ABCs.  In 2011, that same child would be expected to read and do simple math prior to first grade. 

• The American standard is a two-income family.  Preschool and latch-key are the norm, creating long days for both children and parents.  Managing within the structured bureaucracies of preschool and after-school programs sets up behavioral demands that many children cannot meet.

• ADHD became “official” in 1980 in the DSM-III, making it an easy target for the root of misbehavior or poor performance.

• Pharmaceutical companies, because they are very wealthy, fund research and continuing education within the medical profession.  These companies, in turn, become highly influential. 

• Pharmaceutical companies advertise to physicians first, then parents.  These companies are also offering free samples (vouchers for drugs like Adderall) to physicians. 

• Therapy, when offered to ADHD children, is often individual play therapy, which is not effective for this problem. What works is family/parent oriented counseling for behavioral management strategies and support.

As Dr. Diller noted, many children who struggle with mental health disorders or other mental health challenges come from or live in environments that are less than ideal.  As a society, we are quick to throw on the ADHD label, prescribe meds and call it a day.  However, a child living in a home with an abusive parent is probably going to have problems at school.  To be honest, the source of a child’s behavioral problems can stem from a multitude of sources.    

Think of a time, as an adult, in which you had an argument with your partner and had to go to work.  Perhaps you’ve been through a difficult financial time with the holidays around the corner.  Or maybe you have been the adult victim of abuse, and have attempted to carry on a normal daily life.  As a rational adult, it is difficult to stay focused during these times.  A child who lives in a frenzied, callous, and/or abusive environment falls easy to distraction and disappointment.  This environment may be home, school, the community, or all three. 

The only point I will disagree with Dr. Diller on is the final bullet regarding play therapy.  As a proponent of child-centered play, I do not dispute that behavior management intervention is a likely choice to manage ADHD symptoms.  However, as Dr. Diller indicates, ADHD is typically a result of a deficient environment.  Deficient in these terms can include affection, emotional attachment, love, nurturing, or other essential human needs. In turn, ADHD usually presents as a co-morbid disorder.  For those reading who are not familiar with the term, co-morbid means that the client has ADHD and something else that is clinically significant, such as depression.   

Here’s what I have seen.  When kids have ADHD to the extent that requires medication, it’s usually a no-brainer.  There are noticeable symptoms.  Does that mean the parent/guardian should medicate?  That’s up to the individual and their belief system, finances, ability to monitor, willingness to monitor, child’s health, etc. 

Furthermore, not all ADHD diagnoses are the same.  If the hyperactivity component is missing, you may feel the child is just lazy.  An ADHD diagnosis that falls under the inattentive-type may not garner the same attention as the other two.  Hyperactivity and impulsivity, which are a part of the combined-type and hyperactive-impulsive ADHD, are much more obvious and well, annoying to say the least.

My point is this: the symptoms of ADHD parallel other difficulties or disorders.  Is ADHD real?  In my clinical opinion, yes.  Is it as prevalent as reported?  Probably not. 

I believe it is important to step back and take an objective, and individual, look into the child’s world.  Here are some steps to take as a parent or guardian to help establish a baseline of your child’s behavior, as well as a chance to get to know your child a little better.  

• Take a moment to think about your child’s schedule.  Write it down.  Is it consistent or haphazard?  Is your child getting enough sleep?  How much television is he or she watching?  How much time are you spending in one-on-one interactive play/engagement?

• Talk to your child and your child’s teacher(s) about school.  Do you know what is expected of your child?  The sooner your child knows you are there to help, the better.  Ask to sit in on the class if you are allowed. Go to parent-teacher conferences.

• Talk to your child about bullying, drugs, alcohol, and sex.  All in an age-appropriate manner and provide them with tools to protect themselves.  You also can let you child know that you are there for them to talk to about any of the above, no matter how difficult, and will help them.  If you can’t make this promise, don’t say it.

ADHD can be confusing and scary.  Children with ADHD may exhibit severe aggression, irritability, withdrawal, or many other symptoms.  The decision to put a child on medication for ADHD should be well thought out and monitored closely at home and by the child’s prescribing doctor. 

It’s also important to keep in mind that what you think may be ADHD may be a clue to a different problem.  Sometimes a child may have slight tendencies of ADHD, but a bullying problem serves as a magnifying glass.  As always, the most important act you can do as a parent or guardian is engage, 100%.  No phone, no TV, one-on-one.  Ten minutes a day will create a miracle, I encourage even ten minutes a week to start. 

Link to Dr. Diller post:  http://tinyurl.com/692p48h

Children and Adults with Attention-Deficit/Hyperactivity Disorder: http://www.chadd.org/

Simmering Stew II

I took a mental vacation, but I’m back!

As mentioned in my last post, I want to talk about schema development in my second installment. As a reminder, we ALL have schemas! Some of these are healthy, some are not. The unhealthy ones are referred to as maladaptive. It is important to keep in mind that schemas are core beliefs, they are not behaviors. Behaviors are the coping skills we use as a result of our schemas.

Maladaptive schemas develop early on in life, before our pre-teen years. Typically, the deeper the schema, the earlier it developed, and the more difficult to work through. Since we have all been children at one point in our lives, we can all identify with the ups and downs of youth.

If you’ve read my other posts, you may have noticed my love of metaphors. So as not to disappoint, a maladaptive schema is like a pimple. Sometimes a pimple lingers under the surface, rearing its head under duress, refusing to be ignored. A pimple can fester deep within layers of skin, or it may cause a bothersome blemish. Your skin may glow, your pimple undetectable to the eye. It may stick out like a third eye in the center of your forehead for the world to see. The pimple may be caused and then further developed by a multitude of factors. Genetics, poor habits, stress, etc. However, regardless of our pimple(s), there is an Oxypad for us all.

What, exactly, happens for a maladaptive schema to form? This is simple. A need is not met. A basic, human, necessary, and warranted need is not being met in a child’s early years. A need can be something tangible like shelter or food. But it can be intangible as well. Affection, empathy, safety, and autonomy are all examples of needs.

Dr. Young (as mentioned in the previous post), lists four aspects of need development:

1) Caregivers provide TOO LITTLE of a good thing

· Creates a need for love, understanding, stability

2) Traumatization (Presence of danger or threat)

· Creates a need for safety

3) Caregivers provide TOO MUCH of a good thing

· Realistic limits not set

· Creates a need for autonomy

4) Selective Internalization/Identification with significant others

· Child identifies with/internalizes parent’s thoughts, feelings, behaviors

· Creates a need for identity

However, it is also important to note that temperament is a key factor in schema development. As I stated before, some of us are born with oily skin and pores that feel (at times) visible from outer space. In these situations, it makes it tougher to build a resilience to pimples (maladaptive schemas).

At a young age, and in an emotionally threatening situation, a child will do what he or she needs to do to survive. Since children typically cannot physically escape, they develop coping skills to survive. The type or types of coping skills they use will more than likely depend upon their emotional temperament. Sometimes, a child is more resilient (for numerous reasons, not always by birth) and seems to develop a thicker emotional skin.

I will have to say, resilience should not be mistaken for avoidance or over-compensation. Adults who are resistant to self-exploration, content with surface-level functioning, and/or operate on a one-sided range of emotions are most likely plagued by maladaptive schemas and hurting.

What we are left with as adults are scripts, comfortable patterns that we have followed time and time again, even if at times tormenting us. The way to relieve yourself of your schemas is to proactively fight against it. In my first post about schemas, I shared a link to Dr. Young’s Schema Therapy Page. There you can find the Schema Questionnaire and identify your maladaptive schemas. Dr. Young also lists links to resources regarding maladaptive schemas.

A big step in the process of healing is identifying your schemas. However, recognizing and being cognizant of your everyday triggers is also crucial. If you realize some of your schemas may be severe, talking with a professional therapist may help you make the connection between your childhood and your current life patterns.

Next post will be a less heavy on the head ;) Take care, see you soon!

The Simmering Stew of Schemas

I chose to blog about schemas in this post.  My intentions were to create a two-part segment (perhaps three) with this being the second.  However, schemas kept popping up in both my personal and professional lives, and I’m taking it as a sign.

Schemas are beliefs about how we see ourselves, others, and the world.  They are neither fleeting nor easily altered.  Schemas are entrenched and at times, so inconspicuously interwoven, we cannot comprehend the depths they reach.  Think Jacques Cousteau.  James Earl’s voice.  That deep.

Here are some basics about schemas: 

1)  Everybody has them 

2)  The source of most start very early in life  

3)  There are healthy schemas  

4)  There are unhealthy schemas, a.k.a. maladaptive schemas

Personally, I think of maladaptive schemas as a big pot of gumbo.  Mumbo-jumbo gumbo.  There are emotions, memories, sensations, thoughts, and various other ingredients tossed in throughout our lives.  Our pot of gumbo sits on the stove top, simmering, until someone or something comes along and cranks the dial and turns up the heat.  Whoa! What happened?  Our gumbo is boiling and things are bubbling up to the surface that had floated way down to the bottom of the pot. 

During these times, we notice our schemas, or at least we notice our REACTIONS to our schemas.  However, our pot is always simmering, so what is happening between these bouts of intensity?  How do maladaptive schemas even develop?

Although this may appear bass-akwards, I’m going to briefly address maladaptive schema development.  I’ll cover it more in part two. 

During our childhood and adolescence, we have basic needs.  Food, water, shelter, affection, nurturing, protection, empathy, understanding, safety, and guidance.  Huh? Ahh yes, the emotional needs.  Many adults swear up and down, “I had a great childhood!” because their parents did not abuse them or blatantly abandon them.  At times we realize that a parent was physically there, but emotionally absent.  A child may have been overly protected, controlled, or placed on a pedestal.  Of course, some of us experience severe incidents of trauma or prolonged abuse and neglect that lead to the development of pervasive and/or multiple maladaptive schemas.

Dr. Jeffery Young developed schema therapy, co-authored Reinventing Your Life, and has a website with several tools for practitioners or the general public for self-assessment.  I’ll post a link at the end.  Schema therapy is an offshoot of cognitive-behavioral therapy, and attempts to address the source of our vulnerabilities.  Dr. Young came up with eighteen maladaptive schemas: Abandonment/Instability, Emotional Deprivation, Entitlement/Grandiosity, Defectiveness/ Shame, Subjugation, Unrelenting Standards/Hypercriticalness, Mistrust/Abuse, Self-Sacrifice/Recognition-Seeking, Social Isolation/Alienation, Dependence/Incompetence, Vulnerability to Harm or Illness, Enmeshment/Undeveloped Self, Failure, Insufficient Self-Control/Self-Discipline, Approval Seeking, Negativity/Pessimism, Emotional Inhibition, and Punitiveness.

Although schema therapy is typically used with adults, a recent publication, Counseling Children: Core Issues Approach, applies schema therapy among the child and teen population. 

Okay, let’s check on our simmering pot of mumbo-jumbo gumbo.  Why do we even keep this glob of voodoo on the stove?

Because we are human, and the human species are creatures of comfort.  We hold tight to what we know, even when it is unhealthy.  We seek out, sometimes unknowingly, people who will fit our schemas (healthy and maladaptive), because they allow us to perpetuate our schemas and how we see our self, the world, and others.  Makes you wish you were a dog, doesn’t it?

This is what we do to keep that gumbo simmering.  We distort our thinking.  We choose self-defeating patterns.  We develop unbalanced coping styles.  In regards to coping styles, there are three, following the primitive and well-recognized fight, flight, and freeze response.  In relation to schemas, we overcompensate (fight), avoid (flight), or surrender (freeze).  Some of us prefer one particular style, others like to mix it up, which is especially fun for our partner!  Each coping style presents very differently, but stems from the same maladaptive schema.

Let’s use the emotional deprivation schema as a model.   An emotionally deprived person believes his or her emotional needs will never be met.  With this schema, a self-defeating pattern would include choosing partners who are not emotionally available, giving, or willing.  If using overcompensation to cope, this person resembles someone with the “little man syndrome,” provoking fights with their partner.  They may be emotionally demanding of friends, family, and their partner.  Essentially, this person behaves in the complete opposite of the schema in order to hide or prevent a trigger.

Avoidance appears to be self-explanatory.  Yet many may not realize they are employing this coping style.  Traumas are buried involuntarily.  Using emotional deprivation again, a person may avoid intimate relationships or perhaps use illegal substances to numb thoughts, fears, or feelings.  Avoidance, therefore, can be based cognitively, behaviorally, and/or emotionally.

Lastly, we have the surrender coping style, which parallels the primitive freezing instinct.  This stems from the body’s physiological response of immobilizing under duress, perhaps, for example, standing in front of a saber tooth tiger.  In most instances, you would essentially surrender to the trauma and be eaten.  The same concept applies in modern day reality. 

A person with emotional deprivation who surrenders to his or her schema chooses partners who are incapable of providing for their emotional needs, which only reaffirms his or her belief that emotional needs will never be met.  The person with this coping style never asks anyone to meet his or her basic emotional necessities .

Depending on how strong the particular schema and/or severe the trigger, we may use an onslaught of coping styles.  The older we get, we tend to develop into major league pitchers, honing our skills, coming up with sinkers, curve balls, sliders, and the deadly heater (all coping styles) to throw off batters (healthy/unhealthy partners and/or triggers).

If you managed to get through this lengthy blog without being utterly confused or falling asleep and doing a face plant on your keyboard, congrats!  Here is what is wonderful about schemas:  They are a tremendous tool for self-awareness, provide another means to conduct psychoanalysis on others (if you are into that), and most importantly, will actually help you strengthen your relationships with others.

It is the natural tendency to strive towards healing.  By identifying and developing an awareness of your schema, the battle between self-defeat and healing can begin.  Once you recognize your schema, you can begin the process of discovering where it developed and how it has stewed, bubbled, and boiled over the years.  You begin to notice your reactions to your schemas and in time, begin to separate the reaction from the reality. 

Take the time to learn more about these schemas by visiting Dr. Young’s page.  There is too much information to write about and post on a blog which is not entirely devoted to schema theory.  Yet many have written about maladaptive schemas and his work.  You can find his page HERE

I have also attached the Young Schema Inventory in a separate PDF file on this blog page in the right hand column, along with a scoring guide.

If you would like the link for the inventory for the Young Schema Inventory can be located HERE

Have fun, more to come soon!

Jekyll and Hyde Bullying

Last year, my agency was part of an all day educational seminar at a local middle school, in which community professionals presented on various topics to the students. The topics covered life skills, mental health, and other issues the school administration deemed important.  I was given the task to present on bullying. I would give the same talk 8 times that day. Needless to say, I think I should've had some CEUs on bullying coming my way, but oh well. 

In the initial presentation, I asked the students, by a show of hands, if they had been bullied.  The second time around, it dawned on me, and I followed that question by asking who had also bullied. Every class provided interesting yet similar results.  Students would raise their hands both times. Victim and bully, the same kid. Why would somebody do that to someone when they know the fear, humiliation, and anxiety it can cause? 

Then I came across this article, and it provided some affirmation for what I could only hypothesize. The statistics for the Bully-Victim are astounding. Anyone coming in contact with kids, whether it be as a parent, educator, counselor, what have you, needs to be aware of the family dynamics that could be motivating the behavior. Furthermore, are we aware of the potential safety threat in the home of the bully and Bully-Victim?  Please take the time to read the brief article attached. 

http://tinyurl.com/3bwuaqq

Bully-Victims are: 

• More than 3 times likely to report being physically hurt by a family member

• More than 3 times likely to witness family violence 

• More than 3 times likely to report seriously considering suicide and/or intentionally injuring themselves 

With bullying on the forefront, it's important to look beyond the scope of the individual as well as eliminate the black and white thinking in terms of bully vs. victim. 

Just my 2, maybe 3...cents worth ;)

Do we need a dunce cap?

At what point do we stop playing? I mean really playing? Uninhibited, undeterred, and free. At my agency, we transport most our clients. The pre and post session car ride adds an interesting facet to the therapy session. When we get to the parking lot, several of my little clients look for cars, glance at me, and then race to my car. The glance at me is sometimes a taunt, at others an invitation. "Come play, run, race!" Which I do. However I am not in the moment like this child. And I should be.

Children show us, everyday, how to de-stress.  They paint, write, sing, and create for the pleasure of the creation and the activity. They play for the sake of play, not to burn calories and fat. They dream, simply to discover and enjoy the realm their imagination.  Not to fatten their wallet or plan an agenda.

As adults, we smile at the endearing acts and statements of children, yet dismiss them nonchalantly. We rarely consider the child as a teacher, and we should.  I am adding a link to Adora Svitak, a 12 year old who published a book at age 7.  She spoke at the TED conference, addressing the topic of reciprocal learning between adults and kids.  If you don't agree with me, take her word for it...I mean, how many 12 year olds do you know that go on lecture tours? :)  

http://tinyurl.com/y8s9v2w

 "We kids still dream about perfection. And that's a good thing because in order to make anything a reality, you have to dream about it first."  -Adora Svitak

Facing The Music

"Music expresses that which cannot be put into words and cannot remain silent." 

-Victor Hugo

Music moves us all. It is part of our culture, our history, our own personal vibe. Today's teens will be annoyed with the music of tomorrow. Or at least a few will.  

My teen clients are encouraged to express themselves, to share their music (or anything) with me if they wish.  Some scan YouTube, others plug in their mp3 players. They nod their heads in rhythm, and check for my reaction out of the corner of their eye.  I maintain a "therapist's reaction" most of the time, but sometimes I let them know that the lyrics are tough to take.  Why?  Teens aren't idiots, if you don't react, they'll see right through you.

As a trade off, I also share my music. For many of my female teens, I compile a CD of songs to broaden their perspectives on gender, culture, race, and history.  And because I have a reputation to uphold, I keep the music pretty fresh. ;)

I assign it as homework, have the client listen to the songs, and we discuss the lyrics and their reaction to the music. I keep a copy with me to help the discussion.

This was something I tried to help promote self-worth, as well as increase a sense of history in a specific client. Loved it.  Here are a few of the songs I selected:

I Choose - India Arie

Coal War - Joshua James

Melody - Kate Earl

One Day - Matisyahu

She's Got Her Ticket - Tracy Chapman

I'm Feelin Good - Nina Simone

Shelter - Rolling Stones

It Takes A Village, People!

A short time ago, as I was waiting for one of my younger clients outside the school’s main entrance, I noticed a young boy throwing gang signs to a classmate on the bus.  Being a few feet away, I came up behind him and put my hand on his shoulder.  He was barely to my waist.  He quickly looked up, startled.  “Hey there,” I calmly said.  “C’mon man, there’s no need for that.  You don’t have to get into that kinda stuff.”  I smiled, attempting reassurance.  “It’s okay, you’re not in trouble, but what you’re doing, it’s not alright.”  The boy didn’t know what to say, still caught off guard by my interruption. 

A week or two later, I was telling a few colleagues about the incident.  Being that Rockford is a very low SES and gang-prevalent area, there were comments made (somewhat jokingly) that the boy will have someone come after me as a result. 

However, my reasoning for approaching him was simple.   Regardless of who we are, what we do, and where we live, we all have a stake in our community.   The days of the mom and pop stores are gone, and we no longer have the comfort of community “guardians” to keep us in line.  Classrooms are gaining students.  Parents are overworked and stressed, forced to multitask.   And that is if there are two parents.

As a therapist, I see firsthand the effects these stressors have on our youth.  As a citizen, I too am tempted to point the finger at the parent or guardian.  Or perhaps I should blame the teacher, since most of the children I work with spend the majority of their day in a Title I school.  These are the people who are not passing on the lessons to our youth, right?  Not so fast.

Unless you are a hobbit, or have somehow otherwise managed to avoid civilization, (which of course would make it incredibly odd for you to be reading this blog) then you are indeed a part of a community.  This isn’t about volunteering, which is tremendous and a necessity for the soul (in my opinion), but is about your role, duty, commitment, what have you, as a citizen of your community. 

Don’t get me wrong, I know plenty of people who make a habit of this, and do so on a much greater level than I do.  I am the first to raise my hand and admit that I miss opportunities.  It doesn’t take a monumental effort.  Pick up trash along a street.  Go to a park and shoot a ball around with kids.  Make conversation with people who seem lonely or sad.  For one day, hold the door open for anyone.  Paint over playground graffiti.  Bake some cookies for the homeless shelter.  Swing by the local Boys and Girls Club for some play time.

The youth in your community, your ENTIRE community, regardless of SES, race, ethnicity, beliefs, or culture, are in fact, YOUR youth.   They are a reflection of you.  As though they were your kids, grandkids, nieces/nephews, little sister or brother.  If we start viewing our community in this respect, perhaps we all would be a little more likely to take part.