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Cognitive Behaviour Therapy has become one of the more popular interventions for psychological and mental health conditions. CBT, short for Cognitive Behaviour Therapy, is a structured therapeutic method developed by Albert Ellis (called Rational Emotive Therapy and then Rational Emotive Behaviour Therapy at first) and then refined and researched by Aaron Beck. Cognitive Behaviour Therapy is used to help with relationship problems, anger management, depression, anxiety, panic attacks and pain management.

This most recent bit of research looks at a self-directed cognitive behavioural therapy program for with neurological symptoms of pain, weakness and dizziness, for which there are no clear medical causes.  The self-help therapy was used to address these symptoms, along with some minor coaching.  Using a simple CBT self-help manual, along with a few guidance sessions, there was a noted global improvement 2.36-fold greater than with usual care.  Although the overall health impact faded after the first three months, symptom and physical function improvements remained significant at six months.

While there was some fading of the effectiveness, researchers noted that with more intensive in-office CBT those improvements could be sustained!  One problem is that for symptoms such as pain, weakness and dizziness patients object to a referral for a mental health visit. For more information on this research study go to http://www.medpagetoday.com/Neurology/PainManagement/27828#.TkGY4OrSTi8.blogger More information on my services can be found at http://www.relatedminds.com where you will find my pain management page.

On my Blogger site I address an issue of interest to many: “How extensive does an ADHD or ADD assessment need to be? And why do I need all this other testing? My medical doctor just asked me a few questions and he knew I had ADHD!”

This is a complicated issue, and yes a psychological exam or assessment can be expensive and take a lot of time. But often there are good reasons to go beyond the assessment for ADHD your medical doctor may be providing. This blog addresses these issues. Remember, more than 50% of individuals with ADHD (Attention Deficit Hyperactivity Disorder) have a comorbid disorder. This might include a specific learning disability, depression, anxiety or a mood disorder. In my blog I address each of these. So, take a look and see why I suggest that yes, in some cases a quick screening (we do have suggested standards here in BC/Canada and the “screening” really shouldn’t be too quick) might be OK, but much of the time a more complete assessment that addresses learning problems and other disorders is a good idea.  Remember, 46% of children with ADHD also have a learning disability.

Here’s a link to the blog:

http://adhdvancouver.blogspot.com/2011/07/learning-disabilities-and-other.html

Often parents wonder if their school is actually providing ADHD or ADD accommodations that make sense. Or they ask what accommodations they should consider. Recently there was an extensive newspaper article about research that showed British Columbia, including Vancouver, Burnaby, Coquitlam, Maple ridge, New Westminster and other local school districts were some of the worse when it came to providing support services for students with ADHD. While there are always trainings and supports for students with autism, ASD, Asperger’s, physical and other cognitive deficits, there are very few trainings, consultations or other supports for either the students with ADHD of for their teachers. Check out your school district’s list of training programs on a teacher professional development day. You are very unlikely to find any programs relating to ADHD. (I do many speaking engagements and trainings for autism, Aspeger’s and social cognitive deficits in the Burnaby/Vancouver area, but only one time was I asked for training or consultative support for a student with ADHD.) This seems odd, as these are the students teachers feel are the most difficult for them to support. Speak to your school’s principal and parent association about providing this kind of support.

Here are some common ADHD accommodations. You might want to just print this list off and use it as a check list for your child’s school:

(Environmental Accommodations for ADHD | ADD)

PHYSICAL ARRANGEMENT OF ROOM:
__A. seating student near the teacher
__B. seating student near a positive role model
__C. having the teacher standing near the student when giving directions or presenting lessons
__D. avoiding distracting stimuli (air conditioner, high traffic area, etc.)
__E. increasing the distance between the desks
__F. providing an alternative (but positive) work space for the student to move to to complete tasks

LESSON PRESENTATION:
__A. pairing students to check work
__B. writing key points on the board (always in the same place!)
__C. providing peer tutoring
__D. providing visual aids (schedules, what to do next and what to do first visual lists)
__E. providing peer notetaker who share his or her notes
__F. making sure directions are understood by asking the student to repeat what has been said
__G. including a variety of activities during each lesson, including some that are hands on and physical
__H. breaking longer presentations into shorter segments with clear starts and finishes
__I. using computer assisted instruction
__J. providing written outline before the class
__K. allowing student to digitally record lessons
__L. having student review key points orally with a model if necessary
__M. using a system that clearly asks pivotal questions such as: “What do we need to do first”

ASSIGNMENTS and WORKSHEETS
__A. giving extra time to complete tasks
__B. simplifying complex directions, breaking them into components
__C. handing worksheets out one at a time
__D. reducing the reading level of the assignments
__E. requiring fewer correct responses to achieve grade
__F. allowing student to tape record assignments/homework
__G. providing a structured routine in writing form
__H. providing study skills training/learning strategies
__I. giving frequent short quizzes and avoiding long tests
__J. shortening assignments; breaking work Into smaller segments
__K. allowing typewritten or computer printed assignments
__L. rewarding time on-task rather than task completion
__M. using self-monitoring devices such as visual checklists
__N. reducing or removing the need for homework
__O. not grading handwriting

TEST TAKING
__A. a1lowing open book exams
__B. giving exams orally (ie reading test items to student)
__C. giving take-home tests
__D using more objective items (fewer essay responses)
__E. allowing student to give test answers on tape recorder
__F. giving frequent short quizzes, not long exams

ORGANIZATION
__A. providing peer assistance with organizational skills
__B. assigning volunteer homework buddy
__C. allowing student to have an extra set of books at home (critical!)
__D. sending daily/weekly progress reports home (with an emphasis on positives!)
__E. developing a reward system for in-school work and homework completion
__F. providing student with a homework assignment notebook
__G. additional accommodations:

BEHAVIOURS
__A. praising specific behavioUrs
__B. using self-monitoring strategies (visual if possible)
__C. giving extra privileges and rewards
__D. keeping classroom rules simple and clear
__E. making “prudent use” of negative consequences
__F. allowing for short breaks between assignments
__G. cuing student to stay on task (nonverbal signal)
__H. marking student’s correct answers, not his/her mistakes.
__I. implementing a classroom behavior management system ( a token system)
__J. allowing student time out of seat to run errands, etc.
__K. Ignoring inappropriate behaviors not drastically outside classroom limits
__L. using an individualized token system
__M. allowing legitimate movement
__N. contracting with the student
__O. increasing the immediacy of rewards
__P. implementing time-out procedures

Further information about ADHD | ADD assessment and treatment can be found at my website: http://www.relatedminds.com and http://www.adhdhelp.ca

In this video Russell Barkley, Ph.D., discusses the recent advancements in understanding the nature and subtyping of ADHD. as well as recent discoveries in what might cause the disorder, and medications that might help treat ADHD. This video is from the series: M.I.N.D. Institute Lecture Series on Neurodevelopmental Disorders [11/2008] [Health and Medicine] [Show ID: 14660]

Dr. Barkley talks about a very important issue with ADHD, how the problem is one of future orientation, of planning, or thinking ahead, and how the fact that it is so closely connected with the motor area of the brain (a place we do a lot of planning).

Dr. Barkley also looks carefully at many of the advances in the treatment of ADHD. This includes an interesting discussion of the nature of attention. He reviews the six types of inattention, and how ADHD is about sustained attention or persistence. This type of attention is on the motor side of the brain, while the other types are on the perceptual side of the brain. He discusses how they react to stimuli differently. It is a different kind of distraction of attention from that found in depression or anxiety.

Resistance to distraction is also a key component to the issues of ADHD. But again the problem isn’t on the perceptual side of the brain, while with the child with ADHD it is a deficit on the motor abnormality, rather than perceptual side.

Finally he addresses the problem of holding information in mind  helps us stay focused on the task, to return to the task.

Many clients who have watched this video have found it to answer so many questions they have had about themselves and their behaviour. Understanding these deficits helps you develop a plan for action, and not be overwhelmed by feelings of guilt about what you do.

Great video! Enjoy.

For information on my services for the diagnosis of ADHD and treatment for ADHD refer to my website at: www.relatedmindsbc.com/adhd or www.adhdhelp.ca.  You could also start at my general web page at www.relatedminds.com  My offices are located in both Vancouver (Mt. Pleasant area) and Burnaby (near Coquitlam, Port Moody and Maple Ridge).

ADHD (ADD, or Attention Deficit Hyperactivity Disorder) is a “developmental disorder.” That means it starts early in out development. Not at age 45. More likely before the age of 7, and continued on. Perhaps staying the same, or perhaps changing.

Understand what that means. You had a deficit in a cognitive skill at an early age, say age 4, and because of that you didn’t learn certain skills that others learned, or you may have found a way to compensate for the deficit that made sense at age 5, but doesn’t at age 35. So during your development there were certain skills you missed out on that now you find yourself needing.

Organization and planning are two such skills. People with ADHD have a lot of trouble with both of these skills. How you might have learned them at age 4, 5, 6 or so is very different than how your going to learn them now at age 35.  You may have found ways to deal with these skill deficits, like avoiding, procrastinating or maybe the environment was changed to support you (someone checked your homework every night, and your book bag every afternoon). No one is check when your 35.

You can, however, learn these skills. But you need to set up the environment (home, work and friends) to support you in this endeavour. It’s not an easy one, but not impossible by any means. And with the help of an ADHD therapist or coach, you’ll be able to do it.

Learning to organize and plan usually involves the initial step of developing a visual calendar. This mans a paper an pencil calendar you can look at, change, estimate times from and put in front of you and make an estimate of what you need to do, when, and how long it will take. This is a very different process from using a pda or calendar program on your iphone or computer, and we almost always recommend taking a step back to pencil and paper.

From the calendar we develop a simple visual task list, yes, a to do list. But this list needs to do something special, it needs to help you prioritize tasks. That means every day, if not several times a day, checking your calendar for items on your task list and checking your task list for things on your calendar. THEN learning how to prioritize. There is never enough time for anyone, especially someone with ADHD, to complete everything they need to do (or think they need to do). We usually teach a simple prioritizing skills called A, B, C’s.  Rearranging daily tasks into a list of those that you want to remember, those you need to remember and those you need to do, TODAY.  An excellent source f help in developing this calendar and list is a workbook by Steven Safren and Susan Sprich called Mastering Your Adult ADHD.  I suggest getting this workbook and using it with a friend or coach. There are many variations on this approach for ADHD and organization, one called “the three boxes” and another called 1, 2 and 3! They all follow the same process.

Tips: Don’t try to fix everything. Fix what’s most important  to you. If your not sure what that is, talk with a counsellor, therapist or friend to decide.

Have someone monitor your progress! Just like the teacher checked you got your homework written down, and your mom checked your bag before you left …you need someone to check your doing what you agreed to do. After a period of time (a long time) this process will become a habit. But until then, buddy up with someone who promises to check on you.

The secret to being organized is knowing what drawer, box, list, line, space, place or trash can everything is suppose to go in. That means learning to prioritize …. everything. Identify it, give it a rating and know where it goes.  It isn’t just that you have ADD or ADHD that keeps you from getting everything done. The simple truth is we CAN’T get everything done. Figure out what needed to be done and do that. Then move on!

I provide coaching and treatment ofr ADHd in my office in Vancouver and in Burnaby, serving Burnaby, Port Coquitlam, New Westminster, Port Moody and Coquitlam.

For information on assessment and treatment programs offered by Dr. Jim Roche, a Registered Psychologist in British Columbia, please see his web page at www.relatedmindsbc.com or www.relatedmindsbc.com/autism.

Again a school district wanted to know about social skills training for kids with ASD (actually, Asperger’s Disorder or high functioning autism as some people would call it).This request came three minutes after writing an email to another school psychologist who wanted to know about social skills evaluation programs for students with ASD. I suspect that both these programs are being managed by someone with little or no experience in autism, or any real theoretical background for that matter. Suggesting that ASD students, students on the autism spectrum, need social skills training is clearly a sign they are lost in the mae of terminology or don’t understand the nature of ASD.

Sure, kids with ASD (autism) have some strange social skills at times. They come across in a strange way, and this deficit causes problems between them and staff, other students and even their friends. But the issue isn’t one of social skills. A social skills program (like Skills Streaming by Research press, a GREAT social skills program) simply doesn’t address their deficit.  These students with autism have a deficit of perspective taking. Their problem is seeing things from the other persons point of view. It’s a deficit of social reciprocity.

All the social skills training in the world will not teach your child reciprocity and perspective taking. Often, when working with teens with ASD I get, ” Yeah, but it really doesn’t matter….I did the right thing” as an answer to why they did some behaviour, said some statement  or behaved a certain way in spite of what the social results were.

I’ll just give the the bluntest situation, and one that I hear about a lot. A student passes gas, farts, in class. Then when another student makes a comment he gets in a prolonged argument. ” It’s a natural process…” “I had to do it, everyone does, it’s natural.” Because of the student’s rigidity of thinking and inability to accept the viewpoint of others he ends up socially isolated and often picked on. Social skills training is NOT what this student needs.

Working from the perspective of “social learning” we address this student’s deficit in social reciprocity, in perspective taking. The student needs to understand that his actions cause people to react a certain way, and from observing others we learn to understand how we are doing – socially. Mitchell Winner has a program called “social behaviour mapping” in which we engage the student in a process of understanding how others feels and respond by asking new questions. One set of formal questions we ask is: “Was that an expected behaviour, or unexpected?”  Unexpected behaviours make people anxious, nervous and want to avoid you. Expected behaviours are more familiar, and we don’t avoid those.

Sometimes other processes are used, such as social stories, drawings, mapping out the situation visually. This method of intervention addresses the key deficit that is causing the child difficulty: a lack of social understanding. In a social skills class you are unlikely going to get a student to engage in the social behaviour you want because it simply doesn’t make sense to them. Often they already know the proper social skill, and make the choice not to engage in it because it makes no sense to them. Out job is to teach this skill of social reciprocity.

If your school is trying to put your child with ASD (autism, Asperger’s Disorder of NVLD) into a “social skills” group they are setting your child up for more social failure because they are not addressing the real issue. Perhaps they understand and are using the wrong terms? If that’s so, make sure and correct them. I also don’t want people thinking that children with ASD simply lack social skills …. that often leads to a rejecting and punitive environment.  Check out what your school is up to. And for more information feel free to contact me, or look up the work of Mitchell Winner on the web.

What causes many people with ADHD (Attention Deficit Hyperactivity Disorder) their biggest problems is procrastination. With adults with ADHD procrastination is often the result of what is called “cognitive avoidance.” That is, over time you have learned to deliberately postpone dealing with things because you have found you can more easily focus on them when the deadline has finally come. Pressure = Focus.  There is a second aspect of procrastination that takes on its own life: avoidance = less stress. We avoid things and as soon as we make the decision or take the first step in avoiding them we feel relieved of pressure and anxiety.  As you can imagine, even if you are on medication to help with focus, concentration and impulsivity, these factors are still powerful.

What are some of the management tools we can use? Well these include management tools used for many other aspects of ADHD:

1. Make sure you are implementing plans to help with organization and planning. This includes a working appointment calendar, a working to-do list, a notebook or other visual means of breaking tasks into parts and subtasks, and strategies for developing “action plans.”

Often I hear these things worked, “for a while,” but no longer do.  WELL, MEET WITH YOUR THERAPIST OR A BUDDY AT WORK, A FRIEND OR SOMEONE YOU CAN SPEAK TO ABOUT ADHD AND GET SUPERVISED WEEKLY.

You need external reminders, reinforcement and supervision. Find it and use it.

2. Manage your distractibility. If you have a task to do, and you have ADHD, you most certainly will find something else to do instead.  Use a visual system to keep you on track. I often suggest the following”

Take a sheet of paper or a 3X5 card.  Divide it into three columns. Title them as follows:

STUFF     |    IMPORTANT STUFF    |    TO DO NOW

Keep this list and write stuff you think about, don’t want to forget, and just find interesting in the first column. In column two write the 10 things that you SHOULDN’T forget. No more than 10. Erase and change them as time goes on, but limit them to 10. In the final column write 3-5 things to have to do TODAY. Not tomorrow, not tonight, now! First. Or else. Important!!  3 items are usually enough.

Constantly referring to this external visual prompt of what needs to be done will help keep you on task. Review it with you “supervisor/consultant/coach/friend”  This list isn’t just a list of what’s important, it also helps “put away” items that might distract you, and teaches you to pick out what is salient and important. If you didn’t have a problem picking out what was important (to do) you’d have no problems. This simple, free, easy to use method is critical to avoiding procrastination. What should you be doing right now? Look at column 3! It’s right there.

3. If your getting decent therapy, Cognitive Behaviour Therapy of ADHD, you should be reviewing you “thought records,” reviewing “thinking errors” and constantly creating new balanced thoughts.

4. Think visually! Start writing things down. Write out what you might be gaining by procrastinating. Write out what you have to lose, what the consequences are for procrastinating. Draw a line on a sheet of paper and write these things out.  Answer these questions:

What the FIRST step to completing this task?

How many steps are there to this task?

Have I broken it down into parts I can deal with and finish?

Why should I start now?

Don’t set unreasonable goals. Don’t take on more than you know you can do. Cognitive Behaviour Therapy can also help you understand and alter negative thought processes that are supporting your habit of procrastinating.

Now go back. Look at the three items on your to-do list. The ones marked TO DO NOW.

Do the first one. If you need to write out post it notes with the task written in one or two words and put them on your car dashboard, your fridge, your shirt, your desk. When the task is done, take those stickers and put them somewhere you can start collecting prove that you’re doing what needs to be done, when it needs to be done. And THEN take a break.

For more information on ADHD treatment, especially behavioural and cognitive behavioural training for teens and adults with ADHD check out my web page at either http://www.relatedmindsbc.com/adhd or http://www.adhdhelp.ca

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

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

Now, back to video gaming.

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

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

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

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

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

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