Book Review: Executive Functions by Russell Barkley

“The real scholars were left in almost total freedom to ply their studies and their Games, and no one objected that a good many of their works seemed to bring no immediate benefits to the people or the community and, inevitably, seemed to nonscholars merely luxurious frivolities.” – Herman Hesse, Magister Ludi: The Glass Bead Game

Two summers ago, my family and I went on our annual trip to Acadia National Park and Downeast Maine. One of the highlights was a boat ride on Frenchman’s Bay called Diver Ed’s Dive-In Theater. Anyone planning a trip with their kids to Acadia is well-advised to take this tour. Diver Ed, a marine biologist, and his very engaging, multi-degreed wife (nicknamed Captain Evil) take their boat out to a different, randomly chosen spot on the bay each tour. Once they reach their destination, Diver Ed dons his deep sea diving suit and descends to the ocean floor armed with a sophisticated video camera and a collecting bag. He transmits his video feed to a big  screen on deck and Captain Evil describes the images.

The North Atlantic is lousy with starfish (or, more accurately according to Captain Evil, sea stars) and Diver Ed brought a few back up to the boat. Captain Evil mentioned that sea stars have small eyes at the end of each arm. While it was long thought that all they saw were vague, blurry, monochromatic images, Captain Evil reported that new research has proven that they’re also capable of seeing different colors and that when this was discovered, “the two scientists in the world who study this topic were very excited!”

It is with that last thought in mind that I turn to Russell Barkley’s book from 2012 entitled Executive Functions: What They Are, How They Work, and Why They EvolvedFor those readers unfamiliar with Russell Barkley, he’s a rock star within the world of ADHD and is one of the preeminent thinkers and researchers on that topic. A few years back, I read another book of his, Taking Charge of ADHD  and it greatly expanded my understanding of the disorder. I’ve seen him speak a couple of times and if you can manage to battle through his occasional pomposity, he’s a good speaker. So, it was with a good deal of anticipation that I began reading Executive Functions. Unfortunately, I found the book pretty disappointing.

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In the world of human services, executive function has been a decidedly hot topic for the past few years. Delays in executive function are being implicated in more and more negative outcomes. They’re part of the package of symptoms in people with ADHD, Autism Spectrum Disorders, Anxiety Disorders, and other issues that play a big role in social, academic, and occupational struggles. I’ve got some understanding of the subject but, like many other clinicians, I’ve struggled to put my finger on a good definition and develop a comprehensive understanding. My goal in reading the book was to fill in the gaps with some practical, concrete knowledge. It took over a year for me to read this relatively short (209 pages) book and although it’s provided me with some food for thought, there’s not  enough of what I was looking for to justify the slog.

Dr. Barkley states that his book aims to solve a number of problems related to the “definition, conceptualization, and measurement of EF, including the lack of an evolutionary stance toward its existence.” He goes on to write that “…these problems can be addressed by viewing EF as an extended phenotype – a suite of neuropsychological abilities that create profound effects at a considerable distance and across lengthy time spans from the genotype that initially forms them.” Starting with the idea that EF and Self-Regulation are more or less the same concept, Dr. Barkley describes five levels of the EF Phenotype, starting with the “least evolved” level (Instrumental-Self-Directed) and finishing with the “most evolved” (Strategic-Cooperative Level). With the unfolding of each level, new self-regulation skills emerge, each of which, in turn, lead to the development of different individual abilities, cultural phenomena, and institutions necessary for their maintenance. I found the book’s emphasis on the esoteric topic of the evolutionary view of EF to be largely unsatisfying and unhelpful. To paraphrase Captain Evil, maybe the two other scientists studying this topic are very excited about this book but I can’t imagine who else would be. My dissatisfaction was compounded by Barkley’s dry, technical, and dense writing style. Consider the following passage about  the executive function processes involved in remembering to set an alarm clock:

“Telling yourself to in your own mind using self-speech to set the alarm clock at night is EC (Executive Cognition). Actually setting the alarm clock is an EA (Executive Action). In other words, EF can be bifurcated into EC that involve covert forms of SR (Self-Regulation) and into EA that involve overt forms of SR. The latter is praxeological – that is, concerned with human action. EA may arise from having been chosen, initiated, and sustained by the covert mental level of EC. Henceforth I refer to EF in this broad sense of including both executive cognition and executive actions (EF=EC + EA).” 

Got that? There’s going to be a short quiz in the morning.

To be fair, the further I delved into Executive Functions, the more I began to gain some grudging appreciation for the insights contained in the pages. In particular, I found the descriptions of the distinctions between the Tactical-Reciprocal level of EF and the Strategic-Cooperative level, two of the more “evolved” levels of functioning, to be both insightful and helpful. Both levels  reflect an individual’s appreciation of the idea that pursuing goals with other individuals is a valuable way of advancing everybody’s self-interest. However, the jump from the Tactical-Reciprocal level to the Strategic-Cooperative level, which requires a step up the ladder in terms of self-awareness and foresight, entails an understanding that working with others does not merely constitute an effective way for each person to meet their individual goals. The act of working cooperatively also creates greater total value for everyone. To function at that level requires a high level of self-regulation, foresight, and an awareness that maximizing an outcome for a group will, at times, necessitate some short-term roadblocks to each individual’s self-interest.

In the end, I’d gladly trade the highfalutin’, theoretical approach to EF found in this book for a more engaging, concrete, pragmatic approach. Clearly, I am not the audience that Dr. Barkley was writing for. Somewhere, 2 scientists have found a new favorite book.

Posted in Books, Children, Mental Health, Neuropsychology, Social Skills | Tagged , , | 1 Comment

Making It Up As You Go Along…Or Not

Before I went to graduate school and embarked on a professional career, I flirted with the world of hippie-dom for a few years. I was  captivated by Jack Kerouac’s writing that extolled the life of on-the-road spontaneity and the freedom to “dig” all that was around us. I spent my share of time at Grateful Dead shows, captivated as I was by their “make it up as you go along” ethos, embodied in the lyric Gone are the days we stop to decide…Where we should go – We just ride.” Even though I was never a full-fledged hippie (my wife reminds me that I like showers and air conditioning too much to be a real hippie) I entered the world of human services very much in that mindset.

When I started running my own groups, there were times I’d bring that outlook to bear in the way I structured – or rather, didn’t structure – my groups. Rather than creating an agenda for my group, I’d often go into a session with nothing in mind. My feeling was that I’d try to follow the group’s lead, respond to their moods and preferences, and gently steer the agenda in a productive direction rather than imposing a preconceived program that might not have suited that particular group on that particular day.

I don’t run my groups that way anymore. As anyone who saw the Grateful Dead more than a couple of times can attest, while there were many moments of inspiration and empathic collaboration in the music, there were also plenty of times the music fell flat. Group improvisation doesn’t work too well when musicians, for whatever reason, aren’t in sync with each other during a performance. My groups often devolved to a similar state of listlessness or chaos.

I’ve been thinking about this lately because I’ve seen a lot of articles that have been touting the virtues of unstructured play for kids. Pieces in The Washington Post, Education Week, The Atlantic, and other sources point out the many benefits of stepping back and letting kids figure things out for themselves as they just play. In general, I’m a big supporter of this idea. Some of these articles cite studies that link kids’ participation in unstructured play with the development of executive functions. Aside from the empirical support cited for this association in the articles, it makes a great deal of sense on an intuitive level as well. When kids play with each other and don’t have an adult scripting the experience, they need to address issues of time management, emotional regulation, flexibility, impulse control, and a host of other considerations. And they have fun while they’re doing it, which, after all is said and done, is really the point.

While there’s a lot to recommend about this approach to children’s play, its utility isn’t as universal as we’d hope. Among quirky kids – those with ADHD, Autism Spectrum Disorders, Anxiety, and other associated issues – the benefits gleaned from unstructured play are often overwhelmed by the challenges that come along with it.

If you know a parent of a child with ADHD, go ahead and ask him or her what the most challenging parts of a school day are for their child. It’s a good bet that the answer is going to be one of the following: 1) The school bus, 2) Recess, 3) Lunchtime, or 4) Transitions. What do those times have in common? Those are the times during a typical school day when the structure is minimized or non-existent. Social and behavioral expectations are often loosely implied rather than being clearly and explicitly stated. Adults are not positioned to provide a consistent flow of limit-setting or feedback. Kids who are susceptible to becoming overstimulated, distracted, or impulsive tend to get overwhelmed and lose sight of boundaries. Kids who struggle to read social cues or who may have trouble seeing “the big picture” tend to fall through the cracks when the explicit rules and guidelines they rely upon are taken away. Kids who struggle with perspective taking can lose sight of the fact that their peers may not share their enthusiasm for whatever activity or plan they might have in mind. Rather than seeing unstructured times as being fun and enriching, quirky kids may see them as just another frustrating social experience.

So, what are parents of quirky kids to do? Should they try to help their kids avoid failure and frustration by steering them away from unstructured play? Or should they, in effect, throw their kids to the wolves, figuring that the skills they can gain justify the frustrations and stumbles that go along with it. Neither extreme is all that enticing.

The trick is to find a middle ground where skills can be acquired without self-image being devastated in the process. Success depends on many factors but one of the most important is having a good sense about where to set the bar. In general, the right place is at a height that’s challenging for kids but not so challenging that, with some effort, they can’t get over it most of the time. If the bar is too low, kids don’t learn new skills and often wind up getting bored or complacent. Set it too high and the struggles and frustration involved with getting over it wind up drowning out any new skills that may have been acquired along the way.

There are a number of adaptations that you can use that serve the purpose of adding a little bit of structure or scaffolding to unstructured play. Here are just a few:

1) Don’t leave things entirely open ended. Instead of having the kids fashion their own agenda from scratch, offer them a finite number of choices.

2) Place time limits on the unstructured or open-ended aspect of a play date. Suggest to the kids that they play on their own for a certain period of time before you all do an activity together or you begin to set more specific parameters. Try to monitor things as they progress so minor frustration doesn’t escalate quickly into heavy drama.

3) Talk things through with your child prior to the start of the play. Anticipate the potential pitfalls or problem areas and provide suggestions on how to deal with them.

4) Make adaptations that add some structure to activities that are usually open-ended. For example, if the kids opt for playing with Lego’s, sit down and help them figure out what they’re going to build before they get to it.

5) Establish clear rules or boundaries about what is and what is not permitted. Think about what activities have the potential to escalate quickly into conflict and make sure the kids know that they’re not allowed.

With a few tweaks here and there, it’s possible to help quirky kids experience the fun and benefits that can only be gained from unstructured play. Sharing the exhilaration of making it up as you go along leaves you open to new experience and lets you truly live in the moment. Why should the jam bands have all the fun?

 

 

 

 

 

 

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Talking to 7th Graders About Deflated Balls

This past week, there were news stories in the media about the State of the Union Address, chaos in Yemen, and the death of a king in Saudi Arabia. Here in New England, all those stories played second fiddle to news of our beloved New England Patriots and the deflated football scandal. As the Patriots head to the Super Bowl to face the Seattle Seahawks, the story has shifted away from the relative strengths of the two teams to accusations that the Patriots deliberately under inflated 11 out of 12 footballs in their AFC Championship game against the Indianapolis Colts.

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My relationship with the Patriots has been in flux for the past few years. Prior to 2007, I was an avid fan. I watched every game and listened to sports radio, trying to get all the latest news and insights about a team I loved to watch. The Patriots, led by their brilliant coach and general manager, Bill Bellichik, won 3 Super Bowls by playing tough, smart, innovative football. Their players were often cast-offs who had been released by other teams after injuries or a season or two of sub-par performance. Bellichik saw something in them and they played like they had something to prove. They won a lot of football games. Then in 2007, the Patriots were caught illegally videotaping their opponents’ sideline defensive signals. Bellichik was fined $500,000 and the Patriots lost some draft picks. They also lost my respect. When people asked me if I was still a fan, I said “Let’s put it like this…The Patriots are like an old girlfriend to me. We haven’t broken up but we’re definitely seeing other people.”

Even though the Patriots have been competitive over the last few years, this season was the first one in awhile that I got excited about. They have a really exciting team and they’re playing the Seahawks in the Super Bowl. I have an old friend who lives in Seattle and the trash talking between us started back in the regular season. We were both looking forward to ratcheting things up during the Super Bowl. So “Deflate-gate” has been a big disappointment for me.

To be fair to the Patriots, the league hasn’t issued its report yet so it’s still a little premature to start definitively placing blame. However, despite the press conference protestations to the contrary from Bill Bellichik and star quarterback Tom Brady, it’s hard for me to accept the idea that they didn’t know about it. If the league reports otherwise, I’ll change my tune but their “know-nothing” attitudes during their press conferences….well, let’s just say they didn’t blow me away with their credibility.

On Wednesday of this week, the scandal was really starting to heat up. Each Wednesday I run two groups of 7th graders here at Academy MetroWest. I was really curious to get a sense of what kids in this area were thinking about this whole deal so I brought up the topic towards the end of both groups.

The first thing I have to say about these discussions is that I need to give my guys a world of credit for getting to any substance at all. I read one article about this scandal that said that a lingering news story about deflated balls is making 5th graders out of all of us. Personally, it has definitely brought out my inner Beavis and Butthead (“Heh heh…he said deflated balls….heh heh….). Both of my groups made their share of jokes but also did a great job of grappling with the issue.

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My first group is made up by a bunch of kids who are more sports-oriented than most of my other groups. One group member missed our fall sessions because he was on his school’s football team. I started the discussion by asking a general question about what they made of the whole “Deflate-gate” thing. At first, the boys were staunchly in the Patriots’ corner. They claimed that even if the accusations were true, there’s no way that playing with under inflated footballs for one half of a football game could account for the 38 point margin of victory in the game against the Colts. While I happen to believe that’s true, I pressed them further and asked “So it’s ok to cheat as long as it’s just a little bit?” and “Would your opinion be the same if it were the Colts who cheated their way to a victory?” As the discussion progressed, I watched as even the most stalwart Patriots fans in the group started looking…well…deflated. Sometimes I joke that if I can introduce a little despair and pessimism into the life of just one child each day, I can feel fulfilled. I did my job yesterday.

My second group was even more interesting. For the most part, the boys in that group aren’t big sports fans. Some of them have jumped on the Patriots bandwagon for the playoffs but they’re a quirkier lot than my first group. Some of the comments the kids made were along the same lines as the ones I heard in my first group. But one kid had an observation that I thought was pretty astute and it stood out from the rest. He said that if it turns out that the accusations are true and Coach Bellichik ordered the balls to be deflated, the players ought to be really mad at him because as a coach, he’s showing no faith in their ability to win the game fair and square. I hadn’t thought about that and I think it’s a really great insight.

Again, the league hasn’t put out its report yet and for all I know, Bellichik is going to be exonerated. I hope so but I’m not holding my breath.

To me, the most tiresome argument I’ve heard from Patriots fans since Spygate has been that the Patriots and their cheating aren’t so bad because everyone does it. Maybe everyone does cheat but it’s the Patriots who keep getting caught. I talk to kids in my groups about cheating a lot because, as I’ve written in the past, kids with social skills delays tend to be really bad at it. I tell them that most kids, at one point or another, cheat and get away with it. I even tell them that I did it from time to time when I was a kid. While it’s not a great thing to do, it’s pretty common and if you’re smart about it, you can get away with it sometimes. But for kids (or football teams) who keep getting caught, one of two bad things is going on. They’re either cheating very poorly or they’re cheating way too often. In either case, it’s self-defeating. Authority figures are going to be extra vigilant  and you’re going to make yourself look kind of sleazy and a little dim. In the Patriots case, it just makes them look arrogant.

So, I’m anxiously awaiting the NFL’s report. If it turns out that this is just a big misunderstanding, I’ll be happy. I’ll root wholeheartedly for them in the Super Bowl. I cheer them on and yell some vile obscenities at the Seahawks like a true football fan should. On the other hand, if it turns out that the deflated balls came about from an order from on high, then I think it will be time for me to break up with the Patriots for good.

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Book Review: Parenting Without Panic

A few years ago, a couple of teenage boys I was working with asked me a question that must be on the mind of many an adolescent: “Bruce…is bastard a swear word?” I answered that it depends on the context in which it’s used, whereupon one of my young charges replied “Screw context! What the hell has it ever done for us?!?!”

An apt question.

Context is a word that comes up often in the world of Autism. Among the reasons for this is the trouble that people on the spectrum have in the area of central coherence or, more colloquially, seeing the big picture. It can be challenging for many of them to recognize factors such as time and place, nuance, non-verbal cues, and the like, and then adjust their behavior efficiently and intuitively. Context also plays a role in the way most non-Autistic people, or neurotypicals, view the behavior of people on the spectrum. Without any context, that behavior is often seen as being odd, rigid, or obnoxious. That’s a particularly troubling dynamic when the Autistic person in question is a child and the neurotypical person is that child’s parent.

Fortunately, a book published last year can help provide that context. Entitled Parenting Without Panic: A Pocket Support Group for Parents of Children and Teens on the Autism Spectrumthis book provides a helpful lens through which parents of kids on the spectrum can view their children’s behavior. The author, Brenda Dater, is the Director of Child and Teen Services at The Asperger/Autism Network, a wonderful organization located in Watertown, MA that provides services, referrals, and extensive information to families and professionals all over New England. She is also the mother of 3 children, one of whom is diagnosed with Asperger’s Syndrome and another who is diagnosed with ADHD and Generalized Anxiety Disorder. In her book, Ms. Dater brings insight gleaned from both her personal and professional experiences to provide more context and credibility than would be available through just one of those perspectives.

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In the opening chapter, Ms. Dater claims that she wrote the book with the goal of providing the same type of support and information obtained by parents who have attended “topic nights” at AANE. She writes:

Topic nights cover the concerns that parents voice most frequently. Parents often feel anxious as they speculate about their child’s opportunities to make friends. They wonder how to talk with their child about his diagnosis…At topic nights, we begin by taking the pulse of the group to hear about the most pressing concerns.  Once we have a better sense of the specific questions and trepidations surrounding any given topic, we explain why the challenges exist and offer practical strategies…Parents leave feeling understood, validated and better informed.”

Parenting Without Panic covers the issues that parents of kids on the spectrum deal with every day, including behavior, social skills, homework and school issues, relationships with immediate and extended family members, and others.  Throughout the book, Ms. Dater’s writing reflects her considerable professional expertise as well as the wisdom and authority that can only be gained through the day-in/day-out, 24/7  gestalt of parenthood. Parenting Without Panic is suffused with stories and scenarios that will elicit knowing smiles (or cringes) from the reader that makes the book ring true and feel very real.

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Brenda Dater discusses Parenting Without Panic at a December workshop at Academy MetroWest.

Though all the chapters in Parenting Without Panic were valuable, I found the chapter on behavior to be the most compelling. This section offers examples of problematic behaviors described at different AANE topics nights that left group members feeling particularly frustrated or mystified. Ms. Dater, to her credit, stops short of attributing a specific cause to any given behavior but rather responds to each example with the exhortation for the reader to consider factors such as emotional regulation, anxiety, sensory regulation, flexibility, and others. The chapter, and the book as a whole, is thought out and fleshed out in a way that offers parents enough of the right information without overwhelming them with too much information.

Parenting Without Panic is an excellent resource for parents of kids on the spectrum as well as for anyone else who comes in regular contact with this group of children. It can be an indispensable “User’s Guide” and parents may find themselves reading it over and over again in order to help get a better read on their kids’ behavior. Pick up a copy and you can stop wondering what a little context has ever done for you!

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Buddha Granofsky and MVI Talk About Ferguson

In 1988, I was a first year graduate student in the Counseling Psychology program at Tufts. I did my internship that year at The Academy of Physical and Social Development in Newton. The choice to do my internship there had more to do with the fact that it was accessible by public transportation than anything else. Call it karma or call it luck but it couldn’t possibly have been a better fit for me. 26 years later, my current practice is an offshoot of that one.

After finishing my groups one night, I caught a ride home with my supervisor, Dr. John Cloninger. We started talking about psychotherapy and I tried to pick his brains about what he felt were the mechanisms at work in helping people to change. We spoke about a good friend of mine who was really struggling. She and her siblings suffered through chronic physical abuse from their parents when they were kids. My friend was the only one who came through relatively unscathed. She was in medical school while her brothers were both battling severe mental illness. As you can imagine, she carried a lot of emotional baggage and I asked John how a therapist would even begin to work with her. How does a person who carries that around with her continue to honor and care for her brothers and tend to her own emotional well-being at the same time she’s trying to enter a very demanding field? John gave me some very considered answers but finished by saying “With your friend or with anyone else, Bruce…the most important thing you can do for them is to just listen.”

He was right. And not just about psychotherapy.

I’m thinking about this today because of a Facebook exchange I had yesterday with my old friend Charlie. Charlie has had a bigger influence on me and the career choices I’ve made than just about anyone I know, other than my parents. I met him in 1982 when I was a freshman at Hofstra University. He was a sophomore and was taking the same Adolescent Psych. class that I was. I was walking across campus one day when Charlie, a loud, large, African-American dude, stopped me and said “Hey – you’re in my Adolescent Psych. class and I’ve noticed you’ve asked some interesting questions. I’m wondering if you’d be interested in an organization I work for.” He told me about Student Outreach, Hofstra’s Crisis Intervention Center. I came down to the office to check it out and decided to train to become a counselor there. Outreach was founded in the 70’s in response to the increase in drug overdoses on campus but it continued on to help students through just about any type of crisis imaginable on a college campus – from relationship problems to suicide. I was an Outreach counselor for 3 years, co-directing it for 2. I learned a lot about people and their issues working there and continue to draw on those experiences all the time.

I also got to be very good friends with Charlie. Charlie was one of those guys who was interested in everything. He had been a standout football player in Queens as a teenager but was also a wonderful musician (his song “Am I Really Deep or Am I Just a Schmuck?” is one of the funniest things I’ve ever heard and I still remember all the words…well, most of them anyway) and student. One day he was talking to another Outreach counselor about his interest in Buddhism shortly after expressing his deep admiration for one of our psych. professors. The other counselor said “Listen to you!…Freakin’ Buddha Granofsky!” That’s how I still think of Charlie.

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This is a picture of Charlie from back in the day. I’m not sure what he’s singing here but I’d like to think it’s his immortal classic “Am I Really Deep or Am I Just a Schmuck?”

I got my Outreach nickname – MVI, or Most Valuable Intern, from the Samuel Shem satire about modern medicine called The House of GodIt’s kind of a Catch-22 style novel about young doctors. You should read it. It’s funny.

Anyway, when Charlie graduated, we gradually drifted apart but I tracked him down about 15 years ago. To say that he had changed a bit from our college days is a vast understatement. In college, alongside his intellectual gifts and undeniable charisma, Charlie could come across as being on the hedonistic side and he was, if nothing else, a free-thinking iconoclast. When I tracked him down in the late 90’s, he told me that he had become a born-again Christian and was an ordained minister working for the Salvation Army. As a secular Jew who skews to the political left, I was a little worried that my old friend and I might not have much in common anymore. On the other hand, I knew that even though his career path might not be the one I would have predicted, he was undoubtedly doing great work with some of society’s neediest people.

Since Facebook has come along, Charlie and I have been in much more frequent contact. We both try to limit our posts about politics but it’s fair to say that we disagree on almost everything in that realm. Charlie is part of that rare breed that the GOP clamors for – a conservative, evangelical, African-American man. Judging by the demographics from the last election, the Democrats are probably salivating for more people like me, a middle-aged white guy, as well. Occasionally, both of us post about politics. Generally, we respect each other’s intellect and heart but we almost always disagree. For the most part, even when Charlie posts something I disagree with, I try not to join in, given the tendency of political threads on Facebook to degenerate quickly into ugliness and vitriol. Yesterday, he posted about the events in Ferguson and I couldn’t stop myself from responding.

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This is the 2014 version of Charlie

It’s not my intention here to make this a conversation about who’s to blame for Michael Brown’s death or whether or not rioting is the appropriate response to it. It’s a tragedy when an 18 year old is shot and killed. As for the rioting, I think Martin Luther King’s comments about the riots of the late 60’s got it right:

“I think we’ve got to see that a riot is the language of the unheard and what is it that America has failed to hear? It has failed to hear the economic plight of the Negro poor which has worsened over the last few years.”

But then he went on to say:

“Riots are self defeating and socially destructive.” 

Here’s what Charlie had to say about Ferguson on Facebook:

“It was a crazy night last night. Ferguson was again on fire. What did those small business owners do to Michael Brown? How ludicrous it was to see POTUS call for tranquility while Ferguson burned! Michael Brown was a kid who made a stupid choice to rob a convenience store. Stupid. He’s dead because he was stupid. Michael Brown will not, nor can he ever, be considered a civil rights hero.”

When I read it, my first reaction was one of shock that my friend seemed to be chalking this whole thing up to President Obama and a convenience store. My first comment on his thread reflected that shock. Charlie quickly clarified that it wasn’t his intention to blame the President for this and that he recognized that the issue went beyond one kid and his fatal interaction with a police officer. We got into a great private exchange. Charlie focused on how the riots are ultimately self-defeating in the way they destroy the community’s economic base,  the most obvious means that community has for improving its circumstances. In my responses, I recognized the irony of trying to speak with any authority about Michael Brown and urban riots to an African-American man who ministers to his area’s most vulnerable citizens. But I tried to make the point that even if it’s not an entirely rational response, rioting may be seen as the only one available by people who understandably viewed the lack of an indictment as a societal sanction for killing unarmed black teenagers.

Eventually, Charlie and I wound up coming pretty close to agreement. Even before we took our conversation private, he posted this:

“Bruce, I don’t blame POTUS for this, it was simply Chekhovian to see him on the split screen. Brown’s problems and society’s (by extension) are far greater than a convenience store robbery. It was just dumb. Dumb for a kid to steal, dumb for a kid to die over it. Senseless, just as the looting is, and I’m pissed about it. And I am willing to do something about it, beyond long-range criticism.”

And I know that he really is willing to do something about it. Charlie has always been one to put his money where his mouth is. Regardless of our political differences, I would never deny that his love, energy, commitment, and empathy are indomitable forces for change.

In the end, I come back to my old supervisor’s observation that the most important thing we can do is listen. We don’t always have to agree. But the more we listen to each other with real respect, the more we’re likely to learn that our differences are much smaller than our common bonds. Charlie and I have a deep, abiding respect for each other. It would have been very easy for us to lock ourselves into knee-jerk, ideological arguments over this issue. Just watch CNN, Fox, or MSNBC to see how easy that is. Prior to our exchange yesterday, I had a great deal of respect for my old friend. It’s only grown since then. Going into the holiday weekend, I can feel very thankful for that.

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English/Psychobabble Translation Services

A good neuropsychological evaluation is worth its weight in gold.  A thorough assessment provides invaluable data about an individual’s cognitive, emotional, and psychological functioning,  the way s/he processes and organizes information, and perceives and interacts with the world. A trained neuropsychologist takes the thousands of puzzle pieces that go into an assessment to create a coherent, rich picture of the many processes that make a person tick.

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While I don’t do testing myself, I’m an educated and frequent consumer of neuropsychological evaluations. I’ve read hundreds of them over the years and have referred many of my clients for testing. I have a list of “go-to” evaluators that I like to use when I make these referrals. I refer to them because their reports consistently meet 3 criteria that I consider essential to a good evaluation: 1) They do a thorough and insightful job of administering, scoring, and interpreting testing, 2) they take the time to really get to know the individual they are assessing on an interpersonal level, independent of the testing they do,  and reflect that understanding in their reports, and 3) their writing is descriptive, comprehensible, and not weighed down with jargon.

Of these 3 characteristics, the first one – doing a thorough and insightful job of administering, scoring, and interpreting testing – seems to be the least uncommon. The field of psychology involves aspects of both art and science. Testing is perhaps the part of the field that is closest to the science end of the continuum. The people who are drawn to it tend to be strong scientific thinkers and, at least around here in the Boston area, there are a number of neuropsychologists who do excellent testing.

The other 2 skills are a bit “mushier” and, maybe as a result, it’s harder to find practitioners who really have them down. When it comes to sitting down with someone you’re evaluating in order to get to know them, there are some widely used interviewing techniques and protocols that examiners use to elicit information from clients. But this part of the evaluation involves at least as much art as it does science. It’s a skill that can be developed and enhanced over the years but for the most part, you either have it or you don’t. It may be possible to produce a worthwhile evaluation without the qualitative information obtained when you just sit down and get to know a client. But the best ones  use these clinical impressions and stories to provide a multi-dimensional view of a human being rather than a mere summary of test results.

The third characteristic – writing reports that are descriptive, comprehensible, and not entirely suffused with jargon – seems to be the rarest one. Bad writing can take many different forms.  In the medium of the neuropsych. report, its most common expression is in writing aimed at the wrong audience. While reports are often disseminated among  professionals who share a common scientific vocabulary, parents are clearly the main audience. When bringing their children to be evaluated, parents often endure multi-month waiting lists, a high price tag, resistance from their kids, and other challenges. In return, they want a clear understanding of their child’s functioning. Here are a few excerpts (with names removed to protect confidentiality) from some evaluations we’ve seen:

“On tasks that measure perceptual and fluid reasoning, spatial processing, and visual motor integration, ____’s scores fall within the average range. His analysis and synthesis of visual information and abstract, categorical reasoning were adequate, although visual attention/visual discrimination skills were affected by variable attention.”

“On a measure of phonological processing, for conceptualizing changing speech-sound patterns that underlie effective decoding and spelling, ____’s score was in the average range.”

“Diagnostically, ____ is indeed complex and further observations will be needed over time to clarify diagnosis. Poor modulation on several axises – attention, impulse and motor control, mood – suggest “hypofrontality” – i.e., maturational delays of the subcortical-prefrontal system – which can be linked to several diagnoses including Attention Deficit/Hyperactivity Disorder, of a combined type, and a Mood Disorder, of an unspecified nature. (That is, it is unclear if his negativity and emotional lability reflects a Unipolar Depression or early symptoms of a Bipolar Disorder.)”

Huh?!?!

I consider myself to be a fairly fluent psychobabble speaker, but passages like these leave me scratching my head. A parent who has just paid thousands of dollars for such a report is not going to be able to make much use of it without the help of a qualified psychobabble/English translator. Writing like this serves only to prop up the egos of the authors who must view themselves as being just so frightfully clever.

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Last year, I had a conversation with Dr. Gretchen Felopulos, a neuropsychologist at Massachusetts General Hospital – whose writing is excellent, by the way – and she had a great response when I asked her about report writing. She told me that she pushes the post-doctoral students she teaches to write in plain English for reasons centering on their own self-preseveration. Neuropsychologists who are too reliant on jargon will need to spend more time in meetings and on the phone with parents going over not only the important things – testing results and recommendations for example – but also on translating that jargon to English. It’s better to concentrate on writing clearly and comprehensibly to begin with so that time spent with their clients can focus on more important issues.

Unfortunately for parents, the only way to find a neuropsychologist who avoids these pitfalls is to ask around. Talk to other parents or professionals who have been consumers in the past and get their impressions. A good evaluation may be the most important mental health service your child ever receives. To gain a better understanding of your child’s functioning, you shouldn’t need a translator.

 

 

 

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The Welcome Back Kotter School of Limit Setting

In memory of Marcia Strassman, Gabe Kotter’s long suffering wife Julie on the 1970’s sitcom Welcome Back Kotter, I’m reposting an entry I wrote two years ago. Strassman passed away last Friday. R.I.P.

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On the morning of September 10, 1975, as my fellow classmates and I streamed in to Iroquois Middle School for another enthralling day of 6th grade, we found ourselves enthusiastically comparing our favorite moments from a sitcom that had premiered the evening before. At least 12 hours after we had all feasted our eyes and ears on it for the first time, Welcome Back Kotter still had all of us laughing uproariously.

For those unfamiliar with Welcome Back Kotter, the show’s central character was named Gabe Kotter and he was portrayed by Gabe Kaplan. Mr. Kotter was a young teacher who was assigned to teach a high school class comprised of a group of what passed in the 70’s for TV juvenile delinquents. The story went that Mr. Kotter had attended the same high school and had been a student in the same notoriously unmanageable class. The show was noteworthy…

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May We Find Life So Precious….

As a species, we humans are decidedly a mixed bag. Interactions with other people elicit emotions ranging from rage to indifference to joy. For most of us, the frustration inherent in everyday communication can be looked upon as a minor irritant – the cost of doing business. For other people, those annoyances are deal breakers. They see other humans  as means to an end at best and as ubiquitous obstacles at worst and figure “What’s the point?” Human connection for its own sake is not seen as intrinsically rewarding and, as a consequence, is not actively pursued.

 

We run social skills groups with kids and adolescents, many of whom struggle in the realm of social interaction. Among our group members, there’s as much variation in the value placed on social connection as there is among society at large. When parents ask their kids what they like about being in one of our groups, most of our younger kids point to the activities we do and being able to run around in a gym with counselors who understand them. As they get older, they begin to develop an understanding of their experience that suggests a greater appreciation of the abstract. They enjoy being part of a community in which they’re not seen as being “the hyper kid” or as “the quirky kid” because the other kids are just like them. For these older children and adolescents, the fact that they can share their time with others who share similar issues, interests, perceptions, and values is at least as important to their happiness as any activity they happen to share together. Connection, in and of itself, is the important thing.

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There are exceptions. Every once in awhile, we take our groups on excursions outside the comfort of our gym to a nearby restaurant. It’s interesting to see the way kids respond when they’re placed in different settings. Some of them warm to the occasion and enjoy the chance to chat or just hang out with their fellow group members in a new environment. Other kids are reluctant to come along on these outings and their tendency to stay on the periphery is reflects this discomfort. Sometimes, it’s a matter of anxiety but for some other kids, they just don’t see the point. Why would we just want to hang out? When do the activities start?

When kids see the world this way, it’s impossible to actively teach them that social interaction is an inherently worthwhile or valuable pursuit. Regardless of whether this worldview stems from an issue of development or temperament, trying to push them towards a greater appreciation of just being with people is likely to come across as nagging and will probably wind up being counterproductive. The best we can do is to craft a milieu in which shared participation in activities is as easy and enjoyable as possible, with the hope that social interaction becomes more enticing or manageable over time. Yes, it’s important for kids to develop a minimum level of social competence but it’s equally important for adults to help them get there without being judgmental or unrealistic in their expectations.

In late September, I attended Rosh Hashanah services at my temple. Rosh Hashanah, the Jewish New Year, and Yom Kippur, the day of atonement which follows a week later, make up the high holidays – two of the most important of the year. Both holidays emphasize self-reflection. We look to identify ways in which we’ve missed the mark as individuals over the past year, and we consider how we might become better people during the upcoming year. It’s a time of new beginnings and renewal. During the Rosh Hashanah service, I came across a silent meditation in our prayer book that read:

“May we find life so precious that we cannot but share it with the other.”

It’s a beautiful wish for the new year and, as I read it, I thought of the kids I’ve known who didn’t see the point in “just hanging out.” Social interaction is messy, complicated, and often maddening. But it’s also the source of tremendous joy and gratification. May you all find life so precious!

 

 

 

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The Side Effects of Doing Nothing

“Well, I’m not giving my baby any more dangerous drugs. From now on, it’s nothing but fresh air, lots of hugs, and good old-fashioned Ritalin.”      –    Marge Simpson         

To medicate or not to medicate, that is the question. It is, at any rate, for scores of parents of kids and adolescents with ADHD. Paraphrasing the old commercial, at Academy MetroWest, we’re not doctors (and we don’t even play one on TV), but we often serve as sounding boards for parents when they want to discuss this issue.

Conventional wisdom has it that, as a society, we are overmedicating our children. This line of thinking suggests that we have opted to throw pills at kids for behavioral issues that could be better addressed by a return to stricter discipline. In my experience, this problem is vastly overstated. If I wracked my brain, I could probably come up with one or two families I’ve worked with over the years who might plausibly fit that description. But I’ve met many more families in which the kids might benefit from a medication trial but the parents, for one reason or another, have ruled it out.

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There are plenty of reasons for parents to be wary about placing their children on medication. My personal bias is that, for the right reasons and under the guidance of a qualified physician, medication can be an effective way of managing the symptoms of ADHD. Medication can help reduce impulsiveness, distractibility, and hyperactivity, and it can help many people with ADHD learn, succeed, and thrive to a much greater extent than they could without it. When I talk to parents about meds, I try to be upfront about this bias but I also acknowledge that it’s a complicated issue. The decision to place a child on stimulant medication is not an easy one. My role is to present parents with the information I have at my disposal, discuss their concerns, and then respect their final decision. While stimulant medications, the most commonly prescribed class of medication for ADHD, are often easier to manage and come with milder and less frequent side effects than other classes of psychotropic medications, the side effects do need to be considered and are often the reason that parents look for other options. At its core, the decision whether or not to medicate a child comes down to a risk/benefit analysis. Potential therapeutic gains must be weighed against potential side effects. The most frequent side effects center on difficulty with sleep and appetite. Often, the effects are pretty mild and most parents find a way to work around them if the medication has been otherwise helpful. Less frequently, parents report that stimulants can lead to changes in mood and personality in their kids. Mood and personality changes are more problematic and are usually deal-breakers for parents. However, like the other side effects, they tend to go away once the medication has been discontinued.

Recently, I’ve heard more concerns than I used to from parents about the paucity of research on physiological effects of long-term stimulant use. It’s a valid concern. For a number of reasons, the research into the long-term effects of these drugs has been frustratingly scanty. Even though, according to the Child Mind Institute, “a number of studies have followed children with ADHD for longer periods, and none has turned up any negative effects in kids whose parents reported that they were taking medication,” it’s not necessarily the case that future studies won’t find contradictory results. With much of the funding for medication research coming from the pharmaceutical industry, an industry known for their tendency to push the marketing envelope, some caution and skepticism about the research they fund are understandable.

I agree that more research needs to be conducted on the long-term use of stimulants. Parents are right to be concerned about the issue. However, for me, those concerns are, at the very least, balanced out by a more thoroughly researched phenomenon: the side effects of doing nothing. Kids with ADHD face behavioral, academic, social, and family struggles that leave them susceptible to all kinds of negative outcomes. According to the Centers for Disease Control,  parents of children with ADHD report significantly greater levels of problems with peers, as well as greater levels of injuries, inpatient, outpatient, and emergency room admissions,  and greater risks of drunk driving, traffic violations, and motor vehicle accidents. They are more likely to get in trouble with the law, develop problems with substance abuse, underemployment, and have trouble in school. Clinically, the most common dynamic I see resulting from a struggle with ADHD is the development of a very tenuous self-image, owing to the frustration that stems from struggles with peers, parents, and school. After being in a cycle of failure for an extended period of time, kids with ADHD may come to see themselves as being incapable of making friends, succeeding academically, or having a positive relationship with their parents. So they do what they see as the logical thing: They stop trying. If you combine impulsiveness with the sense that it’s pointless to try to manage it, the results can be ugly as well as tragic.

Of course, medication is not the magic bullet. Finding the right dosage of the right medication still comes down to advanced trial and error and it doesn’t always work. But with accurate diagnosis, studies strongly suggest that it’s likely to be helpful.

Again, I’m not a doctor so I’m not in a position to make authoritative statements about whether or not medication is the right option for anyone. I am suggesting that, if and when you start to analyze the risks and benefits of placing your child on medication, you should do the same thing for the prospect of not putting your child on medication. It’s important to note that there are alternatives to medication, with perhaps the most promising one being neurofeedback. This alternative was nicely covered in the excellent blog Climbing the Cinder Cone earlier this week. The research on alternative treatments has not been as thorough as the research on medication and if you’re looking for insurance coverage, you’re not likely to find it for neurofeedback, which can be expensive. This usually leaves  medication as the first line treatment for managing ADHD symptoms. If you have questions about it, find a competent, qualified physician and ask a lot of questions. Do some reading. Join your local CHADD chapter. Examine the risks and benefits and decide what’s right for you and your child.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Posted in Children, Counseling, Family, Medication, Mental Health, Parenting, Psychiatry, Social Skills | Tagged , , , | 3 Comments

Book Review: Parents Have the Power to Make Special Education Work

Recently, my family and I spent a week camping on the coast of Maine. We spent part of the week at a beautiful new campground in the town of Brooklin, right near Blue Hill and Deer Isle. As luck would have it, we wound up adjacent to another family with children close to my daughter’s age. As luck would also have it, one of the children was a 7 year old boy with ADHD. His mom is in the process of negotiating a contentious divorce, keeping her head above water in a demanding job, and managing her introduction to the not-always-friendly world of special education. Like a moth to a flame, I was drawn inextricably into a conversation with her about medication, social skills, behavior charts, and, that old standby…Individualized Education Plans or IEP’s.

Like many parents who receive a sudden introduction to the world of special education, this mom felt like a lone astronaut who crash landed on an alien planet, forced to survive and adapt when everything around her is unfamiliar. Towards the end of our conversation, I gave her a few recommendations.  Among other suggestions, I strongly recommended a book that I just read called Parents Have the Power to Make Special Education Work: An Insider Guide, by Judy Canty Graves and Carson Graves. I have a feeling that I’ll be recommending it a lot over the coming years.

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If the introduction to the world of special ed. can be likened to crash landing on an alien world, then this book is the Fodor’s Travel Guide for that planet. The authors lived on that planet for a long time and in their book they share their wisdom, experience, and advice on  the customs, culture, logistics, and potential bumps in the road involved in such a journey.

In the interest of full disclosure, I’ve known Judy and Carson for a long time and I like them a lot. They are a married couple whose son, now 26 and a college graduate, negotiated the special education maze from pre-school all the way through high school. When I heard that they had written a book about special education, I was excited to read it.

Like a Fodor’s Travel Guide, Parents Have the Power to Make Special Education Work includes a lot of information that parents need but bypasses a lot of the more abstract, background information that they don’t. The book begins with a chapter on IDEA (Individuals with Disabilities Education Act) and other important legal underpinnings of our special education system. It provides valuable context for the rest of the book but after that chapter, it’s devoted exclusively to the nuts and bolts of the system. There are chapters on school personnel and their roles, the evaluation process, Individualized Education Plans (IEP’s), the legal process, and others. The authors also describe the dynamics and pitfalls in the system from a parent’s perspective. Each chapter ends with a section entitled What Parents Can Do that neatly and concisely summarizes the action steps presented in that chapter. For a parent just getting involved in this process, those sections alone are worth the price of the book.

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Carson Graves and Judy Canty Graves, authors of Parents Have the Power to Make Special Education Work: An Insider Guide

If the book has any shortcomings, I’d point to a few instances in which the authors could, for want of a better phrase, cut school systems a little slack. I agree that it’s important to provide some cautionary tales designed to alert parents to the shortcomings in the system, along with ways to deal with them effectively. There are families whose experience with special education has been marred by school professionals who turn a deaf ear to parental concerns, ignore the dictates of the law, and act in ways contrary to the interests of their students. On the other hand, for all the horror stories I hear about special education, I hear a similar number of stories from parents who feel that the system has treated them and their children very well. And while, from a parent’s perspective, battles over funding and services can be maddening, there are  some valid reasons for school districts to be cautious about the way they distribute their  resources. They have to balance out the mandate to provide a free and appropriate public education with the expectation that they’ll be judicious in the way they allocate services and funds. The overwhelming majority of parents seek out services for their children in a scrupulous and responsible way. School systems need to protect themselves from the occasional parents who don’t. More importantly, even though parents remain the best advocates and the most knowledgable sources of information when it comes to their own children, school systems must address the needs of all the students in their districts, which necessitates a “big picture” approach that can conflict with individual parents’ goals. Special ed. departments have many different constituencies with agendas that don’t always coincide. I’ve written about this topic before. There’s a reason there is so much turnover among special education directors.

Despite my quibbling,  the authors make a point to remind parents to work collaboratively with their school systems. And they make that point on more than one occasion. In the end, counselors like me are not the book’s main intended audience. Parents are. Parents just entering the  world of special education need to know what to watch out for and, despite my picky objections to some parts of it, this book presents a valuable, and largely balanced picture of that world. It will be a vital resource for many parents and I will recommend it again and again.

By the way, Judy and Carson will be discussing their book at a free parent workshop at Academy MetroWest. They’ll have copies of their book available for purchase and signing. It takes place on Wednesday evening, October 1, from 7:15pm to 8:45pm. Drop us a line at info@academymetrowest.com for more information or to RSVP.

 

 

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