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What is ADHD?

Attention-deficit/hyperactivity disorder (ADHD) is a multifactorial neurobiological disorder (Curatolo, Paloscia, D’Agati, Moavero, & Pasini, 2009) that affects between 3% and 7% of school aged children in the United States and is the most prevalent neurobehavioral condition among this population in many countries (Findling, 2008).  Although it may be the most studied condition in child psychiatry worldwide, its exact causes  and the exact mechanisms underlying this disorder are still unknown (Cortese, 2012).  It appears to be caused by the confluence of many genetic and environmental risk factors, each having a small effect on increasing vulnerability to the disorder (Curatolo et al., 2009).

This chronic disorder impairs function at both home and at school since it affects attentional and cognitive functions including problem solving, planning, orienting, alerting, cognitive flexibility, sustained attention, response inhibition, and working memory.  Other areas such as motivation and delay aversion are also affected. These impairments create a negative impact on social interactions and adolescents with ADHD are at high risk for low self-esteem and poor peer relationships (Curatolo et al., 2009).   ADHD frequently exists with other neuropsychiatric and neuro-developmental disorders, including oppositional defiant disorder, conduct disorder, anxiety and depressive disorders, developmental coordination disorder, sleep disorders, learning difficulties and substance abuse disorder (Cortese, 2012).

ADHD is a highly inheritable condition with documented brain abnormalities and its symptoms persist into adolescence and adulthood in 37% to 85% of children, according to the National Comorbidity Survey (Findling, 2008).

2.  Historical Perspective of ADHD (How Has Our Understanding Of ADHD Changed Over Time?)

ADHD was first described over 100 years ago by George Still in the Coombs lectures of 1902.  He described this condition as an ‘‘abnormal defect in moral control in children’’.  Encephalitis lethargica, or sleeping sickness appeared as an epidemic during World War I, spread throughout the world, and disappeared in 1927.  After this epidemic, many children showed hyperkinetic behavioral symptoms including hyperkinesis, impulsivity, learning disability, and short attention span and were labeled as “minimal brain damaged” and later as “minimal brain dysfunction”.  In the 1950s, this label was modified to ‘‘hyperactive child syndrome’’.  In 1968 the disorder was renamed in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-II as ‘‘hyperkinetic reaction of childhood’’. (Spencer, Biederman, & Mick, 2007).      During the 1960s and 1970s the focus on what is now ADHD was on motoric hyperactivity and overt impulsivity (Curatolo et al., 2009).

The DSM-III which was published in 1980 represented a paradigm shift in the diagnosis and treatment of ADHD because it began to emphasize inattention as a significant component of the disorder.  The DSM-III also recognized developmental variability in the disorder at different ages and allowed for a residual type if the remaining symptoms caused significant impairment (Spencer et al., 2007).  The DSM-III marked the beginning of attention deficit disorder with or without hyperactivity (Curatolo et al., 2009).  This definition was further defined in the DSM-IV which included three subtypes of ADHD:  predominantly inattentive, predominantly hyperactive-impulsive, and a combined subtype (Spencer et al., 2007).  The clarification of three subtypes led to new theories about the etiology and pathophysiology of ADHD within a more specific brain localization area (Curatolo et al., 2009).

3.  Diagnosis (How Do You Know If You Have ADHD?)

A child with ADHD displays a considerable degree of distractibility, impulsivity, inattentiveness and other hyperactivity that is inappropriate for the child based on the developmental stage of the child.  The diagnosis of ADHD is made after careful examination of the clinical history.  Although ADHD is often observed in early childhood, the current guidelines for diagnosis begin at the age of four years, partly because many overactive toddlers will not develop ADHD.  Children with ADHD may have other common symptoms including low frustration tolerance, shifting activities frequently, difficulty organizing, and daydreaming.  Often these symptoms are pervasive but they may not occur in all settings (Spencer et al., 2007).

The three subtypes of ADHD:  predominantly inattentive, predominantly hyperactive-impulsive, and a combined subtype determine where children struggle the most.  Those children with predominantly inattentive ADHD may have more problems in school and struggle with homework and fewer problems with peers and family.  Since children with this subtype do not display as many behavior problems and are more likely to be female, they often are not diagnosed until late adolescence.  In contrast, children with excessive hyperactive or impulsivity symptoms may do better at school but they struggle more at home and in other less structured environments.  Children with combined subtype have the most co-occurring psychiatric and substance abuse disorders and are most impaired overall (Spencer et al., 2007).

As these children reach adulthood, many of their problems persist.  Previously, it was thought that symptoms would largely go away in adolescence, but research supports the persistence of the disorder and/or associated impairment in the majority of cases.  Although individuals may no longer meet all of the diagnostic criteria of ADHD, they may still suffer from significant impairment.  Diagnosing ADHD in older patients is more complicated for a number of reasons.  First, the original model of ADHD is the DSM-IV was a childhood disorder.  Field trials on children were used to determine the diagnostic criteria (Lahey et al., 1994) and major studies on children were used to confirm the model (Scholte, van Berckelaer-Onnes, & van der Ploeg, 2001) which is why some researchers have hesitated to apply the diagnostic criteria of the DSM-IV to adults (Stein, Fischer, & Szumowski, 1999).  A further complication of diagnosing ADHD in older patients is that evidence suggests that manifestation of symptoms may become more subtle with age (Riccio et al., 2005) although recent work has found that the lack of inhibitory control is the primary characteristic of adult ADHD (Amen, Hanks, & Prunella, 2008; Bekker et al., 2005).

Currently in order for an adult to be diagnosed with ADHD they must have childhood-onset, persistent, and current symptoms of ADHD.  Symptoms in adults often present with marked inattention, distractibility, organization difficulties, and poor efficiency.  These persistent traits often lead to life histories of academic and occupational failure (Spencer et al., 2007).   In addition, adults with ADHD can have serious emotional, relational, and work related consequences including higher prevalence of other medical and behavioral disorders and higher medical costs (Amen et al., 2008).

The most significant and consistent structural imaging findings in children with ADHD include smaller total brain volumes and reduced volumes, in the right frontal lobe, caudate nucleus, the cerebellar hemisphere and posterior inferior lobules of the cerebellar vermis. These early abnormalities of regional brain volumes have also been shown to change over time in children and adolescents with ADHD. Developmental trajectories study showed that volumetric abnormalities in the cerebrum and cerebellum persisted with increasing age, whereas caudate differences versus normal subjects disappeared. Cortical development in children with ADHD shows a marked delay in brain maturation; the gray matter peaks were about 3 years later than in healthy controls. The delay is most prominent in prefrontal regions important for control of cognitive processes including attention and motor planning (Curatolo et al., 2009)

Dr. Jan Dunn provides Online Counseling in Texas to individuals, couples, and families. Telehealth Video Therapy Sessions provides the same treatment as in person therapy sessions. Shifting the therapy office to a clients space makes therapy portable, accessible, confidential, and comfortable. In turn, clients often report feeling more at ease, less stressed, and more apt to open up and, in turn, therapy is more effective. The benefits far outweigh any concerns for most clients, as accessibility to care drastically increases and cancellations drastically decrease. Therapy is delivered in the comfort of your home – when and where you need it.

4.  Physical Differences in the Brain (Are the Brains of Children with ADHD Different?)

Advances in brain imaging studies have significantly contributed to the biological understanding of ADHD.  Although many differences have been identified in the brain structures of children with ADHD, some of these differences are more consistent and more significant than others.  These findings include smaller total brain volumes and reduced volumes in the right frontal lobe, caudate nucleus, the cerebellar hemisphere and posterior inferior lobules of the cerebellar vermis.  These abnormalities change over time in children and adolescents with ADHD.  Studies have shown that although volumetric abnormalities in the cerebrum and cerebellum persist with advancing age, those in the caudate region disappear and are consistent with subjects without ADHD.  Another important finding is that children with ADHD show marked delay in the cortical development of the brain.  The gray matter peaks approximately three years later than subjects with ADHD and the delay is most prominent in the frontal regions which focus on control of cognitive processes including attention and motor planning (Curatolo et al., 2009)

This is the first study to establish neural effects of a cognitive training program in ADHD. Our findings provide preliminary evidence that training of cognitive functions targets critical syndrome-associated structures, and indicate it may improve cognitive performance by enhancing dysregulated fronto-cerebellar circuits. Interestingly, similar results have been demonstrated following methylphenidate administration, suggesting that cognitive training may mimic the effects of psychostimulant medication on the brain. On the whole, our results postulate a neural account for the potency of cognitive training in ADHD patients, and hold clinical implications, supporting the pertinence of training programs as part of standard ADHD-treatment (Hoekzema et al., 2010)

General Guidelines

There is no doubt about it, ADHD is one of the more complex disorders that people suffer.  It impacts how one thinks, how one lives and how one develops relationships in one’s life.  It is highly complex and requires more than just medication.  In fact, the most recent research states that this disorder is a “chronic brain disorder”.  Which means that it is a life long disorder, people are born with it and they die with it.  It impacts a person for their entire life.

It is important to see a provider who truly understands the complexity of ADHD and how best to help.  It is important for the provider to take a multi-interventional approach to helping the individual and/or couple with ADHD.

1.   Medication is certainly important and finding the right medication for you can be challenging; however, very important if you want to have better control of your symptoms.

2.   It is also important to eat a diet high in proteins since the person with ADHD requires more than the average individual.

3.  Exercise intensively at least 20 minutes daily (more if possible).  It has been proven that intense exercise changes the chemistry of the brain, making the brain function better.  Sounds like a good idea for folks who have ADHD!!

4.  There is also a growing body of knowledge that support taking vitamins and minerals to help boost what the ADHD brain needs nutritionally.

Therapy plays a critical part in helping the ADHD individual, parent and/or couple because this disorder is often misunderstood.  It can create so many problems in a marriage that often the ADHD individual has difficulty remaining in a long term relationship.  It takes skills and understanding for marriages to cope with this disorder.  Parents often do not understand the complexity of this disorder, wondering why their child is having so many problems after starting medication.  Medication is only part of the solution.  Specialized parenting skills are needed to help the parent who has an ADHD child.  I call this training the “graduate course” for parents.  Adults with ADHD need assistance because they often have years of failed attempts at relationships, school, work.  These failures result in negative “self talk” which often leads to mood disorders.  It is not uncommon to see young adults with ADHD also suffering from anxiety and/or depression.  They need to learn more about their brains and how best to navigate life to create successes versus failures.

Amy Tuteur M.D.

Photo pexels

How the Body and Mind Talk To One Another

Have you ever been startled by someone suddenly talking to you when you thought you were alone? Even when they apologise for surprising you, your heart goes on pounding in your chest. You are very aware of this sensation. But what kind of experience is it, and what can it tell us about relations between the heart and the brain?

When considering the senses, we tend to think of sight and sound, taste, touch and smell. However, these are classified as exteroceptive senses, that is, they tell us something about the outside world. In contrast, interoception is a sense that informs us about our internal bodily sensations, such as the pounding of our heart, the flutter of butterflies in our stomach or feelings of hunger.

The brain represents, integrates and prioritises interoceptive information from the internal body. These are communicated through a set of distinct neural and humoural (ie, blood-borne) pathways. This sensing of internal states of the body is part of the interplay between body and brain: it maintains homeostasis, the physiological stability necessary for survival; it provides key motivational drivers such as hunger and thirst; it explicitly represents bodily sensations, such as bladder distension. But that is not all, and herein lies the beauty of interoception, as our feelings, thoughts and perceptions are also influenced by the dynamic interaction between body and brain.

The shaping of emotional experience through the body’s internal physiology has long been recognised. The American philosopher William James argued in 1892 that the mental aspects of emotion, the ‘feeling states’, are a product of physiology. He reversed our intuitive causality, arguing that the physiological changes themselves give rise to the emotional state: our heart does not pound because we are afraid; fear arises from our pounding heart. Contemporary experiments demonstrate the neural and mental representation of internal bodily sensations as integral for the experience of emotions; those individuals with heightened interoception tend to experience emotions with greater intensity. The anterior insula is a key brain area, processing both emotions and internal visceral signals, supporting the idea that this area is key in processing internal bodily sensations as a means to inform emotional experience. Individuals with enhanced interoception also have greater activation of the insula during interoceptive processing and enhanced grey-matter density of this area.

So what is enhanced interoception? Some people are more accurate than others at sensing their own internal bodily sensations. While most of us are perhaps aware of our pounding heart when we are startled or have just run for the bus, not everyone can accurately sense their heartbeats when at rest. Interoceptive accuracy can be tested in the lab; we monitor physiological signals and measure how accurately these can be detected. Historically, research has focused on the heart, as these are discrete signals that can easily be quantified. For example, a typical experiment might involve the presentation of a periodic external stimulus (eg, an auditory tone) that is time-locked to the heartbeat, such that each tone (‘beep’) occurs when the heart is beating, or in between heartbeats. Participants state whether this external stimulus is synchronous or asynchronous with their own heart. An individual’s interoceptive accuracy is an index of how well they are able to do this.

It is also possible to measure subjective indices of how accurate people think they are at detecting internal bodily sensations, ascertained via questionnaires and other self-report measures. My work shows that individuals can be interoceptively accurate (ie, good at these heartbeat-perception tests) without being aware that they are. In this way, interoceptive signals can guide and inform without fully penetrating conscious awareness.

Individual differences in interoception can also be investigated using brain-imaging methods, such as through brain representation of afferent signals (eg, heartbeat-evoked potentials expressed in a neural EEG signal). Functional neuroimaging (fMRI) can also be used to investigate which areas of the brain are more active when focusing on an interoceptive signal (eg, the heart) relative to an exteroceptive signal (eg, an auditory tone).

Our hearts do not beat regularly and, while we can identify that our hearts race with fear or exercise, we might not fully appreciate the complexity of the temporal structure underlying our heartbeats. For example, cardiac signatures are also associated with states such as anticipation. Waiting for something to happen can cause our heartrate to slow down: this will happen at traffic lights, when waiting for them to go green. These effects of anticipation, potentially facilitating the body and mind to adopt an action-ready-state, highlight the meaningful composition of internal bodily signals.

Dr. Jan Dunn provides Online Counseling in Texas to individuals, couples, and families. Telehealth Video Therapy Sessions provides the same treatment as in person therapy sessions. Shifting the therapy office to a clients space makes therapy portable, accessible, confidential, and comfortable. In turn, clients often report feeling more at ease, less stressed, and more apt to open up and, in turn, therapy is more effective. The benefits far outweigh any concerns for most clients, as accessibility to care drastically increases and cancellations drastically decrease. Therapy is delivered in the comfort of your home – when and where you need it.

Internal bodily signals can be deeply informative, which is why sensing them can provide an extra channel of information to influence decision making. Gut instinct or intuition during a card game can also be guided by interoception. Bodily signatures (heart rate, skin-conductance response) can signal which cards are good (ie, more likely to be associated with a positive outcome) even in the absence of conscious knowledge that a card is good. Thus, the heart ‘knows’ what the mind does not yet realise, and access to this bodily signature can guide intuitive decision making to a better outcome. In a real-world extrapolation of this, I visited the London Stock Exchange to work with high-frequency traders. These traders claimed that their decisions were often driven by gut instinct, when faced with fast-coming information that the conscious brain could not yet fully process. My colleagues and I demonstrated that interoceptive accuracy was enhanced in those traders who were most adept at trading, potentially grounding their intuitive instincts in a capacity to sense informative changes in internal bodily signals.

An appreciation that bodily signals can guide emotion and cognition provides potential interoceptive mechanisms through which these processes can be disrupted. Alexithymia, defined as an impaired ability to detect and identify emotions, is associated with reduced interoceptive accuracy. Autistic individuals, who often have difficulty in understanding emotions, have also been shown to have impaired interoceptive accuracy. Neural representation of bodily signatures are altered in borderline personality disorder (also known as emotionally unstable personality disorder), and interventions designed to focus on the body, such as mindfulness, have been shown to reduce anxiety. Insight into the nature of these embodied mechanisms opens up potential avenues for further understanding and targeted intervention.

As well as telling us about our own emotions, our bodies respond to the joy, pain and sadness of others. Our hearts can race as loved ones experience fear, and our pupils can adopt a physiological signature of sadness in response to the sadness of others. If you pay attention to your heart and bodily responses, they can tell you how you are feeling, and allow you to share in the emotions of others. Interoception can enhance the depth of our own emotions, emotionally bind us to those around us, and guide our intuitive instincts. We are now learning just how much the way we think and feel is shaped by this dynamic interaction between body and brain.

Sarah Garfinkel is professor of neuroscience and psychiatry at the University of Sussex. Her work has been published in the Harvard Review of Psychiatry and Brain: A Journal of Neurology, among others. She lives in Brighton.

 

Serving Norwalk – Darien – Westport – New Canaan, Connecticut. Helping balance career demands with emotional needs of our families. As a behavioral therapist with training in DBT and CBT, I focus on cognitive distortions and maladaptive behaviors that damage relationships and sabotage personal and professional goals. Relationship Counseling Norwalk therapist Dennis McAllister LCSW, Employing DBT skills of mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness, I help clients learn new strategies for addressing life’s challenges.

Tallae Counseling & Wellness Center

Dwan Reed, Ph.D., LCSW, DTM

I am a certified facilitator for Prepare/Enrich (couples counseling), and a certified Anger Resolution Therapist. I am a yoga and natural health enthusiast. I have been married for twenty-five years and am the mother of two young adult children. I enjoy church ministry, traveling, playing with my pets, and watching investigative crime shows. Dwan Reed, PhD, LCSW, DTM, of Tallae Counseling & Wellness Center is a therapist specializing in Depression Counseling in Spring, TX

Tallae Counseling & Wellness Center
Dwan Reed, Ph.D., LCSW, DTM
Therapist & Prinicipal Owner
Tallae Counseling & Wellness Center
6302 Laver Love Dr.
Spring, TX 77379

832 263 1907

Psychotherapy

Sometimes life can be awfully lonely and anxious. Perhaps you don’t have the sense of fulfillment or connection in life that you want. This work is about far more than symptoms, it’s about the deeper place of who you are. It’s from this place that connection and lasting change will come. It can be vulnerable, but so very brave, to seek help. I offer a safe, comfortable space to process your feelings, and begin moving toward change. Relationships have the power to hurt us, but it is also within relationship that we can be healed.

Therapy is most effective when you feel like you can be yourself. With all the anger, melancholy, and anxiousness. It is from this place that your greatest relief and change comes from. You’re not alone in this work and it is something that we do together.

Colin B. Denney, Ph.D., Psychologist Honolulu

Colin B. Denney, Ph.D., is the Director of the Pacific Psychology Services Center in Honolulu, Hawaii, he is a Child Psychologist Honolulu.

Pacific Psychology Services Center
Honolulu, Hawaii

I provide individual and family therapy with children, adolescents, adults, families, and couples. I also have extensive training and experience with children and adolescents who are struggling in school.

Disorders with which I have particular expertise include Anxiety Disorders, Posttraumatic Stress Disorder (PTSD), Obsessive-Compulsive (OCD) and Related Disorders, Attention Deficit/Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder, Depressive Disorders, and Tic Disorders (including Tourette Syndrome).

I also have a special interest in interventions focused on parent-child relationships. I have received formal training in several well-validated treatments of this kind, including Parent-Child Interaction Therapy (PCIT), Positive Parenting Program (PPP), and Child and Adolescent Relationship Enhancement (CARE).

Drew Tillotson, PsyD., Clinical Psychologist Specializing in Sex Addiction Therapy in San Francisco

Drew Tillotson, PsyD., Clinical Psychologist Specializing in Sex Addiction Therapy in San Francisco

Drew Tillotson is a clinical psychologist with over 19 years experience in the mental health field. He is in private practice in the Lower Pacific Heights area of San Francisco and treats adults in both individual and couples therapy. He specializes in treating sex addiction therapy in San francisco and provides a safe and confidential environment for business professionals, doctors and lawyers who are looking for help. He uses a non-pathological approach to sexual behavior, helping patients understand what causes them to use sex as a way of coping with emotions, stress, fears and insecurities.