Mon, 10 Dec 2018 10:29:48 -0800WeeblyWed, 01 Jul 2015 08:05:42 GMThttp://www.casepsychology.com.au/blog/adhd-treatments-the-good-the-bad-and-the-ineffectiveIn Part One of this series on ADHD, we looked at whether ADHD is actually a real condition. Having established that it most certainly is, we move now to a quick summary of treatments. Some are effective, some not so much ... but parents of kids with ADHD may be vulnerable to misinformation because they want so badly to do the best thing for their child. And in the face of so much conflicting information, it is hard to make decisions about treatments. While I can summarise the state of the scientific literature here, my top recommendation is that you get support from a paediatrician, psychiatrist or clinical psychologist who specialises in ADHD and can help you navigate the minefield of treatment information you're likely to encounter. 

• Medication - Stimulant medication is the number one, gold standard treatment for ADHD. It significantly reduces symptoms and improves long-term functioning in approximately 80% of cases.  Long-term safety studies have found that, overall, medications such as Ritalin are very safe, with few concerning side effects. While some parents worry that the use of stimulant medication places their child at risk of later drug abuse, meta-analysis shows that ADHD medication actually reduces the long term risk of drug and alcohol abuse (possibly as children and adolescents may be less likely to self-medicate or associate with antisocial peers - see Wilens, Faraone, Biederman & Gunawardene, 2003 for more on this subject).

• Psychological Therapies - While medication is the gold standard, there are a number of psychological therapies and interventions that may be beneficial, particularly alongside medication (see Oord, Prins, Oosterlaan, & Emmelkamp, 2008 for meta-analysis). Cognitive and behavioural interventions may include parent training, behavioural therapy, and social/emotional skills training. In particular, there is strong evidence for the use of behavioural therapies and teaching parents how to manage dysregulated and oppositional behaviour. Psychologists can work with families to assist them in developing a positive parenting approach that focuses on reinforcing desired behaviours and effectively managing misconduct. 

• School-Based Interventions - The child with ADHD is likely to struggle in a school setting and their behaviour frequently draws negative attention from teachers. Parents may feel that the school doesn't understand their child's needs or manage their developmental and behavioural issues appropriately. Sometimes, the relationship between home and school completely breaks down. I try to support both parents and teachers to work together in the child's interests. Psychologists can provide teachers and learning support aides with information and support to help them understand more about a child's particular difficulties (for example, poor attention, specific learning difficulties, slow processing speed, or memory issues). We can then work together to develop an effective behaviour management plan to help school manage problem behaviours and learning difficulties.

• Dietary Interventions - You may have heard some people say that ADHD is just a symptom of too much junk food and therefore treatment should simply involve a change in diet! However, there is limited evidence for dietary interventions in ADHD. A minority of children (particularly those with food sensitivities) may benefit from restricted exposure to artificial food colourings (although more research is needed in this area due to the poor quality of some of these studies). There is also some evidence to suggest small beneficial effects for some children who are supplemented with Omega 3 and Omega 6 fatty acids. However, the current scientific evidence does not support the idea that ADHD symptoms are related to sugar or aspartame (see Rytter et al., 2014 for a recent meta-analysis of dietary interventions for ADHD). Any benefits from dietary interventions are negligible when compared to the positive effects of medication.

• Cognitive Training - An increasing number of practitioners (some psychologists included) are offering cognitive training for ADHD. This is also sometimes called 'brain-training' or 'neurotherapy'. This usually involves having the child or adolescent engage in some of kind of task (often computer/tablet-based games) with the supposed goal of improving brain functions related to attention, processing or memory. These types of therapies are often expensive and, frankly, the evidence to support them is very poor. However, those who are selling the therapies may refer to studies that they claim show benefits. Those studies tend to be of poor quality and may even have been conducted by the practitioner or agency selling the therapy! So far, the evidence suggests that cognitive training does not lead to significant or meaningful improvements in ADHD functioning (see Cortese et al, 2015, for the most recent meta-analysis on this topic)

 
So, in short, medication is where it's at for ADHD, and psychological therapies may be a useful adjunct. If you have to choose only one approach, give due consideration to medication. But if there is an option of using both approaches, they may be complementary. Psychologists can also help schools to address issues in that setting. If parents want to explore dietary interventions, many paediatricians are happy to support them to do this, although it's unlikely that limiting sugar is going to change things for your child. And if offered an expensive quick-fix, like cognitive training, it may pay to be sceptical and stick with evidence-based therapies. 

The treatment of ADHD is such a controversial topic and this makes it even more difficult for parents to deaI with the issue. I am always happy to discuss issues related to ADHD with parents at any stage in their ADHD journey; whether that is at the point of initial assessment and diagnosis, or further down the track. For more information or support for your child with ADHD, contact me here



Dr Rosalind Case
PhD, PGDipPsych(Clin), MSocSc, BSocSc(Hons), MAPS
Melbourne, Australia]]>Wed, 01 Jul 2015 08:05:30 GMThttp://www.casepsychology.com.au/blog/is-adhd-realThe Internet is a great thing; it gives us access to a whole world of information. The flipside, however, is that the quality of that information may not be fantastic. It can be very difficult for the average person to work out whether the health information that they are reading online is authoritative. Conspiracy theories, pseudoscience, and armchair expert opinions abound. It's not always easy to tell the difference between an evidence-based summary of the best scientific knowledge available, or a blog masquerading as a news article written by someone with a particular personal agenda.

One of the topics that is really vulnerable to this problem of Internet mythology is Attention Deficit / Hyperactivity Disorder, or ADHD. For the last 25 years, public debate about this disorder has been hot. In particular, the public seems concerned that ADHD is not 'real', and rather is just a label for 'naughty' children. There is also a lot of controversy surrounding the prescription of stimulant medication, such as Ritalin, with some arguing that it constitutes the needless drugging of kids. 

And yet, we continue to diagnose children with ADHD and, in most cases, recommend prescription medication. So why is that psychiatrists, psychologists, occupational therapists and GPs (amongst others) continue to identify ADHD as an issue amongst a small percentage of children?

DEFINING ADHD
First, we need to be clear about what we are talking about when we refer to ADHD. The current Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM V; American Psychiatric Association [APA], 2013) contains the most commonly referred to diagnostic criteria. It's quite detailed; but, to summarise, the criteria are as follows:

Six or more of the following attentional symptoms for more than six months (N.B. symptoms must be inconsistent with developmental level, have a significant negative impact on the child's functioning or on other people, and is distinct from being oppositional or not understanding directions):

• Often fails to attend to details, makes careless mistakes
• Often has difficulty sustaining attention
• Often does not listen
• Often does not follow through and finish tasks
• Often has difficulty organising tasks
• Often avoids or dislikes tasks that require sustained mental effort
• Often loses things
• Often easily distracted 
• Often forgetful

And / or six or more of the following hyperactivity / impulsivity symptoms for more than six months. Again, these must be inconsistent with a child's developmental level (so, quite different to what we might expect of a child that age) and have a significant impact:

• Often fidgets or squirms
• Often leaves seat inappropriately
• Often runs around or climbs inappropriately
• Often has difficulty playing or engaging in leisure activities quietly
• Often seems 'on the go' or 'driven by a motor'
• Often talks incessantly
• Often blurts out answers before question is completed
• Often has difficulty waiting turn
• Often interrupts or intrudes

So, there must be a significant number of these symptoms occurring on a very frequent basis and in such a manner that they significantly interfere with or reduce the quality of a child's social or academic functioning. Furthermore, symptoms must be evident across multiple settings; if they just occur at school, but not at home (or vice versa) then ADHD will not be diagnosed. This is because if a child has these types of difficulties in just one setting, then it suggests that it is not a developmental problem; rather, it may be an environmental or behavioural issue that is related to that setting or context. A child who only demonstrates poor behaviour at home because of parenting issues does not meet diagnostic criteria for ADHD. 

I'm labouring that last point for a reason; so often, I hear people say that there is no such thing as ADHD and that it is simply a label for naughty children who haven't been parented properly. Certainly there are lots of children with ADHD who have come from a family that struggles with positive, effective parenting! However, if a child's behaviour issues are simply related to parenting then, as psychologists, we can help parents to change the child's behaviour through the use of behavioural interventions. When a child has ADHD, however, such behavioural interventions may not be so effective. I have seen many excellent parents struggle with their ADHD child, in spite of the support of skilled behavioural therapists, parenting programmes, and a variety of other therapies.  I would challenge any person who claims that ADHD is simply a symptom of poor parenting to try it for themselves and see how far they get.

So, it's real then?
The scientific evidence that ADHD is real is overwhelming. Seventy five per cent of cases are linked to genetic factors and a range of neurological impairments are implicated in its development. These include disturbances in the neurotransmitter systems associated with the production and distribution of dopamine and norepinephrine, which affect the brain's ability to control behaviour and emotions. Children with ADHD are also more likely to show reductions in some parts of the brain, such as the prefrontal and parietal cortex, and reduced electrical and metabolic activity in the brain. 

If ADHD was not a problem then it, quite simply, wouldn't be a problem. However, ADHD is a serious condition that significantly affects the quality of life of young people. Individuals with ADHD are significantly more likely to experience depression, suicidality, social isolation,  learning difficulties, early educational disengagement, unemployment, antisocial/criminal behaviour, substance abuse, and a variety of calamities associated with impulsive behaviour (e.g. sexually transmitted diseases, traumatic brain injury, etc.). These problems are worse for those who are untreated. If we don't accept that ADHD is real, then we make it harder for people with ADHD to be accurately diagnosed and be treated effectively. Which means we place these young people at risk of much poorer outcomes than they might expect if they have access to the best quality, evidence-based treatments.

Which brings us to the equally hairy topic of treatment! What does the scientific evidence say about interventions for ADHD? Click here for Part Two of this series on ADHD, where we look at treatment.



Dr Rosalind Case
PhD, PGDipPsych(Clin), MSocSc, BSocSc(Hons), MAPS
Clinical Psychologist
Melbourne, Australia]]>Sat, 13 Jun 2015 09:21:09 GMThttp://www.casepsychology.com.au/blog/what-to-do-when-your-child-has-concussionUp to 30% of young people will experience a concussion before they turn 25. That’s a giant proportion of our young people having a dazed and confused moment.

But that’s all it is, right? A moment (or, at least, a day or two) of feeling a bit fuzzy, maybe throwing up a bit, and having a headache? That’s one of the most commonly held misconceptions about concussion.

And while there seems to be increasing media attention about the possible effects of these types of injuries (particularly in the sporting arena), it would seem that concussion is not well understood. Not just by the general public, either. Talk to a few doctors, or your child’s teachers, about what to expect in a child during the days, weeks and months following a concussion and I bet you’ll get a wide range of responses.

So, what’s the deal with concussion and are we supposed to be worried if our kids have one? This area of research has been controversial in the past, with some studies suggesting that kids can have ongoing problems after concussion with their behaviour, emotional functioning, intelligence, memory, attention levels and academic achievement. Other researchers have totally rejected that idea, and insist that concussion is nothing to worry about. Thankfully, it’s an area of research that seems to have gathered steam in the past few years. So the quality of the research being conducted is improving, and there’s more agreement amongst experts about what to expect after a bang on the head.

The consensus seems now to be that it’s not at all unusual for children to experience post-concussive symptoms for several weeks, or even a couple of months. Some of the most common symptoms in children are fatigue, headaches, irritability, behavioural changes, and mood symptoms. For most, these problems won’t last. But, for a minority of children, difficulties can be ongoing. And it seems that the kids who are most at risk of experiencing ongoing problems may be the same kids that were already experiencing other difficulties. Children with behaviour and learning issues, or those from poor or chaotic families, may unfortunately be at higher risk of experiencing complications in their recovery.

Which leads to that old chicken-egg problem; which came first, the problems or the injury? Does the injury simply perpetuate difficulties that the child was already having? Some of the changes that happen after concussion are so subtle, it can be pretty difficult even for experts (let alone parents) to work out what is going on for a child.

So, where does this leave us, as hypervigilant parents waiting for a child’s next injury? If it’s impossible to predict the effect that concussion might have on our precious little one’s life, and difficult to tell whether the concussion is to blame, then how are we supposed to deal with one when it comes along? Thankfully, in spite of this confusion, traumatic brain injury researchers are pretty united when it comes to recommendations for supporting a child after concussion. Some of my favourite tips for parents include:

1. Know what the symptoms of concussion are in children and seek medical advice

According to the World Health Organisation, if your child bangs their head (or even just gets a sudden jolt, like a whiplash – there doesn’t need to be direct force to the head), and if they have any of the following symptoms, then they meet criteria for a diagnosis of traumatic brain injury and should see a doctor immediately:

• Confusion or disorientation
• Loss of memory
• Loss of consciousness
• Any other symptom that could suggest neurological impact (e.g. speech changes, seizures, etc.)

Other concussion symptoms include nausea or vomiting, headaches, visual disturbances and fatigue.
Many people do not realise that concussion is a mild traumatic brain injury; fortunately, its effects are typically less severe than other brain injuries and most people will not require hospitalisation. Mild traumatic brain injuries, or concussions, are also much less likely to cause ongoing symptoms than more severe injuries..

2. Rest your child

A whole heap of parents have told me that they kept their child awake after a concussion as they were always told it was unsafe for a concussed person to sleep. Not true. Sleep is what they need! Yes, it’s a very good idea to monitor a person’s level of consciousness and assess whether there are any changes, but you can still let them sleep for the most part. Your child’s brain may be a little bruised and swollen and needs time to heal.

3. Reduce stimulation

It’s not just sleeping that they need – ideally, your child should have at least a few days of cognitive rest. That means, if possible, a quiet, low-stimuli environment. Keep them home from school and turn off the iPad and the TV wherever possible.

4. DON’T SEND THEM STRAIGHT BACK TO SPORT!

This one is really important. Your child should not return to playing sport for a few weeks, and if they are still demonstrating any post-concussive symptoms then it’s best that they don’t play at all until all symptoms are clear. Not only do they need to reduce physical activity to support their healing, returning to high-risk physical activities (like the playground or sports field) places them at risk of another injury. The more injuries they get, the more likely they are to have ongoing problems as a result of concussion. It may mean you sacrifice the sport season, which might seem like overkill – but this is your child’s brain and development that we’re talking about here. You have a right to prioritise your child’s health and wellbeing over the wants of a disappointed sports coach.

5. Communicate with school

Tell school what has happened and what symptoms your child has had. Ask them to monitor your child and communicate with you if they notice changes. If you think it’s necessary, ask for a short-term care plan to be put in place to adapt your child’s programme – it may be that they are unusually tired after lunch, for example, and need a nap or low-stress activity at that time.

6. If symptoms persist, seek advice and support

If you think that your child is still having problems three to six months after their concussion, it may be useful to get further support from a paediatrician or psychologist who specialises in traumatic brain injury. They can assess your child’s functioning and make recommendations as to how they can be supported, both at home and school.

7. Don’t worry

Remember, many kids get concussion and most do not experience ongoing effects. It helps to be aware that persistent problems are a possibility, but it probably doesn’t help to tie yourself up in knots about it. Let your child climb that tree and remember that, most of the time, the benefits of play outweigh the risks.


This article is an abridged version of one already published by The Hoopla - click here to see the original article, with thanks to The Hoopla. ]]>Thu, 11 Jun 2015 10:09:10 GMThttp://www.casepsychology.com.au/blog/how-do-i-know-if-my-child-needs-a-cognitive-assessmentI am often asked the question: "How do I know if my child needs an assessment?". It can be difficult to know whether assessment is warranted and the process may be quite in-depth. So it's important to be sure that a cognitive or learning assessment is the right thing for your child.

Cognitive assessments (sometimes called neuropsychological assessment or IQ testing) should help us to understand an individual's intellectual strengths and weaknesses, and highlight areas of impairment. This is important because it can help us to explain why an individual might be having problems at school or work. When we know why, then we can start to address the problem with evidence-based strategies and solutions. 
Cognitive assessments typically examine the following things:

• Language skills 
• Perceptual or visual reasoning
• Memory
• Processing Speed

The cognitive assessment process may also include a formal educational assessment in order to examine academic performance and learning. A comprehensive report should always be provided so that this information can be shared with your family, GP, teachers and any other involved professionals that you would like to keep informed.

Intellectual Disability
Cognitive assessment enables us to identify when an individual is experiencing a significant intellectual disability. With proper diagnosis, individuals with intellectual disabilities may then gain access to extra funding, resources and support at both home and school. Accurate diagnosis in these cases is critical when it comes to assisting teachers and families to understand and meet a young person's individual needs.

Learning Disorders
Cognitive assessment is also important in the accurate detection of learning difficulties and disorders, such as dyslexia. With accurate diagnosis, your psychologist can then make practical recommendations and clearly outline what strategies can be used to address any learning difficulties. 

How do I know if my child needs an assessment?
So, what are the key signs that your child might benefit from a cognitive assessment?

• Struggling at school

If your child seems to be struggling to keep up with their schoolwork, particularly in the areas of literacy or maths, it's important to find out why. If your child's teacher expresses concern or advises that your child's performance is significantly behind his/her peers, this is a red flag.

• Poor memory/attention

If your child seems quite forgetful, has difficulty following instructions or organising themselves, or seems very 'dreamy' in class, this could point to a possible memory or attention issue. These types of issues often underpin learning difficulties, so it is important for us to identify the cognitive problem in order to effectively address it.

• Behavioural problems

Some children with cognitive issues also have behavioural issues at home and / or school. They may find it difficult to control anger, inhibit their behaviour and act appropriately. Children with cognitive problems may seem 'immature' compared to their peers and may struggle to fit in socially. These types of problems often become more apparent as a child gets older. Again, it is important for children with behavioural problems to undergo comprehensive clinical assessment; cognitive assessment may be an important part of this process.

• Difficulty with basic skills and self-care

Individuals with cognitive impairments may need more assistance with tasks and independent living. It is very normal for small children to need help with tasks like getting dressed, eating, etc. However, as children grow older we expect them to be able to do more tasks independently. Everybody develops at different rates, but if you or your family doctor have concerns regarding your child's skill level or whether they are meeting appropriate developmental milestones, it is certainly important to seek assessment.


What if my child is gifted?
Just as children with intellectual impairments need to be understood and supported, so do children who are intellectually gifted. Gifted children may be at risk of becoming bored or disengaged at school if they are not properly challenged and stimulated. Cognitive assessment can establish whether a child is gifted and what their particular strengths are. This information can then be provided to teachers to assist them in developing individual learning plans that are specially tailored to the gifted child's needs.

Is this type of assessment right for us?
Some people worry that seeking an assessment may result in their child being labelled. This is a valid concern; a diagnosis may not always be what a family is seeking. It is important that psychologists and other health practitioners consider the possible benefits and downfalls of diagnosis for each individual. Ultimately, we all want what is best for the child and it is crucial for families and clinicians to work together to get the best possible outcomes. If a diagnosis is going to assist a family or a child to access increased resourcing, funding and result in better understanding of that child's needs, then it may well be in the child's best interests to receive a diagnosis. Accurate diagnosis can help us to select the most effective type of intervention, ensuring that your child receives the best possible care. However, if a diagnosis does not help us to understand and better meet a child's needs, then we need to question whether it is appropriate to apply such a label. Sometimes it is enough to simply understand a child's pattern of strengths and weaknesses, regardless of what labels could be applied. These are important discussions for families to have with any psychologist or medical professional involved in their child's assessment and care. 

For more information, or if you would like to know more about how to obtain a cognitive or learning assessment for yourself or someone you love, click here. Alternatively, leave us a message here and we will try to answer your query as soon as possible


Dr Rosalind Case
PhD, PGDipPsych(Clin), MSocSc, BSocSc(Hons), MAPS
CLINICAL PSYCHOLOGIST]]>