ADHD: A VAST Topic

This week, two returning guests discuss ADHD with me through a strengths-based lens. By focusing on positivity and relationships, we move away from what is broken and instead build upon the times where having ADHD has been a strength. Occupational Therapist Maude Le Roux from A Total Approach in Pennsylvania and Licensed Professional Counsellor Mike Fields in Atlanta, who are both Expert Trainers in the Developmental, Individual differences, Relationship-based (DIR) Model, or DIR/Floortime, have extensive experience with ADHD.

Maude sees many children with ADHD in her clinic and does training on ADHD to other professionals, and Mike was diagnosed with ADHD as an adult. In a recent Carlat Psychiatry Podcast episode with psychiatrist Josh Feder and his colleague, Licensed Clinical Social Worker Mara Goverman called, “Reimagining ADHD with Edward Hallowell, MD“, they discussed how Dr. Hallowell, author of Driven to Distraction and ADHD 2.0, reimagines ADHD as VAST, Variable Attention Stimulus Trait. Maude, Mike, and I discuss this vast topic.

What is ‘ADHD’?

Maude says that as an Occupational Therapist, ADHD and DIR/Floortime are both all about development. Most of the research out there including that of Dr. Barkley is focused on ADHD as a medical diagnosis with various pieces attached to it. They don’t talk about ADD, Attention Deficit Disorder, anymore. Now they talk about SCT, which is Sluggish Cognitive Tempo, which is also not a name that people are happy with. ADHD, though, has the hallmark of hyperactivity for six months or longer, Maude explains. You also cannot have another diagnostic category, such as Autism Spectrum Disorder, she adds, even though many autistic individuals meet the diagnosis for the ‘attention deficit’ piece.

Maude looks at it developmentally. In order to have attention, a certain number of building blocks have to be in place, she explains. In the book Images of the Mind, Dr. Michael Posner talks about seven steps of hierarchy in the brain. Maude has summarized them into four pieces that she uses in the developmental continuum to assess her clients. First, you have to be able to register a stimulus from different systems–mostly your auditory and visual systems, but all the systems are involved. Second, you have to orient your body towards that stimulus. You then have to process the information to the cortex, and finally, you give meaning to it in the cortex, which is your attention piece, with attention being known as a cognitive type of skill.

In order to get attention, you have to go through these developmental levels, Maude continues. Many autistic children have sensory and registration issues. There’s a huge commonality with registration, postural orientation, processing speed, and then being able to do attention with meaning. Mike says that all of that sounds about right to him. He was a very energetic, outgoing child whose report cards would say, “If only he would be quiet and pay attention more.” Mike believes he stayed out of trouble because he was so happy-go-lucky. It’s often the quiet, happy kids who we don’t pick up whereas the kids who go into the fight response are the ones who get noticed for needing assessment.

The Profile of Individual Differences

Maude is not a fan of the DSM (Diagnostic and Statistical Manual of Mental Disorders). Each of us has some behaviours that we may see overlap with DSM categories because they are all human behaviours. While agreeing some kind of guide is helpful, Maude asks why it can’t just be considered a ‘profile’? Some of us are a little more careless or distracted than others. Maude doesn’t diagnose. She prefers to look at profiles and seeing behaviours as part of each child’s continuum of human behaviour: to look at their own adaptive response to what’s out there. Labels can really hurt people.

For attention, Maude says, we need all of the cranial nerves of the nervous system to be working together with a particular timing piece. If you’re looking at what the teacher is showing me, I also need to listen to what she’s telling me. If those systems aren’t in synch, they’re not reaching the cortex at the same time. It can feel like watching a badly dubbed movie. This is why kids will look away when listening because they can’t do both together, Maude explains. Maude asks, “Is that an attention deficit or is that a sensory integration dysfunction?”  

If we say, “That child is distractible”, we are labelling it almost like a bad behaviour. If we say, “We have a sensory integration dysfunction in the timing between those systems”, it’s far more a part of a profile, Maude says. Is it a deficit or a weakness? Sometimes it is and yet Maude’s ADHD clients are so creative and full of ideas, which are their strengths. And I like this idea about the profile because it’s what we talk about in the DIR Model: the ‘I’ is Individual differences. And one of the first things we do with parents when meeting about their child is have everyone fill out their own sensory processing profiles.

The Parent Profile 

Often parents learn after their child is on the spectrum that they are on the spectrum as well, or that they have ADHD but they were never diagnosed. I gave an example of how, unlike Maude and Mike who had notes on their school report cards that they could do better, I was a star student and teacher’s pet with no issues. However, when I got to university I found it very difficult to succeed when I was no longer in the safety of relationships and smaller classrooms and when the amount of individual work required increased. I also remembered that in graduate school I was called out for always nodding off in a small seminar class. I noted that I am a sensory seeker like my son and if I’m not multi-tasking, I doze off!

What’s in a Label?

Mike says, from a Floortime perspective, “Who cares” about the labels, though. Labels do help us get services and reimbursement money for our children. That is why there is still a medical model approach with data and things having to be measured to show progress. But sometimes, Mike adds, not everything that can be counted counts, and not everything that counts can be counted. It’s why Dr. Greenspan came up with the Diagnostic Manual for Infancy and Early Childhood, Mike says. Autism is a broad spectrum of experiences and differences, Mike continues. Greenspan and Wieder’s diagnostic manual really gives you the pieces of the profile. 

If someone needs to move a lot or takes longer to process things they see, that information is useful, Mike says, but these descriptions won’t get you insurance coverage (although it’s being worked on through ICDL’s advocacy efforts, and there is a class currently in development on how to write insurance goals from a Floortime perspective). Mike loves the framework that the DIR Model gives him because he loves symbolism and imagery, and this is where his ADHD is a superpower. He can hold bits of information to symbolize larger amounts of information.

Mapping out our Profile

The way Mike teaches Floortime is first by considering the Functional Emotional Developmental Capacities (FEDCs) as a roadmap to figure out what town we’re in. Next, the Individual differences are like the legend for the map. Here you see the places you need to check out on your journey, or here are areas that can be a little tricky or dangerous, so be careful when travelling through these areas. Relationships are the vehicle that we’re travelling in, and affect is the fuel for everything. By focusing on strengths we can rise from where we are already strong and make something happen. 

Mike says that when you follow your interests, you are doing what you love and making meaning from it, versus studying what you had to study in school. Mike says that ADHD is interests-based over priority. Mike just wants people to be happy and successful in the way they want to be rather than telling them how to be. This makes Maude think about how we can be led down a trajectory that doesn’t fit, based on a label of a diagnosis. And what does this do to a child’s psyche, Maude wonders, when they have to go to the nurse’s office each day to take their medicine because without it, they can’t function like their peers?

Sense of Self and Identity

Maude says that because school is mostly left-brain activities like logic, rules, pragmatics, and structure, she wonders what putting kids with ADHD into this trajectory does to their creativity, which is the right-brain. Maude suggests to parents of children with ADHD who find writing tasks challenging to focus on their strengths by writing for them as the child tells them all their ideas, and then compliment all their great ideas. Then say, “Let’s put all those cool thoughts together and create an essay. We’ll get there.“

Mike says that this is where story becomes important and why he got into therapeutic games for growth and healing. We get to act out different characters and try out different experiences, do things we wouldn’t get to do in regular life, and see how that turns out in the safety of the confines of a story or game. Story and identity play a huge part in how we see and feel about ourselves, Mike says. Mike believes that everyone should be able to write their own story and define themselves how they see themselves.

Maude trains her new staff to throw out their idea of having to pack in 10 activities into one session. Instead, follow the child’s strengths and let them experience what it feels like to be Thomas the Tank Engine or the Wizard of Oz. Otherwise, you run the risk of the child feeling that they aren’t good enough if they can’t meet the standards you are setting for them. Maude says we can’t judge the book by its cover, or the child by their label. It’s each child’s story that makes them unique, not the overlap. 

A Statistical Artifact

Maude says that while she understands the need for clustering tendencies for science, she doesn’t like when it harms the child’s identity. This reminded me of the last podcast on constructed emotions where Dr. Lisa Feldman Barrett’s book, How Emotions are Made, described that the average facial expression of emotion doesn’t exist because it’s a statistical artifact like the way 2.1 children doesn’t exist. Similarly, a label does not describe one child. It’s a summary of a population. 

How to Support and Help ADHD

In Josh & Mara’s podcast they described how Dr. Ned was asked by a mother who saw him at a conference to please help her help her son over the phone from the U.S. to where she was in China. Three things helped her child tremendously in quite a short amount of time:

• Stop hitting the child (which hopefully doesn’t happen in schools here)
• Provide the child with tons of love from their caregivers and presume competence
• Cerebellar exercises for balance co-ordination including skateboarding, using a wobble board, standing on one foot with your eyes closed

Movement

In the Sensory Lifestyle podcast with O.T. Virginia Spielmann, she spoke about how important movement is from Elizabeth Torres’ work. Maude says there is a lot of research about how cerebellar activity is the peptides for the system and for joy. She mentions Candace Pert‘s research on the molecules of emotion talking about the whole piece of activity and vestibular activation. As an Occupational Therapist, that is her job, Maude says, to center all the sensory systems around the axis of the vestibular system, and how the vestibular system is the central integrator to auditory, to visual, to proprioception, and all the other pieces. Movement does it.

Maude says that when someone is depressed they move less and are slower in their speech and less expressive. Trauma researchers like Dr. Peter Levine, Pat Ogden, Janina Fisher, and Bessel van der Kolk know this, she says. The body holds the score, they say. The way we move, Maude says, tells people about us. The vestibular system drives attention, integration, praxis, motor planning, and how we time our systems together in order to look and listen to you at the same time. The overlap in the parietal (sensory-motor) and temporal (timing/language) lobes of the brain come together. 

They also come together in the area involved in interoception. Understanding how I feel inside is going to help me understand how you feel, Maude explains. It’s the piece of empathy. You cannot separate the vestibular system from these pieces. That vestibular helps and supports brain development is an absolute researched fact, Maude contends. While Dr. Feder mentioned the benefits of movement in the Carlat podcast, he also brought up another great point. He always wants to try movement and a Floortime approach before prescribing medication, as we discussed in a podcast here before.  

Medication

Dr. Feder said that if the child is progressing in their development, he won’t rush to medication. I shared that doctors have suggested hyperactivity medication for our son numerous times, but we haven’t gone that route because of our son’s developmental progress. Will we need to going forward? Maybe. Mike jokes that he wants that medicine that makes him do stuff that he doesn’t want to do. Mike says that it’s easy to focus and pay attention when it’s something he enjoys. It’s not a deficit, but a regulation issue and a question of how we bring it all together. 

Motivation

Mike says that solving cognitive and emotional problems are abstract. It can be hard and frustrating because we can’t see what we’re trying to do, he continues. We first have to learn through a more concrete and physical way how to solve problems, he suggests. It helps with praxis and motor planning and figuring out sequencing, and then how to adapt when things go wrong. It’s affect that holds all of that together. On her YouTube channel ‘How to ADHD‘, Jessica McCabe talks about how we can trick our minds or reframe things to use what we’re good at, scaffolding weaknesses. 

In a recent episode Mike watched, she talked about body doubling. If there’s something he doesn’t want to do because it’s hard, tedious, or uninteresting to him, so he can’t regulate his attention to persist, being around somebody who’s working makes it easier for him to work. He is not good at structure so he needs to external structure to organize his internal organization. During Covid this has been harder. Mike says he is a pathological extravert and needs people to energize. He’s also noticed that masks have impacted his hearing because he focuses on the mouth when others are talking (and their eyes when he is talking).

Maude says there actually is research to support that. It’s like how we feel like we can’t hear when we take our glasses off. Maude also agrees with Mike adding that the sensory registration of information from the vestibular system really does make you feel productive in your body so that you can become productive in your executive functions. Maude also corroborated Mike’s experience saying that when we don’t feel an internal locus of control, we seek an external locus of control. It applies to all of the co-morbidities too including anxiety and even picky eating, Maude adds.

An Interdisciplinary Approach

Mike says that DIR/Floortime is interdisciplinary because there is no separating out of pieces of ourselves that are all interwoven. The sensory systems, the emotion, the identity, the psyche, the capacity for engagement or reciprocity.  It’s great to get a big picture while seeing individual pieces. It’s messy. It’s easier to be a behaviourist, Mike says.

This week I have an Bonus Podcast for you: some additional content with Mike Fields about working with a coach for his ADHD, more about his ADHD characteristics, about therapies that do or don’t help, strategies that are helpful, how ADHD affects his marriage, and more about Floortime and Individual differences!

Thank you to Maude and Mike for sharing their expertise and experiences on this vast topic. If you enjoyed and found it useful and helpful, please do share it on Facebook or Twitter and feel free to share relevant experiences, questions, or comments in the Comments section below. If it sparked some ideas about spin-off topics related to applying DIR/Floortime or anything we discussed, let me know! 

Until next week, here’s to affecting autism through playful interactions!