Monday, September 19th, 2016
The following is a reprint of an article I wrote this year. Part of the work I do involves helping families with teens or young adults with significant emotional/behavioral struggles. I sometimes consult with therapeutic programs so that they are more sensitive and responsive to LD-related issues and how they impact therapeutic concerns.
Resolving Issues of Learning Disabilities, ADHD and Therapeutic Education
Integrating knowledge from mental and behavioral health with best practices culled from cognitive science is a critical ingredient when considering how therapeutic programs can improve outcomes. Understanding how learning disabilities and the neuro-developmental conditions of ADHD/Executive Functions deficits, and Autism Spectrum Disorder (ASD) impact behavior and mental health, should be a current and on-going goal for our therapeutic community. According to experts, upwards of 60% of adolescents in residential treatment centers for substance abuse have learning disabilities (. Tracking enrollment data from all types of therapeutic programs indicates that students with ASD and ADHD contribute to, and even add to those numbers. Consequently, it’s an imperative that programs and schools become better informed about what science and clinical practice tell us about these conditions and how they impact mental health.
It’s more than self-esteem
Historically there has been a clear and continued awareness of the burdening effect and weakening of self-esteem in students with a history of learning disabilities and related conditions. Schools and programs have been relatively quick to recognize negative effects that stem from unspoken student thoughts, such as “I’m not good enough” and “I’m not smart.” However going further down this path, one understands that perhaps the most damaging aspect is the mindset of reduced self-efficacy, or belief in the effectiveness of one’s own efforts. Frostig’s landmark study was one of the early ones to signal this. Students with LD, ADHD and EF deficits suffer from a limiting belief that their efforts don’t have much to do with the results they see in their lives. This is the real meaning of “learned helplessness.” Further, such students perceive that most interventions, regardless of intention or potential effectiveness, are “done to me.” Partnership becomes much more difficult to achieve.
When I am involved in faculty training, one of the most common misunderstandings I run into involves issues related to processing. The ways in which information (verbal and non verbal) is processed have huge effects on how and whether such students process therapy as well as classroom instruction. When a student who struggles to effectively organize spoken language (and even bright dyslexic students can struggle with this) too much talk therapy is, well, too much talk. This is no trivial matter. I remember the moment when my own stepson advocated for himself by telling us that when he calls home, he doesn’t want his mom and I on separate phones talking together with him at the same time. He gets overwhelmed with the amount and density of language. Now imagine a high-powered and emotionally charged group therapy session. Some students needs appropriate set up and an effective debrief. He/she may also benefit from some version of what’s called skeletal outlining during such a session. It’s important to ask a student even during an individual therapy session to recap the main issues and possible solutions covered. In addition we know from science and practice, that creating schematic visual representations (picture a flow chart or decision tree) helps support weaker language processing, short-term and working memory. Lastly, students who have such language-based learning disabilities including dyslexia, may also struggle to effectively produce precise language on demand. In a therapeutic context this can look like a teenager who is withholding, or even dishonest, unless one looks under the hood, cognitively speaking.
Autism Spectrum Disorder
While it’s outside the scope of this article to discuss all the complexities of students with an Asperger’s presentation, here are a few important paradigms and observations, based in part on my time as an executive director of a school where 60% of our students had Asperger’s Syndrome or Non-Verbal Learning Disabilities. Much of the literature discusses weaknesses in reading the social and non-verbal cues of others. Most programs are at least partially familiar with these issues. What gets less or little attention is the flip side of this; namely weaknesses resulting in under-recognition of their own non-verbal signals. As a result, stress management becomes infinitely more complicated. Literature indicates that the neurobiology of autism spectrum involves right hemisphere weakness, an underperforming insula and an overactive amygdala. Such neurological characteristics help us understand why some students fail to recognize their own signs of distress, why hygiene is an on-going issue and why relatively neutral interactions can seem so threatening. One of the main jobs of the insula is to register and move sensory information from the body and emotional (limbic) centers to the thinking and meta-cognitive parts of the brain. We have to wrestle with this, in order to explicitly work on these areas when treatment planning. In general, students with these types of deficits may benefit from somatic therapies, aspects of mindfulness, and visual-spatial supports.
Executive Function Deficits and Resource Pool Depletion
Dr. Russell Barkley, one of the world’s most respected authorities on ADHD and Executive Function deficits, outlines the concept of resource pool depletion. In essence, every time someone with executive function deficits engages in a task that demands these self-regulation skills, their EF fuel tank is depleted further. Research helps us recognize what to do and how to build up these resources as well as avoid unnecessary depletion. I find that front line staffs of therapeutic programs are hungry for more knowledge in this area.
One of the longstanding and often helpful operating paradigms in therapeutic programs is “natural and logical consequences.” Learning through the experience of mistakes and their consequences feels intuitive and seemingly bulletproof from criticism. However it’s important to recognize its limitations in terms what research tells us. Addicts often defy this logic for example. We know that the powerful forces of addiction often disobey this type of learning from mistakes. These conditions all contain a common denominator: powerful chemical, neurological undercurrents. Consequently, simply waiting for the light bulb to go on for those with significant ADHD and Executive Function deficits is often an exercise in futility. They don’t suffer from a lack of knowing what to do. They suffer with issues of performance. Without knowing how to offer the right types of supports at the “points of performance” teachers and therapists are left to repeatedly apply consequences. It can be a vicious cycle that engenders repeated failure.
Not all therapeutic programs need to become experts in these areas. Learning how to apply awareness of these special needs will wind up helping all students. This is referred to as a universal design approach. Building sidewalk ramps for folks in wheelchairs has given help for people with sprained ankles, skateboarders and parents with strollers and carts. Similarly, employing best practices in reading instruction helps able readers to become advanced readers. This is my hope and perspective of integration between disciplines.