Posted by: faithful | November 10, 2014

misdiagnosis and giftedness in children

That’s not autism: It’s simply a brainy, introverted boy

Autism spectrum diagnoses are up 78 percent in 10 years. We’re dramatically overdiagnosing it in everyday behavior

That's not autism: It's simply a brainy, introverted boy(Credit: Humannet, Luiscar74 via Shutterstock/Salon)

I have followed William in my therapy practice for close to a decade. His story is a prime example of the type of brainy, mentally gifted, single-minded, willful boys who often are falsely diagnosed with autism spectrum disorder when they are assessed as young children. This unfortunate occurrence is partly due to defining autism as a “spectrum disorder,” incorporating mild and severe cases of problematic social communication and interaction, as well as restricted interests and behavior. In its milder form, especially among preschool- and kindergarten-age boys, it is tough to distinguish between early signs of autism spectrum disorder and indications that we have on our hands a young boy who is a budding intellectual, is more interested in studying objects than hanging out with friends, overvalues logic, is socially awkward unless interacting with others who share identical interests or is in a leadership role, learns best when obsessed with a topic, and is overly businesslike and serious in how he socializes. The picture gets even more complicated during the toddler years, when normal, crude assertions of willfulness, tantrums, and lapses in verbal mastery when highly emotional are in full swing. As we shall see, boys like William, who embody a combination of emerging masculine braininess and a difficult toddlerhood, can be fair game for a mild diagnosis of autism spectrum disorder, when it does not apply.

Jacqueline, William’s mother, realized that he was a quirky baby within weeks of his birth. When she held him in her arms, he seemed more fascinated by objects in his field of vision than by faces. The whir and motion of a fan, the tick-tock of a clock, or the drip-drip of a coffeemaker grabbed William’s attention even more than smiling faces, melodic voices, or welcoming eyes. His odd body movements concerned Jacqueline. William often contorted his body and arched his back upwards. He appeared utterly beguiled by the sensory world around him. He labored to prop himself up, as if desperately needing to witness it firsthand.

Some normal developmental milestones did not apply to William. He bypassed a true crawling stage and walked upright by ten and a half months. He babbled as an infant and spoke his first words at twelve months; however, by age two, he was routinely using full sentences and speaking like a little adult.

When William encountered an interesting object or event as a toddler, he became so captivated by it that he completely ignored the people around him. During a music class, he once stood off to the side, staring at a ceiling fan while all of the other kids sat together singing. Then suddenly, William ran toward the teacher. He was mesmerized by the synchronous movement of the teacher’s lips and fingering of guitar strings that together produced melodic sounds, to the point of losing all awareness that his face was just inches away from his teacher’s. At his two-year birthday party, while the other kids were playing in the backyard, William methodically took some folding chairs, lined them up, and pushed them over one at a time—intrigued by the noises the falling chairs made. He repeated this series of events over and over throughout the afternoon, as if conducting a series of well-crafted experiments.

By age three, William began developing a passionate interest in a range of adult-like topics. After being read a book on Pompeii, he talked endlessly for months afterwards about what he had learned. He pressured Jacqueline to check books out of the library on Pompeii in order to satisfy his need for more detailed knowledge on what Roman life was like before Mount Vesuvius erupted and buried the ancient city in ashes. He strove to know more about aqueducts and amphitheaters. He insisted that Jacqueline design a toga for him, which she did. He strutted around the living room not just pretending to be, but believing that he was, a citizen of the Roman Empire, circa AD 79.

Steve, the lovable host of the children’s TV program “Blue’s Clues,” became an idol for William. He avidly watched reruns of the show and lobbied his parents hard for a green shirt, khaki pants, and brown shoes so that he could look just like Steve—no compromises.

Next he became fascinated with the Titanic, amassing a detailed knowledge of the design of the ship. Facts such as the exact length of the Titanic (882 feet, 9 inches) mattered to him. He also knew that its top speed was 23 knots. William insisted on having a uniform just like Captain Smith’s, the officer who was in command of the Titanic. Getting the color and the arrangement of the stripes and buttons correct seemed essential to William when he and his mother designed it. Jacqueline also helped William amass an impressive collection of pictures of ships, ocean liners, and uniformed officers, which he studied on his own for hours on end.

At preschool, William was a veritable pied piper. During his “Titanic phase,” he arrived at school sporting his Captain Smith blazer and cap. He orchestrated Titanic reenactment scenes, assigning roles and telling his classmates where to stand and what to do and say. This would usually go well at first. William’s enthusiasm was intoxicating, and the play scenes he devised were too exciting for the other kids to pass up. However, more often than not, the other kids eventually lost interest and wandered off because of William’s need for them to follow his script.

At home, William’s tantrums were wild and uncontrollable even as he approached age five. When he was asked by his parents to turn the TV off and join the family for dinner, he might scream and yell in protest, writhe around on the floor, and even throw and break things. Invariably, the situation that caused William to fly into a rage involved setting aside what he was doing in the moment to comply with a routine request—such as to get ready for bed or dressed for preschool. He simply hated transitions. Unless his parents regularly planned activities that were in line with his interests, William inevitably became agitated, overactive, and unmanageable.

Mealtime was another “powder keg” situation. William was repulsed by vegetables. If carrots, broccoli, or any other vegetable was placed on his plate, he thought nothing of throwing the entire dish on the floor. All he could stomach was a short menu of items like pizza, hot dogs, or peanut butter sandwiches.

William’s parents were sociable. They spent a great deal of time in the company of other parents and children. They knew William’s tantrums, fussy eating habits, and social difficulties were outside the norm. Their friends’ kids were maturing, while William seemed stuck. When William was five years old, they decided to have him evaluated. A highly respected doctor at a university-based institute was sought out to conduct the initial evaluation. During a twenty-minute observation, William mostly sat staring at the doctor’s bookshelves—either ignoring or providing one-word answers to the questions he was asked. At the end of this brief observation, the doctor concluded that William was “on the spectrum” and had Asperger’s syndrome. The doctor reassured Jacqueline that her son’s difficulties were due to him having a brain disorder and that she should in no way hold herself responsible. He advised her to have further testing conducted through the institute to confirm the diagnosis and to approach her local regional center to obtain services for him—“Mostly as a precaution in case he can’t take care of himself when he gets older.”

Years later, when recounting this experience for me, Jacqueline said this news was like a “blow to the solar plexus.” But she convinced herself that failing to trust the conclusions of a highly respected doctor from a prestigious university hospital was nothing short of staying in denial about William. She followed through with a recommendation to have William more thoroughly assessed by autism experts at this same hospital. Their assessment revealed that William had an IQ of 144—placing him squarely in the mentally gifted range. A formal speech and language assessment indicated that William was well over a year ahead in all areas. However, in the final report, it was noted that while William was alone with the examiner, he was unable to initiate or sustain conversations. He either stared off into the distance or interrupted the examiner to talk about off-topic subjects that were of interest to him—such as tornadoes, hurricanes, and earthquakes. When asked about friends, William made vague references to two girls who had moved away and was unable to recall any recent activities he had engaged in with them. Due mostly to his behavior in the room, the examiner assigned him a diagnosis of autism disorder because of his “communication and qualitative impairments in reciprocal social interaction.” Jacqueline was confused by the report. She wondered if the examiner had taken any time to actively engage William. She knew that William could be quite animated and talkative when adults took a liking to him.

Nevertheless, William’s parents went along with the diagnosis and so began their bewildering odyssey into the mental health field. At the behest of the specialist who assessed William, they secured a lawyer to sue the local regional center to obtain autism services. The regional center had unilaterally denied such services, claiming William needed to have been formally diagnosed as autistic prior to age three. It took $22,000 in legal fees to bring their case before a judge, who ordered William to be formally assessed by a medical doctor at the regional center. That doctor determined that William had full-blown autism and did indeed qualify for services. However, as the years unfolded, William’s parents had lingering doubts. They approached me when he was age eight.

I agreed to meet with William and to offer my clinical judgment. Within minutes of playing with William, I knew, unequivocally, that he was not “on the spectrum.” He was enthralled by the range of dart guns I had in my office and asked if we could play a World War II game. I heartily complied. William took turns being Hitler, then Stalin, mentioning how he was in command of millions of troops who followed his orders. When I playfully acted as one of his minions awaiting orders to shoot the enemy, William became delighted. He threw himself into the role of dictatorial commander and ordered me to shoot an imaginary enemy soldier. I did so, making loud machine-gun noises. William was emotionally beside himself. He quickly asked if he could be Stalin and I could be Hitler, and if I would shoot him. We reenacted this Hitler-shooting-Stalin scene over and over, with William pretending to be in the throes of death, each time using louder gurgling sounds and ever-so-dramatic, jerky body movements.

For me, William’s imaginativeness, as well as the emotional give-and-take in our pretend play interactions, was proof positive that it was folly to consider him autistic in any way.

Fast-forward to the present. William is now a high school student who is very active in student government. He is quite at ease with other teenagers who share his level of intellect. He continues to demonstrate the same thirst for knowledge that he had as a toddler. When classroom subjects interest him, his academic performance is stellar. When they don’t, William’s grades suffer. His report cards often contain peaks and valleys of As and Fs, which is immensely frustrating for his parents. His interests are not highly obscure and detail oriented, characteristic of autism, such as memorizing the names of dinosaurs or the serial numbers on Ford trucks. He is an abstract thinker who labors to understand issues more deeply. For instance, he has a complex understanding of different forms of government, and he is able to articulate the arguments for and against democratic, fascist, and oligarchical arrangements. This conceptual, philosophical way of acquiring knowledge tends not to be autism-friendly.

Granted, William is far more comfortable isolating himself and studying political geography and rock-and-roll memorabilia than he is hanging out at the mall. In addition, he can still explode emotionally when he is forced to switch activities, such as applying himself to his homework rather than researching Fender guitars or the geography of Iceland on the Internet. Moreover, he’ll only incorporate new food items into his diet when he has tried them at a fancy restaurant that doesn’t have kiddie foods such as pizza, hot dogs, or peanut butter sandwiches on the menu. However, these traits and behaviors don’t mean that he’s autism spectrum disordered. They reveal William to be a brainy, somewhat introverted, individualistically minded boy whose overexcitement for ideas and need for control cause problems with parents and peers.

As we shall see, boys with these traits and behaviors are often falsely diagnosed with autism spectrum disorder, especially when they are assessed at younger ages.

The early-diagnosis trap

True autism is a potentially very disabling neurological condition. Roy Richard Grinker, in his acclaimed book “Unstrange Minds,” masterfully documents the challenges he faced raising Isabel, his autistic daughter. At age two, she only made passing eye contact, rarely initiated interactions, and had trouble responding to her name in a consistent fashion. Her play often took the form of rote activities such as drawing the same picture repeatedly or rewinding a DVD to watch the same film clip over and over. Unless awakened each morning with the same utterance, “Get up! Get up!” Isabel became quite agitated. She tended to be very literal and concrete in her language comprehension. Expressions like “I’m so tired I could die” left her apprehensive about actual death. By age five, Isabel remained almost completely nonverbal.

When the signs of autism spectrum disorder are clear, as in Isabel’s case, early detection and intervention are essential to bolster verbal communication and social skills. The brain is simply more malleable when children are young. Isabel’s story in “Unstrange Minds” is a heroic testament to the strides a child can make when afforded the right interventions at the right time.

However, the earlier an evaluation is conducted, the greater the risk of a false diagnosis. Many toddlers can be autistic-like in their behavior when they are stressed. Sometimes the procedures used by experts to evaluate toddlers generate the sort of stress that leads a struggling, but otherwise normally developing, toddler to behavior that is autistic-like.

Nobody has made this point more clearly than the late Dr. Stanley Greenspan, the internationally recognized child psychiatrist who developed the popular Floortime approach to treating autism spectrum disordered kids. In his web-based radio show several years before his death in April 2010, he cited an alarming statistic. Of the two hundred autism assessment programs his team surveyed across the country, many of which were located in prestigious medical centers, only 10 percent emphasized the need to observe a child along with a parent or guardian for more than ten minutes as they spontaneously interacted together. He tended to observe children playing with a parent for forty-five minutes or more, waiting for choice points to engage a child to determine if he or she was capable of more sustained eye contact, elaborate verbalizations, or shared emotional reactions. Dr. Greenspan believed that these conditions of safety and sensitive interaction were essential in order to obtain an accurate reading of a child’s true verbal and social skills.

For a sizable percentage of toddlers who don’t transition well to new surroundings, freeze up with strangers, or temporarily dread being apart from a parent, the formal nature of a structured autism assessment can lead to their becoming mute, hiding under a table, avoiding eye contact, hand flapping, or exhibiting any number of other self-soothing behaviors that get misinterpreted as autistic-like. Trained professionals are supposed to conduct autism assessments in a standardized way. This is clinical jargon for being fairly neutral in one’s approach to the child. This might involve an examiner assuming a seating position that requires a child to turn his or her head ninety degrees to directly look at the examiner when his or her name is called. If the child fails to look up and make direct eye contact with the examiner after his or her name is called aloud several times, the child is considered to be exhibiting autism red-zone behavior. Yet many distressed or slow-to-warm toddlers will only respond to their name if an unfamiliar adult strives to be warm, engaging, and nonthreatening—not just neutral.

It is these autistic-like situational reactions of struggling toddlers during formal testing conditions that make a false diagnosis a real possibility. A 2007 University of North Carolina at Chapel Hill study found that over 30 percent of children diagnosed as autistic at age two no longer fit the diagnosis at age four. Several years ago, data supplied by parents of over seventy-eight thousand three- to seventeen-year-olds, as part of a National Survey of Children’s Health, discovered that nearly 40 percent had a previous, but not a current, diagnosis of autism spectrum disorder.

There are other reasons why a sizable percentage of toddlers get erroneously diagnosed with autism spectrum disorder. Up to one in five two-year-olds are late talkers. They fall below the fifty-word expressive-vocabulary threshold and appear incapable of stringing together two- and three-word phrases. This sort of irregular language development is one of the hallmarks of early autism. Yet it is notoriously difficult to distinguish between toddlers with autism spectrum disorder and those who are afflicted with delayed language development. The situation is further complicated by the fact that toddlers with delayed language development tend to share other features in common with autism spectrum children. Scientific findings at the famed Yale Child Study Center have shown that toddlers with delayed language development are almost identical to their autism spectrum disordered counterparts in their use of eye contact to gauge social interactions, the range of sounds and words they produce, and the emotional give-and-take they are capable of. Consequently, many toddlers who simply don’t meet standard benchmarks for how quickly language should be acquired and social interactions mastered are in the autism red zone.

Expanding autistic phenomena to include picky eating and tantrums only amounts to more confusion when applied to toddlers. The percentage of young children in the United States with poor appetites and picky eating habits is so high that experts writing in the journal Pediatrics in 2007 commented, “It could reasonably be said that eating-behavior problems are a normal feature of toddler life.” Tantrums also are surprisingly frequent and intense during the toddler years. Dr. Gina Mireault, a behavioral sciences professor at Johnson State College in Vermont, studied children from three separate local preschools. She discerned that toddlers had tantrums, on average, once every few days. Almost a third of the parents surveyed considered their child’s tantrum behavior to be distressing or disturbing.

With the push to screen for and detect autism spectrum disorder at progressively younger ages, the risk is greater that late-talking, picky-eating, tantrum-throwing, transition-resistant toddlers will be misperceived as potentially autistic—especially if an evaluation is conducted in which the child is not sensitively engaged and put at ease. The risk is more acute, as I will soon illustrate, if this toddler is likely to develop into an introverted, cognitively gifted boy who tends to be single-minded and willful in his approach to life learning. Even more basic than that, if we don’t have a firm grasp of gender differences in how young children communicate and socialize, we can mistake traditional masculine behavior for high-functioning autism.

How boys communicate and socialize

A book I return to every so often is Eleanor Maccoby’s “The Two Sexes.” Her descriptions of boys’ and girls’ different speech styles jive with what I see daily in my office. She maintains, and I agree, that boys’ speech, on average, tends to be more egoisticthan girls’. Boys are more apt to brag, interrupt, and talk over others, and ignore commands or suggestions. They are more inclined to grandstand and “hold court,” trying to impress listeners with all that they know. They seem to be less socially attuned than girls. They are less likely to scan the faces and body language of others for cues on whether they should stop talking and start listening—for basic social sensitivity reasons.

Simon Baron-Cohen, the Cambridge University professor who popularized the extreme-male-brain theory of autism, would say that boys’ speech is more egoistic because, overall, boys tend to be less empathic than girls. He backs this up with abundant scientific evidence. Putting yourself in someone else’s shoes to figure out what they might be feeling comes more naturally to girls. Girls are simply more inclined to read a person’s facial expressions in order to make sure that they are coming across sensitively. Faces tend to be sources of social feedback for girls in ways that they are not for boys. Dr. Baron-Cohen’s research team has discovered that even at birth, female infants will look longer at faces than male infants and prolong mutual eye gazing.

Many boys just get perplexed when you try to empathize with them. As an example, I recently had the following interaction with Alan, an eight-year-old:

Alan: In my soccer game over the weekend, the other forwards on my team never passed to me. I was so mad.

Dr. Gnaulati: You were mad because your teammates didn’t pass to you, eh.

Alan: Why are you repeating what I just said? Didn’t you hear me?

This interaction with Alan captures how for many boys, grasping the literal content of their verbalizations matters more than “feeling understood.” Appearing attentive, asking probing questions, and reflecting back what someone is saying may be the empathic glue that cements a friendship for the average female. However, for the average male, following along with and responding to the literal content of what they are saying is what’s deemed valuable. A friend is someone who shares your interests and with whom you can have detailed discussions about these interests.

Watch boys at a sleepover and you’ll quickly realize that they need a joint activity to buttress social interaction and verbal dialogue. If that joint activity is a videogame like Red Dead Redemption, the discussion will be peppered with pragmatic exchanges of information about how best to tame horses, free someone who has been kidnapped, or locate animal pelts. Without a joint activity that taps into their preexisting knowledge about that activity, boys are often at a loss for discussion. There are long silences. Eye contact is avoided. Bodies become more wiggly.

Watch girls at a sleepover and any shared activity they engage in is often secondary to the pleasure they seem to derive from just hanging out and talking.

The stereotype of boys as logical, inflexible, and businesslike in their communication habits is more than just a stereotype. A recent massive study out of the University of Florida involving fifty-four hundred children in the United States ages eight to sixteen indicates that twice as many boys as girls fit this thinking-type temperament. Conversely, twice as many girls as boys fit the feeling-type temperament— tactful, friendly, compassionate, and preferring emotion over logic.

Many boys feel compelled to be logical and exact in their use of language. They withdraw and shut down around people who use language more loosely. A glaring example of this was shown to me recently by a fourteen-year-old client named Jordan. His parents brought him in for therapy because he was racking up school detentions for being rude to teachers. Jordan secretly confessed to me that his English teacher must be dumb because she referred to certain assignments as “homework” when she allowed them to be completed in class. She should have renamed them “schoolwork,” he said, because they were being completed at school. In twenty-five years of therapy practice, I’ve never known a girl to make such a comment.

As educated people, we don’t want to believe in overarching differences in communication styles between the sexes. When I was in college in the 1980s and ’90s, “essentialism” was a dirty word. To believe that males and females might be different in essential ways was akin to admitting that you were unenlightened. There’s still a pervasive sense in our culture that to be educated is to be gender-blind, and there is something of a taboo against voicing aloud explanations for a child’s behavior in terms of his or her gender. If you don’t believe me, try uttering some version of the following statements at your son’s next parent-teacher conference: Jamal is so logical and brusque when he talks. I know he needs all our help to ease up. But these are traditional masculine behaviors, after all, and we might need to accept him more for who he is. Or, Billy overtalks and really needs an audience, especially when he has a new favorite hobby or interest. He needs to be a better listener. But he’s not unlike a lot of boys I know.

It’s this public discomfort with discussing children’s gendered behavior that gets many traditionally masculine boys inappropriately labeled as high-functioning autistic. Poor eye contact, long-winded monologues about one’s new favorite topic, being overly serious and businesslike, appearing uninterested in other’s facial expressions, and restricting friendships to those who share one’s interests, may all be signs of Asperger’s syndrome or high-functioning autism. However, these same traits typify boys who are traditionally masculine in their behavior. Parents somehow have to ask the uncomfortable question in the doctor’s office: Is he high-functioning autistic or really a more masculine-identified boy? If it’s the latter, what a boy may need is some combination of acceptance and personal and professional help to finesse his social skills over time—not an incorrect diagnosis and unnecessary medical treatment.

Brainy, introverted boys beware

Let’s return to William. With all respect to the good doctors at the university-based institute who evaluated him, they were not up on the literature on mental giftedness. We know this because William manifested certain brainy, mentally gifted traits that can look autistic-like to the untrained eye, but aren’t. Take his tendency to burrow deep into a topic and crave more and more information on it. There was his Pompeii phase, then his Titanic phase. He just had to learn all that he possibly could about these topics. He talked the ear off of anybody who would listen to him about them. On the face of it, William’s obsessions appeared autistic-like. However, it is the enthusiasm with which he shared his interests with others that distinguishes William as brainy and mentally gifted, rather than autistic in any way. Remember, at preschool, he was sometimes a regular pied piper, amassing a following. Other kids were initially drawn to him when he held court or orchestrated his Titanic play. William lit up emotionally when he commanded the attention of the preschoolers who gathered around him.

When highly restricted interests are shared with relatively little spontaneity and enthusiasm, in ways that fail to entice children to come hither to listen and play—this is when we should suspect autism spectrum disorder. The same is true when a kid talks without interruption about a very technical topic, such as dinosaur names or bus schedules, seemingly indifferent to whether the listener congratulates him for his encyclopedic knowledge or is peeved by the lecture.

Another characteristic of William’s that is evidence of mental giftedness and not autism spectrum disorder is how fluid and changeable his areas of interest could be. As he got older, William became fascinated by subjects as diverse as world geography, ancient history, the lives of rock stars (especially the Beatles), and vintage guitars. He approached his new areas of interest with the same degree of mental engrossment that he had approached his old ones, regardless of how unrelated the new ones were to the old ones. Autism spectrum disordered children tend to hold steadfast to their odd topics of interest over time and not readily substitute one for another.

One of the drawbacks to early screening and detection of high-functioning autism is that small children’s cognitive development isn’t sufficiently mature enough to judge what their sense of humor is like. Often it is a sense of humor that separates true cases of mild autism from mental giftedness. Mildly autistic kids often don’t really comprehend irony, sarcasm, and absurdity. Mentally gifted kids, on the other hand, often thrive on irony, sarcasm, and absurdity. This distinction was brought home to me recently in an interaction with an intellectual eleven-year-old boy named Michael. His lengthy, detailed discourses on planets and the solar system made his parents wonder whether he might have Asperger’s syndrome. One day, after meeting with his mother briefly for a check-in, I went out to the waiting room and warmly greeted Michael: “Speak of the devil, we were just talking about you.” Michael came back to the office and, as he picked up a rubber sword to engage me, jokingly warned, “I am the devil, and you will get burned.” I knew right then and there that Asperger’s was completely out of the question.

Highly intelligent boys who happen to be introverted by temperament are probably the subpopulation of kids who are most likely to be erroneously labeled autistic. In her provocatively titled Psychology Today article “Revenge of the Introvert,” Laurie Helgoe, a self-described card-carrying introvert, captures a key personality characteristic of introverts: “[They] like to think before responding—many prefer to think out what they want to say in advance—and seek facts before expressing opinions.” Introverted, highly intelligent boys may appear vacant and nonresponsive when asked a question like “What is your favorite animal?” Yet in their minds, they may be deeply and actively processing copious amounts of information on types and defining features of animals and zeroing in on precise words to use to articulate their complex thoughts. Thirty seconds, a minute, or even more time may pass before an answer is supplied. In the meantime, the listener might wonder if the boy is deaf or completely self-absorbed.

According to Laurie Helgoe: “Introverts seek time alone because they want time alone.” Brainy, introverted boys may cherish and look forward to alone time, which allows them the opportunity to indulge their intellectual appetites full throttle, amassing knowledge through reading or Internet searches. Solitude creates the time and space they need to totally immerse themselves in their preferred interests. They may get more turned on by studying ideas, pursuing science projects, or by solving math problems than by conversing with people.

In our extroverted culture, where being a “team player” and a “people person” are seen as linchpins of normalcy, the notion that a brainy, introverted boy might legitimately prefer the world of ideas over the world of people is hard for most people to accept. Parents of such boys may feel terribly uneasy about their tendency to want to be alone and try to push their sons to be sociable and to make more friends. But if you get to know such boys, they would much rather be alone reading, writing, or pursuing projects that stimulate their intellect than be socializing with peers who are not their intellectual equals. However, once they come into contact with a kindred spirit, someone who is a true intellectual equal with whom they can share the fullness of their ideas, that person just might become a lifelong friend. Around such kindred spirits, brainy, introverted boys can perk up and appear more extroverted and outgoing, wanting to talk as well as to listen. With people who share their interests, especially people who possess equal or greater knowledge in these areas, brainy, introverted boys can display quite normal social skills.

My way or no way: autonomy seeking, not autism

I’d like to engage the reader in a thought-provoking exercise. I’m going to list a collection of behaviors. As you peruse them, ask yourself if these behaviors are indicative of typical willful male toddlers or of possible autism at this age. Remember, the toddler years are from approximately age one to three.

Doesn’t look when you call their name, even if they seem to hear other sounds
Doesn’t look you in the eye much or at all
Doesn’t notice when you enter or leave a room
Seems to be in their own world
Doesn’t look where you do or follow your finger when you point to something

Leads you by the hand to tell you what they want
Can’t do simple things you ask them to do
Has a lot of tantrums
Prefers to play alone
Wants to always hold a certain object, such as a flashlight Doesn’t play with toys in the usual way

It may surprise the reader to learn that I obtained this list of behaviors from a Consumer Reports health-related article titled “What Are the Symptoms of Autism?” If this exercise left you thinking that these behaviors might be characteristic of both willful male toddlers and autistic children, that’s commendable. This means that you have more than a passing familiarity with early childhood development. It also means that you are keenly aware of how toddler issues can get misconstrued as autistic tendencies.

The glee on the faces of toddlers upon discovering that they can propel themselves away from caregivers and into the world beyond— with the power of their own limbs—says it all. During the first year of life, they were relatively helpless. They were at the complete mercy of caregivers to gauge what they needed. Now their fast-evolving fine-and gross-motor abilities are being put to full use in exploring their surroundings. There is fire in their bellies. They insist on having personal control over what they get to see, hear, touch, smell, and taste and for how long. This is what developmental psychologists call the “need for autonomy” that kicks in during toddlerhood. The word parents tend to use is “willfulness.” There is a world of sensory delight out there for toddlers to discover and sample, and they want nothing to get in their way.

Male toddlers advance at a faster rate than the opposite sex in their gross-motor development and visual-spatial skills. The science is there. Generally speaking, boys are more physically capable of exploring their environments than girls. When they do, objects are likely to be the object of their exploration. Little boys, especially those with strong visual-spatial intelligence, can appear as though they’ve entered a trance when they stare at, squeeze, lick, toss and fetch, arrange, stack, and knock down blocks—only to do it all over again. We forget how immersion in an activity, and repetition of it, can lead to an experience of mastery. Lining up trains in identical order, making the same sounds, and pulling them with the same force can rekindle the same feeling of mastery that was felt the first time this activity went well. Not all repetitiveness and needs for sameness speak to autistic tendencies. When a toddler appears driven to use his body effectively in the accomplishment of a task and to further an experience of mastery, it’s unlikely that he’s on the spectrum no matter how repetitive the task becomes—particularly if that toddler shows self-pride and wants others to share in the excitement of it all, even in quiet and subdued ways.

Boys’ level of engrossment in discovering and manipulating objects can lead them to be oblivious to their surroundings. They may not look up when their name is called. They may appear unconcerned whether you’re in the room or not. Self-absorption while studying objects is expectable behavior for male toddlers, especially for those on the upper end of the bell curve on visual-spatial intelligence.

Parents and educators shouldn’t assume the worst when male toddlers play alone. Research shows that boys are far more likely to engage in solitary play than girls at this age. Many little boys are satisfied playing alone or quietly alongside someone else, lining up toy trains, stacking blocks, or engaging in a range of sensorimotor play activities. It is not until about age four or five that boys are involved in associative play to the same extent as girls. That’s the kind of play where there’s verbal interaction and give-and-take exchanges of toys and ideas.

The difference between a relatively typical male toddler immersed in solitary object play and one who shows early signs of autistic behavior can be subtle. Typically developing male toddlers are more apt to experience periodic separation anxiety. They suddenly wonder where Mommy is. Needing Mommy in these moments takes precedence over the activity in which they were absorbed. Sometimes visually checking in and receiving a reassuring glance back from Mommy is enough. Sometimes more is needed, like approaching her for a hug or a pat on the back. This inspires confidence that Mom will be available if and when needed. The toddler can then go across the room and pick up where he left off playing. This “emotional pit stop” behavior is less apparent with toddlers on the spectrum.

Mentally gifted boys are often perfectionists. Their projects need to be done just right, and they will continue to work on a project until it is exactly what they want. During toddlerhood, when early signs of perfectionism are mixed with regular needs for autonomy, the combination can make a child look very controlling. A cognitively advanced three-year-old boy who is also a perfectionist might spend hours arranging and rearranging, stacking and restacking blocks to construct a castle that he feels needs to be flawless if he’s to be satisfied. Attempts to get his attention, have him come to the kitchen for a snack, or put the blocks aside to get ready for bed are ignored or resisted. When such demands are issued suddenly, without forewarning, and instant compliance is expected, this is the emotional equivalent, for the toddler, of someone purposely tripping and badly injuring a front-place marathon runner right at the finish line. A tantrum is a distinct possibility. The child is in emotional pain due to being unable to prolong and achieve an experience of mastery.

Tantrums during the toddler years are, of course, commonplace. Under normal family circumstances, when a toddler’s maturation is right on schedule, parents can expect a tantrum from their three-to five-year-old once every few days. That was the conclusion of Dr. Gina Mireault’s study, cited earlier. Her research also revealed that the reason top ranked by parents as triggering a toddler’s tantrum is this: “Denial of a request/not getting his or her way.” Most tantrums are triggered by parents directly confronting kids’ assertions of autonomy or by kids’ need to have personal control over what they get to see, hear, touch, smell, and taste, and for how long. Tantrums can be exacerbated by fatigue and hunger. Toddlers have different temperaments, and this influences the frequency, intensity, and duration of tantrums. But in general, tantrums occur because a toddler is denied ice cream before dinner, for example, or is prevented from grabbing Grandma’s expensive Moorcroft pottery dish or insists on watching one more show when it’s bedtime—or any such expectable parental challenge to their need to prolong a pleasurable activity or independently exercise sensorimotor mastery.

The tantrums of autism spectrum kids are less likely to be of the autonomy-assertion or mastery-seeking variety. Their tantrums more often than not reflect sensory overload. They may scream and writhe around on the floor because they are in physical pain due to their nervous system being bombarded by an intolerable level of stimulation. The sights and sounds at the mall when their family is shopping for holiday gifts may put them over the top. The buzz from and brightness of overhead lights might be a trigger. Rituals and routines are relied on to keep sensory stimulation at manageable levels. Tantrums may signal a need to keep a ritual or routine exactly the way it was to protect the kid from sensory overload.

Sometimes what appears to be an autistic-like tantrum is really what Dr. Stanley Greenspan, the world-renowned child psychiatrist, calls “sensory craving.” This applies to toddlers whose ability to self-regulate their feelings while they’re in the act of exploring their environments is underdeveloped:

Many children show a pattern we call “sensory craving,” where they’re running around the house trying to get more sensation into their system, whether it’s staring at fans, or bumping into things or touching everything or just shifting from one toy to another in a seemingly aimless way, or just spinning around and jumping around or shaking their arms and legs in seemingly disjointed ways. These all look like terrible symptoms and they scare parents and they scare some professionals as well, understandably so. But they’re often signs of sensory craving—a child wants more sensory input, but doesn’t know how to do it in an organized social way.

These are toddlers who Dr. Greenspan thinks need abundant “sensory meaningful” interactions with parents and care providers to help them become more self-composed over time. This could amount to matching the child’s energy and activity level in a fun airplane-ride game. Scooping him up, asking him to point his fist in the direction in which he wants to be flown, with a thumbs-up for faster and a thumbs-down for slower, would be an example of a sensory-meaningful interaction that still honors his need for autonomy.

Temper outbursts and quirky behavior around food preferences are widespread among autism spectrum children. But the same can be said of toddlers in general. It’s important to have a sense of perspective regarding the pervasiveness of toddlers’ habit of latching onto preferred foods and rejecting new offerings. A survey of more than three thousand households with infants and toddlers conducted by nutrition experts at the University of Tennessee–Knoxville indicates that a whopping 50 percent of two-year-olds are considered picky eaters by their caregivers. These nutritionists believe the numbers are so high because mothers are not persistent enough in introducing new foods in ways that ensure they’ll eventually be eaten: “When offering a new food, mothers need to provide many more repeated exposures (e.g., eight to 15 times) to enhance acceptance of that food than they currently do.”

Let’s call this the “eight-to-fifteen-times rule.” If a toddler reacts with revulsion, aggressively throwing dishes on the floor or refusing to eat each time a new food item is introduced after eight to fifteen separate attempts, chances are that he or she is a picky eater. This is particularly true if, in the process, the parent stayed calm and conveyed confidence that the new food item was good to eat—not being too insistent on the one hand, or tentative, on the other.

But certainly not all picky eaters are that way because they are on the spectrum. Autism spectrum children who are picky eaters often have odd food preferences, such as only eating foods that are yellow-colored. Their reactions after repeated exposure to new foods frequently remain acute or become even more blustery. It’s not about power struggles and control. A new food item may literally assault their senses. The smell, look, and texture of that food may induce a type of sensory revulsion and disgust. They can’t be around it. Either it goes or the kid does—perhaps agitatedly running off.

Off the spectrum

The younger in age a kid is when professionals screen for milder forms of autism, the greater the risk a struggling kid will be misperceived as a disordered one. A vast number of toddlers present in the doctor’s office with a hodgepodge of social and emotional difficulties, such as poor eye contact, overactivity and underactivity, tantrums, picky eating, quirky interests, or social awkwardness. These phenomena need not be seen as telltale signs of autism spectrum disorder. Sometimes they are merely evidence of a perfect storm of off-beat events in social and emotional development mixed with difficult personality traits—with the upshot that the kid, for the time being, is very out of sorts.

When we mistake a brainy, introverted boy for an autism spectrum disordered one, we devalue his mental gifts. We view his ability to become wholeheartedly engrossed in a topic as a symptom that needs to be stamped out, rather than a form of intellectualism that needs to be cultivated. Boys like William don’t need to be channeled into unwanted and unnecessary social-skills classes to obtain formal instruction on how to start and sustain normal conversations. They don’t need to be prodded to be more sociable with the neighborhood kid whose mind works completely differently from theirs. They need unique school programs that cater to the mentally gifted in which others will not be chagrined by their intense love for ideas and where they have a shot at making true friends and therefore have the opportunity to feel truly sociable.

Excerpted from “Back to Normal: Why Ordinary Childhood Behavior Is Mistaken for ADHD, Bipolar Disorder, and Autism Spectrum Disorder,” by Enrico Gnaulati, Ph.D. (Beacon Press, 2013). Reprinted with permission from Beacon Press.

Enrico Gnaulati is a clinical psychologist who specializes in working with children and families. He is a sought-after public speaker on issues of childhood development and has been widely published in professional medical journals and magazines.

Misdiagnosis and Dual Diagnosis of Gifted Children

Author James T. Webb, Edward R. Amend, Nadia E. Webb, Jean Goerss, Paul Beljan, F. Richard Olenchak Citation Abstracted from: Misdiagnosis and Dual Diagnoses of Gifted Children and Adults: ADHD, bipolar, OCD, Asperger’s, depression, and other disorders. (2004) Scottsdale: Great Potential Press. Available from the publisher.

Misdiagnosis and Dual Diagnosis of Gifted Children

Authors: James T. Webb, Edward R. Amend, Nadia E. Webb, Jean Goerss, Paul Beljan, F. Richard Olenchak

Citation:  Abstracted from Misdiagnosis and Dual Diagnoses of Gifted Children and Adults: ADHD, bipolar, OCD, Asperger’s, depression, and other disorders. (2004) Scottsdale: Great Potential Press. Available from the publisher.

Many gifted and talented children (and adults) are being mis-diagnosed by psychologists, psychiatrists, pediatricians, and other health care professionals. The most common mis-diagnoses are: Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (OD), Obsessive Compulsive Disorder (OCD), and Mood Disorders such as Cyclothymic Disorder, Dysthymic Disorder, Depression, and Bi-Polar Disorder. These common mis-diagnoses stem from an ignorance among professionals about specific social and emotional characteristics of gifted children which are then mistakenly assumed by these professionals to be signs of pathology.

In some situations where gifted children have received a correct diagnosis, giftedness is still a factor that must be considered in treatment, and should really generate a dual diagnosis. For example, existential depression or learning disability, when present in gifted children or adults, requires a different approach because new dimensions are added by the giftedness component. Yet the giftedness component typically is overlooked due to the lack of training and understanding by health care professionals (Webb & Kleine, 1993).

Despite prevalent myths to the contrary, gifted children and adults are at particular psychological risk due to both internal characteristics and situational factors. These internal and situational factors can lead to interpersonal and psychological difficulties for gifted children, and subsequently to mis-diagnoses and inadequate treatment.

Internal Factors
First, let me mention the internal aspects (Webb, 1993). Historically, nearly all of the research on gifted individuals has focused on the intellectual aspects, particularly in an academic sense. Until recently, little attention has been given to personality factors which accompany high intellect and creativity. Even less attention has been given to the observation that these personality factors intensify and have greater life effects when intelligence level increases beyond IQ 130 (Silverman, 1993; Webb, 1993; Winner, 2000).

Perhaps the most universal, yet most often overlooked, characteristic of gifted children and adults is their intensity (Silverman, 1993; Webb, 1993). One mother described it succinctly when she said, “My child’s life motto is that anything worth doing is worth doing to excess.” Gifted children — and gifted adults– often are extremely intense, whether in their emotional response, intellectual pursuits, sibling rivalry, or power struggles with an authority figure. Impatience is also frequently present, both with oneself and with others. The intensity also often manifests itself in heightened motor activity and physical restlessness.

Along with intensity, one typically finds in gifted individuals an extreme sensitivity–to emotions, sounds, touch, taste, etc. These children may burst into tears while watching a sad event on the evening news, keenly hear fluorescent lights, react strongly to smells, insist on having the tags removed from their shirts, must touch everything, or are overly reactive to touch in a tactile-defensive manner.

The gifted individual’s drive to understand, to question, and to search for consistency is likewise inherent and intense, as is the ability to see possibilities and alternatives. All of these characteristics together result in an intense idealism and concern with social and moral issues, which can create anxiety, depression, and a sharp challenging of others who do not share their concerns.

Situational Factors
Situational factors are highly relevant to the problem of mis-diagnosis (Webb, 1993). Intensity, sensitivity, idealism, impatience, questioning the status quo–none of these alone necessarily constitutes a problem. In fact, we generally value these characteristics and behaviors–unless they happen to occur in a tightly structured classroom, or in a highly organized business setting, or if they happen to challenge some cherished tradition, and gifted children are the very ones who challenge traditions or the status quo.

There is a substantial amount of research to indicate that gifted children spend at least one-fourth to one-half of the regular classroom time waiting for others to catch up. Boredom is rampant because of the age tracking in our public schools. Peer relations for gifted children are often difficult (Webb, Meckstroth and Tolan, 1982; Winner, 2000), all the more so because of the internal dyssynchrony (asynchronous development) shown by so many gifted children where their development is uneven across various academic, social, and developmental areas, and where their judgment often lags behind their intellect.

Clearly, there are possible (or even likely) problems that are associated with the characteristic strengths of gifted children. Some of these typical strengths and related problems are shown in Table 1.

Table 1: Possible Problems That May be Associated with Characteristic Strengths of Gifted Children

Strengths Possible Problems
Acquires and retains information quickly. Impatient with slowness of others; dislikes routine and drill; may resist mastering foundational skills; may make concepts unduly complex.
Inquisitive attitude, intellectual curiosity; intrinsic motivation; searching for significance. Asks embarrassing questions; strong-willed; resists direction; seems excessive in interests; expects same of others.
Ability to conceptualize, abstract, synthesize; enjoys problem-solving and intellectual activity. Rejects or omits details; resists practice or drill; questions teaching procedures.
Can see cause–effect relations. Difficulty accepting the illogical-such as feelings, traditions, or matters to be taken on faith.
Love of truth, equity, and fair play. Difficulty in being practical; worry about humanitarian concerns.
Enjoys organizing things and people into structure and order; seeks to systematize. Constructs complicated rules or systems; may be seen as bossy, rude, or domineering.
Large vocabulary and facile verbal proficiency; broad information in advanced areas. May use words to escape or avoid situations; becomes bored with school and age-peers; seen by others as a “know it all.”
Thinks critically; has high expectancies; is self-critical and evaluates others. Critical or intolerant toward others; may become discouraged or depressed; perfectionistic.
Keen observer; willing to consider the unusual; open to new experiences. Overly intense focus; occasional gullibility.
Creative and inventive; likes new ways of doing things. May disrupt plans or reject what is already known; seen by others as different and out of step.
Intense concentration; long attention span in areas of interest; goal-directed behavior; persistence. Resists interruption; neglects duties or people during period of focused interests; stubbornness.
Sensitivity, empathy for others; desire to be accepted by others. Sensitivity to criticism or peer rejection; expects others to have similar values; need for success and recognition; may feel different and alienated.
High energy, alertness, eagerness; periods of intense efforts. Frustration with inactivity; eagerness may disrupt others’ schedules; needs continual stimulation; may be seen as hyperactive.
Independent; prefers individualized work; reliant on self. May reject parent or peer input; non-conformity; may be unconventional.
Diverse interests and abilities; versatility. May appear scattered and disorganized; frustrations over lack of time; others may expect continual competence.
Strong sense of humor. Sees absurdities of situations; humor may not be understood by peers; may become “class clown” to gain attention.

Adapted from Clark (1992) and Seagoe (1974)

Lack of understanding by parents, educators, and health professionals, combined with the problem situations (e.g., lack of appropriately differentiated education) leads to interpersonal problems which are then mis-labeled, and thus prompt the mis-diagnoses. The most common mis-diagnoses are as follows.

Common Mis-Diagnoses
ADHD and Gifted. Many gifted children are being mis-diagnosed as Attention Deficit Hyperactivity Disorder (ADHD). The gifted child’s characteristics of intensity, sensitivity, impatience, and high motor activity can easily be mistaken for ADHD. Some gifted children surely do suffer from ADHD, and thus have a dual diagnosis of gifted and ADHD; but in my opinion, most are not. Few health care professionals give sufficient attention to the words about ADHD in DSM-IV(1994) that say “…inconsistent with developmental level….” The gifted child’s developmental level is different (asynchronous) when compared to other children, and health care professionals need to ask whether the child’s inattentiveness or impulsivity behaviors occur only in some situations but not in others (e.g., at school but not at home; at church, but not at scouts, etc.). If the problem behaviors are situational only, the child is likely not suffering from ADHD.

To further complicate matters, my own clinical observation suggests that about three percent of highly gifted children suffer from a functional borderline hypoglycemic condition. Silverman (1993) has suggested that perhaps the same percentage also suffer from allergies of various kinds. Physical reactions in these conditions, when combined with the intensity and sensitivity, result in behaviors that can mimic ADHD. However, the ADHD-like symptoms in such cases will vary with the time of day, length of time since last meal, type of foods eaten, or exposure to other environmental agents.

Oppositional Defiant Disorder and Gifted. The intensity, sensitivity, and idealism of gifted children often lead others to view them as “strong-willed.” Power struggles with parents and teachers are common, particularly when these children receive criticism, as they often do, for some of the very characteristics that make them gifted (e.g., “Why are you so sensitive, always questioning me, trying to do things a different way,” etc.).

Bi-Polar and other Mood Disorders and Gifted. Recently, I encountered a parent whose highly gifted child had been diagnosed with Bi-Polar Disorder. This intense child, whose parents were going through a bitter divorce, did indeed show extreme mood swings, but, in my view, the diagnosis of Bi-Polar Disorder was off the mark. In adolescence, or sometimes earlier, gifted children often do go through periods of depression related to their disappointed idealism, and their feelings of aloneness and alienation culminate in an existential depression. However, it is not at all clear that this kind of depression warrants such a major diagnosis.

Obsessive-Compulsive Disorder and Gifted. Even as preschoolers, gifted children love to organize people and things into complex frameworks, and get quite upset when others don’t follow their rules or don’t understand their schema. Many gifted first graders are seen as perfectionistic and “bossy” because they try to organize the other children, and sometimes even try to organize their family or the teacher. As they grow up, they continue to search intensely for the “rules of life” and for consistency. Their intellectualizing, sense of urgency, perfectionism, idealism, and intolerance for mistakes may be misunderstood to be signs of Obsessive-Compulsive Disorder or Obsessive-Compulsive Personality Disorder. In some sense, however, giftedness is a dual diagnosis with Obsessive-Compulsive Personality Disorder since intellectualization may be assumed to underlie many of the DSM-IV diagnostic criteria for this disorder.

Dual Diagnoses
Learning Disabilities and Giftedness. Giftedness is a coexisting factor, to be sure, in some diagnoses. One notable example is in diagnosis and treatment of learning disabilities. Few psychologists are aware that inter-subscale scatter on the Wechsler intelligence tests increases as a child’s overall IQ score exceeds 130. In children with a Full Scale IQ score of 140 or greater, it is not uncommon to find a difference of 20 or more points between Verbal IQ and Performance IQ (Silverman, 1993; Webb & Kleine, 1993; Winner, 2000). Most clinical psychologists are taught that such a discrepancy is serious cause for concern regarding possible serious brain dysfunction, including learning disabilities. For highly gifted children, such discrepancy is far less likely to be an indication of pathological brain dysfunction, though it certainly would suggest an unusual learning style and perhaps a relative learning disability.

Similarly, the difference between the highest and lowest scores on individual subscales within intelligence and achievement tests is often quite notable in gifted children. On the Wechsler Intelligence Scale for Children – III, it is not uncommon to find subscale differences greater than seven scale score points for gifted children, particularly those who are highly gifted. These score discrepancies are taken by most psychologists to indicate learning disabilities, and in a functional sense they do represent that. That is, the levels of ability do vary dramatically, though the range may be “only” from Very Superior to Average level of functioning. In this sense, gifted children may not “qualify” for a diagnosis of learning disability, and indeed some schools seem to have a policy of “only one label allowed per student,” and since this student is gifted, he/she can not also be considered learning disabled. However, it is important for psychologists to understand the concept of “asynchronous development” (Silverman, 1993), and to appreciate that most gifted children show such an appreciable, and often significant, scatter of abilities.

Poor handwriting is often used as one indicator of learning disabilities. However, many and perhaps most gifted children will show poor handwriting. Usually this simply represents that their thoughts go so much faster than their hands can move, and that they see little sense in making writing an art form when its primary purpose is to communicate (Webb & Kleine, 1993; Winner, 2000).

Psychologists must understand that, without intervention, self-esteem issues are almost a guarantee in gifted children with learning disabilities as well as those who simply have notable asynchronous development since they tend to evaluate themselves based more on what they cannot do rather than on what they are able to do. Sharing formal ability and achievement test results with gifted children about their particular abilities, combined with reassurance, can often help them develop a more appropriate sense of self-evaluation.

Sleep Disorders and Giftedness. Nightmare Disorder, Sleep Terror Disorder, and Sleepwalking Disorder appear to be more prevalent among gifted children, particularly boys. It is unclear whether this should be considered a mis-diagnosis or a dual diagnosis. Certainly, parents commonly report that their gifted children have dreams that are more vivid, intense, and more often in color, and that a substantial proportion of gifted boys are more prone to sleepwalking and bed wetting, apparently related to their dreams and to being more soundly (i.e., intensely) asleep. Such concordance would suggest that giftedness may need to be considered as a dual diagnosis in these cases, or at least a factor worthy of consideration since the child’s intellect and sense of understanding often can be used to help the child cope with nightmares.

A little known observation concerning sleep in gifted individuals is that about twenty percent of gifted children seem to need significantly less sleep than other children, while another twenty percent appear to need significantly more sleep than other children. Parents report that these sleep patterns show themselves very early in the child’s life, and long-term follow up suggests that the pattern continues into adulthood (Webb & Kleine, 1993; Winner, 2000). Some highly gifted adults appear to average comfortably as few as two or three hours sleep each night, and they have indicated to me that even in childhood they needed only four or five hours sleep.

Multiple Personality Disorders and Giftedness. Though there is little formal study of giftedness factors within MPD, there is anecdotal evidence that the two are related. The conclusion of professionals at the Menninger Foundation was that most MPD patients showed a history of childhood abuse, but also high intellectual abilities which allowed them to create and maintain their elaborate separate personalities (W. H. Smith personal communication, April 18, 1996).

Relational Problems and Giftedness. As one mother told me, “Having a gifted child in the family did not change our family’s lifestyle; it simply destroyed it!” These children can be both exhilarating and exhausting. But because parents often lack information about characteristics of gifted children, the relationship between parent and child can suffer. The child’s behaviors are seen as mischievous, impertinent, weird, or strong-willed, and the child often is criticized or punished for behaviors that really represent curiosity, intensity, sensitivity, or the lag of judgment behind intellect. Thus, intense power struggles, arguments, temper tantrums, sibling rivalry, withdrawal, underachievement, and open flaunting of family and societal traditions may occur within the family.

“Impaired communication” and “inadequate discipline” are specifically listed in the DSM-IV (1994) as areas of concern to be considered in a diagnosis of Parent-Child Relational Problems, and a diagnosis of Sibling Relational Problem is associated with significant impairment of functioning within the family or in one or more siblings. Not surprisingly, these are frequent concerns for parents of gifted children due to the intensity, impatience, asynchronous development, and lag of judgment behind intellect of gifted children.

Health care professionals could benefit from increased knowledge concerning the effects of a gifted child’s behaviors within a family, and thus often avoid mistaken notions about the causes of the problems. The characteristics inherent within gifted children have implications for diagnosis and treatment which could include therapy for the whole family, not in the sense of “treatment,” but to develop coping mechanisms for dealing with the intensity, sensitivity, and the situations which otherwise may cause them problems later (Jacobsen, 1999).

Conclusion
Many of our brightest and most creative minds are not only going unrecognized, but they also are often given diagnoses that indicate pathology. For decades, psychologists and other health care professionals have given great emphasis to the functioning of persons in the lower range of the intellectual spectrum. It is time that we trained health care professionals to give similar attention to our most gifted, talented, and creative children and adults. At the very least, it is imperative that these professionals gain sufficient understanding so that they no longer conclude that certain inherent characteristics of giftedness represent pathology.

References
Clark, B. (1992). Growing up gifted: Developing the potential of children at home and at school, (4th ed.). New York: Macmillan.
Diagnostic and statistical manual of mental disorders, Fourth Edition. (1994). Washington, DC: American Psychiatric Association.
Jacobsen, M.E. (1999). Liberating everyday genius: A revolutionary guide for identifying and mastering your exceptional gifts. New York: Ballantine.
Seagoe, M. (1974). Some learning characteristics of gifted children. In R. Martinson, (Ed.), The identification of the gifted and talented. Ventura, CA: Office of the Ventura County Superintendent of Schools.
Silverman, L. K. (1993). Counseling the gifted and talented. Denver: Love Publishing.
Webb, J. T., & Latimer, D. (1993). ADHD and children who are gifted. Reston, VA: Council for Exceptional Children. ERIC Digests #E522, EDO-EC-93-5.
Webb, J. T. (1993). Nurturing Social-Emotional Development of Gifted Children. In K. A. Heller, F. J. Monks, & A. H. Passow (Eds.), International handbook of research and development of giftedness and talent (pp. 525-538). Oxford: Pergamon Press.
Webb, J. T. & Kleine, P. A. (1993). Assessing gifted and talented children. In J. L. Culbertson, & D. J. Willis (Eds.), Testing young children (pp. 383-407). Austin, TX: Pro-ed.
Webb, J. T., Meckstroth, E. A., & Tolan, S. S. (1982). Guiding the gifted child: A practical source for parents and teachers. Scottsdale, AZ: Gifted Psychology Press (formerly Ohio Psychology Press).
Winner, E. (2000). The origins and ends of giftedness. American Psychologist (55, No. 1), 159-169.

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Posted by: faithful | November 8, 2014

adhd revisited

How ADHD is radically mistreated

Research shows that children with ADHD are often extremely creative. Our institutions are failing them

How ADHD is radically mistreated
This article originally appeared on AlterNet.

In his 2004 book “Creativity is Forever“, Gary Davis reviewed the creativity literature from 1961 to 2003 and identified 22 reoccurring personality traits of creative people. This included 16 “positive” traits (e.g., independent, risk-taking, high energy, curiosity, humor, artistic, emotional) and 6 “negative” traits (e.g., impulsive, hyperactive, argumentative). In her own review of the creativity literature, Bonnie Cramond found that many of these same traits overlap to a substantial degree with behavioral descriptions of Attention Deficit Hyperactive Disorder (ADHD)– including higher levels of spontaneous idea generation, mind wandering, daydreaming, sensation seeking, energy, and impulsivity.

Research since then has supported the notion that people with ADHD characteristics are more likely to reach higher levels of creative thought and achievement than people without these characteristics (see herehereherehereherehereherehere,here, and here). Recent research by Darya Zabelina and colleagues have found that real-life creative achievement is associated with the ability to broaden attention and have a “leaky” mental filter– something in which people with ADHD excel.

Recent work in cognitive neuroscience also suggests a connection between ADHD and creativity (see here and here). Both creative thinkers and people with ADHD show difficulty suppressing brain activity coming from the “Imagination Network“:

 

Of course, whether this is a positive thing or a negative thing depends on the context. The ability to control your attention is most certainly a valuable asset; difficulty inhibiting your inner mind can get in the way of paying attention to a boring classroom lecture or concentrating on a challenging problem. But the ability to keep your inner stream of fantasies, imagination, and daydreams on call can be immensely conducive to creativity. By automatically treating ADHD characteristics as a disability– as we so often do in an educational context– we are unnecessarily letting too many competent and creative kids fall through the cracks.

Nine percent of children aged 5-17 years old are labeled ADHD on average per year, and placed in special education programs. However, new data from The National Center for Learning Disabilities shows that only 1% of students who receive IDEA (Individuals With Disabilities Act) services are in gifted and talented programs, and only 2% are enrolled in an AP course. The report concludes that “students with learning and attention issues are shut out of gifted and AP programs, held back in grade level and suspended from school at higher rates than other students.”

Why does this matter? Consider a new study conducted by C. Matthew Fugate and colleagues. They selected a population of students with ADHD characteristics who were part of a summer residential camp for gifted, creative, and talented students. The large majority of the students were selected for the program because they either scored in the 90th percentile or above on a standardized test, or had a GPA of 3.5 or greater in specific areas (e.g., mathematics, chemistry).

The researchers then compared this ADHD group of students with a non-ADHD group of students who were participating in the same gifted program. They gave all the students tests offluid reasoning, working memory, and creative cognition. Fluid reasoning involves the ability to infer relations and spot novel and complex patterns that draw on minimal prior knowledge and expertise. Working memory involves the ability to control attention and hold multiple streams of information in mind at once. They measured creative cognition by having the students come up with novel drawings that included one of the following elements: an oval shape, incomplete figures, and two straight lines.

The researchers found that students with ADHD characteristics (especially those who scored high in “inattention”) had lower working memory scores than the non-ADHD students, even though they did not differ in their fluid reasoning ability. This is consistent with past research showing that people with ADHD tend to score lower on tests of working memory (see here and here), but these findings also suggest that people with ADHD can still be quite smart despite their reduced ability to hold multiple pieces of information in memory. Also, despite their reduced working memory, 53% of the academically advanced students with ADHD characteristics scored at or above the 70th percentile on the creativity index. In fact, for both the ADHD and the non-ADHD group of students, the poorer the working memory, the higher the creativity!

This obviously has some important educational implications. To be sure, ADHD can make it difficult for students to pay attention in class and organize their lives. The importance of learning key attentional control skills should not be undervalued. But let’s not throw out the baby with the bathwater. As the researchers note, “in the school setting, the challenge becomes how to create an environment in which creativity is emphasized as a pathway to learning as well as an outcome of learning.”

One issue involves the identification of “twice exceptional” students and their appropriate educational programming. Assessments of creativity are notably absent from most gifted and talented programs in this country. Instead of automatically putting children with ADHD characteristics in special education, a broader assessment should be conducted. For one, IQ tests could be administered that focusless on working memory and memorization, and allows for a fairer assessment of fluid reasoning and non-sequential thought among this population of students.

A broader assessment could also allow students with ADHD characteristics to display their creative strengths, including divergent thinking, imagination, and hyperfocus (when interested). People with ADHD often are able to focus better than others when they are deeply engaged in an activity that is personally meaningful to them. Recent research suggests that the brain network that people with ADHD have difficulty suppressing (the “Imagination Network”) is the same brain network that is conducive to flow and engagement among musicians, including jazz musicians and rappers!

 

In terms of programming, problem-based learning (PBL) approaches may enable ADHD students to engage more with the material, and become active learners, rather than passive observers (see here). Additionally, learning can be assessed throughproject-based learning (PBL), in which students demonstrate their knowledge of the course material through the creation of different products (e.g., cartoons, role-playing, blogs, videos, newspaper articles), and the constant revision of these products.

Of course, these same possibilities should extend to all students in the classroom, academically advanced or not. Because we never really know whether an ADHD characteristic is a learning impediment or a creative gift.

Consider the case of John, who in 1949 attended Eton College and dreamed of becoming a scientist. However, last in his class, he received the following comment on his report card:

“His work has been far from satisfactory… he will not listen, but will insist on doing his work in his own way… I believe he has ideas about becoming a Scientist; on his present showing this is quite ridiculous, if he can’t learn simple Biological facts he would have no chance of doing the work of a Specialist, and it would be a sheer waste of time on his part, and of those who have to teach him.”

This was Sir John B. Gurdon, winner of the 2012 Nobel Prize in Physiology or Medicine for his revolutionary research on stem cells. Like so many other highly creative, competent individuals, he might have been referred for testing and given the label “attention deficit hyperactive disorder.”

It’s time to stop letting this happen.

 

Scott Barry Kaufman is adjunct assistant professor of psychology at New York University. He is cofounder of The Creativity Post and writes the blog Beautiful Minds for Scientific American Mind

Posted by: faithful | November 7, 2014

bpd videos: professional and self-help sources

 

Posted by: faithful | November 1, 2014

nea-bpd conference videos from 2005 through 2013

Past Yale NEA-BPD Conferences

2013

Borderline Personality Disorder and Managing Related Cognitive Challenges

  1. Reading and writing deficits are common barriers–Staff communication sheets an diary cards.  –Read forms to the cient.  –Written therapy agreement.  –Move slowly don’t rush informed consent process
  2. All DBT strategies and structure standard:  Stages, hierarchy of targets, validation, contingencies, commitment, etc. –Increased use of orientation
  3. Memory deficits/Difficulty in sequencing  –Behavior analysis: slower process, use of visuals  –Longer time frames–Accessible skills curriculum (Skills system)
  4. Challenges related to generalizing skills (transitions and novelty can elicit dysregulation/avoiding)  –Quick Step Assessment simplification, task analysis, and shaping is necessary with DBT strategies  –Behavioral treatment planning (avoid micro-managing)  –Staff as skills coaches (challenging)
  5. Developmental issues/tensions:            – Polarized behavior with staff team (drive for autonomy)
    –DBT creates an egalitarian playing-field that fosters identity development/self-determination
    –Behavioral treatment planning (reciprocal communication/collaboration vs compliance/controlling
  6. Integration of therapy/environment
    –Training (IDD/MH issues: DBT, skills and skills coaching
    –Consultation to the client, due to developmental issues.

Issues: Cognitive Load Theory–Factors Increasing Cognitive Load (Cognitive Load Theory–Sweller)

Simultaneous Processing of Information
New Information
High Volume of Information
Interactivity of Information
Retrieval of divergent information
Rapid shifts without transition from one topic to another
Strong emotional responses to information
Strong emotional responses to the intervention

Evidence of Dysregulation:

Confusion
Lack of Focus
Resistance
Avoidance
Discomfort
Willfulness

Simplification
Task Analysis
Orienting to all transitions and new topics
Worked examples
Shaping
Validating the person’s experience
Positive reinforcement
Contingency management (letting people know how they are doing)

Emotional
Series of skills (over-learned) to help span the duration/intensity
Ability to be present & effective in the moment (improving self-awareness)
Improved efficacy to manage novel events
Cognition
Designed to facilitate recall and generalization
in complex contexts (implicit)
Structured and flexible (manage humanity)
Builds adaptive schema
Framework increases access to contextual learning
Behavioral
Aids effective transitions through events/system to construct adaptive chains
Map of strategic means to reach goals vs reacting impulsively, reduced avoidance, helps transitions
Developmental
Mobilizes inner wisdom i context
Common language expands relational learning/capacities
Environmental
Tools to actively/effectively manage environment/vehicle for self-determination

  • VIDEO: Panel Discussion; Gabriela Balf, MD, MPH, Julie F. Brown, LICSW, Bessel van der Kolk, MD, Anthony C. Ruocco, PhD, and Annita Sawyer, PhD

2012

Impulsivity, Aggression, and Legal Involvement (Includes links to YouTube videos)

2011

Common and Distinguishing Aspects of Dialectical Behavior Therapy and Mentalization Based Therapy (Video presentations)

2010

Borderline Personality Disorder, Obesity, and Eating Disorders (Includes audio/video presentations)

2009

Borderline Personality Disorder and Problems of Substance Use (Includes audio presentations)

2008

Borderline Personality Disorder, Trauma, and Resiliency (Includes video presentations)

2007

High Risk Adolescents and Their Families, Understanding and Treating Borderline Personality Disorder

2006

Borderline Personality Disorder: Current Research and Treatments Consumer and Family Support Options

2005

Borderline Personality Disorder: Origins, Treatments, and Concerns

Posted by: faithful | November 1, 2014

beyond ptsd to “moral injury”

130226-M-IX060-006The United States Marine Corps Wounded Warrior Regiment provides and facilitates assistance to wounded, ill and injured Marines, sailors attached to or in support of Marine units, and their family members in order to assist them as they return to duty or transition to civilian life. (Photo by Cpl. Tyler L. Main)

“I really don’t like the term ‘PTSD,’” Department of Veterans Affairs psychiatrist Dr. Jonathan Shay told PBS’ “Religion & Ethics Newsweekly” in 2010. “He says the diagnostic definition of “post-traumatic stress disorder” is a fine description of certain instinctual survival skills that persist into everyday life after a person has been in mortal danger — but the definition doesn’t address the entirety of a person’s injury after the trauma of war. “I view the persistence into civilian life after battle,” he says, “… as the simple or primary injury.”

Dr. Shay has his own name for the thing the clinical definition of PTSD leaves out. He calls it “moral injury” — and the term is catching on with both the VA and the Department of Defense.

We’re turning our attention to this idea of moral injury and the limits of the PTSD diagnosis to explore what happens to a person who has experienced combat.

There are no clean lines separating PTSD from moral injury (which is not a diagnosis) — there is no Venn Diagram, as with PTSD and traumatic brain injury but Dr. Shay explains a fundamental difference by using a shrapnel wound as an analogy. (see image following for Venn Diagram)

“Whether it breaks the bone or not,” he says, “that wound is the uncomplicated — or primary — injury. That doesn’t kill the soldier; what kills him are the complications — infection or hemorrhage.”

Post-traumatic stress disorder, Dr. Shay explains, is the primary injury, the “uncomplicated injury.” Moral injury is the infection; it’s the hemorrhaging.

PTSD in service members is often tied to being the target of an attack — or being close in relationship or proximity to that target.

Moral injury, Dr. Shay says, can happen when “there is a betrayal of what’s right by someone who holds legitimate authority in a high-stakes situation.”

That person who’s betraying “what’s right” could be a superior — or that person could be you. Maybe it’s that you killed somebody or were ordered to kill. Or maybe it was something tragic that you could have stopped, but didn’t. Guilt and shame are at the center of moral injury. And, as Dr. Shay describes it, so is a shrinking of what he calls “the moral and social horizon.” When a person’s moral horizon shrinks, he says, so do a person’s ideals and attachments and ambitions.

I first came across Dr. Shay’s name — and his concept of moral injury in combat veterans — in a heart-smashing profile of Noah Pierce published by the formidable Virginia Quarterly Review.

The Life and Lonely Death of Noah PierceThe Life and Lonely Death of Noah Pierce” tells the story of an Iraq War veteran from Sparta, Minnesota, who shot himself in the head in 2007 at the age of 23.

From Ashley Gilbertson’s profile of Pierce:

“When Noah went missing in July 2007, after a harrowing year adjusting to home following two tours in Iraq, police ordered a countywide search. His friend Ryan Nelson thought he might know where to look. When he pulled up to the spot, he immediately recognized Noah’s truck. Inside, Ryan found his friend slumped over the bench seat, his head blown apart, the gun in his right hand. Half a bottle of Jack Daniel’s Special Blend lay on the passenger seat, and beer cans were strewn about. On the dash lay his photo IDs; he had stabbed each photo through the face. And on the floorboard was the scrawled, rambling suicide note. It was his final attempt to explain the horrors he had seen — and committed.”

Gilbertson told Noah’s story to Jonathan Shay. Again, from the article:

“Shay, a psychiatrist who has worked with combat vets for twenty years and authored two books about PTSD — or psychological and moral injury, as he insists it should be known — told me by phone from his Newton, Mass., office, ‘It’s titanic pain that these men live with. They don’t feel that they can get that across, in part because they feel they deserve it, and in part because they don’t feel people will understand it.’

“‘Despair, this word that’s so hard to get our arms around,’ he said. ‘It’s despair that rips people apart [who] feel they’ve become irredeemable.’

“I told Dr. Shay about Noah’s experiences in Iraq, in particular the killing, the loss of comrades, the nightmares. He sounded saddened on the phone, but unsurprised. ‘The flip side of this fellow’s despair was the murderous rages he experienced on his second tour,’ he said. ‘In combat, soldiers become each other’s mothers. The rage, need for revenge, and self-sacrificial commitment toward protecting each other when comrades are killed [are] akin to when a mother’s offspring are put in danger or killed.’

“Dr. Shay explained the nightmares and sleeplessness were one of the major issues. ‘The lack of sleep contributed directly to a loss of control of his own anger, a loss of control of things he felt morally responsible for.’”

Treating moral injury in combat veterans, Dr. Shay said in the PBS interview, happens not in the clinic, but in the community.

”Peers are the key to recovery — I can’t emphasize that enough,” he said. “Credentialed mental health professionals like me have no place in center stage. It’s the veterans themselves, healing each other, that belong at center stage. We are stagehands — get the lights on, sweep out the gum wrappers, count the chairs, make sure it’s a safe and warm enough place…”

He doesn’t write off clinical care, though he does disparage “cookie-cutter treatments.”

“We’re certainly doing a lot of things,” he says, “but whether we’re actually preserving vets’ capacity to have a flourishing life after war, I don’t know. I just don’t know.”


Jeff Severns Guntzel is senior reporter for the Public Insight Network (PIN). He has reported from the Middle East and points all over the United States for a cadre of publications and news organizations that are not usually mentioned in the same sentence, including Punk Planet Magazine, National Catholic Reporter, Village Voice Media, MinnPost.com, and GOOD. He also did time as an editor at Utne Reader.

Read more of Jeff’s reporting as part of the Public Insight Network’s veterans health project on vets and all those working to help them navigate life after combat.

TRANSCRIPT FOR BESSEL VAN DER KOLK — RESTORING THE BODY: YOGA, EMDR, AND TREATING TRAUMA

October 30, 2014

KRISTA TIPPETT, HOST: The psychiatrist Bessel van der Kolk is an innovator in treating the effects of overwhelming experiences on people and society. We call this “trauma” when we encounter it in life and news. And we tend to leap to address it by talking. But Bessel van der Kolk knows how some experiences imprint themselves beyond where language can reach. He explores state of the art therapeutic treatments, including body work like yoga and Eye Movement therapy.

He’s been a leading researcher of traumatic stress since it first became a diagnosis in the wake of the Vietnam War and from there was applied to other populations. A conversation with this psychiatrist is a surprisingly joyful thing. He shares what he and others are learning on this edge of humanity about the complexity of memory, our need for others, and how our brains take care of our bodies.

[music: “Seven League Boots” by Zoe Keating]

BESSEL VAN DER KOLK: You know, I think trauma really does confront you with the best and the worst. You see the horrendous things that people do to each other, but you also see resiliency, the power of love, the power of caring, the power of commitment, the power of commitment to oneself, the knowledge that there are things that are larger than our individual survival. And in some ways, I don’t think you can appreciate the glory of life unless you also know the dark side of life.

MS. TIPPETT: I’m Krista Tippett. And this is On Being.

[music: “Seven League Boots” by Zoe Keating]

MS. TIPPETT: Bessel van der Kolk has just published a new book called The Body Keeps the Score. I spoke with him in 2013.

He is a professor of Psychiatry at Boston University Medical School and he helped found a community-based Trauma Center in Brookline, Massachusetts. As Medical director there, he works with people affected by trauma and adversity to re-establish a sense of safety and predictability in the world, and to reclaim their lives. Bessel van der Kolk was born in the Netherlands, his own father spent time as religious prisoner in a German concentration camp during World War II.

MS. TIPPETT: I always start my conversations with this question whoever I’m speaking with. I’m just wondering, was there a religious or spiritual background to your childhood?

DR. VAN DER KOLK: Yeah, multiplicity. My parents were fundamentalist Christians in some good and some not so good ways. As an adolescent, I spent a fair amount of time in a monastery in France called Taizé.

MS. TIPPETT: Oh, you did? Oh, interesting. So you went to Taizé just …

DR. VAN DER KOLK: Because I loved the music.

MS. TIPPETT: Yeah. You know, this field you’re in of trauma, traumatic stress, nowadays in 2013 this language is everywhere, right? This language of trauma and traumatic stress has made its way into culture, movie, TV scripts, the news, public policy discussions. I’ve read a few different accounts of how you stumbled into this field. Where — how do you trace the beginnings of your research into traumatic stress?

DR. VAN DER KOLK: Well, um, it starts in a very pedestrian way, I mean, as characters from a generation that it was generally recommended that people have their own heads examined, which, I think, is sort of a good idea if you try to help other people. So psychoanalysis was the way to do that back then. And the only program that paid for that was the VA. So I went to work for the VA for the same reason that soldiers go to the VA, namely to get their benefits package.

MS. TIPPETT: This was in the 1970s? Is that right?

DR. VAN DER KOLK: It was in the 1970s, yeah, yeah. And like many of my colleagues, I was just there to as a step in my career. And then the very first person I saw was a Vietnam veteran who had terrible nightmares. I happened to have studied nightmares up to that point and some sleep studies and I knew a little bit how to treat it, so I gave him some medicines to make the nightmares go away.

Two weeks later, he came back and I said, “So how did the medicines work?” And he said, “I did not take your medicines, because I realized I need to have my nightmares because I need to be a living memorial to my friends who died in Vietnam.” And that statement was the opening of my fascination about how people become living testimonials for things that no longer exist, but they need to hold it in their hearts and minds and bodies and brains. The loyalty to the dead, the loyalty to what was just blew me away.

And the veterans really touched me very deeply both for what they had done, how ashamed they were about what they had done, how they went in idealistically, how they came back broken, how they relied on their comrades. And they reminded me, I think, of the uncles and my father, who I grew up with in the Netherlands after the Second World War. So it resonated with me.

MS. TIPPETT: At that time, I believe there was no formal connection made between military service and problems after discharge, right? This diagnosis hadn’t happened?

DR. VAN DER KOLK: Well, it comes and goes. I became quite interested in history of how western culture has looked at trauma.

MS. TIPPETT: Yeah.

DR. VAN DER KOLK: And people were very aware of it in the 1880’s and after the Civil War and during the First World War, and during the Second World War. And then in between it gets forgotten. And so, the way – the time that I got into the field, happened to be a time of ignorance again. It was come and go.

MS. TIPPETT: After the Vietnam War.

DR. VAN DER KOLK: Yeah.

MS. TIPPETT: And my understanding from your writing that this diagnosis of PTSD, the term we use now, came about because of post Vietnam War advocacy.

DR. VAN DER KOLK: Yeah, absolutely. And so later on, I became aware of all sorts of colleagues who had been working with abused kids and rape victims. And they had been trying to get a diagnosis in.

MS. TIPPETT: Hmm.

DR. VAN DER KOLK: And, that group was too small to have any political clout. And it’s really the Vietnam veterans that brought this in and the power of the large numbers of psychiatrists and patients at the VA. That was strong enough to make it an issue and a diagnosis.

MS. TIPPETT: So I think that language you used, a moment ago, about that first veteran you spoke with that he was a living testimonial to his memories and to something that had happened, which no longer was happening, but utterly defined him, right? It’s a good way in to how you define trauma. So I’d like to spend a moment on that. I mean, start with me. How do you describe what this is, trauma, as you deal with it, as you study it, as you treat it?

DR. VAN DER KOLK: Yeah. Well, what I think happens is that people have terrible experiences and we all do and we are a very resilient species. So if we are around people who love us, trust us, take care of us, nurture us when we are down, most people do pretty well with even very horrendous events. But particularly traumas that occur at the hands of people who are supposed to take care of you, if you’re not allowed to feel what you feel, know what your mind cannot integrate what goes on and you can get stuck on the situation. So the social context in which it occurs is fantastically important.

MS. TIPPETT: Something that’s very interesting to me in how you talk about trauma, the experience of trauma, what it is, is how the nature of memory is distorted, that memories are never precise recollections, but that in general as we move through the world, memories become integrated and transformed into stories that help us make sense. But in the case of traumatic memories, they’re not integrated and they’re not even really remembered as much as they’re relived.

DR. VAN DER KOLK: That’s correct. There’s actually a very old observation and it was made extensively in the ’80s and ’90s already by various people, including Freud. That’s really what you see when you see traumatized people. Now these days, the trauma is a popular subject. People say, “Tell me about your trauma.”

MS. TIPPETT: Right.

DR. VAN DER KOLK: But the nature of our trauma is that you actually have no recollection for it as a story in a way. Many victims over time get to tell a story to explain why they are so messed up. But the nature of a traumatic experience is that the brain doesn’t allow a story to be created and here you have an interesting paradox that it’s normal to distort your memories. Like, I’m one out of five kids, when we have a family reunion, we all tell stories about our own childhood and everybody always listens to everybody else’s stories. Did he grow up in the same family as I did?

MS. TIPPETT: Right. There are five versions of every story, yeah.

DR. VAN DER KOLK: Yeah. There’s all these very, very different versions and they barely ever overlap. So, people create their own realities in a way. But what is so extraordinary about trauma, is that these images or sounds or physical sensations don’t change over time. So people who have been molested as kids continue to see the wallpaper of the room in which they were molested. Or when they examine all these priest-abused victims, they keep seeing the silhouette of the priest standing in the door of the bathroom and stuff like that. So it’s these images, these sounds, that don’t get changed. So it’s normal to change.

My old teacher, George Vaillant, did a study that you may have heard about. It’s called the Grant Study. And from 1939 to 1942, they followed the classes at Harvard every five years and it’s going on to this day. Most of them went off to war in 1942 and almost all of them came back in 1945 and they were interviewed. Then they have interviews in 1989, 1990 to 1991. It turns out that the people who did not develop PTSD, which was the vast majority, tell very different stories than, say, back in 1945. So now it was a glorious experience, it was a growth experience and how good it was, how close they were to people and how patriotic they felt. And it’s all sort of cleaned up.

MS. TIPPETT: Right, but it’s become a coherent narrative.

DR. VAN DER KOLK: But it’s very coherent and it’s a nice story and it’s good to listen to it and relatives have all heard it a million times, but because we make happy stories in our mind. People who got traumatized continue to have the same story in 1990 as they told back in 1945, so they cannot transform it. When we treat people, you see the narrative change and people start introducing new elements.

I compare it very much to what happens when people dream. Maybe dreaming is very central here actually in that the natural way in which we deal with difficult stuff is we go to sleep and we dream and next day we feel better. It’s very striking how we get upset and say, “I’m going to move to Florida, bummer day in Boston in the winter.” And the next morning, you wake up and you shovel out your car and everything’s fine.

And so sleep is a very important way in which we restore ourselves. And that process of that restoration that occurs during REM sleep — dream sleep — is probably an important factor in why traumatic memories do not get integrated.

[music: “Drømte Mig en Drøm” by Opiate]

MS. TIPPETT: And also, that gets at the fact that it’s not just cognitive, right? It’s not just a story that you could tell. I mean, it may eventually become a story, but that it’s body memory. It’s a neural net of memory. It’s not just about words that you can formulate.

DR. VAN DER KOLK: Yeah, yeah. It’s amazing to me what a hard time many people I know have with that. This is not about something you think or something you figure out. This is about your body, your organism, having been reset to interpret the world as a terrifying place and yourself as being unsafe. And it has nothing to do with cognition, with, you know, you can say to people, “You shouldn’t feel that way” or “You’re not a bad person” or “It wasn’t your fault.” And people say, “I know that, but I feel that it is.”

It was very striking in our yoga study because we see yoga as one important thing that helps people who’ve been traumatized because they get back into their bodies. How hard it was for people to even during the most blissful part of the yoga practice called Shavasana, what a hard time traumatized people had at that moment to just feel relaxed and safe and feel totally enveloped with goodness, how the sense of goodness and safety disappears out of your body basically.

MS. TIPPETT: I want to talk about yoga in a minute. That’s really, um, I mean, and, um, so — so this gets at why, uh, as you said, I mean, people were talking about this in the late 19th century. Freud talked about it and I guess his phrase was “hysteria.” But something that you seemed to have noticed early on is that traditional therapy was ignoring this sensate dimension of these experiences in trying to reduce it to talk therapy, which absolutely didn’t fit with the experience.

DR. VAN DER KOLK: Right, right. There’s a few people here and there in the last 150 years who do it. The great Frenchman Pierre Janet did, Wilhelm Reich, of course, who then went crazy afterwards. Here and there, people noticed the somatic dimension of it, but by and large, I think psychology training really breeds the tensions of body out of people. It’s a medical training. It’s amazing. Psychiatrists just don’t pay much attention to sensate experience at all.

Antonio Damasio in his books, the feeling of what happens in books like this, really talks about a core experience of ourselves is a somatic experience and that the function of the brain is to take care of the body. But it’s a minority voice. It’s a small voice.

MS. TIPPETT: But it seems to me that what we’re learning from brain imaging is bearing out these kinds of observations. I mean, what are we learning? Is any of this surprising to you?

DR. VAN DER KOLK: What we see is that the parts of the brain that tell people to see clearly and to observe things clearly really get interfered with by trauma and the imprint of trauma is in areas to the brain that really have no access to cognition. So it’s in an area called the periaqueductal gray, which has something to do with the sort of total safety of the body. The amygdala, of course, which is sort of a smoke detector, alarm bell system of the brain that’s where the trauma lands, and trauma makes that part of the brain hypersensitive or renders it totally insensitive.

MS. TIPPETT: And the Broca’s area?

DR. VAN DER KOLK: Well, in our study and some others, I mean, for me it was really the great finding early on, is that when people are into their trauma, Broca’s area shuts down. That is something that almost everybody has experienced. You get really upset with your partner or your kid, suddenly you take leave of your senses and you say horrible things to that person. And afterwards, you say, oh, I didn’t mean to say that.

The reason why you said it is because Broca’s area, which is sort of the part of your brain that helps you to say reasonable things and to understand things and articulate them, shuts down. So when people really become very upset, that whole capacity to put things into words in an articulate way disappears. And for me, that is a very important finding because it helped me to realize that, if people need to overcome the trauma, we need to also find methods to bypass what they call the tyranny of language.

MS. TIPPETT: Don’t ask to be verbal, to verbalize it.

DR. VAN DER KOLK: Or to be reasonable.

MS. TIPPETT: Right. [laughs]

DR. VAN DER KOLK: The trauma is not about being reasonable or to be verbal or to be articulate.

[music: “Third” by Hiatus]

MS. TIPPETT: I’m Krista Tippett and this is On Being. Today with psychiatrist Bessel van der Kolk. He’s a leading innovator in the treatment of traumatic stress.

MS. TIPPETT: So it seems like there are all these impulses that we have that we’re working with all the time that gets so out of whack with trauma, and so, I mean, I’ve understood that it’s not just that we have memories and that we process them in different ways, but also that we are constantly rationalizing, that we have this impulse to rationalize. But then when people are traumatized, they are actually they also have this impulse to rationalize and then become unable to grasp the irrelevance of that memory and that feeling to the present moment.

DR. VAN DER KOLK: Yeah, yeah. So we have these two different parts of our brain and they’re really quite separate. So we have our animal brain that makes you go to sleep, it makes us hungry and makes us turned on to other human beings in a sexual ways, stuff like that. And then we have our rational brain that makes you get along with other people in a civilized way. These two are not all that connected to each other. So the more upset you are, you shut down your rational part of your brain.When you look at the political discourse, everybody can rationalize what they believe in and talk endlessly about why what they believe is the right thing to do while your emotional responses are totally at variance with seemingly rational behaviors. We can talk till we’re blue in the face, but if our primitive part of our brain perceives something in a particular way, it’s almost impossible to talk ourselves out of it which, of course, makes sort of verbal psychotherapy also extremely difficult because that part of the brain is so very hard to access.

MS. TIPPETT: Yeah. We’re pretty fascinating creatures, aren’t we?

DR. VAN DER KOLK: Fascinating, disturbing, glorious, all those things.

MS. TIPPETT: All those things all at once.

DR. VAN DER KOLK: Right. Right.

MS. TIPPETT: So I do want to talk about yoga now, which is something that’s very important to me as well, something I’ve discovered in the last five or six years. How did you get interested — how did you discover yoga and then make that part of this kind of work?

DR. VAN DER KOLK: We actually got into yoga in a very strange way. We learned that there is a way of measuring the integrity of your reptilian brain, i.e., how the very most primitive part of your brain deals with arousal. How you measure that is with something called heart rate variability. It tells you something about how your breath and your heart are in sync with each other.

It turns out that the calmer people are and the more mindful people are, the higher their heart rate variability is. And then we were doing that on some traumatized people and we noticed that they had lousy heart rate variability. Then I thought, so how can we change peoples’ heart rate variability?

MS. TIPPETT: And is this something you’d naturally be aware of or not? You wouldn’t know if it was in sync or out of sync?

DR. VAN DER KOLK: No, but you can measure it and it’s fairly easy to measure it. There are like apps for your iPhone on which you can measure them. But, of course, we do it in a more sophisticated way. So we found this very abnormal heart rate variability in terms of these people and then we heard that there were 17,000 yoga sites that claimed that yoga changed heart rate variability.

A few days later, some yoga teachers walked by our clinic and said, “Hey, do you think you can use this for some project?” And I said, “We sure can. We’d love to see if yoga changes heart rate variability.” This whole yoga thing also fits very well with the increasing recognition that traumatized people cut off their relationship to their bodies.

MS. TIPPETT: Right.

DR. VAN DER KOLK: And I have to give a little bit of background here. Um, way back already in 1872, Charles Darwin wrote a book about emotions in which he talks about how emotions are expressed in things like heartbreak and gut-wrenching experience. So you feel things in your body. And then it became obvious that, if people are in a constant state of heartbreak and gut-wrench, they do everything to shut down those feelings to their body.

One way of doing it is taking drugs and alcohol, and the other thing is that you can just shut down your emotional awareness of your body. And so a very large number of traumatized people who we see, I’d say the majority of the people we treat at the trauma center and in my practice, have cut off relationships to their bodies. They may not feel what’s happening in their bodies. They may not register what goes on with them. And so what became very clear is that we needed to help people for them to feel safe feeling the sensations in their bodies, to start having a relationship with the life of their organism, as I like to call it.

And so a combination of events really led us into exploring yoga for them. And yoga turned out to be a very wonderful method for traumatized people to activate exactly the areas of cautiousness, areas of the brain, the areas of your mind that you need in order to regain ownership over yourself. I don’t think that yoga would be the only way to do it, or I think if you only do yoga, that you can totally take care of it.

But yoga, to my mind, is an important component of an overall healing program and, again, not only yoga. You could do maybe martial arts or qigong, but something that engages your body in a very mindful and purposeful way — with a lot of attention to breathing in particular — resets some critical brain areas that get very disturbed by trauma.

[music: “Sparrow Song” by Keith Kenniff]

MS. TIPPETT: Do you also have a yoga practice?

DR. VAN DER KOLK: I also have a yoga practice, I do. Not enough, of course. None of us ever does enough. But I try to start every day with a yoga practice.

MS. TIPPETT: Now did I read somewhere that you also found that your heart rate variability was not in sync and was not robust enough?

DR. VAN DER KOLK: [laughs] That’s true, that’s true.

MS. TIPPETT: And do you know if yoga has helped you?

DR. VAN DER KOLK: Yeah, it’s a nice even heart rate variability now, yeah.

MS. TIPPETT: I wonder if you have ever heard of somebody named Matthew Sanford, whom I’ve had on my program? He’s actually …

DR. VAN DER KOLK: No.

MS. TIPPETT: He’s a very renowned yoga teacher. He’s been paraplegic since he was 13 and he had no memory of the accident in which he was disabled, and his body remembered it, right? He talks about body memory. It’s the same thing you say, this imprint that trauma has not just on your mind. The other thing that he’s doing recently is actually working with veterans and also working with young women suffering from anorexia and understanding also that, although that seems to be so much an obsession with the body, they are really in a traumatic relationship with their own bodies.

DR. VAN DER KOLK: Absolutely, yes.

MS. TIPPETT: Some of the things he’s doing, which he actually did for me — I did a class with him, like just putting these very comforting weights on certain muscles, so you feel sunk into your body in a way. And I don’t know I just was thinking — I’ve been thinking about this as I’ve been reading about your research.

DR. VAN DER KOLK: Huh? It sounds very sympathetic and very right. The sense of the experiences, of feeling weight and feeling your substance …

MS. TIPPETT: Yes, feeling your substance which is bigger than just feeling a weight on your muscles, isn’t it?

DR. VAN DER KOLK: Yeah. Really feeling your body move and the life inside of yourself is critical. Personally, for example, when people ask me so what sort of treatments have you explored, I’ve always explored every treatment that I explore for other people. What’s been most helpful for me has been rolfing.

MS. TIPPETT: Has been what?

DR. VAN DER KOLK: Rolfing. Rolfing is called after Ida Rolf. It’s a very deep tissue work where people who tear your muscles from your fascia with the idea that, at a certain moment, your body comes to be contracted in a way that you habitually hold yourself. So your body sort of takes on a certain posture. And the idea of rolfing is to really open up all these connections and make the body flexible again in a very deep way.

I had asthma as a kid. I was very sickly as a kid, because I was part of this group in the Netherlands — finally after the war in the Netherlands during which I was born, about 100,000 kids died from starvation, and I was a very sickly kid. I think I carried it in my body for a long time and rolfing helped me to overcome that actually. So now I became flexible and multipotential again.

And for my patients, I always recommend that they see somebody who helps them to really feel their body, experience their body, open up to their bodies. And I refer people always to craniosacral work or Feldenkrais. I think those are all very important components about becoming a healthy person.

MS. TIPPETT: You know, but they’re not that easy to find. They’re still kind of around the edges, Feldenkrais and craniosacral. Isn’t it strange how, in Western culture in a field like psychotherapy or even I see this a lot in religion, in Western culture we turn these things into these chin-up experiences. We separated ourselves, we divided ourselves. I see this — I mean, yoga is everywhere now, right? And people are discovering all kinds of ways, as you say. There are all kinds of other ways to reunite ourselves, but …

DR. VAN DER KOLK: But it’s true. Western culture is astoundingly disembodied and uniquely so. Because of my work, I’ve been to South Africa quite a few times and China and Japan and India. You see that we are much more disembodied. And the way I like to say is that we basically come from a post-alcoholic culture. People whose origins are in Northern Europe had only one way of treating distress: that’s namely with a bottle of alcohol.

North American culture continues to continue that notion. If you feel bad, just take a swig or take a pill. And the notion that you can do things to change the harmony inside of yourself is just not something that we teach in schools and in our culture, in our churches, in our religious practices. And, of course, if you look at religions around the world, they always start with dancing, moving, singing …

MS. TIPPETT: Yeah. Crying, laughing, yeah.

DR. VAN DER KOLK: Physical experiences. And then the more respectable people become, the more stiff they become somehow.

[music: “Scene of the Sunrise” by Miaou]

MS. TIPPETT: You can listen again, download and share this conversation with Bessel van der Kolk through our website, onbeing.org.

Coming up…pondering the collective traumas we experience when far away, tragic events bombard us through the news.

I’m Krista Tippett. On Being continues in a moment.

[music: “Scene of the Sunrise” by Miaou]

MS. TIPPETT: I’m Krista Tippett and this is On Being. Today with psychiatrist Bessel van der Kolk. He’s a long-time clinician and researcher in treating the effects of trauma — “overwhelming experiences” — on individuals and communities. At the community based trauma center he helped found in Brookline, Massachusetts, he investigates state of the art therapeutic treatments, including body work like yoga and Eye Movement Desensitization and Reprocessing therapy — or EMDR.

MS. TIPPETT: I also would like to ask you just about this EMDR, because I had not heard of this before.

DR. VAN DER KOLK: Oh, really?

MS. TIPPETT: No, I haven’t.

DR. VAN DER KOLK: Well, EMDR is a bizarre and wondrous treatment and anybody who first hears about it, myself included, thinks this is pretty hokey and strange. It’s something invented by Francine Shapiro who found that, if you move your eyes from side to side as you think about distressing memories, that the memories lose their power.

And because of some experiences, both with myself, but even more with the patients of mine who told me about their experiences, I took a training in it. It turned out to be incredibly helpful. Then I did what’s probably the largest NIH-funded study on EMDR. And we found that, of people with adult-onset traumas, a one-time trauma as an adult, that it had the best outcome of any treatment that has been published.

What’s intriguing about EMDR is both how well it works and the question is how it works and that got me into this dream stuff that I talked about earlier, and how it does not work through figuring things out and understanding things. But it activates some natural processes in the brain that’s helped you to integrate these past memories.

MS. TIPPETT: I mean, it sounds so simple and even when I was reading about it, moving your eyes back and forth. I mean, is this something that you can do for yourself or is there something more complex going on?

DR. VAN DER KOLK: I imagine it can be done, but it’s usually better if you do it with somebody else who sort of stays with you, helps you to focus, makes eye movement for you by having somebody else follow your fingers. But it is astoundingly effective treatment. And it’s interesting that, even in the most biased studies, the EMDR keeps coming up as this very effective treatment. It’s been very difficult to get funding to find out the very intriguing underlying mechanisms of it. And I think if we really find out the mechanism for EMDR, we’ll understand how the mind works much better. It’s an outstandingly effective treatment.

So if people have had one terrible thing that they cannot get out of their minds, that for me is the treatment of choice. Of course, the people who come to see me in my practice oftentimes have had multiple traumas at the hands of their intimates also, so then it gets much more complicated than just a memory issue. But if it’s just a car accident or a simple assault, it’s astoundingly effective, yeah.

MS. TIPPETT: That’s fascinating. Something else I read is you were reflecting on Hurricane Hugo, hurricanes in general or natural disasters. This phenomenon we see of people helping each other, of getting out there and helping each other and you also look at that and see that it’s not just that people are helping each other. They’re moving their bodies. Again, there’s this physical involvement kind of as antidote to the helplessness of the situation, which is so manifest.

DR. VAN DER KOLK: Good. I’m really glad you read it, because people talk a lot about stress hormones. Our stress hormones are sort of the source of all evil. That’s definitely not true. The stress hormones are good for you. You secrete stress hormones in order to give you the energy to cope under extreme situations. So it gives you that energy to stay up all night with your sick kid or to shovel snow in Minnesota and Boston and stuff like that.

What goes wrong is, if you’re kept from using your stress hormones, if somebody ties you down, if somebody holds you down, if somebody keeps you imprisoned, the stress hormones keep going up, but you cannot discharge it with action. Then the stress hormones really start wreaking havoc with your own internal system.

But as long as you move, you are going to be fine. As we know, after these hurricanes and these terrible things, people get very active and they like to help and they like to do things and they enjoy doing it because it discharges their energy.

MS. TIPPETT: So we are healing ourselves. We don’t realize that, but we know how to …

DR. VAN DER KOLK: We are using our natural system basically. We’re not only healing, we’re coping. We’re just dealing with what we need to cope with. You know, that’s why you have that stuff. That’s why we survive as a species. What was disturbing in Hurricane Hugo, which is my first encounter quite a long time, and as we saw again in New Orleans, is how these victimized populations were prevented from doing something and that’s really what the observation was.

MS. TIPPETT: And that that compounded the trauma.

DR. VAN DER KOLK: Yeah. So I get flown into Puerto Rico after Hurricane Hugo, because I’d written a book about trauma. I knew nothing about disasters, but nobody else knew anything either, so they flew me in. And what struck me, I landed in Puerto Rico and everybody is busy doing stuff and building things and everybody’s too busy to talk to me, because they’re trying to do stuff. But on the same plane that I flew in with, officials from FEMA came in who then made announcements to stop your work until FEMA decides what you’re going to get reimbursed for.

MS. TIPPETT: Right, right.

DR. VAN DER KOLK: And that was the worst thing that could have happened, because now these people were using the energy to fight with each other and to pick war with each other instead of rebuilding their houses. That’s, of course, similar what happened in New Orleans where people also were kept from being agents in their own recovery.

MS. TIPPETT: I wonder how you look at this world we live in now where it feels like there’s an acceleration of what you might call collective traumatic events or tragedies. It seems to be more and more predictable that around the corner there will be a bombing or a school shooting or a terrible event that’s involved with the weather. How does what you know about trauma help you think about this or …

DR. VAN DER KOLK: I’m not sure if I share that view with you. I think there’s so much more news, so we’re much more aware of whatever happens at any particular moment. And of course, the news media, when you wake up in the morning, find the worst thing that happens somewhere in the world to serve it to you for breakfast. So we get served much more. I don’t think there’s more trauma actually.

MS. TIPPETT: You don’t think more bad things happen?

DR. VAN DER KOLK: When I read about how Abe Lincoln grew up,  he’d lost his mother and they moved to houses all the time and they were starving and he had nothing. I mean, you read the stories about all the immigrants, all those people who died and the number of assaults in New York City and around the country. I don’t think we live in the worst world. And I think people are also much more conscious today than they were, let’s say, 100 years ago.

No, I really have studied the history of trauma, and my favorite human folly is the First World War. If you think the world is bad right now, think about the First World War, unbelievable. So I don’t think things are necessarily worse and I think when I go around the country and I see the number of programs that very goodhearted people have for school kids, etc., I’m continuously astounded by the amount of integrity and creativity and good will that I see everywhere around me.

At the same time that you see something as horrendous as in Philadelphia: the school system of the public schools in Philadelphia abolished arts programs, gymnastics, counseling and music programs. I go, where have these people been in order to have a minded focuses? You need to move your body. You need to sing with other people. And if you think that your kids are going to do better if you keep them stock-still in a classroom taking tests, you don’t know anything about human beings.

So you still hear about horrendous things all the time, but I see a great deal of consciousness at the same time and I see that people are really trying to carve out more consciousness and more democracy in the various places around the world.

MS. TIPPETT: Something I’m aware of is how — and this would be different from the First World War era where we get these pictures, these vivid images with this immediacy brought to us, right? And I personally, I think this is true collectively too. I don’t know what to do with those images. It’s so disturbing and then there’s also this impulse that you just have to cut yourself off from that feeling, right, because I can’t do anything for that particular picture. And then there’s this guilt and this feeling that that’s not a satisfactory reaction. I mean, altogether …

DR. VAN DER KOLK: See, there’s a very dark side to this also and that is that there’s a certain tropism, a movement towards misery in our lives so that, if things become too quiet, it becomes boring and when you see the preview of coming attractions in the movie theater, you go like, “Oh, my God. What are these people watching?” People are drawn towards horrendous stuff all the time. So it is part of that dark side of human nature to want to live on that edge. It’s very hard. It’s hard to deal with.

MS. TIPPETT: You know, it’s very hopeful that you spend your life working with trauma, with victims in this research. But you have a pretty refreshingly, hopeful feeling about us as a species.

DR. VAN DER KOLK: Well, you see part of that I get from my patients. What is so gratifying about this work is that you get to see the life force. People go through horrendous stuff everywhere all the time, and yet people go on with their lives.

MS. TIPPETT: And you see that, you experience that again and again.

DR. VAN DER KOLK: I see it all the time. I see kids who grew up under terrible circumstances and some of them do terribly. But then last week, we had our conference here, our annual conference in Boston, and somebody presented her work on doing meditation in maximum security jails. And you see these really bad-ass guys come to life, because of this meditation program.

And, I see people getting better with another program that I’m involved with is a Shakespeare program for juvenile delinquents here in Brookshire County where the judge gives kids a choice between going to prison or being condemned to be a Shakespeare actor.

And, I go to the Shakespeare program and these actors do a beautiful job for these kids and you see these kids come to life as they’re being valued as an actor and a person who is able to talk. What I see is a huge potential that people have to crawl out of their holes.

[music: “Frontiers” by Floratone]

MS. TIPPETT: I’m Krista Tippett and this is On Being. Today with psychiatrist Bessel van der Kolk.

MS. TIPPETT: I read your research and I think about this whole picture that we’ve been discussing of all the different ways people are reaching out for methods to become more self-aware — yoga, meditation, using these insights of neuroscience. Sometimes I wonder if, you know, 50 years from now or 100 years from now, people might look back on therapy the way we did it and we’ve done it for 50 years or whatever, and see it as a really rudimentary step towards a much more profound, reaching for awareness and consciousness, mindfulness.

DR. VAN DER KOLK: Well, I think people have always done good therapy, huh? And our culture and our insurance structure is not really geared towards really very good therapy nor is our psychological training, which is there to fix people and get rid of their disorder as fast as possible. But therapy as in people really getting to know themselves very well and examining themselves and being seen and being heard and being understood has always been around and I think it will always be around.

And I don’t think we’ll ever talk about it as necessarily primitive, because the intimate interchange of people really talking about their deepest feelings and their deepest pain and having persons listen to it has always been, and I think it always will be, a very powerful human experience.

MS. TIPPETT: So the language people sometimes use about trauma would be —  there’s a lot of spiritual language that we intuitively grasp for soul-steeling. I wonder how you think about the human spirit in the context of what you know about trauma and resilience and healing.

DR. VAN DER KOLK: That’s a very tough question.

MS. TIPPETT: I know. I think you’re up to it, though.

DR. VAN DER KOLK: A topic that I tended to stay away from. But, I think trauma really does confront you with the best and the worst, huh? You see the horrendous things that people do to each other, but you also see resiliency, the power of love, the power of caring, the power of commitment, the power of commitment to oneself, to the knowledge that there are things that are larger than our individual survival.

And some of the most spiritual people I know are exactly traumatized people, because they have seen the dark side. In some ways, I don’t think you can appreciate the glory of life unless you also know the dark side of life.

MS. TIPPETT: Right.

DR. VAN DER KOLK: And I think the traumatized people certainly know about the dark side of life, but they also, because of that, see the other side better.

MS. TIPPETT: You said somewhere that PTSD has opened the door to scientific investigation of the nature of human suffering. That’s a profound step, right? I mean, to me that’s the spiritual way to talk about this field with a profound understanding of what the word spiritual means.

DR. VAN DER KOLK: Yeah. Well, you know, I think this field has opened up two areas. One is the area of trauma and survival and suffering, but the other one is also people are studying the nature of human connections and the connection between us, also from a scientific point of view.

As much as trauma has opened up things, I think the other very important arm of scientific discovery is how the human connection is being looked at scientifically now and what really happens when two people see each other, when two people respond to each other, when people mirror each other, when two bodies move together in dancing and smiling and talking.

There’s a whole new field of interpersonal neurobiology that is studying how we are connected with each other and how a lack of connection, particularly early in life, has devastating consequences on the development of mind and brain.

MS. TIPPETT: And it’s true isn’t it from your study that, that if people learn to inhabit their bodies, to be more self-aware, that these qualities and habits can serve, can create resilience, can serve when trauma hits. Is that right?

DR. VAN DER KOLK: Absolutely. So if you particularly — there’s two factors here. One is how your reptilian brain, if you breath quietly in your body and you feel your bodily experience and stuff happens to you, you notice that something is happening out there and you say, oh, this really sucks. This is really unpleasant. But it’s something that is not you. So you don’t necessarily get hijacked by unpleasant experiences.

The big issue for traumatized people is that they don’t own themselves anymore. Any loud sound, anybody insulting them, hurting them, saying bad things, can hijack them away from themselves. And so what we have learned is that what makes you resilient to trauma is to own yourself fully. And if somebody says hurtful or insulting things, you can say, hmm, interesting that person is saying hurtful and insulting things …

MS. TIPPETT: But you can separate your sense of yourself from them.

DR. VAN DER KOLK: Yeah, separate yourself from them. I think we are really beginning to seriously understand how human beings can learn how to do that, to observe and not react.

MS. TIPPETT: I think I just want to come back as we close to this idea that somehow the point of all of this, the take-home for you, and I’m not finding in a quote, is that we have to feel safe, that we have to feel safe and that we have to feel safe that has to be a bodily perception, not just a cognitive perception. And that somehow everything comes back to that.

DR. VAN DER KOLK: But is the foundation, but you need to actually feel that feeling. You need to know what is happening in your body. You need to know where your right toe is or your pinkie is. You need to sort of be aware …

MS. TIPPETT: It’s very nitty-gritty. Is that what you’re saying?

DR. VAN DER KOLK: It’s very, very basic, you know, but sorely lacking in our diagnostic system is simple things like eating and peeing and pooping because they’re the foundation of everything, and breathing. You know, these are foundational things, all of which go wrong when you get traumatized. They’re the most elementary body functions go awry when you are terrified.

So trauma treatment starts at the foundation of a body that can sleep, a body that can rest, a body that feels safe, a body that can move. And I love the example of your guy who’s paraplegic and who does yoga because, even when your body is impaired, he can still learn to own it and to have it.

MS. TIPPETT: Yes. You know, he says he’s not cured, but he’s healed, right? And here’s a striking statement you’ve made that “victims are members of society whose problems represent the memory of suffering, rage, and pain in a world that longs to forget.”

DR. VAN DER KOLK: Did I say that?

MS. TIPPETT: You did.

DR. VAN DER KOLK: That’s brilliant.

MS. TIPPETT: And I find that so worthy of reflection.

DR. VAN DER KOLK: Well, you know, that’s the literature we read. That’s the movies we watch. And that’s what we want to be inspired by. That’s what we observe is that spirit. Toni Morrison and Maya Angelou and these people can talk very articulately about having dealt with and stared adversity in the face and still maintain that humanity and faith. That’s what’s it all about.

[music: “Enjoy the Calm” by Drew Barefoot]

MS. TIPPETT: Bessel van der Kolk is medical director of the Trauma Center at the Justice Resource Institute in Brookline, Massachusetts. He’s also a professor of Psychiatry at Boston University Medical School.

His books include Traumatic Stress: The Effects of Overwhelming Experience on the Mind, Body and Society and, more recently, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma.

[music: “Enjoy the Calm” by Drew Barefoot]

MS. TIPPETT: You can listen again or share this conversation with Bessel van der Kolk, at onbeing.org.

[music: “Trifle (Consoles Because A Trifle Troubles)” by Infradig]

MS. TIPPETT: On Being is Trent Gilliss, Chris Heagle, Lily Percy, Mariah Helgeson, Chris Jones, David Schimke, and Bekah Johnson.

Bessel van der Kolk, M.D.

Dr. van der Kolk, Trauma Center Founder and Medical Director, has been active as a clinician, researcher and teacher in the area of posttraumatic stress and related phenomena since the 1970s. His work integrates developmental, biological, psychodynamic and interpersonal aspects of the impact of trauma and its treatment. His book, Psychological Trauma,was the first integrative text on the subject, painting the far ranging impact of trauma on the entire person and the range of therapeutic issues which need to be addressed for recovery. Dr. van der Kolk and his various collaborators have published extensively on the impact of trauma on development, such as dissociative problems, borderline personality and self-mutilation, cognitive development in traumatized children and adults, and the psychobiology of trauma. He participated in the first neuroimaging study of PTSD, in the first study to link Borderline Personality Disorder with childhood trauma; was co-principal investigator of the DSM IV Field Trials for Post Traumatic Stress Disorder, and is Chair of the NCTSN DSM V workgroup on Developmental Trauma Disorder. His current projects include yoga for treating PTSD, funded by the National Institutes of Health; the use of theater for violence prevention in the Boston public schools, funded by the CDC; the mechanisms of EMDR; sensory integration; and the use of neurofeedback in PTSD. Dr. van der Kolk is past President of the International Society for Traumatic Stress Studies, Professor of Psychiatry at Boston University Medical School, Co-Director of the National Center for Child Traumatic Stress Complex Trauma Network and Medical Director of the Trauma Center at JRI in Brookline, Massachusetts. He continues to teach at universities and hospitals across the United States and around the world, including Europe, Africa, Russia, Australia, Israel, and China. His book, Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society, co-edited with Alexander McFarlane and Lars Weisaeth, explores what we have learned in the past twenty years of the role trauma plays in psychiatric illness. In Dr. van der Kolk’s recently released book (October 2014),The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, he transforms our understanding of traumatic stress, revealing how it literally rearranges the brain’s wiring and offers a bold new paradigm for healing.

2014
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Posted by: faithful | October 23, 2014

prodromal treatment of schizophrenia

October 20, 2014 
Meghan, 23, began experiencing hallucinations at 19. "Driving home, cars' headlights turned into eyes. The grills on the cars turned into mouths and none of them looked happy. It would scare the crap out of me," Meghan says.

Meghan, 23, began experiencing hallucinations at 19. “Driving home, cars’ headlights turned into eyes. The grills on the cars turned into mouths and none of them looked happy. It would scare the crap out of me,” Meghan says.

Marvi Lacar for NPR

The important thing is that Meghan knew something was wrong.

When I met her, she was 23, a smart, wry young woman living with her mother and stepdad in Simi Valley, about an hour north of Los Angeles.

Meghan had just started a training program to become a respiratory therapist. Concerned about future job prospects, she asked NPR not to use her full name.

Five years ago, Meghan’s prospects weren’t nearly so bright. At 19, she had been severely depressed, on and off, for years. During the bad times, she’d hide out in her room making thin, neat cuts with a razor on her upper arm.

“I didn’t do much of anything,” Meghan recalls. “It required too much brain power.”

“Her depression just sucked the life out of you,” Kathy, Meghan’s mother, recalls. “I had no idea what to do or where to go with it.”

One night in 2010, Meghan’s mental state took an ominous turn. Driving home from her job at McDonald’s, she found herself fascinated by the headlights of an oncoming car.

“I had the weird thought of, you know, I’ve never noticed this, but their headlights really look like eyes.”

To Meghan, the car seemed malicious. It wanted to hurt her.

Kathy tried to reason with her.

“Honey, you know it’s a car, right? You know those are headlights,” she recalls pressing her daughter. “You understand that this makes no sense, right?”

“I know,” Meghan answered. “But this is what I see, and it’s scaring me.”

In other words, Meghan had insight, defined in psychiatry as the ability to understand that one’s unusual experiences are attributable to a mental illness.

What Meghan saw did not fit with what she believed. She knew she was hallucinating.

Meghan keeps a photo of her cat, Boo, on the wall in her bedroom. "She would stay in her room and keep to herself," Kathy, Meghan's mother, says. "Sometimes that was a good thing because her depression just sucked the life out of you."

Meghan keeps a photo of her cat, Boo, on the wall in her bedroom. “She would stay in her room and keep to herself,” Kathy, Meghan’s mother, says. “Sometimes that was a good thing because her depression just sucked the life out of you.”

It’s the loss of insight that signals a psychotic break. This can lead to several different diagnoses, but in people ultimately diagnosed with schizophrenia, the break signals the formal onset of the disease. Typically, a first psychotic break occurs in a person’s late teens or early 20s. In men, the range is 15 to 24; in women, 25 to 34.

That first psychotic break can lead to a series of disasters: social isolation, hospitalization, medications with sometimes disabling side effects, and future psychotic episodes.

So, what if you could intervene earlier, before any of that? Could you stop the process from snowballing?

At 19, Meghan hadn’t had a psychotic break. She still had insight. That made her eligible for a new type of program taking shape in California that aims to prevent schizophrenia before it officially begins.

The program draws on research suggesting that schizophrenia unfolds much more slowly than might be obvious, even to families.

“You start to see a decline in their functioning,” says Dr. Daniel Mathalon, who studies brain development in the early stages of psychosis at the University of California, San Francisco.

“They were doing better in school, now they’re doing worse,” he says. “Maybe they had friends but they’re starting to be more isolated.”

Eventually, these subtle behavioral shifts may take on a surreal quality. A young person may hear faint whispers or hissing, or see flashes of light or shadows on the periphery.

“They lack delusional conviction,” explains Mathalon. “They’re experiencing these things; maybe they’re suspicious. But they’re not sure.”

"I valued my ability to think and learn," Meghan says. "To know that the one thing I valued so highly was dissolving away, that I was losing chunks of my sanity with every hallucination. ... That was more terrifying than the monsters that I saw could ever be."

“I valued my ability to think and learn,” Meghan says. “To know that the one thing I valued so highly was dissolving away, that I was losing chunks of my sanity with every hallucination. … That was more terrifying than the monsters that I saw could ever be.”

Psychiatrists have a word for this early stage: prodromal.

Meghan took a screening test developed at Yale University Medical School that identified her as possibly within the prodromal stage of psychosis. That is, her symptoms could be indicative of early psychosis, but weren’t predictive.

She was referred to a clinic in an office park about an hour from her house calledVentura Early Intervention Prevention Services, or VIPS, operated by Alameda-based Telecare Corp.

VIPS is one of a handful of programs that have sprung up in California in recent years, based on a model developed in Maine by psychiatrist Dr. Bill McFarlane.

McFarlane believes that psychosis can be prevented with a range of surprisingly low-tech interventions, almost all of which are designed to reduce stress in the family of the young person who is starting to show symptoms.

McFarlane cites research done at UCLA suggesting that certain kinds of family dynamics — families that don’t communicate well, or are overly critical — can make things worse for a young person at risk of schizophrenia.

Meghan’s family credits the VIPS program for her transformation. “She’s not the broken little girl that she was three years ago,” Meghan’s stepfather, Charlie, says.

“Our theory,” says McFarlane, “was that if you could identify these young people early enough, you could alter some of those family patterns. Then you could work with the family to start behaving not just normally, but in a way that was smarter.”

McFarlane’s programs bring families in for twice-monthly multifamily group therapy sessions, where participants take a nuts-and-bolts approach to resolving disputes at home and softening their responses to what the young person is going through.

“We assume parents can’t figure this out alone,” says McFarlane.

In some cases, participants are also prescribed antipsychotic drugs, especially one called Abilify, which McFarlane and others believe can stem hallucinations.

McFarlane himself is careful about recommending antipsychotic medications.

The drugs, he says, should be used cautiously, at lower doses than would be prescribed for full psychosis, and even then only in young people who aren’t responding to other treatments.

But in programs inspired by his model, the drugs appear to be widely prescribed, including in clients as young as 10 or 13. This fact has become a flashpoint in the conversation around schizophrenia prevention.

“No one is harder to diagnose than a child or a teenager,” says Dr. Allen Frances, a former chair of the psychiatry department at Duke University and chair of the task force that produced the fourth revision of the Diagnostic and Statistical Manual, or DSM-IV, the standard reference for psychiatric diagnoses.

“There are rapid developmental changes from visit to visit,” he says. “The tendency to overdiagnose is particularly problematic in teenagers.”

Frances points to studies showing that if you take three kids, all experiencing those surreal early symptoms, only one will get schizophrenia.

So what about the other two?

Frances says these kids are wrongly labeled and stigmatized. Their parents are terrified. And in many cases, they will be prescribed antipsychotic drugs, which can have serious side effects and haven’t been studied well in children.

“We have to be careful of any new fad in psychiatry,” says Frances. “The field has been filled with fads in the past, and often we learn in retrospect that they’ve done much more harm than good.”

But what Frances calls a fad is to others a model for mental health care.

To see these programs in action, the best place to go is California, where over the past few years a handful of programs have sprung up based on McFarlane’s PIER model.

One, in San Diego, is called Kickstart. Like the others, it’s paid for by a state tax on millionaires, passed by voters in 2004, that funds mental health. Services — everything from homework help to family therapy and outings such as kite-flying expeditions — are offered for free.

Joseph Edwards, Kickstart’s assistant program director, says for teenagers who might be developing schizophrenia, just being outside, with friends, is a kind of therapy.

“They’ll want to isolate,” says Edwards. “There’s sensitivity to a lot of stimulation. And a lot times we’ll see what we call day/night reversal, where they’ll stay up all night and go to sleep in the daytime.”

Edwards says if a teenager is really isolating, a Kickstart worker will drive to his or her house and cajole the person out. Anything, he says, to keep them engaged, with friends in school or at work.

Tony, 13, spends an afternoon at an arcade with Ashley Wood, his occupational therapist in the Kickstart program in San Diego.

Tony, 13, spends an afternoon at an arcade with Ashley Wood, his occupational therapist in the Kickstart program in San Diego.

At an arcade in a strip mall, we meet Ashley Wood, one of Kickstart’s occupational therapists. Wood brought her client, 13-year-old Tony, here as a reward for being cooperative in therapy.

We aren’t using Tony’s full name because he’s a minor, at the request of his parents.

Wood has an easy laugh and teases Tony gently to pull him out of his shell.

“When we first met, he was so quiet,” she says, laughing. “He’s like, ‘Who is this chick?’ “

“Nah,” says Tony, smiling shyly. “I was being a jerk.”

Tony had been getting in fights. He was angry at his mom, angry in school. And there was something else.

“I used to see stuff and hear [stuff],” he tells me.

“Like what?” I ask him. “Like … weird objects,” he responds. When I press him for more details, he shakes his head.

Are Tony’s symptoms the beginning of schizophrenia? Or just the routine weirdness of a teenage brain taking shape?

No one — not Wood, not his therapists — can say for sure.

Wood says what she’s teaching him will be helpful either way: “When he’s frustrated at school or at home, instead of immediately responding, kind of finding a way to communicate. So we’re trying to work on the impulse control as well.”

Impulsive, unruly, prone to angry outbursts, Tony sounds like a lot of 13-year-old kids.

That’s one reason that last year, the American Psychiatric Association opted to exclude the idea of “psychosis risk syndrome” from the DSM-5, the latest version of the manual of mental disorders. The screening test is generally considered to be only 30 percent accurate.

In 2011, a review of prodrome intervention programs called the idea of intervention in pre-schizophrenia “inconclusive.”

“This is an experiment far before its time,” says Allen Frances.

McFarlane believes the benefits of these programs are borne out in the work done at his clinic and others based on his model. In July, he published the results of a two-year study of two groups of young people at risk for, or in the early stage of, schizophrenia, which showed better functional outcomes for those who went through treatment.

He and other proponents say schizophrenia’s early window may be too precious to miss.

“We’re running up against the limits of what we can do for patients who develop schizophrenia, once it goes to chronic stages,” UCSF’s Mathalon says. “I think this is a direction we have to go in, but we have to do it carefully.”

When you talk to people who have been through these programs and ask them what helped them, it is not the drugs, not the diagnosis. It’s the lasting, one-on-one relationships with adults who listen, like Ashley Wood.

Tiffany Martinez, an early client of Bill McFarlane’s in Maine, chokes up when asked to describe what she thinks helped her climb out of an incipient mental health crisis that began when she was in college.

“To share such personal intimate details, you know? To have these people working so hard on it and so devoted and invested in the work,” Martinez, now age 26, says, “it’s like getting a chance. Just the program, what the program stands for alone, is hope.”

That same relief is palpable when you talk to Meghan’s mom, Kathy, and stepfather, Charlie.

“I thought we were going to have to take care of her for the rest of her life,” says Kathy. “I thought she’d forever be marginal, forever be medicated. I thought we’d just have to get used to it.”

Today Meghan is off all her medications. She’s animated, playing board games with her family, excited about being back in school.

Her family credits the VIPS program.

“We were blessed to have this for her,” Charlie says. “We really were. It saved her life.”

Posted by: faithful | October 7, 2014

how to help your children through a parental divorce

What Children Need Most When Their Parents Divorce

Posted: 10/06/2014 1:49 am 
DIVORCE

When parents go through a divorce, children’s psychological needs greatly increase as they live in the middle of an emotional (and perhaps economic) roller coaster filled with guilt, fear and confusion. In Family First: Your Step-by-Step Plan for Creating a Phenomenal Family, Dr. Phil explains the most profound needs of children during this challenging time:

Acceptance
This will be a child’s greatest need because their self-concept is very likely in a fragile and formative stage, especially if they are at a young age. They will try to gain approval because their sense of belonging to the family has been shattered. Children also tend to personalize things and blame themselves, which is another reason they need acceptance. Let them know that they are important, that they are a priority.

Assurance of safety
Parents need to go beyond normal efforts to assure their children that although the family has fragmented, their protection is solid. The key is to maintain a normal pace, boundaries and routines. They need to know that their world is predictable and that it’s not going to change on them.

Freedom from guilt or blame for the divorce

Children often shoulder the blame for the dissolution of a marriage. They personalize their part in the divorce, so they might think: “If only I didn’t make so much noise. If only I didn’t ask for new shoes …” They may think it’s their fault or that somehow they are being punished for their parents’ breakup. Be conscious of this and assure your children they’re blameless.

Structure
With the loss of a family leader from the home, children will check and test for structure, so be sure to give it to them. They need structure more than any other time in their lives, because this is when things seem to be falling apart for them. Enforce discipline consistently and with the right currency for good behavior. They need to see that the world keeps going, and they’re still an integral part of what’s going on.

A stable parent who has the strength to conduct business
Whether or not you feel brave and strong, you have to appear to be the best for your children. They’re worried about you and about your partner, especially if there’s an apparent crisis. Do everything possible to assure them of your strength, and in doing so, you make it possible for them to relax. Show yourself to be a person of strength and resilience.

Let kids be kids
Children should not be given the job of healing your pain. Too often, children serve either as armor or as saviors for their parents in crisis. They don’t need to be dealing with adult issues, and should not know too much about what’s going on between you and your ex-spouse.

There are two primary rules to follow, especially during times of crisis and instability in your family:

1. Do not burden your children with situations they cannot control. Children should not bear such a responsibility. It will promote feelings of helplessness and insecurity, causing them to question their own strengths and abilities.

2. Do not ask your children to deal with adult issues. Children are not equipped to understand adult problems. Their focus should be on navigating the various child development stages they go through.

 

How To Make Your Divorce Less Tough on Your Kids

Posted: 08/26/2014 2:36 pm 
DIVORCE

Making the decision to divorce your partner is not something that should be done lightly, especially when there are children involved. On the other hand, unhappy couples should not stay together solely for the sake of the children. If you and your spouse have exhausted all efforts to rehabilitate your relationship and decided that divorce is the right choice for you, Dr. Phil has this advice:

Put your children’s needs first.
You have a responsibility to your children to do everything you can to ensure that the divorce doesn’t leave permanent scars. Children don’t have the voice and ability to tell you what they think, so it is important to make their best interest your best interest. Take an honest look at yourself and what you’re doing to impact your children. Tell them that they are priority number one: “You’re the most important. You are first in everything we think and do, and we’re going to take care of you.”

Create a new relationship with your ex-spouse.
Don’t think of the divorce as ending the relationship with your ex-husband or ex-wife. Instead, think of it as starting a new one. Your new relationship as divorced parents involves being co-allies, nurturers and protectors of your children. Consider going to post-marital counseling, where you can create a parenting plan and resolve your differences, so you can clearly see what is in the best interest of your children. Find a way to make your children feel that everywhere they turn they see love, support and appreciation.

Communicate clearly with your children.
If communication is vague, children fill in the blanks to the detriment of themselves. They will blame themselves and think that it’s their fault that things have happened. Children can take anything and personalize it. For example, they’ll hear Mom and Dad fighting about money, and they’ll go in their room and say, “Oh, my gosh, I needed $20 yesterday for the school lunches. And if I didn’t eat all the time, maybe they wouldn’t be fighting.”

Don’t put your kids in the middle.
Resolve that there is not going to be a tug- of-war. Don’t put the children in between you and your ex and start pulling on them for their allegiance. Don’t use your children as pawns to find out about the other person or get back at your ex.

Fight in private.
Parents must stop the right-fighting and make a plan to help their children make it through the transition with as little trauma as possible. The kids don’t care who’s right; They want you to shut up! If parents are filled with bitterness and angst and resentment, then their children are going to get pulled back and forth, and that’s not right or fair to them.

Never undermine the other parent.
Don’t attack or criticize your ex in front of the children. Take the high ground and put the children above all of your personal wants and needs. If you behave in such a way as to alienate your child’s mother or father from them, they will resent you for it. The day will come when they will say, “You ran your own agenda and it cost us our mother/father.” You may feel like you might win at the time, but in the long term, they will resent you.

Communicate with your ex regarding child rearing decisions.
Make joint decisions about your children’s wellbeing. Don’t let the children divide you even further by manipulating the parent who is more lenient, etc.

Decide that your children will not come from a broken home; they are just going to have two homes.
Each parent should set up a home in which the children have a bedroom, toys to play with and space to be kids. Make sure the children feel at home in both places.

 

Dr. Phil’s Dos and Dont’s for Co-Parenting with Your Ex

Posted: 08/29/2014 4:24 pm 
DIVORCED PARENTS

No matter how much you hate your ex, if you’ve got kids together then you need to find a way to get along as co-parents.

“You have a lot of divorces that get acrimony and finger-pointing back and forth, but at some point you hope that the parents become fiduciaries and put the child’s best interest above their own agenda,” Dr. Phil tells his guests, Shawn and Kayla, who are in the middle of a heated custody battle.

Dr. Phil shares these co-parenting dos and don’ts:

DOs:

• Remember that the only person you control is you. Take the high road; there’s a lot less traffic up there.
• Think about the effects your actions have on your children.
• Set boundaries with your ex.
• Sit down with your ex and make an affirmative plan that sets aside any differences you may have so you can focus instead on meeting the needs of your children.
• Agree with your ex that you absolutely won’t disparage each other to your children. Further, forbid your children from speaking disrespectfully about the other parent, even though it may be music to your ears.
• Negotiate how you can best handle sharing the children for visitation, holidays, or events.
• Compare notes with your ex before jumping to conclusions or condemning one another about what may have happened.
• Although it may be emotionally painful, make sure that you and your ex keep each other informed about changes in your life circumstances so that the children are never, ever the primary source of information.

DON’Ts:
• Never sabotage your children’s relationship with the other parent.
• Never use your children as pawns to get back at or hurt your ex, or as tools to gain information and manipulate your ex.
• Never transfer hurt feelings and frustrations toward your ex onto your child.
• Never force your children to choose a side when there’s a conflict in scheduling or another planning challenge.
• Never convert guilt into overindulgence when it comes to satisfying your children’s material desires.

 

 

Posted by: faithful | September 19, 2014

what bipolar disorder really feels like

What Bipolar Disorder Really Feels Like

Posted: 09/18/2014 

About 2.6 percent of American adults — nearly 6 million people — have bipolar disorder, according to the National Institute of Mental Health (NIMH). But the disease, characterized by significant and severe mood changes, is still dangerously misunderstood.

Bipolar disorder is vastly different from the normal ups and downs of everyday life, but many have co-opted the term to refer to any old change in thoughts or feelings. The mood swings in someone with bipolar disorder, sometimes also called manic depression, can damage relationships and hurt job performance. It has been estimated that anywhere from 25 to 50 percent of people with bipolar disorder attempt suicide at least once.

Artist Ellen Forney detailed her diagnosis with bipolar disorder in the graphic memoir Marbles: Mania, Depression, Michelangelo, and Me. Forney previously shared her story with us, specifically detailing how her bipolar disorder has affected her creative work.

Below are some poignant pages from the memoir, along with unique commentary into how these panels came to be and what they mean to Forney, in her own words.

2014-09-15-59_Carousel_Forney.jpg

“I’ve heard from a lot of readers that the carousel metaphor has really clarified the different mood states for them. It’s really satisfying when you’re trying to explain something, and a metaphor that makes sense to you also works for someone else. I was originally going to draw a swing — you know, “mood swings” — but side-to-side didn’t work, I needed up-and-down.”

***

 

2014-09-15-77_BedToCouch_Forney.jpg

“A lot of readers have pointed to this page as one they identify with personally. I drew the scene very simply because I wanted it to not be set in time, or even space — it wasn’t what my bed looked like, or my couch, it was just a bed and a couch. It doesn’t even depict me, specifically, it’s mostly about the feeling of weariness and dread, with a tiny, sad bit of hope despite the feeling that all is futile. I do think this scene of having trouble getting out of bed is a common experience on the surface though, too.”

***

2014-09-15-134_SweptAway1_Forney.jpg2014-09-15-135_SweptAway2_Forney.jpg
“It was really satisfying to draw that, to pin it down on paper like a butterfly and examine it; to externalize things that are so confusing if they stay inside. I don’t know if it’s because I’m a swimmer or because I just love the water, but I actually pictured that specifically, that I was feeling “unmoored.” I suppose it’s the flip side of depression’s feeling like drowning.

You can see in that cloud that mania isn’t all euphoric or happy, it’s mostly that everything is punched up. I’m getting swept into that state of mind — the cloud is a thought balloon.”

***

 

2014-09-15-181_MedScout_Forney.jpg

“What meds work or don’t work for any one person is just so hit-or-miss right now. I remember a bipolar friend telling me with a certain backhanded pride that she’d been put on so many meds that she had a whole drawer full of bottles. I wanted to make the most of the absurdity of our victim-pride, so I imagined something like a Benny Hill soundtrack, and just rattled off my failed meds in cartoony, fast-moving panels. The merit badges were both serious — because this is hard, and we deserve some kind of Purple Hearts — and a nod to victim one-upmanship (“How many meds have you been on?” i.e., what are your battle scars?). In my head, this series of pages was really cinematic, like an old silent movie with slapstick in fast motion and tinkly music. That’s the kind of energy I was going after.”

***

 

2014-09-15-113_PoolShower_Forney.jpg

“This is one of my favorite pages. I’ve been a swimmer my whole life; with this page, I can just smell the chlorine, which is a comforting smell to me. I so clearly remember leaning my head against the cool side of the shower and crying and feeling like a weight had lifted. I finally had a sign that things were going to be okay. This page is like a cool drink of water to me — it’s not that the drink makes everything better, because the reason it feels so amazing is because you felt like you were dying of thirst. It’s a resetting.”

***

2014-09-15-231_ManiaPole1_Forney.jpg2014-09-15-232_ManiaPole2_Forney.jpg
“It was satisfying to wrestle something unwieldy like mania into categories and tidy descriptions. I was also hoping to remind other bipolars who miss their manias — especially if they’re tempted to go off their meds — that mania can be terrible, too. It’s hard to describe, and my impression is that there’s a lot of misunderstanding of what mania is.”

***

2014-09-15-144_TellingPeople1_Forney.jpg2014-09-15-145_TellingPeople2_Forney.jpg
“Telling people is hard. But so many people have mental disorders. We have so much company. I wish I could tell everyone that it’d be okay to talk to other people about their illness. In my experience, more often than not, they will share their own personal experience — if not for that person, then their friend or family member. I’m serious: more often than not. Who knew? It’s something I’m privileged now to know, after coming out and talking about my bipolar disorder so openly because of Marbles.

A lot of people came out after Robin Williams’s death, and in general there’s a lot more awareness about mental illness, but for the most part people still don’t feel safe talking abut their personal experiences. I think that the more people come out, the more the stigma will lift, but it’s not easy. I will say for myself, though, that coming out has made me feel infinitely stronger and more resilient.

People sometimes ask me what they might do for a friend of theirs who is either manic or depressed or otherwise having a tough time and is kind of unreachable. My mom played a big role in keeping me afloat — she made it clear that she loved me. Even in my haze of self-negation, there was some deep nut in me that knew she loved me, and I needed to carry on, if not for me then for her. My friends were patient and were there for me when I was ready. Sometimes that’s about what you can do.”

***

All image reprints courtesy of Gotham Books, an imprint of Penguin Random House.

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