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Frequently Asked Questions

The information offered below is not meant to be a consultation or diagnostic of your personal issues. It is offered only as general background information. You should always consult an appropriate professional to discuss, diagnose or treat your personal issues.




Attention Deficit

Brain Injury





Executive Skills

Mental Retardation

Non-verbal LD


Substance Abuse

Video Games

My child is not learning up to par at school. What should I do?

A good place to start is with the teachers. They may work with hundreds of children in a year. And they are seeing your child for an hour or so a day, if not longer than that in the younger grade levels. So, teachers often have a keen sense as to what is going on with a child when performance is not as good as expected.

Kids also can have problems with their hearing and/or vision, and such issues are not always obvious to the untrained eye. An appropriate evaluation through an eye doctor or audiologist is advisable.

Sitting down and talking with your child to get their perspective as to what is happening and why can also be done. However, with younger children they may obviously not have the sophistication to look at themselves that well, much less articulate the difficulties they face. With older children, such as adolescents and teens, issues around dating, alcohol and/or drug use, and the many changes that come with the onset of puberty, can have an impact on a child’s functioning such as the grades they earn.

Discussion with the school guidance counselor or psychologist may also be sought. Use of outside help, such as social workers, psychologists or psychiatrists, may be needed when none of the above methods have provided sufficient answers to meet the parents’ concerns.

What is Asperger's?

Asperger's is conceptualized as being part of what is called the 'autism spectrum disorders.' Some people call Asperger's 'high functioning autism' while others think they are not quite the same. There is also some debate if Asperger's and non-verbal learning disability (NVLD, which is discussed elsewhere on this page) are different names for the same problem, or if they have some subtle differences.

But in general Asperger's involves impairment in some key areas of functioning. Perhaps the most important is that social skills are markedly deficient. Individuals with Asperger's have a much harder time understanding how to interact with people. They seem disinterested or oblivious, and often have few if any friends. If they desire friends, it's hard for them to make and keep any, because what they say and/or do is socially inappropriate. They often invade the personal space of others without realizing that it is not being appreciated. They talk 'at' rather than 'to' others. That is, their conversations are effectively monologues often about a peculiar topic that most people would have no interest in. They also typically do not like participating in social activities like team sports. Eye contact is poorly made.

Additional behaviors that are common with Asperger's include having a very narrow and restricted range of interests. Often these topics have to do with transportation, other aspects of science, or dinosaurs. They can become fixated by trivial behaviors, such as playing with a lace on their shoe for an hour at a time. In relative terms to autistic individuals, language skills are near normal. But, some qualities of their language are still impaired. They have a difficult time understanding elements like tone and inflection which can communicate the speaker's feelings such as if they are happy or angry. Or, they will take statements too literally and so misunderstand idioms or humor. There also can be a stiffness and formality to what is said, rather than being able to talk on a more casual and conversational level. Poor motor skills are also common. I often hear that kids who are even in to their teens have never learned how to ride a two-wheel bike and have no interest to do so. Poor attention to details is common, and a good percentage of kids with Asperger's have been diagnosed with attention deficit disorder (ADHD). Some also are overly sensitive in their senses, such as taking an hour to get socks to feel right on their feet because the seams bother them. Or, shirt tags are bothersome. Some kids cut them out, or go so far as to wear shirts inside out so as not to have the tags touching their skin. Sound can also be upsetting, such as sudden noises like a dog barking. Others are upset with high pitched noises like from kitchen appliances. A third type of noise that some find overly bothersome might be described as the babble of crowds of people such as at a party. These problems are at a level where they impair normal functioning in areas such as socially, academically or occupationally.

Individuals with Asperger's are not mentally retarded. If anything, they can be very smart but they may lack social finesse in how it is displayed. Or, their gift for intelligence may be limited to a very narrow area, such as some aspect of computers or other skill which typically does not involve much if any social interaction.

Treatment of Asperger's is based on a symptomatic and common sense approach. Developing social skills through practice is an important step. Medication can also be used to address some of the problems, such as poor attention or impulsive behavior. For more information on Asperger's, consult the Resources page of this web site.

What is neuropsychological assessment, and who needs it?

Neuropsychological assessment looks more specifically at what are called brain/behavior relationships. Common problems include skills like memory or attention being impaired. Or, executive skills may be deficient. Executive functions can include abilities such as organization and planning; getting started or persisting as needed; stopping when appropriate rather than doing something ad nauseam; being able to monitor for, catch and correct mistakes in a timely manner; and problems with emotional control such as having a short fuse. Neuropsychological assessment can be helpful in figuring out such issues, and what may be causing them.

Difficulties with executive skills, like those noted above, are probably the largest factor for why some people do so poorly in their daily functioning. That is, they may be very bright, such as kids making good grades. Or, adults may have a higher than average IQ. But, their ability to function in an age- and role appropriate manner, and at a level that is commensurate with their innate potential, may be much worse than expected. For example, parents may note that their child is doing homework and understanding the concepts such as the different principles of math. But, the child loses the assignment, or forgets to turn it in. Consequently no credit is received, and the resulting grade for the year may be a D or F, when the child is capable of much better marks given the knowledge they possess.

Adults who are having such problems may be explosive in temper, to the point of their spouse, children or others not being able to tolerate them any longer. Or, they may be so disorganized that similar to what was noted above for kids, they may have an ability but not be able to demonstrate it effectively such as to their employer. This might be noted such as by losing assignments, or coming in chronically late to work.

Neuropsychological assessment can be done on any number of suspected problems. A few of the common difficulties include attention deficit disorder (ADHD), dementia such as from Alzheimer's or strokes, and brain injury such as arising from car accidents.

How long does the testing take, and what does it cost?

How long the total assessment lasts varies with the type of issue being evaluated, as well as the person's age. For young children, such as 6-8 year olds, I figure that they will last no more than 1 - 1 1/2 hours during a session. Some of that time is spent with the parent(s), discussing background history and their concerns, but the child is still wearing out in the process. Younger children tend not to tolerate multiple sessions, and so I try to keep the total evaluation to just 1-2 sessions. With adolescents, perhaps 9-12 years old, I find that most can tolerate 2 - 2 1/2 hours at a time. And, if it's needed, 2-3 sessions may be done to get a complete understanding of their issues. With teens and adults, sessions can be as long as 3-4 hours, and for most just 1-2 visits are needed. With older individuals who may be dealing with dementia, I try to limit the evaluation to a single session, and typically just 1 1/2 hours or so. With much older people, such as those who are 85-90, an even briefer amount of time may be all they can tolerate.

The cost for such services, whether paid for by insurance or the individual, also varies with the extent of the evaluation. I often offer a range of what the expected cost will be, because it is difficult to know in advance just what and how much needs to be assessed until we have had a chance to meet and start discussing your issues in greater detail.

To be more specific: I have worked with some insurance plans where there is no co-pay, no deductible, and hence no cost to the individual. Other insurance plans have had yearly deductibles as high as $2500. - which means that none of the costs of an evaluation will likely be covered, unless the individual already has used a great deal of mental health services. Most commonly, co-pays for those with insurance range from $5. - $50. per session. Most deductibles I see are between $0. - $300. per year. For those without insurance, cost again can vary widely. I try to work with such folks and keep their expenses down as much as possible, doing enough to get them help but not so much that the bill goes through the roof. Typically the cost then ranges from perhaps $350. - $1000.

What types of psychological assessment exist?

Psych testing as it is commonly referred encompasses a very broad spectrum. The two most common in the U.S. are for intelligence (IQ) and personality.

IQ testing can be done for a variety of reasons. Among school age children it may be requested if a kid is not learning up to par. Sometimes the request is to diagnose a problem, such as mental retardation. Once diagnosed, the child is eligible for special services in the school system. One way to diagnose learning disabilities has been to compare a child’s IQ to various academic skills such as reading or math. Generally, intelligence and academic abilities are commensurate with each other. When there is a wide disparity with the academic much weaker, a diagnosis of learning disability can be supported. However, schools are moving away from such a method of LD diagnosis.

Personality assessment can be done for numerous reasons. In some specialized settings, such as alcohol rehab centers, eating disorder clinics, or in-patient hospitals that may treat problems like schizophrenia, the assessment focus may be very narrow, on the particular issue that brought the individual to that facility.

However, many times people come to a psychologist and will say that they, or someone in their family such as a spouse, elderly parent, or child, is having problems and not living life as well, happily, or easily as they expect. In such situations the personality assessment will look at a wide range of possibilities to determine what is happening.

Other types of psych testing can include vocational, industrial/organizational (I/O), and forensic. Vocational assessments may be done on students finishing up high school and college, and looking for some help as to where their vocational interests and skills lie. Others who are making mid-career changes may be seeking the same information.

I/O assessments can involve issues like hiring, placement, or advancement. ‘Fitness for duty’ evaluations occur when a problem has arisen with someone already hired, and the employer needs to better understand what is happening, why, and what should be done. For instance, ‘threats of violence’ or being drunk on the job can trigger these types of evaluations.

Forensic evals cover a wide array of concerns. Some arise over insanity pleas. Others involve whether a person is even capable of standing trial (‘competency’ and ‘criminal responsibility’). Child custody concerns are another major part of forensic cases, where a judge wants to know which parent is (un)fit to care for a child.

Neuropsychological evaluations also exist, and have been detailed in another FAQ on this site.

I think my child has attention deficit disorder (ADHD). How can I tell?

Much has been written about ADHD, and many parents are familiar with some of the common signs of it. There is a need to be careful, and not jump to conclusions. Other difficulties that can look like ADHD include anxiety, depression, trauma to the brain (such as from car accidents, organized sports, various types of falls, brain damage from diseases like infections), manic depression, and substance abuse.

The list offered below are some of the more common symptoms which can be suggestive of ADHD. They are not meant to be diagnostic, and no one should conclude that ADHD is the culprit based solely on some or all of these symptoms being present.
  • Family history of ADHD (parents, siblings, or other close relatives having been diagnosed with the disorder, or strongly suspected of having it, if not formally diagnosed with it)
  • School teachers raising the possibility of it being present in the child
  • Attention span being short, such as a few minutes to a half hour perhaps, for non-entertaining activities. That is, the person may be very attentive for hours on end watching television, or playing video games, but have minimal attention span for tasks like listening in class, or doing homework.
  • Distractibility, so that the person gets easily side tracked on to other activities, and has a hard time finishing tasks that are started
  • Disorganization. A child’s room being messy is probably a universal complaint of parents. But, some kids are far messier than their peers. Other types of disorganization often include doing homework but forgetting to turn it in, or losing it, so that no credit is received. Or, losing personal items, sometimes permanently, such as clothing, wallets, watches, jewelry, books, etc.
  • Having knowledge in one’s head, but having a difficult time getting it on to paper, such as for writing assignments or during tests.
  • Being driven, ‘on the go’ or unable to sit still for long. This can range from being fidgety and squirmy in a chair, to getting up and walking around a classroom, to being antsy and getting up many times and doing something else while watching a television show or movie.
  • Taking much longer to accomplish homework than is expected. For instance, what typically takes the average student thirty minutes to accomplish may require 3-4 hours, and even that may be with considerable support and supervision from parents. Or, among older children, such as in high school or college, what should take perhaps 2-3 drafts of writing to accomplish, may need ten or more, with that much more time taken to do it.
  • Difficulty making and/or holding on to friends. With older individuals, jobs may be lost due to being late, inattentive, or disorganized to the point that the employer can not tolerate such problems occurring so frequently.

Psychological testing for such individuals can help diagnose ADHD and determine if other issues, such as learning disabilities, are present. Testing can also determine if the same symptoms are being caused by some other factor which may require a different treatment approach.

What about diet or natural supplements as a way to treat ADHD?

Dietary approaches have been suggested since the 1970's, when ADHD was blamed on too much sugar and junk food. They were disproved back then, but the idea seems to be making a resurgence. Some people are more sensitive to sugary junk food, and may well 'bounce off the walls' when it is eaten. Improving your child's diet and teaching them good nutritional habits is always advisable. There is growing concern now in medicine, typified by articles in papers and magazines, about childhood obesity and diabetes. Too much junk food is at least partially responsible for these problems. So, I'll always offer encouragement to parents to reduce junk food for their kids. But research to say that an absence of junk food will cure or substantially reduce ADHD is lacking at this time.

There also was some recent research, done on 3 year olds, suggesting that too much food preservatives, such as sodium benzoate, may be a culprit in causing ADHD. Food coloring also has been suggested as a factor for causing ADHD. But, I have seen no other research to back up the theory at this time.

Many parents are more comfortable with the idea of using natural substances, such as vitamins and minerals. The idea is appealing, but definitive research is lacking on this approach. And I've yet to have a single parent in the last 20 years tell me that it has worked for them, and cured or substantially improved their child's ADHD. Caution is also advised, because 'natural' supplements are by no means always safe. Prescription medication has to prove through scientific research that it is safe before it is allowed on the market. The law says that natural supplements have to be proven to be dangerous before they are pulled off the market. Ephedra is perhaps the best known recent example of this law, where people became ill or died before the substance was taken off the shelves. You should always consult a physician before use of such supplements.

What other approaches are there to treating ADHD?

Behavioral approaches exist, such as use of rewards, punishment, time outs, token economies, or just more structure and supervision. Little if any research has found behavioral methods to be effective for ADHD when done in isolation. I've never once heard a parent in my office say "This works!" Instead, I've heard the opposite: "We've tried everything, and nothing has worked. Now what do we do?" Behavioral approaches used in conjunction with medication can be helpful to some kids.

There is also some recent research which has suggested that infants who watch too much television are actually causing their brains to change on some neurological level, leading to ADHD. However, there already has been a rebuttal to such a theory, which basically raises a 'chicken or egg' question to it. That is, does television viewing lead to ADHD? Or, do infants and young children who have ADHD simply watch more television? Which comes first is not known at this time.

It also has been suggested that video games are causing ADHD to some extent. Computerized brain imaging has been done on people who were playing video games. What was found is that an area of the brain called the basal ganglia are activated during such games, and dopamine, one of the brain's chemicals, are released in the process. Dopamine is involved with a number of brain functions, including attention span, focus, and motivation. It is thought that the video games effectively use up the dopamine for awhile, and so it is not available when needed such as for doing homework. In my opinion, playing video games is like eating junk food: they may be fun, but there are better, more wholesome choices available. Reading, playing, or socializing with other kids in various ways are all better than video games in my opinion. Whether cutting down or eliminating video games from your child's daily routine will make a substantial difference in ADHD symptoms can only be determined by trying it. And enforcing the rule can be difficult, given that you may stop the game playing at your house, but not elsewhere such as at a friend's.

Exercise is another option. The research on physical fitness enhancing school performance dates back at least to the 1970's. 'Physical fitness' typically has been measured by looking at kids who get a certain number of hours per week in phys. ed class versus those who get little or none. With appropriate safety precautions, supervision, and use of exercises that are right for a child's age, everything that I have seen says that exercise is beneficial. Much like good diet and nutrition being something that should be taught to a child and maintained throughout their life, exercise is another key to maintaining good physical and mental health. But, this is not a case where your child can go outside, run a lap around the block, and be instantly and permanently cured of ADHD. Appropriate exercise, such as offered by a gym teacher, done regularly and consistently, may help a child in terms of better attention and grades. Much like video games being cut back, whether exercise will substantially improve ADHD symptoms for your child can only be determined by trying it.

There is also something called 'neurofeedback' or 'biofeedback for the brain.' Biofeedback has been around for many years, and is known to be effective for helping a number of problems. The idea behind neurofeedback is that there are several different types of brain waves in all of us. These include being asleep, almost asleep, alert but relaxed, and alert and mentally active such as when doing school work. The brain waves of ADHD individuals are often found to be in the 'almost asleep' stage, even though their bodies are awake. Hence, their poor grades and general functioning. The basic theory behind neurofeedback being used to treat ADHD is 'Why change the brain chemistry through medication to influence the type of brain waves present? Just change the brain waves themselves.'

Neurofeedback involves using a simplified EEG machine, and uses a video game format to offer feedback to the person. (The video games I've seen for neurofeedback have no 'blood and guts' to them, and are more like Pac-Man). The games are controlled by brain waves, not joysticks. If the person has the right kind of brain waves - active and alert - points are earned. With the wrong brain waves (almost asleep) points are lost, or not earned.

The problem with neurofeedback being used to treat ADHD is that there is limited research on it. A modest amount has been done on it since about 1990. It is also considered to be experimental at this time, so many insurance companies will not cover it. Neurofeedback is typically done 2-5 times a week, and may need 2-6 months before results are seen. The cost of a battery of sessions is typically $2000.+ The number of practitioners who are doing it in North Carolina are also very limited. (One web site for neurofeedback lists five people, in Asheville, Greensboro and Charlotte, as being the only professionals within this state who are trained in it.)

What's wrong with being ADHD? Isn't it a way of saying that someone is just an active child?

That may be true at times. ADHD tends to be over diagnosed, under diagnosed, or misdiagnosed. But what is now called ADHD has been recognized for about 100 years, under different names. And current research keeps finding that when ADHD is present, many other problems tend to surface. There is a high incidence of learning disabilities that are associated with ADHD, because it is thought they involve the same chromosomes. Other difficulties arise which can cause trouble for a child or adult with ADHD. Higher rates, often 2-4 times greater, are found for:
  • Kids dropping out of school, which has consequences for the rest of their lives.
  • Becoming involved with nicotine, and possibly alcohol and illicit drugs.
  • Being in a car accident. Such accidents may be only a fender bender. Or, they may involve injury, disability or death to your child and/or someone else on the road. The elevated risk of being in an accident is measured against other teen drivers, who are known to have a high rate of collisions. So the inexperience for driving and the impulsivity of youth are being compounded by ADHD being present in a young driver.
  • Sexually dangerous behavior is greater, which may lead to unwanted pregnancy, or contracting HIV or other sexually-transmitted diseases.
  • In early adulthood, ADHD individuals have a higher rate of quitting or being fired from jobs, which has implications to their being able to support themselves and a family.
  • Separation or divorce.
  • Arrest rates.
  • Problems with emotional functioning, such as stress or depression, are increased.

How can I tell if I’ve suffered a brain injury from a blow to my head?

Many patients I see do not realize for several months that they are having various problems such as with memory or concentration. Such impaired functioning can be subtle, and may not be easily spotted until they attempt to return to their prior functioning, such as work. At that time it may be noticed that they can not function like they were able to prior to the head injury.

Some of the common symptoms that a head injury may have occurred include (these are not meant to be diagnostic by themselves):
  • Loss of consciousness
  • Feeling dazed or confused for some period of time, which can range from seconds or minutes, to hours or days.
  • Headaches that arise after a head trauma, and persist, perhaps for days, weeks, months or years
  • Problems with short term memory
  • Problems with concentration, and paying attention
  • Personality changes, such as being more depressed, irritable, angry, short tempered
  • Changes in sleep patterns
  • Reduced social interest and having less contact with others
  • More easily fatigued

There are different ways that traumatic brain injuries (TBI’s) can be diagnosed. Typically the first potential way to do so is during a visit to a medical doctor, such as the emergency room right after the accident. However, in the vast majority of cases that I see, nothing is found at that time, even when a TBI has occurred. Such ‘false negatives’ are common because the amount of time spent with patients is typically quite brief. Plus, brain damage may not even have occurred yet when the patient is in the ER. Damage may only start to occur, and be noticed, after a day or two if not longer.

Another factor that makes ER doctors miss a lot of diagnoses of TBI is that they are looking more at the structure of the skull and brain such as through x-rays, CAT or MRI scans. Is the skull fractured? Is there bleeding inside the brain? They have minimal ability, given the brevity of most ER visits, to discern if the functioning of the brain has changed. Many patients I see do not realize for several months that problems have occurred. Such impaired functioning can be quite subtle.

Neurologists are also capable of diagnosing TBI’s through an appropriate evaluation which may include tests such as an EEG, which records brain waves. However, neurological evaluations tend to focus more on the ‘lower order’ functioning of the brain, typified by whether or not various reflexes are working properly. If such reflexes are impaired, a serious problem may exist. If they are functioning normally, the ‘higher order’ functions of the brain, such as memory, concentration and ability to think in ways needed for daily living, may still be adversely impacted.

Neuropsychological testing is a third means to evaluate for TBI’s. Its advantage is that it does assess these higher order intellectual functions, which is where the patient is typically having complaints of reduced functioning. However, other factors also need to be considered in doing these evaluations. Personality issues, such as depression or anxiety, may be at least partially responsible for problems with intellectual functioning. Other factors, such as if a person starts to drink too much alcohol, as a form of self-medication, can impact a person’s functioning. Medication side effects, such as narcotic pain killers, or muscle relaxants, can also take their toll on functioning. Consequently, there needs to be a careful evaluation of a person’s issues to get an accurate understanding of what has occurred.

My elderly parent is claiming to see things that aren't there, like bugs or people in the room. Or thinks there are people living under the bed or up in the attic. What's going on?

There are different possibilities that may be responsible for such phenomena. One is that when a person’s vision deteriorates such as from glaucoma, cataracts, or macular degeneration, their ability to see and distinguish what is around them will obviously be lessened. With such poor eyesight shadows that do exist in the room, whether they are from interior objects, or cast by something outside like a tree’s branch may take on seemingly real shapes such as a person. Couple the poor vision with an aging mind, that is not thinking as quickly or clearly as possible, and the type of complaint you mention, of ‘seeing people who aren’t there’ is easier to understand.

As to the ‘person living under the bed’ or ‘the family living in the attic’, one possible culprit is the presence of delirium. What can bring on delirium? There are dozens of possibilities.

The biology of life requires a lot of stability, such as our body temperatures remaining fairly constant. The blood levels of sodium and potassium, pH, sugar, and many other components also need to be tightly regulated. Our organs, such as kidneys, liver, heart and lungs have to function well enough to supply nutrients like oxygen, and effectively remove toxins from our system. When any of those tightly regulated processes becomes defective we have problems. Organs age and break down. Infections including something as seemingly innocuous as one in the urinary tract (UTI’s) can throw a monkey wrench in to part of our biological processes.

Still other possible causes of delirium include medication side effects. In my experience after roughly the age of 60 people are virtually guaranteed to have trouble with tolerating different prescription medications. And the problem grows worse with increasing age, in to the 70’s, 80’s or beyond. Unfortunately, as our bodies tolerate medication less well doctors are prescribing ever more pills to treat the increasing health problems that arise with advancing age. At some point that becomes a recipe for pushing a person ‘over the edge’ and delirium results.

Other common causes of delirium can include recent surgeries, even for seemingly routine issues like hip replacement, which is another way to stress an aged body too much. Dietary problems arise, especially with individuals who live alone. Many elderly women have what I call ‘tea and toast’ diets which are far from being well balanced nutritionally. Others may eat better, but their bodies ability to digest and absorb food deteriorates with age, and so nutritional deficiencies still result.

Determining what is occurring to cause the delirium is very important. Delirium is symptomatic of some life threatening process being present, so that some needed biological stability has been lost. An evaluation by a family doctor, psychiatrist or neuropsychologist is strongly advised, sooner rather than later.

My parent/spouse has become very forgetful. Is this Alzheimer’s, or some other form of dementia?

Maybe, but not necessarily. Short term memory loss, so that a person forgets what is said to, or heard from, others within seconds (or minutes, hours, or a day or so) can be due to a number of different causes. These include:
  • Depression. Older individuals typically are losing to death people very close to them (their own parents, siblings, spouse, life long friends, and sometimes their own children). They typically have declining health, may have multiple diseases, and might be facing a terminal illness such as cancer. Many older individuals are socially isolated, whether they are living in their own homes, a nursing facility or assisted living center, or senior housing. That is, they feel like they have been largely if not entirely forgotten by society as a whole. Given such facts, depression is often present but can be easily missed. Elderly individuals have a surprisingly high rate of suicide. Depressive factors can impair memory functioning. It is possible to treat depression, and restore some or all of the lost memory functioning in the process.
  • Diet. Older individuals may eat minimal amounts of food (‘tea and toast’). Or, they may eat normally, but due to increasing age they do not metabolize nutrients as well as when they were younger. Consequently, it is possible to have nutritional deficiencies result. A family physician should be consulted if this is suspected.
  • Drinking. Older individuals often go unrecognized when they in fact are abusing alcohol. The amount that has to be consumed to be a problem for older individuals is less than for someone younger, given the effects such as from aging, interactions with medication, and a slowed metabolism.
  • Medication. Increased use of medication typically comes with increasing age. Older people may be taking 8-15 medications, for any number of health problems. Side effects from drugs, either individually, or through interactions with other pills, can cause difficulties with memory, concentration, and general thought processes. Having a discussion with the treating physicians about medication and potential side effects may be helpful.

Dementia is an increasingly likely possibility as people age. For instance, estimates have been made that only 3% of individuals at age 65 have Alzheimer’s. But, by the age of 85 roughly 50% are thought to have that disease. Another common problem that can impact memory are strokes, which are often ‘silent.’

How can I tell if my child is depressed? How is it best treated?

Depression in children can show itself in different ways than in adults, and it is may not be as easy to spot. One of the key differences is that the emotional display of depressed kids may be anger or irritability, rather than depression per se. Many kids can have wide mood swings as part of their normal personality. With adolescent development and puberty in particular, such mood swings can become larger and wider, and many parents have a difficult time figuring out if the volatile temperament is 'just normal teenage rebellion' or something more serious, such as depression. Differentiating between these two possibilities is important, because depression carries with it a higher risk of suicide. Suicide is the third leading cause of death among teens in the U.S. It has been estimated by the Centers for Disease Control (CDC) that 1 of every 12 high school students had attempted suicide in the preceding twelve months.

One way to determine if your child is depressed is to look at some of the symptoms that are common between both adults and children. These include 'vegetative' signs, such as changes in sleep or appetite. Depression affects people in different ways. That is, some individuals may sleep or eat too much, while others have too little. It is not so much the amount of sleep or appetite that is occurring but that there has been a major change from what used to exist. Parents also can look at energy and activity level. Has the child become a couch potato? Are they showing less interest in school or friends? Is there more crying than there used to be? Are comments made such as 'I might as well be dead' or 'What's the use of living?' All of these can be evidence of childhood depression.

Depression in kids can be treated through at least three common approaches. One is medication. There is currently a large controversy about how safe it is to use anti-depressant medication on children. There is some suggestion that such drugs can lead to an increase in suicide. The question has yet to be definitively answered. Naturally, many parents are concerned about the possibility of an anti-depressant further endangering their child, and so are leery about using them as a result. Consultation with a medical doctor of your choice, such as a pediatrician or child psychiatrist, is advised to further discuss this issue and answer questions you may have.

A second approach is what adults call physical exercise, and kids might term 'running around having fun.' This can entail activities like playing on team sports, riding a bicycle, or joining in a game of tag. It has been known for about thirty years that physical activity can reduce or eliminate depression in people. More recent research has found that exercise can be as beneficial as medication in its antidepressant effects. The added bonus to kids engaging in such play is that it is typically done with other children, and they can develop more and better friendships, which has its own benefit for beating depression. Moreover, getting kids off the couch and out of the house helps prevent them from moping around and feeling sorry for themselves. That is, physical activity can take their minds off their problems and get them engaged in having fun and socializing with other children.

A third approach is the use of talk therapy. Cognitive-behavioral therapy (CBT) has been around for over thirty years, and is continually found to be effective for treating depression. Briefly, what CBT entails is the idea that thoughts and feelings are a two-way street. That is, how you feel can influence your thoughts. And the opposite is also true: how you think can impact what you feel. And, thoughts are easy to change. A simple and common example of this is the perspective people take on their life, such as it being 'half empty' or 'half full.' A variation on this concept can be found in books like 'The power of positive thinking.' CBT is also considered a brief therapy, with perhaps 8-13 sessions being needed to learn how to use it effectively. There are many books written on the subject, and there are a multitude of web sites which have information on it.

Still other approaches to dealing with depression can include play therapy for children who are too young to be comfortable or skilled in talking at a level that is needed for cognitive therapy. There is also some limited amount of research which suggests that acupuncture might be helpful in treating depression.

How can I tell if my child is dyslexic?

Dyslexia is not always easy to diagnose, because younger children often reverse letters (such as ‘b’ and ‘d’ or ‘p’ and ‘q’). With increasing age, such as by 2nd or 3rd grade, such reversals should diminish and eventually cease for a child who is not dyslexic. However, other difficulties with language processing can also be part of dyslexia. Common difficulties include:
  • Letters, numbers, or symbols continue to be reversed past 2nd grade
  • Phonetic sounds are reversed in pronunciation (e.g. ‘act’ pronounced as “cat”)
  • Reading comprehension is weak
  • The ability to pronounce words fluently and normally, rather than slowly sounding out words by phoneme or syllable
  • Spelling being extremely poor, such as having no vowels at all in words. Or, wildly inaccurate renditions (e.g. ‘chair’ becoming “qtz.”)
  • Writing being slow, labored and slavish such as in copying material.
  • Math problems may see numbers reversed in sequence (e.g. '103' becomes '013'), or they may be inattentive to the operation required (such as adding when subtraction is needed).

Given the importance of reading in general, and as a primary means for learning in school, diagnosing reading difficulties is very important. Generally, the sooner such a diagnosis is made the better, in that the student will not have fallen as far behind. Another reason for helping a dyslexic as early as possible is that the brain is most receptive to developing such skills for only a limited number of years. By roughly 4th or perhaps 5th grade, the neurological wiring of the brain for language skills like reading is fairly complete. Consequently, it is far harder to learn those skills after such an age. Over the years I have seen hundreds of individuals, or their parents, who have told me that they were 'shoved through the school' without ever learning how to read. Most have tried to learn to read as adults and have had at best limited success. It is possible to learn how to read in later years, but it is far easier during the early grade school period.

Dyslexia takes a toll on people in other, more subtle ways. One of the most common is that individuals can develop low self-esteem, become depressed, or think of themselves as being stupid. Not being able to read in our society exacts a high price not only within a school setting, but in other ways such as filling out job applications, understanding highway signs while driving, or even as a parent reading to a young child. Most dyslexic individuals I see have experienced such failures, and feel embarrassed, ashamed or otherwise inadequate - although their suffering is almost always born in silence.

What are executive (or, 'frontal lobe') skills and what can affect their function?

The frontal lobes can be thought of as the most advanced part of the human brain. In simple terms, they are largely responsible for differentiating people from the so-called 'lower order' of animals, such as alligators, horses, cats or guinea pigs. Most animals are limited to acting through little more than instinct and reflex. The ability to think, create novel ideas and products, develop insight and self-awareness, and function in more abstract ways such as through sense of morality or law, are all frontal lobe skills.

A different way of thinking about the frontal lobes is that if you look at a desk top computer you will inevitably find a blizzard of wires connecting the many components (monitor, speakers, internet connection, keyboard, mouse, etc.) together. What would happen if all those myriad of connections were not plugged in to the back of the computer? Information on the internet could not be transferred to the hard drive. Thoughts typed on a keyboard could not be displayed on the monitor. Sound from a music file could not be heard through speakers. The frontal lobes are like the 'mother board' or main CPU of a computer, in terms of linking together the many diverse elements of the brain so that information can be exchanged and acted on in far more flexible ways, rather than only mechanically and instinctually as happens with the lower order of animals.

There is some down side to the frontal lobes, which is where problems arise. One is that wherever there is complexity of function and operation, there is the potential for it breaking down or not functioning correctly for other reasons. The frontal lobes can be affected by a number of factors that occur all too frequently. These include attention deficit disorder (ADHD), traumatic blows to the head such as from car accidents, various diseases such as infectious agents, oxygen deprivation (from problems arising like drowning, heart attacks, or strokes). Aging can also take a toll, in terms of cell death occurring for natural reasons, as well as from factors like high cholesterol plugging up blood vessels.

Yet another reason that people run in to trouble around the frontal lobes is that they do not develop on a neurological level as quickly as we might like or need. They are probably not neurologically mature on average until a person is roughly 25 years old. Often I see teens or individuals in their early 20's, and males in particular, who have qualities such as being impulsive, reckless, acting without regard for potential consequences or without due consideration toward others. I call such behavior 'too much testosterone, too little frontal lobes' and there is much truth to that description. In effect, hormones are creating an overly strong gas pedal, and the under developed frontal lobes of young adults do not create a sufficient balance in 'braking' such behavior.

What is mental retardation?

Mental retardation (MR) is typically defined with two key components. One is IQ score, based on an individually administered test given by a psychologist, which requires that it be below 70. The other component is that the person have significant difficulty in handling various life skills. These can include abilities such as:
  • communication
  • self-care (hygiene, eating, etc.)
  • social skills
  • work
  • leisure
  • health
  • safety
  • traveling around the community by car or public transportation

There was a time in the past that once someone was labeled as being mentally retarded they were warehoused in facilities such as psychiatric hospitals. Thankfully those days are over. But, making the diagnosis is still important. There are a number of kids I have seen over the years where the parents had high hopes and expectations that the child would go to college and develop a professional career. But, when dealing with kids who have limited intelligence such dreams are not realistic. Instead, it is important to put the child on a vocational track. Doing so helps prepare the child to become more independent in a manner they can handle. And, it also allows the parents to seek out additional support while the child is still in school, and even beyond such as in early adulthood through additional vocational training. When individuals have more severe mental retardation, and the child is not expected ever to become fully independent and self-sufficient, such a diagnosis may also help the parents take the necessary legal steps to insure their child is cared for by others when they can no longer do so.

What is non-verbal learning disability?

Non-verbal learning disability (NVLD) has some overlap with attention deficit disorder (ADHD), such as being inattentive and disorganized. There is also some debate among professionals as to whether NVLD and Asperger's are the same disorder, or if there are subtle differences between them.

There are a number of other common symptoms to NVLD, which typically are not found with ADHD. (The following are not meant to be diagnostic, and no one should conclude that NVLD is the culprit based solely on some or all of these symptoms being present.)
  • Difficulties in math, which may include the spatial elements such as lining numbers up appropriately in columns such as for multiplication or division
  • Poor coordination, such as for organized sports, riding a bicycle, or being overly clumsy
  • Poor social skills. This may include not being sensitive to nonverbal communication (e.g. body language). Or, being socially awkward, maladroit, ‘geeky’, uncomfortable and stiff when in the presence of most other people. Few close friends may exist.
  • Poor sense of direction, such as in reading a map, driving a car, getting lost in the neighborhood when walking or riding a bike, etc.
  • A relative strength in language skills, with reading probably the first to be obvious.

Formal assessment can help to identify these issues, which can have a major impact on a child's social, emotional and academic development. My attitude is that which particular label (Asperger's, NVLD, ADHD) is used is mostly moot. Instead, the focus should be more on the symptomatic treatment that will help the child develop as needed. For instance, NVLD and Asperger's both involve pronounced social difficulties, and the difference between them may be likened to varying shades of gray. What is more important than obsessing over a diagnostic label is to help the child develop better social skills, make friends, and be more comfortable dealing with others. Similarly, whether a child is purely NVLD or also qualifies for an ADHD diagnosis is mostly moot. If attention is impaired, regardless of the diagnostic label, the same types of medication that works for ADHD can be employed with NVLD. I do want to say that the diagnosis can be important in certain situations, such as qualifying for additional accommodations in school.

Another point to keep in mind is that kids with NVLD can grow up to be normal, well adjusted and high functioning individuals. Everyone has strengths and weaknesses, or some skills that come easily and others with greater difficulty. The types of strengths and weaknesses of a NVLD child are different than someone who does not have the disorder. But what parents have to keep in mind in raising any child is always the same: improve the weak areas so that they are hopefully at least near average, and capitalize on the natural strengths so that they become even better. The areas that are weaker with NVLD individuals, such as social skills or spatial abilities, may never come as easily and fluently as for others. But, struggling a bit with such issues does not preclude a person from learning to drive a car, getting married, or working and supporting themselves and a family. For more information on NVLD look at the Resources page on this site.

What are seizures? What causes them? And are there emotional or intellectual complications to having them?

Seizures involve an abnormally high amount of electrical activity in the brain usually for just a brief period of time. In simple terms, they can be thought of as being like ‘spikes and surges’ that sometimes occur in a home’s electrical wiring system, so that there is too much voltage for a moment.

As to what causes seizures, there are literally dozens of possibilities. For about two-thirds of people, seizures occur for no known reason. All we can say is they just happen. For the third of individuals who have them for reasons that can be determined, some of the more common causes include:
  • Traumatic blows to the head (such as from car accidents; falls off a ladder or bike, or down stairs; assaults; sports-related injuries such as from baseball, soccer, hockey or football, etc.)
  • High fevers
  • Brain tumors
  • Strokes
  • Use of various legal and illegal substances such as alcohol, cocaine, or amphetamines

There are a number of different types of seizures. Probably the most widely known are ‘grand mal’ seizures which involve a person losing consciousness usually for a few minutes, and having considerable jerking and contractions (convulsions). Much if not all of the brain may become involved in grand mal seizures. Another type is ‘petit mal’ where a smaller region of the brain has excessive electrical activity. The person remains conscious, but is in an altered state of awareness. They may not be responsive to others such as someone talking to them. Paranoid qualities, such as turning their head to look when nothing is there, may occur.

A third type, which I see quite often, is more controversial, and harder to diagnose. It involves what are called ‘sub-clinical’ seizures, which I refer to as being ‘little electrical blips.’ Such sub-clinical episodes are analogous to pre-cancerous cells – a state half way between normal and full blown cancer. The little electrical blips are effectively part way between normal brain activity and a full blown seizure.

Most commonly the symptoms that are suggestive of these sub-clinical episodes occurring involve odd sensory experiences. These might include seeing shadowy, ghost-like visions out of one’s peripheral vision. Or, hearing one's name called out when no one is talking to them. Other common symptoms include noticing unusual smells for no apparent reason, or a having a sense of bugs, where none exist, crawling on one or more areas of the body.

People may not be fully confident that they are having such odd sensory experiences. For instance, a person might see shadowy movement out of their peripheral vision because it is a hallucination triggered by a sub-clinical seizure. Or, it may be seen because there was a real shadow for a moment. My rule of thumb is that having just one or two of these symptoms reduces the likelihood of there being a cause for concern. When a person endorses a large variety of odd sensory experiences, and also has a history of various types of traumatic blows to the head having occurred, I become more suspicious of the possibility that such little blips are the culprit.

Ideally, neurologists should evaluate for all seizure concerns. Other professionals, such as family doctors, pediatricians, psychiatrists or neuropsychologists might also be used to diagnose the presence of seizure activity.

As to the complications that seizures can cause: most individuals who have them lead normal lives. A rule of thumb is that
  • The less often a seizure occurs
  • The smaller amount of brain tissue it involves (e.g. a petit mal involves less brain area than a grand mal)
  • And the better control that medication permits
  • then the less likely there will be significant adverse effects from seizures existing.

Having said that, there can be subtle effects that seizures may cause the individual, even when the three bulleted points noted above are in the favorable direction. Depression occurs at an elevated rate, with roughly a third of all seizure patients having such a problem. Manic episodes also may happen more frequently than in the general population, but not as often as depression. Individuals may have poorer short term memory, slower thinking, greater difficulties with social skills, or decreased or increased sexual drive.

I'm wondering if my teen is drinking alcohol or using drugs. How do I find out?

In my experience most parents have good hunches as to where problems lie with their kids. If you are suspicious that substance abuse is occurring, the odds are that it is. In some cases, there may be a genetic component in families, where the parents and/or various relatives have a history of substance abuse. Genes are powerful, and the risk of having a disorder, such as substance abuse, always increases when genetic factors are present.

However, most often I find parents who are caught by surprise that their kids are drinking or using drugs. That is, the parents are usually the last to learn of the substance abuse. It's like being in a car accident, or diagnosed with a disease such as cancer: we think 'It only happens to the other person.'

There are a couple of ways to figure out what might be happening around substance abuse and your child. The first and most obvious approach is to talk to them. Some kids may be open on the subject. Most won't, and do a pretty good job of hiding the truth from parents. A second approach is to consult with a professional who is experienced with substance abuse. In my experience, adolescents, and older teens to a somewhat less extent, will typically tell a doctor personal matters, such as substance abuse, that they hide from their parents. When kids are less than fully disclosing on the subject, professionals who are experienced with substance abuse can usually figure out at least the basic outline of what is probably happening.

A third approach is to pay attention to possible signs. A drop in grades is common. Major changes in personality, such as suddenly being more depressed, angry, or having significant changes in behavior like sleep patterns or appetite might also be reflective of substance abuse. Obviously, other factors might cause a child to undergo personality changes, such as from the effects of puberty, breaking up a dating relationship, parents divorcing, etc.

A fourth approach is to force alcohol or drug testing on a child. I come across almost no parents who take this approach. It may give you the information you want. But there are some problems with it. One is that it creates considerable hostility, distrust and impediments to communication between parent and child. A battle of wills, anger, and resentment can all result. And you have to do the test while the substance is still in their system. If a teen is getting intoxicated at a party on Friday night at 10 PM, and you test them on Monday morning when the lab opens, you'll find no blood alcohol in their system.

What should I do if my child is drinking or using drugs?

Perhaps the most important factor to dealing with such a problem is to try and keep a balance in your mind and heart as to:
  • what you want on an immediate basis (getting them to stop)
  • what you can do in terms of power over your child and enforcing your will on them (policing them 24/7 becomes increasingly difficult as they get older and become more independent)
  • and what your child needs to learn and accomplish on a long term basis (they have to make some mistakes in growing up, and hopefully any price they pay in the process will not be too high).

There are some factors which probably are working in your favor. First, I usually find the age where kids are starting to get in to drinking or using drugs as being from about 14-17 years old. Rarely do I see someone who has a full-blown problem with alcohol or drugs at that age. Most kids I see are experimenting to varying degrees, and there has been less opportunity and time in which serious damage to their health or legal standing may have occurred.

Secondly, at least until a child is 18, or roughly till they are out of high school, you probably still have some authoritative and parental power over them. They may not like being dragged to see a doctor or counselor, but most will still go with you, albeit grumbling a bit. And as long as they remain minors, you have legal authority over their lives too, and can take charge of their receiving treatment.

Third, if you can keep a fairly even emotional keel over the substance abuse that is occurring - that is, try not to shout and berate - you increase the likelihood that some communication can occur between you and your child which can be helpful in resolving the problems. It may be easier to maintain such an emotional balance with the help of a professional substance abuse therapist, who can facilitate open communication, be a mediator, and guide you in the right direction.

The types of therapists and programs that are available are diverse. They range from Alcoholics Anonymous (AA, and Al-A-Teen), to social workers, psychologists, and psychiatrists. There are out-patient and in-patient programs for education as well as detox, if that is needed. MADD and SADD (Mothers against drunk driving; Students against drunk driving) also exist. You may want to consult your family physician, clergy person, or the Yellow Pages for more specific recommendations as to whom you might contact.

Two final points need to be made here. I do not wish to minimize the risk that can occur from a kid using alcohol or drugs. Anyone who is using needles to inject drugs may run the risk of contracting diseases like hepatitis or HIV. Some drugs, such as cocaine and ecstasy, can cause serious harm to a person, such as brain damage, in a surprisingly short time. Alcohol can have tragic consequences such as from drunk driving accidents where a car load full of teens may result in them being maimed or killed. Given the potential of serious consequences from teen substance abuse, when you learn your child is engaging in drinking or using drugs, you do need to act, and not merely dismiss it as something that will take care of itself.

The final point is that in North Carolina a person is considered a legal adult at the age of 18, unless a judge has adjudicated otherwise. You may be housing, feeding, and paying all their bills, offering love and care, and still thinking of them as a child. But, as soon as they turn 18 under state law you no longer have legal authority over them. What this means is that they have the legal right to say 'no' to your wanting them to start a treatment, such as seeing a therapist. Your child also has to give written permission for professionals treating them to share information with you, such as if they are using illegal drugs. You may still have other types of non-legal authority over your children, based on factors like trust, communication and the overall quality of your relationship.

My teenager is constantly playing video games. What are your thoughts about this?

It takes a long time to obtain definitive research on anything. This can include the connection between cigarette smoking and lung cancer, or the use of hormonal replacement therapy for post-menopausal women and health benefits. Typically 35-50 years are needed before the evidence becomes more conclusive. Video games have been around for 25-30 years. But they really exploded on the scene only in the last decade or so, with the advent of video game stations and more powerful computers. So, definitive research does not yet exist.

Preliminary research, and what I have seen in my own practice, is that kids who play a lot of video games have what I call ‘a well trained mouse clicking finger.’ Research phrases the benefits of video games as ‘stimulation to motor skills and vision.’ What this early research also finds is that what is not being activated are the frontal lobes. (See another FAQ in this section on frontal lobes as to their importance.)

Recent research also has found that around the adolescent years the brain starts paring back nerve connections. This can be likened to the pruning a gardener does to a shrub: having less is better, relative to getting rid of parts that are not contributing to health and vigor. Which brain connections are being pared back? ‘Use it or lose it’ might be the guiding principle. That is, if the mouse clicking region of the brain is being heavily employed, those connections will be preserved. If the region involved with reading or math are not getting much use, their connections may wither away. If such a pattern is occurring, this can have implications for the rest of a person’s life, as to how well developed certain skills are, such as for the 3 R’s of academics.

Other preliminary research in to video games has found that those individuals who played more aggressive video games had more aggressive delinquent behavior, poorer academic marks, more physical altercations with other students, and more numerous arguments with authority figures.

Given that video games permeate almost all homes in this country, what can you do if you’re concerned about this early research? Getting the games out of your home is one solution, but your child’s friends will inevitably have them. A major fight with your child may also result. Restricting access to the games, physically or relative to the number of hours played per day or week, is a second option. Enforcing that can be difficult especially if you’re not always home when your child is. A third approach might be trying to shift their interest by encouraging something healthier. This principle is often employed by people who try dieting. If all you have for snacks are potato chips and cookies, what will you eat when you’re hungry? If you have carrot sticks and fresh fruit handy and within reach, what might you eat? If recreational time in your home encourages conversation, playing Scrabble, or going for a walk or bike ride with your child, video games may lose some of their sway and influence.
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