NESCA is currently accepting Therapy and Executive Function Coaching clients from middle school-age through adulthood with Therapist/Executive Function Coach/Parent Coach Carly Loureiro, MSW, LCSW. Carly specializes in the ASD population and also sees individuals who are highly anxious, depressed, or suffer with low self-esteem. She also offers parent coaching and family sessions when needed. For more information or to schedule appointments, please complete our Intake Form.

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Parenting Orchids and Dandelions

By | NESCA Notes 2019

By: Nancy Roosa, Psy.D.
Pediatric Neuropsychologist, NESCA

I recently evaluated a 15-year-old boy, who we’ll call Sam, whose parents brought him in due to some concerning new behaviors, including failing classes, disobeying his parents’ rules – particularly around curfew and technology use – and smoking marijuana on a daily basis. When meeting Sam, I was amazed at how engaging, polite and good-natured he was. It was hard to imagine this young man disobeying his parents and staying out all night, which he was also doing frequently.

Sam had grown up in an affluent and supportive family, the third of four children. The other three were, like their parents, easy-going, adaptable and successful – academically, socially and athletically. They were on the path to becoming independent and successful adults. Sam had always been a bit different. He was the child who had colic as an infant, sleep disturbances throughout childhood, separation anxiety at preschool, and extreme sensitivity to sensory stimuli. His parents cut tags out of his clothes, bought him loose-fitting pants, and avoided birthday parties at Chuck E. Cheese’s – or almost anywhere there would be crowds of loud children, as these situations could reduce Sam to tears.

When evaluating Sam, I was impressed by his intelligence, quick reasoning and solid academic skills.  There was nothing obvious that standard neuropsychology tests uncovered. But Sam was also open and articulate about his difficulties. He explained that he was easily overwhelmed – “jangled,” he called it – in social situations, in a fast-paced classroom or on an athletic field. When he started ninth grade in a challenging parochial school, he was faced with more stressful situations, academically and socially. He became extremely anxious about tests and lengthy homework assignments, so he fell behind academically and developed pretty serious school anxiety. Given his sensitive nature, he was particularly likely to struggle in a class where the teacher was, in his words, “too strict,” or even “mean.” He wasn’t successful enough socially or athletically to sustain his self-esteem in these areas, particularly compared to his talented siblings. He found himself becoming angry and anxious, and he started using marijuana to calm himself. As he described it, getting high was the only time he felt happy and relaxed.

Sam was clearly struggling, easily meeting criteria for an anxiety disorder and a substance use disorder.  But I wanted to explain some of the “why” behind his struggles, so, in talking to his parents, I relied on the explanation put forth by Dr. W. Thomas Boyce, in his book, Orchids and Dandelions: Why Some Children Struggle and How All Can Thrive. He explains that most children are like dandelions, born with sturdy, resilient temperaments so that they, like dandelions, grow and thrive wherever they land –  assuming there’s some minimal level of appropriate conditions. But about 20% of children are more like orchids. They are born with a very sensitive nervous system, which is highly attuned to all the stimulation in the world around them. Dr. Boyce found that for these children, lower levels of stress precipitated a full-fledged anxiety response, involving the release of stress hormones that create a Fight, Flight or Freeze response – an appropriate response for a life-threatening situation, but not much help when facing, say, a strict teacher or a hard test. These children are therefore much more likely to develop full-blown anxiety disorders. On the positive side, their high level of sensitivity to the world around them means they are typically very empathic and emotionally attuned. Like an orchid with careful nurturing, they will develop into exceptional adults.

Fortunately, many orchids do naturally gain resilience as they grow, according to Elaine Arons, Ph.D. In her book The Sensitive Child, she cites studies that find most children who are shy as preschoolers – suffering social and separation anxiety – will develop coping strategies and not appear shy by the time they reach school age. These orchids gain resilience without losing their sensitivity.

But this positive evolution requires good parenting. While dandelions do fine with the average “good-enough” mother, as famously defined by psychologist Donald Winnicott, orchids need parents to be just a bit better.

How does one do this? How can a well-meaning, good-enough parent help these orchids become better able to manage the squalls, large and small, that occur in any one’s life?

Fortunately, there is a wealth of research – contained in books and articles – on building resilience in children. Most emphasize that we need to allow children to struggle with challenges, even to the point of sometimes failing, so they learn that they can cope and succeed in the face of adversity. This message is clear from the title of several such books: e.g. The Blessing of the Skinned Knee: Using Timeless Teachings to Raise Self-Reliant Children, by Wendy Mogel and The Gift of Failure: How the Best Parents Learn to Let Go So Their Children Can Succeed by Jessica Lahey.

We also have a neurobiological explanation for this process. We know that continued exposure to a stressful situation allows the body to habituate and the terrible feelings – such as fear and panic – that accompany a stress response gradually recede. As this happens, the previously scary situation becomes routine, and the child’s self-confidence and willingness to tackle new risks grows. Every preschool teacher knows this. The crying child who is being left by his parents in an unfamiliar preschool will eventually calm down and start to enjoy himself. The process goes more quickly if parents calmly and confidently reassure the child, then leave. The parent who is also anxious, who hovers over the child, attempting to sooth his fears, only increases the child’s anxiety by sending the message that this IS a scary situation. This phenomenon was dramatically illustrated in a study by Susan Crockenberg and Esther Leerkes (Development and Psychopathology, 2006). They found that 6-month-old children had different levels of reactivity – or startle – in response to unfamiliar stimuli. These infants also showed differences in how much they tried to avoid the situation, versus distracting themselves while staying in the presence of the stimuli. Children with high reactivity and a tendency to withdraw from novel stimuli, along with parents who were less sensitive, were more likely to show high anxiety at 2.5 years of age. Exposure to challenge causes the body to habituate and builds resilience. Trying to avoid stressful situations only exacerbates fears.

However, this can be counterintuitive for parents of very sensitive children. In fact, the more attuned a parent is to his/her child’s sensitivity, the harder it becomes. Sam’s parents had always coddled him a bit more than their other children. Knowing that he didn’t like loud birthday parties, his mother tended to decline these invitations. When he became upset and started to cry at a soccer game, his father felt so sorry for him that he didn’t insist that Sam return the next week. This avoidance did not allow Sam to grow and master new situations, but instead narrowed his world.

This is not to say that Sam’s parents should have been less emotionally attuned. Rather, it’s important for parents of children like Sam to walk a fine line between exposing the child to moderate challenges that he can manage but do not overwhelm him. It’s also important that they stay calm themselves, empathizing with the child’s fears but reassuring him at the same time. Not an easy task.

Fortunately, Sam has many strengths, not the least of which are his sensitivity and his intelligence, as well as great artistic gifts. He also has a solid relationship with his parents, even though it has been quite strained of late. After our evaluation, Sam and his parents decided to place him in a therapeutic wilderness program so he could withdraw from daily pot use in a safe place and learn skills from therapists there, as well as learn from peers who were going through similar struggles. This coming year, he will not return to the challenging parochial school he attended for ninth grade and will instead start at an independent school that offers some academic supports and a flourishing arts program. Sam’s roots are well-established, and with a bit more awareness of the gifts and challenges inherent in his sensitive nature, he is expected to grow into a self-confident and resilient young man.

 

About the Author: 
Roosa

Dr. Roosa has been engaged in providing neuropsychological evaluations for children since 1997. She enjoys working with a range of children, particularly those with autism spectrum disorders, as well as children with attentional issues, executive function deficits, anxiety disorders, learning disabilities, or other social, emotional or behavioral problems. Her evaluations are particularly appropriate for children with complex profiles and those whose presentations do not fit neatly into any one diagnostic box. As part of this process, Dr. Roosa is frequently engaged in school visits, IEP Team Meetings, home observations and phone consultations with collateral providers. Dr. Roosa has also consulted with several area schools, either about individual children or about programmatic concerns. She speaks to parent or school groups, upon request.

Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton and Plainville, Massachusetts, and Londonderry, New Hampshire, serving clients from preschool through young adulthood and their families. For more information, please email info@nesca-newton.com or call 617-658-9800.

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What is Working Memory and How Can We Address It?

By | NESCA Notes 2019

By: Nancy Roosa, Psy.D.
Pediatric Neuropsychologist, NESCA

Melanie is a sweet, hard-working 11-year-old girl whose parents brought her to NESCA for an evaluation to try to understand why she was struggling in school. Melanie was a cheerful, vivacious girl who seemed intelligent, curious and articulate. But she was barely getting by in fifth grade, putting in hours on homework every night on assignments her teachers thought should take 30 minutes. Her parents were concerned about how she was going to manage middle school next year.

During the evaluation, Melanie did quite well on most tests. Her intelligence measured in the “Above Average” range, and her academic skills were solid. She worked hard and even did well on a test of sustained attention. So, it was clear she did not have a classic case of attentional dysregulation.

Upon further analysis, a few striking results emerged. Melanie had a good ability to remember information or work on structured tasks, but got confused on multistep tasks. One important result: she was able to remember and repeat back long strings of digits when repeating them verbatim, but she really struggled when she had to repeat them in reverse. The mental manipulations involved flummoxed her.

This is working memory: the ability to hold multiple bits of information in memory banks while there is another, distracting bit of information processing going on. Working memory is the “working” part of memory, as it holds information long enough for us to use it or store it away in longer-term memory banks. Analogies can be made to computer storage, where current information is held while processing occurs; or a mental chalkboard, where we jot down our ideas while working out a problem. For some children, like Melanie, that computer storage or chalkboard space is quite limited, causing difficulty with many aspects of learning. As a first grader, Melanie easily learned the sounds of letters, but it was harder for her to remember and apply that knowledge while reading words. Similarly, she easily learned math facts, but got stymied on multistep math problems. Finally, she had trouble with multistep directions. When her parents or teachers told her three things to do, her response was typically, “Wait, what?”.

Melanie’s parents were right to be concerned about middle school, since this is when students are presented with more complex assignments, such as lengthy reading and writing assignments, PowerPoint presentations and many other multistep projects, which were going to be hard for her.

Working memory deficits are related to other cognitive processes. Children with attentional regulation deficits or learning disabilities often – but not always – have working memory deficits. However, every child is unique, with an individual set of strengths and weaknesses. Therefore, a comprehensive and well-done evaluation is essential to clarify a child’s specific profile – a vital first step in crafting an appropriate plan for support and treatment.

Now that we identified Melanie’s difficulties as primarily due to working memory deficits, how do we help her?

My recommendations centered first on the types of accommodations Melanie would need in school to manage an uptick in demands.

  • Any complex or multistep assignment needed to be presented in writing so Melanie can refer back to the directions. She should be shown completed models and provided with scoring rubrics.
  • Melanie might need support from a learning specialist to manage complex tasks, by dividing them into component parts, then completing each part and integrating the whole.
  • Melanie should not be expected to take notes while simultaneously listening to a teacher’s instruction. She should be provided with notes or given an outline of the teacher’s talk that she could fill in.
  • Melanie’s pace of work was slow, given the need to frequently check back and remind herself what she was doing. Therefore, teachers should consider giving her shorter homework assignments that focus on quality not quantity, and extra time to complete tests and assignments.

We also discussed the strategies that Melanie would need to learn to compensate for working memory deficits. She was already using some important strategies, likely based on coaching from some talented teachers in her past. She knew she needed to write things down to remember them, so she had become good at creating outlines before she started writing and drawing pictures of math problems. However, as assignments got longer, Melanie was going to need additional strategies. For example, for lengthy reading assignments, Melanie might need to jot down sticky notes on pages or develop an ongoing “story board” to keep track of main character descriptions or plot points.

Once the family brought this information to Melanie’s educational team, they were able to meet and establish important accommodations, including time to work with a learning specialist several times weekly. The team also agreed to continue to monitor her ability to manage future challenges.

Beyond accommodating working memory deficits, there is ongoing research into programs that could actually improve an individual’s working memory. The hope is that by targeted practice, one could strengthen one’s working memory the way we strengthen muscles by working out at the gym. Despite a great deal of research, the preponderance of evidence does not indicate that these kinds of training programs are effective in improving working memory, except on the specific tasks used in the training program itself. At NESCA, we remain optimistic that further research and refinements will eventually yield more promising treatments.

Finally, one of the most important outcomes of the evaluation was a feedback session with Melanie herself, where I explained her learning profile to her in age-appropriate terms. My goal was to help her appreciate her many strengths and understand that her learning challenge was relatively small and specific. She might have to work harder in certain ways, but would be able to be successful in school and life.

At NESCA, we find that when a child is old enough to process this information about their profile, it is vital to provide it. We find that many children, even teenagers and young adults, tend to be black-and-white thinkers. When they struggle in school in any way, they conclude they are “stupid.” It is obviously vital to prevent this kind of global, negative self-concept from developing. Rather, we hope to give the child the self-awareness and confidence to develop and use compensatory strategies, no matter the area of weakness. We need Melanie and children like her to be confident enough to ask a teacher, college professor or even a job supervisor to provide written instructions to a task or go over directions more than once. Our goal is to arm her with enough self-awareness and confidence that she can go into any new situation, as a student or adult, and be successful while not letting her challenges define or limit her.

 

About the Author: 
Roosa

Dr. Roosa has been engaged in providing neuropsychological evaluations for children since 1997. She enjoys working with a range of children, particularly those with autism spectrum disorders, as well as children with attentional issues, executive function deficits, anxiety disorders, learning disabilities, or other social, emotional or behavioral problems. Her evaluations are particularly appropriate for children with complex profiles and those whose presentations do not fit neatly into any one diagnostic box. As part of this process, Dr. Roosa is frequently engaged in school visits, IEP Team Meetings, home observations and phone consultations with collateral providers. Dr. Roosa has also consulted with several area schools, either about individual children or about programmatic concerns. She speaks to parent or school groups, upon request.

 

 

Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton and Plainville, Massachusetts, and Londonderry, New Hampshire, serving clients from preschool through young adulthood and their families. For more information, please email info@nesca-newton.com or call 617-658-9800.