While medication is the mainstay of treating symptoms in ADHD, Edward Hallowell, MD, shares a positive, relationship-based approach to ADHD with practical strategies to help children and adolescents manage ADHD.
Published On: 11/30/2020
Duration: 18 minutes, 10 seconds
Related Article: "Reimagining ADHD," The Carlat Child Psychiatry Report, January/February/March 2020
Dr. Feder: Medication is the mainstay of treating symptoms in ADHD. However, there’s more to treatment than that. The latest issue of The Carlat Child Psychiatry Report includes an interview with Dr. Edward Hallowell, founder of The Hallowell Centers in Boston MetroWest, New York City, San Francisco, and Seattle. He’s also the host of the podcast “Distraction.” Dr. Hallowell’s approach to treating ADHD focuses on positivity and relationships. Mara and I are going to talk more about it in this episode.
Welcome to The Carlat Psychiatry Podcast.
This is a special episode from the child psychiatry team.
I’m Dr. Josh Feder, The Editor-in-Chief of The Carlat Child Psychiatry Report and co-author of The Child Medication Fact Book for Psychiatric Practice.
Mara: And I’m Mara Goverman, a Licensed Clinical Social Worker in Southern California with a private practice.
I’m also a regional director at Real Connections Child Development Institute.
Dr. Feder: Dr. Hallowell is extremely well known in the field. He’s a writer and a speaker, in addition to being a practicing psychologist. He was on the Harvard Medical School faculty for about 20 years. His first book, Driven to Distraction, came out in 1994, and he’s written 19 more books since them. His podcast, Distraction, is great too. If you’re interested in ADHD treatment I highly recommend it.
Mara: He also wrote a book called The Childhood Roots of Adult Happiness. It’s a five step plan for parenting that focuses on positive and helpful attitudes rather than grades, sports, and achievements like that.
Dr. Feder: So we had a great conversation with him, and we’re going to play some of those clips in this episode and talk about them.
Mara: He gave us a preview of his new book, which isn’t even out yet. And it’s an interesting take on ADHD. He’s reimagining the disorder as VAST, which stands for Variable Attention Stimulus Trait.
Dr. Feder: Rebranding ADHD as VAST is part of his larger perspective on these kinds of disorders. Essentially, he’s grappling with the conundrum we’ve all been grappling with. ADHD has commonly come to describe a huge variety of conditions and traits. These can ruin your life … or managed properly they may be an asset.
Mara: This goes back to previous conversations we’ve had about ADHD overdiagnosis. Generally there’s a lot of confusion out there about it as a disorder.
When you talk to patients, families, and educators, you often get a sense that maybe a case of ADHD is just kids acting out and sometimes it gets chalked up to bad parenting.
Dr. Feder: A big part of this is the scope and variety of symptoms and indicators. Dr. Hallowell points out that what we call ADHD is common among people suffering from addiction and people who are unemployed. But it’s also something found in some of the wealthiest and most successful people in our society. It’s something you hear a lot about entrepreneurs. But in those cases people say they are restless and energetic, not hyper and easily distracted.
Mara: The subtitle of Dr. Hallowell’s new book is going to be: . Turning perceived weaknesses into strength is an exciting treatment strategy. The question is, what does it mean for every day practice. How do you actually turn an attention disorder into a strength when you’re working with patients?
Dr. Feder: He had a really great analogy for this. So … think about living with ADHD as being on one of those boats that go under Niagara Falls. Have you ever been on that? It’s thunderous, and there’s water spraying everywhere. So it’s noisy and misty. It’s a fun place to be on a 15 minute boat ride but you don’t want to live there. And that’s what people with ADHD may be dealing with every day, all the time. Dr. Hallowell looks at his job as a clinician as being the person who helps patients build their own hydroelectric plant on that massive waterfall in their minds.
I just love that idea, because we see it all the time when you find the right medication treatment for people suffering from these symptoms, they can suddenly think clearly. It’s like they have their whole mind available to them.
Mara: So as a therapist, the first clinical step I’m taking is to set the table for the patient. Dr. Hallowell has a great line of discussion for this:
1. You’re not lazy or lacking in discipline.
2. You don’t have some insurmountable character flaw.
Dr. Feder: Those first two are great, because a lot of these patients have self-esteem issues because maybe family and teachers have been hard on them leading up to the diagnosis. It takes away the idea that they are broken and they need to be fixed.
Mara: Definitely, so these next two ideas are interesting, and I think pretty promising.
3. You don’t have a deficit disorder. What you have is an abundance of attention … not a deficit of attention.
4. You’re just having trouble channeling it. Focusing it.
Dr. Feder: Building that hydroelectric dam.
Mara: Exactly. So the end result is that the patient and the clinician are on the same page that they are going to harness this abundance of attention to do something great. As a therapist I can say: “Listen to me, I’m going to tell you how to turn this situation into something useful.”
Dr. Feder: Then the question becomes: how do you go about doing that? And clearly going to medication is a big option. There are times when that doesn’t work though. There’s an example of an 8-year-old boy in Shanghai who was in trouble every day at school. They hit him with a stick, and all that. His mother emailed Dr. Hallowell and he gave her some guidance. No medication. In three months he was at the top of his class, no acting out.
Mara: That’s the ideal scenario. Break down the guidance he gave, because it’s pretty fascinating.
Dr. Feder: The first one is going to be pretty obvious to our listeners because most of us don’t live in school systems with corporal punishment.
Stop hitting the kid in school.
Mara: Stop hitting the kid at home too.
Dr. Feder: Yes that too.
Because fear is the real learning disability. In this case it involved the mother talking to the teachers to get them to … you know … put down the ruler or whatever it was they were doing.
The broader point about fear is important here too. It involves having that same reorienting conversation you went over Mara, about harnessing the abundance of attention. Having that same conversation with teachers, relatives, peers, and so on. Because imagine the fear patients are living under in class and socially. Just taking that aggravating fear away, or at least alleviating it, is a big first step.
Mara: So, in general, we’re going to get people in their lives to stop treating them like they are defective in some way, and make them part of the team helping them channel this as a strength.
Dr. Feder: So step two is also interesting. Dr. Hallowell suggested massive amounts of love to the mother.
In a way that meant getting the mother to treat the abundance of attention as a positive quality waiting to be harnessed, and yet another reason why she loves her son so much.
This is a beautiful idea for a lot of reasons but it also has a functional element. It reorients the conversation between the patient and his mother. The patient is going to benefit from hearing it again from their loved ones, not just the clinician in an office visit.
Mara: All right, but all of that seems like something that’s going to give some kind of treatment a better chance at success. It’s not a treatment in itself.
Dr. Feder: Right, you have to do something to actually channel that abundance of attention, and like I said, this particular case was done without medication.
Dr. Hallowell explained to the mother and the boy that he has a race car brain with bicycle brakes. He needed better brakes. And the way he got those was with a regimen of cerebellar exercises.
Mara: This was interesting to me. Let’s list some cerebellar exercises. Basically, they involve balance. So:
Those kinds of things.
Dr. Feder: Yes, we’re talking about any exercises that challenge balance and coordination, such as skiing, skateboarding, and surfing, are helpful, as well as exercises that you can do at home like practicing standing on one foot with your eyes closed or using a wobble board or some other balance toy.
Mara: In this anecdote the patient goes from having a terrible time in school to top of his class in three months with less corporal punishment at school, more love at home, and balance exercises. Is this for real?
Dr. Feder: It’s an amazing anecdote … but that’s just it. It’s just an anectode.
We don’t have any controlled trials showing that cerebellar training techniques are effective. We do have studies showing physical exercise in general is effective as an adjunct treatment.
Dr. Hallowell agrees that more studies are needed, but he’s aware non-medication studies aren’t as likely to be funded as medication studies. However, he’s pretty confident in his methods. He does have some good research to fall back on regarding the role of the cerebellum in brain function.
Roy Rutherford in England, and Jeremy Schmahmann at Harvard Medical School did MRI studies showing that the cerebellum occupies has 75%–80% of the brain’s total neurons but only 10% of brain volume (Schmahmann JD et al, Neuroimage 1999;10(3 Pt 1):233–260). There’s a lot going on there, so if you strengthen the cerebellum, you’re very likely strengthening the entire brain function.
Mara: At this point in our interview Dr. Hallowell shared some more news about upcoming projects. Apparently there’s a documentary coming out in 2021 that will portray more anecdotal success of his methods.
So regardless of whether we get real studies on the cerebellar exercise, it’s going to enter the conversation around these disorders and we might have families asking about them as we discuss treatment plans.
Dr. Feder: It’s already a part of the conversation in other treatment areas. Dr. Elizabeth Torres from Rutgers has been focused on cerebellar function in autism and related disorders. What Dr. Hallowell is saying lines up with her work helping people to be more regulated and manage their sensory systems.
Regardless. Big disclaimer. Nobody is claiming this is a double-blind research based treatment. And until it is, there are going to be reasonable question marks around it.
Mara: Exercise in general has good research behind it for ADHD. So it might as well be surfing and skating right. Especially for us here in Southern California.
It always comes down to this though Josh. How does this affect our practice.
Dr. Feder: Dr. Hallowell has a very positive framework. Look for strengths. Present the disorder as an abundance of attention … not a deficit.
The treatment is a challenge … or an opportunity … to harness that attention.
This sounds pretty familiar actually. I think the way most child psychiatry has that general sense of positivity even if we don’t use that exact language.
Mara: Yeah, when we meet with families for an ADHD diagnosis we don’t throw our hands up and say “This is just terrible.” We focus on the good news, we know what’s going on, and there are lots of ways to make things better.
Dr. Feder: I really like the motto Dr. Hallowell shared with us in the interview:
“No brain is the same.
No brain is the best.
Each brain finds its own special way.”
Mara: That’s a nice way to put it.
Dr. Feder: Another good tip he gave is to build patient history with multiple sources because often ADHD patients are not good self-observers. He recommends neurospych testing if it’s affordable for the patient. That way you get a solid picture of processing speed and memory.
And, of course, medication is still the most likely way to help kids deal with ADHD. Dr. Hallowell presents it as an option with all the information about it’s effectiveness and side effects.
Mara: Download our Informed Consent episode for a complete rundown of this one.
Dr. Feder: He said 9 out of 10 times patients will want to give the medication a try once they know all the facts.
Mara: He also said most of his ADHD don’t need psychotherapy. They need coaching and lifestyle changes on getting organized, dressing in the morning, and finishing homework… etc.
Dr. Feder: Great point. There’s another significant observation we got from Dr. Hallowell. He said:
“We’re living in an epidemic of disconnection.”
This is something that we’ve heard a lot in public discourse. Somehow despite all the connective technology we live with, people are feeling isolated. That is a factor in depression, suicide, addiction, and school shootings. His positive observation is a great point to keep in mind as we go about our work:
“The key to a great life is positive connection--to friends, family, pets, activities, work, nature, places, festivities … connection is free and infinite. People don’t take it seriously, or don’t know how to get it, because they’re shy or depressed. That’s where people need help from folks like you and me …”
That’s a great way to look at our jobs isn’t it.
Mara: It sure is.
Dr. Feder: The full interview is available for subscribers to read in The Carlat Child Psychiatry Report. Hopefully people check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits.
Mara: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry.
Dr. Feder: Yes, the newsletters and books we depend entirely on reader support. There are no ads and our authors don’t receive industry funding. That helps us bring you unbiased information you can trust.
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