Attention Disorders and Arrowsmith Program

What is the underlying cause of attention disorders? The National Institute of Mental Health states that “scientists are not sure what causes ADHD, although many studies suggest that genes play a large role. Like many other illnesses, ADHD probably results from a combination of factors. In addition to genetics, researchers are looking at possible environmental factors, and are studying how brain injuries, nutrition, and the social environment might contribute to ADHD.”

At this point in scientific research there is no definitive answer to this question. Indeed, many parents try a variety of solutions to improve their child’s attention capabilities from the control of diet, to increase in exercise, to neurobiofeedback therapy, to the intake of natural supplements, or to the use of stimulant medication. I have seen positive results from my clients using one or the majority of these intervention methods. As well, I have seen limited results, depending on the client. There is no question that each brain and the environment it lives in is so diverse that it is difficult to imagine a study that can generate one definitive result that proves why a child struggles to attend to information. Parents often attempt to try solutions based on the information they receive and observe their child’s response to that treatment.

The American Academy of Pediatrics published the Clinical Practice Guideline: Treatment of School-Aged Child With Attention-Deficit/Hyperactivity Disorder . They noted that 4% to 12% of school-age children show ADHD behaviours. The guideline stipulated the need for pediatricians to work with other service providers to consider the best treatment plan, management of behaviours and monitoring of outcomes:Primary care clinicians cannot work alone in the treatment of school-aged children with ADHD. Ongoing communication with parents, teachers, and other school-based professionals is necessary to monitor the progress and effectiveness of specific interventions. Parents are key partners in the management plan as sources of information and as the child’s primary caregiver. Integration of services with psychologists, child psychiatrists, neurologists, educational specialists, developmental-behavioral pediatricians, and other mental health professionals may be appropriate for children with ADHD who have coexisting conditions and may continue to have problems in functioning despite treatment. Attention to the child’s social development in community settings other than school requires clinical knowledge of a variety of activities and services in the community.

Researchers also realize that medication is not always the answer for their clients. Dr. David Rabiner noted in a research review study that, “Although medication treatment is effective for many children with ADHD, there remains an important need to explore and develop interventions that can complement or even substitute for medication.” He goes on to state that not all individuals benefit from medication. Some individuals experience adverse affects to medication. Medication benefits do not continue once it is discontinued. Dr. Rabiner notes that, “Because of these limitations, some researchers have pursued cognitive training as an alternative method of treatment. The basic idea behind cognitive training is that important cognitive skills such as attention and working memory can – like any other skill – be strengthened and enhanced with intensive and focused practice. Furthermore, when an individual builds these skills the benefits may endure beyond the time when the actual training is provided.”

The Arrowsmith Program provides one such cognitive intervention service. Over the last 30 years the Arrowsmith Program has successfully improved the executive control abilities of children diagnosed with ADHD. The Arrowsmith Program, founded on neuroscientific research, involves intensive and graduated mental exercises that are designed to strengthen the source of the attention disorders – underlying weak cognitive capacities. Over 30 years of experience the Arrowsmith Program has demonstrated that these affected brain areas can be improved through mental exercises, resulting in increased mental capacities and strengthened learning abilities. Weaker areas of the brain are treated like weak muscles and are intensely stimulated through mental exercises in order to produce strengthened learning capacities. Research at Arrowsmith School has also shown that when the deficient area is improved, the individual’s ability to plan, organize and actively engage in academic work requires less effort.

A significant number of children previously on stimulant medication for ADHD can successfully end this treatment through the Arrowsmith Program. That is, the Arrowsmith Program has found that a portion of children with ADHD actually have multiple cognitive dysfunctions that impact their ability to sustain active engagement in a classroom setting. The ADHD diagnosis is not a primary disorder, but rather secondary to the multiple cognitive weaknesses impacting processing, memorizing or conceptualizing information. David was one such student.

David was given a full psycho-educational assessment for a possible learning disability. He was struggling at school. His mother would have to get him to sit down to do his homework. When she went over his assignment it appeared to her that her son was not listening in class. This was frustrating and resulted in conflicts at home. Yelling, arguing, debating were common social interactions between her and David on a daily basis. She really felt that David was to blame.—if only he could pay attention and work harder. The psycho-educational assessment identified specific learning disabilities. The primary problem appeared to be written expression. The ADHD checklists highlighted ADHD-Inattentive Type as another area of concern. He showed at least six of the nine behaviours often associated with the Inattentive subtype. This included not listening to instructions, difficulty following through on homework or school related activities, forgetting assignments, inability to sustain attention and being easily distracted in class.

David’s mother heard about the Arrowsmith Program through a friend. Through discussion with Arrowsmith staff, it was determined that David had at least 7 specific learning dysfunctions that would impact classroom management. David was then assessed to determine the severity level of his learning dysfunctions and to determine his Arrowsmith cognitive remediation program. Several of the cognitive weaknesses would certainly impact attention control, including weak memory for information and instructions, weak visual-motor integration for printing and copying and a weakness with determining the main idea, also known as saliency determination. After three years of intensive cognitive remediation (brain exercises) David was able to move these learning dysfunctions from a severe level of disability to average ability. He was then capable of listening to instructions, sustaining active engagement on school-related tasks, following through on homework and assignments and was not easily distracted in class. These neurological improvements took hours and hours of cognitive training. Brain change requires active engagement and repetitive brain exercises that require increasing complexity. By improving neurological weaknesses through cognitive intervention training he no longer demonstrated ADHD-like behaviours.

In summary, it is important for those diagnosing and managing children with ADHD to consider cognitive intervention training. The Arrowsmith Program is one such method available in Vancouver, B.C. Results from a 2007 study on the Arrowsmith Program highlighted positive gains in ADHD-like behaviours. The study was completed with the cooperation of the Toronto Catholic School Board, which has used the Arrowsmith Program for the last 12 years (since 1997). The study showed that the students that had completed the Arrowsmith Program and were now fully immersed in regular education classes show significant improvements in following instructions, organization skills and willingness to complete homework. All of the teachers identified a noticeable to extremely noticeable change in the Arrowsmith students’ ability to follow and understand instructions (for those students for whom this was a concern). In regards to willingness to attempt and complete homework, 80% of teachers recognized a noticeable to extremely noticeable change. Only 7 % of teachers noticed no change (for 13% of students this was not a concern). Finally, in regards to organizational skills, 85% of teachers recognized a noticeable to extremely noticeable change. Only 4 % of teachers noticed no change (for 11% of students this was not a concern). Medication for ADHD can certainly provided immediate results, but long-lasting changes in brain functioning can occur through cognitive training methods.

http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/complete-index.shtml
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;108/4/1033
http://www.sharpbrains.com/blog/2008/06/12/promising-cognitive-training-studies-for-adhd/
http://www.arrowsmithschool.org/research.htm

Reflections on 17th National Conference On Learning Disabilities

October 6th, 2009

Dear Friends and Professionals:

On September 25th, 2009, I had the wonderful opportunity to speak at the 17th National Learning Disabilities Conference in Whitehorse. I was invited to speak on the topic of neuroplasticity and learning disabilities. This was the first ever talk about the impact of brain plasticity findings on the field of Learning Disabilities at a national conference in Canada. Psychologists, principals, teachers and parents were present, as were representatives from Learning Disabilities Associations throughout Canada, including the Learning Disabilities Association of Saskatchewan, which is now offering the Arrowsmith Program in their facility.

I began my presentation discussing how the field of Learning Disabilities has focused on reading difficulties. For decades, the focus of remediation and intervention has been on reading and spelling; thus, research funding and practice have focused in on this area of academic achievement. While it is true that there are many children who have reading-based learning disabilities, this focus means that the other types of learning disabilities that impact school, such as written expression and mathematics, are forgotten. In fact, the schools for children with learning disabilities in BC focus exclusively on reading and spelling intervention. As a result, thousands of children in BC are not being given appropriate cognitive intervention. For example, written expression learning disabilities are the most common type of learning disability. There is little support for children with written expression disorders, other than the use of assistive technology such as a laptop or scribe to bypass their learning problems. Additionally, math-based learning disabilities are another common type of problem for children. There is little cognitive intervention or support, other than extra tutoring and allowing these students to use a calculator. Also, approximately 65% to 80% of children with learning disabilities struggle with social perception. Again, little cognitive intervention is available to help children with this neurological difficulty. Finally, reasoning and critical thinking learning disorders are common for children, and there is no cognitive intervention for children with these learning problems. Those listening to my presentation recognized that this is true in schools today – that the focus has been on reading and spelling intervention and that children with other types of learning problems seldom get the help they so desperately need.

The Arrowsmith Program is the first cognitive remediation system that addresses multiple types of learning disabilities. This was a surprise to many who listened to my presentation, who had looked at the Arrowsmith Program solely as a reading intervention, similar to the programs they had been using for years. For many, this was the first time that they had fully recognized the broad scope and potential of the Arrowsmith program. The fact that the Arrowsmith Program addresses reading, math, written expression, reasoning, memory, spatial thinking, social perception, attention, planning and organization was a novel idea to them.

The Arrowsmith Program, founded on neuroscientific research, involves intensive and graduated mental exercises that are designed to strengthen the underlying weak cognitive capacities that are the source of the learning disabilities. Over 30 years of experience has demonstrated that these affected brain areas can be improved through mental exercises, resulting in increased mental capacities and strengthened learning abilities. Underfunctioning areas of the brain are treated like weak muscles and are intensely stimulated through mental exercises to produce strengthened learning capacities. Research at Arrowsmith School has also shown that when the deficient area is improved, the individual’s ability to perform complex tasks such as reading or writing also improves.

The Arrowsmith Program has conducted research showing positive results of the program, and we are excited about the possibility of more research. I believe that this research will be ongoing and will last more than my life time. I hope that educational researchers and policy makers will embrace the contributions from the field of neuroscience and capitalize on scientists’ abilities to measure the brain during learning activities, thereby enabling educational researchers to measure programs and interventions for students with learning disabilities in a new way. For example, many currently-used reading intervention programs, which have been helpful for many children, lack conclusive empirical evidence on their effectiveness – a finding that was somewhat shocking to many of those listening to my presentation, who had believed that these reading intervention methods had been proven by rigorous scientific study. By recognizing the relationship that neuroscientists and educators can have, new measures can be used to investigate claims made about intervention methods currently being promoted, which may have limited empirical evidence behind them. In short, all of us involved in the education of children with learning disabilities need to continue improving our programs through rigorous scientific research.

Recently, an awareness of how important the relationship between education and neuroscience has resulted in the formation of the International Mind, Brain, and Education Society . One of their mandates is to bridge the gap between education and neuroscience. Current research published in Mind, Brain and Education Journal in March 2009, in an article entitled How Many Brains Does It Take to Build a Scientific Groundwork for Learning and Teaching, investigated the challenges of bringing both educators and neuroscientists together for the common purpose of improving educational practice, stating:

Some educational researchers seemed to perceive neuroscience research as a potential threat to principles about learning established by social science research, which they had built their careers on. Furthermore, only a few education policy makers accepted invitations to our meetings, possibly because some of them were intimidated by arcane neuroscience and some of them saw a political danger related to the concerns of educational researchers. Namely, that education had thus far always used the social sciences (psychology, sociology, philosophy, etc) as reference disciplines and they feared that these disciplines would suddenly be neglected and replaced by neuroscience (p 21).

Despite these challenges, many educators and policy-makers understand that, through advances in neuroscience, great progress in educational methods can be made. Advances in neuroscience increase our understanding of how to create and apply educational methods in order to better serve all students.

The final remarks in my presentation referred to the definition of learning disabilities, which states that a learning disability is lifelong. We are observing through the Arrowsmith Program that this does not always need to be the case. Some children who have completed the Arrowsmith Program are no longer classified as having a learning disability in subsequent psycho-educational assessments. This is due to the fact that their cognitive functions and achievement abilities have improved to the point that there is no longer a significant discrepancy between cognitive/intellectual ability and achievement. Thus, the statement that a learning disability is lifelong needs to be questioned with the brain’s ability to change itself.

In closing, I was grateful for the chance to speak at the 17th National Conference on Learning Disabilities. It is exciting to see the Learning Disabilities Associations throughout Canada interested in implementing the Arrowsmith Program. The success of the LDA Saskatchewan Arrowsmith Program is helping the other associations realize what is possible for children with these broad and diverse disabilities. I hope that educational researchers and policy makers will feel inspired by recent research in neuroscience, and visit Arrowsmith schools to witness for themselves the program in action. The Arrowsmith Program is the first intervention program that has utilized both education practice and neuroscience theory to provide comprehensive brain remediation for children with learning disabilities. It is my belief that so much that can be learned by the combined efforts of educators and neuroscientists, and it is my hope that a continued dialogue will further efforts to advance the field of Learning Disabilities.

Sincerely,

Howard Eaton, Ed.M.

Mayes, S.D., & Calhoun, S.L. (2008) Challenging the Assumptions About the Frequency and Coexistence of Learning Disability Types. School Psychology International, 28, 437-448.
http://www.arrowsmithschool.org/research.htm
Florida Centre for Reading Research: Orton-Gillingham Approach http://www.fcrr.org/FCRRreports/PDF/Orton_Gillingham_Approach.pdf
Florida Centre for Reading Research: Wilson Reading System – http://www.fcrr.org/FCRRReports/PDF/wilson.pdf
http://www.imbes.org/
Chiesa, B., Christoph, V., & Hinton, C. (2009) How Many Brains Does It Take to Build a New Light: Knowledge Management Challenges of a Transdisciplinary Project. Mind, Brain, and Education, 3, 17-26.

Learning How To Read A Clock Face

There are times in our lives that we wish we could go back in history and apologize for our mistakes either as a parent or as a teacher.   The Arrowsmith Program, created by Barbara Young, often makes me reflect on the students I have worked with in the past and how much they would have benefited from her program.  Here is just one example of a brain exercise created by Ms. Young many years ago and how it relates to new findings from neuroscience.

For the last 30 years Ms. Young has used the Clocks brain exercise to develop the reasoning abilities of children with learning disabilities.  This brain exercise improves various achievement abilities (reading comprehension and math problem solving) and overall school success.   I have observed reasoning and intelligence measures improve significantly after the Clocks exercise has been completed within the Arrowsmith Program.  Updated psycho-educational assessments show sharp improvements in fluid reasoning and perceptual reasoning abilities of children who have completed the Clocks exercise.  Research in neuroscience, as described below, indirectly highlights some of the reasons why this might be happening.

In 1992, I was a first year Special Education teacher in the small town of Truro, Massachusetts.  I recall telling parents at Individual Educational Program meetings not to worry if their child could not read a clock face.  These parents would come visit my classroom and say, “Sarah can’t tell time and she is in Grade 4.  I am really worried about this.  She has been trying to learn to tell time for 4 years and can’t get it.”  I often said, “don’t worry about it – there are digital watches now.”

I now realize that reading a clock face is an important indicator of a child’s ability to understand multiple concepts and to improve reasoning abilities.  A concept is a general idea derived or inferred from specific instances or occurrences.   The clock face is quite abstract and requires a number of concepts to be understood (such as a 24 hour day, 60 minutes in an hour, 60 seconds in a minute and the knowledge that the hands of a clock face signify a placement in time that is constantly moving forward).  Of course, there are other concepts, such as before and after, that need to be understood when reading a clock.  What is critical for the child is that all of these concepts need to converge into the ability to look at a clock and tell the time.  If the child is struggling to analyze the relationships of all these concepts, it often means they will also struggle with reading comprehension and math problem solving, as these achievement abilities also require the ability to analyze and synthesize a number of concepts simultaneously.

Back in 1992, I was telling parents that these concepts were not important to learn, as their child could simply wear a digital wrist watch; in other words, a child could bypass this problem by using technology or an accommodation (i.e. someone else could tell them the time).  I was also not giving the child the chance to build brain capacities to understand multiple concepts and improving general reasoning ability.  I should have been trying to teach the child how to tell time on a clock face with significant repetition and review.

Current research in neuroscience is indirectly linking the ability to draw and/or imagine clock faces to the location in the brain responsible for this activity.  It is even more fascinating that this is the same region of the brain that differentiates average reasoners from superior reasoners.

In Germany, at the Departments of Neurology and Neuroradiology at the Klinikum der Johann Wolfgang Goethe-Universitat, Frankfurt, the areas of the brain used to imagine clocks were identified by researchers. Luigi Trojano and his colleagues were interested in finding out which area of the brain was involved in spatial analysis when no visual stimulus was present. Their findings were published in Cerebral Cortex (May 2000), which is published by Oxford University Press. These researchers studied seven right-handed post-graduate students ages 23 to 32. The subjects were asked to imagine two analogue clock faces based on times presented to them verbally by the examiner. As they were doing this visual imaging, their brains were being scanned. These researchers noted: “The most striking results of our two experiments demonstrated that cortical activation (as measured by an increase of the fMRI BOLD signal) during the mental clock test was the most prominent in the posterior parietal lobes of both hemispheres.” I will get back to why the activation of the posterial parietal cortex is so important in relationship to the Clocks exercise used with the Arrowsmith Program.

In Japan, at the Department of Neurology and Department of Radiology, Rakuwakai-Otowa Hospital in Kyoto, the areas of the brain that are most activated during the drawings of clocks were identified. Dr. Tadashi Ino and his colleagues studied 18 right-handed volunteers as they drew the hands of a clock while undergoing fMRI. Their findings were published in the journal Neuroscience Research in January of 2003. They discovered that the brain utilized numerous neurological pathways for drawing a clock; however, the most strongly activated areas during clock drawing were the posterial parietal cortex and the dorsal premotor area. The evidence from fMRIs points to the posterial parietal cortex as being a primary cortical location for tasks involved in clocks – whether drawing or imagining.

So, what is the big deal? Here is the connection between using clocks for a brain exercise and the development of reasoning. In 2005, the journal Neuroimage published a research article on intelligence and which specific neural pathways may be involved in reasoning. The research had been conducted in South Korea at the Seoul National University. Various departments were involved, including the School of Biological Sciences, Department of Biology Education. Additionally, the Korea Institute of Brain Science and Department of Psychiatry at the Catholic University in Seoul were also involved. Finally, Yale University and the Department of Psychology were also a part of the study. The lead researcher was Dr. Kun Ho Lee from the School of Biological Sciences at the Seoul National University.

Dr. Lee noted in his study that the parietal, and later prefrontal, cortices have been noted by other researchers as playing a role in fluid reasoning, the control of attention, and working memory. Dr. Lee and his colleagues wanted to discover the brain location for fluid reasoning of intellectually gifted adolescent students. Could they discover the brain region or pathway that was responsible for general intelligence? Dr. Lee studied 36 gifted adolescents from Busan, Korea. Busan is the largest port city in South Korea and is located at the southereastern most tip of the country. It has a population of over 3.6 million and is known as the capital of baseball in South Korea. The 36 gifted adolescent students were from the National Academy of Gifted Adolescents. The students were given the Weschler Adult Intelligence Scale – Revised (Korean version) and the Raven’s Advanced Progressive Matrices (RAPM), which is a standard test for general fluid intelligence. The control group were students from a local high school.

The experimental and control groups were then given fMRI tasks related to reasoning. The students would be placed in the fMRI machine and asked to perform these specific tasks that had increasing levels of reasoning complexity. As they were performing these tasks, the fMRI showed their brain activity, which was being recorded by the researchers. What was their main finding? Dr. Lee and his colleagues wrote: “The main finding of the current study emphasized the role of the posterial parietal region (specifically, bilateral SPL and right IPS (BA 7/40) among the entire network components of g [general intelligence].” The students with the higher levels of intelligence showed greater activation of the posterial parietal regions as the complexity of the reasoning tasks increased. They continued, restating, “In addition, our results demonstrated that the posterior parietal regions including bilateral SPL and right IPS could be the neural correlates for superior general intelligence. These findings would be the early step toward the development of biological measures of g [general intelligence] which leads to new perspectives for behaviour interventions improving general cognitive ability”.

It is important to note that the prefrontal lobes of these students were also activated. There is a specific frontal-parietal relationship, due to the fact that the brain has to think, which is a prefrontal or executive function task. Interestingly, as students become more adept at the various levels of reasoning, the prefrontal activity decreased.

This research, and the findings from the implementation of the Arrowsmith Program at the Eaton Arrowsmith School, highlight how important it is not to ignore the importance of teaching children how to read a clock face. The ability to read a clock face is one of the first indicators of a child’s reasoning capacities and can predict whether long-term educational frustrations might be developing. We have also learned that reasoning can improve dramatically in children with learning disabilities. Children’s reasoning abilities are not fixed, they can change.

Trojan, L., Grossi, Dario., Linden, E.J., Formisano, E., Hacker, H., Zanella, E.F., Goebel, R., Di Salle, D., 2000. Matching Two Imagined Clocks: the Functional Anatomy of Spatial Analysis in the Absence of Visual Stimulation. Cerebral Cortex. 10, 473-481.

Ino, T., Asada, T., Ito, J., Kimura, T., Fukuyama, H., 2002. Parieto-frontal networks for clock drawing revealed with fMRI. Neuroscience Research. 45, 71-77.

Lee, K.H., Choi, Y.Y., Gray, J.R., Cho, S.H., Chae, J., Lee, S., Kim, K., 2005. Neural correlates of superior intelligence: Stronger recruitment of posterior parietal cortex. Neuroimage 29: 578-586.