CAM for ADHD
July 27, 2010
I recently saw an interesting statistic reporting more than 50% of parents use complementary and alternative medicine (CAM) to treat their children’s ADHD. Many parents of ADHD children and adults with ADHD opt to combine conventional treatments, such as stimulant medication, with CAM while others prefer to use nonpharmacological therapies alone. Although most nonpharmacological interventions have limited data to support their benefit, 80% of patients who use natural products consider these to be their primary treatment modality. Yet few disclose this information to their treating physician. If you are using any alternative therapies I would urge you to discuss these with your doctor. The goal is to promote optimal integrative treatment and avoid any potential pitfalls.
Given the frequent use of CAM, I thought it would be helpful to review the common nonpharmacological treatment options for ADHD. Currently the most popular nonconventional ADHD therapies are as follows: dietary changes, herbal supplements, trace elements/vitamins, neurofeedback, essential fatty acids (EFA’s), and yoga/massage for ADHD.
In my experience complimentary and alternative treatments can be safely and effectively integrated with conventional approaches to treating ADHD. Despite the limited data, nonpharmacological treatments have indeed shown some benefits. For example in one research study using dietary changes to treat ADHD, 75% of children showed improvement in their symptoms when food colorings and additives were removed from their diet. Another study showed children and adolescents with low blood levels of ferritin (the storage form of iron in the body) experienced higher rates of ADHD-type symptoms, which improved with taking 80 mg per day of iron. More specifically the kids hyperactive and impulsive symptoms improved with the iron supplementation, but their inattentive symptoms did not.
In a separate small study, ADHD children practicing yoga demonstrated improvements in their symptoms over time compared to the group of ADHD children who did conventional exercise. In support of the argument for combined treatment, children who continued to take simulant medication simultaneously while practicing yoga showed the greatest benefit.
In summary, an integrative care approach - combining conventional with nonconventional therapies – may offer the best potential outcomes for those with ADHD. I encourage patients to talk with their doctors about all treatment options. It is important to inform your treatment providers of any and all interventions you are utilizing (or wish to utilize) so that safe and appropriate care can be implemented and the greatest benefit received.
Calming Strategies for Children
June 7, 2010
“He’s a terror when things don’t go his way … We’re always worried that he’s going to make a scene and embarrass us … We find ourselves walking on eggshells, trying to avoid one of his meltdowns.”
I hear a lot of that kind of thing from parents of children I work with in my practice. They tell me they often feel stressed, overwhelmed and exhausted from their child’s frequent struggles and outbursts. Parents jump at the opportunity to learn some effective strategies for coping with this common challenge.
As children move through their day, they are bound to bump into situations that are potentially upsetting. Some children are born with calmer temperments and better self quieting skills, while others need to actively learn and be taught how to cope with everyday disappointments and frustrations in a positive way. This is one of the most important things a parent can help a child do. No child enjoys being out of control … it’s simply the only tactic he knows. The good news is you can help your child learn strategies to cope with his emotions constructively and have an easier time getting along in the family, with peers and in school. The bonus — you get to have stress relief, too!
Creating a “My Hard Times Board” (suggested by Peg Dawson EdD and Richard Guare PhD in their book “Smart but Scattered”) with your child utilizes an excellent tool for teaching him new calming and coping strategies. Remember these few tips before you begin:
- Child and parent collaborate throughout this entire process.
- Choose a time to design this plan when your child is calm and receptive. Nothing constructive can be developed during an outburst!
- Make sure there’s plenty of opportunity for practice each day. After all, Tiger Woods could never make those spectacular putts without lots of it. Even he misses on occasion and so will your child. Mistakes will happen – you can bank on that. But, your child will be reassured when you let him know that there’s always another chance to try again later.
STEP I: Together with your child, identify and record a couple of the most common triggers to your child’s outbursts (i.e. parents say “no,” plans don’t work out as anticipated, your child is told to stop doing something fun to do something less enjoyable, your child thinks things aren’t fair).
STEP II: Together, list and record your child’s “can’t do” behaviors that he often uses when he is frustrated (i.e. yell, hit, throw things).
STEP III: Together make a list of your child’s “can do” behaviors to replace the undesirable ones that occur when he is beginning to feel upset. This list is most effective when your child’s personal interests are represented so that his choices are engaging and interesting to him. (Examples of “can do” strategies follow after Step IV).
STEP IV: Now that the board or chart has been designed and your child is invested in the process, it’s important to keep it going by implementing the following concepts.
- A good way to get started is to have your child choose one of these strategies (that follow) and practice the technique with your child for a few minutes each morning and after school. During each practice have your child pretend he is getting upset, describe the body sensations he feels when he is angry and rehearse his calming strategy. Expect to practice these strategies many times before seeing your child using them successfully. Research tells us that it takes 21 days to make a new habit.
- You and your child might want to develop a special signal, a visual or verbal cue, that is a reminder to use one of his calming strategies. Remember, when your child chooses one of the positive behaviors on his “can do” list, it’s time to offer up enthusiastic praise and even tangible incentives such as stickers, rewards or special activities. Everyone loves a prize for a job well-done!
Here’s a sampling of “can do” strategies for calming and redirecting behavior. Personalize this list by creating names that resonate with your child.
- Happy Birthday: Teaching children to take deep breaths when they begin to get upset may seem simplistic, but it’s a lifelong skill for managing stress that has emotional, behavioral and physical benefits. Explain to your child that we all have warning signs that tell us we are getting angry. Help your child recognize the signs his body is sending out that lets him know that he’s getting angry (i.e. face gets red; fists clench; heart pounds; breathe faster). When he feels the warning signs, have him take three deep breaths. Next have your child hold up his hand, palm toward his face with fingers spread. Coach your child to blow on each finger as if he is blowing out five birthday candles, one at a time and very slowly. When you see your child getting frustrated, you might say, “Now might be a great time to blow out the candles.” In the beginning you might want to do the breathing along with your child. Set the pace, modeling for your child and letting your calm presence soothe him.
- Cozy & Cool: With your child’s help, create a “safe spot” where he can go to regroup. This special, positive place in the house is where he can go to calm down, sort things out or just chill out when he needs to be alone. It could be a teepee, a beanbag chair, a hammock, or any space your child sees as comfortable and inviting. In the “safe spot” include soft items like blankets, stuffed animals and a basket of quiet time activities that he can play with while relaxing (books, puzzles). Encourage your child to go to his “safe spot” when he feels himself becoming upset. Teach him that sometimes in an angry situation it is best to walk away, go to his “safe spot” and cool down.
- My Never Never Land: Use relaxation visualization to design an imaginary place that makes your child feel calm. Help your child create a mind picture of a special place that makes him feel peaceful with all of the colors, sounds, textures, and smells that go with the memory. For example, a child may have a happy memory of a time at the beach. When he feels upset, he can take a “trip to the beach.” He can close his eyes, smell the ocean air, feel the sand between his toes, and feel the sun shining on him. Given the opportunity to run with this, your child may add props to further enhance the experience. One child I know took his towel and sunglasses to his “beach retreat” whenever he needed a “beach break.” How clever is that!
- Picasso’s Playground. Build a spot that includes an array of art materials that can be used independently as a calming and quieting activity. For some children, working with clay, drawing, or doing crafts is soothing and distracts them from the dilemma at hand. As time goes on, try adding new items to keep up the novelty and high interest of the center. Parents, keep a ready supply of items to have on hand so that you can change and rotate art supplies as needed. Keep your eye out for those treasures that might hold your child’s interest.
- Shake, Rattle & Roll: Your child can take a walk, shoot baskets, jump rope, swing on a swing, kick a soccer ball, bounce a ball, or dance to his favorite music. Some children get calming benefits from physical release.
- Beatles & Beethoven: Create a listening center with a CD player and earphones where your child can go to listen to music, books on tape or sing a song into a microphone. Dust off that old karaoke machine!
- Splish Splash … Takin’ a Bath? For some children, water is soothing and comforting and gives distance from the problem at hand. Try bubbles in the sink, sprinklers in the yard or an old fashioned bubble bath.
There is no single strategy that is good for every child and every family but with lots of practice, role playing, and simulations, children learn new calming techniques that can help them think before they act. Over time, the goal is for your child to develop both the skill and confidence to handle difficult situations on his own without getting upset and losing control. Remember the best way to teach kids how to manage upsetting feelings constructively is to model calmness through your example. Together, and with a lot of patience, much love and lightheartedness, you and your child will find a calmer and more joyful path.
Doreen Fay EdD
Emotional Impulsivity – A Core Component of ADHD
June 6, 2010
Throughout history disorders of attention were described to include symptoms of emotional impulsivity, as seen in writings by Alexander Crichton (1798) and George Still (1902). Problems with regulating emotion were intially recognized as a core feature of ADHD. But during the 1960’s and 1970’s symptoms of emotional impulsivity/emotional self regulation were split off from the core criteria of ADHD as we know them today: inattention, hyperactivity, and impulsivity. Dr. Russell Barkley just published a wonderful discussion article in the Journal of ADHD and Related Disorders arguing that emotional impulsivity should be returned to its proper status as a core symptom of ADHD.
What do we mean by emotional impulsivity? Why does this matter? Examples of emotional impulsivity include impatience, quickness to anger, easily frustrated, over-reactive, and easily excited. These characteristics are frequently seen with ADHD, yet often unrecognized as a core part of the condition. Frighteningly, these folks may be misdiagnosed as having a mood problem such as depression or bipolar disorder instead of what is really going on – their ADHD!
Over the years in practice I have seen many ADHD kids mistakenly labeled as bipolar. Their over-reactive nature gives an impression of a mood problem when the child is instead struggling with self regulation of attention and behavior. They have difficulty putting on the brakes in their brain. Similarly adults with ADHD can be impatient or emotionally over-reactive, which could lead to misdiagnosis. Unrecognized and untreated these features of ADHD can lead to problems at work and home.
I should also mention ADHD frequently does co-exist with Depression, Anxiety, Sleep Disorders, Bipolar disorder,etc so it is indeed possible to have more than one condition. Making an accurate diagnosis can be tricky. If you are seeking an evaluation for ADHD, I encourage you to work with professionals who are specialized in this area. Getting an accurate diagnosis is essential to getting the right treatment.
Theresa Cerulli, M.D.
A New Way to Help Change Your Behavior
May 1, 2010
David told me he needed help getting things done on time, but when I started talking with him about how he managed the details of his life, he stopped talking about changing and started talking about how he had always been late and would never change.
“I always say I will get a project done early, but I never have. I always just end up feeling like such a loser and then I do it again the same way next time. I can’t change.”
Ron came into our first meeting and said his wife was about to leave him because he was never on time.
“I promise to be home before the kids are in bed, but then I just get caught in a project at work and it’s 9:00 PM before I get home. I’ve tried everything, but I’m just not going to change.”
Sheila and Ted were referred by Ted’s doctor for couple’s coaching. When I asked, “What would your life look like if it suddenly improved?” Sheila’s frustration just burst forth.
“He keeps telling me that he’ll do better, but it’s been fifteen years and he still never gets anywhere on time. Am I supposed to act like that’s normal?”
Ted looked up sheepishly and reported, “I feel terrible and I know I’m impossible to live with, but no matter what I try it doesn’t work. I’m just a mess; what can I do?”
Each of these clients ended up making changes that made life easier for them and for their spouses and work colleagues. And where did I suggest they start? By forgiving themselves.
A study by M. Wohl et al, detailed in a paper entitled, “I Forgive Myself, Now I Can Study: How Forgiveness for Procrastinating Can Reduce Future Procrastinating,” gives some interesting evidence that forgiving yourself for messing up can help free you to give a better effort at trying again.
In my practice I’ve seen that an increased ability to implement a new approach, along with an effective technique and the support of an understanding ally can make a huge difference. I encourage my clients to pay close attention to the fact we’re talking about forgiving themselves. And while it may be helpful for their spouse to forgive them, it’s the self-forgiveness and then a sincere new effort that is key.
Did you know that old dogs can learn new tricks? And people of all ages can and do learn new ways to act in their lives, especially if they can forgive themselves for past mistakes.
Give a call if I can help, 978-446-9600.
ADHD and Sleep
March 21, 2010
Children and adults with AD/HD may frequently experience problems with sleep. You may know this all too well in your family. Many people have difficultly falling asleep while others nod off easily, but then wake frequently during the night. Unfortunately the resulting lack of sleep exacerbates the primary AD/HD problems with attention, concentration, and impulsiveness.
Phase delayed sleep is the most common sleep disorder that accompanies AD/HD. Phase delayed sleep disorder is a fancy way to say the person goes to bed too late and then has trouble getting up in the morning. The hypothalamus in our brains helps to regulate sleep/wake cycles and is basically malfunctioning in an individual with phase delayed sleep.
Is your family short on rest? Try good sleep hygiene including consistent sleep/wake times and creating comfort around your bedtime routine. Reduce energizing activities a few hours before going to bed. Leave the shades open so sunlight shines through early in the morning; light tells the brain it is time to get up!
When behavioral strategies fail, consider over the counter remedies such as melatonin or valerian root. These are natural supplements that help induce sleep and have some clinical research studies to support their benefits and safe use.
You may also want to talk to your doctor about medication. There are newer non-addicting sleep medications such as lunesta and rozerem that have been FDA approved for chronic use in adults and other medication options for children with sleep issues. In our practice I do prescribe sleep medications temporarily to assist patients in getting on a good sleep schedule. Once sleep is well regulated, we recommend weaning off the medication and using behavioral strategies to continue getting your zzzz’s.
Have a restful night!
Theresa Cerulli, M.D.
One Approach to Procrastination
February 26, 2010
If you tend to procrastinate until a deadline is on top of you and forcing you to get things done, and you know this is hurting the quality of your work, causing stress to you and probably to your clients, boss or family, then how do you stop procrastinating about dealing with your procrastination?
This might be a fun puzzle if it weren’t so crucial that you find a way to get started changing your approach. One of the common side effects of procrastination is that people in your life lose trust in you and get angry. As you well know, this is usually matched by your own anger at yourself. But this pressure usually doesn’t translate into motivation to get started.
If life were a sport and you were critiquing yourself for missing critical shots because you didn’t keep your eye on the ball, I’d be pointing out that your focus on past mistakes is taking your attention away from the current situation, taking your “eye” off the ball again. Drop the self-critique, get a bit of help with your technique and try again.
The best hitters in baseball look for, and can see, the stitching on the ball as it comes at them at up to a hundred miles an hour. They know that they need to look for this detail to pull their attention to the ball; just looking in the direction of the ball doesn’t allow them to see the tiny changes in directions that they need to see in order to connect with the pitch. Golfers watch the dimples on the ball as it sits on the tee.
To get started on a project, focus on the details of getting started. What project will you start? Schedule it in your calendar. What small, discreet aspect of the project will you do? Define it and plan on doing just that much. What exactly will your next action on the project be? Write it out very simply as a task.
Think about teeing up the project – choose which one you’re going to work on. Keep your head down, your eye on the ball and hit it just well enough to move it down the course and keep it in the fairway – do a small piece of it. Now you’re ready for the next shot – concentrate on the new swing no matter whether you’re in the rough or on the course.
For you baseball fans, what you’re looking for is a single, not a home run; don’t over reach. Just connect with the pitch. Basketball aficionados, take one step and move the ball down the court. Every foot closer to the basket increases the odds of a score. Tennis players, make a solid smooth hit and get the ball across the net and into the court. Now set up for the next shot.
What do you need to get done? Right now schedule a time to work on it, and resolve to treat it like an important meeting. What is the first little step to getting the project started or moving it ahead? Write it down on your task list.
Procrastination can be head faked that easily.
Couples Coaching
January 21, 2010
What is “Couples Coaching”?
Many of my clients who have ADD have exasperated spouses who are upset with them about starting too many projects and finishing too few, interrupting mid sentence, being late, losing keys, cell phone, etc.… I’m sure you can add to this list.
When I suggest the option of couple’s coaching to them, they’re surprised. Couple’s coaching is a relatively new offering for couples struggling with the affects of ADD or ADHD in the family. Couples’ coaching has similarities to, but is quite different from couples counseling, marriage counseling, and psychotherapy.
A traditional coach will work with you or your spouse. A couple’s coach works with you and your spouse. This person is not a life coach, and may or may not be an ADD implementation coach. Couples’ coaches that I recommend have a deep knowledge of relationships, ADD and ADHD, and some training in family work.
Many issues that couples contend with are completely unrelated to ADD. Expectations, communication styles, different ways of figuring things out, needs for intimacy and connection, and money can all create challenges to smooth and comfortable relating. Then there are the ADD-related issues like disorganization, losing focus, clutter, a different sense of time, starting and not completing tasks, impulsive communication and/or decision making… You get the idea.
Partners (non-ADD or less ADD) may contact the coach because they are frustrated or annoyed. People struggling with ADD symptoms may also initiate the call because they really want to please their partners, are trying very hard to make things work better, don’t want to have conflicts, and want to make positive lasting changes.
Coaching can be helpful for both newlyweds and couples who have been together 25 (or 45) years.
At Cerulli and Associates, we have a variety of professionals, including a couple’s coach; Jay Livingston does executive coaching and ADHD coaching, alongside his skillful couples coaching. He and I work closely, sometimes seeing couples together. I’ve found this blending of skills and approaches to work really well for certain couples.
On Second Thought…
January 14, 2010
Some interesting research shows that on first impulse we usually tend to overrate but occasionally underrate our abilities, and it’s only after a moment’s reflection, in which our brain gets a chance to bring its full cognitive capabilities to the evaluation, that we estimate our skills accurately.
You’ve probably heard of the study where almost all drivers rated their driving as better than most other drivers, a clearly unrealistic self-evaluation. Although I’m pretty sure my skills do put me in the top tier of drivers.
Clearly, we sometimes don’t do a good job of evaluating ourselves.
When studies ask self-evaluation questions a second time, after a moment’s pause, the answers are a more realistic assessment. How good are you at estimating time? “Excellent?” How excellent? “Oh, the “pretty ok when I’m paying attention” kind of excellent.”
This information may be particularly important for those with ADHD who have a tendency toward impulsiveness and over-optimistic projections. Think of quickly answering a question about when you will be home with “Half an hour!” After a minute of slowing down and working it out, you might agree that the most likely correct answer would be an hour or more.
By waiting you’ve allowed yourself time to tap into your ability to compute details and mathematically figure out answer to questions, and you’ve allowed your intuitive side time to process unconscious information and experiences you have stored.
“Can you take on this new project?” If you answer “Sure!” without a pause to allow realistic concerns to bubble up, you’re trying to function at your best by using only part of your ability. It is clearly in our long-term interest to pause long enough to give our brains time to bring their full potential to bear on our response.
I’d suggest you pause, breathe, say, “Let me check my schedule and task list.” Do anything to allow your full intelligence and experience time to evaluate your answer.
Releasing Toxic Shame
December 21, 2009
“To feel shame is to feel seen in an exposed and diminished way. …you turn your eyes inward, watching and scrutinizing every minute detail of behavior. This internal critical observation is excruciating.” John Bradshaw
There is perhaps no human emotion more paralyzing than shame, greater even than fear itself. Unfortunately, many of the people who walk into my office are consumed with an overwhelming sense of personal shame. The reasons are as varied as the people themselves.
• I have not succeeded in school because I am too lazy.
• I was victimized as a child and I believe I should have done something to stop it from happening.
• I gamble because it’s the only way I can imagine finding financial freedom, but when I lose, it only makes things worse.
• I don’t speak to my wife the way I should.
• I don’t trust other people.
For one such shame-filled client, I put a sign up in my office which reads:
Attention: You have just entered a shame-free zone
The wording of this sign is purposeful since I believe that therapeutic progress cannot be made if one is mired in that sense of shame. The coat of shame needs to be taken off and left at the door before the real work can be done.
It is important to define the type of shame I am referring to. When we mess up, whether it’s joking with someone in an insensitive manner, or something more egregious, embarrassment assists us in the process of recognizing our mistakes, taking responsibility for them and then making amends for our transgressions. Shame, on the other hand, is a toxic belief that we are unworthy, loveless or unredeemable. “Toxic shame feels much worse than guilt. With guilt, you’ve done something wrong; but you can repair that – you can do something about it. With toxic shame there’s something wrong with you and there’s nothing you can do about it; you are inadequate and defective.” (Leo Booth/John Bradshaw)
Toxic shame seems to condemn us to an existence of self-loathing, endless emotional pain or existing in a state of numbness to the world around us. Shame anesthetizes us to the possibilities of growth and relationship with others. Shame binds us and holds us captive, no different than a prison cell. It is the toxic shame that we need to recognize as destructive and unhelpful if we ever hope to find peace and connection.
There is always a reason why we do the things we do. The fact that we blame ourselves or see ourselves as defective is a construct that most often other people gave us. Take my examples above.
• I have not succeeded in school because I am too lazy.
o If, like many of my clients you have ADHD, you weren’t organically designed to be immediately successful in a classroom. If teachers and parents keep telling you that you just need to work a little harder, what option did you have other than to blame yourself and feel shame?
• I was victimized as a child and I believe I should have done something to stop it from happening.
o This is common reaction of children who have been abused. Adults have the power. It is their responsibility to keep a child safe; not the child’s, and yet most victims take on the burden of trying to figure out how they could have prevented the abuse.
• I gamble because it’s the only way I can imagine finding financial freedom, but when I lose, it only makes things worse.
o When we find ourselves in this type of financial bind, it is easy to understand how desperation drives us toward unlikely hopes about how we can be delivered from our anxiety and fear. Most people don’t confront overwhelming challenges with rational thoughts. And while it is normal to wish financial woes away by gambling, it virtually never works. These are times to ask others for help and ideas about how to move forward to resolve the dilemmas.
• I don’t speak to my wife the way I should.
o While there are many reasons why this may be true, there is usually some environmental factor which fuels this difficulty. If we lacked role models, for example, on how to speak with a spouse, or we struggle with a low self-appraisal, intimate communication with others is never easy.
• I don’t trust other people.
o Trust is something we learn from our parents and other important people in our early years. If adults proved to be untrustworthy, why would we trust anyone? In my experience, most individuals with this type of history have a “wish/fear” related to intimate connections with others. They both long for intimacy and, given the dominant, fearful expectations held tightly within, they reject it. The promise of intimacy and unconditional love is experienced as nothing more than a shallow or empty gesture. The recipient of such an offering, in order to keep themselves safe from the harm of disappointment, believes that they must reject the overture and assume it is not real. They remain “safe” but alone, isolated and shame-filled that they cannot obtain that which they crave.
All of these situations involve people who are simply doing what they were programmed to do, or are responding to painful situations the way most of us would. Why then, is it appropriate to feel guilt and shame for doing what makes sense? I don’t like it when I see people misunderstand their capabilities, or blame themselves for being victimized, or utilizing flawed strategies to make things better, or keeping a distance between themselves and others, but I understand it. I don’t judge it, rather, I attempt to help those “afflicted” with shame understand where it came from and how to put it down! If there is “fault” to be assessed, usually the fault sits with someone or something else. And when people are caught up in shame and guilt, they almost always fall back on the very behaviors and attitudes that keep them in distress or alone.
Once freed from the shame, individuals can then utilize all of their cognitive energies to managing their lives more effectively. No one deserves to sit with crippling and paralyzing shame. Shame doesn’t move people forward, it merely keeps them held back from experiencing life in its fullest form. While we all need to learn from our mistakes, we all too deserve to live an existence free of toxic shame.
Walter Sherburne, LICSW
68 Park Street
Andover, MA 01810
617-797-8739
walter@sherburnecounseling.com
Moving and Fidgeting
December 6, 2009
I was watching a video piece about a stand-up, school-room desk and was pleased to see an accessory it features, a foot swing. Let me back up.
I find myself more and more interested in stand-up desks as a way to counteract the effects of sitting long hours. When I get time to reply to emails or work at my computer, it feels like a great time to be on my feet, moving and maybe even burning a few calories.
So, as I have been perusing the web exploring stand-up desk options. I discovered a company that makes stand-up desks for students that has a “U” shaped metal rod to rest a foot on, and the rod swings. The kids report that it helps them manage their energy and even stay out of trouble – sometimes. I love the idea and have always provided something similar for my clients, many of whom have ADHD.
Every chair in my therapy room has at least one fidget object near it, soft stress balls, clear plastic magic wands with floating confetti inside, coasters, pillows and foot rests are the current selection. Clients find wonderful things to do with these items as they work off enough energy to sit and talk with me. The balls are constantly flying from hand to hand or being thrown in the air and caught one-handed in a continual game of catch, squeezed to a pulp.
The magic wands get twirled between fingers, rolled between hands, stared at with hypnotic attention as the confetti floats languidly down only to have the wand flipped on its end sending the confetti floating down once more, or beat like a drum stick, with an occasionally desperate rhythm, against clients’ legs.
Pillows get hugged, folded, punched and prodded. Coasters are slid, balanced on end, tossed and tapped. Foot rests are pushed and pulled. An observer of my sessions would be hard pressed to find a moment of complete inactivity during the 60 to 90 minute sessions.
One client told me that he knew I understood ADHD the minute he saw the “toys.”
Szifra (Shifra) Birke
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