The Brain's Way of Healing
BY DR. NORMAN DOIDGE
Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder
On his return, Ron Minson found that he was able to take hundreds of people off antidepressants and stimulants like Ritalin used to treat attention deficit disorder (ADD), and use sound therapy instead. He and his wife, Kate O'Brien, soon made a version of the Tomatis equipment that, much like Paul's LiFT, was portable and small enough to fit on a person's belt. At the suggestion of a colleague, Randall Redfield, they integrated movement, balance, and visual exercises with their listening program, so the patient could process several sensations at once, stimulating the brain all the more. They called their program Integrated Listening Systems, or iLs.
Ron reports that over the years he's helped 80 percent of his clients with ADD get better and never again need medication, with its side effects. Of people who have attention deficit hyperactivity disorder (ADHD), a disorder in which people are highly distractible and impulsive and hyperactive, about half get better. The rest are helped with a neuroplastic treatment called neurofeedback (described in Appendix 3).*
Sound therapy works with ADD for a number of reasons. As Paul points out, a good auditory "attention span" is in large part the ability to listen well for a long time, without being distracted by new, irrelevant external stimuli; concentration, he says, is "the ability to cut out parasitic information in order to Tisten to oneself thinking.'" About 50 percent of the children he has treated have attention deficit disorders, though many also have auditory processing problems, learning disorder problems, and hypersensitivities to sound, all of which make it still harder to pay attention. In psychiatry texts, these disorders are always separate, but in the real world, they often come together.
"Gregory," a boy with classic ADHD who came from extremely deprived circumstances, was helped with iLs. His biological parents were homeless crystal meth addicts, and his mother drank vodka during her pregnancy. Gregory was put into state custody, then adopted by a woman I will call "Chloe" and her husband. When Gregory turned three, Chloe observed he was hyperactive. "He was impulsive. He didn't appreciate personal space. If he ran up to a child, he would be right in their face, talking very loud, and would walk into doors, knock his head on tables, had black eyes, and accident after accident." He would also do risky things, fidget, couldn't stay in his seat at school, and disrupted others. He blurted out answers to questions before they were finished, interrupted others, and couldn't play quietly. By the time he was four, his teacher complained daily that "Gregory is out of control." He had symptoms of distractibility, didn't listen to others, didn't finish what he started, because something else caught his attention, and was always losing things. He had all the behavioral symptoms of ADHD and was diagnosed by several physicians, experts in ADHD; he was prescribed the stimulant Adderall.
* There are many children who are mistakenly labeled as having ADD or ADHD in the classroom. This includes children with psychological traumas who are emotionally preoccupied; highly playful children; highly creative and intelligent children who are bored; underexercised children, especially males who require more "rough and tumble play" to learn to control their impulses; children with a sensory processing disorder (discussed below); those with an auditory processing disorder; and "pseudo-ADD" caused by too much time spent using computer devices, as described in The Brain That Changes Itself.
But Chloe was loath to put a child with a developing brain on a stimulant medication. Ritalin given to very young animals appears to lead to depression-like symptoms over the long term. Because these medications don't train a child to focus, the problems return when medication is discontinued.
Instead of filling the prescription, Chloe looked for alternatives. She learned about Kids Kount, a treatment center for children with developmental problems of all kinds. Founded by speech-language pathologist Andrea Pointer, with occupational therapist Shannon Morris, Kids Kount has treated two hundred children using iLs. Gregory underwent iLS twice a week for three months. His ADHD improved. His listening treatment was tailored to his problems. First he was exposed to low frequencies and bone conduction, to stimulate his vestibular apparatus and calm and "ground" him by turning on his parasympathetic nervous system.
"Adding the movement, balance and visual components of iLS while he listened made a huge difference in his ability to pay attention," says Pointer. "The movement triggers dopamine, which is key for motivation and attention. So we were giving him a natural chemical response that medication gives."
I asked Chloe what she noticed. "The calm! I think we saw the calm, after about two and a half weeks. The main difference was his ability to sit still in class, to listen, to follow instructions. It was huge. The overall effect is a lot less impulsivity. Stopping to think about what he is going to do, before he does it."
Getting Gregory to do iLs was not the only change Chloe made. She noticed that he had extraordinary sensitivities to foods with gluten and sugar: "Giving my son sugar is like giving him crack." It made him more hyperactive. A 2013 Harvard study shows that very-high-sugar foods— typically processed foods—actually turn on a part of the brain that is affected by crack and cocaine. He needed to be off sugar, to boost his general brain cell health, but also needed iLs to stimulate and train his attention circuits.
"The difference in my son with iLs, and watching what he eats, is night and day," says Chloe. It was easy to distinguish between the help he was getting from the iLs and his dietary changes. When he went off his diet, the setback was almost immediate. The iLs improvements were slow and steady, and the more Gregory used it, the longer he could go without regular use. Now if he trains every day, then goes without the iLs, the residual effect—the calm—will last four days before some old behaviors start returning.
Chloe says, "The notes home from school now say, 'Gregory had another great day!'"
New Contributions as to How Sound Therapy Works
One of Ron Minson's most important contributions has been to update Alfred Tomatis's theories and resolve some important confusion about how sound therapy works, especially with respect to attention. Most brain scientists have thought of attention as a "higher cortical function," meaning that it is processed in the thin outer layer of the brain. It has long been known that the frontal lobes—at the "top" of the brain—help people form goals, stay on task, and perform more abstract kinds of thought; they are required for maintaining attention. Neuroscientists assumed that attention difficulties were caused by frontal lobe problems. Supporting that assumption was the fact that, on brain scans, people with ADHD have smaller frontal lobes than their more attentive peers.
The confusion that Minson has helped resolve is this. Signals from sound therapy don't go directly to the frontal lobes; rather, they go to various subcortical areas, beneath the cortex, that are involved in processing incoming sensory input. So how can they help improve attention?
Sound therapy can correct attention problems by stimulating all the subcortical areas illustrated in the figure on page 338.
All these subcortical areas in the figure are stimulated initially by sound therapy, especially when combined with movement. Recent brain scan studies have shown that people with ADHD also have decreased brain volume in the cerebellum (which, again, fine-tunes the timing of thoughts and movements, and balance). As a person's ADHD gets worse, the cerebellum decreases further in size. As patients get better, however, the cerebellum increases. Children with ADD who can't wait their turn or blurt out answers are sometimes having trouble timing their
Areas of the subcortical brain that are modulated by sound therapies
in ADD and ADHD
DRAWING NOT GIVEN - THIS IS A TEXT ONLY WEBSITE - Keith Hunt
actions. Tomatiss listening therapy and iLs have an impact on the cerebellum, as well as a huge impact on the vestibular system, which is linked to the cerebellum. Adding balance exercises, which iLs does, further stimulates the cerebellum.
The music in sound therapy turns on and enhances the connection between brain areas that process positive reward (which give us a feeling of pleasure when we accomplish something) and the insula, a cortical area of the brain that is involved in paying attention. This was shown only in 2005, by the neuroscientists Vinod Menon and Daniel Levitin, using fMRI scans.
Stimulating the vestibular system with music and movement therapy causes it to send signals to another subcortical area, the basal ganglia, which is also part of the attention circuit. People with ADHD have smaller basal ganglia. Normally, the basal ganglia contribute to staying focused by inhibiting the brain from doing anything unrelated to the main task. To pay attention to one thing requires inhibiting the temptation to attend to something else. Also, when the basal ganglia are underactive, people will tend to leap before they look, which can show up as hyperactivity and distractibility.
There is a direct link between the ear and the vagus nerve. Sound therapy, as Ron Minson and Pointer explain, stimulates the vagus nerve, which supplies the ear canal and the tympanic membrane. Stephen Porges has shown that the vagus system has many branches. Weve discussed how it turns on the parasympathetic nervous system, to calm a person down. This is especially important in children with attentional and other developmental problems, because they are often very anxious, and in fight-or-flight reactions. But there is another aspect to the vagal system, which Porges calls the "smart vagus"; it allows a person to pay close attention, communicate, and get ready to learn. Stimulating the vagus with the right kind of sound therapy can put a person into a calm focused state, as many who love music know.
Another subcortical area that is stimulated by music is the reticular activating system (see Chapter 3). Reticular means "netlike" or "networklike," and its neurons have short connections with one another, so it resembles a net. This activating system is nestled in the brain stem. It receives input from all the senses and processes the information to determine how awake or aroused and attentive a person should be. When an alarm clock goes off in the morning, it rouses the activating system to awaken the cortex. When turned on "high," the activating system will wake an underaroused person—such as many people with ADD, who are often in a dreamy state. It powers up the cortex from below.
The subcortical brain areas are the first to receive signals from the ear. In people who have subcortical problems and cant handle incoming sensation, the auditory cortex does not get the strong clear signals it needs to do its job. However, argues Minson, they can compensate, to some degree, if they work much harder at paying attention. (We have seen this use of the cortex to perform subcortical activities before: John Pepper used his frontal lobes to do the work of the basal ganglia, when he did his conscious walking technique.) The problem is that this process is exhausting. Ron puts it this way: "If there is poor subcortical organization, you have to use all your cortical resources to perform those subcortical functions. What we are doing, by targeting the subcortex, is improving brain organization from the bottom up." This huge insight applies not only to people with ADD and ADHD but to many children with learning problems and sensory problems, and to children on the autistic spectrum, all of whom have subcortical problems.
The Disorder That Isn't: Sensory Processing Disorder
"Tammy," as I'll call her, was a month old when she became extremely fussy and refused to breast-feed. On the rare occasion when she tried to feed, she gagged, had difficulty swallowing, and started choking. She cried constantly, never fell asleep after a feed, couldn't nap, and was never calm. She couldn't gain weight and couldn't stand being touched.
Tammy's pediatricians jumped to the conclusion she must have reflux, meaning that when she swallowed food, instead of passing from the stomach into the intestines, it would mix with the stomach acid, then go back up the esophagus, causing an acid burn. The doctors gave her medications, which failed, so she was hospitalized and given many invasive tests. A tube with a tiny scissors in it was passed through her mouth down her digestive tract; the doctor snipped off pieces of her esophagus, stomach, and small intestine. All tests came back normal. So they inserted a nasogastric feeding tube into her nose and down into her stomach, but the tube caused great distress. Tammy kept ripping it out. The gastroenterologist told her mother, "If she can't keep the NG tube in, or do bottle feeding, the only alternative is to surgically implant a tube through the front of her abdomen, into her stomach." Surgery was scheduled.
Tammy actually had sensory processing disorder (SPD), not a gastrointestinal problem. Such children feel many sensations too intensely (as though they lack a volume control for incoming sensations), and the brain can't integrate sensations from different senses. Many children with eating problems, including some colicky babies, actually have sensory processing problems, which make them picky eaters. These sensory problems were perfectly summarized in Edgar Allan Poe's 1839 story "The Fall of the House of Usher," wherein the narrator recounts how Roderick Usher described the condition:
He [Roderick] entered, at some length, into what he conceived to be the nature of his malady. It was, he said, a constitutional and a family evil….He suffered much from a morbid acuteness of the senses; the most insipid food was alone endurable; he could wear only garments of certain texture; the odors of all flowers were oppressive; his eyes were tortured by even a faint light; and there were but peculiar sounds, and these from stringed instruments, which did not inspire him with horror.
Note that Roderick could tolerate some peculiar sounds, a point to which we shall return.
One reason Tammy's physicians missed her diagnosis is that a sensory problem is one in which the symptoms are subjective—and babies don't have words to convey their experiences. Sensory problems show up as feeding problems because feeding is about taking in not only food but also sensory information. First the infant sees the breast, looming large, a visual sensation; then she smells the distinct odor of the lactat-ing mother's body; with her touch sense, she feels the engorged nipple in her mouth and the breast on her cheek; then the milk's texture; and finally its sweet taste, and she experiences the warmth of the milk moving into the stomach. An infant must process all these sensations simultaneously, with a developing brain doing this complex integration for the first time! Once this mysterious fluid goes inside, it gives rise to satisfaction, gastrointestinal contractions, and sudden cramps as gas builds up like a ball of internal pressure expanding from within, only relieved when discharged.
A child with a sensory processing disorder experiences all these sensations as an overwhelming barrage from within and without. As Jean Ayres wrote in her 1979 classic describing sensory integration problems, "You can think of sensations as Tood for the brain'; they provide the knowledge needed to direct the body and mind…. Food nourishes your body, but it must be digested to do so….. But without well-organized sensory processes, sensations cannot be digested and nourish the brain." To use Paul Madaule's language, the poorly organized sensory process cannot adequately protect us from the world.
Now imagine the experience of a hypersensitive child—who cant tolerate suckling at her mothers breast—being sent to the hospital and subjected to many surgical procedures, invaded with needles and tubes. The hypersensitive SPD child like Tammy may well get more tests than the child who has a gastrointestinal problem, because the SPD child's tests will always come back negative—triggering more tests. Could any result be more macabre, terrifying, and traumatizing for such a sensitive child?
And yet her physicians didn't think of it, because, unfortunately, this very real diagnosis is one that hasn't been included in the psychiatric or medical diagnostic manuals.
Tammy was seven months old when she began treatment in Denver at Dr. Lucy Miller's STAR Center. STAR stands for Sensory Therapies and Research. Working with Ron Minson, the clinic started her on twenty sessions of sound, with lots of bone conduction and traditional occupational therapy that used movement and sensation, such as brushing her skin to give her tactile stimulation, or gently compressing her joints so she could get a better sense of where her limbs were in space. Three times a week she listened to the iLs music while moving in a small Lycra swing. It was hoped that with this proper "sensory diet" of controlled sound, movement, and balance input that Tammy would learn to integrate them. Sensory integration of simultaneous sensory input occurs in the superior colliculus, a clump of neurons in the brain stem.
She had never liked swinging, "but with headphones on, her body would relax, and she would sit and look up at you calmly," says her mother. "Often she would go to sleep, which was amazing, because she never simply dropped off to sleep.
"Within two and a half weeks we saw dramatic improvement," she says. Tammy's feedings became more frequent, and her behavior changed. She began to regulate and calm herself. Now she is in first grade. "Today she is an absolute joy. Tammy is outgoing, cuddly, smart, and reads two levels above her grade. Her improvement has been drastic and lasting. She has a large repertoire of foods she will accept, and textures don't seem to be a problem. She is comfortable in her own skin." She will not grow up to be like Poe's overexcited, raw, isolated Roderick Usher. She is, as far as I know, the youngest person in the world ever to have undergone a neuroplastic therapy.