- The stimulant medication.
There are some parts of the brain that
I think are worth mentioning.
It might be a little too much anatomy for you
but I think it's important to just hear some of these terms
so that you have some familiarity with them
in terms of neurological factors related to ADHD.
The basal ganglia which is a gray mass deep
in the cerebral hemisphere,
it's a connection between the cerebellum and the cerebrum.
It helps to regulate automatic movement.
Scientist believe that the structures in the basal ganglia
are involved with motor control and movement,
regulating moods, and controlling impulsive outbursts.
As well as circuits for assessing risk and rewards.
The limbic system which includes the amygdala
which is sort of the site of fight or flight.
And is often referred to as the brain's emotional center,
controls emotions such as fear, anger pleasure,
and it identifies what's important and what's not.
It scans the environment for dangers and interests.
The limbic system includes the hippocampus
which plays an important role in memory,
and both long term and short term,
and in spatial memory.
The cerebellum which is back here
and one of the oldest parts of the brain
controls balance contributing to the learning
of coordinated movements and processes,
sensory information used by motor systems.
MRI results have shown that the smaller front regions
of the brain with kids who have ADHD.
These smaller regions have been correlated
to impaired inhibition and attention in children.
There are also sometimes have been some studies
that have shown that there's also a smaller cerebellum.
I think the thing that's worth thinking about
is that the brain structure,
not what's happening on a cellular level
but the brain structure for kids with ADHD
is slightly different and sometimes just
more than slightly different for kids who have ADHD.
Let's talk a little bit about medication.
What are some of the myths of medication?
Number one myth, drugs are over-prescribed
and basically they're bad.
Right now, there's a 4.3% of kids on medication
and a 7.8% prevalence.
Are they over-prescribed?
The drugs are addictive and increase aggressive behavior.
Here's my philosophy about medication.
Medication can help a person distinguish
between the symptoms of ADHD and who that person really is,
and for kids who often feel like they are their ADHD.
Being able to separate the ADHD from the story
that they tell themselves of who they are is critical.
Of course, pills don't teach skills.
Pills are not going to teach children
what executive functions are, how to improve them,
and how to use them more effectively.
Those skills and the scaffolding structure
that kids need to succeed have to be taught
by adults around them.
The pills because of the chemical processes
we just discussed make the children more available
to learn those skills.
The side effects to consider with medication
are well-known.
Lack of appetite, sometimes difficulty falling asleep,
weight loss, increased irritability.
I'm sure there are more that you can think of.
The side effects to consider of not taking meds
would be years of failure.
Repeated school failure
because a child's job is to go to school.
A child's job is to succeed at school
whatever that looks like but certainly not to feel everyday
that you get a blank piece of paper
and its the bane of your existence.
Years of frustration, under achievement,
and troubled relationships.
Those are some of the side effects of not taking medication.
I think each family has to weigh for themselves
what are the risk of taking medication
versus not taking medication?
I'm working with some family now
and they do not want their child taking medication
but the child struggles at school
and the child's self-esteem is affected
by the way the child struggles at school.
It's a tough call.
My job as a therapist, I believe, is to point out
the ways in which medication could be helpful
to discuss their fears with them
and then I have to work with them on where they are.
The drugs work because they increase the availability
of dopamine and norepinephrine,
not just in the frontal lobes
but throughout the brain,
in the circuits where those neurotransmitters tend to run.
The effects of course are idiosyncratic.
There are common side effects like I said
of mild insomnia or appetite suppression,
and sometime tics.
Taking meds though can reduce
the chances of substance abuse later on
because it reduces the child's need to self-medicate.
Now, when the child is nine,
that's not such a big deal
but when the child is 13 or 14 or 15,
it's a bigger deal.
Long-acting meds provide much more
even states of attention overtime
but there can be some rebound when they were off
which means that the families themselves
have to brace themselves and prepare for
that period of rebound, and what to do when it occurs.
I saw a young adult who started taking Focalin at 22.
She said to me, "I don't feel like I've changed.
"But honestly, I feel enhanced.
"It's like glasses for my brain.
"I packed and move myself with listing everything
"this weekend for the first time ever.
"I didn't all last minute."
I have to tell you,
I didn't prompt her for the glasses comment
but I was shocked that she used that
because it was so specific and clear.
I have a male who said,
"The first time I took meds,
"the static went out of my brain
"and I actually got things done efficiently."
What are some of the common medications for ADHD?
In the 1990s, the stimulation prescription rates
more than tripled.
There was a general boom in diagnosis and treatment of ADHD.
The ADHD meds work in different ways.
The stimulants which would be methylphenidate, Ritalin,
Ritalin LA, Focalin, Concerta, Metadate and Mehtylin.
Basically work by blocking the dopamine reuptake system
to allow more dopamine to activate nearby cells.
The Dexedrine-base stimulants stimulate
the release of dopamine and thus increase its levels
at the neurotransmitter sites.
Adderall which is an amphetamine compound,
Adderall, Adderall XR, and Vyvanse.
Adderall combines these processes
and also enhances the action of norepinephrine.
The way most stimulants work is that they're in the system
for anywhere from two to seven hours.
They work within 30 to 45 minutes of taking the pill.
They're generally out of the system within 24 hours.
The research on the long term effects is still being done
with some concerns about growth suppression.
There's a class of nonstimulant medication for ADHD.
Stratera, it blocks primarily the action
of the norepinephrine reuptake system.
Wellbutrin like Effexor or Immipramine
are stimulatory, anti-depressant meds that facilitate
the activity in several neuropathways including dopamine.
They can enhance attention, mood control,
and reduce irritability
but take about a month to start working.
Antihypertensive, Clonidine, Guanfacine, Tenex, Intuniv
reduce the symptoms of hyperactivity and impulsivity
by occupying brain receptors that are sensitive adrenalin
which is hormone.
The SSRIs anti-depressants like Zoloft or Celexa
help control temper flare-ups.
Celexa is useful for anxiety.
I'd like to read you something from a book
that's on your reference list called, "Buzz."
This is an autobiographical piece of work.
This is the mothers who wrote the book,
opinion about drugs, medication.
Then there's the drug dilemma
which goes something like this.
"God forbid, you medicate your distracted child
"because you'll turn that child into a zombie,
"a midget and/or a drug fiend causing lasting damage
"to his brain that we'll only be able to measure
"once he's old enough to sue you
"but God forbid, you don't.
"Because he'll fail at school,
"wind up friendless, lose all self-esteem
"and/or self-medicate i.e. become a drug fiend
"and blame you for your ill-informed parenting
"each day after you drag home from work
"to find him at the age of 34,
"still lying on your living room couch."
There are special medication issues for teenagers.
My experience is that a lot of times,
kids will take their medication pretty compliantly
when they're younger
but at around 13, 14, 15, they start to resist.
Some of their resistance is related to the belief that
I'm crazy.
I'm stupid.
I'm handicapped.
It doesn't work anyway.
I don't feel like myself when I take my pills.
I don't see any benefit.
They give up.
In my practice and I work as I said
pretty much exclusively with kids
with ADD, and ADHD, and learning challenges.
People who go on drug vacations
will frequently do it the following way.
Hide it from their parents and me.
Start to complain of having more difficulties.
The parents are aware that they're having
more difficulties and contact me.
Then there's usually a dramatic
and intense outburst or situation
and the lack of medication is revealed.
I do not believe in, as I said earlier,
telling people that they should
or shouldn't take medication.
I do believe in pointing out the positive effects
of taking medication and the limitations
particularly with teenagers who are right enough
and trying to exert their independence enough
to want to make their own decisions.
One thing that I really try to do is to talk with
the teenager and I would even say young adult
about his or her fears, concerns, likes,
things they like about the medication,
and things they dislike about the medication.
I'd like to try to couch the need for medication
in terms that the teenager finds more acceptable.
In terms of changes that he or she wants
to make about themselves.
I think it's really important to address this idea
of I don't feel like myself.
What is myself feel like?
If you don't feel like yourself,
how can we balance your needing to feel
not like yourself with the things you have
to do with wanting to have time when you're like yourself.
That translates into maybe not taking your medication
on days when you don't have to go to school
or you don't have school work to do.
Taking a break occasionally in that way
can help people feel freed up
from the burden of having to take medication every day
but it can also help teenagers and young adults
see the benefits of the medication
they're actually taking and why it helps them.
I try to emphasize that medication can make the teenager
more available to him or herself
as well as more available to other people,
and to identify who those people are
that that person cares about.
That person if the medication is working
has more control over his or her
innate intellectual gifts and talents.
Also adolescents will try to stop taking their medication
as part of their desire to differentiate from their parents
and what their parents want for them.
And so it's very important to understand
what the adolescent wants for him or herself separate
from what the parent wants.
Sometimes teenagers require
more vigorous monitoring than children.
Sometimes if they have their pills
and a daily pillbox for a week
so that they can take it.
That can be helpful.
You want to make sure that the teen is participating fully
in the treatment decisions and the plans
not just around the medication
but around the goals for understanding,
and intervening with the ADHD.
Sometimes negotiating behavior contracts is important.
There's been a lot of research lately
on the abuse of medication particularly Adderall for kids
who are trying to get into this really top
competitive schools and that the Adderall helps them ...
Or the Ritalin helps them concentrate better
and so they can do more school work.
I think, it's of course, critical to monitor
with the child and the child's parents who's in control
of the medication and how much medication
is being dispensed at a time
and also to talk about the black market
for the ADHD medications.
There are alternatives to medication.
Omega-3 fatty acids can increase
the levels of dopamine in the brain.
Those can be added to the diet through supplements
or they're found in various foods.
Exercise releases endorphins and stimulates
the growth of new neurons so that's always a plus.
There are cerebellar stimulation exercises,
the brain gym, the Dore method, educational kinesiology,
there's biofeedback and relaxation training,
sensory integration training,
other kinds of nutrition and diet.
All of these can help and they're alternatives to medication
but they will not produce the same results
as medication in terms of the ease and efficacy,
and the research related to the medication.
What are some of the co-occurring disorders with ADHD?
Anxiety or OCD, autism spectrum disorders,
depression, auditory processing problems,
sensory integration, oppositional defiant disorder,
specific learning disabilities such as written expression,
dyslexia, and there's a difference
between an impairment in these areas.
Essentially inconvenience or difficulty
so someone may have some difficulty with writing
but it's not an impairment.
It just may take them a little longer
but they can actually do it.
Other people like the white sheet example
that I talked about earlier actually can't write
like nothing happens.
It's really important to distinguish
which is occurring for your client.
Oppositional defiant disorder occurs 40% of the time
in people who have ADHD.
Anxiety disorders occur 34% of the time.
I talked earlier about the kind of hyper-vigilance
that kids with ADHD have in terms of awareness
of what they're missing and worry about
what's going on that they're not attending to.
Conduct disorder's about 14%.
Tic disorder 11% and affective disorders
like depression are about 4%.
The major research from the multimodal treatment
study of children with ADHD in 1999
show that children ages seven to nine
of those children who were diagnosed with ADHD,
70% had another psychiatric disorder.
A later study from Puerto Rico showed
a higher incidence of depressive symptoms.
Boys are often referred for ODD
and girls for anxiety or depression
which will mask the ADHD or the learning disability.
So it's really important to take
a very thorough history where that's concerned.
Kathleen Nadeau has written some terrific books
about girls with ADD.
Here's an example from her book,
"Understanding Girls with ADHD,"
about a girl who is struggling with depression and ADHD.
"I'm not good at anything," Lisa, a ninth grade girl
"with ADHD expressed despairingly.
"With regret and envy, she describe girls in her class
"who had made the cheerleading squad earn top grades,
"or had already completed years of music or dance lessons.
"Developing high levels of skill
"and confidence in the process.
"Liza had taken up and dropped many interests.
"A pattern typical for girls with ADHD.
"At 14, she no longer had any faith in herself
"or in her capacity to stick with any endeavor.
"Easily discouraged and with a low frustration tolerance,
"she pursued each succeeding interests with less
"and less faith that she would discover a talent
"or develop a skill."
Co-existing mood disorders are common
especially in the adolescent years.
And girls are often treated for these
and not evaluated for ADHD.
I have found numerous times in referrals from my practice
or consultation with other therapist,
girls who are referred for persistent
anxiety and depression,
and when evaluated through their school
or through outside psychologists for testing
end up having ADHD that was never diagnosed.
Somatization disorders are common in girls with ADHD,
as are headaches and stomach complaints.
ADHD likely contributes to and causes
oppositional defiant disorder
because of poor emotional regulation,
lack of control of anger, hostility, aggression, outbursts.
ADHD meds reduce ODD
and it can go away within two years of treatment.
Anxiety is the stealth comorbidity disease
and it requires a series of interviews with kids who treat.
The most common anxieties are simple phobias
and separation anxiety in early childhood.
General anxiety disorder increases with age
and is prevalent particularly in girls
but also in boys with ADD, ADHD.
Often there's a parental anxiety in the family system
which contributes the anxiety that the child,
him or herself is feeling.
With anxiety and depression,
you must also evaluate for victimization
either bullying, or sexual, or physical abuse.
In terms of conduct disorder as we know,
conduct disorder is a reflection of limited conscience
and there is a poor treatment prognosis.
Often there's chaotic family structure
that goes along with it and it's related
in terms of what research has found to social disadvantage,
family disruption and poor peer relationships.
Parent divorce is more common and major depression
often co-exist along with the conduct disorder and the ADHD.
In terms of co-occurring disorders,
we have to also talk about learning disorders
which co-exist with ADHD, 24 to 70% of the time.
Dyslexia about 20% of the time.
Expressive and receptive language disorders are common
as is discalculia.
Expressive and receptive language disorders
are present in a high number of children with ADHD.
There are also pragmatic language deficits.
Using language appropriately in social situations.
That could include either excessive verbal output
or decreased verbal output depending on the person,
and the type of ADHD or ADD that he or she has.
Difficulties introducing, and changing topics,
and conversation, problems being specific in choosing words
to express information or emotions,
and difficulty listening.
I want to say something about ADHD versus bipolar disorder.
Bipolar disorder usually of course,
there's a family history of bipolar disorder,
alcoholism, major depression, or mania.
The major symptom is rapidly changing moods
regardless of what's going on in the environment.
In ADHD, there's a family history of school problems,
disorganization, focusing difficulties,
employment difficulties, and the major symptom
is fluctuating attention not fluctuating mood.
There will be fluctuating mood with fluctuating attention
but the primary system is fluctuating attention.
Bipolar kids can be violent, suicidal and extremely rageful.
Bipolar disorder primarily involves huge mood disruptions.
Let me say that again.
Bipolar disorder involves primarily huge mood disruptions
and secondarily, there may be some attention issues
related to that because of the flooding of the mood
and how it's disrupting the child's ability to be present.
In ADHD, there is a longstanding chronic condition
of inattentiveness, lack of focus, impulsivity
that isn't mark by cycling or mania.
In terms of learning disorders,
there's one thing that I actually want
to add which is that ADHD is recognized
by special education laws as a disability.
And a child who is diagnosed with ADHD
is eligible for special education services
whether an individualized education plan
or a 504 accommodations.
It's very important that these kids have these accommodation
and so if there is no formal documentation from a physician
or a psychologist, or someone who's tested the child,
or a treating social worker or family therapist,
it's important that you create that documentation
so that that child can receive services
and accommodations that would help
him or her learn more effectively.
Because of the high comorbidity with learning disorders,
as I said earlier 24 to 70%, unmedicated ADHD
will lower a child's IQ on any kind of school testing
or will lower a child's results
on any kind of school testing.
It's very important that it's diagnosed and documented.
90% of kids with ADHD have poor school performance
because school is the main area in which their inability
to focus, and attend, and concentrate on material
that they're not interested in emerges.
It's been found that if you treat ADHD,
handwriting will improve 60% of the time.
Reading and listening comprehension deficits also improve.
It's also been found that 56% of kids
with ADHD needs academic tutoring,
30% have repeated a grade,
and 35% have been placed in a special class.
Again, I said this earlier so I just want
to reiterate it now.
Poor school performance is usually due to low productivity
not low intelligence and not a lack of capability.
Low academic achievement worsens with age
which means that a nine-year-old who
isn't doing that well in school,
if he or she does not receive proper support
and interventions will bottom
as he gets or she ages, not increase.
They will bottom out.
I'd like to read something from Thomas Brown's book.
"Both writing and reading draw on memory,
"executive processes and thinking processes
"but in different ways because the reading system
"of the brain can refer to written text at any time,
"the memory burden is greatly reduced.
"In contrast, the writing system may place
"a greater burden on working memory
"than does reading comprehension.
"Writing is an immense juggling act
"with more jobs to do than reading.
"The writing jobs include planning,
"generating ideas and setting goals,
"translating those ideas into text,
"transcribing that text, and reviewing, and revising it.
"Control processes for extracting meeting
"from a finished text, i.e. reading,
"are not taxing as the executive processes
"that go into generating and repairing a text
"until it is deemed a final product, writing and editing."
How do we assess for ADHD?
There are several components of a good assessment for ADHD.
There are a variety of paper and pencil techniques
including the child behavior checklist,
the Brown ADD scales, the Vanderbilt scales,
the Conners, and other computerized tests.
Russell Barkley has created a number of forms,
a good developmental history is critical,
taking a school history
either seeing a series of report cards,
speaking to someone at the school,
work history for older teens, family or medical history,
as well as the family psychiatric history is useful,
doing a genogram can be really helpful.
Psychiatric and legal history,
particularly not just for the child
but if there's been anything for the parents,
if that seems like you get a sense
of that might be something you want to know about
and psychological testing.
Let's talk about the treatment for ADHD.
The treatment for ADHD involves identifying
and training executive functioning skills
but also has to focus on the low self-esteem
and persistent sense of failure that kids with ADHD feel.
We have to be able to help them
find successes and expand them.
Ed Hallowell talks a lot about this
that you have to really focus on what's positive
and try to grow that area
because these kids receives so much negative feedback.
That we want them to feel in some areas
that they have skills and success just like their peers.
I believe that it's important to treat kids
and teens with ADHD with positivism,
and success, and orienting them
to those parts of themselves.
The first thing we want to do is we want
to diagnose ADHD but with that diagnosis of course,
we want to identify their talents and their strengths.
I always ask my clients and their parents,
what is so and so good at?
We want to educate the client and the family about ADHD.
We might want to suggest
any kinds of changes in lifestyle
that would support success and positivism.
For example, I work with a family
and their little boy comes home from school
and he plays for an hour and a half.
That includes watching TV and then has dinner.
Then they sit down and do the homework.
He's in second grade.
He can't do any homework at that hour.
He's done.
We've had to adjust what happens
when he comes home from school.
That he can play for half hour,
then do his homework and then watch TV.
That the TV is earned through the incentive.
It's an incentive for doing the homework.
Counseling is very helpful individual and family work.
I like to balance that out.
As teens get older,
they can do obviously more individual work
to help them manage the executive function
and skills that they need on their own.
But in general, most kids and teens need the scaffolding
from their parents and so it's important
that there is collateral family work.
If not, the focus of the therapy can be the family work
if that seems warranted.
There must be collateral family work.
Medication and then discussion of medication,
the options for medication,
and contact with the prescriber is important
as well as coaching,
ADHD coaching is in some ways a field unto itself.
But there are plenty of opportunities for you
to do coaching and the therapy.
I would recommend if you're interested
in learning how to do some more coaching,
or how to talk to the school
and see if there is someone there who could do
some coaching to look at Dawson and Guare's book about that.
Dr. Hallowell identifies a five-step cycle
to the roots of happiness.
The five-step cycle is connection, play,
practice, mastery, and recognition.
I really like to think about that
when I think about treating kids with ADHD.
Who are they connected to?
How can I connect with them?
Are they connected to their families?
Do they play enough?
What do they do for play?
What brings them joy?
What's fun for them?
Practice, what are the areas in which they're struggling?
What are some of their executive weaknesses?
How can I help them practice skills
to strengthen those areas of executive functioning deficits?
Mastery, when there is mastery on
a particular skill or behavior,
how is that acknowledged?
How is that built upon?
Then recognition, recognition of self and other.
How does that child learn how to understand
what's going on with another person
as well as what's going on with himself or herself?
How does that child recognize when he or she needs help?
How does that child ask for that help?
I have a client who recently said to me.
"I'm so tired of focusing on the things
"that I don't do well.
"That's all I think about."
I said, "Well, what you would like to think about instead?"
She said, "I want to spend more time
"on the parts of myself that I like.
"I already have to spend so much time
"on the parts of myself that I don't like."
I thought that was just a beautiful statement
about how it it is to have ADHD
and receive that kind of feedback all the time
about how you're missing the mark
and how important it is to spend time
with yourself on the ways that you hit the mark.
Treatment for ADHD involves
executive functioning skills training as I said before.
But it also has to involve treating the whole person
so that includes speech, any sort of thinking
about language issues, either expressive or receptive,
any kinds of learning challenges,
any kinds of emotional issues
or co-existing disorders, anxiety, depression, et cetera.
If there's any sort of autism spectrum problems,
if there's any kind of oppositional defiance,
a tic disorder.
All of that has to be included
in the treatment plan of a child
as well as what are the family dynamics
in which the child is living?
If we're going to talk about treatment for ADHD,
there has been quite a bit of research on
what's an effective treatment for ADHD?
In the MTA study that I cited from 1999,
they looked at groups of basically a medicational loan,
behavior modification, a combination of medication,
and behavior modification in a community comparison.
The treatment was delivered over a 14-month period.
There was a 68% improvement in a combined group.
That means that is the group in which received
medication and behavior treatment.
That would mean medication and therapy.
There was a 56% improvement in the group
that just had medication.
If you just received behavior modification
with no medication, it was a 34% improvement
and a 25% improvement for a community awareness.
At 24 months, the patterns of the results remains the same.
The behavior interventions were aimed at teaching,
increasing, and cuing skills at key points
of performance and for motivation.
In general social skills groups
don't particularly work for kids with ADHD
because of the inconsistent nature of their results.
There are limited transfer of skills
from inside the group,
what happens during the group
to out of the group situations?
What's more effective for kids is if they're
in a situation that they receive feedback
in that situation or shortly thereafter
about what's happened while it's still in their memory.
Only about one third of kids diagnosed with ADHD
are being referred for mental health services.
That to me is a really big problem
because if you're just taking the pills,
again, you're available for the skills
but you're not really having any kind of process
that's teaching you about what those skills are
directly or addressing some of the emotional responses
that you're having to the skills deficit or acquisition.
And it's not dealing with the ways
of you're perceiving yourself
either socially or within your family.
I want to summarize effective treatment for ADHD.
Parent education about ADHD is critical.
Psychopharmacology, very helpful.
Parent training in behavior and child management,
also critical.
Family therapy can be extremely useful.
Behavioral interventions in the classroom.
Parent support groups such as CHADD.
They're reminding you again that
there's a clear advantage of combined treatment.
so some behavior treatment with some medication treatment.
Let's talk for a minute about treatment
for parents of kids with ADHD.
It's really important that you help the parents
understand and accept that
it is normal and expected to find your loving,
wonderful child extremely challenging at times
especially when he or she is upset with what's going on,
is having difficulty processing,
and can't figure out how to maneuver
the emotional response and the thinking response.
Kids work so hard to keep it together at school
all day long and if they go to after school.
After school, they can be angry, and irritable,
and melt down when they get home.
That isn't necessarily a reflection on the parent
but more of a reflection on the fatigue
that the child is feeling
and cannot hold it together anymore.
I think it's important for parents to understand
this idea that their children maybe
up to three years behind in terms of
their maturation than other kids their age
because a lot of times in my office,
I hear parents say, "Oh, he's 15.
"He doesn't act like he's 15."
I'll say, "Well, that's because developmentally,
"in some ways he's not 15. He's 12."
If you think about him as 12,
it's going to be a lot easier for your and for him
in terms of all of these chores that he doesn't do
or ways that he forgets things.
It's important with parents to review ADHD,
to offer them things to read a book,
a book on a CD, a podcast, something so
that they can start to increase
their fund of information about ADHD.
Help them understand the nature of ADHD,
the causes, the course of ADHD, the various treatments.
In some ways, I believe that the parents have to grieve,
and then accept the ADHD diagnosis.
There is a disappoint that pretty much every parent
I've worked with and I've been doing this for over 20 years,
comes to the table with when their child
is diagnosed with this.
They're upset about it either because
they themselves are dealing with this
and they didn't want their child to deal with it,
or because they never dealt with it,
and they didn't want their child to deal with it,
or they don't understand it.
Whatever their set of beliefs is about having ADHD,
the myths that we talked about earlier,
or their fears, all of that has to be processed
because it interferes consciously or unconsciously
with how they're addressing their kids,
and working with their kids who have ADHD.
You want to help their parents reduce
the expectations of their child by about 30%.
You want to discuss ADHD as a chronic condition.
You want to help them with acceptance
as I said but also advocacy.
They have to start to advocate for their child
and then we want to teach the child
to advocate for him or herself.
One of my proudest moments as a therapist
was when I had been working with a girl
for about a year who had ADHD
and some speech and language difficulties.
She went to school
and she was in a support class.
She was maybe in ninth grade or tenth grade.
She was in the support class.
She had been recently diagnosed and placed there.
This is a different person from the earlier person.
She was in English
and her English teacher was giving her vocabulary tests.
She was failing.
She took her vocabulary test to her support class,
and the teacher said,
"You're not supposed to have vocabulary classes.
"It says on your IEP that you are not supposed
"to have vocabulary classes."
She was very excited to hear this.
I saw her that afternoon after she'd had
this conversation with the teacher,
the support service teacher.
The next day, we talked about it and she decides
she was going to go talk to the teacher.
The next day, she went into class
and she said to the teacher,
"I am not suppose to have vocabulary tests."
The teacher said, "Well, I give vocabulary tests.
"That's part of the curriculum of my classroom."
The girl said,
"I am not supposed to take vocabulary classes.
"It's in my IEP.
"If you have any questions about that,
"you should asked Ms. so and so,
"the teacher of my support class."
This was a huge triumph for her.
She stood up and advocated for herself.
It was a turning point for her in her life.
She was changed from that experience.
We want parents to understand that ADHD
is a disorder of performance, not of skill or intelligence,
doing what you know, the when and where,
not how or what.
Using your past at the point of performance.
That's what ADHD is about.
We want to help parents solve problems
when they occur or as close to it as they occur as possible.
Most ADHD kids have problems with delaying consequences.
You want to help them increase accountability
and the frequency of consequences so it's closed up.
All people involved with a child
have to participate together for the success.
Have them participate as much as possible together.
This means school and extended family
who are active in the child's life.
It means coordinating and meeting
with the teacher and the parent sometimes
so that everybody's on the same page.
Also contacting the pediatrician
or whoever is the prescriber so that
again, that person feels like he or she is in the loop.
You want to teach the parents to notice and appreciate
the small and big changes that their child is doing
but especially the small ones.
Because it's the little things
like telling your teacher that you don't have
to take vocabulary tests.
That's a triumph.
Punishing kids for things that aren't
in their control does not work.
I frequently see parents punishing their kids
for things related to having ADHD.
That does not work.
It creates a bad spiral.
It's important to decipher and know
what is and isn't in your kids control.
Of course, to understand that at some point,
behavior is behavior.
Kids are told to try harder.
Kids with ADHD are especially told to try harder.
They continue over and over to fail
until often they stop trying.
I'd like to read this from Kathleen Nadeau's book,
"Understanding Girls with ADD, ADHD."
"When I get home in the evening,
"I'm in charge of the homework detail.
"Terry argues about everything
"whether or not she has homework,
"how much homework she has,
"how long it will take her to do it,
"what time she should start it,
"and when she should have a break.
"You cannot imagine the battles we have.
"After I haven't seen her all day,
"I hate for this to be the basis of our relationship
"and often we are struggling up until her bedtime.
"We both agree that I have become more
"of a policeman than a dad,
"and neither of us likes it.
"I was complaining about this to Terry's psychologists,
"and she suggested we try a coach.
"Since we hired Julie,
"my interactions with Terry are fun and loving,
"and she gets her work done too.
"A coach is one of the best investments I've ever made."
Now, in this particular situation and some of the situations
I have dealt with in my practice,
a coach can be a tutor as well.
A coach can be someone who takes over
the homework police job for the parent.
That will take that negativity and burden
out of the parent-child relationship
so that the parent-child relationship
is freed up to have the good moments
without this unpleasantness.
Other suggestions for treating parents of kids with ADHD.
You want to help the parents learn
how to cue their children externally
which means make everything concrete.
Say things.
We're going to the store,
you need to put your shoes on.
Then get your coat
and expect that your child will remember
only one or two things at a time.
One of the problems I see is that
a parent of a five-year-old or a six-year-old
or even a seven-year-old with ADHD
will roll out three or four things.
Go to the bathroom, brush your teeth,
and get your stuff so we can go to the car.
The child never gets pass go to the bathroom
because the child doesn't hold all that information
in his or her working memory.
Don't rely so much on mental information
but cue the kids externally.
Sometimes that could be a checklist
in the morning to continue to be able to say your child,
"Refer to your list. Check with your list."
A million times even.
Make time physical.
Remember that these kids don't have
an internal clock that works.
Whatever that looks like, a timer,
teaching them to read obviously a clock
but also maybe having a reminder on a phone,
if they have a phone.
Lots of teenagers with ADHD should use technology
to help them remember things.
There's alerts on the phone.
There are reminders.
It's the best way to help them remember things
without adding the stress of having to remember things.
Break up tasks into an event, a response, and an outcome.
Make the tasks smaller so that they can be completed
and the child can feel a sense of success upon completion.
Give immediate feedback and praise is fine.
I believe in praise.
"Good job, I saw that you got your coat. Nice job."
Or "I saw that you put all your books away.
"I saw that you unpacked your lunch.
"I appreciate that."
Things like that.
Increase personal accountability without blame.
I noticed that when you came home from school,
you didn't unpack you lunch.
I really would like it if you could unpack your lunch.
That means you want to teach parents to reduce delays
and not to expect so that your kids
have a lot of internal motivation
and gratification for things.
You want to change rewards for activities periodically.
Remember what I call the rule of three
which is touch, talk, and eye contact.
Get down to your child's level.
Look down, put a hand on the shoulder and say,
"Susan, I would like you to pick up your room.
"Put all your shoes into your closet."
Look, speak, touch.
Keep a sense of humor.
It's really hard for these parents
to keep a sense of humor
because they're really frustrated and worn down.
A lot of times in my office,
there's a lot of laughter
because I'm able to see that things are funny,
and corky, and eccentric and they don't.
Once we're able to turn it around so it is a little funnier
or they can see the humor in it,
things open up and lighten up.
Anticipate problems settings and help parents make a plan.
That's really important.
Review the plan before an event.
Help parents figure out their priorities and remember them.
Because a lot of times,
there is a huge list of things that parents want
their kids to do differently.
I want them to do this and this, and this, and this.
People can only change one thing at a time.
Pick one and work on that.
When that gets better, you can pick another.
Help parents practice forgiveness of themselves,
of their partner, of their child.
For the kids themselves, in terms of treating them for ADHD,
I do not call it ADHD very often.
Usually, I call it attention-wandering
or whatever term the child
has come up with for him or herself.
Bullet brain, or energy buzz
is another one that people have called or ADLS.
I use the term that the child or teenager has referred to
so that it make sense to them.
It feels less patholigizing.
In this way, I also educate them about ADHD.
I usually explain very simply a little bit
about what's happening in the brain.
Even to second graders because they can understand
that there cells and that there's a chemicals, and changes.
That helps them understand
that something's happening in their brain
but that they themselves are not necessarily at fault.
We discuss and we make every effort
to reduce shame and negativity
including naming famous people
who've had ADHD whether its Michael Phelps,
or Tom Cruise or somebody they really like
in a particular area that's important to them
like a baseball player or a famous dancer.
I will actually give that as homework
to ask them to go online with the parent
for young children and of course,
by themselves if they're older.
And find a list of famous people with ADHD whom they admire.
I work with them on trying to increase accountability.
Many kids with ADHD are skillful deniers.
They'll deny even up to the point
when the evidence is right in front of them.
And so, we try to talk about
what's going on for them internally
when that process of denial
is what they're expressing and bearing down on.
I help them work with me to set up their own goals
for themselves in the treatment
and what steps they would like to make toward that.
I use a strength-based approach with treatment
to address this low self-esteem that I often see
and to talk about the history
of humiliation in school or socially.
I try to help them improve their ability
to read social cues often either in the family setting
or if the child and I are engaged
in playing or conversation.
I help the child slow down to a body-oriented practice
that might make sense to the child or teen,
maybe doing some yoga or some breathing, or visualization.
As I said earlier,
I frequently refer to it as attention-wandering.
I talk with the child about strains
that he or she may feel that they have.
What things they feel good of or proud about?
What weaknesses they see in themselves?
I always ask the three wishes question.
If you could change anything about yourself or your life,
with my magic wand, and you had three wishes,
and you can't wish for more wishes,
what would that be?
I always ask about school likes and dislikes.
I frequently will address areas of pessimism,
isolation and lack of creative outlet.
Often I see kids who just aren't doing anything
that they really love to do.
I really try to work with them on figuring out what that is
and being open to trying it.
I also help them explore greater sense of family connection.
I'm trying to figure out if there is someone
in their family like them who also
has had some attention-wandering.
And what that's like for that person
and to bring that person into therapy,
if it's not a parent or a sibling
but someone they know to talk about it.
So that this child feels less alone
with a particular challenges that he or she is facing.
I try to work with him or her
to increase the ability to self-reflect
by offering feedback when the behaviors occur
and some reflection, what do you notice you're doing?
What do you notice that you might be feeling?
I engage with the child and I encourage
the child to engage in identifying
and creating rewards with parents that work for him or her.
I talk a lot about this idea
of positive reinforcement to combat fear and self-doubt.
Not in such necessarily big words for little children,
although I will talk about it
using those words for older teens.
But more about what kinds of self-talk and messages
that he or she is giving to themselves inside
their head when things don't go the way
that they would like.
I stay very specific.
I have them write things down
and I try to stay as good-humored as I can
even when they're very angry with me for who knows what.
I often invite the child to bring in items of his or hers
that reflect a particular interest.
I had one child who is very interested in poker.
I, myself, know nothing about poker
but I bought a set of chips and cards.
He came in and he would teach me how to play poker.
That's how we would interact
and we would talk about all of this stuff
in the context of playing poker.
There are a few special considerations
in working with teens with ADHD that I want to address.
First of all, teens in general are seeking more freedom.
They want to show greater responsibility.
In general in our society,
there's a cultural value on conformity and education
that puts teens with learning differences at a disadvantage.
For teenagers who want
that greater freedom and independence,
it's really difficult because
having poor organizational skills and poor time management
require greater parental involvement
in their lives at a time when they want less.
Social difficulties are specially painful
for them at this age.
Teens with ADHD suffer from academic problems,
negative self-image, social difficulties with peers,
and often a lack of success
at extracurricular activities as well.
Chronic procrastination, instant gratification, needs,
peer relationship problems, talking too much,
problems reading the reactions of others,
teens with hyperactivity are more often rejected
than other teens,
teens without hyperactivity can be more ignored than others.
These all make adolescence very, very painful
for teenagers with ADHD.
In addition, they still need parental help
to create external structures and they resent that.
They need a treatment to help them improve
their self-monitoring skills and time management.
Teens with ADHD have to learn how to negotiate
with their parents, with their teachers,
with their peers, and with their employers.
This is very difficult for them
because negotiating takes a series
of executive functioning skills that
are still underdeveloped in them
particularly compared to their same age peers.
It involves emotional regulation, inhibition,
and ability to understand themselves
and how they affect others,
some sort of planning and prioritizing.
They have a lot of self-blame and shame
about their executive functioning deficits
that have to be addressed before there
are any interventions or plans
because the shame sabotages any
possible interventions that could help them.
They have to be involved
in co-creating any treatment agenda
or any goal setting that their parents have.
The parent's goal cannot be the goal
of the therapy for an ADHD teen.
It has to be a collaborative goal.
Finally, these teens are not good at multitasking.
They think they are but they're not.
That's something that we have
to start working on immediately.
I think it's worth noting that impulsivity
is looked upon with humor for boys
and frowned upon in girls which makes it hard
to have ADHD for a girl if you're impulsive
and funny if you're a boy.
Even though the consequences are often not that funny.
Self-blame will lead to hopelessness
and depression more often in girls,
and aggression and defiance in boys.
You want to really help the parents prioritize
what is most important to work on.
And not to sweat the small stuff like messy rooms,
and no clean clothes if they're going to school,
and doing their homework and participating in an activity.
That's what's most important
that they're starting to develop a sense
of competency about themselves.
We talked a little bit earlier
about learning disabilities
and their co-occurrence with ADHD.
Really, what I want to say now is that
school is the worst domain of functioning
for children and teens with ADHD.
Because ADHD is a disorder of performance
which means you do what you know and you apply it
when and where you should,
and you use your past to help you with your present.
This is all very difficult for these kids
and because ADHD creates a certain kind of time blindness,
and they're living in the moment,
they can't go back and easily refer to
what happen in the past and bring it
to what they're doing now.
They get stuck.
They live in this process where they're in settings
where they know they really should do something differently
but they're not exactly sure what that thing is
because they can't totally remember it.
This is why the consequences have to happen repeatedly
when the performance problem occurs
so that it can increase accountability
but also start to trigger the memory
and the memory systems will start
to lay into place in the neural pathways.
So that those get stronger
because we want those neural pathways
to remain and not be pruned out.
I have one more thing that I would like to read.
About a girl again from Kathleen Nadeau's book
and what it's like to do homework.
"At 5 pm, in order to begin working,
"Sara looks for a pencil
"and recognizes that the point needs to be sharpened,
"regardless of how sharp it already is.
"She sees that the sharpener is full of wood shavings
"and needs emptying.
"She empties the sharpener over the waste basket
"but some shavings end up on the floor.
"She tries to brush each one under the desk with her hand.
"Finally, Sara sits on the floor amidst piles of papers
"because her desktop is piled with so much clutter
"that she can't work in there.
"Many of her papers are folded into small geometric shapes.
"Some of them figures and some of them are announcements
"from school that were meant for her parents.
"She unfolds one of these
"and thinks of bringing it downstairs to her mother
"but first attempts to refold it along the original lines.
"By now, it is 5:30 and Sara is no closer
"to starting her homework or landing than she was before."
We've talked about ADHD
and a little teeny bit about executive functioning.
Now, we're going to talk more explicitly
about executive functions.
What are executive functions?
The definition of executive function
is that they are thinking and doing skills.
In general, executive functions
which reside in the prefrontal cortex, the oy vey place.
Prioritize, integrate, control other cognitive functions
but they manage self-regulation of the brain as well.
Stress and fatigue hit
the weakest executive function skills.
We have thinking skills.
What are the thinking skills?
Working memory, planning, organization,
time management, and metacognition.
We have the doing skills.
Response inhibition, emotional control,
sustained attention, task initiation,
goal-directed persistence, and flexibility.
Thomas Brown talks about the executive functions
in the terms of thinking about an orchestra.
The brain, and all of the various instruments
so to speak are the orchestra.
The executive functions are a set of conductors.
They tell certain parts of the brain
to do something at a particular time
when a particular task is needing
that skill or function of the brain.
The impairment for people with ADHD
in terms of executive functions lies in their ability
to start and manage these functions
in the right order at the right time.
It doesn't basically lie with the individual musicians.
That is the musicians in the orchestra can play their parts.
For example, processing emotional information
or processing memory.
Those parts generally work but what happens is,
they aren't able to start and follow through,
and move through their job responsibility.
And so what the executive functions do,
the set of skills I listed,
the thinking and the doing skills,
is that they try to start and guide
all of the individual players.
The role of the conductors usually operates
without conscious awareness.
Often people try to tell people
that they've got to control these functions more
which is unlikely.
What you can do is become aware
of what you're executive function limits are
and what kinds of skills you could build to improve them.
Executive functions as I said earlier
are a management set of skills
that involve thinking and doing parts of the brain.
People can have impairments
in executive functioning without having ADHD.
For example, I mentioned my own struggles with timeliness
but people who have ADHD by definition
have impairment in executive functions.
Here is a list of the main kinds of impairments.
Executive functions that are impaired
with in people who have ADHD.
They work in many different combinations.
We have organizing, prioritizing, and activating to work.
That lies in the executive function of activation.
We have focusing, sustaining,
and shifting attention to tasks.
That lies in the executive function of focus.
We have regulating alertness, sustaining attention,
and processing speed.
That lies in the executive function of effort.
We have managing frustration and modulating emotions.
That lies in the emotional aspect of executive functioning.
We have utilizing memory and accessing recall.
That's part of the memory that can be impaired.
Then we have monitoring and self-regulation.
That's involved in metacognition
so how do you understand yourself?
How do you see yourself in the world, in relationship?
What is your perception of yourself?
That is one of the very last skills to develop.
In general executive functions develop by the age of 25,
and it can be because people with ADHD
are up to three years behind in parts of their development.
That will continue into the 20s.
Some of the executive functions in people
with ADHD don't really fully mature
until the ages of around 27 or 28.
ADHD involves two major categories
of executive functioning impairment.
Sustained attention and completion of tasks.
Basically, there's an area called sustained-based context.
What does that mean?
That seems like a lot of big complicated words.
What that means is the ability to sustain attention
based on novelty, the intrinsic value of the tasks,
and the extrinsic consequences of doing
or not doing the task.
If something is fun and interesting,
and immediately rewarding, it's easier to be accomplished.
But goal-directed persistence which is very difficult
for people with ADHD means the person has to create
and hold a mental image of a goal involving
your working memory, create a plan,
and rules to follow through, self-direction,
hold back and control negative feelings associated with
the self-deprivation and discipline
that might make something happen.
Make positive drives in support of a plan
so self-regulation of affect,
and experiment with different approaches to achieving a goal
before choosing one.
That would be planning and sort of flexibility.
All of those things are frequently impaired
in people who have ADHD
in terms of their executive functioning.
Let's talk a little bit about working memory,
ADHD, and executive functioning.
What is working memory?
Working memory allows a person
to hold several things online simultaneously
to facilitate attending to other tasks.
That means if your goal
is to make a peanut butter and jelly sandwich,
you hold that you want
to make the peanut butter and jelly sandwich
but you've got to go through the steps of
taking out the bread, getting the peanut butter,
getting the jelly, maybe getting a plate,
getting a knife to spread it, putting the sandwich together,
putting the things back in the refrigerator,
and then eating the sandwich.
Working memory is also something
that's called the search engine of the brain.
It continuously activates stored memories
of various experiences, physical experiences,
intellectual experiences, emotional experiences,
interpersonal experiences and integrates those memories
with current information to guide
your immediate thoughts and activities.
This working memory is impaired in people with ADHD
because of the things we talked about earlier
in terms of the dopamine, channels in the brain,
and the norepinephrine.
This working memory it's like
the computational space of the brain.
There are networks of neurons that briefly
hold the thoughts and perceptions of each moment
connect them to stored memories
and allow an individual to put experiences together
to make sense of what's going on
in the current moment and act accordingly.
Without it, a person lives in present time
and can't really make historical connections
from five minutes ago.
Using your working memory requires pulling files
out of your memory of information that's needed
for answering a question or performing a task.
Emotion drives this engine.
Working memory also draws on past experience
as I said to relate to a current situation
or a project into the future.
I've made peanut butter and jelly sandwiches before.
I know how to do it.
I'm going to use that to make one now.
Even though I'm really hungry
and I know a part of me wants
to just scoop that peanut butter out of the jar.
I'm going to really take the time and make the sandwich
because that will be more satisfying to me
and my mom won't get mad.
Let's talk about how executive functions ...