1
00:00:01,140 --> 00:00:03,405
- The stimulant medication.

2
00:00:03,884 --> 00:00:04,938
There are some parts of the brain that

3
00:00:04,938 --> 00:00:06,936
I think are worth mentioning.

4
00:00:06,936 --> 00:00:10,486
It might be a little
too much anatomy for you

5
00:00:10,486 --> 00:00:13,784
but I think it's important to
just hear some of these terms

6
00:00:13,784 --> 00:00:16,725
so that you have some
familiarity with them

7
00:00:18,259 --> 00:00:22,090
in terms of neurological
factors related to ADHD.

8
00:00:22,223 --> 00:00:25,699
The basal ganglia which
is a gray mass deep

9
00:00:25,699 --> 00:00:27,805
in the cerebral hemisphere,

10
00:00:27,805 --> 00:00:32,805
it's a connection between the
cerebellum and the cerebrum.

11
00:00:33,541 --> 00:00:38,541
It helps to regulate automatic movement.

12
00:00:38,712 --> 00:00:42,786
Scientist believe that the
structures in the basal ganglia

13
00:00:42,786 --> 00:00:45,579
are involved with motor
control and movement,

14
00:00:45,579 --> 00:00:49,492
regulating moods, and
controlling impulsive outbursts.

15
00:00:49,492 --> 00:00:53,520
As well as circuits for
assessing risk and rewards.

16
00:00:53,628 --> 00:00:56,435
The limbic system which
includes the amygdala

17
00:00:56,435 --> 00:01:00,368
which is sort of the
site of fight or flight.

18
00:01:00,429 --> 00:01:04,064
And is often referred to as
the brain's emotional center,

19
00:01:04,064 --> 00:01:07,572
controls emotions such
as fear, anger pleasure,

20
00:01:07,572 --> 00:01:10,771
and it identifies what's
important and what's not.

21
00:01:10,771 --> 00:01:14,283
It scans the environment
for dangers and interests.

22
00:01:14,283 --> 00:01:16,610
The limbic system includes the hippocampus

23
00:01:16,610 --> 00:01:19,683
which plays an important role in memory,

24
00:01:19,683 --> 00:01:23,316
and both long term and short term,

25
00:01:23,316 --> 00:01:26,456
and in spatial memory.

26
00:01:26,766 --> 00:01:28,596
The cerebellum which is back here

27
00:01:28,596 --> 00:01:30,557
and one of the oldest parts of the brain

28
00:01:30,557 --> 00:01:32,835
controls balance
contributing to the learning

29
00:01:32,835 --> 00:01:35,533
of coordinated movements and processes,

30
00:01:35,533 --> 00:01:39,436
sensory information used by motor systems.

31
00:01:40,041 --> 00:01:45,041
MRI results have shown that
the smaller front regions

32
00:01:45,952 --> 00:01:50,745
of the brain with kids who have ADHD.

33
00:01:51,620 --> 00:01:54,129
These smaller regions have been correlated

34
00:01:54,129 --> 00:01:59,129
to impaired inhibition
and attention in children.

35
00:01:59,197 --> 00:02:01,632
There are also sometimes
have been some studies

36
00:02:01,632 --> 00:02:05,739
that have shown that there's
also a smaller cerebellum.

37
00:02:05,834 --> 00:02:07,637
I think the thing that's
worth thinking about

38
00:02:07,637 --> 00:02:12,037
is that the brain structure,

39
00:02:12,037 --> 00:02:13,876
not what's happening on a cellular level

40
00:02:13,876 --> 00:02:17,839
but the brain structure for kids with ADHD

41
00:02:17,839 --> 00:02:22,763
is slightly different and sometimes just

42
00:02:22,763 --> 00:02:27,361
more than slightly different
for kids who have ADHD.

43
00:02:29,482 --> 00:02:32,262
Let's talk a little bit about medication.

44
00:02:32,262 --> 00:02:34,721
What are some of the myths of medication?

45
00:02:35,244 --> 00:02:38,537
Number one myth, drugs are over-prescribed

46
00:02:38,537 --> 00:02:42,269
and basically they're bad.

47
00:02:45,371 --> 00:02:50,003
Right now, there's a 4.3%
of kids on medication

48
00:02:50,003 --> 00:02:52,781
and a 7.8% prevalence.

49
00:02:52,781 --> 00:02:55,151
Are they over-prescribed?

50
00:02:55,151 --> 00:03:00,151
The drugs are addictive and
increase aggressive behavior.

51
00:03:03,950 --> 00:03:07,822
Here's my philosophy about medication.

52
00:03:07,822 --> 00:03:11,800
Medication can help a person distinguish

53
00:03:11,800 --> 00:03:16,800
between the symptoms of ADHD
and who that person really is,

54
00:03:17,243 --> 00:03:21,908
and for kids who often feel
like they are their ADHD.

55
00:03:21,908 --> 00:03:26,274
Being able to separate
the ADHD from the story

56
00:03:26,274 --> 00:03:30,318
that they tell themselves
of who they are is critical.

57
00:03:30,318 --> 00:03:33,495
Of course, pills don't teach skills.

58
00:03:33,495 --> 00:03:36,054
Pills are not going to teach children

59
00:03:36,054 --> 00:03:39,461
what executive functions
are, how to improve them,

60
00:03:39,461 --> 00:03:42,033
and how to use them more effectively.

61
00:03:42,033 --> 00:03:45,603
Those skills and the scaffolding structure

62
00:03:45,603 --> 00:03:50,096
that kids need to
succeed have to be taught

63
00:03:50,096 --> 00:03:51,935
by adults around them.

64
00:03:51,935 --> 00:03:55,149
The pills because of
the chemical processes

65
00:03:55,149 --> 00:03:58,971
we just discussed make the
children more available

66
00:03:58,971 --> 00:04:02,350
to learn those skills.

67
00:04:03,183 --> 00:04:05,875
The side effects to
consider with medication

68
00:04:05,875 --> 00:04:07,155
are well-known.

69
00:04:07,155 --> 00:04:12,155
Lack of appetite, sometimes
difficulty falling asleep,

70
00:04:13,320 --> 00:04:17,064
weight loss, increased irritability.

71
00:04:18,527 --> 00:04:21,506
I'm sure there are more
that you can think of.

72
00:04:21,506 --> 00:04:26,211
The side effects to
consider of not taking meds

73
00:04:26,211 --> 00:04:29,308
would be years of failure.

74
00:04:29,308 --> 00:04:31,747
Repeated school failure

75
00:04:31,747 --> 00:04:35,349
because a child's job is to go to school.

76
00:04:35,349 --> 00:04:40,349
A child's job is to succeed at school

77
00:04:40,914 --> 00:04:44,922
whatever that looks like but
certainly not to feel everyday

78
00:04:44,922 --> 00:04:46,794
that you get a blank piece of paper

79
00:04:46,794 --> 00:04:50,093
and its the bane of your existence.

80
00:04:51,401 --> 00:04:54,627
Years of frustration, under achievement,

81
00:04:54,627 --> 00:04:56,241
and troubled relationships.

82
00:04:56,241 --> 00:05:00,661
Those are some of the side
effects of not taking medication.

83
00:05:01,681 --> 00:05:04,147
I think each family has
to weigh for themselves

84
00:05:04,147 --> 00:05:06,471
what are the risk of taking medication

85
00:05:06,471 --> 00:05:09,285
versus not taking medication?

86
00:05:09,420 --> 00:05:11,122
I'm working with some family now

87
00:05:11,122 --> 00:05:13,647
and they do not want their
child taking medication

88
00:05:13,647 --> 00:05:16,222
but the child struggles at school

89
00:05:16,222 --> 00:05:18,685
and the child's self-esteem is affected

90
00:05:18,685 --> 00:05:21,950
by the way the child struggles at school.

91
00:05:22,198 --> 00:05:24,103
It's a tough call.

92
00:05:24,724 --> 00:05:29,037
My job as a therapist, I
believe, is to point out

93
00:05:29,037 --> 00:05:32,175
the ways in which
medication could be helpful

94
00:05:32,175 --> 00:05:34,638
to discuss their fears with them

95
00:05:34,638 --> 00:05:38,949
and then I have to work
with them on where they are.

96
00:05:41,174 --> 00:05:46,174
The drugs work because they
increase the availability

97
00:05:46,590 --> 00:05:48,353
of dopamine and norepinephrine,

98
00:05:48,353 --> 00:05:49,724
not just in the frontal lobes

99
00:05:49,724 --> 00:05:51,251
but throughout the brain,

100
00:05:51,251 --> 00:05:56,251
in the circuits where those
neurotransmitters tend to run.

101
00:05:57,498 --> 00:05:59,601
The effects of course are idiosyncratic.

102
00:05:59,601 --> 00:06:01,970
There are common side effects like I said

103
00:06:01,970 --> 00:06:04,234
of mild insomnia or appetite suppression,

104
00:06:04,234 --> 00:06:06,013
and sometime tics.

105
00:06:06,013 --> 00:06:07,671
Taking meds though can reduce

106
00:06:07,671 --> 00:06:10,511
the chances of substance abuse later on

107
00:06:10,511 --> 00:06:14,378
because it reduces the
child's need to self-medicate.

108
00:06:14,484 --> 00:06:15,950
Now, when the child is nine,

109
00:06:15,950 --> 00:06:17,623
that's not such a big deal

110
00:06:17,623 --> 00:06:20,693
but when the child is 13 or 14 or 15,

111
00:06:20,693 --> 00:06:22,782
it's a bigger deal.

112
00:06:22,782 --> 00:06:25,781
Long-acting meds provide much more

113
00:06:25,781 --> 00:06:28,328
even states of attention overtime

114
00:06:28,328 --> 00:06:31,264
but there can be some
rebound when they were off

115
00:06:31,264 --> 00:06:34,006
which means that the families themselves

116
00:06:34,006 --> 00:06:36,876
have to brace themselves and prepare for

117
00:06:36,876 --> 00:06:41,577
that period of rebound, and
what to do when it occurs.

118
00:06:42,808 --> 00:06:47,808
I saw a young adult who
started taking Focalin at 22.

119
00:06:48,419 --> 00:06:53,360
She said to me, "I don't
feel like I've changed.

120
00:06:53,360 --> 00:06:56,853
"But honestly, I feel enhanced.

121
00:06:56,853 --> 00:06:59,989
"It's like glasses for my brain.

122
00:06:59,989 --> 00:07:02,898
"I packed and move myself
with listing everything

123
00:07:02,898 --> 00:07:05,503
"this weekend for the first time ever.

124
00:07:05,503 --> 00:07:08,074
"I didn't all last minute."

125
00:07:08,074 --> 00:07:09,674
I have to tell you,

126
00:07:09,674 --> 00:07:12,209
I didn't prompt her
for the glasses comment

127
00:07:12,209 --> 00:07:16,107
but I was shocked that she used that

128
00:07:16,107 --> 00:07:21,072
because it was so specific and clear.

129
00:07:21,474 --> 00:07:23,314
I have a male who said,

130
00:07:23,314 --> 00:07:24,758
"The first time I took meds,

131
00:07:24,758 --> 00:07:26,624
"the static went out of my brain

132
00:07:26,624 --> 00:07:30,822
"and I actually got
things done efficiently."

133
00:07:33,361 --> 00:07:36,862
What are some of the common
medications for ADHD?

134
00:07:37,233 --> 00:07:41,506
In the 1990s, the stimulation
prescription rates

135
00:07:41,506 --> 00:07:43,329
more than tripled.

136
00:07:43,329 --> 00:07:48,329
There was a general boom in
diagnosis and treatment of ADHD.

137
00:07:51,145 --> 00:07:54,921
The ADHD meds work in different ways.

138
00:07:54,921 --> 00:07:59,054
The stimulants which would
be methylphenidate, Ritalin,

139
00:07:59,054 --> 00:08:04,054
Ritalin LA, Focalin, Concerta,
Metadate and Mehtylin.

140
00:08:07,635 --> 00:08:12,635
Basically work by blocking
the dopamine reuptake system

141
00:08:14,773 --> 00:08:18,934
to allow more dopamine
to activate nearby cells.

142
00:08:19,911 --> 00:08:24,911
The Dexedrine-base stimulants stimulate

143
00:08:25,546 --> 00:08:28,775
the release of dopamine and
thus increase its levels

144
00:08:28,775 --> 00:08:31,225
at the neurotransmitter sites.

145
00:08:31,225 --> 00:08:35,293
Adderall which is an amphetamine compound,

146
00:08:35,293 --> 00:08:39,399
Adderall, Adderall XR, and Vyvanse.

147
00:08:39,630 --> 00:08:41,461
Adderall combines these processes

148
00:08:41,461 --> 00:08:46,461
and also enhances the
action of norepinephrine.

149
00:08:46,935 --> 00:08:49,801
The way most stimulants work
is that they're in the system

150
00:08:49,801 --> 00:08:52,065
for anywhere from two to seven hours.

151
00:08:52,065 --> 00:08:57,065
They work within 30 to 45
minutes of taking the pill.

152
00:08:57,649 --> 00:09:01,319
They're generally out of
the system within 24 hours.

153
00:09:01,319 --> 00:09:05,155
The research on the long term
effects is still being done

154
00:09:05,155 --> 00:09:09,415
with some concerns about
growth suppression.

155
00:09:10,924 --> 00:09:14,762
There's a class of nonstimulant
medication for ADHD.

156
00:09:14,762 --> 00:09:17,998
Stratera, it blocks primarily the action

157
00:09:17,998 --> 00:09:20,336
of the norepinephrine reuptake system.

158
00:09:20,336 --> 00:09:24,140
Wellbutrin like Effexor or Immipramine

159
00:09:24,140 --> 00:09:27,604
are stimulatory, anti-depressant
meds that facilitate

160
00:09:27,604 --> 00:09:31,882
the activity in several
neuropathways including dopamine.

161
00:09:32,973 --> 00:09:35,775
They can enhance attention, mood control,

162
00:09:35,775 --> 00:09:37,477
and reduce irritability

163
00:09:37,477 --> 00:09:41,813
but take about a month to start working.

164
00:09:41,813 --> 00:09:45,729
Antihypertensive, Clonidine,
Guanfacine, Tenex, Intuniv

165
00:09:45,729 --> 00:09:48,473
reduce the symptoms of
hyperactivity and impulsivity

166
00:09:48,473 --> 00:09:52,436
by occupying brain receptors
that are sensitive adrenalin

167
00:09:52,436 --> 00:09:54,807
which is hormone.

168
00:09:54,807 --> 00:09:59,174
The SSRIs anti-depressants
like Zoloft or Celexa

169
00:09:59,174 --> 00:10:00,968
help control temper flare-ups.

170
00:10:00,968 --> 00:10:04,515
Celexa is useful for anxiety.

171
00:10:14,121 --> 00:10:16,557
I'd like to read you something from a book

172
00:10:16,557 --> 00:10:19,832
that's on your reference
list called, "Buzz."

173
00:10:19,832 --> 00:10:24,832
This is an autobiographical piece of work.

174
00:10:25,804 --> 00:10:29,409
This is the mothers who wrote the book,

175
00:10:29,409 --> 00:10:33,073
opinion about drugs, medication.

176
00:10:33,793 --> 00:10:35,580
Then there's the drug dilemma

177
00:10:35,580 --> 00:10:38,011
which goes something like this.

178
00:10:38,011 --> 00:10:41,149
"God forbid, you medicate
your distracted child

179
00:10:41,149 --> 00:10:43,654
"because you'll turn
that child into a zombie,

180
00:10:43,654 --> 00:10:47,058
"a midget and/or a drug
fiend causing lasting damage

181
00:10:47,058 --> 00:10:49,649
"to his brain that we'll
only be able to measure

182
00:10:49,649 --> 00:10:51,929
"once he's old enough to sue you

183
00:10:51,929 --> 00:10:54,830
"but God forbid, you don't.

184
00:10:54,830 --> 00:10:56,668
"Because he'll fail at school,

185
00:10:56,668 --> 00:10:59,466
"wind up friendless, lose all self-esteem

186
00:10:59,466 --> 00:11:02,834
"and/or self-medicate
i.e. become a drug fiend

187
00:11:02,834 --> 00:11:05,498
"and blame you for your
ill-informed parenting

188
00:11:05,498 --> 00:11:07,734
"each day after you drag home from work

189
00:11:07,734 --> 00:11:10,208
"to find him at the age of 34,

190
00:11:10,208 --> 00:11:15,176
"still lying on your living room couch."

191
00:11:21,147 --> 00:11:25,563
There are special medication
issues for teenagers.

192
00:11:27,888 --> 00:11:30,365
My experience is that a lot of times,

193
00:11:30,365 --> 00:11:34,031
kids will take their
medication pretty compliantly

194
00:11:34,031 --> 00:11:35,204
when they're younger

195
00:11:35,204 --> 00:11:40,204
but at around 13, 14,
15, they start to resist.

196
00:11:40,379 --> 00:11:44,872
Some of their resistance is
related to the belief that

197
00:11:44,872 --> 00:11:46,246
I'm crazy.

198
00:11:46,246 --> 00:11:47,650
I'm stupid.

199
00:11:47,650 --> 00:11:49,209
I'm handicapped.

200
00:11:49,209 --> 00:11:51,182
It doesn't work anyway.

201
00:11:53,642 --> 00:11:58,642
I don't feel like myself
when I take my pills.

202
00:12:00,325 --> 00:12:02,828
I don't see any benefit.

203
00:12:05,135 --> 00:12:07,005
They give up.

204
00:12:08,608 --> 00:12:10,872
In my practice and I work as I said

205
00:12:10,872 --> 00:12:12,374
pretty much exclusively with kids

206
00:12:12,374 --> 00:12:16,507
with ADD, and ADHD, and
learning challenges.

207
00:12:18,110 --> 00:12:22,608
People who go on drug vacations

208
00:12:22,608 --> 00:12:26,183
will frequently do it the following way.

209
00:12:26,975 --> 00:12:31,189
Hide it from their parents and me.

210
00:12:31,189 --> 00:12:35,293
Start to complain of
having more difficulties.

211
00:12:35,293 --> 00:12:37,451
The parents are aware that they're having

212
00:12:37,451 --> 00:12:40,803
more difficulties and contact me.

213
00:12:40,803 --> 00:12:43,732
Then there's usually a dramatic

214
00:12:43,732 --> 00:12:48,732
and intense outburst or situation

215
00:12:51,176 --> 00:12:55,174
and the lack of medication is revealed.

216
00:12:56,481 --> 00:13:01,318
I do not believe in, as I said earlier,

217
00:13:01,318 --> 00:13:02,755
telling people that they should

218
00:13:02,755 --> 00:13:04,718
or shouldn't take medication.

219
00:13:04,718 --> 00:13:09,491
I do believe in pointing
out the positive effects

220
00:13:09,491 --> 00:13:12,665
of taking medication and the limitations

221
00:13:12,665 --> 00:13:16,264
particularly with teenagers
who are right enough

222
00:13:16,264 --> 00:13:20,926
and trying to exert
their independence enough

223
00:13:20,926 --> 00:13:24,351
to want to make their own decisions.

224
00:13:24,550 --> 00:13:27,453
One thing that I really
try to do is to talk with

225
00:13:27,453 --> 00:13:30,244
the teenager and I would
even say young adult

226
00:13:30,244 --> 00:13:35,244
about his or her fears, concerns, likes,

227
00:13:35,894 --> 00:13:37,857
things they like about the medication,

228
00:13:37,857 --> 00:13:40,997
and things they dislike
about the medication.

229
00:13:40,997 --> 00:13:45,997
I'd like to try to couch
the need for medication

230
00:13:48,530 --> 00:13:53,332
in terms that the teenager
finds more acceptable.

231
00:13:53,332 --> 00:13:55,971
In terms of changes that he or she wants

232
00:13:55,971 --> 00:13:59,049
to make about themselves.

233
00:13:59,049 --> 00:14:01,617
I think it's really important
to address this idea

234
00:14:01,617 --> 00:14:04,314
of I don't feel like myself.

235
00:14:04,314 --> 00:14:07,455
What is myself feel like?

236
00:14:07,455 --> 00:14:10,417
If you don't feel like yourself,

237
00:14:10,417 --> 00:14:12,848
how can we balance your needing to feel

238
00:14:12,848 --> 00:14:15,032
not like yourself with the things you have

239
00:14:15,032 --> 00:14:19,525
to do with wanting to have
time when you're like yourself.

240
00:14:19,525 --> 00:14:22,473
That translates into maybe
not taking your medication

241
00:14:22,473 --> 00:14:24,473
on days when you don't
have to go to school

242
00:14:24,473 --> 00:14:26,876
or you don't have school work to do.

243
00:14:26,876 --> 00:14:30,182
Taking a break occasionally in that way

244
00:14:30,182 --> 00:14:34,680
can help people feel freed up

245
00:14:34,680 --> 00:14:39,414
from the burden of having
to take medication every day

246
00:14:39,414 --> 00:14:43,661
but it can also help
teenagers and young adults

247
00:14:43,661 --> 00:14:45,799
see the benefits of the medication

248
00:14:45,799 --> 00:14:48,934
they're actually taking
and why it helps them.

249
00:14:50,202 --> 00:14:53,336
I try to emphasize that
medication can make the teenager

250
00:14:53,336 --> 00:14:55,763
more available to him or herself

251
00:14:55,763 --> 00:14:59,343
as well as more available to other people,

252
00:14:59,343 --> 00:15:01,381
and to identify who those people are

253
00:15:01,381 --> 00:15:03,548
that that person cares about.

254
00:15:03,548 --> 00:15:07,386
That person if the medication is working

255
00:15:07,386 --> 00:15:11,216
has more control over his or her

256
00:15:11,216 --> 00:15:15,517
innate intellectual gifts and talents.

257
00:15:16,730 --> 00:15:21,730
Also adolescents will try to
stop taking their medication

258
00:15:23,999 --> 00:15:28,999
as part of their desire to
differentiate from their parents

259
00:15:29,900 --> 00:15:31,911
and what their parents want for them.

260
00:15:31,911 --> 00:15:33,714
And so it's very important to understand

261
00:15:33,714 --> 00:15:37,248
what the adolescent wants
for him or herself separate

262
00:15:37,248 --> 00:15:40,546
from what the parent wants.

263
00:15:40,685 --> 00:15:42,285
Sometimes teenagers require

264
00:15:42,285 --> 00:15:44,925
more vigorous monitoring than children.

265
00:15:44,925 --> 00:15:47,185
Sometimes if they have their pills

266
00:15:47,185 --> 00:15:49,650
and a daily pillbox for a week

267
00:15:49,650 --> 00:15:51,661
so that they can take it.

268
00:15:51,661 --> 00:15:54,392
That can be helpful.

269
00:15:54,392 --> 00:15:59,392
You want to make sure that the
teen is participating fully

270
00:16:01,193 --> 00:16:03,396
in the treatment decisions and the plans

271
00:16:03,396 --> 00:16:05,240
not just around the medication

272
00:16:05,240 --> 00:16:08,111
but around the goals for understanding,

273
00:16:08,111 --> 00:16:13,111
and intervening with the ADHD.

274
00:16:14,648 --> 00:16:19,546
Sometimes negotiating behavior
contracts is important.

275
00:16:19,546 --> 00:16:21,684
There's been a lot of research lately

276
00:16:21,684 --> 00:16:26,684
on the abuse of medication
particularly Adderall for kids

277
00:16:27,096 --> 00:16:31,168
who are trying to get into this really top

278
00:16:31,168 --> 00:16:35,208
competitive schools and that
the Adderall helps them ...

279
00:16:35,208 --> 00:16:38,141
Or the Ritalin helps
them concentrate better

280
00:16:38,141 --> 00:16:41,014
and so they can do more school work.

281
00:16:41,014 --> 00:16:43,884
I think, it's of course,
critical to monitor

282
00:16:43,884 --> 00:16:48,718
with the child and the child's
parents who's in control

283
00:16:48,718 --> 00:16:50,544
of the medication and how much medication

284
00:16:50,544 --> 00:16:53,313
is being dispensed at a time

285
00:16:53,313 --> 00:16:57,194
and also to talk about the black market

286
00:16:57,194 --> 00:16:59,865
for the ADHD medications.

287
00:17:00,454 --> 00:17:04,868
There are alternatives to medication.

288
00:17:04,868 --> 00:17:07,540
Omega-3 fatty acids can increase

289
00:17:07,540 --> 00:17:10,407
the levels of dopamine in the brain.

290
00:17:10,407 --> 00:17:13,637
Those can be added to the
diet through supplements

291
00:17:13,637 --> 00:17:17,177
or they're found in various foods.

292
00:17:17,177 --> 00:17:20,439
Exercise releases
endorphins and stimulates

293
00:17:20,439 --> 00:17:25,222
the growth of new neurons
so that's always a plus.

294
00:17:25,222 --> 00:17:27,821
There are cerebellar
stimulation exercises,

295
00:17:27,821 --> 00:17:31,984
the brain gym, the Dore method,
educational kinesiology,

296
00:17:31,984 --> 00:17:35,091
there's biofeedback and
relaxation training,

297
00:17:35,091 --> 00:17:37,368
sensory integration training,

298
00:17:37,368 --> 00:17:39,193
other kinds of nutrition and diet.

299
00:17:39,193 --> 00:17:42,500
All of these can help and they're
alternatives to medication

300
00:17:42,500 --> 00:17:46,075
but they will not produce the same results

301
00:17:46,075 --> 00:17:51,075
as medication in terms
of the ease and efficacy,

302
00:17:54,248 --> 00:17:57,620
and the research related
to the medication.

303
00:18:02,626 --> 00:18:07,626
What are some of the
co-occurring disorders with ADHD?

304
00:18:08,285 --> 00:18:13,205
Anxiety or OCD, autism spectrum disorders,

305
00:18:13,205 --> 00:18:17,131
depression, auditory processing problems,

306
00:18:17,131 --> 00:18:21,267
sensory integration,
oppositional defiant disorder,

307
00:18:21,267 --> 00:18:24,715
specific learning disabilities
such as written expression,

308
00:18:24,715 --> 00:18:29,715
dyslexia, and there's a difference

309
00:18:30,848 --> 00:18:34,558
between an impairment in these areas.

310
00:18:34,558 --> 00:18:38,362
Essentially inconvenience or difficulty

311
00:18:38,362 --> 00:18:41,662
so someone may have some
difficulty with writing

312
00:18:41,662 --> 00:18:43,255
but it's not an impairment.

313
00:18:43,255 --> 00:18:45,001
It just may take them a little longer

314
00:18:45,001 --> 00:18:46,367
but they can actually do it.

315
00:18:46,367 --> 00:18:48,830
Other people like the white sheet example

316
00:18:48,830 --> 00:18:51,639
that I talked about earlier
actually can't write

317
00:18:51,639 --> 00:18:53,432
like nothing happens.

318
00:18:53,432 --> 00:18:56,272
It's really important to distinguish

319
00:18:56,272 --> 00:19:00,406
which is occurring for your client.

320
00:19:00,406 --> 00:19:04,418
Oppositional defiant disorder
occurs 40% of the time

321
00:19:04,418 --> 00:19:07,653
in people who have ADHD.

322
00:19:09,790 --> 00:19:14,790
Anxiety disorders occur 34% of the time.

323
00:19:15,160 --> 00:19:17,434
I talked earlier about the
kind of hyper-vigilance

324
00:19:17,434 --> 00:19:22,235
that kids with ADHD have
in terms of awareness

325
00:19:22,235 --> 00:19:25,972
of what they're missing and worry about

326
00:19:25,972 --> 00:19:29,648
what's going on that
they're not attending to.

327
00:19:29,648 --> 00:19:32,549
Conduct disorder's about 14%.

328
00:19:32,549 --> 00:19:36,109
Tic disorder 11% and affective disorders

329
00:19:36,109 --> 00:19:39,882
like depression are about 4%.

330
00:19:39,882 --> 00:19:42,321
The major research from
the multimodal treatment

331
00:19:42,321 --> 00:19:45,187
study of children with ADHD in 1999

332
00:19:45,187 --> 00:19:47,829
show that children ages seven to nine

333
00:19:47,829 --> 00:19:50,430
of those children who
were diagnosed with ADHD,

334
00:19:50,430 --> 00:19:53,767
70% had another psychiatric disorder.

335
00:19:53,767 --> 00:19:55,707
A later study from Puerto Rico showed

336
00:19:55,707 --> 00:19:59,211
a higher incidence of depressive symptoms.

337
00:19:59,211 --> 00:20:02,472
Boys are often referred for ODD

338
00:20:02,472 --> 00:20:04,882
and girls for anxiety or depression

339
00:20:04,882 --> 00:20:08,107
which will mask the ADHD
or the learning disability.

340
00:20:08,107 --> 00:20:09,350
So it's really important to take

341
00:20:09,350 --> 00:20:12,791
a very thorough history
where that's concerned.

342
00:20:12,791 --> 00:20:15,350
Kathleen Nadeau has
written some terrific books

343
00:20:15,350 --> 00:20:18,454
about girls with ADD.

344
00:20:18,454 --> 00:20:20,591
Here's an example from her book,

345
00:20:20,591 --> 00:20:24,664
"Understanding Girls with ADHD,"

346
00:20:24,664 --> 00:20:29,664
about a girl who is struggling
with depression and ADHD.

347
00:20:35,242 --> 00:20:38,415
"I'm not good at anything,"
Lisa, a ninth grade girl

348
00:20:38,415 --> 00:20:41,485
"with ADHD expressed despairingly.

349
00:20:41,485 --> 00:20:44,488
"With regret and envy, she
describe girls in her class

350
00:20:44,488 --> 00:20:48,158
"who had made the cheerleading
squad earn top grades,

351
00:20:48,158 --> 00:20:51,987
"or had already completed years
of music or dance lessons.

352
00:20:51,987 --> 00:20:54,031
"Developing high levels of skill

353
00:20:54,031 --> 00:20:56,263
"and confidence in the process.

354
00:20:56,263 --> 00:20:58,991
"Liza had taken up and
dropped many interests.

355
00:20:58,991 --> 00:21:01,908
"A pattern typical for girls with ADHD.

356
00:21:01,908 --> 00:21:05,167
"At 14, she no longer
had any faith in herself

357
00:21:05,167 --> 00:21:08,738
"or in her capacity to
stick with any endeavor.

358
00:21:08,738 --> 00:21:12,439
"Easily discouraged and with
a low frustration tolerance,

359
00:21:12,439 --> 00:21:15,948
"she pursued each succeeding
interests with less

360
00:21:15,948 --> 00:21:19,382
"and less faith that she
would discover a talent

361
00:21:19,382 --> 00:21:22,192
"or develop a skill."

362
00:21:27,864 --> 00:21:31,968
Co-existing mood disorders are common

363
00:21:31,968 --> 00:21:34,326
especially in the adolescent years.

364
00:21:34,326 --> 00:21:36,539
And girls are often treated for these

365
00:21:36,539 --> 00:21:39,304
and not evaluated for ADHD.

366
00:21:39,304 --> 00:21:43,077
I have found numerous times
in referrals from my practice

367
00:21:43,077 --> 00:21:45,804
or consultation with other therapist,

368
00:21:45,804 --> 00:21:48,117
girls who are referred for persistent

369
00:21:48,117 --> 00:21:49,847
anxiety and depression,

370
00:21:49,847 --> 00:21:53,358
and when evaluated through their school

371
00:21:53,358 --> 00:21:58,285
or through outside
psychologists for testing

372
00:21:58,285 --> 00:22:01,967
end up having ADHD that
was never diagnosed.

373
00:22:01,967 --> 00:22:06,805
Somatization disorders are
common in girls with ADHD,

374
00:22:06,805 --> 00:22:10,206
as are headaches and stomach complaints.

375
00:22:11,007 --> 00:22:13,978
ADHD likely contributes to and causes

376
00:22:13,978 --> 00:22:16,101
oppositional defiant disorder

377
00:22:16,101 --> 00:22:19,204
because of poor emotional regulation,

378
00:22:19,204 --> 00:22:24,204
lack of control of anger,
hostility, aggression, outbursts.

379
00:22:24,243 --> 00:22:27,256
ADHD meds reduce ODD

380
00:22:27,256 --> 00:22:31,158
and it can go away within
two years of treatment.

381
00:22:31,158 --> 00:22:35,663
Anxiety is the stealth comorbidity disease

382
00:22:35,663 --> 00:22:39,997
and it requires a series of
interviews with kids who treat.

383
00:22:39,997 --> 00:22:43,037
The most common anxieties
are simple phobias

384
00:22:43,037 --> 00:22:46,437
and separation anxiety in early childhood.

385
00:22:46,437 --> 00:22:50,045
General anxiety disorder
increases with age

386
00:22:50,045 --> 00:22:55,045
and is prevalent particularly in girls

387
00:22:55,278 --> 00:22:59,820
but also in boys with ADD, ADHD.

388
00:22:59,820 --> 00:23:03,282
Often there's a parental
anxiety in the family system

389
00:23:03,282 --> 00:23:05,499
which contributes the
anxiety that the child,

390
00:23:05,499 --> 00:23:07,795
him or herself is feeling.

391
00:23:07,795 --> 00:23:09,832
With anxiety and depression,

392
00:23:09,832 --> 00:23:14,539
you must also evaluate for victimization

393
00:23:14,539 --> 00:23:18,775
either bullying, or
sexual, or physical abuse.

394
00:23:18,775 --> 00:23:21,877
In terms of conduct disorder as we know,

395
00:23:21,877 --> 00:23:25,678
conduct disorder is a
reflection of limited conscience

396
00:23:25,678 --> 00:23:29,244
and there is a poor treatment prognosis.

397
00:23:29,244 --> 00:23:31,155
Often there's chaotic family structure

398
00:23:31,155 --> 00:23:33,624
that goes along with it and it's related

399
00:23:33,624 --> 00:23:38,096
in terms of what research has
found to social disadvantage,

400
00:23:38,096 --> 00:23:41,263
family disruption and
poor peer relationships.

401
00:23:41,263 --> 00:23:44,258
Parent divorce is more
common and major depression

402
00:23:44,258 --> 00:23:49,006
often co-exist along with the
conduct disorder and the ADHD.

403
00:23:51,108 --> 00:23:53,467
In terms of co-occurring disorders,

404
00:23:53,467 --> 00:23:56,444
we have to also talk
about learning disorders

405
00:23:56,444 --> 00:24:01,444
which co-exist with ADHD,
24 to 70% of the time.

406
00:24:01,840 --> 00:24:04,852
Dyslexia about 20% of the time.

407
00:24:04,852 --> 00:24:07,791
Expressive and receptive
language disorders are common

408
00:24:07,791 --> 00:24:10,951
as is discalculia.

409
00:24:12,504 --> 00:24:15,388
Expressive and receptive
language disorders

410
00:24:15,388 --> 00:24:20,161
are present in a high number
of children with ADHD.

411
00:24:20,161 --> 00:24:22,704
There are also pragmatic
language deficits.

412
00:24:22,704 --> 00:24:26,379
Using language appropriately
in social situations.

413
00:24:26,810 --> 00:24:30,408
That could include either
excessive verbal output

414
00:24:30,408 --> 00:24:33,719
or decreased verbal output
depending on the person,

415
00:24:33,719 --> 00:24:37,476
and the type of ADHD or
ADD that he or she has.

416
00:24:37,476 --> 00:24:39,945
Difficulties introducing,
and changing topics,

417
00:24:39,945 --> 00:24:43,856
and conversation, problems
being specific in choosing words

418
00:24:43,856 --> 00:24:47,119
to express information or emotions,

419
00:24:47,119 --> 00:24:49,397
and difficulty listening.

420
00:24:51,332 --> 00:24:56,332
I want to say something about
ADHD versus bipolar disorder.

421
00:24:56,438 --> 00:25:00,138
Bipolar disorder usually of course,

422
00:25:00,138 --> 00:25:02,512
there's a family history
of bipolar disorder,

423
00:25:02,512 --> 00:25:06,851
alcoholism, major depression, or mania.

424
00:25:06,851 --> 00:25:10,622
The major symptom is
rapidly changing moods

425
00:25:10,622 --> 00:25:14,288
regardless of what's going
on in the environment.

426
00:25:14,288 --> 00:25:17,892
In ADHD, there's a family
history of school problems,

427
00:25:17,892 --> 00:25:22,027
disorganization, focusing difficulties,

428
00:25:22,027 --> 00:25:25,737
employment difficulties,
and the major symptom

429
00:25:25,737 --> 00:25:28,931
is fluctuating attention
not fluctuating mood.

430
00:25:28,931 --> 00:25:31,942
There will be fluctuating mood
with fluctuating attention

431
00:25:31,942 --> 00:25:35,544
but the primary system
is fluctuating attention.

432
00:25:35,544 --> 00:25:40,544
Bipolar kids can be violent,
suicidal and extremely rageful.

433
00:25:43,421 --> 00:25:48,421
Bipolar disorder primarily
involves huge mood disruptions.

434
00:25:50,115 --> 00:25:51,724
Let me say that again.

435
00:25:51,724 --> 00:25:55,855
Bipolar disorder involves
primarily huge mood disruptions

436
00:25:55,855 --> 00:25:58,766
and secondarily, there may
be some attention issues

437
00:25:58,766 --> 00:26:03,374
related to that because of
the flooding of the mood

438
00:26:03,374 --> 00:26:07,680
and how it's disrupting the
child's ability to be present.

439
00:26:07,680 --> 00:26:12,178
In ADHD, there is a
longstanding chronic condition

440
00:26:12,178 --> 00:26:16,756
of inattentiveness, lack
of focus, impulsivity

441
00:26:16,756 --> 00:26:21,222
that isn't mark by cycling or mania.

442
00:26:21,560 --> 00:26:25,293
In terms of learning disorders,

443
00:26:25,293 --> 00:26:27,129
there's one thing that I actually want

444
00:26:27,129 --> 00:26:32,129
to add which is that ADHD is recognized

445
00:26:34,233 --> 00:26:37,136
by special education laws as a disability.

446
00:26:37,136 --> 00:26:40,140
And a child who is diagnosed with ADHD

447
00:26:40,140 --> 00:26:43,583
is eligible for special education services

448
00:26:43,583 --> 00:26:47,912
whether an individualized education plan

449
00:26:47,912 --> 00:26:50,421
or a 504 accommodations.

450
00:26:50,421 --> 00:26:55,147
It's very important that these
kids have these accommodation

451
00:26:55,147 --> 00:27:00,147
and so if there is no formal
documentation from a physician

452
00:27:00,999 --> 00:27:05,930
or a psychologist, or someone
who's tested the child,

453
00:27:05,930 --> 00:27:10,139
or a treating social
worker or family therapist,

454
00:27:10,139 --> 00:27:13,744
it's important that you
create that documentation

455
00:27:13,744 --> 00:27:16,646
so that that child can receive services

456
00:27:16,646 --> 00:27:18,282
and accommodations that would help

457
00:27:18,282 --> 00:27:20,939
him or her learn more effectively.

458
00:27:22,353 --> 00:27:25,819
Because of the high comorbidity
with learning disorders,

459
00:27:25,819 --> 00:27:30,819
as I said earlier 24 to
70%, unmedicated ADHD

460
00:27:33,297 --> 00:27:38,229
will lower a child's IQ on
any kind of school testing

461
00:27:38,229 --> 00:27:40,897
or will lower a child's results

462
00:27:40,897 --> 00:27:42,939
on any kind of school testing.

463
00:27:42,939 --> 00:27:47,939
It's very important that it's
diagnosed and documented.

464
00:27:49,178 --> 00:27:53,151
90% of kids with ADHD have
poor school performance

465
00:27:53,151 --> 00:27:58,151
because school is the main
area in which their inability

466
00:27:58,417 --> 00:28:02,752
to focus, and attend, and
concentrate on material

467
00:28:02,752 --> 00:28:07,626
that they're not interested in emerges.

468
00:28:08,055 --> 00:28:11,364
It's been found that if you treat ADHD,

469
00:28:11,364 --> 00:28:15,667
handwriting will improve 60% of the time.

470
00:28:15,667 --> 00:28:20,667
Reading and listening comprehension
deficits also improve.

471
00:28:23,004 --> 00:28:26,982
It's also been found that 56% of kids

472
00:28:26,982 --> 00:28:29,755
with ADHD needs academic tutoring,

473
00:28:29,755 --> 00:28:32,520
30% have repeated a grade,

474
00:28:32,520 --> 00:28:37,520
and 35% have been placed
in a special class.

475
00:28:39,928 --> 00:28:42,267
Again, I said this earlier so I just want

476
00:28:42,267 --> 00:28:44,128
to reiterate it now.

477
00:28:44,128 --> 00:28:49,128
Poor school performance is
usually due to low productivity

478
00:28:50,131 --> 00:28:55,131
not low intelligence and
not a lack of capability.

479
00:28:56,034 --> 00:28:59,778
Low academic achievement worsens with age

480
00:28:59,778 --> 00:29:02,017
which means that a nine-year-old who

481
00:29:02,017 --> 00:29:04,321
isn't doing that well in school,

482
00:29:04,321 --> 00:29:08,692
if he or she does not
receive proper support

483
00:29:08,692 --> 00:29:12,262
and interventions will bottom

484
00:29:12,262 --> 00:29:17,223
as he gets or she ages, not increase.

485
00:29:17,223 --> 00:29:20,637
They will bottom out.

486
00:29:21,908 --> 00:29:25,231
I'd like to read something
from Thomas Brown's book.

487
00:29:25,231 --> 00:29:29,601
"Both writing and reading draw on memory,

488
00:29:29,601 --> 00:29:32,815
"executive processes
and thinking processes

489
00:29:32,815 --> 00:29:36,087
"but in different ways
because the reading system

490
00:29:36,087 --> 00:29:40,456
"of the brain can refer to
written text at any time,

491
00:29:40,456 --> 00:29:44,058
"the memory burden is greatly reduced.

492
00:29:44,058 --> 00:29:47,693
"In contrast, the writing system may place

493
00:29:47,693 --> 00:29:50,391
"a greater burden on working memory

494
00:29:50,391 --> 00:29:52,998
"than does reading comprehension.

495
00:29:52,998 --> 00:29:55,402
"Writing is an immense juggling act

496
00:29:55,402 --> 00:29:58,301
"with more jobs to do than reading.

497
00:29:58,301 --> 00:30:01,702
"The writing jobs include planning,

498
00:30:01,702 --> 00:30:03,840
"generating ideas and setting goals,

499
00:30:03,840 --> 00:30:06,507
"translating those ideas into text,

500
00:30:06,507 --> 00:30:11,507
"transcribing that text, and
reviewing, and revising it.

501
00:30:11,624 --> 00:30:14,291
"Control processes for extracting meeting

502
00:30:14,291 --> 00:30:17,629
"from a finished text, i.e. reading,

503
00:30:17,629 --> 00:30:20,719
"are not taxing as the executive processes

504
00:30:20,719 --> 00:30:23,994
"that go into generating
and repairing a text

505
00:30:23,994 --> 00:30:28,994
"until it is deemed a final
product, writing and editing."

506
00:30:33,465 --> 00:30:37,441
How do we assess for ADHD?

507
00:30:37,441 --> 00:30:42,082
There are several components
of a good assessment for ADHD.

508
00:30:43,081 --> 00:30:45,783
There are a variety of
paper and pencil techniques

509
00:30:45,783 --> 00:30:48,387
including the child behavior checklist,

510
00:30:48,387 --> 00:30:51,620
the Brown ADD scales,
the Vanderbilt scales,

511
00:30:51,620 --> 00:30:54,464
the Conners, and other computerized tests.

512
00:30:54,464 --> 00:30:57,693
Russell Barkley has
created a number of forms,

513
00:30:58,535 --> 00:31:01,603
a good developmental history is critical,

514
00:31:01,603 --> 00:31:03,228
taking a school history

515
00:31:03,228 --> 00:31:07,237
either seeing a series of report cards,

516
00:31:07,237 --> 00:31:09,879
speaking to someone at the school,

517
00:31:09,879 --> 00:31:14,211
work history for older teens,
family or medical history,

518
00:31:14,211 --> 00:31:18,050
as well as the family
psychiatric history is useful,

519
00:31:18,050 --> 00:31:20,485
doing a genogram can be really helpful.

520
00:31:20,485 --> 00:31:22,357
Psychiatric and legal history,

521
00:31:22,357 --> 00:31:24,617
particularly not just for the child

522
00:31:24,617 --> 00:31:26,628
but if there's been
anything for the parents,

523
00:31:26,628 --> 00:31:28,533
if that seems like you get a sense

524
00:31:28,533 --> 00:31:31,137
of that might be something
you want to know about

525
00:31:31,137 --> 00:31:34,286
and psychological testing.

526
00:31:34,773 --> 00:31:37,536
Let's talk about the treatment for ADHD.

527
00:31:38,478 --> 00:31:42,067
The treatment for ADHD
involves identifying

528
00:31:42,067 --> 00:31:46,084
and training executive functioning skills

529
00:31:46,084 --> 00:31:48,976
but also has to focus
on the low self-esteem

530
00:31:48,976 --> 00:31:53,976
and persistent sense of failure
that kids with ADHD feel.

531
00:31:55,295 --> 00:31:57,089
We have to be able to help them

532
00:31:57,089 --> 00:32:00,352
find successes and expand them.

533
00:32:00,352 --> 00:32:03,594
Ed Hallowell talks a lot about this

534
00:32:03,594 --> 00:32:08,594
that you have to really
focus on what's positive

535
00:32:09,869 --> 00:32:11,332
and try to grow that area

536
00:32:11,332 --> 00:32:15,240
because these kids receives
so much negative feedback.

537
00:32:15,240 --> 00:32:19,184
That we want them to feel in some areas

538
00:32:19,184 --> 00:32:24,184
that they have skills and
success just like their peers.

539
00:32:26,388 --> 00:32:29,821
I believe that it's
important to treat kids

540
00:32:29,821 --> 00:32:33,720
and teens with ADHD with positivism,

541
00:32:33,720 --> 00:32:38,720
and success, and orienting them

542
00:32:39,665 --> 00:32:42,532
to those parts of themselves.

543
00:32:43,364 --> 00:32:45,439
The first thing we want to do is we want

544
00:32:45,439 --> 00:32:50,439
to diagnose ADHD but with
that diagnosis of course,

545
00:32:53,411 --> 00:32:56,407
we want to identify their
talents and their strengths.

546
00:32:56,886 --> 00:33:01,519
I always ask my clients and their parents,

547
00:33:01,519 --> 00:33:04,992
what is so and so good at?

548
00:33:05,663 --> 00:33:10,663
We want to educate the client
and the family about ADHD.

549
00:33:12,405 --> 00:33:13,992
We might want to suggest

550
00:33:13,992 --> 00:33:16,334
any kinds of changes in lifestyle

551
00:33:16,334 --> 00:33:21,334
that would support success and positivism.

552
00:33:22,377 --> 00:33:27,052
For example, I work with a family

553
00:33:27,052 --> 00:33:30,141
and their little boy
comes home from school

554
00:33:30,141 --> 00:33:33,557
and he plays for an hour and a half.

555
00:33:33,557 --> 00:33:36,421
That includes watching
TV and then has dinner.

556
00:33:36,421 --> 00:33:38,659
Then they sit down and do the homework.

557
00:33:38,659 --> 00:33:40,893
He's in second grade.

558
00:33:40,893 --> 00:33:44,667
He can't do any homework at that hour.

559
00:33:44,667 --> 00:33:46,571
He's done.

560
00:33:46,571 --> 00:33:49,409
We've had to adjust what happens

561
00:33:49,409 --> 00:33:50,942
when he comes home from school.

562
00:33:50,942 --> 00:33:53,205
That he can play for half hour,

563
00:33:53,205 --> 00:33:57,409
then do his homework and then watch TV.

564
00:33:57,409 --> 00:34:02,009
That the TV is earned
through the incentive.

565
00:34:02,009 --> 00:34:05,853
It's an incentive for doing the homework.

566
00:34:06,377 --> 00:34:11,029
Counseling is very helpful
individual and family work.

567
00:34:11,029 --> 00:34:13,092
I like to balance that out.

568
00:34:13,092 --> 00:34:14,597
As teens get older,

569
00:34:14,597 --> 00:34:17,569
they can do obviously more individual work

570
00:34:17,569 --> 00:34:21,037
to help them manage the executive function

571
00:34:21,037 --> 00:34:22,841
and skills that they need on their own.

572
00:34:22,841 --> 00:34:27,442
But in general, most kids and
teens need the scaffolding

573
00:34:27,442 --> 00:34:29,546
from their parents and so it's important

574
00:34:29,546 --> 00:34:32,279
that there is collateral family work.

575
00:34:32,279 --> 00:34:37,279
If not, the focus of the
therapy can be the family work

576
00:34:38,176 --> 00:34:39,951
if that seems warranted.

577
00:34:39,951 --> 00:34:43,461
There must be collateral family work.

578
00:34:43,461 --> 00:34:46,054
Medication and then
discussion of medication,

579
00:34:46,054 --> 00:34:47,863
the options for medication,

580
00:34:47,863 --> 00:34:51,932
and contact with the
prescriber is important

581
00:34:51,932 --> 00:34:53,663
as well as coaching,

582
00:34:53,663 --> 00:34:58,663
ADHD coaching is in some
ways a field unto itself.

583
00:34:59,135 --> 00:35:02,313
But there are plenty of
opportunities for you

584
00:35:02,313 --> 00:35:04,952
to do coaching and the therapy.

585
00:35:04,952 --> 00:35:07,418
I would recommend if you're interested

586
00:35:07,418 --> 00:35:09,544
in learning how to do some more coaching,

587
00:35:09,544 --> 00:35:12,213
or how to talk to the school

588
00:35:12,213 --> 00:35:13,484
and see if there is
someone there who could do

589
00:35:13,484 --> 00:35:18,484
some coaching to look at Dawson
and Guare's book about that.

590
00:35:22,895 --> 00:35:27,793
Dr. Hallowell identifies a five-step cycle

591
00:35:27,793 --> 00:35:31,037
to the roots of happiness.

592
00:35:31,037 --> 00:35:34,545
The five-step cycle is connection, play,

593
00:35:34,545 --> 00:35:38,872
practice, mastery, and recognition.

594
00:35:39,150 --> 00:35:40,785
I really like to think about that

595
00:35:40,785 --> 00:35:43,846
when I think about
treating kids with ADHD.

596
00:35:43,846 --> 00:35:46,153
Who are they connected to?

597
00:35:46,153 --> 00:35:47,882
How can I connect with them?

598
00:35:47,882 --> 00:35:50,925
Are they connected to their families?

599
00:35:50,925 --> 00:35:52,959
Do they play enough?

600
00:35:52,959 --> 00:35:54,396
What do they do for play?

601
00:35:54,396 --> 00:35:56,360
What brings them joy?

602
00:35:56,360 --> 00:35:58,504
What's fun for them?

603
00:35:58,504 --> 00:36:02,439
Practice, what are the areas
in which they're struggling?

604
00:36:02,439 --> 00:36:07,439
What are some of their
executive weaknesses?

605
00:36:07,498 --> 00:36:10,410
How can I help them practice skills

606
00:36:10,410 --> 00:36:15,410
to strengthen those areas of
executive functioning deficits?

607
00:36:15,619 --> 00:36:18,319
Mastery, when there is mastery on

608
00:36:18,319 --> 00:36:21,112
a particular skill or behavior,

609
00:36:21,112 --> 00:36:23,014
how is that acknowledged?

610
00:36:23,014 --> 00:36:25,089
How is that built upon?

611
00:36:25,089 --> 00:36:29,088
Then recognition, recognition
of self and other.

612
00:36:29,088 --> 00:36:33,358
How does that child
learn how to understand

613
00:36:33,358 --> 00:36:35,060
what's going on with another person

614
00:36:35,060 --> 00:36:38,865
as well as what's going on
with himself or herself?

615
00:36:38,865 --> 00:36:42,782
How does that child recognize
when he or she needs help?

616
00:36:42,782 --> 00:36:47,007
How does that child ask for that help?

617
00:36:47,007 --> 00:36:50,642
I have a client who recently said to me.

618
00:36:50,642 --> 00:36:53,387
"I'm so tired of focusing on the things

619
00:36:53,387 --> 00:36:55,322
"that I don't do well.

620
00:36:55,322 --> 00:36:56,895
"That's all I think about."

621
00:36:56,895 --> 00:37:01,185
I said, "Well, what you would
like to think about instead?"

622
00:37:01,185 --> 00:37:03,388
She said, "I want to spend more time

623
00:37:03,388 --> 00:37:06,130
"on the parts of myself that I like.

624
00:37:06,130 --> 00:37:08,330
"I already have to spend so much time

625
00:37:08,330 --> 00:37:11,808
"on the parts of myself
that I don't like."

626
00:37:11,808 --> 00:37:14,913
I thought that was just
a beautiful statement

627
00:37:14,913 --> 00:37:17,769
about how it it is to have ADHD

628
00:37:17,769 --> 00:37:20,405
and receive that kind
of feedback all the time

629
00:37:20,405 --> 00:37:23,308
about how you're missing the mark

630
00:37:23,308 --> 00:37:26,187
and how important it is to spend time

631
00:37:26,187 --> 00:37:30,728
with yourself on the ways
that you hit the mark.

632
00:37:33,125 --> 00:37:35,022
Treatment for ADHD involves

633
00:37:35,022 --> 00:37:40,022
executive functioning skills
training as I said before.

634
00:37:40,769 --> 00:37:44,665
But it also has to involve
treating the whole person

635
00:37:44,665 --> 00:37:49,665
so that includes speech,
any sort of thinking

636
00:37:49,679 --> 00:37:54,679
about language issues, either
expressive or receptive,

637
00:37:54,679 --> 00:37:56,784
any kinds of learning challenges,

638
00:37:56,784 --> 00:38:00,155
any kinds of emotional issues

639
00:38:00,155 --> 00:38:05,155
or co-existing disorders,
anxiety, depression, et cetera.

640
00:38:06,597 --> 00:38:10,123
If there's any sort of
autism spectrum problems,

641
00:38:10,123 --> 00:38:15,123
if there's any kind of
oppositional defiance,

642
00:38:16,774 --> 00:38:17,938
a tic disorder.

643
00:38:17,938 --> 00:38:19,939
All of that has to be included

644
00:38:19,939 --> 00:38:22,405
in the treatment plan of a child

645
00:38:22,405 --> 00:38:25,316
as well as what are the family dynamics

646
00:38:25,316 --> 00:38:28,379
in which the child is living?

647
00:38:35,019 --> 00:38:37,281
If we're going to talk
about treatment for ADHD,

648
00:38:37,281 --> 00:38:39,188
there has been quite a bit of research on

649
00:38:39,188 --> 00:38:41,432
what's an effective treatment for ADHD?

650
00:38:41,432 --> 00:38:45,203
In the MTA study that I cited from 1999,

651
00:38:45,203 --> 00:38:50,203
they looked at groups of
basically a medicational loan,

652
00:38:50,705 --> 00:38:53,870
behavior modification, a
combination of medication,

653
00:38:53,870 --> 00:38:58,606
and behavior modification
in a community comparison.

654
00:38:58,606 --> 00:39:01,945
The treatment was delivered
over a 14-month period.

655
00:39:01,945 --> 00:39:06,945
There was a 68% improvement
in a combined group.

656
00:39:07,754 --> 00:39:10,059
That means that is the
group in which received

657
00:39:10,059 --> 00:39:12,961
medication and behavior treatment.

658
00:39:12,961 --> 00:39:15,361
That would mean medication and therapy.

659
00:39:15,361 --> 00:39:18,871
There was a 56% improvement in the group

660
00:39:18,871 --> 00:39:21,372
that just had medication.

661
00:39:21,372 --> 00:39:23,208
If you just received behavior modification

662
00:39:23,208 --> 00:39:25,906
with no medication, it
was a 34% improvement

663
00:39:25,906 --> 00:39:30,906
and a 25% improvement for
a community awareness.

664
00:39:33,148 --> 00:39:38,148
At 24 months, the patterns of
the results remains the same.

665
00:39:39,791 --> 00:39:44,791
The behavior interventions
were aimed at teaching,

666
00:39:44,991 --> 00:39:48,688
increasing, and cuing skills at key points

667
00:39:48,688 --> 00:39:52,298
of performance and for motivation.

668
00:39:52,298 --> 00:39:53,662
In general social skills groups

669
00:39:53,662 --> 00:39:55,971
don't particularly work for kids with ADHD

670
00:39:55,971 --> 00:40:00,432
because of the inconsistent
nature of their results.

671
00:40:00,432 --> 00:40:03,303
There are limited transfer of skills

672
00:40:03,303 --> 00:40:04,910
from inside the group,

673
00:40:04,910 --> 00:40:06,313
what happens during the group

674
00:40:06,313 --> 00:40:08,880
to out of the group situations?

675
00:40:08,880 --> 00:40:11,420
What's more effective
for kids is if they're

676
00:40:11,420 --> 00:40:14,358
in a situation that they receive feedback

677
00:40:14,358 --> 00:40:16,781
in that situation or shortly thereafter

678
00:40:16,781 --> 00:40:21,386
about what's happened while
it's still in their memory.

679
00:40:22,859 --> 00:40:26,065
Only about one third of
kids diagnosed with ADHD

680
00:40:26,065 --> 00:40:30,073
are being referred for
mental health services.

681
00:40:30,073 --> 00:40:33,131
That to me is a really big problem

682
00:40:33,131 --> 00:40:35,912
because if you're just taking the pills,

683
00:40:35,912 --> 00:40:39,276
again, you're available for the skills

684
00:40:39,276 --> 00:40:42,949
but you're not really
having any kind of process

685
00:40:42,949 --> 00:40:46,821
that's teaching you about
what those skills are

686
00:40:46,821 --> 00:40:51,821
directly or addressing some
of the emotional responses

687
00:40:51,852 --> 00:40:56,852
that you're having to the
skills deficit or acquisition.

688
00:40:59,963 --> 00:41:02,601
And it's not dealing with the ways

689
00:41:02,601 --> 00:41:07,601
of you're perceiving yourself

690
00:41:07,778 --> 00:41:11,834
either socially or within your family.

691
00:41:11,834 --> 00:41:16,050
I want to summarize
effective treatment for ADHD.

692
00:41:16,179 --> 00:41:20,923
Parent education about ADHD is critical.

693
00:41:20,923 --> 00:41:23,993
Psychopharmacology, very helpful.

694
00:41:23,993 --> 00:41:26,357
Parent training in behavior
and child management,

695
00:41:26,357 --> 00:41:29,328
also critical.

696
00:41:29,367 --> 00:41:32,198
Family therapy can be extremely useful.

697
00:41:32,198 --> 00:41:34,826
Behavioral interventions in the classroom.

698
00:41:34,826 --> 00:41:38,235
Parent support groups such as CHADD.

699
00:41:38,235 --> 00:41:40,567
They're reminding you again that

700
00:41:40,567 --> 00:41:42,911
there's a clear advantage
of combined treatment.

701
00:41:42,911 --> 00:41:47,911
so some behavior treatment
with some medication treatment.

702
00:41:51,809 --> 00:41:53,448
Let's talk for a minute about treatment

703
00:41:53,448 --> 00:41:56,517
for parents of kids with ADHD.

704
00:41:56,517 --> 00:41:59,457
It's really important
that you help the parents

705
00:41:59,457 --> 00:42:01,598
understand and accept that

706
00:42:01,598 --> 00:42:06,400
it is normal and expected
to find your loving,

707
00:42:06,400 --> 00:42:10,268
wonderful child extremely
challenging at times

708
00:42:10,268 --> 00:42:15,268
especially when he or she is
upset with what's going on,

709
00:42:17,581 --> 00:42:19,676
is having difficulty processing,

710
00:42:19,676 --> 00:42:24,676
and can't figure out how to maneuver

711
00:42:25,014 --> 00:42:28,720
the emotional response
and the thinking response.

712
00:42:28,935 --> 00:42:32,416
Kids work so hard to keep
it together at school

713
00:42:32,416 --> 00:42:35,659
all day long and if
they go to after school.

714
00:42:35,659 --> 00:42:39,031
After school, they can
be angry, and irritable,

715
00:42:39,031 --> 00:42:41,023
and melt down when they get home.

716
00:42:41,023 --> 00:42:43,862
That isn't necessarily a
reflection on the parent

717
00:42:43,862 --> 00:42:46,474
but more of a reflection on the fatigue

718
00:42:46,474 --> 00:42:47,874
that the child is feeling

719
00:42:47,874 --> 00:42:51,070
and cannot hold it together anymore.

720
00:42:51,070 --> 00:42:53,245
I think it's important
for parents to understand

721
00:42:53,245 --> 00:42:55,106
this idea that their children maybe

722
00:42:55,106 --> 00:42:57,677
up to three years behind in terms of

723
00:42:57,677 --> 00:43:01,983
their maturation than other kids their age

724
00:43:01,983 --> 00:43:03,623
because a lot of times in my office,

725
00:43:03,623 --> 00:43:07,163
I hear parents say, "Oh, he's 15.

726
00:43:07,163 --> 00:43:09,222
"He doesn't act like he's 15."

727
00:43:09,222 --> 00:43:11,062
I'll say, "Well, that's
because developmentally,

728
00:43:11,062 --> 00:43:14,463
"in some ways he's not 15. He's 12."

729
00:43:14,463 --> 00:43:16,569
If you think about him as 12,

730
00:43:16,569 --> 00:43:19,611
it's going to be a lot
easier for your and for him

731
00:43:19,611 --> 00:43:22,107
in terms of all of these
chores that he doesn't do

732
00:43:22,107 --> 00:43:24,468
or ways that he forgets things.

733
00:43:25,680 --> 00:43:29,473
It's important with
parents to review ADHD,

734
00:43:29,473 --> 00:43:33,447
to offer them things to read a book,

735
00:43:33,447 --> 00:43:37,161
a book on a CD, a podcast, something so

736
00:43:37,161 --> 00:43:38,892
that they can start to increase

737
00:43:38,892 --> 00:43:42,856
their fund of information about ADHD.

738
00:43:42,856 --> 00:43:45,164
Help them understand the nature of ADHD,

739
00:43:45,164 --> 00:43:50,164
the causes, the course of
ADHD, the various treatments.

740
00:43:50,875 --> 00:43:55,875
In some ways, I believe that
the parents have to grieve,

741
00:43:56,708 --> 00:44:00,211
and then accept the ADHD diagnosis.

742
00:44:00,211 --> 00:44:04,479
There is a disappoint that
pretty much every parent

743
00:44:04,479 --> 00:44:07,646
I've worked with and I've been
doing this for over 20 years,

744
00:44:07,646 --> 00:44:10,047
comes to the table with when their child

745
00:44:10,047 --> 00:44:11,996
is diagnosed with this.

746
00:44:11,996 --> 00:44:13,931
They're upset about it either because

747
00:44:13,931 --> 00:44:15,631
they themselves are dealing with this

748
00:44:15,631 --> 00:44:17,693
and they didn't want their
child to deal with it,

749
00:44:17,693 --> 00:44:20,564
or because they never dealt with it,

750
00:44:20,564 --> 00:44:22,837
and they didn't want their
child to deal with it,

751
00:44:22,837 --> 00:44:24,632
or they don't understand it.

752
00:44:24,632 --> 00:44:29,632
Whatever their set of
beliefs is about having ADHD,

753
00:44:29,879 --> 00:44:33,150
the myths that we talked about earlier,

754
00:44:33,150 --> 00:44:36,909
or their fears, all of
that has to be processed

755
00:44:36,909 --> 00:44:41,909
because it interferes
consciously or unconsciously

756
00:44:42,025 --> 00:44:44,756
with how they're addressing their kids,

757
00:44:44,756 --> 00:44:48,991
and working with their kids who have ADHD.

758
00:44:49,296 --> 00:44:51,027
You want to help their parents reduce

759
00:44:51,027 --> 00:44:56,027
the expectations of
their child by about 30%.

760
00:44:59,998 --> 00:45:04,998
You want to discuss ADHD
as a chronic condition.

761
00:45:06,707 --> 00:45:11,707
You want to help them with acceptance

762
00:45:11,809 --> 00:45:14,446
as I said but also advocacy.

763
00:45:14,446 --> 00:45:17,785
They have to start to
advocate for their child

764
00:45:17,785 --> 00:45:19,886
and then we want to teach the child

765
00:45:19,886 --> 00:45:22,554
to advocate for him or herself.

766
00:45:22,554 --> 00:45:25,535
One of my proudest moments as a therapist

767
00:45:25,535 --> 00:45:28,372
was when I had been working with a girl

768
00:45:28,372 --> 00:45:33,372
for about a year who had ADHD

769
00:45:36,846 --> 00:45:41,746
and some speech and language difficulties.

770
00:45:42,743 --> 00:45:44,208
She went to school

771
00:45:44,208 --> 00:45:49,208
and she was in a support class.

772
00:45:49,561 --> 00:45:54,561
She was maybe in ninth
grade or tenth grade.

773
00:45:57,467 --> 00:45:59,234
She was in the support class.

774
00:45:59,234 --> 00:46:04,234
She had been recently
diagnosed and placed there.

775
00:46:06,110 --> 00:46:11,047
This is a different person
from the earlier person.

776
00:46:11,047 --> 00:46:14,380
She was in English

777
00:46:14,380 --> 00:46:18,717
and her English teacher was
giving her vocabulary tests.

778
00:46:18,821 --> 00:46:20,277
She was failing.

779
00:46:20,277 --> 00:46:23,553
She took her vocabulary
test to her support class,

780
00:46:23,553 --> 00:46:26,121
and the teacher said,

781
00:46:26,121 --> 00:46:28,524
"You're not supposed to
have vocabulary classes.

782
00:46:28,524 --> 00:46:31,427
"It says on your IEP
that you are not supposed

783
00:46:31,427 --> 00:46:34,297
"to have vocabulary classes."

784
00:46:34,297 --> 00:46:37,167
She was very excited to hear this.

785
00:46:37,167 --> 00:46:40,103
I saw her that afternoon after she'd had

786
00:46:40,103 --> 00:46:42,376
this conversation with the teacher,

787
00:46:42,376 --> 00:46:45,215
the support service teacher.

788
00:46:45,215 --> 00:46:47,648
The next day, we talked
about it and she decides

789
00:46:47,648 --> 00:46:49,473
she was going to go talk to the teacher.

790
00:46:49,473 --> 00:46:52,156
The next day, she went into class

791
00:46:52,156 --> 00:46:54,618
and she said to the teacher,

792
00:46:54,618 --> 00:46:59,053
"I am not suppose to
have vocabulary tests."

793
00:46:59,053 --> 00:47:01,966
The teacher said, "Well,
I give vocabulary tests.

794
00:47:01,966 --> 00:47:05,664
"That's part of the
curriculum of my classroom."

795
00:47:05,664 --> 00:47:06,866
The girl said,

796
00:47:06,866 --> 00:47:09,064
"I am not supposed to
take vocabulary classes.

797
00:47:09,064 --> 00:47:10,703
"It's in my IEP.

798
00:47:10,703 --> 00:47:12,543
"If you have any questions about that,

799
00:47:12,543 --> 00:47:14,274
"you should asked Ms. so and so,

800
00:47:14,274 --> 00:47:16,913
"the teacher of my support class."

801
00:47:16,913 --> 00:47:19,411
This was a huge triumph for her.

802
00:47:19,411 --> 00:47:23,479
She stood up and advocated for herself.

803
00:47:23,479 --> 00:47:26,322
It was a turning point
for her in her life.

804
00:47:26,322 --> 00:47:30,377
She was changed from that experience.

805
00:47:31,060 --> 00:47:33,463
We want parents to understand that ADHD

806
00:47:33,463 --> 00:47:38,098
is a disorder of performance,
not of skill or intelligence,

807
00:47:38,098 --> 00:47:40,624
doing what you know, the when and where,

808
00:47:40,624 --> 00:47:42,764
not how or what.

809
00:47:42,764 --> 00:47:45,663
Using your past at the
point of performance.

810
00:47:45,663 --> 00:47:48,780
That's what ADHD is about.

811
00:47:48,780 --> 00:47:51,439
We want to help parents solve problems

812
00:47:51,439 --> 00:47:56,439
when they occur or as close to
it as they occur as possible.

813
00:47:56,911 --> 00:48:01,544
Most ADHD kids have problems
with delaying consequences.

814
00:48:01,544 --> 00:48:04,756
You want to help them
increase accountability

815
00:48:04,756 --> 00:48:09,756
and the frequency of
consequences so it's closed up.

816
00:48:10,394 --> 00:48:12,837
All people involved with a child

817
00:48:12,837 --> 00:48:17,241
have to participate
together for the success.

818
00:48:17,241 --> 00:48:20,909
Have them participate as
much as possible together.

819
00:48:20,909 --> 00:48:23,367
This means school and extended family

820
00:48:23,367 --> 00:48:25,973
who are active in the child's life.

821
00:48:25,973 --> 00:48:29,546
It means coordinating and meeting

822
00:48:29,546 --> 00:48:32,312
with the teacher and the parent sometimes

823
00:48:32,312 --> 00:48:35,618
so that everybody's on the same page.

824
00:48:37,321 --> 00:48:39,688
Also contacting the pediatrician

825
00:48:39,688 --> 00:48:41,354
or whoever is the prescriber so that

826
00:48:41,354 --> 00:48:45,457
again, that person feels like
he or she is in the loop.

827
00:48:45,457 --> 00:48:49,155
You want to teach the parents
to notice and appreciate

828
00:48:49,155 --> 00:48:54,155
the small and big changes
that their child is doing

829
00:48:54,396 --> 00:48:57,204
but especially the small ones.

830
00:48:57,204 --> 00:48:59,279
Because it's the little things

831
00:48:59,279 --> 00:49:02,654
like telling your teacher
that you don't have

832
00:49:02,654 --> 00:49:05,816
to take vocabulary tests.

833
00:49:05,816 --> 00:49:07,988
That's a triumph.

834
00:49:10,481 --> 00:49:12,260
Punishing kids for things that aren't

835
00:49:12,260 --> 00:49:15,193
in their control does not work.

836
00:49:15,193 --> 00:49:17,627
I frequently see parents
punishing their kids

837
00:49:17,627 --> 00:49:21,012
for things related to having ADHD.

838
00:49:21,012 --> 00:49:23,239
That does not work.

839
00:49:23,239 --> 00:49:25,899
It creates a bad spiral.

840
00:49:25,899 --> 00:49:28,579
It's important to decipher and know

841
00:49:28,579 --> 00:49:32,416
what is and isn't in your kids control.

842
00:49:32,416 --> 00:49:35,006
Of course, to understand
that at some point,

843
00:49:35,006 --> 00:49:37,231
behavior is behavior.

844
00:49:37,923 --> 00:49:40,545
Kids are told to try harder.

845
00:49:40,545 --> 00:49:44,289
Kids with ADHD are especially
told to try harder.

846
00:49:44,289 --> 00:49:47,094
They continue over and over to fail

847
00:49:47,094 --> 00:49:49,936
until often they stop trying.

848
00:49:51,360 --> 00:49:55,035
I'd like to read this from
Kathleen Nadeau's book,

849
00:49:55,035 --> 00:49:58,639
"Understanding Girls with ADD, ADHD."

850
00:49:59,068 --> 00:50:00,408
"When I get home in the evening,

851
00:50:00,408 --> 00:50:02,505
"I'm in charge of the homework detail.

852
00:50:02,505 --> 00:50:04,313
"Terry argues about everything

853
00:50:04,313 --> 00:50:05,873
"whether or not she has homework,

854
00:50:05,873 --> 00:50:07,181
"how much homework she has,

855
00:50:07,181 --> 00:50:09,317
"how long it will take her to do it,

856
00:50:09,317 --> 00:50:11,349
"what time she should start it,

857
00:50:11,349 --> 00:50:13,185
"and when she should have a break.

858
00:50:13,185 --> 00:50:15,652
"You cannot imagine the battles we have.

859
00:50:15,652 --> 00:50:17,927
"After I haven't seen her all day,

860
00:50:17,927 --> 00:50:21,198
"I hate for this to be the
basis of our relationship

861
00:50:21,198 --> 00:50:25,195
"and often we are struggling
up until her bedtime.

862
00:50:25,195 --> 00:50:27,157
"We both agree that I have become more

863
00:50:27,157 --> 00:50:29,140
"of a policeman than a dad,

864
00:50:29,140 --> 00:50:31,337
"and neither of us likes it.

865
00:50:31,337 --> 00:50:34,270
"I was complaining about this
to Terry's psychologists,

866
00:50:34,270 --> 00:50:36,644
"and she suggested we try a coach.

867
00:50:36,644 --> 00:50:38,235
"Since we hired Julie,

868
00:50:38,235 --> 00:50:41,049
"my interactions with
Terry are fun and loving,

869
00:50:41,049 --> 00:50:43,243
"and she gets her work done too.

870
00:50:43,243 --> 00:50:47,144
"A coach is one of the best
investments I've ever made."

871
00:50:47,392 --> 00:50:50,291
Now, in this particular situation
and some of the situations

872
00:50:50,291 --> 00:50:52,591
I have dealt with in my practice,

873
00:50:52,591 --> 00:50:55,596
a coach can be a tutor as well.

874
00:50:55,596 --> 00:50:58,422
A coach can be someone who takes over

875
00:50:58,422 --> 00:51:01,898
the homework police job for the parent.

876
00:51:01,898 --> 00:51:05,474
That will take that negativity and burden

877
00:51:05,474 --> 00:51:07,905
out of the parent-child relationship

878
00:51:07,905 --> 00:51:09,578
so that the parent-child relationship

879
00:51:09,578 --> 00:51:13,218
is freed up to have the good moments

880
00:51:13,218 --> 00:51:15,980
without this unpleasantness.

881
00:51:18,261 --> 00:51:23,159
Other suggestions for treating
parents of kids with ADHD.

882
00:51:23,159 --> 00:51:25,595
You want to help the parents learn

883
00:51:25,595 --> 00:51:28,931
how to cue their children externally

884
00:51:28,931 --> 00:51:31,398
which means make everything concrete.

885
00:51:31,398 --> 00:51:32,996
Say things.

886
00:51:33,330 --> 00:51:35,338
We're going to the store,

887
00:51:35,338 --> 00:51:37,573
you need to put your shoes on.

888
00:51:37,573 --> 00:51:39,570
Then get your coat

889
00:51:39,570 --> 00:51:41,743
and expect that your child will remember

890
00:51:41,743 --> 00:51:45,035
only one or two things at a time.

891
00:51:45,035 --> 00:51:46,918
One of the problems I see is that

892
00:51:46,918 --> 00:51:49,510
a parent of a five-year-old
or a six-year-old

893
00:51:49,510 --> 00:51:51,588
or even a seven-year-old with ADHD

894
00:51:51,588 --> 00:51:54,812
will roll out three or four things.

895
00:51:54,812 --> 00:51:56,715
Go to the bathroom, brush your teeth,

896
00:51:56,715 --> 00:51:59,362
and get your stuff so
we can go to the car.

897
00:51:59,362 --> 00:52:02,133
The child never gets
pass go to the bathroom

898
00:52:02,133 --> 00:52:05,235
because the child doesn't
hold all that information

899
00:52:05,235 --> 00:52:07,597
in his or her working memory.

900
00:52:07,597 --> 00:52:10,472
Don't rely so much on mental information

901
00:52:10,472 --> 00:52:12,302
but cue the kids externally.

902
00:52:12,302 --> 00:52:14,502
Sometimes that could be a checklist

903
00:52:14,502 --> 00:52:17,209
in the morning to continue
to be able to say your child,

904
00:52:17,209 --> 00:52:19,838
"Refer to your list.
Check with your list."

905
00:52:20,207 --> 00:52:22,846
A million times even.

906
00:52:22,846 --> 00:52:24,309
Make time physical.

907
00:52:24,309 --> 00:52:26,150
Remember that these kids don't have

908
00:52:26,150 --> 00:52:29,191
an internal clock that works.

909
00:52:29,191 --> 00:52:33,221
Whatever that looks like, a timer,

910
00:52:33,221 --> 00:52:38,221
teaching them to read obviously a clock

911
00:52:38,288 --> 00:52:42,624
but also maybe having
a reminder on a phone,

912
00:52:42,624 --> 00:52:44,528
if they have a phone.

913
00:52:44,528 --> 00:52:48,576
Lots of teenagers with
ADHD should use technology

914
00:52:48,576 --> 00:52:51,780
to help them remember things.

915
00:52:51,780 --> 00:52:53,845
There's alerts on the phone.

916
00:52:53,845 --> 00:52:55,276
There are reminders.

917
00:52:55,276 --> 00:52:58,957
It's the best way to
help them remember things

918
00:52:58,957 --> 00:53:02,987
without adding the stress of
having to remember things.

919
00:53:04,058 --> 00:53:09,058
Break up tasks into an event,
a response, and an outcome.

920
00:53:09,233 --> 00:53:12,992
Make the tasks smaller so
that they can be completed

921
00:53:12,992 --> 00:53:17,861
and the child can feel a sense
of success upon completion.

922
00:53:17,861 --> 00:53:21,498
Give immediate feedback
and praise is fine.

923
00:53:21,498 --> 00:53:23,100
I believe in praise.

924
00:53:23,100 --> 00:53:25,881
"Good job, I saw that you
got your coat. Nice job."

925
00:53:25,881 --> 00:53:30,354
Or "I saw that you put
all your books away.

926
00:53:30,354 --> 00:53:32,521
"I saw that you unpacked your lunch.

927
00:53:32,521 --> 00:53:34,020
"I appreciate that."

928
00:53:34,020 --> 00:53:35,751
Things like that.

929
00:53:35,751 --> 00:53:39,357
Increase personal
accountability without blame.

930
00:53:39,357 --> 00:53:42,085
I noticed that when you
came home from school,

931
00:53:42,085 --> 00:53:43,867
you didn't unpack you lunch.

932
00:53:43,867 --> 00:53:48,033
I really would like it if
you could unpack your lunch.

933
00:53:49,140 --> 00:53:52,666
That means you want to teach
parents to reduce delays

934
00:53:52,666 --> 00:53:56,312
and not to expect so that your kids

935
00:53:56,312 --> 00:53:57,638
have a lot of internal motivation

936
00:53:57,638 --> 00:53:59,648
and gratification for things.

937
00:53:59,648 --> 00:54:04,648
You want to change rewards
for activities periodically.

938
00:54:06,483 --> 00:54:09,326
Remember what I call the rule of three

939
00:54:09,326 --> 00:54:12,082
which is touch, talk, and eye contact.

940
00:54:12,082 --> 00:54:14,284
Get down to your child's level.

941
00:54:14,284 --> 00:54:17,823
Look down, put a hand
on the shoulder and say,

942
00:54:20,390 --> 00:54:25,390
"Susan, I would like you
to pick up your room.

943
00:54:25,605 --> 00:54:29,879
"Put all your shoes into your closet."

944
00:54:29,879 --> 00:54:33,236
Look, speak, touch.

945
00:54:33,639 --> 00:54:35,138
Keep a sense of humor.

946
00:54:35,138 --> 00:54:36,577
It's really hard for these parents

947
00:54:36,577 --> 00:54:37,852
to keep a sense of humor

948
00:54:37,852 --> 00:54:41,354
because they're really
frustrated and worn down.

949
00:54:42,754 --> 00:54:44,758
A lot of times in my office,

950
00:54:44,758 --> 00:54:46,287
there's a lot of laughter

951
00:54:46,287 --> 00:54:49,651
because I'm able to see
that things are funny,

952
00:54:49,851 --> 00:54:54,529
and corky, and eccentric and they don't.

953
00:54:54,529 --> 00:54:58,538
Once we're able to turn it
around so it is a little funnier

954
00:54:58,538 --> 00:55:01,642
or they can see the humor in it,

955
00:55:01,642 --> 00:55:04,935
things open up and lighten up.

956
00:55:04,935 --> 00:55:08,716
Anticipate problems settings
and help parents make a plan.

957
00:55:08,716 --> 00:55:10,753
That's really important.

958
00:55:10,753 --> 00:55:13,688
Review the plan before an event.

959
00:55:13,688 --> 00:55:18,688
Help parents figure out their
priorities and remember them.

960
00:55:19,720 --> 00:55:21,296
Because a lot of times,

961
00:55:21,296 --> 00:55:24,233
there is a huge list of
things that parents want

962
00:55:24,233 --> 00:55:25,633
their kids to do differently.

963
00:55:25,633 --> 00:55:29,004
I want them to do this and
this, and this, and this.

964
00:55:29,004 --> 00:55:32,143
People can only change
one thing at a time.

965
00:55:32,143 --> 00:55:33,806
Pick one and work on that.

966
00:55:33,806 --> 00:55:36,547
When that gets better,
you can pick another.

967
00:55:37,808 --> 00:55:42,504
Help parents practice
forgiveness of themselves,

968
00:55:42,504 --> 00:55:45,550
of their partner, of their child.

969
00:55:49,425 --> 00:55:54,425
For the kids themselves, in
terms of treating them for ADHD,

970
00:55:55,259 --> 00:56:00,259
I do not call it ADHD very often.

971
00:56:00,362 --> 00:56:02,325
Usually, I call it attention-wandering

972
00:56:02,325 --> 00:56:04,000
or whatever term the child

973
00:56:04,000 --> 00:56:06,741
has come up with for him or herself.

974
00:56:06,741 --> 00:56:10,680
Bullet brain, or energy buzz

975
00:56:10,680 --> 00:56:14,647
is another one that people
have called or ADLS.

976
00:56:14,647 --> 00:56:19,647
I use the term that the child
or teenager has referred to

977
00:56:20,256 --> 00:56:24,359
so that it make sense to them.

978
00:56:24,359 --> 00:56:27,791
It feels less patholigizing.

979
00:56:27,791 --> 00:56:30,299
In this way, I also
educate them about ADHD.

980
00:56:30,299 --> 00:56:33,164
I usually explain very simply a little bit

981
00:56:33,164 --> 00:56:35,192
about what's happening in the brain.

982
00:56:35,192 --> 00:56:38,328
Even to second graders
because they can understand

983
00:56:38,328 --> 00:56:43,328
that there cells and that
there's a chemicals, and changes.

984
00:56:43,633 --> 00:56:45,538
That helps them understand

985
00:56:45,538 --> 00:56:47,143
that something's happening in their brain

986
00:56:47,143 --> 00:56:51,841
but that they themselves are
not necessarily at fault.

987
00:56:52,922 --> 00:56:55,183
We discuss and we make every effort

988
00:56:55,183 --> 00:56:58,376
to reduce shame and negativity

989
00:56:58,376 --> 00:57:00,951
including naming famous people

990
00:57:00,951 --> 00:57:05,401
who've had ADHD whether
its Michael Phelps,

991
00:57:05,401 --> 00:57:10,401
or Tom Cruise or somebody they really like

992
00:57:11,934 --> 00:57:14,377
in a particular area
that's important to them

993
00:57:14,377 --> 00:57:19,202
like a baseball player or a famous dancer.

994
00:57:20,309 --> 00:57:22,053
I will actually give that as homework

995
00:57:22,053 --> 00:57:24,208
to ask them to go online with the parent

996
00:57:24,208 --> 00:57:26,087
for young children and of course,

997
00:57:26,087 --> 00:57:27,687
by themselves if they're older.

998
00:57:27,687 --> 00:57:32,057
And find a list of famous people
with ADHD whom they admire.

999
00:57:32,057 --> 00:57:35,562
I work with them on trying
to increase accountability.

1000
00:57:35,562 --> 00:57:39,823
Many kids with ADHD are skillful deniers.

1001
00:57:39,823 --> 00:57:42,202
They'll deny even up to the point

1002
00:57:42,202 --> 00:57:44,171
when the evidence is
right in front of them.

1003
00:57:44,171 --> 00:57:45,630
And so, we try to talk about

1004
00:57:45,630 --> 00:57:48,439
what's going on for them internally

1005
00:57:48,439 --> 00:57:50,107
when that process of denial

1006
00:57:50,107 --> 00:57:55,107
is what they're expressing
and bearing down on.

1007
00:57:56,878 --> 00:58:01,590
I help them work with me
to set up their own goals

1008
00:58:01,590 --> 00:58:04,226
for themselves in the treatment

1009
00:58:04,226 --> 00:58:07,584
and what steps they would
like to make toward that.

1010
00:58:09,030 --> 00:58:12,089
I use a strength-based
approach with treatment

1011
00:58:12,089 --> 00:58:15,363
to address this low
self-esteem that I often see

1012
00:58:15,363 --> 00:58:19,108
and to talk about the history

1013
00:58:19,108 --> 00:58:23,070
of humiliation in school or socially.

1014
00:58:23,070 --> 00:58:25,008
I try to help them improve their ability

1015
00:58:25,008 --> 00:58:29,450
to read social cues often
either in the family setting

1016
00:58:29,450 --> 00:58:31,775
or if the child and I are engaged

1017
00:58:31,775 --> 00:58:35,157
in playing or conversation.

1018
00:58:35,456 --> 00:58:38,983
I help the child slow down
to a body-oriented practice

1019
00:58:38,983 --> 00:58:41,464
that might make sense
to the child or teen,

1020
00:58:41,464 --> 00:58:46,464
maybe doing some yoga or some
breathing, or visualization.

1021
00:58:48,805 --> 00:58:49,559
As I said earlier,

1022
00:58:49,559 --> 00:58:54,277
I frequently refer to it
as attention-wandering.

1023
00:58:55,643 --> 00:58:58,371
I talk with the child about strains

1024
00:58:58,371 --> 00:59:01,149
that he or she may feel that they have.

1025
00:59:01,149 --> 00:59:05,314
What things they feel
good of or proud about?

1026
00:59:05,314 --> 00:59:08,058
What weaknesses they see in themselves?

1027
00:59:08,058 --> 00:59:10,558
I always ask the three wishes question.

1028
00:59:10,558 --> 00:59:13,729
If you could change anything
about yourself or your life,

1029
00:59:13,729 --> 00:59:16,523
with my magic wand, and
you had three wishes,

1030
00:59:16,523 --> 00:59:18,223
and you can't wish for more wishes,

1031
00:59:18,223 --> 00:59:20,237
what would that be?

1032
00:59:20,602 --> 00:59:25,068
I always ask about school
likes and dislikes.

1033
00:59:25,068 --> 00:59:28,875
I frequently will address
areas of pessimism,

1034
00:59:28,875 --> 00:59:31,881
isolation and lack of creative outlet.

1035
00:59:31,881 --> 00:59:34,480
Often I see kids who just
aren't doing anything

1036
00:59:34,480 --> 00:59:36,353
that they really love to do.

1037
00:59:36,353 --> 00:59:40,319
I really try to work with them
on figuring out what that is

1038
00:59:40,319 --> 00:59:44,354
and being open to trying it.

1039
00:59:49,795 --> 00:59:53,701
I also help them explore greater
sense of family connection.

1040
00:59:53,701 --> 00:59:56,369
I'm trying to figure
out if there is someone

1041
00:59:56,369 --> 00:59:57,864
in their family like them who also

1042
00:59:57,864 --> 01:00:01,437
has had some attention-wandering.

1043
01:00:02,211 --> 01:00:04,334
And what that's like for that person

1044
01:00:04,334 --> 01:00:06,673
and to bring that person into therapy,

1045
01:00:06,673 --> 01:00:08,878
if it's not a parent or a sibling

1046
01:00:08,878 --> 01:00:12,182
but someone they know to talk about it.

1047
01:00:12,182 --> 01:00:15,191
So that this child feels less alone

1048
01:00:15,191 --> 01:00:20,156
with a particular challenges
that he or she is facing.

1049
01:00:21,165 --> 01:00:22,991
I try to work with him or her

1050
01:00:22,991 --> 01:00:24,754
to increase the ability to self-reflect

1051
01:00:24,754 --> 01:00:27,390
by offering feedback
when the behaviors occur

1052
01:00:27,390 --> 01:00:31,107
and some reflection, what
do you notice you're doing?

1053
01:00:31,107 --> 01:00:34,801
What do you notice that
you might be feeling?

1054
01:00:34,801 --> 01:00:36,766
I engage with the child and I encourage

1055
01:00:36,766 --> 01:00:39,469
the child to engage in identifying

1056
01:00:39,469 --> 01:00:44,040
and creating rewards with
parents that work for him or her.

1057
01:00:45,221 --> 01:00:48,048
I talk a lot about this idea

1058
01:00:48,048 --> 01:00:53,048
of positive reinforcement to
combat fear and self-doubt.

1059
01:00:53,053 --> 01:00:56,253
Not in such necessarily big
words for little children,

1060
01:00:56,253 --> 01:00:57,591
although I will talk about it

1061
01:00:57,591 --> 01:01:00,433
using those words for older teens.

1062
01:01:00,433 --> 01:01:05,433
But more about what kinds
of self-talk and messages

1063
01:01:08,170 --> 01:01:12,773
that he or she is giving
to themselves inside

1064
01:01:12,773 --> 01:01:15,775
their head when things don't go the way

1065
01:01:16,836 --> 01:01:18,945
that they would like.

1066
01:01:18,945 --> 01:01:21,178
I stay very specific.

1067
01:01:21,178 --> 01:01:23,251
I have them write things down

1068
01:01:23,251 --> 01:01:25,225
and I try to stay as good-humored as I can

1069
01:01:25,225 --> 01:01:29,556
even when they're very angry
with me for who knows what.

1070
01:01:30,933 --> 01:01:34,365
I often invite the child to
bring in items of his or hers

1071
01:01:34,365 --> 01:01:37,351
that reflect a particular interest.

1072
01:01:37,474 --> 01:01:41,831
I had one child who is
very interested in poker.

1073
01:01:42,845 --> 01:01:46,804
I, myself, know nothing about poker

1074
01:01:46,804 --> 01:01:50,720
but I bought a set of chips and cards.

1075
01:01:52,612 --> 01:01:56,924
He came in and he would
teach me how to play poker.

1076
01:01:56,924 --> 01:01:58,526
That's how we would interact

1077
01:01:58,526 --> 01:02:00,823
and we would talk about all of this stuff

1078
01:02:00,823 --> 01:02:03,367
in the context of playing poker.

1079
01:02:04,130 --> 01:02:05,999
There are a few special considerations

1080
01:02:05,999 --> 01:02:09,733
in working with teens with
ADHD that I want to address.

1081
01:02:11,438 --> 01:02:16,438
First of all, teens in general
are seeking more freedom.

1082
01:02:18,375 --> 01:02:21,715
They want to show greater responsibility.

1083
01:02:23,678 --> 01:02:25,380
In general in our society,

1084
01:02:25,380 --> 01:02:28,754
there's a cultural value
on conformity and education

1085
01:02:28,754 --> 01:02:32,823
that puts teens with learning
differences at a disadvantage.

1086
01:02:33,961 --> 01:02:35,830
For teenagers who want

1087
01:02:35,830 --> 01:02:39,028
that greater freedom and independence,

1088
01:02:39,028 --> 01:02:40,359
it's really difficult because

1089
01:02:40,359 --> 01:02:44,238
having poor organizational
skills and poor time management

1090
01:02:44,238 --> 01:02:47,064
require greater parental involvement

1091
01:02:47,064 --> 01:02:50,204
in their lives at a time
when they want less.

1092
01:02:51,634 --> 01:02:54,285
Social difficulties are specially painful

1093
01:02:54,285 --> 01:02:56,646
for them at this age.

1094
01:02:56,646 --> 01:03:00,089
Teens with ADHD suffer
from academic problems,

1095
01:03:00,089 --> 01:03:03,788
negative self-image, social
difficulties with peers,

1096
01:03:03,788 --> 01:03:05,423
and often a lack of success

1097
01:03:05,423 --> 01:03:08,384
at extracurricular activities as well.

1098
01:03:08,384 --> 01:03:12,336
Chronic procrastination,
instant gratification, needs,

1099
01:03:12,336 --> 01:03:14,974
peer relationship
problems, talking too much,

1100
01:03:14,974 --> 01:03:18,028
problems reading the reactions of others,

1101
01:03:18,028 --> 01:03:21,243
teens with hyperactivity
are more often rejected

1102
01:03:21,243 --> 01:03:22,833
than other teens,

1103
01:03:22,833 --> 01:03:26,980
teens without hyperactivity can
be more ignored than others.

1104
01:03:27,887 --> 01:03:32,479
These all make adolescence
very, very painful

1105
01:03:32,479 --> 01:03:35,416
for teenagers with ADHD.

1106
01:03:37,755 --> 01:03:39,816
In addition, they still need parental help

1107
01:03:39,816 --> 01:03:43,623
to create external structures
and they resent that.

1108
01:03:44,007 --> 01:03:47,968
They need a treatment to help them improve

1109
01:03:47,968 --> 01:03:52,105
their self-monitoring
skills and time management.

1110
01:03:57,811 --> 01:04:00,917
Teens with ADHD have to
learn how to negotiate

1111
01:04:00,917 --> 01:04:02,616
with their parents, with their teachers,

1112
01:04:02,616 --> 01:04:04,553
with their peers, and
with their employers.

1113
01:04:04,553 --> 01:04:06,922
This is very difficult for them

1114
01:04:06,922 --> 01:04:09,355
because negotiating takes a series

1115
01:04:09,355 --> 01:04:11,091
of executive functioning skills that

1116
01:04:11,091 --> 01:04:13,356
are still underdeveloped in them

1117
01:04:13,356 --> 01:04:15,985
particularly compared
to their same age peers.

1118
01:04:15,985 --> 01:04:20,465
It involves emotional
regulation, inhibition,

1119
01:04:20,465 --> 01:04:23,302
and ability to understand themselves

1120
01:04:23,302 --> 01:04:25,205
and how they affect others,

1121
01:04:25,205 --> 01:04:30,143
some sort of planning and prioritizing.

1122
01:04:30,244 --> 01:04:32,045
They have a lot of self-blame and shame

1123
01:04:32,045 --> 01:04:34,604
about their executive functioning deficits

1124
01:04:34,604 --> 01:04:37,883
that have to be addressed before there

1125
01:04:37,883 --> 01:04:39,674
are any interventions or plans

1126
01:04:39,674 --> 01:04:42,825
because the shame sabotages any

1127
01:04:42,825 --> 01:04:46,151
possible interventions
that could help them.

1128
01:04:47,459 --> 01:04:48,990
They have to be involved

1129
01:04:48,990 --> 01:04:51,765
in co-creating any treatment agenda

1130
01:04:51,765 --> 01:04:55,470
or any goal setting
that their parents have.

1131
01:04:55,470 --> 01:04:58,300
The parent's goal cannot be the goal

1132
01:04:58,300 --> 01:05:00,671
of the therapy for an ADHD teen.

1133
01:05:00,671 --> 01:05:04,045
It has to be a collaborative goal.

1134
01:05:04,447 --> 01:05:08,475
Finally, these teens are
not good at multitasking.

1135
01:05:08,674 --> 01:05:10,843
They think they are but they're not.

1136
01:05:10,843 --> 01:05:12,356
That's something that we have

1137
01:05:12,356 --> 01:05:16,212
to start working on immediately.

1138
01:05:16,522 --> 01:05:19,315
I think it's worth noting that impulsivity

1139
01:05:19,315 --> 01:05:23,296
is looked upon with humor for boys

1140
01:05:23,296 --> 01:05:28,296
and frowned upon in
girls which makes it hard

1141
01:05:28,737 --> 01:05:32,935
to have ADHD for a girl
if you're impulsive

1142
01:05:32,935 --> 01:05:34,805
and funny if you're a boy.

1143
01:05:34,805 --> 01:05:38,615
Even though the consequences
are often not that funny.

1144
01:05:38,615 --> 01:05:41,938
Self-blame will lead to hopelessness

1145
01:05:41,938 --> 01:05:44,181
and depression more often in girls,

1146
01:05:44,181 --> 01:05:48,090
and aggression and defiance in boys.

1147
01:05:48,891 --> 01:05:51,726
You want to really help
the parents prioritize

1148
01:05:51,726 --> 01:05:55,115
what is most important to work on.

1149
01:05:55,115 --> 01:05:58,433
And not to sweat the small
stuff like messy rooms,

1150
01:05:58,433 --> 01:06:01,935
and no clean clothes if
they're going to school,

1151
01:06:01,935 --> 01:06:05,376
and doing their homework and
participating in an activity.

1152
01:06:05,376 --> 01:06:06,967
That's what's most important

1153
01:06:06,967 --> 01:06:08,809
that they're starting to develop a sense

1154
01:06:08,809 --> 01:06:12,402
of competency about themselves.

1155
01:06:12,402 --> 01:06:13,912
We talked a little bit earlier

1156
01:06:13,912 --> 01:06:17,108
about learning disabilities

1157
01:06:17,108 --> 01:06:20,522
and their co-occurrence with ADHD.

1158
01:06:20,522 --> 01:06:24,091
Really, what I want to say now is that

1159
01:06:24,091 --> 01:06:27,324
school is the worst domain of functioning

1160
01:06:27,324 --> 01:06:30,221
for children and teens with ADHD.

1161
01:06:30,221 --> 01:06:34,528
Because ADHD is a disorder of performance

1162
01:06:34,528 --> 01:06:37,974
which means you do what
you know and you apply it

1163
01:06:37,974 --> 01:06:40,236
when and where you should,

1164
01:06:40,236 --> 01:06:44,575
and you use your past to
help you with your present.

1165
01:06:44,575 --> 01:06:48,380
This is all very difficult for these kids

1166
01:06:48,380 --> 01:06:53,380
and because ADHD creates a
certain kind of time blindness,

1167
01:06:54,216 --> 01:06:55,945
and they're living in the moment,

1168
01:06:55,945 --> 01:06:59,783
they can't go back and easily refer to

1169
01:06:59,783 --> 01:07:01,462
what happen in the past and bring it

1170
01:07:01,462 --> 01:07:03,328
to what they're doing now.

1171
01:07:03,328 --> 01:07:06,091
They get stuck.

1172
01:07:07,537 --> 01:07:11,842
They live in this process
where they're in settings

1173
01:07:11,842 --> 01:07:14,541
where they know they really
should do something differently

1174
01:07:14,541 --> 01:07:16,508
but they're not exactly
sure what that thing is

1175
01:07:16,508 --> 01:07:20,005
because they can't totally remember it.

1176
01:07:21,048 --> 01:07:24,542
This is why the consequences
have to happen repeatedly

1177
01:07:24,542 --> 01:07:27,614
when the performance problem occurs

1178
01:07:27,614 --> 01:07:29,721
so that it can increase accountability

1179
01:07:29,721 --> 01:07:33,028
but also start to trigger the memory

1180
01:07:33,028 --> 01:07:36,085
and the memory systems will start

1181
01:07:36,085 --> 01:07:40,457
to lay into place in the neural pathways.

1182
01:07:40,457 --> 01:07:42,668
So that those get stronger

1183
01:07:42,668 --> 01:07:45,367
because we want those neural pathways

1184
01:07:45,367 --> 01:07:49,101
to remain and not be pruned out.

1185
01:07:52,775 --> 01:07:55,951
I have one more thing
that I would like to read.

1186
01:07:56,410 --> 01:08:01,410
About a girl again from
Kathleen Nadeau's book

1187
01:08:01,558 --> 01:08:06,271
and what it's like to do homework.

1188
01:08:07,461 --> 01:08:09,521
"At 5 pm, in order to begin working,

1189
01:08:09,521 --> 01:08:10,995
"Sara looks for a pencil

1190
01:08:10,995 --> 01:08:13,702
"and recognizes that the
point needs to be sharpened,

1191
01:08:13,702 --> 01:08:16,602
"regardless of how sharp it already is.

1192
01:08:16,602 --> 01:08:19,675
"She sees that the sharpener
is full of wood shavings

1193
01:08:19,675 --> 01:08:21,239
"and needs emptying.

1194
01:08:21,239 --> 01:08:23,733
"She empties the sharpener
over the waste basket

1195
01:08:23,733 --> 01:08:26,448
"but some shavings end up on the floor.

1196
01:08:26,448 --> 01:08:29,677
"She tries to brush each one
under the desk with her hand.

1197
01:08:29,677 --> 01:08:32,955
"Finally, Sara sits on the
floor amidst piles of papers

1198
01:08:32,955 --> 01:08:35,978
"because her desktop is
piled with so much clutter

1199
01:08:35,978 --> 01:08:38,114
"that she can't work in there.

1200
01:08:38,114 --> 01:08:42,264
"Many of her papers are folded
into small geometric shapes.

1201
01:08:42,264 --> 01:08:45,426
"Some of them figures and
some of them are announcements

1202
01:08:45,426 --> 01:08:48,667
"from school that were
meant for her parents.

1203
01:08:48,667 --> 01:08:50,199
"She unfolds one of these

1204
01:08:50,199 --> 01:08:52,972
"and thinks of bringing it
downstairs to her mother

1205
01:08:52,972 --> 01:08:56,779
"but first attempts to refold
it along the original lines.

1206
01:08:56,779 --> 01:09:01,179
"By now, it is 5:30 and Sara is no closer

1207
01:09:01,179 --> 01:09:06,179
"to starting her homework or
landing than she was before."

1208
01:09:06,622 --> 01:09:09,187
We've talked about ADHD

1209
01:09:09,187 --> 01:09:11,693
and a little teeny bit
about executive functioning.

1210
01:09:11,693 --> 01:09:15,327
Now, we're going to talk more explicitly

1211
01:09:15,327 --> 01:09:17,496
about executive functions.

1212
01:09:17,496 --> 01:09:19,930
What are executive functions?

1213
01:09:19,930 --> 01:09:21,693
The definition of executive function

1214
01:09:21,693 --> 01:09:25,561
is that they are thinking
and doing skills.

1215
01:09:25,561 --> 01:09:27,903
In general, executive functions

1216
01:09:27,903 --> 01:09:32,903
which reside in the prefrontal
cortex, the oy vey place.

1217
01:09:33,344 --> 01:09:38,344
Prioritize, integrate, control
other cognitive functions

1218
01:09:39,010 --> 01:09:44,010
but they manage self-regulation
of the brain as well.

1219
01:09:44,046 --> 01:09:46,792
Stress and fatigue hit

1220
01:09:46,792 --> 01:09:50,333
the weakest executive function skills.

1221
01:09:50,333 --> 01:09:52,050
We have thinking skills.

1222
01:09:52,050 --> 01:09:53,500
What are the thinking skills?

1223
01:09:53,500 --> 01:09:58,041
Working memory, planning, organization,

1224
01:09:58,041 --> 01:10:01,976
time management, and metacognition.

1225
01:10:02,298 --> 01:10:04,110
We have the doing skills.

1226
01:10:04,110 --> 01:10:07,837
Response inhibition, emotional control,

1227
01:10:07,837 --> 01:10:12,019
sustained attention, task initiation,

1228
01:10:12,019 --> 01:10:16,358
goal-directed persistence,
and flexibility.

1229
01:10:19,895 --> 01:10:23,219
Thomas Brown talks about
the executive functions

1230
01:10:23,219 --> 01:10:27,123
in the terms of thinking
about an orchestra.

1231
01:10:27,123 --> 01:10:30,192
The brain, and all of
the various instruments

1232
01:10:30,192 --> 01:10:32,568
so to speak are the orchestra.

1233
01:10:32,568 --> 01:10:36,839
The executive functions
are a set of conductors.

1234
01:10:36,839 --> 01:10:39,646
They tell certain parts of the brain

1235
01:10:39,646 --> 01:10:41,813
to do something at a particular time

1236
01:10:41,813 --> 01:10:46,447
when a particular task is needing

1237
01:10:46,447 --> 01:10:50,055
that skill or function of the brain.

1238
01:10:51,424 --> 01:10:54,590
The impairment for people with ADHD

1239
01:10:54,590 --> 01:10:58,100
in terms of executive
functions lies in their ability

1240
01:10:58,100 --> 01:11:00,566
to start and manage these functions

1241
01:11:00,566 --> 01:11:04,204
in the right order at the right time.

1242
01:11:04,204 --> 01:11:09,136
It doesn't basically lie with
the individual musicians.

1243
01:11:09,136 --> 01:11:12,702
That is the musicians in the
orchestra can play their parts.

1244
01:11:14,086 --> 01:11:17,744
For example, processing
emotional information

1245
01:11:17,744 --> 01:11:19,087
or processing memory.

1246
01:11:19,087 --> 01:11:22,846
Those parts generally
work but what happens is,

1247
01:11:22,846 --> 01:11:27,846
they aren't able to
start and follow through,

1248
01:11:29,165 --> 01:11:32,630
and move through their job responsibility.

1249
01:11:32,630 --> 01:11:34,702
And so what the executive functions do,

1250
01:11:34,702 --> 01:11:36,605
the set of skills I listed,

1251
01:11:36,605 --> 01:11:38,929
the thinking and the doing skills,

1252
01:11:38,929 --> 01:11:41,334
is that they try to start and guide

1253
01:11:41,334 --> 01:11:44,610
all of the individual players.

1254
01:11:44,610 --> 01:11:47,182
The role of the conductors
usually operates

1255
01:11:47,182 --> 01:11:49,388
without conscious awareness.

1256
01:11:49,388 --> 01:11:51,113
Often people try to tell people

1257
01:11:51,113 --> 01:11:53,781
that they've got to control
these functions more

1258
01:11:53,781 --> 01:11:55,019
which is unlikely.

1259
01:11:55,019 --> 01:11:57,244
What you can do is become aware

1260
01:11:57,244 --> 01:12:00,489
of what you're executive
function limits are

1261
01:12:00,489 --> 01:12:05,188
and what kinds of skills you
could build to improve them.

1262
01:12:09,165 --> 01:12:14,110
Executive functions as I said earlier

1263
01:12:14,110 --> 01:12:17,680
are a management set of skills

1264
01:12:17,680 --> 01:12:22,680
that involve thinking and
doing parts of the brain.

1265
01:12:24,612 --> 01:12:26,556
People can have impairments

1266
01:12:26,556 --> 01:12:30,961
in executive functioning
without having ADHD.

1267
01:12:30,961 --> 01:12:35,292
For example, I mentioned my
own struggles with timeliness

1268
01:12:35,292 --> 01:12:38,959
but people who have ADHD by definition

1269
01:12:38,959 --> 01:12:42,534
have impairment in executive functions.

1270
01:12:42,534 --> 01:12:47,534
Here is a list of the
main kinds of impairments.

1271
01:12:49,141 --> 01:12:52,714
Executive functions that are impaired

1272
01:12:52,714 --> 01:12:54,883
with in people who have ADHD.

1273
01:12:54,883 --> 01:12:57,784
They work in many different combinations.

1274
01:12:57,784 --> 01:13:02,784
We have organizing, prioritizing,
and activating to work.

1275
01:13:03,813 --> 01:13:07,626
That lies in the executive
function of activation.

1276
01:13:07,626 --> 01:13:10,018
We have focusing, sustaining,

1277
01:13:10,018 --> 01:13:12,225
and shifting attention to tasks.

1278
01:13:12,225 --> 01:13:15,899
That lies in the executive
function of focus.

1279
01:13:15,899 --> 01:13:19,338
We have regulating alertness,
sustaining attention,

1280
01:13:19,338 --> 01:13:21,239
and processing speed.

1281
01:13:21,239 --> 01:13:25,180
That lies in the executive
function of effort.

1282
01:13:25,180 --> 01:13:30,180
We have managing frustration
and modulating emotions.

1283
01:13:30,740 --> 01:13:35,155
That lies in the emotional
aspect of executive functioning.

1284
01:13:35,155 --> 01:13:38,617
We have utilizing memory
and accessing recall.

1285
01:13:38,617 --> 01:13:41,722
That's part of the memory
that can be impaired.

1286
01:13:41,722 --> 01:13:45,125
Then we have monitoring
and self-regulation.

1287
01:13:45,125 --> 01:13:47,666
That's involved in metacognition

1288
01:13:47,666 --> 01:13:50,600
so how do you understand yourself?

1289
01:13:50,600 --> 01:13:55,298
How do you see yourself in
the world, in relationship?

1290
01:13:55,298 --> 01:13:58,480
What is your perception of yourself?

1291
01:13:58,480 --> 01:14:02,317
That is one of the very
last skills to develop.

1292
01:14:02,317 --> 01:14:06,387
In general executive functions
develop by the age of 25,

1293
01:14:06,387 --> 01:14:09,022
and it can be because people with ADHD

1294
01:14:09,022 --> 01:14:12,485
are up to three years behind
in parts of their development.

1295
01:14:12,485 --> 01:14:14,888
That will continue into the 20s.

1296
01:14:14,888 --> 01:14:17,027
Some of the executive functions in people

1297
01:14:17,027 --> 01:14:19,931
with ADHD don't really fully mature

1298
01:14:19,931 --> 01:14:24,237
until the ages of around 27 or 28.

1299
01:14:25,498 --> 01:14:28,570
ADHD involves two major categories

1300
01:14:28,570 --> 01:14:31,346
of executive functioning impairment.

1301
01:14:31,346 --> 01:14:36,346
Sustained attention and
completion of tasks.

1302
01:14:36,440 --> 01:14:41,440
Basically, there's an area
called sustained-based context.

1303
01:14:42,755 --> 01:14:44,071
What does that mean?

1304
01:14:44,071 --> 01:14:46,352
That seems like a lot of
big complicated words.

1305
01:14:46,352 --> 01:14:50,595
What that means is the
ability to sustain attention

1306
01:14:50,595 --> 01:14:55,103
based on novelty, the
intrinsic value of the tasks,

1307
01:14:55,103 --> 01:14:58,371
and the extrinsic consequences of doing

1308
01:14:58,371 --> 01:15:00,331
or not doing the task.

1309
01:15:00,331 --> 01:15:02,378
If something is fun and interesting,

1310
01:15:02,378 --> 01:15:06,948
and immediately rewarding,
it's easier to be accomplished.

1311
01:15:06,948 --> 01:15:11,317
But goal-directed persistence
which is very difficult

1312
01:15:11,317 --> 01:15:15,686
for people with ADHD means
the person has to create

1313
01:15:15,686 --> 01:15:19,702
and hold a mental image
of a goal involving

1314
01:15:19,702 --> 01:15:22,623
your working memory, create a plan,

1315
01:15:22,623 --> 01:15:27,257
and rules to follow
through, self-direction,

1316
01:15:27,257 --> 01:15:31,797
hold back and control negative
feelings associated with

1317
01:15:31,797 --> 01:15:33,503
the self-deprivation and discipline

1318
01:15:33,503 --> 01:15:35,842
that might make something happen.

1319
01:15:35,842 --> 01:15:39,080
Make positive drives in support of a plan

1320
01:15:39,080 --> 01:15:41,147
so self-regulation of affect,

1321
01:15:41,577 --> 01:15:45,644
and experiment with different
approaches to achieving a goal

1322
01:15:45,644 --> 01:15:47,345
before choosing one.

1323
01:15:47,345 --> 01:15:52,345
That would be planning
and sort of flexibility.

1324
01:15:52,654 --> 01:15:56,330
All of those things
are frequently impaired

1325
01:15:56,330 --> 01:15:58,020
in people who have ADHD

1326
01:15:58,020 --> 01:16:01,898
in terms of their executive functioning.

1327
01:16:01,898 --> 01:16:03,963
Let's talk a little bit
about working memory,

1328
01:16:03,963 --> 01:16:07,096
ADHD, and executive functioning.

1329
01:16:07,096 --> 01:16:08,519
What is working memory?

1330
01:16:08,519 --> 01:16:10,541
Working memory allows a person

1331
01:16:10,541 --> 01:16:14,379
to hold several things
online simultaneously

1332
01:16:14,379 --> 01:16:17,787
to facilitate attending to other tasks.

1333
01:16:17,787 --> 01:16:19,351
That means if your goal

1334
01:16:19,351 --> 01:16:21,455
is to make a peanut
butter and jelly sandwich,

1335
01:16:21,455 --> 01:16:23,153
you hold that you want

1336
01:16:23,153 --> 01:16:24,713
to make the peanut
butter and jelly sandwich

1337
01:16:24,713 --> 01:16:26,352
but you've got to go through the steps of

1338
01:16:26,352 --> 01:16:29,830
taking out the bread,
getting the peanut butter,

1339
01:16:29,830 --> 01:16:33,730
getting the jelly, maybe getting a plate,

1340
01:16:33,730 --> 01:16:36,898
getting a knife to spread it,
putting the sandwich together,

1341
01:16:36,898 --> 01:16:39,065
putting the things back
in the refrigerator,

1342
01:16:39,065 --> 01:16:42,557
and then eating the sandwich.

1343
01:16:43,004 --> 01:16:44,571
Working memory is also something

1344
01:16:44,571 --> 01:16:47,043
that's called the search
engine of the brain.

1345
01:16:47,043 --> 01:16:50,571
It continuously activates stored memories

1346
01:16:50,571 --> 01:16:54,410
of various experiences,
physical experiences,

1347
01:16:54,410 --> 01:16:57,787
intellectual experiences,
emotional experiences,

1348
01:16:57,787 --> 01:17:02,354
interpersonal experiences
and integrates those memories

1349
01:17:02,354 --> 01:17:05,196
with current information to guide

1350
01:17:05,196 --> 01:17:07,957
your immediate thoughts and activities.

1351
01:17:07,957 --> 01:17:12,957
This working memory is
impaired in people with ADHD

1352
01:17:13,603 --> 01:17:16,505
because of the things
we talked about earlier

1353
01:17:16,505 --> 01:17:20,346
in terms of the dopamine,
channels in the brain,

1354
01:17:20,346 --> 01:17:22,984
and the norepinephrine.

1355
01:17:24,016 --> 01:17:25,310
This working memory it's like

1356
01:17:25,310 --> 01:17:28,013
the computational space of the brain.

1357
01:17:28,013 --> 01:17:30,755
There are networks of neurons that briefly

1358
01:17:30,755 --> 01:17:33,595
hold the thoughts and
perceptions of each moment

1359
01:17:33,595 --> 01:17:35,491
connect them to stored memories

1360
01:17:35,491 --> 01:17:38,461
and allow an individual to
put experiences together

1361
01:17:38,461 --> 01:17:40,132
to make sense of what's going on

1362
01:17:40,132 --> 01:17:43,563
in the current moment and act accordingly.

1363
01:17:43,563 --> 01:17:46,232
Without it, a person lives in present time

1364
01:17:46,232 --> 01:17:48,905
and can't really make
historical connections

1365
01:17:48,905 --> 01:17:51,244
from five minutes ago.

1366
01:17:52,535 --> 01:17:56,448
Using your working memory
requires pulling files

1367
01:17:56,448 --> 01:17:59,110
out of your memory of
information that's needed

1368
01:17:59,110 --> 01:18:02,311
for answering a question
or performing a task.

1369
01:18:02,311 --> 01:18:04,820
Emotion drives this engine.

1370
01:18:04,820 --> 01:18:08,287
Working memory also
draws on past experience

1371
01:18:08,287 --> 01:18:11,232
as I said to relate to a current situation

1372
01:18:11,232 --> 01:18:13,824
or a project into the future.

1373
01:18:13,824 --> 01:18:16,832
I've made peanut butter and
jelly sandwiches before.

1374
01:18:16,832 --> 01:18:18,064
I know how to do it.

1375
01:18:18,064 --> 01:18:21,640
I'm going to use that to make one now.

1376
01:18:21,640 --> 01:18:23,213
Even though I'm really hungry

1377
01:18:23,213 --> 01:18:24,807
and I know a part of me wants

1378
01:18:24,807 --> 01:18:26,944
to just scoop that peanut
butter out of the jar.

1379
01:18:26,944 --> 01:18:28,943
I'm going to really take the
time and make the sandwich

1380
01:18:28,943 --> 01:18:32,283
because that will be more satisfying to me

1381
01:18:32,283 --> 01:18:35,090
and my mom won't get mad.

1382
01:18:36,523 --> 01:18:38,758
Let's talk about how
executive functions ...