1 00:00:00,457 --> 00:00:03,520 - Let's talk about how executive functions develop. 2 00:00:03,858 --> 00:00:07,752 So as we know, executive functions guide behavior. 3 00:00:08,337 --> 00:00:11,640 They reside in the prefrontal cortex, 4 00:00:11,640 --> 00:00:14,808 and these executive functions, about 11 or 12 of them, 5 00:00:14,808 --> 00:00:17,553 have been identified and they work together 6 00:00:17,553 --> 00:00:21,211 as a team of conductors to light up parts of the brain 7 00:00:21,211 --> 00:00:26,211 frequently in collaboration with each other 8 00:00:26,309 --> 00:00:29,436 so that we can move through life planning and organizing 9 00:00:29,436 --> 00:00:32,674 and doing things that are very complicated 10 00:00:32,674 --> 00:00:35,178 and multi-layered. 11 00:00:35,871 --> 00:00:38,643 When we're born, when a baby is born, 12 00:00:38,643 --> 00:00:41,570 brain structures, myelination, the process 13 00:00:41,570 --> 00:00:44,558 of the fatty sheath developing around the neurons 14 00:00:44,558 --> 00:00:48,793 to speed the transmission of the chemical reactions, 15 00:00:48,793 --> 00:00:53,482 the electrical impulses that send one message 16 00:00:53,482 --> 00:00:56,829 from one neuron to another and neurotransmitter reactions 17 00:00:56,829 --> 00:00:58,710 are not fully developed. 18 00:00:59,479 --> 00:01:02,950 Individual physiology, genetics, and the patterns 19 00:01:02,950 --> 00:01:06,744 of human interactions between infants and care takers 20 00:01:06,744 --> 00:01:10,388 all influenced the development of neuro circuitry. 21 00:01:12,371 --> 00:01:14,204 What is the order of the emergence 22 00:01:14,204 --> 00:01:16,754 of these executive functions? 23 00:01:16,754 --> 00:01:20,212 So, the first thing that emerges is response inhibition. 24 00:01:20,212 --> 00:01:23,291 And that's the ability to think before you act. 25 00:01:23,291 --> 00:01:26,985 If there's a behavorial aspect to it, the ability to delay 26 00:01:26,985 --> 00:01:30,069 or respond leading to an immediate consequence. 27 00:01:31,331 --> 00:01:35,909 If I put my hand on something hot and it hurts me, 28 00:01:35,909 --> 00:01:39,117 I'm going to know not to put my hand on something hot, 29 00:01:39,117 --> 00:01:41,686 I'm going to inhibit that response, 30 00:01:41,686 --> 00:01:45,146 that urge to touch that hot thing. 31 00:01:45,146 --> 00:01:47,801 If response inhibition stops ongoing behaviors 32 00:01:47,801 --> 00:01:50,924 when they're unsuccessful, manages distractions 33 00:01:50,924 --> 00:01:53,710 that interfere with other cognitive functions 34 00:01:53,710 --> 00:01:56,021 and it starts at about age three 35 00:01:56,021 --> 00:01:58,903 and is usually developed by the age of 13. 36 00:01:59,826 --> 00:02:04,233 Non-verbal memory is the ability to represent people 37 00:02:04,233 --> 00:02:05,913 and events in the mind. 38 00:02:05,913 --> 00:02:08,161 Hindsight, foresight, and it's kind 39 00:02:08,161 --> 00:02:10,813 of like a spatial sketchpad. 40 00:02:10,813 --> 00:02:14,799 Emotional control, we call this self regulation. 41 00:02:14,799 --> 00:02:17,644 This is the ability to manage your emotions 42 00:02:17,644 --> 00:02:20,647 to achieve goals and direct behavior. 43 00:02:20,647 --> 00:02:24,275 At about six months, an infant develops the basic ability 44 00:02:24,275 --> 00:02:26,190 to hold an image in his or her mind 45 00:02:26,190 --> 00:02:27,831 and move towards something. 46 00:02:27,831 --> 00:02:31,857 This happens to dove tail nicely with the mobility skills 47 00:02:31,857 --> 00:02:34,867 that are developing physically at that time. 48 00:02:34,867 --> 00:02:38,572 Flexibility, this is the executive function 49 00:02:38,572 --> 00:02:42,568 that helps us revise, plans in light of new information 50 00:02:42,568 --> 00:02:45,668 and supports adaptability to change. 51 00:02:45,668 --> 00:02:48,338 We see this in young children all the time. 52 00:02:48,338 --> 00:02:49,784 They try something, 53 00:02:49,784 --> 00:02:54,030 try to put a square peg in a round hole 54 00:02:54,030 --> 00:02:56,877 and it doesn't work and they go to the square hole 55 00:02:56,877 --> 00:02:58,088 and they put the square peg in there. 56 00:02:58,088 --> 00:03:00,709 They've revised their plan in light 57 00:03:00,709 --> 00:03:03,152 of the new information that didn't fit. 58 00:03:03,768 --> 00:03:05,737 Sustained attention, this is the ability 59 00:03:05,737 --> 00:03:09,907 to maintain intention to a situation or task regardless 60 00:03:09,907 --> 00:03:13,767 of fatigue, boredom or distractability. 61 00:03:13,767 --> 00:03:17,308 The next one to develop is initiation of tasks, 62 00:03:17,308 --> 00:03:19,529 the ability to start tasks without 63 00:03:19,529 --> 00:03:23,240 too much procrastination or delay. 64 00:03:29,469 --> 00:03:31,601 We're going to continue reviewing 65 00:03:31,601 --> 00:03:34,225 how these executive functions develop. 66 00:03:34,225 --> 00:03:36,462 So internalization of speech which 67 00:03:36,462 --> 00:03:38,568 is called verbal working memory. 68 00:03:38,568 --> 00:03:41,060 This is using words to communicate thoughts, 69 00:03:41,060 --> 00:03:43,289 feelings, and self-talk. 70 00:03:43,782 --> 00:03:45,759 Vygotski has a model of how language 71 00:03:45,759 --> 00:03:48,505 becomes private and internalized and it's very relevant 72 00:03:48,505 --> 00:03:51,029 to this particular executive function. 73 00:03:51,029 --> 00:03:54,699 And it's very important with people who have ADHD. 74 00:03:55,437 --> 00:03:59,079 From zero to three, children will speak to others. 75 00:03:59,079 --> 00:04:01,593 They don't really have a mind's voice. 76 00:04:01,593 --> 00:04:04,233 Whatever they think, comes right out. 77 00:04:04,725 --> 00:04:05,750 Between the ages of four and five, 78 00:04:05,750 --> 00:04:08,707 the voice turns a little bit back on themselves 79 00:04:08,707 --> 00:04:11,284 and they talk out loud to themselves. 80 00:04:11,284 --> 00:04:15,565 They'll often say, "I do this", or they'll name themselves 81 00:04:15,565 --> 00:04:16,912 and as they're doing an activity, 82 00:04:16,912 --> 00:04:19,262 they'll talk themselves through things. 83 00:04:19,262 --> 00:04:21,630 Around the ages of six to eight, there's a shift 84 00:04:21,630 --> 00:04:24,161 from description to instruction. 85 00:04:24,161 --> 00:04:28,556 The voice in your head develops around age seven. 86 00:04:28,556 --> 00:04:30,301 By age nine, there is no longer 87 00:04:30,301 --> 00:04:32,919 any publicly observable speech. 88 00:04:32,919 --> 00:04:37,124 What that means is that, around four, 89 00:04:38,324 --> 00:04:42,244 what the child will do is say, "I make a picture." 90 00:04:43,197 --> 00:04:47,419 Around six, the child will say, "I want you 91 00:04:47,419 --> 00:04:50,327 "to make a picture of trees." 92 00:04:51,665 --> 00:04:54,701 The self-talk is less about description or, 93 00:04:55,270 --> 00:04:56,920 if the child will talk to himself, and say, 94 00:04:56,920 --> 00:04:58,475 "I'm making a picture" and let's see, 95 00:04:58,475 --> 00:05:01,718 I think I want to put some trees here and some flowers here. 96 00:05:01,718 --> 00:05:04,466 So they talk themselves through their activities. 97 00:05:04,466 --> 00:05:06,746 That's very common from six to eight. 98 00:05:06,746 --> 00:05:10,201 Around age, between ages seven and nine, 99 00:05:10,201 --> 00:05:12,465 the voice that we all have in our heads 100 00:05:12,465 --> 00:05:14,024 of kind of talking ourselves 101 00:05:14,024 --> 00:05:16,925 through things silently, develops. 102 00:05:16,925 --> 00:05:20,619 By about nine, generally most kids don't talk themselves 103 00:05:20,619 --> 00:05:23,061 through things out loud. 104 00:05:23,061 --> 00:05:27,431 With ADHD, kids continue to think 105 00:05:27,431 --> 00:05:30,837 and talk aloud most of the time 106 00:05:30,837 --> 00:05:33,829 because they can't do it in their brains. 107 00:05:33,829 --> 00:05:37,483 There's a failure to internalize that speech, 108 00:05:37,483 --> 00:05:39,730 the switch is broken. 109 00:05:39,730 --> 00:05:42,924 Actually, it's quite helpful for them to be able 110 00:05:42,924 --> 00:05:45,161 to talk themselves through an activity 111 00:05:45,161 --> 00:05:47,838 because it's a way that they organize themselves. 112 00:05:49,745 --> 00:05:51,611 In terms of the next executive function, 113 00:05:51,611 --> 00:05:53,514 planning and prioritizing. 114 00:05:53,514 --> 00:05:56,410 Planning creates a road map to reach a goal. 115 00:05:56,410 --> 00:05:58,706 You divide complex behavioral sequences 116 00:05:58,706 --> 00:06:02,973 into different components to solve new problems, 117 00:06:02,973 --> 00:06:06,698 excuse me, or obtain new goals. 118 00:06:06,698 --> 00:06:08,873 It also is an ability to find a good fit 119 00:06:08,873 --> 00:06:11,139 between a problem and a solution. 120 00:06:11,139 --> 00:06:12,785 The ability to make decisions 121 00:06:12,785 --> 00:06:15,463 about what's important and what's not. 122 00:06:15,463 --> 00:06:19,418 Planning and prioritizing are very important skills 123 00:06:19,418 --> 00:06:24,418 that need to develop particularly as a child becomes 124 00:06:24,593 --> 00:06:27,046 and wants to become more independent. 125 00:06:27,046 --> 00:06:30,453 If I wanna go out with my friends, 126 00:06:30,453 --> 00:06:33,555 then I'll have to do my homework before I go out 127 00:06:33,555 --> 00:06:35,373 or if I want to go out with my friends 128 00:06:35,373 --> 00:06:40,341 and I need a ride from my mom, I have to ask her 129 00:06:41,002 --> 00:06:43,191 more than five minutes before the event, 130 00:06:43,191 --> 00:06:46,207 those kinds of things are very helpful 131 00:06:46,207 --> 00:06:48,961 and important to learn how to do. 132 00:06:49,175 --> 00:06:52,489 Organization, another executive function 133 00:06:52,489 --> 00:06:55,534 which is the ability to create and maintain systems 134 00:06:55,534 --> 00:06:58,214 to keep track of your information and stuff. 135 00:06:58,214 --> 00:07:01,277 That would develop probably next. 136 00:07:01,277 --> 00:07:02,876 Time management. 137 00:07:03,552 --> 00:07:07,073 Time management is tough, as I've said. 138 00:07:07,073 --> 00:07:08,843 It is the ability to develop 139 00:07:08,843 --> 00:07:11,345 accurate time estimation for tasks. 140 00:07:11,345 --> 00:07:14,815 How much time do you have, how you allocate it, 141 00:07:14,815 --> 00:07:17,480 how you budget it, and how to keep within deadlines. 142 00:07:17,480 --> 00:07:21,438 This is extremely difficult for people with ADHD. 143 00:07:21,438 --> 00:07:24,290 Actually, one of the ways that I work with them 144 00:07:24,290 --> 00:07:27,661 on this particular executive function limitation 145 00:07:27,661 --> 00:07:29,362 is backward design. 146 00:07:29,362 --> 00:07:32,086 So we start with when they have to be some where, 147 00:07:32,086 --> 00:07:36,616 and go backwards using an example from their lives, 148 00:07:36,616 --> 00:07:39,321 of something that has happened recently. 149 00:07:39,321 --> 00:07:41,064 How long does it take? 150 00:07:41,064 --> 00:07:43,798 What time, what time, what time? 151 00:07:43,798 --> 00:07:48,150 And to really accurately, as much as possible, 152 00:07:48,150 --> 00:07:50,388 assess how much time things take 153 00:07:50,388 --> 00:07:53,539 and then we add a little extra, ten minutes, 154 00:07:53,539 --> 00:07:57,354 because things almost always take longer than we expect. 155 00:07:57,354 --> 00:07:59,809 But backward design is helpful for them, 156 00:07:59,809 --> 00:08:03,539 it's very concrete, forward design does not work as well. 157 00:08:04,554 --> 00:08:06,506 Because of the planning challenges 158 00:08:06,506 --> 00:08:09,704 that go along with having ADHD. 159 00:08:09,958 --> 00:08:11,699 Persistence to achieve a goal. 160 00:08:11,699 --> 00:08:14,507 This is another key executive function. 161 00:08:14,507 --> 00:08:17,396 We call this persistence or sustained attention 162 00:08:17,396 --> 00:08:19,761 and it's the capacity to follow through on something 163 00:08:19,761 --> 00:08:23,120 without being waylaid by competing interests. 164 00:08:23,120 --> 00:08:28,120 It really depends on immediate versus delayed gratification. 165 00:08:29,420 --> 00:08:31,520 For people with ADHD, they tend 166 00:08:31,520 --> 00:08:33,927 to want immediate gratification. 167 00:08:33,927 --> 00:08:36,248 Unfortunately, a lot of the things we have to do 168 00:08:36,248 --> 00:08:38,735 in the world, particularly in school, 169 00:08:38,735 --> 00:08:41,428 rely on delayed gratification. 170 00:08:44,212 --> 00:08:47,189 You have to learn how to develop the ability 171 00:08:47,189 --> 00:08:50,934 to sustain your attention in the context 172 00:08:50,934 --> 00:08:53,079 where you're operating. 173 00:08:53,079 --> 00:08:57,577 We call that goal directed persistence 174 00:08:57,577 --> 00:09:00,639 and it relies on context 175 00:09:00,639 --> 00:09:03,455 dependent sustained attention. 176 00:09:03,455 --> 00:09:06,394 In plainer or more simpler terms, 177 00:09:06,394 --> 00:09:09,873 if you want to be able to stick with your focus 178 00:09:09,873 --> 00:09:12,958 and stay with your goal, you have to be able 179 00:09:12,958 --> 00:09:16,721 to sustain your attention, regardless of the context 180 00:09:16,721 --> 00:09:18,384 that you're in. 181 00:09:18,384 --> 00:09:21,533 One of the problems for people with ADHD is that, 182 00:09:21,533 --> 00:09:26,205 they actually have trouble doing that. 183 00:09:26,205 --> 00:09:29,625 If the context changes, their ability to sustain 184 00:09:29,625 --> 00:09:32,820 attention changes which makes sense because that's true 185 00:09:32,820 --> 00:09:34,269 for all of us sometimes. 186 00:09:34,269 --> 00:09:37,377 But they have trouble regrouping and refocusing. 187 00:09:38,945 --> 00:09:42,114 Metacognition, one of my favorites actually. 188 00:09:42,114 --> 00:09:47,007 Because it's something I've seen really change over time 189 00:09:47,007 --> 00:09:49,551 in a number of my clients as they've matured. 190 00:09:50,997 --> 00:09:54,220 As they've come to therapy, the skill can be developed 191 00:09:54,220 --> 00:09:55,680 and it's very important. 192 00:09:55,680 --> 00:09:59,865 Metacognition is self involved, self regulation, 193 00:09:59,865 --> 00:10:03,574 as we talked about what that is, the control of emotions, 194 00:10:03,574 --> 00:10:07,616 arousal, and the ability to take perspectives. 195 00:10:07,616 --> 00:10:11,834 The ability to take perspectives is very hard for children 196 00:10:11,834 --> 00:10:14,314 and teenagers with ADHD. 197 00:10:14,314 --> 00:10:17,650 Mostly, metacognition involves 198 00:10:17,650 --> 00:10:21,462 using working memory to talk and look back 199 00:10:21,462 --> 00:10:24,323 on past experiences and situations. 200 00:10:24,323 --> 00:10:28,332 See what you did, look at a current situation, 201 00:10:28,332 --> 00:10:31,052 and evaluate if you need to make changes 202 00:10:31,052 --> 00:10:32,889 on what you're doing. 203 00:10:32,889 --> 00:10:37,411 The key to metacognition is the ability to step back 204 00:10:37,411 --> 00:10:40,855 and take a bird's eye view of yourself. 205 00:10:40,855 --> 00:10:44,195 And ask yourself, "How am I dong? 206 00:10:44,195 --> 00:10:47,144 "How are others perceiving me? 207 00:10:48,451 --> 00:10:51,927 "Is there something that I'm missing?" 208 00:10:51,927 --> 00:10:56,927 This is hard because there's a lot of shame related to ADHD, 209 00:10:57,064 --> 00:11:00,517 embarrassment about missing things and anxiety 210 00:11:00,517 --> 00:11:04,128 about trying to get whatever you're missing. 211 00:11:06,834 --> 00:11:08,258 We're going to talk a little bit more 212 00:11:08,258 --> 00:11:10,651 about how executive functions skills develop. 213 00:11:10,651 --> 00:11:13,384 As I said, they start in infancy 214 00:11:13,384 --> 00:11:16,796 and they continue into adolescence. 215 00:11:17,934 --> 00:11:22,739 Basically there's an external to internal process 216 00:11:22,739 --> 00:11:25,237 and we talked earlier about how parents often 217 00:11:25,237 --> 00:11:28,561 are the executive functions early on for their children 218 00:11:28,561 --> 00:11:33,561 in terms of helping them learn to inhibit their responses, 219 00:11:33,712 --> 00:11:38,712 learn to know, that's hot, that's hot, 220 00:11:39,566 --> 00:11:41,206 you don't want to touch that, 221 00:11:41,206 --> 00:11:44,954 they teach them that or they'll, as I said, 222 00:11:44,954 --> 00:11:48,562 help them figure out, you know, they put their pants 223 00:11:48,562 --> 00:11:51,843 on before you put your shoes on, kind of a thing. 224 00:11:53,534 --> 00:11:56,895 Eventually the things that parents teach them 225 00:11:56,895 --> 00:11:59,774 from the outside, or teachers work with them on, 226 00:11:59,774 --> 00:12:03,110 or you as therapists will work with your clients on, 227 00:12:03,110 --> 00:12:04,929 will become internalized to them, 228 00:12:04,929 --> 00:12:09,796 and they'll start to absorb the routines and the processes 229 00:12:09,796 --> 00:12:12,676 that we're trying to help them become more aware of. 230 00:12:13,814 --> 00:12:16,813 There is a parallel development of the brain 231 00:12:16,813 --> 00:12:19,398 and executive functioning skills. 232 00:12:19,398 --> 00:12:22,009 As the brain changes 233 00:12:22,009 --> 00:12:24,620 over the trajectory of childhood, 234 00:12:24,620 --> 00:12:27,233 adolescence into young adulthood, 235 00:12:27,233 --> 00:12:29,813 so do the executive functioning skills. 236 00:12:29,813 --> 00:12:33,814 In puberty, the size and quantity of neural networks 237 00:12:33,814 --> 00:12:36,241 dramatically increase especially 238 00:12:36,241 --> 00:12:39,162 in the frontal lobes and cerebellum. 239 00:12:39,162 --> 00:12:41,661 And there's also, what I referred to before, 240 00:12:41,661 --> 00:12:45,507 as increased myelination, so the thickening 241 00:12:45,507 --> 00:12:49,688 of the fatty sheath around the neural cells 242 00:12:49,688 --> 00:12:52,424 that's in the corpus callosum that connects 243 00:12:52,424 --> 00:12:54,684 the left and right sides of the brain. 244 00:12:55,330 --> 00:12:58,975 This proliferation of brain cells is followed 245 00:12:58,975 --> 00:13:02,308 by a period of pruning the networks. 246 00:13:02,308 --> 00:13:06,480 The system will operate as efficiently as possible. 247 00:13:06,910 --> 00:13:09,868 The increase in the myelination in the corpus callosum 248 00:13:09,868 --> 00:13:13,173 is critical for the more complex use of language 249 00:13:13,173 --> 00:13:16,257 and logical thinking and metacognition 250 00:13:16,257 --> 00:13:21,212 that we see in later adolescence and early adulthood. 251 00:13:27,024 --> 00:13:31,794 If we look at the development of executive function skills, 252 00:13:31,794 --> 00:13:35,955 that these executive functions skills 253 00:13:35,955 --> 00:13:38,235 have to be taught directly. 254 00:13:38,235 --> 00:13:40,840 The frontal lobes are still developing 255 00:13:40,840 --> 00:13:44,861 and so the skills have to be taught thinking about them 256 00:13:44,861 --> 00:13:48,501 as concrete skills not an innate thing 257 00:13:48,501 --> 00:13:51,291 that you should just know because no one 258 00:13:51,291 --> 00:13:53,466 comes into the world knowing them. 259 00:13:53,466 --> 00:13:56,281 They need to be taught. 260 00:13:56,942 --> 00:13:59,728 Teaching executive functions skills 261 00:13:59,728 --> 00:14:04,228 increases the probability of academic success 262 00:14:04,228 --> 00:14:06,276 and better self esteem. 263 00:14:06,276 --> 00:14:09,198 It's important to remember that the dopamine 264 00:14:09,198 --> 00:14:11,744 and norepinephrine pathways in the brain 265 00:14:11,744 --> 00:14:14,802 are especially slow to develop. 266 00:14:15,401 --> 00:14:20,184 Rather than being angry and frustrated and blaming kids 267 00:14:20,184 --> 00:14:23,977 for what they can't do, we would do much better 268 00:14:23,977 --> 00:14:28,790 to think about this as a developmental sequence problem 269 00:14:29,128 --> 00:14:31,803 with a deficit of skills. 270 00:14:32,650 --> 00:14:35,616 How do we assess executive functioning skills? 271 00:14:35,616 --> 00:14:38,790 Well, we conduct a multi-dimensional assessment. 272 00:14:38,790 --> 00:14:42,709 That would include understanding the pattern of strengths 273 00:14:42,709 --> 00:14:46,193 and weaknesses in the child's executive function skills. 274 00:14:46,193 --> 00:14:49,454 The two critical things that we want to look at 275 00:14:49,454 --> 00:14:52,473 are sustained attention and initiation. 276 00:14:52,473 --> 00:14:55,670 These are not accounted for in standardized testing 277 00:14:55,670 --> 00:14:59,932 because the evaluator will say, "Okay, start," 278 00:14:59,932 --> 00:15:01,957 so the person starts. 279 00:15:02,910 --> 00:15:05,671 We want to get a bunch of information 280 00:15:05,671 --> 00:15:07,771 and that would include: classroom observations, 281 00:15:07,771 --> 00:15:11,071 work samples, behavior checklists such as the BRIEF, 282 00:15:11,071 --> 00:15:15,144 the Brown ADD Scales, the CBCL, the Vanderbilt Scales, 283 00:15:15,144 --> 00:15:18,464 or the BASC, and of course a thorough history 284 00:15:18,464 --> 00:15:20,949 from parents and from teachers. 285 00:15:20,949 --> 00:15:23,605 We went to rely on the process, what we observe 286 00:15:23,605 --> 00:15:27,036 and know about this child, rather than just the scores. 287 00:15:27,852 --> 00:15:30,900 Diagnostic tools include a thorough history 288 00:15:30,900 --> 00:15:35,417 from two separate parties: parents, teachers, the child 289 00:15:35,417 --> 00:15:39,012 him or herself if that's possible, sibling or partner. 290 00:15:39,012 --> 00:15:42,216 Neuropsychological testing could be very helpful. 291 00:15:42,216 --> 00:15:46,683 Hallowell recommends the quantitative electroencephalogram, 292 00:15:46,683 --> 00:15:49,271 the QEEG. 293 00:15:49,577 --> 00:15:52,367 I find the Barclay ADHD and Executive Functions Forms 294 00:15:52,367 --> 00:15:54,809 very helpful and I also find the forms 295 00:15:54,809 --> 00:15:59,809 from Dawon and Guare's books: Smart but Scattered, 296 00:15:59,952 --> 00:16:02,126 and Smart but Scattered Teens. 297 00:16:02,140 --> 00:16:03,701 They have another book, I think, 298 00:16:03,701 --> 00:16:05,724 of just assessing executive functions skills 299 00:16:05,724 --> 00:16:09,298 to be really useful, user friendly 300 00:16:09,990 --> 00:16:12,526 and extremely informative. 301 00:16:13,682 --> 00:16:15,294 Let's talk a little bit about the spectrum 302 00:16:15,294 --> 00:16:17,558 of executive function. 303 00:16:18,897 --> 00:16:20,979 What does it cover in the brain? 304 00:16:20,979 --> 00:16:25,434 So the thing is, you can have executive functions and ADHD 305 00:16:25,434 --> 00:16:27,568 which overlap with the executive functions 306 00:16:27,568 --> 00:16:31,670 and learning disabilities which overlap 307 00:16:31,670 --> 00:16:32,941 with the executive functions. 308 00:16:32,941 --> 00:16:37,476 It's really a broad term and has a lot 309 00:16:37,476 --> 00:16:42,122 of consequences for how someone functions. 310 00:16:42,122 --> 00:16:45,030 All psychiatric and learning disorders 311 00:16:45,030 --> 00:16:48,184 interfere with attention, but it's important 312 00:16:48,184 --> 00:16:53,184 to remember that ADHD is a working memory deficit. 313 00:16:54,147 --> 00:16:56,994 I think it's important that you take a whole child approach 314 00:16:56,994 --> 00:16:59,803 when you work with kids with ADHD. 315 00:17:01,832 --> 00:17:02,636 There's a false belief 316 00:17:02,636 --> 00:17:05,922 that if you fix a disfunctional component 317 00:17:05,922 --> 00:17:08,671 of a child then you fix the child. 318 00:17:08,671 --> 00:17:12,444 If the child has reading trouble, and you "fixed" that, 319 00:17:12,444 --> 00:17:14,482 then you fix the child. 320 00:17:16,697 --> 00:17:18,496 It doesn't always work that way. 321 00:17:18,496 --> 00:17:22,343 We want to think about what helps the whole child manage. 322 00:17:22,343 --> 00:17:25,110 As we know there are three types of learning disabilities: 323 00:17:25,110 --> 00:17:28,743 reading, mathematics and disorders of written expression. 324 00:17:29,035 --> 00:17:32,637 That are especially challenging and have been found 325 00:17:32,637 --> 00:17:35,859 to be associated with ADHD. 326 00:17:37,889 --> 00:17:41,493 How do we intervene to improve executive functions? 327 00:17:41,493 --> 00:17:43,763 Well, we intervene, for one, 328 00:17:43,763 --> 00:17:46,981 at the level of the environment. 329 00:17:46,981 --> 00:17:49,577 What are the expectations of the tasks? 330 00:17:49,577 --> 00:17:52,565 What are the prompts to perform the tasks? 331 00:17:52,565 --> 00:17:56,193 How do the adults interact with the children? 332 00:17:56,608 --> 00:17:58,781 We intervene at the level of the person, 333 00:17:58,781 --> 00:18:01,247 improving the individual's capacity to use his 334 00:18:01,247 --> 00:18:06,087 or her own executive skills through motivation, increased 335 00:18:06,087 --> 00:18:07,701 awareness of what those skills 336 00:18:07,701 --> 00:18:11,096 or deficits are and instruction. 337 00:18:11,096 --> 00:18:15,799 We shift gradually from external to internal dimensions. 338 00:18:15,799 --> 00:18:18,817 We shift from making a checklist that we hang 339 00:18:18,817 --> 00:18:23,174 on the refrigerator to, over time, hoping that parts 340 00:18:23,174 --> 00:18:26,149 of that check list become internalized, which they will, 341 00:18:26,149 --> 00:18:28,334 when there's consistency. 342 00:18:28,334 --> 00:18:32,396 We target only one or two specific behaviors 343 00:18:32,396 --> 00:18:34,291 for change at a time. 344 00:18:34,291 --> 00:18:37,731 There are three key strategies for managing weaknesses 345 00:18:37,731 --> 00:18:39,955 of executive functioning. 346 00:18:39,955 --> 00:18:42,989 As I said, you intervene at the level of the environment, 347 00:18:42,989 --> 00:18:45,412 you intervene at the level of the child. 348 00:18:45,412 --> 00:18:48,638 That means you teach the skill, you motivate the child 349 00:18:48,638 --> 00:18:51,823 to use the skill and you praise or reward the child 350 00:18:51,823 --> 00:18:53,751 for using the skill. 351 00:18:53,751 --> 00:18:57,884 Then you verbalize what you see happening, 352 00:18:57,884 --> 00:19:01,037 so that the child gets another piece of feedback 353 00:19:01,037 --> 00:19:06,037 and another way of externalizing what becomes internal. 354 00:19:06,681 --> 00:19:09,408 General interventions to assist 355 00:19:09,408 --> 00:19:11,552 improving executive function skills 356 00:19:11,552 --> 00:19:14,621 are based on the following questions. 357 00:19:14,621 --> 00:19:17,466 What are your primary goals? 358 00:19:17,466 --> 00:19:21,285 What do you most want to target first? 359 00:19:21,285 --> 00:19:23,467 And then what? 360 00:19:23,467 --> 00:19:24,133 And then what? 361 00:19:24,133 --> 00:19:27,375 If you want to target three or four things at the same time, 362 00:19:27,375 --> 00:19:29,378 and many clients come in and they want 363 00:19:29,378 --> 00:19:32,861 to fix everything, you'll fail. 364 00:19:32,861 --> 00:19:36,360 Pick the most important thing and work on that, 365 00:19:36,360 --> 00:19:38,221 and when there's some success with that, 366 00:19:38,221 --> 00:19:41,284 then you can go on to the next most important thing. 367 00:19:42,513 --> 00:19:44,974 Use worksheets and information from the child, 368 00:19:44,974 --> 00:19:48,361 parents and teachers to determine these. 369 00:19:48,361 --> 00:19:52,764 Remember that all goals should improve self awareness, 370 00:19:52,764 --> 00:19:56,830 self adjustment and metacognition. 371 00:19:56,830 --> 00:20:01,612 Thinking about how the self is in the world. 372 00:20:02,489 --> 00:20:06,009 The best plans, the best ones, 373 00:20:06,009 --> 00:20:10,814 are developed collaboratively with the child 374 00:20:10,814 --> 00:20:13,548 and the parents. 375 00:20:14,593 --> 00:20:19,226 If the child does not buy in to what... 376 00:20:19,226 --> 00:20:21,307 to what a parent, excuse me, thinks 377 00:20:21,307 --> 00:20:24,664 is the most important thing, the child will not actually 378 00:20:24,664 --> 00:20:26,602 be fully participatory. 379 00:20:26,602 --> 00:20:30,273 We want the child to also see what's most important. 380 00:20:30,273 --> 00:20:33,624 If sometimes what the child sees is most important, 381 00:20:33,624 --> 00:20:35,824 is her or her number one, 382 00:20:35,824 --> 00:20:37,671 is the parent's number four or five, 383 00:20:37,672 --> 00:20:38,596 I have to tell you, that I'll lean 384 00:20:38,596 --> 00:20:42,974 in towards the child's choice because I want the child 385 00:20:42,974 --> 00:20:46,414 to start to feel like he or she has some authority 386 00:20:46,414 --> 00:20:49,397 or autonomy in creating the change 387 00:20:49,397 --> 00:20:53,791 that will help him or her feel better. 388 00:20:54,559 --> 00:20:56,359 Another intervention that's really important 389 00:20:56,359 --> 00:20:59,849 is modifying the environment. 390 00:20:59,849 --> 00:21:03,701 What parts of the environment are not supporting change 391 00:21:03,701 --> 00:21:06,008 for this particular child? 392 00:21:06,008 --> 00:21:09,655 What ways could people interact with this child differently? 393 00:21:09,655 --> 00:21:12,677 What are expectations of this child that aren't working? 394 00:21:12,677 --> 00:21:16,663 If we think back to the client that I referred to earlier 395 00:21:16,663 --> 00:21:20,914 who had a teacher who was giving her spelling tests 396 00:21:20,914 --> 00:21:24,199 even though her IEP said no spelling tests. 397 00:21:24,199 --> 00:21:27,408 One of the ways she was able to modify her environment 398 00:21:27,408 --> 00:21:32,112 with her parents' supports and her strategy 399 00:21:32,112 --> 00:21:36,328 teacher's support was to basically confront the teacher 400 00:21:36,328 --> 00:21:38,771 and say, "I am not supposed to take spelling tests." 401 00:21:38,771 --> 00:21:42,395 That was a modification of the environment. 402 00:21:43,103 --> 00:21:46,651 The final way to intervene is you want to describe 403 00:21:46,651 --> 00:21:51,241 the behavior that is troubling or isn't working 404 00:21:51,261 --> 00:21:55,625 in very specific concrete terms. 405 00:21:56,208 --> 00:22:00,728 Otherwise it become an always kind of a thing. 406 00:22:00,728 --> 00:22:03,812 When something is an always kind of a thing, 407 00:22:03,812 --> 00:22:06,378 people with ADHD don't get it 408 00:22:06,378 --> 00:22:08,566 because as soon as they hear, always, 409 00:22:08,566 --> 00:22:10,323 their brains sort of turn off. 410 00:22:10,323 --> 00:22:12,577 But if they hear, "Remember when you did this 411 00:22:12,577 --> 00:22:13,972 "specific thing?" 412 00:22:13,972 --> 00:22:16,146 Then they will actually be able 413 00:22:16,146 --> 00:22:18,642 to look at that specific thing. 414 00:22:25,672 --> 00:22:28,662 How do we modify the environment? 415 00:22:28,730 --> 00:22:32,059 The first way to modify the environment 416 00:22:32,059 --> 00:22:34,791 is to collaborate with the child first 417 00:22:34,791 --> 00:22:37,827 and ask, "What situations have helped you 418 00:22:37,827 --> 00:22:40,611 "foster completion of tasks or using some 419 00:22:40,611 --> 00:22:43,395 "or using some 420 00:22:43,395 --> 00:22:46,181 "of these executive functioning skills successfully 421 00:22:46,181 --> 00:22:49,186 "in the past?" 422 00:22:49,617 --> 00:22:53,348 When we have that information then we want to think 423 00:22:53,348 --> 00:22:56,705 about if we can establish a goodness of fit 424 00:22:56,705 --> 00:23:01,705 between the child's skills and a particular environment. 425 00:23:02,534 --> 00:23:04,352 What we are talking 426 00:23:04,352 --> 00:23:07,633 about is antecedent control. 427 00:23:07,633 --> 00:23:10,777 We want to modify this situation which triggers 428 00:23:10,777 --> 00:23:14,714 the maladaptive behavior and lack of skills. 429 00:23:14,714 --> 00:23:18,207 We want to alter the physical or social situation 430 00:23:18,207 --> 00:23:19,675 as much as possible. 431 00:23:19,675 --> 00:23:24,383 We want to amend the tasks expected of the child. 432 00:23:24,383 --> 00:23:29,312 We want to change how the adult interacts with the child. 433 00:23:29,850 --> 00:23:31,357 This, of course, is all true for teenagers. 434 00:23:31,357 --> 00:23:34,297 I'm just using child for ease of language, 435 00:23:34,297 --> 00:23:37,621 but those are the goals that we want to think about. 436 00:23:38,969 --> 00:23:42,424 Another way that we can really intervene 437 00:23:42,424 --> 00:23:44,832 in helping improve 438 00:23:44,832 --> 00:23:48,888 executive functions are that we want to reduce distractions 439 00:23:48,888 --> 00:23:51,064 for students and sometimes that will mean creating 440 00:23:51,064 --> 00:23:55,782 physical barriers, fences, removing breakable objects like 441 00:23:55,782 --> 00:23:58,776 locking rooms, a tool shed, putting away controls 442 00:23:58,776 --> 00:24:02,380 to the video games, reducing the social complexities 443 00:24:02,380 --> 00:24:05,165 of the situations, changing a social dynamic, 444 00:24:05,165 --> 00:24:07,424 we want to reduce distractions. 445 00:24:07,424 --> 00:24:09,377 We want there to be a place for everything. 446 00:24:09,377 --> 00:24:14,195 Cubbies, bins, hampers, calendars, files, notebooks 447 00:24:14,195 --> 00:24:16,680 and we want to teach the children how to file. 448 00:24:16,680 --> 00:24:18,929 When you get papers from a teacher 449 00:24:18,929 --> 00:24:21,033 and they're three hole punched, they should go 450 00:24:21,033 --> 00:24:24,978 into the binder with each hole in a ring not shoved 451 00:24:24,978 --> 00:24:27,114 into the folder section. 452 00:24:27,114 --> 00:24:29,528 You want to help teach organization, 453 00:24:29,528 --> 00:24:32,486 here's the piece of information that some parents 454 00:24:32,486 --> 00:24:33,946 really don't want to hear, 455 00:24:33,946 --> 00:24:37,980 until they're practically out of high school. 456 00:24:37,980 --> 00:24:42,975 Freshman and sophmores still need 457 00:24:42,975 --> 00:24:44,864 the kind of assistance 458 00:24:44,864 --> 00:24:48,307 with organization if they have ADHD 459 00:24:48,307 --> 00:24:51,695 that sixth, seventh and eighth graders do. 460 00:24:51,695 --> 00:24:53,597 Maybe somewhat different but they will need 461 00:24:53,597 --> 00:24:56,112 some help with their organization. 462 00:24:57,603 --> 00:25:00,247 In terms of electronics, 463 00:25:00,247 --> 00:25:03,453 I would like to say that most teenagers, 464 00:25:03,453 --> 00:25:07,616 and I would say a lot of kids now from ages 12 and up, 465 00:25:07,616 --> 00:25:11,297 have a phone, an iTouch, 466 00:25:13,282 --> 00:25:16,459 or fancy watch or something like that. 467 00:25:17,643 --> 00:25:21,205 Those three devices are going to be their best friend 468 00:25:21,205 --> 00:25:24,354 because most kids, if you ask them 469 00:25:24,354 --> 00:25:27,072 where X, Y, or Z is, they don't know, 470 00:25:27,072 --> 00:25:30,062 but they always know where their phone is. 471 00:25:30,062 --> 00:25:32,074 Or their iTouch. 472 00:25:32,074 --> 00:25:35,116 We want to use the iTouch or the phone 473 00:25:35,116 --> 00:25:40,116 or some comparable kinds of devices to help them organize. 474 00:25:40,219 --> 00:25:43,650 Put items in their calendar, 475 00:25:43,650 --> 00:25:46,127 set alarms to remember, 476 00:25:46,127 --> 00:25:49,019 oh, I gotta take my pills or I have an appointment, 477 00:25:49,019 --> 00:25:51,711 and we want to use those as much as possible 478 00:25:51,711 --> 00:25:55,802 because the phone or the iTouch or whatever 479 00:25:55,802 --> 00:25:58,293 is with them most of the time. 480 00:25:58,293 --> 00:26:02,842 Whereas the notebook, the calendar notebook may not be. 481 00:26:02,842 --> 00:26:06,039 That might require doing things twice 482 00:26:06,039 --> 00:26:09,019 or it might require basically writing down things 483 00:26:09,019 --> 00:26:12,950 in the notebook at school and then having an alarm set 484 00:26:12,950 --> 00:26:16,704 in the phone, you know, when it's time to do your homework, 485 00:26:16,704 --> 00:26:19,861 check calendar for homework. 486 00:26:20,845 --> 00:26:23,527 Rehearse with a child. 487 00:26:23,527 --> 00:26:26,895 What will happen in advance of a particular situation? 488 00:26:26,895 --> 00:26:30,215 If you have a child that gets really overwhelmed 489 00:26:30,215 --> 00:26:34,245 in social situations, and you're having Thanksgiving 490 00:26:34,245 --> 00:26:37,546 at Aunt Shirley's house and there's going to be 25 people, 491 00:26:37,546 --> 00:26:41,553 it would be worth taking some time to talk to that child 492 00:26:41,553 --> 00:26:43,907 about what's going to happen at Aunt Shirley's house 493 00:26:43,907 --> 00:26:46,896 and how you or he can work 494 00:26:46,896 --> 00:26:49,885 on when he feels overwhelmed 495 00:26:49,885 --> 00:26:52,368 or might need a break or maybe you want 496 00:26:52,368 --> 00:26:54,510 to institute a break where you and your child go 497 00:26:54,510 --> 00:26:57,385 up to a room and chill out for a few minutes. 498 00:26:57,385 --> 00:27:00,805 You plan and talk about an event that you know could 499 00:27:00,805 --> 00:27:03,239 be challenging for your child in advance. 500 00:27:03,947 --> 00:27:04,831 Use verbal prompts. 501 00:27:04,831 --> 00:27:06,521 We want parents to use verbal prompts 502 00:27:06,521 --> 00:27:09,794 to remind the child to check a schedule. 503 00:27:09,794 --> 00:27:12,558 For example, a lot of parents I work with complain 504 00:27:12,558 --> 00:27:15,732 they have to say the same thing over and over again. 505 00:27:15,732 --> 00:27:18,222 From the time a child can read, 506 00:27:18,222 --> 00:27:20,040 and even if a child can't read, because you can 507 00:27:20,040 --> 00:27:22,866 do a checklist with pictures of items. 508 00:27:22,866 --> 00:27:26,256 You can put up a list for your child of things 509 00:27:26,256 --> 00:27:28,169 you want him or her to do. 510 00:27:28,169 --> 00:27:32,003 Basically say, over and over, check your list, 511 00:27:32,003 --> 00:27:33,527 check your list. 512 00:27:33,527 --> 00:27:35,460 When things are done on the list, 513 00:27:35,460 --> 00:27:37,484 they can have a pen and check them off. 514 00:27:37,484 --> 00:27:40,758 That is extremely helpful because it teaches the child 515 00:27:40,758 --> 00:27:45,407 the ability to go back and see what has to be done 516 00:27:45,407 --> 00:27:48,535 when something's finished and to start to understand 517 00:27:48,535 --> 00:27:51,785 there's a sequence, I do this and then I do this, 518 00:27:51,785 --> 00:27:52,836 then I do this, 519 00:27:52,836 --> 00:27:57,321 so there are steps to a process. 520 00:27:59,244 --> 00:28:01,574 You want to help the parents give praise 521 00:28:01,574 --> 00:28:04,586 for using executive skills with their children. 522 00:28:04,586 --> 00:28:07,298 When the child is actually checking the list to say, 523 00:28:07,298 --> 00:28:09,465 in the car on the way to school, "I noticed you 524 00:28:09,465 --> 00:28:12,304 "checked your list and did every thing on it, way to go." 525 00:28:13,550 --> 00:28:15,406 You don't have to go overboard but some noticing 526 00:28:15,406 --> 00:28:16,696 that the child is making an effort 527 00:28:16,696 --> 00:28:19,681 in the direction that you want him or her to go on. 528 00:28:20,371 --> 00:28:23,511 In terms of modifications, I believe that a lot 529 00:28:23,511 --> 00:28:28,350 of times what happens is that parents make tasks too long 530 00:28:28,350 --> 00:28:30,552 and complicated for their children 531 00:28:30,552 --> 00:28:32,078 to be able to follow through. 532 00:28:32,078 --> 00:28:36,164 We want to do shorter steps and shorter tasks. 533 00:28:36,164 --> 00:28:39,541 You want to take a task and divide it into parts 534 00:28:39,541 --> 00:28:41,551 with breaks built in. 535 00:28:41,551 --> 00:28:43,663 I have a client... 536 00:28:44,846 --> 00:28:47,494 she hyperfocuses when she does homework. 537 00:28:47,735 --> 00:28:49,889 She'll sit down and she'll work for three hours. 538 00:28:49,889 --> 00:28:52,816 She's not particularly productive but she zones 539 00:28:52,816 --> 00:28:55,574 in and she can't decide what's important. 540 00:28:56,696 --> 00:28:58,524 Recently I gave her the assignment 541 00:28:58,524 --> 00:29:00,484 that when she goes to do her homework, she can work 542 00:29:00,484 --> 00:29:02,322 for an hour which is what she thinks 543 00:29:02,322 --> 00:29:04,870 is her longest period 544 00:29:04,870 --> 00:29:08,841 of reasonable time, she's 17. 545 00:29:09,641 --> 00:29:11,798 Then she has to take a break for 10 minutes 546 00:29:11,798 --> 00:29:15,372 which is timed and then she'll go back for another hour. 547 00:29:15,372 --> 00:29:19,097 She actually can learn how to break. 548 00:29:19,097 --> 00:29:20,979 She doesn't have that mechanism. 549 00:29:20,979 --> 00:29:22,598 We're trying to teach that for her 550 00:29:22,598 --> 00:29:26,407 and it'll be in her phone. 551 00:29:28,611 --> 00:29:31,672 We want to help these kids make a schedule 552 00:29:31,672 --> 00:29:33,480 and stick with the schedule. 553 00:29:33,480 --> 00:29:37,490 Sometimes the challenge is because of the high likelihood 554 00:29:37,490 --> 00:29:41,579 that a child or teen who has ADHD has a parent 555 00:29:41,579 --> 00:29:43,278 who has ADHD. 556 00:29:43,278 --> 00:29:45,855 It's very hard for these parents to remain consistent 557 00:29:45,855 --> 00:29:48,723 with the schedule that's created. 558 00:29:48,723 --> 00:29:50,140 The schedule that's created 559 00:29:50,140 --> 00:29:53,666 has to be simple enough 560 00:29:53,666 --> 00:29:58,666 to follow and simple enough to follow through on. 561 00:30:00,917 --> 00:30:05,205 You want to make steps explicit, no assumptions. 562 00:30:05,743 --> 00:30:09,818 If you think, you do this and this one, you do one thing 563 00:30:09,818 --> 00:30:13,926 on the list, go to the bathroom and you assume 564 00:30:13,926 --> 00:30:16,772 in the bathroom there's also teeth brushing that occurs. 565 00:30:16,772 --> 00:30:17,939 Mm-mm. 566 00:30:17,939 --> 00:30:21,048 Go to the bathroom, brush your teeth, 567 00:30:21,878 --> 00:30:25,636 put your shoes on, you assume maybe you get your coat 568 00:30:25,636 --> 00:30:26,760 at the same time, no. 569 00:30:26,760 --> 00:30:29,659 No assumptions in the beginning. 570 00:30:30,123 --> 00:30:32,728 Include choices for a child. 571 00:30:32,728 --> 00:30:36,937 The child doesn't feel like, I'm being controlled 572 00:30:36,937 --> 00:30:38,177 with every thing that I have to do. 573 00:30:38,177 --> 00:30:40,777 You want the child to be able to make choices 574 00:30:40,777 --> 00:30:44,081 within the schedule or goals 575 00:30:44,081 --> 00:30:47,385 that you're setting up. 576 00:30:47,385 --> 00:30:50,691 Because there's collaboration with the child, 577 00:30:50,691 --> 00:30:54,833 then the child will be involved in what you're setting up. 578 00:30:58,924 --> 00:31:02,755 In terms of specific modifications in a classroom 579 00:31:02,755 --> 00:31:05,945 that can include changing seat arrangements, 580 00:31:07,437 --> 00:31:10,785 basically looking at what's happening in the playground 581 00:31:10,785 --> 00:31:14,109 or free play or lunch, where the child's sitting at lunch. 582 00:31:16,985 --> 00:31:20,356 In terms of making tasks shorter and taking breaks, 583 00:31:20,356 --> 00:31:23,844 the end of the task has to be in sight. 584 00:31:23,844 --> 00:31:28,245 If your child's goal is to write a paper in one sitting, 585 00:31:28,245 --> 00:31:30,469 that will be a failed experience. 586 00:31:30,469 --> 00:31:32,581 If your child's goal was to write a page of words 587 00:31:32,581 --> 00:31:35,293 that might go better. 588 00:31:35,293 --> 00:31:39,628 Make steps very specific and vary the tasks 589 00:31:41,212 --> 00:31:43,074 so that there are choices. 590 00:31:43,074 --> 00:31:46,484 Watch out for open ended tasks like creative works, 591 00:31:46,484 --> 00:31:48,986 expository writing that have no end. 592 00:31:48,986 --> 00:31:53,332 You have to create, even if it's a self induced, 593 00:31:53,332 --> 00:31:56,395 or sort of a false barrier that they can hit 594 00:31:56,395 --> 00:31:59,219 up against it and feel a sense of completion 595 00:31:59,219 --> 00:32:02,998 and the next time, they'll have a little bit more to do. 596 00:32:03,473 --> 00:32:05,526 I wanted to say something about the complexities 597 00:32:05,526 --> 00:32:08,459 of social situations particularly for younger children. 598 00:32:08,459 --> 00:32:12,967 Parents of children with ADHD have to provide supervision 599 00:32:12,967 --> 00:32:16,496 and some influence over social events for these kids. 600 00:32:16,496 --> 00:32:18,892 It's very hard for these children to manage 601 00:32:18,892 --> 00:32:22,323 these situations on their own because of all the things 602 00:32:22,323 --> 00:32:24,382 we've talked about in terms of executive functioning 603 00:32:24,382 --> 00:32:27,070 and some of the challenges. 604 00:32:28,131 --> 00:32:31,024 The parents will need to check in, the parents might need 605 00:32:31,024 --> 00:32:33,720 to participate in the play dates. 606 00:32:34,612 --> 00:32:38,271 Even at the age of eight and nine or 10, 607 00:32:38,271 --> 00:32:41,410 the parents need to check in and structure a particular 608 00:32:41,410 --> 00:32:46,384 snack time, engage the kids in a game. 609 00:32:47,738 --> 00:32:50,651 A child with ADHD may sometimes feel lost 610 00:32:50,651 --> 00:32:54,471 in a play date, not sure what to do, 611 00:32:54,471 --> 00:32:55,863 or it gets boring. 612 00:32:55,863 --> 00:32:58,969 The parent will need to be somewhat engaged 613 00:32:58,969 --> 00:33:01,620 which sometimes is a little challenging for parents 614 00:33:01,620 --> 00:33:03,969 because they think, "Oh, play date, free time for me. 615 00:33:03,969 --> 00:33:05,897 "I can catch up on X,Y and Z." 616 00:33:05,897 --> 00:33:08,341 And that isn't necessarily the case. 617 00:33:09,217 --> 00:33:13,048 How do we teach executive function skills to ADHD kids? 618 00:33:13,308 --> 00:33:16,617 As I said, I really try to emphasize on this talk, 619 00:33:16,617 --> 00:33:19,663 there's a philosophy of a skill deficit 620 00:33:19,663 --> 00:33:23,969 rather than a failure of will, motivation or knowledge. 621 00:33:24,892 --> 00:33:27,671 One of the ways to teach these skills, in fact, 622 00:33:27,671 --> 00:33:30,073 I think it's the only way, you have to teach 623 00:33:30,073 --> 00:33:32,157 the deficient skills directly. 624 00:33:32,157 --> 00:33:36,579 Do not expect these kids to absorb these skills 625 00:33:36,579 --> 00:33:41,373 through observation or what I call, miracle osmosis. 626 00:33:42,665 --> 00:33:44,665 The first thing that has to occur is you must 627 00:33:44,665 --> 00:33:47,854 consider the child's developmental stage and understand 628 00:33:47,854 --> 00:33:51,748 what is typical for that age group. 629 00:33:51,764 --> 00:33:54,920 Then, you need to be able to help the parents 630 00:33:54,920 --> 00:33:57,896 and you will have to do some times in sessions. 631 00:33:57,896 --> 00:34:00,863 Cue the child for tasks. 632 00:34:00,863 --> 00:34:02,718 Keep the tasks brief, 633 00:34:02,718 --> 00:34:06,943 encourage practice using small steps. 634 00:34:06,943 --> 00:34:11,183 Work with the child's desire for mastery and control. 635 00:34:11,183 --> 00:34:13,022 That's really important. 636 00:34:13,022 --> 00:34:16,882 It's important to remember that these kids want to change. 637 00:34:16,882 --> 00:34:19,637 They want things to be different and better for them. 638 00:34:19,637 --> 00:34:23,496 And that, is your best tool 639 00:34:23,496 --> 00:34:25,681 as a therapist. 640 00:34:26,651 --> 00:34:30,358 Create and keep routines and schedules. 641 00:34:30,358 --> 00:34:32,950 This is the third most important thing, 642 00:34:32,950 --> 00:34:35,935 you need to help these families create and keep 643 00:34:35,935 --> 00:34:40,437 routines and schedules that are not too complicated 644 00:34:40,437 --> 00:34:42,727 and that are accessible and involve 645 00:34:42,727 --> 00:34:45,887 the participation of the child. 646 00:34:47,857 --> 00:34:50,537 It's important for parents and the child 647 00:34:50,537 --> 00:34:54,108 to distinguish between have to and want to. 648 00:34:54,108 --> 00:34:55,979 There are two kinds of tasks really, 649 00:34:55,979 --> 00:34:57,866 ones that you're not very good at doing 650 00:34:57,866 --> 00:35:01,778 and ones that you are capable of doing but don't like doing. 651 00:35:02,686 --> 00:35:05,981 Both of these have to be broken down into smaller steps. 652 00:35:10,011 --> 00:35:12,781 If you're not good at it then there are a whole set 653 00:35:12,781 --> 00:35:14,823 of separate issues that have to go on, 654 00:35:14,823 --> 00:35:16,962 which is like a lack of motivation, 655 00:35:16,962 --> 00:35:20,326 a dread of doing something, an avoidance, 656 00:35:22,434 --> 00:35:24,182 that's one category. 657 00:35:24,182 --> 00:35:26,115 The second category is you can do it 658 00:35:26,115 --> 00:35:28,917 but you just don't like it. 659 00:35:32,069 --> 00:35:36,664 There's also things like avoidance, a lack of desire 660 00:35:36,664 --> 00:35:37,749 to actually do it. 661 00:35:37,749 --> 00:35:40,179 In both cases, these kinds 662 00:35:40,179 --> 00:35:43,502 of tasks are have to tasks. 663 00:35:43,502 --> 00:35:47,258 They have to be broken down into small, manageable chunks, 664 00:35:47,258 --> 00:35:52,107 and steps so that you can do something that you don't like 665 00:35:52,107 --> 00:35:55,017 or you know how to do and you still don't like, 666 00:35:55,017 --> 00:35:59,886 or you can't do, do a small piece of it, break, 667 00:35:59,886 --> 00:36:02,304 do a small piece of it, break. 668 00:36:02,304 --> 00:36:05,303 Because ADHD kids and teens do not have the ability 669 00:36:05,303 --> 00:36:07,987 to sustain themselves through an activity 670 00:36:07,987 --> 00:36:12,060 that they do not like or feel like they cannot do. 671 00:36:13,813 --> 00:36:17,285 You can model as a therapist for these kids. 672 00:36:17,285 --> 00:36:20,835 If this were my assignment, I might, 673 00:36:20,835 --> 00:36:24,742 or when I write a paper, I plan to do this or that, 674 00:36:24,742 --> 00:36:26,563 or this is how I take breaks. 675 00:36:26,563 --> 00:36:30,763 Not because you want to basically explain 676 00:36:30,763 --> 00:36:33,527 your way is the best way but because it's helpful 677 00:36:33,527 --> 00:36:38,048 for these kids to understand that other people struggle also 678 00:36:38,048 --> 00:36:40,800 with having to do tasks that they don't like, 679 00:36:40,800 --> 00:36:44,031 having to do things that they know how to do 680 00:36:44,031 --> 00:36:45,689 but they don't want to do and having to do things 681 00:36:45,689 --> 00:36:47,666 that they don't know how to do. 682 00:36:47,666 --> 00:36:50,941 They need to hear what other people's strategies are, 683 00:36:50,941 --> 00:36:55,236 not only from you but from family members. 684 00:36:55,773 --> 00:37:00,226 Remember what these kids do in their brain and to themselves 685 00:37:00,226 --> 00:37:03,048 is a lot of shaming, that I'm different 686 00:37:03,048 --> 00:37:05,276 and I don't do it right. 687 00:37:06,814 --> 00:37:09,950 One of the goals of teaching executive functioning skills 688 00:37:09,950 --> 00:37:14,701 is to enhance self regulatory capacities. 689 00:37:15,085 --> 00:37:17,585 So the ability to push through something 690 00:37:17,585 --> 00:37:21,169 even if you don't like it, to manage your emotions 691 00:37:21,169 --> 00:37:25,135 even if you're struggling or you're mad... 692 00:37:25,135 --> 00:37:27,782 or you're afraid. 693 00:37:30,643 --> 00:37:34,045 To use charts, visual symbols, 694 00:37:34,045 --> 00:37:36,991 and aids, make lists, as I said, daily calendars 695 00:37:36,991 --> 00:37:38,552 for daily activities. 696 00:37:38,552 --> 00:37:43,530 There never can be enough visual aids up for kids with ADHD. 697 00:37:44,760 --> 00:37:47,414 Building choices to give kids some control. 698 00:37:47,414 --> 00:37:50,985 You have math homework, which you don't like, 699 00:37:50,985 --> 00:37:53,802 and you have Spanish, which you also don't like. 700 00:37:53,802 --> 00:37:57,351 You have English, which you like and science which you like. 701 00:37:57,351 --> 00:37:59,818 How do we want to plan our evening with these two things 702 00:37:59,818 --> 00:38:02,210 you don't like and the two that you do. 703 00:38:02,210 --> 00:38:03,711 Ask the child. 704 00:38:03,711 --> 00:38:06,763 The child might say, "I wanna do the things I like first, 705 00:38:06,763 --> 00:38:08,656 "and the things I dislike next." 706 00:38:08,656 --> 00:38:11,939 Or, "I wanna do something I don't like then something I do. 707 00:38:11,939 --> 00:38:13,776 "Then something I don't like, then something I do." 708 00:38:13,776 --> 00:38:16,337 Ask the child for his or her feedback, 709 00:38:16,337 --> 00:38:18,380 so that he feels like he's participating 710 00:38:18,380 --> 00:38:20,936 in what's being set up. 711 00:38:23,273 --> 00:38:26,139 In terms of... 712 00:38:26,139 --> 00:38:29,005 teaching executive functioning skills to kids, 713 00:38:29,005 --> 00:38:30,824 one thing that's important to remember 714 00:38:30,824 --> 00:38:32,887 is that punishment actually doesn't teach 715 00:38:32,887 --> 00:38:34,705 children what to do. 716 00:38:34,705 --> 00:38:38,862 It teaches them what not to do. 717 00:38:38,862 --> 00:38:43,861 What kids with ADHD need are some ideas about what to do. 718 00:38:43,861 --> 00:38:47,259 They need help figuring out what's next. 719 00:38:48,781 --> 00:38:51,473 One thing is to rehearse, practice and review skills 720 00:38:51,473 --> 00:38:53,923 before an event. 721 00:38:54,416 --> 00:38:57,690 As we said, use verbal prompts or reminders, 722 00:38:57,690 --> 00:39:01,104 arrange for visual cues or alarms. 723 00:39:01,104 --> 00:39:04,782 Praise the child or teen for using new skills 724 00:39:04,782 --> 00:39:09,190 and here's the key, debrief 725 00:39:09,190 --> 00:39:12,749 and review a situation afterwards. 726 00:39:12,749 --> 00:39:15,536 Maybe at the time, maybe three days later, 727 00:39:15,536 --> 00:39:18,922 but something that you saw that was good or different. 728 00:39:18,922 --> 00:39:21,619 That's what you want the parents to be able to do. 729 00:39:21,619 --> 00:39:23,493 If sometimes they can't debrief something 730 00:39:23,493 --> 00:39:26,862 until they're in therapy, then you can do it there. 731 00:39:27,785 --> 00:39:29,794 It's important to teach parents that effective praise 732 00:39:29,794 --> 00:39:34,317 is delivered immediately, is specific to the particulars 733 00:39:34,317 --> 00:39:37,825 of the action that you've seen, states the values 734 00:39:37,825 --> 00:39:41,326 of accomplishment, notices hard work, 735 00:39:41,326 --> 00:39:44,342 and trains the child to appreciate his or her 736 00:39:44,342 --> 00:39:47,371 own task accomplishment and problem solving. 737 00:39:48,586 --> 00:39:52,463 That's how we're going to teach metacognition. 738 00:39:52,463 --> 00:39:55,052 We want to interrupt the child 739 00:39:55,052 --> 00:39:57,245 before the child interrupts you and say, 740 00:39:57,245 --> 00:40:00,263 "I really like how you're doing this." 741 00:40:00,263 --> 00:40:04,128 You want to praise the children for using executive skills. 742 00:40:04,128 --> 00:40:07,486 I like three positives for each corrective feedback. 743 00:40:07,486 --> 00:40:10,241 Each time you say, do it this way or don't do it this way, 744 00:40:10,241 --> 00:40:12,442 you try to remember to notice a couple 745 00:40:12,442 --> 00:40:14,963 of good things at the same time. 746 00:40:18,040 --> 00:40:20,533 People ask me a lot about "bribing". 747 00:40:20,533 --> 00:40:22,531 What's a bribe? 748 00:40:23,069 --> 00:40:26,897 I'm going to talk about my view of bribes. 749 00:40:26,897 --> 00:40:30,934 A bribe is when you say to someone, "Here's the money, 750 00:40:30,934 --> 00:40:33,111 "take this bag across the street." 751 00:40:33,111 --> 00:40:36,793 An incentive is if you take this bag across the street, 752 00:40:36,793 --> 00:40:38,712 I'll give you some money. 753 00:40:38,712 --> 00:40:42,117 I don't believe in bribes, but I do believe in incentives. 754 00:40:42,117 --> 00:40:44,476 I have seen them work in the 25 years 755 00:40:44,476 --> 00:40:47,634 that I've been a family and child therapist. 756 00:40:50,985 --> 00:40:53,746 We want to use incentives and self rewards 757 00:40:53,746 --> 00:40:56,880 to enhance motivation and instruction. 758 00:40:58,557 --> 00:41:02,492 You might make a deal with a child, he works for an hour, 759 00:41:02,492 --> 00:41:07,126 does his homework and gets 10 minutes of Facebook time. 760 00:41:07,126 --> 00:41:09,781 Or you might make a deal with a child that 761 00:41:09,781 --> 00:41:14,209 after homework comes the half hour of TV that she's allowed. 762 00:41:14,209 --> 00:41:18,199 Those kinds of things are really helpful 763 00:41:18,199 --> 00:41:20,817 and the agreement would go further. 764 00:41:20,817 --> 00:41:24,932 If you don't do your homework, or you have a tantrum 765 00:41:24,932 --> 00:41:26,545 about doing your homework, then there will 766 00:41:26,545 --> 00:41:28,539 be no TV for you. 767 00:41:28,539 --> 00:41:32,169 That is very hard for some parents to follow through on, 768 00:41:32,169 --> 00:41:37,056 but it's critical that the incentive actually matters 769 00:41:37,056 --> 00:41:41,254 to the child and isn't available if the child doesn't do 770 00:41:41,254 --> 00:41:44,070 what he or she has agreed to do. 771 00:41:45,347 --> 00:41:47,834 Incentives make an effort of learning a skill 772 00:41:47,834 --> 00:41:50,827 and doing a task less distasteful. 773 00:41:50,827 --> 00:41:53,382 They also teach gratification. 774 00:41:53,382 --> 00:41:57,070 What reward can I give myself or motivation can I give, 775 00:41:57,070 --> 00:42:00,775 to get through this unpleasant task? 776 00:42:02,664 --> 00:42:06,639 We want to make sure that adults offer enough support 777 00:42:06,639 --> 00:42:09,527 to help a child feel successful but not too much support 778 00:42:09,527 --> 00:42:11,623 to be doing things for the child. 779 00:42:11,623 --> 00:42:13,642 Adults usually make two mistakes. 780 00:42:13,642 --> 00:42:15,697 There's too much support so the child 781 00:42:15,697 --> 00:42:18,628 fails to learn independence or too little support 782 00:42:18,628 --> 00:42:21,388 that the child repeatedly fails at a task. 783 00:42:21,388 --> 00:42:23,763 That's a really fine line to balance 784 00:42:23,763 --> 00:42:25,286 and it's really important that you work 785 00:42:25,286 --> 00:42:28,108 with your clients on that. 786 00:42:28,287 --> 00:42:32,353 You want to practice in session 787 00:42:32,353 --> 00:42:35,318 teaching, negotiating, and compromise. 788 00:42:35,318 --> 00:42:37,482 This is something that is often really hard for people. 789 00:42:37,482 --> 00:42:39,989 They're not good at it, they're especially triggered 790 00:42:39,989 --> 00:42:43,556 and reactive to things that bother them about their child, 791 00:42:43,556 --> 00:42:45,694 their partner or their dynamic in the family, 792 00:42:45,694 --> 00:42:50,243 and it's critical, critical that you help them with this. 793 00:42:50,869 --> 00:42:53,342 Scaffolding is crucial and it usually takes 794 00:42:53,342 --> 00:42:56,251 a lot longer than expected, 795 00:42:57,021 --> 00:43:01,543 in terms of how much time 796 00:43:01,543 --> 00:43:03,393 it has to be in place. 797 00:43:03,393 --> 00:43:07,359 What happens is usually we create a system 798 00:43:07,359 --> 00:43:10,003 or support or level of support 799 00:43:10,003 --> 00:43:12,647 or some sort of routine 800 00:43:12,647 --> 00:43:15,584 and it's working, yay. 801 00:43:16,168 --> 00:43:19,893 Then what happens is, adults usually take it out too soon. 802 00:43:19,893 --> 00:43:22,477 This is particularly true in school systems 803 00:43:22,477 --> 00:43:25,200 where a child will have extra support 804 00:43:25,200 --> 00:43:27,200 and be doing well and then they'll want to remove 805 00:43:27,200 --> 00:43:28,821 that support the next year 806 00:43:28,821 --> 00:43:31,368 which is a big mistake, big. 807 00:43:31,368 --> 00:43:34,978 Because the child usually needs the support longer 808 00:43:34,978 --> 00:43:37,560 to make sure that those kinds 809 00:43:37,560 --> 00:43:40,437 of changes are internalized. 810 00:43:42,099 --> 00:43:44,843 You don't want to abruptly stop supports, 811 00:43:44,843 --> 00:43:47,928 supervision or incentives. 812 00:43:48,866 --> 00:43:52,024 Whatever there are supports that are being faded out, 813 00:43:52,024 --> 00:43:55,162 they have to be faded out gradually. 814 00:43:58,269 --> 00:44:03,248 There are five keys to executive skill development. 815 00:44:04,624 --> 00:44:08,749 Often over involved parents can be anxious 816 00:44:08,749 --> 00:44:11,234 and they have trouble backing off from their kids 817 00:44:11,234 --> 00:44:14,950 who needed a lot of support who have ADHD. 818 00:44:17,718 --> 00:44:20,822 As a result, the kids sometimes are under responsible 819 00:44:20,822 --> 00:44:24,591 for their own activities and actions. 820 00:44:24,591 --> 00:44:28,041 We want to help create more accountability in the kids, 821 00:44:28,041 --> 00:44:30,715 these are particularly true of teenagers. 822 00:44:30,715 --> 00:44:34,176 Have the adults step back in appropriate ways 823 00:44:34,176 --> 00:44:35,912 but still stay involved in other ways. 824 00:44:35,912 --> 00:44:39,260 For example, when notebooks are concerned. 825 00:44:40,336 --> 00:44:42,664 It's sophmore year and you might want to take your kid 826 00:44:42,664 --> 00:44:46,640 to Office Depot or Staples or where ever 827 00:44:46,640 --> 00:44:49,702 and say, "Okay, how are we going to organize this year? 828 00:44:49,702 --> 00:44:51,365 "Where are you going to put stuff?" 829 00:44:51,365 --> 00:44:53,313 And help them lay it out. 830 00:44:53,313 --> 00:44:56,728 Next year, junior year, have the discussion, 831 00:44:56,728 --> 00:44:58,862 maybe they want to do it themselves, 832 00:44:58,862 --> 00:45:00,606 maybe you want to look at it when it's done, 833 00:45:00,606 --> 00:45:03,462 but you're involved in the process. 834 00:45:04,115 --> 00:45:07,204 You want to help those parents use collaboration, 835 00:45:07,204 --> 00:45:10,922 to create mutual goals of what should be shared 836 00:45:10,922 --> 00:45:12,647 and what can be independent. 837 00:45:12,647 --> 00:45:15,712 You want to rely on the child's sense of what works 838 00:45:15,712 --> 00:45:18,142 for him or her, as well 839 00:45:18,142 --> 00:45:20,961 as the parental observations about that. 840 00:45:22,191 --> 00:45:26,502 It's important for parents to be very clear 841 00:45:26,502 --> 00:45:29,276 about goals and expectations from the very beginning 842 00:45:29,276 --> 00:45:31,624 of any sort of arrangement that they're setting 843 00:45:31,624 --> 00:45:34,383 up with their children. 844 00:45:36,681 --> 00:45:39,843 To make their goals, the steps for a goal, 845 00:45:39,843 --> 00:45:40,739 into a checklist. 846 00:45:40,739 --> 00:45:45,083 For example, if you're working with a family 847 00:45:45,083 --> 00:45:48,668 and the parents complain that the room is a disaster 848 00:45:48,668 --> 00:45:50,637 and the child needs to clean the room. 849 00:45:50,637 --> 00:45:54,642 It would seem to me that perhaps, and this is true 850 00:45:54,642 --> 00:45:57,930 for a lot of kids, they see their room, 851 00:45:57,930 --> 00:46:00,619 it's like a disaster area, it's overwhelming, 852 00:46:00,619 --> 00:46:03,267 they don't even know where to begin. 853 00:46:03,267 --> 00:46:05,634 It might be useful to make a checklist that goes 854 00:46:05,634 --> 00:46:07,114 on their desk or on their door. 855 00:46:07,114 --> 00:46:09,670 You know, to clean your room. 856 00:46:09,670 --> 00:46:12,108 One: Clear off the bed. 857 00:46:12,108 --> 00:46:15,482 Two: Put the dirty clothes in the hamper. 858 00:46:15,482 --> 00:46:18,529 Three: Fold all the clothes that are in a heap. 859 00:46:18,529 --> 00:46:21,691 You know those kinds of things, they seem so simple 860 00:46:21,691 --> 00:46:24,070 and basic but they'r really important 861 00:46:24,070 --> 00:46:27,470 because the child isn't able to do that internally, 862 00:46:27,470 --> 00:46:29,601 him or herself. 863 00:46:32,812 --> 00:46:36,292 You want to help the parents create expectations 864 00:46:36,292 --> 00:46:41,162 of tasks that the child can actually perform and succeed on. 865 00:46:41,162 --> 00:46:44,426 Not continue to... 866 00:46:45,426 --> 00:46:47,398 basically fail at. 867 00:46:47,398 --> 00:46:49,849 Which perpetuates a cycle of anger 868 00:46:49,849 --> 00:46:52,674 and disappointment and shame. 869 00:46:53,889 --> 00:46:56,004 You want to help the parents make the steps 870 00:46:56,004 --> 00:46:59,871 of every single task explicit. 871 00:47:01,178 --> 00:47:05,518 How do you help kids with ADHD develop emotional control? 872 00:47:05,518 --> 00:47:08,541 The first thing is to identify triggers. 873 00:47:08,541 --> 00:47:13,079 Events that cause the child to lose his or her temper. 874 00:47:13,461 --> 00:47:16,242 The second thing to remember is that emotional control 875 00:47:16,242 --> 00:47:17,898 is one of the executive functions 876 00:47:17,898 --> 00:47:20,034 that takes years to develop. 877 00:47:21,557 --> 00:47:24,820 That would mean it's important to make a list of triggers. 878 00:47:27,373 --> 00:47:31,381 What you can and can not do when you're having a hard time 879 00:47:31,381 --> 00:47:34,206 with the child or the teen. 880 00:47:34,328 --> 00:47:37,493 The third thing is to enact a practice session 881 00:47:37,493 --> 00:47:40,228 and connect the process to reward. 882 00:47:42,781 --> 00:47:46,297 Basically you want to help create 883 00:47:46,297 --> 00:47:49,292 and review what happens 884 00:47:49,292 --> 00:47:53,808 when a child is triggered, what the options are, 885 00:47:53,931 --> 00:47:57,888 and what happened and what can be done differently. 886 00:47:57,888 --> 00:48:01,269 It's important to create a plan to manage 887 00:48:01,269 --> 00:48:03,840 or eliminate the triggers, to talk about what losing 888 00:48:03,840 --> 00:48:07,334 your temper looks like and to create a list 889 00:48:07,334 --> 00:48:09,818 of behaviors that are not tolerated regardless 890 00:48:09,818 --> 00:48:12,606 of how angry or upset you are. 891 00:48:12,606 --> 00:48:14,390 That list has to be short 892 00:48:14,390 --> 00:48:17,931 and extremely specific and concrete. 893 00:48:17,931 --> 00:48:20,914 Then you want to make another list. 894 00:48:20,914 --> 00:48:24,274 A list of replacement behaviors. 895 00:48:24,274 --> 00:48:27,152 Things a child can do when he or she is upset 896 00:48:27,152 --> 00:48:30,381 instead of those other things. 897 00:48:30,381 --> 00:48:32,317 That can be listening to music, 898 00:48:32,317 --> 00:48:35,715 that can be having 899 00:48:35,715 --> 00:48:39,361 a soft pillow or something in the basement 900 00:48:39,361 --> 00:48:42,883 that the child can thawap if needed, 901 00:48:42,883 --> 00:48:44,918 that can be taking a walk with the dog. 902 00:48:44,918 --> 00:48:48,545 Whatever it is appropriate for that child, 903 00:48:48,545 --> 00:48:51,531 there should be a list of alternatives. 904 00:48:53,986 --> 00:48:56,442 In terms of school interventions, 905 00:48:59,225 --> 00:49:02,997 the first thing I think is really worth stating 906 00:49:02,997 --> 00:49:05,070 many times is 907 00:49:05,070 --> 00:49:08,927 that the parents must advocate for their kids. 908 00:49:08,927 --> 00:49:13,416 Over and over and over again. 909 00:49:13,416 --> 00:49:17,266 They have to continue to advocate for their kids. 910 00:49:17,266 --> 00:49:19,484 I'm going to read something from the book that's 911 00:49:19,484 --> 00:49:24,313 on your reference list called, Buzz, 912 00:49:24,820 --> 00:49:27,460 and it's about homework. 913 00:49:37,123 --> 00:49:39,880 It's Friday afternoon and I'm in my writing shed 914 00:49:39,880 --> 00:49:42,589 chewing sugarless tangerine gum and agonizing 915 00:49:42,589 --> 00:49:45,296 over a clunky first draft, longing as always 916 00:49:45,296 --> 00:49:48,469 for distraction and although I wouldn't have ordered 917 00:49:48,469 --> 00:49:49,789 this phone call. 918 00:49:49,789 --> 00:49:52,031 The voice belongs to Buzz's English teacher 919 00:49:52,031 --> 00:49:54,751 who is graciously taking time to let me know 920 00:49:54,751 --> 00:49:57,910 he hasn't turned in a major assignment due today 921 00:49:57,910 --> 00:50:00,634 which is news to me, he should've been working 922 00:50:00,695 --> 00:50:02,818 on for the past week. 923 00:50:02,818 --> 00:50:04,496 Buzz is in middle school. 924 00:50:04,496 --> 00:50:06,083 The instruction was to interview someone, 925 00:50:06,083 --> 00:50:08,911 preferably a parent about prejudice. 926 00:50:08,911 --> 00:50:11,564 Buzz hasn't even gotten started. 927 00:50:11,564 --> 00:50:14,660 His teacher isn't sure why that is, but again, 928 00:50:14,660 --> 00:50:18,547 graciously, and maybe because I've met with her three times 929 00:50:18,547 --> 00:50:21,075 by now to plead for understanding. 930 00:50:21,075 --> 00:50:22,903 She offers Buzz a reprieve as long 931 00:50:22,903 --> 00:50:25,891 as he can do this work over the weekend. 932 00:50:26,983 --> 00:50:29,772 Whenever I ask Buzz if he has homework these days, 933 00:50:29,772 --> 00:50:32,243 he tells me that he has already finished it at school. 934 00:50:32,243 --> 00:50:35,190 He won't write assignments in his agenda, 935 00:50:35,190 --> 00:50:38,085 even when Xbox time depends on it, 936 00:50:38,085 --> 00:50:40,792 and there is little else he cares about other than food 937 00:50:40,792 --> 00:50:43,956 which I'm not ready yet to with hold. 938 00:50:43,956 --> 00:50:46,254 So when Buzz comes home this afternoon, 939 00:50:46,254 --> 00:50:48,865 I leave my shed, microwave him a plate 940 00:50:48,865 --> 00:50:51,756 of leftover spaghetti and spend the next half hour 941 00:50:51,756 --> 00:50:54,792 arguing, bribing, threatening, pulling out the TV cord 942 00:50:54,792 --> 00:50:58,989 and hiding it before finally convincing him to get started. 943 00:50:58,989 --> 00:51:00,560 The two of us, I'm well aware, are trapped 944 00:51:00,560 --> 00:51:03,523 in an all but senseless system. 945 00:51:03,523 --> 00:51:07,448 Even as US teachers are piling on ever more homework, 946 00:51:07,448 --> 00:51:09,400 research has shown it doesn't measurably 947 00:51:09,400 --> 00:51:13,582 improve academic achievement in grade school. 948 00:51:13,582 --> 00:51:16,926 Although it can sour kids' attitudes towards school 949 00:51:16,926 --> 00:51:20,213 and increase conflict between them and their parents. 950 00:51:21,028 --> 00:51:22,850 I should probably spend more time complaining 951 00:51:22,850 --> 00:51:26,569 about this to Buzz's principal who already thinks 952 00:51:26,569 --> 00:51:29,874 I'm a crank but in the short term, I just don't want 953 00:51:29,874 --> 00:51:33,180 him to fail, it drives me crazy that I have to work 954 00:51:33,180 --> 00:51:37,826 this hard and it makes me so sad for the worried mothers 955 00:51:37,826 --> 00:51:40,149 who don't even have this option. 956 00:51:40,149 --> 00:51:42,828 Finally, he sits down in front of the computer. 957 00:51:42,828 --> 00:51:45,602 He smooths out the crumpled blue instruction sheet 958 00:51:45,602 --> 00:51:48,023 we fished from the bottom of his backpack. 959 00:51:48,023 --> 00:51:50,943 A trove of ancient cookie crumbs, leaking pens, 960 00:51:50,943 --> 00:51:54,686 unsigned permission slips and unwashed gym shorts, 961 00:51:54,686 --> 00:51:57,738 and he starts typing fast. 962 00:51:57,791 --> 00:52:00,612 Here we have a boy of maybe 12 or 13, 963 00:52:00,612 --> 00:52:05,612 and a mother who is really struggling with how to get him 964 00:52:05,878 --> 00:52:09,768 motivated, started, following through, accountable, 965 00:52:09,768 --> 00:52:12,273 all of the things that I see in parents 966 00:52:12,273 --> 00:52:16,193 I work with of ADHD kids. 967 00:52:17,722 --> 00:52:19,466 Parents have to advocate for their kids 968 00:52:19,466 --> 00:52:22,735 even if the principal thinks they're a crank. 969 00:52:23,050 --> 00:52:25,161 It's important to remember that ADHD kids 970 00:52:25,161 --> 00:52:28,322 can't bind events across time. 971 00:52:28,322 --> 00:52:32,694 To remember the transitions, physical relocations, changes 972 00:52:32,694 --> 00:52:35,930 in schedule and disruptions are especially difficult 973 00:52:35,930 --> 00:52:38,415 for the child with ADHD. 974 00:52:38,415 --> 00:52:42,112 Changing classes, starting a new year, 975 00:52:42,112 --> 00:52:45,079 having a substitute teacher, all of these things 976 00:52:45,079 --> 00:52:47,679 can be very discombobulating. 977 00:52:49,017 --> 00:52:51,348 It's important to teach ADHD kids how to keyboard 978 00:52:51,348 --> 00:52:52,971 as quickly as possible. 979 00:52:52,971 --> 00:52:55,994 Often because there's a motoric aspect of ADHD, 980 00:52:55,994 --> 00:53:00,107 the physical act of writing is very difficult 981 00:53:00,107 --> 00:53:02,913 and as we've said, sometimes actually 982 00:53:02,913 --> 00:53:05,719 the thinking and the language parts 983 00:53:05,719 --> 00:53:08,527 and expressing them verbally are very difficult. 984 00:53:08,527 --> 00:53:11,953 It's good to keyboard, it helps to speed things along. 985 00:53:12,722 --> 00:53:14,962 It's important in the classroom to avoid distracting 986 00:53:14,962 --> 00:53:17,916 stimuli by not placing the child near the heater, 987 00:53:17,916 --> 00:53:20,567 the door, the windows, other children 988 00:53:20,567 --> 00:53:25,410 who have attention issues and to break up tasks. 989 00:53:25,410 --> 00:53:30,410 Teach how to divide a future task into manageable parts. 990 00:53:32,263 --> 00:53:36,420 In terms of giving instructions for ADHD students, 991 00:53:36,420 --> 00:53:38,588 it's important to often provide 992 00:53:38,588 --> 00:53:40,669 an external source of motivation. 993 00:53:40,669 --> 00:53:43,538 She had mentioned taking away the Xbox 994 00:53:43,538 --> 00:53:45,960 but we also want to provide an incentive. 995 00:53:45,960 --> 00:53:49,682 If you write this, you'll get an extra 15 minutes of Xbox. 996 00:53:49,682 --> 00:53:53,115 I've a child who loves Gilmore Girls. 997 00:53:53,115 --> 00:53:55,974 One of her incentives for following through 998 00:53:55,974 --> 00:53:58,933 on the morning routine without having a tantrum 999 00:53:58,933 --> 00:54:02,482 for which she had a checklist is that she got an extra 1000 00:54:02,482 --> 00:54:06,008 15 minutes of Girlmore Girls at night. 1001 00:54:06,931 --> 00:54:08,593 It's important for teachers to remember 1002 00:54:08,593 --> 00:54:11,308 that ADHD kids might need manipulatives 1003 00:54:11,308 --> 00:54:15,980 or a little fidget toy and to make tasks 1004 00:54:15,980 --> 00:54:19,553 as manual as possible when needed. 1005 00:54:19,553 --> 00:54:22,281 It's also important for parents to remember that. 1006 00:54:22,281 --> 00:54:24,225 There might be knee tapping, 1007 00:54:24,225 --> 00:54:29,225 or finger twitching, 1008 00:54:29,377 --> 00:54:30,161 whatever you want to call it. 1009 00:54:30,161 --> 00:54:32,667 There's usually some sort of outlet 1010 00:54:32,667 --> 00:54:35,145 for a kind of... 1011 00:54:35,145 --> 00:54:39,039 internal sense of energy. 1012 00:54:39,039 --> 00:54:42,227 Time outs have to be targeted and limited. 1013 00:54:42,227 --> 00:54:46,596 That's important at home but also important at school. 1014 00:54:46,596 --> 00:54:48,486 The basic rule of thumb, that time outs shouldn't 1015 00:54:48,486 --> 00:54:53,149 be longer than the child's age which I support. 1016 00:54:53,149 --> 00:54:56,392 I think that sometimes in school, the time outs have 1017 00:54:56,407 --> 00:54:58,819 to be targeted for specific kinds of behavior 1018 00:54:58,819 --> 00:55:02,284 and not just general across the board behaviors 1019 00:55:02,284 --> 00:55:06,842 because we want to work with the school, and the parent 1020 00:55:06,842 --> 00:55:09,469 on the same behavior so that their success, 1021 00:55:09,469 --> 00:55:13,318 in that one area of behvior and then, 1022 00:55:13,318 --> 00:55:14,704 we can move on to another. 1023 00:55:14,704 --> 00:55:17,314 It's important to be patient during transitions 1024 00:55:17,314 --> 00:55:21,126 of all types and to create a quiet place in the classroom 1025 00:55:21,126 --> 00:55:25,702 which has reduced stimuli, if that's possible, 1026 00:55:25,702 --> 00:55:28,791 or a place in school that has reduced stimuli. 1027 00:55:28,791 --> 00:55:31,538 I had one student who really had to read 1028 00:55:31,538 --> 00:55:34,762 in her English class and she couldn't stand reading. 1029 00:55:34,762 --> 00:55:37,152 It was distracting, the chair were uncomfortable. 1030 00:55:37,152 --> 00:55:38,600 We were able to arrange with the school 1031 00:55:38,600 --> 00:55:40,313 that she could go down to the library 1032 00:55:40,313 --> 00:55:42,395 which had a big, soft, cozy chair 1033 00:55:42,395 --> 00:55:44,660 and she could sit there and read when there was 1034 00:55:44,660 --> 00:55:45,729 in class reading. 1035 00:55:45,729 --> 00:55:48,536 How do you help ADHD students at home? 1036 00:55:48,536 --> 00:55:51,923 You want to encourage parents to set up a quiet time place 1037 00:55:51,923 --> 00:55:53,609 at home that is for studying. 1038 00:55:53,609 --> 00:55:58,360 Where the child can go and is not distracted by things. 1039 00:55:58,360 --> 00:56:01,589 You want to establish a routine for doing homework. 1040 00:56:01,589 --> 00:56:05,065 You want to create systems to help keep the book bag, 1041 00:56:05,065 --> 00:56:09,583 school work organized, in the notebook, in the backpack. 1042 00:56:11,905 --> 00:56:15,334 You want to create and implement a home school notebook 1043 00:56:15,334 --> 00:56:16,735 of assignments and updates. 1044 00:56:16,735 --> 00:56:18,560 For younger kids that could be a sheet, 1045 00:56:18,560 --> 00:56:21,652 a calendar book, I suggest a calendar book 1046 00:56:21,652 --> 00:56:23,881 as early as possible. 1047 00:56:25,480 --> 00:56:27,685 This kind of daily assignment notebook is very helpful 1048 00:56:27,685 --> 00:56:30,289 because even a second or third grader can see 1049 00:56:30,289 --> 00:56:33,989 what he or she did and check it off which helps, again, 1050 00:56:33,989 --> 00:56:38,688 organize their ability to remember I did this 1051 00:56:38,688 --> 00:56:40,152 and then I have to do this. 1052 00:56:40,152 --> 00:56:43,005 Remember all of these executive function skills 1053 00:56:43,005 --> 00:56:46,489 have to be taught repeatedly over time, 1054 00:56:46,489 --> 00:56:49,327 external to internal. 1055 00:56:49,327 --> 00:56:51,729 You want to make sure the student correctly writes 1056 00:56:51,729 --> 00:56:54,235 down all of these assignments and perhaps to check 1057 00:56:54,235 --> 00:56:56,391 with the teacher each day if necessary, 1058 00:56:56,391 --> 00:56:58,365 I find that's been very helpful. 1059 00:56:58,365 --> 00:57:00,546 It's nice if the parents can sign the notebook 1060 00:57:00,546 --> 00:57:02,609 when their child is younger and in grade school 1061 00:57:02,609 --> 00:57:04,841 and use it as a method of communicating with the teacher 1062 00:57:04,841 --> 00:57:06,741 so they have a way of going back and forth 1063 00:57:06,741 --> 00:57:08,736 on a regular basis. 1064 00:57:08,736 --> 00:57:11,387 There's been a lot of research about mindfulness training 1065 00:57:11,387 --> 00:57:14,531 for parents and children with ADHD. 1066 00:57:14,531 --> 00:57:16,655 It's mostly positive 1067 00:57:16,655 --> 00:57:21,179 but it has to continue over time 1068 00:57:21,179 --> 00:57:24,042 in terms of support for the practice afterwards. 1069 00:57:24,042 --> 00:57:25,749 What the research showed is that people who did 1070 00:57:25,749 --> 00:57:30,088 the mindfulness class but didn't continue with brush up 1071 00:57:30,088 --> 00:57:33,572 classes or follow through, didn't do as well 1072 00:57:33,572 --> 00:57:36,371 or weren't able to keep up with the practice as those 1073 00:57:36,371 --> 00:57:41,173 who did have those refresher workshops. 1074 00:57:47,539 --> 00:57:50,612 What are the parental essentials for student success? 1075 00:57:50,612 --> 00:57:53,881 In my opinion, the number one parental essential 1076 00:57:53,881 --> 00:57:57,783 is regular contact with teachers and administrators 1077 00:57:57,783 --> 00:58:00,847 at their child's school. 1078 00:58:01,134 --> 00:58:03,728 The number two would be, for you as a therapist, 1079 00:58:03,728 --> 00:58:06,952 also to have some contact with someone in the school. 1080 00:58:06,952 --> 00:58:10,590 So that you can have an understanding of what's working 1081 00:58:10,590 --> 00:58:12,563 in the classroom and what's not. 1082 00:58:12,563 --> 00:58:14,465 The parents have to advocate for the child. 1083 00:58:14,465 --> 00:58:18,058 Having a relationship with the school and the teachers 1084 00:58:18,058 --> 00:58:19,587 is helpful, even in high school. 1085 00:58:19,587 --> 00:58:21,973 Most high schools, teachers have email, 1086 00:58:21,973 --> 00:58:26,333 they check their email and they're available to respond. 1087 00:58:26,333 --> 00:58:28,140 If they're not, there's certainly a principal 1088 00:58:28,140 --> 00:58:33,140 or a guidance councillor that can be helpful. 1089 00:58:34,783 --> 00:58:37,415 Progress reports can be really, really helpful 1090 00:58:37,415 --> 00:58:39,995 in finding out how your child's doing. 1091 00:58:39,995 --> 00:58:44,375 Many schools have computer programs that you can link in, 1092 00:58:44,375 --> 00:58:47,950 log in, excuse me, and see the link related 1093 00:58:47,950 --> 00:58:49,876 to how your child is doing. 1094 00:58:49,876 --> 00:58:52,702 Some schools have actual progress reports that the child 1095 00:58:52,702 --> 00:58:54,755 takes around to his or her teachers. 1096 00:58:54,755 --> 00:58:57,276 Or you can set up progress report meetings 1097 00:58:57,276 --> 00:59:00,031 with the teachers, just to get a sense of how your child 1098 00:59:00,031 --> 00:59:04,051 is doing periodically, if you're concerned. 1099 00:59:05,590 --> 00:59:07,336 I think the main thing we want to communicate 1100 00:59:07,336 --> 00:59:10,435 to these parents is get involved and stay involved. 1101 00:59:14,326 --> 00:59:16,109 I'm going to go through a few slides about how you give 1102 00:59:16,109 --> 00:59:18,024 instructions to kids with ADHD 1103 00:59:18,024 --> 00:59:19,949 and some classroom strategies. 1104 00:59:19,949 --> 00:59:21,875 I'm not going to spend a lot of time on these. 1105 00:59:21,875 --> 00:59:25,336 These are mostly resources for you to have 1106 00:59:25,336 --> 00:59:28,338 to share with your clients... 1107 00:59:29,598 --> 00:59:32,051 in your practice. 1108 00:59:32,528 --> 00:59:34,529 One thing that's important when you give instructions 1109 00:59:34,529 --> 00:59:36,911 to kids with ADHD is maintaining eye contact 1110 00:59:36,911 --> 00:59:39,724 during verbal instruction, 1111 00:59:39,970 --> 00:59:41,592 that's really important. 1112 00:59:41,592 --> 00:59:45,000 Two: Give out one task at a time. 1113 00:59:45,000 --> 00:59:48,105 If you make the directions clear and concise 1114 00:59:48,105 --> 00:59:52,850 with one task, the chances are it will be accomplished. 1115 00:59:52,850 --> 00:59:57,422 But if you make it a task and you add the word 'and', 1116 00:59:57,422 --> 00:59:59,536 chances are, it might not get accomplished. 1117 00:59:59,536 --> 01:00:01,950 Particularly for the younger kids. 1118 01:00:01,950 --> 01:00:06,436 Small tasks, one task at a time, eye contact 1119 01:00:06,436 --> 01:00:09,731 and be consistent with the daily instructions. 1120 01:00:10,164 --> 01:00:13,323 Make sure students comprehends instructions 1121 01:00:13,323 --> 01:00:15,611 at the beginning of a class, this is really important 1122 01:00:15,611 --> 01:00:19,562 for teachers, and at the beginning of a task. 1123 01:00:19,931 --> 01:00:24,171 Repeat instructions in a calm, positive manner. 1124 01:00:24,171 --> 01:00:27,488 This is also true for parents and for teachers. 1125 01:00:27,488 --> 01:00:29,999 I like the rule of three. 1126 01:00:29,999 --> 01:00:33,719 I think sometimes it works with... 1127 01:00:35,656 --> 01:00:37,439 teachers and sometimes it doesn't. 1128 01:00:37,439 --> 01:00:40,185 Essentially the rule of three is, I look at the child 1129 01:00:40,185 --> 01:00:43,117 in the eye and I might put a hand on the shoulder 1130 01:00:43,117 --> 01:00:46,299 and I say what I want them to do 1131 01:00:46,299 --> 01:00:48,208 and I ask it to be repeated. 1132 01:00:48,208 --> 01:00:51,718 The hand on the shoulder is optional, but sometimes 1133 01:00:51,718 --> 01:00:54,584 for a parent it helps steady the child 1134 01:00:54,584 --> 01:00:57,967 to actually focus on what the parent is saying. 1135 01:00:57,967 --> 01:01:01,745 In schools that's less optional. 1136 01:01:01,745 --> 01:01:03,335 If you have to repeat the instructions, 1137 01:01:07,842 --> 01:01:12,163 they need to be repeated in a calm and positive manner. 1138 01:01:14,886 --> 01:01:18,401 For classroom strategies, what we want to encourage 1139 01:01:18,401 --> 01:01:21,487 teachers to do is to use external cues. 1140 01:01:21,487 --> 01:01:24,673 Don't rely on mental or auditory information. 1141 01:01:24,673 --> 01:01:28,619 Make lists, posters, signs, remember that auditory 1142 01:01:28,619 --> 01:01:30,703 processing for kids with ADHD 1143 01:01:30,703 --> 01:01:33,326 is not their strongest way 1144 01:01:33,326 --> 01:01:36,720 of learning and sometimes it is. 1145 01:01:36,720 --> 01:01:39,344 Sometimes people really learn only through hearing. 1146 01:01:39,344 --> 01:01:41,697 I have a client who's an adult, 1147 01:01:42,327 --> 01:01:44,580 that's how she remembers all of her information. 1148 01:01:44,580 --> 01:01:46,959 That's how she processes and that's how she remembers. 1149 01:01:46,959 --> 01:01:47,739 Hearing and doing. 1150 01:01:47,739 --> 01:01:51,555 I've another client who's an adult who has ADHD. 1151 01:01:52,247 --> 01:01:55,896 He has to write things down and he has to see them visually. 1152 01:01:55,896 --> 01:01:58,189 They said they've had these strategies 1153 01:01:58,189 --> 01:02:00,269 and ways of learning since they were children. 1154 01:02:00,269 --> 01:02:03,971 I see that in the kids I work with which is so interesting 1155 01:02:03,971 --> 01:02:07,215 to be able to see it in kids and teenagers 1156 01:02:07,215 --> 01:02:11,060 and then people in their forties and fifties. 1157 01:02:12,322 --> 01:02:14,543 We want to make time physical in the classroom, 1158 01:02:14,543 --> 01:02:17,367 don't rely on internal clocks. 1159 01:02:17,367 --> 01:02:19,350 You want to help the child have a timer 1160 01:02:19,350 --> 01:02:22,529 or some way of monitoring the time that's more 1161 01:02:22,529 --> 01:02:26,753 external and physical 1162 01:02:26,753 --> 01:02:31,372 because they can't bind events across time. 1163 01:02:31,372 --> 01:02:34,257 You want to help the child break up tasks. 1164 01:02:34,257 --> 01:02:37,742 Teachers need to teach them how to divide up a task 1165 01:02:37,742 --> 01:02:42,501 into the event, the response and the outcome. 1166 01:02:42,501 --> 01:02:46,630 It's nice to see a child near the teacher 1167 01:02:46,630 --> 01:02:49,655 but as part of the regular class seating. 1168 01:02:49,655 --> 01:02:51,861 I've seen teachers basically put a kid with ADHD 1169 01:02:51,861 --> 01:02:55,486 right next to their desk and every one else is in a circle. 1170 01:02:55,486 --> 01:03:00,416 All that does is make the child feel alienated, 1171 01:03:03,231 --> 01:03:06,233 and different in a very bad way. 1172 01:03:06,233 --> 01:03:09,632 Surround the child with good peer role models, 1173 01:03:09,632 --> 01:03:13,770 so that the child can be around kids who actually 1174 01:03:13,770 --> 01:03:18,181 could help him or her focus or make better choices 1175 01:03:18,181 --> 01:03:21,643 and can see what those choices are. 1176 01:03:21,643 --> 01:03:24,572 You want to encourage peer tutoring 1177 01:03:24,572 --> 01:03:28,003 and cooperative learning when possible. 1178 01:03:30,634 --> 01:03:34,972 How do you help kids with certain specific issues 1179 01:03:34,972 --> 01:03:37,801 related to executive functioning? 1180 01:03:37,801 --> 01:03:40,440 Problems of initiation, getting started. 1181 01:03:40,440 --> 01:03:43,416 It's helpful if the material's pre-taught, 1182 01:03:43,416 --> 01:03:46,243 if the assignment is broken down into parts 1183 01:03:46,243 --> 01:03:50,023 and that you hand out written copies of the assignments. 1184 01:03:50,023 --> 01:03:53,623 For problems of sustaining attention or anxiety, 1185 01:03:53,623 --> 01:03:55,519 use an interactive teaching style, 1186 01:03:55,519 --> 01:04:00,519 provide positive feedback, and offer shorter work periods. 1187 01:04:01,073 --> 01:04:04,850 For problems with shifting or making transitions, 1188 01:04:04,850 --> 01:04:07,867 offer a daily agenda so the child will know 1189 01:04:07,867 --> 01:04:09,165 what to expect. 1190 01:04:09,165 --> 01:04:12,102 Encourage flexibility through self-talk 1191 01:04:12,102 --> 01:04:14,472 and reward flexible behavior. 1192 01:04:14,472 --> 01:04:16,926 I see you doing a great job making the transitions 1193 01:04:16,926 --> 01:04:19,941 and you're coming to our class on time. 1194 01:04:22,110 --> 01:04:24,419 Problems with organization. 1195 01:04:26,527 --> 01:04:29,893 It's sometimes easier for teachers to help students 1196 01:04:29,893 --> 01:04:32,842 understand how to file papers in their notebooks 1197 01:04:32,842 --> 01:04:34,601 than their parents 1198 01:04:34,601 --> 01:04:37,808 because of all the particular 1199 01:04:37,808 --> 01:04:42,046 teen dynamics between separating and wanting space 1200 01:04:42,046 --> 01:04:43,761 and being independent. 1201 01:04:43,761 --> 01:04:47,168 Give extra time for teachers. 1202 01:04:47,168 --> 01:04:48,450 If the teachers could give extra time 1203 01:04:48,450 --> 01:04:51,024 for organizing material or maybe have the student 1204 01:04:51,024 --> 01:04:53,188 come after school for a little help with that, 1205 01:04:53,188 --> 01:04:55,550 that would be great. 1206 01:04:57,165 --> 01:04:59,603 The other thing that really helps with organization 1207 01:04:59,603 --> 01:05:02,130 is to give an ordered list of assignments and activities 1208 01:05:02,130 --> 01:05:05,075 that the child or student is responsible for. 1209 01:05:08,936 --> 01:05:12,806 For problems with planning, you want to explicitly, 1210 01:05:12,806 --> 01:05:16,350 as a teacher, teach planning strategies, 1211 01:05:16,350 --> 01:05:19,030 and that means breaking assignments into parts. 1212 01:05:19,030 --> 01:05:20,796 If you have a research paper, and teachers do this most 1213 01:05:20,796 --> 01:05:23,362 of the time naturally in high school, in the beginning 1214 01:05:23,362 --> 01:05:26,822 in the ninth grade, "You're going to do this part 1215 01:05:26,822 --> 01:05:29,070 "of the research, we're all going to go to the library 1216 01:05:29,070 --> 01:05:31,832 "and we're going to do this part of the research 1217 01:05:31,832 --> 01:05:33,844 "on the computer and then I'd like to see you outline 1218 01:05:33,844 --> 01:05:35,864 "your paper," whatever it is. 1219 01:05:35,864 --> 01:05:39,396 That kind of breaking an assignment down is very helpful 1220 01:05:39,396 --> 01:05:41,719 for someone with ADHD because otherwise they see 1221 01:05:41,719 --> 01:05:45,741 the research paper and it's just so overwhelming 1222 01:05:45,741 --> 01:05:48,466 and there's just so many options and there are lots 1223 01:05:48,466 --> 01:05:50,841 of ways they can do it, and they may or may not 1224 01:05:50,841 --> 01:05:52,451 have the confidence to do it. 1225 01:05:52,451 --> 01:05:53,395 It's very helpful to make it 1226 01:05:53,395 --> 01:05:55,925 a more smaller, manageable task. 1227 01:05:55,925 --> 01:05:59,995 And to create a calendar of when things 1228 01:05:59,995 --> 01:06:03,612 need to be done for that paper. 1229 01:06:06,048 --> 01:06:08,035 This would mean providing steps 1230 01:06:08,035 --> 01:06:11,657 for a multi-step piece of work or project. 1231 01:06:11,657 --> 01:06:14,553 In terms of problems with self monitoring, 1232 01:06:14,553 --> 01:06:18,973 we want to teach them a reverse process 1233 01:06:18,973 --> 01:06:21,648 to check math calculations 1234 01:06:21,648 --> 01:06:25,429 and to use a check off sheet 1235 01:06:25,429 --> 01:06:27,057 to show the completion of assignments. 1236 01:06:27,057 --> 01:06:29,790 Again, if you have things written down in a calendar 1237 01:06:29,790 --> 01:06:32,448 or an assignment book, you check off that you did them. 1238 01:06:34,201 --> 01:06:37,314 The reverse process of math calculations can also 1239 01:06:37,314 --> 01:06:39,972 be very helpful in terms of editing a paper. 1240 01:06:39,972 --> 01:06:42,752 Reading the paper backwards from the bottom up 1241 01:06:42,752 --> 01:06:45,189 and seeing how it goes. 1242 01:06:47,712 --> 01:06:50,502 It's also helpful if the teacher establishes, 1243 01:06:50,502 --> 01:06:53,660 with the student, ways of monitoring performance. 1244 01:06:53,660 --> 01:06:55,594 How do teachers address behavioral 1245 01:06:55,594 --> 01:06:57,508 challenges in the classroom? 1246 01:06:57,508 --> 01:07:01,386 First, they have to calmly, calmly is the big word, 1247 01:07:01,386 --> 01:07:06,386 restate the infraction of the rule and do not debate 1248 01:07:06,486 --> 01:07:09,020 or argue with the student. 1249 01:07:09,020 --> 01:07:12,677 Second, they have to have some pre-established 1250 01:07:12,677 --> 01:07:15,563 consequences for misbehavior. 1251 01:07:15,563 --> 01:07:20,563 Third, they need to administer the consequences immediately 1252 01:07:20,933 --> 01:07:24,617 and support proper behavior with encouragement. 1253 01:07:24,617 --> 01:07:28,466 And four, you have to enforce the rules 1254 01:07:28,466 --> 01:07:30,745 of the classroom consistently. 1255 01:07:30,745 --> 01:07:33,634 This is very hard to do when you have classes of 20, 25, 1256 01:07:33,634 --> 01:07:36,523 of 20, 25, 1257 01:07:36,523 --> 01:07:39,413 sometimes 30 kids in a class. 1258 01:07:39,413 --> 01:07:42,064 For teachers, it's really helpful if you work in a school 1259 01:07:42,064 --> 01:07:46,932 and you have school based practice, to offer or figure out 1260 01:07:46,932 --> 01:07:51,121 with them how to get supervision, discipline... 1261 01:07:57,936 --> 01:08:00,603 It's very important for teachers if you work 1262 01:08:00,603 --> 01:08:04,783 in a school based practice to help them get supervision, 1263 01:08:04,783 --> 01:08:09,139 and peer support and brain storming ideas 1264 01:08:09,928 --> 01:08:13,133 to deal with these kinds of challenging behaviors. 1265 01:08:13,133 --> 01:08:16,079 So that they're not feeling all alone in a classroom 1266 01:08:16,079 --> 01:08:21,079 with a child and they don't end up blaming the child 1267 01:08:21,377 --> 01:08:26,377 and not purposely, although sometimes maybe purposely, 1268 01:08:26,601 --> 01:08:30,066 singling out that child. 1269 01:08:32,230 --> 01:08:35,806 It's important that teachers avoid ridicule and criticism 1270 01:08:35,806 --> 01:08:38,635 publicly of a child, of course at all times, 1271 01:08:38,635 --> 01:08:41,711 but especially with kids with ADHD. 1272 01:08:41,711 --> 01:08:44,714 Because the belief in society is they could change it 1273 01:08:44,714 --> 01:08:46,613 if they wanted to. 1274 01:08:46,613 --> 01:08:50,423 The reality is, as we've talked about today, 1275 01:08:50,423 --> 01:08:54,014 things don't just change because you want them to 1276 01:08:54,014 --> 01:08:54,565 if you have ADHD. 1277 01:08:54,565 --> 01:08:56,977 It is a biologically based disorder, 1278 01:08:56,977 --> 01:09:01,758 and it's based in the brain, so there are a lot 1279 01:09:01,758 --> 01:09:05,935 of very complicated factors that go along with it. 1280 01:09:07,858 --> 01:09:11,898 You want to help a child build self-esteem. 1281 01:09:11,898 --> 01:09:16,063 That's through positive reinforcement, 1282 01:09:16,063 --> 01:09:19,560 whether you call it reward or praise, 1283 01:09:19,560 --> 01:09:22,975 and noticing when things are going well. 1284 01:09:22,975 --> 01:09:25,794 Noticing when a child is doing a good job. 1285 01:09:25,794 --> 01:09:29,754 Teach the child to reward him 1286 01:09:29,754 --> 01:09:32,798 or herself through self-talk. 1287 01:09:33,721 --> 01:09:35,301 That's your job as a therapist. 1288 01:09:35,301 --> 01:09:38,767 What does the child say to him or herself 1289 01:09:38,767 --> 01:09:40,534 when something's gone well? 1290 01:09:40,534 --> 01:09:43,565 Does the child say, "I was lucky," 1291 01:09:43,565 --> 01:09:46,594 or "Yeah, last time it was really bad," 1292 01:09:46,594 --> 01:09:47,991 or " Just wait till next time," 1293 01:09:47,991 --> 01:09:52,652 or does the child say, "Good job, I'm making progress." 1294 01:09:52,652 --> 01:09:56,301 My bet is the child doesn't very often say the last one 1295 01:09:56,301 --> 01:09:59,758 and that's what we want to help that child learn to say. 1296 01:10:01,605 --> 01:10:04,146 What do we want to keep in mind here? 1297 01:10:04,761 --> 01:10:08,626 What are the top 10 reasons for procrastinating? 1298 01:10:15,278 --> 01:10:17,665 Sense of humor goes a long way. 1299 01:10:17,665 --> 01:10:20,610 We want to help families and teachers and kids 1300 01:10:20,610 --> 01:10:23,139 and teachers and kids 1301 01:10:23,139 --> 01:10:26,500 with ADHD themselves be able to laugh 1302 01:10:26,500 --> 01:10:30,630 at some of the things they do and not shame themselves 1303 01:10:30,630 --> 01:10:33,300 or hate themselves for it. 1304 01:10:34,777 --> 01:10:39,777 Home school collaboration is essential for academic success. 1305 01:10:41,564 --> 01:10:43,985 Executive functioning problems 1306 01:10:43,985 --> 01:10:48,961 are not motivational deficits but skill deficits. 1307 01:10:48,961 --> 01:10:53,961 Those skills need to be taught from infancy to adulthood. 1308 01:10:54,976 --> 01:10:58,441 Parents have to teach them, teachers have to teach them, 1309 01:10:58,441 --> 01:11:00,590 and therapists and psychologists 1310 01:11:00,590 --> 01:11:04,564 have to teach them to people with ADHD. 1311 01:11:04,564 --> 01:11:07,026 They do not come naturally, in fact they don't 1312 01:11:07,026 --> 01:11:09,601 really come naturally to anyone. 1313 01:11:09,601 --> 01:11:11,779 It's just the people that don't have ADHD 1314 01:11:11,779 --> 01:11:16,484 learn them more readily than people who do. 1315 01:11:18,589 --> 01:11:20,759 ADHD is a medical condition. 1316 01:11:20,759 --> 01:11:25,759 It is not a failure of will, it is not a choice. 1317 01:11:27,758 --> 01:11:31,121 It's important to remember, as Ross Green says, 1318 01:11:31,121 --> 01:11:34,221 "Kids do well if they can. 1319 01:11:34,221 --> 01:11:38,193 "And if they can't, what is getting in the way 1320 01:11:38,193 --> 01:11:41,253 "of them not doing well?" 1321 01:11:42,547 --> 01:11:46,547 Adult support is key to successful interventions 1322 01:11:46,547 --> 01:11:49,487 and life long learning skills. 1323 01:11:49,487 --> 01:11:54,147 In this way, coaching can be extremely helpful. 1324 01:11:54,147 --> 01:11:58,391 Having someone at the school who's a touchstone 1325 01:11:58,391 --> 01:12:03,359 for a child with ADHD, even five, 10 minutes a day, 1326 01:12:03,359 --> 01:12:06,448 can be extremely helpful. 1327 01:12:10,465 --> 01:12:11,999 Keep in mind, executive functions 1328 01:12:11,999 --> 01:12:15,325 provide structure, organized time. 1329 01:12:15,325 --> 01:12:18,461 It involves initiation, help a person understand 1330 01:12:18,461 --> 01:12:21,597 help a person understand 1331 01:12:21,597 --> 01:12:24,734 and organize and live in their environment. 1332 01:12:26,580 --> 01:12:29,803 To use these executive functions, there are some tips. 1333 01:12:29,803 --> 01:12:33,585 Give reminders, or what we would call cues, use calendars, 1334 01:12:33,585 --> 01:12:37,436 try to stay calm and supportive if you are a family member 1335 01:12:37,436 --> 01:12:40,927 or a professional involved with this child. 1336 01:12:40,927 --> 01:12:43,924 Avoid negative labels. 1337 01:12:43,924 --> 01:12:48,675 Parenthetically, ask what negative labels that child has 1338 01:12:48,675 --> 01:12:51,621 about him or herself. 1339 01:12:51,621 --> 01:12:54,540 Provide breaks. 1340 01:12:54,540 --> 01:12:58,286 Praise efforts that you see toward change 1341 01:12:58,286 --> 01:13:00,024 and doing things differently. 1342 01:13:02,608 --> 01:13:05,644 Create scaffolding and sustain it longer 1343 01:13:05,644 --> 01:13:08,825 than you think it might be necessary. 1344 01:13:10,486 --> 01:13:12,923 What are the keys to personal success and confidence 1345 01:13:12,923 --> 01:13:16,181 for a child or teenager with ADHD? 1346 01:13:16,181 --> 01:13:19,542 Help them organize their environment, praising, 1347 01:13:19,542 --> 01:13:24,085 self initiation and motivation, completion of tasks, 1348 01:13:24,085 --> 01:13:28,696 getting feedback, talking about how time is organized, 1349 01:13:28,696 --> 01:13:31,080 providing scaffolding and keeping it 1350 01:13:31,080 --> 01:13:34,598 in place longer than you think, 1351 01:13:34,598 --> 01:13:37,377 giving any kinds of cues, 1352 01:13:37,377 --> 01:13:41,636 visual, verbal over time, even if you don't want to 1353 01:13:41,636 --> 01:13:45,156 or think they're not necessary. 1354 01:13:45,156 --> 01:13:48,382 Even if the child says, "Oh, my God, 1355 01:13:48,382 --> 01:13:50,025 "you nag me all the time." 1356 01:13:50,025 --> 01:13:53,030 Well, let's talk about what nagging is versus cuing. 1357 01:13:53,030 --> 01:13:56,027 Use technology if that could be helpful. 1358 01:13:56,027 --> 01:14:01,027 Really try to investigate what negative labels that child 1359 01:14:02,569 --> 01:14:06,855 is telling him or herself about having ADHD 1360 01:14:06,855 --> 01:14:09,144 and challenges with executive function. 1361 01:14:09,144 --> 01:14:12,569 Try to avoid making sure that... 1362 01:14:12,569 --> 01:14:15,831 Try to make sure those labels are avoided 1363 01:14:15,831 --> 01:14:18,447 being used in the child's life. 1364 01:14:20,262 --> 01:14:24,516 In Delivered from Distraction, Ned Hallowell talks 1365 01:14:24,516 --> 01:14:27,483 about seven habits to improve effectiveness. 1366 01:14:27,483 --> 01:14:30,921 I wanted to share those with you because I think it's really 1367 01:14:30,921 --> 01:14:35,921 important to take this positive view of child development 1368 01:14:36,361 --> 01:14:41,361 and adolescent development and young adult development. 1369 01:14:41,557 --> 01:14:46,557 When you think about kids with ADHD and executive function 1370 01:14:47,252 --> 01:14:50,097 challenges that we want to get them to a place 1371 01:14:50,097 --> 01:14:53,676 where they feel they have something they're good at 1372 01:14:53,676 --> 01:14:56,322 and they're passionate about and they can pursue a life 1373 01:14:56,322 --> 01:15:00,383 of rich connection to others and something, 1374 01:15:00,383 --> 01:15:05,383 meaningful work and nice, pleasurable hobbies, 1375 01:15:06,653 --> 01:15:10,232 and a life that they feel good about. 1376 01:15:10,232 --> 01:15:13,360 Here are his seven habits to improve effectiveness. 1377 01:15:13,360 --> 01:15:16,544 One: Do what you're good at. 1378 01:15:16,544 --> 01:15:18,756 That would be very true for kids with ADHD. 1379 01:15:18,756 --> 01:15:23,756 Find something they like or they're good at and magnify it. 1380 01:15:23,896 --> 01:15:28,199 Delegate what you're bad at to others, as often as possible. 1381 01:15:28,199 --> 01:15:32,489 That sometimes is hard to do in childhood and adolescence. 1382 01:15:32,489 --> 01:15:35,814 As an adult we can do that. 1383 01:15:35,814 --> 01:15:39,357 I have a client who's an attorney 1384 01:15:39,357 --> 01:15:43,479 and he is not very good with managing his appointments. 1385 01:15:43,479 --> 01:15:48,479 He solved that problem because he has a personal assistant 1386 01:15:48,802 --> 01:15:50,971 or an administrative assistant. 1387 01:15:50,971 --> 01:15:54,505 That's harder for kids but I think it's interesting 1388 01:15:54,505 --> 01:15:57,626 to take that on as a perspective. 1389 01:15:57,626 --> 01:16:01,508 This idea of delegating what you're not good at. 1390 01:16:01,508 --> 01:16:05,062 If you're not good at remembering to take your pills 1391 01:16:05,062 --> 01:16:07,668 in the morning then let's set an alarm for that to happen 1392 01:16:07,668 --> 01:16:09,786 so you don't have to worry about it any more. 1393 01:16:09,786 --> 01:16:13,609 Connect your energy to a creative outlet. 1394 01:16:13,609 --> 01:16:17,792 Most of the kids I see with ADHD, in fact 1395 01:16:17,792 --> 01:16:22,102 almost all of them, have some aspect of creativity. 1396 01:16:22,102 --> 01:16:24,983 That's just fantastic. 1397 01:16:24,983 --> 01:16:29,088 Sense of humor, art, writing, 1398 01:16:29,088 --> 01:16:33,288 drawing, magic cards, gardening, 1399 01:16:33,288 --> 01:16:35,919 there's something that they really love to do. 1400 01:16:35,919 --> 01:16:40,002 I really think that it's important to nurture 1401 01:16:40,002 --> 01:16:43,813 that connection to something that they are creative 1402 01:16:43,813 --> 01:16:47,327 and passionate about. 1403 01:16:48,875 --> 01:16:51,339 Get well organized enough to achieve your goals. 1404 01:16:51,339 --> 01:16:53,913 We've been talking about this today, 1405 01:16:53,913 --> 01:16:56,046 the importance of organization. 1406 01:16:56,046 --> 01:16:59,167 Actually have said that getting organized 1407 01:16:59,167 --> 01:17:02,938 is a goal in of itself. 1408 01:17:02,938 --> 01:17:06,193 In general, getting organized is a means to an end. 1409 01:17:06,193 --> 01:17:09,263 Identifying what that end is and figuring 1410 01:17:09,263 --> 01:17:13,500 out what kinds of organization you need to get to that end 1411 01:17:13,500 --> 01:17:16,756 is part of the process of building 1412 01:17:16,756 --> 01:17:20,110 executive functioning skills. 1413 01:17:20,110 --> 01:17:23,872 We want to help the kids and teens and young adults 1414 01:17:23,872 --> 01:17:26,265 we work with do that. 1415 01:17:26,265 --> 01:17:30,757 Ask for and heed advice from people you trust. 1416 01:17:32,357 --> 01:17:35,428 Well, sometimes that can be challenging for all of us, 1417 01:17:35,428 --> 01:17:39,622 I think it's sometimes especially hard for young people 1418 01:17:39,622 --> 01:17:43,024 with ADHD because of the shame that I've referred to 1419 01:17:43,024 --> 01:17:47,666 and the general sense of not getting things right. 1420 01:17:47,666 --> 01:17:52,666 We want to help them learn how to ask for assistance 1421 01:17:53,211 --> 01:17:56,317 without feeling embarrassed. 1422 01:17:56,317 --> 01:17:59,033 That's an ongoing process, it's not an easy one, 1423 01:17:59,033 --> 01:18:03,743 but it's really critical to their success 1424 01:18:03,743 --> 01:18:07,170 in whatever endeavor they embark on. 1425 01:18:07,170 --> 01:18:12,056 Keep up regular contact with a few close friends. 1426 01:18:14,809 --> 01:18:18,343 Friendships nurture us throughout our whole lives. 1427 01:18:18,343 --> 01:18:23,343 Sometimes for children with ADHD, making friends is hard 1428 01:18:24,626 --> 01:18:28,068 because they misread the social cues around them. 1429 01:18:28,068 --> 01:18:31,638 Sometimes they're so focused on making friends 1430 01:18:31,638 --> 01:18:34,201 that they have a lot of peripheral friendships 1431 01:18:34,201 --> 01:18:36,711 but no real intimacy. 1432 01:18:36,711 --> 01:18:40,053 Sometimes they can be over focused on one person. 1433 01:18:40,053 --> 01:18:43,611 One of the things that's important to think 1434 01:18:43,611 --> 01:18:46,243 about when we work with kids with ADHD 1435 01:18:46,243 --> 01:18:49,806 is to help them understand what it means to be a friend. 1436 01:18:49,806 --> 01:18:51,895 What to expect from another person, 1437 01:18:51,895 --> 01:18:55,422 but also what to expect from yourself. 1438 01:18:55,422 --> 01:19:00,422 The last habit that Hallowell identifies 1439 01:19:01,472 --> 01:19:04,255 is go with your positive side. 1440 01:19:04,255 --> 01:19:07,589 Which I think is a great thing to think about 1441 01:19:07,589 --> 01:19:09,719 which is lead with your strength. 1442 01:19:09,719 --> 01:19:14,621 One of our tasks, as therapists, 1443 01:19:14,621 --> 01:19:18,149 is to help identify what that strength is. 1444 01:19:18,149 --> 01:19:23,149 In the family, in school, in work, socially. 1445 01:19:23,159 --> 01:19:25,186 What are those strengths 1446 01:19:25,186 --> 01:19:29,344 and how can we really nourish them 1447 01:19:29,344 --> 01:19:32,193 so that they continue to grow. 1448 01:19:33,024 --> 01:19:37,662 These kids can feel like they are things they are good at. 1449 01:19:41,307 --> 01:19:45,644 Finally, another quote from Delivered from Distraction. 1450 01:19:45,644 --> 01:19:48,798 And you don't give up, that is another trait 1451 01:19:48,798 --> 01:19:50,563 of people with ADD. 1452 01:19:50,563 --> 01:19:52,051 They keep trying. 1453 01:19:52,051 --> 01:19:54,994 Often they keep trying the same, doomed way, 1454 01:19:54,994 --> 01:19:57,904 but they do keep trying. 1455 01:19:57,904 --> 01:20:01,865 We want to try to help them try in different ways, 1456 01:20:01,865 --> 01:20:05,457 to think in different categories, and ultimately, 1457 01:20:05,457 --> 01:20:10,457 to use that innate desire to keep trying 1458 01:20:11,656 --> 01:20:16,656 to their best interest so that their efforts 1459 01:20:17,473 --> 01:20:20,450 feel rewarding to them. 1460 01:20:20,450 --> 01:20:23,315 Thank you so much for participating 1461 01:20:23,315 --> 01:20:26,641 and understanding ADHD in executive functioning 1462 01:20:26,641 --> 01:20:30,005 in children adolescence. 1463 01:20:30,005 --> 01:20:31,736 I hope this information will be useful 1464 01:20:31,736 --> 01:20:33,428 to you in your practice. 1465 01:20:33,428 --> 01:20:37,288 I hope that you have a wonderful day.