- Let's talk about how executive functions develop.
So as we know, executive functions guide behavior.
They reside in the prefrontal cortex,
and these executive functions, about 11 or 12 of them,
have been identified and they work together
as a team of conductors to light up parts of the brain
frequently in collaboration with each other
so that we can move through life planning and organizing
and doing things that are very complicated
and multi-layered.
When we're born, when a baby is born,
brain structures, myelination, the process
of the fatty sheath developing around the neurons
to speed the transmission of the chemical reactions,
the electrical impulses that send one message
from one neuron to another and neurotransmitter reactions
are not fully developed.
Individual physiology, genetics, and the patterns
of human interactions between infants and care takers
all influenced the development of neuro circuitry.
What is the order of the emergence
of these executive functions?
So, the first thing that emerges is response inhibition.
And that's the ability to think before you act.
If there's a behavorial aspect to it, the ability to delay
or respond leading to an immediate consequence.
If I put my hand on something hot and it hurts me,
I'm going to know not to put my hand on something hot,
I'm going to inhibit that response,
that urge to touch that hot thing.
If response inhibition stops ongoing behaviors
when they're unsuccessful, manages distractions
that interfere with other cognitive functions
and it starts at about age three
and is usually developed by the age of 13.
Non-verbal memory is the ability to represent people
and events in the mind.
Hindsight, foresight, and it's kind
of like a spatial sketchpad.
Emotional control, we call this self regulation.
This is the ability to manage your emotions
to achieve goals and direct behavior.
At about six months, an infant develops the basic ability
to hold an image in his or her mind
and move towards something.
This happens to dove tail nicely with the mobility skills
that are developing physically at that time.
Flexibility, this is the executive function
that helps us revise, plans in light of new information
and supports adaptability to change.
We see this in young children all the time.
They try something,
try to put a square peg in a round hole
and it doesn't work and they go to the square hole
and they put the square peg in there.
They've revised their plan in light
of the new information that didn't fit.
Sustained attention, this is the ability
to maintain intention to a situation or task regardless
of fatigue, boredom or distractability.
The next one to develop is initiation of tasks,
the ability to start tasks without
too much procrastination or delay.
We're going to continue reviewing
how these executive functions develop.
So internalization of speech which
is called verbal working memory.
This is using words to communicate thoughts,
feelings, and self-talk.
Vygotski has a model of how language
becomes private and internalized and it's very relevant
to this particular executive function.
And it's very important with people who have ADHD.
From zero to three, children will speak to others.
They don't really have a mind's voice.
Whatever they think, comes right out.
Between the ages of four and five,
the voice turns a little bit back on themselves
and they talk out loud to themselves.
They'll often say, "I do this", or they'll name themselves
and as they're doing an activity,
they'll talk themselves through things.
Around the ages of six to eight, there's a shift
from description to instruction.
The voice in your head develops around age seven.
By age nine, there is no longer
any publicly observable speech.
What that means is that, around four,
what the child will do is say, "I make a picture."
Around six, the child will say, "I want you
"to make a picture of trees."
The self-talk is less about description or,
if the child will talk to himself, and say,
"I'm making a picture" and let's see,
I think I want to put some trees here and some flowers here.
So they talk themselves through their activities.
That's very common from six to eight.
Around age, between ages seven and nine,
the voice that we all have in our heads
of kind of talking ourselves
through things silently, develops.
By about nine, generally most kids don't talk themselves
through things out loud.
With ADHD, kids continue to think
and talk aloud most of the time
because they can't do it in their brains.
There's a failure to internalize that speech,
the switch is broken.
Actually, it's quite helpful for them to be able
to talk themselves through an activity
because it's a way that they organize themselves.
In terms of the next executive function,
planning and prioritizing.
Planning creates a road map to reach a goal.
You divide complex behavioral sequences
into different components to solve new problems,
excuse me, or obtain new goals.
It also is an ability to find a good fit
between a problem and a solution.
The ability to make decisions
about what's important and what's not.
Planning and prioritizing are very important skills
that need to develop particularly as a child becomes
and wants to become more independent.
If I wanna go out with my friends,
then I'll have to do my homework before I go out
or if I want to go out with my friends
and I need a ride from my mom, I have to ask her
more than five minutes before the event,
those kinds of things are very helpful
and important to learn how to do.
Organization, another executive function
which is the ability to create and maintain systems
to keep track of your information and stuff.
That would develop probably next.
Time management.
Time management is tough, as I've said.
It is the ability to develop
accurate time estimation for tasks.
How much time do you have, how you allocate it,
how you budget it, and how to keep within deadlines.
This is extremely difficult for people with ADHD.
Actually, one of the ways that I work with them
on this particular executive function limitation
is backward design.
So we start with when they have to be some where,
and go backwards using an example from their lives,
of something that has happened recently.
How long does it take?
What time, what time, what time?
And to really accurately, as much as possible,
assess how much time things take
and then we add a little extra, ten minutes,
because things almost always take longer than we expect.
But backward design is helpful for them,
it's very concrete, forward design does not work as well.
Because of the planning challenges
that go along with having ADHD.
Persistence to achieve a goal.
This is another key executive function.
We call this persistence or sustained attention
and it's the capacity to follow through on something
without being waylaid by competing interests.
It really depends on immediate versus delayed gratification.
For people with ADHD, they tend
to want immediate gratification.
Unfortunately, a lot of the things we have to do
in the world, particularly in school,
rely on delayed gratification.
You have to learn how to develop the ability
to sustain your attention in the context
where you're operating.
We call that goal directed persistence
and it relies on context
dependent sustained attention.
In plainer or more simpler terms,
if you want to be able to stick with your focus
and stay with your goal, you have to be able
to sustain your attention, regardless of the context
that you're in.
One of the problems for people with ADHD is that,
they actually have trouble doing that.
If the context changes, their ability to sustain
attention changes which makes sense because that's true
for all of us sometimes.
But they have trouble regrouping and refocusing.
Metacognition, one of my favorites actually.
Because it's something I've seen really change over time
in a number of my clients as they've matured.
As they've come to therapy, the skill can be developed
and it's very important.
Metacognition is self involved, self regulation,
as we talked about what that is, the control of emotions,
arousal, and the ability to take perspectives.
The ability to take perspectives is very hard for children
and teenagers with ADHD.
Mostly, metacognition involves
using working memory to talk and look back
on past experiences and situations.
See what you did, look at a current situation,
and evaluate if you need to make changes
on what you're doing.
The key to metacognition is the ability to step back
and take a bird's eye view of yourself.
And ask yourself, "How am I dong?
"How are others perceiving me?
"Is there something that I'm missing?"
This is hard because there's a lot of shame related to ADHD,
embarrassment about missing things and anxiety
about trying to get whatever you're missing.
We're going to talk a little bit more
about how executive functions skills develop.
As I said, they start in infancy
and they continue into adolescence.
Basically there's an external to internal process
and we talked earlier about how parents often
are the executive functions early on for their children
in terms of helping them learn to inhibit their responses,
learn to know, that's hot, that's hot,
you don't want to touch that,
they teach them that or they'll, as I said,
help them figure out, you know, they put their pants
on before you put your shoes on, kind of a thing.
Eventually the things that parents teach them
from the outside, or teachers work with them on,
or you as therapists will work with your clients on,
will become internalized to them,
and they'll start to absorb the routines and the processes
that we're trying to help them become more aware of.
There is a parallel development of the brain
and executive functioning skills.
As the brain changes
over the trajectory of childhood,
adolescence into young adulthood,
so do the executive functioning skills.
In puberty, the size and quantity of neural networks
dramatically increase especially
in the frontal lobes and cerebellum.
And there's also, what I referred to before,
as increased myelination, so the thickening
of the fatty sheath around the neural cells
that's in the corpus callosum that connects
the left and right sides of the brain.
This proliferation of brain cells is followed
by a period of pruning the networks.
The system will operate as efficiently as possible.
The increase in the myelination in the corpus callosum
is critical for the more complex use of language
and logical thinking and metacognition
that we see in later adolescence and early adulthood.
If we look at the development of executive function skills,
that these executive functions skills
have to be taught directly.
The frontal lobes are still developing
and so the skills have to be taught thinking about them
as concrete skills not an innate thing
that you should just know because no one
comes into the world knowing them.
They need to be taught.
Teaching executive functions skills
increases the probability of academic success
and better self esteem.
It's important to remember that the dopamine
and norepinephrine pathways in the brain
are especially slow to develop.
Rather than being angry and frustrated and blaming kids
for what they can't do, we would do much better
to think about this as a developmental sequence problem
with a deficit of skills.
How do we assess executive functioning skills?
Well, we conduct a multi-dimensional assessment.
That would include understanding the pattern of strengths
and weaknesses in the child's executive function skills.
The two critical things that we want to look at
are sustained attention and initiation.
These are not accounted for in standardized testing
because the evaluator will say, "Okay, start,"
so the person starts.
We want to get a bunch of information
and that would include: classroom observations,
work samples, behavior checklists such as the BRIEF,
the Brown ADD Scales, the CBCL, the Vanderbilt Scales,
or the BASC, and of course a thorough history
from parents and from teachers.
We went to rely on the process, what we observe
and know about this child, rather than just the scores.
Diagnostic tools include a thorough history
from two separate parties: parents, teachers, the child
him or herself if that's possible, sibling or partner.
Neuropsychological testing could be very helpful.
Hallowell recommends the quantitative electroencephalogram,
the QEEG.
I find the Barclay ADHD and Executive Functions Forms
very helpful and I also find the forms
from Dawon and Guare's books: Smart but Scattered,
and Smart but Scattered Teens.
They have another book, I think,
of just assessing executive functions skills
to be really useful, user friendly
and extremely informative.
Let's talk a little bit about the spectrum
of executive function.
What does it cover in the brain?
So the thing is, you can have executive functions and ADHD
which overlap with the executive functions
and learning disabilities which overlap
with the executive functions.
It's really a broad term and has a lot
of consequences for how someone functions.
All psychiatric and learning disorders
interfere with attention, but it's important
to remember that ADHD is a working memory deficit.
I think it's important that you take a whole child approach
when you work with kids with ADHD.
There's a false belief
that if you fix a disfunctional component
of a child then you fix the child.
If the child has reading trouble, and you "fixed" that,
then you fix the child.
It doesn't always work that way.
We want to think about what helps the whole child manage.
As we know there are three types of learning disabilities:
reading, mathematics and disorders of written expression.
That are especially challenging and have been found
to be associated with ADHD.
How do we intervene to improve executive functions?
Well, we intervene, for one,
at the level of the environment.
What are the expectations of the tasks?
What are the prompts to perform the tasks?
How do the adults interact with the children?
We intervene at the level of the person,
improving the individual's capacity to use his
or her own executive skills through motivation, increased
awareness of what those skills
or deficits are and instruction.
We shift gradually from external to internal dimensions.
We shift from making a checklist that we hang
on the refrigerator to, over time, hoping that parts
of that check list become internalized, which they will,
when there's consistency.
We target only one or two specific behaviors
for change at a time.
There are three key strategies for managing weaknesses
of executive functioning.
As I said, you intervene at the level of the environment,
you intervene at the level of the child.
That means you teach the skill, you motivate the child
to use the skill and you praise or reward the child
for using the skill.
Then you verbalize what you see happening,
so that the child gets another piece of feedback
and another way of externalizing what becomes internal.
General interventions to assist
improving executive function skills
are based on the following questions.
What are your primary goals?
What do you most want to target first?
And then what?
If you want to target three or four things at the same time,
and many clients come in and they want
to fix everything, you'll fail.
Pick the most important thing and work on that,
and when there's some success with that,
then you can go on to the next most important thing.
Use worksheets and information from the child,
parents and teachers to determine these.
Remember that all goals should improve self awareness,
self adjustment and metacognition.
Thinking about how the self is in the world.
The best plans, the best ones,
are developed collaboratively with the child
and the parents.
If the child does not buy in to what...
to what a parent, excuse me, thinks
is the most important thing, the child will not actually
be fully participatory.
We want the child to also see what's most important.
If sometimes what the child sees is most important,
is her or her number one,
is the parent's number four or five,
I have to tell you, that I'll lean
in towards the child's choice because I want the child
to start to feel like he or she has some authority
or autonomy in creating the change
that will help him or her feel better.
Another intervention that's really important
is modifying the environment.
What parts of the environment are not supporting change
for this particular child?
What ways could people interact with this child differently?
What are expectations of this child that aren't working?
If we think back to the client that I referred to earlier
who had a teacher who was giving her spelling tests
even though her IEP said no spelling tests.
One of the ways she was able to modify her environment
with her parents' supports and her strategy
teacher's support was to basically confront the teacher
and say, "I am not supposed to take spelling tests."
That was a modification of the environment.
The final way to intervene is you want to describe
the behavior that is troubling or isn't working
in very specific concrete terms.
Otherwise it become an always kind of a thing.
When something is an always kind of a thing,
people with ADHD don't get it
because as soon as they hear, always,
their brains sort of turn off.
But if they hear, "Remember when you did this
"specific thing?"
Then they will actually be able
to look at that specific thing.
How do we modify the environment?
The first way to modify the environment
is to collaborate with the child first
and ask, "What situations have helped you
"foster completion of tasks or using some
"or using some
"of these executive functioning skills successfully
"in the past?"
When we have that information then we want to think
about if we can establish a goodness of fit
between the child's skills and a particular environment.
What we are talking
about is antecedent control.
We want to modify this situation which triggers
the maladaptive behavior and lack of skills.
We want to alter the physical or social situation
as much as possible.
We want to amend the tasks expected of the child.
We want to change how the adult interacts with the child.
This, of course, is all true for teenagers.
I'm just using child for ease of language,
but those are the goals that we want to think about.
Another way that we can really intervene
in helping improve
executive functions are that we want to reduce distractions
for students and sometimes that will mean creating
physical barriers, fences, removing breakable objects like
locking rooms, a tool shed, putting away controls
to the video games, reducing the social complexities
of the situations, changing a social dynamic,
we want to reduce distractions.
We want there to be a place for everything.
Cubbies, bins, hampers, calendars, files, notebooks
and we want to teach the children how to file.
When you get papers from a teacher
and they're three hole punched, they should go
into the binder with each hole in a ring not shoved
into the folder section.
You want to help teach organization,
here's the piece of information that some parents
really don't want to hear,
until they're practically out of high school.
Freshman and sophmores still need
the kind of assistance
with organization if they have ADHD
that sixth, seventh and eighth graders do.
Maybe somewhat different but they will need
some help with their organization.
In terms of electronics,
I would like to say that most teenagers,
and I would say a lot of kids now from ages 12 and up,
have a phone, an iTouch,
or fancy watch or something like that.
Those three devices are going to be their best friend
because most kids, if you ask them
where X, Y, or Z is, they don't know,
but they always know where their phone is.
Or their iTouch.
We want to use the iTouch or the phone
or some comparable kinds of devices to help them organize.
Put items in their calendar,
set alarms to remember,
oh, I gotta take my pills or I have an appointment,
and we want to use those as much as possible
because the phone or the iTouch or whatever
is with them most of the time.
Whereas the notebook, the calendar notebook may not be.
That might require doing things twice
or it might require basically writing down things
in the notebook at school and then having an alarm set
in the phone, you know, when it's time to do your homework,
check calendar for homework.
Rehearse with a child.
What will happen in advance of a particular situation?
If you have a child that gets really overwhelmed
in social situations, and you're having Thanksgiving
at Aunt Shirley's house and there's going to be 25 people,
it would be worth taking some time to talk to that child
about what's going to happen at Aunt Shirley's house
and how you or he can work
on when he feels overwhelmed
or might need a break or maybe you want
to institute a break where you and your child go
up to a room and chill out for a few minutes.
You plan and talk about an event that you know could
be challenging for your child in advance.
Use verbal prompts.
We want parents to use verbal prompts
to remind the child to check a schedule.
For example, a lot of parents I work with complain
they have to say the same thing over and over again.
From the time a child can read,
and even if a child can't read, because you can
do a checklist with pictures of items.
You can put up a list for your child of things
you want him or her to do.
Basically say, over and over, check your list,
check your list.
When things are done on the list,
they can have a pen and check them off.
That is extremely helpful because it teaches the child
the ability to go back and see what has to be done
when something's finished and to start to understand
there's a sequence, I do this and then I do this,
then I do this,
so there are steps to a process.
You want to help the parents give praise
for using executive skills with their children.
When the child is actually checking the list to say,
in the car on the way to school, "I noticed you
"checked your list and did every thing on it, way to go."
You don't have to go overboard but some noticing
that the child is making an effort
in the direction that you want him or her to go on.
In terms of modifications, I believe that a lot
of times what happens is that parents make tasks too long
and complicated for their children
to be able to follow through.
We want to do shorter steps and shorter tasks.
You want to take a task and divide it into parts
with breaks built in.
I have a client...
she hyperfocuses when she does homework.
She'll sit down and she'll work for three hours.
She's not particularly productive but she zones
in and she can't decide what's important.
Recently I gave her the assignment
that when she goes to do her homework, she can work
for an hour which is what she thinks
is her longest period
of reasonable time, she's 17.
Then she has to take a break for 10 minutes
which is timed and then she'll go back for another hour.
She actually can learn how to break.
She doesn't have that mechanism.
We're trying to teach that for her
and it'll be in her phone.
We want to help these kids make a schedule
and stick with the schedule.
Sometimes the challenge is because of the high likelihood
that a child or teen who has ADHD has a parent
who has ADHD.
It's very hard for these parents to remain consistent
with the schedule that's created.
The schedule that's created
has to be simple enough
to follow and simple enough to follow through on.
You want to make steps explicit, no assumptions.
If you think, you do this and this one, you do one thing
on the list, go to the bathroom and you assume
in the bathroom there's also teeth brushing that occurs.
Mm-mm.
Go to the bathroom, brush your teeth,
put your shoes on, you assume maybe you get your coat
at the same time, no.
No assumptions in the beginning.
Include choices for a child.
The child doesn't feel like, I'm being controlled
with every thing that I have to do.
You want the child to be able to make choices
within the schedule or goals
that you're setting up.
Because there's collaboration with the child,
then the child will be involved in what you're setting up.
In terms of specific modifications in a classroom
that can include changing seat arrangements,
basically looking at what's happening in the playground
or free play or lunch, where the child's sitting at lunch.
In terms of making tasks shorter and taking breaks,
the end of the task has to be in sight.
If your child's goal is to write a paper in one sitting,
that will be a failed experience.
If your child's goal was to write a page of words
that might go better.
Make steps very specific and vary the tasks
so that there are choices.
Watch out for open ended tasks like creative works,
expository writing that have no end.
You have to create, even if it's a self induced,
or sort of a false barrier that they can hit
up against it and feel a sense of completion
and the next time, they'll have a little bit more to do.
I wanted to say something about the complexities
of social situations particularly for younger children.
Parents of children with ADHD have to provide supervision
and some influence over social events for these kids.
It's very hard for these children to manage
these situations on their own because of all the things
we've talked about in terms of executive functioning
and some of the challenges.
The parents will need to check in, the parents might need
to participate in the play dates.
Even at the age of eight and nine or 10,
the parents need to check in and structure a particular
snack time, engage the kids in a game.
A child with ADHD may sometimes feel lost
in a play date, not sure what to do,
or it gets boring.
The parent will need to be somewhat engaged
which sometimes is a little challenging for parents
because they think, "Oh, play date, free time for me.
"I can catch up on X,Y and Z."
And that isn't necessarily the case.
How do we teach executive function skills to ADHD kids?
As I said, I really try to emphasize on this talk,
there's a philosophy of a skill deficit
rather than a failure of will, motivation or knowledge.
One of the ways to teach these skills, in fact,
I think it's the only way, you have to teach
the deficient skills directly.
Do not expect these kids to absorb these skills
through observation or what I call, miracle osmosis.
The first thing that has to occur is you must
consider the child's developmental stage and understand
what is typical for that age group.
Then, you need to be able to help the parents
and you will have to do some times in sessions.
Cue the child for tasks.
Keep the tasks brief,
encourage practice using small steps.
Work with the child's desire for mastery and control.
That's really important.
It's important to remember that these kids want to change.
They want things to be different and better for them.
And that, is your best tool
as a therapist.
Create and keep routines and schedules.
This is the third most important thing,
you need to help these families create and keep
routines and schedules that are not too complicated
and that are accessible and involve
the participation of the child.
It's important for parents and the child
to distinguish between have to and want to.
There are two kinds of tasks really,
ones that you're not very good at doing
and ones that you are capable of doing but don't like doing.
Both of these have to be broken down into smaller steps.
If you're not good at it then there are a whole set
of separate issues that have to go on,
which is like a lack of motivation,
a dread of doing something, an avoidance,
that's one category.
The second category is you can do it
but you just don't like it.
There's also things like avoidance, a lack of desire
to actually do it.
In both cases, these kinds
of tasks are have to tasks.
They have to be broken down into small, manageable chunks,
and steps so that you can do something that you don't like
or you know how to do and you still don't like,
or you can't do, do a small piece of it, break,
do a small piece of it, break.
Because ADHD kids and teens do not have the ability
to sustain themselves through an activity
that they do not like or feel like they cannot do.
You can model as a therapist for these kids.
If this were my assignment, I might,
or when I write a paper, I plan to do this or that,
or this is how I take breaks.
Not because you want to basically explain
your way is the best way but because it's helpful
for these kids to understand that other people struggle also
with having to do tasks that they don't like,
having to do things that they know how to do
but they don't want to do and having to do things
that they don't know how to do.
They need to hear what other people's strategies are,
not only from you but from family members.
Remember what these kids do in their brain and to themselves
is a lot of shaming, that I'm different
and I don't do it right.
One of the goals of teaching executive functioning skills
is to enhance self regulatory capacities.
So the ability to push through something
even if you don't like it, to manage your emotions
even if you're struggling or you're mad...
or you're afraid.
To use charts, visual symbols,
and aids, make lists, as I said, daily calendars
for daily activities.
There never can be enough visual aids up for kids with ADHD.
Building choices to give kids some control.
You have math homework, which you don't like,
and you have Spanish, which you also don't like.
You have English, which you like and science which you like.
How do we want to plan our evening with these two things
you don't like and the two that you do.
Ask the child.
The child might say, "I wanna do the things I like first,
"and the things I dislike next."
Or, "I wanna do something I don't like then something I do.
"Then something I don't like, then something I do."
Ask the child for his or her feedback,
so that he feels like he's participating
in what's being set up.
In terms of...
teaching executive functioning skills to kids,
one thing that's important to remember
is that punishment actually doesn't teach
children what to do.
It teaches them what not to do.
What kids with ADHD need are some ideas about what to do.
They need help figuring out what's next.
One thing is to rehearse, practice and review skills
before an event.
As we said, use verbal prompts or reminders,
arrange for visual cues or alarms.
Praise the child or teen for using new skills
and here's the key, debrief
and review a situation afterwards.
Maybe at the time, maybe three days later,
but something that you saw that was good or different.
That's what you want the parents to be able to do.
If sometimes they can't debrief something
until they're in therapy, then you can do it there.
It's important to teach parents that effective praise
is delivered immediately, is specific to the particulars
of the action that you've seen, states the values
of accomplishment, notices hard work,
and trains the child to appreciate his or her
own task accomplishment and problem solving.
That's how we're going to teach metacognition.
We want to interrupt the child
before the child interrupts you and say,
"I really like how you're doing this."
You want to praise the children for using executive skills.
I like three positives for each corrective feedback.
Each time you say, do it this way or don't do it this way,
you try to remember to notice a couple
of good things at the same time.
People ask me a lot about "bribing".
What's a bribe?
I'm going to talk about my view of bribes.
A bribe is when you say to someone, "Here's the money,
"take this bag across the street."
An incentive is if you take this bag across the street,
I'll give you some money.
I don't believe in bribes, but I do believe in incentives.
I have seen them work in the 25 years
that I've been a family and child therapist.
We want to use incentives and self rewards
to enhance motivation and instruction.
You might make a deal with a child, he works for an hour,
does his homework and gets 10 minutes of Facebook time.
Or you might make a deal with a child that
after homework comes the half hour of TV that she's allowed.
Those kinds of things are really helpful
and the agreement would go further.
If you don't do your homework, or you have a tantrum
about doing your homework, then there will
be no TV for you.
That is very hard for some parents to follow through on,
but it's critical that the incentive actually matters
to the child and isn't available if the child doesn't do
what he or she has agreed to do.
Incentives make an effort of learning a skill
and doing a task less distasteful.
They also teach gratification.
What reward can I give myself or motivation can I give,
to get through this unpleasant task?
We want to make sure that adults offer enough support
to help a child feel successful but not too much support
to be doing things for the child.
Adults usually make two mistakes.
There's too much support so the child
fails to learn independence or too little support
that the child repeatedly fails at a task.
That's a really fine line to balance
and it's really important that you work
with your clients on that.
You want to practice in session
teaching, negotiating, and compromise.
This is something that is often really hard for people.
They're not good at it, they're especially triggered
and reactive to things that bother them about their child,
their partner or their dynamic in the family,
and it's critical, critical that you help them with this.
Scaffolding is crucial and it usually takes
a lot longer than expected,
in terms of how much time
it has to be in place.
What happens is usually we create a system
or support or level of support
or some sort of routine
and it's working, yay.
Then what happens is, adults usually take it out too soon.
This is particularly true in school systems
where a child will have extra support
and be doing well and then they'll want to remove
that support the next year
which is a big mistake, big.
Because the child usually needs the support longer
to make sure that those kinds
of changes are internalized.
You don't want to abruptly stop supports,
supervision or incentives.
Whatever there are supports that are being faded out,
they have to be faded out gradually.
There are five keys to executive skill development.
Often over involved parents can be anxious
and they have trouble backing off from their kids
who needed a lot of support who have ADHD.
As a result, the kids sometimes are under responsible
for their own activities and actions.
We want to help create more accountability in the kids,
these are particularly true of teenagers.
Have the adults step back in appropriate ways
but still stay involved in other ways.
For example, when notebooks are concerned.
It's sophmore year and you might want to take your kid
to Office Depot or Staples or where ever
and say, "Okay, how are we going to organize this year?
"Where are you going to put stuff?"
And help them lay it out.
Next year, junior year, have the discussion,
maybe they want to do it themselves,
maybe you want to look at it when it's done,
but you're involved in the process.
You want to help those parents use collaboration,
to create mutual goals of what should be shared
and what can be independent.
You want to rely on the child's sense of what works
for him or her, as well
as the parental observations about that.
It's important for parents to be very clear
about goals and expectations from the very beginning
of any sort of arrangement that they're setting
up with their children.
To make their goals, the steps for a goal,
into a checklist.
For example, if you're working with a family
and the parents complain that the room is a disaster
and the child needs to clean the room.
It would seem to me that perhaps, and this is true
for a lot of kids, they see their room,
it's like a disaster area, it's overwhelming,
they don't even know where to begin.
It might be useful to make a checklist that goes
on their desk or on their door.
You know, to clean your room.
One: Clear off the bed.
Two: Put the dirty clothes in the hamper.
Three: Fold all the clothes that are in a heap.
You know those kinds of things, they seem so simple
and basic but they'r really important
because the child isn't able to do that internally,
him or herself.
You want to help the parents create expectations
of tasks that the child can actually perform and succeed on.
Not continue to...
basically fail at.
Which perpetuates a cycle of anger
and disappointment and shame.
You want to help the parents make the steps
of every single task explicit.
How do you help kids with ADHD develop emotional control?
The first thing is to identify triggers.
Events that cause the child to lose his or her temper.
The second thing to remember is that emotional control
is one of the executive functions
that takes years to develop.
That would mean it's important to make a list of triggers.
What you can and can not do when you're having a hard time
with the child or the teen.
The third thing is to enact a practice session
and connect the process to reward.
Basically you want to help create
and review what happens
when a child is triggered, what the options are,
and what happened and what can be done differently.
It's important to create a plan to manage
or eliminate the triggers, to talk about what losing
your temper looks like and to create a list
of behaviors that are not tolerated regardless
of how angry or upset you are.
That list has to be short
and extremely specific and concrete.
Then you want to make another list.
A list of replacement behaviors.
Things a child can do when he or she is upset
instead of those other things.
That can be listening to music,
that can be having
a soft pillow or something in the basement
that the child can thawap if needed,
that can be taking a walk with the dog.
Whatever it is appropriate for that child,
there should be a list of alternatives.
In terms of school interventions,
the first thing I think is really worth stating
many times is
that the parents must advocate for their kids.
Over and over and over again.
They have to continue to advocate for their kids.
I'm going to read something from the book that's
on your reference list called, Buzz,
and it's about homework.
It's Friday afternoon and I'm in my writing shed
chewing sugarless tangerine gum and agonizing
over a clunky first draft, longing as always
for distraction and although I wouldn't have ordered
this phone call.
The voice belongs to Buzz's English teacher
who is graciously taking time to let me know
he hasn't turned in a major assignment due today
which is news to me, he should've been working
on for the past week.
Buzz is in middle school.
The instruction was to interview someone,
preferably a parent about prejudice.
Buzz hasn't even gotten started.
His teacher isn't sure why that is, but again,
graciously, and maybe because I've met with her three times
by now to plead for understanding.
She offers Buzz a reprieve as long
as he can do this work over the weekend.
Whenever I ask Buzz if he has homework these days,
he tells me that he has already finished it at school.
He won't write assignments in his agenda,
even when Xbox time depends on it,
and there is little else he cares about other than food
which I'm not ready yet to with hold.
So when Buzz comes home this afternoon,
I leave my shed, microwave him a plate
of leftover spaghetti and spend the next half hour
arguing, bribing, threatening, pulling out the TV cord
and hiding it before finally convincing him to get started.
The two of us, I'm well aware, are trapped
in an all but senseless system.
Even as US teachers are piling on ever more homework,
research has shown it doesn't measurably
improve academic achievement in grade school.
Although it can sour kids' attitudes towards school
and increase conflict between them and their parents.
I should probably spend more time complaining
about this to Buzz's principal who already thinks
I'm a crank but in the short term, I just don't want
him to fail, it drives me crazy that I have to work
this hard and it makes me so sad for the worried mothers
who don't even have this option.
Finally, he sits down in front of the computer.
He smooths out the crumpled blue instruction sheet
we fished from the bottom of his backpack.
A trove of ancient cookie crumbs, leaking pens,
unsigned permission slips and unwashed gym shorts,
and he starts typing fast.
Here we have a boy of maybe 12 or 13,
and a mother who is really struggling with how to get him
motivated, started, following through, accountable,
all of the things that I see in parents
I work with of ADHD kids.
Parents have to advocate for their kids
even if the principal thinks they're a crank.
It's important to remember that ADHD kids
can't bind events across time.
To remember the transitions, physical relocations, changes
in schedule and disruptions are especially difficult
for the child with ADHD.
Changing classes, starting a new year,
having a substitute teacher, all of these things
can be very discombobulating.
It's important to teach ADHD kids how to keyboard
as quickly as possible.
Often because there's a motoric aspect of ADHD,
the physical act of writing is very difficult
and as we've said, sometimes actually
the thinking and the language parts
and expressing them verbally are very difficult.
It's good to keyboard, it helps to speed things along.
It's important in the classroom to avoid distracting
stimuli by not placing the child near the heater,
the door, the windows, other children
who have attention issues and to break up tasks.
Teach how to divide a future task into manageable parts.
In terms of giving instructions for ADHD students,
it's important to often provide
an external source of motivation.
She had mentioned taking away the Xbox
but we also want to provide an incentive.
If you write this, you'll get an extra 15 minutes of Xbox.
I've a child who loves Gilmore Girls.
One of her incentives for following through
on the morning routine without having a tantrum
for which she had a checklist is that she got an extra
15 minutes of Girlmore Girls at night.
It's important for teachers to remember
that ADHD kids might need manipulatives
or a little fidget toy and to make tasks
as manual as possible when needed.
It's also important for parents to remember that.
There might be knee tapping,
or finger twitching,
whatever you want to call it.
There's usually some sort of outlet
for a kind of...
internal sense of energy.
Time outs have to be targeted and limited.
That's important at home but also important at school.
The basic rule of thumb, that time outs shouldn't
be longer than the child's age which I support.
I think that sometimes in school, the time outs have
to be targeted for specific kinds of behavior
and not just general across the board behaviors
because we want to work with the school, and the parent
on the same behavior so that their success,
in that one area of behvior and then,
we can move on to another.
It's important to be patient during transitions
of all types and to create a quiet place in the classroom
which has reduced stimuli, if that's possible,
or a place in school that has reduced stimuli.
I had one student who really had to read
in her English class and she couldn't stand reading.
It was distracting, the chair were uncomfortable.
We were able to arrange with the school
that she could go down to the library
which had a big, soft, cozy chair
and she could sit there and read when there was
in class reading.
How do you help ADHD students at home?
You want to encourage parents to set up a quiet time place
at home that is for studying.
Where the child can go and is not distracted by things.
You want to establish a routine for doing homework.
You want to create systems to help keep the book bag,
school work organized, in the notebook, in the backpack.
You want to create and implement a home school notebook
of assignments and updates.
For younger kids that could be a sheet,
a calendar book, I suggest a calendar book
as early as possible.
This kind of daily assignment notebook is very helpful
because even a second or third grader can see
what he or she did and check it off which helps, again,
organize their ability to remember I did this
and then I have to do this.
Remember all of these executive function skills
have to be taught repeatedly over time,
external to internal.
You want to make sure the student correctly writes
down all of these assignments and perhaps to check
with the teacher each day if necessary,
I find that's been very helpful.
It's nice if the parents can sign the notebook
when their child is younger and in grade school
and use it as a method of communicating with the teacher
so they have a way of going back and forth
on a regular basis.
There's been a lot of research about mindfulness training
for parents and children with ADHD.
It's mostly positive
but it has to continue over time
in terms of support for the practice afterwards.
What the research showed is that people who did
the mindfulness class but didn't continue with brush up
classes or follow through, didn't do as well
or weren't able to keep up with the practice as those
who did have those refresher workshops.
What are the parental essentials for student success?
In my opinion, the number one parental essential
is regular contact with teachers and administrators
at their child's school.
The number two would be, for you as a therapist,
also to have some contact with someone in the school.
So that you can have an understanding of what's working
in the classroom and what's not.
The parents have to advocate for the child.
Having a relationship with the school and the teachers
is helpful, even in high school.
Most high schools, teachers have email,
they check their email and they're available to respond.
If they're not, there's certainly a principal
or a guidance councillor that can be helpful.
Progress reports can be really, really helpful
in finding out how your child's doing.
Many schools have computer programs that you can link in,
log in, excuse me, and see the link related
to how your child is doing.
Some schools have actual progress reports that the child
takes around to his or her teachers.
Or you can set up progress report meetings
with the teachers, just to get a sense of how your child
is doing periodically, if you're concerned.
I think the main thing we want to communicate
to these parents is get involved and stay involved.
I'm going to go through a few slides about how you give
instructions to kids with ADHD
and some classroom strategies.
I'm not going to spend a lot of time on these.
These are mostly resources for you to have
to share with your clients...
in your practice.
One thing that's important when you give instructions
to kids with ADHD is maintaining eye contact
during verbal instruction,
that's really important.
Two: Give out one task at a time.
If you make the directions clear and concise
with one task, the chances are it will be accomplished.
But if you make it a task and you add the word 'and',
chances are, it might not get accomplished.
Particularly for the younger kids.
Small tasks, one task at a time, eye contact
and be consistent with the daily instructions.
Make sure students comprehends instructions
at the beginning of a class, this is really important
for teachers, and at the beginning of a task.
Repeat instructions in a calm, positive manner.
This is also true for parents and for teachers.
I like the rule of three.
I think sometimes it works with...
teachers and sometimes it doesn't.
Essentially the rule of three is, I look at the child
in the eye and I might put a hand on the shoulder
and I say what I want them to do
and I ask it to be repeated.
The hand on the shoulder is optional, but sometimes
for a parent it helps steady the child
to actually focus on what the parent is saying.
In schools that's less optional.
If you have to repeat the instructions,
they need to be repeated in a calm and positive manner.
For classroom strategies, what we want to encourage
teachers to do is to use external cues.
Don't rely on mental or auditory information.
Make lists, posters, signs, remember that auditory
processing for kids with ADHD
is not their strongest way
of learning and sometimes it is.
Sometimes people really learn only through hearing.
I have a client who's an adult,
that's how she remembers all of her information.
That's how she processes and that's how she remembers.
Hearing and doing.
I've another client who's an adult who has ADHD.
He has to write things down and he has to see them visually.
They said they've had these strategies
and ways of learning since they were children.
I see that in the kids I work with which is so interesting
to be able to see it in kids and teenagers
and then people in their forties and fifties.
We want to make time physical in the classroom,
don't rely on internal clocks.
You want to help the child have a timer
or some way of monitoring the time that's more
external and physical
because they can't bind events across time.
You want to help the child break up tasks.
Teachers need to teach them how to divide up a task
into the event, the response and the outcome.
It's nice to see a child near the teacher
but as part of the regular class seating.
I've seen teachers basically put a kid with ADHD
right next to their desk and every one else is in a circle.
All that does is make the child feel alienated,
and different in a very bad way.
Surround the child with good peer role models,
so that the child can be around kids who actually
could help him or her focus or make better choices
and can see what those choices are.
You want to encourage peer tutoring
and cooperative learning when possible.
How do you help kids with certain specific issues
related to executive functioning?
Problems of initiation, getting started.
It's helpful if the material's pre-taught,
if the assignment is broken down into parts
and that you hand out written copies of the assignments.
For problems of sustaining attention or anxiety,
use an interactive teaching style,
provide positive feedback, and offer shorter work periods.
For problems with shifting or making transitions,
offer a daily agenda so the child will know
what to expect.
Encourage flexibility through self-talk
and reward flexible behavior.
I see you doing a great job making the transitions
and you're coming to our class on time.
Problems with organization.
It's sometimes easier for teachers to help students
understand how to file papers in their notebooks
than their parents
because of all the particular
teen dynamics between separating and wanting space
and being independent.
Give extra time for teachers.
If the teachers could give extra time
for organizing material or maybe have the student
come after school for a little help with that,
that would be great.
The other thing that really helps with organization
is to give an ordered list of assignments and activities
that the child or student is responsible for.
For problems with planning, you want to explicitly,
as a teacher, teach planning strategies,
and that means breaking assignments into parts.
If you have a research paper, and teachers do this most
of the time naturally in high school, in the beginning
in the ninth grade, "You're going to do this part
"of the research, we're all going to go to the library
"and we're going to do this part of the research
"on the computer and then I'd like to see you outline
"your paper," whatever it is.
That kind of breaking an assignment down is very helpful
for someone with ADHD because otherwise they see
the research paper and it's just so overwhelming
and there's just so many options and there are lots
of ways they can do it, and they may or may not
have the confidence to do it.
It's very helpful to make it
a more smaller, manageable task.
And to create a calendar of when things
need to be done for that paper.
This would mean providing steps
for a multi-step piece of work or project.
In terms of problems with self monitoring,
we want to teach them a reverse process
to check math calculations
and to use a check off sheet
to show the completion of assignments.
Again, if you have things written down in a calendar
or an assignment book, you check off that you did them.
The reverse process of math calculations can also
be very helpful in terms of editing a paper.
Reading the paper backwards from the bottom up
and seeing how it goes.
It's also helpful if the teacher establishes,
with the student, ways of monitoring performance.
How do teachers address behavioral
challenges in the classroom?
First, they have to calmly, calmly is the big word,
restate the infraction of the rule and do not debate
or argue with the student.
Second, they have to have some pre-established
consequences for misbehavior.
Third, they need to administer the consequences immediately
and support proper behavior with encouragement.
And four, you have to enforce the rules
of the classroom consistently.
This is very hard to do when you have classes of 20, 25,
of 20, 25,
sometimes 30 kids in a class.
For teachers, it's really helpful if you work in a school
and you have school based practice, to offer or figure out
with them how to get supervision, discipline...
It's very important for teachers if you work
in a school based practice to help them get supervision,
and peer support and brain storming ideas
to deal with these kinds of challenging behaviors.
So that they're not feeling all alone in a classroom
with a child and they don't end up blaming the child
and not purposely, although sometimes maybe purposely,
singling out that child.
It's important that teachers avoid ridicule and criticism
publicly of a child, of course at all times,
but especially with kids with ADHD.
Because the belief in society is they could change it
if they wanted to.
The reality is, as we've talked about today,
things don't just change because you want them to
if you have ADHD.
It is a biologically based disorder,
and it's based in the brain, so there are a lot
of very complicated factors that go along with it.
You want to help a child build self-esteem.
That's through positive reinforcement,
whether you call it reward or praise,
and noticing when things are going well.
Noticing when a child is doing a good job.
Teach the child to reward him
or herself through self-talk.
That's your job as a therapist.
What does the child say to him or herself
when something's gone well?
Does the child say, "I was lucky,"
or "Yeah, last time it was really bad,"
or " Just wait till next time,"
or does the child say, "Good job, I'm making progress."
My bet is the child doesn't very often say the last one
and that's what we want to help that child learn to say.
What do we want to keep in mind here?
What are the top 10 reasons for procrastinating?
Sense of humor goes a long way.
We want to help families and teachers and kids
with ADHD themselves be able to laugh
at some of the things they do and not shame themselves
or hate themselves for it.
Home school collaboration is essential for academic success.
Executive functioning problems
are not motivational deficits but skill deficits.
Those skills need to be taught from infancy to adulthood.
Parents have to teach them, teachers have to teach them,
and therapists and psychologists
have to teach them to people with ADHD.
They do not come naturally, in fact they don't
really come naturally to anyone.
It's just the people that don't have ADHD
learn them more readily than people who do.
ADHD is a medical condition.
It is not a failure of will, it is not a choice.
It's important to remember, as Ross Green says,
"Kids do well if they can.
"And if they can't, what is getting in the way
"of them not doing well?"
Adult support is key to successful interventions
and life long learning skills.
In this way, coaching can be extremely helpful.
Having someone at the school who's a touchstone
for a child with ADHD, even five, 10 minutes a day,
can be extremely helpful.
Keep in mind, executive functions
provide structure, organized time.
It involves initiation, help a person understand
and organize and live in their environment.
To use these executive functions, there are some tips.
Give reminders, or what we would call cues, use calendars,
try to stay calm and supportive if you are a family member
or a professional involved with this child.
Avoid negative labels.
Parenthetically, ask what negative labels that child has
about him or herself.
Provide breaks.
Praise efforts that you see toward change
and doing things differently.
Create scaffolding and sustain it longer
than you think it might be necessary.
What are the keys to personal success and confidence
for a child or teenager with ADHD?
Help them organize their environment, praising,
self initiation and motivation, completion of tasks,
getting feedback, talking about how time is organized,
providing scaffolding and keeping it
in place longer than you think,
giving any kinds of cues,
visual, verbal over time, even if you don't want to
or think they're not necessary.
Even if the child says, "Oh, my God,
"you nag me all the time."
Well, let's talk about what nagging is versus cuing.
Use technology if that could be helpful.
Really try to investigate what negative labels that child
is telling him or herself about having ADHD
and challenges with executive function.
Try to avoid making sure that...
Try to make sure those labels are avoided
being used in the child's life.
In Delivered from Distraction, Ned Hallowell talks
about seven habits to improve effectiveness.
I wanted to share those with you because I think it's really
important to take this positive view of child development
and adolescent development and young adult development.
When you think about kids with ADHD and executive function
challenges that we want to get them to a place
where they feel they have something they're good at
and they're passionate about and they can pursue a life
of rich connection to others and something,
meaningful work and nice, pleasurable hobbies,
and a life that they feel good about.
Here are his seven habits to improve effectiveness.
One: Do what you're good at.
That would be very true for kids with ADHD.
Find something they like or they're good at and magnify it.
Delegate what you're bad at to others, as often as possible.
That sometimes is hard to do in childhood and adolescence.
As an adult we can do that.
I have a client who's an attorney
and he is not very good with managing his appointments.
He solved that problem because he has a personal assistant
or an administrative assistant.
That's harder for kids but I think it's interesting
to take that on as a perspective.
This idea of delegating what you're not good at.
If you're not good at remembering to take your pills
in the morning then let's set an alarm for that to happen
so you don't have to worry about it any more.
Connect your energy to a creative outlet.
Most of the kids I see with ADHD, in fact
almost all of them, have some aspect of creativity.
That's just fantastic.
Sense of humor, art, writing,
drawing, magic cards, gardening,
there's something that they really love to do.
I really think that it's important to nurture
that connection to something that they are creative
and passionate about.
Get well organized enough to achieve your goals.
We've been talking about this today,
the importance of organization.
Actually have said that getting organized
is a goal in of itself.
In general, getting organized is a means to an end.
Identifying what that end is and figuring
out what kinds of organization you need to get to that end
is part of the process of building
executive functioning skills.
We want to help the kids and teens and young adults
we work with do that.
Ask for and heed advice from people you trust.
Well, sometimes that can be challenging for all of us,
I think it's sometimes especially hard for young people
with ADHD because of the shame that I've referred to
and the general sense of not getting things right.
We want to help them learn how to ask for assistance
without feeling embarrassed.
That's an ongoing process, it's not an easy one,
but it's really critical to their success
in whatever endeavor they embark on.
Keep up regular contact with a few close friends.
Friendships nurture us throughout our whole lives.
Sometimes for children with ADHD, making friends is hard
because they misread the social cues around them.
Sometimes they're so focused on making friends
that they have a lot of peripheral friendships
but no real intimacy.
Sometimes they can be over focused on one person.
One of the things that's important to think
about when we work with kids with ADHD
is to help them understand what it means to be a friend.
What to expect from another person,
but also what to expect from yourself.
The last habit that Hallowell identifies
is go with your positive side.
Which I think is a great thing to think about
which is lead with your strength.
One of our tasks, as therapists,
is to help identify what that strength is.
In the family, in school, in work, socially.
What are those strengths
and how can we really nourish them
so that they continue to grow.
These kids can feel like they are things they are good at.
Finally, another quote from Delivered from Distraction.
And you don't give up, that is another trait
of people with ADD.
They keep trying.
Often they keep trying the same, doomed way,
but they do keep trying.
We want to try to help them try in different ways,
to think in different categories, and ultimately,
to use that innate desire to keep trying
to their best interest so that their efforts
feel rewarding to them.
Thank you so much for participating
and understanding ADHD in executive functioning
in children adolescence.
I hope this information will be useful
to you in your practice.
I hope that you have a wonderful day.