1 00:00:00,801 --> 00:00:04,038 - Let's talk about how executive functions develop. 2 00:00:04,038 --> 00:00:08,475 So, as we know, executive functions guide behavior. 3 00:00:08,736 --> 00:00:12,345 They reside in the prefrontal cortex, 4 00:00:12,345 --> 00:00:15,048 and these executive functions, about 11 or 12 5 00:00:15,048 --> 00:00:18,252 of them have been identified, and they work together 6 00:00:18,252 --> 00:00:21,788 as a team of conductors to light up parts of the brain, 7 00:00:21,788 --> 00:00:26,788 frequently in collaboration with each other, 8 00:00:26,827 --> 00:00:29,163 so that we can move through life planning 9 00:00:29,163 --> 00:00:31,565 and organizing and doing things 10 00:00:31,565 --> 00:00:36,036 that are very complicated and multi-layered. 11 00:00:36,370 --> 00:00:38,872 When we're born, when a baby is born, 12 00:00:38,872 --> 00:00:41,308 brain structures, myelination, 13 00:00:41,308 --> 00:00:43,110 the process of the fatty sheath 14 00:00:43,110 --> 00:00:46,046 developing around the neurons to speed 15 00:00:46,046 --> 00:00:49,549 the transmission of the chemical reactions, 16 00:00:49,549 --> 00:00:52,686 the electrical impulses that send 17 00:00:52,686 --> 00:00:55,422 one message from one neuron to another, 18 00:00:55,422 --> 00:00:59,592 and neurotransmitter reactions are not fully developed. 19 00:00:59,893 --> 00:01:02,529 Individual physiology, genetics, 20 00:01:02,529 --> 00:01:04,665 and the patterns of human interactions 21 00:01:04,665 --> 00:01:06,700 between infants and caretakers 22 00:01:06,700 --> 00:01:11,294 all influence the development of neural circuitry. 23 00:01:12,460 --> 00:01:14,842 What is the order of the emergence 24 00:01:14,842 --> 00:01:17,341 of these executive functions? 25 00:01:17,341 --> 00:01:20,949 So the first thing that emerges is response inhibition. 26 00:01:20,949 --> 00:01:23,950 And that's the ability to think before you act. 27 00:01:23,950 --> 00:01:25,786 If there's a behavioral aspect to it, 28 00:01:25,786 --> 00:01:28,055 the ability to delay a response 29 00:01:28,055 --> 00:01:29,859 leading to an immediate consequence, 30 00:01:29,859 --> 00:01:34,859 so if I put my hand on something hot and it hurts me, 31 00:01:36,329 --> 00:01:39,733 I'm gonna try to know not to put my hand on something hot, 32 00:01:39,733 --> 00:01:44,733 I'm going to inhibit that urge to touch that hot thing. 33 00:01:45,806 --> 00:01:48,208 A response inhibition stops ongoing behaviors 34 00:01:48,208 --> 00:01:51,545 when they're unsuccessful, manages distractions 35 00:01:51,545 --> 00:01:54,448 that interfere with other cognitive functions, 36 00:01:54,448 --> 00:01:56,416 and it starts at about age three 37 00:01:56,416 --> 00:01:59,953 and is usually developed by the age of 13. 38 00:02:00,120 --> 00:02:03,957 Nonverbal memory is the ability to represent 39 00:02:03,957 --> 00:02:08,128 people and events in the mind, hindsight, foresight, 40 00:02:08,128 --> 00:02:11,698 and it's kind of like a spatial sketchpad. 41 00:02:11,865 --> 00:02:15,335 Emotional control, we call this self-regulation. 42 00:02:15,335 --> 00:02:18,004 This is the ability to manage your emotions 43 00:02:18,004 --> 00:02:21,041 to achieve goals and direct behavior. 44 00:02:21,041 --> 00:02:23,510 At about six months, an infant develops 45 00:02:23,510 --> 00:02:26,613 a basic ability to hold an image in his or her mind 46 00:02:26,613 --> 00:02:29,283 and move towards something, and this happens 47 00:02:29,283 --> 00:02:32,452 to dovetail nicely with the mobility skills 48 00:02:32,452 --> 00:02:35,689 that are developing physically at that time. 49 00:02:35,689 --> 00:02:39,060 Flexibility, this is the executive function 50 00:02:39,060 --> 00:02:43,131 that helps us revise plans in light of new information, 51 00:02:43,131 --> 00:02:46,099 and supports adaptability to change. 52 00:02:46,099 --> 00:02:48,735 We see this in young children all the time, 53 00:02:48,735 --> 00:02:50,604 you know, they try something, they try 54 00:02:50,604 --> 00:02:54,507 to put a square peg in a round hole 55 00:02:54,507 --> 00:02:55,842 and it doesn't work, and then they go 56 00:02:55,842 --> 00:02:58,712 to the square hole and they put the square peg in there. 57 00:02:58,712 --> 00:03:00,847 They've revised their plan in light of 58 00:03:00,847 --> 00:03:03,883 the new information, that it didn't fit. 59 00:03:04,117 --> 00:03:06,320 Sustained attention, this is the ability 60 00:03:06,320 --> 00:03:09,222 to maintain attention to a situation or task 61 00:03:09,222 --> 00:03:14,222 regardless of fatigue, boredom, or distractability. 62 00:03:14,764 --> 00:03:17,931 The next one to develop is initiation of tasks. 63 00:03:17,931 --> 00:03:19,699 The ability to start tasks without 64 00:03:19,699 --> 00:03:23,670 too much procrastination or delay. 65 00:03:29,609 --> 00:03:31,978 We're gonna continue reviewing 66 00:03:31,978 --> 00:03:34,481 how these executive functions develop. 67 00:03:34,481 --> 00:03:36,783 So, internalization of speech, 68 00:03:36,783 --> 00:03:38,853 which is called verbal working memory. 69 00:03:38,853 --> 00:03:40,954 This is using words to communicate 70 00:03:40,954 --> 00:03:44,057 thoughts, feelings, and self-talk. 71 00:03:44,057 --> 00:03:45,926 Vygotsky has a model of how language 72 00:03:45,926 --> 00:03:47,894 becomes private and internalized, 73 00:03:47,894 --> 00:03:49,863 and it's very relevant to this 74 00:03:49,863 --> 00:03:51,632 particular executive function, 75 00:03:51,632 --> 00:03:54,935 and it's very important with people who have ADHD. 76 00:03:54,935 --> 00:03:59,706 So, from zero to three, children will speak to others. 77 00:03:59,706 --> 00:04:01,541 They don't really have a mind's voice. 78 00:04:01,541 --> 00:04:04,912 Whatever they think comes right out. 79 00:04:04,912 --> 00:04:06,313 Between the ages of four and five, 80 00:04:06,313 --> 00:04:08,949 the voice turns a little bit back on themselves, 81 00:04:08,949 --> 00:04:11,318 and they talk out loud to themselves. 82 00:04:11,318 --> 00:04:13,887 They'll often say, "I do this," 83 00:04:13,887 --> 00:04:17,658 or they'll name themselves as they're doing an activity, 84 00:04:17,658 --> 00:04:19,894 they'll talk themselves through things. 85 00:04:19,894 --> 00:04:21,361 Around the ages of six to eight 86 00:04:21,361 --> 00:04:24,664 there's a shift from description to instruction. 87 00:04:24,664 --> 00:04:28,668 The voice in your head develops around age seven, 88 00:04:28,668 --> 00:04:30,937 and by age nine there is no longer 89 00:04:30,937 --> 00:04:33,873 any publicly observable speech. 90 00:04:33,873 --> 00:04:38,011 So what that means is that, around four, 91 00:04:38,303 --> 00:04:43,303 what the child will do is say, "I make a picture." 92 00:04:43,683 --> 00:04:47,754 Around six, the child will say "I want you 93 00:04:47,754 --> 00:04:52,660 "to make a picture of trees," or the self-talk 94 00:04:52,660 --> 00:04:56,730 is less about description, or the child will talk 95 00:04:56,730 --> 00:04:58,531 to himself and say "I'm making a picture, 96 00:04:58,531 --> 00:05:01,061 "and let's see, I think I want to put some trees here, 97 00:05:01,061 --> 00:05:02,736 "and some flowers here," so they talk 98 00:05:02,736 --> 00:05:04,738 themselves through their activities, 99 00:05:04,738 --> 00:05:07,603 that's very common from six to eight. 100 00:05:07,607 --> 00:05:10,443 Around age, between ages seven and nine, 101 00:05:10,443 --> 00:05:13,146 the voice that we all have in our heads 102 00:05:13,146 --> 00:05:14,814 of kind of talking ourselves through 103 00:05:14,814 --> 00:05:18,885 things silently develops, and by about nine, 104 00:05:18,885 --> 00:05:20,453 generally most kids don't talk 105 00:05:20,453 --> 00:05:23,823 themselves through things out loud. 106 00:05:23,823 --> 00:05:27,927 With ADHD, kids continue to think 107 00:05:27,927 --> 00:05:31,364 and talk aloud most of the time, 108 00:05:31,364 --> 00:05:34,401 because they can't do it in their brains, 109 00:05:34,401 --> 00:05:38,238 there's a failure to internalize that speech. 110 00:05:38,238 --> 00:05:40,907 The switch is broken, and actually 111 00:05:40,907 --> 00:05:43,310 it's quite helpful for them to be able 112 00:05:43,310 --> 00:05:45,478 to talk themselves through an activity, 113 00:05:45,478 --> 00:05:49,515 because it's a way that they organize themselves. 114 00:05:50,150 --> 00:05:52,052 In terms of the next executive function, 115 00:05:52,052 --> 00:05:54,221 planning and prioritizing, planning 116 00:05:54,221 --> 00:05:57,023 creates a road map to reach a goal, 117 00:05:57,023 --> 00:05:59,159 you divide complex behavioral sequences 118 00:05:59,159 --> 00:06:04,159 into different components to solve new problems, 119 00:06:04,598 --> 00:06:08,101 or attain new goals, and it also is an ability 120 00:06:08,101 --> 00:06:11,738 to find a good fit between a problem and a solution. 121 00:06:11,738 --> 00:06:13,573 The ability to make decisions about 122 00:06:13,573 --> 00:06:15,475 what's important and what's not. 123 00:06:15,475 --> 00:06:19,913 So planning and prioritizing are very important skills 124 00:06:19,913 --> 00:06:23,964 that need to develop, particularly as a child 125 00:06:23,964 --> 00:06:27,487 becomes and wants to become more independent. 126 00:06:27,487 --> 00:06:31,124 So, if I want to go out with my friends, 127 00:06:31,124 --> 00:06:34,227 then I'll have to do my homework before I go out, 128 00:06:34,227 --> 00:06:36,063 or if I want to go out with my friends 129 00:06:36,063 --> 00:06:39,365 and I need a ride from my mom, 130 00:06:39,365 --> 00:06:43,704 I have to ask her more than five minutes before the event. 131 00:06:43,704 --> 00:06:46,806 So, those kinds of things are very helpful 132 00:06:46,806 --> 00:06:49,810 and important to learn how to do. 133 00:06:49,810 --> 00:06:52,752 Organization, another executive function, 134 00:06:52,752 --> 00:06:56,016 which is the ability to create and maintain systems 135 00:06:56,016 --> 00:06:58,551 to keep track of your information and stuff, 136 00:06:58,551 --> 00:07:01,621 that would develop probably next. 137 00:07:01,621 --> 00:07:06,226 Time management, time management is tough (laughs) 138 00:07:06,226 --> 00:07:08,995 as I've said, is the ability to develop 139 00:07:08,995 --> 00:07:11,698 accurate time estimation for tasks, 140 00:07:11,698 --> 00:07:15,168 how much time do you have, how you allocate it, 141 00:07:15,168 --> 00:07:18,104 how to budget it, and how to keep within deadlines. 142 00:07:18,104 --> 00:07:21,875 This is extremely difficult for people with ADHD, 143 00:07:21,875 --> 00:07:25,178 and actually one of the ways that I work with them on this 144 00:07:25,178 --> 00:07:29,750 particular executive function limitation is backward design. 145 00:07:29,750 --> 00:07:32,952 So we start with when they have to be somewhere, 146 00:07:32,952 --> 00:07:37,023 and go backwards, using an example from their lives 147 00:07:37,023 --> 00:07:39,425 of something that's happened recently, 148 00:07:39,425 --> 00:07:44,397 how long does it take, what time, what time, what time, 149 00:07:44,397 --> 00:07:48,468 and to really accurately, as much as possible, 150 00:07:48,468 --> 00:07:50,703 assess how much time things take, 151 00:07:50,703 --> 00:07:53,807 and then we add a little extra ten minutes, 152 00:07:53,807 --> 00:07:58,278 because things almost always take longer than we expect. 153 00:07:58,278 --> 00:08:00,180 But backward design is helpful for them, 154 00:08:00,180 --> 00:08:04,467 it's very concrete, forward design does not work as well, 155 00:08:04,667 --> 00:08:06,786 because of the planning challenges 156 00:08:06,786 --> 00:08:10,456 that go along with having ADHD. 157 00:08:10,456 --> 00:08:12,259 Persistence to achieve a goal. 158 00:08:12,259 --> 00:08:14,928 This is another key executive function. 159 00:08:14,928 --> 00:08:17,831 So, we call this persistence or sustained attention, 160 00:08:17,831 --> 00:08:20,500 and it's the capacity to follow through on something 161 00:08:20,500 --> 00:08:23,703 without being waylaid by competing interests. 162 00:08:23,703 --> 00:08:26,406 And it really depends on immediate 163 00:08:26,406 --> 00:08:29,709 versus delayed gratification, so, 164 00:08:29,709 --> 00:08:32,412 for people with ADHD, they tend to want 165 00:08:32,412 --> 00:08:35,248 immediate gratification, unfortunately, 166 00:08:35,248 --> 00:08:37,251 a lot of things that we have to do in the world, 167 00:08:37,251 --> 00:08:42,222 particularly in school, rely on delayed gratification. 168 00:08:42,222 --> 00:08:46,826 So, you have to learn how to develop 169 00:08:46,826 --> 00:08:49,929 the ability to sustain your attention 170 00:08:49,929 --> 00:08:53,099 in the context where you're operating. 171 00:08:53,099 --> 00:08:57,670 So we call that goal-directed persistence, 172 00:08:57,670 --> 00:09:02,670 and it relies on context-dependent sustained attention. 173 00:09:04,210 --> 00:09:06,746 In plainer, more simpler terms, 174 00:09:06,746 --> 00:09:10,383 if you want to be able to stick with your focus 175 00:09:10,383 --> 00:09:13,353 and stay with your goal, you have to be able 176 00:09:13,353 --> 00:09:16,256 to sustain your attention regardless 177 00:09:16,256 --> 00:09:18,558 of the context that you're in. 178 00:09:18,558 --> 00:09:21,127 And one of the problems for people with ADHD 179 00:09:21,127 --> 00:09:26,127 is that they actually have trouble doing that, 180 00:09:26,666 --> 00:09:29,402 so if the context changes, their ability 181 00:09:29,402 --> 00:09:32,272 to sustain attention changes, which makes sense, 182 00:09:32,272 --> 00:09:34,374 because that's true for all of us sometimes, 183 00:09:34,374 --> 00:09:38,544 but they have trouble regrouping and refocusing. 184 00:09:39,345 --> 00:09:42,650 Metacognition, this is one of my favorites actually, 185 00:09:42,650 --> 00:09:46,119 because it's something that really I've seen 186 00:09:46,119 --> 00:09:48,521 change over time in a number of my clients 187 00:09:48,521 --> 00:09:52,859 as they've matured, and as they've come to therapy, 188 00:09:52,859 --> 00:09:56,462 this skill can be developed, and it's very important. 189 00:09:56,462 --> 00:10:00,400 So, metacognition involves self-regulation, 190 00:10:00,400 --> 00:10:02,202 as we talked about what that is, 191 00:10:02,202 --> 00:10:04,671 the control of emotions, arousal, 192 00:10:04,671 --> 00:10:07,707 and the ability to take perspectives. 193 00:10:07,707 --> 00:10:11,911 The ability to take perspectives is very hard 194 00:10:11,911 --> 00:10:14,981 for children and teenagers with ADHD. 195 00:10:14,981 --> 00:10:19,585 Mostly, metacognition involves using working memory 196 00:10:19,585 --> 00:10:24,585 to talk and look back on past experiences and situations, 197 00:10:24,825 --> 00:10:28,761 see what you did, look at a current situation, 198 00:10:28,761 --> 00:10:30,430 and evaluate if you need to make 199 00:10:30,430 --> 00:10:33,866 changes on what you're doing. 200 00:10:33,900 --> 00:10:36,736 They key to metacognition is the ability 201 00:10:36,736 --> 00:10:41,140 to step back and take a birds-eye view of yourself, 202 00:10:41,140 --> 00:10:44,411 and ask yourself, "How am I doing? 203 00:10:44,411 --> 00:10:48,244 "How are others perceiving me? 204 00:10:48,748 --> 00:10:52,418 "Is there something that I'm missing?" 205 00:10:52,418 --> 00:10:55,921 This is hard, because there's a lot shame 206 00:10:55,921 --> 00:10:59,859 related to ADHD, embarrassment about missing things, 207 00:10:59,859 --> 00:11:04,733 an anxiety about trying to get whatever you're missing. 208 00:11:07,400 --> 00:11:08,562 So we're gonna talk a little bit more 209 00:11:08,562 --> 00:11:11,270 about how executive function skills develop. 210 00:11:11,270 --> 00:11:13,607 So, as I said, they start in infancy 211 00:11:13,607 --> 00:11:16,743 and they continue into adolescence. 212 00:11:16,743 --> 00:11:21,743 And basically, there's an external to internal process. 213 00:11:23,183 --> 00:11:24,851 And we talked earlier about how parents 214 00:11:24,851 --> 00:11:27,086 often are the executive functions 215 00:11:27,086 --> 00:11:29,456 early on for their children in terms of 216 00:11:29,456 --> 00:11:34,456 helping them learn to inhibit their responses, 217 00:11:34,527 --> 00:11:39,482 learn to know that's hot, that's hot, 218 00:11:39,482 --> 00:11:41,968 you don't want to touch that, so they learn, 219 00:11:41,968 --> 00:11:45,271 they teach them that, or they'll, as I said, 220 00:11:45,271 --> 00:11:47,340 help them figure out that you actually 221 00:11:47,340 --> 00:11:49,342 put your pants on before you put 222 00:11:49,342 --> 00:11:52,401 your shoes on, kind of a thing. 223 00:11:53,939 --> 00:11:55,848 And eventually the things that 224 00:11:55,848 --> 00:11:58,218 parents teach them from the outside, 225 00:11:58,218 --> 00:12:00,119 or teachers work with them on, 226 00:12:00,119 --> 00:12:03,055 or you as therapists will work with your clients on, 227 00:12:03,055 --> 00:12:05,525 will become internalized to them 228 00:12:05,525 --> 00:12:08,295 and they'll start to absorb the routines 229 00:12:08,295 --> 00:12:10,763 and the processes that we're trying 230 00:12:10,763 --> 00:12:13,699 to help them become more aware of. 231 00:12:14,233 --> 00:12:15,802 There is a parallel development 232 00:12:15,802 --> 00:12:19,540 of the brain and executive functioning skills. 233 00:12:19,540 --> 00:12:24,444 So as the brain changes over the trajectory 234 00:12:24,444 --> 00:12:27,380 of childhood, adolescence, into young adulthood, 235 00:12:27,380 --> 00:12:30,316 so do the executive functioning skills. 236 00:12:30,316 --> 00:12:33,019 In puberty the size and quantity 237 00:12:33,019 --> 00:12:35,755 of neural networks dramatically increase, 238 00:12:35,755 --> 00:12:39,492 especially in the frontal lobes and the cerebellum. 239 00:12:39,492 --> 00:12:42,128 And there's an also what I've referred to before 240 00:12:42,128 --> 00:12:45,965 as increased myelination, so the thickening 241 00:12:45,965 --> 00:12:50,303 of the fatty sheath around the neural cells 242 00:12:50,303 --> 00:12:52,439 that's in the corpus callosum that connects 243 00:12:52,439 --> 00:12:55,241 the left and right sides of the brain. 244 00:12:55,241 --> 00:12:58,578 So this proliferation of brain cells 245 00:12:58,578 --> 00:13:02,281 is followed by a period of pruning the networks, 246 00:13:02,281 --> 00:13:04,283 so that the system will operate 247 00:13:04,283 --> 00:13:07,887 as efficiently as possible, and the increase 248 00:13:07,887 --> 00:13:10,323 in the myelination in the corpus callosum 249 00:13:10,323 --> 00:13:12,925 is critical for the more complex use 250 00:13:12,925 --> 00:13:16,763 of language and logical thinking, and metacognition 251 00:13:16,763 --> 00:13:21,700 that we see in later adolescence and early adulthood. 252 00:13:27,207 --> 00:13:29,275 So, if we look at the development 253 00:13:29,275 --> 00:13:34,275 of executive function skills, that these 254 00:13:34,580 --> 00:13:38,851 executive function skills have to be taught directly. 255 00:13:38,851 --> 00:13:41,554 The frontal lobes are still developing, 256 00:13:41,554 --> 00:13:43,856 and so the skills have to be taught 257 00:13:43,856 --> 00:13:47,460 thinking about them as concrete skills, 258 00:13:47,460 --> 00:13:50,596 not an innate thing that you should just know, 259 00:13:50,596 --> 00:13:52,732 because no one comes into the world 260 00:13:52,732 --> 00:13:56,669 knowing them, they need to be taught. 261 00:13:57,603 --> 00:14:01,374 Teaching executive function skills increases 262 00:14:01,374 --> 00:14:06,374 the probability of academic success and better self-esteem. 263 00:14:06,879 --> 00:14:09,549 It's important to remember that the dopamine 264 00:14:09,549 --> 00:14:11,951 and norepinephrine pathways in the brain 265 00:14:11,951 --> 00:14:14,420 are especially slow to develop, 266 00:14:14,420 --> 00:14:19,358 so that rather than being angry and frustrated 267 00:14:19,358 --> 00:14:22,194 and blaming kids for what they can't do, 268 00:14:22,194 --> 00:14:25,531 we would do much better to think about this 269 00:14:25,531 --> 00:14:29,469 as a developmental sequence problem 270 00:14:29,469 --> 00:14:32,471 with a deficit of skills. 271 00:14:33,139 --> 00:14:36,008 How do we assess executive functioning skills? 272 00:14:36,008 --> 00:14:39,445 Well, we conduct a multidimensional assessment, 273 00:14:39,445 --> 00:14:42,682 so that would include understanding 274 00:14:42,682 --> 00:14:44,317 the pattern of strengths and weaknesses 275 00:14:44,317 --> 00:14:47,019 in the child's executive function skills. 276 00:14:47,019 --> 00:14:49,989 So, the two critical things that we want to look at 277 00:14:49,989 --> 00:14:53,026 are sustained attention and initiation, 278 00:14:53,026 --> 00:14:55,962 and these are not accounted for in standardized testing, 279 00:14:55,962 --> 00:15:00,099 because the evaluator will say "Okay, start," 280 00:15:00,099 --> 00:15:02,534 so the person starts. 281 00:15:03,548 --> 00:15:05,905 We want to get a bunch of information, 282 00:15:05,905 --> 00:15:08,141 and that would include classroom observations 283 00:15:08,141 --> 00:15:11,711 work samples, behavior checklists such as the BRIEF, 284 00:15:11,711 --> 00:15:14,381 the Brown ADD Scales, the CBCL, 285 00:15:14,381 --> 00:15:16,916 the Vanderbilt scales, or the BASC, 286 00:15:16,916 --> 00:15:18,884 and of course, a thorough history 287 00:15:18,884 --> 00:15:21,321 from parents and from teachers. 288 00:15:21,321 --> 00:15:23,222 We want to rely on the process, 289 00:15:23,222 --> 00:15:25,491 what we observe and know about this child, 290 00:15:25,491 --> 00:15:28,461 rather than just the scores. 291 00:15:28,461 --> 00:15:31,164 Diagnostic tools include a thorough history 292 00:15:31,164 --> 00:15:35,375 from two separate parties, parents, teachers, 293 00:15:35,391 --> 00:15:37,803 the child him or herself if that's possible, 294 00:15:37,803 --> 00:15:41,208 sibling or a partner, neuropsychological testing 295 00:15:41,208 --> 00:15:44,010 can be very helpful, Hallowell recommends 296 00:15:44,010 --> 00:15:47,446 the quantitative electroencephalogram, 297 00:15:47,446 --> 00:15:51,517 the QEEG, I find the Barkley ADHD 298 00:15:51,517 --> 00:15:53,886 and executive function forms very helpful, 299 00:15:53,886 --> 00:15:58,847 and I also find the forms from Dawson and Guare's books, 300 00:15:58,847 --> 00:16:02,862 Smart But Scattered, and Smart But Scattered Teens, 301 00:16:02,862 --> 00:16:04,064 and they have another book I think 302 00:16:04,064 --> 00:16:06,365 of just assessing executive function skills 303 00:16:06,365 --> 00:16:10,181 to be really useful, user-friendly, 304 00:16:10,181 --> 00:16:13,305 and extremely informative. 305 00:16:13,973 --> 00:16:15,141 Let's talk a little bit about 306 00:16:15,141 --> 00:16:18,677 the spectrum of executive function. 307 00:16:19,745 --> 00:16:21,452 What does it cover in the brain? 308 00:16:21,452 --> 00:16:25,017 So, the thing is that you can have executive functions, 309 00:16:25,017 --> 00:16:27,853 and ADHD, which overlap with the executive functions, 310 00:16:27,853 --> 00:16:30,022 and learning disabilities, which 311 00:16:30,022 --> 00:16:33,025 overlap with executive functions. 312 00:16:33,025 --> 00:16:36,862 So it's really a broad term and it has 313 00:16:36,862 --> 00:16:41,862 a lot of consequences for how someone functions. 314 00:16:42,468 --> 00:16:45,438 All psychiatric and learning disoders 315 00:16:45,438 --> 00:16:47,873 interfere with attention. 316 00:16:47,873 --> 00:16:49,375 But it's important to remember 317 00:16:49,375 --> 00:16:53,989 that ADHD is a working memory deficit. 318 00:16:54,868 --> 00:16:57,516 I think it's important that you take a whole child approach 319 00:16:57,516 --> 00:17:00,086 when you work with kids with ADHD. 320 00:17:00,086 --> 00:17:03,354 You know, there's a false belief 321 00:17:03,354 --> 00:17:06,426 that if you fix a dysfunctional component 322 00:17:06,426 --> 00:17:08,561 of a child then you fix the child. 323 00:17:08,561 --> 00:17:10,596 So if the child has reading trouble, 324 00:17:10,596 --> 00:17:14,100 and you "fix that," then you fix the child, 325 00:17:14,100 --> 00:17:18,838 and really, it doesn't always work that way, (laughs) 326 00:17:18,838 --> 00:17:23,176 so we want to think about what helps the whole child manage. 327 00:17:23,176 --> 00:17:25,678 As we know, there are three types of learning disabilities, 328 00:17:25,678 --> 00:17:29,448 reading, mathematics, and disorders of written expression, 329 00:17:29,448 --> 00:17:31,851 that are especially challenging, 330 00:17:31,851 --> 00:17:36,288 and have been found to be associated with ADHD. 331 00:17:38,124 --> 00:17:42,261 How do we intervene to improve executive functions? 332 00:17:42,261 --> 00:17:47,261 Well, we intervene, one, at the level of the environment. 333 00:17:47,600 --> 00:17:50,102 What are the expectations of the tasks? 334 00:17:50,102 --> 00:17:53,072 What are the prompts to perform the tasks? 335 00:17:53,072 --> 00:17:56,742 How do the adults interact with the children? 336 00:17:56,742 --> 00:17:59,111 We intervene at the level of the person, 337 00:17:59,111 --> 00:18:01,147 improving the individual's capacity 338 00:18:01,147 --> 00:18:03,449 to use his or her own executive skills 339 00:18:03,449 --> 00:18:06,986 through motivation, increased awareness 340 00:18:06,986 --> 00:18:11,986 of what those skills or deficits are, and instruction. 341 00:18:12,191 --> 00:18:16,262 We shift gradually from external to internal dimensions, 342 00:18:16,262 --> 00:18:18,764 so we shift from making a checklist 343 00:18:18,764 --> 00:18:22,001 that we hang on the refrigerator, to, over time, 344 00:18:22,001 --> 00:18:25,471 hoping that parts of that checklist become internalized, 345 00:18:25,471 --> 00:18:29,175 which they will, when there's consistency. 346 00:18:29,175 --> 00:18:31,811 We target only one or two specific 347 00:18:31,811 --> 00:18:35,081 behaviors for change at a time. 348 00:18:35,081 --> 00:18:36,483 There are three key strategies 349 00:18:36,483 --> 00:18:40,165 for managing weaknesses of executive functioning. 350 00:18:40,165 --> 00:18:42,354 You, as I said you intervene at the level 351 00:18:42,354 --> 00:18:45,792 of the environment, you intervene at the level of the child, 352 00:18:45,792 --> 00:18:47,626 and that means you teach the skill, 353 00:18:47,626 --> 00:18:50,062 you motivate the child to use the skill, 354 00:18:50,062 --> 00:18:54,166 and you praise or reward the child for using the skill, 355 00:18:54,166 --> 00:18:58,604 and then you verbalize what you see happening 356 00:18:58,604 --> 00:19:01,640 so that the child gets another piece of feedback 357 00:19:01,640 --> 00:19:06,640 and another way of externalizing what becomes internal. 358 00:19:07,213 --> 00:19:10,049 General interventions to assist 359 00:19:10,049 --> 00:19:13,113 improving executive function skills are 360 00:19:13,113 --> 00:19:15,254 based on the following questions. 361 00:19:15,254 --> 00:19:18,157 What are your primary goals? 362 00:19:18,157 --> 00:19:21,927 What do you most want to target first? 363 00:19:21,927 --> 00:19:24,430 And then what? And then what? 364 00:19:24,430 --> 00:19:27,833 If you want to target three or four things at the same time, 365 00:19:27,833 --> 00:19:29,568 and many clients come in and they want 366 00:19:29,568 --> 00:19:33,472 to fix everything, you'll fail. 367 00:19:33,472 --> 00:19:36,609 Pick the most important thing and work on that, 368 00:19:36,609 --> 00:19:38,444 and when there's some success with that, 369 00:19:38,444 --> 00:19:42,106 then you can go on to the next most important thing. 370 00:19:42,882 --> 00:19:45,384 Use worksheets and information from the child, 371 00:19:45,384 --> 00:19:48,654 parents, and teachers to determine these. 372 00:19:48,654 --> 00:19:51,790 Remember that all goals should improve 373 00:19:51,790 --> 00:19:56,790 self-awareness, self-adjustment, and metacognition, 374 00:19:57,030 --> 00:20:02,030 thinking about how the self is in the world. 375 00:20:03,002 --> 00:20:07,206 The best plans, the best ones, are developed 376 00:20:07,206 --> 00:20:12,206 collaboratively with the child and the parents. 377 00:20:15,214 --> 00:20:20,214 If the child does not buy in to what a parent 378 00:20:21,287 --> 00:20:23,389 thinks is the most important thing, 379 00:20:23,389 --> 00:20:27,092 the child will not actually be fully participatory. 380 00:20:27,092 --> 00:20:30,463 We want the child to also see what's most important, 381 00:20:30,463 --> 00:20:32,965 and if sometimes what the child sees 382 00:20:32,965 --> 00:20:36,268 as most important is his or her number one, 383 00:20:36,268 --> 00:20:38,070 is the parent's number four or five, 384 00:20:38,070 --> 00:20:42,308 I have to tell you that I'll lean in to the child's choice, 385 00:20:42,308 --> 00:20:44,576 because I want the child to start to feel 386 00:20:44,576 --> 00:20:47,246 like he or she has some authority 387 00:20:47,246 --> 00:20:49,982 and autonomy in creating the change, 388 00:20:49,982 --> 00:20:54,219 that will help him or her feel better. 389 00:20:54,612 --> 00:20:57,354 Another intervention that's really important 390 00:20:57,370 --> 00:20:59,926 is modifying the environment. 391 00:20:59,926 --> 00:21:01,661 So what parts of the environment 392 00:21:01,661 --> 00:21:05,965 are not supporting change for this particular child? 393 00:21:05,965 --> 00:21:10,102 What ways could people interact with this child differently, 394 00:21:10,102 --> 00:21:13,340 what are expectations of this child that aren't working, 395 00:21:13,340 --> 00:21:18,110 if we think back to the client I referred to earlier 396 00:21:18,110 --> 00:21:21,548 who had a teacher who was giving her spelling tests 397 00:21:21,548 --> 00:21:24,917 even though her IEP said no spelling tests, 398 00:21:24,917 --> 00:21:27,119 one of the ways that she was able to modify 399 00:21:27,119 --> 00:21:29,955 her environment with her parent's support 400 00:21:29,955 --> 00:21:33,459 and her strategies teacher's support 401 00:21:33,459 --> 00:21:36,328 was to basically confront the teacher 402 00:21:36,328 --> 00:21:39,231 and say, "I am not supposed to take spelling tests." 403 00:21:39,231 --> 00:21:43,035 So that was a modification of the environment. 404 00:21:43,035 --> 00:21:45,071 And then the final way to intervene 405 00:21:45,071 --> 00:21:49,375 is you want to describe the behavior 406 00:21:49,375 --> 00:21:51,577 that is troubling or isn't working 407 00:21:51,577 --> 00:21:56,382 in very specific, concrete terms. 408 00:21:56,448 --> 00:22:01,220 Otherwise, it becomes an always kind of a thing. 409 00:22:01,220 --> 00:22:04,123 And when something is an always kind of a thing, 410 00:22:04,123 --> 00:22:06,658 people with ADHD don't get it, 411 00:22:06,658 --> 00:22:08,660 because as soon as they hear "always" 412 00:22:08,660 --> 00:22:10,563 there brain sort of turns off. 413 00:22:10,563 --> 00:22:12,565 But if they hear, "Remember when you did 414 00:22:12,565 --> 00:22:15,768 "this specific thing," then they will actually 415 00:22:15,768 --> 00:22:19,371 be able to look at that specific thing. 416 00:22:26,045 --> 00:22:28,905 How do we modify the environment? 417 00:22:29,367 --> 00:22:32,117 So, the first way to modify the environment 418 00:22:32,117 --> 00:22:35,154 is to collaborate with the child first, 419 00:22:35,154 --> 00:22:38,490 and ask, "What situations have helped you 420 00:22:38,490 --> 00:22:43,490 "foster completion of tasks or using some of these 421 00:22:43,962 --> 00:22:48,962 "executive functioning skills successfully in the past?" 422 00:22:49,736 --> 00:22:52,838 So, when we have that information, 423 00:22:52,838 --> 00:22:55,642 then we want to think about if we can establish 424 00:22:55,642 --> 00:22:59,512 a goodness of fit between the child's skills 425 00:22:59,512 --> 00:23:02,691 and a particular environment. 426 00:23:03,845 --> 00:23:07,920 What we are talking about is antecedent control, 427 00:23:07,920 --> 00:23:11,356 we want to modify the situation which triggers 428 00:23:11,356 --> 00:23:14,760 the maladaptive behavior and lack of skills. 429 00:23:14,760 --> 00:23:16,628 So, we want to alter the physical 430 00:23:16,628 --> 00:23:19,965 or social situation as much as possible, 431 00:23:19,965 --> 00:23:24,870 we want to amend the tasks expected of the child, 432 00:23:24,870 --> 00:23:28,040 and we want to change how the adult 433 00:23:28,040 --> 00:23:30,342 interacts with the child. 434 00:23:30,342 --> 00:23:31,844 This of course is all true for teenagers, 435 00:23:31,844 --> 00:23:34,446 I'm just using child for ease of language, 436 00:23:34,446 --> 00:23:37,816 but those are the goals that we want to think about. 437 00:23:39,318 --> 00:23:43,355 Another way that we can really intervene 438 00:23:43,355 --> 00:23:47,093 in helping improve executive functions 439 00:23:47,093 --> 00:23:50,329 are that we want to reduce distractions for students, 440 00:23:50,329 --> 00:23:53,065 and sometimes that will mean creating physical barriers, 441 00:23:53,065 --> 00:23:56,835 fences, removing breakable objects, locking rooms, 442 00:23:56,835 --> 00:24:00,039 a tool shed, putting away controls to the video games, 443 00:24:00,039 --> 00:24:03,809 reducing the social complexity of situations, 444 00:24:03,809 --> 00:24:07,779 changing a social dynamic, we want to reduce distractions. 445 00:24:07,779 --> 00:24:09,682 We want there to be a place for everything, 446 00:24:09,682 --> 00:24:14,453 cubbies, bins, hampers, calendars, files, notebooks, 447 00:24:14,453 --> 00:24:17,256 and we want to teach the children how to file. 448 00:24:17,256 --> 00:24:18,991 You know, when you get papers from a teacher 449 00:24:18,991 --> 00:24:20,325 and they are three hole punched, 450 00:24:20,325 --> 00:24:24,730 they should go into the binder with each hole in a ring, 451 00:24:24,730 --> 00:24:27,399 not shoved into the folder section. 452 00:24:27,399 --> 00:24:29,368 You want to help teach organization, 453 00:24:29,368 --> 00:24:31,770 and here's the piece of information 454 00:24:31,770 --> 00:24:34,006 some parents really don't want to hear: 455 00:24:34,006 --> 00:24:39,006 until they're practically out of high school. 456 00:24:39,226 --> 00:24:43,415 Freshmen and sophomores still need 457 00:24:43,415 --> 00:24:47,353 the kind of assistance with organization, 458 00:24:47,353 --> 00:24:49,889 if they have ADHD, that sixth, 459 00:24:49,889 --> 00:24:51,990 seventh, and eighth graders do. 460 00:24:51,990 --> 00:24:53,526 It may be somewhat different, but they 461 00:24:53,526 --> 00:24:57,576 will need some help with their organization. 462 00:24:57,930 --> 00:25:01,300 In terms of electronics, I would like to say 463 00:25:01,300 --> 00:25:05,137 that most teenagers, and I would say 464 00:25:05,137 --> 00:25:07,873 a lot of kids now even from ages 12 and up, 465 00:25:07,873 --> 00:25:12,873 have a phone, an iTouch, or you know, 466 00:25:14,880 --> 00:25:17,382 fancy watch or something like that. 467 00:25:17,382 --> 00:25:21,520 Those three devices are going to be their best friend. 468 00:25:21,520 --> 00:25:24,890 Because, most kids, if you ask them 469 00:25:24,890 --> 00:25:27,293 where X, Y, or Z is, they don't know, 470 00:25:27,293 --> 00:25:29,995 but they always know where their phone is, (laughs) 471 00:25:29,995 --> 00:25:33,398 or their iTouch, and so we want to use 472 00:25:33,398 --> 00:25:36,235 the iTouch or the phone, or, you know, 473 00:25:36,235 --> 00:25:39,075 some comparable kinds of devices, 474 00:25:39,075 --> 00:25:41,006 to help them organize. 475 00:25:41,006 --> 00:25:46,006 Put items in their calendar, set alarms to remember, 476 00:25:46,311 --> 00:25:47,946 "Oh, I gotta take my pills," or, 477 00:25:47,946 --> 00:25:49,748 "I have an appointment." 478 00:25:49,748 --> 00:25:52,251 And we want to use those as much as possible 479 00:25:52,251 --> 00:25:56,121 because the phone or the iTouch or whatever 480 00:25:56,121 --> 00:25:58,890 is with them most of the time, 481 00:25:58,890 --> 00:26:03,228 whereas the notebook, the calendar notebook, may not be. 482 00:26:03,228 --> 00:26:06,498 And that might require doing things twice, 483 00:26:06,498 --> 00:26:09,168 or it might require basically writing down 484 00:26:09,168 --> 00:26:11,203 things in the notebook at school, 485 00:26:11,203 --> 00:26:14,473 and then having an alarm set in the phone, 486 00:26:14,473 --> 00:26:17,649 you know, when it's time to do your homework, 487 00:26:17,649 --> 00:26:20,579 check calendar for homework. 488 00:26:21,380 --> 00:26:24,683 Rehearse with a child what will happen 489 00:26:24,683 --> 00:26:27,152 in advance of a particular situation. 490 00:26:27,152 --> 00:26:29,105 So, if you have a child who gets 491 00:26:29,105 --> 00:26:32,124 really overwhelmed in social situations, 492 00:26:32,124 --> 00:26:36,262 and you're having Thanksgiving at Aunt Shirley's house, 493 00:26:36,262 --> 00:26:38,063 and there's gonna be 25 people, 494 00:26:38,063 --> 00:26:40,132 it would be worth taking some time 495 00:26:40,132 --> 00:26:42,768 to talk to that child about what's gonna happen 496 00:26:42,768 --> 00:26:46,705 at Aunt Shirley's house, and how you or he 497 00:26:46,705 --> 00:26:50,342 can work on, when he feels overwhelmed, 498 00:26:50,342 --> 00:26:52,545 or might need a break, or maybe you want 499 00:26:52,545 --> 00:26:54,613 to institute a break where you and your child 500 00:26:54,613 --> 00:26:57,416 go up to a room and just chill out for a few minutes, 501 00:26:57,416 --> 00:27:00,319 but that you plan and talk about an event that you know 502 00:27:00,319 --> 00:27:03,822 could be challenging for your child in advance. 503 00:27:04,056 --> 00:27:06,158 Use verbal prompts, we want parents to use 504 00:27:06,158 --> 00:27:10,162 verbal prompts to remind the child to check a schedule. 505 00:27:10,162 --> 00:27:12,597 So for example, a lot of parents I work with complain 506 00:27:12,597 --> 00:27:14,099 that they have to say the same thing 507 00:27:14,099 --> 00:27:16,101 over and over and over again. 508 00:27:16,101 --> 00:27:18,537 From the time a child can read, 509 00:27:18,537 --> 00:27:20,038 and even if a child can't read, 510 00:27:20,038 --> 00:27:23,075 because you can do a checklist with pictures of items, 511 00:27:23,075 --> 00:27:26,045 you can put up a list for your child 512 00:27:26,045 --> 00:27:28,447 of things that you want him or her to do, 513 00:27:28,447 --> 00:27:31,584 and basically say, over and over, 514 00:27:31,584 --> 00:27:33,919 "Check your list. Check your list." 515 00:27:33,919 --> 00:27:35,354 And when things are done on the list, 516 00:27:35,354 --> 00:27:37,956 they can have a pen and check them off. 517 00:27:37,956 --> 00:27:40,425 That is extremely helpful, because it teaches 518 00:27:40,425 --> 00:27:44,530 the child the ability to go back and see 519 00:27:44,530 --> 00:27:46,698 what has to be done when something's finished, 520 00:27:46,698 --> 00:27:49,968 and, to start to understand that there's a sequence, 521 00:27:49,968 --> 00:27:53,438 "I do this, then I do this, then I do this," 522 00:27:53,438 --> 00:27:58,438 so there are steps to a process. 523 00:27:59,177 --> 00:28:01,179 I think you want to help the parents 524 00:28:01,179 --> 00:28:03,945 give praise for using executive skills 525 00:28:03,945 --> 00:28:05,717 with their children, so when their child 526 00:28:05,717 --> 00:28:08,553 is actually checking the list to say, 527 00:28:08,553 --> 00:28:09,621 in the car on the way to school, 528 00:28:09,621 --> 00:28:10,789 "I noticed you checked your list 529 00:28:10,789 --> 00:28:13,352 "and did everything on it, way to go." 530 00:28:13,860 --> 00:28:14,993 They don't have to go overboard, 531 00:28:14,993 --> 00:28:16,895 but some noticing that the child's making 532 00:28:16,895 --> 00:28:20,565 an effort in the direction you want him or her to go in. 533 00:28:20,966 --> 00:28:23,750 In terms of modifications, I believe that 534 00:28:23,750 --> 00:28:26,773 a lot of times what happens is that parents 535 00:28:26,773 --> 00:28:29,875 make tasks too long and complicated 536 00:28:29,875 --> 00:28:32,811 for their children to be able to follow through. 537 00:28:32,811 --> 00:28:36,748 So we want to do shorter steps and shorter tasks. 538 00:28:36,748 --> 00:28:38,850 And you want to take a task and divide it 539 00:28:38,850 --> 00:28:41,687 into parts with breaks built in. 540 00:28:41,687 --> 00:28:46,591 So, I have a client, and she hyperfocuses 541 00:28:46,591 --> 00:28:48,693 when she does homework, so she'll sit down 542 00:28:48,693 --> 00:28:50,529 and she'll work for three hours, 543 00:28:50,529 --> 00:28:52,664 she's not particularly productive 544 00:28:52,664 --> 00:28:56,068 but she zones in and she can't decide what's important, 545 00:28:56,068 --> 00:28:59,104 and so recently I gave her the assignment 546 00:28:59,104 --> 00:29:00,673 that when she goes to do her homework, 547 00:29:00,673 --> 00:29:02,207 she can work for an hour, which is what 548 00:29:02,207 --> 00:29:07,179 she thinks is her longest reasonable period of time, 549 00:29:07,179 --> 00:29:11,783 she's 17, and then she has to take a break, 550 00:29:11,783 --> 00:29:14,319 for 10 minutes, which is timed, 551 00:29:14,319 --> 00:29:16,054 and then she'll go back for another hour. 552 00:29:16,054 --> 00:29:19,758 So that she actually can learn how to break. 553 00:29:19,758 --> 00:29:21,393 She doesn't have that mechanism, 554 00:29:21,393 --> 00:29:23,161 so we're trying to teach that for her, 555 00:29:23,161 --> 00:29:27,866 and it will be in her phone. 556 00:29:28,900 --> 00:29:31,937 So we want to help these kids make a schedule, 557 00:29:31,937 --> 00:29:33,506 and then stick with the schedule. 558 00:29:33,506 --> 00:29:35,174 And sometimes the challenge is, 559 00:29:35,174 --> 00:29:39,137 because of the high likelihood that a child 560 00:29:39,137 --> 00:29:43,849 or a teen who has ADHD has a parent who has ADHD, 561 00:29:43,849 --> 00:29:46,018 it's very hard for these parents to remain 562 00:29:46,018 --> 00:29:48,921 consistent with the schedule that's created. 563 00:29:48,921 --> 00:29:52,461 So, the schedule that's created has to be 564 00:29:53,738 --> 00:29:57,128 simple enough to follow, and simple enough 565 00:29:57,128 --> 00:30:00,266 to follow through on. 566 00:30:01,233 --> 00:30:05,471 You want to make steps explicit, no assumptions. 567 00:30:05,471 --> 00:30:07,472 So, if you think, well, you do this, 568 00:30:07,472 --> 00:30:09,107 and then of course, this one, you... 569 00:30:09,107 --> 00:30:11,110 you know, you do one thing on the list, 570 00:30:11,110 --> 00:30:12,978 then if, you know, go to the bathroom, 571 00:30:12,978 --> 00:30:15,614 and you assume that in the bathroom there's also 572 00:30:15,614 --> 00:30:18,450 teeth brushing that occurs, mm-mm. 573 00:30:18,450 --> 00:30:20,085 Go to the bathroom. 574 00:30:20,085 --> 00:30:22,487 Brush your teeth. 575 00:30:22,487 --> 00:30:24,456 Put your shoes on. 576 00:30:24,456 --> 00:30:26,658 You assume, maybe, get your coat at the same time? 577 00:30:26,658 --> 00:30:27,392 No. 578 00:30:27,392 --> 00:30:30,095 No assumptions in the beginning. 579 00:30:30,729 --> 00:30:32,998 Include choices for a child. 580 00:30:32,998 --> 00:30:36,335 So, the child doesn't feel like, oh my God, 581 00:30:36,335 --> 00:30:38,604 I'm being controlled with everything I have to do. 582 00:30:38,604 --> 00:30:41,606 You want the child to be able to make choices 583 00:30:41,606 --> 00:30:46,606 within the schedule, or goals that you're setting up. 584 00:30:48,346 --> 00:30:51,217 And because there's collaboration with the child, 585 00:30:51,217 --> 00:30:56,087 then the child will be involved in what you're setting up. 586 00:30:59,157 --> 00:31:03,628 In terms of specific modifications in a classroom 587 00:31:03,628 --> 00:31:07,403 that include changing seat arrangements, 588 00:31:08,064 --> 00:31:10,269 basically looking at what's happening 589 00:31:10,269 --> 00:31:12,904 at the playground, or free play, or lunch, 590 00:31:12,904 --> 00:31:15,673 where the child's sitting at lunch. 591 00:31:17,042 --> 00:31:21,513 In terms of making tasks shorter and taking breaks, 592 00:31:21,513 --> 00:31:24,483 the end of the task has to be in sight. 593 00:31:24,483 --> 00:31:28,720 If your child's goal is to write a paper in one sitting, 594 00:31:28,720 --> 00:31:30,422 that will be a failed experience. 595 00:31:30,422 --> 00:31:31,857 If your child's goal is to write 596 00:31:31,857 --> 00:31:35,593 a page of words, that might go better. 597 00:31:35,862 --> 00:31:40,862 Make steps very specific and vary the tasks 598 00:31:41,757 --> 00:31:43,502 so that there are choices. 599 00:31:43,502 --> 00:31:45,738 And watch out for open-ended tasks 600 00:31:45,738 --> 00:31:49,374 like creative or expository writing that have no end. 601 00:31:49,374 --> 00:31:53,478 You have to create, even if it's a self-induced 602 00:31:53,478 --> 00:31:56,782 or sort of a false barrier, that they can 603 00:31:56,782 --> 00:31:59,684 hit up against it and feel a sense of completion, 604 00:31:59,684 --> 00:32:03,621 and then the next time they'll have a little bit more to do. 605 00:32:04,255 --> 00:32:05,958 I want to say something about the complexity 606 00:32:05,958 --> 00:32:09,394 of social situations, particularly for younger children. 607 00:32:09,394 --> 00:32:12,564 Parents of children with ADHD have to provide 608 00:32:12,564 --> 00:32:14,866 supervision and some influence 609 00:32:14,866 --> 00:32:16,868 over social events for these kids. 610 00:32:16,868 --> 00:32:18,503 It's very hard for these children 611 00:32:18,503 --> 00:32:21,239 to manage the situations on their own, 612 00:32:21,239 --> 00:32:24,042 because of all of things we've talked about in terms of 613 00:32:24,042 --> 00:32:26,611 executive functioning and some of the challenges. 614 00:32:26,611 --> 00:32:30,516 So that the parents will need to check in. 615 00:32:30,516 --> 00:32:34,252 The parents might need to participate in the play dates. 616 00:32:35,251 --> 00:32:39,024 Even at ages eight and nine or ten, 617 00:32:39,024 --> 00:32:40,625 the parents may need to check in, 618 00:32:40,625 --> 00:32:44,187 structure a particular snack time, 619 00:32:44,695 --> 00:32:47,198 engage the kids in a game. 620 00:32:48,228 --> 00:32:53,228 A child with ADHD may sometimes feel lost in a playdate, 621 00:32:53,972 --> 00:32:56,007 not sure what to do, or it gets boring, 622 00:32:56,007 --> 00:32:59,277 so the parent will need to be somewhat engaged, 623 00:32:59,277 --> 00:33:01,946 which sometimes is a little challenging for parents 624 00:33:01,946 --> 00:33:03,515 because they think, "Oh, playdate! 625 00:33:03,515 --> 00:33:06,317 "Free time for me, I can catch up on X, Y, and Z" 626 00:33:06,317 --> 00:33:09,287 and that isn't necessarily the case. 627 00:33:09,788 --> 00:33:13,826 How do we teach executive function skills to ADHD kids? 628 00:33:14,125 --> 00:33:15,760 So, as I said, and I've really tried 629 00:33:15,760 --> 00:33:18,396 to emphasize in this talk, there's a philosophy 630 00:33:18,396 --> 00:33:20,932 of a skill deficit rather than a failure 631 00:33:20,932 --> 00:33:24,469 of will, motivation, or knowledge. 632 00:33:25,274 --> 00:33:27,939 One of the ways to teach these skills, 633 00:33:27,939 --> 00:33:29,407 in fact, I think it's the only way, 634 00:33:29,407 --> 00:33:32,911 is you have to teach the deficient skills directly. 635 00:33:32,911 --> 00:33:37,182 Do not expect these kids to absorb these skills 636 00:33:37,182 --> 00:33:42,182 through observation or what I call miracle osmosis. 637 00:33:43,254 --> 00:33:44,589 The first thing that has to occur 638 00:33:44,589 --> 00:33:47,726 is you must consider the child's developmental stage, 639 00:33:47,726 --> 00:33:52,112 and understand what is typical for that age group. 640 00:33:52,297 --> 00:33:55,968 Then, you need to be able to help the parents, 641 00:33:55,968 --> 00:33:58,770 and you will have to do sometimes in session, 642 00:33:58,770 --> 00:34:01,372 cue the child for tasks. 643 00:34:01,372 --> 00:34:06,372 Keep the tasks brief, encourage practice using small steps, 644 00:34:07,245 --> 00:34:11,950 work with the child's desire for mastery and control. 645 00:34:11,950 --> 00:34:13,418 That's really important. 646 00:34:13,418 --> 00:34:17,188 It's important to remember that these kids want to change, 647 00:34:17,188 --> 00:34:20,358 they want things to be different and better for them, 648 00:34:20,358 --> 00:34:25,358 and that is your best tool as a therapist. 649 00:34:26,831 --> 00:34:31,169 Create and keep routines and schedules. 650 00:34:31,169 --> 00:34:33,872 This is the third most important thing. 651 00:34:33,872 --> 00:34:35,540 You need to help these families 652 00:34:35,540 --> 00:34:38,042 create and keep routines and schedules 653 00:34:38,042 --> 00:34:42,456 that are not too complicated and that are accessible 654 00:34:42,456 --> 00:34:46,984 and involve the participation of the child. 655 00:34:48,553 --> 00:34:51,089 It's important for parents and the child 656 00:34:51,089 --> 00:34:54,425 to distinguish between have to and want to. 657 00:34:54,425 --> 00:34:56,595 So there are two kinds of tasks, really, 658 00:34:56,595 --> 00:34:58,496 ones that you're not very good at doing, 659 00:34:58,496 --> 00:35:02,534 and ones that you're capable of doing, but don't like doing. 660 00:35:02,534 --> 00:35:06,538 So, both of these have to be broken down into smaller steps. 661 00:35:06,538 --> 00:35:11,538 If you're really, if you're not good at it, 662 00:35:11,810 --> 00:35:14,446 then there are a whole set of separate issues 663 00:35:14,446 --> 00:35:15,714 that have to go on, which is like 664 00:35:15,714 --> 00:35:19,684 a lack of motivation, a dread of doing something, 665 00:35:19,684 --> 00:35:24,589 an avoidance, so that's one category. 666 00:35:24,589 --> 00:35:26,191 And then the second category is, 667 00:35:26,191 --> 00:35:28,593 you can do it but you just don't like it. 668 00:35:28,593 --> 00:35:33,593 So, then there's also things like avoidance 669 00:35:35,533 --> 00:35:38,264 and a lack of desire to actually do it. 670 00:35:38,264 --> 00:35:42,207 So in both cases, these kinds of tasks 671 00:35:42,207 --> 00:35:44,743 are have-to tasks, and they have to be 672 00:35:44,743 --> 00:35:49,743 broken down into small, manageable chunks and steps 673 00:35:49,814 --> 00:35:52,817 so that you can kind of do something you don't like, 674 00:35:52,817 --> 00:35:55,620 or you know how to do but you still don't like, 675 00:35:55,620 --> 00:36:00,620 or you can't do, do a small piece of it, break. 676 00:36:00,658 --> 00:36:03,127 Do a small piece of it, break. 677 00:36:03,127 --> 00:36:05,630 Because ADHD kids and teens do not have 678 00:36:05,630 --> 00:36:08,833 the ability to sustain themselves through an activity 679 00:36:08,833 --> 00:36:13,471 that they do not like or feel like they cannot do. 680 00:36:14,539 --> 00:36:17,642 You can model as a therapist for these kids 681 00:36:17,642 --> 00:36:21,212 "Well, if this were my assignment, I might," 682 00:36:21,212 --> 00:36:25,150 or, "When I write a paper, I plan to do this or that" 683 00:36:25,150 --> 00:36:27,018 or, "This is how I take breaks," 684 00:36:27,018 --> 00:36:31,222 not because you want to basically explain 685 00:36:31,222 --> 00:36:33,024 that your way is the best way, 686 00:36:33,024 --> 00:36:34,893 but because it's helpful for these kids 687 00:36:34,893 --> 00:36:38,129 to understand that other people struggle also 688 00:36:38,129 --> 00:36:41,566 with having to do tasks that they (laughs) don't like, 689 00:36:41,566 --> 00:36:44,402 having to do things that they know how to do 690 00:36:44,402 --> 00:36:46,038 but they don't want to do, and having to 691 00:36:46,038 --> 00:36:48,373 do things that they don't know how to do. 692 00:36:48,373 --> 00:36:51,309 They need to hear what other people's strategies are, 693 00:36:51,309 --> 00:36:55,546 so not only from you, but also from family members, 694 00:36:55,546 --> 00:36:59,484 because remember that what these kids do in their brain 695 00:36:59,484 --> 00:37:02,621 and to themselves is a lot of shaming, 696 00:37:02,621 --> 00:37:06,691 that "I'm different, and I don't do it right." 697 00:37:07,525 --> 00:37:10,395 One of the goals of teaching executive functioning skills 698 00:37:10,395 --> 00:37:15,395 is to enhance self-regulatory capacities. 699 00:37:15,834 --> 00:37:18,303 So the ability to push through something 700 00:37:18,303 --> 00:37:20,705 even if you don't like it, to manage 701 00:37:20,705 --> 00:37:23,642 your emotions even if you're struggling, 702 00:37:23,642 --> 00:37:28,642 or you're mad, or you're afraid. 703 00:37:31,182 --> 00:37:35,353 To use charts, visual symbols and aids, 704 00:37:35,353 --> 00:37:39,123 make lists, as I said, daily calendars for daily activities, 705 00:37:39,123 --> 00:37:44,123 there never can be enough visual aids up for kids with ADHD. 706 00:37:45,330 --> 00:37:47,632 Build in choices to give kids some control. 707 00:37:47,632 --> 00:37:51,936 So, you have math homework, which you don't like, 708 00:37:51,936 --> 00:37:54,372 and you have Spanish, which you also don't like, 709 00:37:54,372 --> 00:37:56,140 and you have English, which you like, 710 00:37:56,140 --> 00:37:58,376 and science, which you like, so how 711 00:37:58,376 --> 00:38:00,745 do we want to plan our evening with these two things 712 00:38:00,745 --> 00:38:03,081 you don't like and the two that you do? 713 00:38:03,081 --> 00:38:05,850 Ask the child, and the child might say, 714 00:38:05,850 --> 00:38:07,452 "I want to do the things I like first, 715 00:38:07,452 --> 00:38:09,488 "and the things I dislike next." 716 00:38:09,488 --> 00:38:11,222 Or, "I want to do something I don't like, 717 00:38:11,222 --> 00:38:12,657 "and then something I do, and then something 718 00:38:12,657 --> 00:38:14,225 "I don't like, and then something I do." 719 00:38:14,225 --> 00:38:17,014 Ask the child for his or her feedback so that 720 00:38:17,014 --> 00:38:21,799 he feels like he's participating in what's being set up. 721 00:38:22,700 --> 00:38:27,138 Okay, so, in terms of teaching 722 00:38:27,138 --> 00:38:29,628 executive functioning skills to kids, 723 00:38:29,628 --> 00:38:31,576 one thing that's important to remember 724 00:38:31,576 --> 00:38:34,178 is that punishment actually doesn't teach children 725 00:38:34,178 --> 00:38:38,783 what to do, it teaches them what not to do. 726 00:38:38,783 --> 00:38:41,686 And, what kids with ADHD need are 727 00:38:41,686 --> 00:38:44,822 some ideas about what to do. 728 00:38:44,822 --> 00:38:47,759 They need help figuring out what's next. 729 00:38:47,759 --> 00:38:51,329 So one thing is to rehearse, practice, 730 00:38:51,329 --> 00:38:54,244 and review skills before an event. 731 00:38:54,780 --> 00:38:58,536 As we said, use verbal prompts or reminders. 732 00:38:58,536 --> 00:39:02,040 Arrange for visual cues or alarms. 733 00:39:02,040 --> 00:39:05,877 Praise the child or teen for using new skills. 734 00:39:05,877 --> 00:39:09,781 And, here's the key: debrief 735 00:39:09,781 --> 00:39:13,051 and review a situation afterwards. 736 00:39:13,204 --> 00:39:16,154 Maybe at the time, maybe three days later, 737 00:39:16,154 --> 00:39:19,524 but something that you saw that was good or different. 738 00:39:19,524 --> 00:39:21,860 That's what you want the parents to be able to do. 739 00:39:21,860 --> 00:39:23,995 And if sometimes they can't debrief something 740 00:39:23,995 --> 00:39:27,732 until they're in therapy, then you can do it there. 741 00:39:28,193 --> 00:39:29,467 It's important to teach parents 742 00:39:29,467 --> 00:39:32,870 that effective praise is delivered immediately, 743 00:39:32,870 --> 00:39:34,973 is specific to the particulars 744 00:39:34,973 --> 00:39:37,075 of the action that you've seen, 745 00:39:37,075 --> 00:39:39,977 states the values of accomplishment, 746 00:39:39,977 --> 00:39:42,980 notices hard work, and trains the child 747 00:39:42,980 --> 00:39:45,616 to appreciate his or her own task 748 00:39:45,616 --> 00:39:48,919 accomplishment and problem solving. 749 00:39:49,053 --> 00:39:53,224 That's how we're gonna teach metacognition. 750 00:39:53,391 --> 00:39:55,293 So we want to interrupt the child 751 00:39:55,293 --> 00:39:57,628 before the child interrupts you 752 00:39:57,628 --> 00:40:01,265 and say, "I really like how you're doing this." 753 00:40:01,332 --> 00:40:04,669 You want to praise the children for using executive skills, 754 00:40:04,669 --> 00:40:07,672 I like three positives for each corrective feedback, 755 00:40:07,672 --> 00:40:09,441 so each time you say, "Do it this way" 756 00:40:09,441 --> 00:40:11,242 or "Don't do it this way," that you try 757 00:40:11,242 --> 00:40:15,246 to remember to notice a couple good things at the same time. 758 00:40:18,416 --> 00:40:21,101 People ask me a lot about "bribing." 759 00:40:21,101 --> 00:40:22,387 What's a bribe? 760 00:40:22,387 --> 00:40:27,387 So, um, I'm gonn talk about my view of bribes. 761 00:40:27,792 --> 00:40:29,627 So, a bribe is when you say to someone, 762 00:40:29,627 --> 00:40:34,332 "Here's the money, take this bag across the street." 763 00:40:34,332 --> 00:40:36,601 An incentive is, "If you take this bag 764 00:40:36,601 --> 00:40:38,970 "across the street, I'll give you some money." 765 00:40:38,970 --> 00:40:40,972 Now, I don't believe in bribes, 766 00:40:40,972 --> 00:40:42,607 but I do believe in incentives, 767 00:40:42,607 --> 00:40:44,675 and I have seen them work in the 25 years 768 00:40:44,675 --> 00:40:48,946 that I've been a family and child therapist. 769 00:40:51,849 --> 00:40:54,486 We want to use incentives and self-rewards 770 00:40:54,486 --> 00:40:57,556 to enhance motivation and instruction. 771 00:40:57,556 --> 00:41:01,025 So, you might make a deal with a child 772 00:41:01,025 --> 00:41:04,896 that he works for an hour, does his homework, 773 00:41:04,896 --> 00:41:07,932 and gets ten minutes of Facebook time. 774 00:41:07,932 --> 00:41:11,536 Or, you might make a deal with a child that after homework 775 00:41:11,536 --> 00:41:15,373 comes the half hour of TV that she's allowed. 776 00:41:15,373 --> 00:41:19,177 Those kinds of things are really helpful, 777 00:41:19,177 --> 00:41:21,445 and the agreement would go further. 778 00:41:21,445 --> 00:41:23,982 If you don't do your homework, 779 00:41:23,982 --> 00:41:26,651 or you have a tantrum about doing your homework, 780 00:41:26,651 --> 00:41:29,287 then there will be no TV for you. 781 00:41:29,287 --> 00:41:31,590 And that is very hard for some parents 782 00:41:31,590 --> 00:41:34,358 to follow through on, but it's critical 783 00:41:34,358 --> 00:41:38,829 that the incentive actually matters to the child, 784 00:41:38,829 --> 00:41:41,866 and isn't available if the child doesn't do 785 00:41:41,866 --> 00:41:44,944 what he or she has agreed to do. 786 00:41:45,890 --> 00:41:48,639 Incentives make an effort of learning a skill 787 00:41:48,639 --> 00:41:51,209 and doing a task less distasteful; 788 00:41:51,209 --> 00:41:53,444 they also teach gratification. 789 00:41:53,444 --> 00:41:57,482 "What reward can I give myself, or motivation can I give, 790 00:41:57,482 --> 00:42:01,418 "to get through this unpleasant task?" 791 00:42:03,158 --> 00:42:06,290 We want to make sure that adults offer 792 00:42:06,290 --> 00:42:09,193 enough support to help a child feel successful, 793 00:42:09,193 --> 00:42:12,463 but not too much support to be doing things for the child. 794 00:42:12,463 --> 00:42:14,298 Adults usually make two mistakes: 795 00:42:14,298 --> 00:42:15,766 there's too much support so that 796 00:42:15,766 --> 00:42:18,002 the child fails to learn independence, 797 00:42:18,002 --> 00:42:19,837 or too little support so that the child 798 00:42:19,837 --> 00:42:21,973 repeatedly fails at a task. 799 00:42:21,973 --> 00:42:24,408 That's a really fine line to balance, 800 00:42:24,408 --> 00:42:25,610 and it's really important that you 801 00:42:25,610 --> 00:42:28,203 work with your clients on that. 802 00:42:29,447 --> 00:42:33,011 You want to practice in session 803 00:42:33,011 --> 00:42:35,160 teaching negotiation and compromise. 804 00:42:35,175 --> 00:42:37,955 This is something that's often really hard for people, 805 00:42:37,955 --> 00:42:40,625 they're not good at it, they're especially triggered 806 00:42:40,625 --> 00:42:42,593 and reactive to things that bother them 807 00:42:42,593 --> 00:42:44,929 about their child, or their partner, 808 00:42:44,929 --> 00:42:47,565 or the dynamic in the family, and it's critical, 809 00:42:47,565 --> 00:42:51,068 critical, that you help them with this. 810 00:42:51,369 --> 00:42:54,071 Scaffolding is crucial, and it usually takes 811 00:42:54,071 --> 00:42:58,309 a lot longer than expected in terms 812 00:42:58,309 --> 00:43:03,309 of how much time it has to be in place. 813 00:43:03,814 --> 00:43:07,518 So, what happens is usually we create a system 814 00:43:07,518 --> 00:43:10,588 or a support, a level of support, 815 00:43:10,588 --> 00:43:14,993 or some sort of routine, and it's working. 816 00:43:14,993 --> 00:43:16,746 Yay! (laughs) 817 00:43:16,746 --> 00:43:20,331 Then, what happens is, adults usually take it out too soon. 818 00:43:20,331 --> 00:43:22,867 And this is particularly true in school systems, 819 00:43:22,867 --> 00:43:25,469 where, you know, a child will have extra support 820 00:43:25,469 --> 00:43:27,305 and be doing well, and then they'll want 821 00:43:27,305 --> 00:43:29,206 to remove that support the next year, 822 00:43:29,206 --> 00:43:32,977 which is a big mistake, big, because the child 823 00:43:32,977 --> 00:43:36,314 usually needs the support longer to make sure 824 00:43:36,314 --> 00:43:40,951 that those kinds of changes are internalized. 825 00:43:40,951 --> 00:43:44,288 So, you don't want to abruptly stop 826 00:43:44,288 --> 00:43:48,797 supports, supervision, or incentives. 827 00:43:49,127 --> 00:43:52,530 Whatever there are supports that are being faded out, 828 00:43:52,530 --> 00:43:55,899 they have to be faded out gradually. 829 00:43:59,170 --> 00:44:03,941 There are five keys to executive skill development. 830 00:44:05,810 --> 00:44:09,680 Often over-involved parents can be anxious, 831 00:44:09,680 --> 00:44:12,116 and they have trouble backing off from their kids 832 00:44:12,116 --> 00:44:15,186 who've needed a lot of support who have have ADHD, 833 00:44:15,186 --> 00:44:20,024 and so as a result the kids sometimes 834 00:44:20,024 --> 00:44:25,024 are under-responsible for their own activities and actions. 835 00:44:25,658 --> 00:44:28,966 We want to help create more accountability in the kids, 836 00:44:28,966 --> 00:44:30,969 this is particularly true of teenagers, 837 00:44:30,969 --> 00:44:34,773 and have the adults step back in appropriate ways 838 00:44:34,773 --> 00:44:36,841 but still stay involved in other ways. 839 00:44:36,841 --> 00:44:39,811 So, for example, where the notebooks are concerned, 840 00:44:39,811 --> 00:44:43,381 it's sophomore year and you might want to take your kid 841 00:44:43,381 --> 00:44:47,051 to Office Depot or Staples or wherever, 842 00:44:47,051 --> 00:44:50,155 and say, "Okay, how are we gonna organize this year? 843 00:44:50,155 --> 00:44:54,191 "Where are you gonna put stuff?" and help them lay it out. 844 00:44:54,191 --> 00:44:57,461 Next year, it's junior year, have the discussion. 845 00:44:57,461 --> 00:44:59,296 Maybe they want to do it themselves, 846 00:44:59,296 --> 00:45:01,232 maybe you want to look at it when it's done, 847 00:45:01,232 --> 00:45:04,362 but you're involved in the process. 848 00:45:04,870 --> 00:45:07,738 You want to help those parents use collaboration 849 00:45:07,738 --> 00:45:11,743 to create mutual goals of what should be shared 850 00:45:11,743 --> 00:45:14,545 and what can be independent, and you want to rely 851 00:45:14,545 --> 00:45:17,948 on the child's sense of what works for him or her, 852 00:45:17,948 --> 00:45:21,919 as well as the parental observations about that. 853 00:45:22,720 --> 00:45:26,991 It's important for parents to be very clear 854 00:45:26,991 --> 00:45:29,827 about goals and expectations from the very beginning 855 00:45:29,827 --> 00:45:31,996 of any sort of arrangement that 856 00:45:31,996 --> 00:45:34,732 they're setting up with their children. 857 00:45:37,067 --> 00:45:39,603 And to make their goals, the steps 858 00:45:39,603 --> 00:45:41,572 for a goal into a checklist. 859 00:45:41,572 --> 00:45:46,076 So for example, if you're working with a family, 860 00:45:46,076 --> 00:45:49,547 and the parents complain that the room is a disaster, 861 00:45:49,547 --> 00:45:51,315 and the child needs to clean the room, 862 00:45:51,315 --> 00:45:55,152 then it would seem to me that perhaps, 863 00:45:55,152 --> 00:45:56,987 and this is true for a lot of kids, 864 00:45:56,987 --> 00:46:00,324 they see their room, it's like a disaster area, 865 00:46:00,324 --> 00:46:03,461 it's overwhelming, they don't even know where to begin, 866 00:46:03,461 --> 00:46:05,963 and so it might be useful to make a checklist 867 00:46:05,963 --> 00:46:07,932 that goes in their desk on or on their door, 868 00:46:07,932 --> 00:46:12,736 you know, "To clean their room: one, clear off the bed, 869 00:46:12,736 --> 00:46:15,907 "two, put the dirty clothes in the hamper, 870 00:46:15,907 --> 00:46:19,276 "three, fold all the clothes that are in a heap," 871 00:46:19,276 --> 00:46:20,544 you know, those kinds of things, 872 00:46:20,544 --> 00:46:23,548 they seem so simple and basic, 873 00:46:23,548 --> 00:46:25,816 but they're really important because the child 874 00:46:25,816 --> 00:46:29,553 isn't able to do that internally him or herself. 875 00:46:33,490 --> 00:46:37,139 You want to help the parents create expectations 876 00:46:37,139 --> 00:46:41,699 of tasks that the child can actually perform and succeed on, 877 00:46:41,699 --> 00:46:46,699 not continue to basically fail at, 878 00:46:47,838 --> 00:46:50,474 which perpetuates a cycle of anger 879 00:46:50,474 --> 00:46:53,344 and disappointment and shame. 880 00:46:54,679 --> 00:46:56,406 And you want to help the parents make 881 00:46:56,406 --> 00:47:00,317 the steps of every single task explicit. 882 00:47:01,719 --> 00:47:06,079 How do you help kids with ADHD develop emotional control? 883 00:47:06,423 --> 00:47:09,226 The first thing is to identify triggers, 884 00:47:09,226 --> 00:47:13,423 events that cause the child to lose his or her temper. 885 00:47:13,638 --> 00:47:15,801 The second thing to remember is that 886 00:47:15,801 --> 00:47:18,235 emotional control is one of the executive functions 887 00:47:18,235 --> 00:47:21,138 that takes years to develop. 888 00:47:21,772 --> 00:47:23,441 So, that would mean that it's important 889 00:47:23,441 --> 00:47:27,778 to make a list of triggers, you know, 890 00:47:27,778 --> 00:47:30,462 what you can and cannot do when 891 00:47:30,462 --> 00:47:34,585 you're having a hard time, with the child or the teen. 892 00:47:34,920 --> 00:47:37,721 The third thing is to enact a practice session 893 00:47:37,721 --> 00:47:40,224 and connect the process to a reward. 894 00:47:40,224 --> 00:47:45,224 So, basically you want to help create 895 00:47:47,231 --> 00:47:52,231 and review what happens when a child is triggered, 896 00:47:52,603 --> 00:47:56,340 what the options are, and what happened, 897 00:47:56,340 --> 00:47:59,076 and what could be done differently. 898 00:47:59,076 --> 00:48:00,745 So it's important to create a plan 899 00:48:00,745 --> 00:48:03,280 to manage or eliminate the triggers, 900 00:48:03,280 --> 00:48:06,517 to talk about what losing your temper looks like, 901 00:48:06,517 --> 00:48:09,954 and to create a list of behaviors that are not tolerated 902 00:48:09,954 --> 00:48:13,090 regardless of how angry or upset you are, 903 00:48:13,090 --> 00:48:14,625 and that list has to be short, 904 00:48:14,625 --> 00:48:18,563 and extremely specific and concrete. 905 00:48:18,930 --> 00:48:21,732 And then you want to make another list, 906 00:48:21,732 --> 00:48:24,635 a list of replacement behaviors, 907 00:48:24,635 --> 00:48:27,252 things a child can do when he or she 908 00:48:27,252 --> 00:48:30,641 is upset, instead of those other things. 909 00:48:30,641 --> 00:48:33,377 So, that can be listening to music, 910 00:48:33,377 --> 00:48:38,377 that can be having a soft pillow or something 911 00:48:38,749 --> 00:48:43,655 in the basement that the child can sort of thwop if needed, 912 00:48:43,655 --> 00:48:45,689 that can be taking a walk with the dog, 913 00:48:45,689 --> 00:48:48,993 whatever is appropriate for that child, 914 00:48:48,993 --> 00:48:52,129 there should be a list of alternatives. 915 00:48:54,598 --> 00:48:58,027 In terms of school interventions, 916 00:48:59,964 --> 00:49:04,174 the first thing that I think is really worth stating 917 00:49:04,174 --> 00:49:08,812 many times is that the parents must advocate 918 00:49:08,812 --> 00:49:13,812 for their kids, over, and over, and over again. 919 00:49:14,018 --> 00:49:17,921 They have to continue to advocate for their kids. 920 00:49:17,921 --> 00:49:19,891 I'm gonna read something from the book 921 00:49:19,891 --> 00:49:24,891 that's on your reference list, called Buzz, 922 00:49:25,830 --> 00:49:28,031 and it's about homework. 923 00:49:38,108 --> 00:49:40,844 "It's Friday afternoon, and I'm in my writing shed 924 00:49:40,844 --> 00:49:42,513 "chewing sugarless tangerine gum 925 00:49:42,513 --> 00:49:45,516 "and agonizing over a clunky first draft, 926 00:49:45,516 --> 00:49:47,351 "longing as always for distraction, 927 00:49:47,351 --> 00:49:50,454 "although I wouldn't have ordered this phone call. 928 00:49:50,454 --> 00:49:52,823 "The voice belongs to Buzz's English teacher, 929 00:49:52,823 --> 00:49:55,426 "who is graciously taking time to let me know 930 00:49:55,426 --> 00:49:58,529 "he hasn't turned in a major assignment due today, 931 00:49:58,529 --> 00:50:01,365 "which is news to me, he should have been 932 00:50:01,365 --> 00:50:03,333 "working on for the past week." 933 00:50:03,333 --> 00:50:04,902 Buzz is in middle school. 934 00:50:04,902 --> 00:50:06,971 "The instruction was to interview someone, 935 00:50:06,971 --> 00:50:09,607 "preferably a parent, about prejudice. 936 00:50:09,607 --> 00:50:12,377 "Buzz hasn't even gotten started. 937 00:50:12,377 --> 00:50:15,179 "His teacher isn't sure why that is, but again, 938 00:50:15,179 --> 00:50:17,582 "graciously and maybe also because I've met 939 00:50:17,582 --> 00:50:21,385 "with her three times by now to plead for understanding, 940 00:50:21,385 --> 00:50:23,620 "she offers Buzz a reprieve as long as 941 00:50:23,620 --> 00:50:26,921 "he can do this work over the weekend. 942 00:50:27,337 --> 00:50:30,194 "Whenever I ask Buzz if he has homework these days 943 00:50:30,194 --> 00:50:33,364 "he tells me that he has already finished it at school. 944 00:50:33,364 --> 00:50:35,532 "He won't write assignments in his agenda, 945 00:50:35,532 --> 00:50:38,702 "even when Xbox time depends on it, 946 00:50:38,702 --> 00:50:40,204 "and there is little else he cares about 947 00:50:40,204 --> 00:50:43,941 "other than food, which I'm not ready yet to withhold. 948 00:50:45,042 --> 00:50:46,977 "So when Buzz comes home this afternoon, 949 00:50:46,977 --> 00:50:49,614 "I leave my shed, microwave him a plate 950 00:50:49,614 --> 00:50:51,482 "of leftover spaghetti, and spend 951 00:50:51,482 --> 00:50:53,851 "the next half hour arguing, bribing, 952 00:50:53,851 --> 00:50:56,386 "threatening, pulling out the TV cord and hiding it, 953 00:50:56,386 --> 00:50:59,590 "before finally convincing him to get started. 954 00:50:59,590 --> 00:51:01,625 "The two of us, I'm well aware, are trapped 955 00:51:01,625 --> 00:51:03,794 "in an all but senseless system, 956 00:51:03,794 --> 00:51:08,065 "even as US teachers are piling on ever more homework. 957 00:51:08,065 --> 00:51:10,734 "Research has shown it doesn't measurably improve 958 00:51:10,734 --> 00:51:14,104 "academic achievement in grade school, 959 00:51:14,104 --> 00:51:17,441 "although it can sour kids' attitudes toward school 960 00:51:17,441 --> 00:51:21,211 "and increase conflict between them and their parents. 961 00:51:21,211 --> 00:51:23,347 "I should probably spend more time 962 00:51:23,347 --> 00:51:25,349 "complaining about this to Buzz's principal, 963 00:51:25,349 --> 00:51:28,318 "who already thinks I'm a crank, 964 00:51:28,318 --> 00:51:31,555 "but in the short term, I just don't want him to fail. 965 00:51:31,555 --> 00:51:34,858 "It drives me crazy that I have to work this hard, 966 00:51:34,858 --> 00:51:36,894 "and it makes me so sad to think of all 967 00:51:36,894 --> 00:51:40,297 "the worried mothers who don't even have this option. 968 00:51:40,297 --> 00:51:43,534 "Finally he sits down in front of the computer. 969 00:51:43,534 --> 00:51:46,036 "He smooths out the crumpled blue instruction sheet 970 00:51:46,036 --> 00:51:48,839 "we've fished from the bottom of his backpack, 971 00:51:48,839 --> 00:51:51,374 "a trove of ancient cookie crumbs, leaking pens, 972 00:51:51,374 --> 00:51:54,211 "unsigned permission slips, and unwashed 973 00:51:54,211 --> 00:51:58,015 "gym shorts, and he starts typing fast." 974 00:51:58,448 --> 00:52:01,618 So here we have a boy of maybe 12 or 13, 975 00:52:01,618 --> 00:52:03,921 and a mother who is really struggling 976 00:52:03,921 --> 00:52:08,425 with how to get him motivated, started, 977 00:52:08,425 --> 00:52:11,528 following through, accountable, all of the things 978 00:52:11,528 --> 00:52:16,266 that I see in the parents I work with of ADHD kids. 979 00:52:16,633 --> 00:52:20,304 So, parents have to advocate for their kids, 980 00:52:20,304 --> 00:52:23,307 even if the principal thinks they're a crank. 981 00:52:23,407 --> 00:52:24,474 It's important to remember that 982 00:52:24,474 --> 00:52:29,079 ADHD kids can't bind events across time. 983 00:52:29,079 --> 00:52:33,116 To remember that transitions, physical relocations, 984 00:52:33,116 --> 00:52:35,185 changes in schedule, and disruptions 985 00:52:35,185 --> 00:52:39,122 are especially difficult for the child with ADHD. 986 00:52:39,122 --> 00:52:42,326 Changing classes, starting a new year, 987 00:52:42,326 --> 00:52:45,028 having a substitute teacher, all of these 988 00:52:45,028 --> 00:52:48,298 things can be very discombobulating. 989 00:52:49,199 --> 00:52:51,501 It's important to teach ADHD kids 990 00:52:51,501 --> 00:52:53,637 how to keyboard as quickly as possible. 991 00:52:53,637 --> 00:52:57,174 Often because there's a motoric aspect of ADHD, 992 00:52:57,174 --> 00:53:00,978 the physical act of writing is very difficult, 993 00:53:00,978 --> 00:53:03,418 and as we've said sometimes actually 994 00:53:03,418 --> 00:53:05,782 the thinking and language parts 995 00:53:05,782 --> 00:53:08,518 and expressing them verbally are very difficult, 996 00:53:08,518 --> 00:53:12,770 so it's good to keyboard, it helps speed things along. 997 00:53:13,108 --> 00:53:16,460 It's important in a classroom to avoid distracting stimuli 998 00:53:16,460 --> 00:53:19,463 by not placing the child near the heater, the door, 999 00:53:19,463 --> 00:53:21,405 the windows, other children who have 1000 00:53:21,405 --> 00:53:26,336 attention issues, and to break up tasks. 1001 00:53:26,336 --> 00:53:31,336 Teach how to divide a future task into manageable parts. 1002 00:53:33,010 --> 00:53:37,180 In terms of giving instructions for ADHD students, 1003 00:53:37,180 --> 00:53:39,316 it's important often to provide 1004 00:53:39,316 --> 00:53:41,385 an external source of motivation, 1005 00:53:41,385 --> 00:53:43,987 she had mentioned taking away the Xbox, 1006 00:53:43,987 --> 00:53:46,524 but we also want to provide an incentive, 1007 00:53:46,524 --> 00:53:50,694 "If you write this you'll get an extra 15 minutes of Xbox." 1008 00:53:50,694 --> 00:53:53,263 I have a child who loves Gilmore Girls, 1009 00:53:53,263 --> 00:53:56,834 and so one of her incentives for following through 1010 00:53:56,834 --> 00:53:59,770 on the morning routine without having a tantrum, 1011 00:53:59,770 --> 00:54:03,107 for which she had a checklist, is that she got 1012 00:54:03,107 --> 00:54:07,077 an extra 15 minutes of Gilmore girls at night. 1013 00:54:07,378 --> 00:54:09,212 It's important for teachers to remember 1014 00:54:09,212 --> 00:54:11,982 that ADHD kids might need manipulatives, 1015 00:54:11,982 --> 00:54:15,719 or like a little fidget toy, and to make 1016 00:54:15,719 --> 00:54:20,223 tasks as manual as possible when needed. 1017 00:54:20,223 --> 00:54:22,827 It's also important for parents to remember that, 1018 00:54:22,827 --> 00:54:24,628 that there might be knee tapping, 1019 00:54:24,628 --> 00:54:29,628 or finger, I guess twitching, whatever you want to call it, 1020 00:54:30,734 --> 00:54:33,370 but there's usually some sort of outlet 1021 00:54:33,370 --> 00:54:38,370 for a kind of internal sense of energy. 1022 00:54:39,476 --> 00:54:43,446 And that timeouts have to be targeted, and limited. 1023 00:54:43,481 --> 00:54:47,151 And that's important at home, but also important at school. 1024 00:54:47,151 --> 00:54:48,385 You know, the basic rule of thumb 1025 00:54:48,385 --> 00:54:50,721 is that timeouts shouldn't be longer 1026 00:54:50,721 --> 00:54:53,724 than the child's age, which I support. 1027 00:54:53,724 --> 00:54:55,659 And I think that sometimes in school, 1028 00:54:55,659 --> 00:54:57,861 that the timeouts again have to be targeted 1029 00:54:57,861 --> 00:54:59,629 for specific kinds of behavior, 1030 00:54:59,629 --> 00:55:03,033 and not just general across the board behaviors, 1031 00:55:03,033 --> 00:55:06,436 because we want to work with the school 1032 00:55:06,436 --> 00:55:09,039 and the parent on the same behavior, 1033 00:55:09,039 --> 00:55:13,414 so that there's success in that one area of behavior, 1034 00:55:13,414 --> 00:55:15,445 and then we can move on to another. 1035 00:55:15,445 --> 00:55:17,414 It's important to be patient during 1036 00:55:17,414 --> 00:55:20,183 transitions of all types, and to create 1037 00:55:20,183 --> 00:55:21,818 a quiet place in the classroom which 1038 00:55:21,818 --> 00:55:26,423 has reduced stimuli, if that's possible, 1039 00:55:26,423 --> 00:55:29,359 or a place in school that has reduced stimuli, 1040 00:55:29,359 --> 00:55:31,795 I had one student who really had to read 1041 00:55:31,795 --> 00:55:34,998 in her English class, and she couldn't stand reading, 1042 00:55:34,998 --> 00:55:37,734 it was distracting, the chairs were uncomfortable, 1043 00:55:37,734 --> 00:55:39,302 and we were able to arrange with the school 1044 00:55:39,302 --> 00:55:40,804 that she could go down to the library, 1045 00:55:40,804 --> 00:55:42,706 which had a big soft cozy chair, 1046 00:55:42,706 --> 00:55:44,341 and she could sit there and read 1047 00:55:44,341 --> 00:55:46,510 when there was in-class reading. 1048 00:55:46,510 --> 00:55:49,413 How do you help ADHD students at home? 1049 00:55:49,413 --> 00:55:51,082 You want to encourage parents to set up 1050 00:55:51,082 --> 00:55:54,051 a quiet time place at home that is for studying, 1051 00:55:54,051 --> 00:55:59,051 where the child can go and is not distracted by things. 1052 00:55:59,356 --> 00:56:02,559 You want to establish a routine for doing homework. 1053 00:56:02,559 --> 00:56:04,995 You want to create systems to help keep 1054 00:56:04,995 --> 00:56:07,931 the book bag and the schoolwork organized 1055 00:56:07,931 --> 00:56:11,708 in the notebook, and in the backpack. 1056 00:56:12,738 --> 00:56:15,806 You want to create and implement a home-school notebook 1057 00:56:15,806 --> 00:56:17,941 of assignments and updates, for younger kids 1058 00:56:17,941 --> 00:56:21,178 that could be a sheet, it could be a calendar book, 1059 00:56:21,178 --> 00:56:25,110 I suggest a calendar book as early as possible, 1060 00:56:25,757 --> 00:56:28,385 this kind of daily assignment notebook is very helpful 1061 00:56:28,385 --> 00:56:30,554 because even a second or a third grader 1062 00:56:30,554 --> 00:56:33,490 can see what he or she did and check it off, 1063 00:56:33,490 --> 00:56:37,694 which helps again organize their ability 1064 00:56:37,694 --> 00:56:40,931 to remember, "I did this, and then I have to do this." 1065 00:56:40,931 --> 00:56:43,700 Remember, all of these executive function skills have to be 1066 00:56:43,700 --> 00:56:48,700 taught repeatedly over time, external to internal. 1067 00:56:50,273 --> 00:56:51,241 You want to make sure the student 1068 00:56:51,241 --> 00:56:53,977 correctly writes down all these assignments, 1069 00:56:53,977 --> 00:56:55,779 and perhaps to check with the teacher 1070 00:56:55,779 --> 00:56:59,015 each day if necessary, I find that's been very helpful. 1071 00:56:59,015 --> 00:57:01,118 It's nice if the parents can sign the notebook 1072 00:57:01,118 --> 00:57:03,320 when the child is younger and in grade school, 1073 00:57:03,320 --> 00:57:04,755 and use it as a method of communicating 1074 00:57:04,755 --> 00:57:06,323 with the teacher so that they have a way 1075 00:57:06,323 --> 00:57:09,626 to go back and forth on a regular basis. 1076 00:57:09,626 --> 00:57:10,827 There's been a lot of research about 1077 00:57:10,827 --> 00:57:15,432 mindfulness training for parents and children with ADHD, 1078 00:57:15,432 --> 00:57:20,337 it's mostly positive but it has to continue 1079 00:57:20,337 --> 00:57:23,206 for over time in terms of support 1080 00:57:23,206 --> 00:57:24,975 for the practice afterwards, what the research 1081 00:57:24,975 --> 00:57:27,745 showed is people who did the mindfulness class 1082 00:57:27,745 --> 00:57:31,581 but didn't continue with sort of brush-up classes 1083 00:57:31,581 --> 00:57:34,718 or follow through didn't do as well 1084 00:57:34,718 --> 00:57:36,620 and weren't able to keep up with the practice 1085 00:57:36,620 --> 00:57:41,620 as those who did have those kind of refresher workshops. 1086 00:57:47,964 --> 00:57:51,067 What are the parental essentials for student success? 1087 00:57:51,067 --> 00:57:54,371 In my opinion, the number one parental essential 1088 00:57:54,371 --> 00:57:57,541 is regular contact with teachers 1089 00:57:57,541 --> 00:58:00,444 and administrators at their child's school. 1090 00:58:00,444 --> 00:58:03,980 And the number two would be for you as a therapist 1091 00:58:03,980 --> 00:58:08,241 also to have some contact with someone in the school, 1092 00:58:08,533 --> 00:58:09,953 so that you can have an understanding 1093 00:58:09,953 --> 00:58:13,256 of what's working in the classroom and what's not. 1094 00:58:13,256 --> 00:58:15,158 The parents have to advocate for the child, 1095 00:58:15,158 --> 00:58:17,761 and having a relationship with the school 1096 00:58:17,761 --> 00:58:20,463 and the teachers is helpful, even in high school. 1097 00:58:20,463 --> 00:58:22,699 Most high schools, teachers have email, 1098 00:58:22,699 --> 00:58:25,969 they check their email, and they're available 1099 00:58:25,969 --> 00:58:28,171 to respond, if they're not, there's certainly 1100 00:58:28,171 --> 00:58:33,171 a principal or guidance counselor that can be helpful. 1101 00:58:35,679 --> 00:58:38,148 Progress reports can be really, really helfpul 1102 00:58:38,148 --> 00:58:40,963 in finding out how your child's doing. 1103 00:58:41,117 --> 00:58:43,687 Many schools have computer programs 1104 00:58:43,687 --> 00:58:48,158 that you can log in and see the link 1105 00:58:48,158 --> 00:58:50,594 related to how your child is doing, 1106 00:58:50,594 --> 00:58:52,463 some schools have actual progress reports 1107 00:58:52,463 --> 00:58:55,232 that the child takes around to his or her teachers, 1108 00:58:55,232 --> 00:58:58,335 or you can set up progress report meetings 1109 00:58:58,335 --> 00:58:59,803 with the teachers just to get a sense 1110 00:58:59,803 --> 00:59:04,803 of how your child's doing periodically if you're concerned. 1111 00:59:06,076 --> 00:59:07,744 I think the main thing we want to communicate 1112 00:59:07,744 --> 00:59:11,614 to these parents is get involved and stay involved. 1113 00:59:14,517 --> 00:59:16,152 So, I'm gonna go through a few slides 1114 00:59:16,152 --> 00:59:18,955 about how you give instructions to kids with ADHD, 1115 00:59:18,955 --> 00:59:20,490 and some classroom strategies, 1116 00:59:20,490 --> 00:59:22,559 I'm not gonna spend a lot of time on these, 1117 00:59:22,559 --> 00:59:26,838 these are mostly resources for you to have 1118 00:59:26,838 --> 00:59:31,838 to share with your clients in your practice. 1119 00:59:32,569 --> 00:59:33,871 So, one thing that's really important 1120 00:59:33,871 --> 00:59:35,939 when you give instruction to kids with ADHD 1121 00:59:35,939 --> 00:59:40,243 is maintaining eye contact during verbal instruction. 1122 00:59:40,878 --> 00:59:42,469 That's really important. 1123 00:59:42,469 --> 00:59:45,982 Two, give out one task at a time. 1124 00:59:45,982 --> 00:59:50,720 If you make the directions clear and concise with one task, 1125 00:59:50,720 --> 00:59:53,357 the chances are it would be accomplished. 1126 00:59:53,357 --> 00:59:57,994 But if you make it a task and you add the word "and," 1127 00:59:57,994 --> 01:00:00,063 chances are it might not get accomplished, 1128 01:00:00,063 --> 01:00:02,432 particularly for the younger kids. 1129 01:00:02,432 --> 01:00:07,304 So, small tasks, one task at a time, eye contact. 1130 01:00:07,304 --> 01:00:11,374 And be consistent with the daily instructions. 1131 01:00:11,374 --> 01:00:13,576 Make sure student comprehends instructions 1132 01:00:13,576 --> 01:00:16,546 at the beginning of a class, this is really important 1133 01:00:16,546 --> 01:00:20,817 for teachers, and at the beginning of a task. 1134 01:00:20,817 --> 01:00:24,554 Repeat instructions in a calm, positive manner. 1135 01:00:24,554 --> 01:00:28,676 This is also true for parents and for teachers. 1136 01:00:29,029 --> 01:00:32,762 I like the rule of three, I think sometimes 1137 01:00:32,762 --> 01:00:37,762 it works with teachers and sometimes it doesn't, 1138 01:00:37,901 --> 01:00:40,103 but essentially the rule of three is, 1139 01:00:40,103 --> 01:00:41,871 I look at the child in the eye, 1140 01:00:41,871 --> 01:00:44,374 I might put a hand on a shoulder, 1141 01:00:44,374 --> 01:00:47,210 and then I say what I want them to do 1142 01:00:47,210 --> 01:00:48,960 and I ask it to be repeated. 1143 01:00:48,960 --> 01:00:51,733 The hand on the shoulder is optional, 1144 01:00:51,733 --> 01:00:53,483 but sometimes for a parent it helps 1145 01:00:53,483 --> 01:00:57,554 steady the child to actually focus on what 1146 01:00:57,554 --> 01:01:01,457 the parent's saying, in schools that's less optional. 1147 01:01:02,326 --> 01:01:04,027 If you have to repeat the instructions, 1148 01:01:04,027 --> 01:01:09,027 they need to be repeated in a calm and positive manner. 1149 01:01:15,905 --> 01:01:18,708 For classroom strategies, what we want 1150 01:01:18,708 --> 01:01:21,978 to encourage teachers to do is to use external cues. 1151 01:01:21,978 --> 01:01:25,049 Don't rely on mental or auditory information. 1152 01:01:25,049 --> 01:01:28,284 Make lists, posters, signs, remember that 1153 01:01:28,284 --> 01:01:31,054 sometimes auditory processing for kids with ADHD 1154 01:01:31,054 --> 01:01:35,158 is not their strongest way of learning, 1155 01:01:35,158 --> 01:01:37,928 and sometimes it is, so sometimes people 1156 01:01:37,928 --> 01:01:40,029 really learn only through hearing. 1157 01:01:40,029 --> 01:01:41,531 I have a client who's an adult, and then 1158 01:01:41,531 --> 01:01:45,034 she basically, that's how she remembers all her information. 1159 01:01:45,034 --> 01:01:46,903 That's how she processes, and that's how she remembers. 1160 01:01:46,903 --> 01:01:48,439 Hearing, and doing. 1161 01:01:48,439 --> 01:01:51,108 I have another client who's an adult who has ADHD 1162 01:01:51,108 --> 01:01:54,778 and he has to write things down, 1163 01:01:54,778 --> 01:01:56,567 and he has to see them visually. 1164 01:01:56,567 --> 01:01:58,515 And they said that they've had these strategies 1165 01:01:58,515 --> 01:02:01,017 and ways of learning since they were children. 1166 01:02:01,017 --> 01:02:03,520 And I see that in the kids I work with, 1167 01:02:03,520 --> 01:02:05,889 which is so interesting to be able to see it 1168 01:02:05,889 --> 01:02:08,725 in kids and teenagers, and then 1169 01:02:08,725 --> 01:02:12,262 in people in their 40s and 50s. 1170 01:02:12,861 --> 01:02:15,031 We want to make time physical in a classroom, 1171 01:02:15,031 --> 01:02:17,467 don't rely on internal clocks. 1172 01:02:17,467 --> 01:02:19,703 You want to to help the child have a timer 1173 01:02:19,703 --> 01:02:22,405 or some way of monitoring the time 1174 01:02:22,405 --> 01:02:27,405 that's more external and physical. 1175 01:02:27,610 --> 01:02:31,557 Because they can't bind events across time. 1176 01:02:32,095 --> 01:02:34,884 You want to help the child break up tasks, 1177 01:02:34,884 --> 01:02:36,953 the teachers need to teach them how to 1178 01:02:36,953 --> 01:02:39,957 divide up a task into the event, 1179 01:02:39,957 --> 01:02:43,392 the response, and the outcome. 1180 01:02:44,060 --> 01:02:46,963 It's nice to see a child near the teacher, 1181 01:02:46,963 --> 01:02:49,799 but as part of the regular class seating. 1182 01:02:49,799 --> 01:02:52,636 I've seen teachers basically put a kid with ADHD 1183 01:02:52,636 --> 01:02:54,504 right next to their desk, and then 1184 01:02:54,504 --> 01:02:57,741 everyone else is in a circle, and all that does 1185 01:02:57,741 --> 01:03:01,344 is make the child feel alienated 1186 01:03:01,344 --> 01:03:06,344 and different in a very bad way. 1187 01:03:06,950 --> 01:03:10,699 Surround the child with good peer role models 1188 01:03:10,699 --> 01:03:13,223 so that the child can be around kids 1189 01:03:13,223 --> 01:03:16,793 who actually could help him or her focus 1190 01:03:16,793 --> 01:03:21,793 or make better choices and can see what those choices are. 1191 01:03:22,665 --> 01:03:25,570 You want to encourage peer tutoring 1192 01:03:25,570 --> 01:03:29,138 and cooperative learning when possible. 1193 01:03:31,608 --> 01:03:35,445 How do you help kids with certain specific issues 1194 01:03:35,445 --> 01:03:37,714 related to executive functioning? 1195 01:03:37,714 --> 01:03:41,784 So, problems of initiation, getting started. 1196 01:03:41,784 --> 01:03:44,355 It's helpful if the material's pre-taught, 1197 01:03:44,355 --> 01:03:47,457 the assignments are broken down into parts, 1198 01:03:47,457 --> 01:03:51,027 and that you hand out written copies of the assignments. 1199 01:03:51,027 --> 01:03:53,697 For problems of sustaining attention or anxiety, 1200 01:03:53,697 --> 01:03:56,033 use interactive teaching style, 1201 01:03:56,033 --> 01:04:01,033 provide positive feedback, and offer shorter work periods. 1202 01:04:02,205 --> 01:04:05,675 For problems with shifting or making transitions, 1203 01:04:05,675 --> 01:04:07,544 offer a daily agenda so the child 1204 01:04:07,544 --> 01:04:11,214 will know what to expect, encourage flexibility 1205 01:04:11,214 --> 01:04:14,951 through self-talk, and reward flexible behavior. 1206 01:04:14,951 --> 01:04:16,619 "I see you're doing a great job 1207 01:04:16,619 --> 01:04:18,054 "making the transitions and you're 1208 01:04:18,054 --> 01:04:21,424 "coming to our class on time." 1209 01:04:23,059 --> 01:04:25,958 Problems with organization. 1210 01:04:27,278 --> 01:04:30,804 It's sometimes easier for teachers to help students 1211 01:04:30,804 --> 01:04:33,636 understand how to file papers in their notebook 1212 01:04:33,636 --> 01:04:37,349 than for their parents, because of all of the, 1213 01:04:37,349 --> 01:04:39,776 sort of particularly teen dynamics 1214 01:04:39,776 --> 01:04:44,776 around separating, and wanting space, and being independent. 1215 01:04:45,382 --> 01:04:47,584 Give extra time for teachers, 1216 01:04:47,584 --> 01:04:49,018 if the teachers could give extra time for 1217 01:04:49,018 --> 01:04:51,888 organizing materials, or maybe have the student 1218 01:04:51,888 --> 01:04:53,823 come after school for a little help with that, 1219 01:04:53,823 --> 01:04:58,228 that would be great, and the other thing 1220 01:04:58,228 --> 01:04:59,729 that really helps with organization 1221 01:04:59,729 --> 01:05:01,598 is to give an ordered list of assignments 1222 01:05:01,598 --> 01:05:05,701 and activities that the child or student is responsible for. 1223 01:05:09,918 --> 01:05:11,841 For problems with planning, you want to 1224 01:05:11,841 --> 01:05:16,841 explicitly as a teacher teach planning strategies, 1225 01:05:17,047 --> 01:05:19,115 and that means breaking assignments into parts, 1226 01:05:19,115 --> 01:05:20,583 so if you have a research paper, 1227 01:05:20,583 --> 01:05:21,951 and teachers do this most of the time 1228 01:05:21,951 --> 01:05:24,754 naturally in high school in the beginning, 1229 01:05:24,754 --> 01:05:26,623 in ninth grade, you know, "Okay, you're gonna 1230 01:05:26,623 --> 01:05:28,725 "do this part of the research, and we're all 1231 01:05:28,725 --> 01:05:30,059 "going to the library, and then we're gonna 1232 01:05:30,059 --> 01:05:32,662 "do this part of the research on the computer, 1233 01:05:32,662 --> 01:05:35,666 "and then I'd like to see you outline your paper," 1234 01:05:35,666 --> 01:05:38,068 whatever it is, but that kind of breaking 1235 01:05:38,068 --> 01:05:39,869 an assignment down is very helpful 1236 01:05:39,869 --> 01:05:41,771 for someone with ADHD because otherwise 1237 01:05:41,771 --> 01:05:45,307 they see the research paper, and it's just 1238 01:05:45,307 --> 01:05:47,877 so overwhelming, and there are so many options, 1239 01:05:47,877 --> 01:05:49,812 and there are lots of ways they can do it, 1240 01:05:49,812 --> 01:05:52,248 and they may or may not have the confidence to do it, 1241 01:05:52,248 --> 01:05:53,683 so it's very helpful to make it 1242 01:05:53,683 --> 01:05:57,320 a smaller, more manageable task. 1243 01:05:57,487 --> 01:05:59,706 And to create a calendar of when 1244 01:05:59,706 --> 01:06:04,393 things need to be done for that paper. 1245 01:06:05,895 --> 01:06:07,964 And this would mean providing steps 1246 01:06:07,964 --> 01:06:12,802 for a multi-step piece of work or a project. 1247 01:06:12,969 --> 01:06:16,172 In terms of problems with self-monitoring, 1248 01:06:16,172 --> 01:06:20,043 we want to teach them a reverse process to check 1249 01:06:20,043 --> 01:06:25,043 math calculations, and to use a check-off sheet 1250 01:06:25,615 --> 01:06:27,550 to show the completion of assignments, 1251 01:06:27,550 --> 01:06:29,218 so again, if you have things written down 1252 01:06:29,218 --> 01:06:30,754 in a calendar or an assignment book, 1253 01:06:30,754 --> 01:06:33,089 you check off that you did them, 1254 01:06:33,089 --> 01:06:37,360 and this reverse process of math calculations 1255 01:06:37,360 --> 01:06:40,964 can also be very helpful in terms of editing a paper, 1256 01:06:40,964 --> 01:06:42,632 reading the paper backwards from 1257 01:06:42,632 --> 01:06:46,969 the bottom up, and seeing how it goes. 1258 01:06:48,504 --> 01:06:51,007 It's also helpful if the teacher establishes 1259 01:06:51,007 --> 01:06:54,377 with a student ways of monitoring performance. 1260 01:06:54,377 --> 01:06:55,845 How do teachers address behavioral 1261 01:06:55,845 --> 01:06:58,314 challenges in the classroom? 1262 01:06:58,314 --> 01:07:02,919 First, they have to calmly, calmly is the big word, 1263 01:07:02,919 --> 01:07:05,555 restate the infraction of the rule 1264 01:07:05,555 --> 01:07:09,926 and do not debate or argue with the student. 1265 01:07:09,926 --> 01:07:12,329 Second, they have to have some 1266 01:07:12,329 --> 01:07:16,557 pre-established consequences for a misbehavior. 1267 01:07:17,233 --> 01:07:21,805 Third, they need to administer the consequences immediately 1268 01:07:21,805 --> 01:07:25,608 and support proper behavior with encouragement. 1269 01:07:25,875 --> 01:07:28,678 And four, you have to enforce the rules 1270 01:07:28,678 --> 01:07:31,347 of the classroom consistently. 1271 01:07:31,347 --> 01:07:34,099 This is very hard to do when you have classes 1272 01:07:34,099 --> 01:07:39,099 of 20, 25, sometimes 30 kids in a class, 1273 01:07:39,555 --> 01:07:41,492 and so for teachers it's really helpful 1274 01:07:41,492 --> 01:07:43,192 if you work in a school and you have 1275 01:07:43,192 --> 01:07:46,596 school-based practice to offer them 1276 01:07:46,596 --> 01:07:49,398 or figure out with them how they can get 1277 01:07:49,398 --> 01:07:54,003 supervision, discipline in the... 1278 01:07:58,307 --> 01:08:00,811 it's very important for teachers, 1279 01:08:00,811 --> 01:08:03,180 if you work in school-based practice, 1280 01:08:03,180 --> 01:08:08,180 to help them get supervision, and peer support, 1281 01:08:08,217 --> 01:08:10,887 and brainstorming ideas to deal 1282 01:08:10,887 --> 01:08:13,423 with these kinds of challenging behaviors, 1283 01:08:13,423 --> 01:08:16,659 so that they're not feeling all alone in a classroom 1284 01:08:16,659 --> 01:08:18,428 with a child, and they don't end up 1285 01:08:18,428 --> 01:08:23,099 sort of blaming the child, and, 1286 01:08:23,099 --> 01:08:25,201 not purposefully, although sometimes 1287 01:08:25,201 --> 01:08:30,006 maybe purposefully, sort of singling out that child. 1288 01:08:32,608 --> 01:08:35,045 It's important that teachers avoid ridicule 1289 01:08:35,045 --> 01:08:38,181 and criticism publicly of a child, 1290 01:08:38,181 --> 01:08:41,450 of course at all times but especially kids with ADHD, 1291 01:08:41,450 --> 01:08:44,587 because the belief in society is, 1292 01:08:44,587 --> 01:08:46,989 they could change it if they wanted to. 1293 01:08:46,989 --> 01:08:50,693 And the reality is, as we've talked about today, 1294 01:08:50,693 --> 01:08:53,095 that things don't just change because 1295 01:08:53,095 --> 01:08:55,064 you want them to if you have ADHD, 1296 01:08:55,064 --> 01:08:58,034 that it is a biologically based disorder, 1297 01:08:58,034 --> 01:09:02,271 and it's based in the brain, and so there are a lot 1298 01:09:02,271 --> 01:09:06,408 of very complicated factors that go along with it. 1299 01:09:08,578 --> 01:09:12,915 You want to help a child build self-esteem, 1300 01:09:12,915 --> 01:09:17,553 and that's through positive reinforcement, 1301 01:09:17,553 --> 01:09:20,590 whether you call it reward, or praise, 1302 01:09:20,590 --> 01:09:23,693 and noticing when things are going well, 1303 01:09:23,693 --> 01:09:26,630 noticing when a child is doing a good job. 1304 01:09:26,630 --> 01:09:29,832 And teach the child to reward him 1305 01:09:29,832 --> 01:09:33,269 or herself through self-talk. 1306 01:09:33,269 --> 01:09:36,106 You know, that's your job as the therapist. 1307 01:09:36,106 --> 01:09:38,140 What does the child say to him 1308 01:09:38,140 --> 01:09:41,077 or herself when something's going well? 1309 01:09:41,077 --> 01:09:44,046 Does the child say, "I was lucky?" 1310 01:09:44,046 --> 01:09:47,183 Or, "Yeah, but last time it was really bad," 1311 01:09:47,183 --> 01:09:49,952 or "Just wait til next time," or does the child say, 1312 01:09:49,952 --> 01:09:53,490 "Good job! I'm making progress." 1313 01:09:53,490 --> 01:09:55,458 My bet is the child doesn't very often 1314 01:09:55,458 --> 01:09:57,526 say the last one, and that's what we want 1315 01:09:57,526 --> 01:10:00,697 to help that child learn to say. 1316 01:10:01,530 --> 01:10:04,600 So, what do we want to keep in mind here? 1317 01:10:05,067 --> 01:10:08,604 Hmm, what are the top 10 reasons for procrastinating? 1318 01:10:15,411 --> 01:10:18,247 A sense of humor goes a long way. 1319 01:10:18,247 --> 01:10:22,151 We want to help families and teachers 1320 01:10:22,151 --> 01:10:25,855 and kids with ADHD themselves be able 1321 01:10:25,855 --> 01:10:28,591 to laugh at some of the things they do 1322 01:10:28,591 --> 01:10:33,591 and not shame themselves or hate themselves for it. 1323 01:10:35,632 --> 01:10:40,632 Home/school collaboration is essential for academic success. 1324 01:10:42,105 --> 01:10:45,608 Executive functioning problems are not 1325 01:10:45,608 --> 01:10:49,445 motivational deficits but skill deficits, 1326 01:10:49,445 --> 01:10:51,848 and those skills need to be taught 1327 01:10:51,848 --> 01:10:55,885 from infancy to adulthood, and parents 1328 01:10:55,885 --> 01:10:58,955 have to teach them, and teachers have to teach them, 1329 01:10:58,955 --> 01:11:00,856 and therapist and psychologists 1330 01:11:00,856 --> 01:11:05,088 have to teach them to people with ADHD. 1331 01:11:05,088 --> 01:11:07,030 They do not come naturally, in fact 1332 01:11:07,030 --> 01:11:09,766 they don't really come naturally to anyone, 1333 01:11:09,766 --> 01:11:12,636 it's just that people who don't have ADHD 1334 01:11:12,636 --> 01:11:16,672 learn them more readily than people who do. 1335 01:11:18,007 --> 01:11:21,344 ADHD is a medical condition. 1336 01:11:21,344 --> 01:11:23,980 It is not a failure of will. 1337 01:11:23,980 --> 01:11:26,716 It is not a choice. 1338 01:11:26,716 --> 01:11:29,853 And it's important to remember, 1339 01:11:29,853 --> 01:11:34,853 as Ross Greene says, "Kids do well if they can." 1340 01:11:35,124 --> 01:11:37,393 And if they can't, what is getting 1341 01:11:37,393 --> 01:11:41,631 in the way of them not doing well? 1342 01:11:42,431 --> 01:11:47,069 Adult support is key to successful interventions 1343 01:11:47,069 --> 01:11:50,673 and lifelong learning skills. 1344 01:11:50,673 --> 01:11:54,677 In this way, coaching can be extremely helpful. 1345 01:11:54,677 --> 01:11:58,447 Having someone at the school who's a touchstone 1346 01:11:58,447 --> 01:12:02,651 for a child with ADHD, even five, ten minutes 1347 01:12:02,651 --> 01:12:07,156 a day can be extremely helpful. 1348 01:12:10,126 --> 01:12:12,795 Keep in mind, executive functions 1349 01:12:12,795 --> 01:12:16,799 provide structure, organize time, 1350 01:12:17,600 --> 01:12:22,538 involve initiation, help a person understand 1351 01:12:22,538 --> 01:12:25,865 and organize and live in their environment, 1352 01:12:26,342 --> 01:12:28,745 and to use these executive functions, 1353 01:12:28,745 --> 01:12:31,180 there are some tips, give reminders, 1354 01:12:31,180 --> 01:12:34,984 or what we could call cues, use calendars, 1355 01:12:34,984 --> 01:12:37,486 try to stay calm and supportive if you are 1356 01:12:37,486 --> 01:12:42,125 a family member or a professional involved with this child. 1357 01:12:42,125 --> 01:12:47,125 Avoid negative labels, parenthetically, ask what 1358 01:12:47,196 --> 01:12:51,934 negative labels that child has about him or herself. 1359 01:12:52,435 --> 01:12:54,790 Provide breaks. 1360 01:12:55,251 --> 01:12:57,907 Praise efforts that you see toward 1361 01:12:57,907 --> 01:13:01,343 change and doing things differently. 1362 01:13:02,411 --> 01:13:06,115 And create scaffolding and sustain it, 1363 01:13:06,115 --> 01:13:09,652 longer than you think it might be necessary. 1364 01:13:10,586 --> 01:13:12,555 So what are the keys to personal success 1365 01:13:12,555 --> 01:13:17,226 and confidence for a child or a teenager with ADHD? 1366 01:13:17,226 --> 01:13:19,595 Helping them organize their environment. 1367 01:13:19,595 --> 01:13:22,799 Praising self-initiation and motivation, 1368 01:13:22,799 --> 01:13:25,901 completion of tasks. 1369 01:13:25,901 --> 01:13:29,672 Getting feedback, talking about how time is organized. 1370 01:13:29,672 --> 01:13:31,407 Providing scaffolding and keeping it 1371 01:13:31,407 --> 01:13:33,843 in place longer than you think. 1372 01:13:33,843 --> 01:13:38,843 Giving any kinds of cues, visual, verbal, 1373 01:13:39,949 --> 01:13:41,851 over time, even if you don't want to 1374 01:13:41,851 --> 01:13:46,851 or think they're not necessary, and even if the child says, 1375 01:13:47,657 --> 01:13:50,460 "Oh my God, you nag me all the time." 1376 01:13:50,460 --> 01:13:54,564 Well, let's talk about what nagging is versus cuing. 1377 01:13:54,564 --> 01:13:57,840 Use technology if that can be helpful, 1378 01:13:58,732 --> 01:14:01,403 really try to investigate what 1379 01:14:01,403 --> 01:14:03,873 negative labels that child is telling 1380 01:14:03,873 --> 01:14:07,343 him or herself about having ADHD 1381 01:14:07,343 --> 01:14:09,478 and challenges with executive function, 1382 01:14:09,478 --> 01:14:14,478 and then try to make sure that those labels 1383 01:14:15,217 --> 01:14:19,755 are avoided being used in the child's life. 1384 01:14:21,257 --> 01:14:23,993 In Delivered from Distraction, Ned Hallowell 1385 01:14:23,993 --> 01:14:28,164 talks about seven habits to improve effectiveness, 1386 01:14:28,164 --> 01:14:30,233 and I wanted to share those with you 1387 01:14:30,233 --> 01:14:32,301 because I think it's really important 1388 01:14:32,301 --> 01:14:37,106 to take this positive view of child development, 1389 01:14:37,106 --> 01:14:42,106 and adolescent development, and young adult development, 1390 01:14:42,545 --> 01:14:46,215 when you think about kids with ADHD 1391 01:14:46,215 --> 01:14:48,517 and executive function challenges, 1392 01:14:48,517 --> 01:14:50,653 that we want to get them to a place 1393 01:14:50,653 --> 01:14:52,522 where they feel like they have something 1394 01:14:52,522 --> 01:14:55,124 they're good at it, and they're passionate about, 1395 01:14:55,124 --> 01:15:00,095 and they can pursue a life of rich connection to others, 1396 01:15:00,095 --> 01:15:05,095 and meaningful work, and nice pleasurable hobbies, 1397 01:15:08,008 --> 01:15:10,493 and a life that they feel good about. 1398 01:15:10,493 --> 01:15:14,043 So here are his seven habits to improve effectiveness. 1399 01:15:14,043 --> 01:15:16,712 One, do what you're good at. 1400 01:15:16,712 --> 01:15:19,715 That would be very true for kids with ADHD, find something 1401 01:15:19,715 --> 01:15:24,686 they like, or they're good at, and magnify it. 1402 01:15:25,287 --> 01:15:29,258 Delegate what you're bad at to others, as often as possible. 1403 01:15:29,258 --> 01:15:31,727 That sometimes is hard to do in childhood 1404 01:15:31,727 --> 01:15:35,831 and adolescence, and as an adult, we can do that, 1405 01:15:35,831 --> 01:15:39,869 you know, I have a client who's an attorney, 1406 01:15:39,869 --> 01:15:44,106 and he is not very good with managing his appointments. 1407 01:15:44,106 --> 01:15:47,242 He solved that problem because he has 1408 01:15:47,242 --> 01:15:51,380 a personal assistant or an administrative assistant. 1409 01:15:51,380 --> 01:15:54,149 So, that's harder for kids, but I think 1410 01:15:54,149 --> 01:15:57,353 it's interesting to take that on as a perspective, 1411 01:15:57,353 --> 01:16:01,758 this idea of delegating what you're not good at, 1412 01:16:01,758 --> 01:16:04,293 so if you're not good at remembering 1413 01:16:04,293 --> 01:16:05,728 to take your pills in the morning, 1414 01:16:05,728 --> 01:16:07,663 then let's set an alarm for that to happen 1415 01:16:07,663 --> 01:16:10,766 so you don't have to worry about it anymore. 1416 01:16:11,133 --> 01:16:14,704 Connect your energy to a creative outlet. 1417 01:16:14,704 --> 01:16:17,806 Most of the kids I see with ADHD, in fact, 1418 01:16:17,806 --> 01:16:19,842 I would say almost all of them, 1419 01:16:19,842 --> 01:16:24,842 have some aspect of creativity that's just fantastic, 1420 01:16:25,248 --> 01:16:30,248 a sense of humor, art, writing, drawing, 1421 01:16:30,853 --> 01:16:34,490 magic cards, gardening, there's something 1422 01:16:34,490 --> 01:16:38,194 that they really love to do, and I really 1423 01:16:38,194 --> 01:16:40,329 think that it's important to nurture 1424 01:16:40,329 --> 01:16:42,164 that connection to something that 1425 01:16:42,164 --> 01:16:47,164 they are creative and passionate about. 1426 01:16:48,470 --> 01:16:51,874 Get well organized enough to achieve your goals. 1427 01:16:51,874 --> 01:16:54,310 We've been talking about this today, 1428 01:16:54,310 --> 01:16:57,646 the importance of organization, and actually 1429 01:16:57,646 --> 01:16:59,350 have said that getting organized 1430 01:16:59,350 --> 01:17:01,784 is a goal in and of itself. 1431 01:17:01,784 --> 01:17:06,088 But in general, getting organized is a means to an end. 1432 01:17:06,088 --> 01:17:08,590 So, identifying what that end is, 1433 01:17:08,590 --> 01:17:10,492 and then figuring out what kinds 1434 01:17:10,492 --> 01:17:14,096 of organization you need to get to that end, 1435 01:17:14,096 --> 01:17:17,867 is part of the process of building 1436 01:17:17,867 --> 01:17:22,338 executive functioning skills, and we want to help the kids 1437 01:17:22,338 --> 01:17:26,209 and teens and young adults we work with do that. 1438 01:17:26,209 --> 01:17:31,209 Ask for and heed advice from people you trust. 1439 01:17:33,048 --> 01:17:36,418 Well sometimes that can be challenging for all of us, 1440 01:17:36,418 --> 01:17:38,588 I think it's sometimes especially hard 1441 01:17:38,588 --> 01:17:41,590 for young people with ADHD, because of 1442 01:17:41,590 --> 01:17:43,659 the shame that I've referred to, 1443 01:17:43,659 --> 01:17:48,659 and the general sense of not getting things right. 1444 01:17:49,298 --> 01:17:52,735 So, we want to help them learn how to ask 1445 01:17:52,735 --> 01:17:56,205 for assistance without feeling embarrassed. 1446 01:17:56,205 --> 01:18:00,046 And that's an ongoing process, it's not an easy one. 1447 01:18:00,569 --> 01:18:04,151 But it's really critical to their sucess 1448 01:18:04,243 --> 01:18:08,283 in whatever endeavor they embark on. 1449 01:18:09,018 --> 01:18:13,789 Keep up regular contact with a few close friends. 1450 01:18:15,024 --> 01:18:18,761 You know, friendships nurture us throughout our whole lives. 1451 01:18:18,761 --> 01:18:22,965 And sometimes, for children with ADHD, 1452 01:18:22,965 --> 01:18:26,168 making friends is hard, because they misread 1453 01:18:26,168 --> 01:18:28,470 the social cues around them. 1454 01:18:28,470 --> 01:18:31,673 Sometimes they're so focused on making friends 1455 01:18:31,673 --> 01:18:33,842 that they have a lot of, sort of peripheral 1456 01:18:33,842 --> 01:18:37,245 friendships but no real intimacy. 1457 01:18:37,543 --> 01:18:41,116 Sometimes they can be over-focused on one person. 1458 01:18:41,116 --> 01:18:43,018 So, one of the things that's important 1459 01:18:43,018 --> 01:18:46,355 to think about when we work with kids with ADHD 1460 01:18:46,355 --> 01:18:50,326 is to help them understand what it means to be a friend, 1461 01:18:50,326 --> 01:18:52,428 what to expect from another person, 1462 01:18:52,428 --> 01:18:56,531 but also what to expect from yourself. 1463 01:18:56,899 --> 01:19:01,704 The last habit that Hallowell indentifies 1464 01:19:01,704 --> 01:19:04,373 is go with your positive side, 1465 01:19:04,373 --> 01:19:08,010 which I think is just a great thing to think about, 1466 01:19:08,010 --> 01:19:10,279 which is lead with your strength. 1467 01:19:10,279 --> 01:19:15,279 And one of our tasks as therapists 1468 01:19:15,350 --> 01:19:18,520 is to help identify what that strength is, 1469 01:19:18,520 --> 01:19:23,520 in the family, in school, in work, socially, 1470 01:19:23,892 --> 01:19:26,929 what are those strengths and how can we 1471 01:19:26,929 --> 01:19:31,929 really nourish them so they continue to grow, 1472 01:19:31,934 --> 01:19:35,537 and that these kids can feel like 1473 01:19:35,537 --> 01:19:39,041 there are things they are good at. 1474 01:19:42,578 --> 01:19:46,949 Finally, another quote from Delivered from Distraction, 1475 01:19:46,949 --> 01:19:48,383 "And you don't give up. 1476 01:19:48,383 --> 01:19:50,919 "That is another trait of people with ADD. 1477 01:19:50,919 --> 01:19:52,287 "They keep trying. 1478 01:19:52,287 --> 01:19:54,156 "Often, they keep trying the same, 1479 01:19:54,156 --> 01:19:57,960 "doomed way, but they do keep trying." 1480 01:19:58,260 --> 01:19:59,862 So, we want to try to help them 1481 01:19:59,862 --> 01:20:04,862 try in different ways, to think in different categories, 1482 01:20:04,867 --> 01:20:09,867 and ultimately to use that innate desire 1483 01:20:10,640 --> 01:20:15,640 to keep trying to their best interest, 1484 01:20:16,678 --> 01:20:20,249 so that their efforts feel rewarding to them. 1485 01:20:20,249 --> 01:20:23,719 Thank you so much for participating in 1486 01:20:23,719 --> 01:20:26,655 Understanding ADHD and Executive Functioning 1487 01:20:26,655 --> 01:20:29,458 in Children and Adolescence, I hope this 1488 01:20:29,458 --> 01:20:33,362 information will be useful to you in your practice, 1489 01:20:33,362 --> 01:20:37,165 and I hope that you have a wonderful day.