- Let's talk about how executive functions develop.
So, as we know, executive functions guide behavior.
They reside in the prefrontal cortex,
and these executive functions, about 11 or 12
of them have been identified, and they work together
as a team of conductors to light up parts of the brain,
frequently in collaboration with each other,
so that we can move through life planning
and organizing and doing things
that are very complicated and multi-layered.
When we're born, when a baby is born,
brain structures, myelination,
the process of the fatty sheath
developing around the neurons to speed
the transmission of the chemical reactions,
the electrical impulses that send
one message from one neuron to another,
and neurotransmitter reactions are not fully developed.
Individual physiology, genetics,
and the patterns of human interactions
between infants and caretakers
all influence the development of neural circuitry.
What is the order of the emergence
of these executive functions?
So the first thing that emerges is response inhibition.
And that's the ability to think before you act.
If there's a behavioral aspect to it,
the ability to delay a response
leading to an immediate consequence,
so if I put my hand on something hot and it hurts me,
I'm gonna try to know not to put my hand on something hot,
I'm going to inhibit that urge to touch that hot thing.
A response inhibition stops ongoing behaviors
when they're unsuccessful, manages distractions
that interfere with other cognitive functions,
and it starts at about age three
and is usually developed by the age of 13.
Nonverbal memory is the ability to represent
people and events in the mind, hindsight, foresight,
and it's kind of like a spatial sketchpad.
Emotional control, we call this self-regulation.
This is the ability to manage your emotions
to achieve goals and direct behavior.
At about six months, an infant develops
a basic ability to hold an image in his or her mind
and move towards something, and this happens
to dovetail nicely with the mobility skills
that are developing physically at that time.
Flexibility, this is the executive function
that helps us revise plans in light of new information,
and supports adaptability to change.
We see this in young children all the time,
you know, they try something, they try
to put a square peg in a round hole
and it doesn't work, and then they go
to the square hole and they put the square peg in there.
They've revised their plan in light of
the new information, that it didn't fit.
Sustained attention, this is the ability
to maintain attention to a situation or task
regardless of fatigue, boredom, or distractability.
The next one to develop is initiation of tasks.
The ability to start tasks without
too much procrastination or delay.
We're gonna continue reviewing
how these executive functions develop.
So, internalization of speech,
which is called verbal working memory.
This is using words to communicate
thoughts, feelings, and self-talk.
Vygotsky has a model of how language
becomes private and internalized,
and it's very relevant to this
particular executive function,
and it's very important with people who have ADHD.
So, from zero to three, children will speak to others.
They don't really have a mind's voice.
Whatever they think comes right out.
Between the ages of four and five,
the voice turns a little bit back on themselves,
and they talk out loud to themselves.
They'll often say, "I do this,"
or they'll name themselves as they're doing an activity,
they'll talk themselves through things.
Around the ages of six to eight
there's a shift from description to instruction.
The voice in your head develops around age seven,
and by age nine there is no longer
any publicly observable speech.
So what that means is that, around four,
what the child will do is say, "I make a picture."
Around six, the child will say "I want you
"to make a picture of trees," or the self-talk
is less about description, or the child will talk
to himself and say "I'm making a picture,
"and let's see, I think I want to put some trees here,
"and some flowers here," so they talk
themselves through their activities,
that's very common from six to eight.
Around age, between ages seven and nine,
the voice that we all have in our heads
of kind of talking ourselves through
things silently develops, and by about nine,
generally most kids don't talk
themselves through things out loud.
With ADHD, kids continue to think
and talk aloud most of the time,
because they can't do it in their brains,
there's a failure to internalize that speech.
The switch is broken, and actually
it's quite helpful for them to be able
to talk themselves through an activity,
because it's a way that they organize themselves.
In terms of the next executive function,
planning and prioritizing, planning
creates a road map to reach a goal,
you divide complex behavioral sequences
into different components to solve new problems,
or attain new goals, and it also is an ability
to find a good fit between a problem and a solution.
The ability to make decisions about
what's important and what's not.
So planning and prioritizing are very important skills
that need to develop, particularly as a child
becomes and wants to become more independent.
So, if I want to go out with my friends,
then I'll have to do my homework before I go out,
or if I want to go out with my friends
and I need a ride from my mom,
I have to ask her more than five minutes before the event.
So, those kinds of things are very helpful
and important to learn how to do.
Organization, another executive function,
which is the ability to create and maintain systems
to keep track of your information and stuff,
that would develop probably next.
Time management, time management is tough (laughs)
as I've said, is the ability to develop
accurate time estimation for tasks,
how much time do you have, how you allocate it,
how to budget it, and how to keep within deadlines.
This is extremely difficult for people with ADHD,
and actually one of the ways that I work with them on this
particular executive function limitation is backward design.
So we start with when they have to be somewhere,
and go backwards, using an example from their lives
of something that's happened recently,
how long does it take, what time, what time, what time,
and to really accurately, as much as possible,
assess how much time things take,
and then we add a little extra ten minutes,
because things almost always take longer than we expect.
But backward design is helpful for them,
it's very concrete, forward design does not work as well,
because of the planning challenges
that go along with having ADHD.
Persistence to achieve a goal.
This is another key executive function.
So, we call this persistence or sustained attention,
and it's the capacity to follow through on something
without being waylaid by competing interests.
And it really depends on immediate
versus delayed gratification, so,
for people with ADHD, they tend to want
immediate gratification, unfortunately,
a lot of things that we have to do in the world,
particularly in school, rely on delayed gratification.
So, you have to learn how to develop
the ability to sustain your attention
in the context where you're operating.
So we call that goal-directed persistence,
and it relies on context-dependent sustained attention.
In plainer, more simpler terms,
if you want to be able to stick with your focus
and stay with your goal, you have to be able
to sustain your attention regardless
of the context that you're in.
And one of the problems for people with ADHD
is that they actually have trouble doing that,
so if the context changes, their ability
to sustain attention changes, which makes sense,
because that's true for all of us sometimes,
but they have trouble regrouping and refocusing.
Metacognition, this is one of my favorites actually,
because it's something that really I've seen
change over time in a number of my clients
as they've matured, and as they've come to therapy,
this skill can be developed, and it's very important.
So, metacognition involves self-regulation,
as we talked about what that is,
the control of emotions, arousal,
and the ability to take perspectives.
The ability to take perspectives is very hard
for children and teenagers with ADHD.
Mostly, metacognition involves using working memory
to talk and look back on past experiences and situations,
see what you did, look at a current situation,
and evaluate if you need to make
changes on what you're doing.
They key to metacognition is the ability
to step back and take a birds-eye view of yourself,
and ask yourself, "How am I doing?
"How are others perceiving me?
"Is there something that I'm missing?"
This is hard, because there's a lot shame
related to ADHD, embarrassment about missing things,
an anxiety about trying to get whatever you're missing.
So we're gonna talk a little bit more
about how executive function skills develop.
So, as I said, they start in infancy
and they continue into adolescence.
And basically, there's an external to internal process.
And we talked earlier about how parents
often are the executive functions
early on for their children in terms of
helping them learn to inhibit their responses,
learn to know that's hot, that's hot,
you don't want to touch that, so they learn,
they teach them that, or they'll, as I said,
help them figure out that you actually
put your pants on before you put
your shoes on, kind of a thing.
And eventually the things that
parents teach them from the outside,
or teachers work with them on,
or you as therapists will work with your clients on,
will become internalized to them
and they'll start to absorb the routines
and the processes that we're trying
to help them become more aware of.
There is a parallel development
of the brain and executive functioning skills.
So as the brain changes over the trajectory
of childhood, adolescence, into young adulthood,
so do the executive functioning skills.
In puberty the size and quantity
of neural networks dramatically increase,
especially in the frontal lobes and the cerebellum.
And there's an also what I've referred to before
as increased myelination, so the thickening
of the fatty sheath around the neural cells
that's in the corpus callosum that connects
the left and right sides of the brain.
So this proliferation of brain cells
is followed by a period of pruning the networks,
so that the system will operate
as efficiently as possible, and the increase
in the myelination in the corpus callosum
is critical for the more complex use
of language and logical thinking, and metacognition
that we see in later adolescence and early adulthood.
So, if we look at the development
of executive function skills, that these
executive function skills have to be taught directly.
The frontal lobes are still developing,
and so the skills have to be taught
thinking about them as concrete skills,
not an innate thing that you should just know,
because no one comes into the world
knowing them, they need to be taught.
Teaching executive function skills increases
the probability of academic success and better self-esteem.
It's important to remember that the dopamine
and norepinephrine pathways in the brain
are especially slow to develop,
so that rather than being angry and frustrated
and blaming kids for what they can't do,
we would do much better to think about this
as a developmental sequence problem
with a deficit of skills.
How do we assess executive functioning skills?
Well, we conduct a multidimensional assessment,
so that would include understanding
the pattern of strengths and weaknesses
in the child's executive function skills.
So, the two critical things that we want to look at
are sustained attention and initiation,
and these are not accounted for in standardized testing,
because the evaluator will say "Okay, start,"
so the person starts.
We want to get a bunch of information,
and that would include classroom observations
work samples, behavior checklists such as the BRIEF,
the Brown ADD Scales, the CBCL,
the Vanderbilt scales, or the BASC,
and of course, a thorough history
from parents and from teachers.
We want to rely on the process,
what we observe and know about this child,
rather than just the scores.
Diagnostic tools include a thorough history
from two separate parties, parents, teachers,
the child him or herself if that's possible,
sibling or a partner, neuropsychological testing
can be very helpful, Hallowell recommends
the quantitative electroencephalogram,
the QEEG, I find the Barkley ADHD
and executive function forms very helpful,
and I also find the forms from Dawson and Guare's books,
Smart But Scattered, and Smart But Scattered Teens,
and they have another book I think
of just assessing executive function skills
to be really useful, user-friendly,
and extremely informative.
Let's talk a little bit about
the spectrum of executive function.
What does it cover in the brain?
So, the thing is that you can have executive functions,
and ADHD, which overlap with the executive functions,
and learning disabilities, which
overlap with executive functions.
So it's really a broad term and it has
a lot of consequences for how someone functions.
All psychiatric and learning disoders
interfere with attention.
But it's important to remember
that ADHD is a working memory deficit.
I think it's important that you take a whole child approach
when you work with kids with ADHD.
You know, there's a false belief
that if you fix a dysfunctional component
of a child then you fix the child.
So if the child has reading trouble,
and you "fix that," then you fix the child,
and really, it doesn't always work that way, (laughs)
so we want to think about what helps the whole child manage.
As we know, there are three types of learning disabilities,
reading, mathematics, and disorders of written expression,
that are especially challenging,
and have been found to be associated with ADHD.
How do we intervene to improve executive functions?
Well, we intervene, one, at the level of the environment.
What are the expectations of the tasks?
What are the prompts to perform the tasks?
How do the adults interact with the children?
We intervene at the level of the person,
improving the individual's capacity
to use his or her own executive skills
through motivation, increased awareness
of what those skills or deficits are, and instruction.
We shift gradually from external to internal dimensions,
so we shift from making a checklist
that we hang on the refrigerator, to, over time,
hoping that parts of that checklist become internalized,
which they will, when there's consistency.
We target only one or two specific
behaviors for change at a time.
There are three key strategies
for managing weaknesses of executive functioning.
You, as I said you intervene at the level
of the environment, you intervene at the level of the child,
and that means you teach the skill,
you motivate the child to use the skill,
and you praise or reward the child for using the skill,
and then you verbalize what you see happening
so that the child gets another piece of feedback
and another way of externalizing what becomes internal.
General interventions to assist
improving executive function skills are
based on the following questions.
What are your primary goals?
What do you most want to target first?
And then what? And then what?
If you want to target three or four things at the same time,
and many clients come in and they want
to fix everything, you'll fail.
Pick the most important thing and work on that,
and when there's some success with that,
then you can go on to the next most important thing.
Use worksheets and information from the child,
parents, and teachers to determine these.
Remember that all goals should improve
self-awareness, self-adjustment, and metacognition,
thinking about how the self is in the world.
The best plans, the best ones, are developed
collaboratively with the child and the parents.
If the child does not buy in to what a parent
thinks is the most important thing,
the child will not actually be fully participatory.
We want the child to also see what's most important,
and if sometimes what the child sees
as most important is his or her number one,
is the parent's number four or five,
I have to tell you that I'll lean in to the child's choice,
because I want the child to start to feel
like he or she has some authority
and autonomy in creating the change,
that will help him or her feel better.
Another intervention that's really important
is modifying the environment.
So what parts of the environment
are not supporting change for this particular child?
What ways could people interact with this child differently,
what are expectations of this child that aren't working,
if we think back to the client I referred to earlier
who had a teacher who was giving her spelling tests
even though her IEP said no spelling tests,
one of the ways that she was able to modify
her environment with her parent's support
and her strategies teacher's support
was to basically confront the teacher
and say, "I am not supposed to take spelling tests."
So that was a modification of the environment.
And then the final way to intervene
is you want to describe the behavior
that is troubling or isn't working
in very specific, concrete terms.
Otherwise, it becomes an always kind of a thing.
And when something is an always kind of a thing,
people with ADHD don't get it,
because as soon as they hear "always"
there brain sort of turns off.
But if they hear, "Remember when you did
"this specific thing," then they will actually
be able to look at that specific thing.
How do we modify the environment?
So, the first way to modify the environment
is to collaborate with the child first,
and ask, "What situations have helped you
"foster completion of tasks or using some of these
"executive functioning skills successfully in the past?"
So, when we have that information,
then we want to think about if we can establish
a goodness of fit between the child's skills
and a particular environment.
What we are talking about is antecedent control,
we want to modify the situation which triggers
the maladaptive behavior and lack of skills.
So, we want to alter the physical
or social situation as much as possible,
we want to amend the tasks expected of the child,
and we want to change how the adult
interacts with the child.
This of course is all true for teenagers,
I'm just using child for ease of language,
but those are the goals that we want to think about.
Another way that we can really intervene
in helping improve executive functions
are that we want to reduce distractions for students,
and sometimes that will mean creating physical barriers,
fences, removing breakable objects, locking rooms,
a tool shed, putting away controls to the video games,
reducing the social complexity of situations,
changing a social dynamic, we want to reduce distractions.
We want there to be a place for everything,
cubbies, bins, hampers, calendars, files, notebooks,
and we want to teach the children how to file.
You know, when you get papers from a teacher
and they are three hole punched,
they should go into the binder with each hole in a ring,
not shoved into the folder section.
You want to help teach organization,
and here's the piece of information
some parents really don't want to hear:
until they're practically out of high school.
Freshmen and sophomores still need
the kind of assistance with organization,
if they have ADHD, that sixth,
seventh, and eighth graders do.
It may be somewhat different, but they
will need some help with their organization.
In terms of electronics, I would like to say
that most teenagers, and I would say
a lot of kids now even from ages 12 and up,
have a phone, an iTouch, or you know,
fancy watch or something like that.
Those three devices are going to be their best friend.
Because, most kids, if you ask them
where X, Y, or Z is, they don't know,
but they always know where their phone is, (laughs)
or their iTouch, and so we want to use
the iTouch or the phone, or, you know,
some comparable kinds of devices,
to help them organize.
Put items in their calendar, set alarms to remember,
"Oh, I gotta take my pills," or,
"I have an appointment."
And we want to use those as much as possible
because the phone or the iTouch or whatever
is with them most of the time,
whereas the notebook, the calendar notebook, may not be.
And that might require doing things twice,
or it might require basically writing down
things in the notebook at school,
and then having an alarm set in the phone,
you know, when it's time to do your homework,
check calendar for homework.
Rehearse with a child what will happen
in advance of a particular situation.
So, if you have a child who gets
really overwhelmed in social situations,
and you're having Thanksgiving at Aunt Shirley's house,
and there's gonna be 25 people,
it would be worth taking some time
to talk to that child about what's gonna happen
at Aunt Shirley's house, and how you or he
can work on, when he feels overwhelmed,
or might need a break, or maybe you want
to institute a break where you and your child
go up to a room and just chill out for a few minutes,
but that you plan and talk about an event that you know
could be challenging for your child in advance.
Use verbal prompts, we want parents to use
verbal prompts to remind the child to check a schedule.
So for example, a lot of parents I work with complain
that they have to say the same thing
over and over and over again.
From the time a child can read,
and even if a child can't read,
because you can do a checklist with pictures of items,
you can put up a list for your child
of things that you want him or her to do,
and basically say, over and over,
"Check your list. Check your list."
And when things are done on the list,
they can have a pen and check them off.
That is extremely helpful, because it teaches
the child the ability to go back and see
what has to be done when something's finished,
and, to start to understand that there's a sequence,
"I do this, then I do this, then I do this,"
so there are steps to a process.
I think you want to help the parents
give praise for using executive skills
with their children, so when their child
is actually checking the list to say,
in the car on the way to school,
"I noticed you checked your list
"and did everything on it, way to go."
They don't have to go overboard,
but some noticing that the child's making
an effort in the direction you want him or her to go in.
In terms of modifications, I believe that
a lot of times what happens is that parents
make tasks too long and complicated
for their children to be able to follow through.
So we want to do shorter steps and shorter tasks.
And you want to take a task and divide it
into parts with breaks built in.
So, I have a client, and she hyperfocuses
when she does homework, so she'll sit down
and she'll work for three hours,
she's not particularly productive
but she zones in and she can't decide what's important,
and so recently I gave her the assignment
that when she goes to do her homework,
she can work for an hour, which is what
she thinks is her longest reasonable period of time,
she's 17, and then she has to take a break,
for 10 minutes, which is timed,
and then she'll go back for another hour.
So that she actually can learn how to break.
She doesn't have that mechanism,
so we're trying to teach that for her,
and it will be in her phone.
So we want to help these kids make a schedule,
and then stick with the schedule.
And sometimes the challenge is,
because of the high likelihood that a child
or a teen who has ADHD has a parent who has ADHD,
it's very hard for these parents to remain
consistent with the schedule that's created.
So, the schedule that's created has to be
simple enough to follow, and simple enough
to follow through on.
You want to make steps explicit, no assumptions.
So, if you think, well, you do this,
and then of course, this one, you...
you know, you do one thing on the list,
then if, you know, go to the bathroom,
and you assume that in the bathroom there's also
teeth brushing that occurs, mm-mm.
Go to the bathroom.
Brush your teeth.
Put your shoes on.
You assume, maybe, get your coat at the same time?
No.
No assumptions in the beginning.
Include choices for a child.
So, the child doesn't feel like, oh my God,
I'm being controlled with everything I have to do.
You want the child to be able to make choices
within the schedule, or goals that you're setting up.
And because there's collaboration with the child,
then the child will be involved in what you're setting up.
In terms of specific modifications in a classroom
that include changing seat arrangements,
basically looking at what's happening
at the playground, or free play, or lunch,
where the child's sitting at lunch.
In terms of making tasks shorter and taking breaks,
the end of the task has to be in sight.
If your child's goal is to write a paper in one sitting,
that will be a failed experience.
If your child's goal is to write
a page of words, that might go better.
Make steps very specific and vary the tasks
so that there are choices.
And watch out for open-ended tasks
like creative or expository writing that have no end.
You have to create, even if it's a self-induced
or sort of a false barrier, that they can
hit up against it and feel a sense of completion,
and then the next time they'll have a little bit more to do.
I want to say something about the complexity
of social situations, particularly for younger children.
Parents of children with ADHD have to provide
supervision and some influence
over social events for these kids.
It's very hard for these children
to manage the situations on their own,
because of all of things we've talked about in terms of
executive functioning and some of the challenges.
So that the parents will need to check in.
The parents might need to participate in the play dates.
Even at ages eight and nine or ten,
the parents may need to check in,
structure a particular snack time,
engage the kids in a game.
A child with ADHD may sometimes feel lost in a playdate,
not sure what to do, or it gets boring,
so the parent will need to be somewhat engaged,
which sometimes is a little challenging for parents
because they think, "Oh, playdate!
"Free time for me, I can catch up on X, Y, and Z"
and that isn't necessarily the case.
How do we teach executive function skills to ADHD kids?
So, as I said, and I've really tried
to emphasize in this talk, there's a philosophy
of a skill deficit rather than a failure
of will, motivation, or knowledge.
One of the ways to teach these skills,
in fact, I think it's the only way,
is you have to teach the deficient skills directly.
Do not expect these kids to absorb these skills
through observation or what I call miracle osmosis.
The first thing that has to occur
is you must consider the child's developmental stage,
and understand what is typical for that age group.
Then, you need to be able to help the parents,
and you will have to do sometimes in session,
cue the child for tasks.
Keep the tasks brief, encourage practice using small steps,
work with the child's desire for mastery and control.
That's really important.
It's important to remember that these kids want to change,
they want things to be different and better for them,
and that is your best tool as a therapist.
Create and keep routines and schedules.
This is the third most important thing.
You need to help these families
create and keep routines and schedules
that are not too complicated and that are accessible
and involve the participation of the child.
It's important for parents and the child
to distinguish between have to and want to.
So there are two kinds of tasks, really,
ones that you're not very good at doing,
and ones that you're capable of doing, but don't like doing.
So, both of these have to be broken down into smaller steps.
If you're really, if you're not good at it,
then there are a whole set of separate issues
that have to go on, which is like
a lack of motivation, a dread of doing something,
an avoidance, so that's one category.
And then the second category is,
you can do it but you just don't like it.
So, then there's also things like avoidance
and a lack of desire to actually do it.
So in both cases, these kinds of tasks
are have-to tasks, and they have to be
broken down into small, manageable chunks and steps
so that you can kind of do something you don't like,
or you know how to do but you still don't like,
or you can't do, do a small piece of it, break.
Do a small piece of it, break.
Because ADHD kids and teens do not have
the ability to sustain themselves through an activity
that they do not like or feel like they cannot do.
You can model as a therapist for these kids
"Well, if this were my assignment, I might,"
or, "When I write a paper, I plan to do this or that"
or, "This is how I take breaks,"
not because you want to basically explain
that your way is the best way,
but because it's helpful for these kids
to understand that other people struggle also
with having to do tasks that they (laughs) don't like,
having to do things that they know how to do
but they don't want to do, and having to
do things that they don't know how to do.
They need to hear what other people's strategies are,
so not only from you, but also from family members,
because remember that what these kids do in their brain
and to themselves is a lot of shaming,
that "I'm different, and I don't do it right."
One of the goals of teaching executive functioning skills
is to enhance self-regulatory capacities.
So the ability to push through something
even if you don't like it, to manage
your emotions even if you're struggling,
or you're mad, or you're afraid.
To use charts, visual symbols and aids,
make lists, as I said, daily calendars for daily activities,
there never can be enough visual aids up for kids with ADHD.
Build in choices to give kids some control.
So, you have math homework, which you don't like,
and you have Spanish, which you also don't like,
and you have English, which you like,
and science, which you like, so how
do we want to plan our evening with these two things
you don't like and the two that you do?
Ask the child, and the child might say,
"I want to do the things I like first,
"and the things I dislike next."
Or, "I want to do something I don't like,
"and then something I do, and then something
"I don't like, and then something I do."
Ask the child for his or her feedback so that
he feels like he's participating in what's being set up.
Okay, so, in terms of teaching
executive functioning skills to kids,
one thing that's important to remember
is that punishment actually doesn't teach children
what to do, it teaches them what not to do.
And, what kids with ADHD need are
some ideas about what to do.
They need help figuring out what's next.
So one thing is to rehearse, practice,
and review skills before an event.
As we said, use verbal prompts or reminders.
Arrange for visual cues or alarms.
Praise the child or teen for using new skills.
And, here's the key: debrief
and review a situation afterwards.
Maybe at the time, maybe three days later,
but something that you saw that was good or different.
That's what you want the parents to be able to do.
And if sometimes they can't debrief something
until they're in therapy, then you can do it there.
It's important to teach parents
that effective praise is delivered immediately,
is specific to the particulars
of the action that you've seen,
states the values of accomplishment,
notices hard work, and trains the child
to appreciate his or her own task
accomplishment and problem solving.
That's how we're gonna teach metacognition.
So we want to interrupt the child
before the child interrupts you
and say, "I really like how you're doing this."
You want to praise the children for using executive skills,
I like three positives for each corrective feedback,
so each time you say, "Do it this way"
or "Don't do it this way," that you try
to remember to notice a couple good things at the same time.
People ask me a lot about "bribing."
What's a bribe?
So, um, I'm gonn talk about my view of bribes.
So, a bribe is when you say to someone,
"Here's the money, take this bag across the street."
An incentive is, "If you take this bag
"across the street, I'll give you some money."
Now, I don't believe in bribes,
but I do believe in incentives,
and I have seen them work in the 25 years
that I've been a family and child therapist.
We want to use incentives and self-rewards
to enhance motivation and instruction.
So, you might make a deal with a child
that he works for an hour, does his homework,
and gets ten minutes of Facebook time.
Or, you might make a deal with a child that after homework
comes the half hour of TV that she's allowed.
Those kinds of things are really helpful,
and the agreement would go further.
If you don't do your homework,
or you have a tantrum about doing your homework,
then there will be no TV for you.
And that is very hard for some parents
to follow through on, but it's critical
that the incentive actually matters to the child,
and isn't available if the child doesn't do
what he or she has agreed to do.
Incentives make an effort of learning a skill
and doing a task less distasteful;
they also teach gratification.
"What reward can I give myself, or motivation can I give,
"to get through this unpleasant task?"
We want to make sure that adults offer
enough support to help a child feel successful,
but not too much support to be doing things for the child.
Adults usually make two mistakes:
there's too much support so that
the child fails to learn independence,
or too little support so that the child
repeatedly fails at a task.
That's a really fine line to balance,
and it's really important that you
work with your clients on that.
You want to practice in session
teaching negotiation and compromise.
This is something that's often really hard for people,
they're not good at it, they're especially triggered
and reactive to things that bother them
about their child, or their partner,
or the dynamic in the family, and it's critical,
critical, that you help them with this.
Scaffolding is crucial, and it usually takes
a lot longer than expected in terms
of how much time it has to be in place.
So, what happens is usually we create a system
or a support, a level of support,
or some sort of routine, and it's working.
Yay! (laughs)
Then, what happens is, adults usually take it out too soon.
And this is particularly true in school systems,
where, you know, a child will have extra support
and be doing well, and then they'll want
to remove that support the next year,
which is a big mistake, big, because the child
usually needs the support longer to make sure
that those kinds of changes are internalized.
So, you don't want to abruptly stop
supports, supervision, or incentives.
Whatever there are supports that are being faded out,
they have to be faded out gradually.
There are five keys to executive skill development.
Often over-involved parents can be anxious,
and they have trouble backing off from their kids
who've needed a lot of support who have have ADHD,
and so as a result the kids sometimes
are under-responsible for their own activities and actions.
We want to help create more accountability in the kids,
this is particularly true of teenagers,
and have the adults step back in appropriate ways
but still stay involved in other ways.
So, for example, where the notebooks are concerned,
it's sophomore year and you might want to take your kid
to Office Depot or Staples or wherever,
and say, "Okay, how are we gonna organize this year?
"Where are you gonna put stuff?" and help them lay it out.
Next year, it's junior year, have the discussion.
Maybe they want to do it themselves,
maybe you want to look at it when it's done,
but you're involved in the process.
You want to help those parents use collaboration
to create mutual goals of what should be shared
and what can be independent, and you want to rely
on the child's sense of what works for him or her,
as well as the parental observations about that.
It's important for parents to be very clear
about goals and expectations from the very beginning
of any sort of arrangement that
they're setting up with their children.
And to make their goals, the steps
for a goal into a checklist.
So for example, if you're working with a family,
and the parents complain that the room is a disaster,
and the child needs to clean the room,
then it would seem to me that perhaps,
and this is true for a lot of kids,
they see their room, it's like a disaster area,
it's overwhelming, they don't even know where to begin,
and so it might be useful to make a checklist
that goes in their desk on or on their door,
you know, "To clean their room: one, clear off the bed,
"two, put the dirty clothes in the hamper,
"three, fold all the clothes that are in a heap,"
you know, those kinds of things,
they seem so simple and basic,
but they're really important because the child
isn't able to do that internally him or herself.
You want to help the parents create expectations
of tasks that the child can actually perform and succeed on,
not continue to basically fail at,
which perpetuates a cycle of anger
and disappointment and shame.
And you want to help the parents make
the steps of every single task explicit.
How do you help kids with ADHD develop emotional control?
The first thing is to identify triggers,
events that cause the child to lose his or her temper.
The second thing to remember is that
emotional control is one of the executive functions
that takes years to develop.
So, that would mean that it's important
to make a list of triggers, you know,
what you can and cannot do when
you're having a hard time, with the child or the teen.
The third thing is to enact a practice session
and connect the process to a reward.
So, basically you want to help create
and review what happens when a child is triggered,
what the options are, and what happened,
and what could be done differently.
So it's important to create a plan
to manage or eliminate the triggers,
to talk about what losing your temper looks like,
and to create a list of behaviors that are not tolerated
regardless of how angry or upset you are,
and that list has to be short,
and extremely specific and concrete.
And then you want to make another list,
a list of replacement behaviors,
things a child can do when he or she
is upset, instead of those other things.
So, that can be listening to music,
that can be having a soft pillow or something
in the basement that the child can sort of thwop if needed,
that can be taking a walk with the dog,
whatever is appropriate for that child,
there should be a list of alternatives.
In terms of school interventions,
the first thing that I think is really worth stating
many times is that the parents must advocate
for their kids, over, and over, and over again.
They have to continue to advocate for their kids.
I'm gonna read something from the book
that's on your reference list, called Buzz,
and it's about homework.
"It's Friday afternoon, and I'm in my writing shed
"chewing sugarless tangerine gum
"and agonizing over a clunky first draft,
"longing as always for distraction,
"although I wouldn't have ordered this phone call.
"The voice belongs to Buzz's English teacher,
"who is graciously taking time to let me know
"he hasn't turned in a major assignment due today,
"which is news to me, he should have been
"working on for the past week."
Buzz is in middle school.
"The instruction was to interview someone,
"preferably a parent, about prejudice.
"Buzz hasn't even gotten started.
"His teacher isn't sure why that is, but again,
"graciously and maybe also because I've met
"with her three times by now to plead for understanding,
"she offers Buzz a reprieve as long as
"he can do this work over the weekend.
"Whenever I ask Buzz if he has homework these days
"he tells me that he has already finished it at school.
"He won't write assignments in his agenda,
"even when Xbox time depends on it,
"and there is little else he cares about
"other than food, which I'm not ready yet to withhold.
"So when Buzz comes home this afternoon,
"I leave my shed, microwave him a plate
"of leftover spaghetti, and spend
"the next half hour arguing, bribing,
"threatening, pulling out the TV cord and hiding it,
"before finally convincing him to get started.
"The two of us, I'm well aware, are trapped
"in an all but senseless system,
"even as US teachers are piling on ever more homework.
"Research has shown it doesn't measurably improve
"academic achievement in grade school,
"although it can sour kids' attitudes toward school
"and increase conflict between them and their parents.
"I should probably spend more time
"complaining about this to Buzz's principal,
"who already thinks I'm a crank,
"but in the short term, I just don't want him to fail.
"It drives me crazy that I have to work this hard,
"and it makes me so sad to think of all
"the worried mothers who don't even have this option.
"Finally he sits down in front of the computer.
"He smooths out the crumpled blue instruction sheet
"we've fished from the bottom of his backpack,
"a trove of ancient cookie crumbs, leaking pens,
"unsigned permission slips, and unwashed
"gym shorts, and he starts typing fast."
So here we have a boy of maybe 12 or 13,
and a mother who is really struggling
with how to get him motivated, started,
following through, accountable, all of the things
that I see in the parents I work with of ADHD kids.
So, parents have to advocate for their kids,
even if the principal thinks they're a crank.
It's important to remember that
ADHD kids can't bind events across time.
To remember that transitions, physical relocations,
changes in schedule, and disruptions
are especially difficult for the child with ADHD.
Changing classes, starting a new year,
having a substitute teacher, all of these
things can be very discombobulating.
It's important to teach ADHD kids
how to keyboard as quickly as possible.
Often because there's a motoric aspect of ADHD,
the physical act of writing is very difficult,
and as we've said sometimes actually
the thinking and language parts
and expressing them verbally are very difficult,
so it's good to keyboard, it helps speed things along.
It's important in a classroom to avoid distracting stimuli
by not placing the child near the heater, the door,
the windows, other children who have
attention issues, and to break up tasks.
Teach how to divide a future task into manageable parts.
In terms of giving instructions for ADHD students,
it's important often to provide
an external source of motivation,
she had mentioned taking away the Xbox,
but we also want to provide an incentive,
"If you write this you'll get an extra 15 minutes of Xbox."
I have a child who loves Gilmore Girls,
and so one of her incentives for following through
on the morning routine without having a tantrum,
for which she had a checklist, is that she got
an extra 15 minutes of Gilmore girls at night.
It's important for teachers to remember
that ADHD kids might need manipulatives,
or like a little fidget toy, and to make
tasks as manual as possible when needed.
It's also important for parents to remember that,
that there might be knee tapping,
or finger, I guess twitching, whatever you want to call it,
but there's usually some sort of outlet
for a kind of internal sense of energy.
And that timeouts have to be targeted, and limited.
And that's important at home, but also important at school.
You know, the basic rule of thumb
is that timeouts shouldn't be longer
than the child's age, which I support.
And I think that sometimes in school,
that the timeouts again have to be targeted
for specific kinds of behavior,
and not just general across the board behaviors,
because we want to work with the school
and the parent on the same behavior,
so that there's success in that one area of behavior,
and then we can move on to another.
It's important to be patient during
transitions of all types, and to create
a quiet place in the classroom which
has reduced stimuli, if that's possible,
or a place in school that has reduced stimuli,
I had one student who really had to read
in her English class, and she couldn't stand reading,
it was distracting, the chairs were uncomfortable,
and we were able to arrange with the school
that she could go down to the library,
which had a big soft cozy chair,
and she could sit there and read
when there was in-class reading.
How do you help ADHD students at home?
You want to encourage parents to set up
a quiet time place at home that is for studying,
where the child can go and is not distracted by things.
You want to establish a routine for doing homework.
You want to create systems to help keep
the book bag and the schoolwork organized
in the notebook, and in the backpack.
You want to create and implement a home-school notebook
of assignments and updates, for younger kids
that could be a sheet, it could be a calendar book,
I suggest a calendar book as early as possible,
this kind of daily assignment notebook is very helpful
because even a second or a third grader
can see what he or she did and check it off,
which helps again organize their ability
to remember, "I did this, and then I have to do this."
Remember, all of these executive function skills have to be
taught repeatedly over time, external to internal.
You want to make sure the student
correctly writes down all these assignments,
and perhaps to check with the teacher
each day if necessary, I find that's been very helpful.
It's nice if the parents can sign the notebook
when the child is younger and in grade school,
and use it as a method of communicating
with the teacher so that they have a way
to go back and forth on a regular basis.
There's been a lot of research about
mindfulness training for parents and children with ADHD,
it's mostly positive but it has to continue
for over time in terms of support
for the practice afterwards, what the research
showed is people who did the mindfulness class
but didn't continue with sort of brush-up classes
or follow through didn't do as well
and weren't able to keep up with the practice
as those who did have those kind of refresher workshops.
What are the parental essentials for student success?
In my opinion, the number one parental essential
is regular contact with teachers
and administrators at their child's school.
And the number two would be for you as a therapist
also to have some contact with someone in the school,
so that you can have an understanding
of what's working in the classroom and what's not.
The parents have to advocate for the child,
and having a relationship with the school
and the teachers is helpful, even in high school.
Most high schools, teachers have email,
they check their email, and they're available
to respond, if they're not, there's certainly
a principal or guidance counselor that can be helpful.
Progress reports can be really, really helfpul
in finding out how your child's doing.
Many schools have computer programs
that you can log in and see the link
related to how your child is doing,
some schools have actual progress reports
that the child takes around to his or her teachers,
or you can set up progress report meetings
with the teachers just to get a sense
of how your child's doing periodically if you're concerned.
I think the main thing we want to communicate
to these parents is get involved and stay involved.
So, I'm gonna go through a few slides
about how you give instructions to kids with ADHD,
and some classroom strategies,
I'm not gonna spend a lot of time on these,
these are mostly resources for you to have
to share with your clients in your practice.
So, one thing that's really important
when you give instruction to kids with ADHD
is maintaining eye contact during verbal instruction.
That's really important.
Two, give out one task at a time.
If you make the directions clear and concise with one task,
the chances are it would be accomplished.
But if you make it a task and you add the word "and,"
chances are it might not get accomplished,
particularly for the younger kids.
So, small tasks, one task at a time, eye contact.
And be consistent with the daily instructions.
Make sure student comprehends instructions
at the beginning of a class, this is really important
for teachers, and at the beginning of a task.
Repeat instructions in a calm, positive manner.
This is also true for parents and for teachers.
I like the rule of three, I think sometimes
it works with teachers and sometimes it doesn't,
but essentially the rule of three is,
I look at the child in the eye,
I might put a hand on a shoulder,
and then I say what I want them to do
and I ask it to be repeated.
The hand on the shoulder is optional,
but sometimes for a parent it helps
steady the child to actually focus on what
the parent's saying, in schools that's less optional.
If you have to repeat the instructions,
they need to be repeated in a calm and positive manner.
For classroom strategies, what we want
to encourage teachers to do is to use external cues.
Don't rely on mental or auditory information.
Make lists, posters, signs, remember that
sometimes auditory processing for kids with ADHD
is not their strongest way of learning,
and sometimes it is, so sometimes people
really learn only through hearing.
I have a client who's an adult, and then
she basically, that's how she remembers all her information.
That's how she processes, and that's how she remembers.
Hearing, and doing.
I have another client who's an adult who has ADHD
and he has to write things down,
and he has to see them visually.
And they said that they've had these strategies
and ways of learning since they were children.
And I see that in the kids I work with,
which is so interesting to be able to see it
in kids and teenagers, and then
in people in their 40s and 50s.
We want to make time physical in a classroom,
don't rely on internal clocks.
You want to to help the child have a timer
or some way of monitoring the time
that's more external and physical.
Because they can't bind events across time.
You want to help the child break up tasks,
the teachers need to teach them how to
divide up a task into the event,
the response, and the outcome.
It's nice to see a child near the teacher,
but as part of the regular class seating.
I've seen teachers basically put a kid with ADHD
right next to their desk, and then
everyone else is in a circle, and all that does
is make the child feel alienated
and different in a very bad way.
Surround the child with good peer role models
so that the child can be around kids
who actually could help him or her focus
or make better choices and can see what those choices are.
You want to encourage peer tutoring
and cooperative learning when possible.
How do you help kids with certain specific issues
related to executive functioning?
So, problems of initiation, getting started.
It's helpful if the material's pre-taught,
the assignments are broken down into parts,
and that you hand out written copies of the assignments.
For problems of sustaining attention or anxiety,
use interactive teaching style,
provide positive feedback, and offer shorter work periods.
For problems with shifting or making transitions,
offer a daily agenda so the child
will know what to expect, encourage flexibility
through self-talk, and reward flexible behavior.
"I see you're doing a great job
"making the transitions and you're
"coming to our class on time."
Problems with organization.
It's sometimes easier for teachers to help students
understand how to file papers in their notebook
than for their parents, because of all of the,
sort of particularly teen dynamics
around separating, and wanting space, and being independent.
Give extra time for teachers,
if the teachers could give extra time for
organizing materials, or maybe have the student
come after school for a little help with that,
that would be great, and the other thing
that really helps with organization
is to give an ordered list of assignments
and activities that the child or student is responsible for.
For problems with planning, you want to
explicitly as a teacher teach planning strategies,
and that means breaking assignments into parts,
so if you have a research paper,
and teachers do this most of the time
naturally in high school in the beginning,
in ninth grade, you know, "Okay, you're gonna
"do this part of the research, and we're all
"going to the library, and then we're gonna
"do this part of the research on the computer,
"and then I'd like to see you outline your paper,"
whatever it is, but that kind of breaking
an assignment down is very helpful
for someone with ADHD because otherwise
they see the research paper, and it's just
so overwhelming, and there are so many options,
and there are lots of ways they can do it,
and they may or may not have the confidence to do it,
so it's very helpful to make it
a smaller, more manageable task.
And to create a calendar of when
things need to be done for that paper.
And this would mean providing steps
for a multi-step piece of work or a project.
In terms of problems with self-monitoring,
we want to teach them a reverse process to check
math calculations, and to use a check-off sheet
to show the completion of assignments,
so again, if you have things written down
in a calendar or an assignment book,
you check off that you did them,
and this reverse process of math calculations
can also be very helpful in terms of editing a paper,
reading the paper backwards from
the bottom up, and seeing how it goes.
It's also helpful if the teacher establishes
with a student ways of monitoring performance.
How do teachers address behavioral
challenges in the classroom?
First, they have to calmly, calmly is the big word,
restate the infraction of the rule
and do not debate or argue with the student.
Second, they have to have some
pre-established consequences for a misbehavior.
Third, they need to administer the consequences immediately
and support proper behavior with encouragement.
And four, you have to enforce the rules
of the classroom consistently.
This is very hard to do when you have classes
of 20, 25, sometimes 30 kids in a class,
and so for teachers it's really helpful
if you work in a school and you have
school-based practice to offer them
or figure out with them how they can get
supervision, discipline in the...
it's very important for teachers,
if you work in school-based practice,
to help them get supervision, and peer support,
and brainstorming ideas to deal
with these kinds of challenging behaviors,
so that they're not feeling all alone in a classroom
with a child, and they don't end up
sort of blaming the child, and,
not purposefully, although sometimes
maybe purposefully, sort of singling out that child.
It's important that teachers avoid ridicule
and criticism publicly of a child,
of course at all times but especially kids with ADHD,
because the belief in society is,
they could change it if they wanted to.
And the reality is, as we've talked about today,
that things don't just change because
you want them to if you have ADHD,
that it is a biologically based disorder,
and it's based in the brain, and so there are a lot
of very complicated factors that go along with it.
You want to help a child build self-esteem,
and that's through positive reinforcement,
whether you call it reward, or praise,
and noticing when things are going well,
noticing when a child is doing a good job.
And teach the child to reward him
or herself through self-talk.
You know, that's your job as the therapist.
What does the child say to him
or herself when something's going well?
Does the child say, "I was lucky?"
Or, "Yeah, but last time it was really bad,"
or "Just wait til next time," or does the child say,
"Good job! I'm making progress."
My bet is the child doesn't very often
say the last one, and that's what we want
to help that child learn to say.
So, what do we want to keep in mind here?
Hmm, what are the top 10 reasons for procrastinating?
A sense of humor goes a long way.
We want to help families and teachers
and kids with ADHD themselves be able
to laugh at some of the things they do
and not shame themselves or hate themselves for it.
Home/school collaboration is essential for academic success.
Executive functioning problems are not
motivational deficits but skill deficits,
and those skills need to be taught
from infancy to adulthood, and parents
have to teach them, and teachers have to teach them,
and therapist and psychologists
have to teach them to people with ADHD.
They do not come naturally, in fact
they don't really come naturally to anyone,
it's just that people who don't have ADHD
learn them more readily than people who do.
ADHD is a medical condition.
It is not a failure of will.
It is not a choice.
And it's important to remember,
as Ross Greene says, "Kids do well if they can."
And if they can't, what is getting
in the way of them not doing well?
Adult support is key to successful interventions
and lifelong learning skills.
In this way, coaching can be extremely helpful.
Having someone at the school who's a touchstone
for a child with ADHD, even five, ten minutes
a day can be extremely helpful.
Keep in mind, executive functions
provide structure, organize time,
involve initiation, help a person understand
and organize and live in their environment,
and to use these executive functions,
there are some tips, give reminders,
or what we could call cues, use calendars,
try to stay calm and supportive if you are
a family member or a professional involved with this child.
Avoid negative labels, parenthetically, ask what
negative labels that child has about him or herself.
Provide breaks.
Praise efforts that you see toward
change and doing things differently.
And create scaffolding and sustain it,
longer than you think it might be necessary.
So what are the keys to personal success
and confidence for a child or a teenager with ADHD?
Helping them organize their environment.
Praising self-initiation and motivation,
completion of tasks.
Getting feedback, talking about how time is organized.
Providing scaffolding and keeping it
in place longer than you think.
Giving any kinds of cues, visual, verbal,
over time, even if you don't want to
or think they're not necessary, and even if the child says,
"Oh my God, you nag me all the time."
Well, let's talk about what nagging is versus cuing.
Use technology if that can be helpful,
really try to investigate what
negative labels that child is telling
him or herself about having ADHD
and challenges with executive function,
and then try to make sure that those labels
are avoided being used in the child's life.
In Delivered from Distraction, Ned Hallowell
talks about seven habits to improve effectiveness,
and I wanted to share those with you
because I think it's really important
to take this positive view of child development,
and adolescent development, and young adult development,
when you think about kids with ADHD
and executive function challenges,
that we want to get them to a place
where they feel like they have something
they're good at it, and they're passionate about,
and they can pursue a life of rich connection to others,
and meaningful work, and nice pleasurable hobbies,
and a life that they feel good about.
So here are his seven habits to improve effectiveness.
One, do what you're good at.
That would be very true for kids with ADHD, find something
they like, or they're good at, and magnify it.
Delegate what you're bad at to others, as often as possible.
That sometimes is hard to do in childhood
and adolescence, and as an adult, we can do that,
you know, I have a client who's an attorney,
and he is not very good with managing his appointments.
He solved that problem because he has
a personal assistant or an administrative assistant.
So, that's harder for kids, but I think
it's interesting to take that on as a perspective,
this idea of delegating what you're not good at,
so if you're not good at remembering
to take your pills in the morning,
then let's set an alarm for that to happen
so you don't have to worry about it anymore.
Connect your energy to a creative outlet.
Most of the kids I see with ADHD, in fact,
I would say almost all of them,
have some aspect of creativity that's just fantastic,
a sense of humor, art, writing, drawing,
magic cards, gardening, there's something
that they really love to do, and I really
think that it's important to nurture
that connection to something that
they are creative and passionate about.
Get well organized enough to achieve your goals.
We've been talking about this today,
the importance of organization, and actually
have said that getting organized
is a goal in and of itself.
But in general, getting organized is a means to an end.
So, identifying what that end is,
and then figuring out what kinds
of organization you need to get to that end,
is part of the process of building
executive functioning skills, and we want to help the kids
and teens and young adults we work with do that.
Ask for and heed advice from people you trust.
Well sometimes that can be challenging for all of us,
I think it's sometimes especially hard
for young people with ADHD, because of
the shame that I've referred to,
and the general sense of not getting things right.
So, we want to help them learn how to ask
for assistance without feeling embarrassed.
And that's an ongoing process, it's not an easy one.
But it's really critical to their sucess
in whatever endeavor they embark on.
Keep up regular contact with a few close friends.
You know, friendships nurture us throughout our whole lives.
And sometimes, for children with ADHD,
making friends is hard, because they misread
the social cues around them.
Sometimes they're so focused on making friends
that they have a lot of, sort of peripheral
friendships but no real intimacy.
Sometimes they can be over-focused on one person.
So, one of the things that's important
to think about when we work with kids with ADHD
is to help them understand what it means to be a friend,
what to expect from another person,
but also what to expect from yourself.
The last habit that Hallowell indentifies
is go with your positive side,
which I think is just a great thing to think about,
which is lead with your strength.
And one of our tasks as therapists
is to help identify what that strength is,
in the family, in school, in work, socially,
what are those strengths and how can we
really nourish them so they continue to grow,
and that these kids can feel like
there are things they are good at.
Finally, another quote from Delivered from Distraction,
"And you don't give up.
"That is another trait of people with ADD.
"They keep trying.
"Often, they keep trying the same,
"doomed way, but they do keep trying."
So, we want to try to help them
try in different ways, to think in different categories,
and ultimately to use that innate desire
to keep trying to their best interest,
so that their efforts feel rewarding to them.
Thank you so much for participating in
Understanding ADHD and Executive Functioning
in Children and Adolescence, I hope this
information will be useful to you in your practice,
and I hope that you have a wonderful day.